Sunday, August 8, 2010

Chapter Five. Federal Bureaucracy and Technocracy

This is chapter five in my new book Health Reform in Perspective.

Prologue: A little bureaucracy is a necessary thing. Health benefits must be administered and managed. But when taken to an extreme and misinterpreted as rigidly controlling patient-doctor interaction through technocratic means, a sprawling federal bureaucracy may be unrealistic, over-optimistic, and runs the risk of creating adverse political consequences.

Everybody complains about the growing health care bureaucracy, but few analyze it and tell the reasons why it exists. That’s why we should be grateful to David Brooks, NYT columnist, for explaining what is going on.

Here are a few excerpts from a July 19 column ”The Technocracy Boom” on the bureaucratic mindset that has seized the imagination of the ruling party elite. The mindset is metastasizing in Washington. It is sucking the lifeblood and joy out of American business and health care enterprises. It says that those at the top can dictate what goes on at the bottom.

The italicized sentences are my doing. They explain the reasoning behind the new bureaucracies and the cultural backlash if they fail to do the job they are intended to do.

Here is Brooks speaking.

“In the second part of the period, Democrats were in control. They augmented the national security bureaucracy but spent the bulk of their energies expanding bureaucracies in domestic spheres."

"First, they passed a health care law. This law created 183 new agencies, commissions, panels and other bodies, according to an analysis by Robert E. Moffit of the Heritage Foundation. These include things like the Quality Assurance and Performance Improvement Program, an Interagency Pain Research Coordinating Committee and a Cures Acceleration Network Review Board."

"The purpose of the new apparatus was simple: to give government experts the power to analyze and rationalize the nation’s health care system. A team of experts on the newly created Independent Medicare Advisory Council was ordered to review and streamline Medicare. A team of experts within the Office of Personnel Management was directed to help set standards for insurance companies in the health care exchanges. Teams of experts serving on comparative effectiveness boards were told to survey data and determine which medical treatments work best and most efficiently."

"It’s a progressive era, based on the faith in government experts and their ability to use social science analysis to manage complex systems."

"This progressive era is being promulgated without much popular support. It’s being led by a large class of educated professionals, who have been trained to do technocratic analysis, who believe that more analysis and rule-writing is the solution to social breakdowns, and who have constructed ever-expanding networks of offices, schools and contracts."

"Already this effort is generating a fierce, almost culture-war-style backlash. It is generating a backlash among people who do not have faith in Washington, who do not have faith that trained experts have superior abilities to organize society, who do not believe national rules can successfully contend with the intricacies of local contexts and cultures."

"This progressive era amounts to a high-stakes test. If the country remains safe and the health care and financial reforms work, then we will have witnessed a life-altering event. We’ll have received powerful evidence that central regulations can successfully organize fast-moving information-age societies."

"If the reforms fail — if they kick off devastating unintended consequences or saddle the country with a maze of sclerotic regulations — then the popular backlash will be ferocious. Large sectors of the population will feel as if they were subjected to a doomed experiment they did not consent to. They will feel as if their country has been hijacked by a self-serving professional class mostly interested in providing for themselves."

“If that backlash gains strength, well, what’s the 21st-century version of the guillotine.”

Maybe Brooks is on to something. Maybe, in time, the U.S. will follow Britain’s lead. The new Conservative government there intends to shirk its health care bureaucracy. It plans to shift control of England’s $160 billion annual health budget from a centralized bureaucracy to doctors at the local level. Under the plan, $100 billion to $125 billion a year would be meted out to general practitioners, who would use the money to buy services from hospitals and other health care providers.

The plan would shrink the bureaucracy. The government’s goal to effect $30 billion in “efficiency savings” in the health budget by 2014 and to reduce administrative costs by 45 percent. Tens of thousands of jobs would be lost because layers of bureaucracy would be abolished.
Berwick in His Own Words

What would the new head of CMS think of this turn of events? Donald Berwick, MD, who President Obama appointed as head of CMS in a recess appointment, is a quintessential technocrat. He fervently believes the health care system can be rationalized and improved from the top-down by the federal bureaucracy using data, guidelines, protocols, and evidence-based medicine. He is “in love” with the National Health Service in Britain.

Several readers have asked for a fuller glossary of Donald Berwick quotes so they can judge where the good doctor stands and what his appointment as head of CMS portends for U.S. health care. I do not know about the latter, but I will let him speak for himself on the former.

"I cannot believe that the individual health care consumer can enforce through choice the proper configurations of a system as massive and complex as health care. That is for leaders to do."

"You cap your health care budget, and you make the political and economic choices you need to make to keep affordability within reach."

"Please don't put your faith in market forces. It's a popular idea: that Adam Smith's invisible hand would do a better job of designing care than leaders with plans can."

"Indeed, the Holy Grail of universal coverage in the United States may remain out of reach unless, through rational collective action overriding some individual self-interest, we can reduce per capita costs."

"It may therefore be necessary to set a legislative target for the growth of spending at 1.5 percentage points below currently projected increases and to grant the federal government the authority to reduce updates in Medicare fees if the target is exceeded."

"About 8% of GDP is plenty for 'best known' care."

"A progressive policy regime will control and rationalize financing—control supply."

"The unaided human mind, and the acts of the individual, cannot assure excellence. Health care is a system, and its performance is a systemic property."

"Health care is a common good—single payer, speaking and buying for the common good."

"And it's important also to make health a human right because the main health determinants are not health care but sanitation, nutrition, housing, social justice, employment, and the like."

"Hence, those working in health care delivery may be faced with situations in which it seems that the best course is to manipulate the flawed system for the benefit of a specific patient or segment of the population, rather than to work to improve the delivery of care for all. Such manipulation produces more flaws, and the downward spiral continues."

"For-profit, entrepreneurial providers of medical imaging, renal dialysis, and outpatient surgery, for example, may find their business opportunities constrained."

"One over-demanded service is prevention: annual physicals, screening tests, and other measures that supposedly help catch diseases early."

"I would place a commitment to excellence—standardization to the best-known method—above clinician autonomy as a rule for care."

"Health care has taken a century to learn how badly we need the best of Frederick Taylor [the father of scientific management]. If we can't standardize appropriate parts of our processes to absolute reliability, we cannot approach perfection."

"Young doctors and nurses should emerge from training understanding the values of standardization and the risks of too great an emphasis on individual autonomy."

"Political leaders in the Labour Government have become more enamored of the use of market forces and choice as an engine for change, rather than planned, centrally coordinated technical support."

"The U.K has people in charge of its health care—people with the clear duty and much of the authority to take on the challenge of changing the system as a whole. The U.S. does not."

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