A commenter on my previous post on pay-for-performance asked an excellent question:

So, if it were your job to implement a “quality assurance” system in health care (or specifically in your part of the health care system), where would you start?

Whining is easy in medicine — as in most areas of life — and I generally try to avoid posts which don’t provide some answers or direction to problems detailed. Being part of the problem is easy; being part of the solution more challenging. So I’ll try to collect a few thoughts on how best to achieve quality in medicine. These are very much “If I were King” solutions–in real life, they may pose insurmountable difficulties from an implementation, political, or practical standpoint. But it’s time to pencil outside the lines–our health care system is in serious trouble in many ways, and we cannot keep doing what we are doing forever before a true crisis arises. So here’s a few principles which I believe would make a major difference in health care quality and delivery.

First, let me say a few final words about pay-for-performance, discussed in my previous post. This whole concept strikes me as a solution looking for a problem. Is there really evidence that a significant quantity of the health care paid for by federal programs or private insurance is substandard, and needs incentives to improve? If there is a significant percentage of such care (and who has determined this?), is it the role of government or insurance carriers to improve this quality through their payment mechanisms? And if it is, how likely is it that they can achieve this goal? It would seem that clear answers to such questions should be given before launching out on a potentially gargantuan overhaul of health care reimbursement, with highly unpredictable results.

Even if the answers to the above questions are affirmative (a dubious assumption, at best), quality depends not merely on the facility or health care provider’s performance as individuals (and therefore potentially changeable by incentives), but in many cases depends on socio-economic factors not under the influence of payer incentives. For example, if you are hospitalized in a major city for severe pneumonia or asthma, and require a ventilator to breathe, you will very likely be cared for by a specialist in pulmonary medicine — or at least by an internist with extensive experience in such care. The nurses in your intensive care unit will have abundant experience with ventilators, sophisticated monitoring equipment, and the care routines (regular suctioning, for example) which greatly reduce your risk of complications and increase your chances for a good outcome. If you are hospitalized in a small town hospital, many of these advantages may not be available. How will pay-for-performance change the lack of availability of a pulmonary specialist, the limited nursing experience with ventilator care, unavailability of some monitoring equipment, and other liabilities which are more more likely to be a problem in a small community hospital?

Secondly, when Medicare and third party insurance companies start talking quality, you’d better lose weight, exercise, stop smoking, and hold on to your wallet: what really drives their locomotives is costs, not quality. The underlying presumption here is that by improving quality by monitoring adherence to standards, the costs of health care will decrease. But this is by no means true in every instance; in fact, higher-quality care is commonly more expensive — often quite a bit more. This reality is one of the main factors driving up health care costs. An MRI is a vastly better tool for diagnosing a ruptured disc than a spinal x-ray or a myelogram — and also far more expensive. Minimally invasive surgery which speeds your recovery often involves expensive technology–endoscopes, digital cameras, costly video systems–which exceeds the costs of traditional surgery. New drugs and chemotherapy are much more effective than older ones–and frequently stunningly expensive. We know that preventive medicine works well in some areas — good prenatal care, weight loss, exercise, drug and alcohol avoidance, smoking cessation — but how will paying providers more achieve these notoriously difficult changes in patient behavior?

I have tried to think of any health problem, any type of patient for whom I would significantly change my medical or surgical management based on a financial incentive — I can honestly say I cannot think of a single instance. This is not because my medical management is perfect by any means, or because I am a superior moral being — I most certainly am not–but rather that as a physician I constantly strive to do the best thing for my patients. Part of this drive is idealistic, part ethical, professional, and moral, and part simply the satisfaction and gratification of seeing my patients do well, of a job well-done. I do not believe I am unique in this regard: I am quite sure most physicians operate out of similar motives. Financial incentives to alter care, if anything, exert a pull toward providing care which is less ideal–either for the patient or for society as a whole. The only time I have to pause and ask myself whether I am doing the best thing for a patient is when there is a financial incentive to follow a certain course: am I doing this because of money, or because it is the best thing for the patient? Such distinctions can be surprisingly difficult to discern–my motives are best tested when I go contrary to financial incentives to do the right thing.

Well, enough on pay-for-performance for now. I had planned a single post to put forth some ideas on achieving quality in health care, but I have barely touched on the topic. This topic will work best, it appears, as a series of posts. Here’s a summary of some topical areas I am planning on covering:

• Transparency–why is it easier to buy a used car than to select a physician?
• Reforming the legal system–how the medical malpractice system degrades medical quality
• Reforming the payment model–financial incentives which undermine quality, and how time often equals quality
• Peer review–why it doesn’t work and what to do about it

I suspect other topics may come along as this evolves, so stay tuned. And I’d love to get feedback on these ideas from both health care providers and the folks who see them.

And lest you be bored by health care topics, coming soon will be more on the new Narrows Bridge construction, a puppy update, as well as special treat: Tall Ships Tacoma. Take care, and God bless.