RAND Professor Suggests Ways to Measure Health Care Reform

Ernie Shannon's picture
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RAND Corporation Professor Robert H. Brook recently outlined four measures by which the nation’s health reform law, the Affordable Care Act, should be monitored - - measures, he says, get to the heart and soul of health care reform and its impact on the United States. Headlined in the January 4th issue of the Journal of the American Medical Association, Brook’s comments provide insight into how supporters of the new law see its many provisions unfolding across the American landscape during the next two years and by what standards its success should be considered.

Brook comes to the discussion as the holder of the Distinguished Chair in Health Care Services at the Rand Corporation who served for 19 years as vice president and director of RAND Health. He is an unabashed supporter of the new health care law and says Americans should celebrate its existence and that the law’s passage brings the United States into the civilized world. Brook also admits that successful implementation of the Affordable Care Act will not be a simple process and regardless of one’s attitude toward the law, a new era in U. S. medicine begins in 2014.

“The key question is what potential measures should be monitored to determine both anticipated and unanticipated effects of the new law on the health of the US population,” he said.

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Brook’s first measure is how much success the nation has in dealing with preventable mortality is due to the health care system. He says preventable mortality has many causes “ranging from personal behaviors to social determinants of health to poor inpatient and outpatient care. The goal of health care reform, Brook cites, should be to drive the number and proportion of preventable deaths that are under the control of the medical care system as close to zero as possible. The measure strikes at the heart of recent efforts of the Department of Health and Human Services to focus attention on errors occurring in hospitals. The federal agency recently put hospitals on notice nationwide that data from bloodstream infections occurring during hospitalizations would appear on the popular Medicare website “Hospital Compare.” Hospitals, of course, have been fighting infections that emerge during inpatient treatment for decades and have not been passive observers in the struggle to make hospitalization safer.

The second measure of the law’s success, according to Brook is whether preventable hospitalizations are avoided. He writes that the “United States has a large number of avoidable hospitalizations from ambulatory-sensitive conditions.” Brooks says that by examining the reasons for a hospital admittance, such as for uncontrolled diabetes or asthma, one can determine whether better outpatient care might have avoided the admission. This is a key area of concern and one reason for skyrocketing medical care costs. If, indeed, better outpatient care occurred, might fewer people need to be admitted to a hospital?

Brook’s third measure is, by any standard, laudable, but perhaps impossible to achieve. He claims the success of “health care reform should be whether it increases to 100 percent the number of U.S. residents who have access to a system of care.” He defines a system of care in this way: “A health center that provides high-quality outpatient primary care, but cannot arrange for subspecialty care or hospital care when needed is not a system of care. If a gynecologist needs to treat a woman with severe depression because she has no access to a mental health professional, she has no system of care. If a physician providing emergency are is not capable of reducing a complicated fracture, but must attempt the reduction because no orthopedic surgeon is available, the patient with the fracture does not have a system of care.” To suggest that a system of care is non-existent because a perfect flow of treatment is not always maintained in every medical case is to doom this measure to defeat even before it begins. It also does a tremendous disservice to the men and women of the medical profession to step forward to offer care when it is not always within the carefully prescribed guidelines of the Affordable Care Act.

Rounding out his four-legged stool of health care reform success, Brook wonders if the proper way to monitor the law should be the cost of care divided by the number of individuals who are in a system of care. In leaving the cost factor to last and in giving it the least amount of consideration, Brook may have highlighted the Act’s biggest challenge: paying for the massive provisions its espouses. The latest administration estimates project the cost of health reform at $900-plus billion during the next decade. If the ACA follows the path of most federal programs, the cost will grow beyond present-day projections to the extent that measuring its success on dollars spent will be unreasonable at best.

Brook goes on to list other factors that bear watching in the next few years including years of life lost, disability-free years of life, functional health status, whether care is patient-centered, and the appropriateness of surgery. He also mentions a subject little studied in the initial debates about health care reform and only now getting some attention: the wear and tear on the doctors, nurses, and other health care professionals who actually make the system function at all. The demands placed on them when many more people may be seeking care and the costs they incur acquiring education and training over many years has simply been skimmed over in the arguments for and against reform. The simple fact is that no amount of health care reform on paper, in the law, or in the courts can replace an individual deciding whether to enter the field of medicine in an environment fraught with overwork, tension, and declining remuneration for a skill that costs hundreds of thousands of dollars to develop. If the American health care system is to function in the years ahead, talented men and women must be convinced early in their education that health care is still a venerable and honorable field in which to enter and that the costs will be bearable both during their schooling and after their practice begins.

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