Quality-based health care is based on false assumptions

Of all the radical changes affecting health care that have sent providers reeling, we are about to experience the knockout punch: the effort to change health care reimbursement from a quantity-based to a quality-based system. Of all the changes to health care, I can’t think of any other that has been based on more false assumptions. Given the fact that there is always low hanging fruit, supporters of the quality-based system have pointed to some successes as proof that the new system is working and needs to be implemented across the board. Sometimes circular logic has been used, such as the claim that money has been saved because actions such as payment for readmissions would stop.

Here is my list, feel free to add your own.

1. Physicians were cavalier toward quality in the past.  Nothing could be further from the truth. Physicians were very aware that their livelihoods and reputations were very dependent on good outcomes and satisfied patients. Also, there was the ever-present threat of a malpractice suit. This assumption has gotten so out of hand that some supporters of a quality system have made the outrageous and insulting claim that some physicians have created complications on purpose for financial gain. For me, that was the last straw.

2. Overestimation of the amount of control physicians have over outcomes. This becomes obvious to any provider who has been in practice long enough and humbled enough to realize our limitations.

3. Failure to recognize the difference between an error and a complication. This has been a huge problem ever since the infamous “First do no harm” article appeared. Briefly, a complication is an unwanted medical outcome (noun) while an error is an action (verb) that may or may not lead to a complication.  So, if penicillin is given to a patient with no prior history of exposure and they have a severe anaphylactic reaction that is a complication. If that patient had a known history of allergy and was given the drug, the error is the failure to recognize the allergy history, not the ensuing reaction. Likewise, a post-op infection is a complication. If it is found that then instruments were improperly sterilized, that is the error, not the infection. I have yet to see anyone who has properly made this important distinction, although I do know many have given up trying. Huge mistake.

4. Patients are 100 percent compliant. This is the only way a quality-based system is going to work. Any physician who has in practice long enough recognizes how much patient motivation and, on occasion, secondary gain issues can affect outcomes.

5. Failure to recognize a physician’s experience. Think of it. Which physician would you rather have treating you? The one who has used the same procedure successfully for twenty years, or the one who is now being pressured to follow a cookbook protocol? Worse still, what if you were diabetic and you were unable to even get that procedure because you are now considered to be high-risk?

6. Failure to determine what the patient wants or expects from treatment. Perhaps the elderly patient would prefer to be left alone and live the rest of their life in peace rather than being constantly harassed to control their blood sugar and blood pressure.

7. Painting all providers with the same brush. Admittedly, reimbursement based on quality may be better for some specialties and providers but certainly not all.  A hybrid system may be the best compromise.

After the low-hanging fruit has been picked, there is only one, totally predictable outcome. Physicians are going to avoid treating high risk, non-cooperative patients. It is already happening.

Thomas D. Guastavino is an orthopedic surgeon.

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