Need Care, Should Travel

As tempting as it is to write about the parallels to healthcare of the Texas power/water debacle, or about IBM’s rumored desire to sell off its Watson Health division, I find myself thinking once more about our inability to distinguish quality in our health care. 

I live in Cincinnati (OH).  The metro area has five hospital systems, including an academic medical center (University of Cincinnati), plus a renowned children’s hospital (Cincinnati Children’s) and a VA hospital. Most Cincinnati residents go their entire lives getting all their medical care here. 

That’s the problem.

If, for example, someone in Cincinnati had a serious heart issue, he/she/they should really go to The Cleveland Clinic.  It is known worldwide for its cardiac care and is ranked #1 in the country for it by U.S. News & World Report.   No Cincinnati hospital is nationally ranked in this field. 

For that matter, The Cleveland Clinic is top 10 ranked in 11 other adult specialties as well, plus top 50 in two others.  It’s the #2 hospital in the nation overall (The Mayo Clinic is #1).  Frankly, if something is wrong with you, it would seem worthwhile to drive up to Cleveland to get care there.  But most don’t. 

If that drive is too far, you could go to Columbus, which is only about half as far, where The OSU Wexner Medical Center/The James Hospital is nationally ranked in 9 adult specialties, still higher than any Cincinnati hospital.  Again, though, most don’t.

Whatever state/city you live in, there’s probably a similar dynamic.  Most people have some nationally ranked hospitals within a few hours drive, and everyone is within a few hours flight from some, but all-too-few actively pursue them, despite “centers of excellence” programs that many health plans have used to encourage such travel.  Even people living in cities with such hospitals don’t always choose to get their care from them. 

There may be many reasons why most care remains local.  For one thing, the ratings almost certainly aren’t as accurate as one would like; there is more subjectivity/ambiguity in them than anyone would like.  For another thing, a large chunk of hospital admissions come from emergency room visits, and driving two to three hours to a “better” hospital during an emergency is usually ill-advised.  Travel is a barrier generally; it’s harder on the patient, harder on the family, and those travel expenses/time are usually not reimbursed. 

What, me travel?

Most importantly, though, most people don’t really understand that there might be differences in the quality of care they might expect from different hospitals.  They might be aware of The Cleveland Clinic’s reputation, or have heard of The Mayo Clinic, but the thought of travelling to either doesn’t occur to most.  People in Cincinnati, like people most places, think the care here is just fine, thank you very much.

For most care, that’s probably fine.  If you have a cold or the flu, chances are you can get pretty good care for it locally.  Even if you have a more serious condition like diabetes or asthma, local physicians and hospitals can usually help you manage it well.  But if you need a heart transplant or have a rare form of cancer, you should probably be thinking seriously about travelling.   

The trouble is that there’s no good way to help us distinguish these situations.  For which cases should I be seriously weighing going up to Cleveland for my care?  I can get a heart transplant locally; I can get almost any kind of cancer care I might need here, and, if not, certainly in Columbus.  When is that care likely to be not good enough?

I don’t know, you don’t know, and even “experts” are likely to disagree. 

I wish all the hospital advertising I see spent at least a little time telling me when I shouldn’t go there, instead of telling me why I should always go there.  The facts are that outcomes aren’t the same, that doctors in different hospitals don’t have the same experience/expertise, and that all-things-to-all-people is not the best recipe for best-in-class.  

What we need is what I’ll call a “quality matrix,” indicating when which type of condition needs what “quality” of care.   It might be based on the potential variation in outcomes patients might face based on using different hospitals/physicians. 

Using the USN&WR system, “low variability” conditions could be treated at any hospital (or outpatient by their physicians), but for “medium variability” conditions patients should consider hospitals that are rated at least “high performing,” and for “high variability” conditions, care should be directed to nationally ranked hospitals. 

E.g., outcomes for colds are likely to be similar no matter where/from whom you get treatment, but chances that you’ll survive a heart transplant (and have high quality of life afterward) are heavily dependent on where/from whom you get the transplant.   

I know: we don’t have the data.  We don’t have good data on outcomes for most conditions; we don’t quite understand the interplay between the institutions and the specific clinicians practicing within those institutions (e.g., it’s unlikely that every Cleveland Clinic heart surgeon is better than any Cincinnati heart surgeon).  No patients are the same, outcomes can’t be predicted, and so on. 

In other words, the same excuses we’ve been using for the past fifty years.   

I’m not intending to do business development for The Cleveland Clinic, or, for that matter, for USN&WR.  I’m just using them to make the point.  Pick your preferred hospitals, pick your preferred rating mechanism, but the fact remains that all care is not the same.  Some hospitals are better for some things than others.  We just don’t act as though that was true.

Of course, there would be non-trivial financial implications to such a change.  Hospitals that are not nationally ranked aren’t likely to be willing to give up those more severe patients; instead, they’ve been investing over the past few decades to bring more & more services within their walls.  Whether that results in better outcomes for patients, though, is at best unclear. 

Frankly, I believe our seeming indifference to actually measuring and acting on quality of care is an overarching problem in our healthcare system.  For the most part, we pay regardless of the quality.  Value-based programs are, to date, more for show than for effect. 

I challenge hospitals and health plans to focus on getting patients to the right places for their condition, not just enabling patients’ desire to stay local.  And I challenge more patients to demand better. 

All politics, as they say, is local, but all health care shouldn’t be.