While the need to address disparities in care is well known, few strategies for reducing disparities have been studied systematically.
As the Senate considers the nomination of former Sen. Tom Daschle as secretary of Health and Human Services—and as the nation looks forward to health reform—it is important that policy-makers focus on what it means to “fix” health care and ask some hard questions about how we deliver medical care.
First off, everyone should agree that we must strive to get every American the health care coverage they need.
Second, we can all agree that getting health care costs under control is both a health and economic imperative. Despite the “good news” this week that health care spending rose 6.1 percent to $2.2 trillion in 2007, that slowdown from previous years is still substantially higher than general inflation and health care now gobbles up 16.2 percent of gross domestic product.
But high costs and the uninsured are only the visible problems with health care. The invisible problem is poor quality care. Our third area of agreement must go beyond getting people care, to getting them the right care.
Poor quality care and the uninsured are inextricably linked, even though few understand the link. Poor quality care robs the system of precious resources—dollars and services—that could be used to expand access and coverage.
Lawmakers need look no further than their own backyard to ask questions about the quality and inefficiency problems. Medicare is the largest federal health insurance program, so lawmakers should ask why an elderly person spends about 11 days in the hospital in Bend, Ore., in the last two years of life, compared to 23 in Detroit or nearly 35 in Manhattan. Or why they see doctors about 15 times in Ogden, Utah in the last six months of life compared to 42 in Detroit or 60 in Los Angeles.
They should ask why researchers found that only 57 percent of female patients aged 65–69 in Mississippi got regular mammograms, compared to 70 percent in Michigan or 74 percent in Maine, the top state. Or why in Alaska, only 71 percent of patients with diabetes got important blood tests in 2003–2005, compared to 86 percent in Michigan or 92 percent in Vermont. Or most tragically, why more than 1.6 out of every 1,000 Medicare beneficiaries in Louisiana lost a leg to amputation, compared to 0.9 in Michigan or 0.50 in Utah, a more than three-fold difference from top to bottom?
They should also ask hard questions about why people get care they may not need. Why are antibiotics prescribed inappropriately for children’s ear infections 13 million times a year, when more than 80 percent of infections get better within three days without antibiotics?
Why in a decade did spending for back surgery called lumbar fusion rise 500 percent—from $75 million to $482 million—despite a lack of evidence supporting the effectiveness. And why do some regions of the country use vastly more resources to treat patients with similar illnesses without achieving better outcomes.
They will find what Dartmouth researchers found, that a whopping 30 percent of health care spending—nearly $700 billion a year—pays for services that may not improve people’s health.
That’s money that could be used to cover the uninsured—if we can figure out how.
A good place to start is improving the information we have about the actual performance of doctors and hospitals, with wider spread use of reports such as those Medicare has begun to make available on hospitals; and a few pioneering community organizations, such as the Greater Detroit Area Health Council (GDAHC), have made available on both hospitals and doctors’ practices in their communities (www.SaveLivesSaveDollars.org). Patients need this information to make informed choices about their own care. Doctors and hospitals need this information to help them improve care. And both consumers and purchasers need information about the value they are getting for their health care dollars.
A second step is to put serious dollars into quality improvement efforts, building on Medicare pilot programs that spur hospitals and physician group practices to improve care and launch experiments that encourage disparate medical providers to work in teams to coordinate care and deliver it efficiently.
Finally, our payment system must reward providers for giving patients the right care at the right time, the right way.
Now we pay providers for “doing things”: the more treatments and procedures they provide and the more they use expensive technology, the more they get paid. We need to reward, not punish, providers who deliver high-quality, cost-effective care. Moreover, providers should be fairly compensated for preventive care, for time spent coaching patients, and for coordinating care for those with chronic conditions.
Many of these concepts are being tested on the ground in living laboratories such as GDAHC’s Save Dollars Save Lives campaign, one of 14 communities working with the Robert Wood Johnson Foundation’s Aligning Forces for Quality program to bring together those who get care, give care and pay for care to improve the quality of care.
As Washington turns its eye to health care reform, by all means let’s start with getting everyone access to care, but everyone should also understand that what happens to them once they get inside the hospital or doctors’ office is just as important as getting them in the door.
Risa Lavizzo-Mourey is president and CEO of the Robert Wood Johnson Foundation.
Vernice Davis Anthony is president and CEO of the Greater Detroit Area Health Council.
Courtesy Detroit Free Press
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