Skip to content
  • About
  • Contact
  • Contribute
  • Book
  • Careers
  • Podcast
  • Recommended
  • Speaking
  • All
  • Physician
  • Practice
  • Policy
  • Finance
  • Conditions
  • .edu
  • Patient
  • Meds
  • Tech
  • Social
  • Video
    • All
    • Physician
    • Practice
    • Policy
    • Finance
    • Conditions
    • .edu
    • Patient
    • Meds
    • Tech
    • Social
    • Video
    • About
    • Contact
    • Contribute
    • Book
    • Careers
    • Podcast
    • Recommended
    • Speaking

Value and quality are fuzzy concepts. Here’s why.

Robert Centor, MD
Policy
May 14, 2015
Share
Tweet
Share

Now that we no longer have to worry about the SGR, we have a new worry. The law consolidates several measurement tools into one big tool. CMS has declared that it wants to pay for value. The law provides a blueprint for paying for value. The underlying assumption of this approach is that we can define and measure value through measuring quality components.

Can we define health care value through measurement? Can we balance patient-centered care with performance measurement?

Readers of this blog know that I have frequently written about the pitfalls of performance measurement and why we should not call a conglomeration of those measures quality. As I type so often, quality is a multidimensional structure that differs for each patient. Should we treat type II diabetes the same in a newly diagnosed, otherwise healthy patient as we treat a patient with 20 years of diabetes who is now 85-years-old and has major co-morbidities?

When should we give empiric antibiotics to a patient with dyspnea and cough? Should we assume community acquired pneumonia for any infiltrate, despite lack of fever or productive cough? If we were measuring the sensitivity of rapid treatment of pneumonia, then we would treat more often accepting a lower specificity.

But what if we “cover” the patient with antibiotics for possible pneumonia and the patient develops a C. diff infection? Which performance measure should we use — treating possible pneumonia early to decrease complications and shorten length of stay or avoiding C. diff diarrhea?

What do we measure in our geriatric patients with six diseases, all of which have associated performance measures? And will we have a performance measure for avoiding drug-drug interactions or avoiding drug side effects?

How will we measure bedside manner or helping the patient understand what we are doing or shared decision-making? How will we measure prioritizing the patient’s most acute problem and addressing less dangerous problems until another time?

How will we measure making the proper diagnosis? Will we receive positive points for treating the wrong diagnosis perfectly?

How will we measure working with patients to start palliative care early enough to positively impact their quality of both living and dying?

Most important, should we not hold any performance measure to the same standard that we use to test new drugs? We should require a study showing that introducing a performance measure leads to better patient outcomes. This concept sets a high bar. If we treat one disease well does the patient benefit? Does focusing on one aspect of quality decrease our focus on other issues? Do we get distracted from really listening to the patient because our EHR tells us that we must focus on four performance measures relevant to the patient’s problem list?

When in doubt we often return to our hero Sir William Osler:

The good physician treats the disease; the great physician treats the patient who has the disease.

Could our quest for value actually harm some patients? Medicine is complex. Trying to measure a multidimensional concept like quality if fraught with hazards. Osler again:

ADVERTISEMENT

Variability is the law of life, and as no two faces are the same, so no two bodies are alike, and no two individuals react alike and behave alike under the abnormal conditions which we know as disease.

Some measures are golden, but mostly those that we have tested. We have a responsibility as a profession to challenge this concept without seeing clear evidence that patients benefit from labeling some measures as value. Value and quality are fuzzy concepts. How can one oppose using value and quality? No one opposes the concept, but we all should demand that the implementation of measures does improve patient outcomes. We should all worry.

Robert Centor is an internal medicine physician who blogs at DB’s Medical Rants.

Prev

The time I realized I kicked cancer's ass

May 14, 2015 Kevin 1
…
Next

She took Zofran and her son had a heart defect. Here's why she's not suing.

May 15, 2015 Kevin 1
…

Tagged as: Primary Care

Post navigation

< Previous Post
The time I realized I kicked cancer's ass
Next Post >
She took Zofran and her son had a heart defect. Here's why she's not suing.

ADVERTISEMENT

More by Robert Centor, MD

  • When the problem representation and the illness script do not match

    Robert Centor, MD
  • Think of diagnostic excellence as playing smooth jazz

    Robert Centor, MD
  • When constipation pain was worse than cancer pain

    Robert Centor, MD

More in Policy

  • The CDC’s restructuring: Where is the voice of health care in the room?

    Tarek Khrisat, MD
  • Choosing between care and country: a dual citizen’s Independence Day reflection

    Kathleen Muldoon, PhD
  • How fragmented records and poor tracking degrade patient outcomes

    Michael R. McGuire
  • U.S. health care leadership must prepare for policy-driven change

    Lee Scheinbart, MD
  • How locum tenens work helps physicians and APPs reclaim control

    Brian Sutter
  • Why Medicaid cuts should alarm every doctor

    Ilan Shapiro, MD
  • Most Popular

  • Past Week

    • Why are medical students turning away from primary care? [PODCAST]

      The Podcast by KevinMD | Podcast
    • Why “do no harm” might be harming modern medicine

      Sabooh S. Mubbashar, MD | Physician
    • Here’s what providers really need in a modern EHR

      Laura Kohlhagen, MD, MBA | Tech
    • How New Mexico became a malpractice lawsuit hotspot

      Patrick Hudson, MD | Physician
    • How community paramedicine impacts Indigenous elders

      Noah Weinberg | Conditions
    • Why doctors are reclaiming control from burnout culture

      Maureen Gibbons, MD | Physician
  • Past 6 Months

    • Why tracking cognitive load could save doctors and patients

      Hiba Fatima Hamid | Education
    • Why are medical students turning away from primary care? [PODCAST]

      The Podcast by KevinMD | Podcast
    • What the world must learn from the life and death of Hind Rajab

      Saba Qaiser, RN | Conditions
    • Why “do no harm” might be harming modern medicine

      Sabooh S. Mubbashar, MD | Physician
    • Here’s what providers really need in a modern EHR

      Laura Kohlhagen, MD, MBA | Tech
    • How medical culture hides burnout in plain sight

      Marco Benítez | Conditions
  • Recent Posts

    • The CDC’s restructuring: Where is the voice of health care in the room?

      Tarek Khrisat, MD | Policy
    • Choosing between care and country: a dual citizen’s Independence Day reflection

      Kathleen Muldoon, PhD | Policy
    • What Elon Musk and Diddy reveal about the price of power

      Osmund Agbo, MD | Conditions
    • 3 tips for using AI medical scribes to save time charting

      Erica Dorn, FNP | Tech
    • Why working in Hawai’i health care isn’t all paradise

      Clayton Foster, MD | Physician
    • A physician’s reflection on love, loss, and finding meaning in grief [PODCAST]

      The Podcast by KevinMD | Podcast

Subscribe to KevinMD and never miss a story!

Get free updates delivered free to your inbox.


Find jobs at
Careers by KevinMD.com

Search thousands of physician, PA, NP, and CRNA jobs now.

Learn more

View 20 Comments >

Founded in 2004 by Kevin Pho, MD, KevinMD.com is the web’s leading platform where physicians, advanced practitioners, nurses, medical students, and patients share their insight and tell their stories.

Social

  • Like on Facebook
  • Follow on Twitter
  • Connect on Linkedin
  • Subscribe on Youtube
  • Instagram

ADVERTISEMENT

  • Most Popular

  • Past Week

    • Why are medical students turning away from primary care? [PODCAST]

      The Podcast by KevinMD | Podcast
    • Why “do no harm” might be harming modern medicine

      Sabooh S. Mubbashar, MD | Physician
    • Here’s what providers really need in a modern EHR

      Laura Kohlhagen, MD, MBA | Tech
    • How New Mexico became a malpractice lawsuit hotspot

      Patrick Hudson, MD | Physician
    • How community paramedicine impacts Indigenous elders

      Noah Weinberg | Conditions
    • Why doctors are reclaiming control from burnout culture

      Maureen Gibbons, MD | Physician
  • Past 6 Months

    • Why tracking cognitive load could save doctors and patients

      Hiba Fatima Hamid | Education
    • Why are medical students turning away from primary care? [PODCAST]

      The Podcast by KevinMD | Podcast
    • What the world must learn from the life and death of Hind Rajab

      Saba Qaiser, RN | Conditions
    • Why “do no harm” might be harming modern medicine

      Sabooh S. Mubbashar, MD | Physician
    • Here’s what providers really need in a modern EHR

      Laura Kohlhagen, MD, MBA | Tech
    • How medical culture hides burnout in plain sight

      Marco Benítez | Conditions
  • Recent Posts

    • The CDC’s restructuring: Where is the voice of health care in the room?

      Tarek Khrisat, MD | Policy
    • Choosing between care and country: a dual citizen’s Independence Day reflection

      Kathleen Muldoon, PhD | Policy
    • What Elon Musk and Diddy reveal about the price of power

      Osmund Agbo, MD | Conditions
    • 3 tips for using AI medical scribes to save time charting

      Erica Dorn, FNP | Tech
    • Why working in Hawai’i health care isn’t all paradise

      Clayton Foster, MD | Physician
    • A physician’s reflection on love, loss, and finding meaning in grief [PODCAST]

      The Podcast by KevinMD | Podcast

MedPage Today Professional

An Everyday Health Property Medpage Today
  • Terms of Use | Disclaimer
  • Privacy Policy
  • DMCA Policy
All Content © KevinMD, LLC
Site by Outthink Group

Value and quality are fuzzy concepts. Here’s why.
20 comments

Comments are moderated before they are published. Please read the comment policy.

Loading Comments...