Empowering Patients
Jonathan posed a critical question about how to prevent insurance companies from gaming a premium-support system to cherry-pick the healthiest, cheapest-to-insure customers. The normal response would be to drone on about risk-adjusted premiums, regulations against denying coverage to patients with pre-existing conditions, so on and snore forth.
But another part of the answer is one that progressives should push much harder regardless of what they think about other aspects of health care reform: the government should do far more to enable individuals to distinguish between good and bad doctors, hospitals, and other health care providers. Reliable, clearly presented, easily accessible information about quality of care would have all kinds of virtuous effects, one of which would be to help enable patients to cherry-pick insurers and health care providers rather than the other way around. And such information would help to improve public health and hold down costs, under any system.
Gawande writes:
It used to be assumed that differences among hospitals or doctors in a particular specialty were generally insignificant. If you plotted a graph showing the results of all the centers treating cystic fibrosis—or any other disease, for that matter—people expected that the curve would look something like a shark fin, with most places clustered around the very best outcomes. But the evidence has begun to indicate otherwise. What you tend to find is a bell curve: a handful of teams with disturbingly poor outcomes for their patients, a handful with remarkably good results, and a great undistinguished middle.
In ordinary hernia operations, the chances of recurrence are one in ten for surgeons at the unhappy end of the spectrum, one in twenty for those in the middle majority, and under one in five hundred for a handful. A Scottish study of patients with treatable colon cancer found that the ten-year survival rate ranged from a high of sixty-three per cent to a low of twenty per cent, depending on the surgeon. For heart-bypass patients, even at hospitals with a good volume of experience, risk-adjusted death rates in New York vary from five per cent to under one per cent—and only a very few hospitals are down near the one-per-cent mortality rate.
But Longman also persuasively argues that our current system provides virtually no financial or other incentives to promote quality and that progress on that front will be hard to come by in the absence of a universal system. One obvious reason is that if the public had access to information about specified health care providers comparable to the kinds of detail that Consumer Reports publishes about washing machines, mutual funds, and chocolates, odds are that patients would stop going to providers with lousy numbers. Sort of like an actual market. And health care providers have zero interest in cooperating with anything of the kind. (Efforts like the Cystic Fibrosis Foundation’s almost invariably provide anonymity to the health care providers in return for their data). For insurers, the costs of attaining information about quality exceed the payoffs for a variety of reasons you can find in Longman’s piece.
The push to make real progress toward providing useful information about quality clearly has to come from the government, and the government would only have enough leverage to get the job done under some kind of universal system. The question is, given how much health care providers will resist letting the public know how they’re doing, will emphasizing quality get in the way of real reform by ratcheting up their opposition? I think it’s a chance worth taking because there are political upsides as well, but I’m eager to hear what others think.
Gov. Blago in IL is creating an online list of what hospitals charge for procedures, and their success rates.
June 16, 2005 3:07 PM | Reply | Permalink
I agree that such data should be made public, and argue the point frequently at Maternal and Child Health.
You should not, however, underestimate the technical obstacles to assembling and presenting "[r]eliable, clearly presented, easily accessible information about quality of care." For example, as you clearly understand, it has to be risk-adjusted, but there is no definitive way to do that. The VA system does this better than others, but this in part because they are a centralized care system with a unified electronic medical record. That's what we really want, in my view.
June 16, 2005 3:23 PM | Reply | Permalink
I'm torn by this. The dirty little secret of healthcare in the US is that most of it sucks. I mean, we kill nearly 44,000-94,000 people a year in blatant screwups. It's frightening to think how many more we kill because doctors and hosptials are at various points on the sliding scale of incompetence when it comes to delivering care. So, anything that makes more people aware of this fact and hopefully agitating for change is a good thing in my mind.
But on the other hand, I really feel like these consumer-based approaches put the cart before the horse. In the absence of a universal system, the ability of consumers to act on information is extremely limited. I mean, what's it worth to me that Mt. Sinai has the best heart surgeon in NYC if I'm uninsured and he won't see me?
Furthermore, even in a universal system I don't want to rely on the consumer as the driving force for change. Frankly, people in the healthcare system are sick and they're afraid and they're really not at their most "wait, let me be a little more aggressively empowered about this!" At least I'm not when I have the flu, and I assume I'd be the same if I'd just had a bowel resection.
Beyond that, there's the fact that we simply lack all kinds of important information because doctors don't use computers. And even when we have data, there's all sorts of tricky risk adjustment that has to be done--perversely, the best doctors sometimes have the worst mortality rates because they're operating on the sickest patients. Furthermore, how do we teach people to interpret this data? Innumeracy is pretty widespread, and health data isn't easy to interpret.
The whole "empower patients to change the system" movement isn't a bad thing, but overall I think it's dangerously overpromising and distracting us from other approaches, (like pay for performance, IT investment, universal coverage) that would have a far bigger impact.
So, I'm just going to stick with my current system of choosing my hospitals based on whether they're making or losing money. No joke--it's a predictor of quality.
June 16, 2005 3:55 PM | Reply | Permalink
I think this is a really important post, both substantively, and politically, to answer the question of the voter who's thinking "I already have health insurance. How do I benefit from your health care proposal?" I think altruism by itself is probably enough to sell universal health coverage (the public already supports it by wide margins), but altruism married with self interest is obviously even better.
June 16, 2005 5:30 PM | Reply | Permalink
I am curious.
How many of the people making these proposals have been really sick or had to care for a family member for an extended period of time?
If you haven't been in the system, as a consumer, how can you really be sure what you are proposing will help?
I think what I want is fairly simple. Affordable, preventive care and some kind of help for serious medical and dental problems. A high enough deductible to discourage the hypochondriacs among us from breaking the bank. I can handle the cost of the little stuff, colds, sinus infections, teeth cleanings. Maybe some people can't but then they could be channeled into another program. I think there will probably have to be a cap of some kind and limitations on drastic life-saving procedures.
A good, high-deductible, castastropic coverage, policy that includes preventive care would work for me.
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June 16, 2005 6:17 PM | Reply | Permalink
As always, theorajones hits the nail on the head. The inability of sick patients rationally to analyze their options is also what limits the value of individual market-based reforms, like Health Savings Accounts.
One important barrier to the sort of quality discourse Greg Anrig desires is the medical malpractice system. People and institutions will never allow useful quality data to become widely available when they’re worried about lawsuits at every turn. I’m not for the current version of “tort reform,” mind you, as that’s based upon limiting the remedies available to suffering patients. But until a less punitive system is in place (with ways of making sure bad performers get remedial education and, if necessary, limitation and elimination of privileges) there will always be incentives to hide mistakes. A true quality movement is based on an honest analysis of shortcomings, and the current system doesn’t allow that.
June 16, 2005 7:05 PM | Reply | Permalink
The main benefit to publicizing quality data is that it pushes people to excel. It is true that, generally, joe blow can't run across country to go to the best whatever. But I assure you publishing quality data will ensure that providers have the incentive to adopt best practices. It's coming soon with JCAHO, if it's not here all ready (I don't remember their timetable.) I believe JCAHO plans to make all quality data public. It is a very complex matter, though, as mortality/morbidity stats alone don't tell the tale.
June 16, 2005 8:32 PM | Reply | Permalink
It's worse than that: poorly designed and executed health quality reports might allow physicians to act on the information even though patients cannot. There's some evidence that cardiac surgeons in NY and PA modified their patient selection procedures after the first cardiac surgery reports were published in those states, i.e., procedures may have been denied to patients because surgeons where hoping to avoid high-risk though appropriate care in order to avoid a poor rating (there's also a suggestion that the "cherry-picking" behavior decreased over time, thank goodness). That's nasty stuff.
June 17, 2005 1:25 AM | Reply | Permalink
Right on, Bill. The main thing is to try to create more political energy that would add momentum toward making progress in addressing the very real technical hurdles you describe. The tendency to accept the view that "it's impossible to do" will be difficult to overcome absent more political oomph.--Greg
June 17, 2005 6:25 AM | Reply | Permalink
Tinman, I agree that a quality movement is based on an honest analysis of shortcomings -- but I don't think that the rules of medical malpractice lawsuits are germane to the discussion.
Most important, generalized quality data would not provide enough information to bring a lawsuit, against either a hospital or a doctor. It would, however, give patients some needed information.
As a side note, I'm not sure that providing remedial training to bad doctors is a solution. Most medmal cases turn on a question of whether the doctor was negligent -- did he or she do something egregiously against the standard of care? Some training or refresher courses would be good, and they'd probably improve the quality of care. But the judicial system seems like a good way to simultaneously remunerate patients who have been victimized by inappropriate care and discourage bad medicine.
What I'm saying is that I don't see the two as mutually exclusive; rather, it seems to me that a quality movement in health care and medical malpractice cases can work together for the benefit of all.
June 17, 2005 2:18 PM | Reply | Permalink