It's Efficacy( Does it Work?) -Not Quality That Comes First!- Says Dr. Nortin Hadler
Last Monday, Jan 22, Dr. Nortin Hadler author of probably the most important book on U.S. Health Care The Last Well Person: How to Stay Well Despite the Health-care(2005)System since Ivan Illich's Medical Nemesis written over 30 years ago(1976),wrote a groundbreaking piece for ABC News.
Now Dr Hadler is writing for ABC News and I urge you to track his latest thinking periodically on ABC NEWS
He gave me permission to reprint the essay below from last Monday. It is worth your reading.(I have bolded some statements that especially resonate with me)
"Curing Health Care Insurance-Examining the Insurance Mess - and Its Unspeakable Remedy"
OPINION By NORTIN HADLER, M.D. ABC NEWS
Jan. 22, 2007-None of us needs to be told. The health care delivery system in America is indefensible. About $2 trillion fuels the system, some 16 percent of our national productivity. If we were all covered, that's more than $6,500 per person.
Despite such a fortune, about 40 percent of us can't afford the care we are told we need, either because we are inadequately insured or out-of-pocket payments would bankrupt us.
Medical bills broke the back of more than 40 percent of us who have declared bankruptcy. Even those who feel adequately insured are bedeviled by difficulties in getting care; those inadequately insured are tormented by them.
Despite outcries, this sorry state continues to deteriorate. Why?
Clearly, the cause is not a lack of money. Every other resource-advantaged country indemnifies its entire population with less than half of what we spend, with better national health statistics to show for it.
The problem must reside in the way the money is spent.
Is the "Best" Medicine the Most Effective Medicine?
The guiding principle of all health care reform in America is the belief that American medicine is the "best" in the world.
Reform would tackle misdistribution and the inconsistencies in the quality of care. Once these are overcome, all of us will be afforded the "best" to prevent us from getting sick, and the best to heal us when prevention fails.
The savings that would result from a decrease in the national burden of illness would be enough to provide for adequate distribution of care.
It follows that the goal of health care reform is to make certain that American medicine is performed expertly so as to provide optimal quality of care.
Serving this agenda are national committees to establish the criteria for expert care for particular diseases, national committees to collect the data on how particular states, hospitals or practice groups approach these standards, and national committees to see if it matters.
Much of this effort has taken heart disease as the target because of the volume of cases, the costliness of treating these diseases, and the consensus as to the best care. Many a program has been implemented to move practice up to these standards.
The quality movement is enjoying its day in the sun. Legislators and potentates in the hospital and health insurance industries are beating the drum. Few are questioning the basic premise of the quality movement.
Does it matter to the patient if practice meets these consensus standards? There is a crying need for such heresy.
A recent analysis of the Medicare experience (JAMA, Dec. 13, 2006) should muffle the drumbeat. The degree to which practice met the accepted standards for Medicare patients admitted for heart disease did not predict who lived and who died.
Even for the poster child of the quality movement, heart disease, something is amiss.
Focusing on Quality Alone Could Compromise Care
Why wouldn't performing up to these standards of care for heart disease, to "high performance," be advantageous to the patient?
Maybe the Medicare analysis could not detect the shortcomings in the way doctors and hospitals meet standards of care.
More likely, though, is that the standards of care are far less important than the committees that formulated them pronounce.
If what we do to you doesn't work, or doesn't work much, than it doesn't matter how well we do it. It also doesn't matter how cheaply these services are provided; if it doesn't work it's worthless at any price.
The quality movement is putting the cart before the horse. The "horse" is efficacy.
The quality movement overcame great odds to gain its current influence. Physicians and surgeons, like other professionals, are not reflexively disposed to "outsiders" questioning their competence. Even peer review is a prickly process.
I applaud the quality movement and admire many of its leaders. However, quality is not the goal. It is the process. Efficacy first, then quality, promotes effectiveness.
There is an "effectiveness movement," bloodied and bent but unbowed. It can muster far more illustrative science than the quality movement.
But the forces that thwart the demand for effectiveness are powerful, wealthy and predictable.
Most of the high-ticket items (procedures and pharmaceuticals) are minimally effective, or ineffective. Many of these are considered standards of care. Many are cash cows touted by vested interests.
Effectiveness Key to Performance
From my perspective as a clinician who has cared for patients and taught students for more than three decades, if I have to treat more than 20 patients to do something really meaningful for one, the treatment is marginal; I do not prescribe or advocate it and would have no problem if it was not covered by health insurance.
If this seems extreme, consider the fact that many new and expensive treatments available today do not meet the threshold of meaningful results for even one out of 50 patients.
Furthermore, designing trials to test whether new or old treatments meet this one in 20 level of effectiveness is not difficult, expensive or time consuming. We would no longer be marketed to prescribe and consume minimally effective treatments, or treatments that offered no important improvement over the tried and true.
If we have effectiveness at the base of our health care insurance system, adding cost-effectiveness and quality would be rational and straight forward. We could well afford such a rational health care delivery system, with most of the $2 trillion to spare. We would be more "high performance" than any other country.
And our unsung, well trained and caring physicians, nurses and allied health professionals could get back to serving patients instead of the health care delivery system.
Dr. Nortin Hadler is professor of medicine and microbiology/immunology at the University of North Carolina at Chapel Hill, and an attending rheumatologist for University of North Carolina Hospitals
Hadler is a brilliant courageous iconoclast who is dedicated to science and is meticulous and thorough with his research homework. He may make you squirm or even possibly your blood boil but I for one take his work to the intellectual "bank"
Thanks Nortin!
Dr. Rick Lippin
"Blake"
Now Dr Hadler is writing for ABC News and I urge you to track his latest thinking periodically on ABC NEWS
He gave me permission to reprint the essay below from last Monday. It is worth your reading.(I have bolded some statements that especially resonate with me)
"Curing Health Care Insurance-Examining the Insurance Mess - and Its Unspeakable Remedy"
OPINION By NORTIN HADLER, M.D. ABC NEWS
Jan. 22, 2007-None of us needs to be told. The health care delivery system in America is indefensible. About $2 trillion fuels the system, some 16 percent of our national productivity. If we were all covered, that's more than $6,500 per person.
Despite such a fortune, about 40 percent of us can't afford the care we are told we need, either because we are inadequately insured or out-of-pocket payments would bankrupt us.
Medical bills broke the back of more than 40 percent of us who have declared bankruptcy. Even those who feel adequately insured are bedeviled by difficulties in getting care; those inadequately insured are tormented by them.
Despite outcries, this sorry state continues to deteriorate. Why?
Clearly, the cause is not a lack of money. Every other resource-advantaged country indemnifies its entire population with less than half of what we spend, with better national health statistics to show for it.
The problem must reside in the way the money is spent.
Is the "Best" Medicine the Most Effective Medicine?
The guiding principle of all health care reform in America is the belief that American medicine is the "best" in the world.
Reform would tackle misdistribution and the inconsistencies in the quality of care. Once these are overcome, all of us will be afforded the "best" to prevent us from getting sick, and the best to heal us when prevention fails.
The savings that would result from a decrease in the national burden of illness would be enough to provide for adequate distribution of care.
It follows that the goal of health care reform is to make certain that American medicine is performed expertly so as to provide optimal quality of care.
Serving this agenda are national committees to establish the criteria for expert care for particular diseases, national committees to collect the data on how particular states, hospitals or practice groups approach these standards, and national committees to see if it matters.
Much of this effort has taken heart disease as the target because of the volume of cases, the costliness of treating these diseases, and the consensus as to the best care. Many a program has been implemented to move practice up to these standards.
The quality movement is enjoying its day in the sun. Legislators and potentates in the hospital and health insurance industries are beating the drum. Few are questioning the basic premise of the quality movement.
Does it matter to the patient if practice meets these consensus standards? There is a crying need for such heresy.
A recent analysis of the Medicare experience (JAMA, Dec. 13, 2006) should muffle the drumbeat. The degree to which practice met the accepted standards for Medicare patients admitted for heart disease did not predict who lived and who died.
Even for the poster child of the quality movement, heart disease, something is amiss.
Focusing on Quality Alone Could Compromise Care
Why wouldn't performing up to these standards of care for heart disease, to "high performance," be advantageous to the patient?
Maybe the Medicare analysis could not detect the shortcomings in the way doctors and hospitals meet standards of care.
More likely, though, is that the standards of care are far less important than the committees that formulated them pronounce.
If what we do to you doesn't work, or doesn't work much, than it doesn't matter how well we do it. It also doesn't matter how cheaply these services are provided; if it doesn't work it's worthless at any price.
The quality movement is putting the cart before the horse. The "horse" is efficacy.
The quality movement overcame great odds to gain its current influence. Physicians and surgeons, like other professionals, are not reflexively disposed to "outsiders" questioning their competence. Even peer review is a prickly process.
I applaud the quality movement and admire many of its leaders. However, quality is not the goal. It is the process. Efficacy first, then quality, promotes effectiveness.
There is an "effectiveness movement," bloodied and bent but unbowed. It can muster far more illustrative science than the quality movement.
But the forces that thwart the demand for effectiveness are powerful, wealthy and predictable.
Most of the high-ticket items (procedures and pharmaceuticals) are minimally effective, or ineffective. Many of these are considered standards of care. Many are cash cows touted by vested interests.
Effectiveness Key to Performance
From my perspective as a clinician who has cared for patients and taught students for more than three decades, if I have to treat more than 20 patients to do something really meaningful for one, the treatment is marginal; I do not prescribe or advocate it and would have no problem if it was not covered by health insurance.
If this seems extreme, consider the fact that many new and expensive treatments available today do not meet the threshold of meaningful results for even one out of 50 patients.
Furthermore, designing trials to test whether new or old treatments meet this one in 20 level of effectiveness is not difficult, expensive or time consuming. We would no longer be marketed to prescribe and consume minimally effective treatments, or treatments that offered no important improvement over the tried and true.
If we have effectiveness at the base of our health care insurance system, adding cost-effectiveness and quality would be rational and straight forward. We could well afford such a rational health care delivery system, with most of the $2 trillion to spare. We would be more "high performance" than any other country.
And our unsung, well trained and caring physicians, nurses and allied health professionals could get back to serving patients instead of the health care delivery system.
Dr. Nortin Hadler is professor of medicine and microbiology/immunology at the University of North Carolina at Chapel Hill, and an attending rheumatologist for University of North Carolina Hospitals
Hadler is a brilliant courageous iconoclast who is dedicated to science and is meticulous and thorough with his research homework. He may make you squirm or even possibly your blood boil but I for one take his work to the intellectual "bank"
Thanks Nortin!
Dr. Rick Lippin
"Blake"
posted by Blake at 6:58 AM
4 comments
