A Culture of delusion

Writing columns in the Raleigh (N.C.) News and Observer about health reform has been been harder than I thought it would be, but also more interesting. The columns are to the right side of the blog page. I have had the privilege of interacting with many people whom I never would have met had it not been for my writing in the paper, and gotten to speak with many people and groups.

One of my bottom line conclusions from all of this is that there is a certain delusional quality to what many of us think about health care, especially as it relates to costs.

When I go and talk about reform with groups, I tend to focus on the unsustainable nature of the system. By unsustainable, I mean we can't keep doing what we are doing, it will bankrupt our nation. As I talk through various sets of slides and numbers that illustrate this, there are always knowing nods of agreement. Indeed, it is hard to find someone who won't assent to the notion that we spend too much and that we must do something about it. Then comes the delusional part.

If you talk about things that could slow the rate of cost inflation, low and behold the people who think we spend too much really don't think that at all. Or at least they don't want to do anything to slow the rate of cost inflation. End the tax exclusion of employer paid benefits? That is a tax increase, I work hard for my benefits! Develop lists of procedures that Medicare won't pay for under certain situations? Why that is rationing of care, don't you love your grandmother! And on and on and on.

David Leonhardt has a nice article running through this cultural delusion in the U.S. We say we want to slow the rate of cost inflation, but don't like any of the things that might actually reduce spending. It turns out we want a magic solution, like a ride at Disney World. Not the reality that a dollar of saving is either a dollar of reduced care and/or a dollar of reduced revenue for someone.

One answer that Leonhardt suggests is focusing on the quality side. It turns out that there is lots of evidence that the most expensive thing is not always the best thing. We certainly seem to start with a belief that it is, and efforts to focus more on quality of life improvements and life extension would actually lead to spending reductions in some areas.

I have done some work showing that hospice reduces Medicare expenditures in the last year of life. This is a case whereby people who are in a very difficult situation and are imminently dying choose hospice, a choice the literature says improves quality of life both for patients and their families. And actually saves Medicare a bit of money. Focusing only on end of life or last year of life costs will not be enough, in part because it is not clear when the last year of life began until it ends. More generally, we need to move toward providing patients and providers and payors with information that helps us purchase health care that is productive. By productive, I mean care that increases life span and/or improves quality of life. The reality is that a great deal of what we spend doesn't meet either of these criteria. In the abstract, many will say, ok lets do that. But, once we start to try, they will go insane.

However, we have to do this. We have to take it on head on. There are many policy changes needed. Most importantly, we need a cultural conversation and change that doesn't demonize even asking the questions.