Thanks to ObamaCare, the state of quality measurement in health care is rapidly approaching the state of quality measurement in public education. Process measures dominate. Many of these measures are worthless. They measure nothing that has anything to do with providing actual medical care that successfully cures or alleviates the suffering of sick people in a timely manner.
The following list gives the items chosen to measure the general performance of the Indiana Medicaid program for 2012 with an emphasis on access to care. The good news is that Indiana contracts for an independent outside evaluation of its program. The bad news is that 13 of the 16 measures depend upon whether or not a patient decides to visit the doctor.
In those 13 measures, quality is assumed to be higher if a higher fraction of covered individuals have at least one health care visit. The report continually equates visits with access as in “there were fewer differences in the rate of access to primary care for adults across the regions than was found for children” and “the adults in the 45-64 age range were more likely to access primary care services than the 20-44 range.”
The bulk of the measures show whether an otherwise healthy person came in for a check-up. One of the measures, nutrition and physical activity counseling for children and adolescents, which is satisfied by entering BMI data in a patient record, likely duplicates school programs. Others, like measuring the quality of mental health care by whether or not someone hospitalized with a psychiatric diagnosis shows up for an appointment 7 or 30 days later, are beyond the control of anyone but the patient.
One Medicaid contractor spent money trying to improve its measures. It sent “non-compliant” members a lab-in-envelope that contains everything an individual needs to collect a blood spot specimen and mail it to a laboratory for a cholesterol test. Rewards were offered for completion. Response was nil. It invited all of its customers to two health fairs with free tests. Few showed up. It hired call centers to nag customers and met with primary care providers who had “non-compliant records.” Health spending went up, but people pretty much stayed away from the doctor at the same rate in 2012 as they did in 2008.
While measures that emphasize visits waste money, stand-alone measures that reward managed care systems for low cesarean rates can do physical harm. In general, cesareans help babies. As one study of all California singleton births to low-risk mothers in 1998-2000 pointed out, hospitals with very low cesarean delivery rates tend to have more, and more expensive, neonatal morbidity than hospitals with average cesarean rates. Giving a managed care operator a good rating for doing fewer cesareans without also tracking the health of newborns is also giving it an incentive to compromise care.
Underweight births are another questionable measure. A live underweight baby lowers the quality measure, a dead underweight baby does not. And the line between the two is thin and easily shifted.
Little is known about preventing very low birth-weight births. Smoking cessation programs have likely been moderately effective, but they are now widespread and may be at the point of diminishing returns. Evidence suggests that the effectiveness of nutritional interventions, work counseling, or preterm birth education is minimal.
Expanding prenatal care programs will be of limited benefit. In 2011, only 6 percent of pregnant U.S. women got no prenatal care or waited to get prenatal care in the third trimester. Some observers note that although illicit drug users have a high proportion of underweight newborns, drug-using moms who see a doctor more than five times during pregnancy are likely to have babies of normal birth weight. They suggest that adequate prenatal care may be a surrogate for maternal competency.
Finally, note that none of these measures addresses Medicaid access to specialty care, the real problem known to bedevil patients in government run health systems in the United States and the rest of the world.
Measures of access to care:
- Well child visits in the first 15 months of life — goal is 6 or more visits.
- One or more well child visits in the 3rd through 5th years of life.
- Annual adolescent well care visits.
- Children and adolescents’ access to primary care practitioners.
- Adults’ access to preventive ambulatory services.
- Utilization of imaging studies for low back pain.
Measures of performance improvement:
- Well child visits, all ages.
- Diabetes care, either LDL-C (cholesterol) screening or annual HbA1c plus diabetes retinal exam plus LDL-C screening.
- Follow-up visit after an inpatient mental health hospitalization within 7 and 30 days of hospitalization.
Calculation of core set of children’s health quality measures required by CMS:
- Live births weighing less than 2,500 grams (approximately 5-1/2 pounds).
- Cesarean rate for nulliparous singleton vertex – i.e., normal births not resulting in twins.
- Weight assessment and counseling for nutrition and physical activity for children and adolescents. The measure is the fraction of children with a BMI number in their medical records.
- Developmental screening in first three years of life.
- Ambulatory care emergency department visits.
- Percentage of asthma patients with one or more asthma-related emergency room visits.
- Annual pediatric HbA1c (blood sugar) testing for pediatric patients with diabetes.