Tuesday, November 17, 2009

Dean Flier offers his views

Harvard Medical School Dean Jeffrey Flier offers a thoughtful and honest perspective on the health care bills circulating in Congress in this Wall Street Journal op-ed. Jeff is not just an academic observer. He is an accomplished physician-researcher-educator with lots of experience in the trenches.

He must know that his column will raise the ire of those on one side or the other of the health care debate, and then what he says will likewise be used in the political debate. I am confident that he raises these issues because he senses a need for someone to speak directly and help our political leaders on both sides of the aisle do the right thing.

He starts with a plain-spoken summary: "As the dean of Harvard Medical School I am frequently asked to comment on the health-reform debate. I'd give it a failing grade."

And then he leads to an important point: "Speeches and news reports can lead you to believe that proposed congressional legislation would tackle the problems of cost, access and quality. But that's not true." Hmm, that sounds familiar and is strongly supported by everything I have heard. He continues, "So the overall effort will fail to qualify as reform."

But, for me, the major insight is this: "Worse, currently proposed federal legislation would undermine any potential for real innovation in insurance and the provision of care. It would do so by overregulating the health-care system in the service of special interests such as insurance companies, hospitals, professional organizations and pharmaceutical companies, rather than the patients who should be our primary concern."

And finally: "So the majority of our representatives may congratulate themselves on reducing the number of uninsured, while quietly understanding this can only be the first step of a multiyear process to more drastically change the organization and funding of health care in America. I have met many people for whom this strategy is conscious and explicit.

We should not be making public policy in such a crucial area by keeping the electorate ignorant of the actual road ahead."

8 comments:

Frank said...

Paul,

Can any health care reform be had in the USA? Why is it that we spend so much on health care and yet so many people are left uninsured? Dean Flier is critical of the current process, but is the status quo so much better?

I agree that the electorate is quite ignorant of the road ahead and sadly very few individuals in Dean Flier's position are stepping up to help folks make sense of things and arm them with information so they can better understand the social problem of our current health care system.

It would have been great if Flier would have asked and attempted to answer some questions like how did we get into our current state? What does the future hold if nothing is done? Given the problems with the current legislation, what are some other possible solutions to providing health care to those who do not have it? How can we reasonable control costs? How do we innovate in a changed system? What would it take politically to enact something reasonable and rational? Is the status quo the best solution?

Anonymous said...

Great Op-Ed piece and right on target. I have said on this blog, as well as you Paul, that cost, access and quality are mutually exclusive goals in this reform effort. Based on the current proposal we will have more people covered with reduced payment per unit of service. Therefore utlization will increase and States and the Federal government will have increased cost for Medicaid and Medicare. The "reform" components of the bills such as ACO's, medical homes and payment bundling are modest and not very well defined.

Paul Levy said...

Frank, I think they only gave him 800 words worth of space!

Hsiong said...

The Johns Hopkins Medical Center (yes, the official position of the entire institution) supports a point of view almost diametrically opposite of that of Dean Flier, specifically endorsing capitation and universal health coverage. Why do you think that is?

http://www.hopkinsmedicine.org/mediaII/hopkins_on_health_care/_pdfs/JH_Health_Care_Reform_Position_Paper_9_09.pdf

Anonymous said...

I took a look at the Hopkins information and did not see a disconnect with what FLier is saying. Hopkins advocates ahcnges in the payment system (more capitation etc...) which is health reform by changing the way providers are paid. Flier says that Congress is merely insuring more people and not changing the system. Seems like a similar message to me.

callen said...

I am wholly confused by Flier's claim that "Ultimately, our capacity to innovate and develop new therapies would suffer most of all." He certainly doesn't make a case for this aside from saying that health care costs will continue to go up. What is his evidence/rationale? Health care costs continue to go up in part because of innovation and great new therapies.

callen said...

Does this legislation significantly address cost and quality? No--not nearly as much as it should. But these are also the most politically thorny topics in reform. We saw just last week how people on the right exploited new mammogram recommendations to scare folks about telling them what tests they could have and rationing of care. That was an issue of cost and quality of care (although the panel only considered quality of care, not cost). Folks opposed to the current health care reform bill simultaneously claim the legislation does not do enough to control costs and improve quality, while at the same time opposing any measures to do so as rationing, dictating what is covered, etc.

callen said...

I don't find Flier's "analysis" particularly compelling. "SHOCKER ALERT: political debate on health reform is characterized by exaggerated and often deceptive claims." I do find it amazing however that he implicitly draws an equivalence regarding the nature of the debate on "both sides."

Flier merely lists a litany of problems with the pending legislation, and does so without providing a single productive suggestion or solution for what ought to be done differently. Nor does he mention a single positive thing that this legislation accomplishes.

Essentially, what he is saying is that this legislation has become "health insurance reform," not "health care reform." On this point I largely agree. The bills represent a pragmatic approach to closing the gaps in insurance coverage by building on a mix of employer coverage, other private plans, and a public plan in a health insurance exchange, or exchanges; strengthening Medicare; and expanding Medicaid. In doing so, in many ways it does perpetuate the current system. But if he thinks that upending the current insurance system altogether--rather than trying to better it--would have results any less uncertain, I'd have to strongly disagree.

Flier points out that meaningful "reform" must drastically change the organization and payment of our health system. True. And if only we could throw out our current system and design a rational health system from the bottom up as he seems to support. However, either Flier is unaware of, or unconcerned with the political realities of passing said reform. But then, as Dean of a School as opposed to a policy maker or politician, he has the luxury (and perhaps moral imperative) of staid ideals over political pragmatism.

It is well and good to decry lack of drastic cost controls and new payment methods. What might he suggest be included that doesn't immediately inspire cries of "rationing!"? It is well and good to decry lack of drastic health care organizational change. What might he propose that doesn't fuel insurance industry-funded commercials about "getting in between me and my doctor!"

But Flier claims "there are no provisions to substantively control the growth of costs or raise the quality of care." He seems to have missed any of the provisions that do target cost and quality, a few of which include:
-Instituting value-based benefit design linked to comparative effectiveness research ("death panels!")
-Instituting payment innovation to reward physicians and hospitals for value, not volume
-An Exchange that provides transparency and shifts insurers to compete on value rather than merely for the most healthy enrollees ("socialism!")

These changes mainly allow for further research into payment and delivery redesign. That way the next steps in health care reform can be as evidence-based as possible. I'm unsure upon what evidence Flier would have us base his version of drastic payment cost control reform.

This legislation accomplishes some important reforms in terms of insurance practices, access to insurance, and a modicum of competition. I do agree with Flier that this is certainly just a step in a multiyear process of reform. But I don't fault those trying to pass reform for not advertising the fact that this bill cannot and will not be a panacea.

Flier seems to want to throw the current legislation out, leave folks uninsured, and proceed with the status quo until Democrats and Republicans can agree on completely redesigning our health care delivery and payment system. In sum, there is merit to some of what he points out regarding the shortcomings and consequences of the current legislation, but in total, I find his implicit position absurd. I suspect that Flier he writes this as an academician attempting to be above the political fray, but he only succeeds in sounding naive.