Saturday, December 28, 2013

How can a health care system lead not to ruin but to, actually, health?

After a year of reporting in a series of articles in the New York Times (several of which I have commented on in this blog) on the crisis in health care, Elisabeth Rosenthal summarized her conclusions in a Times piece on December 22, 2013, “Health Care’s Road to Ruin”. As the title makes clear, those conclusions are not positive. She summarizes highlights from her investigations that look at the extremely high cost of health care in the US compared to other countries, the extreme variability in pricing depending upon where you are in the US, and the opaque and incomprehensible methods of coming up with pricing and the regulatory incentives that are continually gamed by providers. On the other end of the spectrum, she summarizes both the poor health outcomes at a population level in the US compared to other countries, and the more personal, poignant and dispiriting stories of individuals who die, are bankrupted, or both by our health “system”.

As Ms. Rosenthal notes, the stories that she tells could be “Extreme anecdotes, perhaps. But the series has prompted more than 10,000 comments of outrage and frustration — from patients, doctors, politicians, even hospital and insurance executives.”  She goes on to discuss the potential solutions that those commenters, and others, have suggested, including regulating prices, making medical schools cheaper or free, not paying fee-for-service that rewards volume rather than quality. But, she says, “the nation is fundamentally handicapped in its quest for cheaper health care: All other developed countries rely on a large degree of direct government intervention, negotiation or rate-setting to achieve lower-priced medical treatment for all citizens. That is not politically acceptable here.”

In reality, however, the idea that the health industry is somehow, before or after the ACA (“Obamacare”) an exemplar of the free market and the success (or not) of private enterprise, is entirely a myth, a facile construct that is used by those making lots of money on the current system to block change. Medicare, as I have discussed (e.g., Outing the RUC: Medicare reimbursement and Primary Care, February 2, 2011), sets the rates that they will pay for Medicare patients, and private insurers pay multiples of Medicare rates. Services as mostly fee-for-service, except in HMOs, and integrated health systems (such as Kaiser), and for Medicare inpatient admissions which are paid at set fees based on the diagnosis (through a system called Diagnosis-Related Groups, or DRGs). The entire system of what is profitable for a health care provider (meaning a hospital or other health care facility or a doctor or group) is based on this policy; it is profitable to provide cancer care because Medicare (and thus other health insurers) pay an enormous amount to administer chemotherapy drugs. Cardiac care, orthopedics and neurosurgical interventions are also very profitable. (Oh! Is that why my hospital chooses to focus on these areas instead of psychiatry, obstetrics and pediatrics?!) The doctors who do all these things want you to think (and think themselves) that it is because what they do is so hard or that they work so hard; it is in fact a regulatory policy glitch. In addition, a majority of the money spent on “health care” is public funds, not private, if you add Medicare, Medicaid, federal, state and local government employees and retirees, and add in the tax break for employer contributions to health insurance (i.e., taxes forgone because this employee reimbursement is not counted as regular income).

So the majority of the money being spent on health care is public money, and the system is already highly government influenced with government policies setting reimbursement rates. The only thing “private” about it is the ownership and profit, both by providers and insurance companies. In other words, it 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. Thus, Rosenthal’s comments, and quotations from others such as Dr. Steven Schroeder of the University of California at San Francisco: “People in fee-for-service are very clever — they stay one step ahead of the formulas to maximize revenue.” But, of course, we the people, through our elected representatives and regulators, allow them to do so. And, therefore, the arcane network of incentives and disincentives built into the ACA to try to get reasonable results at reasonable cost – and still ensure insurance companies make lots of profit.

The solution is very simple; emulating one or the other systems in place in every other Western democracy. The simplest is closest to us is Canada, and a single-payer system, essentially putting everyone into Medicare. Voilá! We are all covered by the same system, providers can provide care to people based upon their disease, not their insurance status, and rates can be set at the level that we as a people are able to tolerate, or willing to pay, for the health care we want and need. The clout of the empowered will bring along benefit for everyone. There will be no more gaming the system, trying to attract certain patients with certain insurance rather than other. Or, in a more complex fashion, we could follow the example of other countries; Switzerland, for example, has multiple private insurance companies rather than a single payer, but they are highly regulated and non-profit; they are told by the government what they can charge and what they must cover.

The argument that Americans will not accept major government involvement and regulation is pretty flawed, both because of the involvement of the government in regulating the health system already (mostly to ensure profit for providers and insurers) and because regular people see the advantage of universal health care. Rosenthal writes that “All other developed countries rely on a large degree of direct government intervention, negotiation or rate-setting to achieve lower-priced medical treatment for all citizens. That is not politically acceptable here.” Study after study has shown strong support for a universal health care system from the American people; however, certain very powerful vested interests would likely lose out:  “’A lot of the complexity of the Affordable Care Act arises from the political need in the U.S. to rely on the private market to provide health care access,’ said Dr. David Blumenthal, a former adviser to President Obama and president of the Commonwealth Fund, a New York-based foundation that focuses on health care.“

The political need is for the wealthy and powerful. This is why ACA ensured that insurance companies would get their cut. Elisabeth Rosenthal does not say so in so many words, but she does say that “…after a year spent hearing from hundreds of patients like Mr. Abrahams, Mr. Landman and Mr. Miller, I know, too, that reforming the nation’s $2.9 trillion health system is urgent, and will not be accomplished with delicate maneuvers at the margins. There are many further interventions that we know will help contain costs and rein in prices. And we’d better start making choices fast.”

A universal health care program, Medicare for all, in which everyone was automatically enrolled just as current Medicare recipients are now, would be just fine.

Saturday, December 21, 2013

Roosevelt University: A commitment to diversity and social justice

On December 13, 2013, I attended the winter Commencement ceremonies at Roosevelt University in Chicago. As a new member of the University’s Board of Trustees, it was my first such event at Roosevelt; the Board had met the day before. I have, of course, been to other graduations. Some have been of family and friends, but most have been as a faculty member in medical school. I have sat on the stage looking out at the assembled graduates and families before, but never in the role of a Trustee, and never at Roosevelt.

Graduations are pretty special events. At the medical school graduation ceremony, we look on as our future colleagues march across the stage, many of them people we know and have taught, while their families watch and clap and sometimes cheer. We have pride in them, and also wonder how fast the time goes, remembering when they were just starting a few short years earlier. But the Roosevelt graduation was different, and not just because it was not a medical school and not just because I was there as a Trustee.

For starters, it was in Chicago’s beautiful Auditorium Theater, in the Auditorium Building designed by Louis Sullivan, opened in 1889 and about to celebrate its 125th anniversary next year. I have been there before but only in the audience; sitting on the stage looking out at this gorgeous auditorium whose balconies soar 6 or 7 stories, filled with 4,000 people, was amazing. Roosevelt owns the Auditorium, and the building has long been its home, but recently the 40-story Wabash Building has been built next to it, rising 40 stories, the top 27 dorms with priceless views, its own architectural splendor complementing in a very different way that of Sullivan.

There were also some special events during the graduation. The honorary degree recipient was Joe Segal, a Roosevelt alumnus who for 60 years has run Chicago’s Jazz Showcase, bringing all of the great jazz artists of those years to perform at a series of venues; I began attending his shows in the 1970s. Danielle Smith, graduating with a bachelor’s degree in Special Education (and a minor in Spanish) was the first-ever current student to be commencement speaker. She was joined on the stage by Sheree Williams, receiving a Master’s in Early Childhood Education, who was the 85,000th graduate of the school (it took 60 years to get to 65,000 and only 6 for the next 20,000).

Those of you who read my last post, Suicide: What can we say?, know that the date, December 13, was also the 11th anniversary of my son Matt’s suicide. While the two facts are coincidental, they are not unrelated; my presence on the Board and thus at the graduation was entirely about Matt. A few years after leaving his first (quite elite) college and then obtaining an associate’s degree, Matt moved back to Chicago and enrolled at Roosevelt. He loved it. It was, and is, a school, originally established to focus on returning GIs and people of color, that both educates young (and older) people from all backgrounds and prides itself on its diversity, and its explicit commitment to social justice. This resonated with Matt, and does with me. I later met President Charles Middleton through the sponsorship that Matt’s mother and I do of the annual Matthew Freeman Lecture in Social Justice (see, most recently, Matthew Freeman Lecture and Awards, 2013, April 26, 2013), and later when he hosted my group of American Council on Education fellows at the university. Dr. Middleton calls Roosevelt the “most diverse private university in the Midwest”, and sitting there as the graduates cross the stage it is not hard to believe. Virtually every race and ethnicity was represented by the graduating students, many obviously first-generation Americans, and the pride in their faces was unmistakable.
In her speech, Ms. Smith spoke about coming to Roosevelt from an all-white, middle-class, suburb, in large part to play tennis – which she did. She also, however, learned about diversity, and met fellow students from all races, religions, ethnicities, and socioeconomic groups, and made them her friends. She talked about a concept that she had never heard of before but was omnipresent at Roosevelt, social justice, which she says will guide the rest of her life. Ms. Williams’ presence on the stage, as 85,000th graduate, may seem like a quirk, but she also is “typical” of Roosevelt; an African-American woman who received her bachelor’s in education there and now her Master’s, and will be teaching second grade in Chicago, before, she plans, to get her doctorate. Wow.

President Middleton, in his closing address, asked several groups to stand. They included the international students, who had to add learning English in addition to their studies, and the families, friends and other supporters who jammed the Auditorium. Most impressive, to me, however, was when he asked all the graduates who were the first members of their families to get a degree at their level to stand. Some were getting doctorates and master’s degrees, but the large majority of the graduates were receiving bachelors. Two-thirds of the graduates stood, to rousing cheers.

There are plenty of colleges that offer the opportunity for students from working-class and poorer backgrounds to get an education, for first-generation students to learn. They include the our community colleges (I still remember a talk at the 2008 ACE Conference by the president of LaGuardia College in NYC, where she said -- as I remember it -- “there are two kinds of colleges; those that try to select the students who will be the best fit at their institutions, and community colleges, that welcome students”), and our state universities. And some are private schools, like Roosevelt. And others may have the explicit commitment to social justice that Roosevelt does.

But I am proud to be associated with one that so overtly and clearly demonstrates it.


Thursday, December 12, 2013

Suicide: What can we say?

On Sunday, September 8, 2013, we participated in the annual Suicide Remembrance Walk in Kansas City’s Loose Park, organized by Suicide Awareness Survivor Support of Missouri and Kansas (SASS/Mo-Kan). An article previewing the walk and interviewing Bonnie and Mickey Swade, our friends who established SASS/Mo-Kan, ran in the Kansas City Star on September 7: “What to say, and not, to those left behind by suicide”. Bonnie and Mickey became our friends because we are members of a club none of us would wish to be in: suicide survivors. Their son Brett completed suicide about a year after our son Matt did, and we were in a support group together before the Swades started their own. Matt’s suicide was on December 13, 2002, which I never thought of as being “Friday the 13th” until I realized that because of the vagaries of leap years, this year, 11 years later, is the first Friday December 13th since then. Thus, this post several months later.

The Remembrance Walk around Loose Park in Kansas City was well-attended on a hot morning, and culminated in all of us standing in a very large circle holding long-stemmed flowers as a distressingly long list of names was read. We counted 7 times when two (and in one case 3) last names were repeated; the list was not in alphabetical order, so this was not coincidence. As much pain it is to have one person you love having committed suicide, two or more is unfathomable. Finally, white doves were released, and the ceremony ended to the strains of “Somewhere over the rainbow”.

I have written about suicide before (July 29, 2009, “Prevention and the “Trap of Meaning”), in which I discussed an article that had recently appeared in JAMA by by Constantine Lyketsos and Margaret Chisholm titled “The trap of meaning: a public health tragedy[1] ). The thrust of that piece was that people -- families, lay persons, psychiatrists, psychologists, philosophers, and others -- search for “meaning”, “reasons” for suicide, and that this is, essentially, pointless at best and, devastating at worst. Suicide is the fatal result of the disease of depression, a disease which is very common and not usually fatal, but can be. It may often be precipitated by a specific event or set of events (as the final episode of chronic heart or lung disease is often preceded by a viral infection) but those are not the cause. The strongest prima facie evidence is that most people in the same circumstances (whether victims or perpetrators of bad things) do not kill themselves. But enough do to have made a long list to have read at the ceremony in Loose Park.

Like everyone else, each person who kills themselves is unique, and their histories differ. Some have made previous attempts, often many times; others gave no clue. Some have been hospitalized, often many times; others never. Some have family who were sitting on the edge, awaiting the suicidal act, trying their best to help to prevent it but helpless to really do so. The families and friends of others had no idea it might happen. While those who attempt or complete suicide are depressed, some very overtly manifest that depression and some not so much. While many people who have depression never attempt suicide, some complete suicide when things are looking, to others, good. Overall, access to effective weapons increases the probability of “success”; the “lethality” (the probability that you will die from an attempt) is about 95% from guns, and only 3% from pills. Therefore, easy access to guns is associated with a higher successful suicide rate; in young men 16-24 the success rate is nearly 10 times higher in low gun control states than in high. I doubt these young men are more depressed, but they have quick and effective methods of turning what may have been relatively transient suicidal thoughts into permanent death. Of course, not all suicides are classified as such; while it is often obvious, sometime it is not: how many one-car accidents, for example, are really suicides? And, because “unsuccessful” suicide attempts are grossly under-reported, the lack of an accurate denominator makes “success” rates very hard pin down.

On one hand, the fact that most suicide attempts are not hospitalized and given intensive treatment seems to me to be a bad idea. Since the greatest predictor of a suicide attempt is a previous suicide attempt, if there is any likelihood that a suicide can be prevented it would be best to intervene at that time and try to treat the depression. On the other hand, I am not sure that there is any good evidence that treatment is terribly effective in preventing suicide. Yes, there are many people who have attempted suicide once and never again, but this may be a result of treatment or the natural history of their disease. There are people who are under intensive treatment when they complete suicide, often when least expected. Indeed, there is evidence that treatment of depression may sometimes paradoxically increase the risk of suicide by getting a person whose depression was so severe that they were unable to act better enough that they can. And, conversely, there is no way of knowing how many times, before a suicide is completed, a planned attempt was put off by an intervention that may not have even been intended, by demonstrating love and letting the person know they were needed.

It doesn’t always work. If the person is unwilling to share their symptoms and is determined to complete suicide, there is no prevention that is effective. My son was 24, deeply loved, lived in a state with strict gun control laws and probably never held a gun before. But he was able to drive to a low gun-control state, buy a carbine and bullets, and complete his suicide. He took his time and planned it, and it is unlikely to have been preventable. But many suicide attempts are not as well planned, are more impulsive, and efforts to prevent these might be successful in many cases. In a classic 1975 article in the Western Journal of Medicine[2] David Rosen interviewed 6 survivors of jumps from the Golden Gate bridge. The emphasis in these interviews is on transcendence and “spiritual rebirth”, but all agreed that putting a “suicide fence” in place might have deterred them and might deter others.

For all of us who wish mightily to prevent disease and death, suicide may be seen as the greatest affront because the death is seen as “unnecessary” and often involves people who were “healthy” (except for their depression), young, and had a future before them – sometimes (as I like to think of Matt’s) a truly promising future. But too often we, in our desire to prevent death and disease, choose to focus on the least effective interventions to do so. We will take unproven drugs (especially if they are “natural” or non-prescription), and clamor for our “right” to have marginally useful or even ineffective screening tests, but there is a vocal movement against immunizations, one of the few preventive interventions that are known to be effective. We decry mass murders in school after school, and bemoan the loss of our young people to both suicide and homicide, but resist regulation of the most effective instruments of death, guns. We all take our shoes off each time we fly because of one failed “shoe-bomber”, but ignore the thousands of deaths on our city streets.

I wish my son had not killed himself. I wish I knew how to have prevented it. I wish I could tell those of you who worry about a loved one how you can prevent it. I wish even more that I could tell those of you who don’t suspect it that you can be secure because in the absence of definite warning signs you can feel safe. I can’t do that. When there are warning signs, take whatever action you can, but the reality is that it may not be effective. When there are no signs, hope that it is because there is no risk.

As individuals, we hope and do what we can. As a society, we should decide on our priorities, and we should be guided by the evidence, not by our fantasies, hopes, or magical thinking.

[1] Lyketsos CG, Chishom MS, “The Trap of Meaning: A Public Health Tragedy”, JAMA. 2009;302(4):432-433. doi:10.1001/jama.2009.1059.
[2] Rosen DH, “Suicide Survivors: A Follow-up Study of Persons Who Survived Jumping from the Golden Gate and San Francisco-Oakland Bay Bridges, West J Med. 1975 April; 122(4): 289–294. PMCID: PMC1129714

Wednesday, December 4, 2013

Medicaid expansion or not: everyone needs coverage

In an echo of my blog post of November 17, 2013, “Dead Man Walking: People still die from lack of health insurance”, the New York Times’ lead article on November 29, 2013 was “Medicaid growth could aggravate doctor shortage”. The main point in my blog was that, to the degree that there is a doctor shortage exacerbated by increasing the number of people who have health insurance (from Medicaid expansion or insurance exchanges or any other reason), the shortage was already there. If the reason that it was not felt earlier was because people, not having health insurance, did not seek care, does not change the fact that these people were here and were as sick as they were or are. To the extent that they were not getting health care because they were uninsured is a scandal. If anything, that people will now have coverage and thus seek care is an unmasking of an extant but unmet need.

The Times article looks particularly at Medicaid because many doctors will not see Medicaid patients since the payments do not cover their costs (or, in many cases, because they can fill their schedules with people who have better-paying health insurance). Those physicians who do accept Medicaid often feel that they will not be able to take more Medicaid patients for the same reason, and it is unlikely that those who are already not accepting Medicaid will begin to. The problem is significant for primary care, even for institutions like Los Angeles’ White Memorial Hospital that already care for large numbers of Medicaid patients. In the NY Times article, my friend Dr. Hector Flores, Chair of the Family Medicine Department at White Memorial, notes that his group’s practice already has 26,000 Medicaid patients and simply does not have capacity to absorb a potential 10,000 more that they anticipate will obtain coverage in their area.

The problem for access to specialists may be even greater. There are already limited numbers of specialists caring for Medicaid patients in California and elsewhere, for the reasons described above: they have enough well-insured patients, and Medicaid (Medi-Cal in California) pays poorly. It is also possible that some specialists have less of a sense of social responsibility (even to care for a small proportion of patients who have Medicaid or are uninsured), and their expectations for income are may be higher. The San Diego ENT physician featured at the start of the Times article, Dr. Ted Mazer, is one of the relatively small number of subspecialists who do take Medicaid, but indicates that he will not be able to take more because of the low reimbursement.

Clearly, Dr. Mazer and Dr. Flores’ group are not the problem, although it is likely that they will bear a great deal of the pressure under Medicaid expansion; if their practices have been accepting of Medicaid up until now, they are likely to get more people coming. The Beverly Hills subspecialists (see: ads in any airline magazine!) who have never seen Medicaid, uninsured, or poor people up until now are unlikely to find them walking into their offices. And, if they call, will not schedule them. So what, in fact, is the real problem?

That depends a bit upon where you sit and how narrow or holistic your viewpoint is. From the point of view of doctors, or the health systems in which they work, the problem is inadequate reimbursement. As a director of a family medicine practice, I know that you have to pay the physicians and the staff. For providers working for salaries, it is the system they work for that needs to make money to pay them. The article notes that community clinics may be able to provide primary care, but does not note that many of them are Federally-Qualified Health Centers (FQHCs) which receive much higher reimbursement for Medicaid and Medicare patients than do other providers. The Affordable Care Act (ACA) will reimburse primary care providers an enhanced amount for Medicaid for two years, through 2014, and yet not only is there no assurance that this will continue, but in many cases has yet to be put into place. And the specialists are not receiving this enhanced reimbursement (although the truth is that many of them already received significantly higher reimbursement for their work than primary care physicians).

From a larger system point of view, Medicaid pays poorly because the federal and state governments that pay for it (although the federal government will pay 100% of the expansion for 4 years and 90% after that) want to spend less. However, they do not want to be perceived as allowing lower quality of care for the patients covered by Medicaid, so they often put in requirements for quality that increase costs to providers which increases the resistance of those already reluctant to accept it. Another factor to be considered is that Medicaid has historically not covered all poor people; rather it mainly covers young children and their mothers, a generally low-risk group. (It also covers nursing home expenses for poor people, which generally consumes a higher percent of the budget.) Expansion of Medicaid to everyone who makes 133% of poverty means that childless adults, including middle-aged people under 65 who have chronic diseases but have been uninsured, will now have coverage.

While the main impact of Medicaid expansion is in states like California that actually have expanded the program, even in states like mine (Kansas), which have not, Medicaid enrollment has gone up because of all the publicity, which has led people already eligible but not enrolled to become aware of their eligibility (called, by experts, the “woodwork effect”). The Kansas Hospital Association has lobbied very hard for Medicaid expansion, but this has not occurred because the state has prioritized its political opposition to “Obamacare”. The problem for hospitals is that the structure of ACA relies on the concurrent implementation of a number of different programs. Medicare reimbursements have been cut, as have “disproportionate share” (DSH) payments to hospitals providing a larger than average portion of unreimbursed care. This was supposed to have been made up for because now formerly uninsured people would be covered by Medicaid (that is hospitals would get something); however, with the requirement that piece removed (thanks to the Supreme Court decision and the political beliefs of governors and state legislatures), the whole operation is unstable. That is, the Medicare and DSH payments are down without increases in Medicaid.

From a larger point of view, of course, the problem is that the whole system is flawed, and while the ACA will help a lot more people, it is incomplete and is dependent on a lot of parts to work correctly and complementarily – and this does not always happen, as with lack of Medicaid expansion. A rational system would be one in which everyone was covered, and at the same rates, so that lower reimbursement for some patients did not discourage their being seen. These are not innovative ideas; these systems exist, in one form or another in every developed country (single payer in Canada, National Health Service in Britain, multi-payer private insurance with set costs and benefits provided by private non-profit insurance companies in Switzerland, and a variety of others in France, Germany, Taiwan, Scandanavia, etc.). If payment were the same for everyone, empowered people would ensure that it was adequate. Payment should be either averaged over the population or tied to the complexity of disease and treatment (rather than what you could do, helpful or not). We would have doctors putting most of their work into the people whose needs were greatest, rather than those whose reimbursement/difficulty of care ratio was highest. There are other alternatives coming from what is often called “the right”, but as summarized in a recent blog post (“You think Obamacare is bad…”) by my colleague Dr. Allen Perkins, they are mostly, on their face, absurd.

Our country can act nobly and often has. ACA was a nice start, but now we need to move to a system that treats people, not “insurees”.

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