PrintApril 9, 2009
Universal health care may kill you
In Wednesday's Opinion Journal there's an article by two practicing medical doctors who are on the faculty of the Harvard Medical School. Their concern is that efforts ostensibly geared toward improving the quality of medical care in the U.S. are also likely to inject a life-threatening rigidity into patient treatment protocols. Drs. Jerome Groopman and Pamela Hartzband take issue with how...
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."
What kind of "specific metrics" are of concern here?
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.
And thus was born what has become a standard, acceptable and "quality metric" clinical practice. But just how much good did this do the patients upon whom such quality of care was imposed? Well, last month the New England Journal of Medicine published the results of a randomized study of more than 6,000 critically ill ICU patients that was conducted in Australia, New Zeeland and Canada. Guess what? More patients died in the tightly regulated group than those cared for with the flexible protocol.
Other studies involving this and other "quality metric" protocols have yielded similar results. That is, Medicare and private insurers demanding that physicians follow rigid and inflexible treatment practices is not always best for the patient. In fact, one such study was discontinued 17 months short of its scheduled completion because of the high numbers of patients on a rigid blood sugar control regimen who were dying.
Keep in mind that fifty cents or more of every health care dollar spent in the U.S. already comes from or through a national, state or local agency. The other half seems well on its way to falling under government jurisdiction. But, government agencies are best at conjuring up, writing, implementing and insisting that everyone follow procedures. As a result, with universal, government-funded health care - even if there are some private care options - relying on an attending physician's Judgment will probably be of ever diminishing importance. Big Brother will have already made all the important decisions.
Including, I suppose, who lives and who dies.
