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Posts Tagged ‘quality control’

As the founder of an important and perhaps the first online patient satisfaction feedback Web site (and the only one I know of that doctors encourage their patients to visit), I am a huge believer in the importance of enhancing the quality of American medical care.

My focus is on helping doctors give patients care that patients perceive is terrific.  Many other people — determined physicians, dedicated scientists — are working to improve the  technical aspects of care, particularly by developing and incorporating measures of quality and by reducing the number of preventable adverse events.

Dr. David Nash, Dean of the School of Population Health and the Thomas Jefferson University, is an expert in this rapidly advancing field.  I talked to him yesterday on the Getting Better Health Care radio program.  You can listen to the program or download the podcast here.

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Oy. The people running South Shore Hospital in Massachusetts must have had a bad day. On July 19, the hospital reported that back-up computer files containing personal, health and financial information on 800,000 people may have been lost.

Electronic record systems have been a boon to the U.S. economy and are poised to help improve medical care in many ways. There are promises of better health care, less error and lower cost. But, like everything else, it comes with potential problems too.  Dr. Dan Siegel explains more about it on the Getting Better Health Care radio program

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Doctors are doing a great job. The distribution of scores is skewed toward scores of 9 and higher. Having an average score of anything less than 9.0 out of 10 is, relative to other doctors, a pretty low score.

Medical systems — hospitals, medical schools, etc. — can focus on their doctors’ absolute scores (how happy patients are) or on relative scores (how high doctors’ scores are compared to their peers). The latter can be problematic.

Doctors who get a 9 out of 10 from all their patients are giving great medical care.  But compared to most doctors, that 9 out of 10 is actually a low score! A doctor with a score in the high 8s might be only at the 25th percentile (ie, a score lower than 75 percent of other doctors). But the great majority of the doctors’ patients may still be extremely pleased with the doctor and the care that doctor provides.

It is interesting to consider how administrators of a large medical center should react to having doctors that average among the 25th percentile of doctors. Should those administrators be concerned that their doctors are doing a poor job relative to other doctors or should they be optimistic that patients love these doctors, that the average score is still 9.0 out of 10? I think focusing on the 25th percentile and saying the doctor is doing poorly is wrong and will leave hardworking doctors feeling demoralized. Letting the doctor know that the average patient gives them a score of 9 out of 10 is likely to be more encouraging, but still allows recognition that there is room for improvement.

Administrators probably realize that having even a small fraction of unhappy patients isn’t good for a health system. Unhappy patients are a risk: they may communicate their bad feelings to other potential patients, but more importantly, they are unhappy. Our raison d’etre is to get patients well and happy!

Settling for a 9.0 out of 10 (knowing that it means that 1 in every 10 or so people may have been very dissatisfied) isn’t good enough for any doctor, especially when we know it means there are patients who were very unhappy with their care. We strive to make every patient completely satisfied with his or her medical experience. Hopefully patient feedback services like DrScore.com will help doctors achieve that goal.

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One of the great ironies of our health care system are copayment assistance programs.  Such programs seem like a wonderful way to help patients obtain access to modern medical treatments.  But as was pointed out in NPR’s This American Life show on health care reform, there’s a “dark side” to these programs.

Here’s how they work. Let’s say a company comes out with a new drug, and they set a price of $800 for a month’s supply. The insurer may cover much of the cost of the drug,  but because the drug is so much more expensive than other options, the insurer puts the drug on “tier 3,” requiring patients to pay 20 percent of the cost. In this example, that’s $160 per month, nearly $2,000 per year, which is a considerable sum of money. Some patients either can’t or won’t pay that much, so to help patients get better access to the drug, the company may offer a rebate or coupon program that cuts the cost of the co-payment from $160 to something far more affordable, perhaps just $10 or $20/month.

This sounds like a great way to help patients, but unfortunately, it is also a great way to game the system and keep the costs of drugs high. The purpose of co-payments is to create some incentive for patients to choose a lower cost product, but the co-payment assistance cards insulate patients from the cost of the drug, so they may choose the higher priced drug even though its benefits may be marginal in relation to the much higher cost. This allows the drug company to continue charging the insurer a very high price, and there is little pressure from the patient to provide lower costs drugs.

Insurers ask patients to pay for a part of the cost in order that patients consider the financial cost of using the biologic. If drug companies are permitted to eliminate the co-payment that insurers have in place, the drug company no longer has to compete on price.

A similar phenomenon happens when doctors see patients without charging co-payments for the visits. The doctor may feel that they are just being nice to patients by not charging the co-payment. But these co-payments have a central place in helping regulate patients’ use of doctors’ services. Doctors can reasonably see a patient without charging the patient (or the insurer) anything if the doctor wants to help the patient out. Taking payments from insurers without trying to collect the co-payment is somewhat dubious and sometimes illegal.

Years ago, while still in training, I went to see a dentist for a regular check-up and to address a minor problem. It was a very rainy day, and I was able to get in right away due to a cancellation. Understanding that I was a student, the dentist offered me a very reasonable, low price for his services. Upon finding out that I was insured, he said I didn’t need to worry about the bill at all, and that he would happily take care of everything directly with the insurer. Almost certainly, he billed the insurer far more than he offered to bill me directly. Insurance doesn’t just insulate the purchasers of services from the cost of the service; the doctors who provide the service have little compunction about charging unseen, third party insurance corporations whatever the doctor can, while many doctors wouldn’t directly charge the patient such a high price.

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There is much rhetoric out there, but the real efforts to improve the American health care system involve several laudable goals, including:  1) control cost, 2) improve quality and 3) improve access. None of  this is going to be easy.

For example, let’s take the first goal of controlling health care  costs. Some people think it’s just a matter of “reigning in the bad  guys.”  They point to “for profit” insurers and health care  organizations as “only in it for the money,” or to for-profit drug  companies who are “only in it for the money” or to doctors who “only care about money.”

But it is never just about the money. The simple, early theories behind managed care were to help patients get access to high quality, cost effective care at an earlier stage while providing incentives to keep costs low. And while pharmaceutical companies are often called on the carpet for the expensive drugs, it’s important to remember that more research and development goes on in the United States than other countries – and these researchers are making many drugs that are actually improving patients’ lives.

We all have financial motivations at some level. But all of us – patients, doctors, insurers, and pharmaceutical company staff – feel that we are contributing something important to the health care system.  Of course our system of insuring medical care has problems. But they are system problems, not problems with the people in any particular part of the system.

Demonizing the people involved in delivering health care isn’t going to solve the problem. To crack that nut, we need to decide how much individual responsibility people need to take for their own health – both in terms of how much a person should pay for health care and how responsible they should be for adhering to their doctors’ recommendations.

I have always advocated for patients to take greater ownership of  their health care, and I created DrScore.com to help them do just that.

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