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Well, Uwe and I are definitely on the same page on this one of course. But this whole discussion does raise, for me, a question about which I have not thought about. And this is a question that, in an ideal world, the conference I'm disrespecting would seriously address. So here's the question: does anybody have good examples of situations in which experts have proposed health care reforms that actually worked? I've done a little work on unicorns and zombies and how, a very large part of the time, whether an idea is any good has no relationship to whether it is promoted in the policy communities, or to whether it is actually "adopted" as policy by political authorities (adoption, here, not being quite the same as *implementation*!) For example, I wrote up a version of this for the 2012 Carnet de Sante de la France, at Jean de Kervasdoue's kind invitation (please excuse the absence of proper punctuation marks). When I presented the english version of the paper to my colleagues in my political science department the response was essentially: "So what? What else is new? Nobody would seriously expect expert advice to be anything other than biased, self-promoting, and wrong." And, one colleague added, "the INTERESTING question is the conditions under which it is at all reliable. Tell us stories about that." It's an interesting challenge. On the whole, I think budget analysis by agencies properly constructed and buffered tends to be pretty good. CBO, if it is wrong, will be wrong because it would be very hard to get it right. This involves some norms of caution, insisting on evidence, etc; that health policy advocates find very narrow and small-minded. http://www.commonwealthfund.org/~/media/Files/Publications/Issue%20Brief/2010/May/1405_Cutler_impact_hlt_reform_on_hlt_sys_spending_ib_v4.pdf (see page 8) I also think that DRGs, though dramatically oversold (in part because they are used for very different purposes and there is only really good evidence that they accomplished much in the U.S., where it wasn't so hard to do better) are, on the whole, a fairly sensible idea. But does anybody else have good examples of expert advice in health care reform, and in particular ideas that are highly promoted in the policy community, actually being based on strong evidence and doing good? There have to be some. Don't there? best, Joe On Fri, Oct 19, 2012 at 1:22 PM, Uwe E. Reinhardt <[log in to unmask]>wrote: > ********** > > It is hard to disagree with Tom’s general argument. There is little wrong > with continuing to explore how to integrate health care to achieve more > cost-effective care.**** > > ** ** > > The problem, as Tom points out, comes when these attempts create a whole > new industry of evangelists and consultants around them, diverting > attention to the elephant in the room.**** > > ** ** > > For years we Americans have lamented the high cost of our health system > and sough to control it by targeting utilization. Someone – it may even > have been Moses – declared eons ago that 30% of health care utilization in > ****America**** is wasted. It is now an unquestioned faith, like the > Virgin Birth. **** > > ** ** > > So we have as a nation fiercely targeted utilization, either through > integrating health care or through high deductible health insurance > policies. It appears to have occurred to very few of the > utilization-control apostles on the conference circuit that when in country > A the prices for virtually any health care good or service are at least > twice as high as they are in country B, health spending per capita in > country A is likely to be much higher than it is in country B. Is that > really so hard to understand? And yet only a handful of us have been able > to get that point across, because we have been howling into the wind of all > these marvelous panaceas coming down the pike, promising to reduce > utilization and eliminating the 30% waste.**** > > ** ** > > For all we know, when the dust has settled, these integrated systems will > be behemoths with monopolistic power, extracting from us through prices > what they don’t want to extract from us anymore through “unnecessary” care. > **** > > ** ** > > I have yet to see a major conference in the ****US**** with the banner: > REDUCING HEALTH CARE PRICES. **** > > ** ** > > ** ** > > ** ** > ------------------------------ > > *From:* [log in to unmask] [mailto:[log in to unmask]] > *Sent:* Friday, October 19, 2012 12:15 PM > *To:* Uwe E. Reinhardt; AAHPN > > *Subject:* Re: FW: Conference Examines the Evidence of "What Works and > Why it Works" in American Healthcare > **** > > ** ** > > So how to put real life back into zombies? Joe's colleague makes the > point, and it will happen eventually re variations. As far as I can tell it > does seem to be happening with work on integrated care - after quite a few > years, there are people looking at integrated care who are interested in > why they haven't got very far in de-fragmenting the world. They are no > longer putting forward pie-in-the-sky pictures of how health care ought to > be (or not doing just that), but putting forward more realistic pictures > which try to include an understanding of the role and power of stakeholders > and their interests, of policy cultures, and so on - i.e. barriers to the > ideal. You could describe this, I suppose, as health services research > taking on board a dose of political economy. Which I think makes for more > realistic action on the future and also succeeds in deflating the hype Uwe > mentions. But there is of course a serious problem with these issues > running along with themselves until they become empty - as has been > mentioned before here, by Joe if I remember correctly, major industries > build themselves up around these topics. Having said that though, we do > need to have some bashes at putting forward the ideal, presenting a > panacea, before we can really understand why it is only a panacea, and then > be rightly-placed to start anew on something more realistic.**** > ------------------------------ > > *From: *"Uwe E. Reinhardt" <[log in to unmask]> **** > > *Sender: *Anglo-American Health Policy Network <**[log in to unmask]**> > **** > > *Date: *Fri, 19 Oct 2012 15:29:57 +0000**** > > *To: *<**[log in to unmask]**>**** > > *ReplyTo: *"Uwe E. Reinhardt" <[log in to unmask]> **** > > *Subject: *Re: FW: Conference Examines the Evidence of "What Works and > Why it Works" in American Healthcare**** > > ** ** > > Yes, Joe, it’s the hype that gets to you, after so many years of hearing > hype. **** > > ** ** > ------------------------------ > > *From:* Anglo-American Health Policy Network [mailto:** > [log in to unmask]**] *On Behalf Of ***Joseph White** > *Sent:* Friday, October 19, 2012 11:11 AM > *To:* **[log in to unmask]** > *Subject:* Re: FW: Conference Examines the Evidence of "What Works and > Why it Works" in American Healthcare**** > > ** ** > > Apropos Mayo... for what it's worth, as I wrote in JHPPL, when the ** > Dartmouth** people seemed to be suggesting that the Cleveland Clinic is > particularly high value, that was met with astonishment in ****Cleveland** > **. If you look at **Dartmouth**'s own data, the Clinic was at the same > cost level as its rival down the street, University Hospitals of **** > Cleveland****. And as for quality measures -- they don't necessarily do > so well. Which may mean the measures are flawed, but still tells you > something about the difference between hype and evidence. > > A colleague was editor of a major HSR journal for years. He tells me > eventually he stopped accepting articles on variations. He'd published > enough, he figured, so that showing variations existed was not > interesting. If he had gotten any that either explained them or showed how > to change the situation he would have published - but he didn't get any of > those.**** > > On Fri, Oct 19, 2012 at 10:20 AM, Alan Maynard <[log in to unmask]> > wrote:**** > > Well said Uwe: what goes around comes around is the title of an editorial > I have written for JHSRP comparing 1976 ****UK**** policy panic and > "solutions" and 2010 McKinsey malarkey/daftness. Practically identical.: > cut practice variations is an age old theme but evidence of reduction there > is little! We do love jumping on the spot!**** > > We limeys are now into Narnia, a cute children's book series, with > particular focus on Bob Evans' zombies and another breed of policies called > unicorns. These are mythical policies with no cost effectiveness evidence > base but continually advocated as "solutions" by policy wonks and "think > tankers" Unicorn policies in ****England**** include "integrated care", > telemedicine, electronic patient record and NHS re-disorganisational > "reform". As Bob emphasised with Zombies, the nice question with Narnia's > unicorns is who are the unicorn masters?!**** > > Be of good cheer and have a nice weekend you all**** > > Alan**** > > On 19 October 2012 14:30, Uwe E. Reinhardt <[log in to unmask]> wrote: > **** > > Although the people speaking at the event are all good and highly > motivated people, it has become something of a traveling road show – like a > Broadway play on the road. Always the same characters (although for unknown > reasons this one lacks Carolyn Clancy of AHRQ) with the same message. So, > Michael, you are right. Go have dinner at Lutece instead, or at Cheesecake. > **** > > **** > > We have had such a road show before, in the 1990s, when “Integrated Health > Care” was the rage. There even was an annual conference called “Integrated > Health Care,” convened annually at the Ritz in ****Naples**, ** Fla.****Steve Shortell, Stuart Altman and I enjoyed them tremendously. > **** > > **** > > Not long ago in DC, I showed an animated slide illustrating how one could > build an integrated health system, layer by layer, starting with the > economic layer and eventually, hopefully, with the clinical layer. People > were stunned when eventually I let out that these slides were 25 years old. > **** > > **** > > We hear so much about high performance systems in the ****US**** – mainly > from the people who run them – but there is a paucity of hard, > comprehensive data on their cost effectiveness. For the most part we hear > anecdotes. I am not saying that they are not high performance or cost > effective. It would just be nice to see some hard data now and then. For > example, do we really know whether the Mayo Clinic is cheaper for given > treatments? That is not what I heard from the former CEO of Minnesota Blue > Cross Blue Shield. **** > > **** > > Uwe**** > > **** > ------------------------------ > > *From:* Anglo-American Health Policy Network [mailto:[log in to unmask]] > *On Behalf Of *Michael Gusmano > *Sent:* Friday, October 19, 2012 8:31 AM > *To:* [log in to unmask] > *Subject:* Re: FW: Conference Examines the Evidence of "What Works and > Why it Works" in American Healthcare**** > > **** > > Thanks for the inserts! I feel better about not attending J**** > > **** > > *From:* Anglo-American Health Policy Network [mailto:[log in to unmask]] > *On Behalf Of *David McDaid > *Sent:* Friday, October 19, 2012 2:18 AM > *To:* [log in to unmask] > *Subject:* FW: FW: Conference Examines the Evidence of "What Works and > Why it Works" in American Healthcare**** > > **** > > **** > > **** > > *From:* **Joseph White** [mailto:[log in to unmask] <[log in to unmask]>] > *Sent:* 19 October 2012 06:43 > *To:* Mcdaid,D > *Subject:* Re: FW: Conference Examines the Evidence of "What Works and > Why it Works" in American Healthcare**** > > **** > > *Inserted! I can't resist...***** > > *cheers,***** > > *Joe***** > > On Fri, Oct 19, 2012 at 1:26 AM, David McDaid <[log in to unmask]> wrote:* > *** > > **** > > **** > > *From:* ECRI Institute [mailto:[log in to unmask]] > *Subject:* Conference Examines the Evidence of "What Works and Why it > Works" in American Healthcare**** > > **** > > <http://link.coremotivesmarketing.com/c/306/66c8142009ffbd867f4e3abf571043d791883b67bb7dc6343bdb5367bbfb5515> > **** > > <http://link.coremotivesmarketing.com/c/306/66c8142009ffbd867f4e3abf571043d791883b67bb7dc6343bdb5367bbfb5515><http://link.coremotivesmarketing.com/c/306/66c8142009ffbd867f4e3abf571043d791883b67bb7dc634b53d1d1cb30fc094> > **[image: Register now]<http://link.coremotivesmarketing.com/c/306/66c8142009ffbd867f4e3abf571043d791883b67bb7dc634b53d1d1cb30fc094> > **<http://link.coremotivesmarketing.com/c/306/66c8142009ffbd867f4e3abf571043d791883b67bb7dc634b53d1d1cb30fc094><http://link.coremotivesmarketing.com/c/306/66c8142009ffbd867f4e3abf571043d791883b67bb7dc634b53d1d1cb30fc094><http://link.coremotivesmarketing.com/c/306/66c8142009ffbd867f4e3abf571043d791883b67bb7dc634b53d1d1cb30fc094><http://link.coremotivesmarketing.com/c/306/66c8142009ffbd867f4e3abf571043d791883b67bb7dc6343bdb5367bbfb5515> > **** > > *CREATING “SYSTEMNESS” WITHIN HEALTHCARE DELIVERY: > Can Success be Proven and Shared? > ECRI Institute’s 19th Annual Conference on the Use of Evidence in Policy > and Practice > November 28 - 29, 2012 > In Washington, DC, at the National Transportation Safety Board Conference > Center<http://link.coremotivesmarketing.com/c/306/66c8142009ffbd867f4e3abf571043d791883b67bb7dc6343bdb5367bbfb5515> > ***** > > *This conference is a free public service; hurry, space is limited, so register > now. > > www.ecri.org/2012conf > Agenda > 40 Distinguished Presenters and Moderators > Earn up to 13 AMA PRA Category 1 Credit(s)tm<http://link.coremotivesmarketing.com/c/306/66c8142009ffbd867f4e3abf571043d791883b67bb7dc6343bdb5367bbfb5515> > ***** > > *ECRI Institute’s 19th Annual Conference, brings together a range of > constituencies, including public and private providers and payers, policy > makers, clinicians, industry, regulators, consumers/patients, and > researchers to examine the evidence of "what works and why it works" in > American healthcare. The conference’s examination of “systemness” will > range broadly, asking thought-provoking questions, > such as:<http://link.coremotivesmarketing.com/c/306/66c8142009ffbd867f4e3abf571043d791883b67bb7dc6343bdb5367bbfb5515> > ***** > > · Are financial incentives alone enough to drive change?<http://link.coremotivesmarketing.com/c/306/66c8142009ffbd867f4e3abf571043d791883b67bb7dc6343bdb5367bbfb5515> > **** > > *No <http://link.coremotivesmarketing.com/c/306/66c8142009ffbd867f4e3abf571043d791883b67bb7dc6343bdb5367bbfb5515> > ***** > > · Do "transformation" units within health systems produce results?<http://link.coremotivesmarketing.com/c/306/66c8142009ffbd867f4e3abf571043d791883b67bb7dc6343bdb5367bbfb5515> > **** > > *Rarely at best. And probably more rarely if called that, as it > causes everybody else in the organization to immediately distrust the unit > <http://link.coremotivesmarketing.com/c/306/66c8142009ffbd867f4e3abf571043d791883b67bb7dc6343bdb5367bbfb5515> > ***** > > · Which elements within mature healthcare systems result in the > best clinical outcomes?<http://link.coremotivesmarketing.com/c/306/66c8142009ffbd867f4e3abf571043d791883b67bb7dc6343bdb5367bbfb5515> > **** > > *Depends on the system. But basically ones in which people have > figured out how to work together and can define the outcome in a way (a) on > which they agree; (b) which they can observe, and (c) which they can achieve<http://link.coremotivesmarketing.com/c/306/66c8142009ffbd867f4e3abf571043d791883b67bb7dc6343bdb5367bbfb5515> > ***** > > · Is there evidence that the use of EHRs promotes more cohesive, > effective, and efficient systems?<http://link.coremotivesmarketing.com/c/306/66c8142009ffbd867f4e3abf571043d791883b67bb7dc6343bdb5367bbfb5515> > **** > > *Somehow somewhere there must be cases. e.g. VHA. Now, is there > evidence that implementation of EHRs is likely under most circumstancesto create increases in effectiveness and efficiency that justify the > investment in terms of time, money, and disruption? No. <http://link.coremotivesmarketing.com/c/306/66c8142009ffbd867f4e3abf571043d791883b67bb7dc6343bdb5367bbfb5515> > ***** > > **** > > Join nearly 50 distinguished speakers and moderators, including: > <http://link.coremotivesmarketing.com/c/306/66c8142009ffbd867f4e3abf571043d791883b67bb7dc6343bdb5367bbfb5515> > **** > > - *John Colmers, MPH, Vice President, Health Care Transformation and > Strategic Planning, Johns Hopkins Health System<http://link.coremotivesmarketing.com/c/306/66c8142009ffbd867f4e3abf571043d791883b67bb7dc6343bdb5367bbfb5515> > * **** > - *Theresa Cullen, MD, MS, Director, Health Informatics, Veterans > Health Administration > <http://link.coremotivesmarketing.com/c/306/66c8142009ffbd867f4e3abf571043d791883b67bb7dc6343bdb5367bbfb5515> > ***** > - *Jessie Gruman, PhD, President, Center for Advancing Health > <http://link.coremotivesmarketing.com/c/306/66c8142009ffbd867f4e3abf571043d791883b67bb7dc6343bdb5367bbfb5515> > ***** > - *Brent James, MD, MStat, Chief Quality Officer and Executive > Director, Institute for Health Care Delivery Research, Intermountain > Healthcare<http://link.coremotivesmarketing.com/c/306/66c8142009ffbd867f4e3abf571043d791883b67bb7dc6343bdb5367bbfb5515> > * **** > - *Sarah Krevans, MBA, MPH, Chief Operating Officer, Sutter Health > <http://link.coremotivesmarketing.com/c/306/66c8142009ffbd867f4e3abf571043d791883b67bb7dc6343bdb5367bbfb5515> > ***** > - *Sharon Levine, MD, Associate Executive Director, the Permanente > Medical Group, Inc., Kaiser Permanente > <http://link.coremotivesmarketing.com/c/306/66c8142009ffbd867f4e3abf571043d791883b67bb7dc6343bdb5367bbfb5515> > ***** > - *Ralph Muller, Chief Executive Officer, University of Pennsylvania > Health System > <http://link.coremotivesmarketing.com/c/306/66c8142009ffbd867f4e3abf571043d791883b67bb7dc6343bdb5367bbfb5515> > ***** > - *Warren Lockette, MD, Deputy Assistant Secretary of Defense, > Clinical and Program Policy; Chief Medical Officer, TRICARE Management > Activity, U.S. Department of Defense<http://link.coremotivesmarketing.com/c/306/66c8142009ffbd867f4e3abf571043d791883b67bb7dc6343bdb5367bbfb5515> > * **** > - *Paul C. Tang, MD, MS, Vice President, Chief Innovation and > Technology Officer, Palo Alto Medical Foundation <http://link.coremotivesmarketing.com/c/306/66c8142009ffbd867f4e3abf571043d791883b67bb7dc6343bdb5367bbfb5515> > * **** > - *Earl Steinberg, MD, Executive Vice President, Innovation & > Dissemination, Geisinger Health System; Chief, Healthcare Solutions > Enterprise > <http://link.coremotivesmarketing.com/c/306/66c8142009ffbd867f4e3abf571043d791883b67bb7dc6343bdb5367bbfb5515> > ***** > > *Session Topics<http://link.coremotivesmarketing.com/c/306/66c8142009ffbd867f4e3abf571043d791883b67bb7dc6343bdb5367bbfb5515> > ***** > > - Developing an Effective Culture: Why Financial Incentives are not > Enough<http://link.coremotivesmarketing.com/c/306/66c8142009ffbd867f4e3abf571043d791883b67bb7dc6343bdb5367bbfb5515> > **** > - Creating Teams to Improve Inter- and Intra- Health System > Operations: Does the Evidence Show Benefit? > <http://link.coremotivesmarketing.com/c/306/66c8142009ffbd867f4e3abf571043d791883b67bb7dc6343bdb5367bbfb5515> > **** > - Transformation Centers and the Evidence: Where Are We Now? > <http://link.coremotivesmarketing.com/c/306/66c8142009ffbd867f4e3abf571043d791883b67bb7dc6343bdb5367bbfb5515> > **** > - The Use of EHR in Furtherance of “Systemness”: Case Studies > <http://link.coremotivesmarketing.com/c/306/66c8142009ffbd867f4e3abf571043d791883b67bb7dc6343bdb5367bbfb5515> > **** > - Beyond the Borders of Traditional Systems: The Changing Locus of > Care? > <http://link.coremotivesmarketing.com/c/306/66c8142009ffbd867f4e3abf571043d791883b67bb7dc6343bdb5367bbfb5515> > **** > - System Evolution: Incorporating New Partners and Partnerships > <http://link.coremotivesmarketing.com/c/306/66c8142009ffbd867f4e3abf571043d791883b67bb7dc6343bdb5367bbfb5515> > **** > - Federal and State Initiatives: What Does the Evidence Show?<http://link.coremotivesmarketing.com/c/306/66c8142009ffbd867f4e3abf571043d791883b67bb7dc6343bdb5367bbfb5515> > **** > - Evidence-Based Management: Lessons and Demands from the Business > World > <http://link.coremotivesmarketing.com/c/306/66c8142009ffbd867f4e3abf571043d791883b67bb7dc6343bdb5367bbfb5515> > **** > - Measuring the Success of Systems > <http://link.coremotivesmarketing.com/c/306/66c8142009ffbd867f4e3abf571043d791883b67bb7dc6343bdb5367bbfb5515> > **** > - Perspectives and Commentary > <http://link.coremotivesmarketing.com/c/306/66c8142009ffbd867f4e3abf571043d791883b67bb7dc6343bdb5367bbfb5515> > **** > - Regulatory and Legal Issues of "Systemness"<http://link.coremotivesmarketing.com/c/306/66c8142009ffbd867f4e3abf571043d791883b67bb7dc6343bdb5367bbfb5515> > **** > > *Register Now > <http://link.coremotivesmarketing.com/c/306/66c8142009ffbd867f4e3abf571043d791883b67bb7dc6343bdb5367bbfb5515> > *<http://link.coremotivesmarketing.com/c/306/66c8142009ffbd867f4e3abf571043d791883b67bb7dc634b53d1d1cb30fc094> > **[image: Register Now]<http://link.coremotivesmarketing.com/c/306/66c8142009ffbd867f4e3abf571043d791883b67bb7dc634b53d1d1cb30fc094> > **<http://link.coremotivesmarketing.com/c/306/66c8142009ffbd867f4e3abf571043d791883b67bb7dc634b53d1d1cb30fc094><http://link.coremotivesmarketing.com/c/306/66c8142009ffbd867f4e3abf571043d791883b67bb7dc634b53d1d1cb30fc094><http://link.coremotivesmarketing.com/c/306/66c8142009ffbd867f4e3abf571043d791883b67bb7dc634b53d1d1cb30fc094><http://link.coremotivesmarketing.com/c/306/66c8142009ffbd867f4e3abf571043d791883b67bb7dc6343bdb5367bbfb5515> > * > *There is no fee to attend this program, but advance registration is > required. > Space is limited to 350 attendees and *early registration is strongly > recommended*.**** > > * > Join the Conversation > Follow us now on Twitter at #EIConf12 and for live tweets during the > conference.<http://link.coremotivesmarketing.com/c/306/66c8142009ffbd867f4e3abf571043d791883b67bb7dc6343bdb5367bbfb5515> > ***** > > * > Questions? > Contact [log in to unmask] or call (610) 825-6000, ext. 5310<http://link.coremotivesmarketing.com/c/306/66c8142009ffbd867f4e3abf571043d791883b67bb7dc6343bdb5367bbfb5515> > ***** > > <http://link.coremotivesmarketing.com/c/306/66c8142009ffbd867f4e3abf571043d791883b67bb7dc6343bdb5367bbfb5515> > **** > > <http://link.coremotivesmarketing.com/c/306/66c8142009ffbd867f4e3abf571043d791883b67bb7dc6343bdb5367bbfb5515> > **** > > <http://link.coremotivesmarketing.com/c/306/66c8142009ffbd867f4e3abf571043d791883b67bb7dc6343bdb5367bbfb5515> > **** > > This email was sent by: > ECRI Institute > 5200 Butler Pike > Plymouth Meeting, PA 19462-1298 > USA > Telephone: +1 (610) 825-6000 > > ECRI Institute Offices: United States, Europe, Asia Pacific, Middle East > > *Privacy:* We respect your need for privacy. 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