Sunday, June 28, 2015

Hold the dicta, please, and give us news.

Dicta is a term used in the legal profession:

The part of a judicial opinion which is merely a judge's editorializing and does not directly address the specifics of the case at bar; extraneous material which is merely informative or explanatory.

I've noticed a tendency on the part of the New York Times to include more and more dicta in its news stories, adding editorial opinion--perhaps in the hope of making a story more interesting to readers--but clearly including content that in previous years would be more appropriately included in editorial pages.

The problem with such material is that it is included without documentation of sources.  The other problem is that it can be of questionable accuracy.  But, because it is contained in the New York Times, it can carry greater weight in the court of public opinion than might occur if it were in your weekly community newspaper.

The Times' recent coverage of the King v. Burwell decision offered such dicta--overstatements and unsupported conclusions.  Let me give you examples:

The law has also, by many accounts, contributed to a significant slowdown in the growth of national health spending and the cost of Medicare.

Use of words like "significant" is troubling and has no place in a news story.  We probably don't expect reporters to use the statistical definition, but we are left without a context for the standard they apply as to what "significant" means.  (One definition I found was "sufficiently great or important to be worthy of attention; noteworthy.")  You judge in this case.  Here's the abstract of an article from Health Affairs:

In 2013 US health care spending increased 3.6 percent to $2.9 trillion, or $9,255 per person. The share of gross domestic product devoted to health care spending has remained at 17.4 percent since 2009. Health care spending decelerated 0.5 percentage point in 2013, compared to 2012, as a result of slower growth in private health insurance and Medicare spending.

Is this "significant?" The Huffington Post offered more context:

The historic slowdown in the growth of health care spending since 2009 -- the lowest rate since the federal government began tracking the data in 1960 -- has sparked a debate about its causes. President Barack Obama partially credits elements of the Affordable Care Act, such as reduced fees for hospital services, for reduced inflation in national expenditures, but there's no consensus among experts. The actuaries at the Centers for Medicare and Medicaid Services are among those who believe the phenomenon is nothing more than a repeat of normal patterns that occur during and after economic recessions like the one that began in 2007.

Hmm, a "repeat of normal patterns." And let's look at the Medicare portion.  Is this about a slowdown in the growth of the cost of Medicare or the amount appropriated to fund Medicare?  Cost would be a reflection of the actual costs of disease treatment per capita. Appropriations are merely an administrative decision to not spend as much, such as results from rate changes or Congressional sequestration. Enrollment is based on demographic trends.  CMS notes:

Let's look further into the "impacts of the ACA" portion. A 2010 CMS report identifies the major Medicare savings that would accrue in the early years of the ACA.   They point to pricing and enforcement provisions--not changes in the structural delivery of care--and note that these are the ones projected to make the biggest difference over time, as well:

As for the items entitled "Improve the delivery of care" and "Reform the delivery system," the jury is still out.

Melanie Evans at Modern Healthcare summarized the situation in late 2014:

The CMS published for the first time the quality and financial performance for individual Pioneer accountable care organizations, a small, select group enlisted for Medicare's most ambitious test of the payment model. First year financial results show health spending slowed as much as 7% (PDF) among some ACOs and accelerated as much as 5% for others. In the second year, health spending slowed as much as 5.4% among those that reduced patients' medical bills and accelerated as much as 5.6% where costs escalated.

Eight of the nine ACOs to walk away from the Pioneer program in the first year reported an acceleration in health spending. Of those that dropped out, seven joined Medicare's less risky ACO option, the Shared Savings Program. But the Pioneer ACO that reported the sharpest acceleration in health spending, Plus North Texas ACO, dropped out entirely after costs grew 5.2% faster than projected. 

Indeed, the CMS ACO program had to be redesigned to postpone downside risk to hold onto hospital system participation.  The Times story does not reference what "many accounts" refers to, but from what I can garner, are the changes "significant?" I judge not.

Let's now proceed to another paragraph of dicta from the Times story: 

Industry executives said the law had fostered a revolution in the delivery of health care, encouraging hospitals large and small to increase the coordination of care and the use of electronic medical records while minimizing the readmission of patients who have been discharged. Doctors and hospitals have accepted that they will be rewarded or penalized for the quality of care they provide: their ability to keep people healthy. 

We could spend pages dissecting this collection of gross generalizations. A revolution? (Again, I found a definition: "A dramatic and wide-reaching change in the way something works or is organized or in people's ideas about it.")  That is hardly the case here.  Some incremental change in some places? Sure. Business as usual in most places? Likely. Talk to doctors and see if they have accepted that the metrics being applied to them and their hospitals truly reflect the quality of care or their ability to keep people healthy. Talk to procedural specialists and ask if the law has made a difference in their clinical judgments to engage in invasive procedures. Ask people what difference the use of EMRs has made in their practice.

The point is that the jury is out on so many of these issues. We don't need dicta in a news story. We need news.  The main proven attribute of the ACA is that more people have access to health insurance.  That's victory enough.


Alice Ackerman, MD, ‏@CloseToHomeMD said...

From Twitter:

You speak the truth @Paulflevy Our news organizations should present the news, and identify commentary as such

Anonymous said...

Right on target...between this and the issues of flawed major studies in prestigious medical journals, we often don't know what to believe.

Anonymous said...

I think you've hit the nail precisely on the head and exposed the creeping tendency for journalists to draw conclusions that may or may not be supported by the facts. For a long time we in the journalism world have joked that the term "sources say" might just as easily reference three reporters in a bar as a truly credible source. Unfortunately, the over-use of confidential sources and the commonplace tendency to draw conclusions for readers apparently too dense to do it on their own are now standard practice, perfected by such would-be bastions of journalism at the NY Times and WaPo.

This ought to be simple -- do your homework, write carefully, tell the story, provide context and trust your readers to draw appropriate conclusions. But, unless your piece is labeled opinion or analysis, leave the words like "significant" out. It's no wonder to me that journalism has lost credibility at a time when it's more desperately needed than ever.

Anonymous said...

It’s not for the reporter to decide—much less declare—that something is significant. The editor does that when he/she decides what’s printed or published (and earlier, if/when an assignment is made). Then it’s up to the reader to decide.

Anonymous said...

One of the reasons for checking out independent bloggers like you is that we can get fact based information, and conclusions that someone with common sense and brain cells and use. There is a problem here in my area because the "monopoly" hospital system buys ads in the only newspaper. They won't print anything but glowing reports.

They also paid one of the TV stations for that.

Paul Levy said...

A response from Dan Kennedy, who teaches journalism at Northeastern University, when I asked him on Twitter for his comments on this post:

"You are asking for a return to the unlamented regime of mindless he said/she said objectivity. But you’re right that when you try to provide explanation and context, you run the risk of making assertions that some will say are inaccurate."

Anonymous said...

On "significant:" This is one of those words good editors watch for to make sure the story supports. "Sweeping" as in sweeping layoffs or sweeping change would fall into that category as well. Same for "controversial." In general they're words to avoid but not ban as the rule of showing not telling comes into play. Better in the lede of a story to be specific about whatever significant thing happened than to use the word significant. Used right, though, it's fine.

Also, these kinds of words often just take up space. The story itself, the meat, and the context you provide, should make clear the significance and to whom.

stacey said...

You can't find a newspaper story without typos anymore. There's barely any editorial process.
I would also suggest that the increase in "dicta" content is directly correlated to the rise in 24/7 news cycle. Dicta is the fill between actual news events.