A new report shows the quality of medical care varies widely at clinics and hospitals across the Puget Sound region in Washington State, with many patients failing to get basic treatment recommended by national guidelines. Nearly half of clinics surveyed were below average at ensuring patients with diabetes got regular eye exams to detect vision problems caused by the disease. The percentage of heart-surgery patients who received standard treatment to prevent blood clots ranged from 59% to 96% at hospitals. The findings were released in the Community Checkup report released by the Puget Sound Health Alliance.
Throughout the presidential campaign, words like "sweeping" and "ambitious" and "reform" have been commonplace in descriptions of President-elect Barack Obama's healthcare agenda. But in recent weeks—and especially since Obama was elected—some very different words have been popping up in discussions of what the next president will really be able to accomplish in the healthcare arena: "incremental" and "phased" and "limited," to name a few.
With a struggling economy and two wars draining resources and leaving much less money to work with than Obama no doubt envisioned, the general consensus from analysts around the country is that Obama's lofty plan—there's another descriptor, "lofty"—will be scaled back considerably. We have a story coming on this topic in December's issue of HealthLeaders magazine, but in short, creating a public plan for the uninsured and expanding SCHIP and expanding Medicaid and investing billions in healthcare information technology and doing everything else Obama wants to do would require, as all of you know, hundreds of billions of dollars—some estimates say more than $1.5 trillion over 10 years.
And when it comes to changing the U.S. healthcare system, our next president has more to worry about than just money. "He is going to face a very difficult road in any event, given the current budget situation and given the projected long-term budget situation and given the complexity and political difficulty of making major changes in so large of an industry," says Henry Aaron, a senior fellow at the Brookings Institution. "We can't afford healthcare reform. But the principal obstacle to achieving it is not the cost but the complexity of the interests and the policy changes involved in healthcare reform."
OK. So a presidential candidate may not be able to deliver everything he promised during the campaign. In the words of Gomer Pyle: Surprise, surprise, surprise. But what about the quality arena specifically? Is the industry likely to see any significant movement?
Here's an abbreviated review of Obama's quality agenda, summarized from his Web site:
Promote patient safety—require providers to report preventable errors.
Align incentives for excellence—providers seeing patients enrolled in the new public plan will be rewarded for achieving performance thresholds.
Comparative effectiveness reviews and research—establish an independent institute to oversee research on comparative effectiveness, with research focused on comparative information on drugs, devices, and procedures to determine which options create the best outcomes.
Tackle disparities in healthcare—tackle the root causes of health disparities by addressing differences in care access; promote prevention efforts; require hospitals and health plans to collect and analyze quality data for disparity populations.
Reform medical malpractice while preserving patient rights—strengthen antitrust laws to prevent insurers from overcharging physicians for their malpractice insurance.
At first glance, some of these seem painfully obvious and read like so much campaign propaganda. "Promote patient safety." Really? What a novel concept. "Tackle disparities in healthcare." In the description of how that will be accomplished, verbs like "address" and "promote" reek of trivial generalization.
Still, patient safety is, in fact, a critical issue. Disparities in care access do exist. And aligning incentives for quality care is a noble idea (assuming the "incentives" are meaningful). In other words, the issues are basically on target. But Obama is likely to encounter the same conflicting agendas and same monetary challenges in implementing quality initiatives as he does with the rest of his plan. Personally, I don't see a lot of slam dunks here. Actually creating an independent institute to oversee research on comparative effectiveness, for example, will face both strong financial headwinds and resistance from people who don't think it's a good idea, anyway. I do agree, however, with the general consensus that momentum remains strong for reform of some kind, even if it is more limited and protracted than Obama's early campaign promises.
What do you think? Which parts of Obama's plan have a real shot, and which parts are already doomed? Send me an e-mail and let me know your thoughts.
Jay Moore is managing editor for HealthLeaders magazine. He can be reached at jmoore@healthleadersmedia.com.
Note: You can sign up to receive HealthLeaders Media QualityLeaders, a free weekly e-newsletter that reports on the top quality issues facing healthcare leaders.
C. diff infections are ailing hospitals as much as 20 times more than previously believed, according to a new survey of U.S. hospitals. The survey reports that more than 7,000 patients are regularly battling such infections.
A judge has heard arguments in the case of a 12-year-old boy who was declared dead by Washington, DC-based Children's National Medical Center, but he held off making a decision until he can hear from the family and medical experts. The boy has brain cancer and has been in the hospital since June 1. The hospital says that he has no brain activity, meeting the legal definition for death in Washington, DC. Doctors declared him dead, and the hospital is asking Judge William Jackson to affirm its judgment that the boy can be taken off life-sustaining equipment.
The Joint Commission has provided Atlanta-based Grady Memorial Hospital with a clean bill of health on safety and care issues almost a year after a critical report threatened the hospital's access to federal money. "Grady is fully accredited," said Kenneth Powers, media relations manager of the Joint Commission. The commission's surprise inspection on Nov. 4 followed months of intense efforts at the hospital to resolve problems identified during an agency inspection in 2007. The inspection last winter found problems with broken equipment, sanitation issues such as housekeeping and staff hand-washing, and documentation of patients.
If you're a baseball fan in New York or Detroit, this has been an autumn of discontent. The New York Yankees, Detroit Tigers, and New York Mets spent gigantic amounts of money on player salaries—they are the top three spenders in the game, in fact—yet somehow failed to make the playoffs. Instead, they spent this fall watching the Tampa Bay Rays, with the second-lowest payroll in baseball, advance to the World Series.
The Rays' success is an example of how analyzing reams of complex data on players' performances and tendencies can improve a team tremendously at a bargain cost. Simply throwing money onto the field in the form of underachieving famous names seldom works.
Healthcare could learn something from our national pastime, according to a recent New York Times op-ed piece penned by an unlikely trio—former House Speaker Newt Gingrich, Sen. John Kerry (D-MA), and Oakland Athletics General Manager Billy Beane. The three men contend that the key to improving healthcare quality is following baseball's lead and adopting a similar evidence-based philosophy.
The authors' assessment of the state of healthcare quality is a blunt one. "Remarkably, a doctor today can get more data on the starting third baseman on his fantasy baseball team than on the effectiveness of life-and-death medical procedures," Gingrich, Kerry, and Beane write. "Studies have shown that most healthcare is not based on clinical studies of what works best and what does not—be it a test, treatment, drug or technology. Instead, most care is based on informed opinion, personal observation or tradition."
Later in the piece, the authors conclude: "To deliver better healthcare, we should learn from the successful teams that have adopted baseball's new evidence-based methods. The best way to start improving quality and lowering costs is to study the stats."
I want to believe this. It's a blueprint that works in many facets of our society. Study the information, formulate a course of action based on that information, and implement improvements. Simple.
Except that healthcare is not baseball.
Don't misunderstand—the idea that care should be based on concrete medical data is an important one. An evidence-based approach to healthcare delivery is a critical piece of the quality puzzle. And the Times piece offers a couple of examples of healthcare organizations achieving measurable success by emphasizing evidence-based care.
But upon further inspection, the healthcare-baseball analogy starts breaking down—and other issues beyond the notion of basing care delivery on data begin to emerge:
No matter what course of care the "evidence" dictates in a given situation, providers still must deal with a third party that often doesn't adequately compensate them for the cost of providing that care. If improving quality and cutting costs were as straightforward as studying the proper data, the industry wouldn't be in this mess.
And speaking of studying data . . . which data? Whose data? Studies drawing any number of conclusions about any number of topics emanate from provider organizations, pharmaceutical companies, managed care organizations, technology vendors, independent associations—you name it. All kinds of stakeholders with all kinds of agendas. All trying to demonstrate why this test or that therapy or this drug regimen is the most cost effective while delivering the best outcomes. Plenty of information is clearly less-than-objective, and I believe many caregivers can recognize that. But there's no singular All-Knowing Book of Medical Evidence.
Most physicians, I believe, are receptive to the possibility of medical data indicating that the way they've always practiced medicine could stand improvement in some way. But some are not. A purely evidence-based approach would not be without pushback.
A person's health is about more than the care provided by physicians and nurses. Environment, genetics, behaviors—all of these affect how well a patient responds to a course of treatment. The "evidence" is only part of the equation.
I know. I shouldn't be so negative. But if we don't train a critical eye on the real issues beneath the surface—and dedicate our best minds and technology and resources to resolving those issues—the ideal of better quality and lower costs will remain just that: an ideal tossed around in abstract op-ed pieces.
A little idealism is healthy. But healthcare, unfortunately, is no leisurely afternoon at the ballpark.
Jay Moore is managing editor for HealthLeaders magazine. He can be reached at jmoore@healthleadersmedia.com.
Note: You can sign up to receive HealthLeaders Media QualityLeaders, a free weekly e-newsletter that reports on the top quality issues facing healthcare leaders.