• There’s quality, and there’s access

    I’ve been rather bothered by the road I’ve found myself on the last few days, defending definitions of access with which I don’t agree. I think a commenter has figured out my problem:

    I think the problem we are having is due to different definitions of quality. Your two examples of waiting for elective procedures and access to the latest technologies are not issues of quality. They are issues of access (which is one of the other legs of the iron triangle) so should be off the table when discussing quality.

    He’s right. Many of the things I’ve seen others label as “quality” really should be labelled as “access”. Reducing the availability of screening procedures or medications is a change in access. Changing the level of providers you see is a change in access, not necessarily quality.

    Point conceded.

    But my larger assertion holds. If we want to hold quality constant, and reduce costs, we are going to have to reduce access by the above definition. That’s what other countries often do. They have great quality, they cost less, but by the above definition, there is some reduction of access. Yes, they are more universal in terms of insurance coverage, but that’s only one facet of access. Other countries  reduced costs come with a reduction in choice, in availability of some procedures or meds, or from some other change.

    Some of my friends on the left are upset at me for believing I’m making an argument that real reform isn’t possible. That’s just not true. I would be totally fine (and in fact happy) with real reform that expanded coverage, reduced costs, kept quality as I define it constant, and reduced (covered) access to stuff evidence indicates people don’t really need. That’s a trade-off I’m willing to make. I imagine many of you are fine with it, too.

    But it is a real trade-off  and we should still acknowledge it as such. I’ve long argued that Canada (as a democracy!) has chosen a health care system that sometimes (but in an overblown way) restricts access to elective procedures in a way to reduce costs. In a rational world, we’d identify that as a fiscally conservative option. We shouldn’t demonize their system, we should recognize what decisions they made to get to where they want to be. Are we willing to make the same trade-offs? If not, then we can’t complain when we get a system that costs so much yet delivers so little.


    • If you posit that the labor market for doctors and other health care professionals is a free market (it’s not necessarily, but bear with me), then couldn’t you theoretically increase access and reduce cost at the same time with a negligible to positive effect on quality simply by increasing the supply of doctors? I’m not advocating for letting anybody with two hands have permission to practice medicine, but you have to admit that we do have many examples of a doctor shortage in this country.

    • The issue of access, as measured by time to service, for elective and semi-elective procedures is interesting since in many cases increasing time to service causes improved effectiveness by discouraging tests and procedures that will not prove necessary or desirable if some time is allowed to pass, and which carry morbidity and mortality risks of their own.

      Delaying surgery (and the associated imaging) for lower back problems often leads to patients finding that the surgery is unnecessary because the problems clear with time. The same is true of many joint procedures and of all sorts of other conditions where pain is the main issue. Delay of coronary artery intervention can greatly reduce the need for surgery as well, as many patients find that medical treatment (which they will also receive if they get the surgery) is effective in dealing with their symptoms without undergoing the risk of the procedures.

      So although delays may be used by other systems partly to save money, they also serve to improve effectiveness in many cases, which is part of the rationale for building delays into the system.

      • And once again, I think you pointed out that definition problem again.

        Reducing access to things that are unneeded (based on effectiveness) is a reduction in access how exactly?

        For instance, I’ve received a lot of diagnostic imaging from MRI scanners. Much of it was not needed according to multiple specialists who ultimately treated me. If doctors didn’t have routine access to that technology, would that be an actual reduction in access?

    • Well said.

      I think the biggest part of the medical costs discussion is about access.

      1. What treatments are so basic that we think everyone should get access?
      2. How do we make the choice (or trade off) when we are in the usual case that we don’t know whether access to a test or procedure will make a difference, but it might.
      3. What treatments should someone be allowed to purchase access to if they want them and can pay?
      4. After answering #3, does our answer to #2 or #1 change?

      Sometimes I think the main difficulty is that we are so hung-up on inequality that if there is a treatment that one person can purchase that anecdotally helped, we feel everyone must have immediate access to it. In which case, we are doomed to either ever rising costs or artificial limitations on some procedures that could help. Neither is appealing.

      • “1. What treatments are so basic that we think everyone should get access?”

        If U.S. politicians ultimately get to answer this question, the list will grow to include all treatments that:
        – increase the likelihood of support for a high-value voter segment;
        – use technology or supplies from businesses within the constituency; and
        – are supported by large political donors.

        Put another way, the answer to 1 will include all treatments that can be depicted as being paid for by someone else.

        • You are being cynical about politicians pandering to the public to get re-election or conspiring to enrich their friends and supporters. I think there is a more fundamental problem that our society has come to the point of strongly holding the views “I should be able to get anything I can pay for” and “No-one should ever get less than anyone else”, with little understanding of middle ground. That unless we can regain the idea that there is middle ground between ideals we have no hope for a solution.

    • I think the fundamental issue is whether or not you are on the frontier of your production possibilities. If so, then the triangle is iron and tradeoffs are necessary. If not, then the triangle is not completely iron and there exist opportunities (thought they may be difficult to find and implement) for all three parts of the triangle to be improved simultaneously.

      • I might even concede this point. I think it would be extremely difficult to identify and implement change,at a national level, that could accomplish this kind of surgical precision.

    • The Dartmouth Atlas has documented two different forms of inefficiency: the overuse of treatments that are not effective, and the underuse of treatments that are known to be effective. Can’t the case be made that each of these is concerned with access and quality? After all, the points of the triangle are connected by the lines.

    • I am basing the following comments on my experience in Minnesota working with public measurement and reporting on quality, with the State employee group insurance plan on risk adjusted comparative provider cost for a commercial population, and in some 20 years of working with providers and health plans on the nuts and bolts of care improvement at the point of service. First, there is significant variation within Minnesota on how well providers do in managing chronic conditions (among other things). Getting all providers to the level of the highest performing groups (and in Minnesota we are dealing with group practice) is a major piece of improving quality – and this is mostly about the commitment of provider leadership to make this a priority, It is rarely an issue of overall resources, though often an issue of how current resources are used. And – Mayo is not among the highest performing groups – though they are getting better. Second, there is a 70-80% variation on risk adjusted total cosgt of care among provider groups in Minnesota – and this is under fee for service medicine with increasing amounts of ACO payment only in the last couple of years. Many of the provider groups with the lowest risk adjusted pmpm are among the highest quality provider groups on public measurement and reporting, So if some groups can do high quality and lower cost care – what do we need to do to get all groups to do this? Finally, Minnesota provider group and health plan leaders are starting a discussion of what it really means to meet the Triple Aim – in particular what it means to meet the affordability leg of the aim. There has been open and frank discussion that the type of waste described in the IOM report is alive and well in Minnesota too – and that one of the task of provider and health plan leaders is how to make it possible to actually take this waste out of the system.

      • This is interesting.

        In light of our ongoing discussion of the amorphous nature of “quality” as a term in health care, what parameters are you using to define quality in your studies? Are you looking at outcomes? At errors and incidents? At readmission?

        Could you give us a list?

        • Let me give you two web sites. The first is Minnesota Community Measurement – http://www.mncm.org – which does public measurement and reporting. The second is the Institute for Clinical Systems Improvement – wwww.icsi.org – which, among other things, has pioneered work on treatment of depression in primary care, developed an embedded decision support system for high tech diagnostic imaging, and co sponsors a project to reduce readmissions, the RARE campaign. I would note that Consumer Reports combined the Community Measurement quality reports with risk adjusted comparative cost data from the NQF endorsed total cost of care measure developed by HealthPartners (Health Plan and Medical Group) and published it as an insert for the most recent issue sent to Minnesota subscribers.

          • Interesting. Obviously a good project.

            Three points:

            1.) I would like to see a little less reliance on lab results as an endpoint and more concentration on hard endpoints, including deaths, hospitalizations, MI and CHF, renal failure, disability, etc. There has been a lot of interesting work lately suggesting that a lot of the stuff that we (American doctors) are focusing on — for example blood lipid levels and use of statin — do not correlate very well with hard endpoints. After all, in the end it does not matter what someone’s LDL level is if it does not result in fewer bad hard endpoint results.

            2.) I would really like to see some measure of movement of variables — start points vs. current position. In medicine, as in education, there is less value in taking a patient who is already doing quite well and improving them slightly than there is in achieving improved but less optimal results in someone who starts in a very bad place.

            3.) I would also like to see some assessment of cost as part of this — another leg of the triangle. Again, spending a lot of extra money to bring lab results a bit closer to optimal may not necessarily be the best way to use resources.

            One thing that did answer one of my concerns was that Health Partners’ performance was mediocre on the study. When you indicated that they were the source of many of the measures it raised the concern they may have stacked the deck in their favor. It looks like they did not.

            • Pat,

              Just to clarify – the HealthPartners total cost of care measure was developed by HealthPartners Health Plan and medical group. The other three major health plans in the Minnesota market all have developed variations on the same thing. The Minnesota Community Meaurement quality measures have been national developed or approved measures – with major clinical participation by docs from Mayo, Park Nicollet, HealthPartners Medical Group, Allina, Fairveiw and other Minnesota medical groups – as well as participation by the medical directors of the health plans. Overall clinical guidance has been provided by ICSI.

    • Here is a two year study of improving quality and efficiency at five large hospital systems (29 clinics).
      This study shows that you can improve quality, improve access, and lower costs all at once.
      Again, I really think that US health care has completely decoupled cost and quality and that your professors need to rethink the “iron triangle”.


    • Having been told over and over by politicians and pundits alike that Mayo and Cleveland Clinics are the gold standard models of healthcare dollar efficiency, I am happy to see that someone has recorded data to the contrary. The local Mayo outpost (Jacksonville) years ago rejected Medicare part B assignment, citing that its payment schedule did not allow for their profitability. More recently they’ve started a $5,000 annual fee concierge service for their primary docs, resulting in second wave of seniors exiting their system. The problem as I see it from the extrapolations of the Dartmouth Medicare data to generalizations about healthcare dollar efficiencies is that patients who fly in to Rochester for care/diagnostics don’t live out their lives there.

      • Jeff h,

        Both the findings of the Darmouth Atlas for Medicare and the findings of Minnesota Community Measurement and the state employee group can be “true”. The Community Measurement data is primarily on primary care clinics. Mayos’ primary care system goes well beyond Rochester into most of southeast Minnesota, much of western Wisconsin and parts of northeastern Iowa. Mayo can give top level specialty and hospital based care and be cost efficient for Medicare and expensive as the dickens in the commercial market, It is now having to put much more focus on the primary care end of their system and to their credit, they are now doing that.

        • I agree with Peter.

          In fact, Mayo Jacksonville has consistently underperformed Mayo Rochester since its founding.

          Many of the “mini-Mayos” scattered around the Upper Midwest have also underperformed to some extent, which may not be surprising since they represented mergers with existing systems, bringing with them the cultures existing in their pre-Mayo days.

          The only Mayo branch that has reached and even exceeded the performance of the mothership is Mayo Scottsdale. Scottsdale has an interesting history, in that for a large part of its early existence, and perhaps even now, it was an “elephants’ graveyard” for Mayo, drawing a large number of veteran Mayo staff who decided to spend the end of their career basking in the sun rather than fighting Upper Midwest winters.

          It seems quite clear that the strength of centers like Mayo Rocherter, the Cleveland iteration of the Cleveland Clinic, and other similar high side outliers in American health care comes from the medical culture of the institutions — the “Mayo Way” in the case of Mayo. It has proven difficult to successfully transplant this culture to other places — although I do believe that the consistent superior performance of Minnesota and Wisconsin on many measures is partly due to the long term impact of 100 years of Mayo trainees diffusing into the surrounding area.

          The institution with the best track record of transplant success has been Kaiser. Four of the nine five star Medicare Advantage programs this year were Kaiser operations, although not all Kaiser transplants have been successful. There I think that the reason is at least partly because Kaiser uses not culture but direct control as its main tool in attaining the physician behaviors it wants to see.

    • As a Quality Control professional in manufacturing, we often faced a similar argument: that you could improve quality, or reduce costs, but you couldn’t do both simultaneously. It proved to be completely bogus. There were many habits, process inefficiencies, training gaps in staff, etc., that simultaneously reduced quality and increased costs. Systematically identifying and eliminating these factors often made possible very significant quality improvements while lowering costs. Its like comparing the Japanese car companies in the 80’s to their US counterparts.

      I have to believe that there are similar opportunities in medicine. In our wild-west free-for-all of a health care system, building the needed culture, establishing the needed incentives for these kinds of changes is surely difficult. But that doesn’t mean it can’t done. In the manufacturing analogy, the changes aren’t made by top-down mandates either. You need to marshal the collective actions of many participants.

      I think an important first step would be building a whole lot more transparency in pricing (a surrogate for productivity), quality outcomes, and actual access experience. I would love to see a sign outside a PCP’s office that says: “In our practice you can get a same-day appointment x% of the time, and y% of our patients can get an appointment within a week.” Or a surgeon’s office “% of my CABG surgeries result in serious complications.”

      I know, I know. Not going to happen anytime soon. But maybe we can takes steps that move us in that direction.