“If I hear Geisinger and Mayo in the same sentence again, I am going to heave!”

Public Policy Contributor Brad Flansbaum writes…

No, that is not my quote, but I did hear it from a guy sitting behind me at a recent conference on health reform.  There are no revelations in this statement, but in that sentiment, I found a kindred spirit.  Me.

The last 12 months of national health care debate have been fascinating.   The power plays by the major stakeholders, the expected and unexpected topics of focus by the press corps, the often unpredictable public polling numbers, and the messaging from the Whitehouse—sometimes highbrow, sometimes funny, sometimes disgusting—all better than reality TV in my book.  You just don’t know what will come next. 

Like the Clinton attempts at health reform, pundits will write books on the events of 2009 and a few images or anecdotes will rise to the surface to capture this moment.  Recall, the brilliant Jon Stewart disassembling Betsy McCaughey over her interpretation of the early drafts of legislation, or denials (and subsequent admissions) of Whitehouse deal making with PhRMA to help grease the sausage making, bill producing skids.  Another classic was Michael Steele, Republican National Committee chair, rallying with seniors to “prevent” Medicare cuts.  Talk about the pot calling the kettle black.  Who would have thunk it?  A comedian, and a damn good one, outshining our best mainstream journalists, our “kick the lobbyists out of DC” administration having a smoke in the AM with a professed enemy, and an RNC fox guarding the Boca Raton hen house.  Ugh.

Regardless of what the future brings, there are statements, ideas, themes, etc., call them what you will, that pass for gospel and are regurgitated weekly.  They won’t die, and as a result of utter mind numbing repetition, I am better able to sort the wheat from the chaff and effectively filter what is really worth reviewing.  Here goes:

  • OK, that guy at the health reform conference.  He punched my ticket.  Any article that has Geisinger, Mayo, Intermountain, or Kaiser listed in any combination gets a pass.  I can finish the sentence for you—“experts state that one-third of health dollars are wasted today and the path to enlightenment is through these systems.”  The answer is yes.  What the sentence does not say is it will take us 10-20 years to get there, not next Tuesday.
  • Any descriptive paragraph that contains the following: “on the table,” “off the table,” “optics,” “atmospherics,” “harmonize,” “skin in the game,” “level playing field,” or “socialism” gets thrown in the trash.  I am letting “bending the cost-curve” stick.  My post and I like the term, what can I say.
  • Any politician that starts or ends his or her thoughts with, “we are responding to the wants and needs of the American people” gets a circular file or click on the remote.  Please pass this message on to Senator’s Reid, Bacaus, Boehner and DeMint: take your hand out of the industry cookie jar and get to work!  Campaign finance reform now.
  • Howard Dean and Newt Gingrich.  Nothing more to add.
  • If I see tort reform and MCO’s as the sole cause of our systems’ ills one more time, my head will explode.  Usually on the WSJ op-ed page, but just about anywhere these days, please take a pass on any lede or header with this theme.  Folks, we are all responsible for this mess, and we need a relook with some critical thinking.
  • When you see the phrases comparative effectiveness research and government bureaucrat between you and your doctor adjoined in any story, run.  Every time I finish a review article in a peer review journal, invariably, the last flourish in the final paragraph goes something like this: “until more evidence is available, a discussion between you and your patient is necessary.”  Umh, call me crazy, but I call this throwing darts at a dartboard (if the public only knew what we don’t know).  That government run “bureaucrat” is likely a health services researcher—who is someone I would look to for guidance (over mine) even for my own family’s health.  Look, we do need some cookbook medicine in our system, as I have tasted some of the meatloaf docs in this country are roasting up …and it is not a blue-plate special at Fred’s Diner.
  • Have you seen this sentence lately: “we must pay docs for quality outcomes.”  Talk about the clothes of the new emperor, if I had a nickel for every politician popping this delicious sound bite off, I could reimburse for quality from my own pocket.  Do I believe in it?  You bet!  Do I want to be compensated based on my performance and help it evolve for the future?  Right on!  However, talk about misguiding the public.  Here is where we stand right now:  if health care were like a restaurant assessment, we would want to remunerate on food quality, waiter service, and presentation.  In 2009, we know just enough about quality to pay on how nice the silverware looks, nothing more.   Read a story with two sentences on how we will cure the system with P4P in 2010, and you got it, litter box time.  Fido is happy.
  • This one is serious.  You want good health care journalism, go to Kaiser Health News, NPR (Julie Rovner is everywhere these days it seems), or The News Hour.  The major newspapers are doing some great investigative stuff as well, particularly the WSJ and its features on the hospital industry.   However, so much of what is out there is junk, and the opinion pages and Sunday news shows are no help.  It is a shame we are losing good health coverage, and one wonders who will kick the tires and look under the hood as next gen health moves forward.  I hope it is not Fox or MSNBC.
  • Actually, on the “what does prevention mean” front, I am more encouraged.  The notion that getting everyone covered would save the system wads of cash was an attractive selling point to reform.  It is only recently I have come around on this as well, and that is secondary to much of the decent treatment on this subject.  Very few preventative measures save money.  Yes, they make us healthier and are intuitively sensible, but no, they are not cost-effective and will expend more than they save.  Once again, any story justifying a full steam ahead strategy, touting the efficiencies of prevention and how it will cure all our ills—watch out and move on to the sports pages.
  • Heard this one: “All parties agree on 80% of reform, it is just that other 20%.”  According to my math, that is a 100% mess.
  • Finally, it still perplexes me that the public has not connected the dots on the money thing: health savings = less waste = saying no to that MRI you wanted = your insurance premiums are going through the roof = you can’t go to the orthopedic surgeon for back pain = your doctor is not always right, the insurance company is not always wrong = tax the rich, obese smoker.

You know why?  We continue to believe the obfuscation and sloganeering from our officials and the front story headlines (we elect what we deserve btw, don’t just blame the pols).  When Hu Jintao starts asking for his IOU’s back, we will begin to get the straight dope.  Until then, expect to hear the same song and dance.  A great quote from Jay Rockefeller (D-WV)

If you really want to be honest about it, eight to 10 percent of the members of Congress understand health care. At maximum. I chaired the intelligence committee, and health care makes it look like riding on a tricycle it’s so complicated. So what you have is lobbyists picking on congressmen who don’t know health-care reform, and they say, you know what, you could get a lot more jobs in your state if you only put more money into oxygen or a certain medical device. If you’re going to do Medicare right, understanding that the trust fund is going to go downhill in 2016, you can’t have Congress making these decisions. You need professionals.

Nice, huh?   Now get back to work and order more tests, we have an industry to run!

Brad Flansbaum

Bradley Flansbaum, DO, MPH, MHM works for Geisinger Health System in Danville, PA in both the divisions of hospital medicine and population health. He began working as a hospitalist in 1996, at the inception of the hospital medicine movement. He is a founding member of the Society of Hospital Medicine and served as a board member and officer. He speaks nationally in promoting hospital medicine and has presented at many statewide meetings and conferences. He is also actively involved in house staff education.

Currently, he serves on the SHM Public Policy Committee and has an interest in payment policy, healthcare market competition, health disparities, cost-effectiveness analysis, and pain and palliative care. He is SHM’s delegate for the AMA House of Delegates.

Dr. Flansbaum received his undergraduate degree from Union College in Schenectady, NY and attended medical school at the New York College of Osteopathic Medicine. He completed his residency and chief residency in Internal Medicine at Long Island Jewish Medical Center in New York. He received his M.P.H. in Health Policy and Management at Columbia University.

He is a political junky, and loves to cook, stay fit, read non-fiction, listen to many genres of music, and is a resident of Danville, PA.

2 Comments

  1. Rob Bessler on November 13, 2009 at 12:33 pm

    Brad,
    Not only are you a talented writer, you make a great number of points. In the perfect world, tell us what you would write as a way to “reform” our sytem.

    Rob

  2. Brad Brad on November 14, 2009 at 2:39 pm

    Rob
    Thanks for the kind words. You have given me a big task, and my ideas about reform are more pragmatic than ideologically driven. What do I mean?

    While I do have some preferences regarding how the system should move, one could envision either a market or regulatory dominant market depending on whether the right safeguards are in place, and here is the key, whether they work!

    As far as a market driven system, how confident are open minded reformers that risk-adjustment schemes will succeed? That health exchanges will be firewalled appropriately? That adverse selection won’t overtake the enrollment process? On the latter in fact, I am very cynical, but who is to say.

    As far as a public system, unlike the pundits who pounce away, the program is not an entitlement and it will rely on its own premiums and pay back all start up costs. Is this realistic? Can we really create a viable insurance company, which in essence it is (and make no bones, it will need to be a behemoth out of the box), building a qualified infrastructure with talented people in a culture of excellence? Medicare uses third party support for a slew of functions, and one can speculate that the buy or build strategy will be the next hurdle if we get a public option. How this plays, no one knows. Also, I am skeptical at the administrative operating costs proponents often quote (“3%”). More efficient yes, but not the home run people claim. For sure, registry creation, scale, transparency, etc., and “do well” intent is embedded in the mission and on this front I am highly encouraged, but Uncle Sam execution and Congressional hamstringing are the proverbial sticky wickets. Again, there is theory, and there is reality…

    I could go on, and these are fleeting thoughts, but the “success or failure” of reform is contingent on whether you believe in the idealized versions of the different plans and the ideologies folks bring to the negotiating table.

    As most spectators are, I am highly skeptical, and at best, whether you deem one approach over another superior, we will measure success in inches, not yards—no matter what path we stumble down. The substrate that is our culture is too darn broken and I don’t see it changing—not until things get truly desperate.

    Regardless of the final product though, the process will be a lot of round hole, square peg type of dickering, make no mistake. Moreover, it so dependent on the legislation, and at this juncture, the bills seem a helluva lot more descriptive than prescriptive to me. Speculation on whether an MCO can or will do “x,” or the HHS Secretary can or will do “y” just seems like a big black box—and with that, how can anyone be expected to make a real EBM type choice. I can only say it is all gut at this point, and betting on efficient reform (I did not say no reform) is like betting on a hapless ball club—hope springs eternal.

    Brad

Leave a Comment