How to Build Better Metrics: Focus on Physician Outcomes

flying cadeuciiQuality measures began as tools to quantify the healthcare process, using outcomes, patient perceptions, and organizational structures associated with the provision of high-quality health care. Overall, the goals should focus on delivery of care that is effective, safe, efficient, and equitable.  Did you notice a particular word missing?  Yes, I missed the word physician too, because they have been left out of the conversation entirely.

Measuring quality healthcare by a patient lab result is like recording a patient’s temperature by waving the thermometer near their face.  One has little to do with the other except for the slight appearance of connection.  Quality must be measured by physician outcomes and not those of patients.  For instance, our county does not have fluorinated water.  Measuring the percentage of children that have cavities is a patient outcome and not an accurate reflection of medical care provided.  A physician outcome would be calculating the percentage of children who received a prescription for supplemental fluoride during their office visit.

If the intended goal is to reduce unnecessary ER visits, then we must determine the root cause.  Patients with private insurance rarely go to the ER for non-emergencies because they pay a large out-of-pocket cost.

Those on Medicare or Medicaid visit the ER for free.  There is no disincentive to visiting the ER, but there needs to be.  In addition, it makes no sense to penalize me for an unnecessary ER visit if I have not seen and evaluated the patient in my office.  The common sense solution is to figure out how many patients seen in my office were then seen in the ER within 24 hours.  That may be a quality indicator.

Asthma and diabetes are two chronic conditions with large costs to the healthcare system.  Compiling statistics about the number of patients who are not well controlled on daily medications is a patient outcome.  How about looking at whether or not patients who presented with these conditions were prescribed the proper maintenance medications in a timely fashion?  How about checking whether we emphasized the importance of daily use of these chronic medications in our clinical note?  Those are physician outcomes and could be used to determine quality. Why are we allowing patient outcomes, for which they alone bear responsibility, to burden us as physicians?

How about paying me for the time spent completing oral rehydration for a moderately dehydrated child in my office?  It takes a few hours to orally rehydrate an infant or small child properly.  In my humble opinion, it is time well spent and avoids an ER visit.  I bill for extended time, but am rarely paid.  It is one of the most satisfying things I do, no parent has required more than one session in my office to be successfully taught this skill to use at home with successive children.  Return on investment for those three hours is unbelievable and pays dividends for years; a parent will almost never need to go to the ER for dehydration again.  How about a metric covering the amount of money saved by patients, insurance, and the government once a pediatrician has taught this essential skill to a family?

My fifth suggestion would be to look at the percentage of children under 5 years of age seen for well child visits annually, rather than viewing value from percentage of children up-to-date on immunizations?  In states, like Washington, there are vaccine exemptions for every reason under the sun.  That metric penalizes a physician for a patient outcome, of which they have no control?  A physician outcome would be documenting the recommendation for immunizations during a well visit by the primary care physician.

A metric tracking exceptional physical exam skill is another worthy physician virtue.  For instance, how frequently does a pediatrician diagnose rare congenital conditions when evaluating a new patient?  Top notch physical exam skills are essential and it this metric would preferentially favor experienced physicians who pay close attention to detail. In 15 years, my list includes a half dozen boys with undiagnosed undescended testicles, two children with choanal atresia requiring surgical intervention, 4 with chromosomal deletion syndromes, and my “holy grail”, an undiagnosed aortic coarctation (narrowing of the main vessel supplying blood to the body) suspected based on physical exam alone.

My idea of “value” is best illustrated by sharing my coarctation story.  A boy came into my office for a well child visit.  He had some behavioral issues, had seen multiple pediatricians over the years due to frequent moves, and brought scant records with him.  He was restless and it was difficult to palpate femoral pulses, but I do this on each and every child at their yearly physical.  Despite my persistence, I was unable to palpate them successfully.  A quick glance at his slightly elevated blood pressure, 128/90, made me pay closer attention.  I repeated it myself with a similar result.

I discussed my concerns with the family, referred him to a cardiologist, and called to discuss the case with the specialist.  Doubtful, the cardiologist told me she would let me know what she thought after evaluation.  Indeed, my diagnosis was spot-on! He underwent surgical correction for his congenital anomaly, (like the others who have transferred in to my practice) and it was a success.  He became quite the star athlete in high school and is entering college this fall.

Value can be defined as both a noun and a verb.  The former denotes having importance, worth, or usefulness. Experienced physicians have stories exactly like the one above; because our care provides tremendous value to the patients we serve.  Business people in healthcare prefer to use value as a verb because it signifies having a monetary gain attached.  Government and insurance companies should stop wasting dollars and cents chasing visions of value, rather use common sense and give physician outcomes the attention they deserve.

Healthcare will be on better footing now and into the future.

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12 replies »

  1. If you believe doctors get to be in charge of anything, you are living under a rock. If you are looking for better care, the solution is simple. Invest in primary care physicians. For every primary care doc added to population of 10,000, mortality decreases by 5.3%. That is nothing to sneeze at.

  2. I agree that quality/performance measurement must avoid over reliance on measures of health status/outcomes that are too far beyond the physician’s or medical team’s control. That would be unfair since people are notoriously fickle and unreliable in adherence to treatment. That said, the argument that we MUST be more focused on outcome versus process measures remains valid and critical to the future of improving care. The medical system simply has to be accountable for that since studies overwhelmingly show that poor outcomes are all too common and are NOT just due to variability in patients or patient behavior; they are due to poor care. And medical care is, in theory, led by doctors…individually and collectively, in teams and systems. Yes, doctors are being asked to take on more of a public health role. And that’s the point! Overall outcomes have to improve, through better adherence to evidence, improved choices, and reductions in unnecessary, wasteful care.

  3. How about if we walk away from “metrics” completely and create an environment – like we used to have – where providers love their work, want to do better, want to exchange information, want to provide better care? Ultimately, metrics are arbitrary, punitive and discouraging. And they don’t remediate. All you know after you measure is that you have defects. Big deal!

    http://www.fixthe bus.com

  4. Coke light is the greatest drink ever in the history of the world! Sold in almost every country outside the US. We would be so much better off if our food “policy” reflected what is best for our population.

  5. Agree with you that we don’t control people and probably shouldn’t. Then why are we being rewarded or penalized based on what these people do?

  6. I would suggest that government intervention inflating particular prices counts as “policy”. And it is a corruption issue as you suggest.

  7. Is it solely because of failed food policy or are political issues and payoffs also involved. When I travel in Mexico I buy Coca Cola and it tastes better than the American counterpart. This is because the government keeps the price of cane sugar high so soft drinks like Coca Cola use higher levels of fructose (less expensive) that likely aren’t as good for our health as sugars with lower levels of fructose.

  8. Agree, Hans. There is an epidemic of diabetes secondary to failed food policy and irresponsible corporate actions reinforced by a complicit regulatory industry. Getting someones A1C to “X” essentially ignores the entire problem. Medicalizing BMI etc is only going to jack up the cost of addressing the root causes in addition to hanging the physician workforce with a problem they are completely unable to solve. Physicians do not control people…and they shouldn’t.

  9. Agreed. My favorite part of your comment was the word “manipulated”. Sums up healthcare numbers perfectly. Thank you.

  10. This is my point exactly! How did we end up with the responsibility for patients choices: good or bad? It will fail, just as it did with No Child Left Behind. You cannot make teachers entirely responsible for the outcome of their students any more than physicians can be for outcomes of their patients. It’s called personal responsibility.

  11. I agree wholeheartedly with your statements about only measuring physician outcomes. The reason all the other measurements are being used on (or against) us is that we have no real Public Health system in this country. My example from the geriatric, or at least Medicare, population is that I get penalized if I don’t come up with a treatment plan and followup timeline for every patient with a body mass index over 30. What society couldn’t fix, the Government has now made the responsibility of our nation’s doctors.

  12. If the left were denied the use of complex manipulated metrics and used outcomes they would have to abandon their claim that the US has terrible health care. Admittedly we could do better at a lower cost, but our outcomes are among the best. They don’t like to look at raw data such as the CONCORD study where cancer survival was compared over five continents for some of the common cancers. The US consistently placed number one or two on each metric. No other nation came close.