Stanley Feld M.D.,FACP,MACE
Various non-physician organizations (NCQA and NDRP) have developed quality measurements that should be used as educational tools for the primary stakeholders. Instead, these quality measurements are code for secondary stakeholders to penalize physicians in the form of P4P. This is the problem in a healthcare system that has generated so much stakeholder mistrust. As long as the insurance industry, the government and the hospitals control the healthcare dollar, I do not believe these initiatives will work. The system must be driven by the patients. The patients must reward the physicians who utilize some of the resources that are being developed. The resources should not be forced on the physicians by the third parties.
The measurements used in evaluating quality lack an understanding of the complexity of the various disease processes or the responsibility of both the physicians and the patients in the patient-physician relationship. Physicians and patients have previously experienced negative information technology with pre-certification requirements for referral and procedures. Unfortunately, information technology does not work all the time. It can not substitute for physician judgment. The pre-certification system was modified so that the physician had to justify his thinking to a computer or review of a newly hired medical director that might not have expertise in that area of medicine. The result was is time comsuming process. The process threatens the physicians’ intellectual and moral integrity while increasing the intensity of mistrust and mutual disrespect.
The organizations developing these quality measures are very sincere and want to fix the healthcare system. It is my belief that it can not be done measuring only one criterion in the definition of medical quality care improvement. I also believe that if you are going to judge physicians it must be done by a peer group in a very discrete manner. Imagine in our litigious society the opportunity the P4P system offers to lawyers in the absence or real tort reform. A new profit center for lawyers will be developed.
The clinical endocrinologist knows it is possible to achieve an excellent HbA1c of 6%. However, it is very difficult. Very compliant diabetic patients can achieve a perfect HbA1c but they fully appreciate the difficulty. Neither the patient nor the physician should be punished for not achieving the goal they are seeking.
The physician-patient teaching relationship has been the tradition in medical care without 3rd party interference. This relationship needs to be promoted. If the punitive measures of reducing reimbursement inherent in P4P drive the Family Practitioners and Internists out of business, who will take care of the 20 million diabetics in the country? I know the 2000 practicing full time clinical endocrinologists can not take care of 20 million diabetics. If the process of quality care measurements were started after the onset of complications, achieving a HbA1c 8.1% would not halt the progression of the impending costly complications.
Each diabetic patient is at a different stage of his disease. Therefore each patient is at different stage of risk for complications. Patients have to be “risk weighted” to guess at the prognosis. Risk weighting is not a science at present. Patients further along the disease complication curve might not be able to have the progression of complications their complications stopped. They may be able to have the progression of complications slowed. However, the cost of treatment at each stage of diabetes mellitus and treatments will be different. The quality care measurement of how many times a HbA1c is done each year and the average level of HbA1c will not measure the skill of the physician or patient in decreasing the cost of the complications of the disease. This is a matter of physician judgment and patient adherence. Information technology can not make those judgments.
A faulty payment system (P4P) that cannot judge physician performance should not be instituted. It will only create a more dysfunctional healthcare system. Patients alone need to determine the quality of their care as previously described. Consumer driven healthcare will drive physicians to increased quality medical care. It can only happen if the healthcare dollar is in the hands of the patient, not the insurance industry or the government. The insurance industry’s and government’s job should be to help physicians develop systems of care and to educate the patient on the principles of good quality care and compliance. Patients must be taught their responsibility to their healthcare and how to use their healthcare dollar wisely. We have the information technology available to teach and reward both patients and physicians (the primary stakeholder). The result would be a competitive improvement is the quality of medical care. Remember the Lasik example.
We as physicians should create the systems of care for our fellow physicians. Many physicians do create systems of care and provide excellent care. However, preventive medicine services and educational services are not compensated or poorly compensated. Only when an environment is created for the success of focused factories for chronic diseases and patients control their health care dollar will we have true quality care. P4P is not the answer!