' 39 IMPROVING THE QUALITY OF HEALTH CARE: A SKEPTIC'S VIEW* ELI GINZBERG, Ph.D. A. Barton Hepburn Professor of Economics Graduate School of Business Director, Conservation of Human Resources Columbia University New York, N.Y.
THE skeptic's role is not a popular one, and to cast serious doubts upon the inauguration of an idealistic new program or movement is not an enviable task. Nevertheless, I shall begin my analysis of the realities underlying responsibility for the quality of health care by addressing three specific themes: i) the operation of the delivery system for health services in the United States and its implications for the assurance of quality, 2) the relation of resources to quality, and 3) the potential value of existing or likely mechanisms for effective intervention on behalf of the assurance of quality. What can be learned about enhancement of the quality of medical care in the United States from our past experience? Historically, the major advance in our system must be attributed to implementation of the Flexner Report, which established minimum standards of medical education. It was reinforced by the subsequent movement toward specialization in American medicine. The introduction of closed hospital staffs was another significant contribution to the assurance of quality which benefitted at least the patients of the affected institutions. Leaving aside the serious implications which this had for those physicians who were excluded from the staff, within the hospital it established sound peer-imposed and peer-enforced standards of performance. Still another significant influence which improved health care has been the public. The consumer, thanks to generally higher levels of education, has become somewhat more skeptical with regard to the efficacy of medical care, and, therefore, more self-protective. Old per*Presented in a panel, Long-Term Implications and Effects, as part of the 1975 Annual Health Conference of the New York Academy of Medicine, The Profesaional Responibility for the Qusality of Health Care, held April 24 and 25, 1975.
Vol. 52, No. 1, January 1976
I 4o
E. GINZBERG
140F.
GINZBERG
ceptions also may be changing. Not all consumers now believe that more medical care is necessarily beneficial or even neutral in its effects; in fact, they believe that it may be harmful. Attitudes toward the health-care system have not been immune to the constructive influence of the vast expansion of education. For example, it is my impression that Dr. Benjamin Spock's book on baby care significantly contributed to health in the United States. Its efficacy was primarily a function of the greatly enhanced level of literacy in the nation; otherwise, such an instrument would have been ineffectual. Beyond these landmark developments, progress toward quality assurance in the United States has been unimpressive. The record of direct governmental intervention has been mediocre at best. Governmental efforts have been concentrated in a few selected areas, such as the establishment of standards for nurseries for the newborn and the imposing of basic safety requirements upon health-care institutions. The government also has developed an elaborate regulating mechanism governing the production and sale of drugs to the public. Beyond this, governmental health authorities have never attempted to undertake any serious form of surveillance of the providers of care, even via simple statistical analysis. As far back as 1949, in a study of hospital care in New York State,' I suggested that it might be useful to have regular governmental review of hospital death rates, the frequency of specific surgical procedures, and other selected operating data-not to control institutional activity, but to be responsive to the appearance of trouble signals. However, health authorities have never utilized such data to monitor our medical-care system. All told, governmental intervention to control the quality of medical care has been weak. What has been the role of professional medical organizations with respect to quality assurance? The medical societies have demonstrated unequivocally that they will not, cannot, and do not really desire to discipline their own members. What other conclusion could be inferred from the fact that approximately 200 disciplinary actions per year are instituted in the whole United States-half of these in California? Efforts to accredit hospitals have been correspondingly mediocre. They have been concerned primarily with structural requirements, the importance of which I do not wish to minimize. Nevertheless, accreditation criteria for all practical purposes have not been extended to Bull. N. Y. Acad. Med.
A
VIEW SKEPTIC7S SKEPTIC'S A
VIEW
I'4'~~~~~~~~~~~~~~~~~ 4I
institutional operations, procedures, and staffing, which go to the heart of quality performance. A final, crucial concern for the enhancement of quality relates to the great variability in acceptable levels of care, depending on the part of the country or city or the particular population group that is being, served. This variability poses a practical no less than a political dilemma, for it implies that the enforcement of rigid standards may eliminate the only source of care available to large numbers of people since poor care occurs far more frequently than is generally realized. However, there is much less need for medical intervention than is commonly perceived; therefore, I am not troubled by the likelihood of any reduction in the volume of care which may be produced. But that is not the generally accepted view. In summary, we are the captives of several difficult problems: Government has been an ineffective intervenor; the profession will not police itself; variability in the standard of care is extreme; and insufficiency of resources is a critical obstacle to the elimination of substandard services. Looking ahead, what can be anticipated? Legislation aimed at the assurance of quality developed from the desire of Congress to control costs. These are fundamentally conflicting goals; to the extent that much of the poor care is attributable to inadequate resources, it must be obvious that measures which concentrate on economy are inconsistent with the improvement of quality. When Professional Standards Review Organizations (PSRO) become fully operational (if ever) they will contribute significantly to the standardization of practice. Whether such standardization will be beneficial is an open question. For example, one distinguished physician estimates that he now spends IO% to 20% of his time on what he terms "defensive medicine"; this will be reinforced by PSRO-induced standardization.2 It is far from obvious to me that this in fact will contribute to the assurance of quality. In preference to the elaboration of the cumbersome mechanism of PSRO, a serious effort toward the assurance of quality care requires a different approach. We might begin by attempting to agree on what constitutes dangerously inadequate care. After establishing such indices, we could use basic hospital data to identify individual institutions which have a high frequency of outcomes which are indicative of deficient Vol. 52, No. 1, January 1976
I 42
142
GINZBERG E. E.
GINZBERG~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
care. Further analysis then would be required to determine what specific practices and procedures were. related to inadequate care and what forms and degrees of control should be instituted. An effort to improve ambulatory care would have to be undertaken at some later date. In addition to understanding the relation between specific interventions and failures of quality, we must remember the importance of adequate financial resources. Without sufficient resources little can be done to improve quality. Finally, it must be emphasized that no advance toward the achievement of high quality is possible in any professional service without the strong support of both the profession and the consumer. In reality, however, it is unlikely that the critical groups-even those within one defined area-can agree on the identification of inadequacies in quality and the resolutions that these require. In my 1949 report, for example, I suggested that New York City was not justified in maintaining its vastly inferior municipal hospital system parallel to the generally superior voluntary system; it was patently wasteful of resources and grossly inequitable to the citizens.3 During the intervening quarter of a century innumerable reports have reached the same conclusion, yet the dual system has been perpetuated and the gap between the better voluntary institutions and the municipal hospitals in New York City continues to widen.4 The question of resources must be constantly in the foreground of discussions about quality, but in reality the mere infusion of funds into the system does not produce better care. Tens of billions of dollars have been allocated to health care since i965; although the number of citizens who are entitled to care has broadened and we have seen some shift in the burden of financing, no significant improvement in quality has yet appeared. In addition, the costs of any form of regulation cannot be ignored. While I do not agree with the Chicago school of economists that the costs of regulation inevitably outweigh any possible benefits,5 the price of controlling complex systems can be extremely high, perhaps incommensurate with the resulting gain. Beyond the dilemma of availability of resources lie the problems inherent in the delivery system for health services. Our pluralistic system incorporates no mechanisms to force changes and no effective substitute for the lack of professional leaders and the indifference of the Bull. N. Y. Acad. Med.
A
A
SKEPTICIS SKEPTIC'S
VIEW
VIEW
I43
'43
medical profession to improvement in the quality of care. This problem is not unique to medicine. Within both the educational and the research communities the same resistance to change is evident for the same reasons. As providers, professional people are interested in practicing according to self-imposed standards which are related primarily to their own optimization system. Hence, external efforts directed at the improvement of quality in which the provider is the critical element are difficult to implement. Further, I do not see the beginning of any serious quality-assurance mechanisms. PSRO is a new and untried mechanism, but it is organizationally top-heavy and cumbersome; I doubt that it can realize the expectations of its proponents. No other mechanisms have shown the power to effect changes either. Despite the existence of a regional hospital authority for over four decades, for example, not until the present fiscal crisis has it been possible to close a municipal hospital in New York City. Although extreme budgetary constraints may produce some peripheral changes, it is probable that the quality of care will be impaired further by any reduction of resources. My concluding observations on assuring responsibility for the quality of health care are these: No professional service can rise above the willingness of the key professional people to cooperate and to lead in instituting change. No improvements in quality can be discussed outside of the context of the allocation of resources; while increased resources are no guarantee of quality, quality cannot be achieved without sufficient resources. It would be a danger and a disservice to the United States to remain inactive in the face of patent defects in our social system. However, it is counterproductive and even risky to propose goals that cannot be reached and to make promises that cannot be fulfilled. In the health-service arena in particular solutions to problems must be designed so that implementation will be feasible given the realities of the system. Discussion QUESTION. Since power and authority emanate from administration, what is your assessment of hospital and medical-care administration as a tool for the improvement of quality? DR. GINZBERG. Power does not emanate from administration per se, but from political centers, and the two are hardly the same. What Vol. 52, No. 1, January 1976
I 44
'44
E. E.
GINZBERG GINZBERG
I have suggested is that power resides with the profession, the consumers who spend money, and the government that makes money available. Administrators are a weak link in this chain. Anyone who believes that a hospital director exercises any significant control has a different view of the operation of a hospital than I do. QUESTION. Accepting your skepticism at face value, what do you suggest that we do now in view of the pending national health insurance?
DR. GINZBERG.
I am cautious about what is pending and how
soon it will materialize. I believe that national health insurance will not be enacted quickly and that when it is enacted it will be of doubtful quality. I see no possibility whatever of raising substantial new sums for health care from the general revenues of the federal government and little chance of increasing Social Security taxes. No matter what labor leaders say, I doubt that they really want national health insurance, because it would mean the loss of their control over health and welfare funds. Therefore, I doubt that any health-care legislation will be passed by the present Congress. If the Democrats win in 1976 we may get some kind of national health insurance, but I expect it to be of the catastrophic type which may introduce greater confusion into an already confused system. QUESTION. Will the history of weak intervention by government in the assurance of quality care change now that the government is paying the bill?
DR. GINZBERG. I doubt that. Our government has been supporting public education in the United States for more than ioo years, and yet the public schools do not educate or are unable to educate youngsters from low income groups, with a few exceptions. I do not believe that there is much correlation between governmental dominance and the quality of performance of a service. QUESTION. What kind of health system would change your skeptical view of American medicine? DR. GINZBERG. I believe that the health-care system has been unduly expanded, in terms both of the professionals' "interest" in the system and the consumers' expectation of what the system can do for them. On the whole, I see little relation between most medical intervention and the health and well-being of the American public. Obviously, that does not mean that I want hospitals to disappear, that I do not Bull. N. Y. Acad. Med.
A SKEPTIC'S VIEW
I 45
think that people ought to receive ambulatory services, or that chronic patients do not need to be helped. But, regrettably, most medical interventions are largely in the neutral area. That is, most patients would improve without the interventions, some patients suffer from the interventions, and many patients who need interventions do not benefit because of the limits of medical science and knowledge. Therefore, I have reservations about the critical importance of health services for the well-being of the public in relation to many other needs. I consider a job, a minimum income, education, increased stability in the urban environment, and the elimination of discrimination to have greater significance for the well-being of individuals and groups than the expanded delivery system for health services. NOTES AND REFERENCES 1. Ginsberg, E.: A Pattern for IHospital Care. New York, Columbia University
Press, 1949, cha1p. 22, pp. 349 ff. 2. Statement made by former president of the American Medical Association at recent private meeting. When it was (qluoted to a professor at a midWest niedical school, he indicated that his colleagues have raised the estimate to 50%! 3. Ginzberg, E., op. cit., chap. 13, pp. 149 ff.
Vol. 52, No. 1, January 1976
4. Ginzberg, E. et al.: Urbait Health Services: The Case of New York. New York, Columbia University Press, 1971. chap. 10, pp. 206 If. 5. Posner, R. A.: Theories of economic regulation. Bell J. Econ. Maniagement Sci. 5:335, 1974; Peltzman, S.: Regulation of Pharmaceutical Imnovation. ACmer. Enterprise Inst. for Public Policy Research Evaluative Studies, No. 15. Washington, D.C., 1974.
THE skeptic's role is not a popular one, and to cast serious doubts upon the inauguration of an idealistic new program or movement is not an enviable task. Nevertheless, I shall begin my analysis of the realities underlying responsibility for the quality of health care by addressing three specific themes: i) the operation of the delivery system for health services in the United States and its implications for the assurance of quality, 2) the relation of resources to quality, and 3) the potential value of existing or likely mechanisms for effective intervention on behalf of the assurance of quality. What can be learned about enhancement of the quality of medical care in the United States from our past experience? Historically, the major advance in our system must be attributed to implementation of the Flexner Report, which established minimum standards of medical education. It was reinforced by the subsequent movement toward specialization in American medicine. The introduction of closed hospital staffs was another significant contribution to the assurance of quality which benefitted at least the patients of the affected institutions. Leaving aside the serious implications which this had for those physicians who were excluded from the staff, within the hospital it established sound peer-imposed and peer-enforced standards of performance. Still another significant influence which improved health care has been the public. The consumer, thanks to generally higher levels of education, has become somewhat more skeptical with regard to the efficacy of medical care, and, therefore, more self-protective. Old per*Presented in a panel, Long-Term Implications and Effects, as part of the 1975 Annual Health Conference of the New York Academy of Medicine, The Profesaional Responibility for the Qusality of Health Care, held April 24 and 25, 1975.
Vol. 52, No. 1, January 1976
I 4o
E. GINZBERG
140F.
GINZBERG
ceptions also may be changing. Not all consumers now believe that more medical care is necessarily beneficial or even neutral in its effects; in fact, they believe that it may be harmful. Attitudes toward the health-care system have not been immune to the constructive influence of the vast expansion of education. For example, it is my impression that Dr. Benjamin Spock's book on baby care significantly contributed to health in the United States. Its efficacy was primarily a function of the greatly enhanced level of literacy in the nation; otherwise, such an instrument would have been ineffectual. Beyond these landmark developments, progress toward quality assurance in the United States has been unimpressive. The record of direct governmental intervention has been mediocre at best. Governmental efforts have been concentrated in a few selected areas, such as the establishment of standards for nurseries for the newborn and the imposing of basic safety requirements upon health-care institutions. The government also has developed an elaborate regulating mechanism governing the production and sale of drugs to the public. Beyond this, governmental health authorities have never attempted to undertake any serious form of surveillance of the providers of care, even via simple statistical analysis. As far back as 1949, in a study of hospital care in New York State,' I suggested that it might be useful to have regular governmental review of hospital death rates, the frequency of specific surgical procedures, and other selected operating data-not to control institutional activity, but to be responsive to the appearance of trouble signals. However, health authorities have never utilized such data to monitor our medical-care system. All told, governmental intervention to control the quality of medical care has been weak. What has been the role of professional medical organizations with respect to quality assurance? The medical societies have demonstrated unequivocally that they will not, cannot, and do not really desire to discipline their own members. What other conclusion could be inferred from the fact that approximately 200 disciplinary actions per year are instituted in the whole United States-half of these in California? Efforts to accredit hospitals have been correspondingly mediocre. They have been concerned primarily with structural requirements, the importance of which I do not wish to minimize. Nevertheless, accreditation criteria for all practical purposes have not been extended to Bull. N. Y. Acad. Med.
A
VIEW SKEPTIC7S SKEPTIC'S A
VIEW
I'4'~~~~~~~~~~~~~~~~~ 4I
institutional operations, procedures, and staffing, which go to the heart of quality performance. A final, crucial concern for the enhancement of quality relates to the great variability in acceptable levels of care, depending on the part of the country or city or the particular population group that is being, served. This variability poses a practical no less than a political dilemma, for it implies that the enforcement of rigid standards may eliminate the only source of care available to large numbers of people since poor care occurs far more frequently than is generally realized. However, there is much less need for medical intervention than is commonly perceived; therefore, I am not troubled by the likelihood of any reduction in the volume of care which may be produced. But that is not the generally accepted view. In summary, we are the captives of several difficult problems: Government has been an ineffective intervenor; the profession will not police itself; variability in the standard of care is extreme; and insufficiency of resources is a critical obstacle to the elimination of substandard services. Looking ahead, what can be anticipated? Legislation aimed at the assurance of quality developed from the desire of Congress to control costs. These are fundamentally conflicting goals; to the extent that much of the poor care is attributable to inadequate resources, it must be obvious that measures which concentrate on economy are inconsistent with the improvement of quality. When Professional Standards Review Organizations (PSRO) become fully operational (if ever) they will contribute significantly to the standardization of practice. Whether such standardization will be beneficial is an open question. For example, one distinguished physician estimates that he now spends IO% to 20% of his time on what he terms "defensive medicine"; this will be reinforced by PSRO-induced standardization.2 It is far from obvious to me that this in fact will contribute to the assurance of quality. In preference to the elaboration of the cumbersome mechanism of PSRO, a serious effort toward the assurance of quality care requires a different approach. We might begin by attempting to agree on what constitutes dangerously inadequate care. After establishing such indices, we could use basic hospital data to identify individual institutions which have a high frequency of outcomes which are indicative of deficient Vol. 52, No. 1, January 1976
I 42
142
GINZBERG E. E.
GINZBERG~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
care. Further analysis then would be required to determine what specific practices and procedures were. related to inadequate care and what forms and degrees of control should be instituted. An effort to improve ambulatory care would have to be undertaken at some later date. In addition to understanding the relation between specific interventions and failures of quality, we must remember the importance of adequate financial resources. Without sufficient resources little can be done to improve quality. Finally, it must be emphasized that no advance toward the achievement of high quality is possible in any professional service without the strong support of both the profession and the consumer. In reality, however, it is unlikely that the critical groups-even those within one defined area-can agree on the identification of inadequacies in quality and the resolutions that these require. In my 1949 report, for example, I suggested that New York City was not justified in maintaining its vastly inferior municipal hospital system parallel to the generally superior voluntary system; it was patently wasteful of resources and grossly inequitable to the citizens.3 During the intervening quarter of a century innumerable reports have reached the same conclusion, yet the dual system has been perpetuated and the gap between the better voluntary institutions and the municipal hospitals in New York City continues to widen.4 The question of resources must be constantly in the foreground of discussions about quality, but in reality the mere infusion of funds into the system does not produce better care. Tens of billions of dollars have been allocated to health care since i965; although the number of citizens who are entitled to care has broadened and we have seen some shift in the burden of financing, no significant improvement in quality has yet appeared. In addition, the costs of any form of regulation cannot be ignored. While I do not agree with the Chicago school of economists that the costs of regulation inevitably outweigh any possible benefits,5 the price of controlling complex systems can be extremely high, perhaps incommensurate with the resulting gain. Beyond the dilemma of availability of resources lie the problems inherent in the delivery system for health services. Our pluralistic system incorporates no mechanisms to force changes and no effective substitute for the lack of professional leaders and the indifference of the Bull. N. Y. Acad. Med.
A
A
SKEPTICIS SKEPTIC'S
VIEW
VIEW
I43
'43
medical profession to improvement in the quality of care. This problem is not unique to medicine. Within both the educational and the research communities the same resistance to change is evident for the same reasons. As providers, professional people are interested in practicing according to self-imposed standards which are related primarily to their own optimization system. Hence, external efforts directed at the improvement of quality in which the provider is the critical element are difficult to implement. Further, I do not see the beginning of any serious quality-assurance mechanisms. PSRO is a new and untried mechanism, but it is organizationally top-heavy and cumbersome; I doubt that it can realize the expectations of its proponents. No other mechanisms have shown the power to effect changes either. Despite the existence of a regional hospital authority for over four decades, for example, not until the present fiscal crisis has it been possible to close a municipal hospital in New York City. Although extreme budgetary constraints may produce some peripheral changes, it is probable that the quality of care will be impaired further by any reduction of resources. My concluding observations on assuring responsibility for the quality of health care are these: No professional service can rise above the willingness of the key professional people to cooperate and to lead in instituting change. No improvements in quality can be discussed outside of the context of the allocation of resources; while increased resources are no guarantee of quality, quality cannot be achieved without sufficient resources. It would be a danger and a disservice to the United States to remain inactive in the face of patent defects in our social system. However, it is counterproductive and even risky to propose goals that cannot be reached and to make promises that cannot be fulfilled. In the health-service arena in particular solutions to problems must be designed so that implementation will be feasible given the realities of the system. Discussion QUESTION. Since power and authority emanate from administration, what is your assessment of hospital and medical-care administration as a tool for the improvement of quality? DR. GINZBERG. Power does not emanate from administration per se, but from political centers, and the two are hardly the same. What Vol. 52, No. 1, January 1976
I 44
'44
E. E.
GINZBERG GINZBERG
I have suggested is that power resides with the profession, the consumers who spend money, and the government that makes money available. Administrators are a weak link in this chain. Anyone who believes that a hospital director exercises any significant control has a different view of the operation of a hospital than I do. QUESTION. Accepting your skepticism at face value, what do you suggest that we do now in view of the pending national health insurance?
DR. GINZBERG.
I am cautious about what is pending and how
soon it will materialize. I believe that national health insurance will not be enacted quickly and that when it is enacted it will be of doubtful quality. I see no possibility whatever of raising substantial new sums for health care from the general revenues of the federal government and little chance of increasing Social Security taxes. No matter what labor leaders say, I doubt that they really want national health insurance, because it would mean the loss of their control over health and welfare funds. Therefore, I doubt that any health-care legislation will be passed by the present Congress. If the Democrats win in 1976 we may get some kind of national health insurance, but I expect it to be of the catastrophic type which may introduce greater confusion into an already confused system. QUESTION. Will the history of weak intervention by government in the assurance of quality care change now that the government is paying the bill?
DR. GINZBERG. I doubt that. Our government has been supporting public education in the United States for more than ioo years, and yet the public schools do not educate or are unable to educate youngsters from low income groups, with a few exceptions. I do not believe that there is much correlation between governmental dominance and the quality of performance of a service. QUESTION. What kind of health system would change your skeptical view of American medicine? DR. GINZBERG. I believe that the health-care system has been unduly expanded, in terms both of the professionals' "interest" in the system and the consumers' expectation of what the system can do for them. On the whole, I see little relation between most medical intervention and the health and well-being of the American public. Obviously, that does not mean that I want hospitals to disappear, that I do not Bull. N. Y. Acad. Med.
A SKEPTIC'S VIEW
I 45
think that people ought to receive ambulatory services, or that chronic patients do not need to be helped. But, regrettably, most medical interventions are largely in the neutral area. That is, most patients would improve without the interventions, some patients suffer from the interventions, and many patients who need interventions do not benefit because of the limits of medical science and knowledge. Therefore, I have reservations about the critical importance of health services for the well-being of the public in relation to many other needs. I consider a job, a minimum income, education, increased stability in the urban environment, and the elimination of discrimination to have greater significance for the well-being of individuals and groups than the expanded delivery system for health services. NOTES AND REFERENCES 1. Ginsberg, E.: A Pattern for IHospital Care. New York, Columbia University
Press, 1949, cha1p. 22, pp. 349 ff. 2. Statement made by former president of the American Medical Association at recent private meeting. When it was (qluoted to a professor at a midWest niedical school, he indicated that his colleagues have raised the estimate to 50%! 3. Ginzberg, E., op. cit., chap. 13, pp. 149 ff.
Vol. 52, No. 1, January 1976
4. Ginzberg, E. et al.: Urbait Health Services: The Case of New York. New York, Columbia University Press, 1971. chap. 10, pp. 206 If. 5. Posner, R. A.: Theories of economic regulation. Bell J. Econ. Maniagement Sci. 5:335, 1974; Peltzman, S.: Regulation of Pharmaceutical Imnovation. ACmer. Enterprise Inst. for Public Policy Research Evaluative Studies, No. 15. Washington, D.C., 1974.
