Comparing Quality In Childbirth: Key Questions For Doctors And Hospitals

I’ve heard from a lot of moms this week about our new online tool for Comparing Childbirth in Massachusetts. It offers a side-by-side review of hospitals using five quality measures.

photo: Matha Bebinger

photo: Matha Bebinger

OK, these mothers say, quality measures are important, but I don’t want to make a decision based on stats alone.

So here’s a way to translate these measures (which experts say are good ways to assess quality) into an action plan. It’s a list of questions you can use when choosing the doctor or midwife who will help deliver your baby. Please add your own below!

Question: What is your C-section rate?
Background: Many childbirth experts say 15 percent is a good target rate. If the rate for your doctor or the hospital where he or she works is higher, have a conversation about why.

Question: When you are called to the labor floor, do you still have responsibilities in the office?
Background: Some hospitals have or are moving to scheduled hours for OBs in Labor and Delivery units. But in many places an OB is pulled between office hours, labor and sometimes surgery as well. Some childbirth experts say these time pressures push doctors to opt for more C-sections that are medically necessary.

Question: What is your practice regarding elective inductions? Do you induce women before 39 weeks if everything is going well? How long do you suggest women wait, past their due date, to be induced?
Background: Many childbirth experts say babies should not be delivered before 39 weeks to avoid complications, and because babies need the last two weeks for brain, lung, and other vital organ development. Some hospitals wait until two weeks after a mom’s due date to induce because waiting for labor to begin naturally can help women avoid a C-section. But inductions are needed in cases where the mom or baby are in distress.

Question: Once you find a doctor you like, if he or she is part of a larger practice, ask…Do all the doctors in your practice share the same philosophy about: inductions, epidurals, when to declare a mom is no longer making progress in labor? Continue reading

Berwick Weighs In On Dispute Over Medical Quality Standards

Medicare’s Pioneer ACOs are arguably leading the most important experiment under the Affordable Care Act.

Back in 2011, just before Medicare named the 32 providers who would test new ways to deliver care with better quality and lower costs, Don Berwick, then the leader of the Centers for Medicare and Medicaid Services (CMS) said, “for Medicare, coordinated care represents the most promising path toward financial sustainability and away from alternatives that shift costs onto patients, providers, and private purchasers,” in this New England Journal of Medicine article.

Don Berwick, former head of Medicare and Medicaid, steps in to mediate a dispute over hospital quality measures.

Don Berwick, former head of Medicare and Medicaid, offers advice on hospital quality measures.

So when Berwick (who is also seriously considering a run for governor of Massachusetts) said last week that he’s advising some Pioneer ACOs in their dispute with CMS about how to measure quality, my ears perked up. Today, he clarified that he’s only spoken to one ACO executive who called to ask for his advice. Berwick points out he can’t, in accordance with federal ethics rules, get involved in direct negotiations.

Berwick says it’s important to “stay on the high road with respect to the purposes here. The idea of ACOs is important and it (quality) is an important component in the whole move toward integrated care. So let’s not throw the baby out here.”

Berwick, who is also busy helping Britian’s National Health Service recover from an “enormous illness”, offers the Pioneer ACOs some guidance.

“As you work through solutions, stay on the high road. And then, try to get to a platform where the discussion is not, will we play or not, but can we work this through at a technical level.” Continue reading

Searching For The Best Colonoscopy In Town


All Martha Bebinger wants is a good colonoscopy. Don’t we all? But look at the lengths she has to go to in order to find out which doctors are good, who finds the polyps and what the actual cost of the procedure is. Her search shows that while everyone in health care talks about the importance of transparency, it’s not here yet. Here’s the top of Martha’s story:

Someday soon, you’ll need a routine medical test, perhaps an ultrasound or a mammogram, and you’ll obviously want the best. But the quality of health care tests and procedures can vary a lot depending on the doctor or hospital, and it’s not easy for patients to find information about quality.

Still, we’re all supposed to be choosing our care more carefully these days. So when I got a scribbled note from my doctor saying that it was time for a colonoscopy, I set out to find the best one in Boston.


I used to think a colonscopy is a colonoscopy, just one of those tests we have to get when we hit middle age. Then I met James Tracey, a gastroenterologist (GI) who does more than a thousand colonoscopies a year. He starts telling me about this running competition he has with other GI docs, one in particular at Hawthorn Medical Associates in North Dartmouth. It’s about who has the highest rate for finding polyps in patients during a colonoscopy.

“When he and I walk down the hall, it wouldn’t be uncommon for him to mention his percentage just to get me going,” Tracey says. “And of course that redoubles my effort that I’m not going to have that edge over me! I’m going to make my numbers as good as his.”

Tracey tells me some doctors in his practice find polyps in twice as many patients as others. Hold on, I think, this seems pretty important. I’m getting this not-so-pleasant test to look for adenomas, those polyps that can develop into colon cancer. So I ask Tracey, why is there such a big difference? He reminds me the colon is a five- to six-foot-long tube packed into the abdomen. Continue reading

Health Care Goes To The Movies — And The Picture Is Bleak

Politico notes that three new films exploring various broken aspects of the health care system — overtreatment, high cost, lack of access and more — are all coming out in the next few days:

We haven’t seen them all ourselves, but just so you know: “Money and Medicine,” shot at UCLA Medical Center in Los Angeles and Intermountain Medical Center in Utah, airs on PBS tonight. “The Waiting Room” goes inside a safety net, Oakland’s Highland Hospital, and it premieres Wednesday in New York. And “Escape Fire,” which we mentioned last week, has held screenings in several cities and med schools and goes into wider release next week.

Maureen Bisognano, CEO of the Institute for Healthcare Improvement here in Cambridge, offers a few more details on Escape Fire, which was inspired by a speech by her predeccessor, Don Berwick. Writing on the IHI leadership blog, she says:

The title is probably familiar to a lot of you since it’s inspired by Don Berwick’s 1999 National Forum keynote in which he recounts the use of a radical approach to wildfire survival —- setting your own smaller fire to prevent the larger fire from overwhelming and consuming you —- and offers this “disruptive (even counterintuitive) innovation” as a metaphor for what’s needed in health care. Don appears in the film, along with journalist Shannon Brownlee, prevention advocate and wellness expert Dr. Andrew Weil, and a host of other innovative leaders in health care.

The film closely follows the often heart-breaking challenges patients and clinicians face as they try to treat, and be treated, in a fragmented, costly, and often ineffective system. I was particularly struck by the account of a young primary care physician from Oregon, and her agonizing decision to leave a practice that was not meeting the needs of her patients, and not satisfying her professionally. The hope and renewed energy she found in pursuing a fellowship and practicing in a new model underline the power and promise of redesigned systems of care.

Before You Claim Global Payments Are Improving Care…

Everyone’s fretting about the cost of medical care, and whether changes in health care delivery and payment systems will save money. But what about the more intimate aspects of medicine? What about the actual care?

WBUR’s Martha Bebinger offers her thoughts:

A Health Affairs report out last week concludes that a relatively new global budget contract in use by Blue Cross Blue Shield of Massachusetts has “improved care.” Hold on. If this is the threshold for success, then the move to global budgets is going to disappoint a lot of regular, non-medical people, like me.

Take a closer look at the evidence of “improved care” in the report. There are two charts (and summaries, both are below). The first includes scores for 21 ways to measure whether patients received recommended preventive or maintenance care. The second looks at whether patients with diabetes, hypertension and cardiovascular disease are more likely to have their ailments under control with care through a global budget than through fee for service. Yes, there is some evidence that patients are receiving better preventive care.

But to me, “improved care” should mean more: Are patients in a global budget healthier, happier and more productive than those who receive are through traditional fee for service? I understand that measuring “health” is really hard. One quality guru told me that the U.S. has not expanded ways to measure health care quality since we started using HEDIS in, was it the early ’90s? OK, but if you can’t tell me I will be healthier under a global payment, then don’t make the claim.

Here are some examples of things I want to know when comparing patients in and outside a global budget:

1) Do your kids with asthma miss fewer days of school?

2) Do adults diagnosed with depression miss less work?

3) Are patients readmitted to the hospital for the same or a similar ailment less frequently?

4) Do patients develop fewer hospital acquired infections?

5) Do moms suffer fewer complications after a normal vaginal delivery?

I don’t want to minimize the importance of helping diabetics keep their blood sugar under control. This is important. But I need more clear, understandable proof of “improved care.” Is it out there?

Here’s the chart on the 21 preventive and maintenance measures:

Continue reading

Sick (And Poor) In Massachusetts: Longer Waits, Less Satisfied Patients

(Harvard School of Public Health/WBUR/Blue Cross Blue Shield of Massachusetts Foundation/Robert Wood Johnson Foundation)

Brecah Bollinger, a 42-year-old mother of three in Quincy, requires a lot of medical treatment. But, she says, she often feels like a critical element is missing from her health care: the caring part.

Diagnosed with an immune system disorder, sarcoidosis, Bollinger has near-constant joint pain, trouble breathing, deafness in one ear and a slew of other symptoms that prevent her from holding a job, she says.

She’s on MassHealth, the state’s subsidized Medicaid program for low-income residents. But Bollinger says that as soon as she steps into the doctor’s office, she enters a world in which she feels inferior — rushed, ignored and discounted at each step. “I call it assembly-line health care,” she says. Doctors have abruptly stopped her from talking by putting a hand in her face, suggested she’s addicted to painkillers and left her alone in an exam room in the middle of a medical history, seemingly too busy to take her myriad symptoms seriously, she says. Although Bollinger reports that she was assigned a primary care doctor five years ago, she’s never seen her: that doctor’s schedule is always full. So Bollinger says she just takes whichever provider happens to be free.

“I’m treated horribly,” she says. “I want my doctor to be thorough even if it takes more than five minutes. Frankly, I’m embarrassed to be on MassHealth — they think, ‘Oh, you’re poor, you must be a drug addict.’ Or, like, ‘Your insurance doesn’t pay me enough to be thorough.’ ”

Despite nearly universal health insurance coverage in Massachusetts, which has clearly helped residents, mainly the poor, gain access to medical care, disparities persist.

Bollinger says she has a friend with renal cell cancer who is covered by private insurance and experiences health care in an entirely different, more humane manner. “She has Blue Cross and they treat her like a queen,” Bollinger says. “They pay for her transportation, and her primary care doctor, on days off, calls her just to check in.”

It’s tough enough being sick, but when you’re sick and poor, you’re far more likely to experience long waits and care that leaves you unsatisfied and feeling discriminated against because you’re on Medicaid or other public insurance.

In our poll, Sick in Massachusetts, we asked residents who said they had a serious illness, medical condition, injury or disability requiring a lot of medical care, or spent at least one night in the hospital within the last year about their experiences. We found that sick people with lower incomes (under $25,000) are significantly less likely than middle-income (from $25,000 to $74,999) and higher-income folks (over $75,000) to say they are very satisfied with their care. And more than one-fourth of the lower-income sick report that they were treated worse than others because of their insurance status, a significantly higher proportion than for middle-income (13%) and higher-income (2%) sick. Continue reading

Consumer Reports Rates Mass. Doctor Groups From Patients’ Perspective

For the first time in its history, Consumer Reports, the trusty rater of cars and appliances, is publishing ratings of nearly 500 primary care physician groups in Massachusetts using data from Massachusetts Health Quality Partners.

The first-in-the-nation ratings, which you can find here, include 329 adult practices and 158 pediatric practices around the state and are drawn from MHQP’s statewide patient experience surveys, conducted every two years since 2006. Consumer Reports is producing a special version of the magazine for distribution in Massachusetts with a 24-page section, “How Does Your Doctor Compare?”

You can’t see how your individual doctor is ranked, but you can look up how his or her practice rates on a range of quality measures, all from the patient’s perspective. These include how well physicians communicate with their patients and coordinate medical care; how well they know their patients; hoe well they give preventive care and advice; and whether patients would be willing to recommend their doctor to family and friends.

The patient experience survey, which includes 47,565 adults and 16,530 parents of children (all with commercial health insurance) also includes questions on patients’ feelings about the rest of the office staff: the nurses, receptionists and the folks who deal with billing and insurance. (Practices had to have at least three physicians to be rated.)

As more patients buy high-deductible health insurance plans and pay more of their own money for medical care, these types of quality ratings will take on added importance, says Barbra Rabson, Executive Director of Massachusetts Health Quality Partners “The need for this information is escalating,” she says. Continue reading

GAO: Health Care Cost Information Tough For Consumers To Obtain

A recent report from the U.S. Government Accountability Office details what many patients already know: when it comes to obtaining information on the cost of health care before getting treatment, consumers are often left in the dark. Here’s what the GAO found:

1. Multiple Factors Undermine Transparency

“Several health care and legal factors may make it difficult for consumers to obtain price information for the health care services they receive, particularly estimates of what their complete costs will be. The health care factors include the difficulty of predicting health care services in advance, billing from multiple providers, and the variety of insurance benefit structures.”

2. Questioning Tests and Insurance Status

“For example, when GAO contacted physicians’ offices to obtain information on the price of a diabetes screening, several representatives said the patient needs to be seen by a physician before the physician could determine which screening tests the patient would need. Continue reading

Hospital Culture Linked To Heart Attack Survival

CEO turnover, attitudes toward medical errors and the overall gestalt of a hospital has a direct impact on heart attack patients’ 30-day survival, according to a Yale study detailed in The Wall Street Journal.

The study, which appear in The Annals of Internal Medicine, concludes:

High-performing hospitals were characterized by an organizational culture that supported efforts to improve…care across the hospital. Evidence-based protocols and processes, although important, may not be sufficient for achieving high hospital performance in care for patients…

In other words the culture and priorities of a hospital may be as important as its medical protocols in terms whether you live or die after a heart attack.

Or, as the story says:

…the presence of a “strong organizational culture” was associated with variances in death rates of as much as 9.5 percentage points.

The researchers conducted interviews with a total of 158 staffers — all involved with heart attack care — at 11 hospitals across the U.S. They found few differences in what protocols the hospitals used in treating heart attacks, but big ones in how hospitals were managed and how they approached quality improvement.

“It’s not so much what they’re doing but how they’re doing it,” Leslie Curry, a researcher at Yale’s Global Health Leadership Institute and lead author of the study…

High turnover among nurses was also a trait of hospitals with high 30-day mortality rates, the researchers found.

Using mistakes as learning experiences as opposed to reasons for punishment was another characteristic of top performers, Curry says. And views of nurses, pharmacists, technicians and even housekeeping staff were highly valued in the team approach used at the best hospitals, she added.

Time To Check On Your Primary Care’s Quality; Latest Statewide Ratings Are Out

Hot off the presses: New data that let you compare your primary care doctor to others statewide on 25 national measures of care, from diabetes to asthma to depression to the simple sore throat. WBUR’s Martha Bebinger reports:

Primary care doctors in Massachusetts are above the national average when it comes to providing preventive care, but there are still wide gaps in the quality of care they deliver.

“What that means is that you’re not getting the same care when you go to different doctors,” says Barbra Rabson, the executive director at Massachusetts Health Quality Partners (MHQP). “As patients we need to look and see how our physicians are doing because we want to make sure we’re going to physicians that are providing the best possible care,” adds Rabson.

MHQP surveyed more than 4,000 primary care doctors for this latest score card on the quality of physician care. The findings show, for example, that many physicians prescribe antibiotics for a sore throat without knowing if their patient has strep. Patients can look for their physician’s results here.

Here’s how MHQP sums up the latest data:

Primary care physicians in Massachusetts are making strides to improve overall care by closing gaps in variation, according to MHQP trend data. For example, colorectal cancer screening is one area of improvement. The screening rates have improved by eight percentage points over the last three years (from 69 to 77%) and variation among medical groups has shrunk by 10 percentage points (from a 47 point difference to a 37 point difference).

But there are areas where not all health care in Massachusetts is the same. When measuring how often a group tested children with a sore throat for strep when prescribing medicine, some groups gave the recommended care 100 percent of the time, while others did so only 37 percent of the time. A variation of 63 percentage points means that patients do not get the same care in every doctor’s office and that some doctors provide patients with a more appropriate level of care.

And here are some wonderfully succinct points fromthe MHQP release: Continue reading