Quality vs. Value

Does "Quality" Help Patients?

Two quality metrics walk into a bar.

One demands, “Give me the best beer you’ve got!”

The other says, “Give me the second-best beer you’ve got.”

The bartender pours the beers and states, “You can have them both for free if you can tell me why this one is better than that one.”

Quality metrics were invented to quantify the ineffable, such as the taste of a fine lager or IPA. These days, we in Colorado are seeing local brews being listed in “International Bitterness Units” (IBU). Some may actually order their choice based upon this listing. At the very least, it gives us something to talk about while enjoying our beer.

Just as listing the IBU is new in beers, metrics did not always exist in medicine. The moment we became serious about quality is often cited as Dr. Philip Caper’s 1988 article “Defining Quality in Medical Care.” Even as medicine invented “quality” in the 1980s, Dr. Caper pointed to some misgivings about the terminology. His Health Affairs article suggests abandoning the word “quality” and rather using three terms that correlate to desirable medical outcomes: efficacy, appropriateness and the caring function. We know that certain interventions are efficacious in certain conditions; we can measure that. We know that certain interventions are appropriate and inappropriate in the sense of utilization; we can measure this. And we know that patients want “caring providers.” We likely cannot measure this very well, but it may be the most important of all the factors. The “quality” of care is more than all of these factors and perhaps quite different entirely.

Despite the prescient warning, we have not abandoned “quality, ” and its continued use has created an entire jargon: quality, measurement and value. Quality creates value. We are all preoccupied with creating value now. The term is rarely defined but often used: creating value to insurers, for payers, for health systems and even for patients. It appears to have a vague but unacknowledged relation to quality.

No one used to ask whether they got value when they went to the doctor’s office. We might have discussed whether we had a good doctor but never whether the experience was valuable. When we buy a car, we sometimes wonder whether we’re getting a good deal and whether the exchange had “value”. But when we sit with friends for a beer at the pub we never ask whether we’re getting a good value out of the experience. The use of value reflects an economic creep of the mission of medicine and a subtle deterioration of the relational aspect of “my doctor.”

Those things that are most important to us, and in some sense are valuable, we never ask if they “provide value.” Nor do we ask whether our evening at the pub was “quality time,” and rarely whether we just drank a “quality” beer. Remember “quality time” spent with our loved ones? Once we started asking this about the time with our children, it already represented an unacknowledged loss of the inherent relational component of life. Just so, once we started using “quality” and “value” in medicine, we had already lost its primary relational component. Although not stated in the original Health Affairs article, the discomfort with the term “quality” reflects a disquiet with conflating efficacy, appropriateness and caring with the much more subtle concept of quality.

Quality itself relates to the humanistic function of medicine, and not to its scientific trappings. As such, it is describable but not measurable. As an individual patient, whether our A1C is less than 9 percent correlates only tangentially with the quality of the care our physician provides. We might do better to have a lower A1C, but the factors involved in lowering our A1C, and how we perceive the care we have received, are not measured by the A1C itself. Presumably, the A1C captures the “efficacy” of the care received. It is a gross injustice to label this as “quality.” Substituting “quality” for “efficacy” defines patients as lifeless objects rather than by their characteristics as human beings.

Pay-for-performance takes medical quality metrics to the next level by using them economically. In our health care system, they are not working to improve care — why? Because the metric does not incentivize doctors to be more human. Instead, it rewards treating patients as commodities and lifeless objects. Doctors resent this incentive because commodification is dehumanizing. As incentives push doctors into becoming more mechanistic, we then invent new metrics such as “satisfaction surveys” to desperately attempt to pull them back towards a humanistic ideal. Satisfaction itself is now a commodity and subject to the rules of the market — massive, absurd inflation everywhere!

However, what does not work on an individual level, can work on a group or institutional level. Some payors, government and private insurance reimburse hospitals (more or less) depending on how they perform on various metrics. With some exceptions, this tactic appears to overall have improved medical care in America. Companies should be held responsible or rewarded for the quality of their products. Corporations have always responded well to financial incentives — it’s why capitalism works!

The fallacy in pay-for-performance resides in the jargon: quality, value and now “aligning incentives.” This innocuous phrase glosses over the distinction between corporations, which thrive because they transcend individual people, and doctors, who thrive because they are humans providing care to other humans. Be careful with your jargon, and be wary of individual metrics. 

If your practice is interested in providing patients with a more “value-based” experience #weshouldtalk