There were two pieces in last week’s JAMA that are worth your time. Both are Viewpoints. First up is “Ending the Cycle of Blame in US Health Care“:
The piece then goes through all of the usual suspects, and talks about how each has been “blamed” for the problem. Read it. You’re sure to find at least one bad guy that resonates with you. Then consider the fact that others will disagree and blame others. It’s not a productive way to move forward.
Despite unparalleled financial and human capital investments, the quality, safety, and value of US health care remain suboptimal. There is general agreement on the scope and implications of these trends, but far less consensus on the fundamental drivers of health system underperformance. The disconnect stems from the fundamental difficulty in identifying the causes behind complex policy problems. In biomedical research and clinical investigation, problems and questions are identified, hypotheses are generated, and data are collected; causality is built into the investigative process Similar assumptions are often applied to policy analysis, but the reality is inherently less precise.
Stone has written extensively on how societies grapple with policy challenges, suggesting that such issues do not have inherent properties that make them more or less likely to be seen as problems. Rather, individual parties and stakeholders construct “causal stories” to attribute blame and responsibility in an effort to shape how societies conceive of and respond to policy challenges. According to Stone, many policy problems do not have objective causes, but subjective narratives about causation that gain variable traction in the public imagination.
Stone’s model of causal stories is manifest in the current national dialogue on health care quality and improvement. Consider how the following narratives—prevalent among researchers, policy makers, journalists, and the public—have been used to assign primary responsibility for health system underperformance and poor health care value to various stakeholders.
The other piece is “Critiquing US Health Care“. It’s mostly an argument about how life expectancy is an imperfect metric of the quality of our healthcare system. I’m less interested in that (as we’ve covered that to death at TIE), than I am in this money quote:
Perhaps US life expectancy might come closer to the life expectancy of other developed democracies, if, as they do, some resources were shifted from mammography and magnetic resonance imaging to primary care. Also, the fact that almost all the other countries have universal health insurance, whereas tens of millions of people in the United States are without such coverage may account for part of the gap in average life expectancy.
A balanced critique of US health care and health policy should also include considerations of other goals in addition to extending life expectancy or reducing health care expenditures. Although difficult to do, it is important to account for quality of life, an appropriate balance between personal and social responsibility, and possible trade-offs among efficiency, freedom of choice, and generational, ethnic, and social equity. Health policy should reflect such considerations as well as more easily measured outcomes.
Most health care problems are complex, and easy answers are usually wrong or incomplete.
These are quick reads, I promise. Take a few minutes and go!
