I will start this rambling by repeating my premise that practicing medicine is much more an art than a science. Physicians use their ever expanding and changing data base of knowledge to practice art, on an individual patient, than practice numbers on a population basis. Often times there is no right answer. There is only trial and error, watchful waiting, comparison of options and "going for it". Medicine is an ever changing art.
Pay for performance is governments way of placing strict data points and creating the illusion of extra money for those who achieve quality. Often times their determination of quality is a yes or no question. Did the patient with heart failure get beta blockers? Did the patient with stroke get aspirin? Did the patient with "pneumonia" get their blood cultures drawn ? Did the patient get antibiotics for pneumonia within 4 hours of presentation to the ED?
My main problem with this system of giving "extra" money (as if the original payment is more than satisfactory, like extra credit per say) for quality is simple. Quality is a moving target. Medical quality is not a physics formula. It is not a mathematical equation. It is biology. And the more we know, the more we don't know. That is undeniable.
For example in the recent rush to meet "quality" indicators for "pneumonia", included were: Get that antibiotic into the patient within 4 hours of ED presentation. Get that blood culture drawn on EVERY patient with "pneumonia" before antibiotics were given.
I can tell you in my clinical practice, I have had maybe less than 2% of patients actually have a positive blood culture for all my "pneumonia" admissions. What a colossal waist of money, time, resources, plastic, computer IT, patient charges and on and on and on. Again, what a waist of money.
Who in their right mind in the land of Dr. Government ever decided that this was quality. It's not my quality. It has benefited my practice/skills not one single bit. It has caused me endless conversations that go like this...
ED Doc: "I've got an 84 yo with 3 day history of fever, cough, and shortness of breath..."Me: "Did you get the blood cultures?"ED Doc: "Yes"Me: "OK, I'll be down there."
Something five years ago I would have never even considered has turned into the most important aspect of that patients care, not because it will make the patient better, but because that is Dr. Government's idea of quality. If you the patient don't get your blood culture drawn, the hospital gets "dinged", the ED doc gets "dinged" and I get "dinged". Is the patient any better or worse? Of course not. But Dr. Government says you are. And those dings get reported everywhere as "The Best Hospitals...", "Your Preferred Docs list includes..." That is their quality.
While we are on the topic of pneumonia, ED door to antibiotic time of 4 hours or less is considered "quality". Dr Government says so. I can assure you that diagnosing pneumonia in the ER is not always a slam dunk. Medicine is an art. Does the patient have fever? Is their white count elevated? Have they been around sick kids? Have they recently taken antibiotics? Do they come for a nursing home, a farm, an apartment in the city, homeless? Are they drinkers? Smokers? COPD'ers? Diabetes? Do they have a history of heart failure? Is the xray "kinda fuzzy"? Is there "kind of" an infiltrate.
Ever time I see a patient everyone of these questions go through my mind to determine whether I think the patient has pneumonia or not. Sometimes pneumonia looks like heart failure. Sometimes it looks like emphysema or asthma. An xray cannot always make the diagnosis. It is the smallest part of the diagnosis. When it is strikingly abnormal, any provider can make the diagnosis. But more often than not the xray is not strikingly abnormal. That's were the physician and the art of medicine becomes paramount.
In Medicare's rush to quality, every possible patient with a possible diagnosis of pneumonia gets antibiotics because nobody wants to be "dinged" I have seen it day in and day out. I practice it myself because I have to. Dr Government, whom I have never met, has decided that a universal medical school exists in Washington that makes medical decisions as if from the land of Oz. I am forced to practice medicare "quality".
Imagine all those antibiotics given to patients without a strong clinical suspicion. Drug resistance, severe clostridium difficile colitis which is running rampant these days because of unrestricted use of antibiotics, cost, time, plastic, IT time, pharmacy time and on and on and on. The fear of getting "dinged" is driving medical "quality". Not to strive for quality.
My quality day in and day out is determined by my knowledge base of data, which I have taken an oath to up hold to the best of my abilities. My knowledge base is verified by my certification in my field as a board certified physician, for which I am required to obtain many hours of education a year and pay thousands of dollars for the opportunity to take my test every 10 years. That is my quality guarantee to you the patient.
My quality is not getting you antibiotics when I think you may not need it, but Medicare says you do. That is Dr Government's idea of quality. I am still searching Google looking for Dr Government's state license and board certification credentials. Quality is a moving target. It works well in yes/no scenarios. Physics/mathematics. Yes Biology? Quality changes every year.Recently published data suggest that perioperative blockers in certain types of surgeries may actually increase morbidity and mortality.
Shocking? I don't think so. The more we know, the less we know. Imagine Medicare's push to "quality". Quality Indicator #67: All patients entering surgery get beta blockers. Imagine Sally dies post op from a stroke potentially caused by "quality" indicator #67. Dr. Government may have just killed Sally. Look at the rash of drugs pulled from the market due to safety concerns, drugs thought to decrease morbidity and mortality.
Is Dr. Government willing to purchase malpractice insurance, to open itself up to lawsuits by the millions when one of their quality indicators show more harm than good. It will happen. Give it time. I guarantee you that. Will they shield themselves under the cloak of national interest. Of course they will. The fall out will be on Lille 'Ol Sally, not Dr. Government. Medicine is an art, much more than a science.
Population based rules should not be applied automatically to individuals. This is the problem with the government (or any major organization) making decisions for patients. Appropriate guidelines for the masses must be tailored to the individual by a doctor who understands the subtleties of their circumstances. People are too complicated for algorithms - and applying them uniformly (without double checking that they're the right thing to do in each case) is unethical in my opinion. The government cannot practice good medicine, no matter who's in power. It takes a conscientious human to apply science correctly in each case. That is the art of medicine, and no machine or complicated predictive equation can do it.
ReplyDeletehear hear.
ReplyDeleteIt has been said that "the trouble with incentives is that they work."
ReplyDeleteThat means greater care and consideration of unforeseen consequences than for other regulation.
Frankly the science is good: survival is better when antibiotics are given in the first hour, but the number of assumptions required to justify an incentive based on that little piece of info is mind-boggling.
If we believe that the mark of a truly excellent physician is knowing when not to follow the standard order set (or algorithm or whatever), then it becomes obvious these "quality" incentives discourage physicians from being excellent. Those who blindly apply the algorithm, defer nuanced judgment, and ignore important individual patient details and preferences will be rewarded. Those who thoughtfully apply their training, knowledge, and experience to the individual in front of them will be penalized when deciding the algorithm doesn't apply.
ReplyDeleteAbsurd, to say the least.