Brent James MD: Senate Testimony

The US Senate Committee on Health, Education, Labor, and Pensions heard testimony on 4/28/09 from Brent James MD, which deserves particular attention.

Dr. James' credentials are impressive:

Brent C. James, M.D., M.Stat.
Member, National Academy of Science’s Institute of Medicine
Chief Quality Officer andExecutive Director
Institute for Health Care Delivery Research
Intermountain Healthcare
36 S. State Street, 16th Floor
Salt Lake City, Utah 84111-1633
(801) 442-3730
Brent.James@imail.org

I am personally acquainted with Dr. James and know him to be a national leader in health care quality improvement. He was one among seven witnesses before the Senate committee on 4/28/09, and I believe was by far the most impressive. Here are excerpts from his remarks (the full testimony is accessible by clicking on the link below):

The key to health reform is payment reform. We believe that the evidence clearly shows that efforts to extend health insurance to all citizens, whether at a State or national level, will rapidly fail unless we are able to control the rapidly rising costs of health care delivery. We recently completed a study, currently under review for publication, that applied quality improvement (sometimes also called process management) principles to estimate waste within current care delivery. The advantage of using a process management approach is that such quality-based waste is, by definition, actionable waste. . .We judged that almost half of all current expenditures in health care delivery are non-value adding from a patient’s perspective. (Unfortunately, one person’s waste may be another person’s income.). . .Under current governmental payment systems, care providers are paid more when patients suffer complications (in sound byte form, “we are paid to harm our patients”). Such circumstances require more care, which means more utilization (the consumption of more units of service). For example, a care delivery group can make much more money by hospitalizing a patient who has congestive heart failure, than by managing that patient so well in an outpatient setting that hospitalization is not necessary. . .Quality measurement is essential. Over the past 20 years, our ability to measure care outcomes has improved dramatically. This primarily came about by using quality improvement (process management) theory. The resulting evidence demonstrated that quality is very highly “process specific.” That is, the fact that a care delivery group does well on one process (e.g., open heart surgery), does not mean that the same group will necessarily do well on any other process (e.g., management of congestive heart failure). . .Even with major advancements in measurement, for most clinical conditions quality measurement is not sufficiently precise to accurately rank physicians, hospitals, or practice groups (references available on request). That fundamental truth has another face: It is easy to scientifically demonstrate that, for most clinical conditions it is impossible to build an evidence-based best practice guideline that perfectly fits any patient. As a result, achieving 100% performance on most quality measures means that a subset of patients received substandard care. On that foundation, a set of key principles for the appropriate design of quality measurement systems has emerged:- Methods exist that build quality measurement and accountability in ways that don’t depend on ranking providers.- Measurement systems must contain a feed-back loop (called “gauge theory” in the quality sciences). . . -Measurement must blend into clinical workflows:(a) The things most needed for solid quality measurement and accountability tend to be those elements that front-line clinicians need to deliver good individual patient care;(b) Embedded data tends to be much more timely and accurate (clinicians use the data, and so help produce both timeliness and accuracy);(c) If accountability measurement is not embedded in work flow, then the measurement system will compete for resources (time and people) at the frontline, potentially damaging clinical performance (quality);(d) Embedded measures lend themselves directly to change – they lead to improvement (in other words, use of “after the fact” measurement not only competes for resources with care delivery, it also competes for resources with improvement). . .-The key to universal access is controlling the rate of increase of health care costs.- The key to controlling health care costs is managing utilization rates.

http://help.senate.gov/Hearings/2009_04_28_b/James.pdf

My comment: Credible sources have stated that if the quality improvement procedures implemented by Dr. James were to be universally implemented in the US, we would see a 30% reduction in US health care costs. This year that would amount to a savings of at least $700 billion dollars. Dr. James himself has stated that another 20% savings is available given our willingness to reduce inefficiencies. We are wasting more than $1 trillion annually in our health system.

However, as Dr. James notes, one person's waste is another person's income. Our political decision must be whether we care about preserving the income of the commercial health interests more than we care about eliminating the waste which is killing our patients, bankrupting our families, and threatening our tax base and economy. Until we are no longer paid to harm our patients, we are letting the good get in the way of the perfect (see the immediate previous posting on this blog).