When Measuring Care Quality, Some Contracts Miss the Mark

Our son, Andrew, recently took the Partnership for Assessment of Readiness for College and Careers (PARCC) test at school. This is one of the many standardized tests students take to evaluate the success of their school. The testing is controversial and a source of stress to most families with school-age children.

After a family dinner of listening to Andrew complain about the testing in school, we were intrigued to see that one of our HBO favorites, John Oliver, had a bit on standardized testing. It was hilarious and a bit naughty, but mainly it made some good points about why standardized testing just isn't delivering the results it aimed for over a decade ago. Not a minute after viewing the piece we turned to each other and said, "Doesn't this remind you of our AQC contract?"

Our alternative quality contract, or AQC, with Blue Cross Blue Shield of Massachusetts (BCBSMA) is a global payment plan for HMO patients. In April, MedPage Today ran a great article about Massachusetts' physicians expressing frustration with the AQC. Frustrations very similar to those expressed by John Oliver about standardized school tests.

AQC, in theory, provides a way to measure and reward quality of care. But when the contract is applied daily in our office the measurements have very little to do with quality and really are just meaningless measures.

The "quality" measures in the AQC contract are limited to measures that the insurance company can easily quantify, not necessarily measures that indicate the quality of healthcare. For example, chlamydia is the most common sexually transmitted infection in adolescents and, for that reason, we follow the American Academy of Pediatrics (AAP) recommendation to routinely screen sexually active teens for chlamydia. However, the AQC "quality" measure only tracks how many adolescent females who are prescribed birth control are screened for chlamydia. The measure doesn't track males. The measure doesn't consider that a female may be on birth control and not sexually active. The AQC measure misses the mark by picking only easy data to measure.

Problems with the chlamydia measure and others like it, however, pale in comparison with the ridiculous AQC patient satisfaction survey. We want to state clearly up front: We love patient feedback. We have employed a SurveyMonkey survey since the day we opened. Patients are invited via a link within 24 hours of their visit to complete our patient satisfaction survey. We take the information very seriously and have changed a number of policies over the years based on that feedback. The proof is in the pudding: Our patients are loyal to us, from birth through age 21. Compare that to most patients who switch insurance plans pretty much on an annual basis.

For the AQC patient satisfaction survey, we are rated in four different categories: communication, access to care, integration of care, and knowledge of the patient (all of these are scored by patient survey). Our current scores are between 88 percent and 96 percent in all ratings which is as high, if not higher, than our peers. We are satisfied by those scores especially since we know these same patients are unhappy with our refusal to give unnecessary antibiotics, our cheerleading for vaccines they don't want, and the ever-increasing deductible bills we send to them. The goal, as set by the AQC contract, is to do better on the survey year after year. That's it: Just do better. There is no consideration as to what is high enough. There is no consideration as to what this score means to the actual overall health of our patients. Just improve. We don't see how to do that without compromising medical decision making or stopping mailing bills.

We only see problems with the AQC growing. BCBSMA is publicly proud of its AQC contracts and is planning on expanding the program to include PPOs. When patients have an HMO we have some influence to limit unnecessary referrals, but with a PPO we often do not find out until after a visit that a patient self-referred to a specialist. We are being set up to fail.

We do not believe the AQC contract has improved the quality of our care and want to be clear that we do not support national expansion of such contracts.

What do you think? Have your current pay for performance contracts improved the quality of care you provide?