Cooling the Medical-Cost Epidemic
A program to develop national standards for a variety of medical procedures could lead to a major breakthrough in the effort to improve health care in the United States while containing its cost.
The implications are profound. Agreement on standards would help eliminate unnecessary operations at a time when studies indicate that many interventions are inappropriate. Beyond that, however, the establishment of agreed parameters would influence medical education, strengthening the direction of instruction. It would also establish a better base on which charges of malpractice can be more rationally judged to eliminate the unnecessary tests and other procedures that doctors sometimes undertake simply to create a defense against potential legal action.
The agreement brings together the RAND Corp. in Santa Monica, the American Medical Assn. and a newly established Academic Medical Center Consortium that includes UCLA. Called “The Clinical Appropriateness Initiative,” the joint program will address immediately the increasingly costly and dangerous practice of unnecessary surgery.
By the end of the year, RAND and the academic centers will complete proposed appropriateness standards on four widely used procedures: cataract, aortic aneurysm, coronary artery bypass surgery and carotid endarterectomy. This will include precise indications of when intervention is or is not appropriate. This work will then be translated by the AMA--working with the medical specialty societies--into “user friendly” guidelines for practicing physicians and surgeons.
In agreeing to the plan, the AMA has apparently made a significant shift of policy from what had appeared to be hostility to efforts to intrude on the individual doctor’s authority for medical decisions. That is a welcome recognition by the AMA that existing practices produce a high ratio of unnecessary operations and costs that have spiraled out of control. It is a tribute to the work at RAND, under the direction of Dr. Robert H. Brook, in devising a way to interpret under what circumstances intervention is appropriate.
The success of the consortium will largely depend on decisions at the federal level. Generous contributions from the John A. Hartford Foundation and the Commonwealth Fund, and in- kind contributions from the AMA, RAND and the academic institutions, are funding its initial work. But federal support also will be required.
Fortunately, establishment of the consortium coincides with the creation last December by Congress of the Agency for Health Care Research and Policy within the Department of Health and Human Services. The agency’s mandate includes preparation of practice guidelines as part of a broader study of cost and quality elements of the health-care system. The agency will be spending more than $30 million this year alone to fund practice guideline research compared to the $1.5 million in foundation grants available to the consortium. A substantial part of the federal funds will be needed for the work of the consortium if duplication of research efforts is to be avoided and development of the guidelines accelerated.
