In Lessons

I recently had the privilege to participate in a panel discussion at the Brookings Institution with two of the nation’s leading healthcare writers and observers: Eric Patashnik, co-author of the new “Unhealthy Politics: The Battle over Evidence-Based Medicine,” and Elisabeth Rosenthal, whose groundbreaking work “An American Sickness: How Health Care Became Big Business and How You Can Take It Back” continues to achieve due praise for its eye-opening insights into the failures of the U.S. healthcare system.

The Brookings event, titled “What Does 21st Century Medicine Look Like?” sought to shed light on the politics surrounding evidence-based medicine and the challenges the government faces in improving evidence-based treatment in the United States. The discussion drew more than 100 attendees, who came from Capitol Hill, administrative agencies, the private sector, nonprofit organizations, the media and advocacy groups.

Those of us on the panel found ourselves in agreement more often than not. In his opening remarks, Eric noted that Americans assume that health care is based on sound science, but that is not necessarily the case. Elisabeth pointed out how healthcare’s biggest players have deeply rooted economic interests, which undercut innovation and evidence-based medicine. I agreed, adding that many Americans think U.S. healthcare is the best in the world, despite the many points of data in scientific literature that prove us wrong. This common misconception is just one factor leading both to poorer quality outcomes and higher costs.

Darrell West, Vice President of Governance Studies and Director of the Center for Technology at Brookings, kicks off the day’s panel with his thoughts on evidence-based medicine in healthcare.

I was asked about the reasons for this dichotomy and what can be done about it. I first pointed to the problem as outline in my own book, “Mistreated: Why We Think We’re Getting Good Healthcare – and Why We’re Usually Wrong.” Decades of psychological research has shown that the promise of financial reward skews our perceptions and distorts objective reality. Within the context of healthcare, as Elisabeth pointed out in her remarks, doctors, hospitals, insurers and drug companies benefit greatly from the current structure and financial model. With little incentive in place to focus doctors on more effective methods of care provision, we must think about ways to shift the structure of care delivery.

For example, moving our payment methodology toward capitation, not fee-for-service, is one way to positively alter behavior. Funding medical care this way discourages delays in care for hospitalized patients, encourages coordination across providers, and improves quality. Further, we must shift away from the fragmented structure of today’s healthcare system toward one that is integrated, both horizontally within specialties and vertically across primary, specialty, and diagnostic care. Integrated delivery systems can maximize collaboration and cooperation, thereby making the provision of care more efficient and effective. And with higher patient volumes, specialists working in integrated care settings can perfect their skills and improve outcomes.

For most of clinical practice, there is a best approach to treating patients, one based on data and evidence. Included in the discussion was the research showing that many expensive procedures – such as knee arthroscopy with meniscus trimming, complex back surgery and prostatectomy – add little value for a high percentage of patients. Perhaps even more striking is how often inexpensive but effective approaches to the prevention of cancer, heart attacks and strokes are omitted by today’s clinicians. If every American physician followed the available evidence-based guidelines, research shows that hundreds of thousands of lives would be saved each year.

We’re at a critical juncture with respect to the future of our healthcare system. There are no quick political fixes that will address the fundamental dysfunction we see in care delivery today. However, there is much we can do to alter the context of American healthcare and to improve the quality care for all Americans. Creating a context in which all doctors have incentives to follow evidence-based guidelines is a great place to start.

Special thanks to the Brookings Institution for hosting us. Located on “Think Tank Row” in Washington, D.C., and founded over a century ago, Brookings strives to “provide innovative and practical recommendations that advance three broad goals: strengthen American democracy; foster the economic and social welfare, security and opportunity of all Americans; and secure a more open, safe, prosperous, and cooperative international system.” Today, Brookings is regarded as one of the nation’s leading think tanks, focusing on the social sciences, economics and foreign policy. It is non-partisan in its offerings, and a frequent reference point for facts and information used by both liberals and conservatives.

Being on a panel with such articulate experts in such a magnificent institution as Brookings was a privilege. I look forward to returning in the future.

Dr. Robert Pearl is the bestselling author of “Mistreated: Why We Think We’re Getting Good Health Care–And Why We’re Usually Wrong” and a Stanford University professor. Follow him on Twitter @RobertPearlMD

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  • Denise Runde
    Reply

    Thank you Robby, for bringing this discussion forward. In spite of your great work along with others at Kaiser, the country continues to point to the epi-pen or other high visibility costs rather than seeing the fundamental system change required to deliver high quality cost effective care. To align medical care with evidence and outcomes rather than productivity. Impossible under fee for service, non group practice model.

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