Tilting at Windmills - health care in the United States, and other topics

Washington Monthly, Oct, 1999 by Charles Peters

Bruce The Innocent * Alms for Buffett * Culinary Cowardice * Brigadier Gigolo * Taking the Sport Fish Logo to Tokyo

HAVE YOU NOTICED THAT YOUR Republican friends who ridicule Hillary Clinton for putting up with Bill are the same people who usually lecture us about the sinfulness of divorce and the importance of couples staying together for life?

"THEY WOULDN'T LET THAT happen," my mother used to assure me whenever I expressed a fear that life might produce an unhappy result. "They" were the respectable authorities, public or private, who she imagined zealously guarding everything from the purity of the water we drank to the competence of the physicians we relied on. That bridge we were crossing wouldn't collapse because "they" wouldn't permit it to be used if it was unsafe. The canned soup would be wholesome because otherwise "they" wouldn't permit it to be sold in the grocery store. And so on. I'm sure you've known other firm believers in "they."

Of course, most of us learn as we go through life that they aren't nearly as reliable as mother thought. But what interests me is how little we do about it, how indifferent we are to checking up on them or, indeed, to finding out if they exist at all.

Consider health. There is, reports a recent Rand study, a "surprisingly small amount of systematic knowledge on the quality of health care delivered in the United States." This is especially troubling because the few studies that exist suggest real problems. Sixteen percent of hysterectomies in 1989-90 and 14 percent of coronary artery bypass operations were found to have been "inappropriate" and the reasons for 25 percent more of the former and for 30 percent more of the latter were less than clear. On the prevention side, only 52 percent of senior citizens are getting the flu shots they need.

One reason there are not enough studies is that doctors tend to resist evaluation that might cast doubt on their competence.

"Orthopedic surgeons went on the warpath in 1994 when a federal study raised questions about the efficacy of surgery for lower back pain," reports science columnist Daniel S. Greenberg. "In sympathy with the irate doctors, Congress whacked the budget of the sponsor of the unwelcome research, the Agency for Health Care Policy and Research in the Department of Health and Human Services"

As A DEVOTED STUDENT OF creative junketeering, I must express my admiration for Robert J. Souse, assistant regional director of the federal aid division of the U.S. Fish and Wildlife Service. He managed to convince his supervisors that the government should pay $14,842 for several trips he took to Brazil and Japan. On the last one to Japan he even managed to get authorization for a limousine. The purpose of his missions: "encouraging these manufacturers to use the Sport Fish logo on sport fishing equipment imported into the United States."

BACK IN 1990 THE NATIONAL Practitioner Data Bank was established to keep track of malpractice suits and disciplinary actions against incompetent physicians. This, it was thought, would prevent bad doctors from moving from state to state or hospital to hospital without having their new employer find out about their records. But the law has been evaded. Hospitals are taking fewer disciplinary actions in order to avoid angering their physicians. "They have to ... make sure they have the allegiance and loyalty and dedication of their [medical] staff," Dr. Roger A. Rosenblatt explained to The Washington Post's Sandra G. Boodman.

If a doctor is suspended, it is often for 29 days. Why? Because the law requires that only suspensions of 30 days or more be reported. And malpractice suits are often settled by having the payments made by health plans, professional corporations, group practices or hospitals--because, if the payment is not made by the doctor himself, it does not have to be reported. Finally, the AMA has succeeded in keeping the data bank off limits to consumers.

SEVERAL YEARS AGO, CLEVELAND businessmen, worried about skyrocketing health insurance costs, established Cleveland Health Quality Choice to monitor the quality of health care in local hospitals. It published reports "showing patient satisfaction levels and death rates for a variety of illnesses and procedures," according to Thomas M. Burton of The Wall Street Journal. Such reports can be valuable because studies have shown that the death rate for stroke patients, for example, can vary from hospital to hospital from zero to 36.8 percent. And in fact, the Cleveland reports did prove valuable. A 1997 article in the American Journal of Medical Quality reported that an 11 percent decrease in death rates after Health Quality Choice was founded. Individual hospitals improved their practices in response to the reports.

But the influential Cleveland Clinic didn't like the reports because, according to one doctor, "they weren't shown to be the best at everything" A hospital that graded well, Mount Sinai Medical Center, did not attract new patients because hospitals were not permitted to advertise the reports. And the public was given less information about the hospitals than the businesses that sponsored the reports. Finally the businesses lost interest because rising medical costs no longer loomed as a major problem for them. So Cleveland Health Quality Choice died.