We Need to Learn What Works for Health

As Congress reassembles and the health reform debate heats up anew, a lot of what is under discussion has to do with correcting a system of unfairness.

The reports, audits and analyses we've written about so much in recent months speak to the wide variations in availability and quality of care, as well as in the differences in costs of services and health insurance.

The poor have a harder time getting quality care than the rich.

The insured have an easier time financing care than the uninsured.

Those in small rural areas have more trouble finding quality care than people in many large urban areas.

Doctors in some high-cost parts of the country get paid a lot for treating patients, while doctors in other high cost parts of the country get paid much less.

The people in McAllen, Texas,  may get too much care, while the people in some communities in Alaska get too little.

In one region of the country, for example, a Medicare beneficiary is eligible for a certain procedure, such as surgery with Cyberknife technology, while in another region, the same beneficiary's Cyberknife procedure would not be reimbursed.

And a lot of this is just unfair, unequal, perhaps even unethical.

But if getting our country to a system of fairness is the argument, then is the next step making sure that healthcare for all is a right? Many in this country don't agree that it is. They perceive it as a fundamental necessity, perhaps, but not as a fundamental right.

But I may be off target.

Ernie Moy, MD, steered me in a slightly different direction. He's the medical officer for the Agency for Health Research and Quality, the federal group that has been churning out volumes of documents showing disparities and inequalities in healthcare services for people across the country.

For his agency, the question is not one of fairness, or rightness or wrongness of access. "Our charge is not ethical in nature, so from our perspective, we don't talk about the ethics of providing care," he says.

Rather, what the AHRQ tries to do is show what is scientifically proven to work.

"We think of it this way: Either a person would benefit from getting a particular service, or they wouldn't benefit. And having different rules, or allowing different rules, suggests that somebody (under one set of rules or another) is getting suboptimal care."

Quality, not fairness, gives the argument a different perspective.

With millions of dollars allocated in stimulus funds, his agency is trying to make sure the right analyses are done so that policymakers and providers will agree on what sorts of fundamental, basic minimum care—care that works pretty much all of the time—can be provided for everyone.

So people in Alaska get the same kind of care as people in Texas, and that in both places the quality of it is just as good—in a proven, scientific sort of way.

"When there is federal financing of healthcare, and there's a public good component to it, you would expect that beneficiaries would receive healthcare under a comparable set of rules," Moy says. But that kind of a system doesn't yet exist.

"If you're a diabetic, there are certain things that you need to have to manage the disease. And yet we see highly variable rates in people getting that care—often related to their insurance coverage, or their race, ethnicity, or the part of the country they're living in."

Moy says, "We don't like disparities because they indicate inefficiencies, departures from high-quality care."

He pointed to a study published in the New England Journal of Medicine by Rand researcher Elizabeth McGlynn several years ago that found that less than 55% of Americans received recommended, preventive, acute, or chronic care.

"The deficits we have identified in adherence to recommended processes for basic care pose serious threats to the health of the American public," the study concluded. ‘Strategies to reduce these deficits in care are warranted."

So maybe thinking about the health reform debate under a light of quality, rather than fairness, does put it in a different perspective.