IOM: Six Aims of Quality Health Care

The balance of health benefits and harm is the essential core of a definition of quality.

Avedis Donabedian

In 2002, the Institute of Medicine published Crossing the Quality Chasm, an influential book that framed all future discussions of quality health care. Crossing came on the heels of the IOM publication To Err Is Human (2000) and a Journal of the American Medical Association report (1998) that warned of "serious and widespread quality problems...throughout American medicine." The report called attention to three broad categories of quality defects:

• underuse, whereby scientifically practices are not used as often as they should be;
• overuse, especially of imaging procedures and prescription of antibiotics; and
• misuse, when a proper procedure is not administered correctly (such as prescribing the wrong drug)

To Err Is Human estimated that as many as 98,000 people dies each year in hospitals from injuries or illness contracted during care.

In Crossing, the IOM outlined six specific aims (explained by Dr. Donald Berwick in the video above) that a health care system system must fulfill to deliver quality care:

1. Safe: Care should be as safe for patients in health care facilities as in their homes;
2. Effective: The science and evidence behind health care should be applied and serve as the standard in the delivery of care;
3. Efficient: Care and service should be cost effective, and waste should be removed from the system;
4. Timely: Patients should experience no waits or delays in receiving care and service;
5. Patient centered: The system of care should revolve around the patient, respect patient preferences, and put the patient in control;
6. Equitable: Unequal treatment should be a fact of the past; disparities in care should be eradicated.

Recognizing that aims must be accompanied by observable metrics, the IOM defined sets of measurements for each aim. For example:

• Safe: Overall mortality rates or the percentage of patients receiving safe care;
• Effective: How well evidenced-based practices are followed, such as the percentage of time diabetic patients receive all recommended care at each visit;
• Efficient: Analysis of the costs of care by patient, provider, organization, and community;
• Timely: Waits and delays in receiving care, service, or results;
• Patient centered: Patient and family satisfaction;
• Equitable: Differences in quality measures by race, gender, income, and other population-based demographic and socioeconomic factors.

Of course, this is all easier said than done. Hospitals could more easily follow evidence-based practices were there a national outcomes data base that provided population-based information. Effecting efficiency programs can mean a complete redesign of institutional culture, as in Virginia Mason's (Seattle) 20-year commitment to Lean management principles. Equitable care is unlikely without a sea change in national health policy (not that there is one) that extends well beyond the limitations of the Affordable Care Act.

The most encouraging developments in the industry-wide reassessment of quality are the recognition that safety and efficiency need not be mutually exclusive, an increased capacity for the practice of evidence-based medicine, and a new emphasis on patients when it comes to setting goals and measuring results.

Source: The Healthcare Quality Book (2nd edition), edited by Elizabeth R. Ransom, Maulik S. Joshi, David B. Nash, and Scott B. Ransom.

Paul Ryan on Single-Payer

As Sam Husseini reports, there is a fair amount of floundering and disingenuousness in Ryan's remarks. It's not the case, for example, that government-run health care has failed wherever it's been tried. The actual track record of government-run health care is good, including in the United States: The VA health care system is highly regarded. Moreover, Ryan's own plan is "patient-centered" only in the sense that it shifts costs onto patients without doing anything to slow medical inflation or end fee-for-service payments.

Also, anyone who thinks that U.S. health care is not rationed hasn't been paying attention. Ryan would state his case more honestly (and accurately) if he said what he apparently believes: De facto rationing by the free market is acceptable, while policy-based rationing by government to assure equal access is not.

Choice?

David Brooks argues that the future of health care comes down to "centralized technocratic" planning or a a free market solution. Health care, he sagely observes, is "phenomenally complicated," then goes on to inform us that providers have more information than patients and that insurance companies "are rapacious and are not in the business of optimizing care."

Brooks then compares what he calls the Affordable Care Act's concentration of cost-control power into a board of fifteen experts with the Republican laissez-faire model, which opposes top-down decision making (at least from the government). Rep. Paul Ryan's proposal to finance U.S. health care with a "premium support system" would replace fee-for-service medicine (in fact, it would not):

Seniors would select from a menu of insurance plans. Their consumer choices would drive a continual, bottom-up process of innovation. Providers could use local knowledge to meet specific circumstances.

Brooks writes with great confidence that this will happen -- presumably due to the Magic of the Market -- without explaining exactly how or why anyone should buy this argument.

Jonathan Cohn points out that the Republican plan has a track record, and that it's not especially encouraging. He argues that Ryancare would effectively eliminate health insurance for elders and summons the 1959 congressional testimony of retired autoworker John Barclay:

We retired workers are very proud of being citizens of the greatest country in the world, but … we cannot think it is the greatest possible country when about 65 percent of the aged do not have any insurance to deal with their needs for hospitalization and medical care. Without such insurance, the retired person must pretty much exhaust any savings he has before he can get free hospitalization. This is a constant source of worry. Many of my acquaintances will not visit a doctor for minor illness because they have no money to pay for drugs. After they exhaust their savings they go on welfare to get medical aid, but then, in many cases, it is too late.

The real difference between Democrats and Republicans on health care is not, Cohn writes, between an idealized free market and Stalinist central planning. Rather,

The most salient difference is that Democrats would preserve Medicare's fundamental guarantee of health benefits at affordable prices. Republicans would not.

Meanwhile, Ezra Klein contests Brooks' claim that

...if 15 Washington-based experts really can save a system as vast as Medicare through a process of top-down control, then this will be the only realm of human endeavor where that sort of engineering actually works.

It happens all the time, Klein writes: Around the world, government-regulated and -planned health care has a excellent track record for controlling costs without sacrificing outcomes.

At The Economist, M.S. dismisses Brooks as well, and focuses on the distortion brought about by the marketing and advertising of drugs and devices. 

As I've written before, Ryancare substitutes ideology for honesty. Brooks sips from this cup of Kool-Aid regularly, rarely if ever pointing out that Ryancare is all in on controlling costs by shifting them to elders. If that's what the country wants, then it's what we should do. But how about being up front about the choice?

Vouchercare

Paul Krugman writes that Vouchercare is not a "new, sustainable version of Medicare." It may be new and I suppose that its adherents can call it whatever they like, but its recipients would not find it especially sustaining.

Vouchercare, a.k.a. the Roadmap for America's Future, would starting in 2022 provide seniors with an average of $11,000 with which to purchase insurance. But there's a catch: That's $11,000 in 2012 dollars. To understand what that means in terms of actual purchasing power, calculate the present value of $11,000 using a discount rate based on historical medical inflation rates (3-5% over the last ten years):

• At 3%: $8,135
• At 4%: $7,431
• At 5%: $6,753

Moreover, Ryancare vouchers are indexed to the general rate of inflation as opposed to the medical rate. The medical rate is historically higher. Suppose that the vouchers grow at an average rate of 3% a year for five years while medical inflation increases at a rate of 4%. Although the payout would be $12,752, the actual purchasing power will have dropped to $7,081. This table shows the declining actual value of the vouchers over 25 years given a medical inflation rate of 4% with the vouchers indexed to 3%:

	Payment	Value
Year 1	$11,000	$7,431
Year 5	12,752	7,081
Year 10	14,783	6,747
Year 15	17,138	6,428
Year 20	19,867	6,125
Year 25	23,032	5,836

The Center on Budget and Policy Priorities, using the CBO assumptions provided by Rep. Ryan, estimates that by 2080, Medicare benefits will have been effectively cut by 76%. And even that may be optimistic: Medicare currently operates with an administrative overhead of 1-2%. One organization estimates health insurance company overhead to be as high as 31%, all of which is passed on to purchasers in the form of reduced purchasing power.

So, Krugman is right: Vouchercare is not Medicare. It would be one thing if its adherents were forthright about their intent to gradually eliminate the government role as a health insurer for elders. Then we could have an honest debate, albeit one they would lose. But, as happens too often in the health care reform discourse, ideology has once again trumped honesty.

Health Reform In Massachusetts

From the New York Times:

Mitt Romney’s defense of the Massachusetts health care reforms was politically self-serving. It was also true.

Despite all of the bashing by conservative commentators and politicians -- and the predictions of doom for national health care reform -- the program he signed into law as governor has been a success. The real lesson from Massachusetts is that health care reform can work, and the national law should work as well or even better.

Read the complete editorial here.

Anecdotal evidence suggests that finding a primary care physician for the first time will take a while, at least until Massachusetts can absorb all of the newly insured people. Although a familiar complaint from the left about the Affordable Care Act is that complete implementation takes too long, adding 32,000,000 people to the American health care apparatus by 2014 is realistically a very ambitious undertaking.

The health care infrastructure has evolved ("designed" is too kind a word) to accommodate different levels of insurance, with the uninsured and underinsured consigned to emergency care. (Which may or may not amount to much: By law, ED's must screen and stabilize anyone reporting to an emergency room for treatment. They must treat only if the screening identifies an actual emergency condition.) Until the infrastructure can adjust and provide an adequate number of primary care physicians and facilities, it's likely that many of the newly insured will continue to seek care in ED's.

Critics will cite what is a period of adjustment as evidence of failure, but the Affordable Care Act is a massive undertaking. Rushes to judgment will make no more sense than declaring the winner of a baseball game based on the score in the first inning.

Reverse Deductible

A problematic byproduct of the American approach to health care has been the divorcing of a substantial number of patients from health care costs. Patients with low deductibles and extensive coverage have little incentive to moderate use of health care; many economists believe that this contributes to medical inflation. Policy analysts from across the political spectrum have recommended higher deductibles as a antidote.

Yesterday during a talk at the University of Washington, Kaiser Permanente CEO George Halvorson turned this argument on its head. Deductibles, he argued, should reflect the French approach and come only after payment had been exhausted. It works like this: Insurers cover a given procedure up to a standard amount. The patient pays anything in excess of that. Halvorson believes that this sets up a a situation in which doctors will compete to design procedures that charge the standard amount. Nothing prevents anyone from charging more for a blue-ribbon approach, but in that case the only people paying more would be those who chose to.

This one is new on me, and I don't know what the arguments against it would be. However, there are definite holes in the idea of charging higher deductibles. For one, companies that offer insurance with low deductibles and extensive coverage are unlikely to change this practice even though it would mean lower costs for them.

Businesses don't offer gold-plated benefits packages out of altruism: They offer such benefits because they are competing for employees. They're unlikely to adopt an approach that would put them at a competitive disadvantage; it would be penny-wise and pound-foolish for Google to lower benefits if that reduced their intellectual capital by putting them at a recruiting disadvantage with Microsoft. Thus, the very people who overuse the health care system would be unaffected by the high-deductible policy meant to curb their enthusiasm...

Halvorson, a Norwegian-American, favored the audience with a Norwegian joke: "Then there was the husband who loved his wife so much that he almost told her"...

The New York Times: The Ryan Plan for Medicaid

Whatever you call this, it's not reform and -- except to its victims -- it's not serious. It is a thinly disguised way for the federal government to wash its hands of the health care needs of 60 million Americans by driving them further into poverty.

The real problem with Medicaid is that it is being overwhelmed by an economy that generates poverty as rabbits generate more rabbits. Today, more than 60 million Americans receive Medicaid, and many economists and sociologists argue that the United States' antiquated definition of poverty keeps as many as 30-60 million more from Medicaid eligibility.

The GINI coefficient has measured income inequality since the 1920s. Without going into a lengthy statistical discourse, the closer a country's measurement to zero, the less its disparity in income.  Sweden has the lowest GINI coefficient (23); the US measure of 45.7 is markedly higher than any country in western Europe, higher than that of Jamaica, equal to Uganda's. Moreover, in the last fifteen years the European Union has declined slightly (from 31.2 to 30.4) while America's has grown from 40.8 to 45.7.

To truly reform Medicaid, the US must reduce the number of people who need it by implementing policies that build the middle class instead of eroding it.