The much ballyhooed White House summit on healthcare created no “aha” moments or Daily Show-worthy gaffes and was about as interesting to watch as Olympic curling.

President Obama was hoping, by force of will, intelligence and gravitas to both sway Republican lawmakers to his point of view (aspirational at best) while simultaneously demonstrating to the American people (and particularly American voters) that his proposal was a moderate one (arguable at worst).

From a communications perspective, he was presented with a classic  Nick Naylor moment. The president didn’t realize the odds were 2-1 against. Not only did he have to prove he was right, he had to demonstrate the other side was wrong.

The GOP had an easier task — to have something constructive to offer, not get shrill (and yell “liar!”) or look at their watches. They succeeded.

House Minority Leader, John Boehner, rather than coming across as “Dr. No,” was the man with a plan – an easy-to-explain 6-point plan. Communications 101. The GOP were combative but collegial. Their sound bites were designed to generate nodding “me toos” across America. The Democrats were uncoordinated and visibly unhappy they were unable to paint themselves as the white knights of healthcare reform.

Obama and the Democratic leadership needed a dynamic event that would galvanize public opinion behind their call for immediate and comprehensive healthcare reform legislation. They needed a hard-hitting Olympic hockey game. But there were no stand-up body checks. Instead, the president looked like a professor grading papers and the whole enterprise looked and sounded like C-SPAN – the American equivalent of Olympic curling. Let the spinning begin.

So long DDMAC.  Hello OPDP.

Under a new proposal, DDMAC will be renamed the Office of Prescription Drug Promotion and have two divisions, one to review direct-to-consumer content and the second focusing on professionally directed promotions. In terms of structure, it would remain directly under the Office of Medical Policy within the Center for Drug Evaluation and Research (CDER).

According to Rachel Behrman, the proposed change would take several months to implement, adding the suggested move “does not signal a change in philosophy or attitude” in DDMAC, but rather reflects the importance of the division within the agency and its overall size.

And, as we all know, Opie springs eternal.

An important article appeared in today’s NYT, describing a new paper by Peter Bach, which is in today’s NEJM. Peter’s paper (“A Map to Bad Policy“) debunks the Dartmouth Atlas and cautions against its use. As I said in the Wash Post in September, the Dartmouth Atlas is the ”Wrong Map for Health Care Reform.”

More damning even than Peter’s analysis was Elliott Fisher’s reply: “Dr. Fisher agreed that the current Atlas measures should not be used to set hospital payment rates, and that looking at the care of patients at the end of life provides only limited insight into the quality of care provided to those patients. He said he and his colleagues should not be held responsible for the misinterpretation of their data.” Really? It was someone else’s interpretation? OK, Elliott, you’re not responsible. Just stand in the corner.

Peter is not the only leading epidemiologist to debunk Dartmouth in recent days. There’s also the report this week from the U of Wisconsin and RWJ by Pat Remington (another leader), showing that people who have the poorest health (and, therefore, the highest health care costs) live in the poorest counties (see my blog report and an earlier discussion of poverty and health care). And there’s the recent paper by Ong and Rosenthal (co-authored by Jose Escarce, editor of HSR, the leading health services research journal), showing that, when all care is measured (not simply end-of-life care, as measured by Dartmouth), hospitals that provide more have lower mortality, which was confirmed in the current issue of Medical Care by Barnato and associates at the U of Pittsburgh. When it rains, it pours.

What’s doubly important about the death of the Dartmouth Atlas is that it was the cornerstone of health care reform. Right from the start, Peter Orszag, director of OMB and the administration’s architect of health care reform, accepted Dartmouth’s ideological principles that health care spending was driven by doctors and hospitals who over-treated and over-charged, to no benefit. The funds for health care reform were readily available by simply getting rid of geographic differences. That alone would save 30% of health care spending ($700B). And that could be accomplished by making everything look like Mayo (white, middle class and efficient) and by having more primary care physicians (which Mayo doesn’t). And best of all, it could assure that no new taxes would be needed, just as President Obama had promised.

And here's Peter Bach explaining why cost driven health care policy is, well, bad for patients...

Say Hospital A and Hospital B each has a group of patients with a fatal disease. Hospital A gives each patient a $1 pill and cures half of them; Hospital B provides no treatment. An Atlas analysis would conclude that Hospital B was more efficient, since it spent less per decedent. But all the patients die at Hospital B, whereas only half of the patientsdo at Hospital A, where the cost per life saved is a bargain at $2. Although $1 cures are rare, changing the price or efficacy of the pill does not alter the fundamental problem with examining costs alone when cost differences are sometimes associate with outcome differences.

And finally Bach challenges what, until recently, the media, most foundation types, the underachieving liberal health bloggers drank as daily Kool-aid,  that the Dartmouth Atlas controlled for severity of illness by looking at only dead people. 

Another methodologic problem is that Atlas analyses assess hospital efficiency overall on thebasis of costs incurred for nonrepresentative patients — decedents who were enrolled in fee-forservice Medicare. This group varies among hospitals in terms of severity of illness and is notrepresentative of a given hospital’s overall spending pattern. Regarding illness severity, Atlas researchers note on their Web site (www.dartmouthatlas.org/faq/ hospital.shtm) that they focus on “patients who died so that [they can be sure] that patients were similarly ill across hospitals,” further explainingthat “by definition, the prognosis of all patients[who died was] identical — all were dead . . . therefore, variations [in resource use] cannot be explainedby differences in the severity of illness.” But since some hospitals take care of sicker patients than others, the average severity of illness of patients who die also varies among hospitals. This fact is being ignored when all spending differences are attributed to differences in efficiency.

“There’s a pretty good correlation between treatment of patients over 65 and under 65,” Fisher said.

In a response published in the New England Journal of Medicine, Fisher wrote that Medicare data is closely associated with a single hospital, making it a good measure of hospital effectiveness.

Bach’s final criticism of the Atlas data focused on the variation of illness severity between hospitals. Because of this variation, hospitals that care for patients with very severe illnesses could appear less efficient than those that take care of patients with less severe cases, even if they actually operate with the same level of efficiency, he said.

Fisher responded in the interview that the Dartmouth Atlas data is “carefully adjusted” for variations such as illness severity, poverty and price differences.

2.  Dartmouth and Fisher claim to limit who they analyze to those with a list of common chronic diagnoses.  All together, that is about 90% of all people who die in Medicare.  Then they adjust for a few things like primary diagnosis and age and sex and stuff.  They have never shown that they can capture the variability between hospitals in severity of illness and they cannot, even using far more sophisticated measures.  But they do not think they need to risk-adjust for the regional variations stuff.  When MedPac did that, most of the variations went away.

Despite all this, both Gawande and Fisher persist in claiming: "that Bach’s criticism does not undermine the main finding of the Atlas data: regional variations in health care spending show that higher costs associated with specialized procedures do not necessarily lead to better health outcomes. Costs can be lowered by creating more accountable hospitals and moving away from a “toxic payment system” that creates incentives for unnecessary tests, according to Fisher."

http://thedartmouth.com/2010/02/22/news/atlas

Why would they say that when the entire methodology is shot to hell?

Because both (and not just them) make big money off of speeches, consulting and businesses that push the less is more approach. 

And the commercialization of the Dartmouth Atlas -- coaching people to ration their own care in my opinion --  culiminated in the formation of a company called Health Dialog by the Dartmouth folks.  HD was purchased by a British concern for $750 million.  And HD has lobbyists in Washington pushing the adoptiong of its products in the current health care reform bill. 

http://www.nytimes.com/2010/02/19/opinion/19krugman.html?em

"What would work? By all means, let’s ban discrimination on the basis of medical history — but we also have to keep healthy people in the risk pool, which means requiring that people purchase insurance. This, in turn, requires substantial aid to lower-income Americans so that they can afford coverage.

And if you put all of that together, you end up with something very much like the health reform bills that have already passed both the House and the Senate.

What about claims that these bills would force Americans into the clutches of greedy insurance companies? Well, the main answer is stronger regulation; but it would also be a very good idea, politically as well as substantively, for the Senate to use reconciliation to put the public option back into its bill."

Maybe the Krug forgets that the it was the very prescriptions he is pushing that helped contribute to the rise in premiums.  That, and the fact that insurance companies tried to hold the line on premium increases in 2008.   In any event, he ignores the fact that individual premiums under Obamacare will increase by up to 35 percent in 2016 as all these regulations kick in (that's according to CBO).   And a  pubiic option will not be less expensive according to both CBO and CMS unless there is some drastic price controls.  That will keep prices in check in the short term, but not overall spending..

Buying across state lines is not a panacea and would likely have unintended consequences (as with any health care policy).    But there are a lot of things that could be done to keep premium costs down and predictable, starting with allowing people to buy catastrophic coverage.   However leftists like Krugman would never allow that choice. 

“Podium policy” (when regulators give speeches or media interviews that announce new regulatory expectations), is never a good idea. And least of all when the policy implicates First Amendment values and involves potential criminal enforcement.

“The bottom line is this is a regulated industry, and if you choose to do promotion in that area just make sure that at the end of the day what we’re looking at is in the best interest of public health.”

When I served at the FDA, we struggled with how to both regulate and advance the new field of pharmacogenomics. As Commissioner McClellan said at the time, “pharmacogenomics is a new field, but we intend to do all we can to use it to promote the development of medicines. By providing practical guidance on how to turn the explosion of pharmacogenomic information into real evidence on new drugs, we are taking an important step toward that goal.”  The same philosophy of “regulator as colleague” should also be true for the new dynamic of social media. It’s like a game of chutes and ladders.  FDA should act as a guide to the ladders and a sentry against the chutes – rather than an as the ogre at the foot of the bridge.

By Jacob Goldstein

Now that it’s expanded health-insurance coverage to nearly all of its citizens, Massachusetts is trying to figure out what to do about the rapid rise of health costs.

The latest proposal comes from the state’s governor, Deval Patrick, who yesterday proposed a bill that would give the state the power to review — and, in some cases, reject — rate increases by doctors and hospitals.

Here’s a key paragraph from the bill:

Any contract under which provider payments increase by an amount in excess of the applicable Consumer Price Index for Medical Care Services shall be presumptively disapproved. The division may conduct a hearing on any contract that is presumptively disapproved and will approve or disapprove the contract based on its findings following the hearing.

The bill would also allow the state to prevent health-insurance plans sold to small businesses from raising premiums by more than 1.5 times the rate of medical inflation, and impose a two-year moratorium on lawmakers mandating new health benefits that plans must cover (those mandates drive up costs).

The Boston Globe said reaction “was mixed, with small business groups expressing cautious optimism, insurers saying the measures do not go far enough, and health care providers worrying that smaller hospitals could be disproportionately harmed and that some might have to lay off caregivers.”

http://blogs.wsj.com/health/2010/02/11/mass-governor-wants-to-cap-hospital-doctor-rate-increases/

Mixed?  I wonder what insurers will say when their rates are capped.  In any event,  price controls will only worsen the shortage of primary care in the Bay State and reduce the availability of services.  

Here is something else Republicans can bring up in their summit:  Government regulation of health care reduces employment and investment.. 

 

"Meanwhile, supporters have spent most of their time on seemingly endless debates with one another about specific legislative provisions — whether to include a public option in the reform legislation, whether to have a single national insurance exchange or separate state exchanges, how to enforce a mandate that everyone carry insurance and how much to spend on subsidies to make that mandate acceptable, how to enforce a mandate on all but small employers to sponsor and pay for basic coverage for their workers, and scores of other complex and bewildering technical provisions.

 Health care reformers in the administration and Congress have a powerful case to make and, on an issue of such enormous importance, a duty to make it. In addition to reminding Americans that reform will protect, not jeopardize, coverage by preventing insurance companies from canceling coverage or jacking up premiums for the sick, reform advocates should remind them that the proposed legislation will bring coverage to tens of millions of currently uninsured Americans and protect it for scores of millions of others. Reform advocates should explain the legislation’s legitimate promise of cost control and quality improvement.