Health Services Research: Trying to Fix a Broken System

A major HSR success has been the sequelae to the Institute of Medicine’s 1999 report that avoidable medical errors result in 98,000 patient deaths annually. That research led many hospitals to adopt one or more key recommendations to care quality improvement via system change: computerized physician order entry, intensivists staffing ICUs, and published data on frequencies and outcomes of common procedures.

Without question, HSR has a noble agenda. Proponents want to chart a public policy course that cuts waste and inefficiencies from the system, gives more people greater access to health care, uses information technology (IT) effectively, reduces medical errors, and eliminates regional variations in care. At HSR’s heart is putting the primary care physician in charge of coordinating and streamlining services. The Commonwealth Fund’s Framework for a High Performance Health Systems for the United States (see sidebar, page 13) advocates a more organized delivery system that emphasizes primary and preventive care that is patient-centered.

What Does It Mean for You?

What will this mean for subspecialty care at medicine’s cutting edge with patient lives at stake? Mark Persky, MD, Chairman of the Otolaryngology/Head and Neck Surgery Department at New York’s Beth Israel Medical Center, expresses little confidence in bureaucratic systems that do little to help him provide and coordinate care for his patients with devastating and aggressive head and neck cancers. The thought of even more bureaucracy doesn’t appeal to him. A patient who has had a jawbone removed needs complicated and intense therapy from a large multidisciplinary team because such surgery affects their appearance and ability to communicate and eat. We need specialized physicians, nurses, radiologists, dentists, speech therapists, and so on to rehabilitate these patients, he says-all that in a tangle of reimbursement systems, mostly Medicare and private insurers that put obstacles in the way of getting patients what they need. Citing the example of the patient whose cancerous jawbone has been removed, Dr. Persky knows that the patient needs a prosthesis with teeth, which Medicare won’t cover because they call it an unreimbursable dental procedure.

Dr. Persky doubts that HSR will have an impact on the morass of bureaucracy where everyone is competing for dollars and patients have to tolerate limited access to the care they need. The big picture is that the government and society have to make important decisions about who gets what kind of care, he says. As for one-payer systems improving things, Dr. Persky currently sees patients coming from Canada and other socialized health care systems to Beth Israel because they can’t wait months for an MRI or PET scan needed to accurately assess their conditions. As Americans, we cannot tolerate limited access to oncology care for complicated and aggressive head and neck cancers that such systems engender. He has other doubts: A primary care physician should not be chosen as the person to coordinate this care. At Beth Israel a well-oiled multidisciplinary team makes decisions, as it should.