Entries for November 2008

Why the U.S. healthcare system (if you want to call it a system, which it isn't) is a mess is obvious. It's mostly because of bureaucratic, inefficient, denial-fixated health insurers—chop out the waste, and escalating costs will come back into line. Considering this albatross as well as various other handicaps, it's amazing that the quality of our healthcare is really good.

Myths, both. Administrative expenses are a relatively small driver of healthcare costs. And the quality of U.S. care not only fails in many respects to measure up to the care delivered in other countries but swings between extremes depending on where you live, the caregiver you see, and the hospital you use. Shannon Brownlee, a visiting scholar at the National Institutes of Health Clinical Center (and a former U.S. News colleague), and oncologist Ezekiel Emanuel, chairman of the center's bioethics department, busted those two myths and three other widespread misconceptions in a well-argued piece in Sunday's Washington Post that is well worth reading.

Lots of talk, not much action—until now. In January, Serigraph Inc., a West Bend, Wis., manufacturer, will become the first U.S. company of any size to embrace medical travel or medical tourism, offering employees the option of having certain nonemergency operations, such as joint replacement, in India. The company will pay all expenses, including travel and lodging for a companion. The incentive for employees is that they don't have to pay a deductible—typically $1,000 to $5,000—or the hospital copay, which would be 10 percent to 20 percent of the charges.

Last May, I went to India and Singapore to explore the trend of growing numbers of under- and uninsured Americans heading to both places and other foreign climes to take advantage of package prices for hip replacement, heart valve repair, spinal surgery, and other elective procedures that can be 80 percent less than the sums charged by U.S. hospitals. To cite one expensive example, heart bypass surgery can easily run up a $70,000 to $133,000 bill at a U.S. center, compared with an average of $7,000 at Indian hospitals catering to westerners. An uninsured patient I interviewed extensively in India paid a total of about $25,000 to have both hips and one knee replaced, including airfare and incidentals. He easily could have paid more than $125,000 at a U.S. hospital. And there are plenty of similar cases of huge price differences.

Last Friday, I criticized a report in the public policy journal Health Affairs arguing that consumers' relatively restrained use of hospital ratings and data (such as America's Best Hospitals) can be blamed on confusion: The ratings and rankings measure different aspects of care, cannot be compared, and often contradict each other. I wrote that consumers can wade through the information, just as families sift through facts and numbers in America's Best Colleges and other college guides of more than 1,500 pages and cobble together custom lists online by sorting and clicking. I charged the study authors with underestimating consumers and condescending to their capabilities to do the same with hospital data.

U.S. News, publisher of the annual "Americas Best Hospitals" rankings, isn't the only hospital-rating game in town. Corporate-backed groups such as Leapfrog and the federal government's Medicare arm, through its Hospital Compare page on the Web, are other examples of public reporting of hospital data and ratings, each with its own unique approach. A new study in Health Affairs , a public-policy journal, concludes that because the ratings measure different qualities and disagree with one another, consumers are confused rather than enlightened. As Health Affairs puts it, sometimes more is less.

I see the point, but I think motivated consumers—as I would call anyone looking for information about particular hospitals—can sort things out better and be smarter than the authors seem to believe they can. And the pot of gold the authors are seeking at rainbow's end—broad-based information that is useful, accurate, and consistent across different reporting platforms—is wishful, almost delusional thinking. Developing a consensus among clinicians, analysts of data quality, and occupants of hospital executive suites about how to define, collect, measure, and report data that is meaningful is far more difficult than herding cats or whatever comparison you want to make.

Last week, a large part of the U.S. News staff busily churned out election coverage while a much smaller team—a couple of Webbies, as we affectionately call our online producers and programmers, plus a data specialist and I—raced to finish up the 2008-09 Best Health Plans rankings. Everything else, including this blog, had to wait at the crossing for the Best Plans train to pass, as all good things eventually must. Now that it has, I need to do a little catching up.

For today, I'll call your attention to "Rub a Dub Dub," a recent blog post in Aggravated DocSurg about showering before an operation. That's what it starts out as, anyway. The blogger is a general surgeon with an attitude, as the blog's name suggests, but the right kind—one of his pastimes is sniffing out claims and studies whose underpinnings are shakier than they seem. He's an informed skeptic. ("Experience is the name everyone gives to their mistakes," an Oscar Wildeism, is one of several quirky quotes at the top.)