Promising Everything

American Medical News reported today that health care quality is improving, although the trend appears to be slowing. They also report that it's pretty hard to correlate quality care with decreased cost of care:

As they state:

"A composite measure of health care quality improved at a 2.3% average annualized rate between 1994 and 2005, with the rate falling to 1.5% from 2000 to 2005. And in a first stab at examining the cost efficiency of the American health care system, AHRQ noted that costs, as estimated by the Centers for Medicare & Medicaid Services, jumped 6.7% from 1994 to 2005.

"AHRQ, part of the U.S. Dept. of Health and Human Services, said in its March report that cost and quality cannot be reliably compared because "expenditures are comprehensively measured, but quality is not."

AHRQ looks at costs and quality

Care for some of the most serious conditions continued to improve each year from 2001 to 2004. Costs also rose during that period. Average annualized change:

Care	Cost increase	Quality improvement
Overall	7.6%	1.9%
Heart disease	12.9%	5.6%
Cancer	9.0%	3.6%
Diabetes mellitus	3.7%	0.6%

Source: U.S. Agency for Healthcare Research and Quality, "National Healthcare Quality Report, 2007" and "National Healthcare Disparities Report, 2007"

I have to assume the bean counters believe that better care means decreased utilization of health care resources. In other words, quality will lead to cost savings. Unfortunately, I don't see it that way for some very important reasons.

1. How much Uncle Sam pays for health care is entirely a function of productivity. Do more, pay more. The more patients a doctor sees, the more he gets paid. The more procedures a doctor does, the more he gets paid. If I do everything right as a primary care physician, have all of my patients get 100% on all of Uncle Sam's 200 quality indicators, I would be perfect in their eyes. But my control ends there. The patient relationship with me ends when they walk out that door.
2. I would then have to assume no other doctor got their mitts on my patient and proceduralized them.
3. Cover Your Ass trumps right care right time, every time.
   
4. I would have to assume practice expenses didn't drive volume of medical services, due to declining payment by third parties.
   
5. I would have to assume technology stood still.
   
6. Patients have to stop asking for the most expensive therapies.
   
7. Patients have to stop demanding what they believe is the best. (FREE=MORE)
8. Patients have to stop living longer due to quality care.
9. Longevity trades some disease states for others. For example, if you don't die of cancer at a young age you die of heart disease and all the expenses that come with it.
   
10. If our goal is to prevent early mortality through quality care, then we have to have an organized plan in place, financially, to allow natural mortality to occur in the last stages of life.
    
11. Unmanaged expectations run rampant
    

Promising everything will lead to providing for nothing.