Quality: the X-Factor in Health Care Debate : Medicine: Clinton’s proposals are defined in dollars and statistics. But patients worry about such intangible things as trust and peace of mind.
Beverly Hills cardiologist Debra R. Judelson owns what she describes lovingly as two “beautiful” pieces of equipment. They are cardiac echo machines--sophisticated devices that take moving, color pictures of the heart. The cost: $200,000 apiece.
In two years, Judelson predicts, these machines will be rendered obsolete by technology that creates three-dimensional images. Ordinarily, she would update them. But this is the era of health care reform, and in the world of medicine, nothing is ordinary anymore.
“I don’t really pay too much attention to how many patients have to use the equipment or the cost per patient,” Judelson says. “But if this is managed care and I cannot charge what I want for my echoes, I’ll keep my equipment until it falls into the ground. If I can’t see the heart clearly because my equipment is old, I might be giving patients worse quality of care.”
Quality. It is fast becoming a buzzword among doctors and patients nervous about the health care reform plan President Clinton is to unveil Wednesday. While the debate on overhauling the nation’s health care system has concentrated on keeping costs down and providing medical care for the estimated 37 million uninsured, critics worry about whether an elusive third ingredient--quality--could be compromised.
Whether the Clinton plan will be accepted by the American people and passed by Congress may depend on whether doctors and their patients are convinced that it will protect quality while it expands access and controls costs.
The plan, outlined in draft form earlier this month, takes great pains to do that. But the order is a tall one, and surveys are already showing that the public has doubts.
A poll released last week by a coalition of consumer groups found that while 84% of Americans approve of their current health care, 46% are very concerned and 30% somewhat concerned that quality will decline with reform. Another survey found that more people were concerned about a decline in quality than any other issue, including freedom to choose one’s own doctor.
Quality, however, is difficult to measure and means different things to different people. The Clinton plan looks at quality in hard-and-fast technical terms, concerning itself with treatment outcomes and how long it takes patients to see a doctor. But for most consumers, quality appears to be linked to more intangible factors. Trust is one. And peace of mind is another--the warm, fuzzy feeling, as one expert put it--that comes with knowing a doctor is willing to spend whatever time and money it takes to keep his patients healthy.
Now that cost has become part of the health care equation, experts say, Americans will be forced to rethink long-held notions about quality in medicine. Clearly, doctors are going to be pressed to think more about how much a procedure costs compared to its benefit. Insurance will not necessarily cover peace of mind. And therein lie the roots of Americans’ fears about quality.
“People are afraid they are going to have to wait too long, that the doctor or nurse won’t have enough time with them, that there will be some important medical technology or drug that will help their problem and they will be denied it because of cost,” says Robert Blendon, a professor of health policy at the Harvard School of Public Health.
Some of these fears may be well-founded, says Robert Brook, an expert in quality of care at RAND Corp., a think tank in Santa Monica. Brook says that while the Clinton plan provides a good framework for ensuring quality, real questions remain about whether it can work.
“There is hardly a hospital or a health plan in this country in which the discussions of quality at the board (of directors) are at the same level as the discussion of the finances of the organization,” he said. “The real question is: Are we really serious, as we cut costs in care, about elevating quality? Or are we going to have nothing but price competition?”
Only too aware that its health reform agenda could rise or fall on the quality issue, the Clinton plan devotes an entire section in its proposal to quality control. The root of the Administration’s argument is that costs can indeed be reined in without sacrificing quality.
The plan seeks to ensure quality in several ways, first by having regional health care alliances collect data on the performance of health plans. This information will be passed along to consumers; the idea is to give people more access to information about doctors and medical institutions so that they can make informed decisions about their own care.
The goal is to be accomplished through “quality report cards” that will compare, for instance, what percentage of children in a given plan receive complete immunizations, or how many women over 50 get annual mammograms, or how much time it takes to get an appointment with the doctor. At a recent press briefing for reporters, Ira Magaziner, the nation’s top health care planner, argued that consumers can “vote with their feet” by leaving one plan for another.
Brook, however, said it will take a huge investment--in the billions, he estimated--to do an effective job of monitoring quality. And other critics, including the American Medical Assn., say it may be asking too much of patients to distinguish quality care from poor care.
“Patients come into the system frequently sick, in pain,” said Nancy Dickey, secretary-treasurer of the AMA’s board of trustees. “They are at somewhat of a disadvantage in a very technical and complicated field to be expected to be their own advocates.”
The Clinton plan would also develop guidelines for doctors and set standards for the treatment of specific diseases and conditions--deciding, for instance, when a patient with heart disease should have an angiogram. The Administration hopes these new standards would help save costs by curbing “defensive medicine,” in which doctors order expensive tests simply because they fear they will be sued if they do not.
To develop these guidelines, the plan would rely on scientific and statistical analyses known as outcome research. By charting vast differences in treatment for the same ailments, outcome studies have proven that the way most American doctors practice--by relying on their own training and intuition--is not always efficient, nor does it always provide the best care.
The problem with outcome research, however, is that there is little of it. The government has initiated several far-reaching outcome studies in the area of emergency medicine, anesthesiology and gynecology. Other studies have been much smaller, and their results have not been universally applied.
One oft-cited outcome study looked at benign prostatic hypertrophy, a condition common to older men in which the prostate is enlarged, making urination painful. While doctors frequently recommend surgery for this condition, Dr. John Wennberg of the Dartmouth Medical School found no evidence that patients lived longer by having the operation. He also found that when all the options and risks were explained to patients and they were given a choice, many preferred simply living with the disorder to undergoing surgery.
“Currently our definition of quality is everything under the sun that could conceivably be of benefit,” said Haavi Morreim, a University of Tennessee philosophy professor who has published a book on the economics of medicine. “Many people seem to think that, ‘When it comes to my health, spare no expense.’ . . . That is an ethic that is embedded in the economics of lavish reimbursement that we used to have. That has got to change.”
