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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