Dr. Costello’s “Best of Health” Quarterly · Vol. II, No. 2 · Summer, 1991
A Graphic Analysis of the Quality of Medicine
*The gray area represents care liable for malpractice.
The Definition of Service
The word ‘service’ is much used and abused in discussing medical care. To clarify, in this Quarterly, service has three meanings:
1) service, as an act of providing medical care, i.e. office visit, or an appendectomy etc.,
2) service, as a responsibility of the profession to the community, and
3) service, the aspect of the timeliness of care, i.e., an acute appendix needs to come out! Or as another example, in a like manner, the rapidity and exactness of service found at a good restaurant.
The term Service Driven Health Care references the third meaning
Quarterly Summary Box
| Year | Season | Articles | Summary |
|---|---|---|---|
| 1991 | Spring | The Quality of Medicine | Quality medicine is expertise and service. |
| The Health Care Players | Only patients and doctors are interested in quality care. |
The way to use this graph is to first, pick a severity of illness; second, move vertically to any of the three curves; and third, move horizontally to the level of medical intervention.
For example, if you are sick enough to be in the Emergency Room, the Cost Driven Curve will put you in the Dr.'s office; the Theoretical Ideal Health Care Curve will put you in the Emergency Room; and the Service Driven Curve will already have you in the hospital.
The Ideal Health Care system will care for the patient at the exact level of intervention required. This is not always possible, but is postulated as the Theoretical Ideal Health Care Curve.
Clearly, this analysis vividly illustrates that a patient will be seen by a Service Driven Care system earlier than by a Cost Driven Care system. The intervention under Service Driven Care will be more aggressive and comprehensive, with anticipatory diagnostic tests and preventive therapy.
A Cost Driven Care system will delay care. The patient will be more ill at the time of intervention and receive crisis care. Its essence will be “no service”. If you had a chance to read the last Quarterly’s discussion on Quality (please see the Quarterly Summary Box on this page). Quality in medical care requires expertise and service. A health care delivery system that ignores either will be inferior.
Other names for Cost Driven Care are “Managed Care Plans”, “Health Maintenance Care”, “Capitated Health Care” and many Government Sponsored Health Care Services such as the Veteran Hospital Services.
Generalizing this form of analysis, any concept or factor that impacts on health care can have its influence evaluated by use of this graph. Let’s discuss examples of malpractice and new technology.
The malpractice fears of the physician push the curve upward and require more studies be done to document the absence of disease. The effect of this on Service Driven Care is to add unnecessary tests to an environment which already is encouraged to do anticipatory care. Conversely, if there is absolutely no retribution for bad care, the Service Driven Care curve will move closer to the Theoretical Ideal Care line and in the instance of negligence, will cross over into the malpractice portion of the graph.
The effect of malpractice fears in a Cost Driven Care environment will be to drive physicians out of medicine because doctors won’t work in an environment of limited earnings and unlimited liability.
New technology that proves to be useful, either by empiric use or by controlled trials, will have the effect of shifting all forms of care toward the Theoretical Ideal Care line. Unfortunately, in the Cost Driven Care system, the new technology will not be introduced in a timely manner. Far more people will die due to the delay in upgrading the technology and the releasing new drugs than will die from adverse reactions. The AIDS Lobby has been pointing out this for years.
In summary, this graph as a method of analyzing health care is valid in that it accurately depicts human nature. The Cost Driven Health Care system removes any incentive to provide anticipatory care. The Service Driven Health Care system uses human nature's desire to be rewarded for effort and consequently provides better care for the patient.
America is in the process of deciding what kind of health care it wants. Please keep these considerations in mind when you hear people discussing this issue.