Quality, quality, quality. What does it mean in health care? A survey from the University of Utah asked over 5000 patients, 687 physicians and 538 employers what they thought. (Utah Survey) When asked if they value quality, service or cost most; 62% of patients said quality and 88% physicians did. Only 26% of patients and 5% of patients indicated that cost was valued most. For employers, employee satisfaction with health care was most important, while 37% said cost and 20% employee productivity. When asked to choose the top five from a list of statements about what they value most in health care, 45% of patients said affordable out-of-pocket costs, 39% said timely appointments, 38% said confidence in a clinician’s skill, 36% said a convenient office and 36% said the provider knows and cares about them and only 32% said my health improves, indicating either an assumption that the care will be good or cynicism that it won’t, so the other stuff matters more. For physicians the top five indicators that they are providing value were that they know and care about the patient, selected by 55%; they order appropriate exams and tests, 55%; the patient’s health improves, 50%; they spend sufficient time with patients, 50% and they included the patient in decision-making, 49%.
Employers top indicators of value were the cost to the employee is affordable, 59%; the cost to the company is affordable, 57% and employees have access to high-quality providers, 55%. The disjunct between patient, provider and employer indicators of value is fairly obvious and probably explains much of the dissatisfaction with the system. patients care about costs and convenience and being respected. Employers care about cost. Providers are oriented toward how patients feel about the interaction and outcomes. Interesting all three groups stated high levels of satisfaction with the quality of health care received/delivered; 80% for patients, 94% for doctors and 83% for employers. But only close to half said the quality of health care in the US is the best in the world; 46% of patients, 48% of physicians and 55% of companies. And they all agree it is too expensive; 83% of patients, 89% of physicians and 84% of employers. But again, a real disjunct in terms of satisfaction with price paid/received. Only 37% of doctors were happy with what they got paid, while 67% of patients were okay with what they paid for health care and 71% of companies were. Significant majorities of each group said physicians should discuss the cost of care with patients, but only 40% of doctors said they think about the cost of care when making decisions. And patients aren’t always willing to pay more for what they value, like short wait times, but they would pay more for having their health improve or having their mental health needs met.
To me, the issue is what is the purpose of a health system, in this case the health system for people living in the United States? And the answer, it seems to me, is that it is to maintain the people in the system in the best possible health and to deliver the best possible outcomes when health care is received. And the best outcomes are those that result in people being in optimal health. Cost obviously has a role to play, but the first question we should ask is whether we are meeting that goal of good health. And if we aren’t, why aren’t we? For many people, perhaps most, the system isn’t meeting that goal. Partly that may be because it isn’t really a system, it is a patchwork. But that may be okay if it maximizes individual freedom and choice. But the main reason the system doesn’t deliver optimal health is because the people in it often engage in poor health behaviors, and the system fails to penalize them for doing so or to give them sufficient incentives to engage in better health behaviors. And until we get hard-nosed, even at risk of being called mean, and recognize people’s ultimate responsibility for their behavior and make them endure the consequences of that behavior, it isn’t going to get better. And no amount of quality measuring, or mobile apps, or other whiz-bang stuff is going to change that fundamental fact. And the survey reflects this problem; 75% of doctors said they are responsible for improving a patient’s health, while only 45% of patients said they had that primary responsibility and an equally number said doctors did; while 39% of employers placed primary responsibility on the patient, while 25% said it was up to the doctor.