Monday, June 22, 2009

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.


Quiact said...

Published on:

The Prevention of Ignorance

Historically, information sources provided to American citizens were limited due to the few methods available to the public, such as radio, TV, or news print. And also this information was subject to being filtered and, in some cases, delayed. This occurred for a number of reasons- which included political ones.

Now, and with great elation, there is the internet, which can be rather beneficial for the average citizen.

Soon after the advent of the internet, web logs were created, that are termed ‘blogs’. At that time, about a decade ago, the blogs were referred to as personal journals or diaries visible on line. As time passed, blogs became a media medium, and blog communities evolved on topics that often were not often addressed in mainstream media.

In addition, blogs provide immediate contributions by others, the readers of the posts of the blog authors, instead of the cumbersomeness of opinion and editorial pieces historically and not always presented in such media forms as newspapers.

The authors of blogs vary as far as their backgrounds and intent of what they present are for exactly, just as with other media forms. Furthermore, they are not exonerated from the legalities of what is written, such as cases of libel. While we can presume that they like to write, they may not be quality writers. But to write is to think, which I believe is a good quality one should have.

Yet presently, blogs have become quite a driving force for those with objectives often opposed by others, and are a threat to others at times, such as big business and politicians- both who presently monitor the progress and content of blogs that provide instant information on events, which might affect their image and activities not yet exposed, as blogs have become a medium of disclosure by whistleblowers, and what is written is typically authentic.
While one disadvantage of blogs is the potential lack of reliability, blogs however do allow in addition to the comments of its readers the posting of authentic documents that typically are not created to be viewed by the public.

For example, blogger Dr. Peter Rost, a whistleblower himself, not long ago posted a newsletter published by pharmaceutical company AstraZeneca on his blog site, and this newsletter was given to him by AstraZeneca's employees who called themselves the ‘AZ Group of Seven’, with the intent of this group being to bring to the attention of others the illegal activity of off-label promotion of one of their cancer drugs promoted by their employer.

Quiact said...

Yet this by amazement is not what caught the attention of so many who viewed the posted newsletter read with great interest by others. It was instead a comment included in this newsletter that was stated by former regional AZ manager Mike Zubalagga, who in this newsletter posted on Dr Rost's blog site, referred to doctors’ offices as ‘buckets of money’.

This and other statements by this man were written during an interview with him by another and then published in this newsletter. Again, the statement was authentic and in writing in this newsletter, which added credibility to the proof that it actually happened.

Mr. Zubalagga was fired the next day due to this comment and its potential effect on the image of his employer. His manager resigned soon afterwards.

And there have been other whistleblower blog cases in addition to this one, so blogs have become a very powerful and threatening medium of information release that does not allow others to prevent such releases. This is true freedom of information- free of alteration or omission- perhaps one step closer to a form of communication utopia, perhaps, and with the ability to both harm and protect others.

Yet again, the information on these blogs should not be taken as absolute truth without proof to verify claims that may be made. Of course, documents that are authentic will be realized by others, as illustrated with the above example.
And this, in my opinion, is the blog’s greatest value, combined with the comments on blogs from the growing number of readers who are allowed to contribute to the subject matter so quickly, which fuels the objectives of the blogs.

Like other written statements, some on such internet sites are composed with respect of the written word. Others are not. It's the freedom that may be most appealing of this new medium which has the ability to convert citizens into journalists who want to contribute to an issue of their concern they share with the blogger.

Because we, the public, have a right to know what we are entitled to know and what we want to know. This is especially true if the information could potentially be adverse to our well-being.

Ignorance is bliss, but knowledge is power.

“Information is the seed of an idea, and only grows when it’s watered.” --- Heinz V. Berger

Dan Abshear