What is High
QUALITY HEALTH
Care Anyway? by Tom James, MD
Ultimately, the secret of quality is love … If you have love, you can then work backward to monitor and improve the system.-Avedis Donabedian, MD, MPH
Altruism has been a hallmark of the medical profession. The term has been defined as acting in the best interests of the patient and placing the patients’ needs above those of the physician. Current pressures on doctors are contributing to professional burnout and to the decline in altruistic medical practice. Doctors worry about the loss of their own professional autonomy as they enter into employment agreements and as they face a barrage of metrics used by payers and health systems. A 2024 study published in the JAMA Health Forum reviewed the number of unique quality metrics for the typical primary care physician. This number ranged from 52 quality measures to 64. Each value-based payment contract averaged 10 measures, so that the contracts’ effect was to multiply these measures, creating a significant administrative burden.
Avedis Donabedian, MD, a professor at the University of Michigan, is considered the father of modern quality measurement. More than 50 years ago, his work, describing high quality health care as structure, process and outcomes, became the bedrock of current metrics. However, he noted that final outcomes for patients were not just predicated on these three pillars, but included patient preferences, family input and environmental influences. In other words, it is not solely what doctors do that determines the quality of care and of outcomes. Patient compliance is highly variable.
Move forward to 35 years ago when the Joint Commission created a new entity, the National Committee on Quality Assurance( NCQA). While the Joint Commission was focused on hospitals
and other health care facilities, NCQA could focus on physicians and ambulatory services. Large employers began facing rapidly increasing health care costs. Using the manufacturing model of reducing“ defects” in the factories, these employers felt“ error reduction” in medicine was key to mitigating costs. The employer groups supported the proliferation of measures derived from the Donabedian model of defining quality of care in terms of standardized metrics of structure, process and intermediate outcomes.
The consulting houses that worked with the large employer on benefit designs advised their clients to look for insurers which included these metrics in reports made available to employers and health plan members. Medicare and Medicaid followed the same path. A whole panoply of measures was now available. Part of the theory was that if there were enough measures on each physician, that a clearer picture of the quality of care would emerge, just as clearly as a Seurat pointillist painting. However, the burden on the physician has been telling … and the vision of the employer community in terms of cost reduction has not been realized.
The American Medical Association frequently publishes articles about quality in terms of specific disease, treatments or procedures. The AMA’ s overarching statement of Quality is found in its Code of Medical Ethics, Section 1.1.6 Quality. This section has six components relating to:
· Keeping current and maintaining professional competence.
· Accountability to patients, families and colleagues, with effec-
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