Health Care Anew

I spent the bulk of my career working in teaching hospitals affiliated with medical schools.  During that time it was commonly understood that those were the hospitals to which you went to get the best care.  With their highly specialized medical faculties, their research programs, their flocks of students and trainees, and the latest equipment and technology, that seemed to be a reasonable assumption. 

As the years went by, I began to have some doubts.  I remained convinced that it remained true for the rare or very complex cases that drew the interest of the faculty but for the other cases, who constituted the vast majority, I wasn’t so sure the care was all that good.  After all, most of the medical work was being done by residents and students who were not yet full-fledged doctors.  And it seemed to me that the faculty members weren’t paying all that much attention to the daily routines of care, being more concerned with the research projects, published papers and visiting lectureships that would promote their careers. 

I also had occasion from time to time to be exposed to some small community hospitals where the care seemed to be to be quite good and where the governing board took an active interest in the performance of the clinical staff. 

All of this led me to the prediction that when the day came that quality was being measured and reported, there were going to be some big surprises.  Places that few had heard of might well turn out to have better numbers than the big and famous ones. 

Now it seems that I may have been right.  Page 6 of the February 13 issue of The Boston Globe carried a story reporting that according to Medicare, “teaching hospitals were about 10 times as likely as other hospitals to have high complication rates.”  Out of 3300 hospitals reviewed, 190 were reported to have very high complication rates and 82 of these were teaching hospitals. 

Predictably, teaching hospitals pooh-poohed the results, saying that the methodology was faulty and didn’t properly take into account the larger portion of complex cases they treated. 

No doubt the methodology is less than perfect, but you can be sure that whoever in Medicare decided to issue the numbers knew what the response would be but thought the data was good enough to warrant publication.  I suspect they were right.

The temptation of politicians to appeal to the disaffected is an important limitation on their ability to implement reform. 

Massachusetts is currently providing a vivid example.  Some time ago, in the name of health care cost reduction, a law was enacted requiring health insurance companies to offer so-called “tiered” policies that, in return for lower premiums, provided for higher deductibles if subscribers used high-cost, prestigious hospitals like the Massachusetts General. 

People signed up.  But of course some of them who didn’t think they’d get sick did get sick, and then wanted to use the big name provider after all.   

They could but found it unpleasant, if not impossible, to pay the higher deductible (like $1500 rather than $100). 

Their plight came to the attention of legislators who, as reported in the February 1 issue of the Boston Globe, have drafted legislation providing for “exceptions.”   

The Globe, in its editorial on the subject, pointed out that since the scope of the problem was not yet known, “….the Legislature should hold off, lest it undermine its own goal of making health care more affordable.” 

Whether or not it will hold off remains to be seen but for me, the lesson to be learned is this:  if you are serious about reform, don’t depend totally on government.