MICHAEL L. MILLENSON
Although we in health care often complain that system reforms are delayed, diluted or derailed by the forces of inertia and incrementalism, we are hardly alone in our frustration. Would-be reformers elsewhere suffer similar setbacks, even when the need for change is painfully obvious.
For example, ten years after terrorists crashed two airliners into the World Trade Center, the United States does not reliably screen cargo transport. The problem is partly technical, but it’s also a matter of mustering the political will to make tough tradeoffs. By comparison, foot-dragging on fixing physician reimbursement formulas pale in importance.
“Misery loves company” admittedly provides a less inspiring invitation to holiday cheer than, “Count your blessings.” Nonetheless, here are three examples of other would-be reformers facing opposition that will sound familiar to anyone trying to make U.S. health care a little more rational.
1. Focusing on cost, rather than value. We may kvetch about the inadequacy of comprehensive reform, but important legislative and regulatory change is a regular occurrence in health care, whether it’s the addition of a drug benefit or a constant ratcheting up of Medicare’s conditions of provider participation. By comparison, a significant overhaul of food regulations hasn’t occurred since the 1930s.
Partly as a result, millions of Americans are sickened and thousands die each year from food-borne illnesses ranging from salmonella in eggs to contaminated spinach. The Food Safety and Modernization Act requires better data from food producers and gives the Food and Drug Administration the power to prevent problems rather than just reacting once they’re discovered. Nonetheless, critics have warned that the new requirements on industry could raise prices at the grocery shelf. Supporters respond that a single e. coli outbreak costs as much as $7 million.
It’s unclear how much of the predicted cost increase is crying wolf and how much is real. More broadly, however, the question is how much we’re willing to pay today for prevention of problems that may wreak a far higher financial and human cost tomorrow.
Oscar Wilde famously said that the cynic is one who knows the price of everything and the value of nothing. We in health care are not alone in battling them.
2. Provider accountability. In recent years, the Department of Education has steadily been pressing for more data to measure the quality of teaching. However, a report this past summer by a liberal think tank concluded that student test scores are not reliable indicators of teacher effectiveness, even with the addition of so-called “value-added modeling.” (Risk adjustment, anyone?) Although comparisons are more sophisticated than in the past, said the report by the Economic Policy Institute, they’re still not accurate enough to be used in evaluating, disciplining or paying teachers and may cause teachers to avoid the neediest students.
On the other hand, the Brookings Institution, another liberal think tank, concluded in November that value-added estimates of teacher effectiveness were similar to predictive measures such as SAT scores for college admission, mortality rates and patient volume for surgeons and hospitals and batting averages for baseball – not perfect, but useful.
3. Using data and evidence to improve performance. “A lot that’s done in [our field] is done because of tradition…They think it will work for everybody when they haven’t evaluated the programs to see why it works.” That quote’s not from a frustrated physician talking about the challenge of implementing evidence-based medicine, it’s from a frustrated cop talking about the challenge of implementing evidence-based policing.
Lawrence P. Sherman, the experimental criminologist who is the father of evidence-based policing, has over the past decade acquired followers like the California police department that’s using sophisticated data mapping techniques to predict where outbreaks of crime are mostly likely to occur. The department then concentrates resources where they’ll be most effective. But some grizzled veterans can’t figure out what the fuss over information technology is all about.
“If you want to really fight crime, just listen to the cops that are out there, on the streets, every day,” advised a skeptical commenter on a law enforcement news website. “Most of the time these so-called highly sophisticated, very expensive computer programs do nothing more than simply verify what the street cop already knows.”
Translating the three examples above into health care terms, what you’re hearing is government regulation is bad, you can’t measure the care I provide and, when it comes to quality, I know it when I see it.
See? It’s not just us. Take what comfort and joy in those tidings that you can.
Michael L. Millenson is the president of Health Quality Advisors LLC, the author of Demanding Medical Excellence: Doctors and Accountability in the Information Age and the Mervin Shalowitz, MD Visiting Scholar at the Kellogg School of Management.