The early signs of trouble appeared more than a decade ago, when the Institute of Medicine published “Crossing the Quality Chasm” and drew attention to tens of thousands of lives impacted by high-variation, low-quality healthcare in the United States. Since then, a steady stream of evidence has shown a massive healthcare quality management problem in this country that is impossible to ignore.
Though awareness of the problem has increased markedly, we are still a long way from solving it. The recent IOM report on misdiagnosis shows that the quality problem persists unabated, profoundly impacting the lives and livelihoods of both consumers and purchasers of healthcare.
Efforts to address low-quality care
Though the variation and opacity in quality persists, it is not due to a lack of effort. Multiple approaches have been attempted to address the problem, with varying degrees of success. Payers have begun to knit together “high performance” networks, carving out low-quality (or low-value) physician groups. Though, their hands are often tied by powerful provider groups that prohibit differentiation of doctors within the same institution.
Employers have tried to work around these issues by contracting directly with centers of excellence, using additional data to select top practitioners for high impact procedures. The government is also playing a role, offering incentives for reporting quality indicators and reducing obvious sources of waste like readmissions. Health systems are beginning to respond to this changing landscape, adopting new documentation, tracking and measurement tools to identify and improve behavior and outcomes.
Regression in high-quality specialty care
Given all of this attention, there is surprisingly little dialogue about the two constituencies most impacted by the challenge of finding high-quality medical care: patients and the primary care doctors that direct them to specialists. At first glance, that statement likely sounds suspect. After all, barriers to access for basic primary care are dropping rapidly as the rise of synchronous and asynchronous telehealth along with new entrants in the retail urgent care space have dramatically expanded the availability of reasonable care for low-acuity issues. Surely those developments have carried with them improvements in identifying quality. However, when you dig deeper, it’s clear that the methods for evaluating and gaining access to high-quality specialty care has not kept pace, and in some cases, has actually regressed.
Take for example the PCP referral to a specialist. This simple decision has become more complicated and constrained. As health systems are consolidating formerly independent physician groups, they move quickly to “capture” referrals. They do this by implementing EHRs with selective interoperability, and referral healthcare quality management tools that prioritize economic relationships over clinical performance. Many of these tools are perfectly appropriate, and offer clinical benefits from continuity of care improvement, but they constrain the role traditionally played by PCPs in identifying and working with high-quality specialists for their patients.
New constraints in the healthcare ecosystem
These new constraints would be less troubling if patients were able to do their own research and make informed decisions. If you believe the hype, you might think this is happening already. Health systems are falling over themselves to reset their nomenclature: patients are consumers, or even customers. Patient satisfaction is actually measured, and at times even disclosed.
Certainly one piece of the patient as consumer narrative is true: patients are paying out of pocket for more of their care than ever before, and this is driving a shift in their behavior. Unfortunately, the market has not evolved in parallel to give patients the tools and information they need to make informed choices. Patients are Googling their MDs, but the results aren’t correlated with getting the quality care they need.
Accessing extraordinary care
Despite this complex and somewhat gloomy picture, there are clear rays of hope. Extraordinary care is available to the vast majority of patients, and new tools exist to ease and guide access. The results can be life-altering.
One of many examples we’ve encountered is the story of Sam, a young patient from Oklahoma we connected with Boston Children’s Hospital. Sam had experienced lifelong incontinence and his treating physician had linked it to a cyst in his spine, recommending he undergo an invasive, rarely performed spinal surgery to correct the problem. By connecting with Boston Children’s and Grand Rounds through a remote expert opinion platform, Sam’s mother was able to get a second opinion strongly advising against the surgery and explaining that not only was the cyst in her son’s spine benign, but the incontinence was due to another issue altogether that could be addressed with a non-invasive procedure. Had Sam and his mother followed the original recommendations and not had access to a true expert, the outcome could have been catastrophic.
The evolution of healthcare data collection
We are on the verge of a revolution in healthcare quality management data collection. Over the last few years, we’ve seen a massive increase in the availability of information on physician performance, and the trend only seems to be accelerating.
Grand Rounds and a few others in the space are using these new sources of data to glean deep insights about physician performance, and in turn, help patients and PCPs identify and access the high-quality providers that are best equipped to meet their clinical needs.
We believe this ultimately is the solution to challenge what the IOM highlighted in Crossing the Quality Chasm. Healthcare has lagged behind other industries in reducing variation and eliminating low-quality products because lemons were indistinguishable. Where in other industries a manufacturer that breaks even one in 20 widgets would quickly fade away, in healthcare, such mishaps all too often pass unnoticed.
As new tools make it possible for patients to identify and seek out high performers, the healthcare industry will have an imperative to either improve or fade away. I’m certain we’ll see a vast improvement in performance that will benefit all participants.
Meet Jacob Best
As Director of Medical Networks Jacob leads the team responsible for expanding relationships with Grand Rounds’ network of physicians & health systems. Grand Rounds partners with the leading providers in the US to extend the reach of their clinical expertise, increasing access and quality. Prior to Grand Rounds, Jacob was Chief of Staff at Emdeon, a leading provider of revenue and payment solutions. Before Emdeon, Jacob held management roles at investment firm Hellman & Friedman, and consultancy Bain & Company. Jacob holds a BA in Human Biology from UVA and an MBA from Stanford.
Hear Jacob speak at MobCon Digital Health April 26.