Every doctor thinks he gives quality care, because quality, like beauty, is very much in the eye of the beholder. However, one thing we can all agree on is this: when you decide to let someone outside of medicine set quality standards, be very careful. Remember when the federal government, in its infinite wisdom, decided that you were going to be paid the maximum amount for high-quality care in the treatment of pneumonia only if you drew blood cultures and treated with antibiotics within a four-hour window? The reason the federal government picked blood cultures as a quality measure was simple: it can be measured. When you cannot measure what’s important, what you can measure becomes important. It took the work of the American College of Emergency Physicians and multiple other professional societies to convince the government that doing blood cultures on pneumonia patients actually has nothing to do with their outcomes.
In all truth, quality is the ability to adhere to a known standard. People can debate the merits of fast food, but nobody debates the fact that McDonald’s set the standard in the industry for high quality, that is, if quality means producing the same product each and every time. Whenever snobs turn up their noses at McDonalds, I always point out that Julia Child, when in a new city and not knowing exactly where to go, had a Big Mac and proclaimed it the best mass-produced meal in America. So what is the ‘known standard’ for measuring quality in medicine? Helping people live longer, healthier lives. But a quality health care system must also interact with the two other variables of our economic system: price and availability. You cannot deal with one issue without dealing with the others to achieve quality. Rolls Royce may make the best cars in the world, but if your standard of quality includes availability – a good car for everyone – Rolls fails the test. The medical parallel is getting a TURP performed in Britain. Do they have excellent surgeons? Yes. Is the cost affordable? Well, actually, it’s free. But unfortunately, you’ll be put into the queue so that you may not get your TURP for six months. While the British find this acceptable, in America things work differently. Urologists are everywhere. If they catch you peeing too slowly in the bathroom, they will offer you a TURP on the spot. In America this kind of care is easily available and of high quality; the problem is the cost. It’s very expensive and available primarily to those who have insurance.
Who, then, is qualified to define quality for American health care? A government program that looks for easily measurable parameters might say that a yearly physical is quality. I would suggest that if you’re OK at age 13, and you’ve had no change in your review of systems, being seen at 14 may be unnecessary. If you suffer from multiple disease entities, then a yearly examination may not be often enough. To think that there is a simple formula that you can apply in order to decide if quality care was given is a myth. The governmental agencies always believe that they know best. I think that’s wrong. Other health care professionals who understand the ramifications of different diseases are in a much better place to determine whether quality care is being delivered.
The problem of overly simplistic, medically illogical parameters of quality will only get worse as more managed care develops, given that managed care always tries to set a fixed dollar return for a physician’s time. The physician then rewards himself by keeping the patient acuity low. It’s easy and profitable seeing healthy people all day. But is that quality care? I would submit that whenever a discussion of quality health care occurs, the cost factor of what is required to live longer, healthier lives is simply a discussion of return on investment. To what degree do we improve the quality of the health care by adding more stuff, more technology, more testing, more treatment modalities? More does not necessarily translate into living longer healthier lives. Without serious discussion of who will set the quality standards, how these standards will be measured and the science that will define that quality, the practice of medicine as we know it is in serious trouble. A return of the pay-for-performance standards like those seen with pneumonia, which were illogical and not supported by scientific fact, will come back to bite us in other areas of the practice unless we as physicians demand a serious place at the table to set quality standards. No physician likes to do this. No physician wants to tell another physician how to practice medicine. But unless we do it, we will place ourselves under the thumb of bureaucrats who do not understand the complexities of medicine and are basically motivated to limit payments to physicians.
These are not easy ‘feel good’ issues. I know it is not considered a great use of your time to be on quality review committees of the hospital, state, or even national level. But if we do not, we will become the enabling victims of those who wish to take control of the practice of medicine. You should look at this type of work as essential, and not merely a burden. Take control of your life. Take control over what is considered to be reasonable care. Take control of the quantity, cost and availability of care, so that we can make intelligent decisions and have reasonable health care for every citizen. It is of precious little use for us to spend huge amounts on care that does little to preserve meaningful life – yet leave countless millions of patients out of the health care system. There is no easy answer. There will be procedures, tests and therapies which may have some marginal benefit, but when weighed against cost, have very little to recommend them. We need to have the courage to say that the health care system is broken, and then engage the system intelligently. We cannot shirk these responsibilities.
Greg Henry, MD, is the founder and CEO of Medical Practice Risk Assessment, Inc. Dr. Henry is a past president of ACEP and directed an ED for 21 years.