I am increasingly concerned about moving to Nationalized Health Care. I understand why our government wants it, and the "fairness" and "equal access" arguments for it. But I fear the inevitable and inadvertent drop in the quality of our health care.
In every case I am aware of, the quality of health care for the majority suffers dramatically in pursuit of providing health care to those who cannot now afford it. Do we have to make the majority suffer for the sake of the minority? Can't we find a better way to help the minority?
Recently I played golf with a friend who lives in Canada. He was here with his wife at the Mayo Clinic for a followup after treatment of a rapidly advancing cancer. He had been told by their doctor back in Canada that it was a good thing she had gone to the US because she would be dead had she received treatment in Canada. The type of treatment she needed simply would not have been paid for by the Canadian Government. Actually, not even available.
He also told the story of another friend who was told he needed an MRI to determine if he had a brain tumor. When told by the Canadian Health System that it would be 12 weeks, he came to the US for an MRI. He did have a brain tumor and needed surgery ASAP. He went back to Canada with these results only to be told they could not work him in for another 15 weeks. So back to the US he came to get the surgery. Well he is alive and others are dead because health care in Canada is rationed because the government simply cannot afford to offer the high quality care that comes with freedom and competition.
Rudy Giuliani was right when he said, "If we have national health care, the Canadians won't have anywhere to go for health care."
Much more could be said about how quality suffers for all wherever nationalized health care is the only option available in a country. See here to see what I mean.
Following is an article from the WSJ outlining yet another reason for keeping government out of your and your doctor's choice for health care. It is very troubling when regulators get involved and IMPOSE "consensus" medical opinion on the freedom of doctors to treat you how they have best learned.
The Obama administration is working with Congress to mandate that all
Medicare payments be tied to "quality metrics." But an analysis of this drive
for better health care reveals a fundamental flaw in how quality is defined and
metrics applied. In too many cases, the quality measures have been hastily
adopted, only to be proven wrong and even potentially dangerous to patients.
Health-policy planners define quality as clinical practice that conforms to consensus guidelines written by experts. The guidelines present specific metrics
for physicians to meet, thus "quality metrics." Since 2003, the federal
government has piloted Medicare projects at more than 260 hospitals to reward
physicians and institutions that meet quality metrics. The program is called
"pay-for-performance." Many private insurers are following suit with similar
In Massachusetts, there are not only carrots but also sticks; physicians who
fail to comply with quality guidelines from certain state-based insurers are
publicly discredited and their patients required to pay up to three times as
much out of pocket to see them. Unfortunately, many states are considering the
Massachusetts model for their local insurance.
How did we get here? Initially, the quality improvement initiatives focused
on patient safety and public-health measures. The hospital was seen as a large
factory where systems needed to be standardized to prevent avoidable errors. A
shocking degree of sloppiness existed with respect to hand washing, for example,
and this largely has been remedied with implementation of standardized
protocols. Similarly, the risk of infection when inserting an intravenous
catheter has fallen sharply since doctors and nurses now abide by guidelines.
Buoyed by these successes, governmental and private insurance regulators now
have overreached. They've turned clinical guidelines for complex diseases into
iron-clad rules, to deleterious effect.
One key quality measure in the ICU became the level of blood sugar in
critically ill patients. Expert panels reviewed data on whether ICU patients
should have insulin therapy adjusted to tightly control their blood sugar,
keeping it within the normal range, or whether a more flexible approach,
allowing some elevation of sugar, was permissible. Expert consensus endorsed
tight control, and this approach was embedded in guidelines from the American
Diabetes Association. The Joint Commission on Accreditation of Healthcare
Organizations, which generates report cards on hospitals, and governmental and
private insurers that pay for care, adopted as a suggested quality metric this
tight control of blood sugar.
A colleague who works in an ICU in a medical center in our state told us how his care of the critically ill is closely monitored. If his patients have blood
sugars that rise above the metric, he must attend what he calls " re-education
sessions" where he is pointedly lectured on the need to adhere to the rule. If
he does not strictly comply, his hospital will be downgraded on its quality
rating and risks financial loss. His status on the faculty is also at risk
should he be seen as delivering low-quality care.
But this coercive approach was turned on its head last month when the New
England Journal of Medicine published a randomized study, by the Australian and
New Zealand Intensive Care Society Clinical Trials Group and the Canadian
Critical Care Trials Group, of more than 6,000 critically ill patients in the
ICU. Half of the patients received insulin to tightly maintain their sugar in
the normal range, and the other half were on a more flexible protocol, allowing
higher sugar levels. More patients died in the tightly regulated group than
those cared for with the flexible protocol.
Similarly, maintaining normal blood sugar in ambulatory diabetics with
vascular problems has been a key quality metric in assessing physician
performance. Yet largely due to two extensive studies published in the June 2008
issue of the New England Journal of Medicine, this is now in serious doubt.
Indeed, in one study of more than 10,000 ambulatory diabetics with
cardiovascular diseases conducted by a group of Canadian and American
researchers (the "ACCORD" study) so many diabetics died in the group where sugar
was tightly regulated that the researchers discontinued the trial 17 months
before its scheduled end.
And just last month, another clinical trial contradicted the expert consensus guidelines that patients with kidney failure on dialysis should be given statin
drugs to prevent heart attack and stroke.
These and other recent examples show why rigid and punitive rules to broadly
standardize care for all patients often break down. Human beings are not uniform
in their biology. A disease with many effects on multiple organs, like diabetes,
acts differently in different people. Medicine is an imperfect science, and its
study is also imperfect. Information evolves and changes. Rather than rigidity,
flexibility is appropriate in applying evidence from clinical trials. To that
end, a good doctor exercises sound clinical judgment by consulting expert
guidelines and assessing ongoing research, but then decides what is quality care
for the individual patient. And what is best sometimes deviates from the
Yet too often quality metrics coerce doctors into rigid and ill-advised
procedures. Orwell could have written about how the word "quality" became
zealously defined by regulators, and then redefined with each change in
consensus guidelines. And Kafka could detail the recent experience of a
pediatrician featured in Vital Signs, the member publication of the
Massachusetts Medical Society. Out of the blue, according to the article, Dr.
Ann T. Nutt received a letter in February from the Massachusetts Group Insurance
Commission on Clinical Performance Improvement informing her that she was no
longer ranked as Tier 1 but had fallen to Tier 3. (Massachusetts and some
private insurers use a three-tier ranking system to incentivize high-quality
care.) She contacted the regulators and insisted that she be given details to
explain her fall in rating.
After much effort, she discovered that in 127 opportunities to comply with
quality metrics, she had met the standards 115 times. But the regulators refused
to provide the names of patients who allegedly had received low quality care, so
she had no way to assess their judgment for herself. The pediatrician fought
back and ultimately learned which guidelines she had failed to follow. Despite
her cogent rebuttal, the regulator denied the appeal and the doctor is still
ranked as Tier 3. She continues to battle the state.
Doubts about the relevance of quality metrics to clinical reality are even
emerging from the federal pilot programs launched in 2003. An analysis of
Medicare pay-for-performance for hip and knee replacement by orthopedic surgeons
at 260 hospitals in 38 states published in the most recent March/April issue of
Health Affairs showed that conforming to or deviating from expert quality
metrics had no relationship to the actual complications or clinical outcomes of
the patients. Similarly, a study led by UCLA researchers of over 5,000 patients
at 91 hospitals published in 2007 in the Journal of the American Medical
Association found that the application of most federal quality process measures
did not change mortality from heart failure.
State pay-for-performance programs also provide disturbing data on the unintended consequences of coercive regulation. Another report in the most
recent Health Affairs evaluating some 35,000 physicians caring for 6.2 million
patients in California revealed that doctors dropped noncompliant patients, or
refused to treat people with complicated illnesses involving many organs, since
their outcomes would make their statistics look bad. And research by the Brigham
and Women's Hospital published last month in the Journal of the American College
of Cardiology indicates that report cards may be pushing Massachusetts
cardiologists to deny lifesaving procedures on very sick heart patients out of
fear of receiving a low grade if the outcome is poor.
Dr. David Sackett, a pioneer of "evidence-based medicine," where results from
clinical trials rather than anecdotes are used to guide physician practice,
famously said, "Half of what you'll learn in medical school will be shown to be
either dead wrong or out of date within five years of your graduation; the
trouble is that nobody can tell you which half -- so the most important thing to
learn is how to learn on your own." Science depends upon such a sentiment, and
honors the doubter and iconoclast who overturns false paradigms.
Before a surgeon begins an operation, he must stop and call a "time-out" to
verify that he has all the correct information and instruments to safely
proceed. We need a national time-out in the rush to mandate what policy makers
term quality care to prevent doing more harm than good.
Dr. Groopman, a staff writer for the New Yorker, and Dr. Hartzband
are on the staff of Beth Israel Deaconess Medical Center in Boston and on the
faculty of Harvard Medical School