End-stage renal disease has been driving me crazy recently. When no one else will dialyze you, the hospital has to. There's this thing called EMTALA law that requires us to...
In medicine, we talk about quality a lot. But most of the time that we are talking about it, we’re really not talking about quality at all. You see, quality means different things to different people and most of the time, we are confusing quality with value.
Value = Quality ÷ Cost
There are 5 faces to
- The physician. When you ask a doctor what quality is in medicine, he/she will tell you that it is getting the right diagnosis, prescribing the right treatment, and doing it in a timely fashion without complications occuring. In other words, quality to the doctor is doing the standard of care in medical practice.
- The patient. To understand what quality means to the patient, all you have to do is look at the questions in the CG-CAHPS survey. There are no questions about correct diagnosis or correct treatment. The questions are all about timeliness of the office visit, whether your questions were answered, and whether you were treated nicely. Because that is what is important to the patient: whether they could get an appointment to see the doctor when they wanted to, whether they had to sit in the waiting room too long, whether they get test results back quickly, and whether everyone in the office is friendly. Most of the time, the patient doesn’t know whether or not the doctor nailed the diagnosis or prescribed the proper medication so they judge the doctor on the service that they received. As physicians, we usually know who the good doctors are and who the bad doctors are – and then it surprises us when the bad doctors are rated higher than the good doctors in patient ratings and reviews. That is because what constitute “good” and “bad” in a doctor means totally different things to patients as opposed to physicians.
- The hospital. Every hospital has a quality department and that department will regularly report quality metrics. But many of these metrics are not really quality metrics, they are value metrics. For example, length of hospital stay, cost per adjusted admission, and emergency department throughput times are reported on just about every hospital quality scorecard in America but these don’t really translate into whether the patient’s disease was diagnosed and treated correctly, they are more directed toward the financial viability of hospital operations. If you examine the HCAHPS survey, then once again, you can get a pretty good idea about how hospital quality is judged: Was it clean? Was it quiet? Did the hospital personnel treat you nicely? Was your pain attended to? There is nothing in the HCAHPS survey about whether your condition was diagnosed correctly and whether the right surgery was performed or right treatment was prescribed.
- The insurance company. I periodically get quality scorecards sent to me from insurance companies that rate me on various metrics that the insurance company considers important. But they are usually dominated by whether or not the level of service charges that I bill are out of line with other pulmonary and critical care physicians. In the value equation, the most important component to the insurance company is cost – whether the doctor is charging too much, whether the doctor orders too many expensive CT scans or MRIs, and whether the medications that the doctor prescribes are the least expensive on the insurance company’s medication formulary. Furthermore, the insurance company is focused on the prevention and effective treatment of those diseases that will affect the patient during the time the insurance company is covering that patient and not with diseases (such as hepatitis C) that will not affect the patient until after they turn 65 and go off of the insurance company’s policy and onto Medicare.
- The employer. In the United States, it is ultimately the employer who pays for most medical care for Americans under age 65. That is because the employer hires the health insurance company to determine which doctors and hospitals to send the employees to and how much to pay those doctors and hospitals. To the employer, quality in medicine means keeping the employee in the workplace as much as possible. That means that the employer values physician evening and weekend office hours so the employee doesn’t have to take time off work for regular visits. It means preventing common illnesses such as influenza so that the employee doesn’t have to take time off work being sick. And it means keeping the employee’s children healthy so the employee does not need to stay home with a sick kid.
So, which of these five faces of quality is correct? The answer: they all are. And we in medical leadership roles need to recognize that quality means different things to different groups and for us to practice high quality medicine, we have to think outside of just what quality means to doctors.
March 30, 2018