Complexity of Managing Health Care Quality
We are reading more and more frequently about the desire of health care reformers to make sure that our health care system delivers only the highest quality. I will not repeat the multiple authorities who point out that, although we spend over $2.3 trillion on health care, our outcomes in life expectancy, infant mortality, and general states of health are nowhere near the top.
It becomes easy to say that we need to monitor and pay for only high quality health care. That is a laudable goal, but far more complex than it first appears. A very insightful op-ed piece appeared in the April 8 Wall Street Journal, entitled “Why ‘Quality Care” is Dangerous” by Drs. Jerome Groopman and Pamela Hartzband.
The fundamental point they make is that many areas of medicine are not about delivering standard, uniform treatments to people, but about recognizing the uniqueness of each person, and tailoring a treatment to that person. For example, one of the fundamental issues we have today is that many individuals have chronic and complex diseases. If someone multiple cardio-vascular conditions, the simple decision about whether to prescribe a blood thinner becomes complex. Blood thinners reduce the risk of plaque formation, but they simultaneously increase the risk of hemorrhaging.
Anti-psychotic drugs effectively treat a significant mental health problem, but they often result in significantly greater incidence of obesity, which puts an already obese person at greater risk of death from cardio-vascular disease or diabetes.
Evidence-based medicine works best in single-disease situations. It does not work as effectively when patients have multiple diseases.
We also are learning that, as Groopman and Hartzband point out, that what is considered “best practice” at a point of time changes in individual situations or even over an entire population as medical science learns more. They used the example of giving patients with kidney failure statin drugs to prevent heart attacks and strokes, which recently was challenged by clinical trial results, but which had been considered a best practice.
My view is that the government should set population-level health and cost guidelines, and should let the results be determined over a population, rather than micromanaging or requiring private sector bodies to micromanage individual physicians or providers. While there will be cases of obvious malpractice that may require micromanagement as a remedial tool, the normal approach should be to look at risk-adjusted population-level data over time, and to make quality judgments and recommendations based on that data.
April 22nd, 2009 at 3:45 pm
The problem with “best practices” and “Quality care” is that many of the items which get those designations were never deserving or valid in the first place and should never have been afforded that status. Statins are a fine example of this.
The medical profession seems to simply regurgitate whatever is being promoted as the item of the day. As a result treatments proposed have to be questioned.
May 10th, 2009 at 11:20 pm
Mike, following your blog and reading of your activities in health care has sparked my interest in this topic. This weekend I attended the United Curch of Christ Ct Conference Annual meeting and listened to presentations on healthcare perspectives by Juan Figueroa (re Sustinet) and Dr. K J Lee who is working on President Obama’s task force regarding Health Care initiatives. I am curious what your thoughts are regarding SustiNet and the proposed CT legislation, and also wondered if you have provided input to the Obama administration. It sees to me you would be a valuable resource.
Ray
I have had the opportunity to offer input to the Obama Administration, as well as to members of Congress and their staffs. Relative to the proposed Connecticut legislation, I have the following views:
-While it makes sense to have a pooling of state and local government employees in a self-insured government employees health plan, I am not in favor of pooling small business employees or non-profits into that plan. Given the technical aspects of the state insurance regulatory system, the likely effect is that the poorest insurance risks and the most expensive participants and businesses will migrate to the State Plan.
-There are many causes of our large uninsured population around the country, but the biggest one is the exorbitant cost of health insurance. Two contributing factors to that are the cost added by states that fail to pay doctors and hospitals adequately for treating Medicaid and SCHIP patients (In CT, the SCHIP program is called HUSKY), the high cost of unnecessary coverage mandates imposed on insurance companies, and the inadequate focus on prevention and wellness. For example, in Connecticut, an insurer of small businesses cannot ask smokers to pay more than non-smokers for health insurance, although it can demand higher payments for life insurance. This is misguided. Sustinet is a good start in addressing this issue, but it does not go far enough.
-We need reform in terms of how we pay doctors and hospitals. We should pay for results, not activities. Sustinet does not have a comprehensive solution for this.
All that being said, I share the goals of Sustinet to get universal, affordable coverage, and it is a good starting point.