Quality Health Care: Delivering on the Promise

In a lively plenary session on Sunday afternoon, Alice Yaker, Executive Director of SHARE, moderated and offered the patient advocate perspective to a diverse panel of leaders in the quality care world. Yaker stressed the NBCCF core values as they apply to quality of care, and described a number of NBCCF’s accomplishments and initiatives in this regard. For example, the value of accountability needs to apply to the role of the FDA before as well as after approval of drugs, and to physicians, who must better explain risks and benefits of treatments to patients.

Carolyn Clancy, MD, Director of the Agency for Health Care Research and Quality, discussed AHRQ’s initiatives in comparative effectiveness research, which allows direct comparison of similar interventions to one another; she emphasized that this process must be transparent at every stage. Comparative effectiveness, she said later, is controversial; in response to audience questions, she answered that although industry fears thumbs up/thumbs down results of comparative effectiveness reports, health care is rarely so simple.

Paul Levy, CEO of the Beth Israel Deaconess Medical Center (BIDMC), pointed out that variation in care is important to monitor, in cases where it is not an aspect of the art of medicine but really reflects a variation in quality. Levy has an influential blog, http://runningahospital.blogspot.com, in which he promotes complete transparency in running his hospital, in some cases forcing the improvement of quality. For example, he has published central-line infection rates, and challenged other hospital executives in the Boston area to do the same. In response to accusations from the other execs that this was an attempt to put BIDMC at a competitive advantage, he countered that publicizing how many people they were killing was hardly a viable marketing strategy! However, Levy said, he believes that his efforts at transparency have succeeded in changing the public discussion in the Boston health care community.

Shannon Brownlee, author of “Overtreated: Why Too Much Medicine is Making Us Sicker and Poorer,” began with the example of high-dose chemotherapy and bone-marrow transplantation. She noted the press’ role in enticing people to demand this treatment and that advocacy groups – except for NBCC – pushed for coverage because it was unfair not to. In the end, clinical trials showed that it really was no better than conventional therapy – arguably more harmful – and much more expensive. She said that geography is destiny in medicine – where you live determines what kind of care you get. A heart attack in Salt Lake City, on average, will cost Medicare half what it costs in Los Angeles, yet in LA the outcome is, on average, worse.

As earlier, the advocates attending the session came up with a wide range of great questions. One was how efforts at health care reform can address political buzzwords that get in the way, such as socialized medicine, managed care, undocumented immigrants, and rationing. Brownlee responded that if “rationing” means that you restrict care that we know will not be helpful, that’s a good thing. Clancy noted that impulses along the lines of “Don’t just stand there, do something,” drive costs, and that the Veterans’ Administration is an example of socialized medicine in the US. Levy then described the two-tier system in the UK, where services that are not covered by the national health system can be purchased privately.

What about universal coverage? Brownlee said yes – but we must, at the same time, contain costs, or else they’ll become unmanageable. Levy agreed that the ongoing Massachusetts experience is much more expensive than anticipated as previously uncovered residents catch up on services. Levy also cautioned, however, that there is not a political consensus behind universal coverage; he advocated an incremental approach in the form of confidence-building measures.

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