Is Accountable Care at Odds with Improved Care?


All physicians want to deliver quality care. But do the checklists required to measure quality really add up to giving patients the results they want? As the American College of Gastroenterology Annual Scientific Meeting gets underway in Honolulu, the question came up in the context of managing irritable bowel disease.

Quality medical care boils down to one sentence, said Gil Melmed, MD, associate clinical professor of medicine at Cedars Sinai Medical Center in Los Angeles, CA. "Do the right thing to help patients," speaking to a packed house at a symposium at the American College of Gastroenterology Annual Scientific Meeting in Honolulu, Oct. 18.

Deciding what that means specifically for patients with inflammatory bowel disease (IBD) is not always easy. For instance, he noted, there is no consensus or even consistent prescribing pattern for using biologics to treat IBD. "In some zipcodes it is less that 5% and in others it is 60%."

The question of whether mucosal healing needs to be total or if it can be incomplete as long as the patients' symptoms are much better is another example.

"There is a tension between 'accountable' care and 'improved' care, he said.

A physician can be a "robust box-checker' when it comes to following guidelines laid out by the Centers for Medicare and Medicaid Services and other entities but still not be all they could be to their patients.

Official quality measure usually focus on doing specific tasks, such as seeing that IBD patients who are candidates for immunosuppressive drugs have all their recommended vaccinations.

But guidelines based on patient surveys show they want doctors to focus on symptoms and the impact they have on their daily lives. Those include eliminating incontinence, night-time bowel movements, needing narcotic drugs, and having to lose days from work.

There are a raft of organizations that put out quality guidelines, Melmed said "There's AGA, CCEA, ImproveCare Now, ABIM MOC," and other checklists generators. But Melmed suggested listening to patients should come first. "Start small," he advised. "Know how many IBD patients you have in your practice and then start your own program to check for quality," he said. "Improve one small area," whether it is developing a program for telling patients they need certain immunizations (and he believes patients are sufficiently invested in their own care that they can be trusted to get them from their primary care physician) or it could be in the practice management arena.

"Check on the timeliness of returned phone calls, getting test results to patients, seeing that they get reminder phone calls," Melmed said.

While there is a lot of variation in how physicians manage patients with IBD, there is consensus on how to make sure patients feel they are being cared for. "Quality measurement in not necessarily quality improvement," he said.

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