September 14th, 2009 by EvanFalchukJD in Better Health Network, Opinion
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Eight quick reactions to the President’s speech:
1. It was a good speech. Reaction around the blogosphere and elsewhere seems to be dependent on how you felt about reform plans going in. If you were in favor, you thought it was terrific (warning strong language at the link); if you were against, you thought it was disingenuous.
2. The interesting question is how people who weren’t sure will react. By this I mean people who are anxious that reform will affect their health care in ways they don’t like. There is still the mixed message that created this anxiety in the first place. On the one hand, the President repeated “Nothing in this plan will require you to change what you have. “ Sounds like no big deal. On the other hand, he quoted Ted Kennedy as saying the plan “is above all a moral issue; at stake are not just the details of policy, but fundamental principles of social justice and the character of our country.” Sounds like a very big deal. Which is it?
3. The boorish Congressman who screamed “you lie!” at Obama during the address must have been confused and thought he was at a town hall meeting. But I’ve always thought it would be cool if we had a “Question Time” like they do in the UK. Presidents would have to face much more interesting and uncomfortable questions than they otherwise get, and it would make for a terrific spectacle. Obviously this wasn’t the time or place for that sort of thing. And if we ever do get an American Question Time, representatives will have to come up with better questions than “you lie,” too.
4. The President talked about “30 million American citizens who cannot get coverage.” This is different from the 46 million “uninsured” he usually talks about. The Associated Press thinks the other 16 million are people who could buy or otherwise get coverage but choose not to, as compared to those who want coverage but can’t afford it.
5. I was surprised to hear the President give more than just a nod to the Facebook health care status update meme. I mean he quoted it directly: “in the United States of America, no one should go broke because they get sick.” This must be the first time a President has ever quoted something from Facebook in an address to Congress – it’s some kind of a milestone for social media. Thoughts on that meme are here.
6. The President talked about the uncompetitive insurance market, noting that “in 34 states, 75 percent of the insurance market is controlled by five or fewer companies.” It sounds like he’s not just talking about the “public option” when he talks about creating competition in these markets. His idea of insurance exchanges and a federal health insurance regulator seem to be direct challenges to the state-by-state system of insurance regulation. It will be interesting to see the reaction of state insurance regulators to this speech.
7. I was right: the President didn’t talk about the three things I said he wouldn’t talk about. In fact, he said almost nothing about the delivery of care- it was all about how to pay for it.
8. The President got some laughs with his comment that he thinks “there remain some significant details to be ironed out.” He’s right, and there’s the rub. Whether and how that ironing out happens was the question before the President’s speech, and it’s still the question today.
*This blog post was originally published at See First Blog*
June 14th, 2009 by EvanFalchukJD in Better Health Network, Health Policy
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Everyone is reading Atul Gawande’s article in the New Yorker about health care costs. But I think most people misunderstand Gawande’s major point.
Everyone’s At It
The conventional wisdom on Gawande’s piece is this: our problems are caused by bad incentives in our health care system. They encourage doctors to overprescribe care. McAllen, Texas is the poster child of this problem. If we can change the economic incentives, doctors will behave better. They will follow medical evidence, not their bottom lines, and from this will emerge a rational, affordable system.
This isn’t what Gawande is saying.
Gawande went to McAllen expecting to see a microcosm of the American health care system. As expected, he found excessive, even abusive spending, and a culture that encouraged both. But he also found that in nearby El Paso, Texas, medicine wasn’t practiced this way, nor in most other places in the country. And so he came up with a surprising insight. Yes, McAllen is a reflection of what can happen based on the incentives in the system. But if every incentive works this way, why is McAllen such an outlier?
Gawande concluded it had to do with the “culture” of medicine in each community. Most doctors go into medicine to help patients. In Gawande’s visit to McAllen, he heard stories that money had become more important than quality care. What Gawande realized was how important this question of “culture” was to how McAllen became McAllen. It made him think of places that had a completely different culture, like the Mayo Clinic.
The doctors of the Mayo Clinic decided, some decades ago, to put medicine first:
The core tenet of the Mayo Clinic is “The needs of the patient come first” — not the convenience of the doctors, not their revenues. The doctors and the nurses, and even the janitors, sat in meetings almost weekly, working on ideas to make the service and the care better, not to get more money out of patients. . . . Mayo promoted leaders who focused first on what was best for patients, and then on how to make this financially feasible.
Gawande couldn’t believe how much time doctors at the Mayo clinic spent with each patient, and how readily they could interact with colleagues on difficult problems. While it is true, the Mayo Clinic has financial arrangements that make this easier, it is the culture of patient care that dominates, not questions of pay:
No one there actually intends to do fewer expensive scans and procedures than is done elsewhere in the country. The aim is to raise quality and to help doctors and other staff members work as a team. But almost by happenstance, the result has been lower costs.
“When doctors put their heads together in a room, when they share expertise, you get more thinking and less testing,” [Denis] Cortes [CEO of the Mayo Clinic] told me
And this is where Gawande is being misunderstood.
The “cost conundrum” that Gawande talks about is not about how to cut costs, or how to change who pays for health care and how much. It’s deeper than that. Gawande’s point is that we have been fixated for so long on the question of money in health care that we are starting to forget about medicine. By focusing on ever more clever ways to pay doctors, we have systematically undervalued everything that makes for high quality medicine. Things like time with your patient, thinking about his or her problems, consulting with colleagues, and coming up with sound advice.
We discount what he calls the “astonishing” accomplishments of the Mayo Clinic on this score. And instead of designing health care reform around ways to help more hospitals become like the Mayo Clinic, we choose instead to think about money, to focus our attention on how to cut costs in places like McAllen.
Politically, it makes sense – it’s convenient to have a poster child like McAllen to explain why one reform plan or another should become law. But the pity is that in this important time of reform we’re not talking about trying to put the needs of the patients first – to put medicine back in the center of health care. The pity is that in spite of the fact that everyone’s reading Gawande’s article, his most important insight is being misunderstood.
If we continue to be focused on money over medicine, we will lose the “war over the culture of medicine – the war over whether our country’s anchor model with be Mayo or McAllen.”
*This blog post was originally published at See First Blog*
