"Values" based care: Public Health, Primary Care, and Medicare for All

Recently, a class of undergraduate freshmen I teach debated the issue “Health Care is a Human Right”. Although we later determined that most of them personally supported that statement, the “no” team did a good job marshalling the arguments of opponents, often citing those of libertarian think tanks such as the CATO Institute (originally founded as the Charles Koch Institute, in case that helps), which identifies itself as promoting "free markets and individual liberty”. This includes identifying health care as a “commodity” and opposition to health care as a right (and thus to universal health coverage) as an infringement upon individual liberty. Essentially these two concepts boil down to the idea that the individual is free to decide what kind of health care they want, or don’t want, and what kind of insurance coverage they want, or don’t want, and can use their money (or not) to purchase this commodity (health care) as opposed to another (I don’t know, say a bass boat).

The hole in this argument is wide enough, though, to drive a bass boat through. It is that not everyone has such a large amount of disposable income that they have the financial options to make such decisions. An old point about commodities having to do with cars, when most Americans bought American brand cars, is that some folks can buy Cadillacs and others Chevrolets. But of course, even if we update this to Beemers and Kias, there are a huge number of people who are buying used cars – often old “junkers” – to try to get to work and shopping. And there are those who can’t afford to buy, insure, and run any car at all and are reliant on public transportation. If there is any public transportation where they live. People without a lot of money (often despite working multiple jobs, even those making quite a bit more than the federal minimum wage of $7.25/hour -- last raised in 2009 when $7.25 was equivalent to about $9 today) make regular trade-offs on what they will spend their money on. Rent? Food? Clothes for the kids? Heat? Electric bill? Gas for the car to get to work, if they have a car? Health and medical care are rarely right up there at the top unless they are actively ill. Indeed, often even chronic diseases don’t get adequately managed, with medications for common conditions such as diabetes and hypertension stretched out. This family – and to a greater or lesser extent, this is probably true of the majority of families – is trying to figure out how to juggle absolute necessities, not luxury goods. The students arguing the “anti” position gamely tried to respond to such concerns, but learned that, outside the walls of conservative think tanks, Congress, state legislatures, and country clubs, there is a limit to the effectiveness of continually repeating “individual liberty” and “commodities”.

Paying for the cost of health care is a real juggling act for the government, although for a different reason from the one the families above are doing. It is balance between wanting to spend less money and continuing to support the profits of health care corporations such as insurance companies, hospital systems, and drug makers. The rational solution to this problem is to decide that it is not the government’s business to guarantee the often obscene profits of such private corporations, but rather to spend the money on whatever maximally increases the level of health of the American people.

This should include at least two major changes: first, a national health insurance plan (such as “Medicare for All”, recently reintroduced with major improvements by Reps. Pramila Jayapal and Debbie DIngell) that ensures that everyone is covered – everyone, all in one plan, no exceptions by age, disease, etc.), and second, a massive and continuing re-investment in public health, the need for which should have been made clear by the COVID pandemic. Historically in the US, in Democratic and Republican administrations, funding for public health is about 1% of the health budget, with the rest going to individual medical care. When we have a crisis, we bemoan the lack of public health infrastructure for a while, but then it recedes. Yet this is the most important component of keeping us healthy. Fighting an active enemy (like COVID) can garner support, while maintaining programs of prevention absent an obvious crisis gets less. How often do we wake up and say “I’m glad I don’t have cholera today because we have clean water and sewage”? And, yet, recently folks in Mississippi and Texas can count themselves lucky that their lack of water did not come with cholera or another infectious disease.

Instead of such wholesale reimagining we have had programs like “value-based care” for Medicare, adopted with the ACA (“Obamacare) in 2010. When this was first rolled out, I was enthusiastic because I misunderstood it – I thought it was about providing care based upon values, presumably decent human values. Sadly, I was wrong. It was about spending less money. Did it work? To do what? If the goal was spend less, yes, to some degree (see Austin Frakt in the NY Times Upshot Oct 9, 2019, “more singles than home runs”). One of the big goals was to substitute “value” for “volume”. Paying for volume, the number of patients seen, was the accepted way to pay doctors. But what does paying for value mean? This whole issue is reviewed by Dr. Don McCanne in his “Quote of the Day” for March 17, 2021 “Policy community hung up on ‘volume to value’”. Dr. McCanne reviews the recent article “The Future of Value-Based Payment: A Roadmap to 2030” from the University of Pennsylvania on the topic, but in his comments he notes that

“All health care has “volume” – time, effort and resources devoted to health care. Volume varies tremendously depending on the clinical situation. Think of management of a common cold as opposed to management of severe multiple injuries in an accident. Can payment schemes ignore volume? Of course not. Volume is built into the problem.”

Here is a volume/value solution that I have discussed before but will now say clearly: Revise the way that physicians (and other providers) are paid so that family physicians and other primary care doctors make at least as much as those providing subspecialty care. This is the third step to add to universal health coverage and investment in public health. When I go to a shoulder orthopedist for the pain in my shoulder, that is the ONLY PROBLEM they deal with. Not BP, not abdominal pain, not my cold -- not even the arthritis in my knees.  My PCP would deal with every problem on my – and all their patients’ -- problem list (to greater or less extent, depending upon severity and acuity), and thus rarely has enough time for any on person. If you go to the cardiologist, and mention that you have knee pain, they say "I don't do knees; here is a referral to the orthopedist". And you go to the orthopedist, they make a recommendation, you come back to the cardiologist who says "I don't do knees; whatever they said". So, for the subspecialist, referral is a time saver.

But if you come to a PC doc and say your knee hurts, they make some diagnostic and treatment suggestions. After examining your knee, maybe ordering imaging and lab, and thinking about it, if they think it might need surgery, they might refer you to the orthopedist. Then you go and the ortho says "maybe surgery", so you come back and ask your PC doc’s opinion, so they read the whole consult and review the films and think about it and discuss it with you. Result: referral for a PC doc makes MORE work.

And they get paid less.

PC docs need more time with everyone, and thus fewer patients each day/week/year. How much money should they make? I don't care, pick a number, but it should be able to be earned by seeing no more than half the number of visits that they currently do. People's complaint is ALWAYS about not having enough time with the doctor.  

So, increase funding for public health, develop a universal single-payer health insurance system, and pay PC docs at least as much per hour or patient as the highest-paid subspecialist in the outpatient setting. 

Now we begin to have “value”!

DTC Advertising on TV illustrates the corruption and inequity of the US medical care system

I don’t watch a lot of live daytime TV. (In fact, I don’t watch a lot of live TV at any time.) I do see it several times a week for the 45 minutes I spend on the elliptical at the gym, which requires that the two TVs be tuned to sports. In practice, that means ESPN and ESPN2 and I try to position myself between them so I can look at whichever has the least boring talk. Daytime is not a time for actual sports; it is all sports talk. And mostly I listen to music in my headphones.

But I did seem to notice a really lot of the commercials were medically-related and aimed at my demographic (ie., “old”). Since I was recently in the hospital for several days and had the TV on different stations, I can attest that this pattern is not limited to sports shows; it is absolutely as ubiquitous on CNN, MSNBC, etc. (can’t personally attest to FoxNews, but I bet it is also true there). Sure, there are a few non-medically related commercials aimed at my demographic (e.g., reverse mortgages) and once in a while even something of more general generational interest – I particularly liked a half-hour infomercial for the NuWave Bravo air fryer/convection oven. But the medically related dominate.

Such commercials include those related to insurance (Medicare supplements and in particular Medicare Advantage – which seems a bit odd, since open enrollment doesn’t start until October), those advertising medical treatments for disease of the age-challenged, and lots of commercials for incredibly expensive recombinant DNA (anything ending in “-ab”) for relatively uncommon diseases. This last group is in the traditional (if your idea of “tradition” is 40 years) mode of direct-to-consumer (DTC) advertising first legalized under the Reagan administration: “ask your doctor if this is right for you”. The implication is that it probably is, although the litany of unpleasant side effects that always starts with bloating, and moves to serious infections, and ends in death, should give us pause. It is certainly right for the drug manufacturer, who – shock! – makes HUGE HUGE HUGE amounts of money on these things. Some of these drugs cost $100,000 a year. There are neurologic drugs that cost $30,000 a MONTH. Or more. Thus it is worth advertising to lots of people in the hope that even a small percentage will “bite”.

NOTE: Most doctors hate this DTC advertising. Yes, it is in part because of how irritating and time consuming it is for patients to come in and keep asking about whether they should be on these drugs. But more important, it is because they are trying to take care of you, to best manage you condition using drugs (when drugs are appropriate) that are the most effective, have the fewest and least dangerous side-effects, and are affordable for you. Why on earth anyone would ever think that a multi-drillion-dollar multi-national drug company would have your health interests at heart more than your doctor? If you think that, 1) you’re wrong, 2) you’ve been watching too much TV.

In addition to the insurance and drug commercials, there are multitudes of miscellaneous others, especially for devices. You can get an app for your phone that will check your EKG. You can get endless numbers of devices that will monitor your blood sugar, many of which apparently come with the added benefit of turning you into a totally fit mountain biker! Indeed, if you have always wanted to play the flute, direct a play, or kayak whitewater, these devices are for you! Also, the you-know-what. And let’s not forget the “mobility devices” like scooters, available at “no cost to you” (although such ads seem a little less common since some of the big operators have been imprisoned). These commercials provide a regular source of income for actors in their 50s playing people in their 70s. Even the ones in scooters look not very old, not very sick, and not very obese. Of course, sometimes they feature a real person in their 70s, if they’re famous. Joe Namath, is, I think, 77.

There seem to be endless ways for the companies to make money off of your Medicare benefit. Medicare Advantage is one issue that deserves a little more discussion, since they often seem to (and may) offer you actual advantage. Medicare Advantage (Medicare Part “C”) takes the money that traditional Medicare would pay, usually has you put in more, and basically puts you in an HMO. You get the benefits of an HMO – stuff not covered by traditional Medicare like maybe eye, ear, dental, or other stuff. Also, the disadvantages, like limited choice of doctors, hospitals, etc., especially if you’re not in your usual geographic area. People with traditional Medicare do not get bills from doctors who are out of network (unless, and this is rare, they have opted out of Medicare altogether), but Medicare Advantage patients do. So, if you never leave your home area, and are happy with the hospitals and doctors in the network, it may be a good choice for you, just as an HMO may be for anyone (disclaimer: probably, however, if you are to choose one, it shouldn’t be the one advertising on TV!)

That’s about you, though. Societally, it is much worse. Medicare Advantage plans, compared to traditional Medicare, have way higher overhead costs (about 12-18% vs about 2%). They also get paid extra by the federal government. Why? Well, you’d have to ask Reagan and his GOP successors; essentially it is part of an effort to privatize as much as possible. And, like most efforts to privatize, actually costs more. And we all, as taxpayers, pay for it.

This is not a benign process, for Medicare, for drugs, for devices. They are selling us very expensive stuff and making a huge profit, while millions of Americans have no health insurance and millions more are grossly underinsured. Discussions about national health insurance proposals often focus on cost, but the stuff being sold in these commercials is part of the structure that causes amazingly inflated costs, making our health system the most expensive (2-3x as much per capita as other industrialized countries) while maintaining among the worst health outcomes of that group of nations. And the burden is not spread equally; those most in need, those who are the poorest, disproportionately minority group members, are the hardest hit. It is inequitable, discriminatory, and immoral.

The bottom line is that all of these commercials propagate a system that is not only vastly inequitable, but is medically inappropriate. A system in which the goal is not to maximize the health of the population, in any fashion but certainly not an equitable one, but rather to maximize the profit for the companies that are advertising, to take money from the rest of the economy and accrue it to themselves. This, of course, is the nature of modern capitalism, but that doesn’t make it good. You have to decide if your health, and the health of your friends, family, community and nation are a core public benefit or a product to be sold, caveat emptor.

The bottom line for the individual is the same as it is for all commercials. They are NOT about YOU. They are about MAKING MONEY for the company sponsoring the commercial. That is all. You are nothing but the vehicle, or perhaps more technically, “sucker”, who will channel that money their way. If you read the fine print it is scary, and that is only the stuff that they are legally required to tell you. Anything that they are not legally required to tell you will not be there. Do not trust them at all. Do not watch them. They are dangerous.

Although I am going to look at see how Consumer Reports rates the NuWave Bravo…