• JAMA: The “Iron Triangle” of Health Care: Access, Cost, and Quality

    In the real world, policy is full of trade-offs. Rarely do we get a chance to have everything go our way. Politicians seem to have a difficult time articulatig this fact of life, though, which often makes what they say sound like nonsense.

    This has always frustrated me, and I talk about it in more depth in my latest piece at the JAMA Forum. Go read and share!


    Austin’s note: No, Aaron is not ignoring his vacation. He prepared this in advance and I have posted it on his behalf. Keep that in mind if you respond in the comments. He likely won’t read them or chime in.

    • Are cost and quality inextricably linked? I can think of many examples where they are not. A drug goes off patent and its cost drops due to competition with generics. Has quality been diminished? Has access been decreased? No, access has increased because the cost dropped and the quality is unchanged. Could this model be applied in all of healthcare? Probably not. Can it be applied in other areas? I don’t see why not.

    • Yes, there are tradeoffs. But I would have liked to see some discussion of how health care systems in Europe and some other places manage to provide better access, equal or better quality AND lower costs than we see in the US.

      Numerous reports indicate that Europeans have more health care encounters than Americans, but the unit prices are so much lower that they still pay much less than we do.

      And what about the experiments in which people received different amounts of care… and the ones who were given more access got lower quality of care… because treatment harms outweighed incremental benefits?

      Like so many things, when it comes to health care, the rules of normal reality don’t always seem to apply… including the ‘iron triangle.’

    • While the iron triangle remains rigidly negative some of the time, there are potential exceptions, even in darkest America.

      Savings in cost can be linked to improvement of access, since the money saved can be used partly to fund increased access. Improvements in quality can occur with savings in cost.

      For example, if all doctors — not just the 55% found to be doing so in recent studies — were to adhere to the standards found to be optimal in the ALLHAT trial on treatment of hypertension, the use of the recommended drugs would have the effect of improving quality while decreasing costs, since the recommended drugs are all generics for which the dispensing fee by pharmacies exceeds the actual costs of the drugs, while the non-compliant choices often involve very expensive proprietary drugs. Given the widespread diagnosis of hypertension and the potential savings per patient in the 45% who now appear to be being poorly managed, the savings from this quality improvement would potentially be billions of dollars per year. Some of that could be used to improve access.

      Improved compliance with best science often involves cost savings while increasing quality, with this just being a particularly clear example. These happy accidents allow us to whip around the triangle in a positive, not negative way.

    • Aaron,

      What about expanding the supply side? Wouldn’t that improve all three?

    • I think the US healthcare system has effective decoupled cost from quality. There is no discernible relationship between cost and quality. It has managed to drive up the cost of all health care regardless of the quality.
      Drugs are a good example. Pharma produces newer more expensive drugs that don’t do as good a job or have more adverse effects that the older cheaper drugs.
      Many diagnostic procedures are performed regardless of the need or cost (think of prostate cancer screening and breast cancer screening).
      The cost of a CT or MRI is dictated by the market control of the radiology center and not by medical necessity or quality of the radiologists.
      Procedures such as stents are inserted regardless of benefit (or harm) to the patient. The cost of a stent has no relationship to the value of the stent.
      There is no relationship between the cost of a doctor visit and the quality of the doctor. They all charge whatever they can get. In fact, doctors and hospitals charge different people different prices for the same services with absolutely no difference in quality.

      I could go on but you get the idea.
      There is no tradeoff between cost and quality in the US healthcare system. They are independent.

      • I agree.

        In particular, we have to start by weaning economists and news media away from the concept that there is some “value” for procedures, tests, treatments, and drugs that is separate from their health care effectiveness. Arguments that changes in care that maintain or enhance effectiveness can reduce value are harmful to the quest for improvements in quality and cost.

        Value cannot be separated from effectiveness because effectiveness is value.

    • At Journal Club this month, we were reviewing an article which looked at the role of imaging (ultrasound, MRI) in the diagnosis of carpal tunnel syndrome (CTS). This led to a discussion of the role of electrodiagnostic testing (NCV/EMG) in the diagnosis of CTS. In all instances, the basis for determining the accuracy of the testing was whether it lined up with the clinical diagnosis based on history and exam. If the history and exam are the “gold standard”, what is the value in adding any expensive testing? ( in Bayesian terms the prior probability of the diagnosis based on history and exam only is so high that any additional evidence does not significantly influence the consequent probability) We had therefore determined that there is no value, when one of the senior surgeons declared that it is better to have “validation” that the clinical impression is correct. How do you validate the gold standard with a test which is less accurate? I think the ubiquity of these imaging and testing modalities are dumbing down our clinical abilities, and leading to increased costs which do not improve quality.