Monthly Archives

March 2010

Health Policy

Health Care Reform

39193670Historic, yes.  In more ways than one.  The nation has set itself on a path toward assuring all Americans access to health and health care services. It was a costly effort, not well-handled by our gifted new president. In the end, the largest Democratic Congressional majority in a long time decided it had to risk its majority status and they did. It was costly in that little was contributed to “bending the cost curve” by our $2.5 trillion a year medical industry.  The insurance industry will play by some new rules which could have been made better had Republicans played ball.  But even insurance will not give up much in exchange for the individual mandate to buy.
It was costly in that good ideas to pay for coverage expansion were rejected either by the “No New Taxes” party or by those already advantaged by the tax code.  The suggestion that the deductibility of charitable contributions and other tax deductions be limited to a Reagan/Clinton era 28% of adjusted gross income was rejected by self-interest.  The long-standing proposal to convert the employer tax subsidy into a lump sum for each American family was rejected by public and private employee unions who “had theirs” and weren’t going to help the have-nots or their own kids and grandkids pay for this.
It was costly to those Democrats who believe that only a single payer or Medicare for all will make health care affordable.  For those who wanted drug companies to have to bargain with large buyers (such as Medicare) the same way every producer bargains with Wal-Mart. For those who believe that treating illegal immigrants worse than we treat convicted felons is not very American.
But health reform is a journey, not a destination. The future of real reform in insurance and in payment policy lies ahead.  This president, like George Bush in the Middle East, went out on a limb (this was a better cause I’d argue) and now he is responsible to see this tree grow and remain healthy.  Republicans also have some responsibility here.  A substantial majority of Americans want health system change.  And a lot of us will be paying so that those in need can have what we have always enjoyed.  Republicans represent us, too…and our children and grandchildren.
This country has been spending a lot more on health care than we get back in value. Sen. Tom Coburn (R-OK) says by one-third.  Now is the time and this is the authority we need to do something about it.

Health Policy

Medical Practice Variation

Source: The Commonwealth Fund, from Eliot Fisher, presentation at Academy Health Annual Research Meeting, June 2006.

Source: The Commonwealth Fund, from Eliot Fisher, presentation at Academy Health Annual Research Meeting, June 2006.

In the February 18 edition of the New York Times, Gardiner Harris writes about Dr. Peter Bach’s research on the Dartmouth Atlas and its use in payment for necessary services. Many of us know Peter from his days in the Bush CMS. His mother lives near us in St. Paul. He’s a good doc and researcher. But he and the article miss the point of effectiveness science and of the work of the Dartmouth Atlas.

Its purpose always has been to demonstrate practice variation among physicians in the same specialty, among hospitals in the same system, between communities and regions, and in the last 24 months of life.  When Dr. Atul Gawande cited the Dartmouth research in his comparisons of McAllen, TX, and El Paso, TX, he also described the McAllen practice community and the supply-related overuse of medical specialty services in McAllen.

Research on the relationship between medical supply and utilization goes back nearly a half century. In the early 1960s, a famous health economist researched hospital construction and hospital utilization and concluded that “if you build them, they’ll get used.” It’s market economics. The cost of putting up a lot of hospitals or buying each new multi-million dollar technology has to be recouped along with a profit to enable the owners to stay in business. So if you overbuild a community’s needs, doctors will overuse to pay for it.

Research on practice variation in the last 24 months of life simply illustrates that costs to payers is directly related to how much specialty service and technology is applied in cases of terminal illness. The UCLA hospital uses resident specialists and Mayo or Geisinger will use less costly physicians to provide care for patients with terminal illness as they approach the end of life.  Others may choose hospice.

The original purpose of Jack Wennberg’s and Elliot Fisher’s work, and Atul Gawande’s examples, is to advocate for changes that enhance the patient’s role in the doctor-patient relationship. Years ago Jack and colleagues advocated for “shared decision-making” at major decision points in patient care. What are the options for treatment and their consequences? Today they advocate “informed patient choice,” meaning that doctors must know everything medical science knows about the diagnosis, and share that reality with a patient, allowing the patient to make the choice, not the doctor.

This is increasingly difficult in a society that develops more information every day than any professional can possibly absorb. But the system could, if it would simply acknowledge its shortcomings and adapt to the systems and information technology changes that surround us in every other walk of life. Until the health care system acknowledges its comparative shortcomings and the cost and health consequences for patients, it will engage in the kinds of useless debates that opponents of comparative effectiveness engender.