What about outcomes? What about quality?
Well, what about them? Nobody in our FTP vignette has any incentive to know about outcomes - except as they may be incidentally useful as a marketing tool.
Gekko doesn’t have any reason to care about clinical outcomes. His outcome is measured by his profit. So as long as he’s making money, his outcome is good - and data on clinical outcomes would only serve to threaten what is now a nice, clean picture. Unless pushed, he sees no reason to invest his resources in collecting such data.
What about Dr. Smith - the PCP who has to decide whether to refer his patients with heart problems to cardiologists in the more expensive Valley View group or those in the less expensive Cormatic Group? Wouldn’t he want to know which group has the better clinical results? Certainly he would, on a professional level. But subconsciously, he realizes that if he had that data, it might give him the wrong answer - there’s at least a good chance that the more expensive group might turn out to achieve better results. That would certainly complicate his referral decisions.
And what about the cardiologists of the thrifty Cormatic Group? Do they really want outcomes data? Well, why should they? They’re already getting the referrals.
Doctors in the profligate Valley View Group are the only ones who have a good reason to care about clinical outcomes; if they turn out to have more favorable outcomes, it might help to exonerate their expensive ways. But even if they take the time and expense to examine the outcomes they achieve in their own practices, there is no way for them to get the comparative data from competitive groups.
So, while there is plenty of talk about outcomes in the Gekkonian HMO world, when you analyze the mechanics, it is difficult to find anyone slogging away in the trenches who really wants to know about them.
But surely somebody wants to know about quality. What about the patients? What about the employers who are paying the bills?
Gekko knows about patients. When patients are faced with a choice between an HMO that’s “free” or an indemnity plan that might cost them an extra fifty or hundred dollars a month, he knows they’re going to pick the HMO. And while they’re picking it, they want to feel good about it. They deeply, sincerely, and desperately want to hear that they’re making a good choice. They want to hear what a high-quality HMO they’re being forced to join. And that’s where quality and marketing come together. To Gekko, quality is marketing.
This is why HMOs over the past few years have gotten away from advertising (and implying ready access to) their fancy, state-of-the-art, high-tech services. Instead, they’ve gone all fluffy, emphasizing warmth, concern, and caring, through filtered lenses and soft music. When you join our HMO, it’s like joining a family. What a good choice you’ve made.
Okay, you might reply, but what about employers? Don’t they want to offer high-quality healthcare to their employees? Well, sort of. What most of them really want is to offer adequate healthcare without losing their shirts on it.
My own eyes were opened on this issue several years ago when I attended a retreat, sponsored by my hospital, that featured a panel discussion by a group of prominent local employers. When asked how they go about assuring themselves that the health coverage they buy for their employees provides high-quality care, the captains of industry responded thusly: “We make widgets, we don’t assess healthcare quality. We don’t know how, and we don’t want to know how. So we’ve got to be practical about it. To us, quality means quiet. As long as we don’t hear more than the average number of complaints from our employees, the health coverage we provide is, by definition, good enough.”
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Men and women like Gekko long ago figured out what their paying customers (the businesses that purchase health insurance for their employees) want. And because of what his customers want, Gekko can define quality as keeping the volume of complaints down to an acceptable level and keeping FTP out of the newspaper.
Efforts are being made on several fronts to measure quality in healthcare, and some of these efforts are having an impact. But these efforts are not originating with Gekkonian-style HMOs, or even from healthcare providers.
