Tuesday, April 22, 2014

Index to Medicine and Social Justice Blog, Year 5, Dec 2012-Nov 2013

Primary Care

Dec 23, 2012: Does AAMC have an answer for the primary care shortage? No.

Feb 8, 2013: Creating more family doctors: should we shorten medical school? How?

Mar 19, 2013: Can you be "too strong" for family medicine?

Jun 2, 2013: Primary Care Contributes More than Money....

Oct 13, 2013: The role of Primary Care in improving health: In the US and around the world

Oct 26, 2013: Why do students not choose primary care?


Health Reform

Feb 2, 2013: Kansas, Medicaid expansion, and human rights

Apr 21, 2013: Payments for surgical complications: With a scalpel or a meat ax?

May 5, 2013: Medicaid Expansion: Do we care for people or not?

May 26, 2013: Medicaid expansion will leave out many of the poorest: What is wrong with this picture?

Jun 16, 2013: "Call the Midwife": If Britain could afford to create a National Health Service after WWII, we can now!

Jul 21, 2013: Changes in the RUC: None.. How come we let a bunch of self-interested doctors decide what they get paid?

Aug 4, 2013: Why poor people choose ERs: we need a system designed to meet everyone’s needs

Sep 29, 2013: What can we really expect from ObamaCare? A lot, actually.

Nov 17, 2013: Dead Man Walking: People still die from lack of health insurance


Health Research and Evidence

Dec 8, 2013: More on mammography: just because you don't like the results doesn't make research junk science

Jan 12, 2013: Mental Illness and Guns: A public health perspective

Jan 19, 2013: Weight and class: who is obese and why should we care?

Jan 26, 2013: The flu is a virus!

Apr 7, 2013: Research on disparities/inequities, in practices and communities needs much greater funding

Apr 14, 2013: Premature babies and informed consent: we need to do it right

Sep 7, 2013: President Bush's stent: inappropriate screening and care for the rich, nothing for the poor


Medical Education

Feb 8, 2013: Creating more family doctors: should we shorten medical school? How?

Mar 19, 2013: Can you be "too strong" for family medicine?

Jul 7, 2013: Why don't graduate medical education programs produce the doctors America needs?

Oct 26, 2013: Why do students not choose primary care?

Nov 3, 2013: Should Medical School last 3 years? If so, which 3?

The Health System and Social Justice

May 19, 2013: Keeping immigrants and all of us healthy is a social task

Jun 16, 2013: "Call the Midwife": If Britain could afford to create a National Health Service after WWII, we can now!

Jun 22, 2013: Moving to Recovery By Design (guesy post by Robert Bowman, MD)

Jan 5, 2013: When is the doctor not needed? And who should take their place?

Feb 16, 2013: Creating team based care: are non-physician providers more effectively used in primary or subspecialty care?

Feb 23, 2013: Corruption and Scandal in the NHS: What happens when you introduce private incentives to public services

Mar 2, 2013: Squeezing the needy: a truly flawed financing system for healthcare

Jul 14, 2013: The State of US Health: improved over 20 years, but not nearly enough

Jul 28, 2013: The high cost of US health care: it's not the colonoscopies, it's the profit

Aug 4, 2013: Why poor people choose ERs: we need a system designed to meet everyone’s needs

Aug 10, 2013: Insufficient outrage: is health care about helping people or enriching providers?

Aug 17, 2013: Status Syndrome: an important determinant of health (guest post by Linda French, MD)

Sep 7, 2013: President Bush's stent: inappropriate screening and care for the rich, nothing for the poor

Oct 6, 2013: Critical access hospitals: Worth subsidizing to help save rural America

Nov 10, 2013: Does quality of care vary by insurance status? Even Medicare? Is that OK?

Nov 17, 2013: Dead Man Walking: People still die from lack of health insurance

Nov 23, 2013: Outliers, Hotspotting, and the Social Determinants of Health

Providers, Values, and Health

Aug 10, 2013: Insufficient outrage: is health care about helping people or enriching providers?

Aug 25, 2013: Physicians' role in controlling health costs: do no financial harm

Sep 1, 2013: Rand Paul on health policy: small brain and no heart

Sep 15, 2013: Competition vs. Coordination in health care: remember the patient!

Sep 22, 2013: Controlling the cost of health care by doing the right thing

Oct 20, 2013: The cost of medical care: bundling tests and blaming the victim

Nov 10, 2013: Does quality of care vary by insurance status? Even Medicare? Is that OK?



Apr 26, 2013: Matthew Freeman Lecture and Awards, 2013

Wednesday, April 9, 2014

Medicare payments to doctors: the big issue is the underpayment for primary care

The Center for Medicare and Medicaid Services (CMS) just published how much money individual doctors get paid from Medicare. This initial version is without names, but undoubtedly the names will eventually be revealed. Enough information is available for Reed Abelson and Sarah Cohen, who wrote the article for the New York Times on April 9, 2014Sliver of Medicare Doctors Get Big Share of Payouts”,   to identify many of the specialties and locations. About ¼ of all Medicare payments, the article tells us, go to about 2% of all doctors. “In 2012, 100 doctors received a total of $610 million, ranging from a Florida ophthalmologist who was paid $21 million by Medicare to dozens of doctors, eye and cancer specialists chief among them, who received more than $4 million each that year.” The largest amount of money was accounted for by office visits, $12B, but this was for 214M visits, with an average reimbursement of $57, in contrast to the Florida ophthalmologist, or to the “Fewer than 1,000 radiation oncologists, for example, received payments totaling $1.1 billion.”

Much of the discussion in the article, and in the comments attached, relates to why so few doctors get so much of the $77B Medicare pays out each year. There are, obviously, concerns about fraud; not only is Medicare seemingly fixated on looking for fraud everywhere but there is good evidence that it has occurred, at least historically. For example a highly paid (by Medicare) Florida ophthalmologist is apparently linked to a previous Medicare fraud scandal in which there was some implication of New Jersey Senator Robert Menendez. “The Office of Inspector General for the Department of Health and Human Services, which serves as a federal watchdog on fraud and abuse for the agency, released a report in December recommending greater scrutiny of those physicians who were Medicare’s highest billers.” I would have to say that this is a much wiser, fairer, and probably more productive strategy than simply trying to find largely unintentional errors in coding for outpatient visits, or checking each hospital admission to see if it could have been an “observation”, which is reimbursed less because it is considered outpatient status, as is done by Medicare’s Recovery Audit Contractors (RACs, or as I have called them, bounty hunters). Also, as I have previously discussed, these efforts are harmful to the patient in a direct financial way; as an “outpatient”, a Medicare recipient in the hospital has much higher out-of-pocket costs than if they are admitted as an inpatient. This is, of course, why CMS wishes to limit some stays, but if a person medically needs to be in the hospital, Medicare should pay for a hospitalization, and not play these games that not only financially penalize the hospital and doctors but more importantly the patient.

The other big area discussed is whether, if not exactly fraud, there is substantial difference in practice (e.g., getting CTs before each procedure, using more expensive drugs, etc.) that some specialists who are highly reimbursed by Medicare are doing more of than others. In addition, the question is “are they doing more procedures” or doing procedures with less strict indications? It is worth looking at; there is no guarantee that, even if some doctors are doing more procedures, having looser criteria for them, using more expensive drugs and tests, that this is not the better way to practice, but there is no guarantee that it is the better way to practice. If some doctors are outliers in their specialty, and their practice characteristics “happen” to end up making them a LOT more money than others, then this is certainly a reasonable basis on which to look more closely at how they are practicing, and what is the evidence basis of appropriate practice.

A third issue is that many of the recipients of the most money from Medicare, particularly oncologists (cancer doctors) and ophthalmologists are using very expensive drugs, which they have to buy first and which Medicare reimburses them for. Thus, this skews their reimbursement upward even though the money (or most of it) does not go to the doctor, but rather to the pharmaceutical company. The article refers to a drug called ranibizumab, injected into the eye by ophthalmologists monthly for age-related macular degeneration. It is very expensive, as are many drugs which are made through recombinant DNA (a lot end in “-ab”) used by oncologists, neurologists, rheumatologists, and gastroenterologists as well. One comment notes that he as a physician only makes 3% on the drug. While it can be argued that this is a significant markup (for example, making $3000 on a $100,000 drug), and that this doesn’t include the doctor’s fee for administering it (substantial), it is unfair to count the full cost of the drug as income for the doctor. Of course, it is income for someone (the pharmaceutical company) which suggests there needs to be substantial investigation into pricing of these drugs. And, of course, if a physician is found to be using a lot of a drug where he (or she) makes a 3% markup rather than prescribing an equally effective drug (if there is one) where there is no markup profit, this would be a bad thing.

However, the most important thing revealed by this data, I believe, is the enormously skewed reimbursement by specialty. It is an excellent window into the incredible differences in reimbursement for different specialties, with the ophthalmologists, radiation oncologists, etc. making huge incomes while primary care doctors (and nurse practitioners) are making $57 for an office visit. This is major. The fact that Medicare pays so fantastically much more for procedures (and, as a note, it is likely that all of the doctors, including the 202 family doctors in the highest-paid 2%, are getting it for doing a lot of procedures) leads to private insurers paying similarly more. And makes these specialties very attractive to medical students because they are lucrative (and often, though not in the case of many surgical specialties, involve fewer hours of work). Which leads to fewer primary care doctors, and a dramatic shortage in this country.

Medicare could change this. It could dramatically, not a little bit, change the reimbursement for cognitive visits to be closer to the payment for these procedures. If it did, so would private insurers. If the income of primary care doctors was 70% of that of specialists (instead of say, 30%) data from Altarum researchers and from Canada suggest that the influence of income on specialty choice would largely disappear. More students would enter primary care, and in time we would begin to see a physician workforce that would be closer to what this country needs, about 50% doctors actually practicing primary care.

It is fine if CMS and the OIG look at these highest billing doctors to make sure that they are not committing overt fraud. It is also fine to look at them and see if they are using criteria for procedures that are not supported by current evidence, or doing too many other tests, or taking kickbacks. It is also a good idea to look at the cost of drugs, especially the portion going to the drug company, as well as the markup for physicians, and to re-present the data excluding that portion of the money the doctor does not get (goes to the pharmaceutical company) from their income.

But the most important result of this report should be to be shocked at the way Medicare enables the continued practice of reimbursing for procedures at such high levels, and to kickstart a complete revision of the Medicare fee schedule to bring reimbursement for different specialties into better balance.
That would be a great outcome!

Thursday, March 27, 2014

Perception of problems in the health care system: will the mighty fall or is there a chance to save it for all of us?

[This is a particularly long post, but I haven't posted for some time. I have been working on a book, and if it ever comes together, this will be part of it.]

There are a lot of problems with our health care system in the US. Undoubtedly, there are problems with all health care systems, but ours has the distinction of being – by far – the most expensive in the world, and yielding health outcomes that are shocking low, especially for the cost. Our outcomes are much worse than those in comparable advanced capitalist democracies, and often follow behind other generally less wealthy countries. There are those who persist in saying “the US has the best healthcare in the world” but to the extent that they are not completely ignorant, or, worse, purposely dissembling for political reasons, they are talking about a narrow portion of health care. First of all, medical care. Second of all, medical care that is accessible, and therefore only for some individuals. Thirdly, mostly rescue care – high intensity, highly-specialized, high-tech, high-cost interventions for individuals with some conditions.

Even within these parameters, the claim is not entirely true. Many of the interventions that are available do not actually prolong life or the quality of life. They exist as goods which can be purchased by those with sufficient resources and sufficient motivation (presumably, ill health that is not responding to other treatment) but do not always (or even most of the time) create benefit that is “patient-important” – elimination of unnecessary death, or increased quality of life. For overall health care, even those with money, access, and insurance do not always get higher quality care; frequently, they have things done to them both diagnostically and therapeutically which they are led to believe may be of benefit to them, but often is not. In fact, these interventions can lead to further interventions, at greater cost in both dollars and discomfort or morbidity to the person, as abnormalities that turn out to be unimportant are chased down. Sometimes, these interventions, available mostly to the best off of us, are actually harmful. The costs are so high, we are seeing a new enterprise, “medical tourism”, in which Americans who need or want more-or-less elective surgery travel to other parts of the world, where the outcomes are as good and the cost is often (even with airfare and hotel!) less than the deductible would be in this country.

When we look at population health, rather than the individual health issues of people in the middle and upper class, the problems are even starker. By virtually every measure, health status in the US lags beyond other wealthy countries, and many less wealthy, in markers such as infant mortality, years of life lost to treatable conditions, disability adjusted life years, and even age of death. Our “between groups” contrasts are very stark in the US, mirroring those of many developing economies, not other “first world” countries. The fortunate among us may get the “best” care for some conditions at the expense (both financial and personal) of over-intervention, but many of us get what is frankly poor care or no care at all.

Finally, most of the negative determinants of health are outside of and before interaction with the medical care, or even any aspect of the health care, system. They are the social determinants of health, the economic status of your family (and of your family of origin; wealthy people born poor, while admirable “Horatio Alger” role models, have worse health status as a group than wealthy people born rich). They include housing, food, education, warmth, discrimination, environmental pollution (much worse in poor communities than in wealthier) and a host of other negative impacts that, in Dr. Camara Jones’ analogy[1], put you closer to the cliff face, more likely to fall off and then be at the mercy of whatever the medical care system does or does not provide.

However, even when people acknowledge that these disparities, inequalities and inequities exist, and that our health system is sorely lacking, there is not agreement on what the most important problems actually are. Even when we eliminate overtly political posturing and consider only the honestly conceived beliefs of different players in the system, there is lack of consensus because there are many different perspectives from which to view the elephant of health care. In addition to the differences in perspective, there are differences in incentives, in the fact that what may be good for some part of the system is bad for others. Physicians and other individual providers, hospitals and health systems, politicians, policy makers and pundit – and of course patients – have different perspectives. And, certainly, there is plenty of blame to go around, and no shortage of others that any of us can point fingers at as the “real” problem.

For a physician who is interested in caring for patients, the regulatory burdens can be the real problem. Days are spent with less and less time providing care to patients, and more and more completing the record (and the evidence is that, whatever the benefits, electronic health records take more time to complete), filling out forms, complying with regulations. Increasingly employed by hospitals and health systems, they are driven to “be productive”, which in a fee-for-service system translates into “see more patients and spend less time with each”.  The number of people who need care is increasing, not just from the one-time bolus of people getting health coverage under ACA, but more from the increase and aging of the population. There are exceptions, systems where care is capitated, where physicians and other providers (especially those in primary care) are organized into teams and paid on the basis of providing comprehensive care for populations rather than for face-to-face encounters, but these are far from the norm. From the perspective of these providers, most of the efforts to increase access have increased their workload, decreased their job satisfaction, and, possibly most important, decreased their sense that they are providing quality health care to their patients.

For hospitals and health systems, which have built enormous physical plants and infrastructures based upon “product lines” that are highly reimbursed (and, more important, have a high return on investment, or high reimbursement-to-cost-of-providing-the-service ratio), the challenge is also regulation, but in a different way, and of changing what is reimbursed. Like physicians, hospitals would like the public to think that they are in the business of delivering quality health care, but the emphasis, whether for-profit or non-profit, is often on the business part. Hospitals and health systems are sometimes run by physicians or other health providers (often with MBA degrees) but are frequently run by accountants. They may do well by their metrics, making (or not losing) money, but this may be a result of providing a particular market segment, or product line, or service to a particular (insured) patient population, rather than providing the most-need healthcare to those who need it most. If policy changes begin to financially reward doing something different than the hospitals have been doing (for example, keeping people out of the hospital) they can restructure, acquire ambulatory practices, fight it and hope it will go away, or go bankrupt. They can adopt collaborative arrangements with their physicians, and sometimes restrict referrals to keep them within the system. Changes in policies and regulations are very challenging, because there is such an enormous capital investment.

Policy makers, politicians, and pundits have different challenges. Politicians want to be re-elected, and so need to satisfy voters, or at least likely voters, or at least those with the most money who will finance their campaigns. Pundits have few restrictions other than their beliefs. Policy makers, who may be politicians or work for them, or may have been or later become pundits, have to implement goals. But sometimes the goals are in conflict. To restrict the potentially inappropriate admission of patients by hospitals in order to collect more money from Medicare, puts policies and practices into place which encourage classifying patients as outpatients (“observation” status). But this then does not eliminate the cost; it both decreases the reimbursement of the hospital and increases the amount that the patient, the Medicare beneficiary, has to pay out of pocket.

Of course, there is the patient, who is ostensibly the focus of all the attention, for whom the entire health system exists, but who is usually the least powerful player in the entire equation. More important, there is not a patient, there are many people with different sets of needs and preferences. Yes, most would like to stay healthy if they are, or get healthy if they can. They may be willing to put a lot of work into it or may have a more passive approach, wanting to be made healthy. They may have very different understandings of health, and different degrees of belief in and trust in physicians or other providers, and indeed in science. Even if they want to trust science and medicine, they are very likely to be confused by the complex way in which new medical knowledge is developed and found to be accurate, scarcely in a linear “this is good for everyone, this is bad for everyone” manner. Their lives may be very busy and have little time to spend at the doctor, or they may see visits to the doctor as one of the more positive and fulfilling experiences that they have. They may “know” what is wrong and what is to be done, and find the doctor to be just a particularly uncooperative store clerk who will not provide them with it, even when the doctor believes that it would be of little or no use, unnecessary and expensive, or even dangerous. They may have the sense of invulnerability that often accompanies youth, or the frailty and fear of old age. They may have cultural beliefs that make it difficult or impossible to understand or accept medical recommendations, and lead to frustration in interactions with the medical system. Even positive developments, such as the “Patient-centered Medical Home” (PCMH), are challenged by the fact that not all patients are the same, and what makes one comfortable, at ease, and feel healed may be a negative for another.

In his sensitive and thoughtful essay on the Health Affairs blog, Matthew Anderson provides us with 9 questions that he has about the PCMH, in the form in which he finds himself working and in the projections for the future.[2] He is certainly not opposed to a conversion of practice to being more patient-centered and less provider-centered, but raises questions about the degree to which the processes that have been put in place in the name of PCMH have actually done this, and whether they have increased or decreased not just his satisfaction as a provider but the quality of care that is provided to patients. Dr. Anderson is neither a Luddite nor a malcontent, but rather is trying to raise his eyes above instrument panel at which he is working to see if the direction in which the ship is sailing is the one we want to go in. He is, above all, focused on the values that we are trying to achieve, and concerned that our over-emphasis on the process, on the plan we have put in place rather than the goal, will not get us where we want to go.

In his book “How the Mighty Fall”[3] business professor Jim Collins puts forward 5 stages of decline in once-great companies. Stage 1 is “Hubris born of success”, Stage 2 is “Undisciplined pursuit of more”, Stage 3 is “Denial of Risk and Peril, Stage 4 is “Grasping for Salvation”, and Stage 5 is “Capitulation to irrelevance or death”. Which stage is your organization in?

Luckily, Collins’ work suggests that turnarounds can happen even in Stage 4. The key is staying true to the key principles and practices of our work. Dr. Anderson’s 9 questions can be a start to guiding us.

[1] Jones CJ, et al., “Addressing the social determinants of children’s health: a cliff analogy”, J Health Care Poor Underserved. 2009;20(4 Suppl):1-12. doi: 10.1353/hpu.0.0228.
[2] Anderson, M, “Nine questions about my new medical home”, Health Affairs blog, March 17 , 2014. http://healthaffairs.org/blog/2014/03/17/nine-questions-about-my-new-medical-home/
[3] Collins J. How the might fall: and why some companies never give in. Collins Business Essentials. New York. 2009.

Wednesday, February 19, 2014

Integrating health systems must be to improve quality, not increase cost

The February 13, 2014 article in the New York Times by Elisabeth Rosenthal, “Apprehensive, many doctors shift to jobs with salaries”, more or less just presents the facts. It notes that the medical placement firm, Merritt Hawkins, says that 64% of jobs this year are salaried as opposed to 11% in 2004, and that it expects it to go up to 75% in the next two years. She cites AMA figures that “…about 60 percent of family doctors and pediatricians, 50 percent of surgeons and 25 percent of surgical subspecialists — such as ophthalmologists and ear, nose and throat surgeons — are employees rather than independent.” In some places it is more dramatic; in Kansas City, there are no longer any cardiologists (a type of internal medicine subspecialist) who are not employed by hospital systems, and oncologists (cancer specialists) are not far behind.

So, is this a good thing? The article suggests yes, but maybe not entirely. It states that “Health economists are nearly unanimous that the United States should move away from fee-for-service payments to doctors, the traditional system where private physicians are paid for each procedure and test,” and I agree, and that “When hospitals gather the right mix of salaried front-line doctors and specialists under one roof, it can yield cost-efficient and coordinated patient care. The Kaiser system in California and Intermountain Healthcare in Utah are considered models for how this can work,” with which I also agree. However, not all health systems are Kaiser or Intermountain Healthcare. The article continues: “But many of the new salaried arrangements have evolved from hospitals looking for new revenues, and could have the opposite effect. For example, when doctors’ practices are bought by a hospital, a colonoscopy or stress test performed in the office can suddenly cost far more because a hospital ‘facility fee’ is tacked on.”

Rosenthal has written about facility fees before, as has Alan Bavley of the Kansas City Star in his “Doctors, Inc.” series (“’Facility fees’ add billions to medical bills”, Dec 29, 2013), and I have commented on it in Changing the structure of health care delivery systems: to benefit the patient, the providers, or the insurers?, January 14, 2014. The new arrangements promise more money, or at least stable incomes, to physicians, and continue to pay the currently-most-highly-paid specialists the most money, with primary care doctors getting less. This is not because hospital systems have anything against primary care, but rather that they are following the money, and these acquisitions have occurred precisely while we are still under fee-for-service reimbursement in most locations. If cardiology or orthopedic or radiologic or neurosurgical procedures bring in great amounts of money to the hospital (“technical fees”) the hospitals like this, and are willing to share some of that money with the doctors to ensure that they keep their patients in their hospital or health system. Primary care does not generate such largesse. Relatively intelligent systems recognize that they need a locked-in “primary care base” to create referrals to their subspecialists, but will pay as little as they can, and demand “high productivity” (which could be seen as “patient churning”), and it is not just primary care: “many doctors on salary are offered bonuses tied to how much billing they generate, which could encourage physicians to order more X-rays and tests.”

Bloomberg News has a more direct take on this phenomenon, stating firmly in an article by Shannon Brownlee and Vikas Saini that “Bigger hospitals mean higher prices, not better care”, February 18, 2014. They cite data from sources such as the Dartmouth Atlas of Health Care, a recent article in Health Affairs[1] which demonstrated that “On average, higher-priced hospitals are bigger, but offer no better quality of care,” and a variety of lawsuits by public agencies (such as the Massachusetts Attorney General) to demonstrate that hospital acquisitions are about market share and control of practices and, ultimately, about money, not quality. “If you think of value as some combination of needed services delivered for the right price, large hospitals are no better than small hospitals on both counts.” As I have written about before, doctors control a lot of costs in the health system, by choosing the tests that they order, deciding whether to admit to the hospital or not, and where they refer. By employing the physicians, hospitals can not only control the latter, but can set criteria requiring physicians to abide by hospital policies on the others. The doctors then become, in the words of this article,  “…another cog in the corporate machine, and many physicians have told us they feel they must skew their medical judgment to keep their jobs.”

This is the nonsense that occurs when things are done piecemeal. Intermountain Health Care and Kaiser are not perfect, but they have used their status as integrated health systems to control costs and increase efficiencies. To the extent that they are also the insurer, it is in their interest to do so. Efforts by the federal government to have others emulate these models through the creation of Accountable Care Organizations (ACOs), without changing the manner of reimbursement, are bound to fail. As Paul Baladian is credited with saying “every system is perfectly designed to get the results that it gets.” If we are getting a system in which hospitals are buying up physician practices so that they can charge insurers, from Medicare to Blue Cross, more; if we are getting a system in which medical decisions are being made in the best financial interests of hospitals rather than the best health interests of patients; if we are getting a system in which we continue to favor some patient over others based upon their income, insurance status, or their type of disease (middle-aged well-insured person who needs a single joint replacement = “good”, older person with multiple chronic medical conditions and “just” Medicare or worse yet uninsured because they are under 65 or undocumented = “bad”), it is because we have perfectly designed it to be so.

Brownlee and Saini offer some suggestions for solutions. They suggest that Medicare expand its “Advance Payment Model,” a program that provides capital to small or rural physician groups, and also particularly about forming multispecialty Accountable Care Organizations driven by primary care.

“Until we give primary-care groups control over what happens to patients, large hospital systems and specialist-dominated groups -- those with greatest access to capital -- will be able to keep raising prices, even as they issue press releases about their plans to control costs and improve care.”

Sounds like a good idea to me. Combine that with a single-payer system that covers everyone, “everybody in, nobody out!” and we may be able to reverse the trend toward higher profit at the expense of lower quality.

[1] White C, Rechovsky JD, Bond AM, “Understanding Differences Between High- And Low-Price Hospitals: Implications For Efforts To Rein In Costs”, Health Affairs, January 2014 10.1377/hlthaff.2013.0747.

Monday, February 10, 2014

Medical communication is indeed often "lost in translation"

I often write about the things that I believe make a big difference in the health of people. Some of these are access to the health system, particularly financial access in the US. The bizarre and inappropriate structure of the US health system in terms of overemphasis on high-tech, subspeciality care at the expense of adequate primary care is extremely important. I also believe that the “social determinants of health”, the characteristics of people’s lives that are not usually considered as part of the health system (socioeconomic status, environmental exposures, stress, education, housing, etc.) are major contributors to health.

I have also written about medicine in terms of recommendations for prevention and screening from different organizations (I tend to advocate for those from the US Preventive Services Task Force) and about treatments that are promoted but are often of minimal benefit and sometimes harm to people. Occasionally, I even venture into the area of medical research, trying to help folks understand how science progresses, and how there is rarely a “breakthrough” as big as the news media like to trumpet. As a medical educator, I am very concerned about how we train doctors, and have also frequently written on that topic.

Most of these themes are focused on “population health” rather than the management of individual patients with individual diseases, not because the latter is unimportant but because these issues are extensively addressed in many other outlets, and the ones that I have described are, I think, not as well understood both by the medical community and the general population. I believe that the almost exclusive emphasis in our country on treatment of individuals limits both our commitment to addressing population and system issues, and the resources available to do so.

However, sometimes there is an issue that is mostly about human behavior, something that could be changed, and would make a big difference in the healthcare experiences of most people. One of those I have touched on before (Medical schools are no place to train physicians, January 5, 2014), because I see it as a key part of medical education, is communication between health care providers and their patients. This was addressed in an outstanding “Opinionator” blog that appeared in the New York Times on February 9, 2014, "Lost in Clinical Translation" by Theresa Brown.

Ms. Brown is apparently a nurse, but what she discusses is at least as applicable to doctors and to other health professionals. Starting with a reference to the Gary Larson “Far Side” cartoon here, she gives excellent examples of failures of communication that were disturbing to patients, but did not, apparently, disturb the health professionals who, presumably, thought they were communicating as clearly as Ginger’s human owner does. One story is of her friend's husband, who a heart procedure called a “cardiac catheterization” to look for blockage in the arteries that supply the heart itself, which can cause a heart attack. (That description is, I hope, clear; when I told my residents, however, I just said “he had a cardiac cath”, which was very clear to them but would likely have mystified most patients.) As it turns out the test was completely normal, but this was not clear to the obviously very worried wife who understood almost nothing about what she was being told (for example, that he was being kept overnight in the intensive care unit because this is routine after such a procedure, not because his condition required intensive care!).

This sort of thing happens a lot. Daily. Hourly. There are many reasons for poor communication to occur between health professionals and patients. Some are that people, when they are scared and sick and in a strange place, have difficulty listening to strange words and understanding unfamiliar concepts. They may have to be told again and again, just as, I tell my students and residents, we all had to study to pass exams even though we'd be "told" everything once, in the lecture. But there are a lot of other things that are our fault, and can be remedied by different behaviors.

One, we – doctors, nurses, and other health professionals -- are very comfortable in the hospital, and we take it in stride; it is our "briar patch" and we're at home, but for patients and families it is a scary place full of thorns. I ask doctors and nurses to think about they would feel if they had to go to court, as witness or defendant or plaintiff, and look at how easily the attorneys comport themselves. It is a good reminder of how patients feel in a hospital.

Two, we speak "medical" fluently. We have such familiarity with both words and concepts that we assume that they mean something to regular people (which is, by the way, the correct English term for "patients" and "patients’ families"). But usually they don't; words that mean very different things sound a lot the same; even if people have heard them before they usually have only a vague idea of what they mean, and the difference between "is" and "is not" is, while obviously very significant, not always clear to folks. I point out, just for an easy one, how often we use "negative" when we are describing a normal test. We should ALWAYS use "normal" or "not normal". "Negative" sounds bad. "Positive" (which is often bad) sounds good!

Three, we often use obfuscating words, unnecessarily medical words when regular ones will do fine, and use lots of modifiers and adverbs that make what we are saying even more unclear. The use of such modifiers ("probably", "likely", "potentially", 'possibly") may make what we say more technically accurate, but can obscure the message. Similarly, we are often uncomfortable giving bad news, and when we use such modifiers we may think we are lightening the load a bit for the patient, but really we are being more unclear. When we hide behind medical words, we are protecting ourselves from having a long and perhaps difficult discussion; completely subconsciously, I'm sure, we expect that maybe they won't understand, and thus won't ask hard questions. Also we tend to speak in the third person, kind of distancing both ourselves (first person) and the patient (second person) from what we are saying. All these are illustrated by thinking about how a statement like "The biopsy result showed that the tumor was probably malignant" conveys a very different (and probably incomprehensible) message than "you have cancer".

It is a lot to think about, but the good part is that these behaviors can change. We just have to want to, and work at it.

NOTE: The Medicine and Social Justice blog will appear less often than it has, intermittently or maybe not at all, for some time. I am on sabbatical and will be engaged in writing a book, more or less on the themes described in the first two paragraphs of this piece, the themes that have been the subject of this blog.

Sunday, February 2, 2014

Health care systems should not be run for profit, but rather for people's health

I wrote in a recent blog (“How can a health care system lead not to ruin but to, actually, health?”, December 28, 2013) that our health care system ”…is a parallel to our financial services industry: private enterprise is given a license to make money from everyone, and the government finances it. The only difference is that for financial services, the government steps in to bail them out only after they have already stolen all our money, while in health services the profit margin is built in from the start.” A recent article in the New York Times, “Hospital chain said to scheme to inflate bills”, by Julie Creswell and Reed Abelson (January 24, 2014) takes this a bit farther.

Discussing the Department of Justice’s decision to join several whistleblower (“qui tam”) lawsuits against the for-profit hospital chain HMA (not to be confused with the nation’s largest, HCA) for aggressive policies that seek to maximize profits by “encouraging” (at threat of termination) doctors to over-admit patients, they quote Sheryl R. Skolnick from CRT Capital, who wrote “Investors seem to think that D.O.J. investigations, qui tam suits and allegations of serious Medicare fraud are simply a cost of doing business.” That’s right. Illegal activity has a price – fines – but the fines are small enough that they do not discourage the illegal activity. The authors write “Many settlements run only into the tens of millions of dollars. That’s a corporate slap on the wrist for companies whose stocks typically soar when executives push the profit envelope. Only if the penalty is at least $500 million, Ms. Skolnick said, are corporations likely to find the cost a deterrent.” Or, of course, if the heads of these corporations are sent to prison, but in another parallel with the financial services industry, this is not happening. Not to Lloyd Blankfein of Goldman Sachs or other financial titans (such as CEO Jamie Dimon of JPMorgan, featured in the same issue of the Times, JPMorgan, fined billions, approves raise for its chief”!), or to Rick Scott, former head of Columbia/HCA when it was fined $1.7 billion in 2003 for massive Medicare fraud). Scott, of course, is now the Governor of Florida.

It is difficult to imagine the hubris and arrogance of the “masters of the universe” who run the financial services industry, or the large hospital corporations. At least, it is for me, and possibly for other people who believe that the health care system should be first, second, third, and last about benefiting people’s health. It does not seem to be for the C-suite executives of even moderate-sized hospitals, who often come from accounting and finance backgrounds. The argument is that if there is “no margin” there is “no mission”, and that in the competitive environment of health care it is necessary to have good business managers to make it possible for a hospital – or hospital system – to even survive, not to mention to prosper.

Good management is important. Good management means the ability to run an organization efficiently, to create effective systems and effective working relationships, to enhance quality and limit unnecessary costs. It is absolutely necessary to build a system that is about benefiting the health of people. This includes financial knowledge and financial management ability. But increasing profit, increasing market share, taking “desirable” customers away from “competitors” has no such place; the health system has no business in being organized in such a way that these things are even possible.

This statement is so completely at odds with the way the health system is currently structured that it bears repeating. There should be no financial incentive for competition in health care. There should not be more services available than a community needs because every hospital wants to provide it and take “customers” from their competitors. If, for example, a community is large enough that it needs one MRI scanner, there should be only one (or 2, or 3, or whatever the medical need is). In the current structure, however, the hospital with that one would have a competitive advantage over other hospitals in the community, so everyone needs one. The same is true for any profitable service: cancer treatment, heart procedures, neurosurgical procedures, etc. Profitable “product lines” are, thus, in oversupply, and this means that they are overused, often with risk to the recipients, and certainly the cost to everyone is increased. Conversely, necessary services that are not profitable, such as burn and trauma care, are rarely in oversupply, frequently relegated to the community’s public hospital, and sometimes not available at all.

A community should have all the health care resources its people need, but should not duplicate – and triplicate – services so each can compete. It is bad in terms of the overall cost, and the oversupply of profitable services, and it is arguably worse in that all these hospitals are competing to get the same patients – those who are well-insured with “high profit” diseases, and to not care for others – uninsured, poor, and those needing services that are not well reimbursed.

This is craziness. Health care is not luxury condominiums, or expensive watches. It is something that every single person should get all of that they need, and no one should get what they do not need. There should be competition between hospitals to be excellent, and measures of excellence should include comprehensiveness, quality, cost-effectiveness, and caring for everyone equitably (not equally, but based upon their health care needs). And, if there are to be financial rewards, they should come for doing this well. There must be no services that are particularly “high-profit”, nor patients whose economic status makes them “undesirable”.

We have a long way to go. Various strategies have been tried in the past, from certificate of need (CON) programs that decided whether a community needed a new pieceof capital equipment in the 1970s and 1980s, to disproportionate share funding for hospital caring for higher percentages of uninsured people and quality improvement organizations more recently. But all of these efforts have been gamed, because there was no comprehensive plan in place to ensure that no patient, and no disease, was more or less profitable than another. We need to have a system in which each person with a health care problem is provided the care that they need. No gold cards. No profitable conditions. Not hard to understand.

The time for this to happen is now.

Sunday, January 26, 2014

Doctors' incomes and patient coverage: both need to be more equal

On Sunday, January 18, 2014, the New York Times ran another stellar front-page piece by Elisabeth Rosenthal addressing the fact that, as the title states clearly, Patients’ Costs Skyrocket; Specialists’ Incomes Soar. It continues, with detailed documentation, her explanation of how providers – in this case doctors, and in particular the most highly paid subspecialists -- game the system of insurance reimbursement to maximize their income, and how patients pay the price. She focuses particularly on dermatologists, whose combination of high income and low workload makes them the exemplar of what medical students call the “ROAD”, the specialties of radiology, ophthalmology, anesthesiology, and dermatology, all of which are known for having high income/work-hours ratios.

Rosenthal addresses in particular a kind of dermatologic surgery called Mohs surgery, which commands a high price. Mohs surgery is very good for its ability to identify margins of a skin cancer and leave less of a scar, but it can be, and often is, overused at high cost. She cites a particular case of a woman who had a small basal cell cancer (the kind that almost never metastasizes and is often simply excised) removed from over her cheekbone and had a bill of over $25,000. “Her bills included $1,833 for the Mohs surgery, $14,407 for the plastic surgeon, $1,000 for the anesthesiologist, and $8,774 for the hospital charges.” The plastic surgeon, by the way, was called in – along with the anesthesiologist – to close the small lesion from the excision that the dermatologist was unwilling to do.

The cases that Rosenthal documents are typical enough that they cannot be  called “abuses” because they are the norm; it is, of course, the entire system that is the abuse. It would be absurd if it were not so real, if it didn’t skew the entire health care system away from primary care and toward specialties where enormous incomes are made by billing – and collecting – for each single activity. Rosenthal describes the RUC, the AMA-convened body that makes “recommendations” to Medicare about the relative value (and thus payment) for procedures, as well as for other forms of patient care -- such as listening to you, examining you, thinking about your problem, making a diagnosis, and recommending treatment -- which are well undervalued compared to procedures. I discussed the RUC, and what I consider its outrageous behavior, in Changes in the RUC: None.. How come we let a bunch of self-interested doctors decide what they get paid?, July 21, 2013, and earlier in  Outing the RUC: Medicare reimbursement and Primary Care, February 2, 2011, but Rosenthal does an excellent job of describing its perverse incentives. Given that Medicare takes the RUC’s recommendations 95% of the time, and that most insurers base their payments on Medicare’s, the RUC, which is heavily stacked against primary care, essentially sets doctors’ reimbursement. And this is not to the benefit of patients, either financially or medically.

In another article, Rules for Equal Coverage by Employers Remain Elusive Under Health Law, buried much farther inside the paper but also very important, Robert Pear describes the fact that the Obama administration has chosen to not (yet) enforce rules which allow companies to offer discriminatory levels of coverage to some employees than to others; generally, “better” coverage to executives than to line workers. There is already a ban on such discrimination in companies that are self-insured, but the Affordable Care Act (ACA) extended this to those who purchase coverage from insurance companies. The possibilities for discrimination are illustrated by the things that are forbidden; for example, covering only executives and not others, paying the full cost of executives’ premiums while making lower-paid workers pay for a portion of their benefits, or offering different terms for coverage of the dependents of executives and other workers.

Of course, the companies (read: the executives who run the companies and stand to benefit from discriminatory practices) disagree. Pear quotes Kathryn Wilber, from the American Benefits Council “which represents many Fortune 500 companies” as saying “Employers should be permitted to provide lower-cost coverage to employees who may not be able to afford the comprehensive coverage being provided to other employee groups,” which, of course, would not be an issue if the company paid for comprehensive coverage for all employees. The one “benefit” that may be excluded from the non-discrimination rules are “certain types of executive physicals”, which is ironic because there is no data that these benefit most people, including executives, but rather increase both the cost of care and the risk (in follow-up tests for false positives) to the patient. Certainly there are some occupations where the risk of something going wrong is high enough that it exceeds the risk of harm, changing the harm/benefit ratio -- airplane pilots for example, or possibly those who drive buses full of school children. But virtually no corporate executives are in this group.

The reason companies want differential benefits is primarily to save money by not offering good coverage to the majority of their employees, and also as a “perk” that they can offer to their executives. It is presented as parallel to other market goods, the difference between “serviceable” and “excellent”. This is even carried over in the metaphor to describe the low-copay plans that the ACA was going to tax, “Cadillac” plans, when everyone knows that a Chevy is just as good at getting you where you want to go, just not in such luxurious circumstances. But this is a lousy metaphor for health care, and confuses two benefits. One, which is the intent of the “Cadillac policy” tax, is whether individuals have to make co-pays or have co-insurance, or have limits on their benefits, or not. This is financial, and is very important. The other, however, is whether some people have coverage that gets them better health care. This is not OK. Obviously, they come together at some point since health care that is unaffordable to a person is unavailable to them, even when it is necessary. Conversely, for those executive physicals, providing a “benefit” that the individual does not have to pay for encourages them to seek unnecessary, and sometimes potentially harmful, care.

It may be that there are certain kinds of “health care” that are in fact reasonable to treat as elective consumer goods which a company might offer to some employees and not others; cosmetic surgery is the classic example (or non-medically-necessary contact lenses or radial keratotomy [Lasik®]; see Rand Paul on health policy: small brain and no heart, September 1, 2013). There also may be some employees for whom the harm/benefit ratio makes certain services of value when it does not for others (the comprehensive exams, “physicals”, for pilots, or Pap smears for women but not men). But, overall, coverage that does not include all necessary care for everyone is inappropriate. In addition, coverage of unnecessary care is as well. It is not Cadillacs vs. Chevies, or Volkwagens vs. Mercedes; it is making sure that everyone is covered for their health care needs. Like every other OECD country does. Like we could do if everyone was in Medicare.

Then instead of buying their executives “Cadillac health plans” to demonstrate how important they are, these companies can just buy them Cadillacs. 

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