The New England Journal of Medicine, in addition to publishing important scientific and medical reports, is highly political. It supports assisted suicide, for example, and even respectfully published the Groningen Protocol—the Dutch check list to determine which babies can be murdered for eugenic reasons based on terminal or disabling conditions.
Not surprisingly, the NEJM has published articles weighing in on the great health care reform debate, such as this one by Michael E. Porter, a Harvard Business School professor. Porter says the answer to the current mess is the establishment of a ”value based system.” From the article:
What we need now is a clear national strategy that sets forth a comprehensive vision for the kind of health care system we want to achieve and a path for getting there. The central focus must be on increasing value for patients — the health outcomes achieved per dollar spent...True reform will require both moving toward universal insurance coverage and restructuring the care delivery system. These two components are profoundly interrelated, and both are essential.Achieving universal coverage is crucial not only for fairness but also to enable a high-value delivery system.
But what does this mean? Would “universal” coverage include illegal aliens? If so, half of Mexico and points South can be expected to try to get across the border. Is it going to include abortion? How about expensive procedures such as IVF, pre-implantation genetic diagnosis, etc.? Beyond the political difficulties, having expansive “universal” coverage will quite literally break the bank. How about assisted suicide? Now there’s a “treatment” where value is very cheap to provide!
The article promotes some things with which I agree, for example allowing private health insurance companies (and public) to compete nationally. But Porter also says everyone should be forced to buy health insurance whether they want it or not. So much for “choice.” But here’s the thing: The proposed system, as described by Porter, makes the old Hillary Health Care plan seem simple:
[W]e need to move to integrated practice units that encompass all the skills and services required over the full cycle of care for each medical condition, including common coexisting conditions and complications. Such units should include outpatient and inpatient care, testing, education and coaching, and rehabilitation within the same actual or virtual organization. This structure, organized around the patient’s needs, will result in care with much higher value and a far better experience for patients.
And this part really raised my hackles (my emphasis):
In order to achieve a value-based delivery system, we need to follow a series of mutually reinforcing steps. First, measurement and dissemination of health outcomes should become mandatory for every provider and every medical condition. Results data not only will drive providers and health plans to improve outcomes and efficiency but also will help patients and health plans choose the best provider teams for their medical circumstances...
Outcomes must be measured over the full cycle of care for a medical condition, not separately for each intervention. Outcomes of care are inherently multidimensional, including not only survival but also the degree of health or recovery achieved, the time needed for recovery, the discomfort of care, and the sustainability of recovery. Outcomes must be adjusted for patients’ initial conditions to eliminate bias against patients with complex cases. We need to measure true health outcomes rather than relying solely on process measures, such as compliance with practice guidelines, which are incomplete and slow to change. We must also stop using one or a few measures as a proxy for a provider’s overall quality of care. Performance on a measure such as mortality within 30 days after acute myocardial infarction, for example, says little about a provider’s care for patients with cancer. Active involvement of the federal government will be needed to ensure universal, consistent, and fair measurement throughout the country, like that already achieved in areas such as organ transplantation.
But organ transplants are relatively rare procedures, numbering in the thousands. We are talking here about measureing hundreds of millions of procedures and outcomes! Talk about turning doctors into paper shufflers! Think of the number of people that will be required just to gather and input the data from the tens of millions of people who receive health care every day. And in the end, it would be about Big Brother, or perhaps Big Triplets, exercising rigid centralized control:
Some new organizations (or combinations of existing ones) will be needed: a new independent body to oversee outcome measurement and reporting, a single entity to review and set HIT standards, and possibly a third body to establish rules for bundled reimbursement. Medicare may be able to take the lead in some areas; for example, Medicare could require experience reporting by providers or combine Parts A and B into one payment.
Hello utilitarian bioethics enforcers!
Health care cannot be controlled centrally by the Feds. It’s too big a sector. Setting up “modules” and trying to measure “value” will turn us into a pretzel—but to mix my metapohrs, one with teeth. Good grief.
