Quality measures began as tools to quantify the health care process, using outcomes, patient perceptions, and organizational structures associated with the provision of high-quality health care. Overall, the goals should focus on delivery of care that is effective, safe, efficient, and equitable. Did you notice a particular word missing? Yes, I missed the word physician too, because they have been left out of the conversation entirely.
Measuring quality health care by a patient lab result is like recording a patient’s temperature by waving the thermometer near their face. One has little to do with the other except for the slight appearance of connection. Quality must be measured by physician outcomes and not those of patients. For instance, our county does not have fluorinated water. Measuring the percentage of children that have cavities is a patient outcome and not an accurate reflection of medical care provided. A physician outcome would be calculating the percentage of children who received a prescription for supplemental fluoride during their office visit.
If the intended goal is to reduce unnecessary ER visits, then we must determine the root cause. Patients with private insurance rarely go to the ER for non-emergencies because they pay a large out-of-pocket cost. Those on Medicare or Medicaid visit the ER for free. There is no disincentive to visiting the ER, but there needs to be. In addition, it makes no sense to penalize me for an unnecessary ER visit if I have not seen and evaluated the patient in my office. The common sense solution is to figure out how many patients seen in my office were then seen in the ER within 24 hours. That may be a quality indicator.
Asthma and diabetes are two chronic conditions with large costs to the health care system. Compiling statistics about the number of patients who are not well controlled on daily medications is a patient outcome. How about looking at whether or not patients who presented with these conditions were prescribed the proper maintenance medications in a timely fashion? How about checking whether we emphasized the importance of daily use of these chronic medications in our clinical note? Those are physician outcomes and could be used to determine quality. Why are we allowing patient outcomes, for which they alone bear responsibility, to burden us as physicians?
How about paying me for the time spent completing oral rehydration for a moderately dehydrated child in my office? It takes a few hours to orally rehydrate an infant or small child properly. In my humble opinion, it is time well spent and avoids an ER visit. I bill for extended time, but am rarely paid. It is one of the most satisfying things I do; no parent has required more than one session in my office to be successfully taught this skill to use at home with successive children. Return on investment for those three hours is unbelievable and pays dividends for years; a parent will almost never need to go to the ER for dehydration again. How about a metric covering the amount of money saved by patients, insurance, and the government once a pediatrician has taught this essential skill to a family?
My fifth suggestion would be to look at the percentage of children under five years of age seen for well-child visits annually, rather than viewing value from percentage of children up-to-date on immunizations? In states, like Washington, there are vaccine exemptions for every reason under the sun. That metric penalizes a physician for a patient outcome, of which they have no control? A physician outcome would be documenting the recommendation for immunizations during a well visit by the primary care physician.
A metric tracking exceptional physical exam skill is another worthy physician virtue. For instance, how frequently does a pediatrician diagnose rare congenital conditions when evaluating a new patient? Top notch physical exam skills are essential and it this metric would preferentially favor experienced physicians who pay close attention to detail. In 15 years, my list includes a half dozen boys with undiagnosed undescended testicles, two children with choanal atresia requiring surgical intervention, 4 with chromosomal deletion syndromes, and my “holy grail,” an undiagnosed aortic coarctation (narrowing of the main vessel supplying blood to the body) suspected based on physical exam alone.
My idea of value is best illustrated by sharing my coarctation story. A boy came into my office for a well-child visit. He had some behavioral issues, had seen multiple pediatricians over the years due to frequent moves, and brought scant records with him. He was restless, and it was difficult to palpate femoral pulses, but I do this on each and every child at their yearly physical. Despite my persistence, I was unable to palpate them successfully. A quick glance at his slightly elevated blood pressure, 128/90, made me pay closer attention. I repeated it myself with a similar result.
I discussed my concerns with the family, referred him to a cardiologist, and called to discuss the case with the specialist. Doubtful, the cardiologist told me she would let me know what she thought after evaluation. Indeed, my diagnosis was spot-on! He underwent surgical correction for his congenital anomaly, (like the others who have transferred into my practice) and it was a success. He became quite the star athlete in high school and is entering college this fall.
Value can be defined as both a noun and a verb. The former denotes having importance, worth, or usefulness. Experienced physicians have stories exactly like the one above; because our care provides tremendous value to the patients we serve. Business people in health care prefer to use value as a verb because it signifies having a monetary gain attached. Government and insurance companies should stop wasting dollars and cents chasing visions of value, rather use common sense and give physician outcomes the attention they deserve. Health care will be on better footing now and into the future.
Niran S. Al-Agba is a pediatrician who blogs at MommyDoc.
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