The sky is not falling

I do not share Davidson's global despair about our health care system. Certainly all kinds of problems exist, from the huge numbers of the uninsured to the insolvency of providers, but fantasizing about a return to the days when physicians had more independent power and privilege is not a productive use of our time. Recently, health care expenditures in the United States have stabilized at about 14% of the gross domestic product.1 This amount seems to be what our society is willing to spend on health care provision. Rather than dreaming up ways to get our politicians to ration health care, as Davidson suggests, we need to learn to spend our health care dollars in more useful ways. The failed Clinton era health care “reforms” (many ultimately implemented by insurance companies) demonstrated that the US government is not trusted to redesign health care. I do not agree that supply, demand, and competition are innately counterproductive to cost-effective, high-quality health care. The supply and demand of services in the health care economy is not static and must be adjusted continuously. The decisions involved are always competitive and always involve resources, such as money or people. The real question is, how should this be done and by whom? I believe that, when possible, evidence-based medicine is the best way to decide what services have clinical value and, therefore, what services to provide. When that degree of certainty is not available, as is most often the case, then a different approach is needed. When care is new, expensive, or unproven (eg, bone marrow transplantation for breast cancer), anyone seeking such treatment should be enrolled in an organized clinical trial, ideally through a community-based research network. Such a network approach should be applied not only to tertiary care, but also to important problems in primary and secondary care. This approach will minimize the expense to the health care system while determining whether an intervention is effective and worth providing to others. To facilitate this research, medical schools will need to be active in such networks, not re moved from the community, as Davidson suggests. For many types of care, a consensus approach may be used, at least until more information is available. Patients need to provide more of the answers where uncertainly exists. We need to activate providers and consumers at the local and individual level to reconfigure health care for the populations they serve. To achieve this goal, we need to develop more information about the day-to-day decisions of providers and consumers and the outcomes of those choices. We need to increase the involvement of patients in their own care, and clinical data generated by patients themselves need to be integrated into our information systems. Patient satisfaction must be emphasized. An example of a step in the right direction is the Health Plan Employers Data & Information Set (HEDIS). This performance measurement tool, which includes more than 50 measures of health care and health plan characteristics, is being promoted by the National Committee on Quality Assurance (www.ncqa.org). Publication of such data spurs competition among health plans to reach the goals for measures that are considered important (eg, control of diabetes as assessed by glycohemoglobin levels). But these measures are not made available across all health plans at the individual provider level. They should be. Consider the Pacific Business Group's Health Scope, which reports similar data on individual medical groups and hospitals (www.healthscope.org). Physicians will steadily improve their performance if regular feedback is provided, the focus remains on the patient, and funding is adequate. Of course, more needs to be known about what measures are important for more types of care, especially chronic illnesses. Physicians and other health care providers, working with local consumers, need to be activated to streamline and reduce the costs of care while providing more care that is actually effective and desired. This goal requires some degree of local organization, such as a local, integrated health care network. Funding through health insurance must be adequate (recently, in California, it has not been), and the health network must be able to document the quality of the health care provided. The idea is to create a stronger link between funding and performance.