Understanding the arguments for specific features of health reform

Posted on 17 June 2009


The Science of Health Care Reform

Author: Robert H. Brook, MD

JAMA. 2009;301(23):2486-2487 (doi:10.1001/jama.2009.866)

Available online: http://jama.ama-assn.org/cgi/content/full/301/23/2486

Robert H. Brook has published nice summary of considerations that need to be made on the part of practitioners in choosing a side in the next battle over the specifics of health care reform. See a few  key points in the excerpt below (edits, links, and emphasis are mine):

The RAND HIE (more) was a population- and community based,
controlled experiment in which families from 6 sites
across the country were randomized to 1 of 5 health insurance
plans…The HIE’s conclusions were straightforward:
(1) increased cost sharing proportionally decreased
health care use and (2) on average, individuals with
free care used about one-third more care than those in costsharing
plans, but at the end of 5 years, they were no healthier
on average than their cost-sharing counterparts….

…The findings of these population-based studies seem to support
policies that reduce service use in most geographic areas
and increase what patients pay for care. Such policies would
not affect population-based health outcomes. However, from
the perspective of an individual patient, the story is quite different.
In the HIE, the reason more care did not improve health
is that providing more care did not improve the quality of care
individuals received. Furthermore, when patients had to pay
for their own care, they reduced use of effective services in
equal proportion to use of ineffective services.

How can physicians change the health care system in ways
that both are sensitive to the needs of individual patients and
reflect population-level data? Some suggestions follow.

First, however health care is reformed, the resulting system
must explicitly assess the appropriateness of any major
medical or surgical procedure before it is performed in
a specific patient.

Second, the assessment of appropriateness must be based
on reliable information.

Third, the problems identified by the HIE and the Dartmouth
Atlas need to be addressed by eliminating unnecessary
care and wasted resources. Informal discussions with
various specialists about the proportion of care they provide
that does not meet their own definition of “necessary”
suggests an amount ranging upward from 20%.

Fourth, it appears that simple interventions involving common
clinical encounters may translate into large savings. For
instance, most physicians order certain tests once a month, see
patients once a year, and draw blood in the morning hours.What
if physicians added 15% to a monthly or yearly interval and extended
the frequency with which procedures are performed by
1 month or 1 year?

Fifth, perhaps it is time to address the affordability question
head-on and insist that research about health care delivery
focus on eliminating unnecessary care and wasted resources.