Friday, November 26, 2010

Not Yet Ready for Accountability in Health Care

There seems to be a growing interest in the idea of accountability in health care, but not in the prospect of actually implementing it.

Evidence of the interest is found in the recently enacted Patient Safety and Affordable Care Act (aka health care reform) which makes provision for something called Accountable Care Organizations – entities that include all the major categories of health care providers, including physicians, designed to be capable of being held accountable for the cost and quality of care.

Then I happened to see the November 19 issue of USA Today in which the lead editorial was titled “Preventable medical mistakes take an intolerable toll.” It bemoaned the large number of medical mishaps and deaths due to preventable error.

The editorial went on to suggest three remedies; checklists such as those used by airline pilots, transparency in which hospital safety records are made public, and financial incentives that refuse to pay for patient care caused by medical mistakes.

But there was no mention of holding anybody accountable.

When Paul O’Neill was CEO of Alcoa, the aluminum company, he took on the goal of eliminating industrial accidents within that company. He reports that in so doing, he proceeded on the assumption that every industrial accident in Alcoa was his fault. He established and implemented protocols that brought every such accident to his attention and required that immediate steps be taken to identify the root causes and implement remedies to keep it from happening again.

When developing its editorial, USA Today might easily have contacted the CEOs of several hospitals, asking them, for example, about the extent to which surgery checklists were being used in their hospitals, inquiring as to the reasons for any lack of use, and then quoting those interviewed by name.

That would be holding somebody in health care accountable. I find it interesting that either it did not occur to anyone at USA Today to do that (though it did publish a companion editorial on the same subject by the CEO of the American Hospital Association) or those responsible thought it would be impertinent to do so.

Either way, it seems as though we are at a point at which it is OK to talk about accountability so long as nobody does anything about it.

Saturday, November 13, 2010

The Rationale for Mandatory Health Insurance

A cardinal feature of the recently enacted Patient Protection and Affordable Care Act, aka health care reform, is the mandatory health insurance provision, which requires everybody (with defined exceptions) to have health insurance or pay a penalty.

During the legislative debate, it was repeatedly pointed out that some people have not been able to afford health insurance and others for various reasons have been unable to get it and that measures should be adopted that address those problems.

The mandatory provision was then justified on the moral grounds that everybody ought to be able to have health insurance.

In retrospect, it may be that a different justification should have been used, one based on the morality of responsibility rather than that of benefit.

One of the strong beliefs of our culture is that the sick and injured should receive care without regard to their ability to pay for it. That belief is expressed in a number of ways, including the legal requirement that hospital emergency rooms treat everybody who requests care, regardless of financial considerations.

But it also seems reasonable to believe that anyone who has the ability, financial and otherwise, to obtain health insurance ought to be required to do so. If they expect to be treated when they become ill or injured, then they ought to be responsible enough to make provision for paying if they are able to do so. If they are unable, they ought to be helped. But if they are able and elect to not do so, they ought to be penalized.

The importance of personal responsibility is a basic tenet of the conservative credo and had the responsibility argument been made, it is difficult to see how people of that persuasion could have opposed it.

Based on the recent elections, the issue seems likely to come up again. Perhaps the responsibility argument could play a useful role in the debate.

Friday, November 12, 2010

Doing It Again

It looks as though we are about to do it again.

High and rising cost is a major issue in health care and there is great interest in doing something about it. But rather than holding doctors, hospitals and other providers responsible for getting their costs under control, with due rewards for those who succeed and penalties for those who don’t, we try to tell them how to do it. The result is that they increase their costs by focusing on doing what they are told rather than on the goal of getting cost down.

The main example has been information technology. Information technology is a tool, not a purpose. But the entire effort has been to get providers to make more use of it, not on achieving the purposes of improving quality and reducing cost. Providers have responded by spending tons of money on hardware and software, thus increasing cost while making only modest progress towards improving quality.

Now it seems that we are about to repeat the error. Among the latest fads in health care is something called the Accountable Care Organization (ACO). The idea of an ACO is to get all the providers of care, including physicians, within a single organizational structure so that care can be better coordinated and more efficient. The recently enacted health care reform legislation provides some money to encourage the development of ACOs.

The November 1 issue of Modern Healthcare has an article about existing ACOs, casting doubt on whether they save any money. Most likely they won’t so long as the emphasis is on creating them rather than on what they are supposed to achieve.

Winston Churchill is reported as having said that the Americans could always be counted on to do the right thing, after they had tried all the others. It looks as though he was onto something.

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