IMPROVING MEDICAL QUALITY

Improving Medical Quality

It uses to be a medical axiom to do the right thing for the patient, no matter what. Well, times have changed. Now the message is to do the right thing for the patient as long as the practice, hospital or insurance company isn’t hurt.

Insurance companies monitor and send dunning letters to doctors rating their performance by how many medications they used, the number of referrals they make to specialists, and how long they keep the patient in the hospital. Officially, these letters are strictly informative, with no rewards or penalties. But they tell the doctor how to do the right thing for the patient.

Today, the insurance company got bolder, setting goals, holding back or delaying dollar payments, for failure to meet these goals. This can account to thousands of dollars. There is no scientific basis for these edicts. One must either go along with it or go out of business.

Point deductions occur if a non-generic drug is prescribed. Doctors are checked to see if the patient had too many tests, or missed immunizations or appointments. and is not using electronic prescribing programs. These electronic programs often fail after 5 pm.

Doctors are motivated with wall plaques, showing goal scores, and quality improvement scores. High grades make the doctor superior to his colleagues and he can earn performance bonuses. All these managing care plans also take precious time from seeing patients.

It is advantageous to take care of people who don’t need much care. It is also a good idea to avoid the unemployed middle class patient. By excluding high-risk patients with preexisting conditions, the insurance company can make a great profit.

The big ploy is to rate one doctor against another and make them all dependent on improving goals and payments, making reimbursement complex, and thus distract them from caring for their patients.

Overhead rises tremendously, with a need for a full time nurse and receptionist to strictly handle all the new quality improvement ideas created by pencil pushers.

There is an incentive to get rid of sick and poor patients. All the programs have everything to do about money and nothing to do about improving patient care.

Doctors have little to say these days about the care of their patients. Template cookbook care is now the order of the day. There is no creative analytic thinking necessary.

Despite a push to increase medical school enrollment by 15%, it’s hard to imagine bright and talented collegians will want to get into medicine. Fill out the checklist and call the insurance company’s phone book operator to see what you are allowed to do for the patients. There is little time to spend listening to patients and asking probing questions. Patients are deprived of true medical care.

I am unaware of any pilot study to see if these programs improve care. No programs can ever be violated and the problems keep mounting.

Do you really think government programs will simplify everything?
Source: NEJM 12.27.2007
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