When is Healthcare “Good Enough”?

If I have a Medicare patient with a hemoglobin A1c greater than 9, my quality rating goes down. The target value is 7 for people under 80 and 8 for people older than that. But as long as my patient is under 9, I’m in good shape.

The magic number for inadeqate blood pressure control is 140/90 or greater. But 139/89 is a passing grade, even though studies have shown that for high risk patients with known heart disease, a target under 120/80 is desirable.

So what’s a busy doctor going to do? I’m afraid the answer in many situations is just aim for good enough, because that’s all we are being measured by.

I worry a little bit that our quality ratings might make us put so much effort into the outliers that we don’t have enough time or energy left to fine-tune the people who are off the mark but not in the range that hurts our scorecards.

Oftentimes the outliers, for example with diabetes, are people who don’t believe in the severity of their situation or people with social circumstances that prevent them from eating healthy, which is often a money problem relating to lack of financial resources to buy healthy foods.

So where do we put our effort? Bringing the few outliers into a desired range or bringing a large number of “good enough” control patients to more ideal levels? Our incentives are aimed at going after the outliers, but maybe we will do more good if we focus more on the relatively large number of patients who are just a little bit below those panic values.

For an individual doctor with a unique patient population, maybe we need to decide where to cut losses for the outliers so that we don’t neglect a larger cohort of patients who might need more focus and attention from us. Because, really, this is about our patient population’s health and well-being, more than our own scorecards.

There was a time when doctors focused on each patient in front of them without considering how that attention would affect other people with bigger problems, or those who didn’t have a doctor to turn to. Now, we have obligations to others, like the insurance companies, which can create tension in our own decision-making about where to put our effort.