The Secrecy of Cost and Quality

While normally a forum for all things exercise science- and Central New York track and field-related, as I'm just back from the AMA conference in San Diego, I thought it would be therapeutic to throw some health policy opinion up on the proverbial running blog. As a full disclaimer, I am by no means an expert in health policy or much else for that matter. I merely hold the belief that patient empowerment and health care improvement shouldn't have to wait in line behind fear of failure. Let me explain.

A medical student section-sponsored resolution was brought forth before the AMA encouraging physicians to make practice-related data publicly available. Presumably, this would spur three major changes:

1) Patients would have more information about the doctors they choose to go see.

2) Physicians would have more information about the doctors they refer patients to.

3) Quality improvements could be realized through measurement of short-comings and process-oriented changes related to such.

Sounds simple enough, right?

Wrong. Some legitimate concerns were raised, namely, the "attribution problem," which relates to the burdensome task of divvying up responsibility for a given patient among the multiple doctors that the patient might see. Other concerns fell on the accuracy front, in that claims data may not reflect the true performance of a physician. Finally, the conventional "I see sicker patients" argument was raised several times, as if the concept of normalization had yet to be invented.

With the belief that the perfect and complicated shouldn't stand in the way of the good and simple, why not start with reporting data where attribution is clear-cut? What percent of at-risk patients were counseled about their weight? Does your practice use an e-prescription system? As far as accuracy is concerned, let's use smart EHR's that enable physicians to collect, analyze, and present the data themselves. Insurance companies are eventually going to do it anyway, but shouldn't doctors be interested in taking a peek at their practice habits over a larger sample size and see how they compare to the practice habits of others? (Believe it or not, while such internal review is nice, making that information public has been shown to be a critical step in seeing that change really is affected.)

There are data beyond outcomes that could be but are currently not reported on consumer websites such as healthgrades.com or insurance search engines. And attribution be damned, why NOT report outcomes data when patient's case is clear-cut? The notion that we don't have the metrics is just plain false, and the belief that patients wouldn't know what to do with quality information is frankly insulting.

On the expense side, cost profiling of physicians is being done whether docs like it or not. Basically, patients get the choice of seeing a "high performance" (i.e. "lower cost") physician, and if they do, they're rewarded by lower co-pays. Doctors hate this idea, but objectively, with the cost of health care soaring in this country, you get the feel that most people think it makes a good bit of sense. Two separate resolutions from Georgia and Florida asked the AMA to seek laws that would make cost-profiling illegal. I hate to say it, but keeping your prices secret from the prospective patient pool is not going to fly for long in our profession. And why should it? I can't think of another industry where the billing structure is so opaque from the moment the customer walks in the office.

A few years back, Andrew Cuomo got it right with his suit against UnitedHealthCare, and in doing so, showed that outlawing cost reporting is not a viable legislative reality. Cuomo's office called for accurate methods (let's move away from a tiered system and allow for some statistical error) of cost reporting in conjunction with quality reporting.

Cost and quality are two sides of the same coin, and both need to be made available to the patient before doctors can claim patient choice is anything more than a nice idea.