For many years I have been measured on the quality of care I provide. For instance:
Diabetes: Patients had to have a HgA1C (a way of estimating average blood sugar for the prior 3 month period) of under 7.
Blood pressure: The current guideline is under 140/90 for those under 60 years of age and under 150/90 for those over 60. For diabetics it needs to be under 140/90.
There are many more…
The kicker was that if I sent a diabetic to an endocrinologist it does not exempt me from the measures for that patient. In fact, the endocrinologist guideline for control in our system was set for a HgA1C of under 8 and yet I was still measured for quality on that same patient for A1C under 7. If that patient’s A1C was 7.8 the endocrinologist got credit for quality care and I did not.
Blood pressure is even more interesting. Let’s say you have great blood pressures at home but like many people, at the doctor’s office your blood pressure shoots up. I can disgnate a “decision point blood pressure” using your home blood pressure average that keeps us both from getting into trouble.
BUT let’s say you also see a surgeon or a cardiologist in the system. Your blood pressure is recorded as elevated and they do not use the decision point blood pressure option because they are NOT graded by the system based on these quality measures. Not even the cardiologists.
Meanwhile, I do not get graded only on the blood pressures that I record during office visits with me. No. I get graded by the LAST blood pressure recorded on the chart, regardless of the provider.
Even if I am doing everything right, I can still take a hit.
All of the dozens of measures affect how much I get paid. They also affect how much an insurance company requires a patient to shell out as their copay to see a particular physician as a way of directing patients to doctors that provide “quality” for less $.
It is inappropriate for an orthopedic surgeon to be responsible for a patient’s blood pressure but a cardiologist should be held to the same standard as the primary care physician. A dermatologist should not have to worry about whether or not a patient received their flu vaccination but the lung specialist and the endocrinologist should.
Furthermore, if I send a patient to a specialist for management of an particular issue, like diabetes or heart failure, the responsibility for the quality of care for those issues should them be assumed exclusively by that specialist. This discordance in standards unfairly penalizes primary care physicians.
It gets complicated, though, doesn’t it? Who is responsible for what and to what standard?
And that is my two cents worth on a Monday morning! 🙂