HEALTH CARE/Joan Retsinas

Quality Schmality

Let’s resuscitate Thorstein Veblen. Let him dissect our “quality” health care. Some Americans believe that, whatever the cost, whatever the gaps in coverage, we have “quality” care. They believe that today’s modus operandi gives us, at least those of us lucky enough to have “quality” insurance, a top-notch product: the best doctors, treatments, medications, and limitless (well, almost limitless – even quality insurers impose limits) hospital stays. And they fear that any kind of government tinkering, in the name of reform, will reduce quality. We will be trading down, from caviar to tilapia, the Ritz to Motel 8.

As Veblen recognized, though, “quality” is a construct that may not necessarily reflect the intrinsic product. Veblen, the economist of America’s gilded age, saw the frenzy of wealthy Americans, intent on buying up “quality” stuff throughout the globe, from furniture to houses to art, as “conspicuous consumption” - they bought to showcase their wealth. And they bought items that were rare, hard to find, entailed hours of labor. They called their goods “quality.” Veblen called them “honorific waste.”

We too value “honorific waste” in the products we buy. Consider two chairs: one made by machine, the other by hand. They look the same (much as zircons and diamonds look the same to the naked eye – and the naked eye is how we see them.) The machine-made chair might be sturdier; yet because the hand-made one entails hours of craftsmanship, we consider it “higher quality.” Often we use cost as a surrogate for quality. And often cost reflects the vagaries of a fickle market. Manolo Blahnik versus Walmart shoes?

With health care, “quality” similarly reflects a hodgepodge of preferences. We implicitly assume that we know what “quality” is. And, much like the conspicuous-consumers of America’s golden age, we value quantity, technological wizardry, and expense. Surely that signals “quality.”

But it doesn’t.

Consider cost. Costlier, more complicated procedures don’t necessarily signal “quality.” Would a patient prefer open heart surgery to a stent? orthopedic surgery over physical therapy? Medically speaking, the “best” treatment might be less invasive, less costly. Today the United States spends more on health care than the rest of the developed world, yet our health indices, including infant mortality, fall short.

We value the panoply of medical imagery, wanting not just old-fashioned x-rays, but MRIs, PET scans, CT scans. We may be the most-tested patients throughout the globe. But more tests, and more exotic ones, don’t necessarily translate into better care.

We want longer hospital stays, instead of rapid discharge. But sometimes a patient benefits from rapid discharge: an octogenarian who stays immobile for too long risks being immobile forever. And long-staying patients too often leave with “hospital-acquired” infections.

We want the personalized attention of the Ritz; surely that connotes quality. Indeed, patient-customers often find their stays enjoyable, but does that enjoyment connote quality care? Do the food, the ambiance, the cleanliness of a hospital – crucial to the quality of a hotel – matter, medically? Does the timely response of staff to patients’ call buttons matter? The noisiness of a hospital keeps patients awake at night, but does that denote poor “quality”? Medicare has delved into the thicket of quality and come up with a genuine measure: the number of patients who survive heart attacks, pneumonia, and heart failure. This, after all, is why patients end up in a hospital: they are at risk of death from one of these conditions. Researchers gathered data from 4700 hospitals and calculated average death rates.

They then identified the 323 hospitals with above-average death rates for all three conditions, and they identified the 13 hospitals with lower-than-average death rates for the conditions.

Their finding was surprising, even counter-intuitive: the hospitals that patients praised in surveys – the ones they considered high quality – weren’t necessarily so. And the ones that patients rated low sometimes emerged high in the government rankings. (USA Today, Steve Sternberg and Christopher Schnaars, August 5, 2011). You can check out your hospital on Medicare’s website.

To assess the “quality” of health care, we need strong statistical measures such as these. Otherwise, we can never improve it. Ironically, health reform promises to emphasize these kinds of measures - in short, to improve quality.

Joan Retsinas is a sociologist who writes about health care in Providence, R.I. Email retsinas@verizon.net.

From The Progressive Populist, September 15, 2011