IntroductionUnderstanding healthcare quality in the United States |
Introduction to U.S. HEalthcare
Preface |
In 2009, a poll done by the Commonwealth Fund found that in the United States, only a quarter of citizens believe that the US healthcare system is functioning well. Indeed, our healthcare system is highly unusual and is certainly one of a kind in the entire world. The US healthcare system is one full of paradoxes which have manifested in a variety of ways. This very well may be the best place in the world to receive treatment for extremely uncommon and complex medical conditions. Congenital insensitivity to pain/anhidrosis (CIPA), for example, is a fatal and exceedingly rare condition of which there has only ever been about 60 documented cases in the US; yet, of the small handful of these cases that the US has seen, all patients have been accurately diagnosed and allowed to live a relatively normal life with a disease that ordinarily precludes survival past childhood.[1] The US, however, may be one of the worst developed countries in the world to have a very common and entirely treatable disease. For example, the diabetes treatment insulin has become extraordinarily expensive in the US for those with inadequate insurance, despite it being quite inexpensive to produce; each year, as insulin becomes more expensive, more Americans are unable to afford their prescriptions, adding to the rising number of "medically preventable deaths" in this country. The US has some of the most rigorous medical schooling standards in the world and yet, it is estimated that the 3rd leading cause of death in this country is medical error.[2] In fact, the US has the highest percentage of medical errors per capita of any OECD country.[3] A recent study by the Peterson G. Foundation found that in 2019, the US spent twice as much money on healthcare (per capita) than the average spending per capita of all other 35 OECD countries.[4] In spite of this massive amount of spending, in 2019, the US also had the highest number of medically preventable deaths per capita of any OECD country.[5]
Fundamentally, the US has the most costly and least accessible healthcare system of any industrialized nation in the world. If the four main pillars of healthcare competency are considered to be cost, quality, access, and satisfaction, how do we determine what impact clinical informatics can have on these? Before we can begin to use informatics to address the shortcomings of US healthcare, we must first understand these shortcomings. If informatics is the answer, then let’s first explore the question.
Notes:
Fundamentally, the US has the most costly and least accessible healthcare system of any industrialized nation in the world. If the four main pillars of healthcare competency are considered to be cost, quality, access, and satisfaction, how do we determine what impact clinical informatics can have on these? Before we can begin to use informatics to address the shortcomings of US healthcare, we must first understand these shortcomings. If informatics is the answer, then let’s first explore the question.
Notes:
- We will be using the textbook "Understanding Health Policy: A Clinical Approach" (Bodenheimer and Grumbach; see reference 6) to explore these topics. All un-cited facts are attributed to this textbook and all chapter listings correspond as such.
- While this is still considered controversial, according to recent changes in APA style, it is appropriate to use the pronoun "they" when referring to someone who's gender is hypothetical, unknown, or irrelevant in addition to individuals that are non-binary or gender non-conforming. In the interest of recognizing that gender is more complicated than the binary options of man and woman, we have adopted this grammar convention. Thus, the use of "they" in place of "he or she" is not a grammatical error, but an intentional choice.
Interconnectedness of Healthcare Quality
Healthcare quality has been a complex issue throughout the history of the United States but has become considerably more fiercely debated in recent decades. Thus far, the debate has revolved largely around the argument of receiving "high-quality" care. But what exactly is "high-quality" care? How we define and think about this central term has large implications for the many debates surround the issue. Probably the simplest working definition would be to say that high-quality healthcare enables the population it serves to be healthy. But if so, what are the components of high-quality care? Working still in ambiguous terms without clear definition muddles the important ongoing political debates and only serves to slow down progress in any direction. This will be a major theme of all the modules you may encounter on this website as will much discussion of exactly what the different terms thrown about in these debates mean. So then, what are the components of high-quality care? Well, it' complicated...
Adequate access to care is certainly one such component and this is perhaps one of the more obvious components that comes to mind. When a patient needs access to healthcare agencies, they must be able to receive the healthcare services that are needed. But already again, another ambiguity has struck! What does it mean to be able to "access" a healthcare agency? Certainly it means one must be able to physically be able to reach a point of care. However, when the cost of health care is too high, it is often the case that people cannot afford necessary care (often, in the US, as a symptom of little or no health insurance) and do not receive proper treatment. This is a case in which someone can physically get to a doctor but is still unable to "access" care. Money impacts the quality of healthcare in a profound way, particularly in the US. While healthcare always has been (and probably always will be) a business, the current healthcare system in the US puts clinics and hospitals in a position that requires them to prioritize profit margins over patient health. And thus we've arrived at another point of contention in the healthcare debate: the myth of the evil care provider. On all sides of the healthcare debate, the hospitals and clinics themselves are often vilified as the culprits of creating inaccessible and exorbitantly expensive healthcare. This is a convenient excuse as it removes all political parties from the liability of tackling the problem. If the problem is blamed on the privately-owned points of care then politicians may claim they "can do nothing" since we live in a country where the government is seen as an agency meant to protect the people (except for when that requires the government to interfere with private business). Blaming the clinics and hospitals is a get-out-jail free card for the politicians that unfortunately not only fails to address any real problems but also makes the problems even worse. Hospitals and clinics are not allowed to pay for things if they cannot afford them and in our current system, they must pay for, well everything. This leads to hospitals and clinics being forced to hike costs, create hidden charges, and overwork staff which, again, only serves to make the quality and accessibility of care worse. One of the sneakier and more recent ways in which clinics maximize profits is by allowing patients request superfluous and redundant testing. In doing so, clinics generate revenue by allowing patients to overpay for care and, with increasing frequency, get trapped in financial crisis.
Adequate scientific knowledge and competent health care providers are two other aspects of high-quality care. The medical knowledge and expertise that a clinical team brings to a patient is of paramount importance to the overall success of the healthcare system. However, as we're seeing more often in the US, medical errors abound, wreaking havoc on the health and finances of patients. Even in the competitive atmosphere of US medical education, US doctors, on average, make many more mistakes than their foreign counterparts in other industrialized countries.[4]
An effective healthcare system must be well-organized and have adequate access to competent staff in order to make high-quality care possible. Inadequate staffing has obvious ill-implications for healthcare consumers but so does the relative distribution of medical staffing which is an issue that is often overlooked. It is known that the US has considerably fewer licensed medical professionals per capita than most other OECD countries. This, perhaps, is not as severe a problem as the fact that the medical professionals that this country does have are all too often concentrated solely on urban centers, leaving their rural counterparts with significantly less access to quality care. It is also no secret that, largely due to privatized health insurance, the US healthcare system is one of the most administratively complex systems in the world which often manifests in the form of poor care quality.
The above points are just a handful of components to high-quality care. But how to we go about optimizing these conditions? One way to do so is by examining clinical practice guidelines. Current guidelines allow doctors to make judgments based on commonly accepted knowledge. However, the problem of clinical practice guidelines, is there is no one-size-fits-all solution when it comes to healthcare. The rules written in the guidelines cannot apply to all situations. This is part of a larger discussion to move more towards individualized treatments and therapies that are motivated by quantitative diagnosis rather than qualitative. Detailed measuring of practice patterns is useful in this regard; we are better able to understand patients' health conditions by providing clinicians with a constant flow of healthcare data. Doctors can thus make more pragmatic and well-informed decisions based on the most up to date information.
Continuous quality improvement means that health care providers should always have the awareness of improving health care quality. There is always room for improvement in healthcare; it is imperative that providers understand that better health care practice is achievable.
Computerized information systems are becoming an increasingly important component of health care quality. They are capable of organizing data in highly efficient and helpful ways but have proven to be strenuous for clinicians when administrative complexity eclipses patient care responsibilities. There are many studies with mixed conclusions on the ability of computerized information systems to improve health care quality. It is important to recognize that implementation of computerized data capture in strictly clinical settings is not powerful enough alone to improve healthcare quality; it takes a combined effort between physicians, healthcare organizations, and healthcare-oriented corporations to improve the overall quality and access of the healthcare system.
One of the leading theories behind increasing the quality of care for those need it is to simply reduce the number of people who need healthcare. This can be though of generally as illness prevention. However, to promote the prevention of illness, there are, more or less, three different components of preventative care:
- Socioeconomic determinants: we know that illness severity is heavily correlated with income and lifestyle conditions; those with lower incomes are more likely to develop chronic illnesses than wealthier people. This is, however, a complicated problem to address as socioeconomic status is inherently interconnected with complex issues of socio/cultural discrimination and systematic inequality.
- Public health: The general level of public health is something that has been a difficult entity to address, not just in the US, but around the world. Exactly how a governmental body can go about improving public health is, once again, a complicated issue which is interconnected to many other societal issues (although there is an increasing body of evidence to suggest that the key to public health may be public education).
- Individualized vs collective health: By this, we mean to ask the question: how does the health of an individual impact the overall general health of their community? And what implications does this have for the medical facilities that serve this community?
Overall, the question of what healthcare quality depends on is one with a complicated answer. When it comes to understanding healthcare, as with many aspects of life, choosing to develop a complex and multi-faceted view is much more difficult (but also much more helpful) than choosing to adopt a simplistic view of things. However, understanding the inner-workings of the US healthcare system is only the first step on the path to fixing the system itself.
Historical development of
Today's Healthcare Problems
Chapter 16 of Bodenheimer and Grumbach evaluates the US healthcare system from the historical perspective. While they do not necessarily dissect the US healthcare system into cost, quality, accessibility, and satisfaction, they dive deep into each of these aspects but mostly focus on how the four major actors in the healthcare industry interact with each other to create the catastrophic healthcare system currently plaguing the US. The four main characters in the healthcare system are:
The tensions and challenges in the healthcare system that have developed over decades are nowhere near being solved, perhaps because there is no perfect solution. There are massive gaps laying between individual-level care and public health; between the quality of care and reducing the cost; between individual practitioners and large-scale hospital systems. None of these conflicts have found balance in the US healthcare system and it is at the expense of the quality of care provided to consumers. It is the responsibility of purchasers, insurers, providers, and industries alike to push for improvements to our unsustainable healthcare system.
- the purchasers who fund the healthcare industry
- the insurers that receive money from the purchasers and, in turn, fund the providers
- the providers that physically administer healthcare services
- the industries (i.e. pharmaceuticals, computer softwares, etc...) that supply providers with the hardware and software which is used in administering healthcare
The tensions and challenges in the healthcare system that have developed over decades are nowhere near being solved, perhaps because there is no perfect solution. There are massive gaps laying between individual-level care and public health; between the quality of care and reducing the cost; between individual practitioners and large-scale hospital systems. None of these conflicts have found balance in the US healthcare system and it is at the expense of the quality of care provided to consumers. It is the responsibility of purchasers, insurers, providers, and industries alike to push for improvements to our unsustainable healthcare system.
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[1] Rahalkar, M. D., Rahalkar, A. M., & Joshi, S. K. (2008). Case series: Congenital insensitivity to pain and anhidrosis. The Indian Journal of Radiology & Imaging, 18(2), 132–134. https://doi.org/10.4103/0971-3026.40296
[2] Daniel, Michael, et al. "Study Suggests Medical Error Now Third Leading Cause of Death in the U.S." Johns Hopkins Medicine,
2016. https://www.hopkinsmedicine.org/news/media/releases/study_suggests_medical_errors_now_third_leading_cause_of_death_in_the_us
[3] https://www.healthsystemtracker.org/chart-collection/quality-u-s-healthcare-system-compare-countries/#item-start
[4] https://www.pgpf.org/blog/2019/07/how-does-the-us-healthcare-system-compare-to-other-countries
[5] Stahel, P. et al. "Why Do Surgeons Continue To Perform Unnecessary Surgery?" Journal of Patient Safety in Surgery (2017). Vol. 11, 1. doi: 10.1186/s13037-016-0117-6
[6] Understanding Health Policy: A Clinical Approach. Thomas Bodenheimer, Kevin Grumbach. 7th edition online. McGraw Hill, New York, NY. Accessed April 2020.
[2] Daniel, Michael, et al. "Study Suggests Medical Error Now Third Leading Cause of Death in the U.S." Johns Hopkins Medicine,
2016. https://www.hopkinsmedicine.org/news/media/releases/study_suggests_medical_errors_now_third_leading_cause_of_death_in_the_us
[3] https://www.healthsystemtracker.org/chart-collection/quality-u-s-healthcare-system-compare-countries/#item-start
[4] https://www.pgpf.org/blog/2019/07/how-does-the-us-healthcare-system-compare-to-other-countries
[5] Stahel, P. et al. "Why Do Surgeons Continue To Perform Unnecessary Surgery?" Journal of Patient Safety in Surgery (2017). Vol. 11, 1. doi: 10.1186/s13037-016-0117-6
[6] Understanding Health Policy: A Clinical Approach. Thomas Bodenheimer, Kevin Grumbach. 7th edition online. McGraw Hill, New York, NY. Accessed April 2020.