Local Lapses, National Dilemma : Medicine: Higher, better-enforced standards will help. But ultimately, only universal health insurance will end substandard care.

A California obstetrician is convicted of murdering eight newborn babies, the result of his repeatedly engaging in grossly incompetent practices. The Board of Medical Quality Assurance is accused of laxity for not having suspended his license when it first investigated several of the deaths. As horrible as this case and other recent reports of doctor lapses are, the idea that we can turn to the courts to ensure that everyone receives appropriate health care is a sad delusion.

If we are serious about ensuring good care, four issues must be addressed:

Gross incompetence. This problem is supposed to be identified by state regulatory agencies. Yet there are no standards to guide them, no mechanism for ensuring the quality of the judges themselves. In most states, boards of quality assurance confirm the credentials of physicians seeking a license. Periodically, they suspend doctors guilty of outrageous misconduct. But rarely do the boards take action in other cases. In some states, quality boards do even less, their work hampered by inadequate funding and the reluctance of physicians to blow the whistle on their colleagues.

Variations in outcomes of care. Even if all the grossly incompetent physicians in the world were purged from the profession tomorrow, patients would still die unnecessarily. Physicians in a hospital where 25% of the heart-attack patients die are not grossly incompetent. But, all other things being equal, who wouldn’t want to be cared for in a hospital with a 20% mortality rate?

Research linking what physicians do to how their patients fare is just beginning. In time, it will serve as a basis for patient-care standards to which physicians can be held accountable. Until then, comparing outcome rates remains the only way consumers can assess the relative competence of health-care providers.

The Health Care Financing Administration currently releases statistics on the mortality rates in hospitals caring for the elderly. But the numbers don’t tell us if hospitals with the higher death rates also provide poorer care, because these rates may also result from random variations or from taking care of more seriously ill patients.

Unnecessary care. National studies suggest that a large minority of surgical and other procedures are unnecessary. These procedures, for which physicians are paid handsomely, can have serious complications. For example, the risk of death after carotid-artery surgery may be as high as 5%. Is the surgeon who performs such an operation blameless in the event of the patient’s death?

Lack of access to care. Most babies who die unnecessarily in the United States do not do so because the obstetrician was incompetent. The infant-mortality rate is high largely because the poor receive inadequate prenatal care and nutrition. Currently, the United States is worst among 19 leading industrialized nations in infant mortality, and the rate is nearly twice as high among nonwhites as among whites. If an obstetrician must spend the rest of his life in jail for the deaths of eight infants, how should we view political leaders who have cut nutrition programs and prenatal care?

The case, then, for organized medicine to develop explicit national patient-care standards is compelling. The American Medical Assn. is taking a hesitant step in this direction by agreeing to generate a set of “practice parameters.” Once these standards are in place, medical quality boards should be given the resources to enforce them.

As for states, they should devote more resources to efforts seeking to determine whether mortality differences among hospitals or practitioners are the result of poorer quality of care or sicker patients. Such studies may reveal that more money is needed to provide good care, particularly in public facilities.

Efforts are under way to develop standards for selected medical procedures. For example, the RAND Corp. has assembled expert panels to determine when it is necessary to perform such procedures as gastrointestinal endoscopy (passing a tube into the stomach), cardiac catheterization (inserting a tube into the heart) and gall bladder surgery.

This is well and good. But there is also a need to improve compliance with such standards. It might help to remove the carrot--paying physicians no more for doing a procedure than for spending comparable time and effort examining a patient. Medicare is moving in that direction.

Access to quality medical care, however, cannot be adequately addressed until everyone has insurance and no provider has an incentive to prefer the insurance of one patient over that of another because of reimbursement or red tape. It is hard to imagine this happening in the absence of a system in which everyone’s insurance comes from one source--a government-sponsored program. Until then, poor women will be at special risk for receiving substandard care, and babies will die.