October 15, 2022
Does Quality Reporting make me a Worse Doctor?
Mrs. Jones, a 68-year-old woman, has a history and diagnosis of hypertension. Her blood pressure, taken correctly at her November office visit, is 139/89.
- Under the Medicare Measures section in the McLaren Physician Partners Top Ten Quality Metrics Quick Reference, blood pressure of 139/89 or less is “adequately controlled”
- Under the 2017 American Heart Association and the American College of Cardiology blood pressure guidelines, 139/89 is Stage 1 Hypertension.
As a provider you can check the box of the quality metric “Controlling High Blood Pressure”, but as a clinician, your obligation to manage her diagnosis with traditional clinical skills and shared-decision making is just beginning.
Quality Measures and Guidelines:
As physicians and advanced practice providers, we are all aware of quality metrics, process metrics, pay for performance, and guidelines attempting to improve quality of care and patient outcomes. CMS wants to make “fee for service” uncomfortable for physicians. Health plans are pushing risk on multiple lines of business in the name of cost and quality.
- These measures and guidelines will impact the type and quality of care we provide to our patients, and how we are paid for it. (1)
- The rationale is public reporting of quality indicators will provide public scrutiny of outcomes to motivate health care to improve the product. (2)
From the Providers Perspective:
- Most physicians are graded on preselected quality measures. Check the box medicine is a severe exaggeration of the use of clinical guidelines. (3)
The fear of the “check the box” approach to clinical medicine is that it will produce physicians with deteriorating clinical skills and diagnostic reasoning. The clinician who follows the protocols need not think deeply about the diagnosis and therapy of individual patients. But we know the skilled clinician integrates information and discusses various approaches to diagnosis and treatment, making appropriate shared decisions with the patient.
The issues of quality care, quality metrics, and clinical management are complex and intertwined. Until we have the “perfect” quality metric, pay for performance process, or evidence-based clinical guidelines, we must marry many variables like interaction between health care provider and patient, patient-oriented outcomes vs disease-oriented indicators, the worth and intent of the quality indicator, and linking compensation with achievement of benchmarks, to name a few.
Please help as we transition to performance and outcome-based metrics, our intent is to address and master quality metrics, without providing substandard care.
References:
- When quality measures interfere with good care, Michael McCutchen MD, Kevin MD.com, April 30/2022.
- Public reporting needs reform, David Hahn MD, Journal of Family Practice, May 2009.
- Practicing ‘Check the Box’ Medicine, Joseph Alpert MD, The American Journal of Medicine, October 14, 2013.