Sunday, December 13, 2009

Health Care Demonstrations, Pilots and Extension Programs. Are They All That When It Comes to Health Reform?

If you're not careful when you read the fawning commentary (for example) about Dr. Atul Gawande's Testing Testing article in The New Yorker, you may end up accepting two canards about the conspicuous absence of any hard solutions to the United States' health care cost inflation in any of the health reform legislation before Gongress:

1) Legislating pilots, demos and other tests of interventions that have the potential to yield up savings is a great idea. There is no single fix for health care cost inflation, so let a thousand flowers bloom

2) Dusting off a cost-savings 'Extension Service,' similar to what the Feds used back in the early 1900s to promote science-based farming, is Washington DC at its best.

Really? The Disease Management Care Blog doesn't share in all the exuberance:

Check out this article from the Heritage Foundation as well as this article from Kaiser Health News that show that Medicare demonstrations are a political graveyard where good ideas go to die. Thanks to Congress' inability to shield its decision-making from all the special interests, the odds of a demo'ed cost-saving intervention actually making it into the Medicare benefit is often zero to none.

In fact, the DMCB is even more cynical. It thinks Congress has historically pressed the 'Demonstration' button when there is nowhere else to hide. Unable to say 'no' to any constituent, our legislators use 'demos' and 'pilots' as a hollow-man substitute for real change.

As for the farmer-like 'extension program,' the DMCB points out that this is not a new idea. But Dr. G is right: it turns out that the latest version of the health reform legislation before the Senate does create State-based competitive grants for primary-care hub-based extension programs to 'educate providers about prevention, health promtion, disease management, and evidence based... therapies and techniques.' While the hub must include a State entity (like a Department of Health) and 'one or more health professions schools in the State,' it's interesting to note that 'other appropriate entities" are allowed to participate.

The only problem? In our evidence-based world of health care, there is really no hard proof that the extension-teacher approach would work. Is health care quality like bushels per acre? Can costs be managed like pounds of fertilizer? Do docs listen when this kind of help is being offered? We don't know, but apparently we may get to find out.

In the meantime, the DMCB is partial to collaborative learning, involving mutliple payors such as in Pennsylvania or Vermont. Given the success of these and other initiatives, the DMCB wonders if the extension approach is really necessary.

No comments: