Thursday, June 21, 2007

The Make-Work Bias Hiding In The Asheville Project

Ask a pharmacist in America, what is the seminal study demonstrating the clinical value of pharmacists, they would quote The Asheville Project. Beginning in 1996, Pharmacists in Asheville, NC improved diabetes patients' HgbA1c goal (a measure of improved blood sugar control), improved blood lipid levels and decreased costs of medical care of at least $2700 /patient/year. Pharmacists coined this study as The Asheville Project with hopes of replicating this study throughout the United States. Pharmacists conceived Asheville as America's hope to the rising cost of care, especially from Diabetes, which ranks high on the nation's list of afflictions.

Before discussing the economic issues hiding in the Asheville project, it needs mentioning that this study lacked a control group. In fact many studies in the U.S., spawned off of the Asheville project, likewise lacked a control group. The question remains how much did the exposure to a pharmacist realistically raise patient outcomes? Could simply meeting with a person dressed in a white coat do the same? What unique expertise only a pharmacist may bring provided the incentive for the patient to live toward better health outcomes and increased medication and lifestyle compliance? Without a control group, studies like Asheville fail to illustrate the unique expertise pharmacists bring to patient care.

I believe the make-work bias that plagues all health care disciplines today, not just pharmacists, contributed to the poor study design of Asheville and other similar studies. The goal of health care economics is not so much to design better studies, but to align the right incentives of all actors in the system toward greater outcomes. Bryan Caplan, an economics professor at George Mason University discusses in part of his work entitled, "The Myth of the Rational Voter", America's make-work bias.

The Lexington column of the Economist summarizes Caplan's make-work bias concept (June 16th, 2007). "[A possibly fictitious story] of an economist visits China under Mao Ze dong. He sees hundreds of workers building a dam with shovels. He asks: 'Why don't they use a mechanical digger?''That would put people out of work,' replies the foreman. 'Oh,' says the economist, 'I thought you were making a dam. If it's jobs you want, take away their shovels and give them spoons.'

This make-work bias that pushes a market toward inefficiency is what drives today's health care business model. A make-work bias hides inside the Asheville project. Pharmacists are eager today to market their skills as clinicians. While I share this drive, I don't believe Asheville was the effective market solution. The desire to expand the pharmacists' turf blinded the Asheville study away from a proper study design. In other words, the investigators of Asheville were more interested in demonstrating a job rather than demonstrating economic value.

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