Has anything in health care improved for the better for us patients… for anyone?
Over 10 years ago as we approached the new millennium I was finishing an intensive Health Policy Fellowship. As a synthesis of all I had seen and learned from an insider’s perspective, I penned a vision of what I thought healthcare should look like in the next century. It was more a statement of some twenty principles and directions rather than specifics. We are now a full decade into the 21st century so it seemed a good time to take a look at my old roadmap. Perhaps it is a measure of my current pessimistic state of mind, but I am not immediately able to declare progress towards any of the goals I envisioned. In fact, it seemed at first blush that despite all the money and best efforts of public and private interests, that most of the items on my wish list were getting worse.
What do you think? Please prove me wrong. Help me indentify something good that has happened to us as collective patients. Is anyone better off? If so, who? Convince me that we are not irreversibly lost in a status quo of decreasing access to healthcare of uncontrollable cost, and of unknowable quality.
This observational study of local variation in hospital charges arose in the environment of one of the most comprehensive state attempts at health care reform. In the early 1990s, at the same time the Clinton health care reform plan was being debated in Washington, the Commonwealth of Kentucky enacted into law a comprehensive reform plan that in many ways was modeled on the Clinton strategy. Alas, we will never know what parts of this state experiment would have succeeded. It was largely repealed two years after enactment due to withering opposition by the health care industry. I have no way of knowing if the situation regarding hospital charges that I present on the KHPI site has changed from 1996. My informed suspicion is that it has not. To this day I still cannot understand my personal medical bills– and I used to be a health executive!
Certainly the same problems of quality and affordability are still with us. Indeed, for affordability, the problem is worse. With respect to quality it is difficult to know whether there has been improvement or not because of the related barrier of non-transparency. Certainly tremendous effort and much money have been put into attempting to measure quality, but I am not personally enthusiastic about the usefulness of the information received. For all the money Medicare and the hospitals themselves put into measuring hospital quality, it could recently be concluded that only a handful of hospitals have a mortality rate for heart attack that is either better or worse than average! I have to ask, why bother measuring at all if your method of study cannot find any difference? Measure something else or measure it differently! It is not true that all hospitals provide care of equal quality, and certainly not for the same cost.
Proposals to make health care information about cost and quality more public are still part of today’s ongoing public policy debate. For that reason, I dusted off this old study. I was an old laboratory scientist back then and this was one of my very first forays into health policy research. I am the first to admit that it was, and is not cutting edge research, but I found it of great interest personally at the time and believe others will too. I abandoned efforts to publish it back then because of objections from my University. Even though such studies of institutional or regional variation make no initial value judgments, this kind of information is embarrassing to some hospitals. I regret that I was not in a position to further test the limits of my academic freedom at the time.
Kentucky’s effort to provide more information to the public in 1995 did not work as planned. It was too easy to ignore by providers, it may not have asked the right initial questions, and the public was not assisted in transforming the information into something they could use. The same forces resisting change then still operate today. As I write this, the outcome of “National Health Care Reform 2010” in Washington is unknown to me. I will not be surprised, but will be disappointed if we are left as a nation with the status quo of declining access to a health care system of unknowable quality.
Peter Hasselbacher, MD E-mail
When I worked in Government and later as a health care lobbyist, I often heard it said, seemingly in the jest of desperation, that the only way we were going to be able to “fix” the health care system was to wait for an economic or other meltdown such that a new health care Phoenix could arise from the ashes. I must confess that this did not seem so outrageous to me at the time, nor does it now. Just as the “Technology Bubble” burst, and then the “Housing Bubble,” and then the “Banking Bubble,” so do I see the pin approaching the “Health Care Bubble.” The unintended consequences of doing something different are less scary to me than the both obvious and unintended consequences of staying the course.
Ten years ago I dreamed (halucinated) a vision of what I thought healthcare should look like in this new mellineum. We are now approaching the end of its first decade and as I plan to update my Vision, I am hard pressed to see that we have made any progress at all. In many ways we are worse. Since few, if any, others think our health care mission has been accomplished, I assume my dreams are shared by at least some others, perhaps even by Dr Scott whose principled (perhaps courageous given the setting) comments stimulated this posting.
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Peter Hassselbacher, MD