I cannot recall an occasion when I have praised New York Times’ columnist David Brooks. And I’m not quite ready to start today.
But I would draw your attention to yesterday’s column. In some ways Brooks understands Obama’s strategy for passing health care reform better than many more liberal pundits.
Brooks describes the first-step as “table-setting: You will spend the first several months of your administration talking grandly about the need for reform. You will invite all interested parties to the table . . . You will talk about things that no sentient person could possibly disagree with — about the need for better information technology and for more preventive care . . . you are getting everybody talking. You are building relationships.” Obama did this very well.
The second step is simple: “In stage two, you pass everything over to Congress.” Obama did just that when he submitted his budget and said, in essence: “I’ve found $600 billion to finance reform. If you don’t like my ideas please come up with some alternatives. And we’ll need roughly another $300 Billion—so perhaps you could think about that too. I’ll be happy to listen to your ideas.”
Brooks speculates on what Obama was thinking “You’ll need these windbags at the end, so you might as well get them busy at the beginning. This will produce a whirl of White Papers, a flurry of committee activity . . .”
This is what I was referring to in a recent post when I talked about how legislators have “flailed about" trying to improve on the president's initial prposal for funding reform. . But I don’t think the president views Congress as merely a collection of wind instruments (Though no doubt he would agree that some definitely belong in that section of the orchestra.)
Where Brooks is supercilious; Obama is sincere. President Obama honestly believes that if you make a rational argument, and appeal to your audience’s better angels, most people can be persuaded to “pitch in" and help make this a stronger, fairer nation.
That is why you have to be careful when you read Brooks’ on the third stage of Obama’s strategy. Here Brooks is imposing his own cynicism on the president’s plan.
And Brooks is doing something that he often does rather well: He appears to be praising a liberal, when in fact he is implying that said liberal is not as honest as he or she seems. (During the Democratic primary, Brooks made an art of left-handed praise for Hillary Clinton.)
Brooks writes: “This brings us to the current stage: The Long Tease. Every player in this game has a favorite idea, and you are open to all of them. The liberals want a public plan, and you’re for it. The budget guys are for slashing Medicare reimbursements, and you’re for that. The doctors want relief from lawsuits, and you’re open to it. . . .”
He continues “You ran on a platform of hope and, boy, are you delivering. Every special interest in Washington lives in hope that they will get their pet idea incorporated into the final bill.
“None will come out and oppose you because they live in hope. .
“This brings you to the final stage, the scrum. This is the set of all-night meetings at the end of the Congressional summer session when all the different pieces actually get put together.
“You want the scrum to be quick so that the bill is passed before some of the interests groups realize that they’ve been decapitated. You want the scrum to be frantic so you can tell your allies that their reservations might destroy the whole effort . . . The scrum will be an ugly, all-out scramble for dough. You can probably get expanded coverage out of it. You can hammer the hospitals and get much of the $1.2 trillion to pay for the expansion.”
The flaw in Brooks’ analysis stems from the fact that he lacks a certain degree of emotional intelligence. Brooks suggests that Obama doesn’t believe in hope, that he uses hope merely to manipulate the players, to keep them pacified until the “final scrum.”
If this were true, Obama would not be so popular with voters. HealthBeat reader Brad F attended the AMA convention and confrims what I have sensed: if you are in the room when President Obmas speaks,,you know that he is genuine. Even through the thickness of a television screen, I have felt, seen and heard the authenticity.
But I do agree with Brooks on an important point: There will be a final scrum—late night meetings, when “the pieces are put together”—just as there were exhausting meetings when the fiscal stimulus package came together . The White House will be in charge, and some special interests will have their heads handed to them– to their total and utter surprise. Once again, White House budget director Peter Orszag will be a key player.
Will the president get everything he hopes for? Probably not. But Brooks is too pessimistic when he addresses the president, saying: “You won’t be able to honestly address the toughest issues and still hold your coalition. You won’t get the kind of structural change that will bring down costs long-term. In the scrum, Congress will embrace the easy stuff and bury the hard stuff.”
I predict that Obama will insist on some of the structural changes that will rein in health care inflation over the long-term. But everything doesn’t have to be made explicit in this year's legislation.
But I'll give Boorks credit: at the end of his column, he is spot-on. He understands that Obama holds the trump card. The devilish details of reform do not have to be spelled out in the legislation, “Which is why you have MedPAC,” Brooks explains. “That’s the Medicare Payment Advisory Commission, hat you want to turn into a health care Federal Reserve Board — an aloof technocratic body of experts that will make tough decisions beyond the reach of politics. You can take every thorny issue, throw it to MedPac and consider it solved.
“Conservatives will claim you’re giving enormous power to an unelected bunch of wonks. They’ll say that health care is too complicated to be run by experts from Washington. But you’ll say that you are rising above politics.”
I agree that, in the end, MedPac is the administration’s secret weapon. Few have read MedPac’s lengthy reports. Obama’s advisers have—and they have done an excellent job of briefing the president on all of the key points: the Dartmouth research, the need for accountable care organizations, and the fact that we are overpaying the least efficient hospitals and doctors—those that over-treat their patients, fail to co-ordinate care, and expose patients to needless risks.
As I have said in the past, MedPac knows where the hazardous waste is. It knows where to find the money to finance universal coverage.
Not everyone understands how much MedPac knows, and how much its in-depth understanding of our Byzantine healthcare non-system will help this administration. Just today, someone in the White House told me, “Most people don’t realize how important MedPac is.” That’s because relatively few people outside of a small circle of policy wonks have read the last three or four years of MedPac’s March and June reports.
Who Is On the MedPac Panel?
In the weeks and months ahead, you are going to be told, over and over again, that the administration wants to have health care decisions overseen by a panel of faceless bureaucrats. Slyly, Brooks calls them “an aloof technocratic body of experts that will make tough decisions beyond the reach of politics.” Once again, he seems to praise—these are men who will rise about the political fray to make the hard decisions–while at the same time planting the idea in your mind that these are cold men (“aloof technocrats”) who care little about you, me or our families.
The subtext is this: they will “ration” care—withholding care we need, leaving us to bleed and die.
In fact, MedPac aims to protect us from being gouged by those who would subject us to overpriced, ineffective and often unproven care. They understand what the Chief Operating Officer of a major New York City hospital was talking about when he told me: “Too often, we judge the quality of hospital care by looking at cardiac surgery, and asking “what percentage of patients died?” What no one ever asks is a more important question: “What percentage of patients needed that surgery in the first place?”
The members of the MedPac panel understand that quality means making sure that “the right patient receives the right treatment at the right time”, because many of them are healers: doctors, a physical therapist, a nurse. . .
In part 2 of this post, I’ll profile who is on the MedPac pane and what they want to do.
Great article Maggie.
I find that it’s been increasingly easy to defuse the opposition of my more conservative friends on healthcare this time around. Knowing that Obama is so reliant on MedPAC recommendations and knowing how sensible MedPAC’s recommendations are, it’s been more difficult for people who are instinctively opposed to “socialized medicine” or whatever it is they think Obama wants to do to remain opposed once they find out what Obama actually wants to do.
I had a long talk with my mom about this. She’s instinctively conservative but when I explained that one of the outcomes could be a system that incentivized her specialist to actually meet with her internist with her in the same room, or would actually incent doctors to respond to emails rather than force an in-person visit, suddenly she can’t wait for Obamacare.
People are very skeptical right now, because they’ve been so conditioned to be so. But when you explain that the first thing this current brand of reform wants to accomplish is to force the system to really ask questions relating to effectiveness and efficiency of care and can provide realistic examples of how reform could bring those changes about, opposition starts dissipating, even among conservatives.
Also, Maggie, I was at HFMA’s ANI conference this week and Gregory Poulsen, Senior VP at Intermountain Healthcare was on a panel and spoke brilliantly about his health system’s efforts to ensure their doctors were consistently delivering the care they know should be delivered (proper medications at discharge on heart failure patients, no voluntary inductions on pregnancies prior to 39 weeks, etc.) rather than spending lots of time and research investigating new designer treatments. Sounds like they use checklists heavily, he actually brought up an example from the airline industry, etc. Anyway, if you weren’t familiar with the work they were doing, you should check it out, he was one of the best speakers all week.
MedPac? Aren’t hese the people that gave use payment by procedure codes that overpay specialists and are primarily responsible for the shortage of primary care physicians? Didn’t they create this mess? What makes you think they are capable of fixing it?
brooks spot on as he often is. history suggests two things. first is they’ll pass a bill written in conference that most won’t have time to read and thus there will be surprises — some major — after enactment. second is there will have to be some adjustments that go well beyond technical corrections. as happened when medicare costs spiralled out of control almost immediately after enactment.
ultimately, tho, they’ll mend rather than end it. so its important to remember that the bill big will be important solely for setting big goals. the real details will be worked out in subsequent years.
I had the same concerns about MedPac as Teo voices but then I thought about the fact that the dysfunctional MCare payment system was created many years ago and that maybe the more recent MedPac reports would show that (finally) the thinking is changing and that new regs will soon follow.
It was a huge disappointment that the RBRVS project that I worked on in the late 1980’s, before going to nursing school, never made good on its stated goal to reduce payments for specialists and increase payment rates for primary care practitioners. In my work as a community health nurse in the inner city I regularly see the harm which these perverted financial incentives have caused.
I’ll be looking forward to Part II of this post — and to the new and improved MCare payment regs!
I loved David Brook’s article and cut it out of the NYT before I saw Maggie’s write up.
As opposed to Maggie, who thought Brooks was too pessimistic, I thought he was not pessimistic enough.
Time will tell. Not only will it be important to see what comes out of the “scrum”, but it will also be interesting to see what the “unintended consequences of well meaning actions” are.
Thanks Maggie,
Goes to show that good ideas from good minds (Brooks/Mahar)are welcome from either side of the political spectrum.
Dr. Rick Lippin
Southampton,pa
Mike,Teo, Jim, Anne, Legacy
Flyer, Dr. Rick
Thank you all. Another very good thread.
Mike–I agree. Anyone who has actually read the MedPac reports (or at least good summaries) realizes that this is a very intelligent, largely
apolitical group that is focused on getting real value for our healthcare dollar: effective care.
You’re right when you say: “People are very skeptical right now, because they’ve been so conditioned to be so.”
It’s been so long since we’ve had “good government” in Washington–strong, intelligent government, focused on the public good. No wonder people are skeptical.
Luckily, the majority trust Obama. That will help.
I’ve never interviewed the folks at Intermountina, but I have read about their work and know that they are excellent.
I’ll keep Poulsen’s name– I should try to interview him. Thanks for the name.
What’s interesting is that the really knowledgable people out there– Intermountain, Geisinger,
MedPac, Dartmouth, Don Berwick at IHI, Bob Wachtner at USCF, Gawande, etc. etc. etc. are all on the same page. They all understand what needs to be done. There is very little disagreement–though everyone agrees it will take many pilot projects to figure out how to get from here to there.
Teo–
No. MedPac is not the group that set the Medicare fees. The RUC did that and continues to update the fee schedule.
MedPac didn’t exist before 1998.
DRGs and the fee schedule were created long before that.
Jim–
You write; “history suggests two things. first is they’ll pass a bill written in conference that most won’t have time to read and thus there will be surprises — some major — after enactment. second is there will have to be some adjustments that go well beyond technical corrections. as happened when medicare costs spiralled out of control almost immediately after enactment.”
” so it will be important solely for setting big goals. the real details will be worked out in subsequent years.”
I agree entirely.
And it’s a good thing that lobbyists and some Congresmen controlled by lobbyists really won’t understand what is happening until after the fact.
(Congressmen who are most beholden to lobbyists–and least interested in the public good– don’t, by and large, have the most intelligent, quickeste and conscientious staff.
Those with excellent staff– Ted Kennedy and Carl Levin come to mind– will be on top of the details and will understand what is going on.
But setting “the big goals” is very important–particularly when it comes to insisting on a “robust” public sector insurance plan that sets standards for private insurers.
Unless it’s there in the original legislation, it will be very,very hard to get that public sector option later.
By “robust” I mean: we don’t want a public sector plan that is forced to sink to the private insurers’ level (paying too much for ineffective, inefficient care.) This, unfortunately, is what the conservatives are aiming for when they talk about a “level playing field.”
We need a public sector plan that is free to raise the bar, giving private insurers an incentive to improve in order to compete.
Anne —
You write that “it was a huge disappointment when RBRVS project that I worked on in the late 1980’s, before going to nursing school, never made good on its stated goal to reduce payments for specialists and increase payment rates for primary care practitioners.”
Yes, I agree. I have never been able to find the story of what went wrong. But somehow, the process was corrupted. Probably a helluva a story –but also probably very complicated–i.e. corrupted in many ways by many interests.
AS I mentioned to Teo, MedPac wasn’t created until 1998, so it was in no way involved.
And, as long as I have been reading the MedPac reports, they have been pointing out that the fee schedule is rigged to favor specialists. (Okay, they don’t use the word “rigged”–but they are very clear.)
Legacy– Glad you liked the Brooks’ article. . .
There are always “unintended cosequences” to everything we humans do. (In other words, this is not limited to what government does).
If you have raised children, I’m sure you’ve experienced unintended consequences resulting from some of your best-intended child-rearing practices.
If one wanted to avoid unintended consequences, one would stay at home– in bed.
Dr.Rick–
Thanks. And I agree that, to a large degree, Brooks understands how politics works in Washington–as does HealthBEat reader Jim Jaffee (see Jim’s comment on this thread.)
Jim has real career experience on the Hill, and while he is more of a centrist than I am (though I would venture, significantly to the left of Brooks, far less cynical and not at all supercilious), Jim also understands how the sausage is made.