October 11, 2015

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.