Opportunity for Reform
Submitted by Dr. JG Kaplan on Wed, 2009-06-17 09:10
The confluence of a health care crisis and a Presidential election has created opportunity for change, but Robert H. Brook, MD, ScD of the Rand Corporation, a non-profit think tank, warns that simultaneously improving health care coverage, the affordability of health care and its quality will be difficult.
I belief Brook's JAMA article, "The Science of Health Care Reform" to be helpful with regard to our understanding how we got to where we are.
He refers to the RAND Health Insurance Experiment (HIE) [1] where families across the country were randomized to receive fee-for-service (FFS) coverage with varying levels of cost sharing, or free care in a health maintenance organization (HMO). The researchers concluded:
- The more the cost sharing, the less health care was used [1]
- When care was free (compared to cost-sharing), on average, 1/3 more care was consumed. Nevertheless, after 5 years, these consumers were "no healthier." [2]
He also cites the Dartmouth Atlas, [3] the seminal research of Dr. Jack Wennberg of Dartmouth on Unwarranted Geographic Variation in the health care industry: "Individuals living in regions of the country that use twice as much health care as other regions are not healthier." [4]
Lest one conclude that policies that "reduce service use" and have patients pay more for what they require, would be effected with impunity, know that "the reason more care did not improve health is that providing more care did not improve the quality of care individuals received." Also, it seems that paying out of pocket reduces one's use of "effective services in equal proportion to use of ineffective services."[1] Let the historical truth be known, however, Harold Luft observed the other side of this in or before 1978. To paraphrase, HMOs achieve their savings not only in discretionary care, but in non-discretionary care, as well.
Luft H. "How Do HMOs Achieve Their Savings? Rhetoric and Evidence. N Eng J Med. 1978; 298(24):1336-1343
Brook, with references (see the original article), adds "perhaps one-third of common medical and surgical procedures are either equivocal (benefit and risk to the patient are about equal) or inappropriate (the procedure will produce more harm than benefit to that patient). Although this finding is disturbing, the relationship of appropriateness assessed at the individual patient level to health care services use in a given area is far more disquieting."
Brook RH.* "The Science of Health Care Reform." JAMA. 2009;301(23):2486-2487 [with 14 references of which 4, are used here]:
1. Newhouse JP, Archibald RW, Bailit HL; et al. Free for All? Lessons From the RAND Health Insurance Experiment. Cambridge, MA: Harvard University Press; 1993.
2. Brook RH, Ware JE Jr, Rogers WH; et al. Does free care improve adults' health? Results from a randomized controlled trial. N Engl J Med. 1983;309(23):1426-1434.
3. Wennberg JE. Tracking the Care of Patients With Severe Chronic Illness: The Dartmouth Atlas of Health Care 2008. Lebanon, NH: Trustees of Dartmouth College; 2008.
4. Skinner J, Chandra A, Goodman D, Fisher ES. The elusive connection between health care spending and quality. Health Aff (Millwood). 2009;28(1):w119-w123.
Politician, if you plan on constraining care by putting up financial barriers or applying supply side economics, patients may suffer. Want to wait for 'comparative effectiveness' research? As stated by Alexander and Stafford, "what good is comparative effectiveness research if it cannot be used to discern anything about value to clinicians, insurers, patients, and society?"
The answer to health care reform is point of contact feedback based on measurement and management; management and measurement—the modus operandi of 'Managed Care' in an information age.
Alexander GC, Stafford RS. "Does Comparative Effectiveness Have a Comparative Edge? JAMA. 2009;301923):2488-2490
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