One Percent…
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I have been, and always will be, a huge fan of Judy Norsigian - the founder and ED of Our Bodies Ourselves. She recently co-authored an op-ed in the Boston Globe called “The Folly of 1 Percent Policy” that reminded me about why I find her so interesting. She and her co-author argue that by focusing on the possibility that one percent of the time something might go wrong, we apply overly invasive - and expensive - health care solutions to people who don’t need them. In this case, they were writing about the rising C-Section rate in the U.S., which they argue is being driven not by clinical necessity, but by a care delivery system that’s using a very invasive and expensive procedure to eliminate the one percent chance that something might go wrong if a baby was delivered vaginally. They then argue that healthy women delivering healthy babies via C-Sections are putting themselves at risk. It’s not a simple procedure.
My own simple metaphor would be using the firehose to put out the match. Yeah, it works, but it’s a lot more than you need, and using it creates its own set of issues and problems.
Norsigian and her co-author go on to say that, “The fact that most of these crises never occur and that countless resources are expended to prevent something that was unlikely to happen anyway is lost in the relief of the immediate positive outcome (a healthy baby or no terrorist attack). In the long run, however, we’ve wasted time and money, created new problems, and ignored systematically documented, if less emotional, evidence. A version of the 1 percent doctrine has been invoked for decades in steering the US healthcare system away from an emphasis on preventive care for the whole population to an obsession with treating rare events. As a debating strategy, the 1 percent doctrine is extremely persuasive. As a policy guideline, it makes no sense in either politics or healthcare.”
Right on, Judy. The op-ed is also available on her website - www.ourbodiesourselves.org.
Charlie,
Thanks for highlighting a terrific article. It inspired a complementary post in my blog on consumerism. The 1% doctrine is extremely dangerous in that it leads to over engineered, highly expensive “solutions” that often don’t impact what actually happens (think about all the effort that the French put into fortifying the Maginot Line), and often have detrimental collateral impact (e.g., many french guns were concentrated in the area bypassed)
If we are to truly believe in evidence-based medicine, outcomes should be the only markers that matter– and they may be publicized by several different infomediaries in the unclean way we see in the rest of the consumer space. The process of innovation is untidy, and unfortunately our regulatory bodies tend to hinder, rather than help, those transformations.
I am reminded of the statistic in the latest Kaiser Family Foundation survey that 22.5% of all healthcare expenditures in the US were spent on 1% of the population. If you apply that to the proposition that healthcare expenditures represent 16% of the economy, that means that about 3.8% of the economy went to address one need of 1% of the nation.
It would be good to study that 1% - obviously they are the critically ill, but what are their demographics, what is the resulting gain for them in terms of lengthening their life expectancy and ability to contribute to society, etc.
It is amazing how often policy does change for the very rare circumstance. The article mentioned by Charlie and the comments that followed are right on. I’m a big fan of tracking costs/ROI/dashboards etc. and in regards to C-Section, it is amazing how high the costs are and how little people understand what is involved in such a procedure. The processes that must take place for a typical C-Section really adds up if you truly analyze the resources utilized. I wonder how often the average american citizen things about this.