Legends of Health Policy & Management

David Chinitz School of Public Health Hebrew University - Hadassah Legends of Health Policy & Management

יעדי הרפורמה: למשל של אובמה • לגבי מערכת הבריאות אנחנו רוצים • הרחבת הנגישות • ריסון עלויות • שיפור איכות

הכלים להשגת היעדים • תחרות • בין היתר: תמריצים לנותני השירותים • מדידת איכות הטיפול

עידן חדש במערכת הבריאות • The United States is on the cusp of a new era, with greater demand for performance information, greater data availability, and a greater willingness to integrate performance information into public policy. This era has immense promise to deliver a learning health care system that encourages collaborative improvements in systems-based care, improves accountability, helps consumers make important choices, and improves quality at an acceptable cost. However, to curtail the possibility of unintended adverse consequences, it is important that we invest in developing sound measures, understand quality measures’ strengths and limitations, study the science of quality measurement, and reduce inaccurate inferences about provider performance

הסתייגויות מתמריצים כספיים • Behavioral economics offers some insights into why, despite intuitive appeal, pay-for-performance may have had a limited impact on improving quality of care. At root, economic incentives seek to change behavior through extrinsic motivation—yet most clinicians want the best outcomes for their patients based on an intrinsic motivation to act in their patient’s best interests. Some of the nation’s most effective quality improvement campaigns – such as those aimed at reducing central line infections and “door-to-balloon” times for heart attack patients requiring surgery to open up occluded arteries – were wholly based on intrinsic motivation combined with effective new strategies, without financial incentives.40

הסתייגויות ממדידת איכות הטיפול • Several challenges of use of quality care measures include the potential for lack of individualized treatment of patients and the attempt to create a single measure to apply to all patients. Some investigators complain that the “average patient” does not exist, and explain that treating patients with mild or early type 2 diabetes with the same goals as patients with later complications of diabetes may lead to ineffective use of resources. • - See more at: file:///C:/Users/Owner/Documents/sabbatical%202012/insead/Impact%20of%20Quality%20Care%20Measures%20on%20Patient%20Care.mht#sthash.7Au3mZ2b.dpuf

משהו בדק אצל הרופאים?

מישהו בדק אצל הרופאים?

איזה אכזבה! That is why the findings of the physician survey conducted by Tilburt and colleagues4 in this issue of JAMA are somewhat discouraging. The findings suggest that physicians do not yet have that “all-hands-on-deck” mentality this historical moment demands. Indeed, the survey of 2556 physicians suggests that in the face of this new and uncertain moment in the reform of the health care system, physicians are lapsing into the well-known, cautious instinctual approaches humans adopt whenever confronted by uncertainty: blame others and persevere with “business as usual.” Will Physicians Lead on Controlling Health Care Costs? Ezekiel J. Emanuel, MD, PhD; Andrew Steinmetz, BA JAMA 2013

הרופאים מתחמקים מאחריות! This is a denial of responsibility. Of course, physicians do not want to be blamed for the country’s major problem. But can they really be both the captain of the health care ship and cede responsibility for cost control to almost everyone else? Physician autonomy and leadership can only be affirmed if accompanied by acceptance of responsibility and accountability. Unless physicians want to be marginalized—unless they are willing to become just another deckhand— they must accept and affirm that they are responsible for controlling health care costs.

Legends of Policy and Management • Economic incentives reign supreme (“Money talks”) • Culture , norms, and values are out of our reach (“This is not Finland”) • Structural changes don’t influence trust (“Trust me, I’m a doctor”) • Measurement is not subject to opportunism (“Numbers don’t lie, but liars love numbers” Mark Twain) • Politics is about politicians and elections (“We had it right, but politics got in the way”) • Health inequalities have to wait for social inequalities (“I’m here to spread the wealth”)

Legends of Health Policy & Management