We should value quality when we shop for health care

Over the years, my husband’s parents, Helen and Dave, have both suffered unnecessarily from bad medical care. They are not alone.

A botched cataract surgery left Helen with a torn iris. One of her eyes can’t adjust to light, and for the last several years she’s worn sunglasses indoors. Her urologist kept treating her with the same antibiotic for urinary tract infections without testing to see what bacteria she had. When her symptoms persisted for months, I finally intervened. I ordered urine testing myself — I’m an internist and infectious disease specialist — and prescribed the right antibiotic.

More recently, Helen’s internist missed a diagnosis of diverticulitis — a colon infection — that landed her in the hospital for a week. Dave was diagnosed with Parkinson’s disease five years ago. His neurologist sent him home with a very expensive new brand name drug, instead of prescribing him the gold standard medication, carbidopa-levodopa. Dave’s fine motor skills and tremors got so bad this past year that he couldn’t manage the buttons and zippers on his clothes. Soon after, he agreed to see another neurologist for a second opinion. She started him on carbidopa-levodopa, and his symptoms improved remarkably.

Perhaps my in-laws have been especially unlucky. But I also know Dave and Helen chose their doctors on the basis of convenience — in their case, location — rather than quality.

This is all too common. When I see new patients in clinic, they rarely tell me they came to our clinic because they heard about the quality of our health care.

As a practicing physician, I know that not all doctors provide the same quality of care, and patients trust the technical aspects of medical care are fairly standardized. But while standards exist, doctors don’t always follow them.

We should value quality when we shop for health care. Like my in-laws, we can be hurt by bad choices. But consumers approach health care differently from other consumer goods. Health care affects us personally. We feel uniquely vulnerable in a way that we don’t when deciding which refrigerator or washing machine to buy. Understanding and navigating health care is complicated and intimidating. It’s also hard as a consumer to feel passionate about the measures we use to track quality in medicine. What does it mean that a higher proportion of one doctor’s diabetic patients have hemoglobin A1c’s at goal than another doctor’s?

In the absence of easily accessible and interpretable information about quality, most patients make decisions about health care based on convenience, cost and the interpersonal aspects of care. All these considerations are important, but they aren’t surrogates for technical quality.

With most consumer goods, cost is a proxy for quality. A more expensive restaurant will generally have a higher Zagat score. A Lexus is a better car than a Kia. But health care is different. A higher sticker price doesn’t necessarily translate to higher quality.

We know if we’ve been kept waiting long for an appointment or if our doctor hasn’t called us back. We know if the receptionist was rude or the nurse was rough. A patient’s experience of health care matters. But a number of the websites where patients may provide doctor ratings can be misleading. They typically capture the opinions of a handful of vocal patients with extremely negative or positive things to say. They may also reflect the opinions of posters who aren’t even patients of that doctor. And some are just inaccurate (one site listed me as an otolaryngologist — I’m not one — at a hospital where I don’t practice).

Medicare will eventually report on physician and hospital quality measures, but what you’ll find online now is limited and unlikely to be any more helpful to the average consumer than the agency’s release of billing data. There have also been local efforts in some parts of the country to collect and digest information on health care quality for consumer consumption, as in Minnesota, Wisconsin, Maine, Massachusetts, Washington, Oregon, New Mexico, Pennsylvania, Detroit, Cincinnati, Cleveland, Memphis, and Humbolt County, California. The most frequent users of these quality reports have been physicians looking to improve their scores, and there has been a positive impact in some places. Blood sugar control among diabetic patients in Detroit improved by 14% between the initial report (in 2006) and 2011. The proportion of seniors vaccinated against pneumonia in Cleveland increased from a quarter to almost three-quarters in a year.

A few states have gone a step further and partnered with Consumer Reports, the ratings guru, to make information on health care quality more accessible to patients in Minnesota, Wisconsin and Massachusetts. These and several other regions are working with Consumer Reports to release more physician report cards starting in 2015.

Employers also recognize the value of high quality care, which saves them money in health care costs. In Maine, for example, the State Employee Health Commission and Jackson Laboratory cut employees’ co-pays and deductibles if they visit highly-rated physicians and hospitals.

Unfortunately, many of us don’t live in parts of the country where good information on health care quality is available. That puts a greater burden on us to learn about and request quality care. Consider reviewing one of these checklists with your doctor at your next appointment: general prevention, heart disease or diabetes.

When you move or change health insurance, be especially careful in choosing your primary care provider and the health system in which the PCP works. The more your doctor values quality, the more likely your doctor is to work with high-quality colleagues. At a minimum, your doctor should be board-certified and in good standing. Ask others who work in health care who they’d recommend. Interview your doctor. Ask doctors how they keep up to date with the latest in medicine: through pharmaceutical company representatives, journals or conferences?

We’ve noticed big changes since my father-in-law Dave started seeing a better neurologist and taking the appropriate Parkinson’s medication. He doesn’t clutch his arms to quiet tremors like he used to. He doesn’t sleep all afternoon, sedated by his old medications. Dave’s back to doing some of the cooking, something he’s always enjoyed. He smiles. It’s good to have him back.

Celine Gounder is a physician and medical journalist.  She can be reached at her self-titled site, CelineGounder.com. All views expressed in this article are hers and should not be attributed to any of her employers.

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  • QQQ

    The fact that the government pushed ACA thru during a
    time when most people are struggling to find jobs that can not support them and their families shows how conceded the government has become… we can’t shop for quality healthcare when most can’t! Pays are getting lowered as prices go up… rent, heat, food, gas, medical, property taxes, house and car ins and so on… Big daddy government should have spent more time on job creation and lowering the cost of these things… But the truth is the government isn’t interested in lowering costs.. the more things cost the more money they make with their stocks and investments and the more tax revenue they take into frivolously spend.

    They say spending is up …. what they don’t say is yea people are spending a little more than they did because prices have gone up it’s not that they are actually buying more stuff the fact is they are buying less and paying more for it… Nor do they tell you just how much of that spending is sitting on credit cards as many are using credit to buy things they need like food and medical until they max out and financially crash!

  • guest

    What you are missing here is that our healthcare system, and maybe our society in general, doesn’t really value quality any more.

    In order to provide quality healthcare, the doctor must be thorough, detail-oriented, and thoughtful. However, these are work qualities that can actually get you in trouble these days.

    The characteristics that are prized are “efficiency,” or the ability to get through a large volume of work in a short period of time, and affability, or the ability to do said large volume of work in an agreeable manner, without offending patients, or co-workers, or more importantly, administrators. Also good is the ability to do your work with an unruffled demeanor while dealing with almost constant interruptions, almost none of which will be in any way urgent or even related to patient care.

    None of these qualities really contribute to the kind of old-fashioned high-quality care that Dr. Gounder is discussing above. They do, however, enable doctors to provide the kind of standardized care that our healthcare corporations and regulatory agencies appear to desire to see. The fact that patients are not really getting good quality care but are getting an empty facsimile of care, is increasingly beside the point.

    • DeceasedMD1

      “Care for Conformity” instead of P4P paraphrasing Dr. Caley. We are basically being ordered to give up our ethics to keep our jobs.

  • Dr. Drake Ramoray

    But what is quality. It certainly isn’t the PQRS crap I’m supposed to report. Am I providing less quality care because I have the most rural practice in the region of my state, cast a wide area for patients, and have a disproportionate number of less affluent patients. Is the fact that my practice has a higher average A1c in my patient population when compared to my colleagues in the ritzy suburbs mean that I am providing less quality care? Or perhaps since I have many patients who can’t afford diabetes medicines invented after 1998 I provide less quality care?

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    Funny you should mention Consumer Reports, because they only “rate” larger practices: “To be included, each doctor’s office must have had three or more doctors at the time of the survey”. So if you move to an area where Consumer Reports is kind enough to “rate” doctors based on data from, and in collaboration with, insurance plans, you won’t find any small practice in the “recommendations”. Talk about skewing the market….

  • DeceasedMD1

    your name says it all! Get out of dodge as fast as u can. Do not walk. Run!

  • DeceasedMD1

    This piece just shows who is running the show. This is not about a few bad apples (docs). Sounds like the MIC ( medical industrial complex) has convinced many docs, why they need their product to sell to pts to “manage them. Imagine when PC is overtaken by NP/PA, they will likely be targets for selling the latest and greatest most expensive and least effective treatment to pts.

  • JR

    This is what drives me crazy about “pay for performance.” Look at how it has failed to improve our schools.

    Impoverished kids have unique needs. The lack of financial stability means their parents can’t pay rent consistently which leads to them moving over and over and over. This leads to a lack of stability everywhere. The children switch from school A to school B and are behind and struggling to catch up, then they switch two years later to school C where they are ahead and now bored.

    The same thing happens with health care and poor kids. Parent finds a doctor that takes medicaid, then they move and have to find a new one, and in the meantime the child is sick, so off to the ER they go because they not only need medical care for the child but the parents needs a sick note for their employer because they’ve missed to much work…

    Perhaps a better answer that pay-for-performace is urgent care centers in impoverished areas that include social services to connect people with needed care. Alas, if there is anything people hate paying more for than “other people’s health care” it’s other people’s social services. Yet, those countries who spend less than the USA but have better health outcomes are spending the money on social services.

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