Maggie Mahar at Healthbeat has a very informative and provocative new post on the complexities of evaluating “quality” in health care vis-a-vis reimbursement.
Here’s the rub. Understandably, new health reform and Medicare approaches to rewarding quality seek to factor in a recognition that doctors treating sicker patients cannot be expected to achieve outcomes equal to doctors treating healthier patients. But how do we accurately assess which patients are sicker? If this is determined by comparing the severity of diagnoses, or the presence of multiple diagnoses, then doctors who “overdiagnose” will be rewarded for their aggressive (and more expensive) testing and diagnosis. And it just so happens that doctors in certain areas (Miami, for one) are well known for more aggressive diagnosis.
The answer to this conundrum? Unfortunately, that’s not entirely clear. But including actual, measurable benefits to patients seems to be an important piece of the puzzle.
All in all, rewarding quality of care appears to be a complex issue that lies right at the heart of meaningful health reform.
A startling study published in the New England Journal of Medicine reveals that just as doctors in some towns are more aggressive in treating their patients, physicians in some places are more likely to send patients for tests, and to subspecialists. As a result, their patients are diagnosed with more diseases. Thus, if a Medicare patient who was living in Phoenix (and feeling perfectly healthy), moves to Miami, he may suddenly discover that he suffers from two or three chronic conditions.
This creates a problem, not only for the patient (am I really sicker?), but for health care reformers who hope to pay hospitals and doctors more for higher quality care. To do that they have to adjust for risk: Providers caring for sicker patients should still be eligible for bonuses, even if their outcomes aren’t as stellar as the results achieved by hospitals that treat more robust patients. But if the majority of Medicare patients in Miami have been diagnosed with one disease or another, does that mean that Medicare should pay Miami’s hospitals more than hospitals in Phoenix because their patients appear more vulnerable– at least on paper? The researchers conclude: “risk-adjustment is going to be tougher than we thought.”
This issue is going to be with us for a good while.
