The New Republic once again lends its pages to
anti-progressive sentiment, this time by allowing two business-people to talk about how to improve medicine. As if doctors and nurses really needed advice from them on how to improve the way they give healthcare. The last time I checked, we went to the doctor because we wanted to feel better when we were sick, not because it was simply a fun thing to do. More below the fold.
You can tell that this article was written by a pair of business-people, and not by actual doctors. The authors contend that better healthcare could be easily attained if only hospitals could be compelled to reveal outcome statistics. The implication is, of course, that patients-- or as the authors might consider them, the "consumers" of medicine-- would be able to pick and choose the best facilities, which would thrive, while ill-performing facilities would deservedly die off. To prove this point, the authors point to a couple of examples: ischemic stroke and cardiothoracic surgery. They approach this problem, however, from the perspective of economists, and not from the perspective of actual health care providers interested in actually caring for patients. It's this same businesslike perspective that has so thoroughly warped modern medicine and made our health care system-- ostensibly one of the world's best-- thoroughly dysfunctional.
I'm not well-enough read up on insurance and HMOs and so forth to speak intelligently on them, so I won't even go there. But having actually worked in a hospital and having actually studied things like stroke intervention guidelines as part of my education, it seems to me that the authors don't really consider why doctors do some of the things they do, and how this affects things like outcome studies.
Take the authors' implication that EMTs do their patients a grave disservice by taking them to the nearest hospital instead of one with better outcome results. (They don't note exactly HOW those better results might be obtained, but no matter-- pretend for the moment that one hospital has a loudly advertised "Stroke Response Team" and the other, tragically, does not.) The authors overlook the fact that in time-critical health crises, choice does not really play a role. In fact, using established protocols like going to the nearest capable hospital system-- one that simply is able to intervene with any and all necessary procedures-- is necessary to streamline healthcare providers' decision-making; in those situations, only certain, specific interventions are clinically proven to achieve results. To wit, whenever a patient has a stroke, it is imperative to deliver care-- with intravenous thrombolytics, for example-- within about 3 hours. This is established and widely known protocol and you'd be hard pressed to find a well-educated doctor who wasn't aware of this. Since time is so critical and since those critical interventions are widely studied and available, having a choice of hospitals to go to seems beside the point.
That sums up the authors' critical (and also wrong) assumption: that healthcare should be about choice because patients always have choice in the matter. They consider it-- like insurance companies do, or like the Republicans who oppose a single-payor healthcare system-- a luxury good, one that is ancillary, rather than essential, to living a healthy life. As if healthcare could be relegated to the same plane as donuts, jewelry, or cars. In reality, healthcare remains an intractable problem for private industry because patients do not choose to get sick and visit doctors; and doctors to not choose the most profitable way of treating patients. Indeed, the most "profitable" way of treating patients is often times to the patient's detriment; current insurance schemes, for example, discourage doctors from accomplishing multiple healthcare goals in a single office visit by refusing to compensate them appropriately for providing quality care. (And this is supposed to be the advantage of the free market? Please). As long as we approach healthcare from a purely business perspective, we can never hope to give quality healthcare to the people who need it most-- often those people can afford it the least.
Providing information about health outcomes-- while laudatory and probably valuable-- is not the panacea that the authors envision it to be. And sometimes, requiring hospitals to provide that sort of information can discourage them from giving the quality health care that they need to give. The authors cite the example of UNOS, the organ donation network, and its database on transplant outcomes. They note that "performance in transplants has contineud to improve" with this system, and claim it even helps out "sicker patients." They attribute this improvement to transplant teams' desire to improve their own performance-- and they are probably right, to a certain extent. But to a very real extent, those improved outcomes, and the improvement in the outcomes of sicker patients, are due in a huge part to patient selection: hospitals are now much more choosy about exactly which patients will receive which organs. Much of the time, this determination is not based upon patient need, or even a first-come-first-served basis, but rather on patients' comorbidities, life-expectancy with their primary illness, and other ancillary factors that have less to do with the patient's need for the transplant and more to do with the ultimate outcome that will benefit the hospital's statistics. Do enough selection, and even "sicker patients" are healthy enough as a population to do better than they were before. That is not the kind of medicine most doctors wish to practice.
Ultimately, when hospitals base their decisions on business considerations and not on science, patients suffer. So while the authors make a valid point in noting that making data more available to patients and doctors and others directly involved in healthcare will likely improve medicine, they fail completely to note one big caveat: that doctors already do this (it's called clinical research), and that the vicissitudes of private industry fundamentally interfere with the altruistic nature of medicine. Outcome studies are valuable, not because they encourage competition between hospitals, but ultimately because they encourage the adoption of better standards throughout the healthcare system. The notion that hospitals and doctors would not provide the best of care to their patients for any reason would be absurd except for the fact that the only reason they don't, these days, is because of the warped attitude of insurance companies and Big Business-- as I've described above. It will only be when private industry gets the hell out of the way of doctors that healthcare in this country will begin to show any signs of improvement.