Tuesday, May 26, 2009

Public and Expert Beliefs about Health Care Reform

Readers who have not made use of the superb information provided by the Kaiser Family Foundation are missing a national treasure. Director Drew Altman's recent two page analysis of the ways in which expert and public views of health care reform differ is a must read. President Obama and his health care team will use it to guide their advocacy messages, and the Republican opposition will use it to encourage fear about what the Democrats propose.

Here are some of the key points that Altman draws from the Kaiser Family Foundation surveys:

  1. Experts believe that up to 30% of the medical care provided is unnecessary, but 2/3 of the public believes that Americans don't get the tests and treatments they need - in other words, that too little care is the problem.

  2. Experts believe that patients should be - and could be - prudent consumers of health care, but only 1/5 of the public has ever inquired about the cost of care.

  3. Experts believe there are big differences in the quality of health care, but 70% of the public believe there are no major quality differences among doctors in their area.

  4. Experts believe that health care consumes too much of the GDP but only 14% of the public has this as a major concern.

  5. Experts attribute the ever escalating cost trend to expensive new technologies and treatments and to limited public understanding of quality and cost. The public sees the major cost drivers as waste,fraud and greedy drug and insurance companies.

We already see demagogic use of public (mis)understanding in the Republican campaign against comparative effectiveness research. If - as virtually every practicing clinician knows - our knowledge of which treatments work better and worse is much too skimpy, comparative effectiveness research is crucial for health care reform. But 55% of the public say that insurance should pay for whatever their doctor recommends, whether it is known to be more effective than alternatives or not. Republicans portray comparative effectiveness research as a ploy to allow "government bureaucrats to tell your doctors what they can and can't prescribe, no matter what your doctor thinks."

Our outlook on health and the health system is driven by emotion at least as much as by rationality. Except for those of us who fall into the "young invincible" category we are vulnerable beings, afraid of illness and mortality, eager to rely on a protective, healing power. That's why we place so much reliance on the opinions of our friends and family - the people we trust - rather than on the grail of evidence based medicine.

It's much easier to visualize demagogic attack on the way experts would reform the health system than it is to picture an equally emotionally alive form of advocacy for the experts' views. I believe that the President himself will have to take the role of an Everyman who (1) wants his doctor to be guided by good information, (2) understands that in the absence of good information, well-intentioned physicians prescribe large amounts of unnecessary and potentially harmful care, and (3) recognizes that runaway health spending actually reduces the overall health of the nation by hijacking funds from other health-promoting social benefits, one of which is higher wages! And we will need a new version of Harry and Louise who endorse evidence based medicine and see constraining our health expenditures as an admirable moral enterprise.

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