Friday, January 16, 2015

Health Reform, Shades of Gray, And What Doctors Really Think

My dear Friend, all theory is gray.

Goethe (1749-1832), Mephistophles and the Student

The color gray conveys uncertainty. And nothing is more gray than the future of health reform.

This day two articles reflect this grayness.

One, “Addressing the Challenge of Gray-Zone Medicine”,New England Journal of Medicine, January 15, 2014. Its authors are from the Harvard Kennedy School, Massachusetts General Hospital, and Press Ganey Associates, all in Boston.

They comment:

“In truth, there are large gray zones in which intervention is clearly neither clearly effective nor clearly ineffective – zones where benefits are unknown or uncertain and value may depend on patients’ preferences and available alternatives.”

The authors posit the notion that shrinking the gray zone and lowering costs resides in four policies: 1) utilization review based on comparative effectiveness; 2) financial incentives based on evidence-based comparisons; 3) bundled payments discouraging unnecessary or questionable care; 4) capitation which does the same as bundled payments.

Their solution is to combine comparative research programs with reimbursement policy to enhance return on investment.

Two, the second article is an interview appearing in The Health Care Blog conducted by Robert Wachter, MD, a West Coast academic credited with launching the hospitalist movement. The title of the interview is “Healthcare and the Second Machine Age.: An Interview with Andy McAfee."

Andy McAfee is associate director of the Center for Digital Business at MIT’s Sloan School of Management. He is also coauthor (with his MIT colleague Erik Brynjolfsson) of the 2014 book, The Second Machine Age: Work, Progress, and Prosperity in a Time of Brilliant Technologies. McAfee is a “technology optimist.” He appreciates the upsides and downsides of IT. The interview will be featured in a continuing series of inteviews in Wachter's forthcoming book on health IT, The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age.

Here are two exchanges in the interview.

Wachter: : We always like to think we’re special in medicine. We’re so different. It’s so complicated. Do you see any fundamental differences between healthcare and other industries that will shape our technology path?

McFee: There are two main things that might retard progress in medicine. The first is healthcare’s payment system, particularly how messed up it is trying to match who benefits versus who pays. The other thing is the culture of medicine. I understand that it’s changing, but there’s still this idea that “how dare you second-guess me, I’m the doctor.”

Wachter: But we can’t be alone in that. I’m sure many industries have their stars – supported by their guilds – who think, “We’re at the top of the heap, with high income and stature. We’re going to fight this technology thing, since it could erode our franchise.”

McFee: Sure, but in the rest of the world eroding the franchise is what it’s all about. It’s Schumpeterian creative destruction , the theory advanced by Austrian economist Joseph Schumpeter – it is, in essence, economic Darwinism, and forms the core of today’s popular notion of “disruptive innovation”, so if you’re behind the times and I’m not, I’m going to come along and displace you and the market will speak to that.

Which brings me to point of this blog. According to a recent Booz Allen survey of 400 doctors, only 10% of specialists like the direction health reform is headed. This is important because two-thirds of American doctors are specialists, and they fear they will become victims of economic Darwinism, sacrificed in the name artificial intelligence.

Specialists do not like being secondary actors of bundled or capitated pay in accountable care organizations, of being singled out as the main perpetrators of high-cost medicine, of being considered raw data for electronic health record systems, and of being second guessed and paid on the basis of that data. Specialists, because of their experience in narrow fields of medicine where many of the uncertainties have been winnowed out before they see a patient referred to them, often deal in fewer uncertainties than primary care physicians seeing data-unfiltered patients and remote data-driven physician makers and technocrats. Specialists believe they deserved to be paid fee-for-service on the basis of their intuitive clinical judgment and skills rather on the basis of some computer algorithm.

When they come down from their Ivory Towers, idealistic technology reformers will confront the reality that America's medical specialists do not agree with the high tech point of view: that payment based on high tech solves high cost health care.

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