NATIONAL HEALTH CARE QUALITY CONTROL: THE ALTERNATIVES
In 1979, Dr. Rosen, a professor at the Columbia University School of Public Health, made a startling statement: “Over the years study after study show that a patient-physician encounter (visit) had a 50% chance of actually improving the health of that patient.” Ed Gluckmann, Co-founder of the CCAHS was in that class of 101 students none of whom challenged Dr. Rosen nor questioned the import of his statement. Worse yet none of us asked a simple question: “If this statement is true that the service did nothing to improve health does that mean the encounter was neutral or was it ineffective and dangerous, thereby possibly causing other clinical conditions”.
In this issue we tried to address ways to improve the quality of clinical practice. Yet, the crucial issue had not been perfected: why improve quality of diagnosis and treatment if its overall efficacy was 50% at best and perhaps dangerous at worse. Also there was no clear, easy to measure definition of quality that would be agreed to by a very significant number of providers and Americans. As we say today if you are looking for a universal definition of quality of clinical care: forget-about-it!
The issue addressed the role of government versus the private sector in the monitoring of quality and expenses (almost always referred to as costs) and the issues of all monitoring being compromised by tendencies to have providers review other providers; secrecy; lack of meaningful disciplinary actions and penalties and the complexities involved in defining ‘quality’.
The role of inspections of facilities was described along with its similar deficiencies. Professional Standards and Review Organizations (PSROs) were a first attempt; most of which was spent jockeying for control and to ensure that these state and regional bodies would not be effective. PSROs were later translated or replaced by Independent Provider Organizations (IPOs). As with the political process when a problem defies solution the name of the problem is changed along with another new committee. In this case PSROs were for the most part replaced by IPOs that met political standards related to control; more so than improved ability to monitor and control quality or costs.
The issue outlines several then major pieces of proposed legislation addressing the establishment of standards and methods to monitor them: the Young, Burleson-McIntyre, Fulton, Kennedy-Corman, and Long-Ribicoff Bills. Each bill included its own variations and additions many of which were tangential to quality. None successfully addressed the issue raised by Dr. Rosen.
Today, the most recent legislation related to medical care and insurance, Affordable Care Act (ACA), seeks to address the issues raised by Dr. Rosen’s statement. But Americans are still enamored with the Dr. Marcus portrayal of medical doctors and the myth that America still has the ‘best’ medical care in the world. Reasonable efforts to control expenses (costs) via the ACA address complex issues that have defied resolution since the mid-1960s. As America’s wellness and health crisis explodes the majority of Americans seeking relief are instead accosted by politically motivated analysis provoking fear of big government as the causes lay almost entirely in the private sector.
The last page of this issue contains a partial list of major legislation in western countries and America related to medical care. That listing shows clearly that western governments have been involved in the wellness and health of their citizens going back to the Anglo-Spanish and Revolutionary Wars.