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Pricing Transparency and Provider Quality: Insights from Utah HIMSS

Posted on September 10, 2018 I Written By

Healthcare as a Human Right. Physician Suicide Loss Survivor. Janae writes about Artificial Intelligence, Virtual Reality, Data Analytics, Engagement and Investing in Healthcare. twitter: @coherencemed

Working to improve Health IT has been a major focus of Utah HIMSS this year. I am honored to serve as part of the Utah HIMSS Board. Utah HIMSS hosts educational events and luncheons for members. On August 29, 2018  the meeting focused on Pricing Transparency and Provider Quality. Health Informatics is positioned to help reduce waste in healthcare and providing better care for patients.

Bob White works with Select Health, one of the major insurance providers in the state, which is a subsidiary of Intermountain Healthcare. He was able to talk about payment models and value based care work within the Select Health group. Providing more visibility into the cost for patients and physicians has been a major focus on Select Health and payer provider entities have a unique market position. They want the cost of care delivery to be lower since they are paying the cost. Point of service adjudication requires that a lot of workflows need to be coordinated before the patient leaves the office.

Bob asked: How often do we feel like we don’t have complete information to know what is going on and what your options are?

One of the most notable things that he spoke about was the lack of adoption. They have great visibility but not everyone knows where to find that information. Some of the employees at Selecthealth have high deductible plans and in effect, become self-pay members. Becoming more educated consumers is a huge part of what Select Health has done with their pricing transparency.

Katie Harwood from the University Of Utah discussed their pricing transparency tool. The University of Utah is one of the first systems in the country to create an online interactive tool to help predict cost to patients. Patients can look up what a procedure might cost and enter information about their copay and caps. Most importantly, the cost estimator included the cost of facility and cost of provider, so patients don’t get stuck with unexpected out of network bills.

The most common search? Vaginal delivery without complications. I was thrilled to hear them speak because I’m pregnant and my provider is with the University of Utah Health. I got a cost estimate on my second visit to the OB and I was pleasantly surprised that they gave that information.  I was able to pay for what (might be) the cost of my maternity care. Being able to plan ahead is very valuable. The University of Utah has invested in creating bundled payment models to improve care coordination and as a patient, having that information has improved my healthcare experience.

While in development, the University of Utah wanted to add appointment scheduling for patients. Harwood mentioned this created a larger data matching challenge, as it was difficult to match exact providers with procedures. Insurance companies are trying to make it easier for patients to schedule and understand what their costs will be, and physician directories create unique challenges. What if you were a surgeon who performed a total knee replacement but you didn’t have the information connected with the correct insurance company for you to appear in the online scheduling tool?

Interestingly, many people go to the cost estimator tool enter “I don’t know” for some of their search criteria such as deductible and copay. Bridging the consumer gap to give even better information and creating the most accurate scheduling possible starts with efforts to create great health IT tools and adjusting them according to user behavior.

Holly Rimmasch from Health Catalyst was able to ask great questions and mentioned a program that Health Catalyst is doing to promote women in health IT. She served as a moderator and has an extensive background with pricing. They have promoted women in Health IT in the Utah area, including providing student scholarships for their Healthcare Analytics Summit in September.  A key question that Holly has focused on is “Are we making a difference in both quality and costs?”  “Does it translate into cost savings for those that are paying?” Part of her work involves bringing data sources together (clinical, financial, claims, etc.) to create transparency to services and care being provided and at what cost.  Over the last 6 years, Holly has been involved in developing a more accurate activity-based costing system. Accurate costing leads to more accurate pricing and more accurate pricing leads to improved price transparency. I am looking forward to learning more about what Health Catalyst does for improving Healthcare IT in Utah.

Norm Thurston is a Utah State Representative and I was surprised how much I enjoyed his presentation and I will tell you why. Norm Thurston has a background in statistics and I felt confident that the Utah legislature was getting good information about improving healthcare. Representative Thurston spoke about the availability of state data to see things like prescribing trends and billing trends among physicians. He asked Bob White about upcoding- and how the government of Utah looks at billing data to make that information more transparent for payers and providers. The checks and balances of legislators asking about trends based on data aren’t something I see every day in healthcare. Data backed inquiry can improve prescribing. Utah has had a decrease in opioid deaths in the last year, and the healthcare system and state efforts have actively used data to improve the numbers. Utah has historically been a state with a problem and has actively worked to improve rates of opioid deaths. One of the audience comments that I enjoyed was a question from Todd Allen, MD about how they evaluate the statistical significance of prescribing and billing differences. How do we know if using this drug or billing code 75% of the time has better outcomes that in the hospital where it is used less than 65% of the time? Having visibility and data is part of the equation for improving healthcare outcomes, and another part is interpreting the data and deciding best practices.

Should Healthcare Orgs Be Required to Do Zero Cost Accounting?

Posted on August 31, 2018 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

During today’s #HITsm chat, Jeremy Coleman made a strong statement about what he believed every healthcare organization should have to do:

What do you think of Jeremy’s idea? Should every healthcare organization be required to do zero cost accounting? Should every hospital know what their trust costs is for someone to spend a night in their inpatient bed?

These are complicated questions, so let’s start the discussion and see if we can share and learn from each other. At the core of these questions to me is a larger question of whether the price of the services we receive in healthcare should be related to their costs. We all know this isn’t the case when we think about the obscene $20 aspirin you get in the hospital. They charge that price for services they offer because they can. Ok, that’s oversimplifying it, but not too much.

Given that costs aren’t associated with the price healthcare organizations charge for things, I wonder how valuable it is to know how much something costs a healthcare organization. Would knowing this information really change how a healthcare organization operates?

What I think we might find if we do this analysis is that the way things are priced in healthcare really makes no sense at all. However, I think it will also illustrate that there’s no easy path to change the way things are priced in healthcare either. It’s going to take a series of incremental changes that in aggregate will equal a dramatic change. I’m just not sure who in healthcare is patient enough to make these types of incremental changes. Plus, many vested interests will fight against these changes.

I wish I remembered who said this, but I recently read someone who said that insurance companies have hidden behind complexity for years. It’s in their best interest to have things so complex that they don’t make sense so that they don’t have to justify the costs. It’s not just insurance companies that have hidden behind complexity in healthcare either.

As Dan Munro, author of Casino Healthcare, often says, “No one group is to blame for the US Healthcare cost crisis because each segment of the industry is complicit.” Said another way, no one wants to mention that the Emperor has No Clothes. I’m afraid this is why we don’t want to do zero cost accounting and really know how much something costs us in healthcare.

Are We Going About Population Health The Wrong Way?

Posted on March 29, 2018 I Written By

Anne Zieger is veteran healthcare branding and communications expert with more than 25 years of industry experience. and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also worked extensively healthcare and health IT organizations, including several Fortune 500 companies. She can be reached at @ziegerhealth or www.ziegerhealthcare.com.

For most of us, the essence population health management is focusing on patients who have already experienced serious adverse health events. But what if that doesn’t work? At least one writer suggests that though it may seem counterintuitive, the best way to reduce needless admissions and other costly problems is to focus on patients identified by predictive health data rather than “gut feelings” or chasing frequent flyers.

Shantanu Phatakwala, managing director of research and development for Evolent Health, argues that focusing on particularly sick patients won’t reduce costs nearly as much as hospital leaders expect, as their assumptions don’t withstand statistical scrutiny.

Today, physicians and care management teams typically target patients with a standard set of characteristics, including recent acute events, signs of health and stability such as recent inpatient admissions and chronic conditions such as diabetes, COPD and heart disease. These metrics come from a treatment mindset rather than a predictive one, according to Phatakwala.

This approach may make sense intellectually, but in reality, it may not have the desired effect. “The reality is that patients who have already had major acute events tend to stabilize, and their future utilization is not as high,” he writes. Meanwhile, health leaders are missing the chance to prevent serious illness in an almost completely different cohort of patients.

To illustrate his point, he tells the story of a commercial entity managing 19,000 lives which began a population health management project. In the beginning, health leaders worked with the data science team, which identified 353 people whose behavior suggested that they were headed for trouble.

The entity then focused its efforts on 253 of the targeted cohort for short-term personal attention, including both personal goals (such as walking their daughter down the aisle at her wedding later that year) and health goals (such as losing 25 pounds). Care managers and nurses helped them develop plans to achieve these goals through self-management.

Meanwhile, the care team overrode data analytics recommendations regarding the remaining 100 patients and did not offer them specialized care interventions during the six-month program.  Lo and behold, care for the patients who didn’t get enrolled in health management programs cost 75% more than for patients who were targeted, at a total cost of $1.4 million. Whew!

None of this is to suggest that intuition is useless. However, this case illustrates the need for trusting data over intuition in some situations. As Phatakwala notes, this can call for a leap of faith, as on the surface it makes more sense to focus on patients who are already sick. But until clinicians feel comfortable working with predictive analytics data, health systems may never achieve the population health management results they seek, he contends. And he seems to have a good point.

To Avoid Readmissions, Hospitals Trying Post-Discharge Clinics

Posted on December 12, 2011 I Written By

Anne Zieger is veteran healthcare branding and communications expert with more than 25 years of industry experience. and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also worked extensively healthcare and health IT organizations, including several Fortune 500 companies. She can be reached at @ziegerhealth or www.ziegerhealthcare.com.

In recent years, hospitals have been under increasing pressure to keep their readmission rates low. The next bump in the road comes in October 2012, when Medicare will begin cutting back on reimbursement for facilities whose readmit rates are too high.

Hospitals are already hard at work at preventing readmissions due to preventable medical errors, which may not be reimbursed at all by Medicare at all. But it seems like they’re still far behind in the care coordination department.

In fact, research suggests that they’re facing an uphill battle, in part because patients often don’t get the kind of follow-up care they need.

In theory, fragile patients  should move smoothly from inpatient care to their PCP, ideally a medical home equipped to coordinate whatever follow-up care needs they have. Few primary care practices are up to speed yet, however.  In fact, some aren’t even sure when their patients are discharged.

How bad is the problem? According to one study quoted in The Hospitalist, only 42 percent of hospitalized Medicare patients had any contact with a primary care physician within 14 days of being discharged.

One solution to this problem might be a “post-discharge” or transitional care clinic offering primary care on or near a hospital’s campus, the article notes. This makes sense. After all, it’s more likely a patient will follow through and get follow-up care if it’s convenient to do so.

The idea behind these clinics isn’t to replace the patient’s existing PCP; instead, the clinic’s hospitalists, advance-practice nurses or PCPs are there to make sure patients absorbed their post-discharge instructions and are compliant with the meds prescribed during their stay.

Some hospitals have invested significant resources in building out transitional clinics, including Beth Israel Deaconess Medical Center, Seattle-based Harborview Medical Center and Tallahassee (Fla.) Memorial Hospital, which partnered with a local health plan to kick off the effort.

That being said, the idea is a new one and few other hospitals have taken the plunge as of yet. It will be interesting to see whether this approach actually works, and particularly, whether one model of transitional care stands out.

P.S.  I’d particularly like to know whether hospitals can accomplish some of these objectives by monitoring patients remotely after they’re discharged. After attending last week’s mHealth show, I’m betting remote monitoring would be cheaper than setting up a new clinic. Can’t wait to see whether hospitals try that route!

 

 

 

Hospital M&A Getting Tough (But Misguided) Scrutiny From Lawmakers

Posted on November 7, 2011 I Written By

Anne Zieger is veteran healthcare branding and communications expert with more than 25 years of industry experience. and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also worked extensively healthcare and health IT organizations, including several Fortune 500 companies. She can be reached at @ziegerhealth or www.ziegerhealthcare.com.

As us in “the biz” know, the pace of hospital M&A isn’t going to slow down anytime soon. Hospitals are huddling together to scale up for countless reasons.

The reasons for hospital consolidation are just about unstoppable, of course, as they include  a) well-founded fears regarding reform, b) trouble carrying the capital capital costs involved in scaling up health IT infrastructure, c) long-term trends squeezing hospital margins and d) the need to participate effectively  in ACOs, HIEs and other alphabet soup organizations.

Unless the government takes over the entire healthcare system and spends these factors away, they’ll push execs into the arms of their peers regardless of what federal policies roll out.  Yes, the FTC can put mergers on hold, and notably, has gone medieval on a few mergers just to prove it can, but let’s not pretend it has the resources to slow hospital consolidation dealflow much either.

So, I must say I was sort of amused to learn that members of the  House Ways and Means Subcommittee on Health took a  stern look at hospital dealmaking and consolidation last month.  You know, to me it’s like standing in a flooded basement in a rainstorm and focusing on a few cracks in the wall — but I digress.

At the hearing, an economics and health policy professor named Martin Gaynor testified that consolidation was picking up speed. He also asserted that studies show hospital prices going up meaningfully whenever hospital markets consolidate.

Geez, Professor Gaynor, you say that like it’s a bad thing! Doesn’t classical economics allow for the supply side folks to work together too, without breaking the system? Whoops, I digress again.

The hearing, which took place in September, also included data from a Rand Corp. study noting that health plans were consolidating dramatically, and that these mergers were giving health plans too much power.  (Wow, imagine that — health plans having too much power?)

Oh, Lord, why does all of this seem beside the point?  Well, probably because it’s not going to help anyone.  Sure, knowing  what impact hospital M&A is having is part of a well-informed Health Subcommittee’s job description.  And I appreciate that the Subcommittee is trying to look at the bigger picture, one which includes both health insurers and hospitals.

But hearings like this, which assume that pricing indicators are the best way to decide whether the public good is being served, strike me as painfully uninformed. While I’m no economist, I have seen a few deals come and go, and some ill-considered attempts to control dealflow too. After following the health market for decades, I’m convinced that playing Whack-A-Mole and slapping down those “bad guys” who are overcharging/underpaying gets us nowhere.

 

Big hospital chains have outlived their usefulness

Posted on April 27, 2011 I Written By

Anne Zieger is veteran healthcare branding and communications expert with more than 25 years of industry experience. and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also worked extensively healthcare and health IT organizations, including several Fortune 500 companies. She can be reached at @ziegerhealth or www.ziegerhealthcare.com.

Regardless of what Community Health Systems execs may think, big, massive, overstuffed hospital mergers aren’t going to work in the next decade.  No amount of economies of scale will make up for the dollars health systems will lose if they decide to operate their business if it were Walmart.

Look at the history of the market.   Massive scaling up of hospital infrastructure — remember the grand Medicare-fueled building party in the 1960s? — has always been followed by financial weakness, overbedded markets and vicious regional competitions nobody can win.  Hospitals that try to reproduce this technique in multiple markets are only going to do worse.

In truth, I imagine CHS and other large hospital players are more focused on generating leverage with payers.  (They mostly have to scream “economies of scale” to satisfy Wall Street investors who wouldn’t know an ICU from an inside pitch.) After all, as reform washes over the land, the big health plans are going to see big upward jolts in their covered base.   And since the newly-insured aren’t likely to be cash cows, health plans are going to be more cost-conscious than ever when they negotiate.

“Massive scaling up of hospital infrastructure — remember the grand Medicare-fueled building party in the late 1960s? — has always been followed by financial weakness, overbedded markets and vicious regional competitions nobody can win.”

That being said, I don’t think creating hospital megaliths will tilt the scales back into balance.  Hospitals will always be on defensive when it comes to health plan contracts;  the brutal fact is that health plans have the money, and hospitals don’t. Hey, you can scream, we’re the best in the region, but let’s face it folks, health plans are more in the quantity than quality game.

So, what do hospitals do to cope with their vulnerability?  Careful, gradual acquisitions in key markets, strategically positioned to streamline the way they run key service lines across a region.  And integration, Lord yes,  but I’d argue creating your own health plan is a much better bet than buying medical practices willy-nilly.  (OK, you can do both, but I’d argue that putting a health plan in place should be the priority.)

By the way, I’d argue that the growth of the ACo concept suggests that I’m not alone — that just about every policymaker thinks that managed care-style medicine needs to be nurtured by providers.

Under these circumstances, big hospital mergers look even worse, as it’s pretty hard to build tight collaborative relationships when all orders have to come from the mothership in Nashville or Dubuque.

No, I say, a time comes for all industries when it’s time to think small, and this is it.  Tenet, HCA, Community Health, the big Catholic systems — now is the time to decentralize aggressively or pay the price. You’ve got three and a half years before reform goes full tilt. Tick tock, folks.

Data from the Kaiser rollout – better than expected?

Posted on August 21, 2010 I Written By

Anne Zieger is veteran healthcare branding and communications expert with more than 25 years of industry experience. and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also worked extensively healthcare and health IT organizations, including several Fortune 500 companies. She can be reached at @ziegerhealth or www.ziegerhealthcare.com.

As promised…

OK, before I get rolling, let’s back up a bit. To those that didn’t see my earlier feature, I’ve been dredging up the days when Kaiser caught a lot of heat for what was reputed to be a $3 billion EMR installation. Today, after four more years,  Kaiser’s EMR rollout is old news. But even though it hit full stride in 2006 or so,  it was such big news that the echoes still remain. So here you have what may be some data from those tumultuous times.

Below, consider the first set of data from (what appears to be) a Kaiser report on its Epic EMR performance. This coincides with the period during the period when whistleblower Justen Deal took his complaints about its performance. Of course, a little bird gave it to me, and as noted previously, I’m fairly sure it wasn’t Justen.

This report, which spans August through November of 2006, looks at a bunch of measurements of network and application performance.  I’m not a technical expert, so I can only guess, but truthfully, it looks like the organization did pretty well, especially since nobody, more or less, knew how to scale an EMR for such as large installation.

Not only that, it seems to me that if only 580,000 user hours were blacked out during those four months, vs. almost 63 million potential hours, it’s pretty good performance.

My main question here, having seen this doc, is whether these are cherry-picked network stats. Personally, I’d like to know more about how the application performed on the ground, what latency/response times were, whether the interface took eleventy-odd months of training to use, whether Kaiser did a good job of integrating other data silos, and perhaps most critically, whether clinical care took a disproportionate hit.

What data would you have wanted to see if you were running the show?  Check below and tell me what you think.

P.S.  By the way, if you want to lighten things up, feel free to check out this video of George Halvorson looking august and scholarly. But I digress…back to the data.
_________________________________________________________________________

Topline Data from August through early November 2006 for KP HealthConnect

Usage Based User Availability: 99.09%
This represents (Potential User Hours- User Impact Hours)/Potential User

Unique Incident reports: 429
These are incidents which affected the deployment, regional or national totals.

Average Concurrent Users: 8,481
Average number of users on the system during a given month

Potential User Hours:  62,895, 096
Average concurrent users * the total hours in the month

User Impact Hours:
572,241
Calculated for every incident by multiplying the actual number of users affected by the duration of the incident.  

 
 

 

Possible Kaiser data, tomorrow, straight from the whistleblower’s mouth

Posted on August 19, 2010 I Written By

Anne Zieger is veteran healthcare branding and communications expert with more than 25 years of industry experience. and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also worked extensively healthcare and health IT organizations, including several Fortune 500 companies. She can be reached at @ziegerhealth or www.ziegerhealthcare.com.

OK, guys, if you know anything I don’t about the machinations around the $3 billion (or $5 billion, name your number) installation of Kaiser’s Epic EMR, now’s the time to share. 

I say that because tomorrow, I’m going to pull together what an anonymous source sent me from the early days of the Epic installation.  We’ll go over it, reader and editor, and see if there’s any news left.  Hope you’ll join me.

If you have anything to add, please do feel free to toss another log onto the fire.

Admittedly, even if genuine — and I have no way of proving that it is — it’s at least four years old. Still, I’m pretty intrigued by it and I hope you will be too.  (By the way, the e-mailer says he’s not the (in)famous Justen Deal, the young man who e-mailed 180,000 Kaiser employees with his EMR concerns. I’d tend to believe Mr. X, since I’ve met the actual Justen and he’s not the anonymous type.)

I’ll catch up with y’all tomorrow.

Kaiser, the whistleblower and the $3 billion EMR

Posted on August 10, 2010 I Written By

Anne Zieger is veteran healthcare branding and communications expert with more than 25 years of industry experience. and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also worked extensively healthcare and health IT organizations, including several Fortune 500 companies. She can be reached at @ziegerhealth or www.ziegerhealthcare.com.

Back in 2003, Kaiser Permanente CEO George Halvorson made a decision which would change the direction of the company.  Though few of his peers had taken the plunge, Halvorson bought an electronic medical records system from EMR vendor Epic and set plans to bring all of his clinicians online.

While there’s nothing so surprising about that — other than the fact that Kaiser was well ahead of the curve, time-wise  — the project’s trajectory was a bit unusual. The EMR installation, which stumbled at more than one point, sprawled over several years and cost a reported $3 billion dollars. Yes, I meant “billion,” in case you fear your eyes are failing you.

Of course, Kaiser is a $30-odd billion company, so if anyone can afford a billion-dollar EMR, it can, but that’s still a whopping health IT investment by any standard.

Not long after the deal got done, Kaiser and its leadership began taking a tremendous amount of flack over the system, which apparently ran into every obstacle an IT project can face. Apparently, doctors were complaining that the EMR was slow and buggy, and worse, that the system was down more than up. But Lord knows, Kaiser had no intention of breaking its 10-year contract with Epic, a vendor whose lock on big deals continues to amaze me.

Then, in 2006, all hell broke loose when a 25-year-old Kaiser employee named Justen Deal managed to get an e-mail message out to all of Kaiser’s 180,000 employees.  Deal argued that the new system, dubbed HealthConnect, was rife with technical problems and couldn’t scale to meet the demands of the organization. The trade press went nuts. Halvorson was forced to defend the installation to the press and even write a letter to the extremely junior employee who’d blown his cover. Hard to tell whether anyone bought Halvorson’s defense, but the bad press died down within six months or so.

OK, fast forward to today.  HealthConnect is fully deployed, and if Kaiser’s Internet folks aren’t shining me on, the system is working pretty well.  Not only is HealthConnect servicing 431 clinics and 35 medical centers, it’s also supporting a personal health record which serves 3 million of Kaiser’s members.

That, at least, was the news from Jan Oldenburg, senior practice leader with the Kaiser Permanente Internet Services Group, whom I spoke with a few months ago.  Patients use the PHR to fill half a million prescriptions, check out 1.2 million test results and make more than 100,000 clinic appointments each month, Oldenburg says.  (Note that she didn’t address how effective the EMR system has been for clinicians — that may mean nothing, but I was a bit curious about the omission.)

Now, my friends, here’s the pop quiz. If you had to guess, do you think that the $3 billion spend was ultimately a good investment?  Do you believe that the Kaiser HealthConnect system will be a greater success with patients than clinicians?  And if clinicians are still using it at gunpoint, should Kaiser shift gears entirely and focus on patient access?

Looking forward to your ideas…this is a tricky one.

Health plan doctor ratings: Will they ever be fair?

Posted on July 21, 2010 I Written By

Anne Zieger is veteran healthcare branding and communications expert with more than 25 years of industry experience. and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also worked extensively healthcare and health IT organizations, including several Fortune 500 companies. She can be reached at @ziegerhealth or www.ziegerhealthcare.com.

Here’s a tough assessment of doctor-ratings schemes by my buddy Joe Paduda of blog Managed Care Matters:

“Some physicians and physician groups are quite upset about insurers’ recent moves to offer employer customers tight, small networks of providers based on quality and cost criteria. In an effort to block these new plans, the AMA and other groups are focusing on the few problems with ratings and avoiding the larger issue – some physicians are just bad actors.

What they should be doing is working closely with health plans and regulators to ensure the rating process is transparent, fair, and objective.”

I’m not sure I agree with Joe, though he is, to be sure, a guy one should take very seriously when it comes to healthcare strategy. I think a lot of the talk about “quality” is just an excuse to squeeze out expensive or challenging doctors and practices.  But what about you?