A look at what's not working in U.S. health care

Good ideas can morph into problematic policies that drive up costs and erode quality. Take diabetes as an example.  We could pose the ultimate goal of effective diabetes management is that a person with diabetes lives as long and as well as they possibly could. This goal is difficult to measure. We pare back our goal until we get to something we can measure: the percentage of people with diabetes who have blood glucose in good control (generally HbA1c<7).

The problem with this paring back of the goal is that managing blood sugar to A1c<7 may not be appropriate in all people with diabetes and some people with diabetes may have other goals of equal if not greater importance to their overall well-being. Reducing meaningful outcomes for a person down to a handful of things that we can measure can have unintended consequences.

Conditions are not the same in all people---an obvious point honored in guidelines that almost all state something to the effect that clinicians should use their best judgement when applying guidelines to a person’s care.  By measuring the rate at which people with diabetes have an A1c<7, we send a message that clinicians should put their judgement and the patient’s individually nuanced goals aside. 

The message of A1c<7 sends the additional signal that the A1c goal is more important than unmeasured work---for instance taking the time to listen and understand a person’s thoughts and concerns regarding their condition that lead them to consider other aspects of their wellbeing more important than an A1c<7.

The U.S. healthcare system abounds in examples of measuring what’s available and missing what’s important.

Harold D. Miller, the President and CEO of the Center for Healthcare Quality and Payment Reform has been studying the U.S. healthcare system for a long time and has a deep understanding of where we’re stuck in our thinking and actions. His Inside Angle podcast gives us much to think about as we envision the gap between good intentions and unintended consequences of our policies.

L. Gordon Moore, MD, is Senior Medical Director, Clinical Strategy and Value-based Care for 3M Health Information Systems.