Metrics did not always exist in medicine.
The moment we got serious about quality is often cited as Caper’s 1988 article “Defining Quality in Medical Care.”
Even as medicine invented “quality” in the 1980s, Caper pointed to some misgivings about the terminology. His Health Affairs article suggests abandoning the word “quality” and instead using three terms that correlate to desirable medical outcomes: efficacy, appropriateness and the caring function.
- We know that certain interventions are efficacious in certain conditions; we can measure that.
- We know that certain interventions are appropriate and inappropriate in the sense of utilization; we can measure this.
- And we know that patients want “caring providers.” We likely cannot measure this very well, but it may be the most important of all the factors.
The “quality” of care is more than all of these factors and perhaps quite different entirely
Despite the prescient warning, we have not abandoned “quality, ” and its continued use has created an entire jargon: quality, measurement and value.
Quality creates value. We are all preoccupied with creating value now.
No one used to ask whether they got value when they went to the doctor’s office. We might have discussed whether we had a good doctor but never whether the experience was valuable
The use of value reflects an economic creep of the mission of medicine and a subtle deterioration of the relational aspect of “my doctor.”
Those things that are most important to us, and in some sense are valuable, we never ask if they “provide value.”
Once we started using “quality” and “value” in medicine, we had already lost its primary relational component. Although not stated in the original Health Affairs article, the discomfort with the term “quality” reflects a disquiet with conflating efficacy, appropriateness and caring with the much more subtle concept of quality.
Quality itself relates to the humanistic function of medicine, and not to its scientific trappings. As such, it is describable but not measurable.
This is just like pain, which is describable but not measurable.
As an individual patient, whether my A1C is less than 9 percent correlates only tangentially with the quality of the care my physician provides. I might do better to have a lower A1C, but the factors involved in lowering my A1C, and how I perceive the care I have received, are not measured by the A1C itself. Presumably, the A1C captures the “efficacy” of the care received. It is a gross injustice to label this as “quality.”
Substituting “quality” for “efficacy” defines patients as lifeless objects rather than by their characteristics as human beings.
This is what most of us feel like in our current medical system, especially when suffering from unmeasurable symptoms.
Pay-for-performance takes medical quality metrics to the next level by using them economically.
In our health care system, they are not working to improve care — why? Because the metric does not incentivize doctors to be more human. Instead, it rewards treating patients as commodities and lifeless objects.
Doctors resent this incentive because commodification is dehumanizing.
Satisfaction itself is now a commodity and subject to the rules of the market — massive, absurd inflation everywhere!
However, what does not work on an individual level, can work on a group or institutional level.
Companies should be held responsible or rewarded for the quality of their products. Corporations have always responded well to financial incentives — it’s why capitalism works!
Except that in our system, financial incentives are often arranged by financiers and created to suit the profit motive.
The fallacy in pay-for-performance resides in the jargon: quality, value and now “aligning incentives.”
This innocuous phrase glosses over the distinction between corporations, which thrive because they transcend individual people, and doctors, who thrive because they are humans providing care to other humans.
Be careful with your jargon, and be wary of individual metrics.