March 14, 2010

Health care reform: how to save lives and money and maybe defuse debates about teaching

Another reason for the House to pass the Senate's health-care bill and both houses to pass a tweak through reconciliation: it would expand existing comparative-effectiveness studies. Currently, massive advertising by pharmaceutics is feeding Americans' existing tendency to ask for huge amounts of wasteful spending on imaging/testing, drugs, and surgery. While NPR has highlighted the cooptation of a research term (osteopenia) in the service of Merck drug sales, it's important to see drug advertising as taking advantage of a broader tendency to overtest and overtreat, not the sole cause. Some other examples: older men take protein-specific antigen (PSA) tests to detect prostate cancer though you'd have to test 1400 men and possibly treat and thus give more than 40 men a substantial risk of impotence and incontinence to save a single life (National Cancer Institute PSA fact sheet). And apparently every year 75,000 people have cement shot into their vertebrae though sham surgery gives close to the same results

The "safe" and thus ineffective way of changing treatment is to give the advice, "ask your doctor." Yeah, right: practicing physicians who see patients 40-60 hours a week are always up on the latest studies published in obscure journals every week or two, and everyone knows that a doctor's advice is always followed. Consider three effective changes in health behavior prompted by research: smoking reductions, switching how parents put their babies to sleep (in terms of positioning), and a reduction in the proportion of older women taking hormone-replacement therapy. 

For example, it took decades for research on the harmful effects of smoking to filter down to behavior. You want to know why my mother quit smoking before I was born? My older siblings told her that it was disgusting, and she became convinced that not only was it unhealthy, it also represented a character weakness. I'm happy that I wasn't exposed to smoking when growing up, and the beginnings of postwar research on smoking's harms was a part in that but not the whole cause. More recently, the Florida Truth campaign was reasonably successful in persuading teenagers that smoking was uncool. Unhealthy? That was going to change behavior on the margins at best. Another social-marketing campaign changed parental behavior on the sleeping position of infants. "Back to sleep" was based on solid research about the relative risks of sudden-infant death and hammered a simple, actionable message rather than talking endlessly about the research. 

If there is a case for research's changing behavior directly, it may be the reduction in hormone-replacement therapy as a result of studies such as the Women's Health Initiative 2002 report on relative risks of using hormone replacement. Even here, I suspect that the drop in use was both from changing recommendations of doctors (the first link in this paragraph is to an article that suggests that the drop in HRT was primarily among those at risk of cardiovascular disease) and possibly also older women's thinking of themselves as savvy consumers--and that can work both in favor of and against cost-effective medical treatment. Fortunately, there is some evidence that the drop in HRT use is leading to a decline in breast cancer. This is a substantial victory for large-scale public-health research.

Why then focus policy on comparative-effectiveness studies rather than rely on the existing hodgepodge system? Insurance companies already try to limit treatment, and they often rely on existing research to justify their decisions. Well, I've got first-hand experience of why bureaucratic mechanisms based in private industry are no more rational than public bureaucracies; though I have a family history justifying early colonoscopies, Blue Cross/Blue Shield of Florida spent several months denying claims. More importantly, the evolution of private decision-making about treatment has led to a lengthy cat-and-mouse game that has not changed the basic tendency of American medicine to overtest and overtreat those with coverage while we fail to cover those who need preventive care and treatment. Then there's the problem with hodgepodge anything: there needs to be balance between investigator-initiated studies and a systematic program of research.

More broadly, there are several benefits of comparative-effectiveness research. First, it provides a level of transparency that industry-generated decisionmaking never can. This is highly dependent on how resistant a comparative-effectiveness program is to corruption, but the private-insurance cat-and-mouse game is a structure guaranteed to lead to distrust and extra costs of operating a system of benefits. The Women's Health Initiative study publication is a case study of why comparative-effectiveness research is not only important in controlling costs but also in saving lives. The WHI study was large and credible, and the reports were published broadly in the general press. Second, the results of comparative-effectiveness research can be the foundations of more secure efforts to change behavior. We're always going to have bad medical-research reporting (quick: is there a research consensus on the effects of coffee drinking?), but it is going to be easier to write guidelines, communicate a message, and gain funding for publicity efforts if it is clear and credible. (Small aside: that's an obvious and appropriate role for foundations, not to fund marginal research but to fund public education efforts based on a solid research consensus.)

Third, a comparative-effectiveness research program can lead to professional standards of care that are less susceptible to manipulation based on context. Yes, doctors will sometimes grump about that. But Atul Gawande might have a few things to say about the value of checklists and the dangers of assuming professionals can just "wing it" when in an examination room. In doing so, health-care reform will move us one step away from thinking about professionals as a hero-artiste, and in turn that will move us in the right direction on talking about teaching.

So, to teaching: Having professional standards of care/practice based on research is a reasonable alternative to either laissez-faire approaches to teaching or assuming that the black box of incentives will magically improve results. That doesn't mean that it's easy. Larry Cuban's response to the story Elizabeth Green wrote for the New York Times is correct: the history of micro-teaching advice is long and not particularly successful. And I have no illusions that just because you say you're in favor of professional standards of care and practice means that there will suddenly be a body of rigorous research.

But anyone who believes in the hero-artiste model of teaching in the public schools needs both a political and ethical reality check. If you're paid by the public purse, you have an obligation to the public. Public school teachers need protection from corruption, unreasonable demands, and retaliation in response to whistleblowing. But that protection doesn't mean that an elementary school teacher should be able to teach what he or she wants, when he or she wants, how he or she wants. The practical and political tradeoff for some autonomy in the classroom is the adherence to recognized norms of professional behavior. That includes how teachers treat students, how they respond to a formal curriculum, and the instructional tactics used.

It's the latter that Green's article addressed. My guess is that teachers can argue either that they should be evaluated based on results or based on professional standards of care/practice tied to research, including research in the future. But you cannot argue that there should be no professional standards, or that a good chunk of them should not be tied to research. The "incentives" focus of much current accountability puts instruction in a black box. I think that's inappropriate public policy, but there has to be an alternative for at least political purposes. Changing the talk about doctors, checklists, and comparative-effectiveness research is a way to show that professionals do not have to be hero-artistes, and that's a healthy direction for the country.

Listen to this article
Posted in Education policy on March 14, 2010 1:02 PM |