No Silver Bullets, Lots of Shortcomings

Goodness gracious. If you think you have a good idea when it comes to solving the twin dilemmas of cost and a quality for chronic conditions, ‘tis the political season. While the Disease Management Care Blog thinks the short term prognosis for meaningful health care reform is poor, that doesn’t mean it’s not smart to get your proposal out there and on the table in the next 85 days. Just in case.

As a public service, the DMCB would like to offer these two Rules for Promoting Your Good Chronic Condition Care Idea:

1. Cast It As A Leading Domestic Policy ‘Silver Bullet.’ Yes, we know chronic illness care is an impossibly obscure tangle of insatiable demand, State and federal regulations, complex actuarial principles, relentless demographics, burgeoning technology and county-by-country variation. That complexity combined with an impatient hunger for reform is the perfect setting for the simplistic Good Idea that offers to cut through the clutter. For examples outside the health policy sphere, think ‘school vouchers,’ ‘flat tax’ or being willing to ‘take a paternity test.’

Examples of Chronic Care Silver Bullets: The electronic medical/health/personal record, pay for performance, single payer system, disease management, health savings accounts, patient centered medical home and an individual insurance market.

2. Do Not Mention Shortcomings (other than cost): Not only will you tarnish the Good Idea and diminish its chance of adoption, we all have a limited attention span that is simply unable to tolerate it. It is OK, however, to mention the cost of [insert a number from 1-100 here] [insert prefix of bil, tril or gazil here] lion dollars because we’ve become used to similar-sounding amounts being spent on Iraq, mortgage lenders and botox.

Examples of shortcoming to not mention: that electronic records can introduce new types of errors, P4P can incent processes not outcomes, single payer systems are notoriously difficult to modify, disease management may not work for all populations, ‘cost sharing’ may really mean ‘cost transfer,’ patient centered medical homes are being piloted (research), not adopted (covered by insurers), many persons with chronic illness are uninsurable and that cost effectiveness studies rely on unfamiliar concepts like QALYs. Mention these and your Silver Bullet will be tarnished.

Examples of excellent SBNS (Silver Bullet, No Shortcomings) rhetoric (italics mine):

From the McCain campaign:

'By emphasizing…..the use of information technology, we can reduce health care costs.'

‘Those obtaining innovative insurance that costs less than the credit can deposit the remainder in expanded Health Savings Accounts’

‘Families should be able to purchase health insurance nationwide, across state lines.’

And in the cost is no object category:

‘…establish a nonprofit corporation that would contract with insurers to cover patients who have been denied insurance and could join with other state plans to enlarge pools and lower overhead costs.’

And from the Obama campaign:

‘Support disease management programs. Seventy five percent of total health care dollars are spent on patients with one or more chronic conditions, such as diabetes, heart disease and high blood pressure.’

‘Providers….will be rewarded for achieving performance thresholds on outcome measures.’

‘…establish an independent institute to guide reviews and research on comparative effectiveness.’

And in the insert number, insert prefix category:

invest $10 billion a year over the next five years to move the U.S. health care system to broad adoption of standards-based electronic health information systems, including electronic health records