Some Say US Healthcare Quality is Among The Best In the World: It Is Not!

Lesson 19: Healthcare for Policymakers

We Rescue Patients With Very Expensive Treatments Like Dialysis Rather Than Slowing Progression of Chronic Kidney Disease with Best Practice Treatments

Since the first of the year, I have been writing about the Singapore health system that is a model for what our healthcare system could be. One of my readers made a comment that deserves a post of its own because it clearly illustrates a point of confusion. The comment said: “The core issue of the U.S. healthcare system is not its quality, which is among the best in the world, but its low cost-effectiveness and the misalignment between the cost of services and their actual value…. Here’s a summary:

1. High Quality but Low Value

The U.S. leads globally in medical technology, advanced treatments, and pharmaceutical innovation, with top-tier hospitals and specialists.”

The US does lead globally in medical technology, advanced treatments, and pharmaceutical innovation with top-tier hospitals and specialists, but those things are not the same as quality and that is a frequent point of confusion. Patients need those things because they did not get best practice treatments (optimal medical therapy) earlier in their disease process when they had uncomplicated or less complicated diabetes, hypertension or high cholesterol.

Let’s talk about an example. Modern smart phones are very innovative technology. It is amazing what they can do, but cell phones are a product, and the quality as a product is different from their status as innovation and technology. Smartphones are considered a "Six Sigma product" because many major phone manufacturers like Motorola and Samsung use Six Sigma methodologies to optimize their production processes, aiming to minimize defects and maximize quality in their smartphone manufacturing, which aligns with the core principles of Six Sigma. Quality in smart phones does not relate to their innovative or advanced technology, but instead to their function. Does the GPS, calculator, calendar, and phone function work just right every time.

The sigma level is a great way of understanding the quality of a product. The Sigma Level is a key indicator of a process’s capability to meet what your customer wants. Smart phones do what you expect them to do 99.99966 percent of the time or greater. Generally, the higher the Sigma Level, the better the process’s capability and quality. Here is the commonly accepted process capability benchmarks in terms of Sigma Levels:

– 1 Sigma: 68.27% of the process output meets customer requirements.

– 3 Sigma: 99.73% of the process output meets customer requirements.

– 4 Sigma: 99.9937% of the process output meets customer requirements.

– 6 Sigma: 99.99966% of the process output meets customer requirements.

Best practice medical treatment for chronic diseases is known as optimal medical therapy (OMT) by healthcare professionals. Optimal medical therapy for treating chronic diseases is a product. It is a product of a systematic process. When treating diabetes, optimal medical therapy is defined by concurrently achieving the goals below for the risk factors listed. There are only five variables. The percentage of your diabetic patients achieving target level of control for these five variables is by far the most important quality measure for patients with diabetes because it determines clinical and financial outcomes. According to the most recent data, only 26% of Americans with diabetes even achieve the less stringent goals of A1C less than 8, BP less than 140/90, and an LDL cholesterol of less than 100. The proportion of those achieving the more effective goals below would be even smaller. Achieving each of these goals is just as important as controlling the sugar level in improving outcomes in patients with diabetes.

The five variables of OMT are the criteria that are most commonly used to determine the quality of care for diabetes and the percentage of your patients achieving those goals concurrently is the most powerful predictor of improved clinical and financial outcomes. New science provides the opportunity to increase the benefits of OMT even more so that it prolongs healthier life and delays complications. For example, we have learned that treating high blood pressure with losartan, lisinopril, amlodipine, and eplerenone or other drugs from those same classes, does not merely lower the blood pressure. Those drugs directly interfere with the molecular biology that makes us age and develop chronic disease more rapidly. They have powerful antioxidant and anti-inflammatory properties. Best practice diet, exercise, and medication management are included in our OMT quality measures and that leads to even better outcomes.

Six sigma quality principles apply to best practice medical care or OMT for diabetes. When we consider sigma performance in the OMT product no one even comes close to one sigma. There is extreme variation in the percentage of patients that achieve the five goals concurrently. Some practices achieve 65%. Other practices achieve 10% and that is really poor, but most practices are not even measuring their concurrent achievement of OMT targets. If you ask any practice leader about their care of patients with diabetes, they are always certain their clinicians are doing as well as anyone could do, but the real data tells a much different story. That is such a shame because better clinical and financial outcomes depend on achieving OMT. If you have diabetes yourself, you can determine if you have achieved OMT in your own case. OMT for arterial disease is the same but the A1c is not important if you don’t have diabetes

Innovation, advanced technology, specialists, and complex hospital systems are important, but they are not the same as quality. The best outcomes in patients with chronic diseases require a systematic approach. The quality of that systematic approach can best be determined by measuring the concurrent accomplishment of the goals for that chronic illness and using the best practice interventions to achieve those goals. Until we figure that out, we will never have better health at lower cost. We should all push for quality improvement in chronic disease management and do some work to understand what that means.