Neal Little, M.D.There’s something that we need to consider in the upcoming healthcare debate about control over the practice of medicine. Recently CMS cancelled a quality measure on beta blockers for MI. Many of us had known for years that this previous benchmark for quality management could not be applied across the board, in the emergency department setting. There was a constant litany of reports against doctors who were just too stupid to know to give this medication, and that compliance was poor. Hospitals were downgraded for their physicians not giving it.

Now all of a sudden, years after we’ve known that they can create problems that outweigh their benefits, they have removed it as a quality measure. Research since 2005, and the removal of the standard by the American College of Cardiology and the American Heart Association in 2007 has finally caught up with CMS. Will anyone be able to ask how many patients had an adverse outcome who received this medication in an attempt to simply comply with guidelines? Will somebody from CMS personally stand up and raise their hand to say that they were responsible for this adverse outcome? If an individual physician screws up, he or she can only do it one patient at a time. Not so for big, powerful standards organizations, they can mandate for the entire country. What is even worse is that they had been ignoring this measure for awhile. This gives you even less comfort about these quality measures. However, the worst of this is the comment that “These measures are not meant to dictate how medicine should be practiced” Really? What else do these standards do? We’ve all had to suffer through the four-hour antibiotic rule for an pneumonia, and the unintended consequences of unnecessary antibiotics for some. Now I have to do a “ time out” before I intubate someone, just because a surgeon might cut off the wrong leg. The fundamental fact is that there is so much variation between patients, and the complexities of their medical conditions, that simple rules that apply to everyone are extremely difficult to formulate.

It seems that there is an unchallenged assumption that uniform care is good care, and we can measure care across very diverse populations and come up with a single score. And then to think that consumers can simply look at the scores and decide that good care is being given is another gigantic leap of faith. Is CMS going to go back and re-rank all the hospitals now that they’ve changed the rule on beta-blockers? Are good hospitals those that refused to comply with the beta-blocker standard? Are those that gave the medication unnecessarily now the bad ones? I’m all for high-quality medical care and measuring good care where it can be measured appropriately, however I’m not sure some of the big powerful organizations are doing patients a favor with many of these rigid, across-the-board quality measures.