What Good Is Access Without Quality?

Despite what some consider excessive education, I regress to using primitive expressions from a very deep and fairly primitive part of my brain when I’m frustrated.  So excuse me a moment while I wail, “Oy Vay!” Thank you – I feel much better now.

You might wonder what brings such an expression to my lips.  And you deserve an answer for faithfully continuing to read while I ventilate some steam.

Every discussion of public health care in this year which is winding down has been totally misguided – and I believe intentionally aimed at misleading the public.

Yes – it is a tragedy that so many people have no health insurance to cover them in time of need.  Yes – it is horrible that many people are financially ruined by medical bills.  Yes – it would be nice if something could be done.

However – call me cynical – I can’t for the life of me see the government as a solution for any of this.

Talk about health care reform this year has actually been about insurance reform.  The President has given many speeches on the topic, but basically avoided what the public seemed to be clamoring for – single-payer insurance.

That is a system where there is only one entity who pays for health care insurance – and that is the federal government.

From the standpoint of the government, this poses one huge, gigantic problem.

Private insurance companies would be eliminated.

You know, those entities that make huge, gigantic campaign contributions and often hire government officials as soon as they are out of office?

Instead, we ended up with a proposal to force everybody to buy insurance – OR ELSE!  That’s right, you could be penalized for not spending money with those private insurance companies.

Sweet deal – if you’re an insurance company.

So that has to be “spun” – as they say – to sound like a good thing.  And that good thing is “access.”

It is said that with such a system those millions of people who have no insurance would have access to health care that they now lack.

I know there is a question of access and it is political and emotional for plenty of folks. But wait, there’s something else. The word and the expression that nobody dares speak. I, of course being fearless, will write it. “Quality of care.” It does not take an enormous dollop of common sense to realize that access without quality is an exercise in futility — the kind of exercise that is more one of politics than health.

“Access” is an empty word, null and void.  We all have access to many things without being able to attain them.  Many people have access to food, since supermarkets are numerous in just about any city of any size.  Yet, there are homeless and starving people that can’t afford to go inside and buy the food they need.

Many people have access to automobiles – all you need is money or credit.  Yet all they can afford to do is walk or take public transportation.

All people actually have access to health care at this time.  Believe it or not, there are laws in place that provide for health care, even for those who can’t afford to pay for it.  In a life-or-death situation, no hospital emergency room can turn you away until you are stabilized.  If your condition is mental or physical, we have both federal and state programs – such as Medicare and Medicaid (In California, it is called Medi-Cal.)

So access is really not an argument.

Quality, however is of supreme importance.  It is something you need to stay alive.

We really need to work on quality of care.  Just ask anybody who has been a patient. What good is access when you are requesting access to some kind of immeasurable gang-fight where your bodily well being is at risk?

Surgery is a good example of a place where quality can be measured — physical measurements and numbers are the things that research statisticians dream about.

At least the ones at Harvard, who went to North Carolina to find a place where people actually seemed interested in improving the quality of care. Checklists upon checklists, the instrument count to make sure nothing is left in the tummy.  Checklists are not a particular object of passion, often avoided whenever possible by physicians, who generally seem to be convinced they know how to do things already and do not like to add a measurable and countable checklist.  Yet checklists are institutional and do not cast aspersions upon individuals, so whatever they are I suppose they are better accepted than, for example, reporting the surgeon showed up for an emergency operation drunk.  (I actually reported this once, in another country.) I ended up doing most of the surgery myself, as I was a surgical resident then.  It was only an appendix, the patient never knew what happened, the surgeon was sanctioned by the rules of the region and I got a handshake from the patient in the morning. The kicker for me was that there really was not a heck of a lot of diminution in surgical error rate with all these measures. And this was absolutely the easiest thing that anybody could have measured. If nothing else, it is a nifty reminder of how people choose topics for research.  More publications, more grants, more tenure. I am not even totally convinced counting surgical errors is a measure of quality care.  I mean, everyone makes errors once in a bit. You open and you take out the sponge and close again and the patient can actually be okay.  How about errors in anesthesia or even plain old medication administration? I mean, those can kill folks. Then pick another specialty like … psychiatry.  People cannot decide what outcome measures are.  People cannot even decide who needs to be more satisfied — doctor or patient.  What about the patient I treated brilliantly for a substance problem and who told me when stone cold sober that he was bored, hated his life, and really enjoyed being a poly-substance dependent prostitute? Quality of care — we got a long road for one or more consistent definitions before we actually improve it.