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The dark side of measuring healthcare quality?

Improving quality in healthcare is an important fundamental goal. New “pay for performance” measures initiated by the Center for Medicare and Medicaid services is a well meaning attempt to provide financial incentives to physicians who demonstrate improved patient outcomes. Unfortunately, this incentive program could backfire.

A recent article in Medical Economics (via Kevin MD) raised the question of “cherry picking and lemon dropping” your way to higher pay. In this frightening scenario, physicians would be tempted to select healthier, more compliant patients for regular treatment in their practices. In this manner, they can demonstrate better outcomes, since the sicker, poorer, or less compliant patients no longer factor into their performance measures. And with the upcoming physician shortage, it really is a seller’s market.

It is critically important for the government programs to allow physicians to accurately risk stratify their patients so that they are not financially penalized for taking care of sicker patients bound to have below average outcomes. The same goes for surgeons, who should not be discouraged from undertaking potentially lifesaving surgeries for patients who are critically ill.

Dr. Kellerman, the president of the American Academy of Family Physicians, reminds us that quality of care is vastly improved by having a central medical home (i.e. one physician who can coordinate care for patients, so they’re not left with a group of disconnected specialists ordering duplicate tests and prescriptions). I personally think that a centralized EMR/PHR controlled by the patient (and located at an Internet based “medical home” complete with disease management tools and the ability to email a physician as needed) would go a long way to improving quality.

What do you think?

This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.


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5 Responses to “The dark side of measuring healthcare quality?”

  1. CharlieSmithMD says:

    Dr. Jones,

    I believe that medical care coordination is best done by a physician with whom the patient has a trusting relationship. That physician should, ideally have an EMR to work from and allow e mail communication with the patient, so that coordination does not require an office visit for every question/clarification needed. A good EMR, configured to provide alerts whenever the patient is due for preventive services and other parameters in patients with chronic disease eliminates concerns about P4P, and will ensure that any compensation based on practice performance will be at the top of your peer group. But, speaking of P4P, I am currently working with our local BC/BS insurer and, I can assure you, it has a long way to go and may never be more than a passing trend.

  2. Anonymous says:

    I believe I am a clear, concise writer, but I have not had much luck communicating with my physician by email. Even if I write only three succinct sentences, I feel that he often responds only to the first sentence. Isn’t there research showing that many/most people skim emails and look for salient words? A comic example was when I referred to “Dr. EM” (the initials of the specialist my doctor had sent me to), and he responded by asking me when I was having an EMG (which I certainly wasn’t!) I don’t think my doctor is careless or neglectful, but email communication seems only to spawn more email in an attempt to get clarification. I’ve decided to avoid it for any substantive issue.

  3. Anonymous says:

    What you’re Describing is only one of the major pitfalls in having government involved in healthcare. Let’s hope Revolution Health succeeds in its mission and makes government intervention lessnecessary in health care.

  4. Dr Rob L says:

    The idea of more complex patients being ignored is no different from what is already happening. We get paid more for quick visits than we do disease management. I think the whole system will eventually change to be a hybrid of care management which is reimbursed for primary care physicians (only possible on EMR as Charlie said) along with a “per hour” fee that physicians will charge for the visits. This would encourage outcomes over volume, but would not overly shift away from getting paid more for hard work. There will be gaming of the system whatever the system is. Just because there are potential abuses does not mean that the system won’t work.

    Rob

  5. Dr Rob L says:

    The idea of more complex patients being ignored is no different from what is already happening. We get paid more for quick visits than we do disease management. I think the whole system will eventually change to be a hybrid of care management which is reimbursed for primary care physicians (only possible on EMR as Charlie said) along with a “per hour” fee that physicians will charge for the visits. This would encourage outcomes over volume, but would not overly shift away from getting paid more for hard work. There will be gaming of the system whatever the system is. Just because there are potential abuses does not mean that the system won’t work.

    Rob

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