Monday, February 26, 2007

A sober discussion on the state of health care

The March 2007 issue of Boston magazine ("Here's to your health") has a fascinating roundtable discussion on health care delivery in Massachusetts led by Jerome Groopman (local physician and writer for the New Yorker), and including:

  • Paul Levy (Beth Israel Deaconness Medical Center)
  • JudyAnn Bigby (MA Secretary of HHS)
  • Paula Griswold (MA Coalition for the Prevention of Medical Errors)
  • Charlie Baker (Harvard Pilgrim Healthcare)
  • Kathleen Davidson (formerly of Boston Medical Center)
  • Victoria McEvoy (MA General West Medical Group)
  • Teresa Schraeder (New England Journal of Medicine)
  • John Wong (Tufts-New England Medical Center)

(It looks like Boston delays on-line availability of its current issue, so if you want to read this in the near future you'll have to either buy it or speed-read it while you're in line at the grocery store).

Among a lot of interesting threads in the discussion was the following:

  • Quality measurement is difficult in part because physicians currently resist measurement, rightly (Bigby), wrongly (Levy), or innately (Baker);
  • Financial incentives that differentiate among physicians using quality measures are problematic because they are too crude (McEvoy), or they measure the wrong things (Groopman, Bigby);
  • One of the biggest problems in health care is that we don't devote enough resources to primary care (Groopman, McEvoy, Baker, Levy), but we're not going to get new money into the system, and reallocating funding from specialties to primary care is pretty much impossible unless Medicare does it first (Baker);

The biggest disconnect (I couldn't tell if it was a real difference of opinion) was on the issue of whether the system is in crisis because of too much change or too little change.

Making the case for too much change, Schraeder argues that the intrusion of "industry" into what has traditionally been been a "non-profit public service" has taken control away from physicians, which presumably has hurt the quality, safety, and efficiency of care. (Schraeder's assertion is only true if you think of independent physicians as being "non-profit" which, of course, they're not.) McEvoy argues that current quality measures imposed by insurers are distorting care away from higher quality, by forcing physicians to spend too much time on the wrong things (and collect data on the wrong things), and not enough time listening to and managing patients.

On the other hand, others argued that the problem is that we've had too little change. Groopman notes that physicians misdiagnose patients perhaps 20-25 percent of the time in the traditional model. Though the Boston article doesn't elaborate on this point, Groopman's article (What's the trouble?) in the January 29 issue of the New Yorker does. In it he describes how snap diagnoses that often turn out to be wrong are the result of traditional and long-standing physician training and decision-making approaches. Not, as McEvoy suggests, from being forced to see too many patients or from the need to fill out templates. Furthering the argument that we need more change, not less, Wong points to the now well-known results from "How good is the quality of healthcare in the United States?" that we only get good care 50 percent of the time.

At one point in the discussion, Charlie Baker noted that the problems of health care are "profoundly more difficult than most people realize." After reading the various viewpoints in this discussion, I think that Baker is a wild-eyed optimist....

No comments: