Under My Skin

Quality Control


I asked a new acquaintance what he does for a living.

"We make call center software," he said. "When you hear, ‘This call may be monitored or recorded for quality and training purposes,’ – that’s us."

"How do you monitor quality?" I asked.

He ticked off several measures: efficiency, productivity, courtesy, and so forth. "All employees get a report card every day, showing where they stand on several parameters, such as how many problems they were able to solve; how long it took; and how many times they interrupted the caller."

"So your quality-control software helps them do their job better," I said.

"Of course," he replied. "If they’re falling short, they meet with a supervisor who reviews calls with them in person, step-by-step, so they see what they need to work on."

That sounds sensible enough. It stands in stark contrast to the way we are measured.

I’ve previously written about how some insurance companies have rated me Tier I (hooray!), then how one of them demoted me to Tier II (the shame!), saddling their patients with a higher copay for choosing a less-efficient, lower-quality doctor like me. I described my Kafkaesque experience trying to learn the charges against me and my futile efforts to overturn or even understand them.

Then last month, I got this year’s rating from one of the insurers – still Tier I (hooray!). Showing either that I really persevere or that I refuse to learn from experience, I wrote the medical director who had signed this latest report card:

Thank you for my grade. Could you please help me understand two criteria on which I seem to have excelled: 1) "fungal infection w/o surgery" and 2) "skin cancer, major, w/o surgery." Is there a fungal infection w/ surgery? Should there be a major skin cancer w/o surgery? Thanks so much.

To my gratified astonishment, he actually called me!

I thanked him for his responsiveness. "The company that developed our software to measure quality and efficiency sold out to another company," he said, "which is now being run by a third firm. But the methodology is very robust." In other words, he had no idea what the numbers meant either.

"As to the two episode treatment groups you questioned," he went on, "a diabetic with actinomycosis may need amputation. ‘Fungal infection without surgery’ would refer to less severe fungi. As to ‘skin cancers, without surgery,’ that just means you performed a biopsy or simple excision, not Mohs or reconstructive surgery."

I thanked him for the clarification, but pressed on. "For fungal infections," I said, "I make a diagnosis and prescribe a generic cream or, occasionally, prescribe an oral treatment. I rarely do a KOH [potassium hydroxide] prep, and in any case don’t bill for it because it’s not covered. Once in a great while I send a nail biopsy or, even more rarely, a culture. As for skin cancers, I do a biopsy to make the diagnosis, and then either perform a simple removal or send the patient elsewhere.

"If I wanted to improve my performance," I concluded, "how much less could I do?" He had no answer.

"I’m happy you rated me Tier I," I said, "though another insurer rated me Tier II on the basis of the same data. When I asked to see those data, they sent me a spreadsheet with 4,700 rows, half with missing demographics, and 27 columns, each with indecipherable acronyms. Can you honestly tell me that my report card gives me what I need to become a better doctor?" Again, he had no answer.

"I’ll tell you what I think," I went on, "You don’t send these reports to improve doctors’ performance, which they obviously can’t. You send them so you can tell your investors, your regulators, and possibly yourselves that you are doing something useful to improve medical quality and efficiency, when in fact you’re engaged in an empty ritual that does nothing of the kind." For a third time, he said nothing.

I thanked him again for his courtesy and hung up.

My little speech will have no impact, but it felt good. If my call center friend’s software doesn’t produce results, his firm will lose sales, revenue, and market share. He, therefore, has to make a product that delivers.

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