Monday, November 10, 2008

It's Not Just the Costs, Stupid, It's the Technology. Insight from the Robert Wood Johnson Foundation

When the Disease Management Care Blog gets an email from the Robert Wood Johnson Foundation, it pays attention. Heck, maybe it is just an internet version of junk mail, but it still makes the DMCB feel good and it’s testimony to how RWJ is correctly paying attention to us bloggers. Are we the internet’s chattering version of AM radio talk shows, or do we perform an important service by providing insight not available elsewhere? RWJ (and Kaiser, by the way) seem to think it’s the latter.

What newsworthy morsel would prompt the RWJ to virtually reach out and touch the DMCB you ask? Paul Ginsburg, President of the Center for Studying Health System Change has authored a report on ‘High and rising health care costs: demystifying U.S. health care spending’ that is posted on the RWJ site. The piece is a well written literature review with no new insights. The good news is that those insights are repackaged with emphasis on all the right places.

There is much to digest here, but the DMCB zeroed in Dr. Ginsberg’s views on the impact of technology. This is the number one driver of cost and includes things like new types of gadgets (e.g., heart catheters for angioplasty), approaches to surgery (e.g., robotic), imaging (e.g., PET scans), monitoring devices (e.g., continuous glucose monitoring for Type 1 diabetes) and pharmaceuticals (biologics). Dr. Ginsberg correctly points out that not all technologic advances are of equal value, but that’s not the problem. The problem is that technology that is intended to be substitutive (that replaces open heart surgery, open prostate surgery, regular x-rays, blood tests and pills) often ends up being additional or expansive (patients who wouldn’t have had open heart surgeries can now get angioplasties, men who would opt to not have prostate surgery agree to robotic, PETs and all the other x-rays are done together and all persons with Type 1 diabetes end up being potential candidates for CGM).

Dr. Ginsberg offers up three options for your consideration:

1. Effectiveness research that separates the wheat from the chaff. He notes this means not only shielding the research from unseemly political or industry pressure to jigger its assessments, but using that tedious, obscure and dreaded metric that has been demystified in a prior DMCB post, the ‘QALY.’

2. Payment reform that puts the brakes on the morphing of substitutive into additive technologies. He notes that the profit margins on angioplasties, robotic surgery, PET scans, continuous glucose monitoring and biologics can be reduced by enlightened fee schedules that make it less attractive to go to market.

3. Consumerism with incentives and support that enable individual patients to avoid new low value technology in favor of the good old stuff or truly valuable new stuff. Think transparency, changes in the tax code, cost sharing, and altering the insurance benefit to cover care that has a low ratio of dollars to QALYs.

The DMCB offers up three thoughts for your consideration:

1. The DMCB has given many Grand Rounds, taught many young physicians, talked to many policy makers and quaffed brewskis with many captains of industry. It can say with great certainty that 99% have idea none what a QALY is or how to apply it in the day to day business of healthcare. That’s not necessarily insurmountable, but it speaks to the specter of a priestly class of Brahmin healthcare economists using a functionally opaque methodology to decide if little Johnny can get cancer treatment. The DMCB gives the idea a ‘C’ grade and advice to proceed with caution.

2. Through much of its career, the DMCB has parked its primary care Toyota next to its specialist colleagues’ Caddies in the doctor’s parking lot, but isn’t resentful. However, it’s not sure making the specialists drive Tato Nanos is necessarily the best answer. Rather, the DMCB remains partial to Porter and Teisberg’s ideas on global payments for episodes of care (a.k.a, conditions and care cycles), which go unmentioned by Dr. Ginsberg; it thinks the docs can sort things out for themselves under such an approach. A ‘D’ grade for not recognizing the merits of others' approaches.

3. What is more valuable than an informed, savvy patient that understands the benefits, risks, alternatives and costs of all the various testing and treatment options? The DMCB would like to point out, however, that provider ‘framing,’ thanks to conscious or unconscious bias, is an under-recognized driver in patient decision making and that there is a huge science on the topic outside the mainstream of medicine. A B+ which would have been an ‘A’ if disease management had been mentioned.

By the way, the DMCB expresses its gratitude to RWJ for the email and for making its report available on line. It would also like to point out that the RWJ is hosting a webinar on Friday, Nov. 14th from 1:00 to 2:30 to discuss this paper and health care costs. In addition to Dr. Ginsburg, David Nexon from AdvaMed and Helen Darling from the National Business Group on Health will provide comments. You can register by e-mailing


Anonymous said...

Jaan...I don't think it's the job of people who work "in" the system, i.e. doctors to fix the system...leave that to people who work "on" the system, e.g. policy experts, regulators, investors. Docs' training leaves them with a very focused, narrow minded, analytical view of the they're looking at a pathology slide or something...this isn't a bad thing, in fact it helps them with things like differential diagnosis and things they really do have to be good at...

Jaan Sidorov said...

Hey... I'm a doctor. So are you. More of us need to speak up, and I'm not talking mainstream organized medicine.

But then again, I have the luxury of being outside the system. That being said, I still think that there may be something to the notion that packaged payment for an episode of care (hospitalization, catheterization, CABG, rehab, primary care and maybe meds) will force us docs to pay better attention around payment and value and being good doctors.

DRGs (packaged payment for inpatient care) eventually led to the physician community recognizing that hospitalists can efficiently manage a length of stay; hospitalists are paid very well.