Choosing Your Doctor Carefully Is the Best Medicine
In this article, Milstein writes about medical quality as he would in a letter to his mother.
Dear Mom,
I’m sorry I can’t be with you this year when you pick a health insurance plan or doctor--and especially if you get sick and need help deciding on the best hospital or treatment. Since I can’t be at your side, I am sending you some advice that I have given to others.
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Why It’s Important to Seek Quality Medical Care
The average quality of American care is not dependable. Here are two important numbers to remember when you think about problems in average quality: 3% and 11%. Three percent was the number of hospital patients who suffered avoidable injury or death due to errors, according to a detailed study of U.S. hospital care by researchers at the Harvard School of Public Health.
Eleven percent was the number of Americans living at home with a common chronic illness (such as high blood pressure or asthma) who were suffering an avoidable medical problem because their doctors were not meeting standards for good quality of care. The second study was by health policy experts at RAND, a research center in Santa Monica.
To put these numbers in perspective, one of the Harvard researchers used his findings to estimate that 180,000 Americans die each year from injuries caused from hospital care. He then estimated how many fully loaded jumbo jets would need to crash each year to cause the same number of deaths. If you don’t count deaths that were unavoidable (such as someone dying because of a severe medication allergy that no one could have known about), the number of avoidable hospital deaths would equal one jumbo jet crash a day. This does not mean doctors and hospitals are not trying to do their best. It means that meeting standards for high quality is difficult and will require major changes in how care is provided and managed.
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How to Get Better Quality of Care
Fortunately, health insurers, doctors, hospitals, employers, unions, consumer groups, government and researchers have been working on solutions. As a result, there are good things you can do. For one thing, you can pick a better quality medical plan. Fortunately, we do have quality-of-care ratings for some health insurance plans. In California, the state has teamed up with a respected quality-review organization and the California Medical Assn. to try to ensure that minimum standards for quality are met by all California HMOs. In addition, many HMOs voluntarily seek performance reviews by the National Committee on Quality Assurance, a national organization that tests HMOs not only for minimum acceptability but also for excellence.
The committee has also developed a quality “report card” for HMOs called HEDIS, which most California HMOs voluntarily report to the public every September. This report includes performance scores on patient satisfaction, preventive services and treatment for several diseases. In addition, the U.S. government makes available to the public other performance information on HMOs offered to Medicare patients.
Unfortunately, for most health insurance plans that are not HMOs, we do not have quality-of-care ratings. Are you better off picking an HMO or a non-HMO insurance plan? Leading researchers conclude that there seems to be no overall differences for a person in average health--no matter which type of plan he or she chooses. There is evidence that some very sick people may be better off avoiding an average HMO. My belief is that quality of care in some HMOs is better, and in other HMOs is worse, than average care outside of HMOs. For example, the 1998 HEDIS report shows quality scores for follow-up care after heart attacks by many California HMOs are much better than scores found in research on non-HMO care.
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Choosing a Doctor
My advice is to pick a doctor based on what physician group they join, advice from other doctors or nurses, their qualifications and your own experience.
Report cards on individual doctors are not available yet, but there are several things you can do to increase your chances of selecting a good doctor. First, find out whether your doctor is a member of one of the physician groups who volunteer to participate in “Physician Value Check,” a public performance report on physician quality.
A doctor who is in one of those groups is willing to have his or her quality scores measured and publicly compared. In addition, if more than one of these physician groups is in your area, consider picking a doctor from the group with higher scores. Second, if you know doctors or nurses, ask them which doctor they would pick for your medical problems. If several doctors or nurses suggest the same physician, that doctor is likely to be better. Lean toward selecting a doctor who is board certified and has hospital privileges, something you can usually find out by asking the doctor’s receptionist or the doctor.
Finally, don’t select a doctor if you don’t have a good feeling when you meet with him or her. Avoid a doctor (or nurse practitioner) who doesn’t listen to you carefully or doesn’t explain things clearly in a way you can understand. Research shows that doctors who help their patients understand their illness and treatment get better results.
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Pick a Hospital Based on Results, Experience and Teaching Status
You can get information on how California hospitals compare in their success for several treatments. Report cards are available on organ transplants, heart attack treatments and making sure newborn babies are ready to go home. In the spring, comparisons of hospitals will also include death rates from coronary artery bypass graft surgery. In addition, the state is working with University of California researchers and hospitals to expand the report card to other hospital treatments.
If you need surgery or other hospitalization for which there is no hospital report card, in 1999 you will be able to use information now being compiled by researchers at UC San Francisco. It will show consumers which treatments are more safely performed in hospitals that have more experience in that treatment and/or which have intern and resident physicians on the premises. It will also show which California hospitals have these safer features. For some conditions, such as high-risk births, going to a hospital with the right features can reduce the chance of death by more than 30%.
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Don’t Be Shy About Asking Your Doctor About All Treatment Choices
Some people are uncomfortable asking their doctor about treatments other than the recommended one. While this is understandable, researchers in Boston have shown that this type of shyness can hurt your health. They found that patients who acted like partners with their doctor in planning treatment achieved better health than did “shy” patients.
Surgical treatment or medicines? Four pills or three pills? The best road to health is to discuss these decisions with your doctor. There are many ways you can improve your knowledge about health care to be a smarter partner with your doctors. People who use the Internet can get access to a lot of good health care information. Be aware that some Internet health information is not necessarily reviewed by medical experts and should be discussed with your doctors.
California’s public libraries not only have useful books, but many also loan out special consumer videotapes. One example of such videos--available at many public libraries--is the “Shared Decision-Making” videos produced at the Dartmouth School of Medicine covering 11 “big decisions” in health care, such as the pros and cons of taking hormone pills for menopause or having prostate surgery.
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Sunshine Is Beginning to Light Up American Health Care
Measuring quality of care and learning how patients, doctors and hospitals can improve it (known as “the quality movement”) is like a burst of sunshine for American health care. The last 10 years have brought new quality report cards and some large improvements in quality. Though still at an early stage, progress is being made. Many organizations have made great contributions, especially here in California. Using this new information to get better quality is partly up to doctors and nurses and partly up to patients.
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Dr. Arnold Milstein, who lives in San Francisco, heads the clinical practice for the consulting firm William M. Mercer Inc. and is medical director of the Pacific Business Group on Health, a coalition of major California employers.
