Atul Gawande, stylistically, is a great writer. He is also a master at telling stories that bring arcane health policy topics to life. But articles written for popular appeal often lack the nuance that a more scholarly treatment would offer. His article in the New Yorker on low value health care suffers from this problem. While one would hardly disagree with his premise that there is waste and inefficiency in health care the article has its issues.
Although Dr. Gawande talks about research findings in a paper that gave him ideas for the piece, he does not cite or even name it. Annoying. I had to do some searching and finally decided it must be this one. It reported that somewhere between and 25 and 40% of Medicare beneficiaries received at least one test or treatment found on the Choosing Wisely don't do list.
Gawande talks a great deal in the article about value. But value in health care is not as straightforward as he seems to indicate. According to the original meaning of evidence based medicine, value is an individual matter and varies from one patient to another. That's not to say that medical decisions are driven by whatever the patient happens to want. Patients often seek ineffective or even harmful treatments. Evidence based medicine integrates the patient's preferences and values with the expertise of the clinician and the best external evidence. Value is not easily defined nor is it measurable, contrary to what some of our opinion leaders want us to think.
Neither the Choosing Wisely list nor the manner in which many policy leaders would choose to use it is evidence based. That raises the question of whether Gawande himself adheres to EBM. In this article, at least, he makes no pretense of doing so. For many of those who support the popular orthodoxy in today's health care discussion it may be safer to remain silent about EBM because its principles go against much of today's policy agenda for reasons I explained here and elsewhere.
After discussing data showing pervasive waste in U.S. health care, Gawande provides a series of anecdotes to illustrate what it looks like and explain why. Patients think more is better, doctors err on the side of doing more (they don't want to miss anything) and technological advances, which often out pace evidence, drive more interventions. He says this about the incentives in health care:
What explained this? Our piecework payment system—rewarding doctors for the quantity of care provided, regardless of the results—was a key factor. The system gives ample reward for overtreatment and no reward for eliminating it. But these inducements applied everywhere.
No reward for eliminating it? There he's flat out wrong. It's not so simple. Health care in the U.S. has been under a mixed set of incentives, both positive and negative, for decades. Capitated payment plans are widespread and have been around for a long time. Hospitals are paid for inpatient care under the Prospective Payment system in which less testing, less care and shorter hospital stays mean more money. Financial incentives for more care do exist but are only part of the picture. There are multiple and complex reasons for out of control costs and it would be naive to assume that bundled or capitated payments, part of the focus of today's accountable care organizations, will necessarily be effective in the long term.
He goes on to illustrate a short term success story with two accountable care organizations in McAllen, Texas. Whether this success will be sustainable remains to be seen. Managed care in the 1990s operated on similar principles but the initial financial success was short lived. It operated on the premise that the best medical care saves money in the long run. That's the idea behind today's accountable care organizations and seems to be Gawande's view. Although highly integrated, evidence based care should be better and less wasteful than much of what takes place in the U.S. today, the idea that better care is less expensive is unproven. It may in fact be more expensive. Much of the gap between existing care and evidence based care is underutilization. Gawande hints that he realizes this:
But not all quality can be measured. It’s possible that we will calibrate things wrongly, and skate past the point where conservative care becomes inadequate care. Then outrage over the billions of dollars in unnecessary stents and surgeries and scans will become outrage over necessary stents and surgeries and scans that were not performed.
In preparing for this post I asked myself what I would do if I were the czar of an accountable care organization. I think I would follow the motto I once picked up from a wise sage: “tools, not rules.” To the extent I could I would subvert all the artificial performance measures and pathways. I would give doctors all the information resources I could and do my best to provide an environment where they could practice integrated, evidence based care.