No, not really. But Wennberg’s disciples at Dartmouth are coming out with so many uncomfortable facts for the medical-industrial complex that it’s hard to keep count. Starting by introducing the notion of practice variation 30 years ago, the group is now turbo-charging its research production, and basically all of it is bad news for anyone pretending that “American health care is the best in the world”. To paraphrase Uwe Reinhardt, how can the American healthcare not be as good as American health care?
In just the last couple of years not only has the Dartmouth crowd found that care delivered in areas with fewer doctors, and using less advanced technology, leads to better outcomes at lower costs, but they’ve also found that academic medical centers vary threefold in their efficiency of inputs (and costs) to get the same outputs, and most recently that hospital system and location is a better indicator of resource use than population acuity.
And, for the medical establishment, the news gets worse. For the last five or so years, those of us who think that we’ve already got plenty of doctors per head, as we doubled the number in medical school in the 1970s and 1980s and are still waiting for the smaller generations trained in the 1960s to retire, have been drowned out by hysteria from the medical establishment about an impending “physician shortage”. That is of course code for the taxpayer (via Medicare which funds most medical education) to support the creation of new physician residency slots, creating more specialists, who’ll then start applying more medical technology to all of us, which will contribute to more flat of the curve medicine. But I won’t give you a potted Fuchs/Enthoven class here (although you can search around plenty in THCB if you want more).
Today in Health Affairs (or you can read the potted version in Forbes), Dartmouth researcher David Goodman and his team (including Wennberg) cry bullshit on the “we need more doctors” meme. While the big academic centers which get the money from training them would love to have more residents, by examining one type of intensive medical process — caring for patients at the end of life in ICUs — Goodman et al shows pretty logically that many major academic centers use far too many physician resources. In other words we could provide equally good (or probably better) care while using many many fewer physician “inputs”. Hence overall we need fewer physicians, more efficiently used.
Of course any English surgeon, whose workloads and consequently surgical speed massively exceed those of their American counterparts, could have told you that. And my father frequently did every time he came back from a “fact-finding” trip over here. And when Goodman et al invoke the most famous name in American medicine, it’s pretty hard to argue with their conclusions:
"We have benchmarks. We have academic medical centers which are highly successful in terms of the care they provide, and we need to start looking to those places as our examples," Goodman said. "We need to study them and understand them and emulate them. The Mayo Clinic has been studied very extensively and is fairly well-understood," he continued. "We should be at a point where we can emulate some of those systems."
Mayo of course has fantastic outcomes at relatively low cost. In this study it used 8.9 physician full-time equivalents per 1,000 patients in the six months before death, while at the other end of the spectrum New York University Medical Center had 28.3. Of course the system-wide implications of all of the Dartmouth research are too awful for the medical establishment to contemplate, because they in the end mean 20 of the 28.3 doctors at NYU going away – and there are enough cab drivers in New York City as it is. And it’s not just New York city doctors that suffer when you extrapolate:
Applying the Rochester standard to the nation’s elderly, the United States has an excess of physician input; it needs 30,163 fewer FTE inputs than were allocated in 2000. Indeed, the current rate of supply growth along with excess capacity is sufficient to accommodate the 56 percent increase (in the number of elderly-MH add) predicted for 2020, with 49,917 physicians to spare.
All this research of course reminds organized medicine, and the industries that feed off its members prescribing more and more technology without caring about the cost, of something Lenin said back in 1923 about “Better fewer but better”. And you know how the American medical establishment hates them commies. On the other hand, it also invites memories similar to what Maggie Thatcher did to the British steel-workers in 1980 — she basically fired 70% of the workforce, but the amount of steel produced stayed the same. Are they going to call Maggie a commie? I think not, but you may have noticed lots of major industries taking the same approach.
So this research will stay ignored. We spend too much on high-tech medicine, we have too many specialists doing too many heroic procedures, and everyone’s very happy about that. Until that is that we notice that we have a health care system that does a shitty job of basic primary care, doesn’t cover 45 million people and costs way too much.
But if word somehow sneaks out that the two sides of that equation might per chance be related, then the pillars of the medical establishment might choose to move to other tactics. And perhaps the Dartmouth crowd might find themselves wearing concrete boots and hanging with Jimmy Hoffa instead.
CODA: And in a quick reminder that doctors are doctors whatever their
passport cover says, this article explains how spending more on health care in
Canada has not
shortened waiting times
In the five years up to 2002-03, the number of angioplasties (to open
arteries) and bypass surgeries increased 51 per cent, the number of joint
replacements rose 30 per cent, and cataract surgeries 32 per cent. But demand
for care seems to have increased just as much, and it’s not just because the
population is aging. "We’ve got way more activity beyond what the demographics
would dictate," said CIHI Chairman Graham Scott:More research is needed
to understand the phenomenon, he said but new technology is probably a factor.
If there are new tools available, such as MRIs, doctors are likely to use them.
If techniques for a certain kind of surgery improve, the procedure will become
more popular.
Duh! They don’t need more research. When the NHS was introduced in
the UK in 1948, the politicians thought that demand would fall after the initial
rush from those who hadn’t had coverage before wound down. But it didn’t. 50
years of data tells us that in health care supply creates its own demand, and
the way to deal with that is to restrict supply.
Categories: Uncategorized
In addition to revealing much about health care costs, the question of end-of-life care in the U.S. has its own, unique problems. Nicholas Christakis’s column in the BMJ summarized some of these (http://christakis.med.harvard.edu/pdfs/BMJ_080809_Terminal_Illness.pdf) from a sociological perspective. In a study we recently did, we found that U.S. physicians have particularly poorly calibrated beliefs over their patients’ chances of survival. American physicians systematically over-estimated their terminally-ill patients’ time left to live. This systematic bias in prognosis may be at work when we observe extraordinary high supply of care in the U.S.
Quite provocative … Great! Let me take a stab at your points.
> When a patient becomes gravely ill and the spending goes through the roof…there is no end point until the patient dies or the family withdraws care…Could healthcare spending be cut in half if there were ethics committees established to review such cases allowing care to be withdrawn earlier even against the wishes of the families?
Hmmm. How might this play out? A committee says “Pull the plug” and the patient dies? It seems this could save big bucks, but there are some tough ethical problems. Rather, instead of pulling the plug, upon the committee concluding there’s nothing more the hospital can do, compassionate home (hospice) care is provided? We then have to think about how to deal with the economic impact on hospitals that depend on end-of-life care for a significant part of their revenue.
> if we head down the path of a single payer system corruption and waste will be a given
Unless there is strong evidence that a single payer system is the only way to provide universal coverage, I agree that we should look to other models.
> I do also have experience with the Kaiser based system and feel that system works well
Kaiser, etc. can be classified as “integrated care,” which the literature says can be an effective model. “Selective diversification” is a similar model recently proposed. I discuss these models and others in a post about redirecting competion.
> There needs to be free market forces driving the change.
Might the solution to the debate between Tom and you be found through policy that disrupts the current healthcare system by putting constraints on the many dysfunctional processes responsible for the healthcare crisis, while enabling rational competition in a market operating within the bounds of social responsibility?
> We need to bring the payers [patients and employers] back into the foreground and they will demand changes to the current system. Until this happens, the insurers and hospitals will continue to rape the system.
To avoid miscommunication, I suggest we use the commone standardized definitions for these terms: “payers” = insurers, “purchasers” = employers, and “consumers” = patients/public.
I agree that having consumers and purchasers push for change is necessary. Purchasers are already having an impact, and I believe their pressure on politicians to lower healthcare costs is what initiated the HHS National Health Information Network initiative. Reaching out to consumers is also vital. So, developing a model that both these groups will stand behind is key, imo.
About who’s raping the system: I can’t place blame on any one group. It seems to me that the negative side of human nature is responsible for corrupting the political and economic systems, upon which our healthcare system is built. It’s all tied together.
Steve
http://stevebeller.blogspot.com/
The problem with healthcare spending also lies in the fact we are dealing with humans rather than objects. When a patient becomes gravely ill and the spending goes through the roof (I believe 90% of the healthcare dollar is spent in the last 30 days of life or something like that??), there is no end point until the patient dies or the family withdraws care (which is usually a rare early event). Now let us look at what happens with a car when it ends up in a wreck. Often an insurance adjuster weighs the cost of repair v replacement and at a certain level of damage will declare the car a “total loss”. Could healthcare spending be cut in half if there were ethics committees established to review such cases allowing care to be withdrawn earlier even against the wishes of the families? This may seem grim but these are the hard decisions that need to be made in the future if healthcare costs are to be controlled. I don’t think society is willing to accept this today. Any thoughts on this?
Unfortunately, I believe if we head down the path of a single payer system corruption and waste will be a given. Does anyone have any experience with TRICARE? I do and it may be the proving ground/blueprint for universal/socialized healthcare (Hillary Care) if it is ever enacted. I do also have experience with the Kaiser based system and feel that system works well from the limited experience I had with it.
Again I think Darwinian forces will be allowed to play out if healthcare is opened to the free market. It is often difficult and nearly impossible to regulate closed markets into forward evolution and improvement. There needs to be free market forces driving the change. Unfortunately, that is what is lacking today in healthcare. Hospitals and insurers often have monopolies in communities and alot of the cost and dollar transfer is hidden from the payer (patients and employers). We need to bring the payers back into the forground and they will demand chages to the current system. Until this happens the insurers and hospitals will continue to rape the system.
I apologize to Mr Leith for calling him a liberal. My mistake.
> It is true that patients can die unnecessarily, remaining very pleased with their docs. Don’t believe them about clinical efficacy and efficiency.
And, a la Dr. House, they can dislike their docs, but get phenomenal care. Of course, being highly satisfied with a doc that gives you great care is what we strive to do.
Also note that I’m not discounting the importance of subjective measures – e.g., patient self-report of physical pain and emotional distress – as vital clinical indicators.
> Your list of five is where I hope things are headed, but we will get there by way of a very crooked (in both senses of the term) path. … Radical transformation is what we are all called to … we have governments in the meantime.
Crooked in the way of adjusting direction to accommodate new knowledge, innovation and occurrences is inevitable since that’s the nature of development/evolution.
Crooked in the way of corrupt political and business manipulation for personal material gain and power, at the expense of the public, I suggest, need not be inevitable despite out shameful history. It gets back to how people’s focus and beliefs reflect our priorities, the models we follow, and the processes we execute. This is where radical transformation is needed. Being a spiritual man (though not necessarily religious in the traditional sense), I share your conviction that such transformation of self and societies is our “fundamental purpose” in life. But (a) with the priorities, models and processes currently valued in country (and others) that are diametrically opposed to this kind of positive social development, and (b) with our government sharing that same mind-set — with all this, I’m leery of putting much hope in a political solution, although I understand your point.
I hope we all can discuss how to enable the leadership we so badly need to have a meaningful impact on driving our country’s transformation to social responsibility, without being forced into corruption itself (I don’t want to revert to negative Machiavellian tactics). It would be ideal if ALL stakeholders win: public, providers, purchasers, AND payers.
A few initial questions I pose for discussion:
What (new) business, political, and healthcare delivery models and strategies are needed?
Where should we focus our efforts to encourage widespread dialogue and pilot studies?
How can blogs have the greatest positive affect? What about other media?
Should positive change be driven by healthcare providers, consumers, employers, or insurers? All of them?
Would it be best to form international alliances?
Steve
http://stevebeller.blogspot.com/
> But I doubt their usefulness as reliable indicators of
> clinical efficacy and efficiency
Oh yes! It is true that patients can die unnecessarily, remaining very pleased with their docs. Don’t believe them about clinical efficacy and efficiency.
Your list of five is where I hope things are headed, but we will get there by way of a very crooked (in both senses of the term) path. Great leadership will be required at every level from the coffee shop to the boardrooms to the White House. Maybe blogs will play a small part .
Radical transformation is what we are all called to, but as St. Paul pointed out, we have governments in the meantime.
t
> Insurance, either by contract or social, is the only reasonable way to finance the risk of serious illness. … The policy “rely on markets” is a non-policy that relies only upon third party enforcement of contracts and tort laws to work. … As soon as you say “policy” you have said “there can be no efficient market: we must intervene for the common good.”
I don’t know what others think, Tom, but if our goal is delivery of quality care for all, I find your argument sound: Without altruistic intervention (aka socially-responsible policy), there is no reasonable way to achieve this goal — unless, possibly, if humanity radically transformed itself … but there’s no sense in waiting.
I suggest, therefore, we focus on defining a consumer-centric economic policy that:
a) Enables providers to compete in a sensible manner in a way that benefits the consumer and society
b) Encourages innovation and efficiency
c) Supports continually improving care quality
d) Provides quality care for all
e) Promotes wellness, public health, and preparedness.
> Patient satisfaction scores are far from useless.
Actually, I agree that patient satisfaction can be a useful indicator of certain things such as convenience and staff friendliness, which can affect quality. But I doubt their usefulness as reliable indicators of clinical efficacy and efficiency — See Connolly, C. (February 16, 2006) Vital Evidence: Taking Patients’ Word May Be Ill-Advised at http://www.washingtonpost.com/wp-dyn/content/article/2006/02/15/AR2006021502362.html. Anyway, my statement reflects our foolish tendency in the past to use a few process metrics and assessment of patient feelings to measure care quality, in lieu of clinical outcomes; I failed to adjust my remarks accordingly and stand corrected.
Steve
http://stevebeller.blogspot.com/
> 2. The problem of price sensitivity when large
> expenditures will be made. Please elaborate, Tom.
I am talking about what happens after a patient gets seriously ill and insurance kicks-in. Once that happens, the patient is almost completely price insensitive. And this is the condition under which the great bulk of healthcare spending occurs, which means there will not be an efficient market in medical services for the sort of services that pare provided for serious illness. Insurance, either by contract or social, is the only reasonable way to finance the risk of serious illness.
> If by “reasonable alternatives” you mean
> alternate healthcare delivery, competition
Primarily these. Financing models don’t matter so much in this discussion, its the delivery I’m focused on. The alternatives to medical treatment are usually suffer, or die, or both. Although there are a few who do, most people do not consider these choices reasonable. The alternative to some particular medical treatment may or may not exist (think masectomy vs. lumpectomy). And there may or may not be alternate providers — in vast expanses of the country there is only one hospital within an 30 minutes of one’s home. When there is more than one, it is two. When there are more than two, they are often organized into “systems” that do not compete among their own members, at least not on price. When there are a few systems, that’s another kind of oligopoly, and they will not compete on price either. They may engage in first-class price discrimination, but that is not price competition. Individual physicians do not compete on price, and have long considered it unethical. It is certainly for them undesirable.
I failed to mention legal barriers to entry in the market: licensure of doctors and nurses, Certificate of Need laws, physicians controlling medical education through state boards, and so-forth. This damps down considerably competition.
Efficient markets in consumer goods exist when something like “breakfast cereal” is the good in question. From that point, the markets are less and less efficient.
> useless patient satisfaction scores
Patients ought to be treated respectfully and we ought to keep our service promises to them. They ought to have more than technical perfection, especially in faith-oriented systems and facilities. Satisfaction surveys get at these sorts of questions, and are quite valuable in pinpointing training and process problems. Patient satisfaction scores are far from useless. They suffer especially from selection bias, but this is well understood.
> who are able to influence policy
From this, I think the gig is up for you. The policy “rely on markets” is a non-policy that relies only upon third party enforcement of contracts and tort laws to work. Some people (radical Libertarians) deny the need for a government even for these. As soon as you say “policy” you have said “there can be no efficient market: we must intervene for the common good.”
I hope this has been sufficiently high-level for surgeons .
t
Wonderful debate about possible futures, which seems to boil down to Tom’s challenge that in order to show that an efficient market can exist you will both have to overcome the information problems (including the ability for patients to understand), the problem of price sensitivity when large expenditures will be made, and the problem of a lack of reasonable alternatives..
Yes, these are some of our greatest challenges to solving the healthcare crisis, along with issues including the limitations of current practice guidelines and quality improvement programs, the shortcomings of today’s HIT systems, and problems with proposed incentive and coverage programs.
In our white paper (due out in a couple of weeks), we present a blueprint for an innovative HIT system that will help deal with some of these problems, and we outline key issues and propose potential drivers for handling many of the other barriers. But for now, I hope we can clarify and discuss each of Tom’s points:
1. Information problems, i.e., the inability of consumers to distinguish among levels of quality because they lack adequate knowledge of the relative cost and degree of defect (underuse, overuse, and misuse) of healthcare resources, so they cannot select providers based on the quality/value of their care.
Well, moves to inform the public of hospital performance has already begun. For example, the New York State Department of Health launched a Web site in January 2006 that compares the performance of hospital regional hospitals by region using process and risk-adjusted outcome measures for common health conditions, as well as the number of common medical and surgical procedures performed annually. These “report cards” are designed, according to State officials, to raise quality by applying competitive market pressures. And in February, the Massachusetts Health Quality Partners group, a coalition of 150 medical groups, posted efficacy data on its web site — measuring the reliability with which patients receive tests and treatments known to improve outcomes — in order to encourage consumers to search for high-quality providers and guide physicians looking to improve their performance.
While these report cards push hospitals to focus on quality improvement, the data are open to misinterpretation, very limited in scope, and may not help providers improve their care quality. This is because the quality measures in use today tend to be based on immature, imprecise, static practice guidelines, and useless patient satisfaction scores , instead of the valid, precise, evolving quality metrics and evidence-based practice guideline outcomes that can only come from the kind of wide-spread, collaborative, interdisciplinary quality improvement efforts we’re proposing.
Providers who are proactive in developing and using guidelines in a way that shows the public they are learning organizations truly dedicated to delivering the ever-increasing care quality are the ones most likely to gain competitive advantage.
2. The problem of price sensitivity when large expenditures will be made. Please elaborate, Tom. Are you talking about the difficulty computing “actual” costs, the problem calculating care “value,” issues related to risk-sharing and amortization, defining “acceptable” profit margins, or what?
3. The problem of a lack of reasonable alternatives. If by “reasonable alternatives” you mean alternate healthcare delivery, competition, and payment models, then dialogues like the ones we’re having will emerge (and are emerging) innovative models (approaches/strategies). These new models should be subject to intense scrutiny by knowledgeable people from multiple disciplines, their assumptions should be critically examined and challenged, alternate views should be discussed, pilot projects studied, etc. This will require collaborative networks of open-minded, critical thinkers who are able to influence policy and serve as leaders guiding the direction of healthcare into the future.
—
Steve is … getting buried too much in the details.
I am extremely detail oriented and apologize to anyone frustrated by the minutiae of my posts. With the devil hiding in the details, and with so many opportunities for misunderstanding, I tend to focus on examining the small parts and then try to construct a holistic view and conclusions from the aggregate. [And when wearing my software programming hat, I must focus on the smallest details or risk a buggy product … but that’s another story.] Anyway, thanks for the pointer, pgbMD, and for putting up with me and engaging in this discussion!
Steve
OK, well maybe Steve sort of agrees with you when he “questions” my prediction that efficient markets can never exist in healthcare.
But in order to show that an efficient market can exist you will both have to overcome the information problems (including the ability for patients to understand), the problem of price sensitivity when large expenditures will be made, and the problem of a lack of reasonable alternatives.
t
> Wrong again Mr T. Their consumption will go down
> significantly for unnecessary care and minimally for
> necessary care.
The best study on the topic (the famous RAND Health Insurance Experiment) confirms that people do respond to prices. But it says also that patients do not know enough to refuse unnecessary/inappropriate care: inappropriate antibiotic use and inappropriate hospitalizations(!) did not change a whit under plans with high co-pays. Patients in the higher out-of-pocket plans also exhibited a greater tendency to have uncontrolled hypertension. Other studies (Lurie) suggest that both these effects are more pronounced among the poor.
There are no studies I know of that look comprehensively at spending and health status under conditions where patients pay out of pocket. The best study (RAND) confirms that people do respond to price, but it only looked at low-cost expenditures, and looked narrowly at health status, and only over about five years.
Fees apparently will chip away at office visits of clearly questionable value, but that’s not where the costs are. And when it is not so clear cut, we will have erred on the side of cheapness: patients don’t know the difference between the flu and meningitis any better than they know whether or not they should have an antibiotic or a proton-pump inhibitor.
You are thinking wishfully and ignoring the realities of healthcare.
> Wrong for a second time (PhD Steve agrees with me
> on this one!!). When will you liberals stop…
I think this is the first time in my life I have been called a liberal.
Steve does not agree with you. You claim an efficient market for medical services can exist.
He has not claimed this. He claims that when providers are subjected (by whom, pray tell?) to reporting requirements sufficient to discriminate differences in quality, patients will choose the better ones, and might pay them more. He rightly wants to engage people in making their healthcare choices through education, but he has not claimed that an efficient market will as a result develop, or that “consumer choice” will “fix healthcare” — i.e. lead to a state we might expect of an approximately ideal competitive market, as we have in haircuts or wheat or clothing. And especially not without regulation. He does not agree with you.
He does not agree with me either. Steve thinks sufficient information can be developed and made understandable to a population that won’t read a newspaper. I’m pretty sure it can’t be, even if the obfuscatory tendencies of the medical profession could be completely overcome.
In Steve’s defense, if all medical services were delivered through Kaiser-style organizations and we could get satisfactory transparency of quality and price at the organizational level, individuals might be able to make rational choices. But Americans have shown they have no interest in organizatons like this.
Further, doing this, we would be creating in each region an oligopoly that does not face competition. We have had industries like this before. Remember the US cars in the 1970’s? Wanna go back to pre-Toyota days?
Even if prices are transparent, “big” costs will always be insured, and patients will be price insensitive at that point, so all the transparency in the world will not drive choices (if any are reasonably available) when big expenditures are going to be made. Price sensitivity is another required condition for an efficient market to exist.
Reasonably available alternaties: This figures in at a couple levels: buy treatment or endure pain; buy from GM or Dodge.
Poor transparency of price and quality, poor price sensitivity with respect to large expenditures, poor availability of reasonable alternatives: this is why I do not think there can ever be in a general way an efficient market in healthcare. None of the requisites are there now, and I do not think they can be.
> Three strikes and you are out. When
> Nighthawk is finally eaten
I have no idea why you mentioned this. I think we are in complete agreement about the process of disintermediation. I helped in a small way to enable it. Maybe you were just on a roll and got carried away.
t
Sorry lost my quotes with the previous post.
>Yes their consumption will go down, right along with their health status. They will consume less unnecessary care, and also less necessary care
Wrong again Mr T. Their consumption will go down significantly for unnecessary care and minimally for necessary care. The necessary care they will seek out. I think even W figured that one out, so it should be easy for a smart lad like yourself. In the totally inefficient TRICARE system (which may be the pancea for Mr T) b/c their were no co-pays and nothing (very minimal) out of pocket the patients came in to the hospital for any reason. Even to get off work!!
>the conditions that make markets efficient do not and cannot exist in healthcare
Wrong for a second time (PhD Steve agrees with me on this one!!). When will you liberals stop using this bogus talking point. Next you will be saying that the conditions for market force efficiency don’t exsist in _______. Just fill in the blank for whatever industry you guys will next try to socialize.
>When I asked whether films would be read in India, I was told no, never! The licensure laws will make it impossible. They certainly do not want a free market. But only because they aren’t real doctors, right?
Three strikes and you are out. When Nighthawk is finally eaten by a larger company they will look to turn a higher profit and start the outsourcing. Just a matter of time. Remember licensure is essentially controlled by the congress and as the medicare/caid/etc costs continue to rise this will be easy prey to save some $$. Radiologists will be the first to be outsourced due to their 100% reliance on technology and the fact the images can be beamed around the world in a heartbeat.
I agree with much of what PhD Steve is saying but I think he is getting buried too much in the details. He would never make a good surgeon.
Great discussions. 🙂
Wrong again Mr T. Their consumption will go down significantly for unnecessary care and minimally for necessary care. The necessary care they will seek out. I think even W figured that one out, so it should be easy for a smart lad like yourself. In the totally inefficient TRICARE system (which may be the pancea for Mr T) b/c their were no co-pays and nothing (very minimal) out of pocket the patients came in to the hospital for any reason. Even to get off work!!
Wrong for a second time (PhD Steve agrees with me on this one!!). When will you liberals stop using this bogus talking point. Next you will be saying that the conditions for market force efficiency don’t exsist in _______. Just fill in the blank for whatever industry you guys will next try to socialize.
Three strikes and you are out. When Nighthawk is finally eaten by a larger company they will look to turn a higher profit and start the outsourcing. Just a matter of time. Remember licensure is essentially controlled by the congress and as the medicare/caid/etc costs continue to rise this will be easy prey to save some $$. Radiologists will be the first to be outsourced due to their 100% reliance on technology and the fact the images can be beamed around the world in a heartbeat.
I agree with much of what PhD Steve is saying but I think he is getting buried too much in the details. He would never make a good surgeon.
Great discussions. 🙂
Great conversation!
> But how do you measure quality of care?
They have thus far focused too much for my taste on process
The two classes of measures used for quality improvement are care process and outcome measures. Process measures are used to evaluate compliance with guidelines, and outcomes measures are used to evaluate the value of the guidelines; but watch out for the possible pitfalls.[i]
Care Process Measures
Process measures of care quality assess whether providers follow predefined procedures for specific patient types, with specific health problems and needs. These procedures are treatments, interventions, prescriptions, etc., which are supported by scientific evidence, or which have limited scientific support, but practitioners can justify their use. The procedures are incorporated into practice guidelines setting particular standards of care, and they become part of a patient’s plan of care. There are many practice guidelines using care process measures.[ii]
Care Outcome Measures
Outcomes measures of care assess the clinical results of an episode of care for particular patient types. These measures may include symptom alleviation, quality of life improvement, length of stay, mortality rates, etc. Care outcomes can also include such measures as patient satisfaction and access to care, total cost of care, etc. There are numerous care outcome measures available, which can be used to evaluate the value of the particular guidelines[iii] and new ones are created regularly. These measures may include symptom alleviation, quality of life improvement, length of stay, mortality rates, cost, risk, etc. They provide feedback for improving quality by helping refine them over time by identifying procedures and systems that work well, and by providing insights into areas where there are opportunities for improvement.
Potential Pitfalls of Quality Measurement
No mater what quality measures are used, there are complex issues to be resolved, such as:
• At what point is there sufficient confidence in an evidence-based practice guideline that there is no longer any need to spend time or money on the continuous evaluation of its reliable and validity?
• When is a definition of quality too narrow, e.g., by focusing on cost or symptom reduction, but not considering prevention, recurrence, coordination and continuity of care, or the patient-physician relationship?
• How do you measure quality when resources are scarce and optimal care for the community may require less than “the best” care for its individual members (e.g., delegating office nurses to perform certain activities that physicians used to do)?
• What is the best way to measure quality if outcomes are more strongly affected by patient compliance than by physician orders? This may occur, for example, if certain providers have personalities that trigger greater patient compliance, and visa versa.
• Is it poor quality care if a provider follows the recommended practice guideline, but the patient is atypical and responds poorly?[iv]
> A giant percentage of what helps patients take care of themselves is the immeasurable quality of the conversation and the perceived care and compassion that a doctor gives the patients.
Providers possess qualities that cannot be readily measure, but which affect the outcomes of practice guidelines, and should therefore by addressed. According to a Stanford School of Medicine Dean’s newsletter, “We can and must, of course, not lose sight of educating our students and trainees to learn, to listen, to reach out and to connect to their patients. Some have called this the ‘art-of-medicine’ others ‘bedside manner’. From my perspective, it is the fundamental underpinning of what makes a great physician. Exceptional scientific knowledge, along with a critical and analytic approach to clinical care that is evidence based and data-driven is essential. But unless these skills are coupled with a caring and compassionate manner, the value of the patient encounter is diminished. Importantly the patient feels less well served and perception of the physician as a ‘healer’ is altered.”[v]
> Tom’s complex medical history is a piece of cake for their evidence-based algorithms and his care is rendered, at least in the doctor’s mind, even before the doctor comes in and spends 6 minutes to examine him.
To be useful, guidelines should be specific enough to have different versions for patients with the same clinical problems depending on their clinician, hospital, location, available resources, patient characteristics and preferences, etc. And they should be accompanied by consumer versions in lay language and be widely publicized and available to inform patients and the public about what their clinicians should be doing.[vi]
They should also be constantly evaluated and revised based on research and sharing of anecdotal observations and lessons learned via a continuous quality improvement process.
As practice guidelines are developed and validated, they should be made available to all stakeholder by storing them in electronic libraries, along with any instructional and reference materials needed to learn about and understand the guidelines, and to use them effectively. The guidelines should be:
• Modified and refined on a continual basis in light of new research findings, so they evolve based on new scientific evidence.
• Tailored to the needs of each stakeholder. For example, consumers would have access to guidelines written in a simplified, non-technical way they can comprehend, while providers would receive technical clinical information.
• Accessible by all stakeholders quickly and easily, through web sites and specially designed software tools.
In addition, there needs to be a very efficient and effective way to disseminate updated clinical knowledge to providers. Since practice guidelines can change rapidly with evolving clinical trials, after-market surveillance, and new classes of drugs and procedures, a technology must be used that actively delivers (“pushes”) the new and refined guidelines to all clinicians immediately.
> bringing down healthcare costs must involve the open marketplace and exposing the consumer directly to the REAL cost of healthcare not just a small co-pay.
Transparency of costs, pricing, and incentives would expose the consumer to important information, although even this can be difficult:
“Assessing the unit costs of each of a large number of services requires major effort to gather information on direct inputs, such as labor, space, supplies, and equipment, and sophisticated formulas to allocate indirect costs, such as general management. Although estimating unit costs can be relatively easy for services in which a purchased input constitutes a large share of the cost, such as drugs or devices, estimating the costs of most services is far more difficult because the most important inputs produce numerous distinct services. …Providers have limited incentives to devote the resources to set charges that accurately reflect relative costs because a large part of their revenue is not directly influenced by their own charge structure. Any one provider’s charge schedule has negligible impact on calculation of prospective payment rates by insurers. Even when private payers negotiate discounts from charges for each hospital, little is gained from a structure that more accurately reflects costs.” Ginsburg & Grossman (2005)
But even when transparency of cost can be calculated accurately, there must be corresponding transparency of clinical outcomes in order to compute a quality/value metric. And as we’ve been discussing, quality is also a difficult thing to measure.
I’m glad we’re discussing these issues and have confidence we can implement effective solutions if we maintain a consumer-centric focus.
> … they [MBAs] failed to recognize that the conditions that make markets efficient do not and cannot exist in healthcare. … failed to find the best care for the buck because they are so poorly equipped to understand what’s required, much less what’s best for the buck. And the literature on practice variation says that docs don’t really know either.
The only thing in this statement I question is the prediction that efficient markets can never exist in healthcare. If the current healthcare system remains unchanged, then you’re certainly correct. But what can change to make the market more efficient?
One idea in the literature is to redirect competition:
Healthcare market forces in America over the past decade have transitioned from managed care and capitation to integrated delivery (integration of health insurance with provider systems) to a vision in which providers compete to improve care quality (better outcomes at lower costs) and consumers choose more efficient providers. There is now debate on whether competition should be redirected by (a) eliminating provider networks and encouraging informed, financially responsible consumers to choose the best provider for each condition; (b) encourage integrated delivery systems with incentives for teams of professionals to provide coordinated, efficient, evidence-based care, supported by state-of-the-art information technology; or (c) basing selection of particular healthcare services on local population needs and core competencies of the providers. See Redirect Competition for more.
> [Healthcare consumers] will consume less unnecessary care, and also less necessary care.
This is one of the criticisms leveled at HSAs. Much depends, imo, on defining “necessity,” along with “quality/value”in terms consumers can understand and appreciate. Yet another worthwhile thing for our country to focus on.
—
[i] For examples of quality measures incorporating both process and clinical outcome measures, see the Doctor’s Office Quality – Information Technology (DOQ-IT) site at http://www.doqit.org/dcs/ContentServer?cid=1111783079915&pagename=DOQIT%2FDOQITPage%2FPageTemplate&c=DOQITPage
[ii] For examples of clinical guidelines with care processes measures, see http://www.guideline.gov/browse/guideline_index.aspx and http://www.ahrq.gov/clinic/cpgonline.htm.
[iii] For examples of care outcome measures for hospitals, see JCAHO’s ORYX measures at http://jcaho.org/pms/core+measures/information+on+final+specifications.htm
[iv] Donabedian, A. (2005). Evaluating the Quality of Medical Care. The Milbank Quarterly 83, 691–729. Available at http://www.milbank.org/quarterly/830416donabedian.pdf
[v]The Dean’s Newsletter – Stanford School of Medicine. (November 10, 2003) Available at http://deansnewsletter.stanford.edu/archive/11_10_03.htm%5Bvi%5D Woolf, S. H., et al. (1999) Potential benefits, limitations, and harms of clinical guidelines. BMJ 318 (20). Available at http://bmj.bmjjournals.com/cgi/reprint/318/7182/527.pdf
Steve
http://stevebeller.blogspot.com/
> But how do you measure quality of care?
There is a growing body of literature on it. The measurements will not be perfect, and will never capture every aspect of a consultative relationship. Maybe you will want to get involved to make them better. They have thus far focused too much for my taste on process. Which is what you are complaining about.
> Once this is done consumtion will go down dramatically
> and the consumer will seek the best care for the buck.
> It don’t take an MBA to figure that one out.
Yes their consumption will go down, right along with their health status. They will consume less unnecessary care, and also less necessary care.
MBAs are the ones who did figure that one out. Except they did not pay attention in their boring, difficult economics courses, what with all that algebra, and they failed to recognize that the conditions that make markets efficient do not and cannot exist in healthcare. But this does not matter to the MBAs — anything that reduces the medical loss ratio for the insurance company is a Good Thing, and will get them their bonuses. Dubya’s an MBA. Harvard. Hmmmm. That explains a lot — Harvard does everything with cases. Probably don’t actually teach any economics. Thanks for the tip.
Anyhow, the Harvard MBAs went ahead, and consumers may have sought, but failed to find the best care for the buck because they are so poorly equipped to understand what’s required, much less what’s best for the buck. And the literature on practice variation says that docs don’t really know either.
> Check out the company Nighthawk.
I personally helped to drive the adoption of the enabling technology (DICOM) when I worked in the Electronic Radiology Lab at Washington University. When I asked whether films would be read in India, I was told no, never! The licensure laws will make it impossible. They certainly do not want a free market. But only because they aren’t real doctors, right?
t
> I’ve got no problem accepting “what the market will
> bear” if it was actually a free market.
I don’t know what you want me to say. Healthcare is not a free market, and it is far from being an efficient market, but there is a price the market will bear nevertheless. It seems to me you will have a problem. Note that I am not particularly an advocate of any of this — its just what I see happening. If you want that little spreadsheet, send me your e-mail address.
t
t
Tom,
How can you argue that we should just accept what the market will bear when healthcare is not a free market? Doctors salaries are not decided by open competition in a free market, they are decided by bureaucrats in Washington DC who run Medicare. Medicare already controls 50% of all healthcare dollars spent in the USA, and by 2020 it will be close to 80%. We are already close to a de facto semi-socialized medical model.
I’ve got no problem accepting “what the market will bear” if it was actually a free market.
Well I guess you guys are coming around (except t the economist) to the fact that bringing down healthcare costs must involve the open marketplace and exposing the consumer directly to the REAL cost of healthcare not just a small co-pay. Once this is done consumtion will go down dramatically and the consumer will seek the best care for the buck. It don’t take an MBA to figure that one out.
Free market healthcare is the only solution to the problem. The current administration sort of realizes this and thus the HSA. The insurers realize this and thus increasing the co-pay is their only solution although a poor one.
Can’t go the way of Canada or Europe unless we want to go bankrupt like they are.
By the way outsourcing physicians has begun. Radiologists will be likely looking for new jobs within 10 years. Check out the company Nighthawk. It won’t be long before most imaging is read overnight by some Indian radiologist and the report beamed back with a smile the next morning. Luckily for me and Dr Hinson, I don’t think this can happen to any significant degree within the surgical fields or Primary Care. I guess in some way we are protected b/c we are real doctors that establish a doctor-patient relationship. Just for disclosure I do own some Nighthawk stock and it was recently highlighted on Jimmy Cramers show.
I do not disagree that to make my proposal fit in with the natural forces of the market process, consumers would need to evaluate the quality of the services they’re given. But how do you measure quality of care? Doing so is much more like evaluating the quality of artists in aa art history book than the quality of contractors in the Yellow Pages.
Uncle Bob goes to see Dr. Jones. Dr. Jones finished med school in the 60s and has practice in town for 25 years. He says hello to the doctor at Susie’s Rise and Shine every morning. He sees Dr. Jones twice a year. His diabetes is mostly controlled, though not as well as it could be. He’s not on an aspirin a day. But when he sees Dr. Jones, they talk about family and old friends and he trusts Dr. Bob and believes that he has him on all the right meds and rarely, if ever misses a dose.
Uncle Tom had a fallout with Dr. Jones several years ago when Dr. Jones’ brother began to date Tom’s ex-wife. Tom has to drive into the big city to see a doctor. It doesn’t matter which doctor he sees, they’re all Ivy League trained and sit on the editorial board of the NEJM. Tom’s complex medical history is a piece of cake for their evidence-based algorhythms and his care is rendered, at least in the doctor’s mind, even before the doctor comes in and spends 6 minutes to examine him. He’s given instructions he does not understand, and prescriptions for medicines he cannot afford, and will not take. He leaves frustrated, but the doctor documents the care he received and submits 32 separate G codes to Medicare, which are translated by a roomful of 1975 IBM card punching computers and interpreted to be consistent with “quality care.”
Uncle Tom dies of a heart attack.
Bean counters will never understand that, when it comes to primary care medicine, a giant percentage of what helps patients take care of themselves is the immeasurable quality of the conversation and the perceived care and compassion that a doctor gives the patients.
Marcus Welby can give you the wrong medicine altogether, and you’ll get better. Dr. House might give you the medicine associated with the best t-scores only to see your health deteriorate.
Well, I tried to send Medical Student a spreadsheet with a very simple-minded operating budget and volume estimates to play with, but his e-mail address is evidently bogus.
t
Med Student says:
> You give me a salary expectation of 100k take
> home, and cost of living/inflation adjustments,
> for a 50 hour work week, with malpractice insurance
> covered by the federal government, and I’ll be fat
> and happy.
I’ll bet you would. If you were in a big enough group, you might expect to work a hours like this. Solo, you will work a about 35 hours/week seeing patients, and then you will have to do the work of a CEO, meet regulatory requirements, do customer service, etc. But that’s if you can realize an average of $220/hour for 35 hours/week. You’ll get two weeks off per year.
I have never, ever gotten cost of living/inflation adjustments. This is a union concept. For professionals of any stripe, our compensation depends on our performance and on market conditions. That’s all. Our education and hard work do not matter. I have a great deal of both, and I know 😉
Malpractice insurance is part of practice overhead. I do not advocate the feds paying it under any circumstance. If things work out the way I think they ought, a primary care doc will pull enough billing to cover reasonable overheads and pay himself between $100 — $150K. But the overheads will be his to manage.
I have sent you a spreadsheet with a very simple-minded operating budget and volume estimates you can play with.
Best,
t
> I didn’t say I’m ignorant of economics.
Sorry about how that came out.
t
Well, Tom, I said I’m not an economist … I didn’t say I’m ignorant of economics. Nevertheless, no one can be authority in every area, I agree that continual learning is a good thing, and it is our good fortune that subject matter experts like you and others here are participating in this forum!
I’m also convinced that a collaborative approach to problem-solving and decision-making is often the best way to spark the kind of innovation, creative ideas, and productive dialogue that leads to the wisest solutions … especially if the participants have a wide diversity of experiences, knowledge, and conflicting viewpoints. Blogs such as THCB, Healthvoices, and others are a great vehicle for this.
I’m also a believer in “using the mirror,” i.e., hold up a vision of the ideal situation and asks questions and examine why it isn’t a reality and what must happen for it to be; and if the ideal unreachable, then determine the best path to follow to make the situation ever better, and make necessary adjustments to the direction along the way as new knowledge emerges and events occur.
It’s obvious that healthcare is incredibly more complex than other industries for many reasons, some of which you point out. I’ve claimed, and to assert, that key to any valid proposal to solving the healthcare crisis is: (a) gaining and disseminating knowledge of the most cost-effective, personalized interventions that keep people well (prevention & maintenance) and make people well (diagnosis & treatment) and (b) a system that enables and encourages consumers and providers to implement those interventions in an efficient and effective manner. If everyone received those interventions in an optimal way, I contend, there would be no healthcare crisis! Of course, this is idealistic. So, we should our focus energies on defining the path that would bring us ever closer to this ideal, then invest heavily on moving closer to making it a reality.
Since both reducing costs and increasing efficacy (i.e., improving care quality/value) are imperative, we must focus finding ways establish economic/payment/funding policies that support scientific/knowledge/quality-improvement processes. If they don’t, we’ll be repeating the mistakes of the past. And this is a complex endeavor since there are numerous interacting variables that impede and drive such an effort, e.g.:
• Impediments from a human nature perspective include ignorance, fear, inertia, self-deception, greed, ego, conflicts of interest, etc.
• Drivers from a human nature perspective include quest for knowledge, compassion, curiosity, innovation, collaboration, talent, awareness of the healthcare crisis and desire to fix it, etc.
• Impediments from a healthcare systems perspective include an irrational payment system, lack of transparency, misdirected competition, lack of leadership, adversarial relationships between payers and providers, the knowledge void, low use of clinical decision support systems, low fidelity, continuity of care problems, practice variations, “low status” of PCPs, etc.
• Drivers from a healthcare systems perspective include wellness programs, quality improvement programs, evidence-based practice guidelines, health IT systems, Advanced Medical Home model, personalized care, incentive programs, RHIOs, integrated delivery systems, etc.
• Impediments from a health sciences perspective include lack of funding, limitations of evidence, time and expense establishing practice guidelines, information overload, uncoordinated research efforts, politicization of research, etc.
• Drivers from a health sciences perspective include our country’s recent focus on healthcare quality, better IT systems, collaborative efforts (largely abroad), growing awareness that science is a vehicle for bridging the knowledge void, etc.
Since our whacky payment system is inextricably tied to dozens of other factors, I’m glad were examining it in the context of the bigger picture.
Discussing monetary issues such as acceptable income levels, a “price-regulator-in-chief,” sensible ways of competition, paying for universal care, etc. are certainly important and I’m eager to share my thoughts, ask questions, research, and learn.
Equally important is dealing with the challenges of knowledge-building, continuous quality improvement, development of next generation health information technologies, and the systemic change needed to drive them – which, I admit, are closer to my heart than debating economic theory.
I believe that finding solutions to all this takes a diverse community collaborating openly and honestly with open minds, critical thinking, and a broad, balanced perspective; people who develop wise policies by focusing on resolving very complex issues that often seem intractable. I just don’t want a repeat of the past, where discussions focused on monetary issues to the exclusion of quality issues, resulting in the implementation of short-sighted, ineffective, fiscal-only strategies that made matters worse. We have a tendency to do this in our country.
Steve
http://stevebeller.blogspot.com/
As a med student, I would gladly go into primary care for 100k salary take home.
I go to one of the best med schools in the country, and I’m about the only one considering primary care. The perception is that specialist pay is much better, PCPs are not respected or valued, and that
Somebody suggested that US doctors salaries should be reduced to what the guys in europe make. If you reduced our salaries to what they get, they would come out far ahead of us because they dont spend tens of thousands of dollars on malpractice insurance or experience the same kind of lawsuit risk we face.
You give me a salary expectation of 100k take home, and cost of living/inflation adjustments, for a 50 hour work week, with malpractice insurance covered by the federal government, and I’ll be fat and happy. I dont think thats too much to ask for undergoing 4 years of college, 4 years of med school, 3 years of residency, and a system in which the government directly controls the salaries of an entire profession. Even firemen and policemen dont operate that kind of national pay scale, cities and counties compete for their services.
If you are going to give us socialized medicine with the same salaries that european doctors get, then at least give us th