In the Race for an Elusive
Metric of Medical Quality, Are High Hospital Readmission Rates Really Valid
Reflections of Poor Quality?
By
Leonard Zwelling
By now, we all know the mantra. Health care reform means
lowering costs, improving access and improving quality. This should not be
mistaken for what the ACA is. It is a bill fulfilling the motto first stated by
Dr. Norman Ornstein when he defined health care reform for a room full of
politicos and the press in November, 2008.
“Everyone’s definition of health care reform is the same. I
pay less!”
The ACA was really a deal not a bill. It’s goal was to
maintain the revenue streams of the major players in the health care industrial
complex. It was essentially the federalization of the health reform deal forged
in one state, Massachusetts, by then Governor Mitt Romney. It had three main
tenets as ObamaCare does. Individual insurance mandates so everyone currently
uninsured must be insured or pay a penalty, premium subsidies for the poor so
that the less fortunate could afford to buy insurance and an electronic health
purchasing marketplace to allow people to buy the best coverage for them and
their families for the amount they could afford. ObamaCare, like RomneyCare,
minimally addresses the reduction of health care costs or the improvement of
quality.
Care costs remain unaddressed because for costs to decrease,
someone has to make less money and no one is stepping up to do this. The
quality challenge is that no one knows what quality looks like because other
than medical professionals, few are qualified to know quality when they see it
except patients whose definition of quality and the definition of the medical
professionals may be quite different.
The patients’ idea of quality is usually measured with
surveys of “patient satisfaction.” Just for the record, let’s define
satisfaction as the absence of desire and realize when you stop wanting you are
likely dead. Patient satisfaction is a marketer’s dream because it generates
jobs for marketers. I have yet to meet the patient whose cancer regressed
faster because the doctor caring for him or her had a Starbucks in the lobby of
their office building, free parking and the most current issues of People
Magazine in the waiting rooms. Patient satisfaction is..in a word..doodoo. Give
any patient the choice at Anderson to be cured by an SOB or wither away at the
hands of Marcus Welby and I think we all know the answer. Patient satisfaction
is not a measure of medical quality. Period. I understand the meaning and
potential benefit of optimizing the hotel functions of a hospital. I have used
these functions in quite a few hospitals including, as I write this. If I want
a good hotel, I will go the Four Seasons.
So then what is quality?
There are two broad categories of quality. There’s the “did
the right things get done” school. The insignia of this school is the check
list and it is not to be taken lightly as checking ID bracelets before giving
blood does save lives. But a check list can only get you so far.
The real measure of quality that most patients (including
me) care about is outcome. Did I or did I not, walk out of St. Luke’s 7 days
after my by-pass surgery. Yes. Check that box.
Was I readmitted a day later with a common post-operative
arrhythmia. Yes. I guess they lose their plus mark. Is this reasonable?
On December 9, I had a particularly large ventral hernia
repair. I had a smaller procedure done initially in July, but while that seemed to go well,
the subcutaneous sutures separated, probably due a Zwelling-revved up immunological
reaction to them and the presence of far more hernias that were not clinically
apparent. All of the greater imperfections probably originated from weakness
to the fascia below my sternum from the 2002 chest crack for my by-pass surgery.
Oh my. Who gets the black mark for readmission? Better yet—who cares?
At no time did I believe that errors were made in deciding
to discharge me or in readmitting me. The doctors responded to what happened TO
ME as an individual patient. I did not matter to them that my complications
were rare ones (although they should have known the risk of operating on a
doctor), they dove in and did what needed to be done.
Does readmission suck? Of course it does. Should we develop
post-discharge systems to make certain patients take their discharge meds,
follow their doctors’ orders and get a leg up on staying healthy (the
accountable care model)? Of course.
But if we wish to measure medical quality, the readmission
rates at hospitals frequented by the well-to-do are likely to have better numbers
than safety net hospitals. If we are looking for a measure of quality, we can
find them. Many people are working hard to do so. But as a well-to-do patient
with fine insurance, I could be getting the worst care in the world from some
the acknowledged best hospitals and doctors in the world. Who knows Most of
us know more about our cell phone than about our doctor.
If you want quality, it may be like pornography. You’ll know
it when you see it. Readmission rates are not good measures of quality.
