Delivery system must be held accountable

Both miss the far larger point: Given the resources consumed in providing healthcare -one dollar in seven of our economy - Americans get far too little in return, with poor access, poor quality, delays, fragmented care, and worse.

It can't be that we spend too little. The real problem is that those responsible for managing the delivery of care do so poorly. Some providers deliver tremendous value across the spectrum of preventive, primary, chronic, acute, intensive, and extended care, while others provide terrible care that is nevertheless costly. Yet, because we reimburse based on time spent and resources consumed, there is no reward to the great providers, and no punishment to the lousy ones.

The solution is to measure and publicize outcomes. Start by identifying the rate at which "never events" occur, such as patient falls, hospital-acquired infections, and medication errors, and then develop quality metrics for high-volume situations, such as management of chronic disease, well births, and so forth. Make those measures public, and let payers and patients pick the providers able to generate the best combinations of quality and cost and shy away from the ones who generate the worst.

Judging by institutions that have moved aggressively in pursuit of perfect patient care, we could probably provide twice the care at half the cost.

Steven Spear
Brookline
The writer is a senior lecturer at Massachusetts Institute of Technology and senior fellow with the Institute for Healthcare Improvement.