Defining Quality in Healthcare

So how do people choose a healthcare provider? We jokingly refer to it as the three C’s – Cost, Conversation and Quality. The truth is there are a lot of factors that go into a healthcare decision, but quality would seem to be what trumps all. But how is quality defined?

There is a lot of talk around quality. It’s another of the industry buzz words like transparency. And like transparency, quality can be entirely subjective. Ask the question, what is quality, and ultimately the answer emerges “I know it when I see it.”

But what are the elements of quality? We speak with people at different levels of income and various walks of life about quality in healthcare all of the time. Our conversations are informal, but interesting. Here is some of what we hear.

Outcomes

Generally the first response we get when we ask some to define quality is “It’s all about outcomes.” – the results. How quickly a doctor’s patient recovers or even how long they survive. There is a significant amount of data out there on outcomes, but if people are honest with themselves and really dive down into how they’ve selected a provider, they realize that outcomes received 3rd, 4th or even less priority in your choice if it ever was given consideration at all. Often times, it is simply assumed based on a provider’s reputation.

Outcomes data is publicly available. Morbidity rate or the number of deaths per hundred or thousand with a certain diagnosis can be a quantifiable metric. So which outcomes data is it? Just be sure to take into account that an oncologist specializing in stage 4 patients is understandably likely to have a higher morbidity rate than an oncologist who sees patients in all stages.

Experience

This is another metric that is available, but open to interpretation. Do you base experience on how many years a doctor has been practicing? Or how many times has a provider performed a certain procedure?

Convenience

In our drive-thru, 24-hour, print on demand society, convenience is a major deciding factor. If you’ve ever been to a retail based clinic, you know just what we mean. It’s a heck of a lot shorter wait than the ER or even your doctor’s office. You might really like your doc, but if you’re sick, who wants to wait until this afternoon or tomorrow?

Where do you get your prescription? Those large chains with a location on virtually every corner are pretty darn convenient. But do they fill the order right the highest percentage of the time? What about the cost tradeoff? Our research shows that those that are most convenient are often the most expensive.

Having sharp chest pains? I bet you didn’t drive anywhere other than the closest emergency room. Do they perform the most open heart surgeries? Are they more likely to try a less invasive solution like a stent before cracking open your chest?

Location

The three most important things in real estate are location, location and location. So how far did you travel for your doc? Did you do a national search to find the best specialists? Did you look internationally? If you live in a small community, you may be fortunate and have a really good set of options for healthcare. But it’s doubtful that you have the top specialists for your specific need. Chances are you’d have to head to a larger city with one or more hospital systems to get the better specialists – though there are exceptions. I know of one instance where a top NY specialist decided he wanted the simpler life and moved to rural

Referral

If real estate is location, location and location, then for providers, it’s referral, referral and referral. Most people go to the provider their physician refers them to. Your physician will direct you to other doctors within their medical system – probably other physicians associated with the hospital(s) where they have privileges.

Many of the large hospital systems have an ongoing practice of purchasing outside clinics. While those are viable businesses and they can justify their purchase through the revenue earned, there is a more important aspect – the referral. Hospitals depend on the front line physicians to make referrals for the higher dollar procedures that their patients will require. There is little better way to ensure that they get those referrals than to tie them into the hospital’s system.

Now don’t get me wrong, federal law prevents doctors from referring patients into businesses from which they profit. But once the doc is in the hospital’s system, the hospital has numerous ways to encourage using their providers. They may offer administrative and billing services, a common appointment setting system, have ongoing internal communications that let their providers know what other providers are available and many other incentives. That may all sound trivial, but doctors are busy people, and just like convenience is a factor for you, so it is for them.

Bedside Manner

How you get along with a physician heavily influences your choice of a provider. It can be the deciding factor in vetoing a doc. Numerous people we talked with have selected a doc because they have a great reputation, have been referred into them and have all the right experience and credentials. And then, they have rejected that provider because of bedside manner. I am guilty of vetoing a provider for my own needs over bedside manner. He scooted in and out and did not give me sufficient time to answer questions and assess my situation. He is head of surgery for a department in a large hospital specializing in that particular field and came recommended by my physician whom I trust.

Cost

Even among the well-to-do and very well insured, we heard, “Cost is not an issue.” But don’t be fooled by that cavalier attitude. Sure in situations of life and death, no one asks about the costs. But when it’s not, it is all about the dollar spent. Even if you don’t think so, your insurer probably does, and your provider is trying to watch that dollar as well. Providers will often try the least invasive and least costly procedures first before moving into the more expensive procedures and/or referring you on to a specialist. It may be in part because that’s what the insurer will allow, and it may be an effort by your provider to watch what they know you are not. So even if cost is not an issue, be aware that it is distinctly a factor in your care and may be part of what determines when and to which provider you ultimately get referred.

Cost can be a major consideration for uninsured, underinsured, treatment outside of coverage or whatever the reason. The rates providers billed, get reimbursed, their insurance paid and their patients paid are all readily available. Just check out the Compare tab in the change:healthcare website.

And if you think that costs are not an issue, consider how providers handle their billing – what they get pre-authorized, what is covered or not could determine what part of the bill you get stuck with at the end of the day. Providers who are on top of their billing may do a good job of making sure they get the insurer to pay most of the bill and minimize the cost to their patients. If they are not, you may wind up with more of the bill than you would have with another provider who did a better job. So it’s important to see how your provider fares in what the patient is left paying versus other providers of the same services and procedures.

Network

Your insurance network plays a strong role. This is a factor that ties closely into the issue of cost since going out of network generally implies a higher cost for a provider. However, if youve ever gone through a list of doctors within different plans to find out if your doctors are listed there, your network is influencing which docs you will see. Any future selections are then constrained to those providers in network since they are often inclined to refer to other providers who are in the same network.

Your insurer will provide you with a directory of providers who are in-network. What about those who are not? You’ll have to go someplace else for that list.

The Water Cooler and Over the Fence

Choosing your healthcare provider is arguably the most important decision you will make in your life. It can literally be a life and death type of decision. And what ultimately decides where you go comes down to that conversation that you have over the back fence with your neighbor or friend or the water cooler conversation with a co-worker (who, by the way, shares the same network you do through your common employer).

If your source is a qualified medical professional, their opinion carries great weight. But if it’s not, it’s really more of an assessment of that person’s personal experience. They are reacting to their personal outcome, the convenience of the doctor, the proximity to them, the referral they got from another physician, the amount their insurer left them to foot, the doctor’s bedside manner, their compatibility with that physician’s personality, or the conversation that they had with someone last week over the fence or at the water cooler.

What’s a Responsible Healthcare Consumer To Do?

Do your research. Seek out the quantifiable data and select a few providers. Call around. Ask about them. Google them. See what other people are saying about them. And when all else fails, go see them. Have an office visit. See what you think. After all, it’s your health we’re talking about here, not that annoying guy in accounting.

What did I miss? Any other suggestions? We would love to hear them.