Patient Safety and Self-Managed Medical Care

Howard Long, MD, MPH
Article Type: 
May/June 2000
Volume Number: 
Issue Number: 

Letter to David M. Lawrence, MD
Chairman and CEO
Kaiser Permanente
Oakland, CA

Dear Dr. Lawrence,
Would health care be safer with control like air traffic (as you suggested at Town Hall in November --- or with self-managed medical savings accounts?

Evidence from self-managed MSA vouchers seems to confirm Bastiat's conclusion of The Law with, "Now that legislators and do-gooders have so futilely inflicted so many systems on society, may they finally end where they should have begun, may they discard all systems and try liberty."

...You cited illustrative anecdotes about hospital mistakes. Anecdotes also suggest how self-management improves safety. Last week, a 4-month-old girl with cough was not improved by a week of the new standard for treatment of bronchitis, albuterol.

My careful examination with stereophonic stethoscope revealed both rales and faint wheeze. Were these audible to managed physicians, forced to spend more time doctoring the record than doctoring the patient?

With nebulized corticoid and oral cephalosporin, the symptoms cleared in 3 days. Cost to the parent was $40 (including medicine) --- much less than for work lost to get "free" care.

A retired teacher had an ominous whoosh in her neck, "I've been telling my [Kaiser] doctor for a year my bridge and golf are off. She listens to my neck but doesn't say anything!" Carotid echograms showed "under 60 percent obstruction" to the contracting radiologist who might wonder about contract renewal if frequent surgical indication were found. Because of an endarterectomy revealing 95 percent obstruction, the retiree again enjoys bridge and golf. Self-management improves safety.

Howard Long, MD, MPH
Pleasanton, CA


Dear Dr. Long,
Thank you for your letter dated December 16, 1999, concerning patient safety and self-managed care. You pose interesting questions about safety and self-management of care. However, you argue as though the choices are either/or ones. I think this obscures the matter considerably. Here's my perspective.

All the evidence I've seen suggests that greater self-management and regulation are required to improve patient safety. Moreover, Medical Savings Accounts can alter incentives in such a way that people take greater responsibility for their care and the quality of care they're receiving. Based on what we've learned from looking at other fields, health care will also benefit from better organization and more safety-focused internal operating systems, especially in those places where errors can have the most disastrous result (e.g., prescription drug use, surgical suites, anesthesia, invasive procedures, and the like). Unfortunately, medical care is not well organized and all of us have over-relied on the myth of perfect performance at the expense of safety systems development.

There's no evidence to support the assertion that managed care, HMOs, or Kaiser have reduced safety or quality. The Institute of Medicine's report published in 1999 in JAMA (September) concluded that quality of care problems are ubiquitous and unrelated to managed care. Most quality of care problems identified in the major studies of the issue predate the introduction of managed care, in fact. In other words, quality and safety problems aren't now and can't be laid at the feet of the way health care is financed.

Finally, I don't think all regulation is bad. I favor regulation that creates a safe legal climate within which to conduct investigations for purposes of learning about causes of errors that result in death or injury. We don't presently have this. I favor regulation that creates a place responsible for capturing and analyzing significant errors, again for purposes of learning. I favor regulation that provides funding for research into new ways to understand and prevent errors from occurring. And I favor regulation that enables voluntary reporting of "near misses"...errors that occurred but didn't result in injury or death. Other industries have found them to be the primary source of insight into error causes and prevention. Our experience in health care in adverse drug event and anesthesiology suggest that the opportunities in health care are similar.

David M. Lawrence, MD
Chairman and CEO
Kaiser Permanente
Oakland, CA


Dear Dr. Lawrence,
Thank you for your letter dated 01/12/00...I agree that, "especially in those places where disastrous results (e.g., prescription drug use, surgical suites, anesthesia, invasive procedures, and the like), care will also benefit from better organization and more safety-focused internal operating systems."

Indeed, lower cost (and presumably greater safety) has been observed when catastrophic care was combined with MSAs. Internal operating systems function better with incentives for personal responsibility, like MSAs. Could a Kaiser catastrophic option and MSAs increase Kaiser profits and patient safety?

Howard Long, MD, MPH
Pleasanton, CA

Correspondence originally published in the Medical Sentinel 2000;5(3);73-77. Copyright©2000 Association of American Physicians and Surgeons (AAPS).

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