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June 2007
A recent article (May 2007) on the “Health of Nations”[1] provided some interesting comparisons. Who has the highest level of choice and responsiveness (that must be US), can see any doctor or specialist we want (that sort of sounds like US), as many times as we want (maybe that’s not US), without referrals or permission (that’s definitely not US). A survey by the World Health Organization identifies France as having the most choice and responsiveness. The US ranks #37.
Here’s the explanation that was offered [1]: “The goal of healthcare is to get everyone covered, at the lowest possible cost, with the highest possible quality. But in the United States, there is another element in the equations that mucks up the outcome. Our system seeks to get everyone covered, at the lowest possible cost, with the highest possible quality, while generating the maximum possible profits. Within that context, the trade-offs and outcomes all seem to benefit the last goal, and so we tolerate 45 million uninsured Americans, unbelievably high prices, and a fractured system that lacks the proper incentives to deliver high-quality care.”
In the US, only the VA system ranks high in quality, choice, and responsiveness. But the VA is “socialized medicine,” a naughty word that we dare not even mention in public nor in politics, even though that approach has been demonstrated to be the most effective in the US marketplace.
A much more detailed accounting of the problems with the US healthcare system has been provided in the book “Money-Driven Medicine” [2]. By business standards, US healthcare is wildly successful. Everyone is making money! Only the patients are unhappy because of the high cost and low quality. As one US healthcare economist has been quoted as sayingt: “Bad quality is good for business” [3]. Bad quality means more business, doing things over, or doing things to take care of complications and side-effects, or doing things to correct the harm done earlier.
“What if medical care came with a 90-day warranty?” That’s the opening line in a recent newspaper article “In push for better care, a heart-surgery warranty” which made the front page of The New York Times [4]. Proving a warranty would mean that complications, side-effects, and poor outcome would be covered without any additional payment. As reported, the Geisinger Health Systems group is the first to offer a warranty on healthcare services. “…Geisinger’s effort is noteworthy as a distinct departure from the typical medical reimbursement system in this country, under which doctors and hospitals are paid mainly for delivering more care – not necessarily better care.” [4]
Dilbert recently clarified the priorities in the business model during a conversation with management, which went as follows:
Manager: “Remember, quality is our top priority.”
Dilbert: “Question: Is it more important than safety?
Manager: “Ooh… I forgot about that one.”
Dilbert: “Is quality more important than obeying the law?”
Manager: “Well…, probably not.”
Dilbert “If we could maximize shareholder value by selling lower quality items, wouldn’t we have a fiduciary responsibility to do it?
Manager: “I’m sure quality is in the top four.”
Dilbert: “What if we had to lie to achieve quality?”
This whole scenario has happened and continues to happen in healthcare organizations and laboratories in the US today! The reality today is represented by CQI - Continuous Quality Issues, not Continuous Quality Improvement. Quality is important, but patient safety is the new movement in healthcare. Quality and safety are important, but obeying the law, i.e., compliance, is more important. Quality and safety and compliance are important, but making money is even more important!
In spite of all the quality issues in healthcare, we continue to believe that the US healthcare is the best that money can buy! Of course, a lot of people don’t have the money to buy good healthcare, but those of us who are fortunate know we have the best access, choice, and responsive healthcare available, right?
Dilbert’s last question is perhaps the most challenging – “What if we had to lie to achieve quality?” Consciously, or unconsciously, have we been deceiving ourselves about the quality of healthcare and the quality of laboratory testing? Or, stated more politely, have we made assumptions that are not well founded? Like assumptions about the analytical quality of laboratory tests being better than needed for medical care, or assumptions about how little QC is needed because today’s methods are so good, which rests on the further assumption that methods today actually achieve the quality required for medical care, which rests on the assumption that we know the quality required for medical care and make use of quality goals for objective management of quality in our laboratories, which we don’t.
I often use the analogy that quality is a lot like truth. It’s a complex concept that has many dimensions. When applied to a laboratory test, the test should tell the truth, whole truth, and nothing but the truth, otherwise it won’t provide reliable evidence for use in care of a patient. Consider the truth component to be the quality required by the test to be medically useful; consider the whole truth to represent the analytical performance needed by the method to produce a truthful test result; consider the “nothing but the truth” to be the quality control needed to assure nothing has gone wrong and to verify the attainment of the intended quality of the test results. The “nothing but the truth” dimension should be the laboratory warrantee or guaranty of the quality of the test results!
Healthcare in the US is destined for a revolution in the near future. The money has run out. We can’t afford to continue to increase the expenditures for healthcare. There is widespread agreement that healthcare must be fixed, even though there is not yet much agreement how to fix it. However, one political commentator recently noted the lack of difference in many of the healthcare proposals come from some of the current presidential candidates. All of them agree that healthcare must be fixed, American business is now in agreement and the American people are certainly looking for changes in healthcare!
The changes that will occur will cause instability that will contribute to variation and problems with quality, meaning that the quality of healthcare in the US will probably get worse before it gets better. In the midst of this instability, laboratories need to be a constant source of truthful information to provide an anchor for quality. We can and should warrantee or guarantee the quality of test results. That’s the practical meaning of the ISO 15189 guidance to “verify the attainment of the intended quality of test results.” It’s good advice and we can do it! We just have to want to do it!
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