"One Cannot Measure What One Does Not Manage": The Centrality and Inevitability of Measurement and Management (Part XIII-l)

August 12, 2009
Jeff Kaplan

To reiterate—the big opportunity in healthcare reform is in being aware of what's going on and what is not—measuring and managing; managing and measuring.

To reiterate—the big opportunity in healthcare reform is in being aware of what's going on and what is not—measuring and managing; managing and measuring. This notion is fundamental and absolutely required. Nevertheless, it is only skirted over in recent publications and discussions.

Here follow actual or paraphrased statements that miss the centrality of measurement and management in healthcare reform efforts:

  • Universal health care coverage that improves quality and reins in costs appears as a possibility for the first time since 1994
  • "Proposed reforms vary from marketplace competition to heavy governmental intervention to increasing patient/family responsibility to bearing down on physician practices. [However, counter arguments are all too familiar:] Market proponents claim that government intervention will stifle innovation, lower quality, and drive up costs. Supporters of a bigger role for the government respond that health care markets are dysfunctional. According to this view, competition in health care does not work as it does in other sectors of the economy, but instead generates high costs and wasteful spending."

Orentlicher D. "Health Care Reform; Beyond Ideology." JAMA. 2009;301(17):1816-1818.

However, cost control may be "An even more important reason for reform" than providing universal coverage. Clearly, "the United States spends far more on health care than any other country. Inexorable growth in expenditures threatens the Medicare trust fund and the federal government's budget over the next 2 decades. With the twin demographic juggernauts of an aging population and an obesity/diabetes epidemic naturally pushing more costs onto Medicare...." the writing is on the wall.

"So where does responsibility for controlling costs rest? Health insurers certainly have the motive, opportunity, and means to take action. They use disease management and wellness programs to promote health. Using information on health care use and maintaining control over payment, they can undertake prior authorization, utilization review, and some case management in an effort to ensure care is necessary and appropriate. This is a proper role for insurers, although their distance from the actual provision of care limits what they can do."

Furthermore, market-based systems that pick and chose who has the least risk — give me a break!

End result? Rely on the federal government? We all agree that means relying on cost controls; Is that their 'final answer'? Moreover, when you 'squeeze a balloon' here and there, it pops out in a different here and there. Guidelines and protocols that treat all patients the same? Give me another break!

Brennan TA, Mello MM. "Incremental Health Care Reform." JAMA. 2009;301(17):1814-1816.

Unwarranted Geographic Variation in the health care industry is the broad category of research pioneered by Jack Wennberg of Dartmouth. Current applications of it are telling: "Compared with similar countries, such as Canada, Germany, and the United Kingdom, the United States has higher administrative costs, higher wages for health care workers and professionals, and higher use of expensive, high-technology interventions, and it delivers more wasteful (ie, unnecessary or inappropriate) care. Support for the last point is derived from data showing wide geographical variations in Medicare spending without evidence of superior health outcomes in high-cost areas (and some evidence of the opposite). The Obama administration has emphasized elimination of wasteful care. Others have focused on administrative costs, arguing that private insurers' reliance on medical underwriting, advertising, utilization management, and insurance "product" development all represent costs without benefits."

Sessions SY, Detsky AS. "Employment and US Health Care Reform; Saving Jobs While Cutting Costs." JAMA. 2009;301(17):1811-1813.

In "The Struggle for Reform—Challenges and Hopes for Comprehensive Health Care Legislation," John Iglehart, Health Affairs founding editor, mentions the real bottom line issue—"can we do cost control" by saying: "There has been 'strong agreement that measures to improve efficiency and reduce health care costs are essential." Nevertheless, David Bowen, who directs Kennedy's health staff, is promoting 38 possible measures while lamenting that legislative committees fail to reach consensus. He warns, "the ensuing controversies may be as intense as the fight over the creation of a public insurance plan."

The big opportunity in healthcare reform I have been advocating is 'measurement and management' and, in my opinion, that may be the ONLY real opportunity. If we don't begin to manage care, we will be left with poor value, accusations of physicians' ripping off the system, accessibility problems, a surfeit of specialists and a dearth of PCPs, private interests (let the patients be damned), protectionism, the munificent insurance industry "willing" to insure persons with preexisting conditions, and the rest is politics as usual.