Do Medical Quality Measures Result in Greater Harm than Good
By Pamela D. Wilson, CSA, MS, BS/BA, CG
There is discussion in health care circles about “quality metrics”, for example standards that must be met by physicians in order to ensure certain levels of patient care and in return that ensure certain levels of physician reimbursement. Many states also have pay for performance programs.
Hand washing is a simple example. Imagine that the likelihood of infection being passed hand to hand or hand to mouth decreases with the activity of hand washing. Washing your hands is a very simple act that can help avoid catching a cold. According to the Centers for Disease Control, hand washing is the single most important means of preventing the spread of infection. Thus it would be logical to believe that by implementing a standardized protocol for hand washing (quality metric) in hospitals, medical offices etc. that the risk of passing on infection is likely to decrease.
In a recent Wall Street Journal Article, (1) mention was made of physicians in California dropping non-compliant patients or refusing to treat people with complicated illnesses because their less than stellar outcomes may result in poor scores and lower financial reimbursement for physicians. This questions the logic of quality metrics in compromising the care of critically ill patients. If the likelihood of failure is great in any endeavor and there is a financial or personal penalty then who will be willing to try at all?
This has become a significant issue with the recently passed healthcare act. The portion relating to Patient Re-hospitalization that results in financial penalties to hospitals for readmitting patients with certain conditions within a 30 day time frame is actually resulting in older adults needing care not being admitted to hospitals. Seriously, did the government really believe that hospitals would not find ways around being financially penalized?
A study recently released by the ACCORD group closely monitored blood glucose levels in individuals with Type II diabetes. (2) Unless you’ve had a family member hospitalized, you may or may not know that monitoring blood glucose levels became a quality measure in hospital intensive care wards. I’ve questioned the need myself when my clients in the hospital were given insulin injections when they’ve never had a diabetic day in their life. Why treat something that never existed in the first place? Answer: quality metrics.
Recent research by the ACCORD group noted a 22% higher mortality rate in the tightly controlled blood glucose group. A study performed in Australia and New Zealand showed similar results. Reading this, one might conclude that that the use of quality metrics may be detrimental to life. If you or any of your family members have a trip to the local emergency room and are given insulin, ask why. This could be critically important to you and the long term well being of your family member.
The quality measure for insulin is not the first measure to be found suspect, beta blockers and door to door antibiotics are another two measures now questioned. (2) What happened to the idea of conducting research on proposed quality standards before the standards are actually recommended for widespread use? Drug companies cannot release drugs until after years of testing and quality control. Why should general health care be different when it has an equal potential of harm?
Obama’s budget plan for health care reports that “savings from cutting down on hospital readmissions could top $26 billion in 10 years by combining incentives and penalties to get patients and hospitals to be more efficient.” (4) Help me understand how a hospital can control individual choices made when a patient leaves the hospital? And why a hospital should be fined for something they cannot control? Unless responsibility, prevention and education are pushed down to the consumer level there will be no opportunity for change in health care.
Many of my clients have had previous hospitalizations. Many of them do not follow medical recommendations, and would be considered non-compliant relative to taking prescription medications, actively participating in physical therapy, modifying diets, following up with their primary care physician and other suggestions unless we closely monitor these activities for them. Many times close monitoring involves the participation of an available family member or an advocate like my company who is retained to monitor care. This must be a voluntary act or decision on the part of the individual needing care. The role of monitor is the role we play with many of my clients who have the desire not to return to the hospital and to remain as independent as possible.
My father-in-law underwent treatment for lung cancer costing hundreds of thousands of dollars in chemotherapy and radiation treatments paid for by his insurance company. However he continued to smoke cigarettes due to a longstanding nicotine addiction. A logical person might ask, why treat him at all for cancer if the likelihood of recovery is poor especially when he chooses to continue the activity that caused the illness in the first place? Was the continued cigarette smoking a response to stress knowing that his condition was likely incurable?
Should we have more strict requirements for those receiving treatment to ensure precious health care dollars are not wasted? Where are physicians who are willing to have realistic discussions with patients about prognosis so that health care dollars are not spent because an individual is led to believe that they have a significant chance of cure? Doctors, hospitals and other heat care associations can only control a limited number of factors.
Human nature and choice controls the rest. Penalizing physicians and institutions for issues outside of their control will only lead to patients receiving a lower quality of care in order to avoid penalties. Penalizing individuals may result in more progress and lower costs if the burden of choice and pressure is placed where it belongs. After all physicians take an oath to do no harm, let’s allow them to do their jobs without penalty. It’s patient choice and action that dictates the rest.
(1) Groopman, Jerome and Pamela Hartzband, Why Quality Care is Dangerous. Wall Street Journal, 4/8/09, A-13.
(2) Clinical News: Diabetes Care Recommendations Were Inverted in 2008. American Journal of Nursing, January 2009, Vol. 109, No. 1, p21.
(3) Wachter’s World http://www.the-hospitalist.org/blog, 3/30, 4/4, 4/16/09
(4) Favole, Jared A. Readmitted Patients Cost Billions, Wall Street Journal 4/2/09, D4.
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