Occasional Brief Observations: Health care re-form XIV (The numbers)

Saturday, October 31, 2009

Health care re-form XIV (The numbers)

In the health care reform, strike that, health insurance reform debate many numbers are bandied about by those on both sides of every argument - numbers re costs, extent of coverage, and so on. Some would appear to be pretty straight forward, such as the slides above (public opinion re an employer mandate, and the increase in health insurance premium costs, both courtesy of the Kaiser Family Foundation's Fast Facts). However, any one closely following the issue will soon realize that often (to borrow a line from Gilbert & Sullivan's HMS Pinafore) "things are seldom what they seem." A few examples:

OK, so this first example is not specific to the reform legislation, it is a study that shows that "a key statistic that consumer groups and the media often use when compiling hospital report cards and national rankings can be misleading." However, this kind of transparency and reporting (i.e. provider report cards) is touted as important in allowing consumers to inform their health care choices. Unfortunately, providing meaningful outcome results is a very complex business, that is prone to error, misrepresentation, and even outright manipulation. How is the consumer to know that their informed decision actually is? The jury is still out...
In June, Atul Gawande wrote an article in The New Yorker, 'The Cost Conundrum. What a Texas town can teach us about health care,' which turned the national spotlight on McAllen, Texas. This hit like a bombshell, was picked up by paper and blogs around the country, and by politicians all the way up to the President. The received wisdom that most took away was that the core problem was over testing by physicians (caused by perverse financial incentives.) Very few publicly took issue with the article and its interpretation... (example of one that did, here, and Gawande's response...). However, the article 'McAllen: A Tale of Three Counties' did a very detailed analysis of the numbers, comparing McAllen to El Paso and Grand Junction, and came to a different conclusion: "McAllen is different from many areas of the United States: it is sicker and poorer. The observed differences in the rates of chronic disease are highest for those conditions rampant in low income American populations: diabetes and heart disease. Further, Medicare beneficiaries in McAllen have significantly higher rates of co-occurring chronic conditions. As a result the costs of caring for McAllen Medicare population appears high in comparison to other areas but not abnormally so. McAllen suffers from a tremendous burden, but it not caused by its physicians: the care they provide leads to costs that are substantially comparable to the other counties in the article once adjustments are made for the magnitude of the health problems they face. The disturbing pattern of physician practices uncovered by Dr. Gawande sounds a warning not because it foretells a McAllen-like future but because it portrays the on-going crisis that affects both McAllen and Grand Junction and it is national in scope. Physician culture is only part of the McAllen story." However, good luck seeing this more nuanced view, it is significantly easier to propagate the "excessive testing" and "greedy doctor" arguments! (Note: this analysis seems plausible and a good application of the facts... However, it is possible that it too is a mis-application of the statistics. The fact that this blogger can't be sure either way is proof, were that needed, of a) the complexity of the issue and, b) that it is too easy to draw the wrong conclusions given the complexity of the issues and the confounding variables. In other words, exactly the same point that this blog entry is arguing!)

The article 'Data Fuel Regional Fight on Medicare Spending' gives us an additional example of problems with health care statistics. It's long been argued that the levels of health care spending in some areas (for example New York, New Jersey, California) are much higher because providers in those geographical locations practice more intensive medicine, and that the government (Medicare) could save very significant amounts of money if providers (doctors, hospitals, etc.) in all areas could be "as efficient as those in lower-cost states like Iowa, Minnesota, Washington and Wisconsin." The fact that there is a huge geographic variance in Medicare rates is taken as prima facie evidence of poor practice, inefficiencies, and even malfeasance. Politicians, as usual, are all over this, and seeking to make sure that their particular geographic location is taken care of. “In 2006, Medicare spent $6,671 on the average beneficiary in Waterloo, Iowa, compared with $16,351 in Miami,” said Mr. Braley, who lives in Waterloo... Meanwhile "Representative David R. Obey, Democrat of Wisconsin and chairman of the House Appropriations Committee, recently told the administration, “These reimbursement disparities are outrageous.” Unfortunately, some health care leaders are attempting to leverage these disparities in their favor as well... (see article for examples). When the Medicare Payment Advisory Commission looked at this issue it confirmed the geographic disparities. However, it found that they were could be mostly chalked up to "local differences in the cost of providing care and in the health status of beneficiaries, as well as by extra payments, authorized by Congress, for hospitals that train doctors or treat large numbers of low-income patients." After adjusting for these factors high cost areas such as Boston and New York turned out to be below the national average in costs! Bottom line: the numbers being bandied about represent very complex realities, which are not taken into account by the various parties to the debate while conclusions are being drawn from them.

OK, this blogger is not arguing that things are so complex that a paralysis should set in, and that nothing should be done. What he is arguing is that it behooves the various parties to the health care reform, (strike that, health insurance reform) debate to take the time to correctly and completely understand the issues and the numbers, otherwise the resulting legislation will have many unhappy and unintended consequences...

Also, perhaps it might be a good idea for them to keep the lessons of the "Quick reminder" blog entry of 29th September, 2008 in mind!

Saturday, October 31, 2009

Health care re-form XIV (The numbers)

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