Evaluating the Medical Care System: Effectiveness, Efficiency, and Equity
Lu Ann Aday, Charles E. Begley, David R. Lairson, and Carl H. Slater
Health Administration Press, Ann Arbor, MI
1993, 222 pp., $32 (paperback)
After the meltdown of the Clinton administration health plan but before the 104th Congress started debate on welfare reform, I found it an appropriate time to read Evaluating the Medical Care System: Effectiveness, Efficiency, and Equity. This well-organized and clearly written book offers an exquisite historical perspective on many health services research concepts and methods. In addition, the authors explain how to use the social sciences "to illustrate the measurement and relevance of effectiveness, efficiency, and equity as criteria for evaluating health care system performance" (p. xi).
The text focuses on the tools (data and methodology) that academicians often use to determine how we Americans might reform our health and welfare systems. One of the many virtues of this book is that Lu Ann Aday and her colleagues first clearly set out the concepts of effectiveness, efficiency, and equity of access and then provide "evidence and an application" — how these concepts can be used.
The book's background sources and analyses are primarily pre-1992. It therefore overlooks the current importance of such procompetitive themes as managed care, capitated payment, and networking. This comment may be immaterial to some potential readers as Chapters 2 and 3, which center on effectiveness, respond to far broader conceptual questions such as: What contribution do medical care services make to the health of a population? How do medical services improve the health status of patients who enter the system? These discussions can be particularly beneficial when reviewing the options to appropriately measure health effectiveness or to compare the health status of various populations.
I was intrigued with the authors' conclusion in Chapter 3, which states that outcomes assessment and management can significantly improve the quality of patient care and reduce health costs. There could be more fiction than substance to their argument that some of the best academic minds can definitely solve the problem of improving quality while lowering costs.
This book is more valuable from a theoretical than a pragmatic point of view. It is well known, for example, that each year Boston hospitals have twice the number of patient days per 1,000 persons than New Haven, CT. Both of these cities are internationally renowned as referral centers. The most plausible explanations of these differences are that physicians in the two cities have different practice patterns, and that Boston has more doctors and acute care beds per 1,000 persons than New Haven. How is it possible to arrive at valid national effectiveness, efficiency, and equity standards from such findings?
Chapters 4 and 5 focus on the efficiency of our delivery system. The authors argue that the American health system does not achieve maximum value from its allocated resources because of "our peculiar mix of open-ended pluralistic financing" (p. 108) and the lack of planning and effective regulation. Most of our nation's healthcare leaders would also disagree with the authors' conclusion that "micro incentives [managed care] have yet to demonstrate the ability to control cost, making allocative efficiency unlikely" (p. 112). These arguments could be more compelling if Aday et al. had considered that the French, German, and Japanese multipayer systems set global budgetary targets on hospital and physician services (with the latter group being paid on a fee-for-service basis) and spend a considerably smaller portion of their gross domestic product for healthcare than the single-payer Canadian system.
Chapters 6 and 7 respond affirmatively to the perennial question of whether equity of access implies a right to medical care; and then summarize "the evidence on the extent to which the goal of equity of access to medical care has been achieved" (p. 17). Their discussions on how universal health insurance might contribute to further equity of access are well balanced, but the three health reform options proposed have limited value today, since they require — at a minimum — employer mandates for full-time employees. Aday and colleagues carefully analyze and document the effects of employer mandates, but it is unlikely that this option will gain much attention in Washington, DC. Welfare reform has taken center stage and President Clinton is not likely to sign any measures beyond minor health insurance reform before the 1996 election.
The book's final two chapters examine the relationship between health services research and policy analysis. It is valuable, at least conceptually, to use effectiveness research in any policy analysis, as proposed by Aday et al. in Chapter 8. But, as the authors admit, over the past two decades such endeavors have produced verified data for only a small number of medical conditions and procedures. When states have issued findings for cardiac catheterization and open-heart surgery, for example, these results usually have been out-of-date. In addition, providers often claim that either the data or the analysis is flawed. It seems unlikely that the medical profession and the hospitals in the United States, which have seldom lacked ingenuity in the past, will accept — without significant resistance — any additional clinical and administrative outcome controls.
Evaluating the Medical Care System is a neatly crafted, well-documented book for graduate students in social sciences or health services management and for health services researchers interested in learning how we arrived where we are today in our efforts to study the effectiveness, efficiency, and equity of our delivery system. It is less appropriate for those health services executives who seek pragmatic answers to fairly complicated operational issues within our current procompetitive healthcare environment.
Thomas P. Weil, PhD
President
Bedford Health Associates, Inc.
Asheville, NC