"One Cannot Measure What One Does Not Manage": Rationing and Reform (Part XIII-s)

July 28, 2009
Jeff Kaplan

On the one hand, there's rationing... And on the other hand, there's measurement and management...

On the one hand, there's rationing...

See "Why We Must Ration Health Care; A utilitarian philosopher's argument for placing a dollar value on human life" by Peter Singer, The NY Times, pub. July 15, 2009

I'm not saying I'm in favor of rationing, only that the article is rational as it speaks to inevitably having to make hard choices. The article closes with:

"It is common for opponents of health care rationing to point to Canada and Britain as examples of where we might end up if we get 'socialized medicine.' On a blog on Fox News earlier this year, the conservative writer John Lott wrote, 'Americans should ask Canadians and Brits — people who have long suffered from rationing — how happy they are with central government decisions on eliminating ‘unnecessary’ health care.' There is no particular reason that the United States should copy the British or Canadian forms of universal coverage, rather than one of the different arrangements that have developed in other industrialized nations, some of which may be better. But as it happens, last year the Gallup organization did ask Canadians and Brits, and people in many different countries, if they have confidence in “health care or medical systems” in their country. In Canada, 73 percent answered this question affirmatively. Coincidentally, an identical percentage of Britons gave the same answer. In the United States, despite spending much more, per person, on health care, the figure was only 56 percent."

And on the other hand, there's measurement and management....

In "Health Care 2009: A Strategy for Health Care Reform — Toward a Value-Based System," [N Eng J Med (July 9, 2009)], Dr. Porter laments the fact that "Despite many waves of debate and piecemeal reforms, the US. health care system remains largely the same as it was decades ago. We have seen no convincing approach to changing the unsustainable trajectory of the system, much less to offsetting the rising costs of an aging population and new medical advances." He augurs as have many of the prescient for a value-based approach, one that will align the incentives so that patients have the best care and the doctors who provide the best care are recognized.

Here's the short list of his recommendations: 1) Universal coverage that supports the aforementioned objective—achieving value (and does not allow cream-skimming by insurance companies). 2) Allow employers to promote health and coverage. 3) Promote health and coverage to those who don't have access to #2. 4) Community rate (rather than experience rate) and pool the risk. 5) Subsidize those who cannot afford to pay for coverage. 6) Require coverage.

ME Porter, PhD (Harvard Business School, Boston) "Health Care 2009: A Strategy for Health Care Reform — Toward a Value-Based System."

To my way of thinking, true healthcare reform is impossible without measurement and management. In quality improvement and utilization management, we need 'outcome,' as opposed to just 'process' measurement. We should acuity-adjust and present information about the longitudinal picture; ie, an 'episode of care.' Clearly there must be every form of prevention: primary (eg, community education), secondary (eg, diagnostic → intervention), and tertiary (after the diagnosis has been made). We must involve the patient in their care—financially, philosophically, and practically. We must manage the care in an effective and efficient way using devices that collect data and translate that into information (eg, the electronic medical record (EMR); health information technology (HIT). Finally, we must align the incentives and have providers compete on value.