Quantifying quality doesn’t help patients

Quantifying quality doesn’t help patients | KevinMD.com | Kjell Benson, MD | April 4, 2017

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.

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One thought on “Quantifying quality doesn’t help patients

  1. Kathy C

    This use of jargon, and other language tactics is how we got to have the most expensive and least effective Healthcare in the developed world. The clever use of language, Marketing techniques and deliberate misdirection, has helped to improve profitability. If we look at Facts, like the amount of money spent, the number of people, and rank our odds, we would see that Healthcare issues, should be Front Page News. Instead the language and discussion have been channeled into certain narratives. Instead of doing a tangible Cost benefit Analysis, they truncated the conversations, into discussions of intangible metrics like quality. The Industries used the considerable profits, to obscure the facts. One very clear way to do this was to change the languages, and control the Media coverage.
    The language has changed considerably with a focus on Public relations and hype. The Business Pages, fluff for the latest technology Investments, using words like “innovation,” and “groundbreaking.” There has been no quantitative coverage of Healthcare with numbers and Facts. Instead we are inundated with “Good News” about the local Healthcare System. The Facts are in short supply, instead we have Anecdotal coverage of one person who claims they had a good outcome. The media actively promoted “Quality” a meaningless metric used in Advertising. The Industry found that an easily distracted public would be more inclined ot ignore the facts, when they are inundated with nonsense.
    The Industries had to anticipate the use of data. They hyped the “Data Driven Revolution,” there are some of us who remember one of the reasons we did not have a functioning Healthcare System was different Record keeping Systems, and lack of coordination. The “Healthcare Reform” was supposed to change all of that. The Industry anticipated this, and used every tactic in their considerable arsenal, to avoid any quantitative measuring. Rather simple Metrics like the Death Rate, or number of infections, at a given hospital, had to be obscured. Of course there should have been an adjustment based on Income disparities, which was another way they justified the Rates. The theme of any “News’ about our seriously under-performing Healthcare System, justified the Costs an inefficiency by repeating the same Story-line. The reason we can’t base our Article on Facts, is because there are “Poor People” Over utilizing the System.
    Our Local Hospital is a Religious Non Profit, which charges the Insurance Company as much or more than a similar For Profit Hospital. The Theme in every “Local Paper” is that we can’t expect much, because too many poor people are over using the E.R. They justified the ridiculously expensive Billings with that tired line. If we accidentally came across a fact, we could disregard it. The “News” even explained away the Anecdotal Evidence. The people we know that had bad outcomes were not relevant. They probably just did not take care of themselves, it was their fault.
    They used Customer Service Surveys, to mislead the Public. A simple Questionnaire about “Quality” was given to every patient. The Rating System on the questionnaire was essentially meaningless, it has questions on the amount of time waiting for an Appointment, and observations on the “Niceness” of the Staff. Of course a patient has no way of knowing if they received the care that they needed. There is no way for the Patient to know if they got the bast Medical treatment. They are merely rating the niceness and efficiency of the Staff. People are often concerned about the nice lady at the desk, they have to give a positive rating, because that person could lost their job. The Questions on the Survey are irrelevant, yet they are treated as a quantitative Measurement of Healthcare. The News Articles and Advertising repeated this useless information to promote the System.
    we are now in the Post fact Era. Journalists either did nto have access to data, could not be bothered, or were afraid of a negative Article about a Billion Dollar Industry. Our “little” “local Hospital,” is part of a National Corporation with Billions in assets. They have the best and most expensive Lawyers, so drawing the attention of them in any :Article” would be very bad for any future career. The Industry has access to the best Public Relations, and media savvy trend analyzers. They can get out in front of any Healthcare “News.”
    The NIH occasionally releases Factual issues, based on Data. When a recent Information release about “Super-bugs” was trending on the Search Engines and Facebook, the Industry was already ahead of it. A local “Journalist” got in front of that Story. He ran an Article, which was not only Advertising for the Stock Pages, but Misinformation. The Gist of the Article was that our local Hospital had already dealt with the Super Bug issue, we did not have anything to worry about. Some of us know that the Facts tell us the local Hospital has a High Infection Rate. We even know people that have died from preventable Infections, or people that had to be Hospitalized longer because they caught an infection there.
    Infection Rates are one of the few Metrics that Medicare ( The Largest Insurer) is able to collect Data on. They have to imply this information from Billing, and Compliant Hospitals. CMS Medicare is not allowed to count every case, the Reporting Requirements are voluntary. The Industry told Congress and the Regulatory Boards, that Information could make a Hospital look bad unfairly. They claimed it was “Government Overreach.” With an Anti Government Congress, that has taken millions from the Industry, of course they agreed. This type of interference with Data Collection, was done to anticipate any concern of the Industry. It was also one of the Industries biggest concerns about the ACA. They viewed collecting data as Intrusion, in a For Profit Industry. The Industry used Patient Privacy Concerns, and an Orwellian mis-information campaign. The monitored Patient groups and steered the conversation. They could even create Petitions, appearing to be in the Patients Interest, that really only increased their own profitability.
    We have all been Hoodwinked, the Media, owned by the same Interests as the Industry, has been selling the “For Profit System” they conveniently leave out Facts. One concerning Fact is the amount of money the taxpayers are putting into the System. We have an Unholy Alliance of Big Pharma, and the Insurance and Medical Industries. In order to increase profitability the Public has to Be misinformed, the Media helped them direct the Conversion. “Quality” became a measure of Performance instead of Facts, Numbers and Statistics. They threw out some “Red Herrings” like “Empathy” and “Bedside Manner.” Things that had nothing to do with surviving a Medial Incident, or avoiding an Infection. The Media tells us that we can “Shop Around” and compare Hospitals. If one were to look for specific information, like the difference in one Surgical Procedure, at different Hospitals. The Internet gives us the appearance of Knowledge, Instant Access to information. We can look at the NIH, CMS and other Data Bases, then there are various “Quality Organizations.” CMS can only Report on certain Procedures, they have to get the Permission and compliance from a hospital to do any Comparison Studies. The Participating Healthcare Institution, can back out of the Study if they don’t like the results. This further distorts the Data, and renders a lot of Studies meaningless. We can only look at what they are allowed to count. It is what is not there that is the problem. Measuring Quality gave the Industries a meaningless Data Point, that they could focus on, instead of Facts. Journalists did not notice, they don’t have much Science or Math background.
    Scientists are supposed to march on Washington this weekend. Our Country was at the forefront of Science for decades. Our Tax Dollars supported the Science that took us to the Moon, and developed the Cell Phone. The Technology exceeded our understanding. Facts have been exchanged for opinion. The Science our Nation invested in was undermined for the personal gain, of a few billionaires. The manipulation of Data was extremely Profitable, especially since it was a New frontier. People who understood this made billions of dollars on massive but trivial looking financial data observations. The trick was to avoid observation, and the wrath of the populace. So they created Scapegoats and boogeymen. That was easier than Math. Now we have Quality Measurements replacing Facts Numbers, and Statistics, they are just easier.
    “It is difficult to get a man to understand something when his salary depends upon his not understanding it.” Upton Sinclair.

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