Wednesday, December 5, 2007

Quality - “Quality:” It Depends on What “Is” Is

President Bill Clinton will be remembered for saying, “It depends on what ‘is’ is.”

Similarly quality of care will be judged for what “is” is in the eyes of beholders.

For years, a debate has waged as to what makes for the best “quality” – solo, small, or large practices. As pointed out in the November 26 AMA Medical News, “Bigger Practice, Better Quality?” it depends on what you think quality is.

If you think quality is a more intimate, responsive, and closer relationship with your patients, solo or small practices may be your gig. Solo doctors, such at L. Gordon Morre or Rochester, New York , or John Brady, of Newport News, Virginia, family physicians both, feel they are delivering higher quality care than they did as members of larger groups.

They do so be cutting overhead, using EMRs, taking a proactive approach to caring for patients with chronic disease, being available 24 hours a day, answering their own phone, and seeing patients on the day they call. There are now about 100 similar solo groups operating in the U.S, along with roughly 500 concierge or retainer practices.

But if you think quality is defined and measured by more acceptable and concrete measurements, the big groups win hands down. A cross-sectional study of 119 California groups pitted against small groups found the following.

Quality measures, large groups vs. small groups

1. Mammography, 73%, 58%

2. Pap smear screening, 53%, 30%

3. Chlamydia screening, 235, 9%

4. Diabetic eye screeing, 42%, 29%

5. Asthma-control, medication,77%, 76%\

6. Beta blocker after acute MI, 80%, 69%

Quality improvement strategies, large groups vs. small groups

1. have an EMR, 37%, 2%

2. Offer quality bonuses to physicians, 32%, 13%

3. Provide reminders about missed:

--Mammography appointments, 74%, 28%

--Diabetic eye screening, 53%, 18%

--Well-child immunizations or visits, 47%, 10%

-- Influenza vaccine, 54%, 25%.

Like I said, the perception of quality depends on what “is” is – on what you perceive quality to be. Whoever is “right,” more doctors are switching from smaller to larger groups as indicated.

% of doctors in small vs. larger groups, 1996-1997 vs 2004-2005

1. 1-2 physicians, 42% to 33%

2. 3-5 physicians, 12% to 10%

3. 6-50, 13%, to 17%

4. 50+. 3% to 4%

5. Medical schools, 7 to 9%

6. Hospitals, 11% to 13%.

One piece of information missing is what patients consider to be quality. This is essential. After all, first visits of some 50% of patients are with primary care physicians in small groups (National Center of Health Statistics, 2005).

John Guaspari, a management guru, has written in his book I Know It When I See It: A Modern Fable about Quality (1991) that anyone who thinks they know quality when they see it is living a myth.

Can the same thing be said of patients? And if not, how can this lack of knowledge of quality by patients be overcome? By health plan steerage of patients to doctors with documented quality? By public disclosure of quality data? By marketing of their quality data by large groups?

I am dubious about the effectiveness and propriety of any of these approaches. There are intangibles of doctor-patient relationships that transcend data. Still I have no doubt large practices, given their resources, can take a more systematic, organized, and purposeful approach towards quality.

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