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.
