Monday, May 4, 2009

Going All In

A fascinating profile in last week's New Yorker on Peter Orszag, the budget director in the Obama Administration. This guy is a true believer. He's going all in on Comparative Effectiveness Research as a solution not just to health care reform, but to the entire financial infrastructure of this country.

Orszag is convinced that rising federal health-care costs are the most important cause of long-term deficits. As a fellow at the Brookings Institution, he became obsessed with the findings of a research team at Dartmouth showing that some regions of the country spend far more money on health care than others but that patients in those high-spending areas don’t have better outcomes than those in regions that spend less money. If spending more on health care has no correlation with making people healthier, then there must be enormous savings that a smart government, by determining precisely which medical procedures are worth financing and which are not, could wring out of the system. “I spent several months in very intense study,” Orszag told me. “The reason that I wanted to go to C.B.O. was I thought that was one of the key bodies that could really delve into what we could do about it.”

Seems just a tad audacious, no? A giant federal bureaucracy will need to be created to guide us silly doctors through the complexities of diagnosis and treatment. Clearly, a centralized planning behemoth will be able to stay on top of the latest innovations and evidence better than anyone involved in the actual delivery of medicine, and subsequently facilitate the smooth, effortless transmission of the new paradigms all the way down the line to your local podunk hospital. At least that's what Peter Orszag thinks. Added bonus: reduced deficits, save the banks, and end the recession!


HMS said...

Hence the term, audacity of hope.

Dire circumstance calls for equally drastic measures. We don't zap someone with 200 joules of electricity unless it's a dangerous but reversible cardiac rhythms.

Hopefully, all the investment (red ink) today will prove worthwhile 15 years down the road.

james gaulte said...

Nothing sharpens your mind and super-charges your motivation than to have to know something or review something that you will/might need to care for a real life patient (and to keep him that way).The folks on the Fed Med agency's CER panel may well mean well and so may Mr. Orszag but those who deal only with aggregate inputs and outcomes do not have a clue as to the complexities and nuances that are involved in dealing with real people and making decisions which may be determinative of life and death.He may have spent "months of intense study" while physicians have only spent years or decades.

Anonymous said...

audacity of hope maybe?


He is threatening to change the entire game. The Dartmouth study was pretty phenomenal though. More orthos= more hip replacements, which did not equate to healthier patients. Might be smart to reign that crap in.

I'm not sure what your worried about though. Unless you make most of your money whacking out parathyroid glands (see I learned), I think just about every study in existence is going to support removing solid tumors, appendices and all the other life saving procedures you do.

Anonymous said...

Take it easy. It's very unlikely that Orszag would make such big decisions without any input from health care professionals.

Andrew_M_Garland said...

Orszag said: "If spending more on health care has no correlation with making people healthier, then there must be enormous savings that a smart government could wring out of the system, by determining precisely which medical procedures are worth financing and which are not"

(1) Finding that costs differ between regions is interesting, a reason to find out why, not assume where the answer is.

(2)The big "IF". That is a big assumption, that there is "no correlation" between cost and benefit. So, there is no reason for Orszag to find out why. He must appoint a bureaucracy, who will UNDOUBTEDLY find out how to cut costs. That is grunt work, not for the likes of Orszag.

(3)"a smart government". Where is that? How do we create that? Has there been one before? "Determining precisely" also reminds me of government.

(4)"which medical procedures are worth financing". Why wait for the bureaucracy to find out why costs vary by region? He already "knows" that it is the frequency and type of procedures that are used. Promote the cheap ones, and cut the expensive ones. He already "knows" that this will not change the outcomes (see 2).

Buckeye, do you have any insights into regional differences in medical expense? (Or, is it a formula error or typo in a spreadsheet somewhere?)

All people and organizations seek income and avoid costs. Socialized healthcare gets its payments up-front and delivers services after the fact. How hard will a system work to earn the money that it has already been paid? How will socialized medicine command the correct amount of money from its political managers? This is something that everyone understands intuitively. A customer is lost without competition for his dollar.

Begging for Medical CareThe bureaucracy sees you as a cost, especially if you have already paid.

Anonymous said...

If the physicians can't police themselves, then others will.
We have high malpractice because we don't have a viable system in place to report bad actors, and have lost the trust of the public. We'll have gov't involved in care decisions if we don't find a way to ensure that evidence-based practice is always the basis for care of our patients.

Let the Personal Responsibility begin at home - and in our practice. Just as patients need to be responsible for practicing healthy behaviors - and aid in reducing the costs to society, docs must practice responsibly - and aid in reducing cost to society.

More orthos = more need for procedures to support their lifestyles, regardless of whether the procedure helps the patient.

Educating the public about effectiveness of therapies may help some - but only those patients that want to learn. Too many will just say "whatever you think is best, Doctor." Even if what is best is the doc's bank account.

Anonymous said...

Interestingly enough, it is Rahm Emmanuel's brother, Ezekiel Emmanuel MD, who is drafting up most of this legislation. Take it for what you will.

walt dandy said...

We're all screwed. I don't know how to say that any other way.

Anonymous said...

Re: Walt Dandy

NOT unless we just sit here passively and whine.

Jeffrey Parks MD FACS said...

The Dartmouth Atlas report is a useful descriptive study. The idea that there is not a direct correlation between outcomes and the amount we spend on health care is something that mandates further investigation. But my God, to throw your entire political weight behind this is just astounding.

Comparative Effectiveness Research is a great initiative but it didn't help me save an old guy a few weeks ago with toxic megacolon from c diff colitis. Half those patients may die no matter what you do but an early operation is their only chance. Strict federally mandated guidelines likely would take that option out of my hands (and the patient's) for the sake of "cost effective health delivery"....

I'm just sayin...things are always a lot more complicated than our DC policy wonks would like them to be.

Anonymous said...

what will this do for 'woo' medicine? will acupuncture and chiropractic medicine bear the brunt?

Anonymous said...

Heck, Accupuncturists and Chiropracters are ALREADY treatin Diabetes and Hypertension, no reason they can't treat Gallstones too. Sure, you'll have the occasional liver failure and gall bladder perf, but they'll make up for it with a lower DVT rate...

pro-healthcare reform said...

It is a multi-directional reform. Your participation is appreciated.

WHAT? We want certainty? We want a guarantee of success? We want the "right" to say that "i told you so" if the reform failed to achieve its aim? Since when do we have such certainty in real life? Call it cliche if you like, it will be an uphill battle that's for sure. A lot problems we face in health care are as deeply rooted as they are systematic.

Money (flyaway insurance & drug cost), patient behaviors and provider behaviors are among the aspects of the system that need an update. Arguably, our healthcare system has not evolved in accordance with societal needs since 1920's (and was successfully hijacked by profiteers 2-3 decades down the road).

Anonymous said...

Have you wondered: since when has it become SO expensive to seek reasonable health care?

"Let’s just spend our money wisely. It’s just common sense; not an evil plot" (link1, link2).

Anonymous said...

"...patient behaviors...." (article)

[Classic] American lifestyle needs an update.

Anonymous said...

"...hijacked by profiteers...." (video)

[Classic] American consumerism* and entrepreneurship* also need a make-over.

* supply and demand