RTRP Health Care: Quality Control

Today we finish outlining the problems our health care system faces. We have previously discussed costs and access. Today we address poor quality control and preventable medical errors.

Our system suffers from wasteful over-treatment, exposes patients to an amazingly high risk of under-treatment, and results in an incredible number of preventable injuries. The existing mechanisms for monitoring quality control are simply inadequate.

Over-Treatment Wastes Billions

As noted previously, over-treatment, i.e. the providing of medically unnecessary tests or procedures, wasted $500-$700 billion in 2007. Yet, as also shown, only a small portion of that amount -- between $6 billion and $66 billion -- can be attributable to defensive medicine, i.e. lawyers. The rest, according to a study by Dartmouth’s Institute for Health Policy and Clinical Practice, was caused primarily by the lack of clear national standards. Indeed, recent studies have shown that many doctors lack adequate information on the risks/benefits of common treatments.

This leads to inconsistent care, including both the over-treatment mentioned and under-treatment. Under-treatment occurs when patients do not receive care that is both cost effective and medically effective. For example, the Dartmouth study found that patients had just a 50% chance of receiving flu shots, where appropriate, or receiving aspirin or beta-blockers following a heart attack, or receiving antibiotics to treat pneumonia, even though these treatments are inexpensive and are well known to improve patient health in those situations.

Another recent study, found that doctors fail to tell patients about abnormal test results 7% of the time -- 1 out of every 14 tests. This study, of the records of 5,000 patients who were tested for high cholesterol, diabetes, colon cancer or breast cancer, found significant variances in the performance of doctors, with some failing to inform patients as often as 26% of the time. This inconsistency frustrates early diagnosis, which is the key to effective treatment.

Preventable Medical Injuries

More significantly, however, the lack of standards and poor supervision/ oversight lead to a vast number of preventable medical errors each year that result in significant injuries.

A study by Healthgrades of 37 million patient records from 2000-2002 found that an average of 195,000 hospital deaths each year were the result of preventable medical errors. (A prior, smaller study by the Institute of Medicine estimated that medical errors cost 98,000 lives in 1999.). According to Healthgrades, even a 20% improvement in just the areas of failure to rescue, bed sores, postoperative sepsis and postoperative pulmonary embolism could alone save 39,000 people each year.

A 2006 study by the Institute of Medicine found that 1.5 million preventable drug-related injuries occur each year.

A 1997 study published in the American Medical News, estimated that cost of treating injuries resulting from medical error could be as high as $200 billion annually, and adversely affect the lives of tens of million of Americans. Bringing this figure forward to present day dollars would yield $520 billion, and this figure does not take into account lost wages, lost productivity or other non-treatment costs.

So why aren’t the current oversight mechanisms working?

Boards of Medicine Are Failing At Policing The Profession

The groups primarily tasked with ensuring the quality of health care in the United States are the state medical boards. However, these boards show a wild variation in disciplinary rates, a variation one would not expect if they were maintaining a consistent level of quality.

For example, in 2001, fourteen states and the District of Columbia disciplined less than two physicians per 1000. D.C. disciplined 0.73 per 1000. At the same time, the top ten states disciplined more than five physicians per 1000, with Alaska disciplining 10.52 per 1000.

That is 14 times the rate of the District of Columbia Medical Board. So unless you believe that Alaska doctors are simply 14 times more dangerous than D.C. doctors, then it is clear that a different level of oversight is being applied in different states (there is no regional pattern to this data either).

This data raises serious questions about the extent to which medical boards are protecting patients from bad doctors. Indeed, concerns have been raised about (1) whether these boards are adequately funded and staffed, (2) whether they conduct appropriate investigations, (3) whether they are independent of state medical societies and political influence, and (4) whether the disciplinary structure is itself reasonable.

Hospital Oversight Is Even Worse

Changes in the law have allowed hospitals to escape liability for the actions of doctors by separating themselves from the doctors. Thus, more and more doctors are being made independent contractors of the hospital, with the limited oversight that entails. And while hospitals ostensibly monitor doctors when deciding whether or not to extend or revoke hospital privileges, these credentialing committees are slow to revoke privileges, because they are more concerned with legal maneuvers than doctor oversight. Indeed, there is a perception that being too aggressive about oversight will lead to litigation, either by doctors or by patients who learn that their doctor was suspended.

Medical Malpractice Fails As Quality Control

Some (mainly lawyers) argue that medical malpractice serves the function of ensuring quality control by providing doctors with an incentive to take appropriate care. Thus, they oppose anything that reduces their ability to sue doctors.

However, the Congressional Budget Office rejects this reasoning. According to the CBO, “it is not obvious that the current tort system provides effective incentives to control such injuries.”

For example, the CBO notes, health care providers generally are not exposed to the financial costs of their own malpractice, because they carry insurance. Moreover, the evidence shows malpractice claims are far too few to provide an effective deterrent. According to the CBO, of the 27,179 estimated instances of malpractice in New York in 1984, only 415 (1.5%) resulted in claims being made. Therefore, it is likely that malpractice provides little incentive for providers to exercise greater care.

Conclusion

Thus, effective reform must:

1. Reduce over-testing,
2. Improve compliance with the standard of care,
3. Reduce the number of preventable medical injuries, and
4. Find an effective manner to oversee the medical profession to ensure quality control.