Thursday, July 04, 2013

The "I want the best" quality measure in healthcare

On The Incidental Economist, Bill Gardner rather wearily brushes off claims, based on personal experience, that the U.S. has "the best healthcare in the world." He outsources to Aaron Carroll the marshaling of evidence that "on most important measures, the US has poorer quality of care than comparable countries" and concentrates on a prior question: what do we mean by quality of care? He then offers a breakdown of quality measures which, for policy purposes, may be comprehensive, but which I think misses a dimension that may be in the minds of many who claim "best" status for the U.S. Here are Gardner's "dimensions of health quality*":
  • The hotel experience. Some hospitals are nicer places to stay than others. This may seem trivial in the context of life and death, but any hospital manager will tell you that ‘hotel quality’ matters to patients.
  • The relationship experience. Did the health care providers treat you with respect? Were they considerate of your religious beliefs? The well-educated readers of this blog may have difficulty imagining that they would not be well-treated by health care providers. But disrespect may be a primary consideration if you are poor, speak a language other than English, live outside the mainstream culture, or are mentally ill.
  • The rightness of treatments. By the ‘right’ treatment, I mean the one that was most likely to benefit you.
  • Safety. Were you harmed through error or neglect while you were in care?
In response, I posted this comment:

One more dimension, perhaps: I suspect that often when people think about U.S. “quality” (particularly with a chauvinistic bias), they’re thinking not so much of the appropriateness of treatment as of the likelihood of getting a difficult or expensive or cutting-edge treatment if you think you need it.

A heightened possibility of getting such treatment may be statistically eclipsed on quality measures by frequent overtreatment, or poor safety procedures, or lack of access to decent care for large segments of the population. But I think it’s psychologically important to a lot of people — e.g. those with a fair amount of power in the patient role, that is, those with good insurance.
I will admit to being somewhat susceptible, with some internal resistance (and sometimes not enough), to this "fifth dimension."  In my immediate family there have been two instances of what you might call top quality treatment by this measure -- one of them (I think) good and appropriate, the other completely wasteful.  The first was hip labral surgery for my son at the Hospital for Special Surgery in New York -- a world-class, cutting edge surgery that we were fortunate to have covered by our insurance and that seems to have worked as intended after a year in which my son was unable to run at all or walk extended distances. We did do a fair amount of due diligence before opting for the surgery, and there seemed to be no other good way for my son to become mobile again.

While we have been plagued with some balance billing by hospital subsidiaries, getting a little taste of the insanity of the U.S. healthcare payment tangle, the procedure was in the end essentially entirely covered. We are very, perhaps unfairly, fortunate that my son was able to access this treatment. The quality of care was by some measures perhaps best-in-world, albeit with Byzantine, only-in-America billing on broken-out services like that of the anesthesiologist  ($3,000-plus, a particularly egregious feeding at the healthcare trough recently exposed by the Times as par for the course for that specialty).

The second was a completely unnecessary heart workup I let myself in for a few years ago, for which the hospital billed around $20k, also covered by insurance.  I won't bore readers with the details, but I was weak in response to provider pressure: After two EKGs those attending me basically knew my heart health was good, but by failing to leave "against advice" I succumbed to a stress test with those massive before-and-after CT-scans. A week later, I learned from yet another Times exposé (this one? -- not sure) that  these tests are a much-prescribed overtreatment that subjects you to the equivalent of 750 x-rays. I feel like there was bad karma (in the form of radiation?) in that waste. I am ashamed to have taken it lying down.

* It  pleases me that Gardner introduces his breakout of quality measures like this: " there are at least four dimensions of health care quality."  That is, he avoids the common self-help genre and pseudo-social-scientific claim that a categorization cooked up for convenience is definitive and inherently right: the seven habits of highly effective people, the five stages of grief, etc. 

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