We all remember Glinda's famous line to Dorothy when she first steps out of her windswept house into the Land of Oz; clearly possessing supernatural powers the citizens wished to know were they to be used for good or ill.
Metaphorically the parallels to health care reform could not be more direct: an enormous maelstrom of change has been unleashed on the body politic. Amid all the turbulence and noise, the central element that it will deposit into our land is a strange new creature named Cost Effectiveness. What we don't know is if this creature is ultimately a good witch or not.
A bit of background. I'll loosely define Cost Effectiveness as looking at data to assess what produces similar "results" with the lowest net cost. As a simple example, if you have prostate cancer do you have surgery, do chemo, or a seed implant? Each has their merits and their downsides; they each also have different costs. The purpose of Cost Effectiveness studies is to say, when things are essentially the same, choose the cheaper option (Ok, I'm grossly oversimplifying here, but this is a blog column not a book).
Many health care policy experts believe Cost Effectiveness to be a Good Witch. The basic argument is simple: health care costs are growing rapidly and if the rate is not reduced it will seriously constrain government spending before the end of this decade. Worse, when you strip away all the political posturing, health care cost growth largely boils down to having more older people (who have greater health care needs) and increasingly expensive ways to treat them. The theory is Cost Effectiveness will reduce the rate of growth; the policy wonks wants it to be a Good Witch because the alternative is rationing (as is happening already across most of Europe).
Having resided for many years in the 'Swamp of Outcomes Analysis' I can attest that there is plenty of room for Cost Effectiveness to be successfully applied. To protect confidentiality I'll simply cite the famed DOD study, which is public. They studied C-section rates across 85 VA hospitals, the range of C-sections was between 6% and 17% of live births. Drilling into the details the single best explanation for the higher rates was 'physician decision' meaning physician convenience. Worse, anytime C-sections went above 10% there were far more complications and costs, with no difference in results (infant mortality or days spent post birth in hospital). I can attest similar 'physician decision' variance occurs across the spectrum, even in items as simple as use of antibiotics and that some of the worst offenders are not in poor neighborhoods but in the high end suburbs.
So, health care reform is chock full of initiatives to support Cost Effectiveness: Boards are established to evaluate what is 'optimal care'; billions are allocated to support research, billions more for electronic medical records and IT systems to collect even more data. A cornucopia of offerings for the Good Witch who will save health care.
But before we all begin celebrating its worth a deeper dive. The Great and Powerful new Board of Cost Effectiveness will make their decree: protocol X is preferred. Such information is routinely published today yet a recent survey of data by Medco, a major insurer of pharmacy services, showed 30-50% of doctors were not following recognized best practices TEN YEARS AFTER endorsement by the appropriate medical Academy. With cost pressure mounting how long will it be before Board 'advise' turns into Board Mandates and the Good Witch of Cost Containment becomes the Bad Witch who says only one treatment option is allowed (unless you can afford it on your own)
So here lies the fulcrum of the debate. No one can argue that there are not serious savings to be made from gaining greater adoption of more cost effective practices yet no one would want an inflexible 'paint by the numbers' approach either. One hears many physician complaints already about 'cookbook medicine' but if there is not a more open and aggressive voluntary adoption of Cost Effectiveness information it is likely to result in more severe and involuntary means of adoption. After all, the DOD was able to implement is changes because military doctors have to follow orders.
In the Bill everything is carefully positioned as 'advisory'
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