The New Health Dialogue

The 1940 biopic Dr. Ehrlich’s Magic Bullet made famous both the physician who found a treatment for syphilis and the idea there was a single cure for every disease. Most of the old infectious killers have been eradicated, or nearly so, by drugs and vaccines, but the era of the magic bullet is coming to a close. Today’s medical challenges are chronic diseases like diabetes, heart disease, cancer, and Alzheimer’s – diseases that can’t be cured, but only prevented or managed – and we’re trying to address them with a health care delivery system made inefficient in part by the fact that it is caring for chronically ill patients as if they had acute ailments.    

Yet the notion that there’s a single solution to the conundrum of today’s health care delivery system lives on. Proponents of ideas like consumer-driven health care, electronic medical records, the patient centered medical home, comparative effectiveness research, ACOs, and training primary care doctors like to imagine that their preferred solution is the magic bullet, the one technocratic fix that’s going to bring down costs and improve quality.

Maybe it’s time to take a hint from another complex problem: climate change. In a paper published in Science in 2004, climate scientists Robert Socolow and Stephen Pacala argued that rather than waiting around for some new innovation that will magically make all that excess carbon go away, we should be tackling carbon emissions with existing technologies.

Socolow and Pacala called their seven intervention ideas “wedges” because of their shape on the graph (left). Each intervention has a small effect on the level of carbon dioxide emissions, and each effect shows up on the graph as a slice of the stabilization triangle, shaped like a wedge. Put into effect simultaneously, there are enough emissions-reducing technologies–such as carbon capture and storage at power plants and broader use of solar, wind, and nuclear power—to stabilize carbon dioxide levels in the atmosphere for the next 50 years.

In a speech last week at a Health Affairs briefing on “The New Urgency of Cost Control,” Don Berwick, the Administrator of the Center for Medicare and Medicaid Services, applied Socolow and Pacala’s idea to health care costs, arguing that we need to look at a broad range of existing delivery and payment system reforms—each of which is too small to stabilize medical costs individually, but that meet that goal when taken together.

Berwick named six stabilization wedges in his speech: eliminating overtreatment; improving coordination of care; reducing process failures that lead to hospital-acquired infections and other errors; reducing administrative costs; making sense of how we pay for medical care; and eliminating waste, fraud, and abuse of the medical system. All of those can be tackled with policy options familiar to the health policy field. It’s time to take them mainstream all at once.

But, and there’s always a but in health care, no single player in the health care system—not even the colossus that is CMS—can make these reforms happen on its own. The private sector can’t get it done independently, though, either. Cooperation among private payers, patients, doctors, and regulators is needed. Congressional action is necessary to create the regulatory and payment framework to encourage payment reform, eliminate incentives for overtreatment, encourage cost-reducing medical device innovation, cut bureaucratic overhead, etc, etc, etc.

 One problem with Congressional action, though, is that it requires a “score” from the Congressional Budget Office (CBO), an estimate of the measure’s effect on the federal budget over the next ten years. That “next ten years” bit is a deal-killer for a lot of potential savings around prevention of chronic illnesses, which often take decades to manifest themselves.

The CBO score is even more important than usual, in the current deficit-focused political environment, but so far the CBO has been reluctant to score medical delivery reforms as deficit-reducing. Perhaps the most appropriate thing for the CBO to do is to admit they can’t evaluate delivery reforms until they see them in action, and on more than just a pilot scale. Alternatively, the CBO should be able to generate an estimated budgetary effect of delivery reform based on the pilot projects that have already been tried.  

One way or another, we need to get over our wish for magic bullets.