Map of life expectancy at birth from Global Education Project.

Friday, March 16, 2007

Sorry for the absence

I was in meeting most of Wednesday, and didn't have a chance to post, then I was disconnected from Your Intertubes for a while as I had a new cable service installed. Whoa, what a difference!

Anyhow, the meeting, in a complicated and peripheral way, concerned the burgeoning Pay for Performance movement in health care, whereby Medicare, Medicaid, and private health plans give providers - mostly hospitals - bonuses for following certain standard, supposedly best procedures with high percentages of their patients. These are things like giving people an aspirin right away when they come into the ED with an apparent heart attack, and giving them a prescription for beta blockers when they leave the hospital, etc.

It sounds like a good idea -- if you're supposed to do it, then why the hell don't you and why not offer a financial incentive to make sure you do? The main trouble is that, at this point, we don't have a lot of evidence linking these supposedly best practices to better patient outcomes. Another problem with all this is that by the time you get to the hospital with some serious condition, it's already too late, and wouldn't it have been better to prevent it? But there are daunting conceptual and practical difficulties when it comes to implementing this sort of system with primary care practices.

For one thing, doctors can offer all the interventions they should to control high blood pressure and cholesterol, prevent diabetes, etc., but the patients have to actually carry them out -- take pills, lose weight, etc. -- and there's no sense writing a prescription for somebody who isn't going to take the stuff, but as a physician you don't want to be penalized in that situation. Doctors have to use judgment and do what's right in specific situations -- formulaic guidelines don't work very well. Another problem is that it is just technically very difficult and expensive to collect the data that would be necessary.

There are great difficulties trying to measure, or even define, quality in health care. But we do want to get our money's worth. I'll have more to say about this in the days ahead.

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