EDITORIAL

What Is Quality in Medical Care?

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ith the passage of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), the bill repealing the Sustainable Growth Rate (SGR, which threatened physicians with draconian reductions in already pitiful Medicare payments), many physicians are now heaving a sigh of relief. That may be a bit premature. For one thing, MACRA gives physicians a 0.5% increase in payments each year through 2019, then no increase through 2025. Even with inflation rates of 2 to 3% for the next decade (assuming that they remain that low), this would result in a reduction in the actual value of Medicare payments to doctors by >25% compared to their 2014 levels. This cut is greater than the 21% sudden reduction that the SGR threatened, but it would take place slowly, over 10 years rather than all at once. The saving grace in this bill is supposed to be a meritbased incentive payment system (MIPS), which would allow physicians to earn 5% more than the basic Medicare payment rate for meeting certain “quality” goals. These MIPS payments would supersede the current Medicare incentive payment systems. For physicians participating in the MIPS, there would also be downside risk (ie, poor performance could result in Medicare rates lower than the baseline levels). As always, the devil will be in the details, and the details in this case will be how we determine what is “quality” in medicine. In the new law, the Secretary of Health and Human Services is charged with deciding on a means for assessing the performance of each provider. But are there reasonable measures that could be applied, for example, to neurologists? When a friend or colleague asks me for a referral to a neurologist, I always try to steer them to the person who I think can provide the best quality care. Everyone knows the 3 A’s of being a successful medical practitioner: ability, affability, and availability. As the chief of a neurology service, I see lots of neurologists in practice and the long-term results of their work. I judge ability based upon accuracy of diagnosis, efficiency of workup, and outcomes of therapy. Affability is also important, especially as it affects the outcome of the care. A dour doctor, whose patients do not follow up, get the testing that is recommended, or take the appropriate therapies because they lack confidence in the doctor, is not very effective. Conversely, many patients overvalue a doctor who is a nice person, but perhaps not the most accurate or efficient clinician. Of course, I try to avoid both

extremes, and only recommend highly able doctors who have what I consider good bedside manner that instills confidence in the patient. I also avoid recommending a practitioner who has no appointments available for the next 6 months. A brilliant doctor, who is a wonderful person, but cannot see the patient for the better part of a year, or who does not set aside adequate time for return visits to follow through on the treatment plan, is not much help. Doctors within a field generally know these things about their colleagues, with whom they share and interchange patients, but outsiders rarely do. That is why friends and colleagues come to us and ask for referrals. Conversely, each of these 3 A’s is difficult to measure. So, when we have to come up with measures of quality for neurological care, what will we use as metrics? This problem poses a real danger; in lieu of measuring what is really important (is this someone a knowledgeable practitioner in the same field would send a friend or family member to), we may end up with a plan that measures things that are easy to measure, but largely irrelevant. We would not have to look far to find such schemes. Most of the Accountable Care plans that my physician group contracts with have such measures. The measures tend to be related to simple things (was a HbA1c ordered on a diabetic; was a patient with cholesterol above a certain threshold prescribed a statin). But it would be very hard to capture what a neurologist does using such measures. When I was a medical intern I would see 5 patients in an afternoon in primary care clinic; 3 would have diabetes, 3 would have high blood pressure, 3 would have congestive heart failure, and 3 would have high cholesterol. Fortunately for them, it was not the same 3 people with all of these disorders, but the point is that the disorders occurred commonly. One could make an attempt to measure the quality of primary care by taking simple measures of things that occur commonly. Neurology is not like that. Despite neurologists seeing about 5% of the volume of an internal medicine service, we have 10 different subspecialties within neurology. Many of those subspecialties contain a wide range of problems and diagnoses. It might be possible to come up with measures of quality for neurologists who see Parkinson patients, or stroke patients, or patients with peripheral neuropathy. But none of these relatively common neurological disorders represent more than about 5 to 10% of neurological patients. It is nothing like a primary

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care clinic, where more than half of the patients seen on a typical afternoon may have 1 or more of the 2 or 3 most common diagnoses. More importantly, asking neurologists who see certain types of patients to perform specific tests or document particular findings would really not be a measure of quality of care. Once the measures become known, hitting them would become a rote exercise. Asking about sleep disorders in all Parkinson patients? Sure, I can do that. Getting a HbA1c on all new patients with peripheral neuropathy? A breeze. Order a statin on all new stroke patients? No problem. But then, by concentrating on these things that are being measured, do we shortchange the other things that should be done, but which are not being measured? Do we force clinicians down rote diagnostic and treatment pathways that make us lose sight of why we are there in the first place? Do we miss the fact that the “Parkinson” patient really has progressive supranuclear palsy? That the “stroke” was really due to intravascular lymphoma, not atherosclerosis? That the “peripheral neuropathy” is paraneoplastic rather than diabetic? There is danger in medicine in focusing too much on the disease that the patient has, rather than the patient who has the disease. Will rote measures take us even further down that path? Who measures the downside of fossilizing clinical thinking into a set of rote hoops to be jumped through, whether they fit the patient or not? I would argue, strongly, that the Secretary of Health and Human Services is not the right person to attempt this task. This should not be done by political appointees

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or by faceless bureaucrats. Rather, the Centers for Medicare and Medicaid Services should be asking the leaders of American medicine, in our case the leaders of our major professional organizations, the American Academy of Neurology, the American Neurological Association, and the Child Neurology Society, to come up with measures that actually fit the way neurologists work, and (we hope) actually have something to do with real quality of care. We, the neurologists who will be governed by these rules for the next decade, should be meeting now to come up with ways to provide true measures of quality that rise above the current generation of mindless and senseless pseudomeasures. If we fail in this task, or delay in taking it up, we will certainly have to live with the disastrous consequences, as will our patients.

Potential Conflicts of Interest Nothing to report.

Clifford B. Saper, MD, PhD Department of Neurology Beth Israel Deaconess Medical Center Harvard Medical School Boston, MA

DOI: 10.1002/ana.24435

Volume 77, No. 6

What is quality in medical care?

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