Redefi ning Health Care Systems ROBERT H. BROOK For more information on this publication, visit www.rand.org/t/cp788 Library of Congress Cataloging-in-Publication Data Brook, Robert H. (Robert Henry), 1943- , author, editor. Redefining health care systems / Robert H. Brook. p. ; cm. "The third section of the book comprises a series of short commentaries on specific issues, originally published in JAMA between March 2009 and March 2012." Includes bibliographical references. ISBN 978-0-8330-9040-9 (pbk. : alk. paper) I. JAMA. II. Title. [DNLM: 1. Delivery of Health Care—organization & administration—United States. 2. Health Status—United States. 3. Health Services Research—United States. W 84 AA1]. RA398.A3 362.10973—dc23 2015013738 Published by the RAND Corporation, Santa Monica, Calif. © Copyright 2015 RAND Corporation R® is a registered trademark. 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RAND’s publications do not necessarily reflect the opinions of its research clients and sponsors. Support RAND Make a tax-deductible charitable contribution at www.rand.org/giving/contribute www.rand.org Dedication This book is dedicated to David K. and Carol A. Richards to honor their moral com- passes, which always point true north; to acknowledge their sustained intellectual, emotional, and financial support; and to thank them for being true friends of RAND. iii Contents Dedication ............................................................................................ iii Introduction ........................................................................................... 1 EXPLOITING THE KNOWLEDGE BASE OF HEALTH SERVICES RESEARCH Core Facts Derived from 50 Years of Health Services Research ............................. 5 1. Health Status Can Be Measured .................................................................. 6 2. Free Care Increases Health Service Use but Does Not Improve Health ..................... 8 3. Patient Copayments Strongly Influence Health Care Use ..................................... 9 4. How Physicians Are Paid Influences How They Practice ...................................... 9 5. Quality of Care Can Be Measured ...............................................................10 6. Quality of Care Varies .............................................................................13 7. The Appropriateness of Care Can Be Determined .............................................14 8. Geography Is a Strong Predictor of Health Service Use .......................................15 9. Depression, a Leading Cause of Morbidity, Is Poorly Detected and Poorly Treated .......16 10. Physicians and Patients Need Tools to Support Decisionmaking ..........................17 11. One Person’s Waste Is Another’s Income .......................................................18 12. Social Factors Are Powerful Determinants of Health ........................................19 Science and Technology Will Increase Health Care Costs .................................. 20 How Health Services Research Can Fix the Health Care System ..........................21 STORIES Story One: Why Fixing Simple Problems in Medicine Would Dramatically Increase Quality ................................................................................31 Story Two: Whom Does the Institutional Review Board Protect? .........................32 Story Three: Introducing Quality Measurement to the Wild West ........................35 Story Four: Passionate Responses to the Notion of Change .................................37 Story Five: Why Free Care Doesn’t Improve Health ......................................... 38 Story Six: Age and Resistance to Change ...................................................... 38 Story Seven: Resisting Funder Pushback When Findings Don’t Match Expectations .................................................................................... 40 v vi Redefining Health Care Systems Story Eight: Transparency and Responsibility .................................................41 Conclusion ........................................................................................................................ 42 COMMENTARIES Quality, Transparency, and the US Government ..............................................45 The Science of Health Care Reform ..............................................................49 Possible Outcomes of Comparative Effectiveness Research .................................53 Assessing the Appropriateness of Care—Its Time Has Come ...............................57 Disruption and Innovation in Health Care .....................................................61 Continuing Medical Education: Let the Guessing Begin ....................................65 The Primary Care Physician and Health Care Reform .......................................69 Rights and Responsibilities in Health Care: Striking a Balance ...........................73 Medical Leadership in an Increasingly Complex World .................................... 77 Physician Compensation, Cost, and Quality ...................................................81 What If Physicians Actually Had to Control Medical Costs? ...............................85 The End of the Quality Improvement Movement: Long Live Improving Value .........89 A Physician = Emotion + Passion + Science .....................................................93 Is Choice of Physician and Hospital an Essential Benefit? .................................. 97 Health Services Research and Clinical Practice ............................................. 101 Accountable Care Organizations and Community Empowerment ...................... 105 Facts, Facts, Facts: What Is a Physician to Do? .............................................. 109 The Role of Physicians in Controlling Medical Care Costs and Reducing Waste ..... 113 Can the Patient-Centered Outcomes Research Institute Become Relevant to Controlling Medical Costs and Improving Value? ..................................... 117 Two Years and Counting: How Will the Effects of the Affordable Care Act Be Monitored? ..................................................................................... 121 Do Physicians Need a “Shopping Cart” for Health Care Services? ...................... 125 Vision and Persistence: Changing the Education of Physicians Is Possible ............ 129 Why Not Big Ideas and Big Interventions? ................................................... 133 About the Author .................................................................................. 137 Introduction This book provides a scientific and personal perspective on health services research over the last half-century. Its purpose is to suggest how that science base, constructed over decades of sustained effort, can stimulate innovative thinking about how to make health care systems safer, more efficient, more cost-effective, and more patient-centered even as they respond to the needs of diverse communities. There are three models for producing health: • The first is the classical medical model—i.e., physicians, hospitals, nursing homes, and all the other things that we associate with the health care system. • The second is the public health model—e.g., ensuring food safety, preventing or controlling pandemics, helping communities prepare for and respond to disasters. • The third is the social determinants of health model—i.e., understanding how education, wealth, and similar characteristics affect the health status of individu- als and communities. The science base examined in this book is relevant to all three models. The initial essay by Robert Brook, “Exploiting the Knowledge Base of Health Ser- vices Research,” co-authored with Mary Vaiana, provides a perspective on the major achievements of health services research over five decades. For example, we now know how to measure health status and the appropriateness and quality of care. We under- stand the link between how much people pay for care and how much they use. We know that how physicians are paid for care influences the way they practice. We know that depression is one of the leading causes of morbidity in the world. We realize that the most powerful determinants of health are not the newest drugs or surgical techniques—they are social determinants, such as education and income. In the essay, Brook and Vaiana argue that we can make almost any reasonable health policy work if the policy takes the relevant science into account. In the current blizzard of suggestions for how to reform, refine, and redefine health care, the core facts produced by health services research should serve as a sanity check. Political per- spectives may, and do,