Doctors Critique Oregon-Style Cost-Benefit Approach to Healthcare Reform . . . But Not So Fast!

Noted surgeon and social-medical commentator Atul Gawande MD hosted a video roundtable in 2014 entitled “Avoiding Low-Value Care.” His panel seemingly challenged the idea that low-value care can be avoided, which is the crux of the cost-benefit approach to healthcare reform.

But on closer look Dr. Gawande and panel may actually, in fact, be validating the concept.

The roundtable was moderated by Dr. Gawande, a professor of surgery and public health at Harvard. The panelists included Carrie Colla PhD, a health economist at Dartmouth Medical School; Scott Halpern MD, PhD, who teaches medicine, ethics and health policy at University of Pennsylvania; and Bruce Landon, MD, MBA, professor of health policy and medicine at Harvard.

Here are some quotes from Dr. Gawande’s panel citing problems with the use of a cost-benefit approach to eliminate low-value care.

• “It turns out that there are very, very few services that are low-value in all clinical situations.” (Landon)
• “It’s incredibly difficult to draw lines, particularly because all our definitions are predicated at the population level. And population-level estimates don’t apply very naturally to individual patients.” (Halpern)
• “It’s going to be hard to address the problem of low-value care by having payers and policymakers make the rules, because there’s this clinical heterogeneity story [each patient is different] . . . So you really need to sort of have a clinically nuanced approach, which is difficult to do through payer-based rules or broader policies.” (Landon)
• “And we [physicians] tend to do a bit better when we are taking the lead on something than when we are following recommendations, or heavier-handed interventions still, that we don’t control.” (Halpern)
• “We really don’t know whether those things will work in the case of low-value care.” (Colla)
• “You know, at the end of the day, we’re taking care of patients, and we need to do what’s right for our patients. Even if something ends up on one of these low-value lists, sometimes it’s going to be high-value. If we believe that as physicians, that’s something we need to make happen.” (Landon)
• “What’s your level of worry that we’re going to end up denying people high-value care?” (Gawande)
• From a policy perspective, we can only use payment incentives where we think we have really good measurement. And I think measurement in this area has a long way to go.” (Colla)

On the other hand, the panelists agree with claims made in other posts on this blog-site impugning soaring costs and advocating cost constraints guided by cost-benefit analysis:

• “The enormous cost of health care in the United States, driven by technological advances, the fee-for-service system, and increasing patient demands, among other factors, has inspired new efforts to assess the true value, or the cost-benefit ratio, of our commonly provided services.” (Gawande) (See multiple posts, including Segment 5 – Why Is U.S. Healthcare So Expensive?)
• “Accountable care organizations, global payment policies . . . actually give incentives to providers and provider systems to say where is the low-value stuff that we can cut” (Landon) (See Will These Ideas Fix U.S. Healthcare?)
• “Choosing Wisely campaign. . . There are now upwards of 60 lists, totaling 300 or more recommendations of services that tend to be utilized in common practice for which the value is not deemed to be high, for sure, and may in fact be negative – in fact, the harms outweigh the benefits” (Halpern) (See Segment 6 – Why Healthcare Cost Is a Problem and The Problem of Diminishing Marginal Benefit in Healthcare.)
• “Prostate cancer screening, the PSA test, . . . is now a U.S. Preventive Services Task Force grade D recommendation . . . D means essentially ’Do not do.’ “ (Halpern) (See Segment 6 – Why Healthcare Cost Is a Problem)
• “I think there’s a much broader recognition societally that we’re spending too much on health care, and that it’s coming at the expense of doing things like hiring more teachers, hiring more police officers, rebuilding our schools, rebuilding our infrastructure.” (Colla) (See Segment 6 – Why Healthcare Cost Is a Problem)

Panelists also agreed with the fundamental premise that low-value care can be identified and constrained, and that this premise can underpin reform of the healthcare system:

• “The real legacy of efforts like the Choosing Wisely campaign will not be to demarcate items that we should do less, . . . but rather creating a new culture of practicing medicine in which we remove our traditional taboos against discussing costs . . .” (Halpern)
• “I agree. I think the Choosing Wisely program, along with the U.S. Preventive Services Task Force, has moved the dialogue in a different way in the last few years. There’s a lot more public discussion around a lot of these things, which I think will be useful . . . [and] about what’s the right level for policy to intervene, to make optimal social choices, in a sense.” (Colla)

Blogger’s Conclusions:

• From the doctors’ ground-level perspective face-to-face with individual patients, there are many nuances and technical challenges to eliminating low-value care. These obstacles reveal the fallacy entailed with trying to fix healthcare from inside the healthcare system. I claim that from a higher-altitude perspective focused from outside the system on the common good, these obstacles can be reframed as mere technicalities. Such technical details can eventually be entrusted back to the doctors to work out, but only after public leaders outside the system have first set out the broader goals and strategies for healthcare reform and cost control.
• The doctors acknowledge that approaches like the “Choosing Wisely Campaign” will appropriately target low-value care. They also acknowledge availability of a range of policy options (like tiered formularies, utilization review, doctor-led guidelines, insurance incentives, etc) to do the job. Options could be tailored to each reform objective, and then would need to be deployed, monitored, and refined over time to ensure effectiveness in reining in costs and avoidance of unintended consequences.
• The expert panelists expressed a laudable reluctance to insert cost considerations into their medical calculus for treating individual patients. This time honored principle not to financially exploit patients – or their insurers — goes back to Hippocrates’ time. This is one more reason that healthcare reform and cost control cannot reasonably be left to the doctors – that’s not their job!

Overall, the thoughtful academic medicine experts on the panel all validate that costs are the central problem with the American healthcare system. Their proposed solutions are all based on cost-benefit assessments of value, such as used in 1994 by the Oregon Health Plan. But their comments show that reform will need to come from outside the healthcare system, not from doctors alone.

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