Research
in the Medical Marketplace
Engineers emphasize efficiency, an attribute seldom
ascribed to America's healthcare system. Efficiency involves
using the minimal resources required to get a job done.
So bridges are typically built to last decades carrying
traffic including heavy trucks, even though it would
be possible to build them to withstand centuries of use
by military tanks. Hitting the latter target would, of
course, be much more expensive.
What would happen if engineers took control of our medical
delivery system? They'd probably resist the trend toward
increasing specialization and try to reverse it by making
greater use of cheaper talent with limited skills to
handle simple problems, arguing that an internist isn't
required to prescribe a remedy for a head cold.
Past such efforts, involving physician assistants, nurses
and midwives, have had a mixed record. The medical establishment
doesn't cede power easily. The percentage of American
babies delivered by midwives more than doubled (to 7.6%)
in recent years, but remains less than a tenth as high
as the norm in several Western European nations that
have infant mortality rates significantly below ours.
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Jessie
Gruman
President
and Executive Director
Center for the
Advancement of Health
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The latest battle
in this war began when several big retailers -
including powerhouses like CVS and Wal-Mart - announced
plans to open many in-store clinics where simple
problems could be dealt with quickly and cheaply.
As anticipated, more traditional providers who
are accustomed to dealing with such health matters
themselves were not pleased and launched a counterattack.
Their concerns were outlined at a recent American
Medical Association session where retreaded complaints
about patients being treated by people who lacked
adequate competence were trotted out along with
a new question about whether clinics could be viewed
as commercial ventures designed to boost in-store
prescription sales.
What does the evidence show? In this era of evidence-based
medicine, we need data to compare not only different
treatments but also different treatment venues.
No one claims that America's physicians are perfect.
Both research and malpractice judgments suggest
that they sometimes perform in a suboptimal fashion.
The relevant question is whether in-store clinic
personnel err significantly more often than physicians
do.
There could be public benefit in a study comparing
how the two groups perform. Maybe the AMA could
help fund it. Perhaps they could minimize their
cost and gain credibility by inviting stores sponsoring
the clinics to share research expenses.
If the AMA is more concerned about patient protection
than self-protection, it should focus more on care
and less on credentials. In many situations, getting
adequate care quickly and conveniently trumps getting
perfect care slowly and dearly.
The issue of whether clinics will promote prescription
sales raises a different set of questions. It isn't
immediately obvious that harm is incurred by receiving
both your diagnosis and prescribed pills in one
visit. In other contexts, that's called one-stop
shopping and is viewed as advantageous.
Of course, there is a possibility that the clinics
will push unneeded pills, showing greater loyalty
to their corporate sponsors than their patients.
It would be reasonably easy to track whether they
were more likely to write prescriptions than doctors
were when confronted with similar apparent conflicts
of interest.
Anyone interested in studying this question could
save time and trouble by recycling protocols used
in reviewing whether physicians owning electrocardiograph
or MRI machines were more likely to subject their
patients to them.
In medicine, as in other areas of our economy,
money talks (sometimes in an uncomfortably loud
voice). The question raised by the new clinics
is whether the pursuit of profit can actually moderate
costs.
Consumers exercise control over much of America's
economy. Ultimately, it is their decision about
patronizing facilities that promise fast, cheap
relief for simple problems. But they can only do
so wisely if they have the evidence with which
to understand the trade-offs and guide their choices.
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