By Steven H. Woolf
Sunday, January 8, 2006
We tend to view medical advances -- the breakthroughs that produce better medications, technology and procedures -- as the front line in the war on disease. They capture the media's attention; we marvel over the technological wizardry and the ingenuity of scientists; and to the afflicted, each advance gives hope of a cure. The federal government invests billions of dollars in this enterprise, and competition for better products drives the highly lucrative pharmaceutical and medical device industries.
But the promise of a cure requires an additional step: Patients must receive the treatments promptly and properly. This step requires a well-functioning system to deliver care, which our country lacks. We spend far more money on inventing new treatments than on research into how to deliver them. Last year, Congress gave $29 billion to the National Institutes of Health, most of it to devise better treatments. The smaller federal agency responsible for solving problems with the delivery of health care, the Agency for Healthcare Research and Quality (AHRQ) , received only $320 million. Starkly put, for every dollar Congress allocates to develop breakthrough treatments, it allocates one penny to ensure that Americans actually receive them.
This imbalance in investment may cost more lives than it saves. A recent analysis by our research team at Virginia Commonwealth University demonstrated that developing new treatments often does less good than ensuring the delivery of older drugs to all those in need.
For example, we estimated that reminding physicians to offer cholesterol treatments to patients seen in the doctor's office would be seven times more effective in preventing heart attack deaths than replacing older cholesterol-lowering drugs with more potent medicines, such as those touted on TV. Even something as simple as more reliably prescribing aspirin, which we have known for a decade can prevent strokes, would prevent more strokes than prescribing the slightly more potent new clot-busting medicines that drug companies have spent billions of dollars to develop.
Physicians like me are admonished to close these gaps in the health care delivery system, and there are helpful steps we can take in our daily work. But to expect physicians to fix the problem without making larger system changes is like telling pilots to stop flying into other aircraft and not providing them with an effective air traffic control system.
As an individual physician, I cannot restructure referral and communication systems between local doctors' offices so that my patients experience seamless handoffs when they go elsewhere for tests or consultations. I cannot create electronic tools for my community to remind me and my patients when tests and shots are due and to enable doctors elsewhere to quickly retrieve and examine my patients' medical histories.
I cannot abolish the insurance company policies that prevent my patients from obtaining quality care when they should. I cannot create consumer Web sites that would enable my patients to learn more about their diagnoses, look up test results and exercise more control over their health. I cannot curtail rising pharmacy bills that force my patients to stop getting refills. Those changes can be implemented by those who manage the systems, not by individual physicians.
For now, the statistics on the quality of care in America remain disturbing: According to a widely cited study in the New England Journal of Medicine, Americans receive only 55 percent of recommended health care services. And according to the Commonwealth Fund -- a nonprofit whose mission is to promote a high-performing health care system -- nearly one-third of the adult population, or 61 million people, cannot obtain care because they are uninsured or underinsured. Even the insured struggle with out-of-pocket medical expenses, a leading cause of personal bankruptcy.
The public complains of delays, rushed visits, impersonal attention and medical errors. In a world that has embraced modern information technology, most doctors' offices still use paper charts and regularly misplace lab reports and telephone messages. Fragmentation in the system is worsening, causing clumsy handoffs and miscommunication between doctors. And every aspect of this crisis is worse for the elderly, minorities and the poor.
I am not advocating that medical advances be abandoned in favor of system solutions -- both are vital. But our leaders do need to find a new equilibrium between investing in new treatments and investing in delivering them. Politicians who neglect the unraveling of the health care system are missing Americans' rising frustration and anger with doctors, hospitals and insurance companies. A recent poll by the Kaiser Family Foundation found that 56 percent of Americans are worried that health care is worsening. In a 2004 survey conducted by the Commonwealth Fund, 69 percent of Americans felt that improving the quality of medical care should be a chief concern for Congress.
Beyond dissatisfaction, the larger problem with our focus on medical breakthroughs is that more Americans will die as a result. Solutions that make the delivery of quality care more systematic are not as sexy as robotic surgery, gene mapping and other medical advances, but they are more apt to save lives. Failing to establish systems to ensure that everyone receives recommended care is causing greater disease and deaths at levels that can rarely be offset by medical advances.
Our inattention to quality of health care delivery is not only bad for our health, but for the economy. The United States spends 15 percent of its gross domestic product on health care, twice the average per capita spending of all industrialized countries. As the costs of treating disease spiral upward, higher costs are being shifted to employees, who find their co-payments, insurance premiums and deductibles climbing. At such a time, the business case for repairing a dysfunctional delivery system could not be stronger.
Establishing organized systems of care would reduce disease complications and related treatment costs, lower waste and administrative costs created by inefficiency and produce a healthier, more productive workforce.
Faced with this logic, why do our political leaders invest so little in such solutions and continue to pour billions of dollars into the development of new treatments? For some, it is because they share the public's misconception that medical advances are more important than repairing the delivery system. Others may not understand how bad the health care system has become. Budget pressures keep some lawmakers from doing more about quality. Spending two cents at AHRQ for every NIH dollar would double the AHRQ budget to $600 million per year, but that is a non-starter on Capitol Hill.
In the end, however, it all comes down to priorities. No organized political constituency is devoted to lobbying Congress to improve the quality of health, but perhaps it is time for the American people to express themselves. After all, it is their health at stake.
Perhaps we have reached a point when progress in providing good care -- when needed, with compassion and skill and without errors -- would impress the public as a more meaningful "medical advance" than the rollout of the latest device or pill.
This year's congressional elections offer an opportunity to place the importance of quality care on the national political agenda. Other issues are important, but this is a matter of life and death.
Steven Woolf is a professor of family medicine, epidemiology and community health at Virginia Commonwealth University.