Daily Archives: November 23, 2009

Continuous Quality Improvement In Health Care?

In the United States, we love competition. It tends to drive efficiency: our goods get better and cheaper at the same time. But there are exceptions, and health care is one of them. Sure, we continue to see new technologies and brilliant innovations introduced that promise to prevent, treat, or cure illness, but things aren’t getting cheaper. In fact, prices are going up faster in health care than they are in any other sector of the economy. People like to claim that this is because of the high cost of research and development that drives medical innovation, but technology in all other areas from automobiles to big screen TVs refute this view. As they’ve gotten bigger and better, they’ve also begun to cost less.

As Harold Pollack points out, the problem in health care is one of perverse incentives that encourages overutilization by rewarding providers on the basis of quantity supplied and removing the conditions that would make consumers place limits on the quantity of care they demand. All of this is further confounded by the fact that we lack information on what care works and what care doesn’t. In an excellent story in the New York Times Magazine, David Leonhardt makes the case that change can happen–that health care can become more efficient–and he cites the work of Dr. Brent James to prove it.

James is a surgeon by training with a passion for improving health care quality. His approach is one familiar to most in the quality control division of other sectors: continuous quality improvement. How does he go about it? Basically, he and his colleagues draft care protocols for given situations and then gather data and revise the protocols based on that data. In short, it’s about continuing to make steps in the right direction. It also relies heavily on electronic medical records to facilitate the process at both ends: gathering data from physicians, but also prompting them to follow the current protocol.

Leonhardt also acknowledges the work of Dr. Jerome Groopman, whose book How Doctors Think is rather anti-protocol, preferring the physician to think outside the box to successfully treat non-textbook cases. But Dr. James’ protocol doesn’t prevent physicians from treating patients as they see fit. Instead, it just reminds them of the protocol and gives them the option of overriding it.

I think they’re both right. Doctors do need to be able to synthesize a large amount of information and handle the “tricky” patients. That’s why I and so many others love to watch the brilliant–if completely fictitious–diagnosticians on House. At the same time, physicians are likely to benefit from a better understanding of what typically does or does not work given the indications. We don’t have enough of that in medicine now, and it costs us thousands of lives and billions of dollars in wasted procedures every year. As my childhood report cards would say: Needs Improvement.

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Posted by on November 23, 2009 in Uncategorized


The House and The Senate

Back when I was hemorrhaging cash to get a masters degree from George Washington University, I learned a handy policy analysis skill: the side-by-side table. It is just what you think it would be. Well, assuming you know what a table is, and what it means for something to be displayed side-by-side. The real question is: What is being compared? In this case, it’s the House’s health reform bill vis-a-vis the Senate’s health reform bill. I waited until the Senate voted to open debate on the floor before bringing you this information. (I didn’t want to act too prematurely, after all.) But the vote passed 60-39 kicking off what’s sure to be fun for those of you who like to watch the few minutes of entertaining antics that are interspersed throughout hours of dull-enough-to-kill-you coverage on C-SPAN.

Now, if it were an assignment for school, or if I were actually being paid to work on this, I’d present you with my very own side-by-side analysis of the two bills. Alas, neither of those things is true. As a result, I’m just going to give you the briefest of my thoughts–those who want more than that are encouraged to take me out for dinner, or at least a drink–and then point you in the direction of some excellent resources created by those who do get paid to do this sort of thing.

Alright, here’s my quick and dirty analysis: The House bill does more to cover the uninsured than the Senate bill, offers a slightly stronger version of the public option and puts more stringent mandates on individuals and employers than does the Senate. Oh, and both bills plan to pay for all this in different ways. Assuming the Senate passes a bill, what do I think will happen in conference? Obviously, I think the conference report will fall somewhere in between the House and the Senate versions, but I think that things in the final bill will be closer to the Senate bill if only because clearing the Senate represents a more challenging procedural hurdle (60 votes to end the filibuster and all that).

Okay. Now for the side-by-side table. The best one I’ve seen yet comes from Kathleen Masterson at NPR with the assistance of Mary Agnes Carey of Kaiser Health News. You can see their work here. The best thing about it, in my opinion, is the “Likely In Final Bill?”-o-meter that gives an indication of what will or won’t make it out of conference.

Erica Werner and Ricardo Alonso-Zaldivar of the Associated Press also have a nice comparison here. It’s primary drawback? It’s just text with clear headings rather than a pretty table.

For those of you who are intimidated by the side-by-side table or just prefer to get your information in a more indirect prose form, you should check out the stories from The Washington Post or The New York Times. (I’m especially fond of the Times piece, which is co-authored by the brilliant Robert Pear.) Of course, last but not least, is the fine blog work of Jonathan Cohn. You should be reading him all the time anyway.

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Posted by on November 23, 2009 in Uncategorized

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