Thursday, May 31, 2012

 Selective Omission  of Data to Judge Physicians, Lower Costs, and  Improve Health Outcomes
Not only our actions, but our omissions become our destiny.
Abraham Verghese, MD, Cutting for Stone (Vintage Books, 2009)
May 31, 2012 -  Lies, damned  lies, and  statistics " is an overused  phrase describing the persuasive power of numbers, particularly the selective use of data  to bolster weak arguments.  
I prefer a variation of Mae West aphorism, “It’s not the men in your life that matters,  it’s the life in your men.”

In the case of health care,  desicatted data does not tell the story of what's occurring on the front lines of care, in the lifes of people or thier doctors.

I would paraphrase  the  Mae West line  to read,“It’s not the data that matters, but how the data is used that matters."
Health system and physician critics selective omit  data to condemn the U.S. health system.  
·         That   the U.S. compares unfavorably to other nations in longevity.  True enough, if you omit the fact that if you include our homicide and accident rates.  If you include these statistics,  we rank right up there. 

·         That the U.S. lags behind most other nations in overall care, when in fact we do better in prompt access to specialists and high tech care and in our outcomes in treating diabetes, heart disease, and cancer.

·         That American physicians make more than physicians in other nations is often bewailed.   Again, this is true, unless you include the prohibitive costs of U.S. medical education, often resulting in $200,000 medical education indebtedness of doctors entering practice,  and malpractice premiums,  often exceeding $100,000 for high tech specialists.  Subtract these costs from American physician incomes, and you get an entirely different pictureI
The selective use of data is often used to subtly portray American physicians as fee-for-service gold diggers prospecting for money by doing more unnecessary procedures to bolster their income(Joe Klein,  “Accountable Health Care,” Time Magazine,  May 29, 2012).
The argument for accountability goes: If only we could make physicians more “accountable” by placing them on salaries, devoid of personal gain'  if only they would practice in accountable care organizations as part of teams delivering coordinated, continuous data-based care based on comparative outcomes,  all would be well. U.S. health cost statistics compared other nations would improve, incomes for doctors would drop, health outcomes would improve
This is persuasive stuff. It is the essence of Obamacare and the regulations, mandates, and sanctions it would impose upon physicians,    But it creates tensions among the policymakers, academics,  and progressive-minded journalist who would have physicians do things their way.
Kevin Pho, MD,  America’s foremost physician blogger, beautifully captures the the dilemma is this blog post.
The Tension between Physicians and Health Policy Experts
By Kevin Pho, MD, in
"There’s an underlying tension between physicians and health policy experts."
"Health policy experts take subtle jibes against physicians in their analyses, with many feeling American doctors are overpaid, which exacerbates health costs. They tend to be politically progressive, and generally dismiss the issues that most doctors care deeply about. Medical malpractice, tort reform and the cost of medical education, for instance."
"And doctors can be antagonistic to policy experts. As most wonks are not physicians themselves, doctors generally discount their opinions, since they haven’t gone through the rigors of physician training, and are shielded from the day to day realities of practicing medicine."
"Yes, I’m generalizing, but those are the themes I’ve observed from the health reform conversation over the past few years"
"But if we are to fix our health system, both sides need to come together."
"Consider a recent NEJM piece, which asks the following:"
Are U.S. physicians sufficiently visionary, public-minded, and well led to respond to this national fiscal and ethical imperative? It’s a $640 billion question.
Merrill Goozner, a progressive policy commentator, answers:
The short answer, of course, is no. If they were public spirited, would they lobbying as hard as they are to restore physician pay — the so-called “doc fix” — which will cost the government another $300 billion for Medicare over the next decade."
I"t’s a subtle physician-antagonistic response that policy wonks on the progressive side — Goozner, Ezra Klein, Maggie Mahar, and Paul Krugman, to name a few — occasionally make that only exacerbates the discord."
"Yet, to successfully reform our health system, doctors need to be at the forefront, not policy experts. And I’m not saying that because I’m a physician myself. The data says so."
"A Gallup poll, conducted in 2009, found that physicians garnered the highest level of public trust when it came to health reform."
"Patients still trust their doctors. Which is why it baffles me when policy experts don’t give doctors many olive branches when making their health reform arguments. Given the rancor surrounding the debate, it seems that reformers could use all the support they can get."

"Take the contentious issue of physician salaries, for instance. Most progressive wonks feel that American doctors are overpaid, and in their ideal world, would like a single payer system where doctors are on a salary in line with the rest of the world. Ezra Klein, for instance, continually points to France to illustrate this point."

Well, it’s no surprise that doctors are hostile to that worldview. Of course, no one likes to get their pay cut. But, why not balance the argument by including the cost of American medical education? Yes, American doctors are paid more than any other physician in the world. But look at what it costs to train them:
"If policy experts included medical education reform (or medical malpractice reform) with their arguments for paying doctors less, it would be better accepted by the medical community. I’ve written before that more than a few doctors would exchange medical school debt relief in exchange for a strict salary. Or medical malpractice reform in exchange for less pay."

"I appreciate the data-driven arguments that policy wonks present to illustrate, and potentially solve, our dysfunctional health system. But charts by themselves cannot convince the public, whose acceptance is key to any variation of health reform."
"To do so, health reformers need doctors on their side. Why policy experts don’t make more of an effort to sway more doctors is a mystery to me, and a tragically missed opportunity."
Tweet:  Health policy makers selectively omit data to put the U.S. health system in a bad light.

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