Critical access hospitals: Worth subsidizing to help save rural America

If you live in a sparsely populated area, you may find it difficult to obtain medical care because doctors and hospitals are far away. The issue of geographic isolation is independent of insurance status; it is a problem that plagues Canada, where everyone has health insurance through its single payer system (coincidentally called “Medicare”), but most of the people are concentrated within a short distance of the US border, and there are vast stretches of empty (or, more to the point in this case, almost empty) land. The situation is exacerbated further by the fact that many people living in rural areas work in jobs that have a higher risk of injury which might need care (e.g., farming, ranching, logging), and by the fact that a greater percentage of people living in rural areas are older, and thus more likely to have chronic disease. However, hospitals serving rural areas are small, and may not bring in enough revenue to support their fixed costs, so hundreds of rural hospitals closed in the 1980s and 1990s.

In response, Congress created the Critical Access Hospitals (CAH) designation in 1997, allowing hospitals that meet certain criteria (initially being greater than 35 miles apart) to receive increased reimbursement from Medicare at 101% of their costs. This was very successful, not only permitting the survival of many existing rural hospitals, but the creation of new ones, particularly when states were allowed to add other criteria to the designation, creating “Necessary Provider” Critical Access Hospitals, NP-CAH. The existence of these hospitals has been seen as a top priority for many rural communities, and for the states that they are located in. However, a recent report (OEI-05-12-00080) by the Department of Health and Human Services’ Office of the Inspector General (HHS-OIG) suggests that a stricter application of the distance criterion (even 15 miles, not 35) would mean that many of these hospitals would no longer receive 101% of their costs, and that this would result in the saving of $449 million to Medicare. They provide us with a sample map of Missouri, showing which hospitals would be affected.

As reported by Mike Shields of the Kansas Health Institute (KHI) in “Inspector general’s report has rural hospitals worried”, this has the National Rural Health Association raising the alarm. It is of special interest in the middle of the country. Kansas, where former governor and current HHS Secretary Kathleen Sebelius certified 31 additional hospitals under the NP-CAH criteria, leads the nation with 83 CAHs; Iowa is second with 82. According to the OIG, “There are more than 1,300 CAHs in the United States. CAHs are located in every State except Connecticut, Delaware, Maryland, New Jersey, and Rhode Island. CAHs provided care for approximately 2.3 million beneficiaries in 2011. Medicare and beneficiaries paid approximately $8.5 billion for this care.” So it is not surprising that these hospitals, their trade association, and the states in which they are located, are very concerned; many of them would likely close if they didn’t receive the excess payments from Medicare. The question is: would it be a good idea?

Essentially, the key part of that question is not whether it would save money for Medicare; clearly it would. The question is “would it harm the access of rural people to necessary medical care”? I don’t know the answer to that; or, rather, I know the answer is that it would but I don’t know how much. Could people drive 15 miles farther to the next hospital? Probably. Many of them are already driving a number of miles. Would this be inconvenient? Probably. After all, a large percentage of the users of these hospitals (most of which are also the locations of the doctors’ or other health providers’ practices) are older, thus Medicare’s interest in them. Would people be less likely to get necessary preventive and treatment care for none emergencies? Possibly. Distance is a big issue, especially if you have to be picked up and driven by someone else. Would there be disparities in which rural residents see decreased access? Almost certainly. Many rural people with high incomes often go to larger facilities in bigger cities, or to “destination” centers, like the Mayo Clinic, for their regular care. Obviously, the poor will have less access.

But would it save sufficient money to justify this? What is the cost/benefit to saving $449 million to Medicare against the – what? Lives? Convenience? of a bunch of rural Americans? Very hard to measure, although I again (see “Why poor people choose ERs: we need a system designed to meet everyone’s needs”, August 4, 2013) call attention to the fact that “convenience” is a loaded word that does not convey the full impact of time, transportation, and competing demands that affect the lives of the most needy. It is probably a matter of priorities, and of course, who you are. Are you the majority of people, including Medicare recipients, who live in major metropolitan areas, and for whom the sheer distance to a hospital is not among the many problems that you have accessing care (although transportation might well be) or the 20% or so who live in these rural areas?

One additional point that can be brought up on either side of the argument is that CAHs are often critical in other ways, such as their economic impact on their communities. Many are among the largest employers in their towns. They are a sense of civic pride. One I know about is Kiowa County Hospital in Greensburg, Kansas, a town of 1500 in the southwestern part of the state. On May 4, 2007, most of Greensburg was leveled by a tornado. Because I drive through it a few times a year, I have watched its rebuilding and taken pictures of it. For several years, the hospital was located in Quonset huts on the north side of US Highway 54. In rebuilding the town, Greensburg, with the support of many organizations, sought to make it in many ways a model of what a small town could be, including in ways that encouraged health, such as having schools and public buildings in downtown, walkable, rather than on cheaper land on the outskirts requiring a car. And they rebuilt the hospital, which is now “the first LEED Platinum Certified Critical Access Hospital in the United States.”

So what? I mean, it’s nice that Greensburg rebuilt in an environmentally positive and health-oriented way, and that Kiowa County Hospital is LEED platinum. Yes, it’s nice that rural communities take pride in their local hospitals, and that they provide jobs for the people who live there. It’s nice that the folks who live in these parts of the country don’t have to drive quite so far to get medical care. But is that a reason for Medicare to spend all that money to subsidize them, to keep them open?

I think so. I think that, from a health point of view, minimizing the already-long distances many rural Americans have to travel to access care is a good thing. I think that having institutions that provide jobs and stabilize communities and possibly even keep towns alive is a good thing. You can say “only 20% of Americans live in rural areas”, but that is 20% of Americans. My concern is not nostalgia for a pastoral way of life I have never known, but rather a concern for these communities and the people who live there as needing support as much as poor and middle-class people in cities and suburbs. I note the irony that Kansas’ two Republican senators are very strong advocates for rural hospitals while supporting their party’s policies on cutting services for the needy, and that its Republican governor (and former senator) is a leading advocate for “let’s do whatever we can to help the Koch brothers by cutting taxes on fossil fuel producers”. But we have spent, and continue to spend, billions upon billions of dollars on subsidizing bankers, financiers, and the wealthiest American individuals, companies and businesses.

Spending a little bit on keeping rural hospitals alive seems like a whole lot better thing to do.

What can we really expect from ObamaCare? A lot, actually.

Despite the constant refrain heard from many (particularly Republicans, particularly in Congress, and particularly from the particularly self-promoting Sen. Ted Cruz of Texas) that “ObamaCare” (the Affordable Care Act, ACA) is the first sign of the coming apocalypse, and concerns from people like me that it is a great deal for insurance companies and will still leave many people without coverage, it is going to happen and it is going to be a good thing for the health of many people. It’s too bad that the crêpe being hung by the nay-sayers is believed by so many, largely a result of it being so well funded. Of course, this doesn’t mean that Sen. Cruz is going to change his tune or that I am going to stop worry about those who continue to be without insurance (especially in states that don’t expand Medicaid, like mine).

Some have suggested that the biggest fear Republicans have is that it will work, and people will benefit, and that now is the time to scare people to try to get rid of it, since once it is in place people will not want to give it up (see: Medicare). Right now, satirist Andy Borowitz can make fun of the right’s hyperbole with bits like “Fox News: Obama In Plot To Force Americans To Live Longer”, but when people actually do get health care, and the costs do go down, and maybe they do live longer, or at least live in better health (longer “healthy life expectancy”, or HALE; see The State of US Health: improved over 20 years, but not nearly enough”, July 14, 2013), they are going to be happy with it. When you can get health insurance even though you have a pre-existing condition, when you can get health insurance on the exchange marketplace even though your employer hasn’t offered health insurance to you, when you can afford the premiums because those between 133% and 400% of the poverty level will get federal subsidies, it is not likely to make you unhappy and you are very unlikely to want to give it up.

Of course, those who are under 133% of poverty were to have been covered by Medicaid expansion, and this is not going to happen in a lot of states, so these folks will be left out. Chang and Davis, writing in the Sept-Oct issue of the Annals of Family Medicine examined “Potential Adult Medicaid Beneficiaries Under the Patient Protection and Affordable Care Act Compared With Current Adult Medicaid Beneficiaries”. Using a large federal database (NHANES) they compared over 13 million people in each category, and found that the potential beneficiaries were more likely to be male and white and to have about the same level of educational attainment as current recipients. They also had better self-reported health status, and were less likely to be obese or depressed. The prevalence of diabetes and hypertension were about the same, and the potential beneficiaries were more likely to be smokers and heavier drinkers. So, in general, expanding Medicaid to this larger population would result in a healthier (and thus less costly) group to care for, although with significant risk factors. This is related to the argument I have for expanding Medicare to include everyone (a single-payer health system): the highest cost utilizers, the old and disabled, are already in it and expanding it will, thus, not cost as much more as one might think (or certainly not as much as using the private insurance market as we currently do, or even under the Obamacare expansion).

Two editorials accompany this article. Danel Derksen discusses how the ACA will offer opportunities for (and challenges to) both family physicians and public health, while J.P. Silvers compares the objectives of the plan and the results that it is likely to achieve in the real (“imperfect”) world, with emphasis on the potential for “market failure” as the limiting factor. He lists the 3 main objectives of the ACA as 1) reforming the private insurance market, 2) expanding Medicaid, and 3) changing the way that medical decisions are made. The first, the effort to get those currently left out of the insurance market primarily because they are self-employed or work for small companies, is to be accomplished by the subsidized health insurance exchanges, with quite significant subsidies; the idea is that competition will lead to lower prices and better coverage. If this doesn’t happen (“market failure”) then the goal is not going to be achieved. So far, I note, in most states it seems to be working.

Expansion of Medicaid to cover people who are below 133% of poverty and yet not currently eligible was a cornerstone of the program, and the one that the Supreme Court made optional; per this map from the www.Bankrate.com website, 23 states + DC will be expanding Medicaid, 21 will not be, and 6 are undecided. The fact that the federal government will be paying for it seems to have convinced several Republican-controlled states (e.g., Arkansas, Kentucky, North Dakota, and Arizona) that it would be a good idea. Of course, it is a good idea, and not doing it is a way for those who are themselves “feeding at the public trough” (legislators who get publicly-funded insurance) to punish the needy, falsely cloaking themselves in the language of conservatism. As Silvers notes, to really improve health, Medicaid rates will need to be high enough that providers will actually care for beneficiaries.

The third area is changing medical decision making, to both improve the quality of care and lower the cost, issues about which I have often written (see, for example, Controlling the cost of health care by doing the right thing, Sept 22, 2013). Silvers cites, in particular, comparative effectiveness research (CER) which will show us which things work and which things cost the least to achieve comparable results, and which, it is to be hoped, would actually change medical practice. He then goes on to describe the factors which exist in our “imperfect world” that threaten the achievement of these goals, because “There are serious problems in the way the US health system is organized and paid, in the information and choices available, and in the ability of participants to respond to the pressures and incentives provided in reform.” The three classes of problems he discusses are “when decisions are delegated to someone who is supposed to act strictly in our interest as an agent, but doesn’t”, such as brokers who are paid commissions from someone else for signing us up; limits on potential competitors (as arising from pharmaceutical patent protection); and “when one party in a transaction has differential information that allows them to dominate or exploit decisions”, in play with regard to physicians, hospitals, drug companies, insurance companies, and almost everyone involved in health care compared to regular folks. He notes “Finally, the plethora of perverse payment incentives is the most obvious problem in having informed free choice leading to the optimal outcomes desired.”

And this is the real point. The web of multiple strategies for achieving coverage are incredibly complicated, with roots in both the Clinton plan and Massachusetts’ “Romneycare’ and (ironically) in the ideas of right-wing think tanks over the last several decades. This patchwork of fixes has always been a Republican (and conservative Democratic) hallmark. While Silvers titles his final section “What does it mean for the future and what can be done?”, in fact he mostly tells us what the risks are rather than what could be done. There are many who suggest (or fear) that the biggest threat from a potential failure of Obamacare would be that it would make the fact that a single-payer system would be much simpler and effective more obvious; see Morici “First Obamacare, Then a Single Payer System” on www.breitbart.com, cited by Don McCanne in Quote of the Day.

That’d be nice.

Controlling the cost of health care by doing the right thing

The cost of health care and ways to decrease it are a recurring drumbeat in politics, including on this blog. However, I like many others, have also emphasized the need to increase access to necessary health and medical care to all people who need it, and to create social conditions that decrease the burden of ill health. Federal efforts have finally come up with the Affordable Care Act (ACA, Obamacare), passed in 2010, and since 2012 object of continued efforts by Republicans in Congress and in those states in which they control the governor’s office and state house to repeal or gut it. In states, most effort is focused on Medicaid, which is funded by both federal and state money. In some states, most notably Oregon (“The Oregon Lottery: Far from enough, but at least they are doing something”, July 19, 2012), this effort has been combined with increasing access; in most it has just been about cutting expenditures.


On August 4, 2013 (“Why poor people choose ERs: we need a system designed to meet everyone’s needs”), I wrote about an article from Health Affairs ¹that studied the reasons that poor people use hospital emergency rooms “inappropriately” for care, to the frustration of the ERs, primary care doctors, payers (in this case, where patients were either uninsured or covered by Medicaid, mostly government) and health policy experts. The 3 major groups of reasons were quality (perceived quality, which I believe is not valid), cost (a matter not of overall cost but out-of-pocket cost to the user at the time of service) and convenience, which I argue is a misleading word for describing a place that is actually open and will see you when you can get there.  “…it is not “convenient”,” I wrote, “to wait 6 hours in an ER to be seen; if this is better than the alternative, the alternative is seriously flawed!”


What would be a mistake, however, would be to presume that it is just inappropriate use of health services by poor people that drives up the cost of care. Indeed, this is only a small part of the “excess” cost (defined as “cost in excess of what would be needed to be provide quality care to everyone) in the US. Another good definition of “excess cost” might be the additional cost per capita spent in this country compared to many other developed countries whose health outcomes are much better than ours. For this, there are different reasons. I have discussed many of them in earlier posts, and they include procedures that didn’t need to be done, over-utilization of high-technology, under-utilization of primary care, and poor geographic distribution of medical care. To a large extent, these are summarized by the two quotes I used in The high cost of US health care: it's not the colonoscopies, it's the profit”, July 28, 2013: “Using health care as a driver of corporate economics as opposed to a public good is the fundamental cause of our medical inflation,” (Richard Wender, MD) and “The US health care system is not designed to get you the care you need, it is designed to get you the care that someone can make a profit giving you.” (Lee Green, MD).


There are other causes as well. One big one, referred to above and discussed at some length in “To improve health the US must spend more on social services”, December 18, 2011, is the fact that the US does not provide anywhere near the overall social service safety net that other developed countries do. In those other countries there is much more spent to ensure that people have adequate food, housing, education, and a living wage, which are all drivers of health status.


Another big cause, though, are our preferences, our desires, as consumers, for “all that money can buy” when it comes to our health. While this may be especially true when, as health economists often point out, it is not directly your money, but your insurance company’s, I know plenty of cases in which families have wiped out their life savings, wiped out their retirement accounts, wiped out the money that could have supported the survivors (especially true when the patient was the primary breadwinner) in pursuit of “one more” vain attempt at cure. I do not mean to suggest that treatments with reasonable probabilities of meaningful benefit should be withheld. Nor do I mean to blame just the individuals and families; clearly in most of these cases there were doctors and other health professionals holding out hope (“well, maybe we could try another bone marrow transplant and it might help”) without making sufficiently clear what both what they meant by “help” and what the odds were of success.


Yet, many doctors (including me) and hospitals will tell you that they have often recommended against interventions because they have little or no likelihood of meaningful benefit, and often a significant risk of harm, only to be told by the patient and/or family that they want to “do everything”. Often these people suspect that if they had more money, or if they were a different color, or if they were in a “better” hospital, the providers wouldn’t be suggesting that they forgo further intervention. I don’t doubt that this is sometimes justified, and I’m sure that if a patient has enough money to spend there will be someone, somewhere, whether “quack” or a “legitimate” medical center, who will take it to “do something”. But this doesn’t make it right or good. I have not seen such studies but would not be surprised if it were shown that many of those with the most resources are among those with the most unpleasant deaths; our culture values intervention, and they have the money to find some who is willing to make a profit intervening.


Everyone dies. We would all like, and like for our loved ones, to live as long as possible if our lives have meaning – some physical and/or intellectual function, some ability to contribute to or benefit from others. We would like, and like for our loved ones, to be comfortable and pain-free as we approach death. We don’t want to think that money which could help us or our loved ones is being “saved” just so it can be used to provide services to others who are richer or louder. But when something will not “help” in any meaningful way that we understand it, and which may hurt, it should not be done, and we should demand that it not be done. Not doing is often more appropriate and more powerful than doing. We must shame health care providers who advertise and promulgate interventions that are unproven, or will not help, or will harm, because they can make a profit doing it.


If we are to get to this place as a society, where the US health care system is one designed to get you the care you need rather than to get you the care that someone can make a profit giving you, we are going to have to change our attitudes. And that change of attitudes and behavior needs to start at the top of the social and economic scale, not at the bottom. No unnecessary stents for President Bush, no “executive physicals”, no inappropriate end of life interventions for the wealthy. Where the “best” in healthcare is not defined as the “most”, but the most effective and most appropriate.


A health system in which health and health care for everyone is the goal of our society.

1  Kangovi S, et al., “Understanding Why Patients Of Low Socioeconomic Status Prefer Hospitals Over Ambulatory Care” , Health Aff July 2013   vol. 32  no. 7  1196-1203; doi: 10.1377/hlthaff.2012.0825  

Competition vs. Coordination in health care: remember the patient!

Two of the most prominent policy recommendations for improving the health care “system” in the US have been increasing coordination of care and increasing competition. Both have very positive aspects, and I have written positively about the potential of both approaches, but also about the very real pitfalls. Coordination of care sounds like a “no-brainer”; everyone would like the physicians caring for them in one setting (say, in the hospital, or on a visit to a specialist, or in a rehabilitation facility or even nursing home or home care) to know what has been done to them previously, what the results have been, and what their previous providers thought. At the minimum, we want to think that there is communication, and that (often expensive) lab tests and x-rays are not repeated for no reason other than that our current provider cannot access those done somewhere else. In addition, coordination of care should mean that care is delivered in the most appropriate setting, often the most cost-effective setting, and that when we move from one setting (say, outpatient to inpatient, or inpatient to rehab) it is for good reasons based on what is best for our health, and not for bad reasons (say, what makes the most money for the providers).

Competition in health care also has value if it prevents artificially inflated charges and cost, just as it does in other parts of the market place. This may be most obvious in price-sensitive elective care, such as the Lasik® and contact lenses cited by Sen. Rand Paul, but is most important when it is absent and prices rise, such as in the case of hospitals (like Bayonne Medical Center; see The high cost of US health care: it's not the colonoscopies, it's the profit, July 28, 2013) that have a lock on a market. While business leaders  often extol the benefit of competition, in fact all prefer to have a monopoly on the market (or at least be part of a oligopoly, where only a few players exist in a market and often collude on pricing) as it maximizes their profit. Airfares are a good example; I live in Kansas City, and if I fly to NYC, the round-trip fare for a non-stop is more than twice what it is to fly to Washington, DC. This was not always true; there used to be several airlines flying non-stop from KC to NY, but now there is one. There are at least 2 flying to DC.

OK, so both coordination of care and competition can be beneficial in the healthcare marketplace. But what about when they are in competition with each other? This is the subject of a “Perspective” in the New England Journal of Medicine by Katherine Baicker and Helen Levy, “Coordination versus competition in health care reform”,[1] August 29, 2013. They point out that despite the potential benefits of care coordination, and its older cousin, consolidation, it can be anti-competitive and some health care consolidations have been investigated by the Federal Trade Commission for this very reason. The problem is not an ideological commitment to competition, it is the results: the merger of two hospitals providing similar care raises prices, as does movement of care from low-cost venues such as doctor’s offices to higher-cost (and reimbursement) venues such as surgi-centers and hospitals (see again July 28 post). Baicker and Levy note the “subtler” issue of bundling, such as occurs in the case of computer software, where in order to get one product a company makes which you want, you are forced (or encouraged, through a big discount) to buy others you may not want; to get a lower price on that great browser you have to buy the operating system, or the word-processing software. It certainly can and does occur in healthcare:  “…bundling offers providers who have market power in one product domain (such as tertiary hospital care) an opportunity to dampen competition in other product domains (such as primary care) by requiring insurers to contract with them for both products in order to receive discounts.”

Health information technology is a prime example of the tension. Heavily pushed, and subsidized, by the federal government as a way to improve coordination of care, it “can in theory promote both competition and coordination, but only if they are implemented well — an interoperable health information technology (IT) environment, for example, should promote both, but health IT without interoperability may simply lock patients in to their current providers or provider networks by making it difficult or costly to move their records, reducing competition. The opportunities for a win–win are limited.” Most providers who use EMRs will acknowledge their advantages (“I know what is happening elsewhere – at least within the system”) but complain about the huge amount of time it takes to enter data, and the fact that many large systems have bought the components of systems that facilitate billing, but often not those that offer great patient care advantages (such as the creation of “registries”, i.e., lists of the patients with similar conditions, such as diabetes, that may need similar regular interventions). And interoperability? No way. “Provider lock” – getting a healthcare system to spend so much money on your EMR product that they can’t change – has become the main strategy for most health IT companies. “The worst nightmare of most health IT companies,” says a friend who is in the field, “is that Apple will get involved and create a product that works better and is easy to use. And will probably be cheaper. So they want to lock you in.”

Baicker and Levy make three suggestions for how this tension might be resolved. One, look for “win-win” situations (could this be health IT? they ask). Two, have courts that enforce anti-trust laws look explicitly at the trade-offs. Three, look across silos to see how a seemingly positive change in one area would potentially have a negative effect in another. These are all good suggestions, but all limited and quite “iffy”. And all, I point out, as often is the case in rarefied discussions of health policy, missing the most important point: What is best for the health and health care of people, or patients? Not “consumers”, these largely hypothetical well-informed people whose problems are so non-urgent and budgets so large that they can shop for health care as they might for shoes, but the people who are sick, who are stuck in their health plans (whether government like Medicare and Medicaid or because their employer only offers one) or are uninsured?

This is where the doctors, who are often criticized (even by me; see Physicians' role in controlling health costs: do no financial harm, August 25 2013) are often right when they talk about meddling by bureaucrats. The issue is, however, that the policies adopted by Medicare and private insurers (often quite different, per Baicker and Levy) are indirect; they attempt to influence both the quality and cost of care by financial incentives or disincentives, and this permits – indeed encourages – gaming of the system, trying to maximize income while minimizing cost and risk. This is obvious, but is still true, and its impact is often to the disadvantage of people. The solution may well be more explicit regulation to directly address what needs to happen. Not micromanagement (“use this drug”), although following evidence-based treatment approaches might be among them, but those that explicitly encourage high-quality, cost-effective care. Coordinate care, but block monopolies; encourage consolidation between organizations providing complementary rather than the same services; do not pay increased costs because a system has a monopoly; demand that health IT systems be interoperable; measure quality outcomes that control for severity of illness and the socioeconomic risk factors of patients.

A single-payer health system, Medicare-for-all, could have the clout to make this happen. It could also run the risk of “non-competitiveness”. However, if we are all in, if even the most privileged have to use it, then that will protect the interests of the most vulnerable better than any form of competition that allows private companies to opt out of covering them, and puts the poor and sick and old in a separate system in which others do not have a stake.

It would be evidence of a core commitment to social justice.

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[1] Baicker K, Levy H, “Coordination versus competition in health care reform”, NEJM 29Aug 2013; 369(9):789-91, DOI: 10.1056/NEJMp1306268

President Bush's stent: inappropriate screening and care for the rich, nothing for the poor

One of the recurrent themes of this blog has been the importance of everyone having access to necessary medical care, and how the US compares poorly to other developed countries in that it does not cover everyone. Another recurrent theme has been that many medical procedures are unnecessary, sometimes even harmful, but are nonetheless provided to people who have the money or insurance to pay for them. This is not to say that greed is always the motivator; there is a powerful, if often incorrect, belief that to do something is better than to do nothing.

In this context, it is interesting to read “President Bush’s unnecessary heart surgery”, a Washington Post “Viewpoint” by Vinay Prasad and Adam Cifu published August 9, 2013. As part of his “annual physical”, the former President  (who is “…widely regarded as a model of physical fitness”), received, in addition to (presumably) the screening tests and immunizations recommended by the evidence, a cardiac stress test. Discovering an abnormality on that test led to his having a CT angiogram and finally placement of a cardiac stent.

One interpretation of this story might be “he’s lucky they did the test; they found something wrong and fixed it”. I’m afraid, along with Prasad and Cifu, that this might be the lesson taken from it by many people, and the result could be more people requesting such a test because, “hey, they found something wrong with President Bush – could I also have such a problem?” This would be unfortunate, because it is incorrect. President Bush – based on the information provided – should not have had the stress test and not have had the stent placed.

The key point is in understanding that he was (by all reports) asymptomatic. “Before he underwent his annual physical, Mr. Bush reportedly had no symptoms. Quite the opposite: His exercise tolerance was astonishing for his age, 67. He rode more than 30 miles in the heat on a bike ride for veterans injured in the wars in Iraq and Afghanistan.” While the definition of screening tests is that they are done on asymptomatic people, there are a number of criteria that have to also be present, among them that the test should detect a condition before it is symptomatic, and there should be an intervention that will prevent progression if disease is discovered. So, isn’t that true in this case? He did have the disease, a narrowing in one of his coronary arteries, right? So isn’t it good that it was discovered.

As Prasad and Cifu discuss, however, there is no evidence that stenting a coronary artery prolongs life.  “It is worth noting that at least two large randomized trials show that stenting these sorts of lesions does not improve survival.” Even for higher risk patients than Mr. Bush, survival is not increased. However, if people have symptoms of chest pain that appears cardiac in origin, for whom stress testing may be indicated (not a screening test now; they are symptomatic), treatment by angioplasty, stenting, or even bypass surgery can ease or relieve the pain. That is a good thing. But for Mr. Bush, who had no pain, there can, by definition, be no pain relief. There was some additional risk, however; in addition to the inherent low risk of doing the procedure (such as bleeding and stroke, and even, rarely, death), he now has to take anti-platelet drugs, which also confer some risk. And a stent only holds open the spot it is in; it does not prevent progression of coronary artery disease elsewhere.

The larger issue of the “annual physical” (which I have addressed previously in “ The "Annual Physical": Screening, equity, and evidence”, July 4, 2012, citing Elizabeth Rosenthal’s NY Times article “Let’s (not) get physicals”) was again the subject of a popular article, “The case against the annual checkup” by Brian Palmer on Slate.com on August 20, 2013, which states: “There are two kinds of arguments against the adult annual health checkup. The first has to do with the health care system overall, and the second has to do with you personally.” Palmer does add that

“It’s important to separate preventive care from annual checkups. Only one-half of annual checkups actually include a preventive health procedure such as a mammogram, cholesterol testing, or a check for prostate cancer. (Annual gynecological visits are excluded from these numbers, although the evidence supporting those is not particularly overwhelming either.) More importantly, only 20 percent of the preventive health services provided in the United States are delivered at annual checkups.”

He has a pretty good point, although he includes prostate cancer screening, which is not recommended or beneficial, in his list, something Prasad and Cifu do not. But I would take issue with his suggestion that you only visit the doctor when you are sick, which is in fact when doctors tend to work in the preventive services the other 80% of the time.

There are a couple of reasons for this, but the main one is that there are a lot of people (even older people at higher risk) who do not get sick, or at least sick enough to decide to come to the doctor, or at least sick enough to decide to take off from work and maybe lose income to come to the doctor. And they could benefit from preventive care as well. The list of preventive services changes from time to time, which it should as new evidence emerges, but includes immunizations, screening, and education. The list of conditions for which screening is effective and recommended by the evidence is relatively short (despite our natural desire to have more, more effective, tests) and does not include prostate cancer or ovarian cancer (thus, no reason for an asymptomatic woman to have a “routine” bimanual pelvic exam), but does include Pap smear for cervical cancer, colorectal cancer screening (which can be done with colonoscopy or regular stool screening for occult blood), bone density screening for certain age groups, and mammography. There are also recommended screening for other conditions: hyperlipidemia (mainly cholesterol), abdominal aortic aneurysm (once, in men over 60 who have smoked), HIV and Hepatitis C, as well as some screens for people who are themselves asymptomatic but whose family history places them at higher risk for a condition (e.g., diabetes). (See the Guide to Preventive Services 2012, Recommendations of the US Preventive Services Task Force, on the website of the Agency for Healthcare Research and Policy.)

Immunizations include not only annual influenza shots, but also less-frequent pneumococcal vaccine and tetanus/diphtheria/pertussis boosters, which are often not up-to-date in adults. Education may be the most important: counseling on diet, exercise, smoking, alcohol, drugs, and risk behaviors, as well as identifying victims of violence (domestic or otherwise) should not wait until these conditions have resulted in symptomatic disease.

Perhaps these preventive services should not be “annual”; there is no magic to this number, but it was chosen because it is easy to remember. Certainly many of these preventive services (now including Pap smears, bone density and mammograms) are recommended less frequently than yearly. Perhaps they can be as well delivered by other health professionals as by physicians. But there is benefit to preventive care even for asymptomatic people, and not the least is noted by Palmer: “They build relationships between doctor and patient, and open lines of communication are important in medicine.”  Yes, there are certainly many risks, which I have often pointed out, to over-testing and over-medicalization. But there are also risks to not having preventive care. And, of course, the key point here is equity: those most at risk of “too much” care and too many interventions are the more well-to-do, well-educated, and well-insured. Those most at risk of too little care, too little screening and immunization and education about how to reduce their risks and early identification of disease are the poorer, less educated, and uninsured.

The fact is that health care, like most things in our society, is very different for different socioeconomic classes. Cautioning against overuse by the privileged is one thing; being sure that this does not bleed into justifications for limiting access to necessary care for the less privileged is quite another.

Rand Paul on health policy: small brain and no heart

While politicians are rarely elected to office because of their profession (I seem to remember that when in elementary school we learned that the second most common profession in the NY state legislature, after attorneys, was undertakers!), the fact is that often fellow legislators often turn to their colleagues with expertise in a certain area to understand bills with technical implications. Legislators who are physicians, nurses and pharmacists, for example, may have influence on bills related to health care. (This is provided, of course, that they don’t involve touchstone ideological issues like abortion where facts are routinely ignored and new ones, such as “abortion causes breast cancer”, are invented.) Thus, physicians like former US Senate Majority Leader Bill Frist, a cardiac surgeon (and member of the family that founded and controlled HCA, the nation’s largest for-profit hospital chain) had great influence on medical matters.

So it is relevant to look at statements by Sen. Rand Paul (R, KY) about healthcare. Primarily known as a prominent libertarian conservative and Tea Party favorite, as well as a probable Republican presidential contender, Paul is an ophthalmologist, an eye surgeon, and thus probably is presumed to have credibility on healthcare issues. This does not seem to be diminished by the fact that he has not been Board-Certified by the mainstream American Board of Ophthalmology since 2005, being rather certified by the National Board of Ophthalmology, which, coincidentally, he founded and is president of (the Louisville Courier-Journal link is no longer live, but it is referenced in TPM). Perhaps this appeals to his libertarian base; perhaps it even is honorable if it is truly based (as he states) on “…a principled stand in response to the ABO’s ‘decision to grandfather in the older ophthalmologists and not require them to recertify….I thought this was hypocritical and unjust for the older ophthalmologists to exempt themselves from the recertification exam.’”

So what does Sen. Paul have to say about important health policy issues? Unsurprisingly he is a strong opponent of “Obamacare” and, for that matter, any universal healthcare system. He apparently has a fair amount to say about this it in his book, “Government Bullies”, which I have not read. I did, however, hear him discuss it at some length with John Oliver on a “Daily Show” appearance on August 12, 2013. His main point is that, unlike “most legislators” who have “dinosaur syndrome -- small brains and big hearts” (news to me about politicians, at least the “big heart” part. And, by the way, where does he get the idea that dinosaurs had big "hearts" other than in the physical sense?), he can help solve problems because he is not in that mold (I think he was referring to the “small brain” part, but I’m not sure!). He called upon his experience as an eye surgeon to demonstrate how the “market” controls costs by referring to how it led to big price drops for two major procedures in his specialty, Lasik® surgery and contact lenses. With regard to the former, he notes that competition among ophthalmologists has led to dramatic decreases in charges (and costs) from over $2000 an eye to less than $500. The competition for contact lenses was with large retailers like Wal-Mart, which forced him to drop his charges in order to compete. Neither was covered by insurance, so he uses them as examples of how this could work for all the other things that are covered by insurance and to which people are price-insensitive.

All but the last of these assertions are true as far as they go. The cost of both Lasik® and contact lenses have indeed dropped. So, will this work for all health costs? No, absolutely not. There is a reason that these two procedures are not covered by insurance; they are both elective procedures and thus (like cosmetic surgery and many consumer items) can be reasonably subject to market forces. One has a much cheaper and effective option that works for the medical problem: wear glasses. If you are considering Lasik or contact lenses, you can choose to not buy them now and wait until prices come down. However, most of healthcare is not elective (thus more like food and housing). Emergencies are emergencies and need to be addressed now, by the most available provider (see The high cost of US health care: it's not the colonoscopies, it's the profit, July 28, 2013, for a discussion about how hospitals like Bayonne Medical Center have turned this into a profit-making strategy).

Mark Ebell, MD, a family physician and expert in evidence-based medicine, notes a more apt comparison: “If you have a stick in your eye, I doubt that you are price shopping or waiting for ads on the radio to advertise a special for removal of sticks in the eye.” No doubt; and while not all necessary healthcare is about emergencies, most of it is not about elective procedures. Chronic diseases like hypertension and diabetes need to be treated in order to prevent their progression to serious outcomes. Preventive care like screening for cancer and immunizations are only of value if they happen before the onset of disease. Neither Lasik nor contact lenses prevent either disease or its progression. 

Dr. Ebell is unhappy that Mr. Oliver, usually quite clever, completely missed this point, and it is an extremely important one. While I do not know if Sen. Paul is aware of this and is dissembling in using this inappropriate and simplistic example as a justification for his anti-government ideology, or is he actually believes it, the fact is that it is not at all a valid argument for a market-based health system. The empiric evidence is there, both in comparisons to other developed countries and in internal comparisons between state and local experimental government and insurance programs in the US: providing comprehensive health care at costs that do not discourage or make it impossible for people to access it improves health status. Conversely, there is excellent evidence that obstacles to healthcare access do discourage people from seeking it and do result in worse health outcomes, for individuals, populations and nations.

The danger in an argument such as Sen. Paul’s is two-fold. One is that, coming from the Republicans’ most prominent physician, it will reinforce the beliefs of those who already think that the market will solve the healthcare crisis. The other is that people who are not such ideologues but whose exposure to the health system, because of a fortunate combination of relative youth, good health, and economic security, is largely for such elective, minor or episodic care, may say “yeah, that seems right”. But it isn’t; it’s wrong. A recent NPR “Marketplace” show focused on the ACA’s requirements for individual health insurance policies that preclude many low-coverage, high-deductible options currently available.[1] It featured a self-employed Californian who noted that he was having to pay much more for insurance now, even though he was never sick and, in the last 14 years, had visited a doctor only a few times. It didn’t give his age, but whatever it was he will, in the future, be older; this is a certainty. And, as we get older the probability of needing health care increases. The old maxim about the stock market – that past performance is not a guarantee of future performance – is even more true for one’s health. It is at best risky and at worst foolhardy; the more apt comparison may be to the person who falls off a 20-story building and is heard by people as he passes each floor saying “so far, so good”. Making public policy on such a basis is nonsensical.

Dr. Ebell  says, regarding Sen. Paul’s analysis, “it makes me crazy. Big brain and no heart is a bad combination.” He is right about that, but more important is that there is no evidence that Sen. Paul’s analysis indicates big brain at all.

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[1] For a good discussion of the insurance exchanges, see Harvey Matoren’s blog “The Patient’s Advocate” for August 21, 2013, and for a state-by-state portrayal of federal/state involvement in the exchanges, the Commonwealth Fund website, http://thepatientsadvocate.blogspot.com/2013/08/what-are-these-health-care-exchanges.html

Physicians' role in controlling health costs: do no financial harm

There are a lot of people and companies out there who are making, or seeking to make, a profit on delivering health care. I have written about this often. However, it is in fact physicians who control many of the expenditures, and thus the cost; they are the ones who order the tests, prescribe the medicines, use the devices, refer to each other, advise their patients regarding the most appropriate treatment. To the extent that physicians (and other providers who have this power) exert it wisely, judiciously, and appropriately, the cost of care might begin to be controlled. Yes, there will still be tensions between cost and benefit, between benefit to a single person vs. benefit to the whole population, between what the goals of care are, and the degree to which physician choices are limited, but cost consciousness among physicians would go a long way.

It was, therefore, disappointing to read the results of a survey of US physicians recently published in JAMA. In “Views of US Physicians About Controlling Health Care Costs”, Jon C. Tilburt and colleagues randomly surveyed 2665 physicians (a 65% response rate, pretty good) about a variety of issues regarding cost control in health care. Most of those surveyed did not believe that physicians had any major responsibility for controlling health care costs;  it was “the other guys”:

‘Most believed that trial lawyers (60%), health insurance companies (59%), hospitals and health systems (56%), pharmaceutical and device manufacturers (56%), and patients (52%) have a “major responsibility” for reducing health care costs, whereas only 36% reported that practicing physicians have “major responsibility.”’

Whether 50-60% of doctors believing something can be considered “most” is open to question, but there is no doubt that when only 36% of doctors believe that they have a major responsibility, most do not. This is, of course, as I have noted above, incorrect. Do they really believe it? If so, this would imply that they believe that they, and other doctors, are doing all they can already, within the limits of their ethical responsibilities to their patients. However, their responses to other questions in the survey cast doubt on whether they actually are, or even think that they are. While ‘More than 90% of physicians expressed some or strong enthusiasm for -improving conditions for evidence-based decisions, including “expanding access to quality and safety data,” “promoting head-to-head trials of competing treatments,” and “limiting corporate influence on physician behavior,”’, only 51% were strongly enthusiastic about “limiting access to expensive treatments with little net benefit”. Since another 38% were “somewhat enthusiastic”, the article’s contention that it was “relatively strong support” is justifiable; still, it is pretty scary to think that half of doctors are not strongly enthusiastic about this issue.

When it comes to physician reimbursement, it is unsurprising that doctors are very chary of any new models, since most have been doing pretty well with the old ones. Thus, only 7% supported elimination of “fee-for-service” (FFS), in which doctors get paid for what they do (and, as we have often discussed, get paid more for doing more, whether necessary or not, and a lot more for doing procedures) rather than getting a global fee for caring for patients (which, in full disclosure, I have advocated). It is also not surprising that those physicians who were paid salary only or salary-plus-bonus were more than three times as likely to support elimination of FFS. Self-interest is a powerful motivator.

In an accompanying editorial, “Will physicians lead on controlling health costs?”, the ubiquitous Ezekiel Emanuel (former Obama health advisor and now apparently the “go-to” guy on health policy for JAMA and the New England Journal) and Andrew Steinmetz, come to the unavoidable conclusion that, at least for now, the answer is no. This disturbs them, and they spend a lot of time showing why these doctors are wrong. They note that “Not unlike the public, physicians embraced reforms that are sufficiently vague that they may offer only modest improvements but certainly will not transform the health care system,” which seems to be true; if this survey indeed reflects physician opinion, they don’t want transformation of the system. After all, Emanuel and Steinmetz concede, “Change is hard,” but they are very clear that it needs to happen, and the editorial (which I agree with a lot of) tends to get more shrill as it goes on. They take heart in faint positives:

“…not all the results are discouraging. Physicians do seem to recognize that health care costs are important. For instance, 51% strongly disagreed that the cost of a test or medication is only important if the patient has to pay for out of pocket; 85% strongly or moderately agreed that trying to contain costs is the responsibility of every physician; and 66% disagreed that there is too much emphasis on costs of tests and procedures.”

How much hope does it give you that half of doctors do not strongly disagree that cost of medication is only an issue if it is coming directly out of a patient’s pocket? I imagine it gives pharmaceutical companies a great deal. They note that 70% support continuity of care (a good thing, why not?) but add that it is “…another reform not proven to reduce costs or reengineer the system,” losing sight of the fact that those are not the only two goals; providing better care to people is another!

Physicians often don’t want to do the hard work of having to make difficult decisions of what is the best treatment for individuals even considering risk/benefit to the individual, not to mention harder to measure (and more controversial) work of balancing of benefit to the individual vs. the whole society. It is much easier for someone else to make those decisions, allowing you to be free to criticize them and tell your patients “it’s not my fault”. But it is disingenuous. With authority comes responsibility. If physicians want to continue to have significant autonomy in the decisions that they make, they need to take on responsibility for the impact. Saying “I just made this decision because it was best for my patient and I can’t be responsible for overall health costs” is a little like saying that the candy bar wrapper you just chucked out the window of your car isn’t responsible for the garbage all over our roads. More important, and concerning, is the finding that there is little sense of responsibility for choosing the right treatment – not the newest, or most expensive – for the individual.

In a recent JAMA “Viewpoint”, the same issue is addressed by Christopher Moriates and colleagues in “First, Do No (Financial) Harm”[1]. They argue that, in this context, physicians have 4 responsibilities. The first two are innovative and good ideas:

·         Screen for financial harm, i.e., what will it cost this person out of pocket and can they afford it?;

·         Adopt a universal approach, i.e., do with everyone. As with HIV screening, or asking about risk behaviors, don’t assume you can “tell” who is at risk; doing it with everyone means those you ask are not being “singled out”;

The last two are less innovative but equally important, and address what I have discussed above:

·         Understand financial ramifications and value of recommendations, and

·         Optimize care plans for individual patients.

The authors provide a nice “box” showing how this might work for the problem of back pain.

Actually, if one looks at past health reforms, physicians as a group have never been in the lead. AMA shot down both President Truman’s national health insurance proposal and strongly opposed Medicare and in 1965. Change is hard, and it is particularly hard when there is good chance that change will not be beneficial for your pocketbook. But change is necessary. Not necessarily in, or only in, the areas that Ezekiel and Steinmetz focus on (reducing costs and “re-engineering the system”) but certainly in ensuring money is not wasted, quality of care is high, people have trust in their providers, and that the ethical principle of justice – that EVERYONE with the same conditions has access to the same diagnostic and treatment options – is adhered to.

We certainly don’t have the latter, and it is perhaps the most important. People --  doctors, patients and others -- cannot let that concern be lost as we “re-engineer”.

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[1] Moriates C, Shah NT, Arora VM, “First, Do No (Financial) Harm”, JAMA. 2013;310(6):577-578. doi:10.1001/jama.2013.7516.

Status Syndrome: an important determinant of health

This is a guest post by Linda French, MD, who is Chair of the Department of Family Medicine at the University of Toledo School of Medicine.

In a recent blog (Keeping immigrants and all of us healthy is a social task), May 19, 2013), my good friend Josh Freeman wrote about the social determinants of health. When I commented that arguably the most important determinant was missing from his list he suggested that I write this book review blog as his guest. While I had long ago read quite a few papers on the topic of social determinants of health and health disparities that addressed the material that Josh covered in his blog, for me it was an eye-opening experience to read a book a few years ago by Michael Marmot (2004), The Status Syndrome: How Social Standing Affects Our Health and Longevity[1]. I found Professor Marmot’s explanations to provide a unifying idea that resonated with me.

Everyone knows that wealthier people are on average healthier than poorer people. However, it doesn’t follow that wealthier countries, including the United State (US), are necessarily healthier than poorer countries. For example, three countries that I am rather familiar with, Chile, Costa Rica, and Cuba, have life expectancies and other population health statistics that are as good or better than ours despite huge differences in average wealth.

Professor Marmot’s thesis is that, after a minimal threshold, it is not so much absolute differences in material means that makes wealthier people healthier, but rather their perceptions of their social status within their reference group. To quote him,

“The remarkable finding is that among all of these people [i.e. the groups he studied], the higher the status in the pecking order, the healthier they are likely to be. In other words, health follows a social gradient. I call this the status syndrome.”

Professor Marmot is a British physician and epidemiologist from University College, London. His book carefully presents the evidence that it is the psychological experience of how much control you believe you have and your opportunities for full participation in society that is at the heart of social determinants of health.  He presents evidence from many countries and comparisons between them, and evidence related to individuals within different types of social hierarchies, and finally ends with evidence that countries with less inequality are healthier than those with more.

One example that he discusses in detail is that British office workers at the bottom of the office hierarchy have a higher risk of heart attacks than senior managers at the top, while just a generation ago popular wisdom was that highly successful “type A” personality people in stressful jobs were more prone to coronary artery disease.

Before reading his book I had seen some documentaries on primates that suggested that lower status animals had poorer health and reproductive outcomes and shorter lives on average compared with high status animals that was relatively unrelated to sufficient access to resources such as food. In addition I lived for a number of years in Chile as a young adult; my middle class income by Chilean standards was dire poverty by US standards. I was an American expatriate, a status  that was highly regarded in Chile, and also during some of those years I was a medical student. Despite the fact that I was really poor by US standards I was happy and healthy and my children also seemed as happy and healthy as US kids. After returning to the US I read some papers that included data to show that the generation of newly arrived Hispanic immigrants enjoy relatively good health outcomes, which deteriorate in subsequent generations despite the fact that the families have acquired more material wealth in absolute terms. No good explanations were included for the findings in those papers. After reading The Status Syndrome it made sense to me. The initial immigrants were probably using their country of origin as the social reference and subsequent generations had a US social frame of reference. I concluded that minority groups in this country have health disparities in large part due to the experiences of inequality and discrimination relatively more than due to absolute access to material means or even specific services - including health services.

In the latter part of his book Professor Marmot demonstrates that the countries with the best health statistics in the world are those that are both relatively wealthy and more equal. Examples of such countries are Sweden and Japan. On the other hand, countries at the other end of the spectrum present a reaffirming contrast. He spends the latter part of the book arguing for a political agenda in favor of reduction in social inequality.

If you haven’t figured it out by now, I highly recommend this book. It will transform how you think about the social determinants of health.

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[1] Marmot, Michael. The Status Syndrome: How Social Standing Affects Our Health and Longevity. Owl Books. Henry Holt and Company. New York. 2004.

Insufficient outrage: is health care about helping people or enriching providers?

The NY Times has been running a series of articles on the cost of health care, which presumably have engendered anger and frustration in many, if not most, readers. I discussed one of them,  “The $2.7 Trillion medical bill”, on Jul 28, 2013 (The high cost of US health care: it's not the colonoscopies, it's the profit). It used colonoscopies as an example of why we have such high health-care costs. A more recent piece on the cost of delivering a baby, Paying Till It Hurts: American Way of Birth, Costliest in the World (July 1, 2013) documents the cost of that procedure. Many letters followed, most irate and some discussing the conundrums; for example, our expectation of every birth and baby being perfect, backed up by the threat of lawsuits, requires the presence – and frequently deployment – of enormously high-tech resources for every normal delivery.

One particularly articulate and irate response came in an Op-Ed by H. Gilbert Welch, a professor of medicine at the Dartmouth Institute for Health Policy and Clinical Practice, “Diagnosis: Insufficient Outrage”, published July 4, 2013. Welch states that he is “…not talking about a violation of federal or state statutes, like Medicare or Medicaid fraud, although crime in that sense definitely exists. I’m talking instead about the violation of an ethical standard, of the very “calling” of medicine.” He goes on to carefully describe both the incredible increase in prices for medical care and the excess use of the procedures that cost the most. He adds that the prices are only partially felt by the end-user (people) because Medicare, Medicaid and commercial insurers pay far lower amounts than the posted prices, but that the portion paid by people is going up, and of course the uninsured are charged full price. He notes that “They are largely young and employed (albeit poorly) and have little education,” although in fact many are older, and unemployed (remember Medicaid insures only poor people, but far from all poor people).

His description of the huge prices ($108 for a $5 tube of ointment, etc.) has become familiar, and is reminiscent of the $100 hammers bought by the Defense Department several decades ago. Less familiar, but at least as scary, is the increase he describes in charges that come solely from the purchase of physician practices by hospitals, which allows them to charge the higher fees that Medicare allows hospitals, called facility fees. In one place where this was done, the amount paid by Medicare for an electrocardiogram went up from $200 to $471, and for a colonoscopy from $2000 to $8000, in one year for the same procedure in the same location.

Welch says that “The word ‘crime’ is awfully strong. Many prefer to call all this a problem of perverse incentives: good people, working in a bad system,” but it is pretty clear that he has not convinced himself, not to mention me. And yet, I know the pressures that physicians and hospitals are under to make more money. After all, hospitals are run by businessmen, and buying up all those physician practices and having to pay the doctors does not come cheap, especially when insurers, particularly Medicare, are focusing on saving money by reducing their reimbursements.  It is a fascinating, if not encouraging, situation, where I can read all these exposes of medical excesses and then go back to work and hear from our own hospital leaders what strategies that they are going to need to employ to continue to make money in a challenging and competitive environment.

Welch says that “Medical care is intended to help people, not enrich providers.” I agree, and maybe you do too, but there is an enormous industry built around medical care and lots of providers (doctors and hospitals and owners of various for-profit facilities, not to mention the pharmaceutical and device industries, and insurance companies) who are indeed getting very rich. And many of them are running very scared that their riches will decrease. If we want a medical care system that is indeed intended to help people rather than enrich providers, there needs to be a major change in the way that it is paid for. We need to devise a system that encourages the provision of high-quality, appropriate care to everyone who needs it. And does not provide unnecessary or potentially harmful care to anyone. And is not so complicated that it encourages work-arounds to cherry-pick profitable patients or do more profitable procedures.

For starters, we need to have one payer, a single payer for everyone so no people are “more desirable” or “less desirable” based upon their insurance coverage (or lack thereof). That system needs to have a component (not the RUC, see Changes in the RUC: None.. How come we let a bunch of self-interested doctors decide what they get paid?, July 21, 2013) that evaluates what a reasonable cost is for that care, including a reasonable profit margin for the provider. It needs to have a component that evaluates new technologies to assess whether they offer benefit over existing diagnostic and treatment modalities, and to whom, and to not encourage over-proliferation of expensive technologies (such as the proton-beam accelerators Welch describes) because  “if we don’t have one, they’ll go to the other guys”. Incredibly expensive technologies, such as proton-beam accelerators, should be purchased by the single payer system, regionally administered, and available to everyone. 

The profit-making competitive marketplace works for many goods and services. It has no place in our health care.  

Why poor people choose ERs: we need a system designed to meet everyone’s needs

“Understanding Why Patients Of Low Socioeconomic Status Prefer Hospitals Over Ambulatory Care”[1], by Shreya Kangovi and her colleagues in the July, 2013 issue of Health Affairs, tries to help us answer that question in order, presumably, to help re-design ambulatory care in order to change that preference. A general assumption of health policy is that use of hospital emergency rooms for “routine care” is expensive, inappropriate, provides worse patient outcomes, distracts emergency room staff from caring for the true emergencies that they are presumably there for, and is a significant cause of the overall high health care spending in the US. Although the whole article is available on-line only to Health Affairs subscribers, a summary is presented on the Robert Wood Johnson Foundation (RJWF) website, because Dr. Kangovi was an RJWF Clinical Scholar.

The authors conducted a qualitative study interviewing 64 people who frequently used the emergency room as their source of medical care, using trained community members to engender greater trust on the part of the patients, mostly lower income African-Americans, to conduct the interviews, in two hospitals in the Philadelphia area.  “Study respondents (both the insured and uninsured) explained that they consciously chose the ER because the care was cheaper, the quality of care was seemingly better, transportation options were more readily accessible, and, in some cases, the hospital offered more respite than a physician’s office.”

These findings should be surprising to many students of public policy, but they were the legitimate perspectives of the people who were using these services, those Kangovi correctly notes, whose “…voices are seldom heard in policy discussions.”  Understanding their concerns is critical, not because they are always “right”, or represent everyone, but because those concerns reflect their experiences, and the degree to which our current strategies are not working, and the degree to which our future strategies are unlikely to work if they do not take into consideration these issues. Three themes generated by the researchers, with supporting quotes from the folks who were interviewed:

• Convenience. “You must call on the same day to set up a [primary] care appointment … whenever they can fit you in.” This open-access scheduling resulted in people taking days off from work and still being unable to see a doctor. It also made it impossible for many to access transportation covered by Medicaid because the transport arrangements had to made 72 hours in advance. Late hospital hours also made care more available.  
• Cost. “I don’t have a co-pay in the ER, but my primary [physician] may send me to two or three specialists and sometimes there is a co-pay for them. Plus there’s time off from work to go to several appointments.”
• Quality. “The [primary care doctor] never treated me or my husband aggressively to get blood pressure under control. I went to the hospital and they had it under control in four days. The [physician] had three years.”

Any health care provider who has worked in an ER or in ambulatory care can validate these concerns, and also respond to them. The most obvious is Cost. Obviously care in an ER is not free; indeed the cost is a major driver of efforts to get people to not use it. But the patient, at the time of service, doesn’t have to put down cash, put down a co-payment, put down real money now. There will be a bill, but that will be something that goes on their (likely existing and mounting) debt burden.

Convenience is, perhaps, a poor choice of words; it suggests something purely volitional, as if people were choosing to have their hair done during the day rather than go to the doctor. Convenience in the way that a middle class person understands it is not what these folks are talking about. They may not have a car or a family member with one (or perhaps it is being used by a family member to get to work), public transportation may be unavailable, unreliable or inaccessible to them given their medical problems, and if they have jobs, they are often not those that just allow you to take a sick day to go to the doctor, but mean they lose pay. Despite efforts to have “extended hours”, most ambulatory care offices are open mainly during regular business hours, during the day weekdays, when the folks who work there want to work, not when it is necessarily most “convenient” for patients. Let’s get this straight, it is not “convenient” to wait 6 hours in an ER to be seen; if this is better than the alternative, the alternative is seriously flawed!

Quality is another issue, and the quotation chosen is very open to criticism. The hospital had 4 days of complete control of the person’s life, giving them their medicines and minimizing any external issues, while the doctor had 3 years in which the person was responsible for taking their medicine, choosing their diet, and deciding where to rank health among the many competing priorities in their lives. As any of us who have worked in medicine know, the control that was achieved in the hospital may well evaporate once someone is back in their regular environment.

Really, this is largely an issue of money, of resources. The authors emphasize that not all the patients were uninsured, but those who had insurance almost all had Medicaid. Not only is Medicaid not equivalent to private insurance (it pays less and lots of doctors do not take it) but it is only available to really poor people. People who are poor enough to have Medicaid have all those issues listed above under “Convenience” and “Cost” that go beyond the direct cost of medical care, but inform every decision that they make in their lives.

Policy is made, in almost every area, by the “haves”, those with money and political power. At the rawest, it is a blatant example of “let’s do for us, and screw those without power”, as for example the farm bill that cuts food stamps for the neediest while continuing support for giant agribusiness (well discussed by Paul Krugman in  “Hunger Games, USA”, NY Times July , 2013[2]). More subtly, and with much less intentionality, not to mention hostility, it is made from the perspective of people who have a lot, who cannot even imagine the lives, decisions, and trade-offs made every day by “have-nots”. The “haves” may identify a lot that is wrong with the health care system, but they do not even think of things like not having transportation, or not being able to take off from work to go to clinics open during working hours, or not having childcare. They are not mean people, but they do not see.

In her comments, Kangovi looks at plans to develop Accountable Care Organizations (ACOs). “Our findings suggest that these efforts could backfire by making hospitals even more attractive to these patients. We also debunk the notion that people from these groups abuse the emergency room for no reason and need to be taught how to use it properly.”  The real issue is that there are not the financial incentives to provide high-quality care that is accessible in terms of both cost and the other obstacles people face (e.g., transportation, childcare, office hours). The financial incentives are to try to avoid these patients all together, keep them out of the ER, keep them out of your office; to develop “Patient-Centered Medical Homes” that are centered around the kinds of patients you want to have, and not those you would rather not have show up (and go to the ER!).

We need a system that, first of all, ensures that taking care of everyone is (at least financially) desirable. That means a system in which everyone has the same insurance coverage (a single-payer system), and one that is designed to pay more when providing care for people with greater needs, both medical and social. We need a wrap-around system that enables the most needy to have access to the transportation, childcare and other issues that they need to be able to utilize their medical coverage, and to the education, jobs, food, and housing that they need to be able to have a reasonable chance at health. We don’t need a patchwork system of “good ideas” that do not, in themselves or together, create a real safety net for people.

If we have one that is so full of holes that gaming it for profit is the main activity of hospitals, doctors, and other providers, we have no reason to be critical of the least powerful finding the ways around it that work best for them.

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[1] Kangovi S, et al., “Understanding Why Patients Of Low Socioeconomic Status Prefer Hospitals Over Ambulatory Care” , Health Aff July 2013   vol. 32  no. 7  1196-1203; doi: 10.1377/hlthaff.2012.0825  

[2] Krugman indicates the logic “…goes something like this: ‘You’re personally free to help the poor. But the government has no right to take people’s money’ — frequently, at this point, they add the words ‘at the point of a gun” — “and force them to give it to the poor.’  It is, however, apparently perfectly O.K. to take people’s money at the point of a gun and force them to give it to agribusinesses and the wealthy.”