The odds of health care quality

March 30th, 2006 by Julie Ferguson

DB’s Medical Rants discusses an L.A. Times article that reports on a recent study in the New England Journal of Medicine about quality of health care. The study shows that, rich or poor, most people only get the right medical care about 50% of the time. This study didn’t deal with access of care; rather, it looked at the care that is provided.

“Recommended care included things that have been scientifically shown to be medically effective and are accepted as the best standard for various conditions. The researchers looked at 439 such measures of quality for 30 common medical conditions and preventive care.

For example, after a patient has a heart attack, doctors should prescribe a beta blocker, a follow-up treatment shown to save lives, but they do so only half the time. An anti-inflammatory steroid inhaler is the first line of treatment for someone with asthma, yet only one in two asthmatics receive a prescription when they need it. And patients have about a 50% chance of getting the right diagnostic test if they have pneumonia.”

Fragmentation is one of the primary reasons for the breakdown in quality that the study cites. Most people have mutiple physicians and see a variety of specialists in the course of receiving care, The study is interesting in and of itself, and DB’s comments about the survey were also noteworthy:

“… patients generally benefit when one physician understands their problems and manages all those problems. Yet our reimbursement system provides incentives against that rational system. Subspecialists can care for a single problem and receive the same (or greater) reimbursement for a visit.

If we want better quality, we must understand and learn how much time good quality takes. It will take more time for each visit, but I believe that time (and appropriate reimbursement) will be the key factor in improving health care. No other profession works under, or is asked to work under, such severe time pressures.”

It would be interesting to see how a similar health care quality study in the context of workers compensation would play out. The playing field is level among patients since work-related injuries are all covered by the same benefits, at least on a state by state basis. However, physician reimbursement is discounted right from the get-go, and networks often demand further discounts on top of that – hardly an incentive system designed to foster quality. The conventional wisdom would generally support the idea that an expert primary physician would produce the best outcomes. Fragmentation of care can be a significant issue, and it would appear that case management has evolved largely to address this and to ensure continuity of care, to expedite the recovery process, and to foster good communication across multiple providers.
Discounts continue to be one of the primary attributes that employers use as a purchasing criteria for medical care. If one accepts the premise that quality care translates to better outcomes – recovery and the return to work – then it would seem in everyone’s best interests to ensure quality. To ask physicians to do more — as they must by the very nature of workers compensation — and to do it for less seems like the wrong way to go about ensuring quality. Minimizing costs in workers compensation is largely contingent on aligning incentives for all participants – physicians are no exception.