During my med school psychiatry rotation, I was taught not to shy away from discussing suicide with a depressed patient. “You won’t be suggesting something they haven’t thought about,” my professor told me back in 1982. “By not raising it, you add to the sense of stigma and it just becomes the elephant in the room.” I later came to appreciate that discussing dying with patients nearing the end of life is much the same.
From these experiences, I learned that while it’s completely natural to tiptoe around difficult issues, it’s sometimes the wrong approach. I wonder whether we’re making this mistake when it comes to discussing healthcare cost reduction. As with the depressed or dying patient, speaking in code is always risky, since it gets in the way of honest, straightforward dialogue. Moreover, in this case, using squishy language may open the door for misunderstandings, even obfuscation – such as when efforts to save money are clothed in the more politically acceptable garb of quality.
Here is that proverbial elephant: Everybody knows that the costs of healthcare are unsustainable. Everybody knows that while we’ll start off on a perfectly reasonable – and non-controversial – mission to remove “waste, fraud, and abuse” from the system, we’ll eventually have to confront hard questions regarding high-cost/low-value tests and treatments. And everybody knows that the final outcome of this will be rationing, in one form or another. The math simply doesn’t work out any other way.
But talk of “death panels” has created such timidity that well-meaning people and organizations are searching for euphemisms for their sensible – critical, actually – cost-reduction initiatives. For example:
- The American College of Physicians recently announced a new push for “parsimonious care,” which sounds like something the aristocrats on Downton Abbey might say.
- The ABIM Foundation’s campaign – which has signed up more than a dozen specialty societies, all pledging to reduce the use of certain low-yield procedures or tests – goes under the name of “Choosing Wisely.” Who could be against choosing wisely?
- The Archives of Internal Medicine has been running an influential series called “Less is More,” bringing to mind the famous “reversible raincoat” school of speechmaking, whose apogees were “Ask not what you can do for your country…” and “The only thing we have to fear…”
- “Lean” aficionados focus on “removing muda” (Japanese for “waste”), which is drawn from Toyota Production System lingo and thus seems foreign and a little exotic. But it has several disadvantages: first, muda sounds dirty in English, and second, Toyota’s reputation for building perfect cars is no longer, well, unsullied.
Whatever the words, the typical appeal is to the individual – this costly care will harm you, Jane Q. Patient – rather than to the need to eschew low-value care (or, as recently proposed by Larry McMahon and Vineet Chopra of the University of Michigan, making patients responsible for the costs of low-value care out of their own pockets) for individuals in the name of benefiting the entire population. While framing things in the former way in individualistic America is politically astute, we need to face facts: most Americans believe they should have access to whatever treatment might work, and they view skeptically anyone who stands between them and this right. During my recent sabbatical in London I was amazed by the degree to which British patients and families simply accepted the doctor’s paternalistic declaration that there were no more curative arrows in his or her quiver. In my experience, most American patients don’t buy it – they want a second opinion and an MRI.
The hopes of achieving cost reduction by appealing to individual patients’ self-interest may also run into the buzz saw of our national Culture Wars. A recent article by UCSF geriatrician Eric Widera and colleagues reviewed patients’ attitudes toward “miracles” in their care. In one survey, 57 percent of Americans believed that divine intervention from God could save a person, even if the physician deemed further care to be futile. In such an environment, a doctor who says, “I’m sorry, there’s nothing more we can do,” can be accused of being not only anti-hope, but anti-God. (By the way, this belief in miracles has its, er, genesis in both religion and television: one study found that Americans believed that in-hospital CPR had a success rate of about 70 percent, precisely the success rate of Codes on medical TV shows [the actual success rate is about 15 percent]. If before the Code Blue the TV doctor or nurse said, “it would be a miracle” if the patient survived, the post-CPR survival rate was 100 percent.)
And so we just keep doing, bringing our country a little closer to financial ruin with each passing day.
Our careful language regarding cost reduction carries the risk of rendering our conversations on this topic opaque, which is what usually happens when we’re not quite saying what we mean. Against that background, you can bet that some folks (read: payers) will begin framing cost savings as being about quality or safety; i.e., the numerator, not the denominator of the value (quality divided by cost) equation. They will be correct some of the time, such as when we reduce the number of unnecessary CT scans or unwarranted stents. At other times, though, such language will allow people and organizations with cost-cutting agendas to shield themselves from owning up to their part in this challenging but critical debate.
And it will be awfully hard to tell these two circumstances apart.
We’ve seen this movie before. In the early days of managed care, when the science of quality measurement was far less mature than it is today, some healthcare insurers included C-section rates and hospital lengths of stays among their “quality measures.” Since no one knows the “right” rate of C-sections or number of hospital days, these really aren’t quality measures; they’re measures of resource use. In 2007, physician groups in New York State successfully challenged Aetna, CIGNA, and United HealthCare on the grounds that their MD “quality ratings” (used to create tiered physician networks) were actually unadulterated measures of expenditures.
And last month, the National Quality Forum, an organization whose raison d’être has traditionally been to vet and certify quality and safety measures, endorsed several “resource use” measures involving cardiovascular, diabetes, and overall primary care. NQF didn’t explicitly say that it was getting into a new ballgame – that of cost or waste reduction – but rather, in the words of senior VP Dr. Helen Burstin, that “cost and quality need to be reported together.” The NQF uses robust methods and has broad participation, and so its entry into the cost reduction arena is great. But when an organization whose name is “Quality” turns its attention to resource use, it won’t be long before some claim that performance on these new measures reflects a practice’s quality rather than its costs. It might or might not.
The problem, you see, is that less sometimes is more. But sometimes, less is less.
There are likely to be many cost-reduction efforts that don’t harm quality, safety, and the patient’s experience – and even some that improve them. Fantastic – we should be doing everything we can to identify these areas and make them happen. The fact that America’s premier healthcare organizations are finally addressing the staggering costs of care is a most welcome development. And their decision to choose their words carefully while traversing a political terrain strewn with landmines is completely understandable.
But ultimately, we will need to come to grips with the need to call it as we see it. We must bend the cost curve quickly and sharply, and that will invariably entail some hard choices. To make those choices thoughtfully will require lots of information about both the numerator and the denominator of the value equation, and correct interpretation of these data will demand a gimlet-eyed understanding of which part we’re talking about. Getting this right is less about quality, parsimony, or wisdom than it is about self-preservation – of our healthcare system and our national economy.