Primary Care Corner with Geoffrey Modest MD: Are Healthcare Metrics Good for Our Health?

By Dr. Geoffrey Modest

The NY Times had a recent editorial by Robert Wachter, a professor of medicine at UCSF, suggesting that focusing on specific metrics/measurements may distort good quality care (see http://www.nytimes.com/2016/01/17/opinion/sunday/how-measurement-fails-doctors-and-teachers.html?emc=eta1&_r=0 ). [Thanks to Karen Henley for bringing this to my attention]. His points:

• It is important to use metrics as part of the assessment of health care quality purview
• There certainly is a basis to look at some issues of health care maintenance, or trying to decrease medical errors
• But,
  • “There are so many different hospital ratings that more than 1,600 medical centers can now lay claim to being included on a ‘top 100’, ‘honor roll’, ‘grade A” or ‘best hospitals’ list”
  • Electronic medical records are supposed to help with the metrics/quality, but a 2013 study showed that they were the leading cause of doctor burnout, and ER doctors click a mouse 4,000 times during a 10-hour shift. [And, I would add, computers can decrease many aspects of quality, such as really listening to the patient and having good, empathic eye contact. See https://stg-blogs.bmj.com/bmjebmspotlight/2015/12/22/primary-care-corner-with-geoffrey-modest-md-provider-computer-use-and-patient-satisfaction/​ ]
  • He argues that “measurement cannot go away”, but that what we measure should be important clinical targets [I.e., not just the easy computer-generated claims-based ones], and that clinicians should be involved in the process of determining those metrics. He contrasts a really good measurement (certain hospital-acquired infections) with probably less useful ones (e.g., did the provider provide discharge instructions on asthma?, which is may be just remembering to check a box and giving the patient some pieces of paper, which they often do not look at later, without even going through the intended comprehensive patient education). And there needs to be a way to make these targets appropriate for different populations

• But,
  • There are innumerable times that I get healthcare insurers sending me notifications that my nonhypertensive, nonproteinuric diabetic patient is not on the preferred ACE/ARB (and diabetes organizations have stated that these are not appropriate, for at least the last couple of years). These “reminders” add to the dramatically increasing amount of paperwork/emails/computer work that consumes my day…
  • I am put in a conflicting position: pretty commonly, I have patients ​come to me who have not had an A1c for the past 4-6 months, where getting the test is clinically useless. A frequent scenario is that they were out of the country for a few months and ran out of their meds (and Medicaid, a frequent insurer for my patients, will not give more than a 30-day supply of meds and they cannot be picked up early). So, when the patient returns to see me, their blood sugar is high, I reinstate their meds, and plan, appropriately I think, to check their A1c in 2-3 months. BUT if I do not check the A1C in the earlier visit, I get zinged by the insurance company (which I might get anyway, since the A1C will be “uncontrolled”), which affects the income to our health center.
  • Paying attention to some of the metrics takes time away from what may be the most important patient issues (getting a lot of testing may undercut my and the patient’s focus on the real issue: the fact that they are now homeless, do not have any income, are victims of domestic violence….  and that should take precedence). The point is that providing high-quality health care reflects a complex provider-patient relationship, where we (provider and patient) are sorting through an array of potentially complex medical, psychological/psychiatric, and social/behavioral issues, and by being pushed to focus on the mammogram or A1C, or discussing the risks and benefits of low-dose chest CT in smokers, is really a distraction in our way-too limited time together.
  • And, pay-for-performance (PFP, the system by some insurers to financially reward clinicians or their groups for adhering to the metrics) in studies a couple of years ago mostly showed that well-organized and well-funded, mostly middle-class organizations did well (and got extra money), and they did well on these metrics even before there was PFP. Less well-funded institutions did not get the monetary benefit of the PFP money, and really needed more money to help set up better organized systems.
  • So, I am certain there are lots of inefficiencies in the current system and that we as clinicians have missed important chances to provide accepted preventive interventions. And I support the concept of reminders and setting up systems in the practice to improve our performance (though the thrust in “poorly-performing” practices should be to help them financially and organizationally in improving their systems and not effectively decreasing their income). But these reward systems need to be appropriate clinically, derived from the local community needs, vary depending on the community (e.g., in some communities, rewards should be greater for screening for domestic violence, abuse, etc than A1C levels), be flexible enough to allow for clinician/patient discretion in their encounters (and dealing with social issues may happen much more often in some communities/clinics, such as a “healthcare for the homeless” clinic, where holding them to the same % target for some preventive services may be less appropriate), and be focused on helping practices in providing high quality care for their specific communities.