The health care industry accounts for $1 trillion in yearly expenditures. It represents approximately 14 percent of gross domestic product. No industry of comparable size exists in our economy. Yet it operates without a systemwide framework for defining, measuring, and ensuring quality. In what other industry would that be tolerated by the American public?
Take the airline industry. After the TWA and ValuJet crashes last year, the government swung into action: The FAA and the FBI launched multimillion-dollar investigations; congressional hearings were called almost immediately; a presidential commission on airline safety headed by the vice president was announced, and sweeping new regulations were unveiled just a few months later; and every sector of the airline industry came under intense scrutiny by Congress and the news media. On average, plane crashes take approximately 700 American lives every year.
Now look at the health care industry, where every year an estimated 180,000 Americans die unnecessarily as a result of errors in medical treatment. An additional 1.3 million are injured, with 1 million of those injuries considered preventable. Despite the alarming prevalence of medical errors in the health care system, no federal investigations are launched, Congress pays little or no attention, and the public is generally unaware.
The "dirty little secret" of the world's best health care system is that it is operating in a quality-control vacuum with no universal guidelines for procedures or practices. Our system could be better, safer, and less expensive if we devoted just a fraction of the attention to quality in health care that we do to safety in the airline industry. And the results would be more far-reaching.
THE basic quality problems are: overuse, when a health service is provided in circumstances where its risks outweigh its benefits; underuse, the failure to provide a service that provides a benefit and saves money in the long run; and misuse, when a beneficial service is provided poorly, resulting in a preventable complication. Today there are no commonly accepted parameters for determining which procedures provide the greatest benefit at the lowest cost. There are no universally accepted cost/benefit analyses for specific drugs to treat specific diseases. There are no systematic methods of changing medical behaviors that may be the result of ignorance of the latest treatments and technologies, as opposed to carelessness or incompetence.
In the absence of quality-assurance measures, we have moved toward a system that rewards lower cost and does not adequately concern itself with quality. Ironically, a system that puts a premium on lower costs actually can turn out to be more expensive in the long run because of ineffective and inappropriate initial treatments. Attention has focused on "inputs" rather than on "outcomes" - the price of the treatments, rather than the value of the results. If quality guidelines are to be set, the outcome side of the equation is the one that needs to be researched and analyzed.
Quality-assurance studies throughout the health care industry would identify what works and what doesn't - and better yet, what works and what works better. Tried and true methods would constantly be reexamined against new and improved ideas.
Addressing the quality issue in an aggressive and comprehensive manner must be our highest priority. President Clinton recently announced his Advisory Commission on Consumer Protection and Quality in the Health Care Industry. What better body to begin the process whereby we, as a nation, create systemwide quality guidelines and accountability, and provide better, more equitable and affordable health care. If the commission does its job, and if consumers and providers act upon its recommendations, we just might be on our way to "first, doing no harm."
* Henry E. Simmons, president and founder of The National Coalition on Health Care, was deputy assistant secretary for health in the Nixon and Ford administrations.