Correspondence
Quality and the Medical Marketplace
N Engl J Med 1997; 336:807-809March 13, 1997
- Article
To the Editor:
The editorial by Drs. Angell and Kassirer (Sept. 19 issue)1 is cute but fails to answer the question, Where did all those elephants — whose excreta is unmanageable — come from? At a time of hand wringing in medicine, we seem to be blind to the source of the problem. We have fought for more and more investment in basic research and won. We have also refused to reduce our training mills, especially for postgraduate education. As the fruits of these investments flow into the medical marketplace, a diarrhea of elephantine proportions, we should remember who provided this purgative. No one ever said the conquest of disease and the pursuit of health would be cheap. However, medicine has invested nothing to prevent the cost escalation that has occurred and was to some degree predictable.
1 ReferencesCharles E. Lewis, M.D.
University of California at Los Angeles, Los Angeles, CA 900951
Angell M ,Kassirer JP . Quality and the medical marketplace -- following elephants. N Engl J Med 1996;335:883-885
Full Text | Web of Science | Medline
To the Editor:
Angell and Kassirer suggest that there is a causative interaction between the sweeping economic movement toward managed care and for-profit medicine, on the one hand, and an expanding scientific focus on the quality of medical care, on the other. However, they provide no evidence that the relation is more than circumstantial. Moreover, they imply that the quality movement in medicine was born out of skepticism that health maintenance organizations (HMOs), managed-care groups, and payers could and would monitor and enhance the quality of the services they provide to patients. Though this hypothesis is sensible, the editorial lacks sound empirical evidence. It is equally plausible that the quality movement is the logical result of an increasing number of studies revealing substantial variation in risk-adjusted outcomes among patients undergoing common surgical procedures,1 the results of which are widely publicized in the lay press, or studies revealing low rates of physician prescription of drugs that have established roles in the treatment of specific disorders.2 Some employer-payers, scrutinizing the cost effectiveness of the health care systems they underwrite, are pressing medical providers to adopt the same principles of quality assurance and improvement that they have applied successfully to their production of goods and services.
2 ReferencesEdward F. Philbin, M.D.
Massachusetts General Hospital, Boston, MA 021141
Hannan EL ,Kilburn H Jr ,O'Donnell JF ,Lukacik G ,Shields EP . Adult open heart surgery in New York State: an analysis of risk factors and hospital mortality rates. JAMA 1990;264:2768-2774
CrossRef | Web of Science | Medline2
Philbin EF ,Andreaou C ,Rocco TA ,Lynch LJ ,Baker SL . Patterns of angiotensin-converting enzyme inhibitor use in congestive heart failure in two community hospitals. Am J Cardiol 1996;77:832-838
CrossRef | Web of Science | Medline
To the Editor:
As medical directors of nonprofit HMOs in Massachusetts, we are responding to the editorial by Angell and Kassirer. There is no evidence to support the pejorative assertion that HMO-affiliated physicians, who represent the vast majority of Massachusetts physicians, place financial gain ahead of the needs of individual patients. At the patient level, failing to provide medically necessary care is unethical, unprofessional, and in some cases, illegal. At the population level, it is a bad financial strategy because it costs more in the long term.
HMOs do not avoid risk by seeking to enroll healthier populations. Indeed, Massachusetts HMOs compete aggressively to enroll Medicare and Medicaid patients — populations known to be sicker, poorer, and older and requiring a more complex mix of health and social services. HMOs emphasize prevention because it is cost effective and because avoidance of illness should be the focus of every health care delivery system. Our goal is to provide the best value, not necessarily the lowest premium. In attempting to attain that goal, we willingly hold our plans accountable to patients, purchasers, and society at large.
Studies consistently validate HMOs in terms of cost and quality. A review of the literature published between 1980 and 1994 revealed that HMOs equaled or exceeded fee-for-service care with respect to 14 of 17 quality measures.1 Berwick reported that major studies “consistently show . . . that costs are lower in managed-care systems, with quality equal to or better than that in fee-for-service care.” 2
The value of process measures is mistakenly disregarded. As Brook et al. point out, both process and outcome measures are useful, and “process data are usually more sensitive measures of quality than outcome data, because a poor outcome does not occur every time there is an error in the provision of care.” 3 Many process measures have a demonstrated causal association with outcomes and are considered intermediate outcome measures (e.g., mammography, pap smears, and pediatric immunizations).
Three issues prevent us from casting aside process measures: many outcome measures require sample sizes too large for the average HMO to collect, the lack of a risk adjuster prevents meaningful comparisons of outcomes among plans, and the relatively long length of time required by outcome studies may delay improvements that could be highlighted by more timely process measures. Outcome measures are used by HMOs where feasible. Standards set by the Health Plan Employer Data and Information Set 3.0 and the National Committee for Quality Assurance now include outcome measures. Until meaningful, reliable, and statistically valid outcome measures are devised, process and intermediate outcome measures will continue to be an integral part of quality improvement.
3 ReferencesPhilip Boulter, M.D.
Tufts Affiliated Health Plan, Waltham, MA 02254Joseph L. Dorsey, M.D.
Harvard Pilgrim Health Care, Brookline, MA 02146Kathleen Goonan, M.D.
Massachusetts Blue Cross–Blue Shield, Boston, MA 02210Joel Kaufman, M.D.
Fallon Community Health Plan, Worcester, MA 01608Frank Reilly, M.D.
Kaiser Permanente, Western Massachusetts, Amherst, MA 01002Robert A. Witzburg, M.D.
Neighborhood Health Plan, Boston, MA 022101
Miller RH ,Luft HS . Managed care plan performance since 1980: a literature analysis. JAMA 1994;271:1512-1519
CrossRef | Web of Science | Medline2
Berwick DM . Payment by capitation and the quality of care. N Engl J Med 1996;335:1227-1231
Full Text | Web of Science | Medline3
Brook RH ,McGlynn EA ,Cleary PD . Measuring quality of care. N Engl J Med 1996;335:966-970
Full Text | Web of Science | Medline
To the Editor:
For a marketplace to work efficiently and effectively, buyers (both patients and purchasers) need adequate information. That we lack all the desired information is a result of the historical absence of outcome-based performance measurement in medicine. Only with the demand from public and private purchasers for health-system accountability and for comparable quality data has such information begun to be made available. That all the necessary information is not yet available does not mean that the marketplace cannot function well; it only means that we need to further refine measurement tools such as the Health Plan Employer Data and Information Set to measure the quality of care for the acutely and chronically ill more accurately.
Michael H. Bailit, M.M.
Massachusetts Executive Office of Health and Human Services, Boston, MA 02111Author/Editor Response
The editors reply:
The open-ended fee-for-service system, which preferentially rewarded costly procedures and specialist care, was highly inflationary, as implied by Dr. Lewis, but at least doctors were paid for doing more for their patients, not less, and the incentives were obvious to patients. In prepaid managed-care plans, doctors are encouraged to limit their patients' care, and they often have direct financial incentives to do so, which are hidden from patients. In our view, neither system is desirable; it certainly does not follow that the only alternative to an unbridled fee-for-service system is replacement with market-driven managed care dominated by large employers and investor-owned health plans.
Research on variation in medical practice, which Dr. Philbin refers to, was coincident with the move toward prepaid managed care as the answer to the problem of increasing health care costs. Research on how to measure and monitor quality is even more recent. It would be very hard, if not impossible, to prove that concern for quality was the consequence of financial incentives to stint on medical care, but common sense suggests that they are at least partly related. In any case, there can be no doubt that doctors, as employees of managed-care organizations, are pulled between their employers and their patients.
Contrary to the assertions of Boulter and colleagues, we did not say that HMO-affiliated physicians place financial gain ahead of the needs of individual patients, only that they may be pressured in one way or another to put the organization's interests ahead of their patients' needs. Those pressures are so obviously troublesome that the U.S. Congress and several state legislatures are taking the extraordinary step of passing laws to curtail them. Even nonprofit group- and staff-model HMOs that once sheltered their doctors from the economic interests of the organization are adopting some of the same strategies for limiting care as investor-owned plans. As Boulter and colleagues know, what constitutes medically necessary care is often arguable. Very few doctors would withhold clearly life-saving care, even at the cost of their jobs, but matters may be different when there is more ambiguity. To say it is “unethical, unprofessional, and in some cases, illegal” for doctors to respond to the very conditions managed-care plans deliberately create smacks of blaming the victim — in this case, the doctor caught between a rock and a hard place. Boulter and colleagues also offer no evidence to support their contention that it costs more in the long run to withhold care from a population than to provide it. Suppose they are wrong about this? Suppose it costs a managed-care plan more, not less, to provide good medical care, including preventive care? What would the plan do, given the harsh, competitive environment?
Despite the optimism of Mr. Bailit and Boulter et al., quality measures are in their infancy. The question is whether they are good enough, even though not perfect, to counter the financial incentives to stint on care. We think they are not and that relying on them now would be falsely reassuring.
Marcia Angell, M.D.
Jerome P. Kassirer, M.D.
