On Mon, 13 Dec 2004, Thompson, Kenneth wrote:
> given this, why is it that the best care in american appears to be
> delivered by some of the larger systems? clearly there must be some
> relationship between central resources and local ones. but how to
> optimize that relationship?
The particular situation of high-quality care being delivered by large
systems points out something much closer to what this listserv is really
about: idealism. It has long been observed that certain large systems
deliver higher quality care than private practice or even some prestigious
hospitals. That was part of the idea behind the Nixon administration's
advancement of HMOs (they coined the term, actually - Kaiser et al. were
Prepaid Group Practices before that). To understand why it's important to
look carefully at which large systems deliver the best care: places like
Kaiser, Group Health of Puget Sound, Health Insurance Plan of Greater New
York are the classic examples.
How do they do it? Health services researchers identified three
mechanisms: selective recruitment, group practice effect, and idealism.
Selective recruitment because Kaiser would hire only better docs, whereas
any schmoe who could make it through med school could hang out a shingle
in private practice. Group practice effect is what happens in my office
every day: my colleagues and I consult amongst ourselves, keeping each
other up on the literature and polishing our knowledge, an effect very
difficult to replicate in a one- or two-doc shop. Idealism because of why
Kaiser, Group Health, etc. exist.
The HMOs that consistently deliver high quality care are what health
services researchers refer to as the "HMO Movement" HMOs. Those are very
different animals from the "HMO Industry" HMOs. The former exist because
they believe in quality and efficiency; their mission is to serve
patients, and they were doing it even when the deck was stacked against
them. The latter exist because the TEFRA law changes under Nixon made it
economically attractive and payers wanted to control costs. Their mission
is financial, and as this group has observed repeatedly they approach that
mission with all the ethics of Enron or WorldCom.
The large systems that deliver high quality care are the "movement"
systems, those idealistically-based systems that believe in quality care
and have finance people to keep them solvent so they can pursue that
ideal. The systems we discuss so often on this group are "industry"
systems, run by money people, to whom docs are just the means of
production and patients are merely market share.
No amount of free market incentive alignment, government regulatory
micromanagement, liability threat, or anything else will ever turn the
latter into the former. The system behaves in the best interest of
patients if and only if people who have ideals and ethics run the system.
I often muse on how worrisome it is that stuff that starts out as wonderful, idealistic, and fruitful stuff gets turned into something else. The HMO movement is a perfect example of how wonderful ideas to improve medical practice get perverted. Love the comparison between "idealism-based" and "industry-based" HMOs.
ReplyDeleteSeeing "evidence-based medicine" ideas get used to contest provision of care by groups such as the Texas Association of Business who are really motivated to minimize care for quite other reasons and use many other quite spurious reasons to oppose it is another example of terrific, humane ideas and the horrific path they can sometimes take.
Basically, I guess you not only have to look at what people say but at what they want. And that's much more evident from their past actions than from their sweet words.
The flip side of this is that idealistic people in or dealing with non-idealistic institutions often subvert the rules and regulations to give good care anyhow, to the extent they can. But it's a shame they have to, and sometimes they are quite unable to. And they jeopardize themselves and can get accused of "fraud and abuse." But if the industry folks pervert the idealist's dreams, it's only fair for the idealists to subvert their plans in return.