Members of Congress are seriously considering proposals to rein in the growth of health spending by taking tens of billions of dollars of Medicare money away from doctors and hospitals in high-cost areas and using it to help cover the uninsured or treat patients in lower-cost regions reports Robert Pear in the NY Times today. This is but another step towards curtailing the skyrocketing costs of health care in the US that President Obama has called ‘the biggest threat to our nation’s balance sheet.’
Findings from a series of studies he cites in the article point out that in higher spending areas of the country, Medicare patients have fewer visits to primary care physicians, are referred more to specialists and are hospitalized more frequently. Yet, these higher cost areas do not show better health outcomes than the lower costs ones. The Director of the OMB says: …health spending could be reduced by as much as 30 percent, or $700 billion a year, without compromising the quality of care, if more doctors and hospitals practiced like those in low-cost areas.
But, other researchers and policymakers are not so convinced by the data (especially those from high cost areas naturally).
This debate has taken hold because in many meetimgs President Obama is quoting from an article in The New Yorker in which the author, Atul Gawande, visits McAllen, Texas, (among the highest Medicare cost areas in the country) to discover the reasons why. His first finding: the hospital CEOs and doctors in McAllen did not know they were unique. One CEO was ‘surprised’ and genuinely interested in seeing the data; another attempted to explain it away by suggesting that patients were better off in ways not measured by the surveys. Some physicians he talked with were ‘dubious’ and ‘skeptical’ of the claim that health care was so expensive. Arguments about having a less healthy population, protection against threats of malpractice suits, and offering better services were summarily shot down by one of their own:
‘We all know these arguments are bullshit. There is overutilization here, pure and simple.’ Doctors, he said, were racking up charges with extra tests, services, and procedures.
An analysis of Medicare payment data support his contention.
In contrast, in Rochester, MN where the Mayo Clinic is located, health care costs rank in the lowest 15 percent in the country. Gawande frames the issue as this (note: this is where social marketing kicks in):
Most Americans would be delighted to have the quality of care found in places like Rochester, Minnesota, or Seattle, Washington, or Durham, North Carolina - all of which have world-class hospitals and costs that fall below the national average. If we brought the cost curve in the expensive places down to their level, Medicare’s problems (indeed, almost all the federal government’s budget problems for the next fifty years) would be solved. The difficulty is how to go about it. Physicians in places like McAllen behave differently from others. The $2.4-trillion question is why. Unless we figure it out, health reform will fail.
The first insight he came away with was: …[hospital administrators and physicians] have only the vaguest notion of whether the doctors are making their communities as healthy as they can, or whether they are more or less efficient than their counterparts elsewhere. The second was to answer the question – why aren’t more areas like McAllen, which is clearly responding to market forces and economic incentives, instead of how did McAllen become the anomaly? A nice use of the positive deviant approach to uncover the high leverage behaviors.
Answers that presented themselves were better communication, coordination of information, community peer review and reducing economic incentives to physicians to cherry-pick patients and self-refer (for tests and other procedures) by putting them on salaries. In the case of the Mayo Clinic, there is also a collaborative culture where ‘the needs of the patient come first.’
Gawande writes: Somewhere in the United States at this moment, a patient with chest pain, or a tumor, or a cough is seeing a doctor. And the damning question we have to ask is whether the doctor is set up to meet the needs of the patient, first and foremost, or to maximize revenue.
He goes on to note that the health care reform debate tends to center on who writes the checks. I also have been troubled by some advocates for health information technology ‘solutions’ to health care costs who focus on how these will make the lives of health care provider, billers and payers easier – the patients come last, if indeed their needs are discussed at all! For Gawande the lesson from positive deviants is clear: [in] high-quality, low-cost communities…someone has to be accountable for the totality of care. Otherwise, you get a system that has no brakes. Now that would make a nice platform for a reinvented public health system!
His proposal is to create accountable health organizations in which doctors collaborate to increase prevention services and the quality of care, while discouraging overtreatment, undertreatment, and sheer profiteering. He offers that this will require experimentation, research and dissemination of effective practices to address these core issues. And it will take time – a decade or more he presumes.
From a social marketing POV, the shift in thinking Gawande and others are proposing walks away, rightly, from solely focusing on the economic policy levers – the easy ones too often reached for by policymakers in the face of seemingly intractable, wicked problems of all sorts. The marketing mix heuristic offers a wider aperture to address more of the problem, and potentially focus on the more important aspects of it – not just who pays the bills, but to what purpose?
Perhaps the biggest issue I see here is one of information asymmetry. It happened in McAllen with the CEOs and physicians (they honestly had no idea they were the big spenders). It happens between patients and their providers and insurance carriers. What gets fogged over in the health care reform debate is the lack of access to timely information one can understand and act on that is hindering health care administrators, health care providers, and patients from acting in more responsible ways. Not in the streamlined version of fiscal responsibility health IT offers providers and payors, but in responsible and accountable patient management practices that provide high quality care and improve community health. And I believe that it focusing the debate on the lack of standardized reporting systems, fracturing of medical information and other payment-related issues that keeps the power in the hands of the few rather than with the community. It keeps us asking the wrong questions so that they don't have to worry about the answers. Entrenched health insurance and health care provider interests will not easily shift to a paradigm of conversations about transparency and community (social) accountability – they threaten the foundations on their business model.
The next issue Gawande touches on is how to create incentives for innovation. Not incentives for how health care is delivered per se, but for how the system is structured. Who gets rewarded for devising the next Mayo Clinic or Grand Junction, CO model, or even adopting one of them? Who is rewarded for taking on the task of truly disseminating best practices in this regard by segmenting the marketplace and designing approaches that are tailored to their circumstances, and not simply by writing more reports. When does stimulus money become a driver for investing in innovation and prototyping new models of health care delivery; if ever there were a case to be made for ‘critical infrastructure,’ doesn’t health care deserve to be at the top of the list?
Why don’t we think about health care delivery as a service delivery system with all the inherent, and yes idiosyncratic, marketing problems that beset every other service delivery system (marketing, that is, that goes beyond the objectives of reputation enhancement, branding, staff recruitment and patient referrals. See McDondald’s sacred text and ask yourself if any health care organization you know could come up with one). Some of the marketing problems include recognizing that our service offerings are totally out of whack – where preventive medicine is the last thought (and funded), not the first. Where access to information is a critical problem for the system, while access to care remains a priority for too many people. Where the incentives for service delivery exist for the insurers, health care organizations and individual practitioner’s self-interest, and not those of the patients and the communities in which they live and serve. And where policy communication is centered around the hospitals, the providers, and the payors – not the patients. Social marketing offers some complimentary ways to think about and get to work on designing health care reform. We start by asking – what is best for the patient [attributes of patient-centered care]? And we would be thinking about policy makers as a key audience.