Here we come, kicking and screaming, into the world of 21st-century health care. The need for better access and cost control is acknowledged. Fortunately, there are U.S. communities whose experiences can yield approaches to avoid and ones to emulate.
When it comes to health care, higher cost doesn’t translate to higher quality, whether measured in survival, ability to function or satisfaction with the care received. Economists at Dartmouth found that a state’s Medicare quality ranking tended to be negatively correlated with the money spent there. McAllen, Texas, has the dubious distinction of the most expensive health-care market in the country.
“In 2006, Medicare spent $15,000 per enrollee here, almost twice the national average and $3,000 more per person than the average person in McAllen earns,” Atul Gawande wrote in the June 1 New Yorker. Yet McAllen’s five largest hospitals performed on average worse than the neighboring similar community on 23 of 25 of Medicare’s metrics of care.
One reason higher cost doesn’t translate to better outcome is that complications can arise from treatment, so any treatment that was not absolutely necessary may cause more harm than good.
A more mundane but essential reason is that there is no accountability for the big picture. Gawande writes that the hospital administration has “only the vaguest notion of whether the doctors are making their communities as healthy as they can, or whether they are more or less efficient than their counterparts elsewhere.”
By contrast, he profiles organizations such as the Mayo Clinics in which patients’ needs are more important than doctor convenience or revenues. “When doctors put their heads together in a room, when they share expertise, you get more thinking and less testing,” a Mayo doctor told him. This “accountable-care” organization model has been adapted at nonprofit hospitals around the country with excellent results.
Given the need to control costs and outcomes, will expanding access involve rationing, as some fear? The truth is, it always has, and as long as we keep innovating and finding new and better ways to repair body parts, it always will.
The history of organ donation shows the progress we have made in trying to provide fair access to health care, despite changing ideas of what is fair. In mid-20th-century Seattle, an artificial kidney machine was procured, and doctors were faced with deciding who would get to use it. A committee including a minister, a homemaker, a banker and a labor leader considered factors such as church attendance, marital status and net worth, according to Larissa MacFarquhar in a July 27 New Yorker article. Those criteria wouldn’t hold now, but the need to apportion limited supply persists.
In the early 1990s, Oregon began covering a list of Medicaid services based on a ranking of the assessed value of each service. Various medical treatments are ranked according to their effectiveness and cost, and those that rank low are not covered. Although critics bemoan this as health-care rationing, supporters argue that this system results in better care to a larger proportion of the needy population.
The brightest spot in this health-care conundrum is that most likely there’s almost universal agreement on baseline issues: We want a country where no one dies for lack of health care, and health-care costs are currently unsustainable. The solutions are out there. We can design workable systems using parts that are available now and have enough flexibility to be self-correcting as conditions change. We can do this.
— Karen Telleen-Lawton’s column is a mélange of observations supporting sustainability. Graze her writing and excerpts from Canyon Voices: The Nature of Rattlesnake Canyon at www.CanyonVoices.com.
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