Tuesday, April 12, 2011

Outmoded Concept?

Quality, that is.  Has its day come and gone?  There was serious question a few months ago over continuation of the Baldrige award on the grounds that it was no longer relevant.  There was an article in, I think the NEJM last year suggesting that the quality movement had totally failed to produce any tangible results in healthcare.  The measures of healthcare done by AHRQ and NAHQ are indeed static.  Nothing is getting better. 
One can (and I have) argue about the relevance of the metrics, but nothing is improving.  Nothing.  True, there are poster-child stories about this hospital or that doing something great, but the overall system is static.  Why?

I think we have to go back to someone’s saying that a given system produces the results its designed to produce.  If you want a different result, you have to re-design the production system.  Healthcare was never designed to produce “quality.”  P4P and other metrics were pasted on to an existing system with no provision for motivation.  OK, some trivial financial rewards, but no hospital would go out of business because they failed to meet standards.  No provider would lose business to a competitor who provides a better service or a lower price.

In the business world, if a competitor provides better or cheaper products than you, people will stop buying your product, and you’re out of business.  So you work very hard to provide what your customers want at a lower cost than your competitor.  Not true in healthcare.  Pricing and purchase decisions are driven by small monopolies.  Competition is for insured lives and not over price of procedures or convenience for patients.

When goods or services first enter the market, they command a premium price driven by innovation.  The iPhone is a good example.  The world was full of cell phones, but this was an entirely new concept in electronic communication.  People bought it, and it was/is a high profit item for Apple.

Fast forward now to the point where that product has become a commodity. Generally speaking, prices come down. Dramatically. Competition is no longer about innovation, it’s about price, packaging, convenience, etc. Stuff gets cheap.  Want to see a commodity? Copy machine paper.  What brand does your company use?  I’ll wager you don’t know or care.  It’s all pretty much alike, so purchase decisions are made on price, delivery, etc.  A certain basic quality is assumed--maybe even specified by standards. 

Most of healthcare is a commodity today.  All surgeons read the same journals, use the same instruments.  Protocols drive family practice encounters.  Want a mammogram?  You’ll get the same exam with the same results, regardless of where you go.  Where is quality in this system?  Why would any provider or institution spend time or money pursuing better quality?  There is no reward.  It doesn’t sell.  In fact, it’s difficult to define quality in a system like U.S. healthcare, beyond conformance to accepted practices.

We have been pursuing Quality as an end in itself, when it should be viewed as a tool to  achieve a bigger market share.  That would require the creation of a market in healthcare--real competition for goods and services, mostly on the basis of price.  In such a world, everyone wins.

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