Health Care Exists for the Patient
The patient must be at the center of all efforts toward reform. Changes in our health care system are only meaningful to the extent that they increase Americans' access to and quality of available care. One question must be asked regarding every proposed reform of our system: does this proposed change improve patient access or does it improve quality of care? No other question is worth asking if the answer to the preceding question is "NO".
All Spending is Not Created Equal
Increased spending does not ensure increased quality. Our nation cannot afford to simply spend more money within our current system. Some increased spending, such as spending on primary care and primary prevention, has been shown to improve Americans' health and lower overall health care costs while other spending, such as too much spending on procedures, may actually lower quality of care.
Let's Pay for Performance
Reform efforts should include the creation of national databases with mandatory reporting requirements to answer quality and other crucial questions. Questions should be of the following type: What procedures are our doctors performing that require further follow-up procedures due to ineffectiveness? To what extent does self-referral to physician owned imaging or surgery centers change practice pattern and result in over utilization and risk to the patient? Which medical devices (such as heart implants or joint replacements) last the longest, have the lowest need for revision surgery, and result in the fewest complications? Performance measures should be patient centered; in other words, performance improvement should deliver results that matter to patients.
Resources Are Finite, But This Does Not Alter Our Duty to Provide Care
Health care providers of all types, especially those receiving the highest reimbursements, must recognize that current compensation levels throughout healthcare are unsustainable. Mathematics is a stubborn discipline; if current spending is bankrupting the system, eventually, spending will be reduced to an affordable level. Some of us working within the American health care establishment will need to accept less compensation to make the system work.
The patient must be at the center of all efforts toward reform. Changes in our health care system are only meaningful to the extent that they increase Americans' access to and quality of available care. One question must be asked regarding every proposed reform of our system: does this proposed change improve patient access or does it improve quality of care? No other question is worth asking if the answer to the preceding question is "NO".
All Spending is Not Created Equal
Increased spending does not ensure increased quality. Our nation cannot afford to simply spend more money within our current system. Some increased spending, such as spending on primary care and primary prevention, has been shown to improve Americans' health and lower overall health care costs while other spending, such as too much spending on procedures, may actually lower quality of care.
Let's Pay for Performance
Reform efforts should include the creation of national databases with mandatory reporting requirements to answer quality and other crucial questions. Questions should be of the following type: What procedures are our doctors performing that require further follow-up procedures due to ineffectiveness? To what extent does self-referral to physician owned imaging or surgery centers change practice pattern and result in over utilization and risk to the patient? Which medical devices (such as heart implants or joint replacements) last the longest, have the lowest need for revision surgery, and result in the fewest complications? Performance measures should be patient centered; in other words, performance improvement should deliver results that matter to patients.
Resources Are Finite, But This Does Not Alter Our Duty to Provide Care
Health care providers of all types, especially those receiving the highest reimbursements, must recognize that current compensation levels throughout healthcare are unsustainable. Mathematics is a stubborn discipline; if current spending is bankrupting the system, eventually, spending will be reduced to an affordable level. Some of us working within the American health care establishment will need to accept less compensation to make the system work.
The Potential of Reform: An Example from Our Specialty
J. Bruce Moseley and his colleagues surprised the orthopedic community in 2002 with a controlled clinical study published in The New England Journal of Medicine that showed that arthroscopy was an ineffective treatment for knee arthritis. Using data published in 1996, the authors also commented that "[m]ore than 650,000 such procedures are performed each year at a cost of roughly $5,000 each" for a total cost of over $3 billion at that time. The orthopedic community raised many criticisms of the study's methodology and did not accept the results. To address these criticisms, Alexandra Kirkley et al. published a new study in 2008, again in The New England Journal of Medicine, that once again showed that "[a]rthroscopic surgery for osteoarthritis of the knee provides no additional benefit to optimized physical and medical therapy." This time, leaders within the orthopedic community embraced the results, and the issue appears to be settled in the medical literature.
One would think that, in light of such scientific evidence, practice patterns would change immediately--that arthroscopy in arthritic knees would become a relatively uncommon procedure reserved for unusual circumstances. However, based on discussions that I have had with many practicing orthopedists from different parts of the country, not much has changed; doctors who already felt that the procedure was ineffective in arthritic knees point to the study to confirm their beliefs while those who use the procedure still feel that it can help some of their patients, at least for a short time. Many orthopedists, therefore, continue to perform arthroscopy routinely for the treatment of arthritic knees, typically removing torn, degenerative menisci (cartilage). Motives range from personal finances to the desire to keep a struggling hospital's surgery suite busy to the belief that the procedure sometimes really can work. Unfortunately, motivation hardly matters when a doctor routinely performs a procedure that has been shown to provide "no additional benefit" to a group of patients for whom he is using it.
Problems inherent in this situation include the following three. First, like all procedures, this one entails peri-operative morbidity--it hurts. The knee can swell; the patient can limp; pain meds can produce constipation or other side effects. Second, the performance of this procedure comes with a financial cost; costs include the surgical fees, the anesthesiologist's fees, fees for medicine or physical therapy, and then all of the facility fees for the use of the operating and recovery room. Finally, while it is a relatively safe procedure, there are risks to the patient, including the risk of infection or a blood clot. These risks are real; my sister's father-in-law died from a pulmonary embolism after a knee scope. So, not only does the procedure inflict peri-operative pain and suffering on the individual patients who undergo it, we are spending money to lower quality of care. Any complications or discomfort from a procedure that provides no benefit must, by definition, lower the quality of care of those patients who receive it.
What lessons for reform can we learn from this example? First, health care costs can be cut without lowering quality of care. We need to spend our money more wisely; these types of situations exist, not only in different areas of orthopedics, but throughout medicine. This is just one multibillion dollar example. Second, our country needs much more robust health care data collection systems. The study that Dr. Moseley cited to conclude that this procedure was performed 650,000 times each year occurred in 1996. It was not repeated until 2006 and the data were not finalized until Sept. 2009!! While the data do demonstrate that the rate of arthroscopy had increased to 956,000 by 2006, one could not discern exactly how often a knee scope was performed for the diagnosis of arthritis. The numbers suggest it is still not uncommon, but the collected information is inadequate to answer the question. How can our country hope to improve health care quality or spend our money more effectively with such scanty data?
Third, physicians ultimately drive nearly all health care decisions; they should be part of a solution. Many options exist to do this: Medicare could select panels of experts to regularly determine coverage for procedures, tests, or any existing therapy in a manner similar to the way in which the FDA relies on experts to decide on the merits of new drugs. This would have the advantage of allowing physicians to continue to make health care decisions and would also begin to move the country toward greater emphasis on evidence based medicine. Fees for therapies or tests that are proven to be of limited utility could be reduced; this would leave physicians free to perform the procedures or order the tests in the unusual circumstance where they might be useful but would also provide a financial disincentive to the routine performance of such tests or treatments.
Whatever solution is devised, I use this example to show that reform efforts have great promise, but simply moving money around by changing health care payors will yield little in terms of quality improvement. Furthermore, I caution that simply cutting reimbursement rates without further reform could paradoxically lead to greater over utilization of therapies or tests as providers attempt to maintain their income. Our system can be improved; quality care can be delivered without the need for huge new sources of revenue. However, fundamental reforms are required to meaningfully improve the system.
One would think that, in light of such scientific evidence, practice patterns would change immediately--that arthroscopy in arthritic knees would become a relatively uncommon procedure reserved for unusual circumstances. However, based on discussions that I have had with many practicing orthopedists from different parts of the country, not much has changed; doctors who already felt that the procedure was ineffective in arthritic knees point to the study to confirm their beliefs while those who use the procedure still feel that it can help some of their patients, at least for a short time. Many orthopedists, therefore, continue to perform arthroscopy routinely for the treatment of arthritic knees, typically removing torn, degenerative menisci (cartilage). Motives range from personal finances to the desire to keep a struggling hospital's surgery suite busy to the belief that the procedure sometimes really can work. Unfortunately, motivation hardly matters when a doctor routinely performs a procedure that has been shown to provide "no additional benefit" to a group of patients for whom he is using it.
Problems inherent in this situation include the following three. First, like all procedures, this one entails peri-operative morbidity--it hurts. The knee can swell; the patient can limp; pain meds can produce constipation or other side effects. Second, the performance of this procedure comes with a financial cost; costs include the surgical fees, the anesthesiologist's fees, fees for medicine or physical therapy, and then all of the facility fees for the use of the operating and recovery room. Finally, while it is a relatively safe procedure, there are risks to the patient, including the risk of infection or a blood clot. These risks are real; my sister's father-in-law died from a pulmonary embolism after a knee scope. So, not only does the procedure inflict peri-operative pain and suffering on the individual patients who undergo it, we are spending money to lower quality of care. Any complications or discomfort from a procedure that provides no benefit must, by definition, lower the quality of care of those patients who receive it.
What lessons for reform can we learn from this example? First, health care costs can be cut without lowering quality of care. We need to spend our money more wisely; these types of situations exist, not only in different areas of orthopedics, but throughout medicine. This is just one multibillion dollar example. Second, our country needs much more robust health care data collection systems. The study that Dr. Moseley cited to conclude that this procedure was performed 650,000 times each year occurred in 1996. It was not repeated until 2006 and the data were not finalized until Sept. 2009!! While the data do demonstrate that the rate of arthroscopy had increased to 956,000 by 2006, one could not discern exactly how often a knee scope was performed for the diagnosis of arthritis. The numbers suggest it is still not uncommon, but the collected information is inadequate to answer the question. How can our country hope to improve health care quality or spend our money more effectively with such scanty data?
Third, physicians ultimately drive nearly all health care decisions; they should be part of a solution. Many options exist to do this: Medicare could select panels of experts to regularly determine coverage for procedures, tests, or any existing therapy in a manner similar to the way in which the FDA relies on experts to decide on the merits of new drugs. This would have the advantage of allowing physicians to continue to make health care decisions and would also begin to move the country toward greater emphasis on evidence based medicine. Fees for therapies or tests that are proven to be of limited utility could be reduced; this would leave physicians free to perform the procedures or order the tests in the unusual circumstance where they might be useful but would also provide a financial disincentive to the routine performance of such tests or treatments.
Whatever solution is devised, I use this example to show that reform efforts have great promise, but simply moving money around by changing health care payors will yield little in terms of quality improvement. Furthermore, I caution that simply cutting reimbursement rates without further reform could paradoxically lead to greater over utilization of therapies or tests as providers attempt to maintain their income. Our system can be improved; quality care can be delivered without the need for huge new sources of revenue. However, fundamental reforms are required to meaningfully improve the system.
Fac fortia et patere.