Cambodia 483

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! πŸ™‚


90 thoughts on “Measured

    • I had a scheduled day off today but came in to help see patients this AM because they were getting hammered. I had no nurse but with acute visits scheduled every 30 minutes it went beautifully. You can believe everyone had all of their preventive measures addressed! πŸ™‚ Too bad I cannot maintain this kind of pace all the time!

      Liked by 1 person

    • Possibly. Guidelines themselves are not the problem provided they are applied equitably and are evidence based. I have too many endocrinologists who simply don’t care about managing a patient’s blood sugar tightly. Perhaps they become numbed by their many out of control patients? Dunno. But I would like for us all to be measured by the same stick.

      Liked by 1 person

  1. I found interesting what you said about blood pressure readings being higher at the doctor’s office than at home. My husband used to take me to my Remicade treatments, and my blood pressure was always unusually high when I got there. Then, I started driving myself, and the nurses are amazed at how my blood pressure readings have dropped. I suspect a correlation, don’t you?

    Liked by 1 person

  2. Seems as though you have brought to our attention 4 important issues.
    * Specialists being measured by different criteria than you are.
    * Being accountable for things that are out of your control.
    * Specialists using different medical criteria for success with the patients.
    * Being evaluated based on numeric measures of your patients. Oh, plus complaints—can’t leave that out.

    Since I have no experience as a medical provider, and no solutions to offer, I would seem to be in a perfect position to comment. The first two issues are systemic problems; artifacts of your corporate environment. They could be fixed by fiat from on high. Unhappily, they won’t be.

    The third is a medical issue. It should be fixed by consultation among the providers (all of them), but it is probably a result of the activities of that MBA-boy in charge of cost control. After all, tighter standards for specialists means more specialist hours, higher cost, and less left over for the investors.

    The last is a two-part philosophical issue. On the one hand, that MBA-boy likes it because it is far more precise than trying to assess things like your ability to get patients to accept treatment by calming their fears (more precise, but possibly less accurate). On the other hand, it is part of the current fad of assigning numbers (and then measuring them) to every facet of our lives. I think the theory is that the more numbers you know about yourself, the better you understand how you are doing. “Well, my numbers are good, so I must be well and happy.” Personally, I don’t think it works that way, but then I don’t record my entire life on FaceBook, or tweet my location every few minutes. I don’t wear a watch, so I don’t even know what time it is. And, I don’t want to know that much about you, either, even if we are good friends. I’m just not fit for modern life. But, how can this be? My numbers are good, so I must be happy.

    Liked by 1 person

  3. This may be somewhat off topic, but what do you think about Jimmy Carter’s announcement that he is “cancer free”? I’m happy for him, but at the same time it just seems like it might be giving false hope to patients who also have advanced melanoma. His doctor has dialed it back a bit to “in remission,” but still… Your thoughts?

    Liked by 1 person

  4. Wow I thought Home Care was fubar…you are worse. and it is so unfair. If a patient gets discharged from the hospital on Friday, as so many are, are we go out an open them on Saturday…. and we see they have a massive infection, we get dinged…. or they end up on Monday going back in to the hospital because of the infection, we get dinged. Argggh. It is all a ploy to get more money and has nothing to do with the patient.

    Liked by 1 person

  5. I spent the greater part of my career in developing and monitoring standards of performance in our industry. What you’ve described makes no sense to me.
    How can you possibly be evaluated against a measurement that you don’t control? That’s a basic tenet of performance measurements. At best, you can only attempt to influence behaviours that could improve the measurement. Duh.

    Liked by 1 person

  6. My BP is up and down. Must drive my doc crazy. Insurance reform is definitely needed. Repealing Obama Care is the only thing you hear about. No solutions. That’s what I want to hear about. Are these people making all these rules even doctors?

    Liked by 1 person

    • Mondays are the worst days for being over run. Fridays are often terribly busy, too, but sometimes people just don’t show up. I guess they think better of spending part of a long weekend at the doctor’s office. πŸ˜‰


  7. Why do I find this all a bit upsetting? You’d think important guidelines like this would be written in stone and not subject to all these vicissitudes and interpretations. It’s like sausage. The less you know what goes on behind the scenes, the better off you are.

    Liked by 1 person

  8. This is the world reduced to numbers…like the teacher responsible for test grades based on cumulative learning. I think it’s particularly bad for doctors though. People are not numbers! and…numbers can mean different things for different people in different situations. Subtlety is not a corporate or political strength, though… (K)

    Liked by 2 people

  9. The variables Blues. Per situation the variables may change.

    Human “Changes in variables tend to be constant.”
    Manager “So, we limit our measures.”
    Human “What if the limited measures are incomplete?”
    Manager “We are always right, fuck the variables.”
    Human “…”

    Liked by 1 person

  10. No one really understands the complexities of another person’s life (or life’s work), but too many people are ready to criticize and/or offer suggestions/solutions to improve the problems they see. Your post was a very effective reminder at how very complicated your work is. There are never simple solutions to complex issues. Never.

    Liked by 1 person

  11. I am everyday more dismayed at how “measurement” is taking over, in a – sometimes – most stupid way. Been in market research all my life, and some of the research we used to measure customer satisfaction. Now we are faced with overmeasurement. Every bank transaction i have on or off-line with an exec is measured. 100% sample! (Crossed-eye emoticon) A waste of time, permanent pressure on the people measured. Terabytes of data produced with probably no human being analyzing the data, and the computer just spits out deviations. Now in your case it is worse, since the standards for spitting out deviations are not… “standard”.
    Take a deep breath. Or write a paper…

    Liked by 1 person

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