There's the soft rationing of managed care, and then there's "quality."

Mark McClellan, now at a think tank, chooses the latter option. He's not just another yahoo in the healthcare debate. He's an MD, and he headed up the FDA and CMS during the 2000s. http://en.wikipedia.org/wiki/Mark_McClellan

He wrote about healthcare reform here:

http://thegovmonitor.com/world_news/united_states/experts-skeptical-heal...

The response is this:

I'm pretty sure it's tough to measure quality. Sure, we are picking some of the "low hanging fruits" such as not paying for the most preventable complications in hospitalized patients. Such policies are changing behaviors.

While using reimbursements to shape behavior is an old Uncle Sam trick (think of the tax code), capturing quality can be like catching lightning in a bottle. The reason is it's hard to define quality care, and you have to do things like determine how sick patients are before they get a particular diagnosis. This means point scores quantifying illness, and these are notoriously inaccurate.

The real question we are asking with quality is whether the patient did better or worse than would be expected for a patient in his condition. For healthy patients, or people with only one illness, that's pretty easy to do. For sick patients, it gets very murky.

So while we definitely need better tools to quantify illness and prognosticate. The insurance companies probably have these tools. What do they do? Do they have metrics of quality already? They definitely have metrics of resource utilization.

I would love to chat quality with Dr. McClellan.