In This Issue
The American legal system for redressing harms resulting from medical care has been much criticized for its cost, seeming capriciousness, and inadequacies in stimulating prevention. The first article in this issue of The Milbank Quarterly proposes moving malpractice claims from the tort system into an alternative administrative system known as a health court. A recent report by the Institute of Medicine (IOM) summarizes evidence showing that most medical errors do not result in lawsuits, that most legal claims are not related to negligent care, and that the awards for some patients (and their attorneys) are disproportionately large in relation to the injuries suffered, whereas awards received by many other claimants do not even cover the costs of their ongoing care (Institute of Medicine 2002). The IOM report further noted that the “apparent randomness” and delays associated with the current system “attenuate the signal that liability is supposed to send to health care providers regarding the need for quality improvement.”
In “‘Health Courts’ and Accountability for Patient Safety,” Michelle Mello, David Studdert, Allen Kachalia, and Troyen Brennan argue that the health court idea, first introduced some years ago (Weiler 1991), deserves new attention in view of current concerns about the malpractice system and the evidence that medical errors are at once common, consequential, and usually not reported (Institute of Medicine 1999). The authors, who are among the leaders of empirical research in this field, suggest that a demonstration project on the health court idea be carried out by an insurer or group of insurers.
Mello and her colleagues describe how health courts might work, which includes a standard based on avoidability rather than negligence. They also describe how such systems have worked in other countries. They argue that the advantage of the system they envision is a greater likelihood of a “culture of safety and disclosure” that would enhance the ability of medical institutions to address the causes of avoidable harms to patients. To facilitate such a culture, they recommend that, except in extreme cases, the health courts be insulated from disciplinary authorities. Although this and other aspects of their proposal will be controversial, the authors make a strong case for the feasibility and positive consequences of health courts.
Even though the prevalence of disability has been declining among the elderly, the growing size of this population makes the prevention of disability a challenge of considerable policy importance. The article “Promoting Declines in the Prevalence of Late-Life Disability: Comparisons of Three Potentially High-Impact Interventions,” by Vicki Freedman, Nancy Hodgson, Joanne Lynn, Brenda Spillman, Timothy Waidmann, Anne Wilkinson, and Douglas Wolf, addresses this issue.
The authors present a framework for comparing the population-level effects of interventions designed to reduce the prevalence of disability, which they define as the inability to carry out daily activities independently. Their framework includes risk factors, size of the target population, and the effects of interventions on risk factors, competing factors, and length of life. Using the available literature, they illustrate the framework’s utility in comparing the costs, cost-effectiveness, and, most important, the benefits of three late-life interventions: physical activity, depression screening and treatment, and fall prevention. They conclude that “in the short run, prevention of falls through multi-component strategies would likely have a greater effect than would exercise or depression interventions alone.” The comparative longer-term effects depend on how the intervention interacts with mortality and other risks for disability.
Efforts to increase health insurance coverage in the United States now include programs at the county level, as the next article describes. In “A Tale of Two Counties: Expanding Health Insurance Coverage for Children in California,” Embry Howell and Dana Hughes report on the results of an evaluation of recent “Children’s Health Initiatives” in Santa Clara and San Mateo counties. These initiatives included both an intensive outreach effort to enroll children in programs for which they are already eligible and a new health insurance program (Healthy Kids) for uninsured children who are not eligible for existing programs, in many cases because of their immigrant status.
Howell and Hughes describe how these programs were organized, funded, and administered, as well as the concerns that they have raised (e.g., further fragmentation of enrollment systems). They also analyze changes in enrollment in the several programs available for low-income children, as well as changes in the utilization of services. They report evidence of substantial declines in the number of hospital discharges and outpatient visits for uninsured children and a roughly corresponding increase in the number of children funded by public programs. Both of these counties have relatively high-income populations and were able to marshal some special funding sources (including a tobacco tax and private foundations), but their experience nevertheless lays out one way of addressing one of the major problems of American health policy.
Substance abuse is a significant problem in this country’s welfare population, even though it is less prevalent than once thought (Metsch and Pollack 2005). Among the barriers to treatment is the limited available information about the cost-effectiveness of such treatment for this population. That’s the topic of the next article in this issue, “The Effect of Substance Abuse Treatment on Medicaid Expenditures among General Assistance Welfare Clients in Washington State,” by Thomas Wickizer, Antoinette Krupski, Kenneth Stark, David Mancuso, and Kevin Campbell. They compared substance abusers in the welfare population who received treatment with those who did not and found that treatment was associated with a 35 percent savings in annual medical expenses, an amount equal to the cost of treatment. They conclude that cost-containment decisions by various states to reduce access to substance abuse treatment for people receiving welfare are likely to have counterproductive effects on medical expenditures. In addition, they note that substance abuse treatment in this population is associated with reduced criminal activity and higher employment.
The concept of evidence-based decision making has taken root in many areas of health care, from clinical settings to health management. The idea that policy decisions should take account of available evidence seems incontrovertible. Nonetheless, some researchers have advised caution regarding how that evidence is applied (e.g., Kravitz, Duan, and Braslow 2004). In the final article in this issue, Sheena Asthana and Joyce Halliday raise concerns about Great Britain’s current use of evidence to reduce health disparities within its population.
In “Developing an Evidence Base for Policies and Interventions to Address Health Inequalities: The Analysis of ‘Public Health Regimes,'” Asthana and Halliday argue that systematic reviews are inadequate as a “stand-alone tool” for guiding policy. Rather, they contend, the evidence should be incorporated into a broader framework of a “public health regime,” referring to the overall legislative, social, political, and economic context in which public health interventions might be used. The context provided by public health regimes, they believe, greatly influences whether evidence-based interventions are effective, and should not be ignored.
Bradford H. Gray
Editor, The Milbank Quarterly
Institute of Medicine. 1999. To Err Is Human: Building a Safer Health System. Washington, D.C.: National Academy Press.
Institute of Medicine. 2002. Fostering Rapid Advances in Health Care: Learning from System Demonstrations. Washington, D.C.: National Academy Press.
Kravitz, R.L., N. Duan, and J. Braslow. 2004. Evidence-Based Medicine, Heterogeneity of Treatment Effects, and Trouble with Averages.The Milbank Quarterly 82:661–87.
Metsch, L., and H. Pollack. 2005. Welfare Reform and Substance Abuse. The Milbank Quarterly 83(1):65–99.
Weiler, Paul C. 1991. Medical Malpractice on Trial. Cambridge, Mass.: Harvard University Press.
Author(s): Bradford H. Gray
Volume 84, Issue 3 (pages 455–458)
Published in 2006