My friend and college classmate Ted Marmor (see his recent post here) and Jonathan Oberlander have a short but illuminating article in a recent issue of the Journal of General Internal Medicine – “From HMOs to ACOs: The Quest for the Holy Grail in U.S. Health Policy.” They offer a chastening analysis of our almost theological belief in the existence of a “‘Big Fix,’ a reform that will decisively rein in spending and simultaneously improve the coordination and quality of medical care.”
Marmor and Oberlander identify three drivers of our tenacious search for health policy miracles. First, “because panaceas promise to moderate spending by reducing ineffective care, improving coordination, and keeping people healthy, such policies offer the prospect of painless cost control,” a view that politicians find irresistible. Second, “reform ideas are framed in ways that make rational criticism seem implausible . . . . The language used to describe many health reforms is meant to convince rather than to describe and explain.” Who would oppose the idea of a medical home, of maintaining health, or of giving consumers choices? Finally, they believe that “absence of a coherent national system” makes us powerless to control costs, and in our powerless state we solace ourselves with recurrent bouts of faith in salvation through health maintenance organizations, managed care, health savings accounts, consumer-directed care, pay for performance, and more.
This endless search “for a transcendent solution inevitably produces a cycle of exaggerated expectations, followed by deep disappointment.” Because our need to believe that the policy answer is at hand and that the persuasive labels given to the magic bullet de jour embody reliable truths, we characteristically underestimate the challenges a reform will face, and don’t acknowledge just how hard it will be to scale up a promising innovation and make it generalizable. I was guilty of this in my early days of practicing at the not-for-profit Harvard Community Health Plan HMO. I believed prepaid group practice and salaried physicians was the right way for American medicine to go. I still believe it’s an excellent model and get my own medical care from the system, but I recognize that the model has had limited appeal. As good as it may be, it’s not a panacea.
Marmor and Oberlander conclude with a proposal of their own:
“We believe that the U.S. needs less innovation and more emulation. That is, in order to control costs effectively Americans should focus less on (re)inventing the latest delivery system or payment method, and instead pay more attention to what other countries do to slow health care spending. Global budgets, fee schedules, systemwide payment rules, and concentrated purchasing power may not be modern, exciting or ‘transformational.’ But they have the advantage of working.”
I share their view that universal insurance and a global budget for the health system is the right way to go. But we should heed their warning about irrational exuberance. We’ve had universal insurance for the over 65 population since 1965, but Congress still doesn’t let CMS take cost into account in managing Medicare.
We Americans are consistent in thinking about health care in terms of magic. Our belief in magical health policy bullets that will solve the cost problem is mirrored in our belief that magical clinical bullets will forestall death (almost) forever. The quest for clinical miracles even when they’re not to be had can cause harm at every age, but it has special relevance for the over 65 generation. Over the years the primary care residents I teach have used the term “flogging” for the overly aggressive care they see seniors receiving in the hospital, based on the hope that one more chemotherapy or one more surgery will halt the inevitable.
In the world of health policy, magical thinking leads to the cycle of ineffective reforms and recurrent disappointment that Marmor and Oberlander describe. In the world of clinical care, magical thinking leads to overtreatment and neglect of patient and family values. Our country and the over 65 generation need more realism from policy leaders and clinicians.
James Sabin, M.D., 73, is an organizer of Over 65 and a clinical professor of psychiatry at Harvard Medical School.