In our recent paper criticizing how industrial Quality Improvement has been misapplied to primary care, we didn’t just complain, we made suggestions for a better way forward. This was under the assumption that regulators and payers will continue to insist on some kind of numeric reporting of outcomes by physicians or practices whether physicians like it or not, or whether it’s really useful and fair or not.
Almost all of the traditional quality measurements used by Medicare and the insurance companies measure things doctors do to people: order blood tests and mammograms, order treatments such as specific drugs for some chronic diseases. Almost all of these traditional measures are of interventions that actually INCREASE the total cost of care. Therefore doing more of these things will not do anything to bring down the exorbitant cost of U.S. healthcare, but will in fact make the situation worse.
The value family physicians bring to both their patients and the greater system is often in the things they don’t do to people: not ordering a CT scan for every patient that utters the phrases headache or belly pain, for example. One conversation a family physician has to talk a patient out of an unnecessary test saves the system sometimes thousands of dollars, more money than the physician generates in gross revenue for the entire day. But there is no code for the physician to even tell the computer what he or she just did that was so valuable.
The Choosing Wisely campaign provides a start for possible metrics that might actually be meaningful for situations where a physician gets credit for not ordering something. We still have to be careful about not using 0% or 100% as targets. These should never be the targets. Sometimes ordering one of these tests is the best care for an individual patient.
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