qotd: Health policy experts versus everyone else: Why do the experts believe themselves?

ABIM Foundation
May 1, 2014
Results from a National Survey of Physicians
Unnecessary Tests and Procedures In the Health Care System: What
Physicians Say About The Problem, the Causes, and the Solutions

Nearly three-quarters (73 percent) of physicians say the frequency of
unnecessary tests and procedures in the health care system is a very (29
percent) or somewhat (44 percent) serious problem. ….

The top reasons physicians say they order unnecessary tests and
procedures are concern about malpractice issues (52 percent say a major
reason), just to be safe (36 percent), and wanting more information for
reassurance (30 percent). …

The second-tier influences are patients' insistence (28 percent) and
wanting to keep patients happy (23 percent). Third-tier reasons include
other factors such as … the fee-for-service system (5 percent)…. [p 5]

http://www.choosingwisely.org/wp-content/uploads/2014/04/042814_Final-Choosing-Wisely-Survey-Report.pdf

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New England Journal of Medicine
2013; 368:2029-2032
Phasing out fee-for-service payment
By William Frist and Steven Schroeder

The fee-for-service mechanism of paying physicians is the major driver
of higher health care costs in the United States [citation omitted] …..
The long-range solution is [to] shift from a payment system based on a
fee-for-service model to one based on value through mechanisms such as
bundled payment, capitation, and increased financial risk sharing.

http://www.nejm.org/doi/full/10.1056/NEJMsb1302322

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Comment by Kip Sullivan JD

There is an enormous gap between the opinions of the health policy elite
in this country and those of the public, including physicians. The
health policy elite find this gap too boring to analyze. They know why
this gap exists. The problem is not them, it's the hoi polloi and the
doctors. Patients are bewitched by "technology" and think "more is
better," and doctors' minds are warped by the incentives of the
fee-for-service system. It does not occur to health policy experts that
there might be something very wrong with their culture. The idea that
there is even a "culture" within the health policy establishment would
strike the establishment as at best uninteresting and at worst silly.
That this culture might be dysfunctional is unthinkable. In their view,
the only "culture" that needs analysis is that of the medical profession
and of the unwashed masses.

Although the gap between public and expert opinion was documented by the
early 1990s, the health policy community has shown no interest in
understanding its cause. For the health policy elite, there is nothing
to explain: The public is wrong and they are right. Pollster Daniel
Yankelovich articulated the establishment point of view in a 1995 paper
on the muddled debate about the Clintons' Health Security Act. "The
nation's leadership and the public are carrying out a bizarre dialogue
of the deaf," Yankelovich wrote. "The nation's elites have little
trouble conversing with one another, but when it comes to engaging the
public, there is an astonishing lack of dialogue." [p. 8]
http://content.healthaffairs.org/content/14/1/7.full.pdf+html?sid=fa42b84d-5f51-458f-bde1-d42bcbd15855


The problem, said Yankelovich, is the public does not agree with the
experts' diagnosis of the health care crisis. Virtually the entire
health policy establishment thinks US expenditures are high because the
volume of health care is excessive. But the public disagrees. As
Yankelovich put it, "[M]ost Americans attribute the rising costs of
health care to waste, fraud, greed, and inefficiency, [and] they assume
that whatever is wrong can be fixed by cracking down on these
expressions of venality…." [p. 14] The public, Yankelovich concluded, is
"on a collision course with the majority of experts". [p. 14]
Yankelovich's explanation for this standoff was "lack of realism" and
"wishful thinking" by the masses. The elite couldn't possibly be wrong.

The health policy cognoscenti treat the gap between physician and expert
opinion with the same incuriosity and arrogance. The latest evidence of
how drastically physician opinion departs from that of the establishment
appeared in a poll published by the ABIM Foundation (created by the
American Board of Internal Medicine) on May 1. The poll found that only
5 percent of physicians believe the fee-for-service payment method is a
major cause of overuse of medical care. The three most common
explanations doctors offered were variations on the same theme: Reducing
uncertainty. Other polls report similar results
http://www.unitedhealthgroup.com/~/media/UHG/PDF/2012/UNH-Working-Paper-8.ashx
(see p. 8) http://jama.jamanetwork.com/article.aspx?articleid=1719740
(see Table 3).

The health policy elite emphatically disagrees. "The fee-for-service
model is like asking a butcher how much steak you should eat," Jonathan
Gruber, a prominent advisor to the Obama administration, "explained" to NPR.
http://www.npr.org/templates/story/story.php?storyId=106859968

According to former Senator William Frist and Steven Schroeder (see
article quoted above), the "fee-for-service mechanism is the major
driver of higher health care costs."

How do we explain this divergence of opinion? I propose a modest
hypothesis: That the health policy community is as deeply influenced by
incentives peculiar to their profession as physicians are by incentives
peculiar to their profession. I propose that researchers both inside and
outside the health policy community begin their analysis of my
hypothesis by documenting the pattern I have outlined above – the
experts' habit of issuing pronouncements on the allegedly irresponsible
behavior of doctors as the chief cause of the health care crisis – and
comparing that pattern with analogous patterns in physician
explanations. Investigators would then examine the evidence behind the
different world views.

Let me offer an illustration. The paper from the New England Journal of
Medicine quoted above – "Phasing out fee-for-service payment" –
contained one of those extremely rare instances in which proponents of
the FFS-is-to-blame diagnosis tried to document their claim. The
authors, Frist and Schroeder, cited one and only one paper – a paper
published in 2011 by Laugeson and Glied entitled, "Higher fees paid to
US physicians drive higher spending for physician services compared to
other countries."
http://content.healthaffairs.org/content/30/9/1647.abstract The paper
didn't merely fail to support Frist and Schroeder's claim, it
contradicted it. It demonstrated that volume of services (in other
words, overuse) could not explain why expenditures on physicians are so
much higher in the US than in other countries that also rely primarily
on the FFS method, and that higher physician fees in the US explained
the difference. To paraphrase Gerard Anderson et al.
http://content.healthaffairs.org/content/22/3/89.full.pdf+html, it's the
prices stupid, not FFS.

Researchers investigating my hypothesis might ask, What incentives are
Frist and Schroeder exposed to that would incline them to make such a
sloppy mistake? Do proponents of the FFS-is-to-blame mantra and managed
care in general make more money, publish more often, advance faster
within the ranks of politics and academia, have greater access to the
media, or have more luck raising money from foundations than, say,
single-payer advocates or observers who are less passionate about their
criticism of doctors and patients?
I'm not proposing to exempt doctors and patients from similar scrutiny.
I'm proposing that the scrutiny, at long last, become even-handed. I
have little doubt even-handed scrutiny would either force the health
policy illuminati to honor the rules of scientific discourse and stop
promoting diagnoses and solutions with little or no evidence, or it
would lower the credibility of the illuminati in the eyes of the public
and the media. In either event, the decks would be cleared for a real
debate about single payer. Then the most profound gap between the public
(including physicians) and the experts would become more visible: By
large majorities the public supports single-payer.
http://www.pnhp.org/sites/default/files/docs/2011/Kip-Sullivan-Two-thirds-support-medicare-for-all.pdf