In part I, I presented you wish some admittedly artificial categories of problems in our health care system. First we discussed patient-centered problems. Today, we'll look at problems posed by medical science and practice itself.
The science of medicine is not always compatible with the practice of medicine. Medicine is still largely a cottage industry, with hard-working, independent practitioners working in small or medium-sized practices. Aside from licensing statutes, there are no official guidelines that doctors must follow to be officially "certified". Once a doctor has a license, they can pretty much practice as they see fit, with only the threat of litigation or the less realistic threat of medical board censure to rein them in. Is this a good thing, a bad thing, or doesn't it much matter? How does this affect the health care system as a whole?
- Quality: The quality of medical practice is essentially unregulated. There is no objective way for a patient to judge the care they receive. There is a patchwork of systems that grade doctors and hospitals on various measures, but these are rarely patient-centered. Many HMOs, for instance, track how much money their doctors spend, and rate the doctors based on this. This can even lead to doctors being dropped from health plans, independent of the quality of care they provide. There are also statistics gathered on complication rates in hospitals and other related statistics. None of this data is centralized and available to help guide health care decisions.
In medicne, it's not clear what quality measures should be followed or how these measures should affect individual doctors or hospitals. Medicare is now penalizing hospitals whose medicare patients suffer complications. Is this a good thing? Will this cause hospitals to cover up or otherwise misrepresent complications rather than investigate and mitigate problems? Does this type of penalty have any benefit?
- Evidence and Outcomes: What is it to be a "good" doctor? How can we measure this, and what should we do with the data? Because human beings are inexact, so is medical science, but some things can be measured. For example, the success of certain surgeries can be measured by complication and reoperation rates, but this has huge pitfalls; many doctors see a healthier or higher risk population, so using success rates to compare doctors can be invalid. What might be more useful to both patients and doctors is making evidence for certain practices available, and tracking the use of these practices.
For example, I treat many diabetics. Evidence shows that diabetics who have blood sugar, blood pressure, cholesterol, eye, and foot checks do better. A system could track me to see if I actually order these things (and take into account whether patients follow through). This would be much better than tracking how good my diabetics' blood sugars are, since I shouldn't be "graded" on my patients "failures". This type of thing is already being done by some insurance companies, but there is no good system in place. To continue the example, I belong to a physicians' group that gets money back from insurers for tracking these measures. But to track them, they give me a bunch of forms and ask me to find time to fill them out on each patient. If my EHR would simply collect the data automatically (which is technically feasible), the data could be transmitted to the relevant party.
Many of these potential solutions require the collection and dissemination of outcomes data, tort reform, mandatory reporting, and a willingness of doctors to give up a measure of autonomy. These are not changes that can be made piecemeal.
Next up, the doctors' sob story.