A Better-Quality Alternative: Single-Payer National Health System Reform
3. Continuity of primary care is needed to overcome fragmentation and overspecialization among health care practitioners and institutions. Patients need care coordinated by the primary care provider of their choice. Whether evaluating a confused elderly patient or discontinuing aggressive care to a patient with emphysema, a continuing physician-patient relationship is the essential foundation that allows physicians to practice conservative, sensitive, appropriate, cost-effective medicine. Competitive models that encourage patients to switch among competing plans discourage ongoing relationships.41 Competition also blunts incentives for prevention because the resulting savings are likely to accrue long after the patient has switched to a rival plan.
As practitioners, we do quality work when patients can trust that we will be available with the time, independent judgment, and familiarity with their problems to give them skillful personal attention. Cost-containment efforts designed to limit utilization have counterproductively undermined this primary caring role. Erecting financial barriers to discourage contact, penalizing the primary practitioner for ordering tests and consultations, and intrusive utilization review measures have contributed to growing dissatisfaction with primary care practice.42,43
4. A standardized confidential electronic medical record and resulting database are key to supporting clinical practice and creating the information infrastructure needed to improve care overall. Information technology should allow us to zoom in to focus on the microdetails of why a particular clinical decision was made, as well as give a macro-overview of disease patterns in populations. Its memory should permit panning backward and forward in time, seeing our own patients' past histories, as well as aggregating data to project disease natural history and response to interventions.
Unfortunately, implementation of medical computing has been driven by insurance/billing imperatives, often ignoring information needs for improved patient care. The Institute of Medicine Committee on Improving the Medical Record has documented the ways that paper-based medical records and computerized laboratory and claims data fail to coalesce into integrated patient care records, capable not only of storing patient data but also of improving the quality of care.44 Consider routine yet currently difficult clinical decisions, such as whether a patient's wound requires a tetanus shot, or a positive syphilis serology result requires treatment, or a decreased hematocrit requires further workup. Computer technology should permit us to track patients over time across multiple sites and support higher-quality clinical decision making. Its potential for real-time reminders, prescribing, and bibliographic assistance is vast but unrealized.44, 45
Realizing the computer's quality support potential hinges on strong guarantees of personal data confidentiality,44 uniformity and integrity of data systems, availability of aggregate data in the public domain,46 and minimization of costs, especially for software development and data acquisition. Creating national standards for protection of patients' privacy is one of the most important issues that health system reform must address, yet prospects for federal leadership appear to be confused and uncertain.47, 48 The United States lags behind other countries in developing a secure clinical information infrastructure because it lacks a unified approach. No public entity has sufficient scope or authority to spearhead this project.49
Despite a lengthy section on information automation, the Clinton proposal perpetuates the primacy of financial data to the neglect of clinical information by calling for computerized billing but not computerized patient care records.50 Furthermore, managed competition compromises this crucial tool for advancing the public's health by fragmenting information among competing health plans and creates incentives for distortion (ie, "diagnosis creep") that arise when data are linked to financial rewards.51
5. Health care delivery must be guided by the precepts of continuous quality improvement (CQI). Improved data combined with statistical thinking permit a more scientific practice of medicine. Five ideas are basic to CQI22, 52, 53:
- Systems improvement: addressing underlying causes of problems rather than inspecting for and micromanaging individual practice variations.
- Teamwork and cooperation: shift from fear, individual blame, and competition toward cooperation to improve interactions within and between organizations.
- Overriding commitment to quality: quality should be the foremost mission and central preoccupation of health system leaders and reform efforts; cost savings derive from this primary commitment to quality.
- Improvement of processes: quality can be continually improved by study, innovation, and simplification of the numerous small steps involved in performing daily tasks, leading to an organizational atmosphere of experimentation and productive change.
- Empowerment of workers and customers: frontline workers must have the authority, resources, and statistical tools to conduct process improvements. Patients' voices must be amplified so that their needs can be better addressed as the central aim of health care.
Current widespread endorsement of CQI belies a continuing focus on external inspection, short-term financial gain as the measure of success, inefficient cost-control measures, and disruptions of physicians' relationships with patients and colleagues as employers and insurers seek the lowest price (New York Times. January 24, 1993:1).22, 41, 43, 54 Under our current system, each insurer must protect its financial stake through these shortsighted measures that disrupt overall quality. Well situated to exercise such undesirable options, insurers cannot risk the long-term commitments to patients and providers, plus loss of management prerogatives, inherent in the five elements of CQI.
Improving individual providers' care can best be accomplished via supporting their ability to practice quality care coupled with pooled outcomes data and patient feedback. This contrasts to the current punitive, exclusionary, and competitive approaches. The thrust of CQI is to improve the norm of performance rather than to merely identify outliers. Where individual competence and performance deficiencies do exist, they must be conscientiously evaluated and definitively resolved. Continuous quality improvement creates a climate and provides tools to accomplish this more fairly and constructively.
6. New forums for enhanced public accountability are needed to improve clinical quality, to address and prevent malpractice, and to engage practitioners in partnerships with their peers and patients to guide and evaluate care. Patients' and practitioners' mutual de- sire to redress and prevent suboptimal medical outcomes should make them natural allies. Instead, we are witnessing growing antagonisms. The narrow emphasis on antagonistic all-or-none approaches, such as lawsuits, or exiting one plan for another, constrains consumers from maximally exercising choices, sharing in decision making, and being genuinely involved in oversight and helping to pre- vent malpractice.
The Harvard Malpractice Study demonstrated that one in 25 hospitalized patients suffered a disabling iatrogenic injury, one quarter of these as a result of negligence.16 Reconciling consumers' legitimate demands to improve this performance with the need to protect confidentiality, the need to nurture candid professional introspection, and the cur- rent inadequacy of outcomes data for judging quality55 poses difficult challenges. This requires trust and cooperation. Although we believe that a no-fault approach to malpractice is most consistent with the logic of CQI (which seeks prevention over blame) and universal coverage (which would already provide lifetime health benefits for iatrogenic injuries, thus obviating the need to sue for such benefits), additional research is needed on questions of deterrence and effectiveness.
Just as the concept of informed con- sent was once foreign, today's physicians are unaccustomed to thinking constructively about creating a health sphere in which difficult issues and alternatives are openly discussed. Gathering data about care practices and turning those data into information to be shared with peers and the public must become a key ethical duty.46, 66, 57 New vistas for more public yet scientific and collegial oversight include designing and evaluating practice guidelines58; evaluation of patient satisfaction, complaint, and outcomes data, such as delayed or missed diagnoses59; ombudsman programs; alternative ways to adjudicate malpractice allegations16; interactive decision-making computer technology60; and more meaningful regulatory activities.61-64
In the event of a medical mishap or untimely death, patients or relatives want an explanation and an opportunity to ask questions and receive full and honest answers, things we often fail to provide.65 For centuries, the autopsy has fulfilled an important "convening" function for the profession to engage such questions and admit mistakes (unfortunately this valuable tool is increasingly neglected).66 Practice databases may facilitate an analogous convening forum for bringing together the profession and the public to examine our record, thereby fulfilling our obligations for expanded public accountability.
7. Financial neutrality of medical decision making is essential to reconcile distorting influences of physician payment mechanisms with ubiquitous uncertainties in clinical medicine. Payment incentives may distort the quality of medical services. Fee-for-service favors excessive use of services, while capitation payment may encourage undertreatment.54, 67 To lessen this tendency for physician payment to distort treatment decisions, we must strive to remove personal financial considerations from clinical decision making.
Self-referral by physicians to medical facilities from which they profit is a particularly egregious example of a financial incentive distorting a physician's practice. Physician ownership of diagnostic imaging centers is associated with a referral rate four times that of their noninvesting physician colleagues.68 Similarly deplorable are managed care arrangements that directly tie physicians' incomes to withholding referrals for diagnostic tests, specialty consultation, or hospitalization. These arrangements create an unacceptable conflict between a patient's welfare and a physician's financial interest. Even not-for- profit physician networks, portrayed by Clinton plan advocates as alternatives to insurance company or managed care inducements,69 perpetuate this conflict of interest when they make providers assume "financial risk" for their patients.
Physicians do need to make more cost-conscious and cost-efficient decisions. However, we reject approaches that expect improved decision making to derive from tinkering with physician rewards. The problem is not insufficient motivation; it is uncertainty which, as many have noted, is ubiquitous in medicine.70 Financial incentives to manipulate physicians to do more or less conceal rather than address our clinical knowledge deficits. Physicians respond best to efforts, based on their intrinsic values, that motivate and involve them directly in improving patient care. Even when forced to choose between maximizing patient outcomes over their own financial gain, physicians typically choose to improve care.71
We recognize that financial neutrality is an ideal. No payment mechanism completely eliminates the influence of payment on treatment. For example, while payment by salary separates day-to-day clinical decisions from financial considerations, it can encourage undertreatment or the avoidance of more complex patients who require expensive care. The current British approach, capitation supplemented with added fees for preventive services and complex cases, illustrates one possible alternative.72 Such arrangements at least channel incentives toward mutually agreed on positive objectives rather than creating conflicts and lack of trust that poison provider-patient relationships.
8. Emphasis should shift from micromanagement of providers' practices to macroallocation decisions. Public control over expenditures can improve quality by promoting regionalization, coordination, and prevention. The uncontrolled proliferation and duplication of expensive technology in our present system, considered by some the sine qua non of US high-quality care, both adds to cost and detracts from quality.
For example, because we have too many mammography machines, each is underutilized. This doubles the cost of each test. As a result, many women cannot afford screening. Thus, because we have too many mammography machines, we have too little breast cancer screening.73
For technically complex procedures, an inverse relationship between volume and mortality rates has generally been observed.74 Yet, in the RAND appropriateness study, one fourth of the surgeons performing carotid endarterectomies did only one such procedure per year (on Medicare patients). Three of four surgeons performed fewer than 10 endarterectomies - the average annual number performed by these surgeons was 3.4, a number most would consider too few to maintain proficiency.75