July 23, 2009

Health Care is Unsolvable This Way Mr. President

The OECD put out a report in 2006, on Health Care Quality Indicators. In evaluating and comparing transnational health care systems they based the broad assessments on a number of factors. These factors were as follows;

In order to simplify the number of dimensions it's worth grouping them a little more tightly, which I've arbitrarily done below.

Quality consists of most of the dimensions above - effectiveness, safety, responsiveness, acceptability, appropriateness, timeliness, capability and continuity

Quantity consists of accessibility and also timeliness (which is in a way, a sub-dimension of quality too)

Equity is it's own dimension, and

Cost is it's own dimension as well.

These 4 dimensions represent competing requirements for a health care industry. They need to provide the best quality care, to as many people as possible (quantity) as fairly as possible (equity) and as inexpensively as possible. Clearly these are competing priority. Now try to imagine that those 4 dimensions are equidistant from each other.
Quality versus Quantity: Assume you have 1 doctor and 100 patients that need to be seen. The doctor works 8 hours a day. He's overworked and gets no lunch. So he's on duty 480 minutes per day. How does he divide his time? Well he could spend all 480 minutes on one patient. That patient would have the BEST possible health care for her sprained ankle imaginable. But the other 99 patients would be pretty upset. Conversely he could spend exactly one minute with each patient. Great for a small cut, but bad for that sprained ankle or the other patient with a tumor. The best solution is somewhere in between, and likely not the same amount of time between patients. These health care requirements compete with each other.

Quality versus Cost The patient with the scraped knee needs a bandage. There's cheap bandages ($1 each) or gauze ($4 each) or the newly developed anti-bacterial liquid oxygenated free radical inhibiting thermo bandages ($1000, don't look it up they don't really exist). Obviously the latter bandage offers the best protection and recovery opportunity but it costs a lot of money (regardless of who pays for it). Conversely the cheapest bandage might not be as good as the middle choice but it is cheaper. Again - the dimensions compete with each other.

Quality versus Equity: Going back to our 100 patients, let's assume that patients are prioritized on a triage system; Urgent, non-urgent and ambulatory (there are actually two other levels, but let's keep it simple). By the very nature of the varying degrees of importance, some patients will be seen sooner than others, even if they arrived at the medical facility much later than someone less critical. By the very nature of the responsiveness and/or timeliness (quality) to critical care patients, they are foregoing equality (equity) of the patients. In other words they are based on malady not people. All afflictions are not equal, and by not taking a first come first serve approach to address the urgency of the situation, the medical practitioners are sacrificing the equality (equity) of treatment to all patients.

Quantity versus Cost: Doctors and nurses are a finite resource. In our example above, we could improve the amount of time the doctor could spend with each patient if we were to hire a second doctor. The obvious downside? It will cost more to pay two doctors than to pay one.

Quantity versus Equity: This is a variation of the Quality versus Equity issue. If every one of our 100 patients merited equal time with the doctor then it would have to be set to the level that provided adequate time with the worst case patient. Otherwise the doctor is wasting 10 minutes with a patient who needs an hour, and spending 10 minutes with a patient who needs 2 minutes. Equity is an amorphous dimensional goal anyway. Are we talking about equal treatment for equal conditions? And if so, does that mean that every doctor has to have the same skill level as every other doctor? If we doubled the doctors and the 2nd doctor was better than the first, in order for everyone to have equal care, they would need to see the second doctor, and the first might as well be standing outside selling gum. And it's not just true for doctors and nurses - think of the divergent quality of beds, sheets, and hospital equipment. And think of the location of hospitals. Do we want everyone to have to travel the same maximum distance to a hospital? If that's the case does it apply to sparsely populated areas of Alaska? How many hospitals would it take? And if we did that, then the hospitals would have to be smaller there than say in L.A., which itself is an inequality. Head-spinning.

Cost versus Equity: This one is likewise a spin-off of quantity versus equity. In order to ensure that each of our 100 patients gets the same treatment, we are going to as mentioned above, bring the level up to the highest required patient visit time, not the lowest. It means more doctor hours and more expensive supplies. In other words equality costs more money. alternatively you could lower the standards so that everyone gets the same doctor time, but at the minimum level required for the least in need patient. It would be far cheaper and equality would be assured, but quality would suffer in most cases except for that 100th patient who needed the least attention.

What has Obama promised? Universal Health Care (quantity and some degree of equity) with no or little additional cost. All that leaves is quality to surrender ground in exchange for these other promises. Either quality goes down or one or more of his portions of Obama-care promises has to give.

There are no easy trade offs here, because everything is a trade off. Don't be fooled by the cost-savings argument the President is making about savings. If there are savings to be found in the system they have been found by someone already. If the President is bound and determined to redistribute the wealth of those who are leveraging any found savings by spreading the benefit around you run into another supply and demand issue. If the savings mean reducing insurance company profits, it means reducing available coverage. Why provide a service for sale if your profits no longer exist? You'd better move that investment elsewhere. The only option left is to replace the missing coverage with Government Health Care - something he said he wasn't going to force upon Americans. Oops.

I'm just saying.

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