Friday, July 22, 2011

Whose perspective?

After a long hiatus filled with travel, work and lack of inspiration to write anything, I have chosen this arguably hottest day of the year to venture forth again. But I will make this brief, as it seems that everything that needs to be thought and said has already been thought and said. Yet who is listening?

Anyhow, to suspend my natural cynicism, I want to talk about perspective. No, not the perspective that makes parallel lines converge in the distance, but the one that gets lost in many of our political, civic, business, and, yes, even scientific discussions. I am talking about my perspective, your perspective, societal perspective, etc. I was inspired to write this because of these tweets by Gary Schwitzer to Kaiser Health News about a story on their web site:
Linking out to the story, I learned that a consulting arm of Disney is teaching hospitals about hospitality. Since there is going to be a financial incentive for these hospitals to deliver good customer service, many are feeling that an investment in this type of training will help them maximize these new reimbursements. Hurrah and ta-da! 

Well, Gary likes to burst these one-sided bubbles, and so he rightfully asked about the costs. What was baffling to me was the response by the KHNews who did not seem to appreciate the importance of reporting the costs or the various perspectives that these costs represent. So, this seemed like a teachable moment, and here is the teaching.

In outcomes research, we are always interested in understanding the perspective for both the costs and the benefits of interventions. In health outcomes these perspectives are broadly represented by the patient, the provider, the hospital, the payer, the employer, the manufacturer, the society, to name a few. These are just some of the examples of the usual stakeholders involved in healthcare decisions. Because our healthcare is such a fragmented disaster, many of these perspectives find themselves at odds with one another. Just think of the patient who wants to get what she perceives as a life-saving treatment that in reality has a 1% chance of helping at a cost of $600,000 per treatment course. From her perspective, since she is insured, this investment is well worth the cost. For a payer, however, this means $600,000 (multiply this by 100 in order to determine the cost to save 1 life) that cannot be spent on something else that can help more people more predictably. And if this payer is the taxpayer, the societal perspective enters the picture, where we have to decide what amount of money is worth spending on possibly saving one life -- is $60 million reasonable? Perhaps. But these are not simple questions, and, as such, do not have simple answers. In addition, all conversations that we hear or engage in have multiple perspectives. This is why a black-and-white approach is so divisive: it generally emphasizes two diametrically opposed perspectives. 

So, next time you hear about death panels or Mickey Mouse teaching hospitals how to maximize their revenue, consider the broader implications from may different perspectives. Chances are you will find yourself agreeing with more than one point of view. And when this happens, you will know that you have learned an important lesson and can now start engaging in more nuanced and thus productive debates, many of which will shape our society's future.

h/t to @garyschwitzer for this KHN story      

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