Dr. Andy

Reflections on medicine and biology among other things

Monday, March 14, 2005

Quality, not cost

is what medical reform should focus on, according to Harvard economist David Cutler:

Cutler's approach is radically different. He says that most health-care spending is actually good. Spending has been rising, he says, because it delivers positive, and measurable, economic value, and because it can do more things that Americans want. Therefore, Cutler says, we should focus on improving the quality of care rather than on reducing our consumption of it. Rather than pay less, he wants to pay more wisely -- to encourage health-care providers to do more of what they should and less of what is wasteful.

The lengthy article in yesterday's New York Times magazine spells out some of Cutler's work in this area and his prescriptions for improvement. He is obviously a smart guy, so read it all.

I think he is right that cost may not be as big a problem as we think. Sure we spend more than any other society ever has on health care (and more per capita than China spends on everything, as the article points out), but so what? Should we spend more on Ipods or lattes?
We are also the most affluent society ever and health is very important to people. Health care improvements do a lot of good, even if they don't save money.

I just read an article which looked at pneumococcal infections in Atlanta before and after introduction of Prevnar, an antipneumococcal vaccine which kids now get routinely. There was a >50% overall decrease in invasive pneumococcal infections with >80% decrease for kids >2 and >70% for kids 2-4. My calcualtion is that in the Atlanta area (~3.1 million population per article) this saved around 500 infectons per year. Given that 3.5% of infections were CSF, that is 17 or 18 cases of meningitis per year. As a father and a pediatrician, I would put a very, very high value of preventing a case of meningitis.

I agree with the article that quality improvement could be far more effective:

There is an aphorism for such behavior in the business world: ''You manage what you measure.'' If doctors measure how long it takes to deliver an EKG, then EKG's are delivered faster.

Currently, a lot of "quality improvement" is crap. Someone decides we have to measure patient pain better, so now everyone who comes to allergy clinic gets a questionairre to rate their (or their child's) pain on a scale of 1-10. Of course, most of our patients don't come for pain, so the sheet is a waste of eveyone's time and gets ignored by nurses and doctors and just adds to the pile of useless papers.

I don't think implementing better examples will be easy or that good programs are even intuitively obvious, but I think with focus people can come up with better ideas.

One big problem is the goals of health care researchers. Business executives and consultants want to cut costs and improve efficiency so they get more money. Health care researchers mostly want to do studies they can get published so they get promoted. Right now, not much health research focuses on actually improving things, becasue it is hard to do (also true in business) but also hard to publish. The Kaiser and General Motors initiatives are exceptions.

Finally I liked Cutler's emphasis on what is possible in the US. I think he is right that it would be almost impossible to go to single payer health care here because too many people are dead set against it. And rationing spending, discouraging innovation, decreasing access to specialists etc. just won't work in America, whatever one's view of their desirability.

So all in all I agree with a lot of Cutler's ideas. I do agree with the criticism that at some point we need to address how much we are spending on health care:

According to Henry Aaron of the Brookings Institution, ''We can't continue to provide all care for all people.''

Or as I'd put it, we can't give everyone the same level of health care that the richest part of our population is willing to pay for. Nonetheless we should try to get the most we can out of what we do spend.


At 7:28 AM, Blogger jb said...

There will never be any progress in the whole health care financing mess as long as the great majority of dollars spent represent Other People's Money. The proportion of money that I "spend" by recommending/prescribing/doing tests, treatments, operations, or medications that is OPM is >90%. Rarely do I decide to do an appendectomy on clinical grounds alone these days, as the CT has already been done before I'm called. The ER doc has spent OPM, covering his fanny and making my life easier, with minimal marginal benefit to the patient. Rarely do I spend time explaining how to do dressing changes to the patient with an open wound; I merely write an Rx to my friendly local physical therapist and she does the care, again at the expense of OPM and at minimal marginal benefit to the patient. We all write prescriptions "just in case," and we all cover ourselves by advising patients to go to the ER "if things don't improve." Again, spending OPM with minimal benefit to the patient. HSAs may help, if allowed to expand to an economically meaningful extent. Otherwise we're doomed.


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