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How Can We Improve Health Care Quality? Change the System

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In his notable book Black Swan, author Nassim Nicholas Taleb made a very interesting observation about the United States’s response to the terrorist attacks of Sept. 11, 2001. The fear brought on by such a horrific act overtook the nation, and protection from further such attacks was both explicitly and implicitly demanded. As we all know, airport security was dramatically increased in the aftermath, along with a few other changes that have proven to be very effective in improving aviation safety. However, Taleb points out the solution didn’t fit the problem. What we aimed to do was to eliminate or at least decrease terrorist attacks against U.S. citizens, but we instead learned how to keep airplanes from being flown into buildings or being blown up. We became adept at preventing a very specific and rare type of terrorist attack, not of preventing a broad range of attacks.

It is unfortunate that our health care system acts in a very similar way. Everything in health care is connected. If you want to decrease costs, it will affect quality; if you want to improve the quality of care provided and/or the patient experience, then you can’t encourage increased “efficiency” of seeing more patients in a shorter amount of time. Changing one thing changes another, often in unfortunate ways.

When the incomparable Institute of Medicine report "Crossing the Quality Chasm" was released in 2001, the need to improve the care we deliver was illuminated for us all. Since the quality of care provided is dependent upon the structure of health care delivery, the payment model, and the inclusion of patient participation, amongst many other factors, only addressing the problem from one angle is more likely to cause further problems as opposed to fixing anything. One of the main results has been the monitoring of often irrelevant metrics for individual clinicians by regulators and third-party payers, who now see themselves as the authority on care, as I’ve written about previously on Op-Med.

These metrics are expected to be achieved in the very structure that facilitated the decline in quality: short office visits with increasing documentation requirements, no financial support for ancillary staff to assist in achieving better patient outcomes, etc. Thus, the actual “quality” of care has not changed in a sustainable way, and such efforts have likely even contributed to further elevations in the cost of care. As Dr. Sandeep Jauhar stated in his book Doctored, “The more pressure on doctors to cut costs by working harder and faster, with shorter hospital stays and quicker pt turnover, the more uncertainty doctors often feel, and therefore the more likely they are to utilize CT scans, MRIs, expert consultations, and so on. There is no more wasteful entity in medicine than a rushed doctor."

The common solution that we hear for our health care ills is more technology. Precision medicine. More personalized medicine in the hands of patients through apps on smart phones. Different surgical instruments to supposedly improve outcomes. But as former Centers for Medicare and Medicaid Services official Andy Slavitt pointed out in a speech last year, we’ve never had a deficiency of technology—what we have is a deficiency in implementation. Technology won’t save us but restructuring the system might. Plenty of proven ideas exist in the realm of health care where we could actually affect improvements in quality, lower costs, and patient and clinician satisfaction through more global reforms and changes.

But we don’t want to do that. Concepts such as the patient-centered medical home and accountable care organizations are showing increasing worth in changing the delivery of efficient, quality, and cost-effective health care, but we haven’t shown a willingness to invest in the specific aspects of these models that have proven to work best. We want to essentially beef up airport security to prevent an in-air terrorist attack, not actually decrease the total number of attacks.

The problem is an aggregate one, not a specific one. Building upon a flawed system, as we have attempted (and are attempting) to do is one fraught with failure, though there is simply too much money to be made in the status quo to change it significantly. So are we interested in real solutions or pretend ones? We will continue to have pretend solutions until physicians and patients are put in charge of health care decisions.

Dr. Kyle Bradford Jones is a board-certified family physician at the University of Utah School of Medicine. He practices at the Neurobehavior HOME Program, a patient-centered medical home for individuals with developmental disabilities. He is very interested in how technology and social media can be used to improve overall health and clinical care.

Dr. Jones is a 2018–2019 Doximity Author.

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