Monday, May 22, 2006

According to ACP, Quality initiatives takes time and money and (so far) no reimbursement

The ACP observer-an American College of Physician's monthly newspaper format publication- has a section called "Measuring Performance"

The May 2,2006 presents the reader with anecdotal material about several internists' efforts to "close [various] quality gaps".

One internist is said to have spent an estimated $15,000 to increase the number of her diabetic patients getting the recommended annual ophthalmologist eye exam. They finally "solved" the problem (at the beginning only 35% of her patients received the exam annually) by having her office call the eye doc's office and make appointments for all 2,000 of her diabetic patients. At 15 k per project you have to wonder how much quality this physician can afford while waiting for the P4W repayment for her efforts down the road.

Other physicians' efforts are described in the article including the experience of one physician whose practice not only had to foot the increased overhead bill(s) of quality project(s) but two physicians left the practice because they were unwilling to accept the higher costs of running the practice.

The quality issues described in this article and the ones often discussed seem to be those related to patient compliance,for example, patients taking their aspirin everyday, patients getting their colon cancer screening, etc. I have a problem accepting the concept that there is a quality problem with physician's care in the circumstance wherein the patient -for whatever reason-does not comply with the advice. How far does one have to go to maximize compliance? Is there at some point a tension with the concept of patient autonomy and respect for patient's decisions? Do patients have to be monitored like children to be sure they are taking their vitamins ? Are we moving towards a version of extreme "paternalism", with a new twist -the twist being -"not only do we know what is best for you we going to check up on you to make sure you do it?

The article says "Until reimbursement becomes a reality,quality improvement efforts can cost more that they can yield financially" As CMS and third party payers continue to decrease reimbursements,ACP's solution,in part, seems to be to encourage internists to spend money on quality projects that may be reimbursed someday and for which we still await evidence that it all will really improve patient care.

The "lets narrow the quality gaps" movements is part of the ACP's scheme to salvage internal medicine. Their own publication's article about the grass root efforts along those lines is more likely to discourage than energize private doctors to join the effort. Bottom line losses have to impact decisions. On a more fundamental level, I believe labeling these simplistic projects based on some organization's arbitrary "quality target" as improving quality is flawed. The author quotes a IM residency quality project involving encouraging diabetic patients to have an annual foot exam involving in part having "a colorful brochure in the waiting room with tips of what to ask the doctor".

I cannot help but remember when being an internist was more about having the skills and dedication to take care of patients with complex (and simple) medical problems than having colorful brochures in the office exhorting patients to do the preventive medicine measure of the day.

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