NCHC Writer
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Henry E. Simmons, M.D., M.P.H., F.A.C.P.
President and Founder of the

      The health care industry accounts for a trillion dollars in yearly expenditures. It represents approximately 14 percent of GDP. No industry of comparable size exists in our economy. Yet it operates without a system-wide framework for defining, measuring and ensuring quality. In what other industry would that be tolerated by the American public?

      Look at the airline industry. When the TWA and ValuJet crashes occurred last year, the Government swung into action: the Federal Aviation Administration and the FBI launched year-long multi-million dollar investigations; Congressional hearings were called almost immediately; a presidential commission on airline safety, headed by the Vice President, was announced and sweeping new regulations were unveiled jut a few months later; and every sector of the airline industry came under intense scrutiny by Congress and the media. On average, plane crashes take approximately 700 American lives every year.

      Now look at the health care industry where an estimated 180,000 – yes, one hundred and eighty thousand – Americans die unnecessarily due to errors in medical treatment. An additional 1.3 million are injured, with one million of those injuries considered preventable. The death rate is equivalent to three jumbo-jet crashes every two days.* Despite the alarming prevalence of medical errors in the health care system, no federal investigations are launched, Congress pays little or no attention, and the public is generally unaware.

      The “dirty little secret” of the world’s best health care system is that the industry is operating in a quality control vacuum with no universally accepted guidelines for procedures or practices. Our health care system could be better, safer and less expensive, if we devote just a fraction of the attention to quality in health care as we do to safety in the airline industry. And the results would be more far-reaching.

      The basic quality problems are: overuse, when a health service is provided in circumstances where its risks outweigh its benefits, thereby incurring unnecessary costs and more harm than benefit to the patient; underuse, the failure to provide a service that provides a benefit and saves money in the long run; and misuse, when a beneficial service is provided poorly, resulting in a preventable complication. Unfortunately, as the industry stands today, there are no commonly accepted parameters for determining which procedures provide the greatest benefit at the lowest cost. There are no universally accepted cost/benefit analyses for specific drugs to treat specific diseases. And there are no systematic methods of changing medical behaviors which may be the result of ignorance of the latest treatments and technologies, as opposed to the carelessness or incompetence.

      In the absence of quality assurance measures, we have moved steadily toward a system that rewards lower cost and does not adequately concern itself with quality. Ironically, a system that puts a premium on lower costs, can actually turn out to be more expensive in the long run because of ineffective and inappropriate initial treatments. As a means of controlling costs, attention has focused on “inputs” rather than on “outcomes” — the price of the treatments, rather than on the value of the results. Clearly, if quality guidelines are to be set, the outcomes side of the equation is the one that needs to be researched and analyzed.

      Quality assurance studies throughout the health care industry would identify what works and what doesn’t; and better yet, what works and works better. Tried and true methods would constantly be re-examined against new and improved ideas. Such an enlightened industry would know that low cost alone does not always equate with value or excellence, or even efficiency.

      Addressing the quality issue in an aggressive and comprehensive manner must be our highest priority in health care. Recently, President Clinton announced his Advisory Commission on Consumer Protection and Quality in the Health Care Industry. What better body to begin the process whereby we, as a nation, create system-wide quality guidelines and accountability, and at the same time provide better, more equitable and affordable health care? If the commission does its job, and if consumers and providers act upon it recommendations, we just might be on our way to “first, doing no harm.”

      * Lucian L. Leape, MD, “Error in Medicine,” Journal of American Medicine (JAMA). December 21, 1994 – Vol. 272, No. 23.