Why consensus health care reform won't work.

Why consensus health care reform won't work.

Why consensus health care reform won't work.

Gossip, speculation, and scuttlebutt about politics.
April 10 2009 6:16 PM

Against Consensus

Why the most politically radical health care solution is also the most fiscally conservative.

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It's difficult to be against anything that promotes "quality," and compiling better information about what works and what doesn't is obviously worthwhile. But one lesson of No Child Left Behind, the national education-standards reform implemented by President George W. Bush, is that protocols can be imposed so ham-handedly that they snuff out creativity and eliminate the possibility of treating the individuals they're meant to help as, well, individuals. This in a realm—deciding what children should learn—that's simple and straightforward compared with deciding how best to treat the sick. In an April 8 Wall Street Journal op-ed, Jerome Groopman and Pamela Hartzband argued that government regulators have already begun to overreach on "quality metrics." They cited as an example a widely used protocol requiring hospital intensive-care units to keep the blood sugar of critically ill patients below a certain level. A medical colleague of Groopman's and Hartzband's in Massachusetts, which adopted this protocol, told them "how his care of the critically ill is closely monitored":

If his patients have blood sugars that rise above the metric, he must attend what he calls "re-education sessions" where he is pointedly lectured on the need to adhere to the rule. If he does not strictly comply, his hospital will be downgraded on its quality rating and risks financial loss. His status on the faculty is also at risk should he be seen as delivering low-quality care.


In March, the New England Journal of Medicine published a study of 6,000 critically ill ICU patients that suggested the protocols had it exactly wrong—survival rates for patients whose doctors followed the blood-sugar protocol were lower than those for patients whose doctors ignored the protocol. "Human beings are not uniform in their biology," Groopman and Hartzband explained. "A disease with many effects on multiple organs, like diabetes, acts differently in different people." Moreover, "Medicine is an imperfect science," and the best-available information about treatments is subject to frequent change.

Obviously, there's great potential value in having the government compile information about best medical practices and even in using that information to impose guidelines. Strict rules about obvious things like hand-washing have been implemented to good effect. But, in general, quality standards must be applied with sufficient flexibility to take into account the human variety and medical uncertainty that Groopman and Hartzband discussed. Where to draw the line is a question well beyond my inexpert understanding of medicine, but it seems a good bet that using quality metrics with the goal of pushing costs down, as opposed to improving patient care, would create just the regimentation Groopman and Hartzband fear. Cutting U.S. health care spending by one-third through the use of evidence-driven protocols, as Longman and Boshara believe possible, would surely inhibit physician care to the serious detriment of patients' health. (Their book's other proposals for reforming health care, especially the creation of a civilian hospital network modeled on the Veterans Administration, are much more persuasive. I should probably note here that Groopman, Hartzband, and Longman are all friends of mine.)

If you really want to rein in health care costs, then consensus reform options like creating a comparative effectiveness board won't get you very far. For the true spending hawk, I see no practical alternative to the "socialist" public option.

[Update, April 13: In his invaluable health care blog, "The Treatment," on the New Republic's Web site, Jonathan Cohn touts a new article  in Annals of Internal Medicine by Theodore Marmor, Jonathan Oberlander, and Joseph White. Marmor et al. are, like me, skeptical about the possibility of achieving significant cost control with the less-controversial health reform proposals under consideration. Preventive care, they say, typically adds to spending, and "we lack evidence that paying providers on the basis of outcomes will reduce spending on medical care." The financial benefit from electronic medical records is also oversold, they argue, a point Groopman and Hartzband also made  in a March Wall Street Journal op-ed.]