Quality

Months ago, in one of several posts about the daVinci Robot Surgical System,(also here and here), we wrote about Paul Levy's struggle over whether to purchase one for Beth Israel Deaconess Medical Center in Boston, where he is CEO. Levy revisited the topic in a post he called "Uncle!"

He's still not convinced whether the clinical efficiency measures up to the manufacturers' marketing efficiency, but concluded he had to surrender to the technology arms race... one reason which health costs are pushed ever higher. He wrote:

It is not every day the U.S. loses to the Dutch. Heck, even when our wooden-shod friends were favored in soccer over the U.S. in group play at the Olympics this summer, the U.S. came from behind to tie.

But when it comes to the quality of health care services, particularly taking care of people with chronic disease, the Netherlands runs way ahead of us.

So do Australia, New Zealand, France, Germany, the United Kingdom and Canada.

The Commonwealth Fund and Harris Interactive's 2008 survey of access and efficiency of health care services offered to chronically ill adults in eight industrialized countries provides yet more evidence that we in the U.S. do a terrible job of caring for patients with ongoing conditions. Despite far outspending the other seven countries surveyed, and despite high cost sharing even for insured patients, the U.S. was the hands-down survey loser. It's another reminder that our anachronistic system is designed to respond to acute, episodic illnesses, not prevent complications or deterioration of patients with chronic conditions.

Stop the world. Primary care doctors want to get off.

A survey by the Physicians' Foundation, which promotes better doctor-patient relationships, found that nearly half the primary care physicians would do something else if they could. Patients aren't the headaches, as much as red tape from both private insurers and government programs.

We already have a shortage of primary care doctors (family medicine, internal medicine, pediatrics, geriatrics etc). A CNN report on the survey noted that the AMA recently predicted the shortfall would grow to around 40,000 by 2025. For reasons of prestige, money and lifestyle—some of which is built into a medical payment system that favors specialty medicine over primary care—med students are opting for specialties like orthopedics and dermatology over primary medicine. (The New England Journal of Medicine recently published a series of Perspectives on Primary Care, and the full texts are available free here)

We're pretty used to hearing about regional variation in medical costs and practices, but we still get pretty surprised (even if we shouldn't by now) by how much variation there is in adjacent zip codes. Even in cities that we tend to think of as sensible places, like Seattle. If you can always get a good cup of coffee, how come you can't always get good diabetes care?

A recent study, described in the Seattle Times, shows significant variability in the five-county Puget Sound region. With way too many patients not getting appropriate basic treatment.

Nearly half of clinics surveyed were below average at ensuring patients with diabetes got regular eye exams to detect vision problems caused by the disease. The percentage of heart-surgery patients who received standard treatment to prevent blood clots ranged from 59 percent to 96 percent at area hospitals. And at some clinics, fewer than one-in-four sexually active young women were screened for chlamydia, a bacterial infection that can cause infertility and other complications.

PricewaterhouseCoopers has released an analysis of the Obama health plan suggesting it would eliminate two-thirds of the uninsured at a cost of $75 billion a year.

Interesting, the authors of the report suggest that our current financial crisis, far from impeding reform efforts, could actually spur lawmakers into action. In a press release, PwC's David Levy, MD said:

The financial crisis could accelerate health reform rather than be a roadblock to it. Right now, we have an historic opportunity to fix our broken health system as many forces converge around bringing better value for patients, and those forces could become unleashed by a new President who has pledged to make healthcare reform a priority of his administration.

The full report is available here, with registration. Among its other findings:

Senate Finance Committee Chairman Max Baucus (D-MT) today released a health reform blueprint that would aspire to provide meaningful and affordable coverage to all Americans. The 98-page document—released just eight days after the election—provides further evidence of a growing coalition in Congress eager to tackle health reform in the coming year. Sen. Edward Kennedy (D-MA) promises his version before inauguration. Sen. Ron Wyden (D-OR) already has a bipartisan plan he developed with Sen. Bob Bennett (R-UT).

Baucus in a news conference addressed both the moral and economic imperatives of health reform, and linked coverage for all Americans to quality improvements in the health care system. He said he would work to make reform bipartisan -- not just in a token bipartisan sense but in a broad cooperative push aimed at getting around 80 of the 100 Senate votes for refom. He expressed confidence that he would be able to work with fellow Democrats, including of course President-elect Barack Obama.

FLYP, a pretty cool interactive online magazine, takes a look at what's ahead for the Obama administration. New America health policy director Len Nichols was among the experts providing advice. His suggestion is not surprising: fix health care.

Len looked both back to the lessons of the Clinton years and forward to how to realistically bring about change. Fixing the health care delivery system—creating an infrastructure that allows better decision-making clinical tools and use of best practices and comparative effectiveness data—will take five to seven years, he predicted. That means we need to "start this afternoon."

Len also strongly believes that, as hard as it is to get bipartisan agreement on something as complex as health care, it's even harder to pass (let alone sustain in the long-run) significant reform without bipartisanship. That doesn't mean you need unanimity, but you do have to find some way of accommodating different values and priorities. A bipartisan deal should create a health care system that will finally make sure that everyone has affordable health coverage, with help for low-income people, but doing it in a way that preserves choice and (fairly-regulated, level-playing-field) markets. Doing nothing, he says, is not an option.

President-Elect Obama and Senator McCain set perfect tones for the governance we need in their gracious speeches last night. Both emphasized healing and working together. These are two concepts that presidential candidates understand uniquely, having seen and navigated the profound diversity of people and views that comprise our nation. Their call for cooperation and bipartisanship will prove vitally necessary in the quest for health reform—real health reform, not lowest common denominator milquetoast. 

Part of the need for bipartisanship is simple math. Whatever the final makeup of the Senate (and we may not know for a while), we know that neither the Democrats nor the pro-reform camp will reach the magic, filibuster-proof 60-vote threshold.  Furthermore, there is no guarantee that Democrats will unite unanimously in favor of any legislation, especially legislation as complex as health reform. Therefore, especially given the leadership displayed by both McCain and Obama last night, we view the potential composition of the Senate as an opportunity far more than a challenge.

We write often about how inefficiently we provide care in the U.S., and how a top order of business for the next administration should be establishing a comparative effectiveness entity to help sort out what works and what doesn't. A story in today's New York Times about a court ruling on Medicare spending stresses the importance of having independent analysis about effectiveness.

The article reports that a Federal District Court in Washington blocked the Bush administration's effort to save money on Medicare by paying only for the least expensive treatment for a condition—in this legal case, chronic obstructionary pulmonary disease.

The administration wanted the Health and Human Services Secretary to have more discretion over Medicare payment policies. The judge said Congress sets detailed formulas.

We think this begs an important question. Do lawmakers really know whether drug A or drug B is really better for COPD? Do cabinet secretaries? The answers should rather be based on independent, reliable, untainted science and public health data. You can't make cost-benefit analysis without knowing the benefits. And if we really make an effort to get good data, to pay for effective quality care and not waste so much money on unproven or outright unnecessary care (maybe $700 to $800 billion a year), the cost piece of that equation may not be quite so daunting.

The folks over at the Center for American Progress believe, as we do, that health reform is about more than making sure people have insurance. It's about retooling our health care delivery system so that it provides high quality care, spends health dollars sensibly, addresses chronic disease, and promotes public health. (In the unlikely case that you need any reminder about the chronic disease and public health messages, check out the CDC report that the diabetes rate has nearly doubled in the U.S.)

There are lots of ideas about how to repair our health care system. We write about them a lot, and MedPac has pulled a lot of the ideas together in its own reform roadmap for the elderly. CAP pulled together some of its own health experts as well as some other think-tankers and policy types to try to further braid the strands of these reform ideas. The result is a new book, The Health Care Delivery System: A Blueprint for Reform. You can download it here, and or read the Overview and Recommendations. We haven't read the whole book yet (although in the past we've spoken with and blogged about quite a few of the contributors), but here are a few key points from the summary: