he father of the HMO movement has given up on the ability of doctors and health plans to guarantee safe medical care and now calls for strong government regulation to improve the ''unacceptable'' quality of American medicine.
The impetus to improve medical care ''is not going to come from within'' the health system, Dr. Paul M. Ellwood declared yesterday at a Harvard University conference.
Ellwood, who coined the term ''health maintenance organization'' and is arguably the nation's most influential health policy guru, startled his audience with a strongly worded indictment of US health care and the unwillingness of doctors and health plans to improve it.
Ellwood's change of heart largely results from a recent near-disastrous encounter with the health care system and his family's experiences, he says.
''Uneven health care in the United States is a national disgrace. It's unacceptable, and it can't be allowed to continue,'' said Ellwood, whose Wyoming-based Jackson Hole Group has been a wellspring of ideas that have transformed US health care in the last 30 years.
Ellwood called for government regulation of health care quality - review and disclosure of mortality rates, treatment complications, success in treating diseases such as high blood pressure and diabetes, and other indices of care. ''Ultimately this thing is going to require government intervention,'' he said. ''The question is what form government intervention will take. I think whatever it is, it's going to have to be a condition of doing business.''
Even those who disagreed with Ellwood about the need for government regulation said his opinions are likely to carry great weight - and possibly light a fire under efforts by physicians and health plans to mount voluntary quality-improvement efforts.
''Because it's Dr. Ellwood saying this, more people will hear and listen,'' said Dr. Terry Hammons, an assistant vice president of the American Medical Association who is leading an AMA program that encourages doctors to examine their performance and sharpen their skills.
The 72-year-old Ellwood, an adviser of presidents from Richard Nixon to Bill Clinton, has been a champion of market forces to lower the price and raise the quality of health care. ''We thought in proposing the HMO idea that they would respond to both price and quality demands,'' he said.
While competition temporarily tamed the double-digit medical care inflation of the 1980s, Ellwood concludes that market forces will never work to improve quality, nor will voluntary efforts by doctors and health plans. (He also predicted that double-digit increases in health insurance premiums will soon return ''with a vengeance,'' citing fiscal hemorrhages at Harvard-Pilgrim Health Care and elsewhere.)
Ellwood's new position in favor of government policing - perhaps along the lines of the ''safety first'' approach of the Federal Aviation Administration - emerged from his own chilling experience after a life-threatening accident a year ago.
A fall from his horse crushed a vertebra in Ellwood's neck, but did not sever his spinal cord. ''If it had, I would have ended up like Christopher Reeve - or worse,'' Ellwood said, referring to the movie star whose equestrian accident left him paraplegic.
However, immediately after the accident a sudden move could have severed Ellwood's spinal cord.
The fact that Ellwood is not paralyzed today, he said, is no thanks to the care he received. He recounted a series of near-miss medical adventures that could well have left him paralyzed.
Encountering a young neurosurgical resident, Ellwood was immediately commanded to stand up - a potentially disastrous maneuver. ''But I did it,'' he said. ''I was sedated - and he was a doctor. When you're a patient you're vulnerable and the power slips away from you.''
That night, the protective collar he was wearing came off, ''and the nurses didn't know how to put it back on.''
The next day, the surgeon said he didn't need a special surgically installed brace to immobilize his head and refused to install it when Ellwood insisted. A second surgeon also refused to do the operation ''because I wasn't referred by the first doctor and because it was his golf day.''
Eventually Ellwood got the care he needed, but he said the experience - coupled with other recent instances of poor care given to family members - drove him to conclude that the quality of American medical care is worse than he realized.
''It doesn't make any difference how powerful you are or how much you know,'' Ellwood said. ''Patients can get just atrocious care and can do very little about it. I've increasingly felt that we've got to shift the power to the patient.''
Ellwood's bad experience did not involve an HMO but rather traditional, fee-for-service doctors working in an institution that was part of a national for-profit hospital chain. But he said care is no better in prepaid health plans, or HMOs, and that the idea that such plans would compete on quality has not worked as he thought it would.
''A Kaiser official told me the other day, `Until better quality attracts more patients, I don't care about it any more.''' Ellwood said. ''We've been talking about quality improvement for 30 or 40 years without much to show for it.''
Ellwood said he has been asked if he is ''disillusioned'' with the US health care system. ''I'd have to say no, I'm mad - in part because I've learned that terrible care can happen to anyone,'' he said.
Ellwood's critique, and his call for government regulation, generated skepticism rather than opposition.
The AMA's Hammons, for instance, acknowledged that he too has been disappointed by physicians' unwillingness to participate in voluntary quality-improvement programs. But he warned that public disclosure of physician data would result in doctors digging in their heels.
''If we try to push too much, I think we'll end up with a great deal of passive-aggressive behavior - a skill we learn in medical school,'' Hammons said.
Some differed with Ellwood's flat pronouncement that technical problems in measuring quality have essentially been solved.
''It's really hard to say, `Your hospital, or your doctor, or your HMO, is better than that one,''' said Paul D. Cleary, a Harvard authority on quality measurement. ''At the same time, I don't think we should be daunted.''
The political obstacles to government regulation are formidable, some observers said.
Ellwood responded that it will take time to build political pressure for such a change. ''You've just got to keep the heat on,'' he said. ''We've got to build a consumer movement here.''
Meanwhile, he agreed with some observers that the specter of government regulation might accelerate voluntary efforts among health care providers to improve care.
''That's why I say these things,'' he said in an interview.
Brian McGrory
Latest regional news
