Making Medicine Great Again

The annual Lown Institute Conference advocates for the “right” kind of patient care, as in “the correct course of action.” But the political meanings of “right” and “left” also echo, sounding like a healthcare version of the recover-lost-glory demands of Donald Trump and the moral crusade of Bernie Sanders.

The program for this year’s meeting, held in Chicago, urged attendees to “take back health [care];” you could almost hear a Trumpian, “Make medicine great again!” In an opening address, the institute’s senior vice president, Shannon Brownlee, proclaimed, “We are gathered out of a shared sense of moral purpose and a shared sense of outrage at the state of American healthcare.” The targets of that outrage that “we” need to take back healthcare from comprised a Sanders-type litany of the “pharma, biotech and device companies…[who] have illegally marketed products.”

There was one more villain, very carefully defined. That would be “a culture of overtesting and overtreatment…[that] harms patients, clinicians and communities.” Got that? While Brownlee’s acclaimed 2007 book, Overtreated, repeatedly highlights the abuses of fee-for-service medicine, the Lown Institute’s namesake founder and its president are academic physicians. And so, the doctors and hospitals responsible for and often profiting from overtreatment magically become just one more set of victims of the “culture.”

Ideological blinders notwithstanding, the institute’s work celebrates and highlights an impressive array of individuals working diligently for every conceivable kind of “right care.” There was Dr. Jeffrey Brenner, a Camden, NJ family physician whose description of his dogged, data-driven efforts on behalf of the poor and sick brought a standing ovation. And Dr. Joanne Lynn, a long-time advocate for the frail elderly, explaining why a MediCaring community model that mixed medical and social services was what the vulnerable old and their families really needed.

For the policy wonks, there was Lauren Taylor, co-author of The American Health Care Paradox: Why Spending More is Getting Us Less, showing how the billions of dollars spent on unnecessary and ineffective medical care “crowd out” desperately needed money for education, housing and other social services. And for those focusing (literally) at the bedside, a University of California-San Francisco physician described an effort to reduce the frequency with which hospital patients are poked and prodded for blood work. The program was dubbed, “Think twice, stick once.”

True to its grassroots ambitions, the institute has established “right care” programs with chief residents at 32 academic institutions. Lown will keep contact with those individuals as they progress in their careers, while also working with the chief residents who take their place. Lown also maintains friendly relations with Choosing Wisely, a parallel initiative against overuse that 70 specialty societies. In addition, a fledgling Right Care Alliance has set up separate councils focused on issues, such as science and evidence, and medical specialties, such as cardiology.

I’ve followed the institute’s work since its inception, and this is the second conference I’ve attended. As much as I find Lown informative and inspirational, whether it can be influential remains a big question mark. An Institute of Medicine analysis of U.S. healthcare expenditures found $210 billion in unnecessary services in 2009. If you want to wrest away that magnitude of money, yo need to demonstrate some “might” to go with “right.”

So, for instance, though “Think twice, stick once,” was launched last year as a national initiative, at its home institution it hasn’t even spread beyond the Department of Medicine that birthed it. In political terms, this as if Bernie Sanders couldn’t win the Vermont primary.

Or take a much more economically and clinically significant example of overuse. About a half million kids go to the emergency room each year with some sort of head trauma. Research presented at Lown showed eliminating routine CT scans for those children did not hurt health outcomes, even while it eliminated the health risk of unnecessary drugs, surgery and radiation exposure. All well and good in theory. However, if Lown wants to change the “culture” that prompts those scan orders, it needs to show genuine public support. I suggest finding some moms willing to publicly agree that not treating their child’s “intracranial bleeds and skull fractures” (as the research phrased it) was perfectly fine since, of course, those problems would likely to heal on their own (another research finding). Absent that kind of support, that, good luck getting any insurer or hospital exec in their right mind to take on that overtreatment challenge.

Finally, Medicare and private payers are laboring hard to replace fee-for-service payment with reimbursement tied to precisely the type of goals Lown wants to achieve. That’s the “us” the institute should be mobilizing its followers to support, rather than, like Trump, appealing to a mythical past (here’s one of my articles on that topic) or, like Sanders, promising a utopian future.

After all, one can be both an idealist and realist, particularly about financial incentives. As Dr. Deborah Korenstein of Memorial Sloan Kettering Cancer Center put it about unnecessary treatments at the end of life, “Bundle the payment, then people will focus on what’s really best for the patient.”

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