Long Live Quality

tired doctorOver the last several years there has been increasing emphasis on “quality” in the field of medicine.  On the surface this sounds good.  After all, who wants poor quality healthcare?   The problem is that the excuse of increasing quality is being used for ever increasing central planning in the area of healthcare.  A long list of countries have tried, central planning in the area of politics and economics.  In every case, they have shown the utopian theories of central planning results not in improved quality, but rather a decline in quality.  It concentrates all power in the hands of a few, very fallible human beings.    Progress stagnates.  It exterminates individuality, free choice and innovation.   (As an aside, even a holy, perfect God did not choose to institute central planning.  He knows man is going to make harmful choices, but still gives man free choice.)

The consequences of central planning are now happening in health care.  Medical facilities are coalescing into ever larger organizations.  Rather than lowering costs, as was promised, it is raising the price of healthcare.  Healthcare is being depersonalized.    Large healthcare mega companies are eliminating options for students, patients and those employed in the health care field.

Medical care is being dictated by one size fits all protocols, rather than the best judgment of the patient and their physician.  The last couple decades emphasis on patient rights and patient centered ethics is being thrown out the window in favor of a single model of health care for the entire population.

This is starkly illustrated by what is currently going on in hospitals with regards to vaccines.  The central planners at the CDC  have decided that a woman should get a TdaP (Tetanus, Diphtheria,  acellular Pertussis) shot every pregnancy.  This is the result of an acknowledgment that the pertussis component of the TdaP is not as effective as we wish.  It has been decided that the solution to this is to give the TdaP more often.  Thus, pregnant women can potentially get multiple TdaPs in a very short period of time.  There have been no studies to show this strategy is effective and causes no harm, but it has been declared as the correct thing to do by those with no responsibility.

Next enters the money.  The real objective for “paying for quality” is not increasing quality, but rather for the payers to pay less for the healthcare delivered to the patients.   In the effort to spend less on healthcare we are moving to pay for “quality” instead of the amount of work done.  One of the items that has been determined to be a part of quality is immunization rates.   The rate of giving new moms a TdaP is being measured.  If the required percentage of women are not given a TdaP, then the reimbursement to the hospital is reduced (the goal of the payers).  The hospital cannot tolerate a reduction in cash flow, so now they are threatening the nurses, if immunization rates are not adequate.  The nurses are being told their salaries will be reduced if immunization rates do not meet the benchmark.  They are made to feel guilty, saying it is their fault their coworkers are paid less because they are not pushing moms to get their TdaP.  It has gotten so bad that moms are no longer being offered a TdaP, but rather the injection is brought in and the mom is told this is a medicine your doctor has ordered for you to get (a falsehood, as it is an automatic order, created by the hospital hierarchy).  They do not even tell them what the injection contains, unless asked.

This is one of the reasons the vast majority of pediatric practices refuse to provide medical care to children who are not following the CDC vaccine schedule.  Their vaccination rates are being audited and their reimbursements reduced if they have too low a vaccine rate.

All patients (and that is all of us) are being pushed to comply with the definition of quality as determined by “expert” organizations.  Those organizations are unaccountable to the patient or even the doctor.  They are not only fallible human organizations, but are also influenced by other factors than just what is the best medical care for the population, much less individuals.

Defining quality is very difficult.  We have this concept that every issue in medicine has a single correct solution.  In reality, we are all different biologically and psychologically.  Therefore what a study indicates is the best solution for a majority of people, does not tell you what the result will be when applied to any given individual.  We need to be able to customize.

We have to remember that science changes constantly.  (Be skeptical of any politician or other leader who defines right and wrong by what “scientists say”). What is defined as the best medical treatment today, may well change in a few years.  However, if “quality” protocols lock us into a given treatment, we will be extremely slow to improve our care.

“Quality” today is defined by things that can be easily counted.  It totally ignores softer, but even more important factors such as  accuracy of diagnosis; your doctor listening to you; ease of access to your doctor; what it costs you to get the care you need; your concerns being taken seriously.

“Quality” is currently defined by process, rather than outcome.  In fact, in today’s world, one can have a good outcome, happy patients, lower cost care provided, but if the doctor did not follow the externally defined protocol  he/she can be in big trouble.  On the other hand, one can have a misdiagnosis, large sums of money spent, unhappy patients, poor outcome and even death; as long as the protocol has been followed, the medical hierarchy says quality health care has been delivered.

We all want to receive high quality health care, but  “quality” is not as easily defined as it sounds.  “Quality” can also be misused to manipulate, stifle innovation and hurt individuals.  We need to be careful about jumping on the “quality” bandwagon.