Turning Errors into Gold
By now, most readers of P&T are familiar with the series of recent reports from the Institute of Medicine (IOM) that are encouraging health care organizations and purchasers to implement policies that would enable health care to become more “safe, effective, patient-centered, timely, efficient, and equitable.” These Washington-based policy makers from the IOM have exhorted us to develop the key financing and payment mechanisms to support these goals, but they have not offered specific practical approaches for doing so. My good friend David Lansky, PhD, president of the Foundation for Accountability (FACCT) in Portland, Oregon, has outlined a perspective to effectively deal with this challenge in the policy journal Health Affairs.
FACCT is the only not-for-profit, nationally prominent, consumer-focused research organization that attempts to improve health care in the U.S. The organization has a long history of “telling it like it is” from the consumer’s perspective and backs up its statements with outstandingly good research. I have had the privilege of working with FACCT since 1997, and I now chair its board of directors. I wish I could take credit for one of David’s outstanding ideas, as outlined in the Health Affairs article. Allow me to summarize the main issues he discusses.
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Although the IOM reports have garnered widespread and well-deserved press, from an institutional perspective these reports represent a form of unfunded mandate—exhortation without dollars attached. Recent evidence as to how Congress views quality improvement and efficiency is also slim. For example, the annual budget for the Agency for Healthcare Research and Quality (AHRQ) represents only 1.3% of the entire budget of the National Institutes of Health (NIH). The Centers for Medicare & Medicaid Services (CMS), formerly the Health Care Financing Administration (HCFA), contracts with peer-review organizations, for a total of about $235 million a year for quality oversight and improvement. This represents less than one-tenth of 1% of the entire budget for the Medicare program on an annual basis. Do you know of another $218 billion company that spends less than one-tenth of 1% evaluating the quality of its products?
Here is where David’s axiomatic and refreshing idea comes into play. Let us assume that Congress adopts legislation and creates the statutory underpinnings for a Medicare drug benefit. Many people, including myself, would agree that this would go a long way toward helping our senior citizens gain access to appropriate pharmaceuticals. It does seem silly that we pay billions of dollars annually for in-patient care when we might be able to decrease that pot with appropriate outpatient pharmacological intervention. Yet if a drug benefit were enacted, there are a number of sobering realities we would face.
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Even though Americans spent an estimated $132 billion on prescriptions in the year 2000, we have little evidence regarding the value or the overall impact of that expense. Our readers know, for example, that despite the billions of dollars spent on cholesterol-lowering medications, many studies show that patients never achieve their targeted cholesterol levels. Errors in outpatient prescription fulfillment are rampant, having reached a rate of 24% in some geographical areas. This means, of course, that approximately 25% of prescriptions contain some kind of error—in dosage, format, or lack of accompanying patient education materials.
