By Robert Bazell Chief science and health correspondent
NBC News
updated 5/22/2007 9:36:58 AM ET 2007-05-22T13:36:58
COMMENTARY

Do you think you are getting good medical care? Chances are, you do. But it may not be as good as you think.

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In the debate over health care reform, certain ideas suddenly become quite fashionable with pundits. A current notion is that most Americans are indeed satisfied with their health care — or at least don’t want it to change much.

The numbers support this notion. A poll conducted last October by the Kaiser Family Foundation, ABC News and USA Today revealed that 89 percent of Americans are personally satisfied with their health care.

Sure, everyone knows about the 45 million uninsured in the U.S., but three times that many people do have health insurance.

Most people have heard the statistics that we pay ridiculously more for our health than other industrialized countries (twice as much per person as Germany, for example) and that our outcomes are far worse (the U.S. is 45th in the world in life expectancy, according to the Central Intelligence Agency's World Factbook). We hear the numbers about the massive death rates from medical errors in this country. And we all hate rising premiums and co-pays, and fear losing our insurance. 

Doing just fine, thank you
But when it comes to proposals to change the system, a “not in my backyard” syndrome sets in. Most people believe things are personally "justfine, thank you." They fear systemic change might make the situation worse for them. This head-in-the-sand denial is hindering meaningful reform of an ailing health care system.

Even if people are satisfied with their own doctor and the care they receive, there is plenty of evidence that health care in this country needs to improve.

In medicine, unlike the automobile or appliance industries, a satisfied customer is hardly the best indicator of a good product. That is certainly true from the perspective of those who pay for the care, including taxpayers and insurers. If someone complaining of mild chest pain arrives at the doctor and gets a fancy $30,000 MRI that reveals no heart problems, he or she would likely be thrilled. Never mind that a routine electrocardiogram — which costs a few hundred dollars at most — and an antacid tablet might have accomplished the same result.

It is not just a question of extra expense. Cancer patients who suffer the horrible side effects of unneeded chemotherapy often believe their doctor saved their life. How could they know the treatment was unnecessary?

You may come away from a doctor checkup feeling OK, but a survey by the RAND Corporation, published in the New England Journal of Medicine in 2003, revealed that almost half of Americans treated for common conditions were receiving substandard care. The authors concluded their findings “pose serious threats to the health of the American public.”

Good medicine isn't easy
Developing good medicine isn't always easy.

A major fad of health care reform is called “Pay for Performance.” In recent years several public and private groups, including the National Committee for Quality Assurance, have been working to detail the basic standards of care for hospitals, doctors and health insurance plans. The goal is to give individuals and employers the tools to make wise decisions. The government agency that runs Medicare and Medicaid fully endorses the idea and has begun providing financial incentives for hospitals that meet specific detailed goals. Last month the agency said it would pay doctors a 1.5 percent bonus for agreeing to comply with the guidelines. Private insurers usually follow the agency’s lead.

The guidelines are neither surprising, nor difficult. Offer influenza vaccine and smoking-cessation advice. Get blood sugar, cholesterol and blood pressure under control in diabetics. Take similar proven actions for other conditions.

So far there's little evidence that “Pay for Performance” means better care.

Just like the frequent examinations required by the No Child Left Behind law can encourage teachers to “teach to the test” rather than educate the students, “Pay for Performance” can yield unintended consequences. To get the extra pay, hospitals rush to comply with the guidelines. In an article last year in the Journal of the American Medical Association (JAMA), Dr. Robert Wachter detailed how ridiculous it had become at his hospital, the University of California, San Francisco Medical Center. Non-physician “case managers,” he wrote, will question a doctor as to whether a patient with a severe infection or a heart attack had smoking-cessation advice or a flu shot — even before they get the treatment needed to save their lives.

A study last December in JAMA found no improvement in mortality at hospitals that were best at meeting the guidelines.

The offer of a little extra cash for individual doctors to comply with the guidelines is too new to see any results. It is likely that many doctors will resent the extra paperwork and the intrusion on their prerogative to practice medicine as they see fit.

Besides, why should doctors change if most Americans are still satisfied with their care? Ultimately, the fear of losing insurance and the ever-increasing premiums and co-pays will convince people we really aren’t getting that good of care and that we need change.

Unfortunately, we are not there yet.

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