Woodstock of the Wonks: The Health Policy Establishment Honors One of its Own - Michael L. Millenson

You might call it the Washington Woodstock of the Wonks.

Hundreds of members of the health policy establishment gathered in the nation’s capital last Thursday to celebrate the 25th anniversary of the premier health policy journal, Health Affairs, and honor editor-in-chief John Iglehart on his retirement from the position he’s held since the journal’s founding. How a publication whose first issue is dated Winter, 1981 can celebrate a 25th anniversary on the eve of Winter, 2007 was a question that went unanswered. On the other hand, when’s the last time numbers coming out of Washington actually added up?

The day featured a Health Policy Summit filled with a blue-ribbon list of speakers followed by a dinner gala designed to provide a bit of a financial cushion for a journal highly dependent on the generosity of a handful of grantmakers. The Summit yielded a number of interesting nuggets of information, which this blog will address tomorrow. But just as significant were the insights about the health policy world that were not explicitly stated. These included:

The creation of an “establishment.” Health Affairs became the premier journal of health policy in part because its founders deliberately set out to create a health policy establishment. The conservative do-gooders of Project HOPE recruited Iglehart, a journalist rather than an academic, to create an analog to Foreign Affairs, the journal that allows the foreign policy establishment to talk among themselves. Conspiracy theorists may suspect Princeton’s Uwe Reinhardt was deliberately groomed as the health policy answer to Harvard’s Henry Kissinger.

Health policy goes global. As if to emphasize the convergence of the two journals’ spheres of influence, the gathering featured a major address by Cheryl Scott, who went from heading a Seattle health plan to CEO of the Bill & Melinda Gates Foundation. The foundation, which focuses on health disparities in the U.S. and abroad, has begun funding Health Affairs to devote regular attention to the global scope of these types of issues. Earlier in the day, Sir Donald Berwick, president of the Institute for Healthcare Improvement, highlighted the way in which IHI has expanded internationally, including projects in South Africa and Malawi. Berwick also pointed to IHI’s ongoing work on a hospital mortality measure with Britain’s Sir Brian Jarman. (As an American citizen, Berwick actually received only honorary knighthood, but since this blog owes its existence to a Brit, it seemed acceptable to throw in the “sir.”)

The Internet changes everything and nothing. In its first quarter century, Health Affairs published nearly 4,000 articles. In its next quarter century, that number will increase exponentially both because of the print publication’s greater frequency of publication and the move to publish some articles directly on the Web. The original circulation of a few thousand print subscribers has grown to more than 11,000 print and Web subscriptions, with a site that attracted over sixteen million page views in 2006. The journal even has a blog. What has not changed, however, is that timely and accessible content is important only if people want to read it. That, in turn, relates to both what is said and how it is said. Iglehart and his hand-picked successor, health economist James C. Robinson, share a deep understanding of this reality despite the stylistic differences of an ex-wire service reporter from Milwaukee and an academic superstar at University of California, Berkeley. John, as one colleague said in tribute, is health care’s Columbo, the old-fashioned TV detective who deceived the fast-lane bad guys with a pseudo-slow style that masked a razor-sharp mind. Jamie in my view, is more likely to suggest CSI:Miami’s David Caruso.

The difference between “medicine” and “health care.” The major sponsors of the 2007 Health Policy Summit and a subsequent dinner gala were foundations, health plans and drug companies. In the sixth and lowest tier of sponsorship, forking over chump change of ten grand each, were the American Hospital Association, the American Academy of Family Physicians and the Association of American Medical Colleges. On reflection, this makes sense, given that the central problem in health care policy is the unrestrainable and unjustifiable growth in the cost of care prescribed by doctors and frequently delivered by hospitals. Put another way, health plans have prospered as the cost controllers; providers have suffered as the cost controllees. As for drug companies, they’re the savvy guys who spread their bets, ensuring an open door and a welcoming ear no matter who’s in power.

The unvarying persistence of practice variation. Dartmouth’s John Wennberg, founder of the Center for the Clinical Evaluative Services, was honored as the most influential health services researcher over the past 25 years. Truth be told, he published his first paper on practice variation in 1973, but didn’t hit the “big time” until a prescient Iglehart devoted the journal’s second-ever theme issue to “variations in medical practice” in 1984. Congress immediately responded with hearings, and, struck by the enormous potential of consistently appropriate medical practice to save money and save lives, eventually decided to study the problem some more. This, in turn, paved the way for Wennberg’s son, David, to grow up, go to medical school and start publishing practice variation studies of his own. HealthDialog, where David Wennberg is a senior executive, is an outgrowth of the non-profit Dartmouth center founded by Jack. It’s unclear whether any of David’s children will continue in the family business, but neither Wennberg père nor fils seemed worried that practice variation will have successfully been addressed between now and the time they finish high school, college, medical school and post-graduate residency and research training.

Over the past quarter century, the advent of a large and highly trained health care research community has meant a dramatic improvement in the ability to point out inefficiencies in the health care system, such as practice variation; to document in ever greater detail the economic and human costs; and to suggest a range of possible solutions. But the success that health researchers have had in persuading policymakers to adopt these proposed solutions, many of which engender strong political opposition, is probably equivalent to the influence that experts in foreign affairs have had in persuading the United States to adopt a rational course in foreign policy.

As for health researchers’ impact on the public – did I mention that the United States does not yet have universal health insurance?  But, of course, that’s no reason not to continue trying.

Michael L. Millenson, whose 25 years in health care began in 1982, is president of Health Quality Advisors LLC in Highland Park, IL.