How "Quality and Value" are double-speak for the lack of both: The bankruptcy of health c
In the era of health care reform, two words consistently are employed to describe the strategy being used to cut cost: quality and value. What do these words mean? We have discussed their use many times in these blogs, and have shown that they often diverge sharply from their purpose. In fact, nothing wastes physician time, and gets in the way of the doctor-physician interaction, more than having to focus on adhering to Medicare’s report card of quality. How effective are Medicare’s (and for that matter, Blue Cross’s and virtually all other insurance companies) quality indicators? Do they help improve outcome and cut cost? Is paying doctors for their “quality performance” an effective way to assure better care, and are doctors who score high on quality indicators helping their patients more than lower quality performers? And to take it to another level, is the use of electronic medical records—another way that insurances like Medicare have assured that doctors engage in quality care—an effective means of promoting quality and value? Certainly, electronic medical records (EMRs) are among the most demeaned appendages of medical reform. Reformers suggest that despite their burden, EMRs are necessary for the promotion of quality and value. But do EMRs and performance measures actually work?
A recent article in the Annals of Internal Medicine joins a large body of literature, some of which I have discussed in my book and in these blogs, that suggest there is no evidence that pay for performance has any impact on health care outcome or cost. Starting this year, a large part of physician pay is going to be tied to these pay for performance quality measures, even though they have never been shown to achieve any beneficial goals. Medicare has laid out a complex series of hoops that doctors must jump through to prove that they are practicing with high quality, with promised cuts to those of us whose performance by these quality measures is found to be lacking. An accompanying editorial in Annals highlights the danger of basing payment on a nebulous program.
An example of the folly of quality measures came to light recently when two large medical organizations—the American College of Physicians (ACP) and the American Academy of Family Physicians (AAFP)—disputed the quality indicators being used by Medicare regarding blood pressure. Based on a single, small, and flawed study called SPRINT, which we have discussed in this blog, a study that has virtually no precedent (previous studies all demonstrated results that verged sharply from SPRINT’s conclusions), Medicare has stated that elderly people under the age 85 must have their blood pressure below 140, and should have their blood pressure below 120, for their physicians to pass the quality measure. From my own experience, many older people will feint, be tired, be more confused, be dizzy, and have organ problems when their pressure is under 120, and many of them cannot tolerate pressures even below 140. In fact, while SPRINT did not measure the life-altering side effects that lower blood pressure inflicts on some frail elderly, it did find that 20/1000 people who achieved target low pressures suffered serious harm, while only 3.5/1000 had significant benefit. A subsequent study, HOPE-3, showed a similar number of serious side effects, but found no benefit of driving the blood pressure very low; in fact, there were 8/1000 additional deaths in that group. As a doctor, I have a choice: take care of my patient competently, or follow the quality measure. ACP and AAFP have looked at the issue and come to a more realistic conclusion that reflects clinical reality: 150 is probably a more scientifically sound blood pressure goal for the elderly. But Medicare’s guidelines are holding to SPRINT’s numbers. Thus, we are being judged on a quality measure that is inaccurate and antithetical to good care. What is more frightening, a doctor who overtreats his/her elderly patient and drops the blood pressure to such low levels that the patient’s life is at risk and he/she cannot function, will pass the quality measure. How is this a road to quality and value?
Electronic Medical Records (EMRs) have a similarly dismal track record in improving quality and cutting cost. A recent Medical Economics article tries to explain why the EMR system, which always ranks high on the list of what triggers physician burnout, has failed to improve the efficiency of care. The systems are not inter-operable (they don’t talk to each other), they are difficult to use, and they are not designed for the health care arena. All of this is made more difficult by insurances like Medicare, which tell doctors exactly how they have to use their EMR, which boxes must be checked, which actions must be completed, and how all that has to be recorded for us to avoid getting a pay cut. Just this year I received a letter from Medicare stating that I did not perform well enough on my EMR report card and will be getting a 3% pay cut this year on all my Medicare billing. The formula for avoiding a pay reduction is complicated and time consuming and requires mental, physical, and financial investment. How does this help me to better take care of my patients and to promote quality and value? It is bad enough that much of my focus and attention must be on typing Medicare’s mandatory template into the computer during an office visit, something that detracts from my ability to interact with and focus on my patient, but it is deleterious to my practice that even if I use the EMR I may get a substantial cut in Medicare reimbursement if I cannot complete every task as Medicare demands. Further, not a single study has demonstrated that the use of EMRs has improved quality or cost; sometimes just the opposite has been demonstrated. And EMRs are the highest cost to our overhead other than salaries. They are expensive, detract from the doctor-patient experience, do not improve outcome, and lead to pay cuts and stress for physicians. This is yet another pay for performance quality indicator that reformers tout and which is worth than useless; it is damaging.
In the end, if we really want to improve quality and cut cost, it is time to stop using double-speak and to look at the drivers of low value, high cost health care. I have discussed this in many other blogs. The answer is not in paying doctors for some inaccurate measure of performance. The answer is in paying doctors for the value of their care. In the next blog, we will return to primary care, and some novel ideas, and new articles, that can help make it the real engine of quality and value in our system.