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July 22, 2009
How Should We Measure Quality?
I received an interesting comment with regards of how we should measure health care quality. What is the proper way to measure health care quality? Is measuring health care outcomes the proper way to gauge it? Should we not be comparing ourselves to other countries? Is the amount of money invest into health care correlated to quality? Or does that not even matter especially when we compare health systems with less funding and less technology to ours but still have comparable outcomes?
The World Health Organization published an article entitled "Benchmarks of fairness for health care reform: a policy tool for developing countries" (to read the entire thing which is awesome, go here: http://www.who.int/bulletin/archives/78(6)740.pdf) in 2000. The WHO developed these benchmarks to be used as a tool to gauge whether a health system works or not:
1. Intersectoral Public Health - Does the nation provide basic nutrition, housing, sanitation, clean water, reduced exposure to toxins, education and health education, and public safety? Does the nation have infrastructure for monitoring health status inequalities? Does the nation try to improve social determinants of health?
US: I'd say so for the most part. Out of 10, I'd give us an 7 - we need to work on those social determinants more and some places are better than others. And we have PLENTY of inequalities in health care.
2. Financial Barriers to Equitable Access - Is there universal health care? How many costs are covered by insurance?
US: Clearly, we don't have universal health care. And there are enormous financial barriers to equitable access....and equitable access doesn't really exist here. So I'll give a score of 2.
3. Nonfinancial Barriers to Access - Does geography, gender, or cultural factors affect one's ability to get care? Does discrimination based on gender, sex, religion, race, sexual disease and class exist in health care?
US: A black baby born in the same place as a white baby has higher risk factors for disease just based on their race. In rural areas, there are less doctors available. Medicaid patients are turned away from doctors routinely and while this is not a direct example of class being a barrier, it is indirectly. Score: 4
4. Comprehensiveness of Benefits and Tiering: Are all services affordable? Are things categorically exclusive? Has there been reform to give uniform quality of care?
US: All services aren't affordable as many Americans (47 million) cannot afford healthcare. Additionally, even the working poor can't afford healthcare and many services are not available to people who do have insurance and thus, have to pay out of pocket. Tiering is not a huge issue in the US but there are not uniform standards of care met throughout the country as of yet. Score: 5
5. Equitable Financing: Is financing by ability to pay for both tax-based systems or premium-based systems? For out of pocket services, is the burden shifted mainly to the sick and not the entire population?
US: Managed care is unique in that due to the fact that a certain company has the same insurance, the premiums are based on the community of workers rather than the risk of each worker. This is great for many employees as it drives premiums down. However, financing of these premiums is not by ability to pay but based on how many benefits you want. Out of pocket services are mostly shouldered by the person affected in the US and not the entire population. Score: 6
6. Efficacy, Efficiency, and Quality of Care: (Definitely my favorite benchmark) Is there a primary health care focus? Is evidence-based practice used routinely? Are there measures to improve quality?
US: For our health care system, this is a mixed bag. On one hand, physicians do try and use evidence-based practice and guidelines are set by this research. Many organizations exist that advise the government regarding the quality of care such as the Institute of Medicine, Agency for Healthcare Research and Equality, Public Citizen, and many more. Besides this, money is poured into the health care system to improve equality by providing experimental drugs and research grants, new technology, and other administrative costs. However, we have a shortage in primary health care doctors throughout the country. The amount of money we put into improving quality of care through new technology does not seem to cause an improvement in health care outcomes, especially when compared to other countries:
We are 37th in the world in terms of health care outcomes.
Score: 4
7. Administrative Efficiency: Are administrative overheads minimized? Is there cost-reducing purchasing for services and medications? Is cost-shifting minimized? Is there minimal abuse, fraud, and inappropriate incentives?
US: Administrative costs are the highest in the US compared to the rest of the globe - 3 times higher than industrialized countries with the lowest rates. Medications are much costlier in the US compared to our neighbors in Canada. Cost shifting is not minimized and is many times left on the patient.
Score: 3
8. Democratic Accountability and Empowerment: Are there public, explicit procedures for evaluating services? Is there transparency? Are there fair grievance procedures such as malpractice? Is there enough privacy protection? Do people feel empowered to debate and discuss health care and actively engage for change?
US: It has taken 30 years for reform to be revisited again and we saw in the 1990s how health care reform was killed by insurance companies and Republicans. This time, we are making a difference - services have been evaluated painstakingly and are being rethought. Malpractice is rampant and has driven many a physician out of service but malpractice can be a result of the interaction between the patient and doctor rather than the doctor actually making a mistake.
Score: 5
9. Patient and Provider Autonomy: ....you get it.
US: Score: 9 -- Patients have the right to any treatment they want as long as they have enough reasoning. Doctors can take a more paternalistic approach to medicine although this is discouraged but all in all, doctors and patients can do as they please.
So these are the 9 benchmarks. Do you think they're worth using to evaluate our own health care?
Posted by Reshma Ramachandran at July 22, 2009 10:54 PM
