Blogs vs. Traditional Journals in Health Care Policy Making: McAllen Texas as an Example (and the possibility that it's not an outlier)

Atul Gawande’s New Yorker McAllen Texas article is the policy zombie that refuses to die. The big news is that while this still-walking undead has generated some vigorous debate, it's prompted a fascinating insight about the growing role of non-traditional media in driving health reform.

First off, there’s a lengthy Health Affairs academic, contrasting policy and business-oriented roundabout on McAllen from the learned Elliott Fisher, Gail Wilensky, Robert Berenson and Robert Galvin. Don’t want to read all 16 pages? Neither did the Disease Management Care Blog, who was reminded of an exchange by its spawn years back. The daughter was talking about something extremely remarkable to the utter boredom of her brother. Seeing her enthusiasm wasn’t being shared by the lout, she stopped and asked him what was wrong. He laconically replied the topic was interesting enough, but she was ‘using too many words.’

Thanks to some Argentinean Torrentes and grilled salmon, the wordiness became tolerable and can be summarized for your quoting pleasure as follows:

Fisher: Being from the outfit that brought out the Dartmouth Atlas, he finds Gawande’s lay person style to be an accurate portrayal of the science of variation. Given the public’s interest in health reform, the article's timing was perfect. Dr. Fisher is against slashing prices in an effort to cap McAllen’s expenses and prefers the use of positive incentives, bundled payments and better integration of primary care and specialist physicians.

Wilensky: This former Medicare and Medicaid administrator is concerned that the article may have been too simplistic and missed some other explanations, other than dysfunctional incentives, for McAllen’s outlier status. That being said, she thinks the phenomenon is real and physicians need to be better aware of it. It’d be nice to fashion some turbocharged demos to attack variation, but in the meantime, she doubts physicians are ready to walk away from old fashioned fee-for-service (FFS).

Berenson: He spotted McAllen back in 2003 but no one paid attention. Medicare might want to investigate for fraud and abuse and, if none is present, he’ll chalk it up to the community’s practice style. Speaking of which, Boston, Chicago and Atlanta have much to be desired in their practice styles also. He likes accountable care organizations (ACOs) because they don’t have to take on insurance risk and accurate risk adjusted payments are within reach. If it’s done right, physicians might even be willing to give up on FFS. He also warns that bundled payments don’t necessarily mean that a population will have better outcomes or that hospitals won’t come to dominate the health care scene.

Galvin: This General Electric medical director was also struck by how unaware the McAllen physicians were about their outlier status. He isn’t sure that (ACOs) are a proven answer to the problem of variation and, what’s more, they could become local monopolies. He prefers comparative effectiveness research linked to yet-to-be-developed payment models.

As pointed out in another post, the DMCB agrees there is variation but points out that outliers are a) randomly inevitable in any large market and b) don’t necessarily hold any lessons that can’t be learned by studying the average. The trick is to tell the difference between randomness and causality, which was conspicuously absent in Gawande's article.

But hold on. Maybe McAllen isn’t even an outlier if Medicare enrollment, socioeconomic status and disease burden are properly accounted for. Check out this very important analysis that was posted by health services researcher Daniel Gilden on the Health Care Blog. He concludes that McAllen’s utilization patterns are high, but if careful and standard statistical methods are used to neutralize the cost drivers outside of the physicians’ control, McAllen is decidedly close to the average. In contrast to the Health Affairs posting, every word on this very important article has huge implications for the argument that physicians have run amok with unwarranted practice styles.

So here’s the real lesson: Classic journals like Health Affairs and the New England Journal and their go-to authors still have a role to play in policy discussions but alternative media, like the blogs, are becoming remarkably nimble in ‘posting’ insights that seem to be out of reach of these traditional information venues. While policy giants went on and on and on in the staid Health Affairs, Mr. Gilden chose the non-traditional but widely read THCB to post an important and provocative analysis that will undoubtedly garner significant attention. It's deja vu all over again for the DMCB and its spawn.

That’s why the DMCB hasn’t submitted many manuscripts lately to any journals. Sure, keeping a blog is fun and just as remunerative as assigning eternal copyright to the publisher for free, but the emerging potential of the web as the most important source of health policy information is truly remarkable.