Clinical Practice Guidelines: Not only ineffective and dangerous, but expensive too!
Quality indicators are becoming progressively more accepted among health care reformers, who believe that the quality of a physician’s care can be measured with easily defined metrics. The folly of that presumption is tackled in my book and in this blog. Now we are learning about another dark side of quality measures: they are very costly.
A recent survey published in Health Affairs (March, 2016) demonstrats the financial burden that quality measurements impose on physician practices. Most practices surveyed spent on average 15 hours a week per doctor adhering to quality measures, with 4 hours of that time delegated to the doctor and the rest of the time falling on the laps of office staff. Primary care doctors spent more time than any other doctors surveyed. In general, the cost per doctor from quality measures due to non-reimbursable time spent was $40,000 per year. The cost to the system was $15.4 billion!
Are quality measures worth this excessive financial and time burden placed on primary care doctors who are already facing reimbursement cuts and increased regulatory time constraints? Do they actually help doctors to provide better care to their patients and to improve doctor knowledge? Do these measures improve doctor and patient satisfaction and enhance shared decision making?
The answer to all of the above is NO. The details of why are in my book and have been validated by an ample number of studies. In a nut shell, not a single study has shown that quality measures actually enhance quality. In fact, these measures are generic requirements that impede shared decision making by favoring a top-down approach. To pass a measure, doctors must tell patients what to do based on the script provided to them through the quality measures; patients’ own opinions can only get in the way. And although what is good for(and desired by) one patient is not necessarily good for another, clinical indicators view all patients as being the same. Even more significantly, quality measures can be dangerous by promoting overtreatment. No measures chastise doctors for ordering too many tests and procedures, for lowering patients’ blood pressures and sugars so much that they fall and are dizzy, for over-medicating them to the extent that they have side effects and their quality of life declines. In fact, the more doctors test and treat and the less they listen to their patients, the better they will do with quality indicators. Finally, patients often have individual needs and issues that they want to discuss with their doctor. But since doctors must be focused on quality indicators during visits, they typically do not have time to address what is important to the patient. What the framers of these indicators do not realize is that doctors have limited time in every visit, and thus are unable to actually address patient needs due to time spent with clinical indicators.
So, is it worth $15 billion to implement a program that is ineffective, medically dangerous, and antithetical to patient centered care? Is it worth dropping a $40,000 a year burden on the laps of primary care doctors who are struggling now to take care of their patients effectively and humanely? Why are our reformers so intent to force quality indicators down the throats of doctors and patients when they do not work and are prohibitively expensive?
Many of us have implored Medicare and other insurance companies to drop or radically improve quality measures. I have written that the best measure of quality is to assess whether doctors accurately speak with patients about the risks and benefits of drugs, tests, and procedures. For example, doctors should not be rewarded if their patients get a mammogram and berated if they do not. Rather, they should be rewarded if they discuss the risks and benefits of mammograms with such tools as BRCTs, and it should not matter if patients actually get the mammogram or not (it is the decision of the patient after the discussion). Ultimately effective shared decision making using accurate tools like BRCTs (the theaters I typically use in my blogs) will lead to higher quality and lower cost by giving more choice to patients. Once patients understand the risks and benefits of an intervention, and can assess those risks/benefits in the context of their individual conditions and needs, then they can make decisions rationally. Studies show, in fact, that such shared decision making leads to less over-testing and fewer adverse reactions.
It’s time that we look at quality reporting for what it is: A costly burden on patients and doctors that accomplishes nothing of value and that can cause significant harm. It’s also time that we put our heads together and fix the problem rather than simply perpetuating a system that doctors and patients have clearly rejected.