Health Care Quality Illusions

David Lazarus is a reporter on consumer issues for the LA Times. His family recently became big-time consumers of health when his wife spent a week in an intensive care unit. Coming out of this ordeal, he concluded that the

US health system has flaws, but not in quality of care.

This is reminiscent of Senator Ron Johnson’s Wall Street Journal editorial in 2009. Thinking about quality rather than price, and generalizing from the successful care that his daughter received, Senator Johnson argued that the US has

the finest health-care system in the world.

Senator McConnell similarly believes that

we have the best health care in the world.

These gentleman acknowledge that there are important concerns about the cost of health care and how families finance that cost. But leaving these concerns aside, they believe that the quality of US health care is superb.

Aaron wrote a definitive series of posts on the quality of US healthcare (start here) and concluded that on most important measures, the US has poorer quality of care than comparable countries. If Aaron can’t persuade you on that point, there’s not much I can say.

What I want to add, however, is that thinking about quality of care as a debate about whether the US is number 1 is too simple and unhelpful. We need to ask questions about quality in the right way to make real progress. Here are three questions to challenge how you think about quality of care.

1. Is quality of health care a single dimension?

Lazarus and the Senators are confident that we can discuss quality of health care on a single dimension. To the contrary, there are at least four dimensions of health care quality.

  • The hotel experience. Some hospitals are nicer places to stay than others. This may seem trivial in the context of life and death, but any hospital manager will tell you that ‘hotel quality’ matters to patients.
  • The relationship experience. Did the health care providers treat you with respect? Were they considerate of your religious beliefs? The well-educated readers of this blog may have difficulty imagining that they would not be well-treated by health care providers. But disrespect may be a primary consideration if you are poor, speak a language other than English, live outside the mainstream culture, or are mentally ill.
  • The rightness of treatments. By the ‘right’ treatment, I mean the one that was most likely to benefit you.
  • Safety. Were you harmed through error or neglect while you were in care?

Because quality has multiple dimensions, it’s not clear how we should rank order countries (or hospitals, or doctors, etc). If A provides better hotels and more of the right treatments, but B treats patients more respectfully and delivers care more safely, who is better overall? To say that health care is better in one country than another, we must either identify which dimension we are talking about or, if we are thinking holistically about quality, we need to specify how we weight the dimensions to come up with an overall ranking. Aaron was writing about safety and getting the right treatments, but in most public debates it’s not clear what people are talking about.

2. Can you judge the quality of care from personal experience?

Lazarus and Senator Johnson judged health care quality based on their family experience. Should we take this testimony seriously? If we are talking about the hotel experience or the relationship experience, we certainly should. In these matters the patient or the family are the relevant authorities.

If we are talking about the rightness of treatments, however, things are more complex.

There are some aspects of care that any of us can judge. I’ve been cared for or worked in hospitals that were filthy and where I’ve seen insects that shouldn’t be there. Once, I laid in a hospital bed for 10 hours with a heart rate topping 200 beats per minute waiting for a cardiologist to see me. (This problem was resolved when my physician wife informed the staff that she was leaving my bedside and would return with a rocket launcher if they didn’t promptly find someone who knew what they were doing.)

In most cases, however, it is impossible for someone to judge the rightness of treatment from his personal experience of care. This is not just because the issue is technical and requires professional knowledge. The bigger issue is that you can’t judge the rightness of treatment from personal experience, because rightness depends on a counterfactual. The right treatment is the one that was expected to produce outcomes that were better than the expected outcomes of alternative treatments. But we only have personal experience of the care that we actually received. By the way, your doctor, despite all of her training, is in the same fix you are. She can only see the outcome of the care you got, not the outcome of the care you might have gotten.

The only way to judge the rightness of your treatment is to look at the outcomes of many people like you who got your treatment and compare them to many other people similar to you who got other treatments. This involves data, ideally collected through randomized trials. Expert medical opinion — unless it is based on this kind of evidence — is a very poor alternative to data. And personal testimony is worth nothing at all.

3. Should we think about the quality of care comparatively, or in absolute terms?

There are heated debates about where the US ranks in the quality of care (and I am with Aaron about where the US ranks). But really, I don’t think that this matters. I don’t care whether US surgical wound infection rates are worse than, say, the Swedes. What I want is that the US wound infection rate, whatever it is, should be cut in half. Instead of thinking comparatively, we should look at quality in absolute terms: how good is contemporary US care relative to how good it can be?  

So here is how I would like to see discussion of quality change. First, recognize that quality has many important components. Second, the rightness of treatment can’t be evaluated from anyone’s testimony about their wife or daughter; or by the opinions of white-coated experts. You need to look carefully at the evidence.  Finally, let’s get past the question of ‘Is American First’? Even where America is first, what matters is that American health care could be better.


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