Healthcare Reform: Managing What You Measure

The Affordable Care Act (Obamacare) expanded health coverage to millions of people. It did little or nothing to control costs, and is just the tip of the iceberg in improving the quality of care.

Think about how you select your health care providers. Who recommended them? If it was a friend, what does he or she know about the practice of medicine? I did a statistical study when I was managing medical groups. It proved that patients rated their physician by his staff’s attitude.

Think about it. You see the doctor for about 5 minutes. He looks at the information an assistant took down, asks a few questions, and delivers his verdict. Was your visit pleasant? If so, it probably didn’t have much to do with the doctor. So it’s likely that your friend gave you a recommendation heavily influenced by his or her impression of a nurse or receptionist.

Was the doctor you are thinking of recommended by another doctor? I have some more surprising news. Unless they are collaborating on a treatment plan, physicians rarely know much about a colleague’s practice patterns. I used to recruit docs to sit on M&M panels. M&M stands for Morbidity and Mortality; in other words, the process that (sometimes) occurs when a treatment goes wrong.

There were many times when our participating reviewers were aghast at the standard of care delivered by someone they knew well. I’d hear things like “He recommended WHAT? That treatment was discredited 15 years ago. My God, I’ve been sending my patients to him all this time!”

How do docs decide who is the best doctor? Often, it is by the same trappings of wealth that you might use. If he has a big house, expensive car and custom made suits, he is successful. Success=ability=quality, right?

Not at all. I knew of a surgeon who officed in the most expensive medical office building in Beverly Hills. His waiting room was literally packed with the rich and famous. Too bad his outcome rate was worse than most first-year residents. Paying a premium price in health care frequently has more to do with someone’s marketing than their proficiency.

How can you find out if a physician is really good at what he or she does? Unfortunately, you probably can’t. The necessary information often isn’t collected. If it is collected, it may not be accurate. If it is accurate, it likely won’t be reported.

Outcomes are hard to measure. In New York City a few years ago a magazine collected the results of all heart surgeries and reported them. They ranked the surgeons by the success of their operations. Great, right? Not so fast.

It turned out that the success rate was highly sensitive to the patient demographics of the practice. In other words. surgeons who operated on wealthier patients, people who had better educations, more dietary awareness, and greater financial resources for follow up treatment and support, had better outcomes. Not surprising.

In fact, the surgeon rated as the worst in the city was one who specialized in taking all the high risk patients that his colleagues were afraid to operate on. They referred to him because he was the most skilled among them, but the measurements said he was a disaster because of his adverse patient selection.

So if we do collect data, we don’t report it because simple yardsticks are too misleading to be of general use. If it is reported without explaining the many subtle variances that affect the data, and it could destroy a career without justification or even due process.

President Obama ran for his first term on a platform that included a national outcomes and best practices database. That, like a few of his good ideas, is proving to be a bigger challenge than anticipated. Measuring medical outcomes is complicated, sensitive, fraught with pitfalls and difficult to communicate. It is something only the government can do, but unfortunately it isn’t the kind of thing the government does well.

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