1. An inherent or distinguishing characteristic; a property
2. Essential character; nature
3. Degree or grade of excellence
I recently had the privilege to be in San Angelo, Texas. While there, I had the occasion to eat at a famous local eatery called Mr. T’s. The restaurant has been in continuous operation since the 1920’s and has quite a loyal local following. Among many things, Mr. T is famous for his fresh pies – banana cream, peach cobbler, and host of other virtuosities rapinously consumed daily by the hungry hordes. Mr. T has earned a reputation for quality pies, as the standing room only lunch crowd can attest.
The healthcare quality pie does not currently have such a great reputation. While everyone agrees that measuring and monitoring quality are essential to creating a consumer market for healthcare, there is little agreement and even less adoption of measures that actually matter in the delivery of high quality healthcare. Current measures, as seen in the “pay for process” (as opposed to “reward for results”) programs do not provide a complete view of healthcare quality. The notion that we have to start somewhere can only be used for a few more years, before that tired and hollow sounding argument falls flat.
I would like to suggest we consider some of the major ingredients to include, a perhaps a major one to avoid, in delivering a healthcare quality pie:
1. Quality Measures. Who defines which measures actual matter? Who is the best person, group, or organization to correctly identify, define, and standardized quality measures? Is it NQF? NCQA? IOM? Alot of great work has been advanced in this area, and I believe there is significant room to continue to move the conversation forward. It should continue to be a well established and even better funded mandate to reach national consensus on determining the measures that actual describe the delivery of high quality healthcare. I am thankful that many smart and talented people are working on this. I consider nationally recognized standards for healthcare quality are a core key ingredients for baking a healthcare quality pie.
2. Physicians. As expected, physicians are generally not very happy about the whole quality ratings game. In some cases the questions of validity are legitimate, and the uneven and often non-transparent reporting of measures is problematic. But alot of what I hear from physicians is just general griping about the inequity of being measured. I am uninterested, and I would dare say so is the public, in this component of the concern from physicians. If you are a high quality provider, your objective results should do all the talking for you. Instead of trying to slow the Mississippi, I would ask that physicians work to define and promote those measures that really matter in the quality scheme of things. This is the way to make sure that fully-baked, physician-approved measures can be brought forward in the creation of a true healthcare “market”.
3. Conflicted Third Parties. These are the potentially sour ingredients that should assiduously avoid in preparing our high quality pie. While there is the temptation to include these elements for flavoring, there is a strong tendency for their mephetic contributions to spoil the entire creation. Conflicted third-parties can be defined by any entity whose objectives may be in conflict, or contradict, the interest of the healthcare consumer. This would include payors, employers, or other organizations incented to benefit at the expense of the consumer (ie, anyone who benefits from the “culture of denial” pervasive among the insurance industry). This was painfully obvious in the recent United Healthcare scandal squished by the New York State Attorney General. The way the story read was that the Attorney General was NOT pleased with the attempt to dress the proverbial “low cost” wolf in “healthcare quality” wool. The problem with this type of bogus use of the fledgling quality measures is that one bad seed, can an entire quality (apple) pie ruin.
4. Health Care Consumers. Finally, the whipped cream and cherries carefully added on top of a fully baked healthcare quality pie. Consumers are the ultimate beneficiaries of having access to meaningful healthcare quality measures. The intent of appropriate measures is to spur innovation in all the right areas . . . the creation of a true healthcare market, the positive influence of both professional and financial incentive to provide evidence based care, and adoption of several new concepts around appropriate “reward for results” initiatives could help motivate and encourage the development of performance incentive programs. I think the use of consumer ratings systems could be a good warmup act of a far more meaningful reporting of evidence-based outcome measures that truly delivery high quality healthcare.
I am strong advocate of having physician-influence, nationally-approved quality standards that actually measure the delivery of high quality healthcare. I have no delusion about the challenges inherent in determining all the right ingredients (quality measures), allowing these to come together under the right baking conditions (physicians delivering high quality care), assiduously weeding out bad actors who seek to use the ingredients in nefarious ways (conflicted third parties), and ultimately and patiently awaiting until the fully baked pie can be eagerly consumed (by the next generation of healthcare consumers).
Now that is a quality pie even Mr. T could be proud of!
2 comments on “How to Ruin a Quality Pie”
Hi Scott, I’ve just started reading your blog and I appreciate your points of interest. I am a medical student just being introduced to the world of health policy, and blogs like yours sure help me get my bearings on the subject.
As for physicians helping to develop quality measures, I couldn’t agree more. I interned at the AMA and learned that for the past handful of years, they have been resisting the introduction of these members. Recently, when they finally realized that quality measures were going to be a reality, they finally started working with CMS and AHIC to make sure whatever measures were put in place would be fairly evaluative.
I have heard complaints that quality measures would unfairly compare apples to oranges – some physicians practice in localities with poorer health than others, and some physicians may focus on patients with worse prognoses. Additionally, some physicians work in more technological and better equipped facilities than others. Would the type and location of a physician’s practice have any bearing on the measured quality of care?
A while back I met with a group setting up a Chartered Value Exchange for the state of Utah.(See http://www.hhs.gov/valuedriven/communities/valueexchanges/exchanges.html) Participants included health insurance execs, hospital execs, physicians, and others. In the course of a discussion on quality indicators, a hospital CEO said that what we really needed was fewer indicators, because collecting them creates so much administrative overhead. At that time I objected on the grounds that existing vetted measures only address a tiny fraction of current health care. This past week I was reading the list of PQRI measures (http://www.cms.hhs.gov/PQRI/Downloads/2008PQRIMeasureSpecs.pdf) and this drove the point home to me even more strongly — it’s just such a limited picture into quality.
On top of that administrative overhead, there is enormous political overhead involved in getting measures approved in the first place. This just doesn’t strike me as a system that is likely to promote innovation.
Wouldn’t it make more sense to have a dynamic marketplace for quality measurement involving independent third parties? Consumer Reports doesn’t have to get consensus from the car manufacturers before publishing an evaluation of pickup trucks — could that be a model for health care?
Brian Jackson, MD, MS
University of Utah; ARUP Laboratories