Better Care is Cheaper Care

I'm about 95% in agreement with this approach. All faculty at my institution, which is one of the most famous academic medical institutions and hospitals in the world, are given regular performance feedback about various quality measures including length of stay, readmission rates, cost per patient (adjusted for severity of illness), and patient satisfaction surveys. Not surprisingly, some of our numbers are WORSE than small community hospitals. Part of this is attributable to the patient severity at a referral center, part of it to the somewhat disjointed care and volume of physicians in a teaching institution (everyone is seen by students, interns, residents, fellows, consultants, and they all rotate on and off service at different schedules). There are also core treatment measures that we're evaluated on in order to reduce variability in patient care. This stuff isn't rocket science, but MOST patients with coronary artery disease should be on aspirin or another anti-platelet agent, MOST patients with systolic heart failure should be on an ACE-inhibitor or angiotensin receptor blocker, so we get evaluated for this. Performance incentives exist for achieving a certain degree of quality with these measures.

These are VERY important bits of data for patients to have as well. It's difficult for them to use, though, because in general patients go to hospitals based on geography and on the referral network of their outpatient doctors, not just on statistics. There are also ways in which quality reporting can be misleading. For instance, all lawsuits (even unsuccessful ones) need to be reported and made public. So if you sue your doctor for malpractice for implanting an alien baby in your brain, the doctor is going to get a huge black mark on their public records.

But I totally 100% agree that transparency is the key to reducing variability in practice. There may not be a dogmatic "right" way to treat an illness, but the variability in practice is out of proportion to the evidence.



I'd also add that to say "better care is cheaper care" is a very loaded and potentially misleading phrase. Care isn't necessarily better because it's cheaper or because it's less. However reducing needless variability is both cheaper AND better.

Unfortunately it is not quite so clear cut.
For instance hospital infection rates.
Once a hospital or a clinic knows that its infection rate is being listed as a public report, their behaviour and their reporting change.
Was that really an infection? or
Just a little redness and puffiness around the wound a few days post operative.

It is an unfortunate aspect of quality control and quality imporvement that if the reports are available to the public or to lawyers the informational content, reporting criteria, and behavior changes not always for the better and not always in pursuit of truth. Public reporting can actually impair the process of quality improvement.
Hospitals at tertiary referral centers which take more severe, unusual, rare or complicated cases always have higher mortality and complications than community hospitals. It is very hard to correct for this.
Physicians with the best reputations often get the most difficult cases.
Bad outcomes are not necessarily an indication of bad care.
There are as they say lies, dammed lies and statistics.

Public ranking of hospitals and physicians on the basis of this kind of data collection may not be the best way to impove quality or lower costs. This is not an argument against data collection but a caution about its use and interpretation.

I hope we learned from this instance that mainstream medicine isn't out to kill people and isn't necessarily expensive either

You're right about the first and wrong about the second. We're not out to kill people. We are expensive -- very expensive. We're so expensive that virtually no one can afford health care itself -- people have to have insurance policies.

There are cheaper ways of doing things, and the costs can be attributed to a number of systemic issues (i.e. not just the human "value" of the care), but it's damned expensive no matter what.

---------- Post added 10-07-2009 at 11:39 PM ----------

The ones that generate quality reports are fairly well-defined. Catheter-associated UTIs, vascular catheter-associated bacteremia, post-CABG mediastinitis, these are not the most elusive things on earth to diagnose, and the variability in diagnostic accuracy is much lower than the actual variability in infection rates. Where I work they post the catheter-associated bacteremia rates on the door to every ICU, there for the patients and families to see. They do it because they're proud of their control measures.

They can by using "case mix index" measures. It's not perfect, but it's a fairly quantitative way of describing the severity of patients. In part this depends on documentation practices. Medicare reimburses at a higher rate for sepsis, because it's a severe disease -- but the word matters. If you document "sepsis secondary to UTI", that is sufficient for Medicare's audits, but if you document "urosepsis", the exact same disease, it is not.

At any rate, there are so many studies now that correlate surgical outcomes with the experience of the surgeon that subspecialty volume becomes yet another core measure that patients need to see.

Well, it's a motivational tool for hospitals. I trained in Boston, and the competition was utterly vicious between hospitals there. They all want to be in the top quintile or whatever of hospitals nationwide for this or that measure.

Well yeah I see wat you mean but in the case of the US there is unnecessary private insurance red tape and bla bla bla

That's part of it. Medical liability is part of it, not so much because of the size of the settlements and insurance alone, but because it gets people to practice very defensively and overtreat/overstudy. Part of it is that access to primary care is bad for poor people, so the Emergency Room gets overutilized. Part of it is that a disproportionate amount of money gets spent on critical care and aggressive care in very elderly people at the end of their life. And part of it is that individual patients are not really 'buyers' in the financial relationship, so they don't have the leverage to negotiate down prices.

In Sverige, a medical appointment typically costs ~$20

Of course, the real cost is a lot more but it has to do with the clever economics of how the cost is distributed and maintained low

Just spent $175 to renew my state medical license for the next 12 months -- and about an hour answering questions and updating information. It would take a whole day of patient care in Sverige to pay myself back for that.

um wait

is that a good thing or a bad thing

also we aren't comparing apples and apples: cost of living and bla bla bla are different there

it's not good or bad, just a thing. During medical school, residency, and fellowship, the board exams I had to take (six of them) cost around $7000 altogether, not counting all the other licensure and credentialing costs. It's expensive. There are so many damn costs involved. The board examiners charge that much because they can. It's cyclical -- doctors make a good living, so you can charge them a lot. This relationship of necessity is what drives up the price of healthcare from all sorts of other angles too (why not charge $500 a dose for a new medicine if everyone needs it).

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Most politicians chooses the shortest way out, which usually is the worst.

In Denmark we have an ancient saying "don't pee in your pants to get warm" (since it will only get far worse in the long run and eventually kill you, due to loss of heat in the winter time) ..this is exatly what the politician are doing (figuratively speaking)