Notes from Eric
September 2011
Health care’s elusive big idea: Less is more
Americans are drowning in data while starving for transformational ideas. So writes Neal Gabler in his August 13 New York Times piece, “The Elusive Big Idea.”
Think Albert Einstein’s theory of relativity, Marshall McLuhan’s “medium is the message,” and Betty Friedan’s “feminine mystique.” Concepts like these let us “get our minds around our existence and attempt to answer the big daunting questions of our lives,” wrote Gabler, of the University of Southern California. Such visionary ideas could once “ignite fires of debate, incite revolutions, and fundamentally change the way we look at and think about the world.”
I thought about our work and our nation’s struggle with health care costs in a floundering economy. We’ve had 45 years of experiments in health care policy and finance. We’ve spent many billions of public and private dollars on health research. We now have access to unprecedented volumes of data from electronic medical records and health plan information systems. Still, the solution to the cost crisis can seem elusive as ever. What is the fundamental “big idea” that Americans are missing?
Nine days after the Gabler piece, Group Health e-mail buzzed with another New York Times article, “Cut Medicare, Help Patients.” Its authors, former White House advisors Drs. Ezekiel Emanuel and Jeffrey Liebman, warned “Medicare is going to be cut.... The only question is whether the cuts will be smart ones.”
They spotlighted providers eliminating waste without harming patient care—and in some cases, actually improving it. One example they hailed: Group Health’s medical home pilot, which boosted quality while reducing emergency visits, hospitalizations, and overall costs. They cited other instances where providers:
- forego tests, treatment, and procedures that don’t work,
- recommend low-cost alternatives to pricey care that gets comparable outcomes, and
- stop giving care that ultimately causes more harm than good.
So here it is, under our noses—the elusive big idea that might fix American health care—if only our society can embrace it: Less is more.
It’s a simple concept that too few have grasped. Our nation’s dominant fee-for-service health care economy rewards providers for giving more care—not less. Even in capitated systems like Group Health—where doctors are paid per patient rather than per service provided—community norms may pressure clinicians to do more care than necessary.
Without a major finance overhaul, a call for less care threatens many health worker incomes. Patients also resist change because they tend to trust their providers’ advice; they don’t see the business plan behind the clinician, the incentive to sell more of this test or that procedure to meet margin. Add the political spectacle of candidates equating health reform with “death panels,” and it’s easy to see why many Americans fear substantive reform.
Despite resistance to “less is more,” however, there’s great opportunity for positive change. As Dr. Charles Kilo and I described in the Journal of the American Medical Association (JAMA), current excesses in American health care may actually outweigh its benefits. We spend money on care that harms or doesn’t work. And mushrooming health care spending diverts money from areas such as education, environment, and infrastructure, where spending can improve health more than the same amount of medical spending does.
Group Health is helping to change this reality through research and innovation. We’re evaluating the effectiveness and costs of various models of care. We’re learning the comparative values of approaches to common problems like back pain, obesity, depression, high blood pressure, and diabetes. We’re exploring ways to help patients take charge of their health behaviors, leading healthier lives that require less—not more—health care. And rather than drowning in data, as Gabler suggests, our multidisciplinary teams of biostatisticians, epidemiologists, and economists are discovering new methods to harness the power of emerging information resources.
As debates over the federal deficit and health reform continue, Group Health Research Institute is preparing for change.
Traditionally, health institutes like ours have asked, “What else can we do to help people lose weight, prevent cancer, manage chronic illness?” We’ll keep asking such questions. But it’s become even more imperative to ask, “How can we control costs without harming care?” “In studying treatment, when is less actually more?”
Such questions are sensitive and challenge many fundamental notions about health care. But now is the time to embrace big ideas.
—Eric
Read Neal Gabler’s New York Times article, “The Elusive Big Idea.”
Read Drs. Ezekiel Emanuel and Jeffrey Liebman’s New York Times article, “Cut Medicare, Help Patients.”
Read Drs. Eric B. Larson’s and Charles Kilo’s JAMA article, “Exploring the Harmful Effects of Health Care.”