I see it's time again for my spiel about the quality of medical care in this country.

The high cost of health care in this country is related to one major component, quality of care that is given to patients thorough a complete cycle of treatment related to a medical condition; a single payer system would not address this issue and switching to a single payer system could make the problems surrounding quality worse than they are.

The Institute of Medicine has done a study entitled “To Err is Human”: it can be read in PDF format. This study shows more people die in a given year as a result of medical errors than from the combined total of deaths from motor vehicle accidents (43,458), breast cancer (42,297), or AIDS (16,516.)

Total national costs (lost income, lost household production, disability and health care costs) of preventable adverse events (medical errors resulting in injury) are estimated to be between $17 billion and $29 billion annually; health care costs represent over one-half of these numbers. All of these numbers are on the conservative side, other studies conservatively place the total number of deaths due to medical errors at 284,000 in the calendar year 2004. Lower quality in medical care exists because of treatment errors and diagnosis; these errors cause overall costs to our society to increase in an unspecified manner because of the need for repeated treatment to address the issue of “fixing the problem” or loss in productivity as the patient is kept away from normal duties.

The authors of the study make this important observation:

     But not all the costs can be directly measured. Errors are also costly in terms of loss of trust in the system by patients and diminished satisfaction by both patients and health professionals. Patients who experience a longer hospital stay or disability as a result of errors pay with physical and psychological discomfort. Health care professionals pay with loss of morale and frustration at not being able to provide the best care possible. Employers and society, in general, pay in terms of lost worker productivity, reduced school attendance by children, and lower levels of population health status

Our medical system, in short, is broken. Delivery of heath care does not reach as many people as it might possibly when it is needed. The system delivers care to people who may not need procedures or treatment. The system is broken because there is no method of effective competition to weed out suppliers, professionals and health care plans that do not deliver effective care despite all of the money that is thrown their way. Again, from the authors of the study we should consider this:

   Yet silence surrounds this issue. For the most part, consumers believe they are protected. Media coverage has been limited to reporting of anecdotal cases. Licensure and accreditation confer, in the eyes of the public, a “Good Housekeeping Seal of Approval.” Yet, licensing and accreditation processes have focused only limited attention on the issue, and even these minimal efforts have confronted some resistance from health care organizations and providers. Providers also perceive the medical liability system as a serious impediment to systematic efforts to uncover and learn from errors.

What's wrong? How do we heal the fractured medical care system in this country?
     Usually the market system, over the long haul, can provide better products when competition works in conjunction with consumer education. The improvements in auto safety come to mind; when auto companies saw their competitors brag about safety features, a band wagon effect was created and the product got better in terms of safety, i.e. glass was given shatter proof' qualities, seat belts were provided for each passenger, the interiors were rendered less harmful to passengers during crash situations, etc. The health care system has no such consumer advocacy system, one can only assume the average patient has been intimidated because of years of propaganda; most of us assume the doctor knows best' or change providers in a worse case scenario. The failure of the delivery system in the medical field is evident in the variations in cost across the country; costs in the US as a whole vary from one region to another, higher costs do not translate to better care. Louisiana has the highest Medicare payments (over $8,000 per patient) and yet has the lowest quality. This wide variance is probably due to providers not having access to education about better methods or not having the skills required due to lack of practice. In the medical care field, those facilities or professionals delivering poor quality care do not go out of business, we have no real way of knowing who they are, unless we dredge up the statistics from scholarly studies such as those cited earlier.

In our current system, competition is involved with the wrong issues and produces the wrong results, health care systems fight (and onlookers in government and other business sectors are cheerleading) to contain costs with so called managed care bureaucracies; these Byzantine systems, with there endless algorithmic twists, are providing no real element of competition. Provider groups and health care plans fight the use of new technology, instead of welcoming it where it could provide better care at lower overall costs. Another element of competition is cost shifting, for example large health care groups gang up on the pharmaceutical companies and bargain for lower rates for their members. Meanwhile the members of Big Pharma are free to scalp the unwary consumer who pays on their own, without the protection of a friendly robber baron. In other words, a lot of so called competition is really just the big team members beating up on each other, providing no additional value in patient care and leaving those outside the arena without any recourse but to fork over. This scenario could be extended to all and every arena in the national game' of seeking health care.

The context in which health care is purchased further exacerbates these problems. Group purchasers have made few demands for improvements in safety. Employers are happy to sign their group over to any list of providers a health care plan offers without asking for accountability in terms of overall patient care.

The only way to change the horrible quality issue is to make health care providers, suppliers (pharmaceutical companies, makers of equipment, etc. ) and facilities compete on the basis of quantifiable outcomes for overall patient care through the whole cycle of treatment related to a medical condition. Competing on value is a positive-sum competition from which all system participants can benefit. The citation listed below shows how medical providers, when driven by organized patient concerns as well as those of their attendant consumer advocates have been able to push an information based system of clinics and doctors into new realms of achievement based on a constantly spiraling curve of improvement. Those areas of treatment are pediatric oncology, cystic fibrosis, kidney dialysis, intensive care and cardiac surgery. With expert input, data in these areas was made public and more and more patients migrated to those providers whose patient outcomes were consistently high. These areas of medical procedure have not been plagued by the high costs and disappointing outcomes seen in other areas.

Health Care reform will not be complete or serve those who are often most in need, without serious consideration of a plan that is built universal, mandatory health insurance and consistent standards for health plan coverage, However, policy efforts driven by discussion throughout our society have usually missed the critical insight that the government's most important role is to enable competition based on value so that the nation will be able to afford quality health care for everyone. This enabling process would start with a published effort showing who the best providers are.

I strongly urge anyone who is concerned about health care to give up on the idea of a single payer system. A medicare style system, without the drive of competition, would only perpetuate the horrors of our current system. We can only lower the costs of the system overall if as many participants are brought in as possible, (which would involve government subsidies for many) and if all of the current players, health care providers, health care plans and consumers agree to sit down and ask the government to mandate that results based on the results of medical care given be widely published and discussed. How do any of us know how to chose a doctor, laboratory or clinic? We are better prepared to set up a home theater system than we are able to take care of our medical needs and care for ourselves and our loved ones.

The above contains ideas gleaned from an excellent source, Redefining Health Care; Creating Value-Based Competition on Results by Michael E Porter and Elizabeth Olmsted Teisberg published by Harvard Business School Press. It's available at Amazon.com, search in books by the author's full name.

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Tuesday, January 15, 2008 8:25 PM “ Let me give you a word of the philosophy of reform. The whole history of the progress of human liberty shows that all concessions yet made to her august claims, have been born of earnest struggle. The conflict has been exciting, agitating, all-absorbing, and for the time being, putting all other tumults to silence. It must do this or it does nothing. If there is no struggle there is no progress. Those who profess to favor freedom and yet depreciate agitation, are men who want crops without plowing up the ground, they want rain without thunder and lightening. They want the ocean without the awful roar of its many waters.” “This struggle may be a moral one, or it may be a physical one, and it may be both moral and physical, but it must be a struggle. Power concedes nothing without a demand. It never did and it never will. Find out just what any people will quietly submit to and you have found out the exact measure of injustice and wrong which will be imposed upon them, and these will continue till they are resisted with either words or blows, or with both. The limits of tyrants are prescribed by the endurance of those whom they oppress. In the light of these ideas, Negroes will be hunted at the North, and held and flogged at the South so long as they submit to those devilish outrages, and make no resistance, either moral or physical. Men may not get all they pay for in this world; but they must certainly pay for all they get. If we ever get free from the oppressions and wrongs heaped upon us, we must pay for their removal. We must do this by labor, by suffering, by sacrifice, and if needs be, by our lives and the lives of others.”         Frederick Douglass, 1857