President's Page

President's Page
December 2007

The Quality Chasm:
Create a unified stand against faulty categorization

by James T. Norwood, MD
2007 DCMS President

When I hear the term “Quality Chasm” I usually think of the comparison between the goal for quality health care compared to the reality. Like most of you I have spent my career working to provide the highest quality health care to my patients, or to teach those principles to residents and students. I have an in-depth interest in quality care. I spent over nine years on Baylor’s departmental Quality Assurance Committee, five of those years as the chair. I am certified by the American Board of Quality Assurance and Utilization Review Physicians, and for a while I was a member of the American College of Medical Quality. I have seen the progression/evolution from retrospective physician review, to continuous quality improvement, to the emphasis on “systems” and their quality. Now we have the pay-for-performance mantra based on the premise that high quality health care will translate in to lower cost health care.

This latest philosophy has created a new quality chasm. On one side is evidence-based quality care, and on the other is economic-based care disguised as “quality” care. I am sure you have read how Blue Cross Blue Shield rolled out its plan to assign physicians different colored ribbons based on the “quality” of the care they administered to their patients. Patients were encouraged to see “blue ribbon” physicians with the insinuation they would receive better care. The flaws in this system were numerous. The assignment of “blue ribbon” care was based on insurance-company claims data, not clinical data. If BCBS had no data on you, the physician, regarding a particular issue, they simply assigned you a lower ranking rather than research the issue or ask you about it. This all came to a head earlier this year when BCBS pulled its current “quality” program, but promised they will soon roll out another. And they are not the only ones.

Nationally we are seeing more companies doing the same thing, specifically Cigna and United Healthcare. United reported it had an independent organization that analyzes its data but failed to mention that this organization is a subsidiary of United—a clear conflict of interest. Cigna recently reached a settlement with New York Attorney General Andrew Cuomo six months after an investigation into how Cigna put together its recommended physician list.

There are two points I want to make. First, this issue of wrapping economics in the façade of “quality” is not going away. Keep your guard up for any attempt to have the word “quality” wrapped around economic credentialing. Quality measures should be evidenced-based and derived from clinical activity, not billing activity. Measures not based on clinical evidence can lead to erroneous if not fatal results. For example, several years ago there was a philosophy that by not encouraging smokers to quit their habit, they would actually die at an earlier age and therefore not be as expensive to care for. An economic argument was made to therefore not push smoking-cessation programs in hopes of reducing healthcare costs in general. In fact, evidence from research has shown just the opposite. Smokers do indeed shorten their lives by an average of 10 years when they continue to smoke, but the last years of a smoker’s life use up more healthcare dollars than a nonsmoker living past the age of 90. Added together, all smoking-related illnesses make up the overwhelming majority of preventable healthcare expense in our nation. Recent research presented at the TMA Fall Summit showed that smoking- and obesity-related health expenses made up over 75% of all preventable health care expenses, and that physician-directed health care (you know, the things that get you assigned a blue ribbon) only accounted for 10% to 15% of the total.

The second point I want to make is that it has been organized medicine that has confronted the insurance companies about these ranking schemes. How many times as a single physician have you complained to an insurance company, only to be ignored? It was gratifying to see how your county medical society and the TMA confronted BCBS with the flaws in its system. It has been state medical societies and the AMA nationwide that have brought these ranking systems to the attention of state governments and regulatory agencies. For these and many other reasons, I cannot emphasize enough the importance of belonging to the Dallas County Medical Society, TMA, and AMA. We are a family. Like any family we do not agree on everything, but when the time comes we can present a united front, including persuasive and evidence-based arguments for the health and well being of our patients and profession.

Something different now. In the January issue of the Dallas Medical Journal I mentioned the creativity my niece showed in using a piece of burned hot dog on the hook of her pink princess fishing rod to catch a catfish. Late this summer she balanced her baited rod momentarily on the edge of the dock while she got a drink of juice—only to have a lurking fish grab the bait and drag the whole rod and reel into the lake! I spent an hour diving around the dock in search of the prized fishing equipment but sadly, never found it. After a couple of whimpers, with new determination my niece suddenly found an old broken rod, put a line on it, had me bait it with more burned hot dog, and went right back to fishing. Her perseverance and adaptability is an inspiration to all of us on this turbulent sea of health care. Thank you for your participation in and support of our DCMS mission these last 12 months. It has been my great privilege and pleasure to serve as your president.

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