A Health Policy Addict’s Summer Reading List

If you’ve been following health policy for a generation, as I have, these past few weeks have been the Olympics, the U.S. Open, the Super Bowl, and a Clarence Clemons sax solo during a Springsteen encore rolled into one. With the moment of change upon us (he says hopefully), the mix of science and skulduggery, blowhards and brinksmanship, and demons and demigods is simply breathtaking.

The creation of healthcare legislation is particularly sausage-like, and we’re seeing it in real time – this is the first legislative Donnybrook coming at us in blogs, tweets, and YouTube clips. I know that the lives and livelihoods of real people are at stake, but forgive me if I find it amazingly interesting; yes, even fun.

I can’t possibly choose a single article or topic in the midst of all this Shock and Awe. So here’s my Top 10 list of recent newspaper stories, journal articles, blogs, and audio/video clips, accompanied by my take on each.

1-3: The Dartmouth, Gawande, and McAllen Stories
I’ve already blogged about Atul Gawande’s spectacular New Yorker article – that rare piece of journalism that truly informs, even catalyzes, a national debate. Now I point you to Atul’s interview (#1) on this week’s Fresh Air. The man is staggeringly insightful (extra bonus: a brilliant, talented surgeon without an ounce of arrogance!). It’s well worth listening to.

The Gawande article managed to catapult 20 years of peer-reviewed literature (now called the “Dartmouth Atlas” for short) into health policy orbit. Not surprisingly, people who don’t like the Dartmouth results (mostly those who find themselves on the short end of the quality vs. cost equation) have begun shooting the messenger, arguing that the methodology doesn’t sufficiently account for patient demographics, patient-driven demand, better outcomes, or the phase of the moon. I find the Dartmouth data compelling and robust (truth-in-advertising: my region, the SF Bay Area, and my hospital, UCSF Medical Center, come out well in the analyses). A terrific Health Affairs Blog posting (#2) by Harvard professor Amitabh Chandra defends the Dartmouth findings and thoughtful describes their implications for policy change.

Unfortunately, in response to the Gawande article and the Dartmouth data, some pretty destructive ideas are floating around – one is to cut Medicare payments to “inefficient” states and redirect the money to more efficient ones. This is a profoundly unfair sledgehammer of a response – just consider our situation in San Francisco, an “efficient” city in a moderately “inefficient” state. Moreover, it won’t change anybody’s practice (other than by inducing the docs in “inefficient states” to increase their volumes to preserve their incomes) and it will lead to access problems. Sorry, but the solution won’t come from redirecting resources – we need to develop a set of incentives and structures that rewards good and penalizes bad behavior. There is no shortcut, a point well made by Professor Chandra.

Bored of Dartmouth yet? If not, read the Health Affairs transcript of the roundtable discussion (#3) with Bob Berenson of the Urban Institute, Bob Galvin of GE, Gail Wilensky of Project HOPE, and Dartmouth’s own Eliott Fisher.

The discussants chew on the Dartmouth results and the buzz generated by the Gawande article – even raising the possibility that the Gawande piece will be to cost/quality what To Err is Human was to patient safety. Perhaps. Wilensky argues that most variations are seen in areas of clinical uncertainty, but Fisher counters that variations persist even when there is strong evidence regarding the best course of action. And Berenson doesn’t tiptoe around a hard truth: some of the excess costs in communities like McAllen represent fraud and abuse, not just practice style differences.

(By the way, can you imagine how those docs who took up Atul’s offer for some chit-chat over a nice dinner are feeling now that their community has become the Love Canal of health care costs? Some in Congress are even thinking of investigating McAllen’s docs and hospitals. It can’t be fun times in the McAllen doctor’s lounge this week.)

As a bonus, the roundtable includes a very thoughtful discussion of the advantages and challenges of bundled payments. The participants voice concerns about such payments leading to an even more hospital-centric system (if hospitals become the recipients of the payments), or of large “Accountable Care Organizations” engaging in monopolistic pricing, thereby defeating the cost-reduction purpose. The end of the piece gets a bit wonky, but overall, an interesting discussion by some key insiders.

4. Bob Brook on “The Science of Health Care Reform”
When Eliott Fisher was in diapers, Bob Brook of RAND was the dean of American health services researchers. In a JAMA article, Brook notes that the Dartmouth Atlas is only of the two studies (in Dartmouth’s case, series of studies) to address the science of health care reform. The other, the RAND Health Insurance Experiment (HIE), conducted 30 years ago, provided crucial insights into the impact of cost sharing and insurance on patient and provider actions. The HIE proved that cost-sharing by patients does reduce healthcare use and costs, but that the foregone care is both effective and ineffective.

Brook conducted a series of studies in the 80s and 90s that focused on “appropriateness” – finding that about one-third of care is either equivocal (no certain benefit) or frankly inappropriate. Brook’s work suggests that a big part of addressing the challenges of variations and cost-control must be met by efforts to eliminate inappropriate care – ultimately by not paying for it.

It’s now clichéd to say, but remember, one person’s inappropriate care is another person’s mortgage payments. Beware, Donnybrook ahead!

5. David Leonhardt on Healthcare Rationing
David Leonhardt of the NY Times writes brilliantly about kitchen-table economics; he’s particularly splendid when he turns to healthcare, as he often does. Ultimately, while there may be some “painless” savings in cutting out fraud and abuse, driving McAllen to be more like El Paso, and purging inappropriate care, at some point, the dreaded “R” word will rear its head. Expect to hear it in TV commercials alongside “Government takeovers” and “bureaucrats deciding instead of doctors” – Luntzian buzzwords designed to induce fear and stifle debate.

But, as David notes, we already ration healthcare in three ways: we ration wages (skyrocketing healthcare costs lead to wage cuts); we ration health insurance (there’s not enough money left to insure everybody or to make purchasing healthcare coverage affordable); and we ration prevention and coordination of care (we spend so much money on high end care that we can’t afford decent primary care and prevention). The question is not whether we will ration (a wise man once said that deciding whether to ration healthcare is like deciding whether to respect the laws of gravity) but whether we will do it wisely.

A couple of more overtly political pieces in the NY Times caught my eye…

6. David Brooks on Obama’s End Game
Brooks, whose politics I sometimes disagree with but whose insights are always knife-sharp, wrote of the three stages of the Obama health reform plan: Table-setting (“this is important, we need change”); followed by Passing Everything to Congress (“You’ll need these windbags at the end, so you might as well get them busy at the beginning,” writes Brooks; more on this later); and finally “The Scrum” – “… an ugly, all-out scramble for dough.” Brooks argues that this third stage will end with Obama turfing all the hard decisions – namely, how to allocate the money – to a newly empowered Medicare Payment Advisory Commission, which becomes a sort-of Federal Reserve for healthcare.

I think Brooks has probably gotten the President’s playbook right. But in this 24-hour news-cycle era, the smoke has been sucked out of the smoke-filled room. I don’t think a punt to MedPAC will work, but we’ll see.

But before we get to The Scrum, we have to get past the windbags, which leads me to…

7. The Obama Team’s Congressional Strategy
Last month, the NY Times Sunday Magazine ran a great piece chronicling Brook’s second stage – the punt to Congress. The story of how the White House has hired dozens of key former congressional staffers and distributed perks like invitations to movie screenings and Easter-egg rolls to advance its causes makes great reading, in the tradition of Machiavelli. “We have a tracking system,” boasts Rahm Emanuel, describing the way the White House allocates goodies to VIPs. “Who came to watch the football game? Who came to watch the basketball game?” But, just as Obama can’t completely turf the hard stuff to MedPAC, at some point he’ll need to grab the reins back from Congress and lead. The fascinating article ends with this:

At critical times in his young political life, and several times already in his presidency, Obama has fallen back on his gift for explanation and oratory to try to change the dynamic of a national debate…. It seems likely that Obama, who has to this point focused on a sophisticated legislative strategy for achieving health care reform, will at some point soon have to take his case to the public instead – this time asking Americans not just to support an ambitious expansion of government but to accept the sacrifices necessary to do it. Only a president will make that case, and only a president can.

8. Troy Brennan and Michelle Mello on Med Mal
It was only a matter of time before the question turned to medical malpractice – if only because the AMA is going to have to be thrown a bone to keep its powder dry over possible pay cuts. Most of the intellectual contributions to our understanding of med mal have come from Troy Brennan and his colleagues. Troy left Harvard a few years ago to become a corporate executive, but he reconnected with his colleague Michelle Mello to write a superb article in this week’s NEJM on liability reform and its place in the broader policy debate.

Obama might be open to a tribunal approach – enlisting neutral experts and judges rather than dueling experts testifying before juries. Or he might go for an approach in which following an evidence-based guideline shields providers from liability. The problem is that the former approach is untested, and the latter was of little help when it was trialed in Maine. The Administration is dead-set against pain-and-suffering caps, which actually do decrease the frequency of lawsuits. Brennan’s long-favored solution, a no-fault compensation system (like New Zealand’s), isn’t even on the political radar screen.

Will malpractice reform end up in the final legislative sausage? If it turns out to be the price of getting the docs’ cooperation (perhaps in the face of cuts in procedure compensation or the scuttling of fee-for-service), then the trial lawyers might just find themselves pushed under the bus.

9: Maggie Mahar on the CBO Speed Bump
In the past few days, the politics have heated up around the Congressional Budget Office’s “scoring” of various draft legislative proposals, projections that indicate that the package might cost $1.6 trillion over 10 years (about $600 billion more than earlier guestimates). The great Maggie Mahar is all over it in her Health Beat blog, in an optimistic post that even includes her correspondence with White House budget director Orszag (does that guy ever sleep?). The vested interests are hammering on the CBO numbers to paint healthcare reform as dead (and Obama as a big spending liberal who will bankrupt the country without even achieving universal coverage). Read Maggie’s post to separate the facts from the spin.

10. On Lag Putts and Swatted Flies
My last pick is actually two favorites that follow the same theme: lighthearted pieces that might seem to have absolutely nothing to do with healthcare reform. But they do.

With the U.S. Open being played this weekend on the golf course I grew up on (Bethpage State Park), and since I’m a big fan of the cognitive psychology work of Amos Tversky and Daniel Kahneman, I was struck by a NY Times article called “Settling for Par: Pros More Likely to Play it Safe.” According to a Wharton analysis of 1.6 million PGA tour putts, pro golfers – yes, even Tiger Woods – are not entirely rational actors. How can that be?

Particularly on mid-range putts (6-12 feet), the average pro is about 3% less likely to make a putt when putting for birdie than when putting for par from precisely the same distance. Pros (who often dispute findings that conflict with their core beliefs or make them appear irrational – for example, no pro hoops player believed the data that proved that the “hot hand” is a myth) completely accepted these data as a classic example of risk aversion – the preference to avoid a nasty outcome (a bogey) trumps the joy of a perceived gain (a birdie). As pro Justin Leonard observed,

When putting for birdie, you realize that, most of the time, it’s acceptable to make par. When you’re putting for par, there’s probably a greater sense of urgency, so therefore you’re willing to be more aggressive in order not to drop a shot. It makes sense.

Of course, it makes precisely no sense, since a stroke is a stroke, and the final standings – on which millions of dollars hinge – don’t care whether an extra stroke came from making a bogey instead of a par or a par instead of a birdie. But pro golfers, as it turns out, are human (Tiger’s birdie/par mismatch was at about the tour average of 3%).

The second is Stephen Colbert’s riff on “Murder in the White House” – reflections on President Obama’s successful swatting of a fly during a recent on-camera interview. “In other news,” Colbert begins solemnly, “a fly family is mourning tonight after the brutal slaying of their father.” He then interviews “the wife and 93 children” of said fly.

What do pro golfers and Obama’s dead fly have to do with healthcare? People will fight harder to prevent losing something than they will to obtain comparable gains. Expect stakeholders with an interest in the present system to use every tool at their disposal to prevent a metaphorical three-putt. It’s only natural.

And the President, who has shown a tendency toward pragmatism and a reluctance to ruffle too many feathers, is going to have to make some enemies if he wants to get healthcare reform done. We all know that the status quo is disastrous, but there are plenty of people who are highly invested in it. Expect a fight to the death; some flies will need to be crushed.

Sure, the final healthcare “sausage” will be influenced by both science and politics. Even so, this is mostly a debate of ideas, and the profusion of new media creates an unprecedented opportunity to follow and influence these ideas… in real time. I’ll keep reading, watching, and commenting, and I hope you will too.

3 Responses to “A Health Policy Addict’s Summer Reading List”

  1. menoalittle June 20, 2009 at 8:19 pm #

    Bob,

    The compendium is concise and educational and many thank you for it.
    I would like to propose that the following be required reading of the President, his health care advisors, the ONCHIT, the HHS, and the Congress of the United States:

    http://www.lakemedelsverket.se/upload/foretag/medicinteknik/en/Medical-Information-Systems-Report_2009-06-18.pdf

    http://www.lakemedelsverket.se/english/All-news/NYHETER—2009/Improving-patient-safety-in-the-EU-Many-Medical-Information-Systems-should-be-classified-as-Medical-Devices/

    It would behoove those who religiously believe unfettered HIT devices to be the keystone of health care reform to become better informed of the facts and need for strict pre-market and after market surveillance.

    Best regards,

    Menoalittle

  2. MKirschMD June 21, 2009 at 7:53 pm #

    I have read the Gawande article and the New York Times pieces. Every breathing American knows there is an avalanche of medical excess that is drowning us financially and decreasing medical quality. Dartmouth has been pointing out for years now that regions of the country that spend more money often have inferior outcomes. Why do physicians order so much unnecessary medical care? While some of this can be accounted for by a desire for more income or to minimize litigation risk, this is not the whole story. Patient demand is an important factor also. There is also a culture of medical excess that has taken on a life of its own. In other words, doctors order more tests simply because this is the way medicine is practiced today. Physicians, who are at Ground Zero, are uniquely positioned to have a huge dand favorable impact on health care reform. Every medical test, treatment, prescription and consultation is ordered by a doctor. However, as every clinician realizes, making the diagnosis is often much easer than prescribing an effective treatment. The simple rules I learned in medical training are timeless. Is the medical test absolutely necessary? Will the results change the management of the patient? Is there a cheaper or safer alternative test or treatment available?
    http://www.MDWhistleblower.blogspot.com

  3. MHA Plus 18 Years Experience July 2, 2009 at 3:41 pm #

    Thank you for the awesome reading list! Just this past weekend, President Obama started his campaign to reach out to the American public on health care reform. I personally attended a National Healthcare Day of Service event in Florida. I thought I was going to an event like a health fair but it turned out to be a panel discussion about health care reform followed by a question and answer session. I actually was recruited upon entry at the event to be a panel speaker. I had a blast sharing my healthcare experiences and insight with the general public. I left with a sense that I have a voice as strong as the insurance industry and big pharma.

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