• There’s quality, and there’s quality

    So right as I left for vacation last week, JAMA posted my piece on the iron triangle of health care. A lot of you took exception with the following:

    When I talk about health policy, I often refer to the iron triangle of health care. The 3 components of the triangle are access, cost, and quality. One of my professors in medical school used this concept to illustrate the inherent trade-offs in health care systems. His point was that at any time, you can improve 1 or perhaps even 2 of these things, but it had to come at the expense of the third.

    I can make the health care system cheaper (improve cost), but that can happen only if I reduce access in some way or reduce quality. I can improve quality, but that will either result in increased costs or reduced access. And of course, I can increase access—as the Affordable Care Act (ACA) does—but that will either cost a lot of money (it does) or result in reduced quality.

    Anyone who tells you that he or she can make the health care system more universal, improve quality, and also reduce costs is in denial or misleading you.

    In emails, in comments, or in other blog posts, many of you asserted that we can do all three things. Many of you pointed out that other health care systems in other countries are universal, cost less, and do better in terms of quality.

    Let’s start with the fact that if I could start building a new health case system from scratch, there’s no doubt in my mind we could do better than what we have right now. But my argument was more about how we make changes to the existing system. Without scrapping the current system, it really is impossible to make changes to what we have without the iron triangle coming into play.

    But the larger issue is that when all of you are telling me about “quality” in other health care systems, you’re ignoring that in many ways that others find important, they are worse off in terms of “quality”. I’ve made clear how I define quality. I would imagine that many of you taking issue with my post have similar definitions. But many, many other people disagree.

    Some of those other health care systems pay their physicians far less than we do. Lots of people see that as a reduction in “quality”. Some of those other health care systems don’t let you get all the screening tests you desire, regardless of their proven effectiveness. Lots of people see that as a reduction in “quality”. Some of those health care systems restrict easy access to elective procedures. Lots of people see that as a reduction in “quality”. Some of those health care systems provide much less in terms of choice, whether it be for insurance, physicians, or pharmaceuticals. Lots of people see that as a reduction in “quality”. Some of those health care systems don’t introduce new technology or drugs as quickly. Lots of people see that as a reduction in “quality”. Some of those health care systems regulate things more closely. Lots of people see that as a reduction in “quality”. Some of those health care systems do less to encourage innovation or entrepreneurship. Lots of people see that as a reduction in “quality”.

    And so on and so forth.

    Please know that I don’t define “quality” this way. For me, it’s hard outcomes. But I recognize that I’m willing to see changes in areas of process, including wait times, choice, profit, etc. in order to improve the things I care about. I’m willing to accept the trade offs in order to get the improvements I want. I bet lots of you are, too.

    Unfortunately, lots of Americans aren’t. As long as we ignore their values, though, we will fail to engage them. Every time we say that we can reduce cost, improve access, and nothing will change with respect to quality, we are implicitly ignoring what others want in terms of quality.

    A better debate would acknowledge the changes that would occur in terms of “quality” and make the case that they are acceptable losses to get better costs and get better access. We can do that.


    • It is possible to have more access, more quality and lower costs under reasonable definitions of these terms. Other countries do so, as you seem to acknowledge.

      However, we can come up with definitions of these terms that make the task impossible. To me, that illustrates more that we can play games with definitions than any substantive barrier.

      Your first two definitions are good examples:

      If you define quality as paying as much as we do today (“pay their physicians far less than we do”), then you can’t lower costs without lowering quality. If you define access as giving people what they want without limit (“all the screening tests you desire”), then you can’t improve access while lowering costs.

      The problems are, of course, we can’t lower costs without paying less and no economic system is able to distribute infinite amounts of any valuable resource.

      Other countries do substantially better on all three of the metrics. In order for us to do as well, we will have to make substantial changes (there’s no hard line between substantial changes and not continuing our existing system). How do you do substantially better without making substantial changes?

      • See my other response. I don’t know how to convince you that others disagree with you in terms of your definitions of quality. I don’t, but I’m not representative of the country.

        The reason I write 10 part series on the topic is to try and convince people to change their minds.

        There are people who believe that getting unlimited mammograms is the hallmark of a good health care system. They think that other systems are bad for not providing those. Yes, I’d cut it. Yes, I believe that quality as I define it would hold. But others would see it as death panels.

        Simply stating that people don’t believe this won’t work.

    • My experience with Swiss doctors is that they are, indeed, paid less than US doctors, but the quality of the patient experience is far higher. I can usually get an appointment the same day I call. My doctor is never in a hurry, and always asks about health concerns beyond the immediate issue that brought me to his office. He handles all of his insurance billing with less than one full-time employee, and it is always accurate. Oh yeah, I can call him on the phone if I have a question or concern, and he replies within an hour.

      So I guess I don’t in any way equate “pay doctors less” with lower quality. And I seriously doubt that anyone else who had this experience would either (except, of course, the doctors!).

      • It’s not only the doctors. Every time doctors threaten to revolt over reimbursement, many, many people start screaming.

        You’re still making my point. You don’t see that doctor salary needs to tie into quality. I often feel the same way. But lots and lots of other people do. In fact, they are making the argument that the $716 billion cuts in Medicare (some through the IPAB) will impact quality through reduced clinical reimbursement.

        People feel this way. I think you will make more headway by engaging them in their beliefs and convincing them that these reductions in “quality” aren’t meaningful. I don’t think stating that “there will be no reductions in quality” will work.

        • The people complaining about the $716 billion reduction are the same people who complain that we must change Medicare because it is unsustainable.

          If cuts are made, they complain that cuts will hurt. If cuts are not made, they complain that it’s too expensive. In other words, there are no circumstances that do not generate complaints. The leaders of these arguments have a clear political agenda.

          • No, they all don’t. There are people completely divorced from politics who think that mammograms save lives. Who think that PSAs save lives. Who think that waiting for an elective procedure is horrific. Who think that not getting the newest, fanciest, most unproven medication is socialism.

            We’re not disagreeing here. You’re saying that what you give up to improve access and reduce costs as other countries have done is acceptable to you. You are fine with the tradeoffs. But can we both agree that those tradeoffs (even if you’re fine with them) exist?

    • I wonder if you add “choice” or “autonomy” to the equation it will clarify things (both patient and provider autonomy). We may be able to improve 2 or 3 of those things, but we can’t get all 4.

    • It is possible that easing licensing restrictions could improve access, quality and cost. Since being good at school can be quite different from being good at work, a provider shortage can keep some bad practitioners in and good would be practitioners out.

    • Your point — that the word quality is amorphous in nature and its definition, especially in health care, is subject to reinterpretation by anyone with access to a platform to broadcast from — is well taken.

      That is the reason that I find “quality” a much less useful term than the other two legs of the “triangle,” both of which can be measured fairly well to very well, depending on the effort that investigators are willing to expend. Quality, since it is much less will defined and has no real consensus definition, cannot be measured with anything resembling precision.

      I would propose replacing the term “quality” in discussion of health care with the term “effectiveness.” In turn, “effectiveness” can be measured fairly well be measuring outcomes.

      If paying doctors higher salaries increases desirable health outcomes, it increases effectiveness. If it does not, it does not. The same is true of everything from “quality assurance” programs to decisions regarding insurance or government payment for various health care practices to wait times for procedures.

      Measuring effectiveness by evaluation of outcomes by hard endpoints is, of course, the essence of most good health care research.

      We can measure this, it will be meaningful in terms of what we measure, and, yes, at this point existing evidence shows cost does not have to go up nor access down for effectiveness to improve.

      • I agree with everything you said. I think we can reduce costs and increase access while not impacting effectiveness. We do that by eliminating waste.

        But as I’ve said before, one man’s waste is another man’s “quality”.

        • I would actually argue that we can decrease cost and increase effectiveness, and that the savings can then be used to increase access.

          The issue of physician compliance with the ALLHAT study results is an excellent example. The entire British National Health system is another.

    • You sound a little like John Goodman with his just off-stage cadre of wrong headed mainstream health policy advocates telling us to do things that John is all a rush to tell us are wrong. Quality isn’t how much more we pay doctors than they produce in economic benefit. Period. Quaility isn’t excess. Period. Which is not to say that your professor didn’t mean well. My hospital administration professors told me the same thing, except about hospital adiminstrator compensation, of course.

      • Wow. Do you really deny that there are people who truly believe that waiting for elective procedures is a sign of poor quality?

        Do you really deny that there are people who truly believe that if they can’t have the latest technology and medications, that’s a sign of poor quality?

        I’m not asking you to believe that these are examples of poor quality. I don’t think they are. But do you deny that some people do? And do you deny that these things might happen in ways you want to reform the health care system?

        • 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.

          I have looked through your post of quality and if you take out the “access” parts then I really don’t think any of them are dependent on cost. The US health care system has completely decoupled cost from quality. I can’t think of any examples where you pay more for better quality or less for worse quality. The cost of everything is fixed and completely independent of quality.

          I can think of a lot of examples where you can do less of something (unnecessary tests and procedures) and improve quality but again this is a question of access, not quality.

          Can you give an example of something where you pay more for better quality or less for worse quality in the US healthcare system?

        • I get the impression that some people have a different definition of quality. In some cases it might be reasonable, say waiting for an elective procedure that has a benefit.

          But if people think that access to the latest technology and medication regardless of outcome or a certain level of doctor pay falls under quality, I think they are using the term “quality” incorrectly. And it needs to be explained. If it is too difficult to explain, then perhaps the experts should start using a new term that doesn’t have this baggage.

        • Maybe I missed your point. Yes people believe those things; alas, they are mistaken. Waste is not quality. Worse, per Dartmouth in a half a dozen different demonstrations, excess is anti-quality. We do harm when we indulge in excess. But perhaps that is exactly what you said.

    • Yes, there are clearly people who believe that “quality” means giving people as many prostate cancer screenings as they want, using MRIs and CTs to diagnose everything under the sun, and paying doctors like Alex Rodriguez of the Yankees. You clearly believe that their definitions are wrong. But I think your ultimate question about how to incorporate their values and their opinions is flawed. In my mind, the question we should be asking themselves is how do we change their minds and get them to come around to a definition based on a better definition of quality? Similar questions abound for cost and access.

      • No, that’s the questions I ask all the time. It’s what I try to do with this blog.

        I’m frustrated not with people who engage and try to change minds, but who pretend that there are no minds to change.

        • I sympathize with your frustration, and agree that people genuinely believe some of the definitions of quality they espouse. That is why I argue that people trying to impose scientific rigor on the study of health care economics and sociology should stop using the term quality and substitute the term effectiveness, as measured by outcomes, since quality cannot be successfully defined and therefore cannot be measured, and therefore is not a valid topic for science, but rather for advertising and market research.

          For people struggling with this, I will offer an analogy. Which is the higher quality car, a Toyota Prius or a Mercedes SLS? The answer is that the question can’t be answered, since the criteria of the customers of the two cars are completely different. The Prius gets superior fuel mileage, carries more people, has better reliability, is cheaper to buy and costs less to operate, and will serve the need for transportation. The SLS is faster, more luxurious, has more exciting esthetics, and in addition to transportation makes a statement about the owner that he or she may desire. In the end, asking this question is futile, since there is almost no overlap in the standards that attract one group of customers or the other.