Improve care, lower costs

HealthScienceHealthcare ProvidersIllnessesMedicineInsuranceFamily

Americans like to complain about the healthcare system, but they're unnerved by many of the proposals for improving it. More than 90% of those surveyed last fall by the Deloitte Center for Health Solutions said that healthcare costs are a threat to their personal financial security, and 80% gave the system a mediocre grade or worse. Yet less than half favored measures to promote electronic medical records, the use of scientifically proven treatments or more monitoring of the safety and effectiveness of drugs. Evidently, we'd rather live with the shortcomings we know about than risk more severe ones.

One encouraging thing about healthcare reform, however, is that improving the quality of care can help slow the debilitating increase in costs. It's good for all. And although the changes required won't be easy, they're essential to the crucial third piece of the healthcare reform puzzle, which is providing coverage to all Americans.

Healthcare providers, academics, analysts and insurers agree that the starting point to improving quality is in adding to the ranks of primary-care doctors and giving them a more proactive role in maintaining their patients' health. According to the American Academy of Family Physicians, other industrialized nations have found that adding one primary-care physician for every 20,000 people decreased the number of unexpected premature deaths by 9%. It also decreased hospitalizations and reduced the amount of care required for many ailments. It's not enough, though, just to have more of these doctors; they also need to expand their contacts with patients, promoting healthy behavior, managing chronic conditions and coordinating the care delivered by specialists, clinics, hospitals and other parts of the healthcare system. Such coordination is rare outside of tightly integrated providers such as the Mayo Clinic, and quality suffers as a result.

The main reason for the shortage of primary-care doctors is that Medicare, Medicaid and private insurers don't pay enough for the work they perform. The current system generally reimburses providers for what they do to their patients, not how well their patients stay, which means it undervalues immunizations, routine checkups and other services that can ward off or mitigate ailments. As Dr. Ted Epperly, president of the family physicians group, has noted, insurers will pay a lot to amputate the leg of a diabetic patient, but not so much to provide the services that might have prevented the amputation. Consequently, the U.S. has a lower percentage of primary-care physicians (about 30%) than other industrialized nations. Worse, the number of med-school graduates choosing primary-care fields is declining rapidly, dropping by half since 1997.

The current reimbursement regime also gives primary-care doctors an incentive to spend less time with patients in order to rush more of them through their offices. They order more tests and call in specialists more frequently than they would if they could afford to spend more time on diagnoses. That's another reason why a bigger investment in primary care should lead to savings in the overall system.

A second step toward higher-quality care is developing treatment standards to guide doctors, clinics and hospitals. This is a controversial move because of the fear that Washington would use the standards as a pretext to limit spending on expensive drugs or interventions near the end of life. Yet even if medicine remains an art as well as a science, it seems foolish not to look at the results of different treatments to try to discern which ones work best under various circumstances. Too little is known about the best way to respond to too many ailments.

The point isn't just to alert doctors to the industry's best practices. It's also to help patients choose among treatment options, especially if the research on comparative effectiveness were to be accompanied by data on how much the approaches cost. Even patients with insurance can face significant out-of-pocket expenses, so information about cost and effectiveness would help them weigh their doctors' advice against experiences from across the industry.

Having physicians lead the research would help reassure the public that the primary goal is to improve care, not to save money. To give those treatment standards teeth, however, they should influence reimbursements -- for example, insurance companies could offer higher payments to doctors and hospitals that meet them.

A third step is to promote the use of information technology in tracking patient care. There are many reasons to switch from paper to electronic medical records, but the most compelling is that it gives healthcare providers better tools for managing patient care. These include systems that guide which medicines are prescribed, what dosages are ordered and when they are to be administered -- three of the most common sources of medical foul-ups. Such technologies have cut errors by half or more.

In addition to averting potentially lethal errors, these systems can help doctors make sure patients pursue the follow-up care they often neglect after they leave the office, much to their own detriment. Software can also help physicians diagnose ailments and adhere to industry standards for treating them. Today, however, electronic medical records are the exception, not the rule. The high cost of converting to these systems is daunting, especially for smaller medical practices (which is why Congress provided about $20 billion in subsidies for electronic medical records earlier this year). Other challenges include the lack of a standard format for sharing electronic records among healthcare providers, and the privacy risks posed by putting such sensitive data into electronic form. Yet the improvements in quality and physician productivity are more than enough to justify making the switch, and doing it soon.

Copyright © 2014, Los Angeles Times
Related Content
HealthScienceHealthcare ProvidersIllnessesMedicineInsuranceFamily
  • L.A.'s missed chance to count the homeless
    L.A.'s missed chance to count the homeless

    Counting the homeless in Los Angeles County may not be as difficult as housing them all, but it is a daunting challenge nonetheless. In early 2013, an army of 5,000 volunteers, under the direction of the Los Angeles Homeless Services Authority — a joint agency of the county and city — fanned...

  • Runoff runaround at the L.A. Community College District

    Two years ago, Gov. Jerry Brown signed a peculiarly anti-democratic bill into law, ending the requirement that the Los Angeles Community College District hold runoff elections for the board of trustees. In late June, the board voted 4 to 2, with one abstention, to take advantage of that new...

  • Why should unions negotiate for workers who don't pay their fair share?
    Why should unions negotiate for workers who don't pay their fair share?

    Last week in Harris vs. Quinn, the U.S. Supreme Court put unions in a bind when it ruled that unionized home-care workers cannot be required to pay for the representation that unions are required by law to provide to them. In cases across the country, including at least one in California...

  • What do the Hobby Lobby backers want women to be?
    What do the Hobby Lobby backers want women to be?

    In the fallout surrounding last week's Supreme Court Hobby Lobby decision, a lot of people have been wondering exactly what role the Christian right thinks women should play in society and how birth control detracts from it.

  • How cop cams can help ordinary citizens
    How cop cams can help ordinary citizens

    When Amarildo de Souza, an unemployed bricklayer who lived in Rio de Janeiro's largest favela, left home one evening last July, his intention was simply to pick up a few things at the market. Instead, he was caught up in a drug sweep and taken to the neighborhood police headquarters.

  • City Council may get pulled into fight over secretive DWP nonprofits
    City Council may get pulled into fight over secretive DWP nonprofits

    For months now the Los Angeles City Council has been able to sit on the sidelines while Mayor Eric Garcetti, Controller Ron Galperin and City Atty. Mike Feuer have engaged in an increasingly nasty fight with union leaders over revealing how two secretive nonprofits spent $40 million from...