An article in the Sunday Chicago Tribune about hospital report cards reminds me of just how difficult it is for most consumers to shop for high quality medical care. There is nothing more important than our health and there is abundant evidence that the quality of health care varies widely across providers and is often unacceptably low. Yet consumers spend far more time shopping around for cell phones and DVD players than they do for hospitals and doctors.
Part of this is what I call “Lake Wobegone Syndrome.” (You remember Garrison Keillor’s Lake Wobegone, where “men are strong, women are handsome, and all of the children are above average. Well, we live in a kind of medical care Lake Wobegone, where every patient believes that their provider is above average. That’s hogwash, of course.) But part of the problem is that it is virtually impossible to be a well-informed healthcare consumer, even if you tried. So Illinois wants to join the swelling ranks of private and public sector organizations publishing hospital quality “report cards.” Unfortunately, the state missed its target date for releasing the rankings. Even if the state did publish rankings, which were to cover things like surgical mortality and preventable medical errors, I don’t think it would have been very helpful.
It certainly would have done me very little good during my latest encounter with the healthcare system.
You know about my wrist surgery. I had capsulodesis surgery to repair an old ligament tear. A bone in the wrist was repositioned and held in place with wrist capsule. I have had some complications that have caused me great pain and may threaten my long term prognosis. I don’t know if my provider was at fault, and I wonder if I did my due diligence when I chose him. Like most patients selecting specialists, I relied on a referral from my primary care physician. The only “shopping” I did was to learn that the surgeon was trained at top hospitals.
I could not have done much more. There are no report cards for this procedure. Even if they were, they probably would have covered things like surgical mortality or preventable medical errors. The things I would really want to know about – pain, functional status, nerve damage – are not even on report card radar screens. This is a problem for lots of patients trying to be good shoppers. Patients seeking the best possible care for joint replacement, asthma, diabetes, even cancer, have little useful information to go by. Those who bother to search out websites like HealthGrades learn about things like surgical complication rates – stuff that is easy to measure given current documentation, but barely the tip of the quality iceberg. This is like trying to buy a new car when all you know is the rate at which the transmission breaks down.
Many states are working on improving report cards and most of the presidential candidates are talking the talk as well. Do they realize how much more needs to be done? We need to collect so much more data about outcomes, and we also need to collect more data to perform adequate risk adjustment. Who will collect this data? How will it be linked across providers so we can relate long term outcomes to the doctors and hospitals that provided the initial care?
But here is the rub. I would not have needed this surgery or suffered all the subsequent complications if I had been properly diagnosed twelve years ago when I first injured my wrist. (The doctor told me that I probably had a mild sprain when, in all likelihood, I had a complete ligament tear.) No one has yet to produce a report card for diagnostic accuracy. Yet isn’t that at least half of what matters in medicine? Medicine in the United States has always glamorized surgeons, who in an important sense are nothing more than highly paid mechanics. The report card movement will let us all down if it does not include the diagnosticians. I don’t have any good ideas about how to make this happen.
I have heard you warn about a possible race to the bottom if price competition intensifies without commensurate quality competition. Has my experience left me overly depressed? Can we have meaningful quality competition?
You focus attention on a critical issue. It’s a nice idea to provide consumers with information to allow them to better shop for care. But what information and how to use it? I think you make two important points I would like to follow up on.
The first point is that at the level of individual treatments, expect possibly for a few relatively high volume, high risk procedures like open heart surgery, it may not be possible to say very much. I suspect meaningful data you or I could use to shop for a wrist surgery isn’t going to happen anytime soon, especially where there are extenuating circumstances—e.g. repair of an old injury. Personally, what I’d like best to know is whether I’m dealing with a delivery organization that has a strong commitment to monitoring and seeking (successfully) to improve it. However, how to evaluate this clearly isn’t simple. I’d bet: a) your providers would be the first to say they have a strong commitment to quality improvement; and b) the problems you had never got on their screen.
A second important point is that quality improvement efforts tend to emphasize procedures and not cognitive dimensions of care. I’d argue there is nothing unique about this. The focus on procedures runs through the whole system. A good example is the Medicare RBRVS payment system for physicians. At least nominally, a long standing goal of the RBRVS has been increasing relative payment for evaluation and management services, including diagnostic evaluation. But as Paul Ginsburg and Robert Berenson point out in a sobering article in the New England Journal this spring (NEJM 356:12), de facto the tilt of the system over time has been to discourage physicians from practicing in primary care and to encourage a procedurally oriented style of care. If we are serious about high quality care, we need to fix not just information collecting and reporting systems. We need to rebalance how we pay for care to make sure evaluation and management get appropriate attention.