This is the problem
‘The U.S. spends more per person on health care than any other country, but in overall quality, its care ranks 37th in the world, says a World Health Organization (WHO) analysis.’
WHO Press Release June 21, 2000|
"The American healthcare system is at once the most expensive and the most inadequate system in the developed world," Dr. Marcia Angell, editor of the New England Journal of Medicine (1999;340:48)
The following comments are specific to the USA health system but the trends in terms of cost and quality of clinical decision making substantially characterise the Australian and European systems as well.
estimated 15% rise in medical costs this year.
The USA spends approx. 16.5% of GDP on health compared to many other developed countries, such as Australia where figures are of the order of 8.5-9.0% of G.D.P., with a budget estimate this year of around 1.2 trillion dollars. It is part of the national mythology that the reason for the extraordinary cost burden in the USA is the quality and technical level of the medical care provided.
Additionally 44M people in the USA are uninsured - getting only very basic emergency care.
The cost revelation is news to no one.
Quality in Healthcare
In contrast, only recently has public attention been focused on the question of quality in healthcare, an important issue in its own right but also one of the major contributors to health costs. The central problem is clinical decision making. The current appalling average level of clinical decision making was most recently disclosed in the March 1, 2001 US Government sponsored Washington Institute of Medicine (WIM) survey of health care in America. The report was titled
‘Crossing the Quality Chasm’ and was endorsed by every major medical group in the USA. It surprised many outside of the health field for the first time.
The report quantitatively confirmed Dr Angell’s above evaluation and the WHO analysis.
The following excerpt is from Associated Press’s summary of the report on March 2, 2001
`The frustration levels of both patients and clinicians have probably never been higher,'' the report said. ``Health care today harms too frequently and routinely fails to deliver its potential benefits.'' Among the most alarming findings: It can take 17 years for important medical discoveries to become accepted and used by the average doctor. For example, heart medicines called beta blockers were proved more than 10 years ago to increase significantly a person's chances of survival after a heart attack. But nearly half of heart attack victims still do not receive them, said Dr. Lucian Leape of Harvard University, a co-author of the report.’
The same issue has been raised by leading figures in the health field over the last decade.
E.g. A National Press Club speech by David Lawrence, MD, chairman and CEO, Kaiser Foundation Health Plan & Hospitals, July 14, 1999
‘Last fall, a group of us from the Institute of Medicine of the National Academy of Sciences published the results of an intensive multi-year study of health care quality in the United States. We concluded that:
"Serious and widespread quality problems exist throughout American medicine. These problems, which may be classified as underuse, overuse, or misuse, occur in small and large communities alike, in all parts of the country, and with approximately equal frequency in managed care and fee-for-service systems of care. Very large numbers of Americans are harmed as a direct result. Quality of care is the problem, not managed care."
‘... it is generally accepted that more than half of practicing physicians do not use currently available scientific evidence in their care for patients.’
‘most consumers continue to believe in the myth of Marcus Welby, the unbridled benefits of technology, and the assumption that competence and safety are spread evenly and consistently throughout the health care system. If passengers were asked to fly with a commercial airline organized like most health care, they wouldn't get on the plane!’
E.g. Michael L. Millenson a principal in the Health Care and Group Benefits practice of William M. Mercer in Chicago and author of ‘Demanding Medical Excellence: Doctors and Accountability in the Information Age’
‘... study after study documents that important therapeutic advances that have been shown to be effective often take years to work their way into everyday care. This grim failure costs many thousands of lives annually. The most formidable barrier to consistent excellence in American medicine is the failure by well-intentioned and competent physicians to carefully examine what works best and then integrate those findings - from the research literature and from systematic evaluation of everyday care - into routine use. Despite clinical advances that can significantly reduced death and disability, "how good we are" is nowhere close to "how good we could be."
In the late 1980s Dr. Albert Mulley, chief of general medicine at Massachusetts General Hospital and Dr. Jack Wennberg of Dartmouth College demonstrated vast differences in medical practice based on where a patient lives. Men in Washington State, for instance, were five to six times as likely to undergo surgery for prostate cancer as men in Connecticut. Two percent of breast cancer patients in Ogden, Utah, got breast-conserving surgery compared with 35 percent in Pittsburgh. This extraordinary variation in many treatments for many diseases was replicated across the whole country. It was not related even to issues like the presumed quality of the medical centers. Whatever the optimal treatment for any of the conditions, clearly many people were not receiving it. Eventually this extraordinary geographical variability in clinical treatment was extensively documented in the Dartmouth Medical Atlas.
‘Geographic variations in surgery rates and outcomes are associated with three factors: (1) the poor quality of science to provide guidance to physicians making clinical decisions; (2) the sometimes poor quality of clinical decision making, and (3) the variations across hospitals and physicians in the skill with which the surgical care is delivered.’
The notion that geography dictated treatment "shook the foundational belief that medicine was determined by good science," Dr. Mulley said. 2
The world’s foremost medical journal, The Lancet, on Sept 29, 2000 reported a large outcome analysis on women who’d had lumpectomies for breast cancer. It was a follow up study of 143,000 women who had received breast cancer treatment in America between 1983 and 1995. Clearly patients or their relatives at the time were unaware of the very substantial research that reflected on this critical decision making.
Some 35 % of them had not had lymph node biopsies or radiation treatment, very important concurrent treatments, well documented since 1980. Without these, the breast cancer recurrence rate doubles. These two studies graphically support the view expressed, usually in closed medical circles but increasingly also in the community, that there is a wide discrepancy between solid evidenced based clinical practice and what often takes place. The breast cancer study alone suggests that some thousands of women have died or will die as a consequence of those clinical decisions. The scale of the problem hinted at here dwarfs the issue of recent national concern - morbidity and mortality due to hospital errors. 5
‘Improvements in patient safety should pay for themselves. Dr. Donald Berwick, president of the Institute for Healthcare Improvement, estimates that we would reduce the nation's health care bill by 30% ($333 billion in 1999) if we applied across the health care system what we already know. The evidence is persuasive: just as in other sectors of our economy, it costs less to do things right for our patients than to fix the consequences.
Our science, our technology, our medical care, our understanding of what works and what doesn't in medicine are the best in the world and getting better.
But the care which is delivered in this country is compromised by the delivery system through which most Americans receive it. That century old system can no longer do the job. It is obsolete.’
The N Y Times on June 24, 2001 quoted Dr. Lucian L. Leape, a professor at the Harvard University School of Public Health and the co-author of two major reports on health-care quality from the Institute of Medicine of the National Academy of Sciences
‘... given the fact that only a few cases go to external review, patients' rights legislation is "unlikely to lead to dire consequences. But," he added, " neither is it likely to improve health outcomes very much."
To truly improve the quality of medical care, Washington needs to look in a different direction, says Dr. Leape. The scandalous fact about American health care, he and other experts have noted, is how little of what physicians do is backed by careful scientific evidence. A committee of the Institute of Medicine concluded this year that the nation's health-care system is a "tangled, highly fragmented web that often wastes resources by providing unnecessary services and duplicating efforts, leaving unaccountable gaps in care and failing to build on the strength of all health professionals." The panel called for reorganization and reform to fix "a disjointed and inefficient system."
Dr. Leape and other experts estimate that perhaps 20 percent to 30 percent of medical procedures are wrongly prescribed.’
The cost of Medical Indemnity Insurance in the US is a component of the nation’s inflated cost burden and now ranges from $50,000 to $250,000 per year for 440,000 doctors.
Research around the world shows errors in clinical decision making and poor doctor/patient communication are the chief causes of litigation and thus the premium rates.
The way that poor clinical decision making drives costs is through-
The Patient Bill of Rights just passed by the US Senate for the first time allows consumers to sue Health insurance companies for inadequate medical care.
As insurance companies are major employers of doctors in the USA they will be legally coupled for the first time to the issue of clinical decision making.
This is the problem
This is the problem
This is the problem