The cost of health care: Prevention and Indication “creep”, drugs, and the Sanders plan

.
The cost of medical care is rising. Some of this is from actual new forms of treatment and new technologies that benefit the health of individual people, and sometimes of populations. Some of it is from the enormously inefficient (as well as inequitable) “non-system” of health care delivery and insurance that exists in this country. Some of it is from the aging of our populations, resulting in an increase in the group of people who have the most chronic diseases and thus the greatest health needs. In addition, those new treatments successfully keep people alive who would have died from their conditions in the past, allowing them to develop new and even more complex conditions. In the near future, some of the increased cost will be the result of the coverage, mandated by the Affordable Care Act (ACA, “health reform”) of 30 million additional people, with their attendant pent-up health needs. And, of course, much of it is from gross greed and enormous profits being taken from the “health care dollar” by some by providers (hospitals, nursing homes and physicians), but also – particularly -- by insurance companies and drug and device manufacturers.

I have addressed many of these issues in the past, and will continue to do so. A recent blog (Insurance company profits up and patient care down, May 17, 2011) addressed insurance company profit, others have looked at the burden created by the aging population and the newly insured (e.g., Primary Care, Medical School Debt, and US Health Needs: Analysis from the Graham Center, May 30, 2011 ). Other blog posts have looked at the health insurance system (I have been, I hope, very clear in my endorsement of a single-payer system as the best method for providing not only equitable health coverage, but the platform for cost saving and quality improvement). Today, I would like to look at two others, the explosion of new treatments and technologies and their overuse, and the cost of pharmaceuticals.

Increased attention is being paid to the overuse of many procedures for invalid indications or in people who are not likely to benefit from (and may be harmed by) them. Rita F. Redberg’s Op-Ed piece in the NY Times “Squandering Medicare’s money”, May 25, 2011), discusses 5 procedures that fall into this category. These include screening tests --  colonoscopy on people over 75, Pap smears on women over 65, PSA screening for men over 75 (although note that I have often written that its indications are dubious in all men, e.g. October 27, 2009: PSA Screening: “One of Medicine's Great Success Stories"?). They also include several procedures for vertebral fractures, the use of cardiac stents rather than drugs in prevention of heart attack, and the implantation of cardiac defibrillators in patients who will not benefit (Redberg is a cardiologist). Medicare pays for all of these, and many of them, particularly the procedures, but also the screening tests (because of the procedures that are likely to follow positive screens) have significant risks. (See also “Sales Tactics on Implants Raise Doubts”, NY Times, May 31, 2011).

The same theme is addressed in a recent commentary in JAMA by Djulbegovic and Paul, “From efficacy to effectiveness in the face of uncertainty: indication creep and prevention creep.”[1] Although brief, it contains some concepts that might require explanation for those unfamiliar with research and epidemiology. Initially, they address 3 types of research: “Therapeutic and prevention clinical research is typically performed to address questions of efficacy (“Can intervention work in the ideal study setting?”), effectiveness (“Does it work, generalized to real-world settings and applied to individual patients?”), and cost-effectiveness (“Is it worth it and should it be paid for?”)” [my bolding]. They go on to observe that most research, particularly that funded by drug and device makers (but also by the National Institutes of Health, NIH), is in the first category, efficacy, and that, while there have been increasing calls for more effectiveness research, this is unlikely to happen for most of the clinical decisions in treatment and prevention, primarily because such studies are difficult to do and costly.

The result is that clinicians have to make decisions about the use of these tests and therapies in the real world and in patients whose characteristics (such as age, other co-existing illnesses, other treatments that they have been on, etc.) are different from those of the group studied in the efficacy trials. Clinicians also may use them to treat conditions – known as “indications” -- other than those that were studied and for which the drugs were approved by the Food and Drug Administration (“indication creep”). If a drug is used for a condition (“indication”) for which it is not approved, it could be of benefit. However, it could also be of no benefit (but definite cost), and might even (not infrequently) cause harm. When screening tests are used in populations for whom they are not indicated, as those discussed by Dr. Redberg, as well as in the several blog posts about PSA and breast cancer screening (see March 15, 2011: Men’s Health? Women’s Health? Valid screening opportunities or “Hallmark Holidays”?, October 30, 2010: Breast cancer screening: conflicting evidence? what are the important questions for health?), we have “prevention creep”.

Doctors and other providers could, of course, choose to not use drugs indications or populations outside of those for which it was approved, and not use screening tests outside of the populations in whom it was studied. Djulbegovic and Paul, however, spend some time discussing why it is more likely that they will opt for screening a wider population than not, and why they will use drugs for treatment of conditions for which they were not approved (“off-label indications”). This last is particularly probable when other treatments have not worked, and someone (perhaps the drug company?) has suggested that the drug might work for this condition. This is because doctors are more likely to regret not doing something than doing something, despite the ancient injunction primum non nocere, “first, do no harm”. If the treatment doesn’t work, so be it; if it causes harm there may be regret, but it may be attributed to the underlying disease. If the treatment is not done, regret ensues because the physician thinks of what benefit might have occurred more than what harm may have befallen the patient. And, of course, while all recommendations to use drugs for “off-label” indications do not come from drug manufacturers, they obviously benefit financially from the wider use of the drug, and thus have little incentive to conduct or fund effectiveness, or certainly cost-effective, studies.

Which brings us to the cost of drugs. Anyone who is on drugs currently under patent (i.e., non-generic) knows their high cost. Generics are drugs which are the same as the original brand-name product but are usually much cheaper. We have heard about efforts to import drugs from Canada and other countries because they cost less. This was even suggested by members of Congress during discussion of the Medicare Part “D” drug benefit, which is bizarre since those drugs are often made in the US. They are sold in Canada at lower prices because of Canadian government regulation. In passing Part “D” such regulation of drug costs (using Medicare’s enormous purchasing power) was explicitly forbidden. (Who lobbied for that, do you think?) Drug companies say their costs are high because of research and development of new drugs. In fact most of their R&D costs are for “me-too” drugs – modifying a popular and big-selling drug made by another manufacturer, or their own drug that might be going off patent – so that they can get a patent. Then they spend far more than what they spend on R&D on marketing, to try to establish this new brand and get consumer loyalty. An example is when Prilosec®, omeprazole, went generic – and even over the counter, without prescription -- the manufacturer modified the formula slightly to be longer acting and began marketing “the purple pill”, Nexium®, no more effective.

A new proposal that would lower drug costs to US consumers by as much as 90% has been made by Senator Bernard Sanders (I, VT), as reported by Dean Baker in the HuffPost Business on June 11, 2011, Bernie Sanders Tries Some Clear Thinking on Prescription Drugs. Sen. Sanders essentially proposes that the government buy out all existing, and future, patents on prescription drugs, making them available at far lower cost. The cost of buying out the patents would be paid for by the enormous savings to Medicare on the cost of buying the drugs. These savings would be so great that, even after buying the patents, the government would save an enormous amount of money. It is a very good proposal, one that would be effective, and would compensate drug manufacturers as well as benefit the government and patients. Of course, the compensation would be less than the billions that big PharMa makes on selling these enormously highly-priced drugs, so they will certainly lobby – probably effectively – against it.

Our health remains hostage to the financial benefit of private corporations. Why should this surprise us, when all of our lives also are? The question is when are we, as health care providers and as citizens, going to decide that we will no longer allow their financial interest to stand in the way of quality and cost-effective health care.

---

1 Djulbegovic B, Paul A., From efficacy to effectiveness in the face of uncertainty: indication creep and prevention creep”, JAMA. 2011 May 18;305(19):2005-6..

The real face of lack of access to health care

.

I have often written about the fact that lack of health insurance is a major source of cost for the health system. People without insurance often cannot afford to pay doctors or buy medications, and so do not seek care for treatable illnesses until they are so far gone that they can no longer be ignored, and then show up in the Emergency Room and require admission and treatment for advanced disease (for example, in Does the nation need a clear policy on a right to basic health care?, April 10, 2009). The cost is not only enormous in human terms -- treatable diseases converted into much more serious conditions because they haven’t been treated -- although this is the most important. It is also much more costly in terms of actual health care dollars, as these advanced conditions are much more difficult and expensive to treat.

However, as in every area, what affects us most are not the data or the statistics, but the individual stories of individual people.  These are the stories that touch our hearts because they we can identify with them – they could be our stories, or those of our friends or neighbors or relatives. These are the stories that make the evening news, the stories that might persuade a legislator to become interested in a problem, the stories that motivate us to send a donation to a worthy cause.

This was brought home to me very starkly when I recently served as the attending physician on our inpatient service in the hospital. We take care of a lot of patients, and they are very sick. Their medical diagnoses varied: kidney failure, diabetic ketoacidosis, malignant hypertension, severe asthma exacerbation, infections in a variety of places, etc. But, really, the most common diagnosis was lack of access to health care, mainly because of lack of health insurance. While not all these people are poor, they, like most people, have limited incomes, and have many other basic needs (rent, food, caring for their children) that compete with health care for the dollars available. Asymptomatic diseases (or conditions with “tolerable” symptoms) often seem to be a lower priority.

I’d like to share some of their stories, although obviously I cannot share their names or present too many actual details about them; I’ll make up initials and change some details that do not affect the essential issues. These are real people, with real names and real problems.

·     AG has diabetes and high blood pressure. (These two conditions, diabetes and high blood pressure, are going to be a recurrent theme; they are the mainstay, most-common, diseases of any general adult medicine practice. They are treatable, but when not well controlled their complications -- strokes or kidney failure or heart attacks or amputations – are also major contributors to the work of many subspecialists: cardiologists and endocrinologists and nephrologists and neurologists and surgeons and orthopedists, just to name a few.) AG had lost his job, and while unemployed and without health insurance he hadn’t been going to the doctor. Luckily, his chronic diseases weren’t bothering him much, except for a small sore on the bottom of his foot. High blood pressure often causes no symptoms, until the stroke or heart attack; foot sores in diabetes are a big threat, because the disease both diminishes the sensation of pain, so it doesn’t hurt much, and the circulation of blood so it doesn’t heal well, but the lack of pain makes it seem not so bad. He finally found a job, a reasonably good job with the promise of health insurance after a while. Unfortunately, it involved walking almost 20 miles per day, not a good thing for his foot. The foot developed a severe infection, requiring expensive hospitalization for intravenous antibiotics, and might still need to be amputated.

·     PS also has diabetes, which, especially when untreated, makes one susceptible to infections, and he has had several of them. Now, in late middle age, he presents with a very serious infection, requiring not only intravenous antibiotics, but surgery to clean out the pus, resulting in an open wound. A machine attached to drain out the residual infection and keep it clean will need to be regularly replaced, for many weeks as he continues the intravenous antibiotics. Fortunately (should you ever be in a similar situation), home health can be arranged to provide these services. Provided you have health insurance coverage. Oh yes, and a home. PS has neither. Makes follow-up care a little more difficult.

·    DR is a good deal younger but also had a severe infection requiring long-term antibiotics for a foot infection, after an unsuccessful attempt at outpatient treatment. And, yes, his diabetes is uncontrolled because he hasn’t had insurance and so hasn’t gone to the doctor or taken his medicine in quite a while. He also had lost over 80% of his kidney function, so he’ll be on dialysis soon. There is a “silver lining” (!); thanks to a law passed early in the 1970s, anyone with end-stage kidney disease requiring dialysis is eligible for Medicare, so he will be insured. Of course, the cost to Medicare will be far, far more than would have been the treatment of his diabetes, had he had coverage before the “end stage”.

·     MT will also become insured through this wonderful program, although her kidney failure is due mainly to untreated high blood pressure rather than diabetes. As I noted above, high blood pressure is often asymptomatic (thus the sobriquet “silent killer”); she didn’t have insurance or money so didn’t go to the doctor to find out how uncontrolled it was, as it slowly destroyed her kidneys.

Not all of our patients’ problems came from diabetes or infections, and not everyone who is uninsured is poor.

·     KF has asthma, pretty severe asthma, for which he was taking an inhaler to be able to breathe. It is a bronchodilator (airway-opener), the right drug for an acute attack, but KF’s attack never went away and he was taking far more of it than was safe. And spending an awful lot of money on it. It is available for a much lower cost at some pharmacies that provide certain generic medications for $4, but he didn’t know that. He does now, after being in the hospital for a week getting expensive breathing treatments. It’s a good thing, too, because the other inhalers that he needs to prevent (or at least decrease the frequency and severity of) these attacks, steroids and sustained-release bronchodilators, cost a lot, well over $100 per inhaler. They have been around for a long time, so one would expect that by now at least some of them would be available generically and cheaper. But there’s a great story here. The propellant in these inhalers used to be fluorocarbons, but these, as we know, destroy the ozone layer and contribute to a lot of bad environmental effects. So they were made illegal, and the pharmaceutical manufacturers had to replace them with environmentally safe propellants. Good for the environment. Unfortunately, bad for KF and millions of other people with asthma; using a different propellant meant that the drug was a “new formulation”, which allowed the drug makers to extend their patents for many years. So low-cost inhaled steroids are still not available. This is a cruel joke, but it is not a joke. The pharmaceutical companies will not suffer; only patients will.

AG, PS, DR, MT, and KF were all people we cared for in one week, and they were not the only ones with a primary diagnosis of lack of health insurance coverage. Of course, we also took care of lots of sick people with health insurance; I don’t work in a “safety net” hospital. People with insurance, even with good insurance (and certainly not all insurance is “good”, not all insurance covers necessary medications and tests) also get serious diseases and need to be hospitalized. But the people whose stories I have told, and others I have not discussed, stand out because they didn’t have to be as sick as they were and require the costly services that they did. That they were, and did, is not only immoral and bad medicine, it is bad economics. It is inexcusable.

Maybe DR and MT would not have had kidney failure and need dialysis if they had Medicare or any other kind of coverage before needing it. Maybe everybody should have Medicare. In a future blog, I’ll discuss the proposals to “save Medicare” that are currently being floated, but now I’d just like to have some thought given to saving these actual people. Got any ideas?

.

Barbara Starfield

By now I assume that most readers of this blog are aware of the sudden death of Dr. Barbara Starfield this weekend. I have attached the letter from the Dean of the School of Public Health at Johns Hopkins, where she was a professor. Before I received this (indirectly) I first heard the news forward from literally around the world -- a US colleague forwarded a note from a colleague in Greece who had gotten it from one in South Africa. Since then, through various sources, I have received the news forward from a number of other countries; she was truly an internationally respected scholar.

In case there is anyone who doesn't know, Dr. Starfield, a pediatrician, was the pre-eminent scholar on health workforce policy. Her work, and that of her colleagues, on the benefits of systems based in primary care to the health of populations, generated the evidence that is much of the underpinning of current efforts to increase primary care in the US.

I, we, all of us, are greatly indebted to her, and those of us who did not know her personally will miss her leadership. 
-------
Dear colleagues,

I have very sad news. Barbara Starfield, professor of Health Policy
and Management, died Friday evening of an apparent heart attack while
swimming—an activity that she dearly loved.

Our School has lost one of its great leaders. Barbara was a giant in
the field of primary care and health policy who mentored many of us.
Her work led to the development of important methodological tools for
assessing diagnosed morbidity burden and had worldwide impact. She was
steadfast in her belief that a quality primary care system is critical
to the future of health care in this country and worldwide and
received numerous accolades for her work in this important area.

Barbara came to Johns Hopkins in 1959 as a fellow in pediatrics at the
School of Medicine. She joined our School in 1962 where she earned her
MPH in epidemiology. As professor, she went on to lead the Division of
Health Policy in the Department of Health Policy and Management from
1975 to 1994. After stepping down as Division head, Barbara remained
an active member of the HPM faculty and was founding director of the
Primary Care Policy Center. She was named Distinguished University
Professor in 1994. Barbara was greatly admired as a teacher, mentor
and colleague.

I am sure that I speak for all of us when I say that my deepest
sympathies are with Tony Holtzman--Barbara’s husband, her four
children, her eight grandchildren, as well her many friends and
colleagues around the world.

We’ll provide information about funeral arrangements and a memorial
service when they are available.

Mike

Michael J. Klag, MD, MPH

Dean
Johns Hopkins Bloomberg School of Public Health

EMRs and Primary Care: The good, the bad, and the challenges

One of the centerpieces of health reform as promulgated by almost everyone, and very much the Affordable Care Act (ACA) is the use of electronic medical records (EMR, also called, in a more inclusive formulation, electronic health records, or EHR). The Health Information Technology for Economic and Clinical Health Act (HITECH) specifically addresses specifications for EMRs. Demonstration of effective use of EMRs, including “e-prescribing” (in which prescriptions are routed electronically directly from the physician’s office to the patient’s pharmacy of choice), maintenance of patient registries (who in your practice has diabetes?) and compliance with a set of quality measures (What percent of the people in your practice with diabetes have had their sugar measured? What percent are in control?) account for a great deal of the added payment for chronic disease management, as well as payment for patient-centered medical homes (PCMH).

EMRs are a good thing for many reasons. At the simplest level, the fact that the records are on-line, rather than in paper charts, means that they don’t get “lost” and any doctor can see the notes of any other doctor. A number of years ago, prior to going to a real EMR, a large public hospital with many clinics where temporarily lost charts often meant that patient notes generated in one clinic visit were unavailable to another clinic, scanned literally millions of pages into a very basic EMR. While having none of the advantages described below, even this primitive method was a real step forward for them in being able to access the records. At their best, EMRs allow effective communication between doctors in a practice. For large multispecialty practices, this can also be between different specialists, and can even be integrated with the hospital’s medical record so that information from hospitalizations is immediately available in the same “chart”. The more that information is put in “digitally retrievable” format rather than free text, the more easily and thoroughly that a patient’s health trajectory can be understood. This is not only for numeric values, such as lab results and blood pressures that can be displayed on a flowsheet or graph, but even for history and physical items: Was that heart murmur present at the last visit? What is the history of the different medications that the patient has been on? Patient registries, as noted in the first paragraph, become an effective way of evaluating and improving the care given in the entire practice, not just for one patient, and are almost impossible without an EMR.

EMRs are not problem-free, however. The most common issue for physicians is that charting takes longer; filling in all this data takes time. This is worst when a new EMR is implemented, as old data has to be input (and this can even be when changing EMRs, not just going from paper, since of course they rarely “talk to” each other), but continues to be, on average, more time consuming than paper charting. In part, this may be because the notes are “more thorough”, or, looking at it the other way, that paper chart notes were inadequate. But it is also because the very structured nature of the EMR requires that a significant number of things be  entered/clicked (even to indicate “not applicable” or its digital equivalent) that would have appropriately not been mentioned in a paper note. Much of this added documentation goes beyond the information necessary to provide medical care for the patient, but is required to comply with government regulations and ensure that the document is “legally” sound. (It is a time long since the medical record existed solely as a reminder to the physician of what s/he had done for the patient in the past!) In addition, some of those regulations require the physician, as opposed to another health professional such as a nurse, to personally document certain items in the record, often to a degree that seems unreasonable to physicians.

There is an ironic turn to this. Most discussion in public policy circles is directed to increased inter-professional function and team work, as characterized by the patient-centered medical home. In part, this is because the current and projected shortage of primary care physicians means that there is no way that they, working alone, will be able to meet the health needs of the American people; if they are already working on a “hamster wheel” (see Family Medicine in the Era of Health Reform - 3, May 23, 2011), the changes described by Phillips (see Primary Care, Medical School Debt, and US Health Needs: Analysis from the Graham Center, May 30, 2011 ) and discussed in detail by Margolius and Bodenheimer[1], will increase the burden beyond any hope of sustainability. In addition, an effectively functioning team of health professionals (including nurses, pharmacists, social workers, and others[2]) makes for higher quality care. This is very clearly articulated in Dr. Atul Gawande’s recent address to the Harvard Medical School commencement, “Cowboys and Pit Crews” published on his New Yorker  blog. The irony is the increased requirements mentioned above, sometimes explicitly stated in law, but often in federal regulations and most commonly by Medicare “carriers” and interpreted by institutional compliance officers, have increased what the physician, him or herself, needs to document in the medical record (and, by implication, have actually done him or herself). These requirements both decrease effective team function, and increase the burden of electronic charting.

Thus, the ability of the EMR to record, and hopefully make retrievable, large amounts of data, raises the expectation that that data will be inputted, and also allows monitoring to ensure -- in the cases where lawyers or compliance officers have concern – which individual is doing it. In any new technology that increases the ease of accomplishing something, or the availability of a person or data, there is the corresponding tendency to expect it; this often has the ironic effect of increasing, rather than decreasing, workload. The internet and email allow us to work from home; cell phones, pagers, and email all increase our availability even when not at work or at home. This allows us more flexibility, but it has also led to the expectation of immediate access and, for many professionals including physicians, the virtual elimination of the concept of “work” versus “off” hours. The electronic medical record allows me to chart from home – or anywhere I can get an internet connection – and so I do.

The introduction of a new EMR, already a complex, difficult and daunting process, is also often used to change workflow, the processes by which the work of the practice is accomplished. This is virtually always a mistake, for providers and staff must now learn not only how to navigate and document in a new and strange systems, but to do things in a completely different way. The changes may be desirable, or they may not be, but certainly will require time and effort to identify whether they are, work it out, and “get it right”. Thus, it is greatly preferable to change that workflow prior to institution of the EMR (or if necessary after it is successfully adopted); the alternative is that learning new processes, especially when they are poorly conceived, gets lumped in with and blamed upon the EMR, increasing resistance to its adoption and potential benefits.

An interesting, and perhaps important, sidelight of the introduction of the EMR in our family medicine clinic was that the implementation team, composed of experts from the computer company and “superusers” of nurses from our group practice, saw how much more complicated the practice – and thus the documentation – is in primary care than in other specialties. In most sub-specialty practice, a few diagnoses -- and thus a few types of workflow and documentation strategies -- account for almost all visits, while in primary care the breadth of encounters (acute/chronic, prevention, adult/child/pregnancy, medical/psychosocial) in a single session, combined with the complexity of dealing with multiple chronic conditions based in a variety of organ systems rather than one, is actually breathtaking (see, for example, Primary Care: What takes so much time? And how are we paying for it?, May 21, 2010, "Uncomplicated" Primary Care?, Oct 8, 2009). Contrary to what they had been led to believe, they discovered that primary care was harder and more complex and more difficult to document – and of course required seeing more patients in shorter amounts of time for less reimbursement (which also leads to an ability to afford fewer support staff). This team, at least, gained a new respect for what primary care practice involves.

As we inevitably and inexorably move to reliance upon EMRs, we must be on guard to resist all the temptations to load every possible expectation upon them, and upon the providers who use them. They have enormous potential to not only increase quality but to increase teamwork and communication, and to even be labor-saving, but only if used wisely and judiciously.

---

[1] Margolius D, Bodenheimer T, “Transforming primary care: from past practice to the practice of the future”, Health Aff (Millwood). 2010 May;29(5):779-84.

[2] Even, for example, lawyers. A number of practices, particularly in academic medical centers (including our family medicine clinic at KUMC) have legal partnerships where lawyers (often from Legal Aid) and law students help patients with legal problems they could not otherwise get help with, right in the clinic. It is amazing how often a person’s health improves when they no longer are as worried about their immigration status, getting evicted, receiving benefits, or the implications of divorce, among other issues.

Comments on Free Medical Schools

Today (Monday June 6) in the NY Times letters section there are a number of letters regarding the Op-Ed on Free Medical Schools by Bach and Kocher that was the subject of my blog yesterday. They all disagree with them. This is fine; what is surprising is that the Times apparently got no articulate supportive letters, or they probably would have published them.
Comments included the impact of lifestyle, money made after entering the profession (these were the main ones by the generalists, both internists) prestige, the mastery of a body of knowledge (predictably from the subspecialist writers).
I stand by my comments; free medical schools would help get folks into primary care. The other issues, particularly the shockingly inequitable reimbursement for practicing physicians, absolutely need to be addressed. I have talked about the myth of "body of knowledge" or complexity, and lifestyle is a big challenge -- but it is clearly wrong that a subspecialist should have a "better" (ie, less work) lifestyle for more money!

Would free medical schools increase primary care?

.

An op-ed by Peter B. Bach and Robert Kocher in the NY Times March 28, 2011, “Why medical school should be free”, makes a strong argument for just that. They acknowledge that this might seem unreasonable given the fact that physicians, regardless of specialty, make so much more that the average American; indeed are “all but 2 of the 15 highest paid professions”. This data is from the Bureau of Labor Statistics, published just a week earlier. An article by Harry Bradford in the Huffington Post, “America’s 10 best paying professions: Bureau of Labor Statistics”, that indicates that 9 of those top 10 are physicians, surgeons and dentists, with CEOs the only non-medical profession cracking the group, and that at #9, ahead of psychiatrists (#10) but just behind family and general practitioners (#8). The actual numbers from BLS may be suspect; while $174K for FPs may be close to correct, there is no where I know of, one could hire an anesthesiologist for anything close to as little as $220K (or radiologist or orthopedist or surgeon).

So why shouldn’t students pay to get into such lucrative professions? After all, other schools, professional and non-professional, cost money; this is true whether the degree is in law, business, engineering and accounting, which all pay relatively well, or  music, art, teaching and social work, which pay much more poorly. What is special about physicians that should make them be able to go to school for free, as do, say, firefighters and police? Bach and Kocher argue that the high cost of medical education, with students currently averaging over $150,000 in debt and rising, contributes significantly to both the shortage of primary care physicians that this country desperately needs and will continue to need in increasing numbers, and the cost of health care, with physicians entering the specialties that make lots of money by doing lots of highly-reimbursed procedures, many of which may not be medically necessary. As discussed in the recent blog piece Primary Care, Medical School Debt, and US Health Needs: Analysis from the Graham Center (May 30, 2011), the shortage of primary care doctors is projected to significantly increase as a result of the aging of the population, the influx of formerly uninsured people through ACA, and the fact that students are entering primary care at a rate too low (just over 20%) to even replace the already-too-low percent of the physician workforce that is now primary care (just over 30%), not to mention raise it to the necessary 40%-50%. By making medical school free, and thus eliminating this debt burden, students who were interested in primary care would have far less disincentive to entering the field – and earn very good livings, as what is currently the 8^th most highly paid profession.

Going beyond this, Bach and Kocher suggest a creative method of financing the estimated $2.5 billion that this would cost (based on average current medical school tuition): charging for post-graduate (residency) training in non-primary care specialties. Medical school graduation (unlike most other schools, including graduate schools) does not prepare one to be a doctor; rather it prepares the student to be trained in a medical specialty (residency). Residents are not charged tuition, but are instead paid as workers (although it is often considered an educational “stipend”; labor law decisions have varied from state to state). Under this proposal, students entering primary care residencies would continue to receive the stipend, while those entering other specialties (in which they could expect to make a great deal more money) would actually pay (they suggest $50,000 a year, in current $) that would be put into a pool to cover the cost of medical school tuition. The actual process of collecting this money and transferring it to the medical schools, as well as controls on methods of gaming the system (for one, they note, medical schools raising the tuition as students no longer have to pay it themselves) would have to be fairly complex. Nonetheless, this is a great idea; if medical school and residency together are the educational requirement for practicing medicine, then the basic education would be free to the student while entry into higher-income specialties would require additional years of, essentially, tuition. There would be no restrictions imposed upon student choice, but the financial incentives would significantly switch from the “voodoo” workforce policy Dr. Phillips identifies (see May 30, 2011 blog) to one that is aligned with desired outcomes.

A particularly attractive aspect of this proposal is that it would not further add to the debt burden of lower-income students seeking to become primary care physicians; in the May 30, 2011 blog I quote E. Grey Dimond, founding dean of the University of Missouri-Kansas City Medical School (now the highest-tuition school in the US) saying “Farm kids in Missouri from little towns that need doctors can’t pay what we have to have.” Under the system proposed by Bach and Kocher, those farm kids – and kids from underserved urban areas – would have a chance to gain a medical education and return to serve their communities.

The other ostensible benefit, decreasing medical costs, is not likely to come from this policy alone, however. Indeed, those students entering those more highly paid specialties would wish to maintain their incomes at high levels to justify the additional cost of their education. If there indeed are many procedures being done which are not medically indicated, and there is evidence that there are (see, for example, Rita F. Redberg’s Op-Ed piece in the NY Times “Squandering Medicare’s money”, May 25, 2011), the way to reduce them is to place further restrictions on them and decrease the amount that they are reimbursed by Medicare and other payers. This would further decrease the financial incentive to choose these specialties instead of primary care.

An alternative, however, is to continue to pursue – and exacerbate – “voodoo” workforce policy. The AMA’s “RUC”, described in Outing the RUC: Medicare reimbursement and Primary Care, February 2, 2011, which is only willing to consider increased payments for primary care if the entire pie is increased thus permitting other specialists to not make any less, is a great example of how to do this. Another is the policy of “balanced benefits” contained in two bills, the Medicare Patient Empowerment Acts, introduced in the House by Rep. Tom Price and Senate by Sen. Lisa Murkowski, and strongly endorsed by the AMA, and described in detail by Dr. Don McCanne’s “Quote of the Day” on May 27, 2011.Hidden by the high-sounding names, this bill would destroy Medicare as it currently exists, and replace it with a de jure, as well as de facto, two-class system of health care. Under the current Medicare law, physicians who accept Medicare have to accept the amount Medicare pays for a given service, plus the amount that Medicare determines to be patient responsibility, as payment in full.  Under these new bills, Medicare patients could see physicians who do not now accept Medicare, use their Medicare benefits to pay the what it pays, and then pay out of pocket the difference between that and the doctor’s charge. Essentially, this would turn all but high-income Medicare beneficiaries into the equivalent of Medicaid recipients.

It is a vile proposal, which would harm most Medicare patients and pad the incomes of physicians. It is more than embarrassing that it has been so strongly endorsed by the AMA and many other physician groups, who are clearly in the business of increasing the income of their members rather than benefiting patients. Dr. McCanne notes that the American Academy of Family Physicians and the American College of Physicians (internists) are conspicuously absent from the group of endorsers. For that he, and I, and the members of these organizations, are grateful. The AMA and the other endorsers of the Price and Murkowski bills deserve the strongest condemnation from Medicare beneficiaries, their families, and the American people.