In this week's issue of JAMA, Jha and Zaslavsky discuss the issue on outcome quality reporting on physicians and health care networks, concerning the problem that lower socio-economic status (SES) members of society have poorer outcomes than those member in higher SES strata. If the system judges the quality of a practice by outcomes, and a particular practice or sub-population within a practice has patients who are predominantly in a lower SES, does a physician caring for such patients risk lowering his or her quality and value-based ratings?
Jha and Zaslavsky illustrate with a hypothetical scenario very much like what I’ve suggested to prospective clients. Imagine two practices in different communities - one is in a poor community of people who generally have a low SES, and one is in a wealthier suburb with above-average SES. Say the outcome scores of the two practices happened to be the same, would that mean they are performing equally? Or would the practice in the suburb be underperforming?
More realistically, the practice in the poor community will have outcomes that aren’t as good, because health ecology determines ~85% of health outcomes. But if practices are going to be held accountable based on outcome quality, how can one compare two such practices when one of them has a population burdened with more health disparities? How (or can) one fairly adjust for disparities?
Most electronic medical records and claims databases probably can’t characterize disparities much better than a zip code distribution of the patient population. Moreover, few practices have the technological capability of correlating outcomes with measures of disparity, which might be a way of adjusting quality scores. Jha and Zaslavsky note that some critics have expressed a concern that such statistical manipulations might codify “soft bigotry of low expectations”, and lead to “tacit acceptance of a lower quality of care for socially disadvantaged patients”. At the very least, it would introduce a great deal of disagreement and contentiousness over how scores should be adjusted! More likely, it will drive practices away from serving neighborhoods with high levels of disparity.
But what if America looked at it differently? Instead of evaluating doctors on outcomes, what if we evaluate them on how well they engage with their patients and work to address their patients needs, bringing in community resources to fill the gaps in care and breaking down barriers to better health? Rather than judging physicians, hospitals and health networks on outcomes or costs, we should judge them on how well they engage with their community to help patients overcome their unique troubles and barriers to health.
Carol Dweck has a lifetime of research showing that people do better in all aspects of life when they focus on process, engagement and growth, rather than on achieving specific goals. Should our health care system focus on engagement, rather than on outcomes? For people in health professions and management, most of whom have spent their entire lives setting goals to judge their achievements, this is a challenging new way to think.
One of the “Mom tests” is, if it were your Mom, what would you do for her? Great doctors do for everyone the same thing they would do for his or her own Mom. I suggest not trying to tell your Mom what a great value of health care services you’re going sell her (she’s been skeptical of that ruse for your entire life!). But she'll know you really love her if you figure out how to overcome her challenges and troubles, so she can realize her desire to remain independent, proud of you and happy to not be a burden on you. Having had lots of discussions in confidence with my patients about their greatest fears, I believe that is nearly every Mom’s most dearly held dream. She will be very disappointed in you if you come at her with a great value.
The "Mom test" path to health care quality is:
• Her health literacy figures prominently,
• Her diet and good nutrition figure very prominently,
• Keeping her physically active and remaining robust enough to stay independent may well be the most important issue,
• We must help her cope with the stresses of growing old (often saying a final good-bye to her friends, one by one),
• Her transportation needs and finances have to be coordinated,
• She must be protected from falls and accidents, and
• She needs a support system to help her to stay in her own home.
Mom also needs to take her medications, which (of course) adhere the latest guidelines, and she must get on the scale for her daily weight…but that all comes after her health ecology issues have been solved. All of which are essential to keeping her proud of you and relieved that she is not being a burden.
Health care professionals tend to think of this constellation of concerns as geriatrics, but look at the above list again. Aren’t they really true for everyone, no matter how old? Especially for persons who have developed a chronic condition?
Having a clear and quantifiable estimate of Mom’s health ecology is central to how well she does. The purpose of risk assessment tools like our Sustainable Health Questionnaire is not merely to measure risk, but to help align resources to Mom’s needs, coordinate the covered benefits in her health plan and fill the gaps in her health ecology - which all must be in place before her doctor can maximize medical management of her chronic conditions.
Health care leadership might be amazed by the sterling value and quality that America can achieve (for Mom and everyone else). But to get there, we all need to study Dweck, let go of some goal-oriented thinking, and learn to assess quality based on process and engagement.
Geoffrey E. Moore, MD FACSM
Jha AK, Zaslavsky AM. Quality reporting that addresses disparities in health care. JAMA, 2014; 312(3):225-226.
Dweck CS. Self-Theories: Their Role in Motivation, Personality and Development. Psychology Press, New York, 2000.