Flatlined: Resuscitating American Medicine

Chapter 22. Positioning of an American Medical Quality System

The concept of a center that evaluates technology is not new. Support for the idea has been steadily building in the insurance industry and among many policy groups in Washington.1 What is new—and essential— is the concept of an entity that also reforms the medical industry by performing experiments in health care financing and delving into the functions of hospitals and clinics to discover efficient processes and then facilitates the teaching of how to implement these processes. What is also new is the concept of an entity that systematically fills in the gaps in knowledge needed to set benchmarks and then generates a medical consensus to establish standards of quality medical practice. A technology assessment center alone will not save much money. In fact, the Congressional Budget Office has judged that a center that merely compares the effectiveness of treatments would save only about 6 billion dollars over ten years.2 The scope of the U.S. medical problem requires bigger thinking and bigger action, but even an institute restricted to measuring the effectiveness of medical interventions is controversial. So you can imagine the resistance to what I propose here. Everyone supports technology development because there are no losers, but technology assessment is not very popular because there are 261 22 Positioning of an American Medical Quality System The American Medical Quality System would provide the information and the payment models needed to alter insurance payment policy nationally and the reporting and education needed to inform the public. CH022.qxd 10/7/08 10:16 AM Page 261 losers. The 700 billion dollars in waste associated with unnecessary treatments has to come out of someone’s pocket. NIH research helps develop new technology, and the agency enjoys vastly more funding than its sister agencies—about four times more than the CDC and fifteen times more than the FDA. The NIH has the support of industry, medical schools, scienti fic societies, and disease societies such as the American Cancer Society and the American Heart Association. All profit from its work. It has no opponents and few detractors. What other federal agency can make that claim? Yet in 2003 only about 5 percent of the money allocated by the federal government to medical research was used to determine how best to deliver medical services.3 Research to find out what works in medicine had no status until 1989, when legislation established the Agency for Health Care Policy and Research with the mission to research the outcomes of medical treatment , develop guidelines for best medical practices, and advise Medicare on payment policy. But two simultaneous events in 1994 nearly cost the agency its life.4 The first was that it began to do its job. A review of the data on spine fusion had found there was no evidence that back fusion, a widely performed procedure, was effective and that it had a high complication rate. Agency staff proposed studies to find out more, but a professional society of spine surgeons, the North American Spine Society, attacked their conclusions. Moreover, a back surgeon from northern Virginia, Dr. Neil Kahanovitz, formed the Center for Patient Advocacy, which organized a letter-writing campaign to Congress. Through personal contacts in the House of Representatives, he succeeded in convincing a number of representatives that the agency’s position on back surgery was based on unsound research and was a waste of taxpayers’ money. Kahanovitz’s efforts were perfectly timed with a second 1994 event: Republican control of the House. As a federal body managed by the executive branch, the agency had naturally provided information and analyses to support the Clinton administration’s Health Security Act. But now its association with the executive branch made it vulnerable to enemies. Fueled by Kahanovitz’s lobbying, members of Congress accused it of “wastefulness and unwarranted interference in the practice of medicine.”5 REFORMING AMERICAN HEALTH CARE 262 CH022.qxd 10/7/08 10:16 AM Page 262 The Agency for Health Care Policy and Research barely survived the attack. It was dealt a 21-percent budget cut and renamed the Agency for Healthcare Research and Quality after its teeth were filed to nubs. Its successor agency was forced to abandon controversial topics that might affect payment policy. Its current budget is that of the NIH. The country depends upon the Federal Reserve System for objective financial decisions. AMQS’s dynamics should be the...