Needed: Medical test pilots

Howard Hiatt

February 24, 1993|By Howard Hiatt

IF Hillary Rodham Clinton's task force seeking answers to our health-care problems were commissioned instead to come forward with a new antibiotic or surgical procedure, it would carry out many pilot experiments before making sweeping recommendations.

No biological scientist would commit large amounts of human or economic resources without favorable preliminary evidence.

But Americans generally treat social experiments differently.

Experts agree an idea has merit, a campaign is launched to win decision-makers and the public, often huge sums are appropriated, the effort is carried out on a large scale and little is done to insure adequate evaluation and mid-course corrections.

The appalling condition of America's health-care system partly reflects the disastrous unforeseen consequences of "solutions" undertaken without pilot studies.

For example, the effort to cut medical costs by requiring doctors to obtain permission from insurance bureaucrats before hospitalizing patients generates its own costs in patients' safety well as in time and money.

If this approach had been tested in a single state before it was imposed on the nation, its defects would have been readily apparent.

The search for ways to control costs and provide care for the 37 million uninsured and many more inadequately insured Americans while maintaining high quality is far more complicated than many biomedical experiments.

This was evident in a report Sunday that Clinton advisers say it will be impossible to provide care to everyone soon if the administration wants to finance it by using savings from overhauling the system.

Take "managed competition," which is said to be the path chosen by the task force for cost containment. This arrangement would encourage private insurers to bid against each other for the opportunity to provide coverage for all aspects of medical care.

Will it control costs but not sacrifice quality? Or just add to the mountain of paperwork? Nobody knows.

The task force surely is aware that Canada's successful universal coverage and cost-control arrangements differ from province to province. It was almost 25 years after Saskatchewan undertook its own experiment, followed by programs in the other provinces, before Ottawa legislated universal coverage.

Germany and Britain, whose systems we also look to for guidance, began important elements of their programs more than 100 and 50 years, respectively, before today's arrangements were put in place. We should avail ourselves of lessons from these and other experiments, successful and unsuccessful, around the world.

America's potential laboratories for pilot studies are the 50 states, combinations of states, and state regions. For example, important experiments are under way in New Jersey, Maryland, Vermont, Minnesota, Oregon, Hawaii and Rochester, N.Y. A major achievement would be to encourage more.

The administration could mandate universal comprehensive coverage of prescribed quality with managed competition or another approach to cost containment for the nation.

States and regions would be encouraged not to participate if they could devise superior solutions tailored to their needs. There would be basic requirements for opting out: The jurisdictions would have to provide coverage of acute, chronic and catastrophic illness for everyone, emphasize primary care and prevention and demonstrate that they are upholding high standards of care.

As in Canada, when its national program was begun, our federal carrot would be matching dollars. Additional incentives might be tied to the degrees of cost savings and of improved quality when compared with the previous year's performance.

Combining the experimental method and America's free-market approach could enable us to reach the health-care goals we all share.

Howard Hiatt, senior physician at Brigham and Women's Hospital in Boston, is author of "Medical Lifeboat: Will There Be Room for You in the Health Care System?"

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