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Monday, September 06, 2010
Cost control requires information
By Winthrop Quigley
Of the Journal
Now that the Congress and President Barack Obama have decided they want a privately run, free-market health care system, consumers and providers must cope with the system's lack of many of the elements essential to free market economies.
One of the most critical missing elements is information, especially the information other industries disclose to customers through pricing.
Consumers of care don't pay the bill, the insurance companies do, so the consumer has no means, let alone incentive, to judge if the cost of care is worth the value received. Prices aren't set by supply and demand as much as they are by negotiations between payers and providers. Greater supply of medical providers usually leads to greater consumption of care and higher costs. Some equipment is purchased by hospitals not to satisfy patient demand but to facilitate physician recruitment.
James E. Bailey, an internist and a professor at the University of Tennessee Health Science Center in Memphis, says the payment systems in health care reward throughput – getting lots of patients into a practice and doing as many things as possible to them, whether the care makes sense or not. Therefore, Bailey told me during a break in a series of lectures he delivered in Albuquerque last month, the systems used by health care providers are designed to accomplish throughput.
Policy makers keep trying to overcome that information deficit. Health Savings Accounts, for example, are supposed to encourage patients to be smarter consumers by making them pay for more of their care out of pocket in return for tax-advantaged savings. The Centers for Medicare and Medicaid Services puts quality reviews of nursing homes and hospitals on its website, hoping that when (and if) consumers choose the better facilities, the other facilities will respond to lost business by improving.
Bailey has helped create a similar website in Memphis to publicly report the quality of physicians in the community.
Bailey is a leader in the national Aligning Forces for Quality effort, sponsored by the Robert Wood Johnson Foundation, to replace throughput with quality and efficiency. He visited with physicians and other providers as the guest of the New Mexico Medical Review Association, which is also part of Aligning Forces and is working with providers and agencies to implement physician quality public reporting in New Mexico.
The goal "is not to let any group look bad," but to help providers improve their quality of care, which means some providers must transform their practices from a throughput design to a quality design, Bailey said. Collecting information about quality is just the first step. "Doctors aren't trained in industrial design," Bailey said. "It's difficult for a primary care provider (to implement new quality measures) because they don't have the tools. They certainly don't have the money to pay for the tools. It's almost unconscionable to do public reporting without providing doctors with a mechanism for improving quality."
"A large number of physicians are very concerned about the whole idea of public reporting," said Lynn Bryant, an internist and president of the New Mexico Medical Society. "But the overall idea of reporting parameters and outcomes is a good one. Most physicians would agree with that. That's information the patient needs to know in terms of who do they go to see about a particular problem."
That said, getting useful information about physician quality into patients' hands is hard to do.
New Mexico doesn't collect the data, Bryant said. Few private practices have the computer systems required to collect data, the systems that do exist generally don't talk to each other easily, and the data collected are not necessarily consistent or useful. There is a statewide effort going on to solve that problem, but "most of what we have is billing data," Bryant said. Those data don't always reflect the quality of care that is delivered. For example, a physician's practice may include 60 patients who statistics might say should receive a flu shot, but billing data show only 30 got one. That may mean the physician is running a sloppy operation, but it also might mean that the other 30 are allergic to the vaccine or refused the shot for personal reasons. Billing data won't show that.
"The Health Department has reasonably good immunization data on children," Bryant said. "The New Mexico Medical Review Association has a number of different quality markers in Medicare-aged patients. Then we have this whole middle range of patients we only have hospital data on. We can tell you if they had heart attack and if they got aspirin on their way into the hospital. We can't tell you about that in physicians' offices."
Medical science isn't even sure what quality means sometimes. An article in Proto, a magazine published by Massachusetts General Hospital, says that "it can be almost impossible to produce the kind of rock-solid evidence that will convince physicians and the public that a particular intervention, preventive measure or diagnostic test really is the best medicine." There are only a couple of dozen disease conditions the enjoy more or less universal agreement over what the best care is. If we don't know what quality is, consumers can't go looking for it.
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