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Thu Jun 12, 2014, 09:13 PM

Health "Metrics": A New Way to Discriminate Against the Sick and Poor

Imagine two clinics, Clinic A and Clinic B. They are located in the same city. They are part of the same charitable public clinic system. They serve the same low income, uninsured patients. And, they both have to "prove" that they are delivering quality patient care. How do you prove an intangible? Right now, it is all about "metrics." How many of your female patients over 40 have had their annual mammogram? How many patients over 50 have had a colonoscopy. Are people getting their flu vaccines? How many people who fill out surveys rate their doctor as "excellent"? How long do patients have to wait for an appointment? How many diabetics have had an eye exam? Have an a1c under 8?

These "metrics" are important numbers. They determine raises. Bonuses. Who gets promoted. Who gets to take control of large piles of public cash which go to fund health care for the indigent. With so much as stake, you can't blame a savvy clinic director or manager for trying to find shortcuts. It is hard to get a homeless patient who does not speak English to get a mammogram. It is easy to get a low income English speaking computer literate health conscience graduate student to get her health screens done. It is easy to control the diabetes in someone with mild diabetes. It is difficult to keep that A1c under 8---another metric---if the diabetic is blind, has no feet, has no money, and is on insulin he can not afford.

So, what do you do, if you are Clinic B and if you want to prove that you are the clinic that deserves the funding? Do you try harder? Can you really hope to get that blind, double amputee diabetic's a1c down below 8? No. No matter how hard you try, you know that you can't do it. So, you do something much easier. You send the blind, double amputee brittle diabetic to clinic A, your rival. You hold on to as many healthy, borderline poor, compliant, health conscious, normal weight, English speaking literate patients as you can attract, and you find some pretense to send the undesirables away. They were "noncompliant." They missed too many appointments---it is sort of hard for a blind, double amputee to get to the clinic sometimes. You tell a patient "No, you can't have any valium for your nocturnal spasms for your multiple sclerosis but there is a doctor as clinic A who will write that prescription." You say "No, I can't prescribe pain pills for your mother's cancer, but the doctors at clinic A can." You schedule them with doctors at clinic A.

What do you do if you are clinic A and you happen to believe that your charitable clinic system is here to serve the poor and the disabled? Do you send back the sick, illiterate, noncompliant, pain wracked patients that clinic B keeps dumping on you? Or, do you gather them into the fold of your already bursting at the seams practice and try to give them the care they need, too, even though your facility's resources are already stretched to the maximum? Even if it means that your doctors are now seeing too many patients each day, and the patients are mad because they have to wait for appointments, so they write angry evaluations. It's ok. You can put up with the abuse. You have to. Someone has to do the right thing.

Say Clinic A "does the right thing" because Clinic B won't? What happens to Clinic A's "metrics"? That's right. They go into the toilet. What happens to Clinic B's metrics? That's right. They shine. And what happens the next time all the clinics in the system are evaluated? Clinic B is held up as a model of efficiency and quality care, while clinic A is warned sternly that it must try harder. Clinic B's director gets a promotion. Clinic B gets more money. Clinic A eventually gets shut down.

There is no link. This is a 100% real story. I am the eyewitness. I won't tell you in what major metropolitan area it is happening. It is very likely happening in the city where you live. And in the VA where your dad goes. This is what happens when you use something as easily manipulated as a "metric" to determine quality of care.

And it gets worse. Lots of private insurers use them. They know that doctors who are attempting to improve their own "metrics" will quickly realize that the easiest way to do it is to dump all the sick and poor patients. You don't think that doctors in private practice would do something like that? You don't think they could live with themselves if they sent away the sick and the poor in order to increase their own profits? If those who are charged with taking care of the sick and the poor---employees of our public health clinics will resort to such tactics in order to increase their power within a public health system, then anyone will.

Something to think about the next time you are guilty of going to see a doctor while "medically complicated."

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Arrow 6 replies Author Time Post
Reply Health "Metrics": A New Way to Discriminate Against the Sick and Poor (Original post)
McCamy Taylor Jun 2014 OP
Mnemosyne Jun 2014 #1
Hoyt Jun 2014 #2
McCamy Taylor Jun 2014 #3
Hoyt Jun 2014 #4
Half-Century Man Jun 2014 #5
JDPriestly Jun 2014 #6

Response to McCamy Taylor (Original post)

Thu Jun 12, 2014, 09:38 PM

1. K&R for more visibility. Good one. nt

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Response to McCamy Taylor (Original post)

Thu Jun 12, 2014, 10:05 PM

2. Good post. While those measures are important, they need to add measures taking into account patient

conditions. For example, Medicare Advantage payments are adjusted somewhat to take into account patients who are "sicker than average."

It is also sad clinics and healthcare providers have to be incentivized to ensure vaccines are administered; patients are referred for mammorams, colonoscopies, eye exams for diabetics, etc.

It's a difficult process to handle quality and affordable healthcare for millions of people. Unfortunately measures are necessary because even healthcare providers (clinical and admin) don't always do the right thing for patients.

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Response to Hoyt (Reply #2)

Thu Jun 12, 2014, 10:13 PM

3. Absolutely right. Severity adjustment is all that is needed to make it work.

However, while Medicare uses severity adjusted data---proof that the federal government wants to make sure that quality care is being given, the organization that employees Clinic A and Clinic B has repeated resisted requests to use severity adjustment--almost as if the administration is attempting to reward public health officials who drive away the sick and poor, presumably because they do not "waste" the organization's money on the sick and poor, leaving the organization more to spend on executive salaries and bonuses. At least, that is the way I see it. I would love to hear about a private such as United or Aetna that combines "metrics" with a solid "severity" adjustment when determining physician's quality of care. Anyone know of a private that does this? I am certain that all the privates can tell you within a penny exactly how "sick" every single member is---that's what they do---but do they ever share that data with the providers and congratulate them on taking good care of especially difficult patients? Or, do they complain that their terminal cancer patients aren't getting enough screening mammograms and colonoscopies?

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Response to McCamy Taylor (Reply #3)

Thu Jun 12, 2014, 10:36 PM

4. One day they'll get it right, but some of us won't live to see it.

I guess slow progress is better than no progress.

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Response to McCamy Taylor (Original post)

Thu Jun 12, 2014, 11:21 PM

5. Part of the "Figures don't lie, but liars can figure" thing.

From my personal experiences in Corporate America.
To gauge the effectiveness of something a measurement must be taken; that's common sense.
Those with an agenda usually try to control the "what to be measured" and "how to measure".
Agendas can be pro-common good, pro-exclusive good, or sometimes un-understandable without peyote.





One of the easiest ways to curtail the affects of metrics, as we are currently suffering through, is remove profit from the equation. Totally. Relating to the OP, this will greatly reduce the transfer of patients. Install some common good metrics like "ratio of difficult cases handled", "effective treatments on first visits" and "gaps in health care services resulting in patient movement to a different facility".

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Response to McCamy Taylor (Original post)

Fri Jun 13, 2014, 12:12 AM

6. The metrics used in education and in other non-profits work the same way.

Metrics are not the way to mete out scarce dollars for really needy people. They just don't work well.

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