Cost, Quality, Value and


Leonard Zwelling

         M. Gregg Bloche, a physician and attorney from Georegtown,
has written a superb opinion piece in the March 17 issue of the New England Journal of Medicine entitled
“Scandal as a Sentinel Event—Recognizing Hidden Cost-Quality Trade-offs.”
Here’s the link:

         In the piece he discusses the cost-quality trade-off as
manifested by scandals in the VA system here in the States and in the National
Health System in the UK. In both cases it at first appears that promised
service to a given population of patients was just lack luster and no one
seemed to care. But investigations proved otherwise.

         The real culprit was underinvestment in support for care on
top of unattainable quality measures and squeezes on the cost side. What a
surprise! Not!

         I worked at an institution that claimed to be providing high
quality, efficient care. It was only when I made myself a patient in the clinic
I was supposed to be overseeing, but was not because that power had been ceded
to a non-physician Chief Operating Officer, that I appreciated what the doctors
had been complaining about. They were supposed to be doing top quality work in
15-minute patient care aliquots regardless of the acuity of the patient. I
filled out 20 pages of forms for my new patient visit only to have my new PCP
have none of the information before she saw me. She sat on a low stool, computer
on her lap, typing away while not looking at me as she asked me the same
questions that I had answered on the form. She examined me while I was fully
clothed, including tie, because she had another patient to see in 15 minutes.
This is not quality care and it is neither efficient nor cost effective because
other than hypertension, fever or tachycardia, the physician could not have
acquired any useful data about me and my blood pressure, pulse and temperature
were assessed by a medical assistant, not the doc.

         Bloche also addresses how the various care models like ACOs
or bundled payments do not really incentivize good care at all. His point is
that there is a legitimate trade-off between cost savings and quality care and
that the trade-off needs to be acknowledged and be dealt with.

         This may be abundantly true in cancer care where costs,
especially of new drugs, can be astronomical and benefits, a few weeks of life
extension, can be meager. A real discussion without the war cry of “rationing”
would benefit the delivery of all care, but especially cancer care. Who really
needs chemotherapy? What about third-line drugs? Do you really need to follow
asymptomatic survivors of primary breast cancer looking for metastases every 3
to 6 months with MRIs and CT scans. Will that change anything? Do we really
need to do spiral CT scans on past smokers to screen for lung cancer and if so
what are we giving up to use money for that purpose? Vaccinating kids?

         Like it or not, medicine is now a business. The cost, price,
quality and availability of what we do as caregivers must be assessed with the
knowledge that raising the value of one thing may lower the value of the other.
We must strive to limit the damage to care quality that cost containment may
necessitate, but we also must identify things we need to do and those we do not
and why. And how much we are willing to pay as a nation to boost quality.

         Lastly, I sure hope doctors are involved in that assessment.
The last thing patients need are lawyers, actuaries and congressmen making the

Leonard Zwelling