Part One of this series seems to have struck a nerve, so we continue...
1. Waste not, want not
IOM breaks down that number as follows:
Drilling down yet further, we find that a goodly portion of the unnecessary is tied into the litigation-driven mess of defensive medicine. In that vein, it has been estimated that 40 percent of all radiology is otherwise needless. Not quite as bad as 90 percent of all e-mail being spam, but you get the point.
As to fraud, it's no surprise that most of that is connected with Medicare and Medicaid, but the private insurers could also step up their fraud detection. A big factor in excessive administrative costs is unnecessary documentation. No worries, though, as this is slated to become electronic by next year. Perhaps there will be some savings in terms of physical storage of this stuff. Stay tuned.
Regarding inefficiently delivered services, the ugly specter of medical errors rears its head, and beyond being "inefficient," errors claim thousands of lives each year. High prices and missed prevention opportunities lead us into our next forbidden topic...
2. The intractable problem of health care outcome metrics, in a disease care paradigm
The only way to judge if a price is high is to understand what you're paying for. But in a technical field like health care, that is no simple matter. As long as our system puts its greatest emphasis on acute care, one approach would be to determine if the patient were cured. Even with this, complications ensue. In the case of serious illness, experts will differ as to what constitutes a "cure," or refrain altogether from using the word. Except from the lips of the patient himself or his family, when was the last time you heard of someone being cured of cancer?
More than that, quality of life issues inevitably come to the fore. Radical therapies to "cure" the patient may leave him less than whole in the process, and can render him more prone to other conditions.
In cancer, officials often speak of the five year survival rate, taken from the time of first diagnosis. However, this measurement of outcome uses a stacked deck. Based on a very early diagnosis and less-than-effective treatment, a patient surviving five years plus one day, only to die the following day, would have made the grade, but what does it prove?
Bearing all of this in mind, what happens when we track the progress of a particular patient with some serious condition through the system? We are still faced with the rather significant problem of normalizing his experience against all others with the same disease, and removing a large number of confounding factors. Heck, we first have to decide which factors are "confounding."
So, what about prevention? Let's draw an analogy from home and workplace safety. Falls have always been a major source of injury. In approaching the "fall problem," I suppose that we could determine--with great effort--the normalized outcomes of all fall victims. Or, we could put measures in place that would prevent the falls from occurring. Then, our metric could be simply "How many falls occurred this year?" Hopefully, the preventive measures would reduce that number.
True health care should not fear such metrics. Are there fewer cases of lung cancer, diabetes, or heart disease this year? If not, why not?
Michael D. Shaw
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