My fundamental beef with CMS's PQRI and NCQA's PCMH is the flawed premise that primary care quality should be measured by the sum of organ system management.
The essential value of primary care is not the sum of organ part management but the comprehensive care we give to people.
1: People are much more complex than their organs.
It is possible to maximize adherence to an organ system guideline and create an overall decline in health & well being. The feedback from patients is along the lines of "yes, doctor, but my quality of life is terrible."
2: Excellence in organ system management does not translate to excellence in primary care.
A decade of teaching the Chronic Care Model all over the US demonstrate the lack of 'spread' from excellent condition management to excellence overall. The recent study of the massive p4p program in the UK's NHS demonstrates the same.
3: Excellence in primary care is linked to overall population health improvement and reduced costs, organ system management is not.
What's the ultimate goal - every diabetic person gets great guideline adherent-care or we serve all our patients well?
Ultimately we want both, but the premise that we can do both by starting with a paradigm based in organ system management flies in the face of years of experience observing this approach fail across the US (with very rare exception) and the evidence in numerous studies.
Because it is a fundamentally flawed paradigm that impedes our ability to deliver on the true quality of care we offer as primary care, we must reject PQRI and other flawed p4p approaches.
L Gordon Moore
I understand the logic and absolutely commend your practice's effort and intent and certainly agree wholeheartedly that almost any extra resource to primary care could be worth the effort.
My beef is with the subtle yet profound implications of the underlying assumption that PQRI data has anything to do with good comprehensive care. This assumption is made by those who set up the program and is the same basic assumption behind p4p, the medical home pilots, and insurer driven quality programs. While the specific manifestation of measures may differ from program to program, they all rest on the idea that there's a link between 'well managed condition X' and 'good comprehensive care.'
The crux of the tension is based on the concept of the greater good. Specialty care is about maximizing condition management and has the opposite effect of good comprehensive care (improved overall population health, improved experience of care).
Primary care is about maximizing the greater good - first for the individual, then in the context of their family, community. When our energies are diverted into efforts that detract from the core of effective primary care we detract from the overall good, we fail at the essential task that makes primary care the foundation of good health care.
Don't leave the PQRI money on the table. We can't afford to have more good practices like yours slip away, but at the same time we have to stand up and cry 'foul' to well-intended tactics based on flawed assumptions that subvert the very core of our value to society.
Posted by: Gordon Moore | September 01, 2009 at 11:01 AM
I had a nice email exchange with a colleague. I'll post her email and then my response. LGM
While I agree with you on this, Gordon, we’re not going to leave money lying on the table. CMS just wants you to report that you’re paying attention to the PQRI matters. If we are providing good comprehensive care to our patients, then that means that we are at least watching the diabetic’s A1C levels, etc. That is what the reporting to CMS for PQRI is about: that we are paying attention and providing good comprehensive care, not that the patient falls into their “perfect” parameters (which is where many of the insurance carrier’s P4P measures are focused).
PQRI does not equal P4P. I would love to see more of the P4P issues change to be more like CMS PQRI.
Karen
Posted by: Gordon Moore | September 01, 2009 at 11:00 AM