Friday, January 4, 2008

Quality Challenged Patient Choicery (QCPC), the NCQA and Mr. Cuomo

In 1997, the Annals of Internal Medicine published a seminal article on the Medical Home. Von Korff and colleagues at Health Care of Puget Sound, discerning usual one-on-one care was not up to the task of chronic illness care, argued for a different approach using 1) collaborative provider-patient agreement on the active medical problems, 2) mutually agreed-upon goal setting and planning, 3) provision of patient self-management training and 4) active and sustained follow-up. Note that Advanced Medical Home proposals by the American College of Physicians and the American Academy of Family Practice include “patient self management support” that ideally includes helping health care consumers decide what to treat and how to treat it.

What does this have to do with the National Committee on Quality Assurance (NCQA)? Quality assessment measurement approaches used by the NCQA and others for conditions like diabetes mellitus, high cholesterol, hypertension or need for vaccinations or cancer screening don’t give credit for "negative" patient preferences. So, if a fully informed patient chooses, despite documented state of the art engagement/education/empowerment, to eat fried chicken, use elevators, not take pills and avoid getting poked or naked, they are batched along with the all the other woeful shortcomings of U.S. healthcare.

Here are the commonly encountered retorts to the problem of quality-challenged patient choicery (QCPC):

If patients refuse, the education was obviously substandard.” Yes, but...

there is a wealth of data showing patients vary greatly in their willingness make changes. Furthermore, it turns out patients require a higher level of risk before a treatment is accepted. That's not all that irrational given the tastiness of fried chicken, dangers of stairs, medication side effects, and the under-recognized burden of false positive screening tests. And then there is implacable patient irrationality.

The physician is still responsible.” Yes but...

there is a big difference between being responsible and being in control. Ask any married man for details. I think the point is made.

Patient refusals account for only a part of the low quality.” Yes, but...

the amount is unknown and it could be underestimated.

It washes out.” Yes but…

this presupposes that the distribution of patient refusals is evenly and randomly distributed across populations. This may be true for health insurers with large numbers of patients. Unfortunately, that is not the case among the low numbers of patients across individual physicians, where random variation can result in some physicians having more QCPC, more responsibility and less control. If pay for performance dollars are at stake, that can also unfairly mean less money or being shut out of a network.

It’s not our fault, the market is demanding 100% quality.” Yes but…

like the market can’t understand patient rights? Or health insurers don’t have a responsibility to help their customers understand what physician level data does and does not tell them?

By the way, while the nation's health insurers may tell us it’s just too hard to collect these data, don’t believe it. Not when chart reviews are used in other quality measures or when disease management organizations and/or clinic-based medical home team members can use their skill sets and information technology to deliver the education and document (and possibly even submit a claim that reflects?) patients'/enrollee preferences.

The New York Attorney General has established de facto national health insurer physician evaluation guidelines. Rumor has it that the NCQA may be an independent evaluator under the agreement and have a major role in determining how those guidelines are enforced. Let’s hope patient preferences are included as an evaluation co-variate.

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