Safety experts are fed up with healthcare workers who do not comply with hand washing and influenza vaccination mandates. It's time to take a new approach to ensuring compliance, they say.
The Institute feels so strongly about the need for personal responsibility on the part of healthcare workers that it recommends employees be fired if they repeatedly and deliberately flout basic and easily met patient safety requirements.
Hand washing and mandatory flu vaccinations are the first two safety practices the Leape Institute wants hospitals to enforce, according to Robert Wachter, MD, an NPSF board member. He wrote about the matter in the HealthAffairs Blog last month.
"The right of "individual veto" cannot be considered more important than safety practices that are backed by "sufficiently compelling supportive evidence," Wachter argues in the Health Affairs piece. "They (hospitals) must be willing to terminate clinicians for deliberate and repetitive non-compliance."
Wachter, a member of the Institute and a professor and interim chairman of the Department of Medicine at the University of California, San Francisco, explained his position further when I reached him by phone recently.
"Up until now," he told me, "hospitals approached these safety practices with the outlook that healthcare workers knew they should follow them, but there were no consequences if they didn't. We exhorted people to follow them and we created systems to make it easier for them. But compliance is still not where it should be."
TheInstitute calls for near-100 % compliance for handwashingand flu vaccinations, the first two safety measures on its list of criteria to help hospitals determine when a practice should be placed on a "Must Do" list. Wachter writes:
"Of course, there will be exceptions, such as emergency procedures in which there isn't time for hand hygiene, or legitimate medical reasons to forego influenza vaccination, but such circumstances are rare and should not weaken the general expectation for compliance. Central to this argument is that clinicians cannot choose, as individuals, to forego "must do" practices."
Universal compliance is feasible; indeed, compliance rates close to 100% have already been achieved in some institutions, though such rates are far from typical. Both practices have been endorsed by the National Quality Forum, relevant specialty societies, and broad professional consensus."
Put Processes in Place
Frank Federico, RPh, executive director, strategic partners, for the Institute for Healthcare Improvement, agrees with the Institute's call for accountability and consequences, but with a caveat: "Before a hospital requires 100% accountability, we must make sure that we have the appropriate processes in place and that we have made it as easy as possible for employees to comply with these safety practices."
Robert Wachter, MD
Writes Wachter:
"Just as we believe that individual clinicians will be driven to universal compliance out of professionalism, we believe that healthcare leaders will create systems to facilitate and measure compliance out of their desire to do the right thing."
Erin S. DuPree, MD, chief medical officer and vice president for The Joint Commission Center for Transforming Healthcare, says The Joint Commission has historically required healthcare facilities to reach a high level of hand hygiene compliance.
"We learned through our work in the Center that many hospitals do not have unbiased, accurate measurement systems to determine actual hand hygiene performance which is necessary for improvement efforts. The Center's work with leading hospitals uncovered the root causes of this chronic patient safety problem and developed solutions to facilitate organizations capacity to improve hand washing and ultimately get to the aim of 100," she says.
Hospitals claiming they cannot meet these standards are in the wrong business, Wachter writes:
"We are even less sympathetic to the frequently heard argument that these standards will put hospitals (or clinicians) out of business. Hospitals or clinicians unable to achieve uniform adherence with "must do" practices should not be in the business of delivering health care."
No-blame Philosophy
The University of California San Francisco Medical Center hires people to secretly observe employees' hand washing practices, Wachter says. Individuals are not cited. Instead, the reports are unit-based and have helped push hand washing compliance to almost 100%.
The Institute doesn't specifically prescribe how hospitals should go about ensuring that employees adhere to these practices. But individual facilities may be creative in coming up with solutions, Wachter suggests.
Answers to multiple choice questions and brief comments on patient satisfaction surveys don't tell providers the whole story. Qualitative reports, in the form of detailed patient stories, can better capture information of value to providers, researchers say.
One of the benefits of being a journalist is that I get to tell other people's stories. Heart-breaking stories, informative stories, far-fetched stories, and funny stories. I find developing a rapport with the people I interview before start asking questions is usually a good idea. So I ask people about what they are passionate about, such as hobbies, families, or social causes. If they sense I am interested in them, they usually become amenable to answering more probing questions.
My method is not based on science, but it usually works.
Some healthcare researchers also believe that eliciting patients' stories or personal narratives is more useful toward gaining an understanding of patient satisfaction than the traditional Q&A format now used in most surveys.
Mark J. Schlesinger
And they believe there is a scientific way in which these stories can be gleaned. In a New England Journal of Medicine article published this month, the authors propose that patient narratives can provide rich, relevant information about the areas in which clinicians need to improve.
"What we are trying to get at… is that in order to really make sense of people's experiences you need to get them to tell the full story of what their encounters were like," says Mark J. Schlesinger, professor of health policy, Yale University School of Public Health. "We need to start thinking about how we rigorously ask people about their stories instead of just having them leave comments"
Narratives Tell a Fuller Story
"The incorporation of narrative feedback into public reporting can highlight aspects of quality that are missing from conventional surveys," the article says. "In addition, elicitation of narrative feedback can encourage participation in patient experience surveys by allowing consumers to report what matters most to them."
Schlesinger and his colleagues have been studying the best ways to construct surveys for more than three years. Although their research focuses on physician visits, he says it applies to other healthcare settings as well.
"Qualitative reports from patients about healthcare represent an essential missing link both for consumers seeking to understand the experience[s] of other patients and for physicians seeking to learn from patients to improve quality," the article says. "
Framing the Questions Right
Using data collected from the current surveys makes it difficult to ferret out what is really going on with patients. Schlesinger and his fellow researchers explored the most effective ways to frame questions to draw the kind of information they were seeking. "We wanted to get at the ways in which patients interact with the people they come across during a visit and elicit the information that would be most useful for clinicians and consumers," he says.
The protocol developed by the researchers is a framework of questions that they believe prompts patients to openly tell their stories. The questions guide the narrative by asking patients what their expectations were when they went for the visit, whether those expectations were filled, and if unfulfilled, what they did about it.
Schlesinger and his colleagues are continuing their research to answer questions such as whether the protocol does what is expected when field tested and exactly how the narratives can be used in healthcare surveys.
Lessons from the National Health Service
Using narratives to gather patient feedback is not new. The Centers for Medicare & Medicaid Services' HCAHPS program (Hospital Consumer Assessment of Healthcare Providers and Systems) has spawned an industry of private firms willing to survey hospital patients for a price. But the information is private and only seen by certain healthcare leaders within the hospital. The information is not transparent, Schlesinger says.
In the United Kingdom, where most healthcare is free to all UK residents, things are different. The National Health Service allows patients to post their stories, good or bad, about hospitals and physicians on its public website. Patients rate their encounters by stars and hospital and providers have an opportunity to post their response to the narratives.
Schlesinger says the U.S. isn't anywhere near that level of gathering and using narratives to inform consumers or healthcare workers when choosing providers or hospitals. But, he says, "A lot of people in the field think there is a need for this type of work and that it needs to be taken seriously."
To use narratives on the same scale as the NHS means gathering stories from millions of patients across the country and then hiring people to comb through the data and weed out information that is inappropriate. "It requires a big commitment of money and resources to make this work," he says.
Schlesinger believes, however, that when it comes to patient surveys, "The right story is the full story."
Hospitals with boards and management practices that actively monitor quality and patient safety, as well as budgets and finances, have higher quality outcomes, researchers find.
Hospital boards that place quality and patient safety higher on their agenda somehow improve the performance of front-line management and clinical quality outcomes, a recent study has found.
"Conceptually, everybody understands that good leadership at the board level matters," says Thomas Tsai, MD, a surgical resident at Brigham and Women's Hospital and research associate at the Harvard T.H. Chan School of Public Health and the lead author of the study published in the August 4 issue of Health Affairs.
"But this is one of the first papers to empirically show the connection between hospital board and management practices. We also demonstrate that both hospital boards and managements practices are then, in turn, related to the clinical quality of a hospital."
Thomas Tsai, MD
Exactly how hospital boards impact clinical performance is unclear and needs to be further investigated, Tsai says.
Characteristics of Quality-focused Boards
Survey questions used in the study were placed in two categories—the composition and attributes of the board, and the board's actions. The first category examined whether boards:
Listed quality as a frequent agenda item
Valued clinical quality as a priority
Contained members experienced with quality
Were engaged in quality issues
The second category focused on what the board was actually doing to improve quality. Researchers wanted to know about:
The use of dashboards to study quality measures and outcomes
The setting of goals and dissemination of these goals throughout the hospital
CEO evaluation and remuneration based on safety measures and outcomes
The use of data for feedback, incentives, or awards
High quality hospitals with better management had boards that were more engaged with dashboards, data, and frequent discussions on quality and patient safety, Tsai says.
Importance of Front-line Managers
The study did not look at the relationship between boards and the C-suite. Instead, it examined the relationship of boards to front-line management practices and the quality of care delivered.
"Managers of hospitals were defined as clinical service leaders and represented a diversity of professional backgrounds including physicians and nurse managers," the study says. "Mid-level and front-line managers were selected because they were senior enough to have an overview of management practices, yet still be involved in day-to-day operations and, therefore, more likely to have a direct relationship with care delivery in each hospital."
Front-line managers were deliberately included to see how leadership decisions regarding quality filter down and impact delivery of care, Tsai says.
An 'Underappreciated Opportunity for Quality Improvement
Quality and patient safety initiatives usually focus on clinical provider outcomes. But the results of this study show there is a definitive link between hospital boards, front-line management, and quality of care.
"The data suggests this is an underappreciated opportunity for quality improvement," he says. "We need to think beyond focusing only on clinicians to thinking about how the overall hospital organization is aligned with clinical quality metrics."
For example, if a hospital has a high surgical infection rate, it may not be enough to just target improvement efforts on individual surgeons or revamp guidelines in the OR, Tsai says. "We may need to think more broadly about hospital culture and whether we should be thinking about managers and boards reviewing this type of quality data as well."
"Our goal is that this study will motivate future research and provide an opportunity to improve the quality of management practices in hospitals," Tsai says.
Research finds that 90% of the cost to meet the American Board of Internal Medicine's Maintenance of Certification requirements is attributable to revenue lost because of the time it takes physicians to fulfill those requirements.
I didn't know when I started to look into the American Board of Internal Medicine's Maintenance of Certification requirements that I would feel like the girl who kicked the hornet's nest.
Sure internists, hospitalists and internal medicine subspecialists became enraged last year when ABIM raised expectations in continuous professional development by increasing the number of MOC points required.Physicians complained vigorously that the learning activities associated with earning MOC points are frequently irrelevant to the practice of medicine.
But the discontent abated somewhat in February after ABIM conceded that it had made mistakes and started changing MOC requirements based on feedback from the internal medicine community. But these changes may not be enough.
Last week, however, tensions flared again with online publication of a study in which MOC costs were analyzed. The study's objective was to estimate the total cost of the 2015 version of the MOC program and the incremental cost relative to the 2013 version.
The study, published in theAnnals of Internal Medicine, found that the estimated cumulative costs for the 2015 MOC will be $5.7 billion over 10 years, $1.2 billion more than the 2013 MOC. The clincher is that 90% of those costs are opportunity costs—revenue lost because of the time it takes physicians to meet the certification requirements.
Richard J. Baron, MD
Internists will incur an average of $23,607 in MOC costs over 10 years, ranging from $16,725 for general internists to $40,495 for hematologists-oncologists, the study shows.
It points out that "Subspecialists face higher costs than general internists, primarily because they take additional certification examinations that generate more fees and a greater time outlay."
A Substantial [Cost] Underestimate
"Our study highlights that the key driver of MOC costs is the physician time required to complete MOC activities, which accounts for nine of every 10 dollars spent on MOC," the study states. The ABIM has previously suggested that participation in MOC will cost $200 to $400 per year; this is a substantial underestimate precisely because it overlooks time costs. Efforts to decrease the cost of MOC should therefore focus on reducing demands on physician time."
Richard J. Baron, MD, president and CEO of the ABIM, a member of its board of directors, and an internist and geriatrician with more than 30 years of community practice, understands that physicians are busy professionals. "We want to minimize the way in which they experience hurdles with the program and congruent professional self-development," he told me. "We have already implemented many of the suggestions mentioned in the article."
I asked Dhruv S. Kazi, MD, one of the study's authors, why he and his fellow authors decided to do the study in light of the ABIM concessions. "It occurred to me it was an historic opportunity to inform the conversation," he said.
Then I asked if he was satisfied with ABIM's ongoing efforts to meet internists concerns. "The changes announced in February are definitely a step in the right direction in helping the time burden," Kazi acknowledges. One of ABIM's reforms, allowing more of state required continuing medical education to be counted toward MOC, is helpful, he says. But the study calls for "increasing integration with existing continuing education activities."
Baron argues that the study's authors are not familiar enough with the wide range of CMEs that are now accepted toward MOCs.
Can't They All Just Get Along?
Kazi's biggest objection to the MOC requirements is that there is no hard evidence to prove that the cost in money and time actually improves the quality of patients' care. "There is plenty of evidence within healthcare to demonstrate that just doing something because you think it is effective is not good enough," he says.
Dhruv S. Kazi, MD
Of course, ABIM disagrees. Baron says that a study published last year in the Journal of the American Medical Association looked at the connection between MOC and costs and demonstrates that MOC can lead to savings.
Kazi dismisses the study's value: "In clinical medicine we seek high-quality of evidence of efficacy and safety. Policy interventions, particularly when they are expensive, should be held to the same evidentiary standards."
If sound evidence were available proving that the current MOC requirements was worth the costs, made physicians more knowledgeable, and improved patient care, Kazi says he would be satisfied and no longer object to it.
ABIM and the internal medicine community need to figure this out, and quickly. Patients don't have much sympathy for physicians complaining about lost money and time, especially when it could impact patients' health.
States are slowly enacting laws on healthcare price transparency, but consumers lack adequate access to meaningful price information in most of them, say two reform-driven nonprofit organizations.
The only state with healthcare price transparency laws in place that effectively enable consumers to find the cost of medical procedures before selecting a hospital is New Hampshire.
Meanwhile, neighboring Massachusetts, a medical mecca, plummeted from a B last year to an F. It has plenty of company at the bottom; 45 states flunked.
The only other states that passed were Colorado and Maine, which received Bs, and Vermont and Virginia, which received Cs.
The report card reviewed "whether states had passed laws or regulations requiring healthcare price information be made public and examined how well those laws were being put into action by providing residents with access to meaningful price information through public websites and the use of all-payer claims databases (APCDs) as data sources for those sites."
But despite the dismal showing, Healthcare Incentives Improvement Institute Executive Director Francois de Brantes expects better grades in the next couple of years because legislation in favor of transparency laws has been introduced in numerous states.
"It is not just wishful thinking," he says, "the states that passed new laws just need time to implement them." For example, Connecticut passed legislation in June with aggressive language seeking more healthcare price transparency.
This is the third report card released by the two nonprofits. De Brantes believes the previous cards spurred the flurry of legislation. All states should look to New Hampshire as an example of how to do it right, he says. In one the year, the state rebounded from a grade of F to an A.
"The state's new website, NH HealthCost, is now a prime example of a price transparency website built with consumers in mind," the 2015 report states. "The site accounts for both insured and uninsured patients and provides great details on the methodology in consumer-friendly terms."
Massachusetts lost its previously high rating because, "in 2014, legislation went into effect that placed the responsibility of transparency on health plans, and the government mandated website went dark."
Payers and Providers are Barriers to Transparency
The reluctance of insurance companies and hospitals and health systems to release pricing information is preventing many states from achieving full transparency, de Brantes says.
Francois de Brantes
Some bills will not pass because of "pressure from providers, payers, and other suppliers to the industry that benefit from price opacity," the report states. "That pressure often rests on spurious arguments about price as a trade secret and/or the potential for a state law on transparency to violate contracted terms between payers, providers, and suppliers."
New Hampshire did not need approval from insurance carriers or providers to develop NH HealthCost. "If so, we may not have been successful," New Hampshire health policy analyst Tyler Brannen said in an email. "The carriers and providers resisted the initiative at first. But [they] learned to embrace the tool because it allowed them to better understand their relative position in the market and relieve them from some of the responsibility to provide cost information to patients and plan members themselves."
The path toward transparency in New Hampshire was cleared by the New Hampshire Comprehensive Health Care Information System(NH CHIS), a joint project between the New Hampshire Department of Health and Human Services and the New Hampshire Insurance Department.
It was created by a state statute to make healthcare data available as a resource for insurers, employers, providers, purchasers of healthcare, and state agencies. Under a memorandum of understanding between the two state agencies, NH CHIS maintains commercial claims and eligibility data, Medicaid claims and eligibility data, NH hospital discharge data, and health plan performance data.
A Bumpy Road
Oregon may get a higher grade in 2016, depending on whether a new transparency website is built by then and how valuable the pricing information proves to be, de Brantes says. SB 900, supported by the Oregon Association of Hospitals and Health Systems(OAHHS), was passed and signed into law in July.
The law requires the Oregon Health Authority to establish a website where consumers can find the median prices paid by procedure to hospitals for 150 inpatient and outpatient procedures, says Philip Schmidt, director of public affairs for OAHHS. The information will come from the state's All Payer All Claims database, rather than the hospitals themselves.
But OSPIRG, a consumer advocacy group, thinks the site's data will have limited value for consumers because it will not reveal what individual payers have paid for specific procedures or tell consumers more precisely what a specific procedure's cost will be.
"It doesn't put any of the responsibility for revealing prices on healthcare providers," O'Brien says. "The industry itself needs to provide their pricing data."
SB 900 was crafted using recommendations from report card sponsor Catalyst for Payment Reforms, Schmidt says. "Our bill took Catalyst's reforms and put them into action." The information will give consumers an approximation of pricing so they can go back to their insurers and tell them they want to go to a hospital where a specific procedure is less expensive, he says.
In New Hampshire, payers and providers more easily accepted transparency because the website's' methodology uses bundled rates, which do not allow the website user to know everything about the underlying fee schedules or the payer-provider contract terms, says policy analyst Brannen.
Payer-provider contract terms are one of the reasons given for not wanting the costs of specific procedures listed on transparency websites, de Brantes says.
As for Oregon, both OSPIRG's O'Brien and OAHHS's Schmidt say the state's report card is likely to improve from an F once the law is fully implemented. How many grades higher is the question.
The improper use of personal protective equipment among healthcare workers is "pretty pervasive in all institutions," says a researcher.
Nine months after a Texas nurse contracted Ebola from a patient and a National Nurses United survey found that 85% of RNs reported they had not been adequately trained to protect themselves from infection, researchers find that training for healthcare workers using personal protective equipment remains lacking.
Less than half of healthcare workers observed at a large Midwestern health system correctly removed their personal protective equipment (PPE), putting themselves at risk for infection, according to a study published in the American Journal of Infection Control.
Nasia Safdar, MD, PhD
"As a result of the recent Ebola virus outbreak, the critical issue of proper PPE removal has come front and center," says Nasia Safdar, MD, PhD, associate professor of infectious diseases at the University of Wisconsin School of Medicine and Public Health and associate chief of staff for research at the William S. Middleton VA Hospital, Madison, WI.
"Healthcare facilities should use this opportunity of heightened interest to undertake practice improvement focused on PPE removal protocol, including technique, for all healthcare-associated conditions that require the donning and doffing of PPE," she says.
Although the study included only healthcare workers at the University of Wisconsin, Madison, it is likely that employees of other US healthcare facilities are also improperly removing their PPE. Safdar says she believes the practice is "pretty pervasive in all institutions."
The University of Chicago Medical Center's director of infection control agrees with Safdar, "People are contaminating themselves probably 50% of the time," says Sylvia Garcia-Houchins, RN, CIC.
"These breaches of PPE removal protocol may be due to a lack of awareness of the proper procedure, time constraints, or lack of realization of the importance of proper PPE removal," Safdar says.
Much of the problem stems from nurses, physicians, and other healthcare workers not being properly trained and then tested during their professional education, Garcia-Houchins says. "People modify the process for whatever works for them. Nobody is telling them this is the way it should be done." Orientation for new employees at the University of Chicago now includes training and testing for the proper donning and removal of PPE, adds Garcia-Houchins. "We are doing something about it."
Methodology The University of Wisconsin study was done by direct observation of healthcare workers using the Centers for Disease Control and Prevention's guidelines for PPE removal for contact isolation.
CDC recommendations state that state the healthcare workers should remove contaminated gloves first followed by gentle removal of the gown from the back of the neck while in the isolation patient's room.
The observers noted if healthcare workers took the following actions:
Removed gowns first
Removed gloves first
Removed gowns in a manner that was not gentle
Removed gloves in a manner that was not gentle
Properly disposed of PPE in the patient room
Disposed of PPE in the hallway
Removed PPE in the correct order
Removed PPE in the correct order
Wore PPE in hall
Removed PPE in the correct order but did so with flourish
Removed PPE in the correct order and did so without flourish
Removed PPE in the correct order and disposed of it in the patient room
The scoring was done by calculating what percentage of healthcare workers performed the 12 actions above.
"We found that the majority of HCWs did not remove PPE in the correct order. Further, many of those who did remove the PPE in the correct order failed to properly dispose of their contaminated PPE in the isolated patient's room. Deviations from protocol were common," the authors wrote.
The poor compliance reveals that further education and collaboration with hospital and healthcare leaders to improve compliance is needed, Safdar said.
In response, the University of Wisconsin, Madison, has started reeducating its healthcare workers about how to properly remove PPE and its importance. It is using teaching methods already in place at the hospital, including grand rounds discussions, infection control liaisons for each unit, and interactive education programs. The frequency of the training was increased and all staff members are required to attend.
With the introduction of Ebola patients in the US, the University of Chicago began retraining staff on proper use of PPE, Garcia-Houchins says. "We practiced using powder and other substances to simulate the virus to show how correct removal of PPE protects against self-contamination."
The ED staff went through three sets of training and had to prove they were competent in PPE removal, she said.
Before the arrival of Ebola patients in the U.S. last year, the chance of contamination through PPE removal for contact isolation was considered slim. Healthcare workers could not see the direct consequences of incorrectly removing gloves and gowns, Nafdar says.
The consequences became clear last fall when a Texas nurse contracted the disease while caring for the first patient to be diagnosed and treated for Ebola in the US, even though she was wearing the CDC recommended PPE.
ProPublica's rating system for surgeons is under fire for using data from Medicare claims rather than quality-based, clinical outcomes. But despite those flaws, it's a step forward on the march to physician transparency.
I recently needed minor surgery on my arm, and I wanted a surgeon with some OR street cred. So I asked an MRI technician at the hospital where I would be having the surgery who she would recommend.
"I'm not supposed to tell you," she said. But she scribbled a name on a scrap of paper and handed it to me, as though it were a code to a nuclear detonator.
There's got to be a better way to vet surgeons. The not-for-profit public interest group ProPublica thinks it has one.
It's the Surgeon Scorecard, a searchable database of surgeons rated by mortality and complication rates. It's a tool for helping consumers select surgeons based on Medicare claims data associated with eight common elective surgeries.
But since its release last week, the scorecard has been kicking up a nuclear dust storm in the hallowed halls of many surgical departments and online.
Jeffrey B. Matthews, MD, professor of surgery and chair, department of surgery, at the University of Chicago, believes the scorecard's information is meaningless for both consumers and surgeons.
"It is a big stretch if you are using that scorecard's data to choose a surgeon," he says. A look at the measure of Chicago's surgeons who perform gallbladder surgery is extremely inaccurate based on the scorecard, he emphasized. "The confidence intervals are so wide that an apparently medium-risk surgeon might in fact be high-risk or low-risk, and then you are trying to compare that to, say an apparently low-risk surgeon with just-as-wide confidence levels."
Ashish Jha, MD, professor of International Health, director of the Harvard Global Health Institute in the Department of Health Policy and Management, advised ProPublica as it researched, collected, and analyzed the data. Other healthcare experts also guided them along the way.
Jeffrey B. Matthews, MD
He acknowledges that the scorecard has flaws, but says there is nothing better available and it's long past time for the healthcare system itself to develop a better tool for consumers.
Methodology ProPublica used Medicare billing records on death and complication rates of surgeons who did knee replacements, hip replacements, three types of spinal fusions, gall bladder removals, prostate removals, and prostate resections.
The most often cited criticisms of the scorecard from surgeons I talked with is that Medicare data is based on administrative needs and delivered under the fee-for-service model, rather than on quality-based, clinical outcomes. The number of procedures per surgeon is also too small, they told me.
The data doesn't convey a good indication of a surgeon's ability, says John Birkmeyer, MD, executive vice president, Integrated Delivery System and chief academic officer, Dartmouth-Hitchcock Medical Center. "But I also believe that almost any data is better than no data at all."
John Birkmeyer, MD
"There are probably two or three major challenges with the scorecard's data," he says. "It is based on fee-for-service claims and on incredibly small numbers. Also, the types of procedures included account for only a minority of procedures a surgeon does."
Surgery is complicated and has many variables that determine the outcome, Matthews says. "It's very hard to boil surgeon quality down to a single number. It is especially difficult to do this from billing records."
"ProPublica tried to deal with risk adjustment for sicker patients; they should be given credit for that," Jha says. "They used the best methodology available. Is it perfect? No."
The rub is that the clinical data that's needed to achieve higher accuracy is only available from hospitals and healthcare systems. Despite calls for transparency, nobody in the healthcare system has shared it publicly in a useful way to consumers, says Jha.
Although he empathizes with surgeons' arguments against the scorecard, Jha says his response to them is, "'What are you doing about it? Do you have a better idea now?' Until I get a clear explanation, I'll defend the scorecard."
Toward Better Data Accuracy
The American College of Surgeons is collecting data and working toward more clinically relevant outcomes for analysis," says David Hoyt, MD, FACS, executive director of the American College of Surgeons. "But it takes time and effort to extract the data that is most useful."
Charles Mick, MD
"I personally think the professional societies have an obligation to generate standards of practice for their specialties and measurements for the standards, and then make some or all of the information publicly available, says Guy Clifton, MD, a former neurosurgeon and now CEO of Rockford, IL-basedActin Care Groups, whichcoordinates care for employees of self-insured employers.
Most surgeons I interviewed told me that despite its flaws, they believe the ProPublica scorecard is a good place to start when talking about the transparency of physician quality. "But it should be only one piece of information used when making the decision, says Charles Mick, MD, an orthopedic surgeon and former president of the North American Spine Society.
Narrower networks of providers and increased premiums could erode quality. Or patient outcomes could improve if insurers are as interested in quality care as they are in market share. It's complicated.
The words "choice," "networks," and "access" are mentioned most often in conversations about healthcare quality and insurance industry consolidation. Whether market consolidation will widen access and networks, reduce choices of providers, or make consumers pay more for them; depends on who you talk to.
Robert J. Town, PhD
Even the experts admit no one knows how the healthcare industry will shake out once the ongoing consolidation of health insurance companies, as well as the merging of hospital systems and larger physician groups, is finished.
"It could be a good thing, depending on how insurers structure their networks," Robert J. Town, PhD, a professor in the Health Care Management Department in the Wharton School at the University of Pennsylvania told me.
If they choose, insurers could narrow their networks of hospitals and physicians by focusing on measures of quality that consumers may not be as adept at observing or judging, he says. If insurers are smart buyers of quality health services, consumers will benefit. That's the best case scenario, he adds.
Quality of care could suffer, though, if insurers craft narrower networks just to gain greater bargaining power with physicians and hospitals, unrelated to quality, Town says. This would leave consumers fewer choices, but not necessarily better quality.
Peter Pronovost, MD, PhD, FCCMD, director of the Armstrong Institute for Patient Safety and Quality, senior vice president for patient safety and quality at Johns Hopkins Medicine, agrees the consolidation could help drive quality improvement through narrower networks that select higher quality providers.
He told me that a smaller pool of insurance companies could also lead to better quality if insurers are willing to agree on quality of care measures and the administrative forms required of providers.
"Every insurer has its own dashboard of quality and safety measurement data that they use to evaluate services," he says. "Some of them are quite similar in concept but their definitions vary. Hospital systems have already been encouraging insurers to agree on valid measures that are more standardized," he adds.
Insurers also have different administrative processes and forms to submit claims for payment, Pronovost says. The more variation, the more waste. Standardization could help here as well.
"We need to hire extra staff to cut the data for how each insurer wants it done," Pronovost says. "If we could reduce redundancy in the types of measures (and forms) required we would be able to focus more of our resources on improving performance rather than spending money on just collecting and reporting he data."
Peter Pronovost, MD, PhD
Aetna boasts that its merger with Humana will create higher quality care for its consumers at less cost. The merger, says an Aetna press release, "builds on each company's respective efforts to provide innovative, technology-driven products, services, and solutions to build healthier populations, promote higher quality health care at lower cost, and offer greater transparency and convenience for consumers."
Providers who will be negotiating with these mega-sized companies for payment doubt the mergers will improve quality, however. They believe consolidation leads to narrower provider networks and fewer choices for quality care.
Like schoolyard bullies, larger companies will have more strength in the marketplace when contracting for services with providers, Robert L. Wergin, MD, FAAFP, president of the American Academy of Family Physicians told me this week. Small hospitals and physician groups will especially feel the pain from having less bargaining power for reimbursement, he adds.
But Pronovost counters that large, academic medical centers may be the ones excluded from networks because of their higher costs for research, treatment of more complicated cases, and the training of future physicians.
Robert L. Wergin, MD
Organizations React
AAFP sent a letter to the chairman of the Federal Trade Commission, saying: "Proponents of mergers in the (health insurance) industry will proclaim that consolidation will make the industry more efficient and, therefore, more affordable for individual consumers. However, in our opinion, mergers in the health insurance industry would have an immediate and profound impact on the availability and affordability of health insurance for millions of consumers."
The American Medical Association concurs. "The dominant market power of big health insurers increases the risk of anti-competitive behavior that harms patients as health insurers substitute corporate policy over good clinical decisions," AMA President Steven J. Stack. M.D, said in a short statement released after news of the merger last week.
But assuming that insurers are only interested in profits and not quality is off base, Wharton's Town says: "They are interested in both.
