Friday, May 25, 2007

Reforming health care data, policy, and practice

At the Forum's Viewpoint Luncheon May 9, we had a panel of speakers representing the various health care reform plans now being batted about in Madison, as well as a speaker representing a more market-based view. All of the panelists agreed that costs (as well as access) are a problem and they all agreed that better information on cost and quality would benefit patients/consumers. But their opinions varied as to which policies would provide the best solutions, and even as to whether enacted legislation should be the default remedy.

What was missing from the conversation was the influence of practice: Can changes in how doctors practice lower costs? We've all heard by now about the experiment by Kaiser Permanente that found simple changes in hand-washing protocol resulted in fewer infections in patients. A post on the Wall Street Journal's health blog last week highlighted how a Utah health system dramatically reduced the number of babies needing costly newborn intensive care by postponing elective inductions of labor until 39 weeks gestation or later. And there's a relatively new book out by Maggie Mahar that controversially argues new and better medical equipment results in doctors eager to use new technology ordering tests merely because they can. From a Washington Monthly review of the book:

...[M]edicine is particularly vulnerable to perversions of Say’s Law, which states that supply creates its own demand. Diving into the data, Mahar relates Dartmouth researcher Jack Wennberg’s findings that the amount of care a patient receives is scarily dependent on where he lives. The more specialists, hospitals, and doctors you’ve got access to, the more surgeries, medicines, and treatments you’re likely to undergo. Worse, there’s no evidence that the outcomes differ between the two groups, and plenty of evidence that they don’t. Indeed, for those receiving the most intense care, the outcomes are worse—a predictable finding, considering the risk of complications, physician error, and infections.

The most effective changes in practice result from data analysis. Thus, transparency of data not only benefits us as consumers when we "shop" for care, but also as patients when a clinic, hospital, or health care system notices an unhealthy data trend and makes changes. But, no matter how transparent the data, savings will not occur unless the health care provider is willing to change its practices even if revenues could decrease in the long-run from healthier patients. That's were policy comes in. As health care becomes more profit driven, policies that provide incentives for cost-saving changes in practice may be needed.

The Milwaukee Journal Sentinel's Sunday Crossroads section May 20 included a roundtable discussion of health care experts. Two of these experts explicitly mentioned provider practices as an area in which improvement is needed, and the others made mention of better efficiency among providers. But efficiency is not the same concept. The doctors in Utah that were scheduling elective inductions probably believed they were being efficient by attempting to manage deliveries in a more predictable manner. Meanwhile, none of the doctors saw the deleterious and costly effects of the early inductions within their own patient groups; it was not until the administrators of the system put the data all together that the doctors became convinced their practices should change. And every hospital that operates its own array of high tech diagnostic equipment likely does so in the name of efficiency--and from the vantage point of a patient impatient for results, it is efficient. But it is costly, as well.

We are remiss when debating health care reform if we don't include policy, data transparency, and practice in our talking points. All three ingredients are necessary for reform to be made.

No comments: