A Model For Health Care That Pays For Quality:Good Luck

There was an interesting article today in the New York Times Business News section, entitled ” A Model for Health Care that Pays for Quality.” written by Milt Freudenheim. Apparently, the National Committee for Quality Assurance (NCQA), “a nonprofit focused on health care plans” (this is the organization that has for many years orchestrated reporting of quality data by HMOs and other large health care delivery organizations) is working on ways to get physicians to spend more face-to-face time with patients as a means of improving patient care outcomes. I guess the idea is to reward physicians for spending more time with patients- I assume this means paying them more? The article says that many large employers and insurers are “getting on board” with the idea, which is already being studied here and there.

How much time do physicians spend with patients now?

There are lots of data to show that the average face-to-face time between physicians and patients at clinic visits is brief- the average time is about 7 minutes. In contrast, the waiting room time before scheduled visits is quite impressively lengthy. There are also lots of data to show that many physicians do not follow recommended guidelines for patient care for this or that condition or for a given set of symptoms. I am not aware, however, of any data to show that longer encounters would make any difference in outcomes.

What is going on?

As best I can tell, employers and insurers would like to see better patient care outcomes because that’s nice (I asume that’s one reason?) and because it might have an impact on the high and steadily rising costs of health care. Of course we already know, notably from Kaiser-Permanente studies, that “better” health care saves money by resulting in better outcomes, at least in the areas of cancer, diabetes, and heart disease. Putting lots of effort into managing chronic disorders before preventable complications develop really works (I have discussed the Kaiser data in earlier entries). I do not know if focusing on physician-patient time is of any benefit. I would doubt it. I do not mean to imply that more time for patient clinic visits wouldn’t help, but trying to reward physicians who are not presently practicing high quality medicine by rewarding them simply for spending more time with their patients would not necessarily result in better care. In fact, if it is true that we have a big physician shortage and poor access to physicians by patients, slowing down the clinics will only make things worse.

What makes for a “good” physician?

It is very difficult to describe what makes one physician a good one and another one not so good. In my experience, patients generally don’t have a clue in determining which physician truly knows what he is doing or not. Often, patients mistakenly confuse the difference between a likeable doc and a competent one. It drives me crazy when I see people in a social setting who tell me how wonderful their physicians are when I know the docs are truly menaces (it is, of course, a  moral/ethical dilemma of whether to offer an opinion- so far I have been chicken to do so, unless the person is truly seeking my medical opinion about the physician).

“Good” physicians already spend what time is necessary to sort out what is going on with their patients. It may mean they make less money (time is money even in medicine) but it’s just something they have decided to do. Also, some physicians are very good at sorting things out quickly- some can never figure out what’s going on no matter how much time they take (it’s a good thing my doctoring skills are not judged by how quickly I can get New York Times cross word puzzles done!).

What should be done?

The NCQA should focus its energy on those things it knows best- developing parameters for assessing quality of care. They have already done a very good job in the area of diabetes care. They need to extend well-validated measurements of quality to many other chronic and acute conditions. Organizations can audit charts to determine how well their physicians are doing to with regard to the quality measures. These data can then be shared with the physicians (many insurers already do this).

I believe that a very worthy addition to the process is a “required” (I don’t know how to force a patient to do it, although the Japanese do) annual health assessment by ones primary care physician. This assessment could include a questionnaire that the patient fills out in advance which can help alert the physician to possible health problems and to the patient’s preventive heatlh care status (e.g., ? needing a PSA, a mammogram, herpes zoster vaccination). Of course, we will need an adequate number of primary care docs who have the necessary time to spend to accomplish all this- that is one of the biggest obstacles to my proposal.

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