Archive for January, 2008

The Fallacy of Excellence

Tuesday, January 1st, 2008

“We have the best doctors and hospitals, and we have the best health care system in the world,” I heard a Republican candidate for president say the other day. It rolled off his tongue very smoothly. The audience applauded, nodding quietly in assent. (I couldn’t see them well enough – the camera was on him – but it felt like they were nodding.)

The candidate’s statement struck me for two reasons. First, you don’t hear it much these days. Almost everyone from CEOs to presidential hopefuls to policy wonkettes seems to think health care is broken, or in deep crisis. So when John McCain said it, it was kind of a nice retro moment, back to a time when almost everyone in America agreed with the three-step statement: best doctors, best hospitals, best health care system.

Second, what struck me was the fact that the audience applauded and nodded in agreement (in my mind’s eye). In my rattling around American health care I see this all the time, among lay audiences, hospital board members and a lot of business people. I have come to call it the “fallacy of excellence.”

Only as Good as the System

There is a common perception that quality of inputs equals quality of performance and outcomes. Health care delivery has become mind-bogglingly complicated, but we still like to cling to the simple, reassuring notion that if we have really well-trained doctors and nurses, and we put them in nice new sparkling buildings and provide them with lots of new technology, we will always deliver excellent care. I don’t believe that. While having well-trained staff and good facilities may be necessary conditions, they are far from sufficient.

The health care glitterati agree that it takes a “system” to deliver safe, reliable, high-quality, cost-effective care, from the very top level of policy to the micro-organization of care. The general public knows only too well the downside of a lack of systemness: from the 47 million uninsured, to the lack of coordination of caregivers, to the absence of a medical home. The public may know the system doesn’t work, but it seems to me they still cling to the notion that more is better, that good doctors and hospitals guarantee good quality, and (maybe by inference) that higher costs and prices are associated with excellence in outcomes.

I see this in the eyes of lay board members at hospital retreats. I hear it in the questions from general audiences. And I see it in folks whose eyes glaze over in disbelief that cost and quality may be correlated inversely (namely, that high cost is associated with poor quality, an assertion that has increasing evidence behind it from the Dartmouth Atlas of Health Care to the Premier pay-for-performance experiments with the Centers for Medicare & Medicaid Services).

If the public, doctors and hospital trustees are aligned in the fallacy of excellence, that behavior may foreshadow a rocky road for some important policy initiatives, such as:

Pay-for-performance (P4P) initiatives that reward efficiency. Increasingly the P4P movement will incorporate so-called efficiency measures into its programs. This reinforces the notion that high-quality care can also be of lower cost.

High-performance networks. Similarly, patients will be asked to believe that lower-cost performers are also higher quality as they are directed to so-called high-performing providers that are low-cost and high-quality.

Center for comparative effectiveness. Increasingly, there are calls from health policy groups (including America’s Health Insurance Plans and the Committee for Economic Development) for the creation of a national independent center to evaluate the cost-effectiveness of new medical technologies and provide side-by-side analysis of the effectiveness of new technologies against existing therapies.

Changing the Mind-Set

In my humble opinion, there needs to be a national campaign to educate the public (and maybe even the doctors and hospital trustees) that more is not better, that outcomes cannot be guaranteed by excellence of inputs, and that it takes a system at both the macro and micro levels to deliver good health care.

The Institute of Medicine has done a brilliant job of documenting the value of systemness in its path-breaking reports. But we need to popularize the message and educate the public that systems of care matter. Otherwise, the fallacy of excellence will dominate the public discourse on health care – from presidential campaign debates to hospital board retreats – and we will continue to spend more and get less than we should.

Ian Morrison is an author, consultant and futurist based in Menlo Park, Calif. This article 1st appeared on January 8, 2008 in HHN Magazine online site.