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Family Physician Quality – A New Way Forward

August 22, 2017

Wrapping up my series on our recent paper criticizing how industrial Quality Improvement has been misapplied to primary care, (and sorry for the gap in wrapping this up), I want to share my own thoughts on a way forward.

First, in our paper, we proposed very aspirational measurements such as missed days at work or school, days of functionality, total mortality, and so on. I actually hold out little hope that billing/administrative data that Medicare or the insurance companies use (or add in geospatial data) will ever adequately risk-adjust populations to the point that the quality of the work of the physicians and their work environments can be separated from the nature of the populations of patients they care for. Physicians who care for vulnerable populations in the Mississippi delta will forever look worse than those who care for upper income populations in suburban Denver. The computers will not be able to fix this.

Many doctors will likely have the attitude that no one needs to measure their work. Between their years of dedicated training, state medical board oversight, and the constant threat of malpractice suits, that’s enough oversight and checks and balances.

But the regulators and people from governments and the private sector will continue to be frustrated and angry at the cost of healthcare and faithfully believe that more administrative oversight will improve the system, in spite of years of evidence that it really doesn’t help much, and in spite of the evidence for the huge amount of administrative cost in the U.S. healthcare system, much higher than any other system in the world. Unfortunately for U.S. physicians, they aren’t going away and they won’t care if we say, “We’re professionals, just trust us.”

On the other hand, it would be wrong on so many levels to continue meaningless use, HEDIS, and their offspring. So where is the middle ground?

I think family physicians, and all physicians for that matter, must acknowledge that there are rare, but present, poorly functioning physicians in our midst. We see them when we get records from them after a patient transfers care to us. We hear it in patient stories about their previous experiences. It’s rare, but it happens.

We have to take some professional responsibility for our ranks to be fully accountable to our patients and policy makers. How do we do this? We proactively monitor each others’ work.

This is a scary proposition and if we’re not careful, we could become our own hated and useless bureaucrats. I think the Scots might be ahead of this curve and all of us need to watch their national experiment. They have decided to abandon the Quality and Outcomes Framework, which means no more meaningless measurements. They have announced they will carry out more qualitative reviews of each other, details to follow.

I can imagine there will be no great way to do this. What busy physician would ever want to have an outsider, even another family physician, invade his professional space?  Should we all take an hour a week to journal?  This seems like a stretch. But I do think that as long as the inspector respects the complexity of our work and understands that there are often lots of reasonable ways for a family physician to manage the concerns of a complex patient, then the experience could be somewhat reaffirming and possibly educational. The challenge will be figuring out which possible knowledge or process of care gaps represent a meaningful opportunity for improvement vs. a physician who has good reasons to throw away the textbook when caring for a patient with complexities.

As long as the inspecting family physician has an understanding that she is looking for unusual care patterns, understood by perhaps perusing 30 or so representative charts, and rarely identifying a singular outlandish decision, then this could work. A physician who has 10 diabetics whose A1cs are 10 and just on sulfonylreas with no indication that he thinks this is a problem, needs to be called out. A physician who sells Noni juice out of her office at $80 a bottle needs to be called out. The only way this can happen is if another physician gets in his business.

It won’t be painless, but a necessary concession we must make to keep the bureaucrats and business suits from making our care worse, which they have done persistently and reliably the last 30 years.

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