Monday, June 15, 2009

The Quality of Health Care

The most idealistic health care reformers tend to focus upon expanding access to products and services without reference to the quality, or costs associated with providing that access. In the real world, when we make a purchase we do so based on quality and cost and providers are forced to compete based on the basis of either quality or cost. Unfortunately, this mechanism has been disabled by the U.S. government and the health care industry.

Let’s agree that no one wants universal access to low quality health care. While this sounds reasonable enough, the quality of health care is notoriously difficult to measure. The word “quality” raises the question of value and is expressed as “good” or “bad.” A necessary condition for the determination of quality is the capacity of the buyer to judge between good and bad: call it quality- sensitivity. Access to reliable qualitative information is a necessary condition for quality-sensitivity. In health care the quality-sensitivity of individual buyers is shaped by many factors. However, patients actually have notoriously imperfect information about the quality of their insurance, products, services, and providers.

As stated in my previous blog, the quality of health insurance is usually measured in terms of comprehensiveness, and most Americans have very little reliable information at their disposal in respect to the quality of their health insurance policies. In other words, you usually become quality-sensitive to the comprehensiveness of your insurance AFTER your providers file a claim, it’s rejected by your insurance company, and you get a bill from a provider. Although in recent years insurance language has become a bit more penetrable, it is still notoriously difficult for buyers to make informed decisions about the quality of the insurance products they purchase. The ability of the insurance industry to disguise the quality of its products behind a wall of impenetrable jargon has produced an epidemic of quality insensitivity within that industry. Unfortunately, we do eventually become quality- sensitive after we discover that out health insurance lacks comprehensiveness.

If we lack sufficient information in regard to the quality of our health insurance, we are equally ignorant of the quality of the products and services offered by its providers. The quality of the products and services is based on “safety and effectiveness,” which are determined by scientific investigations supervised by an understaffed and under-funded Food and Drug Administration. We also lack reliable qualitative information in regard to the providers of health care; especially the quality of physicians, allied health professionals, and hospitals. Information in regard to malpractice lawsuits and infection rates of hospitals are systemically well hidden. Given the elusive nature of the quality of health insurance, products and services, providers, and institutions the quality of our national health care system is ultimately inscrutable.

National reformers typically cite statistical data indicating that the U.S. system lags behind other industrialized nations in certain qualitative measures such as: infant mortality and life expectancy. But the basic problem is that national statistics mask local and regional variation: especially in large populous nations. Obviously, the United States has a much larger and has a more diverse population than Canada and European countries, and therefore, we would naturally expect to find a lot more local and regional variation in terms of infant mortality and life expectancy.

As stated in my earlier blog, national statistics also mask variation in access to health care between rural and urban areas. Based on commonly cited statistics, the United States (as a whole) ranks 32nd in infant mortality: with rate of about 6.3 per thousand births. Iceland ranks first with a rate of 2.9, followed by Japan at 3.2. However, this less than flattering statistic masks local and regional variation. For example, despite having one of the best neonatal intensive care units in the world (Children’s Hospital) Hamilton County, Ohio has an infant mortality rate of 13.9, or about twice the national average. Another problem with these rankings is the reliability of the reporting. In Cincinnati, the infant mortality rate says more about the lifestyles of mothers than it does about access to high quality of health care products and services.

As for life expectancy, the U.S. ranks 38th with Japan and Hong Kong ranked first at 82.6. Again, life expectancy in the United States is almost certainly influenced more by culture than the quality of health care. Highly variable infant mortality rates, murder rates, and cancer rates also tend to drag down life expectancy rates in the United States.

Certainly one indication of quality in any national health care system is its comprehensiveness; that is, the sheer number of products and services can be accessed in any geographical location. If sheer comprehensiveness were the only measure of quality, the United States would lead the world. However, comprehensiveness alone may not be the most enlightening measure of quality. Much of the comprehensiveness of the U.S. health care system includes both medical therapies that cure diseases (cancer drugs), but also medical enhancements that improve the quality of our lives (erectile dysfunction drugs, motorized wheel chairs, in vitro fertilization). Although this distinction between therapy and enhancement seems to be fairly objective, it is far from crystal-clear.

Another often-cited indication of low quality of health care is the incidence of medical mistakes, malpractice lawsuits, and the corresponding rise in the cost of malpractice insurance. However, the incidence of medical mistakes is highly variable. It is certainly true that some medical specialties are more susceptible to catastrophic error than others. Obstetrics, for example is especially prone to error, not because of professional incompetence, but because of cultural forces that encourage high risk pregnancies such as: postponed parenthood, poor prenatal care, and religious beliefs that expound the infinite value of fetuses. Our perception of medical mistakes also has a lot to do our overly idealistic expectations, coupled with a staggering number of predatory lawyers that stalk the deep pockets of health care providers. While it is certainly true that many medical mistakes are avoidable to the extent that practitioners can be better trained and facilities can be more fully staffed, these reforms are not costless. Not every mid-sized city can afford high quality neonatal intensive care units, cardiac units, or state-of-the- art trauma centers served by a fleet of helicopters.

Finally, there has been very little discourse concerning the relationship between the quality of health care products and services and the scientific research and development that generates those products and services. Characteristically, most qualitative appraisals of the health care system in the United States discount what we do best. To the extent that it makes sense to talk about nation states in a global scientific and economic environment, research laboratories in the United States still account for most of the comprehensiveness of health care worldwide. For better or worse, governmental agencies such as the National Science Foundation and the National Institutes of Health provide funding for most of that research. Moreover, many of the best medical schools and research universities laboratories are located in the United States. In short, if we bracket issues of “access” and “cost,” the U.S. has the most comprehensive health care system in the world. Indeed, that’s why desperate patients from all over the come to the United States for “state-of-the-art” medical treatment.

Much of the comprehensiveness of the “medical model” of health care in the United States is rooted in “heroic medicine.” But the quality of state-of-the-art heroic therapies is difficult to measure, especially in light of the variable quality of the Food and Drug Administration’s efforts to regulate the research and development of new drugs. As health care in the United States becomes increasingly “heroic,” we can expect a higher research and development costs and a higher incidence of treatment failure and more malpractice lawsuits.

In the United States, quality sensitivity has also been undermined by cultural forces that allow low quality providers (physicians, hospitals, pharmaceutical corporations, insurance companies etc.) to control the flow of qualitative information. Although, much of this machinery has been undermined by mass media, especially Internet sites (, it is still very difficult to access useful qualitative information on physicians, hospitals, and pharmaceutical products.

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