Sunday, September 12, 2010

The Yellow Cake of Passing a Health Reform Bill

Knowing that the facts on the ground didn’t support its ideology, the Administration resorted to a sordid mix of selective disclosures, dissembling, outright spin and occasional bullying. Career analysts were ignored. What was left of the truth was stretched. The lazy media were rolled. A preconceived plot, engineered to support a dangerous dogma and short-term political gain, swamped a craven political opposition. The entire stinky premise was accepted hook line and sinker by a gullible public. When things didn’t quite work out as planned, it's only then that critics emerged to use hindsight to connect the dots. Administration excuses notwithstanding, there were serious allegations that the American people had been lied to.

The invasion of Iraq, you ask?

Off topic, says the Disease Management Care Blog. Yet, the DMCB wonders if a similar scenario could be unfolding for Mr. Obama and his fellow Democrats over the health reform legislation. Unbiased and informed observers have long been legitimately skeptical of the intellectual underpinnings of the Affordable Care Act. They doubted that it would simultaneously bend the cost curve, increase quality, expand coverage and rationalize health care. After-the-fact contrary information (for example, here, here and here) has begun to pop up faster than MSNBC's evening broadcasting of unflattering pictures of Tea Party candidates. As for the bullying, you be the judge.

And now, the Dartmouth Atlas - the Bible of the Beltway, those Groupies of GeoMapping, the Mavens of Medicare, the Prophets of Physician Behavior, the Oracles of Obamacare, the Viziers of Variation and those Diviners for the Democrats - has come out with another inconvenient healthcare truth: that the local availability of primary care may have little relationship with local health care quality.

Using their considerable expertise in navigating Medicare’s fee for service (FFS) data sets, the folks at the Dartmouth Atlas (DA) examined enrollment (including race) and medical claims data to look at the the relationship between primary care office availability and visits versus quality of care for diabetes and the incidence of limb amputations. The DA researchers geographically split the country up according to over 3400 “hospital service areas” (HSAs) (defined by how patients travel for inpatient care) from 2003 to 2007. Based on the utterances from the Administration, you'd think that HSAs with a lot of primary care providers would have many primary care office visits which in turn would lead to better health care. Right?

What was found was that about 78% of Medicare beneficiaries in the various HSAs typically see a PCP at least once a year with a range that extends from 60% (the Bronx HSA) to 90% (in a South Carolina HSA). Blacks were less likely to have a visit than whites (70% vs. 78%). There was, however, very little relationship between the HSA area supply of primary care physicians and the likelihood of a beneficiary having at least one visit (though the relationship was slightly stronger when analyzed by family physicians vs. other types of primary care). What’s more, there was also little correlation between having one primary care encounter and subsequently having a high number of primary care claims.

At a greater level of detail, however, there was only a modest correlation between having had at least one primary care visit and mammogram and A1c diabetes testing. This didn’t hold up at all for other types of diabetes testing (for example, eye examinations), getting a leg amputation (something that could be prevented if diabetes or atherosclerosis was aggressively treated) or being hospitalized for a bucket of “ambulatory care sensitive conditions.”

Expansion of primary care has been a linchpin of health reform, leading to programs like this. While there are other studies (like this) that show there may be an association between primary care and quality, this negative report from the highly regarded DA isn't helping the Obama Administration regain any momentum in the political rearguard defense of health reform. The DMCB, based on plenty of studies, has always doubted the primary care yellowcake of the Administration's case for the ACA - not because there may or may not be an association, but because it's never been clear that the importation of primary care into areas of high utilization would do any good. The DA study makes things even worse.

Mr. Obama summed things up best at his Sept 10 news conference:

"Bending the cost curve on health care is hard to do."

No kidding. While that may either be a) a new administration insight or b) an excuse for not finding any weapons of mass cost containment, the DMCB worries that the recognition of just how hard it is was known prior to March 23. If that's the case, why wasn't that shared during its pre-passage war planning? Was it because they had already decided to pass a bill no matter what and at any price, using any means necessary? Has this become the standard approach of the political class of both parties?

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