The devil in the details
When it comes to U.S. health care reform, writes DR. BARRY KISLOFF, there are no simple answers
Our nation’s health care system is being evaluated and judged as never before. With the introduction of federal and state tax dollars into provider payment upon the passage of Medicare and Medicaid in 1965, the expansion of health care costs to greater than 10 percent of the GDP in 1980 and the welcoming of baby boomers into Medicare in 2011, it is clear that the ever-escalating cost of health care services is unsustainable. Complicating the conundrum is the desired progress of medical technology, which, while welcomed for the benefits it bequeaths, nonetheless seems to inevitably add to the cost of delivering services. Finally, the result of our spending, in terms of readily measured health outcomes, is at best modest when compared with other economically developed nations. The problems of our current system are easy to define and, in a broad sense, generally agreed upon. However, correcting them lends further credence to the phrase “the devil is in the details.”
In an effort to remodel our health care system, well-intended reformers have sought to create a more efficient means of delivering services. Their efforts have revealed perceived faults in our current manner of reimbursing health care services. Among the issues raised are: a la carte payment for services rendered, which encourages overuse and waste; too large a role for private insurers in the marketplace whose pursuit of profits both discourages delivery of needed services while hiking costs entirely unrelated to delivery of health care services; the lack of actionable information on medical mistakes; and an absence of price and quality transparency to guide consumers to the most cost-efficient care.
Unfortunately, our current era of hyper partisanship has encouraged hyperbole and misrepresentation in many areas of vital national interest. The attention showered upon health care reform has not escaped this pox. Simply put, the basic question in the reformation of American health care delivery is this: How can we maintain quality while reducing costs? Unfortunately, quality in medicine is difficult to define.
A casual perusal of our leading health care journals yields ongoing, valid disagreements on which drugs and interventions constitute the most appropriate care. Best approaches to treatments change on an almost daily basis. Reformers have called for wider use of Clinical Practice Guidelines as the best approach to and intervention for a host of diseases. Such guidelines, once promulgated, tend to ossify quickly and thus, if not changed on a frequent basis, can lead to what, for the precious moment, is considered substandard or (in today’s parlance) inefficient care. Moreover, recent studies of malpractice litigation have, not surprisingly, revealed that very rarely do guidelines fit a given medical problem in the individual patient, thus further
confirming the intensely personal nature of the provider-patient relationship.
A recent Forum piece stated that wasteful medical practice accounts for 30 percent to 40 percent of U.S. health care spending and that the majority of diabetics and those with chronic lung disease are on incorrect medication (“Beyond Beltway Blathering on Health Care,” April 2). The former figure, gently put, is highly dubious and subject to much interpretation. Like many purchases in life, waste is in the eye of the consumer. This has been repeatedly demonstrated by the limited penetration of health maintenance organizations into the marketplace where growth has been constrained by consumerdriven litigation over perceived budget-mandated limitations on care delivery.
The latter claim, which likely provided those readers suffering with those maladies more than a few moments of disquiet, would seem dubious at best and downright erroneous at worst. Upon these pages, the frequency of mortal medical error has also been confidently announced at a quarter of a million souls per annum. This figure is never acknowledged as controversial and at variance with the most universally accepted numbers in this matter as published in 1999 by the Institute of Medicine and titled “To Err is Human.” The institute’s estimation, also subject to varying interpretation, places mortality due to medical error in the United States at between 44,000 and 98,000 per year. While any misapplication or misadministration of a drug or surgical procedure is one too many, the casual and unacknowledged use of potentially inflated figures to make a point does not further a rational consideration of a serious issue.
It seems as if the word “transparency” has become a shibboleth to the entry of any discussion of import. Health care reformers have repeatedly stated that health care is uniquely opaque as a result of “information asymmetry” between the provider and recipient. Thus the call for more information to be provided to the patient with more decision-making on care to be left to the consumer/patient.
As to the unique “information asymmetry” involved, I would ask readers to ponder their information disequilibrium when involved with their plumbers, auto technicians, financial advisers and so on. This is not to denigrate the need for information exchange in any transaction but to point out that medicine is not unique in terms of consumer innocence.
Ultimately the consumer must trust that it is precisely that knowledge differential that brought them to seek out those special services. Attempts to categorize a given health care provider as a quality purveyor of services is indeed needed but extremely hard to quantify given differentials in the age, economic status and severity of illness in any given patient population. It is doubtful that a practitioner has a patient population of sufficient size to draw truly valid practice quality comparisons relative to their practice peers. Young, economically advantaged and healthy patients can make even the most compromised practitioner seem “efficient.” The problem of rendering care for the seriously ill bedevils health care providers as well as economists.
The essential point to be made as we grapple with the reformation of U.S. health care is that there are no simple answers. Oversimplification and casual reporting of data merely politicizes and poisons the potential outcomes. The public deserves accurate reporting of the problems besetting health care delivery, not randomly chosen and often poorly documented information on the problems at hand.
We need reform of the system, based upon carefully researched, valid data that most, if not all, parties can agree upon. Only then will we have a chance to make positive, enduring changes to health care delivery.