Quality Of Care

Difficult To Measure, Hard To Reward

If many healthcare gurus have their way, medical providers will soon be rewarded on the basis of the quality of care they produce. Thus the potential challenge: Whose quality, and who gets to decide “quality” was delivered? Is it solely good outcomes of bargain priced care, or does it include compassionate or attentive attitudes and thoroughness?

Sometimes doing nothing is the best care for a problem. Is this good quality even if a disagreeing patient thinks something should have been done? If a provider gets sued for malpractice, does this mean he or she is off the “quality list” even though the lawsuit may have been frivolous?

The experience of my friend Roger, who recently sought treatment for a ganglion cyst, has brought this topic to the premium spot in my mind. It simply has to be dissected and examined.

Ganglion cyst (common, ganglion); def; a benign accumulation of thick, sticky, clear, slimy fluid occurring near the joint from which it arose, most commonly the wrist; like a balloon filled with goo rather than air or water.

A GC may be treated with neglect, forcible rupture, injection with a steroid, or surgical removal, and in all cases there is a probability of recurrence ranging from 25% to 100%.

Those are the basics, now for the quality issue from several points of view.

Grandma, 1898: “Lay that thing down on the table, and I’ll give it a whack with the dictionary. Then go do your chores.” Quality level – 5 of 5. Cost, $0

Family Doc, 1945: “Put your wrist on my exam table, and I will give it a quick thump with my old copy of Grey’s Anatomy. Then we’ll wrap it up and send you back to work tomorrow.” Quality level – 4/5. Cost, $12

Serial Physicians, with well-insured patient, 2007: “First we’ll get permission from the primary person, then we’ll pass it through the skin guy, but you’ll probably end up with the orthopedist who can’t move off the dime without at least an MRI, and then he’ll discuss treatment options, and their drawbacks, plus the fact that the stupid thing is going to come back most of the time anyway regardless of the method used, and by the way, you have just spent three months navigating the system. Feel better? Oh, here's the orthopedist now. Let's have him bust your bubble with his special tool – it’s a gold-foil wrapped first edition of Moby Dick.” Quality level – 0 to 4/5. Cost, incl MRI, $1250 minimum

Salaried Physician employed by National Health Service, 2015: “What you have is a ganglion cyst. I am permitted to treat you, but there is only one method for which I am qualified. It’s called ‘ganglion cyst, uncomplicated, small; induced rupture of, by impact method.’ There are some restrictions about which I am obliged to inform you fully. First, I have to do it – you are not permitted to see anyone above my level without first obtaining permission from the Secretary For Health Affairs, who is currently a Democrat, and thus not likely to pass along any favors to you, a registered Republican. Second – there will be no discussion of ‘options’, nor will there be second opinions. Not allowed. Third – Due to content, many previously used items are no longer employed. The impacting book, or more properly, the Book Of Impact, we must use contains no references to race, religion, sexual preference, country of origin, gender inequality, socio-economic status, or hair color. Got all that? Then we’re ready to proceed. But wait! I forgot to tell you. There is only one copy of this book in our region, and your wait will be -----.” (Computerized voice: “---approximately 7 months.”) Quality level – 0 to 0.5 of 5 depending on your politics. Cost, $0 out of wallet at this time, $1250 annual increase in your income tax.

There. That about covers the quality issue, which according to our figures places Grandma at the top of the pay-for-quality scale and salaried government employees at the bottom.