Wednesday, May 20, 2009

Obama’s New York Times interview

Bob Wachter was wowed by President Obama’s recent NYT interview. He wrote:

In addition to Obama’s intelligence and forthrightness (with the exception of one dollop of purposeful disingenuousness, which I’ll get to later), I was floored by his personal knowledge of and passion for healthcare issues – particularly the increasingly contentious comparative effectiveness question…

The interview covered multiple aspects of economic policy. Although a superficial reading suggested a leader who’s knowledgeable, articulate and has some good ideas there was this uneasy feeling about an agenda to redistribute wealth somewhere between the lines. But today I’ll focus on the health care discussion, one of six sections of the interview.

First a general observation. Nowhere in the interview did Obama say he intended to enact anything. Instead he talked about a conversation (he used the word four times). Now that’s the disingenuousness Bob was talking about. With a congress poised to give him virtually anything he wants (oh, for the days of gridlock) and all that passion for health issues we can be sure it’ll be more than a conversation.

Before I get to the meat of the health care discussion, wasteful spending and comparative effectiveness research, I have to say I was mildly impressed by his balanced view on medical consumerism:

I have always said, though, that we should not overstate the degree to which consumers rather than doctors are going to be driving treatment, because, I just speak from my own experience, I’m a pretty-well-educated layperson when it comes to medical care; I know how to ask good questions of my doctor. But ultimately, he’s the guy with the medical degree. So, if he tells me, You know what, you’ve got such-and-such and you need to take such-and-such, I don’t go around arguing with him or go online to see if I can find a better opinion than his.

And so, in that sense, there’s always going to be an asymmetry of information between patient and provider.

How about that? Our President thinks a little paternalism is a good thing! (Contrast that with Don Berwick’s extreme idea of patient centered care). That paternalism, of course, has a dark side when its responsibility shifts from the individual doctor to the government. Note that Obama went on to say:

And part of what I think government can do effectively is to be an honest broker in assessing and evaluating treatment options.

And that brings us to the matter of wasteful spending and comparative effectiveness research. I’ve recently blogged extensively about the dishonesty in the discussions about CER as well as the massive conflict of interest in the government’s plan for implementation. Concerning wasteful spending on healthcare Obama said this:

And so if it turns out that doctors in Florida are spending 25 percent more on treating their patients as doctors in Minnesota, and the doctors in Minnesota are getting outcomes that are just as good — then us going down to Florida and pointing out that this is how folks in Minnesota are doing it and they seem to be getting pretty good outcomes, and are there particular reasons why you’re doing what you’re doing? — I think that conversation will ultimately yield some significant savings and some significant benefits.

The premise behind that statement and other comments President Obama made in the interview---that doctors really want to do what’s best for the individual patient and the medical commons---is where policy discussions should start. But does he really mean it? Wachter once again weighed in with a more cynical view of our professionalism:

But notice Obama the Politician at work. He knows full well that simply providing doctors in Florida information about how Minnesota docs practice ain’t gonna do the trick. (“Oh, really. Sure, now that I know about how they do things in Minneapolis, I’ll cut my cath volume by 30%!” I don’t think so.)

What’s interesting is that no one in this discussion (except for one of Bob’s commenters) mentioned the malpractice crisis as a cause of excessive spending, or of variation among regions. It just so happens that according to a recent Pacific Research Institute report Florida ranks worst of all 50 states in terms of malpractice litigation risks! Hmmm….

The agenda for more and more government control over health care is fueled by Dartmouth Atlas data which demonstrate regional variations in spending with no correlation between spending and quality or outcomes. I would like to see some Dartmouth maps relating spending by region to malpractice climates (read Kevin’s USA Today op-ed about how defensive medicine and the fear of being sued drives unnecessary spending), obesity, crime or tobacco use. Those are embedded cultural factors driving practice variation and need to be addressed at their sources. But practice variations data have been used to politicize comparative effectiveness research. If the problem, as the boosters of government sponsored CER contend, is that doctors don’t have enough data to make rational clinical decisions, then what must follow is some absurd notion that docs in some regions as opposed to docs in other regions just don’t have research findings to help make decisions. (And if the cause of practice variation is greed and self interest does that mean some geographic regions breed better ethics and more altruism than others?). The use of Dartmouth Atlas data to support an agenda for more government control over health care (oh, for the days of gridlock) is simplistic.

There’s no government fix for health care. As I said before I start with the premise that most doctors really want to practice efficient medicine based on the best evidence, but are beset with barriers. Public policy should start with that premise by addressing those barriers and giving doctors tools, not rules to put evidence into practice. That might lead to more efficient practice in all areas of the country.


james gaulte said...

I am glad to see someone pointing out that the Dartmouth Atlas data does not logically lead to the recommendation for CER or cer.I admire and am impressed by your energy to continue the discussion and your skill in doing so.

Christian Sinclair, MD said...

I was really impressed with his take on end of life care. Realizing that policy at the group level is much different then actions at the individual level regarding his Grandmother's hip fracture repair and subsequent death a few weeks later.

Here are more of my thoughts from this interview on Pallimed.Thanks for keeping this in the news some more. I am hopeful medical bloggers might prove to be a broad discussion ground on health care reform.

Maybe we should get a team blog together with a few of the more prominent physician bloggers to present a single place to really hash some of these things out. A stronger current united compared to several turbulent eddies.

Anonymous said...

After being butchered by a dozen doctors in a row in two different states, all of them with 'excellent' reputations, and told that the various problems I had along the way (necrotic graft, infection, hemorrhage, genital mutilation, back strain from self-care, sacroiliac rupture, pelvic floor dysfunction, raging neuropathy, raging radiculopathy) were 'just in your head'...

then denied any form of compensation when the attorneys all told me that malpractice caps made it impossible for them to take my case on contingency...

even though my first surgeon abandoned me while I was still in the hospital bed and the hospital refused to stop the bleeding or fix the graft...

I have to take issue with the rosy pronouncement that doctors just want what is best for their patients, especially since one doctor who I filed a complaint against told the regulatory agency a bald-faced lie about the ridiculous quantity of 'samples' he handed me while simultaneously maligning me as a psychotic basket case in my medical records, as several other doctors did.

Medicine is a business, and just like a corporation, the first and only practical obligation a doctor has is to make money. If a doctor can do that while ruining the lives of patients, a doctor will do so, particularly if the malpractice laws are defanged and there is no formal governmental review beyond the lapdog processes now in place, and good medicine is so much more of a bother.

This is why medicine has been socialized into a legal right in most of the industrialized world -- to prevent people like me from being mauled by a profit-oriented system that has quality of care as the last priority.

I really doubt my comments will be posted or given any credence here, but I sure wish to heck I could post a picture of the mess between my legs and have you respond to that... or at least get my 'insurance' to pay for a power wheel chair so that I can get out and shop.