Tuesday, June 2, 2009

Proof vs. Assurance on the Medical Home: Lessons from Hollywood

In the science fiction-action film Aliens, Ellen Ripley (played by Sigourney Weaver) returns to deep space with a contingent of brave Marines to face her fears and do battle with a race of mucousy, parasitic, acid-blooded and poly-mandibular lizards. The TV remote wielding Disease Management Care Blog, to the lingering disappointment of the spouse, cannot resist the genre and will always pause on that movie (at least when the plentiful action scenes are being shown; it surfs on when insufferably precious Newt starts shrieking. Puh-lease).

A favorite scene? When the brainy and and equally clueless Marine Lieutenant sends his tough men and women into harm's way, only to watch his battle plan unravel over multiple data feeds. Ripley cuts through the clutter, discerns the brewing disaster and saves many of the humans with astronomical pluck and a cinematic disregard for planetary speed limits. Take that, Evil Aliens!

In addition to Sigourney's edgy sexiness, the DMCB likes the scene because of what it teaches us about the contrast between data versus determination, between analysis versus action between doing what's correct versus doing what's right. Ripley's interstellar derring-do portrays that classic right vs. left brain human struggle well enough: it earned $86 million out of the gates in its 1986 release.

For an excellent discussion of a more slow motion and real life example of this tension between knowledge vs. faith, check out Brady Augustine's Medicaid Front Page blog. He's come up with a wonderful dimension on the debate about the patient centered medical home. Legislators are going to have to work their way through the same judgment about what the science tells us about the medical home versus a gut-instinct call on whether it's worth billions of Federal largesse. The information is very spotty, opinions abound on both sides of the debate and Aliens are lurking. Do we continue to watch the monitors and wait for more pilot data or for another demo, or do we crash the gates and just pay for the damn thing? Mosh pit indeed.

Keep in mind that making a gut call in favor of action isn't necessarily that good either. If you haven't seen Aliens, you should know that the Marines were ordered to not use explosive ordinance in their space-guns because it would precipitate a runaway nuclear reaction. Fearing for their safety, they disregarded orders and ironically showed how the hapless Marine Lieutenant was right all along.

It sort of reminds the DMCB of a saying from a former star-crossed Defense Secretary about going to war with the equipment that you have, not with the equipment you wish you had. Physicians have to make judgments on the likelihood of disease and the risks and benefits of treatment based on an inexact science and poor information all the time. Businessmen frequently have to assess quirky market conditions and fickle consumer confidence. Sometimes the professionals sit tight, sometimes not.

So, welcome your Congressional Representative and Senators to the club. They are going to have to decide if PCMH data about cost savings are insufficient and if that is reason enough to pause further and see if things unravel, or take a page out of Ripley's Book on How to Deal with Aliens. Both sides of the debate will use the data to justify their judgment calls, but don't let that fool you: they are going to have to guess.

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