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What Defines Quality Care and Who Can Afford It?

Interesting thoughts from The Happy Hospitalist:

How do you define quality care?…

If preventing 90% of in-hospital DVT’s with a medicine that cost $30 a day was quality, so be it.

What if you could prevent 99% of in hospital DVT’s with a medicine that cost $300 a day. Would the 90% be quality or the 99% be quality? What if it cost $3,000 a day to prevent 99.99% of in- hospital DVT’s?

Which effort would be considered quality? Who defines the cut off, and at what price?

Here’s what he has to say about Pay for Performance measures, and why they won’t add up to significant savings:

Unfortunately, the measures being undertaken for quality initiatives are, from my stand point, minuscule in terms of the overall potential cost savings to the system.

And the reason is simply, at least in my part of the medical physician spectrum, a very large chunk of health care expenditures comes in the form of evaluation, and not management…

In the medical profession, there exists a sense of universal freedom to order tests, xrays, labs, and procedures with a sense of unlimited funding. Somebody will pay for it. My patient sitting in front of me is the center of my attention and their needs supersede all other needs from a social/financial point of view of the nation…
Where are the government incentives for quality medicine in the evaluation of disease?
Where is your bonus payment for not ordering the heart cath?
For not ordering the CT Angiogram?
Where is your physician bonus payment for not ruling out a low probability DVT?
Or not ordering an EGD?
For choosing watchful waiting.
Where are your quality bonus payments for evaluation of illness?
They simply don’t exist. Because doing so would overtly ration the public and create a firestorm.

Is the storm coming nonetheless?This post originally appeared on Dr. Val’s blog at

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2 Responses to “What Defines Quality Care and Who Can Afford It?”

  1. DrDavid says:

    Oh, I ABSOLUTELY have to agree with HH on at least one point:  the system is set up in an unbalanced way… to de-value the management aspect of what we do.  This is one of my most common rants when I am on service and faced with writing my daily “notes” that are designed, near as I can tell, simply to justify billing.  There is tremendous emphasis on jotting down history (a 4 point review of systems every day, even for a kid sitting and getting chemo but otherwise totally stable), and almost NO emphasis on the assessment and plan (ie. management).  Patients come to us for management, and it’s management that separates good from merely average care.  But the billing system so de-emphasizes documentation of what I think is going on and what I’m going to do about it.  And that’s sad, because that’s the most important service I offer my patients.

  2. Dr. Scherger says:

    I do not question the points made here, but it does not do justice to the modern quality movement.  Just look at what the Save 100,000 Lives campaign by IHI did, and the reduction of many complications, saving money.  Look at the IOM Crossing the Quality Chasm Report (2001) and how these quality initiatives have been put into hospital accreditation.  In the (primitive past) medicine was paid simply for doing, no questions asked.  Now medicine will (and should) get paid for results.  Quality reporting is here to stay.  They bar is being raised.  And payment will no longer be given for shoddy quality.  This is modern medicine, and pay for performance is only an small, early part of this revolution.

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