We are in a political race and when I hear Mrs. Clinton talk up quality in health care as she did on last night's televised debate, I get really nervous.
I have seen an organization's ratings for patient satisfaction rise from dead last to number 2 in three months. It is a testament to the effort of the organization and its response to poor performance -- as well as to statistical over-sensitivity to minor changes.
We don't really know what quality is in health care, but we know that there are processes that should be paid attention to. Our measures are being used in prime-time, although they show wide variation and are sloppier than slapping a horse-shoe on a seal flipper. We have made great strides, but we are in the infancy of a new field.
We should be unafraid to use the best data available, but we must also retain a sensitivity to the limitations of our data. Sometimes our best data is not really actionable.
Hillary's position sounds sensible, as far as any political platform can sound like anything at all. Quality health outcomes was the passion that motivated my pursuing a higher degree and together with management skills put me in the middle of performance improvement time and again. But awareness of the power and limitations of PI is important.
We are attempting to reduce variation amongst numerous process measures that we know are important to obtaining good health outcomes. But the link between process and biological outcomes remains inferential and subject to numerous additional extraneous influences. The socio-economic obstacles, for example, to patients' participation in their treatment plans affect performance that is over-attributed to physicians. Never-events are really rare "accidents" that can be systematically and impressively reduced, but it is helpful to remember that the random nature of the universe is impossible to deny, even if its effects can be mitigated.
It seems inevitable that a health care plan of some sort is coming, we'd better start looking at details to make sure that political rhetoric does not morph into magical thinking about health care quality. " The other $55 billion would come from the modernization and the efficiencies that I believe we can obtain," Hillary declared.
I certainly hope we can become so much more efficient at work as to save $55 Billion.
Friday, February 1, 2008
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3 comments:
I disagree that some sort of change is coming. The general inertia of our government will prevent any sort of real progress: just look at the way the Senate and the House are fighting over the details of the stimulus package right now.
Economic indicators are drifting to the bad zone. While in slower economic times health care access becomes more of an issue to the newly unemployed, it also reduces any sort of government revenue that could be directed towards changing health care. It will be very hard for many politicians to support a plan that everyone acknowledges will have significant start-up costs. Extra taxes on those who still have jobs will not be popular.
I don't believe the Democrats have enough of a majority to jam a controversial issue through the legislature when ultra-liberal California couldn't pass their version with the strong support of their Republican governor.
Long-term, I think some change is coming. I don't expect it in the immediate future.
Inevitably, any federally sponsored initiative will resolve itself as a cut in provider reimbursement. In the feds view, depriving us of money will force us to be more efficient. If only they would take their own medicine - do lower taxes mean more efficient government?
The moment we start reimbursing based on evidence is the moment that surgeons get put out of business. I'm really surprised that Whipples are still the standard of care for pancreatic cancer.
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