(Note: this was also published at improvehealthcare.wordpress.com)
Harvard Medical School’s Department of Health Care Policy put an incredible event on this past Monday. The video and suggested reading are available on the website. The speakers were: David Cutler (Harvard), Allan Detsky (University of Toronto), David Goldhill (Media and Technology executive), and Daniel Kessler (Stanford).
Overall, I thought that the symposium was tremendous. Often speakers don’t want to disagree with either others ideas too much, or they disagree about minute details–at this event, there was no shortage of (very respectful) disagreement. I walked away feeling like I understand the nature and magnitude of the complexities of health care reform much better than when I entered and armed with some new language and frameworks with which to approach the issues. The longer I work in health delivery, the more I’m struck by the different sense of urgencies people feel: the speakers seemed intent of understanding the nature of the beast and saw it as a precursor to reforming health care. All except Cutler felt that the pending legislation was trivial or harmful, but failed to offer other actionable recommendations. I’m torn on this–I think history shows countless examples of how we’ve dug ourselves into a hole by not appreciating a problem fully. On the other hand, when the decision not to act may result in suffering and/or death, there does seem to be a moral imperative to get out of the ivory tower and get busy (recent post by Bill Easterly on the pointlessness of airport security makes me a little wary to assert this too confidently or with too much moral indignation).
Recently I’ve been thinking a lot about the constitution–somehow, a bunch of white guys in a room (many of whom believed in slavery and were not keen on gender equity), centuries ago, managed to create a document that remains pretty relevant, with only a few alterations and additions, in our court system today. Is there an analogous product in health reform? Even looking at the structure of Medicare, passed in the 1960s, it’s clear how far our understanding of health and disease, and our ability to prevent, diagnose and treat have come. In many ways, its our advancements that have cursed us financially. If we are to develop a durable health policy, it must build in room for changes in what health, health care, and medical services entail, as one would assume that they will continue to change, and in changes that we, where we stand now and even with all available information, cannot really conceive.
A few highlights and specific comments on the various speakers:
I thought Cutler outlined some of the existing system-level failures in health care very well. Having been immersed in Michael Porter’s philosophy, I took issue with his liberal use of the phrase “value-based health care” when primarily outlining ways that the operational efficiency of health delivery could be improved, rather than strategically reconfiguring the systems more fundamentally. I doubt that just moving along the curve that we’re on will be enough to resolve the issues. For example, he mentions that (preventable) rehospitalizations are too common and the burden of acute care episodes is an indicator of “low productivity” in the health care sector. Making hospitals “more efficient” will not necessarily result in the preventive care and changes in consumer behavior that could truly drive down that demand. Some of the issues that he raised are pretty grim: most hospitals have more administrators than medical personnel. He mentioned that additional spending not associated with better outcomes (even when controlling for “everything you could think of”); in Atul Gawande’s piece on McAllen, he goes so far as to quote study results from Dartmouth showing that the higher the average medicare spending, the WORSE the quality. Yikes!
Cutler admitted that he thought that health care was supply driven–providers were much more sensitive to changes in policy than consumers, and to create large-scale change, we should focus on them. Sounds good in theory, but upon thinking about this, I wondered if the insensitivity of consumer demand was a product of the system, rather than a precondition, and something that required change as much as any other part of the broken system. Ultimately, if I’m the one whose most affected by my health (and though my roommate may argue otherwise when I’m complaining endlessly about a minor tweak in my knee, I think that’s true), empowering/encourage/forcing/choose your own verb ME to act in my own self interest seems like a necessary part of a functioning and rational health system.
Detsky appealed to the sociologist in me. It’s a false comparison to just look at the health systems of different countries and say, which one’s the best? All are embedded in a larger governmental, historical and cultural framework. In the same way that those who went to see Toyota’s secret to high quality cars produced at low costs, took away the parts they liked and implemented them at home, only to find them completely ineffective, we can’t treat other health systems as a menu of items. Nor could we import one as is. Detsky explained this clearly and with an adorable amount of Canadian pride. I hadn’t really considered, until he said it, that the major motivation of the American society right now around health care reform right now in the U.S. is motivated by fear of losing one’s insurance. It’s not the uninsured that are up in arms. Fear is usually posed as an irrational emotion–does this have implications for our ability to pass rational legislation that gets popular support? How manipulable is it?
Which leads nicely into Goldhill, a very cool head despite joining the health care debate after watching his father died of a hospital-acquired infection, who lays out how patients are not regarded nor treated as customers by the system (and the incentives discourage it). Goldhill described health insurance (differentiating it from coverage, care, services, and just straight up health) a form of financing that comes with “heavy administrative costs”; ideal for circumstances that rarely occur, but when they do, are very costly (true for car insurance and life insurance). According to him, we never acknowledge the trade-offs: if we didn’t pay so much into the system, we’d have a whole lot more to spend–on education, wealth accumulation, etc. Things that most likely could be good for our health (gym membership? entering the NYC marathon at the STEEP price of $185!) and our happiness. But we’ve been conditioned to think that the only way to have financial security for our health is the existing system. And NOT consider the trade offs (security is priceless). Or, even really evaluate the trade-offs–the body of literature looking at what the money could have done if we’d not poured it all into health care is scant if not nonexistent altogether. Most of his points are laid of fairly clearly in his (rather long, but worthwhile) piece “How American Health Care Killed my Father” in the Atlantic, so I won’t summarize, but, his value to me (again, the sociological bias), was that as a health care outsider, he noticed the special language that has evolved (when was the last time you heard “price” of services mentioned in the dialog? Cost and reimbursement rates are two more frequent terms) and he approaches health care with a business-oriented perspective that has been relatively absent. Is he an expert? No. Should we put him in charge of reform? No. Should we be able to answer the questions he poses? Definitely, and I think that was his main value as a speaker: raising questions that are currently unanswerable (including those about tradeoff), and fairly fundamental if our ultimate goal is improving health (and perhaps even more broadly, well being) at the population level (vs. salvaging a broken system).
I’m interested in his assertion that health care costs are growing faster than income across the globe—is it possible that the U.S. is just ahead of the curve in reaching the breaking point? Maybe more on this another day; I’d like to explore a little deeper and see what statistics and explanations are out there.
Kessler summarized a lot of what had already been said and added a bit more of a legal, economic perspective, including a reference an article by Greg Mankiw (Harvard professor of economics and adviser to President George Bush) that explained the marginal tax rate disincentives embedded in the proposed health care legislation. Another piece he commented on was Gawande’s recent article on agriculture along with Alan Enthoven’s impassioned response on the Health Affairs’ blog. While he was pro-experimentation, he cautioned, “We can’t treat experiments as a cure—by definition, we don’t know if they will work.” He also compared current reforms (from the industry perspective) as the razor blade strategy–they can let the government drive down the cost of the razor all day, because they know that we still have to buy the blades (and they’ll retain control of that price and make up the difference there). Without fundamental change, they keep winning because the game just changes superficially.
Several have argued that without broad support from physicians, any legislation will never pass. As Leonard Schaeffer (University of Southern California) mentioned during his comments and build-up to a question to the speakers, the New England Journal of Medicine recently reported that the majority of physicians are not in favor of measures that use cost-effectiveness data to reduce utilization of services. Will popular fear overcome faith in physicians?
I asked a few doctors-in-training for their thoughts on the event. Their comments included:
[what I found most poignant were] “Mr. Goldhill’s comments that his dry-cleaner was ahead of his doctor on implementing IT because the incentives are so perversely aligned in healthcare that providers have no reason to improve”. Alluding to that sense of urgency: The “alternative perspectives” presented in this symposium were not proposed adjustments to reform, innovative solutions or visionary proposals in any respect. The entire discussion revolved around critiquing the reform bill and postulating the direst outcomes, Some points were valid and significantly concerning, the legislation is far from perfect, but reform is inevitable and we have to face difficult realties. Why is so much of the time and engery of these brilliant experts spent nitpicking and naysaying instead of formulating solutions of their own? In this critical time, we need more than just perspectives.” (From Ian Metzler, Harvard Medical School class of 2012; 2009 IHC Director)
Another felt that the central issues on his mind were not addressed in the debate. “Few have seriously addressed the question: what would happen if the bill passes, medical expenses skyrocket, but the projected savings don’t materialize? Some of the speakers offered an ominously plausible scenario in which Medicare and Medicaid go bankrupt, leaving a great number of Americans without insurance. By then the political climate would by necessity favor the idea of a nationalized single-payer system, but many lives would be lost along the way. Hopefully it won’t take a national medical catastrophe for Washington to look beyond partisan interests and put in the sincere effort and resources needed to enact true reform.” (David Mou, Harvard Medical School class of 2013, 2010 IHC Director)
The speakers spent little time discussing how to engage physicians in the process of creating, advocating for, or implementing worthwhile reform, even when directly asked about physician opposition to current legislative activities. Can we just view physicians as a part of the system–once we figure out how all the pieces fit together, we can just assume that they’ll tow the line? Or, are they destined to be leaders, whether for better or for worse?
My only regret: that it happened at Harvard, and not in Washington. Hopefully we don’t have to wait a generation to get to the action.
Harvard Medical School’s Department of Health Care Policy put an incredible event on this past Monday. The video and suggested reading are available on the website. The speakers were: David Cutler (Harvard), Allan Detsky (University of Toronto), David Goldhill (Media and Technology executive), and Daniel Kessler (Stanford).
Overall, I thought that the symposium was tremendous. Often speakers don’t want to disagree with either others ideas too much, or they disagree about minute details–at this event, there was no shortage of (very respectful) disagreement. I walked away feeling like I understand the nature and magnitude of the complexities of health care reform much better than when I entered and armed with some new language and frameworks with which to approach the issues. The longer I work in health delivery, the more I’m struck by the different sense of urgencies people feel: the speakers seemed intent of understanding the nature of the beast and saw it as a precursor to reforming health care. All except Cutler felt that the pending legislation was trivial or harmful, but failed to offer other actionable recommendations. I’m torn on this–I think history shows countless examples of how we’ve dug ourselves into a hole by not appreciating a problem fully. On the other hand, when the decision not to act may result in suffering and/or death, there does seem to be a moral imperative to get out of the ivory tower and get busy (recent post by Bill Easterly on the pointlessness of airport security makes me a little wary to assert this too confidently or with too much moral indignation).
Recently I’ve been thinking a lot about the constitution–somehow, a bunch of white guys in a room (many of whom believed in slavery and were not keen on gender equity), centuries ago, managed to create a document that remains pretty relevant, with only a few alterations and additions, in our court system today. Is there an analogous product in health reform? Even looking at the structure of Medicare, passed in the 1960s, it’s clear how far our understanding of health and disease, and our ability to prevent, diagnose and treat have come. In many ways, its our advancements that have cursed us financially. If we are to develop a durable health policy, it must build in room for changes in what health, health care, and medical services entail, as one would assume that they will continue to change, and in changes that we, where we stand now and even with all available information, cannot really conceive.
A few highlights and specific comments on the various speakers:
I thought Cutler outlined some of the existing system-level failures in health care very well. Having been immersed in Michael Porter’s philosophy, I took issue with his liberal use of the phrase “value-based health care” when primarily outlining ways that the operational efficiency of health delivery could be improved, rather than strategically reconfiguring the systems more fundamentally. I doubt that just moving along the curve that we’re on will be enough to resolve the issues. For example, he mentions that (preventable) rehospitalizations are too common and the burden of acute care episodes is an indicator of “low productivity” in the health care sector. Making hospitals “more efficient” will not necessarily result in the preventive care and changes in consumer behavior that could truly drive down that demand. Some of the issues that he raised are pretty grim: most hospitals have more administrators than medical personnel. He mentioned that additional spending not associated with better outcomes (even when controlling for “everything you could think of”); in Atul Gawande’s piece on McAllen, he goes so far as to quote study results from Dartmouth showing that the higher the average medicare spending, the WORSE the quality. Yikes!
Cutler admitted that he thought that health care was supply driven–providers were much more sensitive to changes in policy than consumers, and to create large-scale change, we should focus on them. Sounds good in theory, but upon thinking about this, I wondered if the insensitivity of consumer demand was a product of the system, rather than a precondition, and something that required change as much as any other part of the broken system. Ultimately, if I’m the one whose most affected by my health (and though my roommate may argue otherwise when I’m complaining endlessly about a minor tweak in my knee, I think that’s true), empowering/encourage/forcing/choose your own verb ME to act in my own self interest seems like a necessary part of a functioning and rational health system.
Detsky appealed to the sociologist in me. It’s a false comparison to just look at the health systems of different countries and say, which one’s the best? All are embedded in a larger governmental, historical and cultural framework. In the same way that those who went to see Toyota’s secret to high quality cars produced at low costs, took away the parts they liked and implemented them at home, only to find them completely ineffective, we can’t treat other health systems as a menu of items. Nor could we import one as is. Detsky explained this clearly and with an adorable amount of Canadian pride. I hadn’t really considered, until he said it, that the major motivation of the American society right now around health care reform right now in the U.S. is motivated by fear of losing one’s insurance. It’s not the uninsured that are up in arms. Fear is usually posed as an irrational emotion–does this have implications for our ability to pass rational legislation that gets popular support? How manipulable is it?
Which leads nicely into Goldhill, a very cool head despite joining the health care debate after watching his father died of a hospital-acquired infection, who lays out how patients are not regarded nor treated as customers by the system (and the incentives discourage it). Goldhill described health insurance (differentiating it from coverage, care, services, and just straight up health) a form of financing that comes with “heavy administrative costs”; ideal for circumstances that rarely occur, but when they do, are very costly (true for car insurance and life insurance). According to him, we never acknowledge the trade-offs: if we didn’t pay so much into the system, we’d have a whole lot more to spend–on education, wealth accumulation, etc. Things that most likely could be good for our health (gym membership? entering the NYC marathon at the STEEP price of $185!) and our happiness. But we’ve been conditioned to think that the only way to have financial security for our health is the existing system. And NOT consider the trade offs (security is priceless). Or, even really evaluate the trade-offs–the body of literature looking at what the money could have done if we’d not poured it all into health care is scant if not nonexistent altogether. Most of his points are laid of fairly clearly in his (rather long, but worthwhile) piece “How American Health Care Killed my Father” in the Atlantic, so I won’t summarize, but, his value to me (again, the sociological bias), was that as a health care outsider, he noticed the special language that has evolved (when was the last time you heard “price” of services mentioned in the dialog? Cost and reimbursement rates are two more frequent terms) and he approaches health care with a business-oriented perspective that has been relatively absent. Is he an expert? No. Should we put him in charge of reform? No. Should we be able to answer the questions he poses? Definitely, and I think that was his main value as a speaker: raising questions that are currently unanswerable (including those about tradeoff), and fairly fundamental if our ultimate goal is improving health (and perhaps even more broadly, well being) at the population level (vs. salvaging a broken system).
I’m interested in his assertion that health care costs are growing faster than income across the globe—is it possible that the U.S. is just ahead of the curve in reaching the breaking point? Maybe more on this another day; I’d like to explore a little deeper and see what statistics and explanations are out there.
Kessler summarized a lot of what had already been said and added a bit more of a legal, economic perspective, including a reference an article by Greg Mankiw (Harvard professor of economics and adviser to President George Bush) that explained the marginal tax rate disincentives embedded in the proposed health care legislation. Another piece he commented on was Gawande’s recent article on agriculture along with Alan Enthoven’s impassioned response on the Health Affairs’ blog. While he was pro-experimentation, he cautioned, “We can’t treat experiments as a cure—by definition, we don’t know if they will work.” He also compared current reforms (from the industry perspective) as the razor blade strategy–they can let the government drive down the cost of the razor all day, because they know that we still have to buy the blades (and they’ll retain control of that price and make up the difference there). Without fundamental change, they keep winning because the game just changes superficially.
Several have argued that without broad support from physicians, any legislation will never pass. As Leonard Schaeffer (University of Southern California) mentioned during his comments and build-up to a question to the speakers, the New England Journal of Medicine recently reported that the majority of physicians are not in favor of measures that use cost-effectiveness data to reduce utilization of services. Will popular fear overcome faith in physicians?
I asked a few doctors-in-training for their thoughts on the event. Their comments included:
[what I found most poignant were] “Mr. Goldhill’s comments that his dry-cleaner was ahead of his doctor on implementing IT because the incentives are so perversely aligned in healthcare that providers have no reason to improve”. Alluding to that sense of urgency: The “alternative perspectives” presented in this symposium were not proposed adjustments to reform, innovative solutions or visionary proposals in any respect. The entire discussion revolved around critiquing the reform bill and postulating the direst outcomes, Some points were valid and significantly concerning, the legislation is far from perfect, but reform is inevitable and we have to face difficult realties. Why is so much of the time and engery of these brilliant experts spent nitpicking and naysaying instead of formulating solutions of their own? In this critical time, we need more than just perspectives.” (From Ian Metzler, Harvard Medical School class of 2012; 2009 IHC Director)
Another felt that the central issues on his mind were not addressed in the debate. “Few have seriously addressed the question: what would happen if the bill passes, medical expenses skyrocket, but the projected savings don’t materialize? Some of the speakers offered an ominously plausible scenario in which Medicare and Medicaid go bankrupt, leaving a great number of Americans without insurance. By then the political climate would by necessity favor the idea of a nationalized single-payer system, but many lives would be lost along the way. Hopefully it won’t take a national medical catastrophe for Washington to look beyond partisan interests and put in the sincere effort and resources needed to enact true reform.” (David Mou, Harvard Medical School class of 2013, 2010 IHC Director)
The speakers spent little time discussing how to engage physicians in the process of creating, advocating for, or implementing worthwhile reform, even when directly asked about physician opposition to current legislative activities. Can we just view physicians as a part of the system–once we figure out how all the pieces fit together, we can just assume that they’ll tow the line? Or, are they destined to be leaders, whether for better or for worse?
My only regret: that it happened at Harvard, and not in Washington. Hopefully we don’t have to wait a generation to get to the action.
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