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
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
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,
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
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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