Primary care, specialty care: what about health?

Three “Perspectives” in the September 6 issue of the New England Journal of Medicine address different, but clearly related, aspects of the transformation of health care. I have previously discussed one of them, “Becoming a physician: the developing vision of primary care" by Barnes, and Comfort in Social determinants key to the future of Primary Care (September 22, 2012). The two others are "What business are we in? The emergence of health as the business of health care"^[1], by Asch and Volpp from the Wharton School of the University of Pennsylvania, and "From Sick Care to health care -- re-engineering prevention into the US health system" by Marvasti and Stafford.^[2] Taken as a whole, the three provide some significant insight to the current US healthcare delivery system, the changes that need to be made in it, and the way we will get there.

Asch and Volpp discuss the need to shift from "what can we produce" (health care) to "what do people want" (health). They use the parallels of the failure of major industries (railroads in the last century; Eastman Kodak in this) to make this distinction. Each of those industries made the mistake of confusing what they produced with what people wanted when they bought their products. Thus, railroad companies provided railroads, when customers wanted transportation of goods and people; when alternatives (trucking, air) became available they were unable to adjust (although in Europe they did a pretty good job). Similarly, Kodak made film when what people wanted was to store images of their lives. Asch and Volpp do not mention that the ad agencies got this right (“we create memories”) but the corporation did not move into the digital age early enough and, last year, went into Chapter 11 bankruptcy.

The “health care” industry provides, at best, health care, but more often just medical care, and most especially disease care. People seek it out because it is what available; what they want is health, to not be sick, in pain, disabled. This is of course why “mainstream” medicine is not the only source of treatment people seek. It explains the allure, and extensive use, of products of the “alternative care” industry, which ranges from degreed practitioners like chiropractors and naturopaths to long-used herbal and other cultural treatments dispensed by various methods (botánicas and the Internet), to Eastern medicine such as acupuncture, to religious rituals including American Indian healing, Catholic exorcisms, and the rituals of Santeria, Candomblé, and Voodoo derived from Africa, to straightforward quackery. “Integrative medicine” is an effort by traditional western medicine to employ many of these techniques and traditions. While we probably would actually prefer the diagnostic and treatment magic of Star Trek’s doctors, we’d certainly like the magic pill, elixir, injection, herb, or prayer that would heal all our ills – preferably with no real or sustained effort on our parts, and without side effects. Interestingly, while “alternative” medicine is seen as more “holistic”, it is in fact often more biologically reductionistic, using interventions (e.g., enemas, diet changes, supplements) to cure social and psychological problems (see my 2005 piece “Towards a definition of holism” in the British Journal of General Practice).^[3]

Perhaps this is all “quackery”, or just some of it is and others are not. In mainstream American medicine, something doesn’t become a real disease until there is a test for it – or better yet a drug for it – thus the medicalization of many things that people have experienced as part of the mortal coil for thousands of years. Some things that were accepted as “part of life” (and death) are now diagnosable and treatable; others might be in the future. But those of us in the “health care” industry need to understand that folks will only buy what we are selling if it is, on the whole, the most effective way for them to get what they want: health.

Marvasti and Stafford discuss the need to change from a system designed to treat acute conditions and acute exacerbations of chronic diseases to one in which, in Fries' model, of "morbidity compression", "in which the disease-free life span is extended through the prevention of disease complications and the symptom burden is compressed into a limited period preceding death." This dovetails well with what I have discussed above; people want to be healthy. They recognize that they are going to die, but they want to do this quickly, painlessly, and at the end of a long and healthy life. As a loved one of mine who is closer to this than many puts it, “someday I just won’t wake up”. Morbidity compression. If he is lucky, if we are all lucky, that will be how it happens.

But right now, our health care system is in fact designed to treat acute conditions and acute exacerbations of chronic disease, not to maintain the care and the health of people who have not yet developed chronic disease or are stable. More to the point, our system does this because this is what is paid for; we are just scratching the surface of the ideas of “chronic disease management”. In fact, we pay so well for acute interventions that hospitals are hiring acute “interventionalists” at extraordinary salaries compared to their colleagues in the same specialties that actually manage people over time. For example, “stroke neurologists”, or sometimes interventional neuroradiologists, who can inject clot-busters into the arteries of people with acute strokes make perhaps 2-3 times what a neurologist who just manages chronic neurologic diseases does (not that much more than regular radiologists, who are overall much higher paid); this is because the hospitals that employ them are so highly reimbursed for these procedures.

The need to manage actual people, especially when they have chronic disease, not just an acute episode, is obvious to most of us. It may even be obvious to the insurance companies and other payers, to the hospitals who support the acute interventionalists, but so far they haven’t changed what it is that they pay for, what it is that is financially incented. I write a lot about primary care, but it is not only primary care. Commenting on my last piece, Social determinants key to the future of Primary Care, a neurologist colleague who cares for people with Amyotrophic Lateral Sclerosis (ALS), Lou Gehrig’s Disease, a terrible and always fatal degenerative condition that satisfies almost none of the criteria for “morbidity compression”, wrote:

But the group health care model is also the best for chronic rare diseases managed by subspecialists....this is what we do in ALS clinic on Monday mornings. You should come visit, Josh, at 8 when all the folks (speech therapy, physical therapy, occupational therapy, social workers, dieticians, equipment providers, respiratory therapy) meet with the neuromuscular neurologists to discuss each case. Then we see them and all weigh in and we give patient a printout with advice from each. But, alas, there is no way to pay for this without support from local and national foundations....Medicare doesn't cover it by far.

I wrote back:

Of course. In this sense, you are sharing the same issues as primary care doctors -- you are managing patients, not just a single episode of disease. Certainly ALS is a disease, but it is a chronic one that takes over people's -- and their family's -- lives, and requires not only complex and interdisciplinary, but long-term, management. Indeed, the concept of the medical home was developed in the 1960s by the specialty pediatricians managing kids with chronic diseases such as cystic fibrosis, juvenile diabetes, and sickle cell, which share with ALS the fact that there is one disease that dominates the lives of the patient and their family; to care for it requires managing not just the disease but working with the whole person and their family. It can also (but is not always in practice) be true of HIV clinics.

This is less true of many other adult diseases, which often co-exist --diabetes, hypertension, congestive heart failure, chronic lung disease, depression, arthritis -- so that one specialist is not interested in (or perhaps capable of) managing them all -- thus primary care for adults, geriatricians, etc.

It is virtually not at all true of those who do radiology, anesthesiology, single-time consults, or one-shot surgery, or one-shot-into-the-cerebral artery neuro-interventionalists. Or, to be short, any of the folks making a lot of money for single things, while the stuff that you do in ALS clinic is not paid for.

This is insane. We do not have a health system, and we do not even have a health care system. We have a medical care system, with the emphasis on the medical. It is fine to pay for an episode of care, but it is much more important to reward care.

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[1] Asch DA, Volpp KG, “What Business Are We In? The Emergence of Health as the Business of Health Care”, NEJM 367(10);887-89. DOI: 10.1056/NEJMp1206862

[2] Marvasti FF, Stafford RS, “From Sick Care to health care -- re-engineering prevention into the US health system", NEJM, 367(10);889-91. DOI: 10.1056/NEJMp1206230

[3] Freeman J, “Towards a definition of holism”, Br J Gen Pract. 2005 Feb;55(511):154-5. PMC1463203

Social determinants key to the future of Primary Care

A "Perspective" in the September 6 issue of the New England Journal of Medicine, "Becoming a physician: the developing vision of primary care"[1] by Kathleen A. Barnes, Jason C. Kroening-Roche, and Branden W. Comfort*, addresses the change in the practice of primary care enabled by changes in payment and structure and how this is more attractive to medical students. All three are medical students (although Kroening-Roche already has both his MD and MPH) from schools in different parts of the country (Harvard, Oregon, and Kansas); they met at the Harvard School of Public Health, and all of whom seem to be interested in being primary care physicians. They describe a model – or, more accurately, as they say, a vision – of primary care practice in which they see themselves in the future, and about which they are enthusiastic. By extension, one would hope that this is also true of many other medical students.

The practice that they describe is quite detailed in many ways:

 "…a day in a primary care office would begin with a team huddle….The team would discuss the day's patients and their concerns. They would review quality metrics, emphasize their quality-improvement cycle for the week, and celebrate the team's progress in caring for its community of patients…The RN would manage his or her own panel of patients with stable chronic disease, calling them with personal reminders and using physician-directed protocols…The social worker, nutritionist, and behavioral therapist would work with the physician to address the layers of complexity involved in keeping patients healthy. Clinic visits would ideally be nearly twice as long as they are now…"

It sounds great. As the authors note, there are practices that are working toward, and in some cases have begun to achieve this "new model" of care; these 3 did not originate these ideas. Practitioners and thinkers such as Tom Bodenheimer, Joe Scherger, Bob Phillips, and Kevin Grumbach have written about this, and many practices, particularly integrated groups such as Kaiser Permanente, Inter-Mountain Health Care, and Geisinger Clinic have implemented many of these characteristics. But will it be the future of all health care? Will, importantly, these changes – or ones like them – both provide the functionality that the health system needs from primary care and the physicians entering into this practice?

In many articles, including Transforming primary care: from past practice to the practice of the future [2], Bodenheimer has emphasized the need for teams from a practical standpoint – there are more people needing care and not enough primary care physicians to provide it. Phillips ("O Brother Where Art Thou: An Odyssey for Generalism", presented at the Society of Teachers of Family Medicine Annual Conference in May, 2011) shows data indicating that even including "mid-level providers" such as advanced practice nurses and physician's assistants there are way too few primary care providers, and the trajectory of production is in the wrong direction. Our own data[3] show the marked decrease in the number of medical students entering family medicine (and other primary care specialties) in the last dozen years. So it is profoundly to be hoped that the model of care described by these authors develops, that they are able to develop it, and that it will attract more future physicians.

While practice change is hard, and culture change is harder, there are issues that these authors talk about but do not seem to overly worry them. They note the importance of the Affordable Care Act, and how it "…emphasizes population health and primary care services, and establishes accountable care organizations that require strong primary care foundations," but do not, in my opinion, adequately address two key challenges to implementation that will present profound obstacles to the achievement of their vision.

The first is payment, reimbursement, allocation of health care dollars. They assume that, "…thanks to a restructured reimbursement system," medical assistants will "…have protected time to provide health coaching for behavior change and to ensure that the patients on their panel were current with their preventive care." Because reimbursement would be "…through global payments linking hospitals to primary care practices, the physician, too, would have a financial incentive to keep patients healthy…."  It is a great model, and one that I agree with, but it hasn't happened in most places. Because it is more costly and requires significant investment in prevention and primary care, and since there are unlikely to be additional dollars in the health system, it will mean lower reimbursement for hospitalizations, for procedures, and for the specialists who are the currently the most highly paid. This, I would argue, would not be a bad thing, but it will not happen easily. Those who are doing well under the current system are going to fight to hold on to it, and the reimbursement structure is not changing quickly enough to push such change outside of integrated health systems – and even within many of them.

The second is what can be summarized as the "social determinants of health". Good public health students, they observe that "…the health care system must strive to affect more than the 10% of premature mortality that is influenced by medical treatment," and note correctly that "Primary care cannot be primary without the recognition that it is communities that experience health and sickness. Providing better health care is imperative but insufficient." 

This is true, but there is more to it. Health care, in itself, even well-organized with adequate numbers of primary care practices working in teams, and collaborating with public health workers, and going out into the community, and employing culturally-competent health navigators/guides/case managers/promotoras, is not going to do it alone. The social determinants of health have to be addressed by the entire society.

Poverty, unstable housing, food insecurity, cold, and the social threats that often accompany the communities in which they are prevalent (violence, drug use, abuse, etc.) will continue to create situations in which people are not healthy and need medical care. Even in the larger society, in the part where people are not living at the edge, there are many anti-health forces; stress (including the stress of working harder and at more jobs to keep away from the edge), the ubiquity and ease of access of poor quality, high-calorie food, and the shredding of the social safety net that is almost gone for at the bottom and fraying at the sides (Social Security, Medicare), are not harbingers of a happier, healthier society.

I am thrilled about the enthusiasm of these young physicians and physicians-to-be, and their commitment to primary care and a new kind of practice. They begin by observing, echoing Bob Dylan from 50 years ago, and more important the movement that was growing then, that "times are changing", but I fear we are not yet clear what that change will be; there is tremendous energy – and even more money – behind a change that will be for the worse for everyone except the most privileged.

They end by saying that "We are here to engage in and advance the movement." They are talking about transforming primary care, but I hope that they and their colleagues recognize that it will not be enough unless they are willing to engage in and advance the movement to transform society.

*In full disclosure, one of the authors, Branden Comfort, is a student at the KU School of Medicine. Although he has spent his clinical years at our Wichita campus, I know him well because we worked together in the student run free clinic (and he was my advisee) in his first two years here in Kansas City.

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[1] Barnes KA, Kroening-Roche JC, Comfort BW, "The developing vision of primary care", NEJM Sept 6, 2012;367(10):891-4.

[2] 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.

[3] Freeman J, Delzell J, ""Medical School Graduates Entering Family Medicine: Increasing The Overall Number", Family Medicine, October 2012, in press.

Research basic and applied: we need them both

 “Not every mystery has to be solved, and not every problem has to be addressed. That’s hard to get your brain around.”

This statement was the coda of a very good article, “Overtreatment is taking a harmful toll”, by Tara Parker-Pope, in the NY Times, August 28, 2012. The topic of the article, and the implication by the speaker, who was talking about her own family’s health care and unnecessary testing, is one that I have written about several times recently, in terms of both screening tests (“The "Annual Physical": Screening, equity, and evidence”, July 4, 2012) and investigation and treatment of disease (“Rationing, Waste, and Useless Interventions”, June 21, 2012). Thus, I certainly agree that there is too much testing and too much intervention, and that it has a high cost in both dollars and in potential risk to people (the English word for what the health system calls “patients”). So why do I feel a little uncomfortable with the quotation above?

I think it is because I very strongly believe that the decision on what tests to do and what interventions to take should be informed, as much as possible by the evidence. That evidence, I have also argued, should come from research, from well-designed studies, from science. This is also costly, but it is necessary. Your treatment should be based on evidence and probability gathered from studies of large populations. Without it, doctors and other health professionals are flying blind, with treatments based on their own experience, or worse yet “what makes sense”. Sometimes the doctor’s own experience is a good guide, if they see a lot of patients with the same problem, and have reason to know what works. It is even better when they can bring in knowledge of the local community (e.g., what antibiotics are common bugs resistant to here? What are the common belief systems of the people that I care for?) and better yet if they actually know you, and what you value, and what your medical history is, and what your belief system is, and what is most likely to engage your effort in the interest of your health.

But it is better if the set of options from which they choose are all based in evidence. That something makes sense, I have often pointed out to medical students and residents, makes it a research question, not an answer. If something makes sense, based on what we already know, it is likely to be a more valuable thing to study than something that does not make sense. However, until the study, or more likely several studies, are done we won’t know if it is, in fact, true. Human beings, both in terms of their biology and behavior, are too complex, and have too many different systems interacting with each other, to predict accurately how something that “makes sense” based on one of those dimensions is likely to turn out.

The thing is that not all research is immediately clinically relevant. Sometimes it is; the “Ottawa rules”, developed by research done in Canada, provide physicians with evidence based guidelines about when it is appropriate to do x-rays for injured ankles, knees, and feet – common problems. Other studies investigate whether particular drugs may provide real benefit to people with more uncommon problems. This is particularly satisfying when the drug is not some new, expensive blockbuster but something cheap and common like aspirin or folic acid. Or when an old drug, all but abandoned for its original purpose, turns out to be very effective for another condition entirely. (One of my colleagues just demonstrated this for an old heart drug that works for a rare neuromuscular condition – coming soon to your local JAMA!) But much research is at a very basic level. Before those drugs can be tested on particular conditions, they have to be developed. Before they can be developed, the biological and biochemical mechanisms upon which they have an effect have to be identified. Just as, before we can send rockets to the moon, we need to understand physics. Science, what in medicine we call “basic science”, has to continually move forward, and this requires not solely focusing on what might be of practical use tomorrow, but what is still a mystery that has to be solved.

I find it almost ironic that I am writing this defense of basic science research. Just recently, I was in NYC and went to brunch at the riverpark restaurant. On the block leading to it is a big vegetable gardens where they grow many of their own ingredients, much of it surrounded by a big wooden fence. And, since it is right there at Bellevue Hospital and NYU Medical Center and Rockefeller University, that fence is decorated with pictures and biographies of Nobel Prize winners in Medicine who had ties to NYC. My reaction was that all of these people (even if they had MD degrees) were doing laboratory, basic science research, not clinical research, even though the prize is for “Medicine”. Of course, having won Nobel Prizes, their research led to important practical breakthroughs, but for every Nobel Prize winner who discovers something that will make a major difference in health, there are thousands and thousands of others, working in laboratories everywhere, and this work is necessary.

Personally, I don’t think it is necessarily necessary that it  be done in medical schools, whether NYU or the University of Kansas, rather than in research institutes like Rockefeller or Kansas City’s Stowers Institute (or Karolinska in Sweden or the Pasteur Institute in France). I find, as a family doctor, that the fact that much basic research in human biology is done at medical schools leads to what I think are negative “side effects”. I believe that there is an over-emphasis on teaching medical students biological sciences in great detail (often at the level of minutia) and an under-emphasis on the social sciences. I think that these areas are just as important – maybe more important for the practicing physician -- but are usually not considered as “core” to medical student teaching.

In part this is because those working in the social sciences are most often “there”, at the main campus, not “here”, at the medical school. I am proud that the research conducted by faculty in my department is mostly community-based, looking at determinants of health and health disparities. But, whether biomedical research should be as important a part of medical schools as it usually is, or not, it is absolutely clear that it needs to occur, and that scientists need to solve mysteries.

Every mystery? Well, of course, that will never happen. And even for the ones they solve, the results are not always beneficial for folks. We can map the human genome! We can tell you if you and your family members are at increased risk for a terrible disease! Of course, often we cannot do anything about it, but it can make you depressed and pessimistic, and maybe you’ll lose your health insurance. So maybe we don’t need to tell your insurer, or even tell you, but getting to be able to do something about it first requires doing the science.

And of course there is a big difference between uncovering the mysteries of the universe, and even of finding evidence for what is appropriate diagnosis and treatment in populations, and in having to investigate everything in you. The father of another person quoted in the article developed delirium from overtreatment with drugs that was mistaken for dementia. “I don’t know if we have too many specialists and every one is trying to practice their specialty, but it should not have happened.” I agree; too many mistakes, too many errors (see Medical errors: to err may be human, but we need systems to decrease them, August 10, 2012) can come from there being too many specialists combined with too little communication.

The quote at the top of this piece notes that not everything has to be addressed and that this is hard to wrap your brain around, but it shouldn’t be.  All that research in the basic and clinical sciences should help us to understand when we need to investigate (do a CT scan for a black eye, in another example from the article, say) and when we don’t.

Often we should leave well enough alone. 

Financial Incentives, maybe; corporate profit, no!

If we truly wish to move toward a healthcare system which delivers high quality in a reliable manner, one of the great flaws of our current system is that incentives are not always lined up to achieve that goal. Indeed, we could make a strong argument that incentives, particularly financial incentives, often lead healthcare providers (sometimes individuals, but certainly large organizations such as hospitals, nursing home and hospital chains, pharmaceutical companies, device manufacturers) in the wrong direction. That is, they pursue financial profitability rather than the highest quality of care for our people.

Sometimes these two run together, and sometimes they do not. If the disease you have is one that is well-provided for and you have the money or insurance to pay for it, you are in luck. If you don’t have financial access to care, or your disease’s “product line” was not one deemed financially profitable enough for your hospital or health system to invest in, you are not. Similarly, if you have a disease that lots of others share, pharma is always ready to provide a drug for it – particularly if it is still patented; if you have an “orphan” disease, you may not be able to get treatment, or it can cost (truly) more than $100,000 a year.

The federal government, through Medicare, has sought to use financial incentives to (most often) control costs and (sometimes) to encourage quality; this occurs under both Republican and Democratic administrations, but is also a big feature of the Affordable Care Act (ACA). One example going back to the 1980s, is the reimbursement of hospitals for what Medicare has figured is the appropriate cost of care for a particular set of diagnoses, rather than by whatever the hospital charges. Under ACA and in incentive plans in place from private insurers, doctors get more money if they do more of the “right” things and fewer of the “wrong” things. Financial incentives can also be used by organizations to encourage certain types of performance in its employees or contractors. Examples include incentive payments for generating more revenue, or financial penalties written into a contract for poor performance. Financial incentives are not unique to health care and, in fact, have been used and studied in many other industries. Their use in health care is not unique to the US.The question is, however, “do they work?”

This is the question that a group of Australian scholars led by Paul Glasziou sought to answer in an “Analysis” published in the British Medical Journal (subscription required), “When financial incentives do more good than harm: a checklist.”[1] Glasziou and his colleagues review the data on the effectiveness of financial incentives in both health care and other industries, and focus upon a meta-analysis by Jenkins et al.[2], and two Cochrane studies, one an analysis of 4 systematic reviews (? a meta-meta analysis?)[3] by Flodgren et al., and one looking at primary care by Scott, et al.[4] Basically, the results were mixed; sometimes they worked (to achieve the desired ends) and sometimes they didn’t. Glasziou observes: “While incentives for individuals have been extensively examined, group rewards are less well understood….Finally, and most crucially, most studies gathered few data on potential unintended consequences, such as attention shift, gaming, and loss of motivation.” (Again, see Daniel Pink, “Drive”, on Motivation).

In an effort to help identify what works, Glasziou has developed a 9-item “checklist” for financial incentives in healthcare that is the centerpiece of this article. Six items are related to the question “Is there a remediable problem in routine clinical care?”, and 3 are related to Design and Implementation. The first six are:

1. Does the desired clinical action improve patient outcomes?

2. Will undesirable clinical behavior persist without intervention?

3. Are there valid, reliable, and practical measures of the desired clinical behavior?

4. Have the barriers and enablers to improving clinical behavior been assessed?

5. Will financial incentives work, and better than other interventions to change behavior, and

why?

6. Will benefits clearly outweigh any unintended harmful effects, and at an acceptable cost?

And the 3 regarding implementation are:

7. Are systems and structures needed for the change in place?

8. How much should be paid, to whom, and for how long?

9. How will the financial incentives be delivered?

They provide explanations of each of these and include a useful table that uses real life positive and negative examples to illustrate their points. For example, regarding #1 they note that the UK has provided financial incentives to get the glycated hemoglobin level in people with type 2 diabetes below 7%, despite several studies showing no patient benefit. (This is an example of “expert opinion” governing practice ever after contradicted by good research.) #2 means some behaviors occur or extinguish if effective processes are put in place without financial incentives. #3 is important because of the cost of implementation (“We found no studies on the cost of collecting clinical indicators.”); one of the great complaints of providers is that they spend so much time providing information to various oversight bodies that they haven’t sufficient time to provide good patient care.

Criterion #5 relates to the issue of “what, in fact, motivates people?” Criterion #6 is, I believe, relates to the greatest flaws in most of our financial incentive (often called “pay for performance” systems. The four behaviors most often creating harmful effects have all been discussed in this blog:

Attention shift (focusing on the area being rewarded distracts from attention to other areas);

Gaming (a huge negative especially for large organizations). This specifically refers to manipulating data to look “good” on the measurement, but also includes upcoding and what might be called intentional attention shift, where the organization focuses, on purpose, on to the areas that make it the most money and neglects others;

Harm to the patient clinician relationship, when the patient, often correctly, feels that it is not her/his benefit but some external target that is motivating providers;

Reduction in equity. This is extremely important. I have written extensively about health disparities; this point is meant to drive home the reality that this inequities, or disparities, can persist even when there is an overall improvement in the areas being measured.

Most of these issues and several others derive from the simplistic application of financial rewards to complex interdependent systems. Financial incentives assume that paying more for a service will

lead to better quality or additional capacity, or both. However, because money is only one of many internal and external influences on clinical behavior, many factors will moderate the size and direction of any response. The evidence on whether financial incentives are more effective than other interventions is often weak and poorly reported.”

These authors are from Australia, which like most developed countries, has a national health insurance system. (See the map[5]).  The data they cite is world-wide, but largely from their country, the UK (which also has a national health system) and the US (which does not). The real problems of health disparities and inequity are enormous in our country. They are not modified by the presence of a national health system, which reduces many of the financial barriers to health care; indeed they are exacerbated by a make-money, business-success psychology of providers that may be worse in the for-profit sector but essentially drives the non-profit sector as well.

 

The application of a simplistic corporate psychology to health care delivery can lead to poorer quality and greater inequity in any country. In combination with an entire system built on making money, gaming the system, and excluding the poor, and making corporate profit (see graph) it is a disaster. Our disaster.

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[1] Glasziou P, et al., When financial incentives do more good than harm: a checklist, BMJ 2012;345:e5047 doi 10,1136/bmj.e5037, published August 20, 2012

[2] Jenkins GD, Mitra A, Gupta N, Shaw JD. Are financial incentives related to performance? A meta-analytic review of empirical research. J Appl Psychol 1998;83:777-87.

[3] Flodgren G, Eccles MP, Shepperd S, Scott A, Parmelli E, Beyer FR. An overview of reviews evaluating the effectiveness of financial incentives in changing healthcare professional behaviours and patient outcomes. Cochrane Database Syst Rev 2011;7:CD009255.

[4] Scott A, Sivey P, Ait Ouakrim D, Willenberg L, Naccarella L, Furler J, et al. The effect of financial incentives on the quality of health care provided by primary care physicians. Cochrane Database Syst Rev 2011;9:CD008451.

[5] Interestingly, this map, from the Atlantic, may make us think that the aloneness of the US in not having national health care is less serious than it is. Most adults are used to seeing map projections that inflate the size of Europe and North America. This is a geographically more accurate map, but if it were in our “accustomed” projections would be even more green.

Quality and price for everyone: Bigger may be better in some ways, but not all

Atul Gawande, MD, a Harvard surgeon at Brigham and Women’s Hospital in Boston, regularly contributes significant and provocative articles to the New Yorker under the head “Annals of Medicine”. In recent years I have written about several of these, including the “The Cost Conundrum”, June 1, 2009 (my comments in Medicare Costs: "All Politics are Local", June 11, 2009), “The Hot Spotters”, January 24, 2011 (Freedom abroad, health at home: experiments in preventive health care, February 13, 2011 and Camden and you: the cost of health care to communities, February 18, 2011), and “Cowboys and Pit Crews”,  May 26, 2011 (EMRs and Primary Care: The good, the bad, and the challenges, June 11, 2011 and Physician Oaths and Social Responsibility, July 11, 2011). His latest contribution, “Big Med”, August 13, 2012, continues his outstanding tradition of thinking outside the box, making important connections, and writing for a popular-but-educated audience.

“Big Med” starts with a visit to the popular restaurant chain, The Cheesecake Factory, and proceeds with his investigation into how it works and works effectively. This chain provides an enormous variety of menu choices, high quality both in terms of ingredients and taste (perhaps not the gourmet’s standard, but really good food), excellent consistency, and reasonable prices. It does not take a huge step to understand the relevant metaphors for health care, and in particular hospital care. Hospitals provide a huge menu of services, and we would all like them to be consistently of high quality and available at a reasonable cost. Unfortunately, they’re not. Gawande searches for how The Cheesecake Factory does it, and comes up with some excellent suggestions for health care.

He starts with the key ideas mentioned above: people should be able to go into a hospital and expect the best care and the best possible outcomes. These should be consistently delivered, and delivered at many locations (not necessarily every hospital for every procedure – to extend the analogy, The Cheesecake Factory has lots of restaurants, but not in every town) and done in a cost-effective way. While with restaurants, each of us knows what we like and whether something tastes good and whether we think we have gotten value for our dollar this is not true for health care. Most people (including physicians outside their own specialty) have little idea of what is quality in medicine. They can tell if they had a good outcome (“I’m better”), but not if it was the intervention that made it better, or perhaps just speeded up – or retarded – natural healing. They can tell if they had a bad outcome (or their survivors can), but not if this was unavoidable. (The current method we have for adjudicating this – malpractice suits – is entirely invalid.) They do not know if their outcome would have been better in a different hospital or with a different doctor or team, or even in the same hospital with the same doctor on a different day. They certainly don’t know whether what they, or their insurer, are paying is appropriate for the value.[1]

Gawande writes that “Big chains thrive because they provide goods and services of greater variety, better quality, and lower cost than would otherwise be available. Size is the key…We can bristle at the idea of chains and mass production, with their homogeneity, predictability, and constant genuflection to the value-for-money god. Then you spend a bad night in a “quaint” “one of a kind” bed-and-breakfast that turns out to have a manic, halitoxic innkeeper who can’t keep the hot water running, and it’s right back to the Hyatt. Medicine, though, had held out against the trend. Physicians were always predominantly self-employed, working alone or in small private-practice groups. American hospitals tended to be community-based. But that’s changing. Hospitals and clinics have been forming into large conglomerates. And physicians—facing escalating demands to lower costs, adopt expensive information technology, and account for performance—have been flocking to join them.”

He goes on to describe examples of how American medical care is changing, focusing on the experience of his mother getting a knee replacement at his hospital by a surgeon (not the most famous) who has organized a standardized system for delivering this care, using a (large) team. This surgeon has also accomplished the remarkable (to anyone who knows surgeons) feat of getting all the prima donna orthopedists at his hospital to agree to use the same prosthesis. The principle, just as in the casual dining area, is find out who does it best, identify the characteristics that make it so (removing the chaff and nonsense that may be associated but are just noise, often costly noise), and replicate it.

Applying this principle requires not only standardization, but size. Every hospital cannot be a mom-and-pop store, and the cost savings from scale are what make the whole thing possible. Yes, medical care cannot be completely reduced to recipes, and this can be a real danger. Individual doctors are different, and their skills are different not only by specialty or subspecialty, but in the way they interact with their patients. Some people may like a doctor who is older, or younger; a doctor who is a woman, or a man; a doctor who is more formal, or more casual. Some want a doctor who will explain things to them and elicit their beliefs and desires, and make them the educated “decider”; others want a doctor who is more didactic and authoritative. None of these is the “best” for someone who does not share those values; each is the “best” for those of us who do. The only caveat is when a particular approach actually makes a difference in the health outcomes for all people, not just those who “like” the doctor’s style.

Another danger in size and scale is that many of the processes and procedures that are put in place by these big, standardized organizations do not improve health outcomes, and may even limit them by taking time and energy from the things that do. Management in health care is still very much tied to “Motivation 2.0” (see “Drive”, by Daniel Pink[2], and my comments in The Primary Care Conundrum, August 18, 2012).  Many big food, or hotel, or hospital chains do not provide quality, and most certainly do not contain costs; see, for example, “A giant hospital chain is blazing a profit trail”, by Julie Creswell and Reed Abelson in the New York Times August 14, 2012, about Hospital Corporation of America (HCA). Like HCA, “big” is not a panacea, and can be a negative for social values and social justice.

Gawande includes important cautions:

"Yet it seems strange to pin our hopes on chains. We have no guarantee that Big Medicine will serve the social good. Whatever the industry, an increase in size and control creates the conditions for monopoly, which could do the opposite of what we want: suppress innovation and drive up costs over time. In the past, certainly, health-care systems that pursued size and market power were better at raising prices than at lowering them….

“The vast savings of Big Medicine could be widely shared-or reserved for a few. The clinicians who are trying to reinvent medicine aren't doing it to make hedge-fund managers and bondholders richer; they want to see that everyone benefits from the savings their work generates-and that won't be automatic….

"Our new models come from industries that have learned to increase the capabilities and efficiency of the human beings who work for them. Yet the same industries have also tended to devalue those employees. The frontline worker, whether he is making cars, solar panels, or wasabi-crusted ahi tuna, now generates unprecedented value but receives little of the wealth he is creating. Can we avoid this as we revolutionize health care?"

I don’t know, but I hope so. Holding on to old ways of doing things when they are not the best (or even very good), or the idea that each doctor can use a different prosthesis and they are all the best, is bad. Devaluing individual workers, whether they are physicians or technicians or cleaners, is bad. Developing ways of delivering high-quality care which is what both individual people and the whole society needs is good.

Good outcomes will certainly not come from the drive to maximize profit. To get truly good outcomes, we must put people and put social justice at the center of any change.

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[1] I love this part: “Historically, doctors have been paid for services, not results. In the eighteenth century B.C., Hammurabi’s code instructed that a surgeon be paid ten shekels of silver every time he performed a procedure for a patrician—opening an abscess or treating a cataract with his bronze lancet. It also instructed that if the patient should die or lose an eye, the surgeon’s hands be cut off. Apparently, the Mesopotamian surgeons’ lobby got this results clause dropped. Since then, we’ve generally been paid for what we do, whatever happens.”

[2] Pink, Daniel H, “Drive: the surprising truth about what motivates us”, Riverhead Books, New York 2009.

So, two things.
1. I changed the blog template. I hope you like it; I'm not sure I do, but it seems that blogger doesn't actually offer the old one anymore anyway.

2. I still, despite changing my pw and using Google "verify" am getting what I interpret as hacked spam -- items I obviously didn't create appearing in my "draft blog" list. I'll change pw again, but don't know how this is happening, and apparently no one else does either.

The Primary Care Conundrum

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The primary care conundrum:

We need more primary care doctors.

We treat primary care doctors relatively poorly, thus discouraging medical students from entering the field.

This issue has been one of the recurring themes in the discussion of health reform, and I have written about it often. People argue around the edges of the conversation:

·         It is not only primary care doctors that are relatively underpaid; so are many non-procedural specialists.

·         There is not going to be an increase in the payment to physicians, so higher-paid specialists are going to have to take less money.

·         It is not just about money; it is about lifestyle. Primary care doctors have to work too hard.

·         It is not just about money; it is about status. Primary care doctors have lower status.

·         It is not just about money; it is about intelligence. Primary care is just too easy.

·         It is not just about money; it is about unrealistic expectations. Primary care is just too complex.

And on and on. These are not silly or spurious or even inaccurate statements, although the last two might be considered another “primary care conundrum”, the one to which medical students are often subjected. All of these are things that family medicine and other primary care specialties have to think about, and address to the extent that it is within their control. I have, for example, talked about the selecting medical students who are likely to be more interested in primary care and underserved (both rural and urban) practice, as well as about making the curriculum more supportive of primary care. However, it is, ultimately, not the responsibility of the primary care specialties, or even the medical educators, but rather of the overall society to develop policies of reimbursement that encourage primary care – if that is what the society wants and needs.

Thus “Payment reform for primary care within the Accountable Care Organization”,[1] by Goroll and Schoenbaum in the August 8, 2012 JAMA is appropriately subtitled “A critical issue for health system reform”. While it may not really be all about the money, a good part of it certainly is. One doesn’t have to be an economist who believes that everything can be reduced to, or expressed in terms of, money, to recognize that lifestyle and status are just other manifestations of money. If you make more (or, more to the point, if the services that you render are reimbursed at higher levels), you can work (if you choose) less, or a health system employing you can hire more people to do that work. Status is measured by many yardsticks, but most of them, at least in our society (since we do not have inherited titles) have to do with money.

Goroll and Schoenbaum, from, respectively, the Massachusetts General Hospital and the Josiah Macy, Jr. Foundation, focus their discussion on Accountable Care Organizations, or ACOs. These are a centerpiece of the health reform law (ACA), but most experts believe that, whether ACA survives or not (it has survived the Supreme Court, but there will be continuing challenges, particularly if the Republican Party takes the Senate and/or White House in 2012) it is the wave of the future. This is because it is both a framework for increasing quality and for saving money; saving money is the main thing that virtually all politicians and pundits talk about in regard to health care. Even providers do so, although they mostly focus on saving it on other aspects of the health system.

In a sense, this last is what ACOs seek to avoid; by assigning patients to an ACO that provides comprehensive care – ambulatory, hospital, post-hospital – for lives (in insurance parlance) or people (in English) it seeks to avoid “blaming the other”:

·         We took good care of them, but when they went to the hospital they received poor care or unnecessary procedures.

·         The “local doctor” didn’t provide adequate care, but luckily we in the hospital could save the patient.

·         We did great care in the hospital, but the nursing home (or patient’s family) didn’t, so the patient suffered, or had to be readmitted, or died.

·         They discharged the patient – home or to the nursing home – too soon, so despite our excellent care the patient suffered, or had to be readmitted, or died.

The devil, as always, is in the details. How will this be different from the managed care of the past? (“I heard this all back in 1995,” says a colleague.) In order to avoid some of the politically unpopular characteristics of “managed care”, the ACA does not contain a requirement that patients receive care only from the ACO to which they are assigned. However, if they are cared for elsewhere, how can the ACO ensure either the quality or the cost? Who will care for the uninsured? How will (and they will) providers (including hospitals, doctors, nursing homes) game the system to maximize their advantage by passing the buck, cherry picking the relatively health, emphasizing high-reimbursement and de-emphasizing low reimbursement care? How will (and here “Will it?” is still a question) that be rectified?

The important point of the JAMA article is made in the beginning: that “Primary care, the foundation of the ACO, requires payment reform to enable and make durable its transformation into a high-performance model such as the patient-centered medical home.” Primary care is the foundation of the ACO, just as it is the foundation of any effectively-functioning health system. The authors cite 3 main obstacles to increasing payment for primary care: 1) Inertia. It is not the way our incredibly elaborate and expensive payment system is currently structured, and changing it will be hard; 2) Resistance. The development of new systems and funding will require, particularly in a setting in which overall funding will not appreciably increase, the reallocation of money from one set of groups to others, and this certainly will (and already has) meet with resistance by those who will lose money. 3)  “Motivation 2.0”. “…many health care executives (including some physician managers) believe that physicians work harder under fee for service and that productivity is at risk of faltering under payment systems that do not maintain a strong, volume-based incentive.”

The first two are obvious and will have to be strongly and persistently addressed if there is to be any success in re-engineering the health care system; there is no one who will fight so hard as a group whose privileges, no matter how unfairly earned, are being threatened. However, the third is more questionable. Another colleague asked “is there any evidence that this is not true?” Indeed, there is some evidence that it is; in the 1990s when hospitals and health systems bought out physician practices, they often found that the physicians, now salaried, were less productive than when they were in practices where their income came from productivity. The flaw there is that the same standards were being used for measurement: how many patients were seen, how many wRVUs (a measure, albeit imperfect, of physician productivity). It was not measured by whether the quality of patients’ health was improved. Perhaps by seeing fewer patients-per-day, for longer visits when they need them, or providing care in teams and by phone and email when appropriate, fewer return visits would be needed (bad if reimbursement is all fee-for-service) and delivered in teams.

Goroll and Schoenbaum do not, actually, use the phrase “Motivation 2.0”. This comes from Daniel H. Pink, a business management author, from his book “Drive”, published in 2009 and one of the most influential management books in recent years.[2] Pink contrasts the management style based on this sort of motivation (2.0, not the “1.0” that was ancient man’s – survival), the dominant one of the 20^th century and into the 21^st with a new understanding of what motivates people and what kind of management is most effective. He draws on decades of psychological and sociological and business research, as well as actual implementations in management practice, to clarify what this new appreciation, “Motivation 3.0” is. I recommend reading the book, quite short and easy.

But understanding and implementing effective motivational practices will certainly not, in itself, solve health care. Making sure that there are systems to ensure quality, and that they are available to everyone, is the sine qua non.

  

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[1] Goroll A H and Schoenbaum SC, “Payment reform for primary care within the Accountable Care Organization”, JAMA 8Aug2012;308(6):577-8.

[2] Pink, Daniel H, “Drive: the surprising truth about what motivates us”, Riverhead Books, New York 2009.

Medical errors: to err may be human, but we need systems to decrease them

An op-ed by Sanjay Gupta, MD, the Atlanta neurosurgeon and CNN medical correspondent, appeared in the New York Times on August 1, 2012. “More treatment, more mistakes” makes the case that medical errors are common and that they are largely due to the pressure to “do more”, to do more tests, to do more x-rays, to do more surgery. This is not news in itself; the Institute of Medicine (IOM) of the National Academy of Sciences published its study “To Err is Human” in September 1999, observing that between 44,000 and 98,000 deaths occurred per year as a result of medical errors (full text available at http://www.nap.edu/openbook.php?isbn=0309068371).

To Err is Human itself was not the beginning of the study of medical errors. It uses a taxonomy dividing errors into “Diagnostic”, “Treatment”, “Preventive” and “Other”, published 6 years earlier in a study by Lucian Leape, et al., in the Quality Review Bulletin.[1] To Err is Human detailed the variety of types of medical errors that could occur, the relative frequency with which they occurred, and the reasons why they occurred, and provided suggestions as to how to prevent them from occurring. The Institute for Healthcare Improvement (IHI), founded by Leape and former CMS director Don Berwick (who were among the authors of the IOM report) has been working on this issue for more than 25 years. Its “100,000 lives campaign” sought to save that many lives by having hospitals sign on to implementation of certain strategies that had been shown to reduce errors. These included “timeouts” in surgery to be certain that everything was correct (right patient, right part of the body, etc.) before beginning, particular ways of managing people on breathing machines in intensive care units to prevent “ventilator associated pneumonia”, and the like.

A key point is that very few of these errors are intentional – they are not malpractice in the traditional sense, they are rarely the result of physicians being “bad doctors” – and yet people, avoidably, die from them. A key part of the strategies promulgated by people like Berwick and Leape, IHI, by the IOM report, and others working in the field is to employ the systematic approach to error reduction developed in other industries, such as airlines. (A common trope is that if airlines had errors as frequently as medicine, a jumbo jet full of people would be crashing several times a day.) Continuing follow-ups have looked a “how we are doing”, such as in “Five years after ‘To err is human’: what have we learned?” by Leape and Berwick in JAMA in 2005[2] and the summary of it by the Commonwealth Fund.

It is in the context of this history that Gupta’s article appears. Its main significance is that it brings to public (New York Times) attention the fact that these problems still exist, and that despite progress (and there has been much) there is much that still needs to be addressed. It is a balanced presentation, but does emphasize the point in the title – that more treatment leads to more errors, or, to put it another way, that more is certainly not always better. He cites “Rule #13” from the novel “House of God”, written by Stephen Bergman, MD (under the pseudonym Samuel Shem) in 1979: “The delivery of medical care is to do as much nothing as possible,” a restatement of the dictum primum non nocere, first do no harm.

An interesting series of letters responding Gupta’s paper appeared under the heading “Taking steps to reduce medical errors” in the Times on August 4. One of them is from Bergman, who echoes Gupta’s concept that fear of malpractice suits (the “whining motor behind doctors’ ordering unnecessary, pricey tests,”) is the cause of many errors, and applauds interventions such as surgical time outs. However, another letter, from Niall O’Dowd, the uncle of Rory Staunton, the 12-year old boy who died after being treated for a “minor” scrape in the NYU Hospital emergency department (see Jim Dwyer, “An infection, unnoticed, turns unstoppable”, NY Times July 10, 2012 and many follow-up articles including a column by Maureen Dowd “The boy who wanted to fly”, 3 days later), points out that there are also dangers, as in his nephew’s case, from doing too little.

Mr. O’Dowd focuses, naturally, on the emergency department, which is where his nephew was treated, inadequately as it turns out. Emergency departments are seeing more and more patients, and are responsible for a very large and increasing number of admissions to hospitals, as detailed in a recent New England Journal of Medicine article by Schuur and Venkatesh, “The growing role of emergency departments in hospital admissions”.[3]  They identify a number of trends that tend to increase the use of the emergency room as a source of care, particularly for acute conditions. These include the lack of availability of acute-care appointments in primary care practices, and the lack of the high-tech instruments such as CT scanners that permit EDs to rapidly diagnose and admit – or rule out and then discharge – conditions such as heart attack and stroke.  They also include public education campaigns that urge people to go to the ED when they have symptoms that could be heart attack or stroke, and, of course, the fact that lack of insurance prevents people from accessing health care in most other settings (federal law requires EDs to assess anyone who presents there). While the fact that the increase in admissions from the ED may have something to do with their “lower threshold” (“…emergency physicians are trained to assume the worst and are more likely to admit patients with uncertain diagnoses and with whom they don't have an ongoing relationship, and that they are unwilling to discharge patients when they cannot guarantee outpatient follow-up,”) it is also possible that in their pressure to diagnose and admit the most sick, they could possibly undertreat some, like Rory Staunton, who do not appear to be so ill.

Mr. Staunton may have benefited from antibiotics he did not get. Other letter writers speak of both the dangers of underusing antibiotics and overusing them; however, the settings they describe (critical care units in the first case, treating viral syndromes in the second) are very different. Doing a lot is not necessarily wrong, or right. Doing little is not necessarily wrong, or right. Both can cause errors, and both can save lives. Yet a fifth letter writer suggests “our mission is clear: if it’s right for the patient, it’s the right thing to do.”

This is true as far as it goes; the difficulty is in ensuring what is right for the patient. But systems, checklists, timeouts, and consistent rules can go a long way to making this be the case. And if people with non-acute, non-emergent conditions can get in to see their doctors, and as important, have doctors and can have the health insurance that allows them to be seen, it would help even more.

This is something that we must not lose sight of; as Schiff, Bindman, Brennan et al note in a 1994 JAMA article, denial of care is the “gravest of all quality defects.”[4]

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[1] Leape L; Lawthers A, Brennan, T, et al. ,“Preventing Medical Injury”. Qual Rev Bull. 19(5):144–149, 1993.

[2] Leape L, Berwick D, “Five years after to err is human: what have we learned?” JAMA. 2005;293(19):2384-2390

[3] Schuur JD, Venkatesh AK, “The growing role of emergency departments in hospital admission”, NEJM 2Aug2012;367(5):391-3.

[4] Schiff G, Bindman A, Brennan T, et al., “A Better-Quality Alternative: A Single-Payer National Health System Reform”, JAMA. 1994;272(10):803-808.

Doctor shortage or shortage of the right doctors?

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The lead article in the New York Times (right column, front page, by Annie Lowrey and Robert Pear) on Sunday, July 29, 2012, has the provocative headline “Doctor shortage likely to worsen with health law.” My first instinctive reaction was “What? I don’t know of any part of the new health law, the ACA, that will reduce the number of doctors!” Then, reading the first sub-head, I realized what they meant. “Primary care is scarce”, something I well know and have written a lot about, and then, in smaller type, “Expanded coverage, but a greater strain on a burdened system.”

What they are saying is that the shortage of physicians, especially primary care physicians, will effectively increase (get worse) as millions more people gain insurance coverage under ACA. This will happen both through expansion of Medicaid coverage or through health insurance exchanges that will permit both individuals and small companies that have not previously had or offered health insurance to buy it at much lower rates. The expansion of health insurance coverage to these groups is a good thing; it will eliminate a major barrier to quality health care, itself a component of good health. Unfortunately, phrasing the problem in the way that the NYT headline does is likely to inflame displeasure with the law among those who, through ignorance or selfishness or both, are happy to draw up the bridge behind themselves, not wishing to share their, often limited, access to doctors with the newly insured. Surely, this is not an acceptable reaction.

The problem is that there are too few doctors to provide each person with full access to care, especially in an aging population because, as noted in a quote from Dr. Darrell G. Kirch, president of the Association of American Medical Colleges (AAMC) “Older Americans require significantly more health care…Older individuals are more likely to have multiple chronic conditions, requiring more intensive, coordinated care.” It is, however, much more about the poor distribution of doctors by specialty (too few primary care physicians, too many of many varieties of subspecialists), by geography (too few in rural and poorer areas, too many in more affluent and suburban areas), and by the insurance status of the patients that they care for (too few who take Medicaid, and even Medicare, and too many willing to care for only those with insurance that reimburses more). And, relevant to the cost of care, too many whose business model is built upon doing high-cost, high-profit procedures even when they are marginally (or not at all) beneficial to the patient, rather than providing the comprehensive care needs of people.

Sadly, and for the wrong reasons, some of this may not come true, so some of the fears of the already-insured may be mitigated. Many states have indicated their plans to not participate in Medicaid expansion despite the financial incentives to do so (the federal government will pay 100% for the next several years, and 90% thereafter). These same states, as well as others, also pay so little under Medicaid that many doctors won’t see Medicaid patients. Unfortunately for that ignorant-or-selfish-or-both minority of seniors who say “keep the government’s hands off my Medicare!”, many of those same doctors are now refusing to accept Medicare patients. Hey, if they can make a big living without it, why should they take care of your mother? So if you are not on Medicaid OR Medicare maybe you’re safe – if you live in a relatively affluent part of an urban area, and have private insurance, and especially if you are in an integrated health system such as Kaiser that provides a strong primary care base.

The NYT article indicates that “Physician compensation is also an issue. The proportion of medical students choosing to enter primary care has declined in the past 15 years, as average earnings for primary care doctors and specialists, like orthopedic surgeons and radiologists, have diverged. A study by the Medical Group Management Association found that in 2010, primary care doctors made about $200,000 a year. Specialists often made twice as much.” In fact the gap is much greater than that between primary care physicians and specialists “like orthopedic surgeons and radiologists”; it can be several times greater. (This is because “specialists” includes, in addition, doctors like psychiatrists and some pediatric and medical subspecialists who earn much closer to what primary care doctors do, and thus bring down the “specialist” average.) A recent estimate was that an anesthesiologist can anticipate earning $7 million more in a career than a family physician!

I woke the other day to NPR to hear Republican senator Orrin Hatch saying “To be clear, it is a disgrace that so many American families go without health insurance coverage.” I was nearly ecstatic; to agree that something is a problem is the first step to getting together to solve it. And, surely, that something is “a disgrace” is even worse than being a problem. I turned up the radio to find out how Sen. Hatch and the Republicans were going to solve it. Unfortunately, that was not to be. It was a sound bite in a story by Julie Rovner titled “GOP Says Coverage For The Uninsured Is No Longer The Priority” (July 27, 2012). I hadn’t known it ever was a priority for the GOP, but this piece laid any doubts to rest. Worse than the double-talk from Hatch was Senate majority leader Mitch McConnell, in this excerpt:

McConnell: "Let me tell you what we're not going to do. We're not going to turn the American health care system into a Western European system. That is exactly what is at the heart of Obamacare. They want to have the federal government take over all of American health care."

By "Western European," McConnell means government-run or primarily government-run. Western European countries also pretty much don't have people who don't have health insurance. And by the way, there are closer to 50 million Americans without health insurance; 30 million is the number the health law is estimated likely to cover.

McConnell never says what the GOP is going to do, but you can be sure it will not have anything to do with covering everyone. This is too bad; there are possible solutions, and many of them are even based in the marketplace. Step one is for Medicare to completely revamp its reimbursement policies. This is because, to a large degree, Medicare reimbursement is the basis for all insurance reimbursement; while they may pay more (say, 1.5x Medicare) the ratios are the same, so if Medicare changes what it reimburses for primary care relative to subspecialty care, other insurers will follow.

In biological systems, the normal situation is to have “negative feedback loops.” For example, if the thyroid gland is producing enough thyroid hormone, it shuts down production in the pituitary gland of another hormone that stimulates the thyroid. When there is not enough thyroid hormone in the blood stream, the low levels stimulate the pituitary to become active, activating the thyroid gland. This is functional. Imagine how dysfunctional a “positive feedback loop” would be – the more the thyroid produced thyroid hormone, the more the pituitary would produce its stimulant, creating yet more thyroid hormone, and soon we’d all be hyper-thyroid and dead!

This is like the current medical reimbursement system. We pay doctors more to do procedures, pay them more to take care of only a few diagnoses in a limited organ system, pay them more if they live in an expensive area, and even more if they refuse to care for those on government insurance. This is a positive feedback loop where you economically do the best being a medical “partialist” in a nice suburban area taking care of relatively well-off people, and worst being a generalist in a rural area taking care of people who need it. Or, if you choose, work less than full time and still make a good living.

Medicare should immediately begin reimbursing primary care at a higher rate, including for the effort and cost of managing chronic disease, so that the income differential between generalists and specialists largely disappears. Then it should increase payments for doctors working in more rural and remote areas, not for “desirable” urban and suburban areas. Doctors practicing in urban underserved areas should get smaller incremental payments (after all, they can live in a “good” neighborhood and commute).

We will still have a shortage of doctors until the pipeline fills, but such a system will decrease the financial impetus to be yet another subspecialist in a metropolitan area that already has enough, and increase the impetus to become a generalist in an underserved area. If we are to depend on the market, this is the kind of market-based approach we need.