Obama and Unwarranted Variation

I watched with interest Obama’s press conference from Wednesday night, as I’m sure many people did. I think he handled himself quite well and showed an impressive command of the issues. I think the discussion definitely favors healthcare reform when it is kept high level, which is why it concerns me that the Senate is now delaying a vote on healthcare until after the August recess.

A few high level things that I noted throughout the conference: there were at least two points at which Obama used the term “unwarranted” in his answers. One was when he was talking about tonsillectomies; the other was when he was talking about bonuses for bank executives. Of course, “unwarranted” is the first half of a famous phrase in healthcare: Unwarranted Variation. This is the phenomenon observed in Medicare data that the delivery of healthcare in different regions around the country differs for reasons that have nothing whatsoever to do with illness, medical need, or evidence based medicine.

These observations were made by Dr. Jack Wennberg and colleagues at Dartmouth, and have been documented in an important project called The Dartmouth Atlas. The Dartmouth Atlas, in turn has been referenced by the likes of Peter Orszag, Obama’s Director of the Office of Management and Budget. (Incidentally, Orszag's Special Advisor for Health Policy is Ezekiel Emmanuel--Obama Chief of Staff Rahm Emmanuel's brother.) By some estimates, if unwarranted variation was completely eliminated, it would reduce Medicare costs by as much as 30 percent.

(As an aside, I think it is interesting that he is starting a subtle mantra of unwarranted variation as a bad thing, and the unseemly association of “unwarranted” with bank bonuses. If everyone had the same visceral reaction to unwarranted variation that they have to unwarranted bank exec bonuses, we'd all be much better off.)

In essence there are three categories of Unwarranted Variation:

• Effective care: Care where the evidence is incontrovertible, yet not delivered. For example, if you have had a heart attack, you should be taking beta-blocker (BB) medication. Only about 45% of patients are adherent with a BB in their first year post-heart attack. This under-use of care is unwarranted variation.
• Preference Sensitive Care: Care where the evidence supports different interventions, each with equal clinical validity. NOTE: on the link, there is a box in the lower left hand corner of the front page that talks about…wait for it….tonsillectomies. That’s right, the very example that Obama gave in his press conference concerning preference sensitive conditions is talked about as the classic example of preference sensitive care. Another more recent example (with great cost comparisons of treatments, is David Leonhardt’s discussion of Prostate Cancer in the NYTimes.
• Supply Sensitive Care: Care that tends to be driven the availability of services, not by improvements in quality. It is, in part, related to Roemer’s Law, but has broader implications. Diagnostic imaging, is a great example. When a new MRI machine is available in a community, it gets used, but the quality of the care being delivered does not appreciably improve. But perhaps most scarily, on pg. 3 of the attached brief, there is actually evidence to suggest that more care isn’t just more expensive, it can be deadly. As the brief states, “The study (comparing outcomes for patients with one of three conditions) showed increased mortality rates in regions with greater care intensity.” Yowza.

I think unwarranted variation is a great example if the way in which the healthcare debate is extremely complicated. This suggests that the problems with our healthcare delivery system are not merely about providing more care or less care, but both—as well as care that is just different.

Let me explain: if we are talking about delivering effective care, people need it, so we are talking about MORE CARE. If we are talking about supply sensitive care, we are talking about delivering LESS CARE, because too much of it is a bad thing. And if we are talking about preference sensitive care, we need to deliver DIFFERENT CARE.

And one of the real questions for healthcare reform, is how to use public policy to address unwarranted variation. This is a fairly nuanced point that has trouble making it through the cacophony of vitriol on healthcare reform. However, steps are being made in this direction.

Perhaps most importantly, the ARRA legislation (the “stimulus bill” that was passed in February) included a provision to create the “Federal Coordinating Council for Comparative Effectiveness Research” and funded it with $1.1 Billion. Some of this will get at issues of unwarranted variation; others will address lacunae in research around the delivery of qualityhealthcare.

As I said earlier, I think the major thrust of this round of reform efforts is on coverage. Lets get the 45+ million Americans without coverage covered. Then lets really start tweaking the system so we 1) know what quality is; 2) measure and report on it; and 3) incent providers to provide it—financially or otherwise.