July 18, 1993
"Attack of the Bean-counters - Nobody Likes Being Evaluated, But the U.S. Economy Can't Continue Forking Over Hundreds of Billions for Health Care, Trusting That It Will Be Spent Wisely"
San Jose Mercury News
By Timothy Taylor
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WITH THEIR sharp pencils at the ready position, the bean-counters, the number-crunchers, and the statistical quality management priesthood are invading the health care industry. Here are a few examples.

In March, United Healthcare Corp. of Minneapolis became the first major health care provider to give itself a public report card. UHC collected data on everything from the rate of childhood immunizations to the rate of low birthweight babies, from administrative costs per person to patient satisfaction, and published the results along with comparable national averages.

About a month later, the Cleveland Health Quality Choice Program, backed by companies, physicians and hospitals, offered detailed analysis of what diagnoses are made, what procedures performed, and how well patients liked the result for 31 hospitals in the Cleveland area. Similar surveys are now under way in Orlando, Cincinnati and elsewhere around the country.

U.S. News and World Report, in its issue of July 12, includes its annual listing of "America's Best Hospitals," which ranks the care provided at 1,488 hospitals around the country in 16 different medical specialties, from AIDS to urology. The survey uses factors like the number of nurses, residents and board-certified MDs; the available technology; mortality rates; discharge planning and service mix; and a number of other factors.

Of course, ranking hospitals and doctors is not a new idea. The Health Care Financing Administration has been releasing hospital death rates since 1986. Large health maintenance organizations, like Kaiser Permanente, have been keeping track of the performance of individual doctors for years. And Mercury News Washington Bureau reporter R.A. Zaldivar wrote in last Sunday's paper that according to one survey, "55 percent of hospitals believe it's proper to deny privileges to a doctor who costs them too much."

As business and government struggle to keep medical care costs under some semblance of control, these hard-eyed, cold-blooded evaluations of health care will only increase.

Statistical comparisons may be the spice of life to sports fans, but when life and health are on the line, the numbers take on potentially frightening consequences. If a doctor's patients stay in the hospital longer than average, for example, it may be that the doctor is a specialist who sees sicker people. No one wants patients to be tossed from their hospital bed, or denied a useful test or operation, because the hospital or doctor has reached a monthly quota for that medical procedure.

American culture has traditionally given great deference to doctors, on the assumption that they were always acting in the best interests of patients. But while the overwhelming majority of doctors do try their best, the hard truth is that the health care industry is subject to many of the same flaws as other enormous industries. It can be alternately faddish, or hidebound and slow to change.

Consider, for example, the problem of a doctor trying to decide on the best treatment for a given disease. The doctor can gather information from personal experience, but even if a treatment has worked acceptably well, how can the doctor know whether an alternate treatment might be an improvement? Colleagues can offer advice, but the group consensus often ends up merely reinforcing itself, rather than considering alternatives. Medical journals offer another source of information, but there are literally scores of journals, and their information and recommendations often conflict to some extent.

To make matters worse, new treatments and new combinations of old treatments are constantly being proposed. As one health care economist summed up: "The inference problem confronting doctors who wish to determine the efficacy of any specific intervention is hellishly complex." And remember, if a doctor tries a different treatment and it turns out badly, a malpractice suit is likely to follow.

The provision of medical care settles into patterns that are only partly related to health. Considerable research has shown that well-known procedures like tonsillectomies, hysterectomies, Caesarean sections, coronary bypass surgery, and many others are done two, three, and four times as often in some U.S. cities as others. The cities with high-intensity medical care don't seem healthier -- it's just the local, self-reinforcing pattern.

Studies published by the Rand Corporation in the late 1980s pointed out that if patients were required to make substantial co-payments for medical care, they ended up receiving one-third less care, with no discernible impact on their health. Based on this sort of evidence, it is a common estimate that as much as one-third of what America spends on health care will provide no therapeutic benefit.

Nobody likes being evaluated: not high school students or job applicants, not teachers or universities, not assembly line workers or CEOs. If you rank 100 people or institutions, you'll make perhaps 3 friends from the top of the list, and 97 enemies.

But even though rankings and statistics can be misleading or misused, and the limitations on any particular medical care statistic should be remembered, the alternative is no longer acceptable. The United States economy can't just fork over $900 billion for health care this year, and simply trust that it will all be spent wisely and well.

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