Much in the news now is the question of medical care,
including the issue of a single payer system, i.e., government run
health insurance for all, as it is usually considered. Whether or
not a single payer system is, after balancing its pros and cons,
the most desirable solution for a major problem is something this
writer does not know. But there is something relating to the health
care system that I feel fairly confident about. Listen up, as they
say.
Recently, I interviewed a University of Virginia
professor for one hour about health care for MSL’s television
show called Books Of Our Time. The professor, Elizabeth Teisberg,
has co-authored a book called Redefining Health Care with Professor
Michael Porter of Harvard. Remarkably, both Teisberg and Porter
are business school professors, not doctors or medical school professors.
They have of course studied the health care system
extensively and, as I understand it, they believe that their most
important idea is that competition in medicine must be, as they
might put it, restructured in order to provide better care at lower
cost. Yes, better care at lower cost because, contrary to what is
wrongly intuitive to Americans (one often sees something of the
same phenomenon in higher education), more expensive does not always
mean better. Sometimes less expensive is better because, as Teisberg
and Porter believe about health care, less expensive can reflect
experience, sometimes vast experience instead of merely little experience,
can reflect better ways of doing things, and can reflect avoidance
of wasteful, useless, but expensive treatments.
What would restructuring the health care system mean
in practice, according to Teisberg and Porter? Without getting into
all the numerous details, let me give an example. It involves what
the authors call competition at the “medical condition”
level. Suppose the issue is spinal injuries. As Teisberg and Porter
describe it (if my understanding is correct), today doctors in different
departments of a hospital will be involved in the treatment. They
will be orthopods, radiologists, surgeons, anesthesiologists, and
what not. This, the authors say, is not the way it should be done.
Rather, a hospital should have a department dedicated to spinal
problems, with all the necessary different kinds of specialists
being a part of that department. This will give all of them more
experience with and knowledge of the relevant kind of medical problem
-- spinal problems -- will foster communication among the different
specialists and thereby lead to better treatments, will create a
body of knowledge among the different specialists about what treatments
do or don’t work, will encourage desirable experimentation
to discover better methods, and so forth. There should be similar
specialty departments for heart problems, brain problems, diabetes,
kidney problems and all sorts of “medical conditions.”
Teisberg and Porter say that not every hospital,
clinic, etc. should attempt to have a specialty department for every
“medical condition.” Rather, each should have specialties
in what it can do well but not in other medical conditions. This
will eliminate the horrendous cost of purchasing very expensive
machines, used for particular medical conditions, that lie fallow
too much of the time in given hospitals or clinics and, when used,
are used by doctors who lack sufficient experience with the particular
medical condition.
The competition in medicine, the authors say will
be to provide both the best and least expensive care at the “medical
condition” level -- the best and least expensive care for
spinal problems, kidney problems, heart problems, etc., etc. Hospitals
or clinics which provide the best care at the least cost will get
the most business and, very importantly, other doctors and institutions
will begin using (will find it competitively necessary to use) the
practices which the successful ones have shown are the best to date.
Teisberg and Porter also say that their ideas are
not out of the blue. Rather, there are institutions which have begun
using those ideas, both ideas mentioned here already plus others
discussed below. I must say that, since interviewing Teisberg, I
have noticed occasional articles that would appear to bear out the
claim that various institutions are adopting, or making use of,
the pertinent ideas.
As said, the authors believe that their most important
idea is that of competition at the medical condition level. That
is why I’ve explained the idea, albeit briefly (and only as
I best understand it). But presumptuous as it is for this writer
to say so -- since I know so little about the subject -- one is
not absolutely sure that the idea they think their most important
is in fact their most important. For the existence of competition
at the medical condition level depends on another factor which they
extensively discuss and which is important to true competition (not
the phony competition that so often prevails) in any field. It depends
on information being available to the public on quality and cost.
Information on quality and cost is the necessary fundament of true
competition. Otherwise people are buying blind, are buying high
cost items because advertising has persuaded them, etc.
Teisberg and Porter make clear that, currently, information
about quality and cost of care is preeminently unavailable in the
health care field. Doctors, clinics, hospitals, etc. are not required
to assess the quality of the care they are providing -- i.e., the
outcomes of that care -- or whether they are providing it less expensively
or more expensively than other providers are. There are few statistics
about these matters. So people don’t really know whether one
cancer center is doing a better job than another (i.e., is achieving
better outcomes), whether one heart center is doing a better job
than another, whether a given surgeon is a disaster who loses a
disproportionate number of patients, whether a given internist misdiagnoses
patients at an unacceptably high level, etc. Patients don’t
know this, nor do their family doctors who refer them to one specialist
or hospital rather than another, nor do insurers or HMOs who pay
doctors. In short, everyone is flying blind.
This might not matter if all doctors, hospitals,
clinics, etc. were equal and therefore fungible. But differences
in quality and results (i.e., medical outcomes) are staggering,
are off the wall, if one is to believe Teisberg and Porter, as this
writer surely does on this score because there are always vast differences
among practitioners of any field. (There recently was an article,
I think in The Boston Globe, which said that statistics
about Massachusetts heart surgeons showed that there were some whose
results (outcomes) were so much worse than others that they were
“outliers” -- and had left the state. That there could
be “outliers” of this kind and degree in heart surgery
is frightening.) Because of the vast discrepancy in the quality
of different providers (in their medical outcomes), it is obviously
essential to hoped-for improvements in medicine that extensive statistics
begin to be kept and made available. This will enable doctors and
other medical advisers to refer patients to, and will cause patients
to “patronize,” the better providers, who, if Teisberg
and Porter are right, also will often be the less expensive ones
because their quality will, in part, reflect experience and, in
various ways, consequent efficiency. It likely will also cause “inferior”
providers to clean up their acts, by emulating the techniques of
the better ones out of both pride and the necessities of business.
The idea that there is a vast discrepancy in the
quality of health care providers, and that statistical comparisons
of quality (outcomes) and cost are basically unavailable in medicine
today, leads to several questions or comments. Doctors, one gathers,
are usually very intelligent persons these days. For decades, after
all, medical schools have chosen from among the cream of the intellectual
crop. Doctors also are said to work ungodly hours. How is it, then,
that (aside from drunkenness) some of them practice at a level as
low as is indicated by Teisberg and Porter? Well, Teisberg said
in the TV interview that there is just too much information for
doctors to keep up with it all. Even so, a layman is a little hard
pressed to understand why differences in quality are so marked.
Then, too, there is the matter of the importance
of statistical information on quality (outcomes) and cost becoming
available regardless of what other types of improvements are made
in the health care system -- regardless of whether doctors and institutions
begin structuring their practices around and competing at the “medical
condition” level, as the coauthors would like, whether we
go to a single payer system (which the coauthors do not favor because
they fear that consequent universally required rules would stifle
innovation), or whether other changes are made. Whatever is done
in health care, it seems to this writer, at least, that information
on relative quality and cost is a sine qua non of improvement.
Even in a single payer system, for example, you would want statistical
analyses of quality (outcomes) and cost so that all providers could
adopt the practices that work best, and may be less expensive as
well.
Then there is the fundamental question of whether
it is possible to develop the kinds of accurate statistical analysis
of quality (outcomes) and cost that are needed. For decades, I think,
medicine has often resisted comparisons of the quality of care because
doctors don’t want to be shown up, and because of concern
that the statistics could be misleading because, for example, a
hospital (such as a teaching hospital) could show bad mortality
rates, but that would be due to the fact it took the most difficult
cases. Yet the difficulty of the cases would not be taken into account.
Teisberg and Porter say that it now is possible to
produce “risk adjusted” figures on the quality of care
(on outcomes), figures that by appropriate techniques take account
of the differences in the difficulty of cases. They further claim
that there already are some medical institutions which are doing
this, say that the practice is increasing, and make suggestions
as to the types of organizations which could appropriately create
the metrics (e.g., organizations of medical specialties, insurers,
health maintenance organizations).
To this writer, as said, the most crucial necessity
in medical care is to begin making the needed information available
to patients, referring doctors, medical advisers, the general public,
etc. Just as in every other walk of life -- let me repeat that --
just as in every other walk of life, a lack of publicly available
information, sometimes because of deliberate secrecy, leads to bad
results (a fact which all are acquainted with when it comes to governmental
matters of all types and to unethical and dishonest conduct by large
corporations, and which some are acquainted with in other fields,
e.g., accreditation of law schools or certain other types of institutions).
If we want to improve the situation in the field of health care,
it is essential, it seems to me, to vastly improve the amount of
information that is publicly available about outcomes and costs.
Two last points. At various places in their book,
Teisberg and Porter mention various institutions which, they say,
create, to one degree or another, the kinds of information about
outcomes that people need. At the end of the television interview,
which will be shown on Comcast’s Channel 8 on Sunday, January
21st in New England and on a Sunday in February in the Mid-Atlantic
states, our producers have listed the names, addresses, phone numbers
and email addresses of the institutions that Teisberg and Porter
mention. The producers have done this so that persons who want or
need the information will have access to it. For the same reason,
I have appended the list at the end of this commentary.
Also, some might want to see the interview (because
of the importance of the coauthors’ points and because, while
I think I’ve got things right in this commentary, Teisberg
is a far more knowledgeable expositor). For those who might want
to see and hear what she has to say, the interview, in addition
to being broadcast on Comcast’s CN8 on Sunday, January 21st,
at 11:00 a.m. in New England and on a Sunday in February in the
Mid-Atlantic states, will also be viewable in its entirety on the
web as of Thursday, January 18th at noon. Go to Google, click on
video, and then type the name of the program, Redefining Health
Care.
List Of Institutions That, According To Redefining
Health Care, Create Analyses Of Medical Results (Outcomes) To One
Degree Or Another
Consumers Medical Resource
Toll-Free: 1-888-426-7435
Best Time to Reach between hours 8:30 a.m. – 5 p.m. EST, M-F
Best Doctors, Inc.
One Boston Place, 32nd Floor
Boston, MA 02108
617-426-3666
Toll-Free: 1-800-223-5003
Email: [email protected]
Preferred Global Health
133 Federal Street
Boston, MA 02110
617-369-7900
National Quality Forum
601 13th Street, NW, Suite 500 North
Washington, DC 20005
202-783-1300
Email:
[email protected]
Pinnacle Care International
250 West Pratt Street, Suite 1100
Baltimore, MD 21201
1-866-752-1712
The Leapfrog Group
c/o Academy Health
1801 K Street, NW, Suite 701-L
Washington, DC 20006
202-292-6713
Email: [email protected]
Wisconsin Collaborative for Healthcare Quality
P.O. Box 258100
Madison, WI 53725-8100
608-250-1223
Email: [email protected]
The National Committee For Quality Assurance
2000 L Street, Suite 500
Washington, DC 20036
202-955-3500
Institute For Healthcare Improvement
20 University Road, 7th Floor
Cambridge, MA 02138
617-301-4800
Toll-Free: 1-866-787-0831
Pacific Business Group On Health
221 Main Street, Suite 1500
San Francisco, CA 94105
415-281-8660
Email: [email protected]
United Resource Networks
MN010-E169
6300 Olson Memorial Highway
Golden Valley, MN 55427
Toll-Free: 1-800-847-2050
Alpha-1 Foundation
2937 SW 27th Avenue, Suite 302
Miami, FL 33133
305-567-9888
Toll-Free: 1-877-2-CURE-A1
BC columnist Lawrence R. Velvel,
JD, is the Dean of Massachusetts
School of Law. Click
here to contact Dean Velvel. |