Thursday, March 28, 2013

Stand up. Disagree. Debate.

An open letter to @commonwealthfnd  and @CPR4healthcare:

I published an article here on Tuesday suggesting that a report issued by the Commonwealth Fund was deeply flawed.  As a courtesy, I tweeted the post on Twitter to the Fund for your reaction.

Imagine my surprise when you quickly seemed to walk away from the report.

Ok, maybe I got it wrong.  It wasn't a Commonwealth Fund report after all.  You just helped fund it.  But, after all, it was consistent with policy prescriptions offered by the Fund.

So, last night I tweeted a bit more:

And also sent a direct message to the CEO of the Fund:

As a reminder, here is a repeat of my direct disagreement:

Here's my take--and I am open for correction:  I know of no substantive analysis that shows that the clinical variation that exists in the United State and across the world, across all methods of payment and institutional delivery systems, is tied to the rate design used to pay for care.  I know of no substantive analyses that shows that the use of methods included in the "reform" definition offered by the Commonwealth Fund have made a difference, over time, in the health care costs incurred in various regions.

I continued:

I do know that a substantial portion of society's health care costs are spent on an incredibly small percentage of the population.  Rather than trying to redesign an entire system, why not focus on improving case management of that small percentage?  Rather than trying to transform an entire payment regime into a risk-based system that has incredible complexity--in terms of allocating that risk across and within a provider network--why not simply pay cognitive specialists more, so they can spend more time with patients and keep the patients away from expensive tests and hospital admissions?

There is no monopoly on insights in this field.  I again invite correction. Will you respond?  Will you stand by your work?  Will you engage in debate?  You are not alone in your views.  But there are many who disagree, too.  This is too important to let stand unanswered.


Anonymous said...

Paul it is hard to fathom how behavioral interventions will change the highest cost patients since those are often people in the final year of their life?

Will you for example be sending psychologists into the ICU to tell people they should have eaten better when they were growing up poor? Or talking to people on a vent about their high risk behavior?

The flaws in the US health care system are not the result of american's being somehow lazy or making poorer choices compared to those in the rest of the industrialized world but the out-dated and clearly discredited payment systems we use to compensate health care executives, insurance companies and those that add little value to the stream.

The problem doesn't lie with irresponsible patients but with the system itself and therefore requires a sytems level intervention (and might include things like the social determinates of health vs risk sharing).

Blaming the victim however really isn't a solution and would be politically taboo in any other area but health care.

charlie said...

Spot on Paul. 50% of healthcare costs are tied to 5% of the population - 30% to 1%. And here in MA, the Attorney General has done several reports that explode the idea that payment models drive either physician group decision-making or total cost of care. We've had herd mentality approaches to solutions in health care for as long as I've been around the field - and we are up to our necks in another one right now.

Paul Levy said...

I wasn't blaming the victims at all. I wasn't talking about behavioral changes. I was talking about better case management.

I don't understand how your comment with regard to payment systems comports with your concern about executives and insurance companies. Unless you mean that there should be a single payer system. Or limits on executive pay.

But that is not the topic at hand here. The topic at hand is the design of payments to hospitals and doctors for care, i.e., fee for service, capitated, or other.

(Even under the Comm Fund approach, by the way, insurance companies and executives will do very well indeed. In fact the insurance companies do better, as they are assured revenue and are freed from actuarial risk.)

Paul Levy said...

Thanks, Charlie!

Paul Levy said...

Here's more on this topic from a previous post:

Suzanne Delbanco said...

Reprinting comment from post below:

Paul, thank you for sharing your thoughts. Now that I have had some time, I've shared mine; as they exceed the space limit here, please visit

Paul Levy said...

Thanks, Suzanne. I'll leave it to others to review your post and offer their thoughts.