04/27/2008 01:56 pm ET Updated Nov 17, 2011

The Triple Standard

The phrase double standard refers to situations where the rules are (unfairly) different for one group compared to another. The classic instance is men versus women. In the workplace, a woman is often paid less than a man for doing the same job. In sexual behavior, what is okay for a man is not acceptable in a woman.

When there are two groups playing by different rules, it is a double standard. In healthcare, since there are three groups of players, there is a triple standard.

Everyone knows that you make better decisions if you have evidence before deciding (anything). Those who practice medicine are committed to standard #1: evidence-based decision-making. When your doctor suggests a treatment, she is supposed to have reviewed the literature, studied cases similar to yours, and have scientific support - evidence or what you might call the "beef" - for her recommendation.

Those who manage health care sometimes talk about evidence but generally they have no proof that what they decide has worked in the past. They never test in advance to see if something will work when they implement. They are not held to a standard of "evidence-based decision-making" even though their decisions impact patient outcomes just as much as (or more than) the providers. Managers are not considered responsible or accountable: standard #2.

Those who regulate healthcare may not "practice medicine" but their decisions have greater impacts on more patients than all nurses and doctors. HIPAA (Health Insurance Portability and Accountability Act) severely restricts how health information can be shared. This increases the chance of error and reduces efficiency as well as effectiveness, all in the name of medical confidentiality. HIPAA is the reason why your name is not on the outside of your hospital chart, why medical research is constrained, and why I am prohibited from emailing my consultation letters to referring physicians.

The decision to pass HIPAA was based solely on logic. There was no evidence about the magnitude of the confidentiality problem and no data after passage about its impacts, very much including the costs. Those new barriers you see in the dentist's office that prevent you from seeing any computer screen are a response to HIPAA. Where does the money come from for those barriers, or the hours required for HIPAA training, or the salaries for compliance oversight officers? [The answer to that question is: out of your pocket or instead of money for your child's public school.]

Regulators and legislators are not obligated to use evidence-based decision-making. Worse, when they say they want to follow-up their own decisions, they do not. In 1995, Congress passed UMRA (Unfunded Mandate Reconciliation Act) to see how many healthcare laws that Congress passed had no funding. Nine years later, when the GAO (Government Accounting Office) studied UMRA, they found that Congress obeyed itself 11% of the time. In other words, for 89% of the bills that Congress passed, bills that mandated costly actions by healthcare organizations, there was no evidence of what they cost or where the money would come from. Congress was ignoring - actually disobeying - Congress. You might call this standard #3.

Part of the reason why healthcare does not work; why costs keep rising without let-up, why doctors and nurses are leaving; and why an estimated 98,000 people die avoidably in US hospitals each year, is the Triple Standard.

Those who like to assign blame might read the above and immediately point their disapproving fingers at the providers who make errors; at the managers who talk about evidence but do not walk their talk; or at the regulators who eschew evidence and depend on logic. Do not! The bad apples are not in hospitals or in Washington. There is only one big bad apple: it is called our healthcare System. To begin fixing it, we could reject the triple standard and demand a uniform standard for all: no decision without evidence.