I See the Elephant in the Room -- Making Care Affordable

December 17, 2010
Jeff Kaplan, MD

In which the author offers a 10-item to-do list for making health care more affordable.

On December 3, 2010 I posted, "We Deserve Better: 10 Steps to Delivering Quality Health Care." In that post, I moved past the little we currently have to show for our quality management efforts and offered 10 practical steps to meaningful health care reform that encompasses public health and preventive services, forces shared responsibility and self-examination, and applies peer pressure where and when it is needed.

Yes, I remain optimistic that we can improve both the quality and the value of care, but I must emphasize that we must unfreeze and think differently. Regardless of approach, however, the objectives of quality improvement are to restore equity in access, and to provide optimal and cost-effective, salutary care. How do we get there? The community of interest in this discussion includes all of us -- patients, practitioners, allied health care workers, insurers, regulators -- we are all in this together! Take any of these players out of the picture and the “elephant in the room” hides from view -- it's a sleight of hand where the insurers and big business of medicine convince you to spend more and get less; where the uninsured go to the ER and further fractionate the care; where the old adage “a stitch in time saves nine” becomes meaningless.

We can no longer tolerate siloed business practices in health care any more than we can consider thinking that the following defects in health care quality improvement are good for us: quality of process, rather than outcomes; quality of care without regard to its cost; waste and/or duplication; overtreatment for want of a conversation with the patient; defensive (ie, CYA) medicine practices, etc. With that admonition (and of course within the limits of confidentiality), we must be prepared to measure and manage simultaneously the costs and the quality of care. I don't care if you call it “Managed Care” or “Care Management.” Suffice it to say, either requires you to see the care longitudinally, share information and shift the paradigm from piecework toward well-coordinated care, non-fractionated care that is efficacious as well as cost-efficient.

In their JAMA article "Toward an Outcomes-based Health Care System; A View from the United Kingdom," James. Mountford, MD, and Charlie Davie, MD, look at the “making care affordable” elephant in the room (goes by the name of "value—useful health outputs divided by the resources needed to achieve them”). Although the context of this article is England, it is no different from here in the US -- each country is fighting a burning need to reduce health care expenditures while the flames of demand for services spread out of control (from technological progress, an aging population, increasing expectations, and population growth). The costs of care, even in countries that spend appreciably less then we do in achieving the same or better outcomes, are clearly out of control. It has become an ethical imperative to strive for value.

To paraphrase these authors, here's a reasonable to-do list, but first it must be clear that we should be measuring the quality of care in terms of optimal use of resources and desired health outcomes (ie, those deemed useful by both patients and society).

10 Steps to making care affordable:

  1. Focus on outcomes, not just processes
  2. Focus on outcomes that are relevant (for example, tight control in some type II diabetics can lead to greater mortality).
  3. Risk adjust data to reflect the severity of the case mix; this allows apples to be compared to apples.
  4. Use quality measures that "matter most to patients, comparing performance to relevant peers, and continually striving to improve results over time should be core to what clinicians do. However, the NHS focus on eliminating errors and on complying with minimum standards has not encouraged clinicians to view quality measurement and improvement as central to their professionalism."
  5. Rather than a "snapshot," [one should require] a longitudinal, whole-system approach to measuring and managing quality… Considering quality [only] for the acute phase of an illness in isolation is similar to judging the quality of a vacation overall by considering only the hotel check-in process."
  6. Primary through quaternary prevention medicine strategies each have their place and are important.
  7. What works? Efficacy -- pay for it (along with the obverse: Don't pay for that which does not work).
  8. What works well for the particular patient and condition(s)? Effectiveness -- measure it and give feedback. Realign the incentives to maximize this.
  9. What gives the best bang for the buck? Cost-benefit. Realign the incentives to optimize that.
  10. What should be covered best? That which is most cost-effective.