Monday, May 26, 2008

Micromanaging the System

We should have learned by now that trying to micromanage complex systems only leads to grief.

The May 22, 2008 issue of The Boston Globe reported that the Massachusetts Medical Society (MMS) had decided to file suit to derail “a two-year-old plan under which physicians are ranked for cost and quality measures by health plans associated with the Group Insurance Commission, the agency that oversees health insurance for thousands of public employees at state and local levels.”

MMS claims that the program has been unfairly ranking individual physicians using “inaccurate, unreliable and invalid tools and data.”

There are some 30,000 licensed physicians in Massachusetts. When you consider what would be involved in trying to rank that many doctors, given the wide variation in the way data is recorded and kept, the accusation should come as no surprise. My guess is that there is scant possibility of developing tools and data that are accurate, reliable, and valid enough to be both fair and credible.

In a separate article, that same issue of the Globe reported the intention of a US congressional panel to introduce legislation requiring health insurers to pay for a minimum 48-hour hospital stay after breast cancer treatment. Surgeon Kristen Zarfos had testified that thousands of patients undergoing mastectomy (one assumes not radical mastectomy) were being treated as day surgeries because their insurance companies would not pay for a longer stay. If there was evidence that this practice is harmful, it wasn’t mentioned in the article.

This is no way to run health care. What we ought to have is a system of health care institutions with responsibility for the full range of care provided in them, including the care provided by physicians. Those institutions ought to compete with other health care institutions for business. Purchasers of care would make their own evaluations, applying their judgment to whatever data they could collect. The tendency over time would be for business to gravitate to institutions that provide care of lower cost and higher quality.

That approach would be a lot more practical than somebody in Boston comparing the performance of surgeons in Plymouth with that of surgeons in Pittsfield, or than someone in Washington, D.C. deciding how long a mastectomy patient in Idaho should stay in the hospital.

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