Who Determines Quality in Health Care?

By Richard A. Armstrong MD FACS

Today, it doesn’t matter if you are a patient or a doctor, everywhere you turn someone is measuring something or surveying something or requiring the reporting of metrics. Patients are flooded with satisfaction surveys, doctors are inundated with pay for performance reporting requirements, physician quality reporting systems and, soon on the horizon from the federal government, the new Merit Based Incentive System. It’s enough to make your head spin. So, just exactly what is going on?

In the name of improving “quality” in the delivery of health care services, multiple entities are heavily invested in the process. They often claim it is to “protect the public”, but all of this activity really boils down to one unified theme…who pays?

It is true that health care is complicated. What is also true is that it is a huge segment of our national economic activity. An estimated $3.5 trillion moves through our health care economy yearly. It should be no surprise that those who are purchasing health care would be concerned about the quality and value of their purchase. What is problematic is this…how do you measure it? Also, how can anyone be certain that they are measuring the “correct” things?

I am a general surgeon in a small community. It is always helpful for me to examine the basics when trying to analyze a complex situation. This is no different.

Health care is a service industry. Those who provide care, in my case as a surgeon, are serving a customer base. I am quite aware that referring to patients as “customers” is bothersome to many, so I’ll ask for your patience as we work through this analysis. Let’s walk through a common example to illustrate this point.

We’ll call my patient Jack. Jack is a middle aged man with an inguinal hernia…a bulge in his groin. The hernia is interfering with his ability to work so his family doctor has referred Jack to me to for surgery. The referral to me from the family doctor is the result of Jack’s doctor’s previous experiences with my treatment of patients with hernias. Other patients have concluded that I do quality work which they find valuable. You may see where I am going with this.

Jack is well known in town. Every morning before work Jack meets his friends for breakfast at the local diner. The diner is a popular place. Regulars include the owner of a car dealership, a banker, an insurance broker, a mortician and often the superintendent of schools. Everyone knows Jack and they share stories in the morning over coffee, eggs and bacon. Jack tells his friends that he is going to have his hernia fixed…by me.

The day of Jack’s surgery arrives. He is checked in and I spend some time with him checking over details and also meet with his wife and daughter to answer questions and let them know we’ll take good care of Jack and I’ll speak with them as soon as his hernia surgery is over. I return to the operating room, Jack is anesthetized and the procedure begins.

In my mind, as I repair Jack’s hernia, who is the “quality assurance committee” looking over my shoulder? You guessed correctly…Jack’s family, the owner of the car dealership, the banker, the insurance broker, the mortician, the superintendent of schools, and most importantly, the owner of the diner who knows everyone in town. Imagine the conversation at the diner if Jack’s hernia repair turns our poorly, if he gets an infection or he has chronic pain and can’t work or his hernia recurs. From the moment I first meet Jack in the office, until his final post-op visit the onus is on me, the provider of the service, to provide Jack, the “customer” with a quality experience which he values. If I do my job well, from start to finish, what will Jack talk about at the diner? Also what impression will I leave in the mind of Jack’s family doctor?

My intention would be to leave a positive impression on Jack, everyone at the diner and Jack’s doctor. The reason is quite clear. If I am not trusted to repair more hernias for patients like Jack, I can’t pay my bills or feed my family or walk into the local diner and shake hands as their trusted surgeon.

 In this example it would be disingenuous of me to claim that determining quality and value in the provision of health care services is as straight forward as my interaction with Jack, but it isn’t that far off. What has become problematic in our current payment systems is the identification of who exactly is the customer in this transaction. Ideally, as in the example above, the doctor should be working for the patient. But what happens when a third party, a private insurance company or the government is the purchaser of health care on behalf of the patient consumer? We are experiencing that today in America and the confusion is becoming mind numbing for both patients and doctors.

As we all work though this together it is helpful for us to define the relationship between those who provide the care and those who consume it. In our profession this is referred to as the physician-patient relationship. There is a professional component to the relationship which has resulted over centuries in doctors being trusted by patients. There is also an economic component where in its most direct form the patient as consumer pays the doctor as provider a fee for the service rendered, as in any business transaction. It has been the intrusion of our expanding and more complex third party payment systems which have made this so confusing to both patients and their doctors.

As we all work through this as a nation it would be wise to keep in mind that we all know how true the story of Jack and his hernia repair is and how it is repeated thousands of times every day across the nation. Our “system” needs to focus clearly on producing high quality physicians and surgeons who understand why Jack and his family need quality care and that ultimately we are responsible to them, the patients.

It is no surprise that those who are paying for the services expect quality and value. Maybe it would be wise for all of us to re-evaluate how we are paying instead of expanding ever more complex, confusing and expensive “quality assurance” processes.



  1. Marion Mass

    Great analogy! Could I take it a step further and suggest that Jack and all his friends know quality when they see it? Almost anyone else extra pretending they are needed to insure this quality is really just economically and intellectually ‘jacking off’

  2. Margaret stephan

    Too true and sad. My only hope is getting older and will not need this absurdity of monitored health care forgetting every patient with same dx needs different care.

  3. Great article! And exactly why I’ve opened up my own Direct Primary Care practice – it returns the focus to the patient-doctor relationship, and I get to work for my patients – not insurance companies, not big hospital systems, not the government!

  4. Dick,
    Your mastery of the information and delivery of your message is succinct, easy to understand. With your permission, I’d like to use this analogy to speak to local groups such as the Rotary and the Lyons. In my community, a letter like this to the editor of our local newspaper could stimulate conversation as you described because, Jack has already had his hernia repaired by his trusted surgeon, is back to work and is either struggling with the third party payor or appalled by the disparity between what was billed and what was paid. Jack understands the value of a trusted surgeon and knows there’s something wrong here but does not know what to do about it. This could spark engaging dialogue which easily could include local, state and federal elected officials.
    May I use your words and story?

    Washington, DC 20052

  5. I believe “Lyons” perhaps should be “Lions” if you would kindly correct. Thanks. Judy

  6. K Murray Leisure MD

    Excellent, Dr Armstrong. Like, five stars.

  7. The answer to your question? The physician, the patient and the other providers and provider organizations determine quality in health and health care. With regard to “Business of Medicine” metrics? The benchmarks are notoriously low and in fact often substandard. So, let’s get together, physicians with the patients … I repeat … PHYSICIANS WITH THE PATIENTS to get back on track with useful and valuable quality and performance improvement metrics that are consistent with our professional roots and values.
    Michael F. Mascia, MD, MPH
    Founder and President, Veritas Health Care, the non profit

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