22 September 2009

Paying for Quality

Ezra has a cool theme day with a whole bunch of health care delivery experts talking about cool or useful avenues for reforming health care delivery.  I'd recommend it to anyone serious about understanding the complexity and challenges of reform.  But one thing in his intro really caught my eye:

Delivery System Day!
Fairly few political journalists know anything at all about the medical delivery system.  Despite my best efforts, I'd include myself in that number. I focus too much on insurance. And I don't have as tight a grasp on medical delivery questions as I'd like. I get the basic sketch -- pay for quality rather than volume, manage care coherently rather than episodically, develop evidence and integrate it with IT platforms that help providers put the knowledge into practice...
I just don't know how this is ever going to work in real life.  Quality is such a nifty goal that sounds good and certainly has some elements that can be defined and measured and in certain chronic diseases can certainly do a lot to improve care and save money.  Ditto for the "medical home" or "continuum of care" or whatever buzzword we're using for that this week.

Here's the problem: there is such a narrow subset of medical problems that can be managed with this sort of approach that its effect on health care systems and health care expenditures can only be marginal.  For example, the patients I saw last night had:
  • Acute Appendicitis
  • Increased pain s/p hysterectomy
  • Closed head injury wanting narcotics
  • Suicidal ideation
  • Chest pain and anxiety
  • Facial wound bleeding due to coumadin
  • First trimester vaginal bleeding (three of these)
  • Nonspecific pelvic pain
  • Child with fever
  • Tonsilitis
  • Suspected child abuse
  • Migraine headache
  • Incarcerated inguinal hernia
  • Acute kidney stone
  • Fainting
  • Patellar dislocation
These are the ones I remember -- I saw over thirty patients.  It was a high-volume, low-acuity night.  So how on earth are we going to define "quality" for these disparate complaints?  I'm sure there are some easy things we can identify: the febrile child should have had blood cultures, maybe, and the syncope needed an EKG.  But the buzzwords fail when you look at the panoply of issues and complaints that people come to the ER with.  I have no clue what the "medical home" will do for the anxious person with chest pain. Again, this is not to say that chronic disease management isn't a great thing, and blood sugar control and blood pressure control and all that are great goals.  We can save some money with that.  We can reduce human suffering.  organizational quality is something I really believe in.  But it's not enough to completely modify the mode of health care delivery, or reimbursement.  That extra 2% of my medicare reimbursement I receive for participating in PQRI is not going to revolutionize the way the ER works, and, forgive the negativism, but any effort to expand it to a global program is bound to fail.


  1. Any time my husband and I have gone to the ER it has been because as you know a common way things progress is: Guy gets up feeling a little off, goes to work anyway, gets worse at work, gets off work, comes home and is worse enough that he listens to his wife and goes to the doctor. Except that when you work second shift, the point at which he says, "Ok, you win, I can't cope any longer" is around two am. No minute clinics open then. Family doctor isn't holding office hours. Not much we can do except go bother the ER people with what we know could be handled with a call to the family doctor if, you know, we could do that at two am.

  2. It worries me a bit that all the emphasis on quality is going to result in someone like me, who is healthy and inexpensive, getting hounded into quarterly doctor's visits to manage non-issues, while little time is spent actually, y'know, examining and educating me on topics other than the designated non-issues measured by the metrics. I do already get glossy nastygrams from my insurance about properly managing my asthma (my "only if I inhale a cat" asthma) with frequent doctor's visits. Unless my PCP enjoys boredom-for-pay, everyone loses in that scenario.


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