Orthopedist vs. Anesthesia and a Pair of Articles Putting the ACA in Historical Perspective

Extranormal produces great 'homemade' videos.  Some of the pronunciation of medical terms is rough (asystole = the heart has stopped for my nonmedical readers. Temperature of 29= 84 degrees F, and normal pH is 7.4)

By the way, a nicely paired set of articles by perceptive NY Times journalists today and tomorrow.

Today, David Leonhardt reminds us that this quote

“We are against forcing all citizens, regardless of need, into a compulsory government program,” said one prominent critic of the new health care law. It is socialized medicine, he argued. If it stands, he said, “one of these days, you and I are going to spend our sunset years telling our children, and our children’s children, what it once was like in America when men were free.”


is from Ronald Reagan talking about Medicare in the 1960s.   He goes on to discuss the tension between Americans who believe in individual responsibility (the laissez fair conservatives) and those who believe in a minimum standard of living (progressives.)  Both traditions have played a role in America's success; the tension remains


Tomorrow, Matt Bai reminds us that Social Security started collecting premiums in 1935 but didn't pay out pensions until 1941 - and was under siege for decades until it became a critical part of our social fabric (and until most families were getting some benefit from the program).  He suggests that the final analysis of the Affordable Care Act can't be written for a generation. 

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Council of Economic Advisors: Economic Growth is Dependent on Controlling Health Care Costs

Anyone who doubts the importance of controlling health care costs should look at the graphs in the report from the Council of Economic Advisors.  Economists generally agree that a major reason that family income has been stagnant for decades in the face of higher worker productivity is that the extra dollars have gone into into health care.  The Council estimates that health care reform will produce higher growth (as much as 4% increase in GDP by 2030) by freeing up resources for other investment, decreasing workforce disability, and lower government and employer insurance costs.  This will lead to higher family income as well as lower federal deficits.

Wednesday addendum: David Leonhardt of the NY Times weighs in, noting that the "insurance lock" of the current system contributes to what he calls our "innovation deficit," where 1.5 million don't change jobs because they don't want to jeopardize their current insurance.

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Brent James and Intermountain Health - Following Rules Improves Care

Tomorrow’s New York Times Magazine  has a thoughtful piece by economics reporter David Leonhart about Brent James, the Chief Quality Officer at Intermountain Health, a hospital system in Utah.  Intermountain is often cited as one of the “high value” health care delivery systems – it has lower complication rates and lower overall costs.   Intermountain, under James’ leadership, has developed detailed “best practice” algorithms for at least 50 conditions representing half of all hospitalized patients, and has gone through the difficult process of convincing doctors that they should follow the rules, rather than their “gut.”

Leonhart points out that in most industries, developing methods to lower the resource costs while maintaining or increasing quality allows growth in market share.   However, under fee for service reimbursement, a hospital like Intermountain loses money when it prevents complications – because it is no longer paid to treat those complications.  For instance, Intermountain says it lost $329,000 by standardizing protocols for inducing labor in expectant mothers (and decreasing babies with premature lungs).  Toyota doesn’t lose money by making cars that were more reliable.  If it did, we would all still be driving AMC Ramblers (a notoriously unreliable car from the 1960s)!

I also appreciate that Leonhart referenced the ongoing debate between those who emphasize the “art” of medicine, like Jerome Groopman, and those who espouse the science like Brent James.  “Cookbook medicine” is not right for every patient, and good physicians know when to deviate from evidence-based rules.  But at least half of all patients are cared for by below average physicians, and populations have better outcomes when physicians follow rules more closely.    Furthermore, the evidence-based rules generally don’t favor the most expensive approach to an individual patient’s treatment.   Comparative effectiveness research could help us enlarge the body of evidence and create more rules.  When physicians and care teams follow those rules, outcomes will be better and physicians can focus on difficult decisions where the evidence is less clear and where their wisdom and expertise will really drive more value for patients.

Much of the change that will decrease the rate of health care inflation has to come in the delivery system (where 85+% of all the dollars are spent).  Intermountain offers the promise of evidence based care that is better and saves money.  Let’s hope the health care reform that passes is able to provide incentives for more organizations to follow this approach.

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