Questions on the Materials for the First Day of Class
Note that few of these questions have right or wrong answers; most are intended to invite brainstorming and highlight policy challenges. Please jot down some notes about your responses to each of the questions below. I will not collect them, but your notes will help facilitate our discussion.
- Why is it so hard, in the words of UCLA Health System President David Feinberg, MD, to “decrease inefficiencies that don’t add value to care”? What are some barriers to decreasing inefficiencies?
- In the video, Brent James, MD, the Chief Quality Officer for Intermountain Healthcare, says that “we get screwed by the reimbursement system, but patients come first.” What change did Intermountain Healthcare implement that lowered the amount of money it made? Why did the change save “the people of Utah” so much money? How could the law could promote a better “alignment of incentives” in this type of situation?
- How is the standard of care set for routine prostate cancer screening? Why does it matter what the standard is? In medicine’s “zones of gray,” who should decide what to do, and on what basis?
- Why should we care about the regional variations in treatment illuminated by Elliott Fisher, MD, Director of Population Health and Health Policy at the Dartmouth Atlas? He asserts that the United States can reduce overall spending on medical care without rationing. Do you agree?
- Were you surprised by the downsides of “too much medical care” as presented by Shannon Brownlee, Acting Director of the Health Policy Program at the New America Foundation? Given that so many people in this country get too little medical care, should we should worry about overtreatment?
- Overkill makes many of the same points about too much medical care. Dr. Gawande singles out Virginia Mason Medical Center as providing the right care amount of care for one patient. What do you think VM’s financial incentives were when that patient presented for treatment? How did VM overcome those incentives? Is that model “scalable” to the rest of the nation?
- In Overkill, Dr. Gawande writes about his earlier article, The Cost Conundrum. In the latter article Dr. Gawande described the much higher physician costs he found in McAllen, Texas, than in El Paso, Texas. What were the reasons for the differences? How could the lower costs in El Paso be replicated in McAllen?
- In the second assigned article by Dr. Gawande, The Price Conundrum, he explains that he had relied on Medicare data when he wrote the Cost Conundrum, but that late in 2015 (just before he wrote The Price Conundrum), data from three large commercial insurers had become available. Did this data follow the same pattern Dr. Gawande had found in McAllen and El Paso? Why or why not?
- Was there anything else in these materials that particularly struck you? Any scenario that seemed particularly bad or good? Any conclusions particularly well or poorly supported? Anything else you hope to discuss during the course?
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