Thomas Edison’s famous quote: “Genius is one percent inspiration and ninety-nine percent perspiration” applies to every idea in health care policy, even those that only rise to level of common sense. Why the sweat? Because policy prescriptions need precise definitions to become operational: definitions of measures, standards, processes and outcomes. Definitions are difficult enough to create on a technical level, but to be useful they must also be understood and accepted by all participants.
Transparency in health care, for example, is one of the many phrases in health policy whose definition often varies from the reader to reader. In general transparency means more information available to decision makers: consumers, providers, or policy makers. Operationalizing transparency however requires exact standards, precise wording, and clear goals.
For example it is often asserted (by myself and others) that if consumers had information on the costs of health care services and the quality of those services their decisions would drive the market toward the provision of cost-effective care. So all we need is to measure and report the quality of health care. A general (although not necessary a generally agreed on) definition of the quality of a health care service would be the addition to health created by that service. One (but not the only) problem with that definition is that decades of sophisticated research has not yet produced a single agreed upon definition of health. It’s difficult to measure additions to something when you haven’t determined how to measure that something. Nonetheless we have developed literally thousands of measures based on peer reviewed research that are related to health care quality. The problem is to organize, interpret and disseminate that information in a format that consumers and others can use in decision making.
Another example of where lack of precise definitions creates problems is malpractice reform. It has been asserted that reforming our judicial system to limit malpractice suits would go a long way to reducing health care costs. One study claims that over one of every four dollars spent in the health care system is due to “defensive medicine”. Definitions matter here.
My dictionary defines malpractice as a “failure to render proper services through reprehensible ignorance or negligence or through criminal intent.” The definition of defensive medicine has dramatic implications for policy if indeed 25% of our medical dollars are spent on defensive medicine.
What if defensive medicine is defined as care provided solely to prevent or win lawsuits with no effect on health? The implication would be that we could go a long way to solving our health care cost crisis (and a large part of our Federal budget crisis) simply by banning malpractice suits and thereby removing the need for defensive medicine. It also implies that health care providers are engaging in massive fraud and malpractice in order to avoid malpractice suits. Since the study which generated the estimate was based on a survey of physicians its unlikely that they had this definition of defensive medicine in mind when they responded to the survey.
Suppose we go to the other extreme and assume that while defensive medicine is practiced to avoid and/or win lawsuits, it’s effective in that regard because it actually improves health. In that case, banning malpractice suits may save money but it would also decrease health. That might imply that the threat of malpractice is acting as a quality assurance mechanism.
Evaluating the trade-off between cost and quality requires both an objective assessment of the health forgone and a subjective assessment of the value of that health. Which brings us back to the definition(s) of health care quality and health itself.
We have come a long way in the measurement of health care quality in the last two decades. There are many procedures and disease states for we can quite precisely define and measure the increments of health provided by specific health services. We have begun to tie reimbursement to those measures. We have not yet found a precise set of aggregate health care quality measures that consumers, judges, juries, and other decision makers can use to allocate scarce health care resources.