HEALTHCARE DELIVERY
Commentary: Garson's "physicians, coverage, quality, and cost: the intertwined caduceus"
Kevin A. Schulman, MD*,*
* Center for Clinical and Genetic Economics, Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina, USA
Manuscript received July 10, 2003;
revised manuscript received July 21, 2003,
accepted July 27, 2003.
* Reprint requests and correspondence: Dr. Kevin A. Schulman, Center for Clinical and Genetic Economics, Duke Clinical Research Institute, P.O. Box 17969, Durham, North Carolina 27715, USA.
kevin.schulman{at}duke.edu
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Abstract
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It is not sufficient to recommend that we adopt information systems, promote cost-effective care, improve processes of care through education, and implement evidence-based practice. Specific strategies must be tested, reformulated, and tested again so that policymakers will have a useful set of strategies available to them.
Health policy analysts have developed a substantial catalog of the problems facing the U.S. healthcare system. They describe a system burdened by waste and undermined by the uneven quality of care it provides and the obstacles it presents to the uninsured. In this issue of the Journal, Dr. Arthur Garson (1) summarizes many of the most important problems, including the continued growth of the uninsured population, the need for improved quality of care and new forms of resource allocation, the high cost of clinical practice, increasing legal pressures on clinicians, and workforce shortages.
Dr. Garson (1) is not the first to describe the problems, yet each year the problems continue unabated. Moreover, the solutions Dr. Garson (1) offers have been described many times—data standards and information technology, evidence-based practice, new modes of reimbursement, and so on. Strategies for achieving these goals, if implemented, might address systemwide problems in healthcare. Unfortunately, evidence to support those strategies is limited. More importantly, our understanding of the mechanisms that underlie the failings of our healthcare system is almost nonexistent. The research agenda for the medical community must go much further than that suggested by Dr. Garson (1). It is no longer enough to remind ourselves of the usual catalog of solutions. Specific strategies must be tested, reformulated, and tested again so that policymakers will have a useful set of strategies available to them.
For example, information technology is often promoted as an essential component of quality improvement. A recent article on computerized physician order entry (CPOE)—a promising use of technology at the health system level—reviews various strategies for CPOE implementation as well as their costs and benefits (2). As the authors note, however, CPOE is understudied. Although strategies for implementing CPOE have existed for three decades, there is little consensus about which will work best. Proposals to solve system-level problems in healthcare are numerous, but there is little evidence about whether any of the strategies works. Not only is there insufficient political will among policymakers to make substantial investments in improving the healthcare system but also it is unclear whether the proposed strategies would be successful even if implemented.
Cardiology researchers have consistently raised the bar for other disciplines. Much of the research into costs, quality, and access was first developed in cardiology, and cardiologists continue to have a more active research program in these areas than do researchers in other disciplines. At the same time, while researchers have characterized the clinical importance of costs, quality, and access, our research program has not led us to adopt an agenda for action that will allow us to translate our research into policy or even into our own practices. If we are unable to offer the kinds of data that tell policymakers which quality improvement strategies will work, the medical community runs the risk of being disenfranchised from the political leadership of this country as they deliberate over healthcare reform.
After a turbulent decade of advocacy, medical leadership and the medical community must re-engage in the health policy process in a more systematic fashion. When policymakers finally undertake the broad political action and consensus-building necessary to address costs, quality, or access, we must be ready with evidence about which strategies will work best to address those goals. It is insufficient to recommend that we adopt information systems, promote cost-effective care, improve processes of care through education, and implement evidence-based practice. Such recommendations are becoming cliché, yet we have no evidence that any particular approach for achieving those goals is better than any other. Only determined efforts on the part of the medical community will develop such an evidence base. We should not underestimate the magnitude of this task. Our obligation as responsible stewards of the system will be as challenging as any basic research project now underway.
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References
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1. Garson A, Jr. U.S. healthcare: the intertwined caduceus of physicians, coverage, quality, and cost. J Am Coll Cardiol 2004;43:1–5
2. Kuperman GJ, Gibson RF. Computer physician order entry: benefits, costs, and issues. Ann Intern Med. 2003;139:31–39[Abstract/Free Full Text]
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