Monthly Archives: July 2009

The Institute of Medicine (IOM) has addressed seven key health care reform questions and offered answers that capture today’s consensus. No surprises, but good clear analyses. But what if the underlying conceptual framework is not an excessive use of services by wrongly incentivized providers but the tragic over-use of services by the poor? Here are seven “what ifs” plus an eighth question.

1. Is health care too expensive?
What if health care is the economy, the major source of jobs and the basis for America’s worker productivity? And what if the problem is an unfair insurance system and inequitable distribution of fiscal responsibility?

2. How much too expensive is it?
What if regional variation is not a manifestation of excessive spending but of income inequality and the intersection of wealth and poverty? And what if differences in price and economic development, rather than waste and inefficiency, differentiate costs among countries?

 3. Where’s the excess?
What if the major excesses are not unwarranted services, fragmented delivery, administrative costs, malpractice expenses and myriad others, all of which contribute, but the costly and inefficient delivery of services to the nation’s poorest?

 4. What’s driving the growth?
What if growth of health care is a necessary constituent of a technologically-advanced nation and factors such as aging and life-style simply define major targets of that growth?

 5. What are the key levers for change?
What if professional regulation and practice incentives are the problem and not the solution? And what if professional autonomy is the friend of quality?

 6. Which initiatives can make a difference?
What if pay-for-value, specification of services and national guidelines distort the clinical process, increase overall costs and impair aggregate outcomes? 

7. How much difference?  
What if more than 10% could be saved if costs for the poorest 25% of the population were the same as for the other 75%?

8. Why does the word “poverty” not appear in the IOM’s list of seven (or anywhere else)?

It’s tonsils that vary, but just on the right.  The left one stays in – it’s always in sight. 

The right one goes fast, ’cause the profits are higher.  Those damn greedy doctors, they lie, yes they’re liars. 

They tell you that right one, must go down the drain.  But it’s money they’re after, not less patient’s pain.

So health care reform’s in a terrible mess.  It’s more tonsils and deficits, unless doctors do less.

The Dartmouth Atlas Frequently Asked Questions section asks: “How do you ensure some patients were not more severely ill than others?” Here’s the Dartmouth answer:  “The study only focused on patients who died so we could be sure that patients were similarly ill across hospitals. By definition, the prognosis of all the patients in the cohort was identical – all were dead after the interval of observation. Therefore, variations cannot be explained by differences in the severity of individuals’ illnesses.”

So, let’s see. A hospital where a senior gets minimal care after an acute MI and dies in 36 hours is efficient, but a hospital where his identical twin got a full range of care and survived, only to die of a second MI on the golf course six months later is inefficient. OK, I get it. Similarly dead. Even similarly ill, at the start.  But where would you go for care? And who would ever judge “efficiency” this way?