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It's the quality, stupid!

July 21, 2010
by H. Steven Moffic, MD
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I hope that my 7-year-old grandson, Noah, will forgive me for using the word "stupid." Whenever I slip, he reminds me of what my daughter Stacia has taught him about not saying "bad" words: "Don't say stupid, Hey-Hey!" I also apologize to any of you who takes the title personally or finds the word offensive.

My excuse is that I am just referring to President Clinton's use of the word. "It's the economy, stupid" was the phrase that seemed to capture the public's imagination and catapult Clinton's successful presidential campaign in 1992. It put focus on an area neglected by George H. W. Bush.

Unfortunately, the economy is back in focus. Actually, in healthcare, which President Clinton of course failed to reform, the focus on its cost to the economy never left. The combination of escalating costs with lessening access to care finally seemed to be enough for President Obama to succeed with some reform.

Getting less attention has been improving quality of care. However, Obama's choice to run Medicare and Medicaid, Dr. Donald Berwick, is starting to bring quality back into the spotlight. For many years, Dr. Berwick has been called a visionary by some for trying to improve the quality and safety of care. Interestingly enough, President Obama had to make his appointment during a recent Senate recess to avoid a prolonged delay for an office unmanned since 2006. Given that in the long run, better quality should actually reduce costs, maybe Clinton's phrase should be slightly altered to: It's the quality, stupid!

After all, access to care is only important if the care is of good quality. The need to drastically improve that is once again clear in a new report from the Commonwealth Fund titled "Mirror, Mirror on the Wall: How the Performance of the U.S. Health System Compares Internationally." It shows that increased access does not necessarily correlate with quality of care.

Out of 7 countries, The United States ran dead last, even though we spend twice as much as the other countries. Obviously, spending more money does not guarantee adequate access and quality. Not much new here. What may be a surprise, though, is that Canada, touted as a potential model for universal healthcare reform, only ranks just ahead of us in sixth place. All the countries but the USA have universal access.

Ranked first was the Netherlands. It was followed by Britain (a country Dr. Berwick admires), Australia, Germany, and New Zealand. I'm not sure why France was not included. Making a difference seems to be excellent social welfare programs, complete access to prescription drugs, and dental coverage.

In the study, the Commonwealth Fund defines high-quality care as "care that is effective, safe, co-ordinated, and patient-centered." Canada ranks last here, attributed to a lack of focus on prevention, medical errors, poor communication with patients, poor coordination of chronic illness treatment, and the relative lack of electronic medical records. Recently, during my vacation in Canada, the citizens seemed to agree with the report.




An additional "immense challenge" quality of mental health care to be added to Dr. Moffic's list is the grossly destructive influence of the managed care industry.

As someone who once worked in the belly of the beast I saw how impossible it was to keep administrators from diverting more and more of mental health clinicians' work time from direct patient care to struggling with specious "medical necessity" and other authorization and reimbursement issues.

The system relentlessly imposed increasing constraints on clinical judgment and attempted to stamp out any psychiatrist's service other than "med checks".

Only federal regulation had a shot at confining managed care to making care more cost-efficient rather than allowing it to maximize the fortunes of its top executives at the expense of health care quality. Failure of the recent "health care reform" kerfuffle to face the managed care industry down is something that 7-year-old Noah is unlikely to forgive when he becomes aware of what the older generation is leaving for him.

/Myron Pulier, MD


H. Steven Moffic

H. Steven Moffic

H. Steven Moffic, M.D. retired from the clinical practice of psychiatry and his tenured...

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