Saturday, February 23, 2013

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

The United Kingdom has a National Health Service which covers everyone (although it allows those with private insurance to access care elsewhere). While not perfect – nothing is – and historically underfunded, it is one very reasonable model for how we could ensure access to health care for everyone. It goes back to the post-WW II period, when the British Labor Party made the decision to expand the existing National Health Insurance program to create the NHS through the political process, while in the US the emphasis among unions was to use collective bargaining to get health insurance as a member benefit.

But the NHS, while profoundly supported by the vast majority of British people, has been a target of attacks by Conservative governments since the Thatcher years. One of the big changes was the creation of several regional “trusts”, quasi-public entities that were invested with NHS funds and made responsible for the provision of care in their regions. This was consistent with the Tory assertion (held even more strongly in the US) that the private sector, or as close as they could get politically to the private sector, would be more efficient and effective than a public “bureaucracy”. Success at meeting "targets" (often high production with inadequate resources) could lead a trust to "foundation" status, where they would have even more control.

Many in Britain had their doubts, certainly among those to the left of the Conservatives. There was concern that the trusts might not be responsive to the health care needs of the people and might be more concerned with enhancing their own salaries, perks, and power. Conservatives (small 'c') tend to believe that government bureaucracies are more inefficient; those on the left see more evidence that privatization is much more likely to serve the self-interest of those in control than the interests of those who are supposed to be served.

I recently read the 1996 mystery novel “Quite Ugly One Morning” by the Scottish writer Christopher Brookmyre. One of the major plot lines involves corruption in the Edinburgh-based regional NHS trust. I don’t want to spoil the plot, and I do recommend the book, but the portrayal of self-serving, stealing, and lack of attention to the actual care of the patients of the NHS was scary. Of course, it was a novel; there were not actual patients being harmed by corruption in the actual regional NHS trusts in the actual United Kingdom. After all, I thought, the British don’t do such things. We do, but that is because so much of our system is private and for-profit. Surely the British value the NHS too much for such things to really happen.

Wrong. It appears, however, that this in fact has been happening. In “English hospital report cites ‘appalling’ suffering”, NY Times February 6, 2013, Sarah Lyall describes conditions cited in a government report on Stafford Hospital, operated by the Mid-Staffordshire Trust: “Shockingly bad care and inhumane treatment at a hospital in the Midlands led to hundreds of unnecessary deaths and stripped countless patients of their dignity and self-respect, according to a scathing report published on Wednesday…. The report, which examined conditions at Stafford Hospital in Staffordshire over a 50-month period between 2005 and 2009, cites example after example of horrific treatment: patients left unbathed and lying in their own urine and excrement; patients left so thirsty that they drank water from vases; patients denied medication, pain relief and food by callous and overworked staff members; patients who contracted infections due to filthy conditions; and patients sent home to die after being given the wrong diagnoses.”

HUNDREDS of people. Maybe as many as 1200 people died unnecessarily. And, in the followup of this scandal, there are investigations into at least 14 other trusts, reported across the British press such as this article in the Telegraph, Head of NHS ignored warning that patients were in danger, alleges whistleblower”. One of these trusts is United Lincolnshire, whose former chief executive has turned whistleblower, accusing the head of the entire NHS, Sir David Nicholson, of ignoring warnings that substandard care was being provided there. The whistleblower, Gary Walker, was fired from his job and paid off to the tune of about a half-million pounds, to keep quiet.

This would be a great example of “life imitating art” if it weren’t for all the people who died or suffered serious morbidity as a result of “…its efforts to balance its books and save $16 million in 2006 and 2007 in order to achieve so-called foundation-trust status, which made it semi-independent of control by the central government, the hospital laid off too many people and focused relentlessly on external objectives rather than patient care,” (NY Times).  As further documented in the report, this was essentially “speed up”, a condition familiar to assembly-line workers.

Speaking in the House of Commons,” the NY Times article goes on, “Prime Minister David Cameron apologized for the way the system had allowed ‘horrific abuse to go unchecked and unchallenged’ for so long. So deeply rooted was the trouble, he said, that ‘we cannot say with confidence that failings of care are limited to one hospital.’” Apparently not, given the accusations at Lincolnshire. However, despite these accusations, and perhaps more damningly, the fact that he was the Chief Executive of the Mid-Staffordshire trust during much of the time that the scandalous activities were occurring there, Nicholson is staying put, and so far the government is backing him. (more coverage in the Mail (Feb 13 and 17).

Well, he is staying put so far, but people in Britain far and wide are calling for his resignation, as well they might. Demonstrations in support of the NHS as a system designed to serve the people, not its administrators, have broken out across Britain; an example is this wonderful “Youtube” video of a “flash mob choir” (!) at King’s Cross railroad station in London singing in support of National Health (h/t Alex Scott-Samuel).

It would be possible to pin these atrocities on the National Health Service, as an example of the failing of socialized medicine, but that would be wrong. It would even be wrong to point out that the problem is chronic under-funding of the NHS. The problem, in fact, is a public good being run for private benefit, for the temptation of even great “autonomy” (read: potential for exploitation) by becoming a “foundation” led to deaths far in excess of the scale fictionally portrayed by Brookmyre in the mid-90s. The NHS does not suffer because it is tasked with providing health care to all of the British people; it suffers when a lack of adequate regulation and supervision allow such abuses to go unchecked.

The British people deserve much better. So, for that matter, do Americans. Let’s listen to the “flash mob choir” again!

Saturday, February 16, 2013

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

The shortage of primary care physicians in the US, which I have often discussed (most recently in “When is the doctor not needed? And who should take their place?, January 5, 2013), has become a national theme. The Robert Graham Center of the American Academy of Family Physicians (AAFP) has done much of the work in documenting this shortage, such as in the article “Projecting US Primary Care Physician Workforce Need” by Petteson, et al., discussed in my post “Health reform, ACA, and Primary Care: Is there still a conundrum?”, December 24, 2012. Essentially the problem is we have too few primary care doctors for the current population, the demand for them will continue to grow, and the rate of production (medical students entering primary care specialties) is below that even needed to replace those who retire. The growth in demand is a result of (in order of impact): population growth, aging of the population, and a more-or-less-one-time blip from increasing coverage under ACA (although for the latter, the people with a need for care were already there; it is just that with having insurance they will be able to seek it more easily).

 In a recent issue of Health Affairs, Green and colleagues argue that “Primary Care Physician Shortages Could Be Eliminated Through Use Of Teams, Nonphysicians, And Electronic Communication “.[1] This is not a new concept; it is a central component of what is known as the “Patient Centered Medical Home”. The article suggests that many functions now carried out by physicians can be done by others, ranging from nurse practitioners and physician’s assistants, to nurses, to others on the health care “team”. It also suggests that many problems that now require face-to-face communication (trips to the doctor’s office) could be done by phone or “virtually”, such as by structured email or web-based visits. Thomas Bodenheimer and his colleagues in San Francisco have done much of the work in this area, most recently published in Annals of Family MedicineEstimating a Reasonable Patient Panel Size for Primary Care Physicians With Team-Based Task Delegation”.[2]

Green, et al., use computer simulation models to estimate the “panel size” (number of patients that can be cared for per doctor) by the employment of such techniques; they add calculations for “pooling” of physicians, that is, sharing of patients among a group of doctors. This allows greater efficiency by “smoothing out the bumps” that may occur when one physicians has more or fewer patients coming in for same-day care or not showing up for their appointments by allocating them among the group. Using these statistical models they estimate that the ability of patients to access care (get in to be seen) would be dramatically increased by the implementation of such policies.

The work done by both the Green and Bodenheimer groups is convincing, and provides a model for more efficient primary care practice that would help to address the problems our country faces from having too few primary care doctors. Indeed, these approaches utilize the “crisis” as a way to actually improve both access to and quality of patient care. There are, however, challenges to implementation of this model. One is payment; while health systems in many parts of the nation have demonstrated that it is possible to restructure their practices to achieve these advantages, this is most effective in settings in which the provider is also the insurer (notably Kaiser). In those parts of the country where this model of care is less prevalent, where most payment to medical providers is “fee for service” for face-to-face visits to doctors, there is not only no incentive to change, there is a large negative financial incentive since any non-face-to-face care is, essentially given out free.

A second challenge is that such models only work where there is a large enough concentration of patients and providers to achieve the benefits of scale; as with most such analyses, it leaves out the needs of rural populations. Some large systems, such as Geisinger in Pennsylvania, have been successful in creating such efficiencies in their clinics in rural areas, but Geisinger is atypical; there are not many like it. In addition, it is a financially integrated system (like Kaiser) – that is, it is also the payer -- and it works in a relatively-densely populated rural area of northeastern Pennsylvania, not like the vast empty frontier counties of the West.

It is interesting to me that so much of this emphasis on efficiencies, and particularly the use of professionals other than physicians to provide care, has been on primary care. This, I am sure, is due in part to the need for primary care in all settings, while much specialty care can be centralized in larger cities. It is also because there is not a shortage of many non-primary-care specialists for the needs of the population (although there are for some, such as general surgery, especially in non-urban areas). The reason usually given for this non-shortage is largely that these specialists make so much more money than primary care doctors, so medical students are attracted to them. To the extent that some specialties also have more regular work hours and a limited scope of work, it may also increase their attractiveness.

The limited scope of work (although not, necessarily, less difficult work, especially when considering surgical interventions) also makes them, in many ways, more appropriate fields to use non-physician professionals than primary care. This is the reverse of the usual assumptions that sub-specialists are seeing difficult problems, while primary care providers see mostly colds and blood pressure checks. In fact, primary care is complex, as it sees both undifferentiated patients and those with multiple chronic diseases. Most specialty care is more routine, seeing a much more limited set of diagnoses with a more limited set of interventions; for the typical subspecialist, less than a half dozen diagnoses may account for 80% of visits, while for a family doctor the top 20 are probably 30%. Thus, the breadth of knowledge and skills in making complex decisions and appropriately prioritizing problems, require a level of sophistication and training not taught or developed in most other health professionals (family nurse practitioners are one other provider group where there is at least an effort to have this breadth of training). It is, then unsurprising that most of the tasks suggested for nurses and others to increase the efficiency of primary care practices have limited scope: maintaining disease registries, calling for recommended preventive care, screening a small set of diagnoses.

This type of narrow, in-depth scope of work is much more characteristic of subspecialty care, and it is one of the reasons why expanded-scope nurses and physician’s assistants have found so much use in these practices. They follow people with congestive heart failure for cardiologists or diabetes for endocrinologists, they manage chemotherapy recipients for oncologists, they use algorithms to care for people in intensive care units, they do pre- and post-operative care for orthopedists and other surgeons. And they do not go outside of the set of diagnoses and treatment options with which they are familiar; following the model of the physicians with whom they work, when a patient’s problem is not in their narrow area, it is referred.

The targeted but limited expertise of such nurse specialists have explains why they function so well clinically in subspecialties. What explains why it works financially is that the doctors (or hospitals, or health systems) that employ them are reimbursed at subspecialist physician rates (already very high) for work that is done by others; thus they can afford to pay such “physician extenders” relatively well compared to folks working in primary care. Reimbursement for “teams” follows the model of reimbursement for physicians: care for a limited set of diagnoses in a detailed way, especially when it involves procedures, is paid much better than management of complex sets of interactive diagnoses.

Unfortunately, the problem with such practice is challenging because the same person often has multiple conditions, and interventions that help one may make another worse. While efforts to build teams, and have each professional work at the “top of their license”, is important, so is payment. As long as primary care is reimbursed at lower rates it will continue to face challenges in recruitment of physicians, nurses, and other team members. 

We need to develop and implement great strategies for team-based care. We also need to dramatically decrease the ratio of income for subspecialists and their subspecialist teams relative to those working in primary care.

[1] Green LV, Savin S, Lu Y, “Primary Care Physician Shortages Could Be Eliminated Through Use Of Teams, Nonphysicians, And Electronic Communication”, Health Affairs, 32, no.1 (2013):11-19
doi: 10.1377/hlthaff.2012.1086
[2] Altschuler J, Margolius D, Bodenheimer T, Grumbach K, “Estimating a Reasonable Patient Panel Size for Primary Care Physicians With Team-Based Task Delegation” , September/October 2012 vol. 10 no. 5396-400 doi:10.1370/afm.1400

Friday, February 8, 2013

Creating more family doctors: should we shorten medical school? How?

At the recently-completed Society of Teachers of Family Medicine (STFM) Conference on Medical Student Education, held in San Antonio, one of the big areas of discussion was the shortening of the medical school experience to 3 years for students planning to enter family medicine. Steven Berk, Dean of the Texas Tech University School of Medicine, and Betsy Goebel Jones from the Department of Family Medicine, described the Lubbock medical school’s recently-instituted program in a plenary presentation, and a later seminar featured presenters from several other schools which have instituted or are planning such tracks, including the Savannah campus of Mercer University School of Medicine, Medical College of Wisconsin, as well as Texas Tech. The goal of such tracks is to increase the number of students choosing to enter family medicine by eliminating one year of school, and thus tuition; these schools believe that this financial incentive at least helps a little to offset the lower income that accrues to family physicians compared to other specialists. To the extent that these students then enter family medicine residencies at those same schools, it also decreases uncertainty for both the student and the program.

The most direct forebears of these programs were in the 1990s, at some of the same schools. They offered an “accelerated track” for family medicine, in which students began their first year of FM residency while completing their final year of medical school, getting the MD degree after that year. While initially approved by the American Board of Family Medicine as a pilot, these programs were closed when the decision was made by the body that accredits residencies that one could not get credit for residency training until after receiving the MD degree. This latest effort gets around this by granting the MD degree after 3 years, mainly by compressing the final year of medical school; in most schools the fourth year is already largely used for electives.

Not all accelerated MD programs are about increasing the number of primary care, or certainly family medicine, physicians. A program at the NYU School of Medicine, which remains one of the few US medical schools to not even have a Family Medicine department, was featured in the New York Times "N.Y.U. and Other Medical Schools Offer Shorter Course in Training, for Less Tuition" by Anemona Harticollis, December 24, 2012. While the Texas Tech and Mercer-Savannah programs are also mentioned, NYU’s program is clearly not about producing more of the primary care physicians that the US needs, as this is not something NYU seems to care about at all. As of now all of these programs are “tracks”, rather than for all students; they recruit “high-performing” students who can finish the traditional curriculum in a shorter time.

Interestingly, these current programs do not focus on shortening the amount of time or changing the content of the first two years of medical school, the “basic science” years. This struck me as odd, because when I went to medical school (Loyola-Stritch) in the mid-1970s, it was precisely this component that was shortened (to 12 months, with 2 full years of clinical training). Loyola was far from the only school to do so during that period; my current school, the University of Kansas and many others did so; according to an article by Walling and Merando in Academic Medicine[1] “…By 1973, 27% of U.S. schools offered compressed three year curricula.”  For most, this was not a “track” but was the curriculum for all students. The primary method of shortening the curriculum was abbreviating the time spent in basic science, although the amount varied (at KU it was 15 months). It is thus, to me, surprising that in the current efforts to decrease the length of training very little attention has been paid to shortening the basic sciences. Walling and Merando note that “Although educational outcomes were very similar for three-year and four-year curricula, most schools subsequently reinstated the fourth year to provide students with a broader clinical experience.” I don’t completely buy that; at least at Loyola, the clinical experience was not shortened during its 3-year curriculum. It surprised me in talking to people at the conference that so few even knew about these “experiments” from the 1970s.

My guess is that the current efforts focus on reducing the 4th year rather than the first two years because of politics. No one “owns” the 4th year, but the first two years are “owned” by the basic sciences in most medical schools, and by a strong advocacy constituency in the Association of American Medical Colleges (AAMC), the National Board of Medical Examiners (NBME) which offers the US Medical Licensing Examinations (USMLE) and other groups. They have strongly resisted efforts to decrease the time spent on basic science teaching in medical schools individually, as well as nationally. An effort by the NBME to combine the 3 “steps” of the USMLE into two was seen as “elimination of Step 1” and generated huge opposition from the basic science community; the change has been put on hold for several years.

While the need for students to pass “Step 1” is often used as the ultimate reason to not cut back biologic science curricular time, the fact is that students can pass this test with significantly pared-down content. Hopefully, however, there is a better reason to teach basic sciences. That would be that learning the concepts that are important for everyone training to be a doctor to know rather than forcing the memorization of details that are irrelevant, can be looked up, or are likely to change regularly. It means both subjecting the content of curriculum to the this test of relevance, and increasing the breadth of disciplines included as “basic” to include social sciences such as psychology, anthropology, sociology, epidemiology. The teaching -- and testing -- of all this material should focus on understanding concepts, solving problems, and knowing where to look up detailed facts, rather than memorization.
We do need more primary care doctors, and more family physicians to meet the health needs of the American people. We need to do everything possible to make this happen, and addressing financial incentives is a big part of it. Another plenary presentation at the meeting from STFM President Jerry Kruse addressed the successful efforts in Canada to increase the number of primary care doctors (in that country, all family physicians); the key element is decreasing the ratio between primary care and specialist income, and the effective ratio is between 80-85%. There are also good arguments for decreasing the cost of medical education, and perhaps shortening medical school is one method of doing so, especially if it can be done without sacrificing important training; it certainly needs to be relevant training.

But these efforts – to increase the primary care workforce and to consider the appropriate length of medical education – are different. They may complement each other, or may not. The strategies that we employ should be based on their effectiveness at achieving our goals, and for that to happen we need to be clear on what those goals are.  Piecemeal approaches may ultimately work, but they are not the most efficient ways of approaching the problem.

Of course, in terms of health insurance reform, piecemeal is the way we have chosen to go rather than a comprehensive national health program such as Medicare for All; why would we expect a more rational approach to improving medical education?

[1] Walling A, Merando A, “The Fourth Year of Medical Education: A Literature Review”, Acad Med  November 2010  85(11): 1698-1704.

Saturday, February 2, 2013

Kansas, Medicaid expansion, and human rights

In his well-covered “state of the state” speech, the Governor of Kansas, Sam Brownback (full text from the Lawrence Journal World, reported by the Kansas City Star or as you prefer either the Huffington Post’s reporting of it or the Kansas City Business Journal’s), addressed the thorny issue of Medicaid, the program that ostensibly provides medical coverage for the poor, but in reality only covers a portion of them. Most states do not cover childless adults, no matter how poor, unless they are demonstrably disabled, and what qualifies varies from state to state. The financial standard for eligibility is also very variable from state to state; in many places, including Kansas, it is well below the poverty line. Most Medicaid recipients are children in dire poverty and their mothers, and most Medicaid dollars are spent on nursing home care for the medically indigent (and, given the cost of nursing home care, it is really easy to become indigent if you are in one for very long). One of the mainstays of increased coverage for the uninsured in the Affordable Care Act (ACA) is the expansion of Medicaid to all people under about 140% of the federal poverty level.

Brownback said that “Many states have made the choice to either kick people off Medicaid or pay doctors less. Neither of those choices provides better outcomes. Kansas has a better solution,” but, while whether it is better or not may depend upon one’s interpretation of that word, it is not likely to cover more Kansans. He has indicated that no state money would be spent on expanding Medicaid. This does not, however, mean that there will be no Medicaid expansion in Kansas, as for the first several years the costs of such expansion under the ACA will be 100% borne by the federal government. If the state opts for taking the money (and the governor, unlike many other very conservative governors in the US, has been coy about this) it will be able to do so without state dollars. Brownback is committed to eliminating the state income tax, to compete with states like Texas (“Look out Texas, here comes Kansas!”) and is confident, along with his funders like “Americans for Prosperity”, that business growth resulting from his already-implemented tax cut, which has cut almost 1/3 of the state budget income, will more than make up for it (critics note that other states without income taxes have other big sources of revenue, such as oil in Texas and tourism in Florida, that Kansas does not have). This job growth is also part of his plan for getting people off Medicaid With jobs providing an off ramp from Medicaid, we will be able help those in need of services and reduce our waiting list.” (Did I mention there was a waiting list?) But, of course, this assumes that those jobs will come with health insurance. Definitely not a certainty, as most will be low-wage jobs, the kind most likely to not have health insurance coverage, and a state requirement for such coverage is definitely not something supported by the Governor or his political allies.

Whether Brownback will actually refuse the federal funds is uncertain; not all conservative governors have stuck to this principled, if cruel, position. Governor Jan Brewer of Arizona, a darling of the right with her aggressive enforcement of Arizona’s anti-immigrant laws (in an interesting coincidence, largely written by Kansas Secretary of State Kris Kobach), has reluctantly agreed to accept this money (“Medicaid expansion is delicate maneuver for Arizona’s Republican governor”, New York Times, January 20, 2013), as have Republican governors Susana Martinez of New Mexico and Brian Sandoval of Nevada. Of course, all three have a large and growing Latino population which supports and will benefit from Medicaid expansion, and whose votes are becoming increasingly important. Latinos are also the fastest growing population in Kansas, accounting for 70% of the state’s population growth from 2000-2010; they are not only in the bigger cities such as Wichita and Kansas City – the state’s first majority-minority counties are in its southwest -- but they are still not a significant enough voting block for Brownback to have any concern that they might swing an election to a Democrat. Indeed, in the 2012 election, extremely conservative Republicans supported by the Governor and lots of money from Wichita’s Koch brothers unseated most of the states just very conservative Republicans in primaries, giving him control of the state senate as well as house. Indeed, one of those defeated was the Senate majority leader, a rancher from the far southwestern corner of the state where the Latino vote did not prevent him from being beaten by a Koch-funded political newcomer.

Of course, there are reasons to doubt the core economics of Governor Brownback’s policies, based on the state’s economy picking up as a result of his tax cuts; even if one believes that will happen, it will be a long time and those whose benefits have been cut (who, given that the vast majority of the state budget is spent on education, followed by Medicaid and other core social services for the aged and disabled, will be the most vulnerable and our future) will suffer. As for the benefit of no state income tax, I lived in Texas, and the result is that every other tax is burdensome, and those taxes are much more unfair than a graduated income tax: real estate taxes that hurt the elderly and sales taxes that hurt those for whom the costs of the necessities of life are most of their income.

Expanding Medicaid, as called for by ACA, will not solve the problems of uninsurance. There remain not only the undocumented, but those who are employed by businesses that do not provide health insurance, including many that are too small to be required to do so even under the new law (and these are the jobs that Brownback’s policies, if they are successful, are most likely to create). But it will certainly help many families. And that should be the role of government, to help its people survive, and become educated, and be able to maintain their health. Economic growth will likely follow, at least much more likely than by cutting the taxes on the most wealthy.

And of course, at the most basic level, economic growth is not the goal; it is at best a strategy for improving the lives of our people. An article in Kansas City Star on January 20, 2013 ( “As the number of minority students grows in area schools, a learning gap remains” addresses the growth of minority, African-American and Latino, students in suburban as well as inner-city school districts. The article notes that the way school taxes are tied to real estate, “The rich get richer.” But it also quotes an educational leader who notes that “The moral imperative is now an economic imperative….The purchasing power of the new generation will depend heavily on the achievement of students of color. Social Security will need their economic success.
‘Everyone needs to understand…Someone else’s child is directly linked to your economic security.’” That is all true, but, at bottom, the core reason to provide education and health care is not so people will be able buy more stuff.

Recently, I saw the movie Les Misérables. I may be one of the few who did not see the stage play, but I am familiar with the story and loved the Jean-Paul Belmondo version set in WW II. Yes, it was long and not every actor was a great singer, but it told the story, and the story is of the oppression of the poor by those with power, and the occasional brave resistance of people who speak truth to power. And, in the last scene, after Jean Valjean dies, he is transported to a heaven not of clouds and harps and angels with wings, but one in which he and all of those who fought with him are standing on a barricade, continuing the fight.

Yes, the rich and powerful will buy and will influence politicians, and they will often win. But as health workers, and as citizens, it is our job to keep on advocating for the core needs of people, especially education and health care, to be met, not as a byproduct of economic development but as a human right.

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