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A Quality Quickie

I’ve mentioned the quality issue a couple of times, and have somewhat denigrated the quality movement as being made irrelevant by the backlash against managed care.  However, given the IOM’s "To Err is Human" report on medical errors and more recent "Crossing the Quality Chasm" (note: scroll down for exec sum), it would be unfair to ignore those who are trying to raise its public visibility, such as the CHCF promoting a series on it.  This video about the "Hospitalization from Hell" mostly by Paul Cleary (from Harvard — Here’s the article), is long (50 mins) but if you have a good connection and Realplayer, it’s well worth watching. Clearly suggests that the application of known quality processes used in most industries are still very limited in health care, and that the case he uses as an example is very applicable to most  health care organizations. One of his solutions is that local units and individuals must take responsibility for organizing their own quality process improvement, collect good and useful data, and engage the operations research specialists. This is not unlike the strategy that the German Army used to overrun the French in 1945 — command was decentralized to small units working with knowledge of wider goals (as argued in James Q. Wilson’s book "Bureaucracy"). There are also serious efforts funded by several Foundations to improve quality processes, such as this one in Washington state, funded by RWJ and "blogged" by many of its participants including Marcus Pierson, MD.

The problem here is that I heard all this in 1989, and Don Berwick, the guru of TQM in hospitals wrote the same stuff then as he is writing now.  Every other industry has been forced into using quality improvement techniques.  So this morning I heard about 2 examples of patients I know in the SF Bay Area who were served very badly.  One was not called back as promised about a potentially very serious test result. After calling the medical group, no one could locate the result or the file.  And then they couldn’t do anything other than give the patient another appointment. The other concerns a new patient who was left on hold for 25 minutes by the medical group. Let’s face it, none of us would put up with this from any other type of consumer service organization.  Why do we expect it from health care orgs, and is it our fault for doing so?

Performance-based pay in health care?

Given some off-this-stage politicking I’ve been involved in, the Medicare drug coverage argument, and the recent "Physicians" plan in JAMA proposing single-payer, this Forbes article caught my attention. I subscribed to Forbes for a while and they never ceased to amaze me with how captured they were by new Internet business models while they decried any attempt to reform old-world fee-for-service medicine. Now even Forbes is coming out in limited favor of some type of pay for performance linked to basic quality guidelines. Back in 1997 my IFTF colleagues (especially Greg Schmidt) and I forecast that insurers paying some type of reward for performance would account for a sizable minority of the health care system by 2010.  In the RWJ-sponsored "Health & Health Care in America: A Ten year Forecast" we wrote:

"…a separate type of payment system will develop. Plans and intermediaries will devise reimbursement programmes that give providers incentives to deliver care in a manner that improves quality, customer satisfaction, patient tenure in the plan, and outcomes, as well as productivity and cost-effectiveness. We dub this system ‘performance-based reimbursement’, as payments will depend on the providers’ performance on a strung of relevant algorithms. By the latter part of the next decade this system will be the single most important way of paying provider organizations, although the old methods will still be a part of the system."

Well on re-reading this section I note that the accompanying chart had Performance-based pay at only 15% of all dollars by 2010, with the rest evenly split between prospective payment (DRGs and capitation) and FFS land.  So when you’re busting to get out a big report not every word will be internally consistent.  And this change (should it happen) would certainly seem revolutionary compared to what has happened in the first five years of our 13 year forecast. At the time the report was written there were already HMOs paying some limited amount to medical groups based on quality metrics.  Since then the quality movement seems to have somewhat been the baby thrown out with the bathwater of the managed care backlash.  But I think that as the initial foregin policy concerns of the first Bush administration fade, and even if it doesn’t pass Drug Coverage this year, Congress will return to the future of Medicare as a whole.  And if the political right (as represented by Forbes) is starting to think about the possiblity of performance based-pay, then the mainstream private health payers will start to introduce it too. When that happens, we’ll be on for another round of changes in care delivery and provider organization.

Quality

All you need to know about health care quality is encapsulated in Ian Morrison’s line–"you can tell a quality doctor when the people in the waiting room make more money than you do".  The latest Harris Poll on the subject shows that "Reputation", and the reccomendations of families and friends are still what drives doctor choice, while for hospital choice, whether the patient’s insurance plan covers it is added into the mix. (Although virtually all plans cover all hospitals unless Sutter and Blue Cross are fighting again!).  Only 20% said that they would choose a doctor because the doctor had been highly rated in a published evalutation of doctors. (Harris’s site is down at the moment, but their healthcare section should be here and is well worth cruising through). So well over a decade into NCQA and all that, we’re a long, long way from Consumer Reports

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