In a nondescript computer room in Hinsdale Hospital, Barbara Murphy applies the tools of modern management to the age-old questions of who lives, who dies and why.
Why did a 52-year-old man with congestive heart failure die in the hospital? Was an 85-year-old woman with the same problem sent home too soon?
Is there any pattern to deaths in the intensive care unit?
For at least preliminary answers, Murphy, a registered nurse, turns to a computer system that performs a remarkable trick. By using information on a patient`s symptoms, it scores how sick a patient is shortly after he enters the hospital and tracks what care he is given during his stay.
The change in these two scores lets Hinsdale see for the first time what the physician and nurses did to make the patient healthier or sicker. A committee of physicians takes a closer look at what seem to be problem cases. Says Murphy, who heads the hospital`s quality assurance department:
”It`s the only way to get a handle on the quality of patient care.”
Computer systems such as the one Murphy uses reflect a basic change in how doctors are looking at the quality of medical care. The interest isn`t new; what is different is that for the first time in medical history, doctors and hospitals are being judged on an objective scale showing how well patients do under their care.
That kind of rating of the outcome of care promises, in turn, a fundamental shift in the physician-patient relationship.
Says Carolyne Davis, a consultant and former head of the Medicare program: ”It`s only a step away before we see Hospital Consumer Digest or Physician Consumer Digest . . . that looks at real outcome measures.”
The roots of this change can be traced to a new trend toward ”managing” medicine. The idea is that applying the principles of competition and business efficiency to health care will give patients better care at a more reasonable price.
As a first step, those paying most of the nation`s medical bills, primarily the government and large corporations, have deployed increasingly sophisticated systems to measure the cost of care. But measuring quality has lagged despite widespread agreement that it is critical to know whether care is good or bad, not just cheap.
”For the same price, you get different products,” notes Dr. John Kelly, medical director of California Medical Review Inc.
In part, systems to measure quality have been scarce because the task is daunting. It requires calibration of such elusive terms as ”health” and
”sickness.” In addition, many physicians remain convinced that their judgment is sufficient.
Dr. James Todd, a surgeon who is the American Medical Association`s senior deputy executive vice president, expresses a common view: ”Quality is kind of like pornography. I can`t define it, but I know it when I see it.”
Todd`s certainty aside, the search for a way to ”objectively” define high-quality medicine has become pressing. Though computerized measurement systems remain controversial–critics argue that no ”black box” should define medical standards–the principle that defective medical care should be screened out in the same way that flawed automobiles are taken off the assembly line is gaining widespread acceptance.
Indeed, the Journal of the AMA advised physicians in an editorial last year to pay attention to the industrial definition of quality: ”conformance to requirements.” The editorial went on to commend the work of the American Society for Quality Control, whose members are primarily manufacturers.
”The single most important thing that American medicine and its societies at this time should do is define quality indicators and follow them,” contends Dr. George Lundberg, the AMA`s vice president for scientific affairs and the editor of the Journal.
Dr. Alan Brewster, president of MediQual Systems Inc., which designed the computer system being used by Hinsdale Hospital, adds: ”Individual doctors have to lose autonomy to move to the next level” of quality.
Physicians may have little choice. The effort to manage health care has ushered in ”cost-effective” medicine. Physicians and hospitals that are more expensive than their peers are being asked to prove that they are worth the extra money.
”It`s tough to be cheap and good. It`s easy to be cheap and bad,”
points out Walter McClure, head of the Center for Policy Studies, a health research group.
Without some way to measure quality, ”the guys who have the most to lose are the quality physicians and hospitals,” McClure says.
Some employers also worry that a move to low-bid medicine could endanger their workers.
”We`ve accused the doctor of playing God for years now,” muses Jack Mulligan, director of compensation and benefits for Garrett Corp., a Los Angeles-based aerospace company. ”How much of that role have we assumed?”
Critics say, quite a bit.
”It is not clear that what`s being squeezed out is the unnecessary stuff,” contends Uwe Reinhardt, professor of political economy at Princeton University. ”We have no idea. We`re flying blind, and maybe we like it that way.”
The Medicare program may be one example of the problem. In 1983, the government changed how it paid hospitals so they would profit by discharging elderly patients more quickly. The goal was to reduce unnecessary
hospitalization.
The new payment system quickly cut the number of hospital admissions and the length of stay of the elderly.
However, the Health Care Financing Administration (HCFA), which runs Medicare, didn`t begin an intensive effort to analyze how patient care was affected until a congressional hearing spotlighted stories about sick patients sent home from the hospital too soon.
And nearly four years after the change, HCFA has released no report on how the quality of patient care has been affected.
”We knew it (the new payment system) could have some effects in terms of quality,” says Jeffrey Merrill, a former senior HCFA official now with the Robert Wood Johnson Foundation. ”We could have looked first, (but) nobody cared.”
Employers sometimes do no better than government in paying as much attention to the quality of medicine as its cost. A group of large employers in Rockford conducted a much-publicized search for ”quality” hospitals and doctors. The companies ended up contracting with the least costly medical providers, paying little but surface attention to quality, says a consultant who spearheaded the project.
”They didn`t really end up evaluating the hospitals,” says Marilyn Plomann, a former consultant who now heads the Illinois Health Care Cost Containment Council. ”They were looking for a discount.”
To be sure, the vagueness of medical standards can discourage a layman. For example, research pioneered by Dr. John Wennberg, a professor at Dartmouth College, showed that the way in which doctors practice varies widely even within small geographic areas. Wennberg found that the rate of hysterectomies in New England ranged from 30 per 10,000 people in a small Vermont community to 90 per 10,000 people in a small town in Maine.
Which of the two groups of doctors is giving ”appropriate” care remains unclear.
Hospitals, too, often operate with vague standards, not even agreeing on how often it is ”normal” for patients to become infected during their hospital stay with a problem unrelated to their original illness.
Unlike with airlines or banks, there is no government regulator to step into the breach. Says the Center for Policy Studies` McClure: ”The Federal Aviation Administration works because when it fails it kills people a planeload at a time, and that`s big news. Medical care kills people one at a time.”
Medical peer review, a system in which doctors oversee each other`s work, is supposed to ensure that each life is held sacred. Nonetheless, though the commitment of good doctors to high standards continues to be the cornerstone of American medicine, the peer review process has become increasingly troubled.
For one thing, a growing number of physicians disciplined by their peers refuse to swallow the disagreeable medicine. Instead, they sue everyone involved. Peer review has become entangled in litigation involving everything from malpractice to antitrust. Many doctors say caution has replaced candor in the discussions of many hospital review committees.
Peer review also can be affected by doctors` economic dependence on each other. Dr. Donald Hanscom, a gastroenterologist at Hinsdale Hospital, discovered that many family practitioners resented his efforts to curb their use of a procedure to examine the inside of a patient`s stomach. Though lucrative, that procedure is done too often, says Hanscom, citing guidelines issued by his specialty society.
”My surveillance . . . has cut off about 30 percent of my referrals from family practitioners,” says Hanscom, a former president of Hinsdale`s medical staff. ”Some of them have decided, `The next time I need a gastroenterologist, I`ll call somebody else.` ”
Similarly, the director of nursing at a Milwaukee hospital tells how the medical director of the intensive care unit avoids angering other physicians when the unit fills up and some patients need to be moved. Rather than telling colleagues that their patients don`t need intensive care, the medical director ”transfers his own patients,” the nurse says.
She adds: ”He`s not going to stick his neck out because he`s a cardiologist and needs referrals.”
Hospital politics can intimidate would-be whistle-blowers. Dr. Russell Welch, a St. Paul anesthesiologist, says he was bothered when an orthopedic surgeon at one hospital repeatedly performed operations with a medical book open.
”He told me he was looking at the screw sizes,” says Welch. ”(But) he did it often enough that in my heart of hearts I didn`t believe him.”
Welch says the doctor was affiliated with an HMO that accounted for a third of the hospital`s business. Previous complaints about that group`s physicians went unanswered, Welch contends.
”I didn`t see I was going to get anywhere by constantly getting people up before peer review, (so) I chose the coward`s way out,” he says. ”I left.”
Objectively measuring the outcome of care promises to bypass many of the problems of peer review. So, the concept has acquired some powerful backers.
Dr. William Roper, HCFA administrator, has endorsed objective measurement of medical outcomes to determine quality and promised that information his agency obtains will be made available to consumers.
”If you believe in a competitive health-care system, you`ve got to believe in informed consumers,” Roper says.
The Joint Commission on Accreditation of Hospitals, a group dominated by physicians and hospitals, has said it will require outcomes measurement in hospitals by 1991. The commission accredits about five-sixths of the nation`s community hospitals. Its stamp of approval allows the facilities to serve Medicare patients without a separate government inspection.
Says Dr. Dennis O`Leary, commission president: ”We have not only an ability to set standards but to enforce them.”
Meanwhile, Blue Cross and Blue Shield of Minnesota is requiring hospitals to buy the computerized MediQual system used by Hinsdale Hospital. The
”Blues,” in turn, will use the information to negotiate contracts with those hospitals. The Pennsylvania Health Care Cost Containment Council, a government agency, also mandated use of the system after the state required information on the cost and quality of medical care.
In Northern Indiana, Inland Steel Co. has asked all the hospitals that serve its employees to report the information needed by the system to the company; Inland bought a MediQual system. Because the steelmaker covers 60,000 workers, retirees and their families in northwestern Indiana, spending $60 million to $75 million annually, all 10 hospitals in the region have complied with its request.
Using the system, Inland`s medical department has discovered that some hospitals are performing Caesarian sections on workers or wives of workers
”probably twice as much as is needed,” says Dr. Jack Lange, the company`s medical director.
Says Julio Padilla, the project director: ”If we get quality health care, cost will be driven down, we feel. . . . Eventually, we`ll be able to select out physicians with the use of” the MediQual system.
MediQual Chairman Charles Jacobs applauds the strategy. ”You go to the hospital and say: `If you cannot control your surgeons, we`re going to take our business away from you.` ”
But the push toward standardizing care has dangers. MediQual, for instance, is based on proprietary information that the company will not disclose and is subject to debate by the profession. Critics also say it is limited in its quality measurements.
Others worry that too much of an emphasis on standards will encourage mediocrity. ”When you try to standardize something, you not only bring the lower end up to the standard, you lose the innovative expansions of medicine,” contends Dr. Donald Crandall, head of an AMA committee on the quality of medical care.
In addition, standards to measure care given outside the hospital, in an outpatient center or a doctor`s office, have lagged far behind measures of quality in the hospital. But the quality of individual doctors can vary even within high-quality hospitals.
Merrill of the Robert Wood Johnson Foundation, which funds health care research, says: ”The system is becoming more outpatient oriented, and there`s no way we know of to measure quality on an outpatient basis.”
Despite that, Congress is requiring the HCFA to review the care in doctors` offices beginning Jan. 1, 1989.
Consumer activists argue that making doctors and hospitals compete on the basis of quality can only help patients. A California hospital has taken a full-page advertisement in the Wall Street Journal to publicize data showing that it had the ”lowest mortality rates for heart bypass surgery in U.S. hospitals.”
”Bad medicine is what`s costing us a lot of money, not good medicine. If you cut out unnecessary medicine, there would be no cost crisis,” argues Charles Inlander, head of the People`s Medical Society, a consumer group based in Emmaus, Pa.
Says Inlander: ”We as consumers are not going to tolerate second-class care.”
THURSDAY: How ”managed” medicine may help the rich and hurt the poor.
