ACA benefit programs: will state to state variation be good or bad?

With the passage of the Affordable Care Act (ACA) a larger portion of Americans will be getting health care coverage. For some, such as young adults who can now be kept on their parents’ insurance until 26 (provided their parents have insurance that covers family members!), there has already been benefit. As the 2014 roll-out of the most significant benefits gets closer, there is a lot of focus on the details, including the flexibility given to states to determine the benefits package that companies will have to offer, and whether it will be good or bad.

Writing in the New England Journal of Medicine, Alan Weil, MPP JD (“The value of federalism in providing essential health benefits”)^[1], provides a positive slant on the “federalist” approach to ACA roll-out, in which individual states will have flexibility in choosing which of 10 plans for providing “essential health benefit” (EHBs) they will use. While there are 10 EHBs that must be included, and the state insurance exchanges’ benefits must be based on a “typical insurance plan”, states will have considerable latitude in determining both what is “typical” and what scope to offer for these services; in addition, states will decide whether these plans need to cover benefits beyond those 10, and which they will be. Weil sees this as a good thing, citing the “states as a laboratory for good policy” in the sense that there will be different approaches. He cites 3 benefits: 1) different states, trying different approaches, will see which work “best” in the real world. For example, a single decision made by the federal government on what benefit package to offer (seen as the alternative) would, perhaps, cover treatments that turn out to not be of real benefit to people (he cites autologous bone marrow transplantation as an example of a treatment that was widely covered before it was found to be ineffective); 2) the “typical insurance plan” mandate would make people “have a plan similar to what their neighbors already have”; and 3) it would be consistent with local values. This last is somewhat problematic, since states are hardly very “local”, and have proven themselves to be very willing to enact policies that punish minority points of view (or even majorities, since much power resides, as at the federal level, with those constituencies with the most resources).

In the same issue of NEJM, Jennifer Prah Ruger PhD, writes “Fair enough? Inviting inequities in state health benefits”[2]. She makes many points about potential lack of equity in treatment that are not only possible, but are likely to result from allowing such state-to-state variation. The fact that Weil feels he has already dispensed with the “equity” argument: “The most common, but least convincing, argument against the secretary's federalist approach has to do with equity. It is a truism that state flexibility will yield differences within the country and that those differences cannot be defended on the basis of differing basic human needs for health care services. But those inequities must be viewed in context…” does not make such criticism illegitimate. In fact, Weil is making Prah Ruger’s point, that individuals will suffer negative health consequences because they live in one state rather than another. He sees this as acceptable; she does not. The strongest point that Weil makes is that a single national decision on a benefits package may yield a bad one; Prah Ruger argues that at least it would be consistent. I tend to agree more with her. While some states may have more generous benefits (and even better, since “more generous” is not always better if it provides access to ineffective or harmful services), many – and probably more -- will offer less than a federal program would. The current Medicaid program is a good example of how widely disparate benefits packages can be between states and how much people can suffer from a lack of benefit.

The most important point that Prah Ruger makes derives, interestingly, from Aristotle, the principles of horizontal and vertical equity. Vertical equity means that people with different sets of needs receive different quantity and quality of services (she uses the example of the difference between the treatment needed by people with conjunctivitis and glaucoma to restore “normal ocular function”; perhaps a better one would be between those with myopia and glaucoma). Horizontal equity would require that different people with the same needs have the same treatment options available. She makes clear that such principles do not require that everyone get the same benefits or the same outcomes, but that the principle of proportionality should apply, “…that similar cases should be treated similarly and different cases differently, in proportion to their differences.”

Vertical equity, in which everyone gets the same services whether they need them or not, obviously does not make sense. While the same services should be available to everyone when they need them, whether employed by ACA, a national health insurance system, or private insurance companies, it does not make sense to offer the wrong services to people when they are more expensive, nor is it reasonable to offer inadequate services because they are less effective. Understanding the relative cost and benefit of services to different people in different sets of circumstances is critical to both containing cost and increasing quality. A very interesting “Viewpoint” on this issue is offered by Robert H. Brook, MD ScD in JAMA (“Do physicians need a ‘shopping cart’ for health care services?”^[3]). He describes the on-line shopping most of us are familiar with, which gives us the cost of the items that we are interesting in purchasing, offers us both alternatives and other options that “people who bought this item might be interested in”, and tabulates what we have ordered in our shopping cart. And gives us at least two opportunities to not order, by asking us to confirm our intention. He does not argue that physicians should always order cheaper tests or therapies, but by knowing what the “basket of services” they are ordering for patients would cost, both for the patient and the insurer (“For example, if the insurance company paid the pharmacy $80 and the patient paid $8, the cost of this service is $88,”), they would have a better sense of what was of most value.

Horizontal equity, however, is really the most important issue. The absence of this characteristic is the fatal flaw in our current “system” and is likely to continue even with ACA. It means that everyone doesn’t get the most appropriate therapy for their condition, but rather that some people do not get enough, while others may get too much and even suffer ill effects as a result. Despite scare stories about rationing, the fact is that we have always had rationing, but it has been on the basis of the resources (mainly financial) a person has rather than on the basis of need. The problem with having different options in different states is that it will be the most disenfranchised who lose out in the states with meaner benefit packages, while those with resources will be able to access care.

Making the right care available to all the people who need it is the only reasonable goal for a health system. The rest is distraction.

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[1] Weil A, The value of federalism in defining essential health benefits.,N Engl J Med. 2012 Feb 23;366(8):679-81

[2] Ruger JP, Fair enough? Inviting inequities in state health benefits.,N Engl J Med. 2012 Feb 23;366(8):681-3

[3] Brook RH, Do physicians need a "shopping cart" for health care services? JAMA. 2012 Feb 22;307(8):791-2.

Latinos and health care in Kansas City, Kansas

Kansas City, Kansas, where I live, makes up the bulk of Wyandotte County. It is the poorest county in Kansas, with a large number of low-income residents of all ethnicities, and stands in many ways in stark contrast to Johnson County to its south, Kansas’ richest county. It is not as poor or depressed as Camden, NJ (see February 18, 2012 blog, Camden and you: the cost of health care to communities); while it has lost many blue-collar industrial jobs, a large number still remain in its Fairfax industrial district (including a GM plant) and along the two enormous trainyards in town. Many of the workers in those plants no longer live in KCK (as the city is known to distinguish it from KCMO). It is seen as a regional “success story” because of the development in the western part of the county around the NASCAR track (and now including a huge mall with Cabela’s, Nebraska Furniture Mart, and a new professional soccer stadium). However, all occurred with tax abatements from the county, so people’s property tax assessments are very high because the value of the real estate is low.

KCK was incorporated early in the 20^th century, combining a number of independent towns, most based around a primary industry, and sometimes even named for it (Argentine, home of a silver smelter, and Armourdale, where there was a meat-packing plant). Much of its history – and present – is determined by its border with Missouri; even today, living in this metropolitan area is greatly affected by being in two states. The Missouri River divides Missouri and Kansas south to Kansas City, where it turns east toward St. Louis, and most of the border between the two states is a two lane street. Quindaro, in the northeast part of the city, is on the Missouri River; it was settled by African-American slaves who crossed the river from Parkville, MO, and, after being dragged south by the current, coming out in the free state of Kansas. Quindaro was a major underground railroad center, and the ruins of the original settlement are now an archeological site, with a statue of John Brown on what was the campus of Western University. The current Quindaro neighborhood is overwhelmingly Black and poor.

Latinos, mostly from Mexico, arrived in 3 waves. The first came to help build the railroads that have been so central to KCK, the second to work in the silver smelter, and the most recent, as in so many US cities over the last 10-20 years, looking for any kind of jobs. 70% of the population increase in Kansas from 2000 to 2010 was Latino; while there are other concentrations, especially in southwest Kansas where there are meatpacking plants and the first majority-minority counties in the state, KCK is definitely a center for Mexican-Americans. The new Latino population is overflowing the boundaries of the traditional Hispanic community, the Argentine (a little confusing, as it is named for silver, not the country of origin of its Spanish-speaking majority), to cover much of the city. A huge mural portrays the history of Argentine, including the migrations of blacks and Latinos and the “clash of cultures” seen in the segment reproduced here.

The Latino community of KCK, like others, suffers the health problems associated with poverty, with young families, and with chronic diseases. The youth of this population means that pregnancy and childbirth, and well-child care, are a dominant health need. Diabetes is very common in the community. And many people do not have good health care access. Most of the industries in town are small, and do not offer health insurance, or offer it with very high premiums, copayments and deductibles. At a time when the National Business Group for Health, representing mostly Fortune 500 companies whose employees have the best health insurance, is predicting big increases in employee premiums, copayments, and deductibles, workers at small companies will be harder hit. And, of course, a large portion of Latino workers are undocumented, and thus ineligible for insurance, although most pay taxes. Even their children, who should be eligible for Medicaid or SCHIP, often do not have coverage because their parents are afraid to enroll them. This is not an idle worry in a state whose legislature is trying to deny in-state tuition at its public universities to students who are legal citizens and residents, often born here, but whose parents are undocumented.

As the poorest county in Kansas, Wyandotte County also has the poorest health status in rankings of Kansas’ 105 counties by the Kansas Health Institute in 2009. In national health rankings by the Robert Wood Johnson Foundation in 2011, Wyandotte County came in at 95 – because there was no data for 10 of the state’s smaller counties. As recently as February, 2012, the Community Dashboard published by Kansas Health Matters, continues, unsurprisingly, to show major health challenges. These go far beyond access to medical care to include the entire gamut of the social determinants of health. Access to preventive care and to early diagnosis and treatment of disease is important, but so is having a place to live. And enough heat in the winter. And enough food to eat. And a safe neighborhood, and safe housing. Often providers decry patients missing their appointments; a recent home visit by a health worker found the steps to be so rotten in front of the house of one such patient that it was lucky they didn’t try to come in – they likely would have fallen and broken their hip.

But access to medical care is an important component of health, and it is limited for residents of KCK. Being in Kansas, there are no publicly funded hospitals (there is one across the state line in Kansas City, MO); there are no publicly funded clinics (as there are in San Antonio, TX, where I used to live). There is no state, county, or municipal funding to provide health care to the uninsured and underserved, not in Wyandotte County or even in the very wealthy (but still with a large number of poor, including Latino poor, residents) Johnson County.  The Affordable Care Act (ACA) promises to increase the number of Americans with insurance, and will make a large difference for many, but will be far from a solution to the issues confronting Latinos in KCK.

First, of course, undocumented people will still not be covered. Then, much of the increase in coverage for the poor will be in the form of expanded Medicaid eligibility, largely funded by the federal government, in 2014. Of course, this depends on finding providers who will accept Medicaid rates.  Many of the Latino and other workers in KCK work for companies too small to be required to provide coverage. People who are not Medicaid eligible or undocumented may be offered the opportunity to purchase insurance, or required to if the “individual mandate” is ruled legal by the Supreme Court, but are not likely to be able to afford quality coverage. We read a lot about “quality of care”, but “quality of coverage” is also important – not all insurance is the same. There are often high premiums, co-payments, and deductibles and also low maximal coverage limits. ACA will help to some degree, but many of our people will be left out in the cold.

KCK has a number of “safety net” clinics, if no publicly funded ones. There are a couple of branches of a Missouri-based Federally-Qualified Health Center (FQHC), but these depend on the higher reimbursement they receive from Medicare and Medicaid; recently the one in the Quindaro moved several miles further west, to a neighborhood with more of these government-insured patients. This was better for their business plan than staying in a neighborhood full of uninsured people, but it left Northeast KCK with no doctors. Luckily, another safety-net, which doesn’t get increased Medicare/Medicaid reimbursement and depends on both grants and paying everyone (including the doctors) $14/h, opened a branch in the community. So, at least, there are community organizations, like these clinics, and the student-run free clinic, and Latino community service agencies, to help. But the need is far greater.

And, of course, like elsewhere, there are not enough primary care providers, especially with the new people to be covered under ACA. This is documented in a recent Washington Post piece “Success of health reform hinges on hiring 30,000 primary care doctors by 2015”. Of course, to “hire” them, they have to exist. Which means training them. Which means paying them enough, compared to other specialists, that medical students choose to enter them.

The health problems faced by Latinos in Kansas City, KS, are not unique. But they are serious. And they demand serious solutions, to be confronted by the city, county and state as well as the federal government and insurance companies. And that is yet to happen.

Camden and you: the cost of health care to communities

Dr. Jeffrey Brenner, Executive Director of the Camden (NJ) Coalition of Healthcare Providers, spoke at the recent Society of Teachers of Family Medicine (STFM) Medical Student Education conference, on “Bending the Cost Curve and Improving Quality in One of America’s Poorest Cities” (powerpoint available at the Family Medicine Digital Resource Library, www.fmdrl.org). His work first came to major national attention about a year ago with the publication of the New Yorker article “The Hot Spotters” by Dr. Atul Gawande (January 24, 2011). This article discussed how Dr. Brenner and colleagues had used mapping techniques to identify where the largest number, and highest cost, utilizers of health care services in Camden lived, and developed programs to try to address their needs. These programs both improved their health and lowered the cost of care. This is not magic or simple; it requires hard work and results can be slow, but they do make a difference. 

Dr. Brenner’s talk had two major sections. The first dealt with both the high cost of care in the US and the bizarre way that the money spent on care is allocated. One component is the huge regional disparity in the cost of care that is not explained by the overall cost of living. This topic is the subject of an earlier Gawande New Yorker piece, “The Cost Conundrum” (June 1, 2009), which focuses on the enormous difference in per capita Medicare expenditures in two similar Texas communities on the Mexican border: McAllen (one of the highest cost) and El Paso (one of the lowest). Brenner and Camden are in New Jersey, the state with the highest per capita expenditure in the nation, especially in the last 2 years of life (see his slide #5). Beyond the regional variation in health costs is the enormous disparity in what kinds of care Medicare, Medicaid, and other insurers pay for. They pay for procedures, but not for preventive care. Hospital emergency care is paid for, primary care is not. Early diagnosis and intervention that can make a difference both to people, in terms of the quality of their lives, and to the system, in terms of preventing future high costs are not paid for. Those later high-cost interventions, which former head of the Center for Medicare and Medicaid Services (CMS), Donald Berwick, MD, refers to as “rescue care” (see interview in the film “Money-driven medicine: the real reason health care costs so much”, also discussed by Bill Moyers August 28, 2009), of course are. That is, the US health system excels, rather than in primary and preventive care. This model is also illustrated in cartoon form by Camara Phyllis Jones, MD, of the Centers for Disease Control, in “Social Determinants of Health and Equity, the Impacts of Racism on Health”, which I have previous cited (Social Determinants, Personal Responsibility, and Health System Outcomes, September 12, 2010).

 Jeff Brenner had a solo practice in Camden (slide #2), but despite being willing to work for very little, cuts to Medicaid reimbursement made it impossible for him to continue to run the business and stay In practice. But, while reimbursement to primary care providers like him are cut, the cost of late-stage care is driving our national debt, with expenditures on health care rising as Social Security and other obligations are relatively static (see graphic).

The other part of Dr. Brenner’s talk dealt with conditions in Camden, a destitute, end-of-the-road, best-days-are-far-behind, city of just under 80,000 across the Delaware River from Philadelphia, and the programs that have been developed to begin to help the people who live there. Brenner and his colleagues were able to pinpoint two buildings where the highest utilization of services, and thus cost, was located. Gawande states “…that between January of 2002 and June of 2008 some nine hundred people in the two buildings accounted for more than four thousand hospital visits and about two hundred million dollars in health-care bills. One patient had three hundred and twenty-four admissions in five years. The most expensive patient cost insurers $3.5 million.” But Dr. Brenner’s main point is that these patients did not see value for this cost. When he later helped to organize the residents of one of these two sites, the Northgate II apartment complex (slide #13), the residents could not believe that this much money had been spent on them. They felt that they were not even able to see a doctor when they were sick, not to mention get preventive care and management of their health conditions. For a tiny fraction of this money, Brenner and his colleagues were able to start a small clinic in the building, staffed by a nurse practitioner, to deliver primary care to its residents. They set up a broad-based coalition, staring with area churches, to help develop a systematic response (slides 15-20). They even managed to get legislation in New Jersey to establish a demonstration project for Medicaid accountable care (slide 21).

The work done by Dr. Brenner and others is beginning to be replicated in other cities in New Jersey (Atlantic City, also discussed by Gawande, and more recently Newark) and across the country. The Camden collaborative is part of a national coalition of community groups, predominantly faith-based, called PICO that is working in cities across the country to address many of the same needs that people have wherever they live. They are beginning to recognize that the way money is spent in the US health care system is perverse and backward, rewarding providers for high-cost interventions rather than for keeping people as health as possible. Just as the residents of Northgate II could not believe that tens of millions of dollars had been spent on their healthcare when it felt to them as if they had such limited access, people around the nation are realizing the same thing.

People live in communities where there are no jobs for those who are capable of work, and where the rest of society puts its (literally) most toxic contamination further adding to their health stressors (portrayed by Brenner in slides not on line). They live in communities that are often “food deserts” without access to healthful nutrition. Their neighborhoods are not safe, both in terms of crime and in terms of toxic waste. Their homes are often inadequate, and they may not have heat in the winter. When they do develop chronic disease, there is no primary care in their community (see what happened to Dr. Brenner’s practice) and sometimes they cannot even get downstairs because the elevator is broken and their untreated chronic conditions make it impossible to walk down stairs. Their basic social structure is often disrupted to non-existent. They do not have to core survival needs of life met, and they do not have reasonable access to basic health care, but when they do make it to the emergency room, millions of dollars of medical care is provided. The fact is that we patch holes in people’s lives and communities with dollars spent on medical care. Think of the irony here: to us, to our country, and most painfully to these people.

And things are not as bad for the economically better off, for the working and middle class, for folks who do not live in Camden or similar communities, it is still not so good. We are all part of a health care system in which providers game the system to do the services that make the most money by delivering them to the best insured. We are part of a health care system that emphasizes expensive “rescue care” rather than primary care; that emphasizes medical care rather than the basic social needs people have that will move them farther from the “edge of the cliff” (as depicted by the CDC’s Dr. Camara Phyllis Jones in “Social Determinants of Health and Equity, the Impacts of Racism on Health”, discussed in my blog Social Determinants, Personal Responsibility, and Health System Outcomes, September 12, 2010).

Of course, while Jeff Brenner and others are mostly concerned with improving the lives and health of people, the amazing thing is that this can be done by lowering costs. Of course, costs to one part of the system are profits to another, so those profiting from the current arrangement are predictably resisting change. But this opportunity, to spend less overall to improve health, is one we cannot afford – in financial or human terms – to pass up.

The high cost of drugs: treating cancer and cholesterol while building profit

The cost of drugs can be enormous, as anyone who is on many of them, or even one expensive one, can tell you. For most people with good health insurance, the amount that they pay is only a portion of the cost (as with much of health care); still, the co-payments for some drugs, particularly non-generics, can be high enough to be significant for even upper-middle-class people. Lower income people may have to choose between medication and other frivolities – like food. For very high cost drugs, like many of those made artificially by “recombinant DNA” that are used for conditions including cancers, autoimmune diseases like rheumatoid arthritis, neurologic conditions like multiple sclerosis, and inflammatory bowel disease like Crohn’s, the cost is enormous.

The high cost of cancer drugs, in particular, is the foundation of several industries. The most obvious, of course, are the drug companies who manufacture them, and make great profits. The markup price that health insurers (including Medicare) pay for the administration of these drugs, however, is a major source of revenue for hospitals and the doctors who supervise their administration. The staggering growth of “cancer centers” in almost every hospital that can put one together is testimony to this. Most hospitals pursue certain “product lines” (sorry if it offends you to be a widget in a product line) that they see as the most profitable. Yes, medical need is one component; there has to be demand. Clearly cancer, and heart disease are very common and very serious for the people who have them, as well as being high-profit product lines. If less common, diseases that can be treated by neurosurgery are also serious. Indeed, even some neurological conditions that have not been historically treated by surgery, such as stroke, are becoming profit centers when procedural intervention (by, “interventional radiologists”) can be used to treat them. But there are lots of conditions which are also common and serious and are not among the “product lines” hospitals often develop because they are not “profit lines”; obstetrics and psychiatry and pediatrics come to mind (although neonatal intensive care and pediatric cancer treatment, as well as certain types of high-intervention obstetrics, are exceptions).

It is that cancer-drug markup that makes treating cancer profitable. Anecdote: a relatively high-income colleague received the bill for her first set of breast cancer chemotherapy. $30,000. Her husband hid it for several months. (“That’s not so bad,” she was told by a staff member, “we recently had an uninsured woman get a bill for $45,000.” Didn’t make her feel a lot better.) After that initial event, her copayments for treatment were on the order of $600 a month. Because she had good insurance. And she could afford it. Not without some pain, you understand, but much more than someone in one of the lower income groups. Or who is uninsured. Sure, she is happy her cancer could be treated. The point is that hospitals invest in – and advertise their expertise in -- treatment for this kind of disease, and not that kind of disease based on the profitability of it, not the seriousness of the disease.

In addition to the hospitals and the pharmaceutical manufacturers, scientists and the universities that they often work for depend on deals with drug manufacturers to bring their discoveries to market. This can be very lucrative for the universities who employ these scientists, as well as (often) the scientists themselves. It is big business. Bad? Not necessarily. Only a small percentage of the compounds being researched lead to profitable drugs, which is one of the main arguments that pharmaceutical companies use for their high prices and profits (they are consistently, and by far, the most profitable industries in the world if we include only those industries that produce something; the financial industry is something else). Of course, by the way, most of the initial research that produces these new drugs is supported by the National Institutes of Health (NIH) -- which would be you, the taxpayer. So most of those compounds are developed and studied at public expense; then only the most promising are bought by drug companies. Yes, many of these don’t become marketable, not to mention blockbuster profit centers, but the yield is much greater than it was before all the publicly-funded research culled them out. Oh, by the way, even though you funded that research, you don’t get a discount on the drugs that finally come to market. Sorry.

Sometimes, of course, there are drugs that are “blockbusters”, and they are not always the most expensive cancer drugs. They are big because they treat (or sometimes are thought to treat) conditions that are very common, so that there are millions of users. These are not as likely to support the development of new hospital product lines (where the profit-per-user has to be very high) but make a lot of money for the manufacturers. In the past these have included anti-anxiety drugs of the benzodiazepine class (eg., Valium ®, Librium ®), non-steroidal anti-inflammatory drugs (NSAIDs) for arthritis pain (including a few taken off the market for major side effects like Vioxx ®), and most recently “statin” drugs that reduce cholesterol. These drugs not only work for that purpose, they seem to have other beneficial effects in prevention of heart disease, the reasons for which are not entirely understood, so they are very popular. While selling such heavily-used drugs is always profitable, the greatest profit comes in the first decade (or so) when it is under patent and there are no generic competitors.

In a recent Perspective, “Generic atorvastatin and health care costs”,  in the New England Journal of Medicine, Jackevicius and colleagues look at the impact of the costs of statin drugs on health care costs by examining the projected savings on atorvastatin, initially sold as Lipitor®, which became generic this last November.[1] They used the data on the gradual price reduction that followed simvastatin (Zocor®) becoming generic in 2006. There are some differences; atorvastatin is more potent than simvastatin and less likely to cause muscle pain (myopathy), so it may be preferable to many. When neither was generic, Lipitor® had by far the biggest share of the market, but when simvastatin became generic in 2006, it became the biggest seller, with Lipitor® dropping precipitously and brand name Zocor® almost disappearing. Because of its two advantages (greater potency, less myopathy) generic atorvastatin should become the number one statin in the near future. The savings are projected to be enormous: “The overall cost savings from the availability of generic atorvastatin are projected to reach $4.5 billion annually by 2014, equivalent to 23% of total expenditures on statins in that year.”

That’s a lot of money. It is good to be saving it. However, that “saving” means that we have been spending it for the last decade or more. Yes, drug companies deserve to make a profit. Yes, there are investments made that need to be recouped. But this – like, if perhaps not quite so egregious as what we have seen lately in the financial sector – seems to be excessive.

We should not use drugs that harm us or are unnecessary. The question is can we, as individuals or a society, afford to pay so much for the drugs we need in order for their profits to be so high?

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[1] Jackevicius CA, Chou MM, Ross JS, Shah ND, Krumholz HM, “Generic atorvastatin and health care costs”, NEJM 19Jan2012;366(3):201-3.

Komen and Planned Parenthood: The politics of abortion meet the politics of breast cancer

As of this posting it appears that Komen has restored its funding for Planned Parenthood. I thought I would run this post anyway. I think it makes some important points.

As reported in the New York Times on February 1, 2012, “Cancer group halts financing to Planned Parenthood”, the Susan G. Komen Foundation will abruptly end a program that gave about $700,000 to 19 Planned Parenthood (PP) affiliates to fund breast mammograms and ultrasounds for women who cannot afford them. Just to be clear, the Komen Foundation, the world’s largest breast cancer foundation which is famous for its pink ribbons and “Run for the Cure” races, has not changed its position on screening for breast cancer. It just doesn’t want to fund this screeining through Planned Parenthood, which will present a problem for the three-quarters of a million women who have had their mammograms through that organization.

Why? There has been a very long standing relationship between these two organizations committed to women’s health, and this decision seems to be very sudden. According to the Times, “A spokeswoman for the Komen foundation, Leslie Aun, told The Associated Press that the main factor in the decision was a new rule adopted by Komen that prohibits grants to organizations being investigated by local, state or federal authorities. Ms. Aun told The A.P. that Planned Parenthood was therefore disqualified from financing because of an inquiry being conducted by Representative Cliff Stearns, Republican of Florida, who is looking at how Planned Parenthood spends and reports its money.”

On the face of it, this is absurd; any state legislator can do an investigation into any organization for any reason, and they do. Unlike investigations by law enforcement bodies, in which presumably there is at least a reasonable suspicion of illegal activity. It can only be inferred that this “new rule” was specifically instituted to remove funding for PP. And Komen didn’t have to wait for Rep. Stearns; my state of Kansas has been regularly investigating our Planned Parenthood, starting under former Attorney General Phill Kline, who illegally kept subpoenaed records after he left office. When it finally went to trial after several years, the case was decided by a jury in less than 30 minutes, for PP. More recently, the current administration (also, coincidentally, Republican) has tried promulgating new health department rules regulating abortion providers that were absurdly picky, such as the size of janitorial closets. This has also been discarded.

Wait, Planned Parenthood does abortions? Could that be part of the reason? Why yes. Some, but not all, PP affiliates perform abortions. PP provides comprehensive women’s health services, including contraception and education, as well as breast cancer screening. The Times article notes that many have suggested that it is pressure from right-wing anti-abortion groups that has caused this action. For example, “…in December, LifeWay Christian Resources, which is owned by the Southern Baptist Convention, said it was recalling a pink Bible it was selling at Walmart and other stores because a dollar per copy was going to the Komen foundation and the foundation supported Planned Parenthood.” Of course, this is not really a different reason; the reason that Rep. Stearns and AG Kline and others have for investigating PP is because they do abortions.

In further “explanation” (since the original one was so nonsensical), the Komen “…foundation issued a statement saying it was seeking to ‘strengthen our grants program’ and had ‘implemented more stringent eligibility and performance criteria….While it is regrettable when changes in priorities and policies affect any of our grantees, such as a longstanding partner like Planned Parenthood, we must continue to evolve to best meet the needs of the women we serve and most fully advance our mission.” I had to include this last sentence so that I can recommend that you copy it and save it for a time when you need a piece of corporate double-speak jargon that says nothing except “We’re lying here.”

Planned Parenthood affiliates who do offer abortion services see them as part of the continuum of women’s health care. They offer sex education and contraception, but sometimes this fails – or hasn’t been used -- and women seek an abortion, which may be their first contact with PP. And they may then avail themselves of PP’s other services so they do not have another unwanted pregnancy.  Of course, there are many people who are opposed to abortion who support these other missions (contraception and sex education, as well as breast cancer screening). Therefore, PP usually segregates its funds so that only donations that are unrestricted or specifically intended to support abortion services are used for that purpose. However, there are many others, particularly organized “right-to-life” groups, who are not only opposed to abortion, but to the other missions as well.

A rational, data-driven approach would note that the only things that have ever been shown to reduce the abortion rate are comprehensive sex education and easy availability of contraception. This is why the abortion rate in many countries where abortion is legal is lower than in others where it is not – because those same countries provide sex education and contraception. And, of course, they also provide safe abortions so that the women who receive them are much less likely to develop infections, become sterile, or die.

The only way to understand the opposition to contraception and sex education is to recognize that it is really about being opposed to sex. If you hold the view that sex should only occur in marriage, and then only for the purpose of procreation (thus, only heterosexual marriage), and should not be for fun (and maybe should not ever be fun) this starts to make sense. In a bizarre way. Of course, this excepts the many religious and anti-abortion leaders who are involved in active and extramarital sex. They seem to have no problem telling women what to do with their lives, while living their own lives in total hypocrisy. Of course, but these are mostly men, so what do you expect? They don’t get pregnant.

In another big news item in the same issue of the Times, we are informed that rates of second surgery after lumpectomy for breast cancer vary widely by surgeon, from 0% - 70%. (Breast Cancer Surgery Rules Are Called Unclear by Denise Grady reports on Variability in Reexcision Following Breast Conservation Surgery by Lawrence McCahill and colleagues, published in JAMA, February 1, 2012. In doing lumpectomy for breast cancer, there is a cosmetic reason for taking only the least amount of tissue necessary to remove all the cancer. After all, this is the reason that lumpectomy was developed to replace mastectomy. Sometimes, on pathological examination, the “margins” are not “clear”; that is, cancer cells are found microscopically up to or past the border of the excision, and an additional surgery is required to get the rest. The question is whether there are surgeons who regularly seem to do this more often, that is take too little tissue, rather than random variation; the answer seems to be “yes”.

However, the study shows that there seem to be many more surgeons who often do a second surgery even though the margins are clear than there are surgeons who regularly take too little and need to repeat the surgery. This also means that many surgeons who have the former practice may often take too much tissue the first time to avoid the repeat surgery. This is because they believe that there need to be larger margins of normal tissue, of 2-5mm, between the cancer the edge of the excision. Comments by McCahill and other expert breast surgeons indicate that there is no data showing the larger margins provide any lower rate of recurrence than smaller ones.

What is clear, however, is that cancers found earlier and smaller are more likely to require less invasive surgery and have a greater chance of recovery. While the age of starting and the frequency of screening may be controversial (see my perspective on October 30, 2010, Breast cancer screening: conflicting evidence? what are the important questions for health?), it is hard to argue that having making it more difficult to obtain that screening for 750,000 women who use Planned Parenthood is good policy if your goal is to identify and treat breast cancer as early as possible.

Which, of course, is supposed to be the Komen Foundation’s mission.

 The “Lede” story on the Komen Foundation’s reversal, Cancer Group Backs Down on Cutting Off Planned Parenthood quotes Komen’s Twitter post (@komenforthecure): “We want to apologize for recent decisions that cast doubt upon our commitment to our mission of saving women’s lives.”

And for thinking that they could just do this and not ignite a firestorm of protest. Good to see some life in the reproductive rights movement! The anti-abortion-people-who-talk-only-to-themselves-so-much-they-think-everyone-agrees-with-them were unsuccessful in this attempt. Hopefully the women’s health and pro-choice community can remember that these rights are not guaranteed by anything but the willingness of the people to fight for them.

"Abandoning ship": is debunking ineffective screening and therapy removing hope or just removing risk?

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Sometimes I think I sound like a real medical nihilist, since many of my blogs have been about purported treatments that are ineffective, dangerous, done too often, and cost a lot of money (Cardiac stents and profit-driven corruption: do anti-fraud rules address the problem?, December 24, 2010; Greed, corruption and medical procedures: ignoring or suppressing the evidence?, August 12, 2011; Men’s Health? Women’s Health? Valid screening opportunities or “Hallmark Holidays”?, March 15, 2011).  It is a somewhat distressing feeling. I am a doctor; I want to help people, to relieve their suffering, to help facilitate the cure of their diseases. More than that, I am a family doctor, and have a strong preference for prevention, for early detection of disease when it is still treatable rather than waiting for it to be too far gone for treatment to be effective. In addition, I have regularly criticized our health non-system for leaving out too many people, creating financial disincentives for them to seek care early. This leads to their waiting until their diseases become so uncontrolled that they present to the emergency room, then require admission and costly care, making it worse for them (most important) and more expensive for everyone. So I think prevention and early intervention is a really good thing, and it would be great to have tests that could identify disease early in its course so that we can change its trajectory.

But because I want these things to be true doesn’t make them true, as I discuss in the recent post Avastin®, Plan B®, and Magical Thinking, December 31, 2011. Because we can screen you for something doesn’t mean that we should; because a test can be done doesn’t mean that it is a good test. "A good test", in my opinion, is one that has sufficient sensitivity (rate of being positive when a condition is present) or specificity (rate of being negative when a condition is absent) to tell us whether a you have a disease, or if it matters. Because it can be done also doesn’t mean that it is cost-effective. Because a treatment exists doesn’t mean it is a good treatment, a safe treatment, an effective treatment. And, as with most things being sold, the greater the publicity and advertising around it, the more it means someone will be making money on it, which does not exclude its being of benefit, but is certainly not the same thing.

Sometimes, when evidence is discovered that a test or treatment is not of benefit, eventually we stop doing it. "Eventually", however, may be a lot longer than you might think. In a recent “Viewpoint” in JAMA, Prasad, Cifu, and Ionannidis address “Reversals of established medical practice: evidence to abandon ship”[1]. They note that while “Ideally, good medical practices are replaced by better ones, based on robust comparative trials in which new interventions outperform older ones and establish new standards of care. Often, however, established standards must be abandoned not because a better replacement has been identified but simply because what was thought to be beneficial was not.” They go on to discuss a number of treatments that have been “standard of care” but were shown by good, randomized controlled trials, to be ineffective or even dangerous (not to say expensive). These include stenting of coronary arteries for stable coronary artery disease (CAD), postmenopausal hormone therapy to prevent CAD, vertebroplasty for osteoporotic fractures, bevucizamab for breast cancer.

Scarily, but unsurprisingly, “true believers” continued to defend these interventions even after the evidence was clear (their livelihoods depend upon it), and in many cases these treatments continue to be offered and performed. “There are thousands of clinical trials, but most deal with trivialities or efforts to buttress the sales of specific products,” and it is only “Rarely [that]…some investigators find the courage to test established ‘truths’ with large, rigorous randomized trials”. Prasad and colleagues have done many of these latter trials; indeed John Ioannidis is the “guru” of debunking treatments with poor evidence (see David H. Freedman’s article in the November 2011 Atlantic “Lies, damned lies, and medical science.”) The authors have some suggestions, including limiting the role of manufacturers (of drugs, devices, tests) from conducting the trials on them, although they should pay for them: “Large trials of new innovations should be designed and conducted by investigators without conflicts of interest, under the auspices of nonconflicted scientific bodies. Instead of designing, controlling, and conducting the trials, manufacturers may offer the respective budget to a centralized public pool of funding, keeping the trial design and conduct independent.”

Prevention and screening are also subject to the lure of magical-thinking-compounded-by-the-greed-of-the sellers. Screening for prostate cancer with the use of prostate-specific antigen (PSA) testing is a good recent example about which I have written (while the lack of effectiveness of treatments for prostate cancer is would be included in the group of ineffective therapies that Prasad and colleagues have written about). Pap smears are pretty good screening tests for cervical cancer, but most other cancer screening tests (even mammograms and colon cancer screening, probably the next best) are not nearly as good. Every time there is a recommendation to decrease the frequency of screening (Pap smears, mammography) or not do them at all (PSAs or pelvic exams) there is an outcry from people who think that something has been taken from them. In a scientific sense, what has been taken is unnecessary testing that doesn’t lower their risk of bad outcomes, costs money, and can have significant morbidity when positive screens need additional, more invasive tests, to follow up. But, in a more metaphysical sense, what has been taken is hope, the idea that there is something that they can do that will prevent something bad from happening to them. Something that, while perhaps a little risky (if you understand or believe it), is relatively easy. And also, frankly, something someone else, rather than you, can do. Not like, say, dieting or giving up smoking or exercising. And this false concept is encouraged by half-truths promulgated by passionate advocates of interventions with limited proven benefit, whether traditional allopathic or “alternative”.

Even public health advocates sometimes get so passionate about the health benefits of what they are advocating that they may miss other issues. For example, consider a recent discussion on a progressive public health listserve about “portion control” (limiting the amount eaten at one sitting). This is an important and effective method of addressing obesity, which is in fact a major health problem in this country, but the discussion raised many other issues. These included concerns about “blaming the victim” -- expecting self-control (difficult enough) from people who had historically not had that control in the face of major initiatives by fast-food purveyors to push large portions. Another was the economics involved in asking poor people to pay “more for less” while corporations continue to make huge profits from them. It can, and often is, as difficult for public health advocates to recognize problems arising from their positions and passions as it is for providers or manufacturers to back off from theirs.

The difference, of course, is that the former are really invested in the health of the public, while the latter are invested mostly in, well, their investments.

[1] Prasad V, Cifu A, Ioannidis JPA, Reversals of established medical practices: evidence to abandon ship”, JAMA 4Jan2012;307(1):37-8.

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One thing to NOT worry about: paying for health care -- in France

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I recently saw the film Le Havre, a film set in that French city and made, in French, by Finnish director Aki Kaurismäki. It was a very good film, generally well-reviewed (here is the New York Times review), and part of its appeal for me is its unabashed portrayal of working-class people as the central characters. One of the plots involves the illness of the female lead, Arletty, who suffers severe abdominal pain, is brought to the hospital, and is told that it will be terminal (although, the doctor observes, “miracles do happen”.) I don’t need to share any more of the plot, because what I found striking was really incidental to it.

Kaurismäki goes to some length to depict both the poverty and dignity of his characters. It is an imaginable working class poverty -- this is not the Mumbai of Slumdog Millionaire – but it is certainly poverty. Arletty’s husband is a shoeshine man; they live on an alley off a small street in a house that evokes the apartment of Ralph and Alice Kramden on The Honeymooners. When he sees his wife in such pain, her husband’s main concern is how he will get her to the hospital. He goes to the street to ask a shopkeeper if he can use her phone (they don’t have one), and she offers to drive them.

What is not a concern is whether they can afford her medical care. As I am used to being in the US, to caring for people of limited means, of seeing people in the free clinic who cannot afford to go to the doctor or people admitted to the hospital when they finally show up in the emergency room with disease that is far gone because they haven’t sought care, I found this a bit jarring. I was waiting for Arletty to protest that it was “nothing” (she has been in some denial already), for fear that they couldn’t afford medical care. But she doesn’t, and he says nothing about it, and goes off to find transportation. We could see the same thing in an American movie, and we would expect the same thing in our own lives – when your wife is really sick, you take her to the hospital, you worry about the bills later.

Except that wasn’t why. They weren’t worried about the bills. Because it was France. With a national health insurance system, where everyone, even the wife of a self-employed shoeshine guy living in a tiny house off an alley, has health coverage. In the film, Arletty is in the hospital for several weeks, but of all the issues that occur, how the couple will pay for it never comes up. Not at all. It is not even a thought in their minds. But it is a thought in mine, and I keep having to remind myself that it is not part of the plot because it is not an issue that French people have to concern themselves with. The illness, yes. Whether she will survive, yes. Whether he will earn enough money each day to buy dinner, yes. But not how to pay for several weeks of hospitalization. Amazing.

There was another aspect of the healthcare portrayed in the film that struck me. The hospital was simple and unostentatious. It looked a little dated, old-fashioned, like the houses and the shops and the working-class lives of the characters, even though the film and its theme are contemporary. Maybe this is also something about France. The hospital is clean, freshly-painted, with clean linen, and private rooms, and IV poles and doctors and nurses. But it is simple. The ceilings are not high, there is not expensive art on the walls, or carpets, or hallways twice as wide as they need to be. It is functional. It is not third-world, but it is basic. It is pretty unlike my hospital, or most of the hospitals that we see in the US (except some of the oldest public institutions). If someone with private health insurance saw this hospital in, say, Kansas City, they would be unimpressed. They might rather, next time, seek one that was “nicer”. Fancier. With really good hotel accommodations. This is what we look for in the US, what we expect. Surely this is what they lose in such national-health-insurance countries as France.

I checked this with a friend, who is from Canada. He said that this is the way hospitals in Canada are; clean, and functional, but not fancy. He told me he was shocked when his wife had a baby in Kansas City and there were hardwood floors. What for, he wondered? Of course, we know what they are for. They are to help to provide a competitive advantage, to make people choose one hospital over another. For the same reason that hospitals buy new MRI scanners when the hospital down the street has one that is underutilized. Why they have fundraisers to be able to support their cancer center, to attract people with cancer (and, of course, insurance!) to them, rather than to the perfectly good cancer center across town. Why, as depicted in a recent New York Times “Opinionator” by Ezekiel Emanuel and Stephen D. Pearson (“It costs more, but is it worth more?”), hospitals such as Mayo Clinic are building their own billion-dollar proton-beam accelerators to treat cancer when there are more than enough in the country to treat the relatively small number of people who require this kind of cancer therapy.

Because, in the US, healthcare provision functions much more as a business than as a social good. The “product” is healthcare for people, but the product is only of value when it can be sold to those who can pay. We have hospitals that compete for some of our people, while there are others who can barely get care. This competition model can work, just as it works for other products – vendors compete for those who can afford it and ignore those who cannot. If we want healthcare to be an industry, a business, rather than health care.

Le Havre is a very good film, and it does not shy away from social issues. In fact, it addresses many of them. But access to health care is not one, it is not Sicko! The themes I discuss here are just in the background of the film,and I imagine they are not even noticed by French audiences. Or Finnish ones. Being able to afford medical care is not an issue in those places.

Which is as it should be.

It’s definitely not about the bike – but is it even about ACOs?

One of the major features of the Affordable Care Act (ACA) is the idea of Accountable Care Organizations (ACOs). The final regulations from Medicare were issued in October, 2011, so the creation of ACOs seems to be moving forward. ACOs will be groups of primary care doctors, specialists, hospitals, and possible other providers who act together to provide comprehensive care, and receive either more money from Medicare (and probably, eventually, other payers) or, at least, smaller reductions in payments. The only thing that is definitely required to form an ACO is a group of primary care doctors, but since groups of primary care doctors rarely have sufficient capital to fund the necessary infrastructure, so it is likely that almost all will include at least one hospital.

The stated purpose behind encouraging ACOs is to increase quality. It is easy enough to see how quality could be improved in our non-system of health. Because the bar is so low, there are tremendous opportunities that come from lack of organization and coordination of care. Hospitals get paid for caring for people who are admitted. Thus, up to a point (the point at which payments do not exceed costs), they want admissions. Patients prefer to stay healthy, or at least healthy enough to not have to be admitted to the hospital, and hopefully their primary care doctors support this goal. Hospitals have already started being financially penalized by not receiving reimbursement from Medicare for readmissions for the same problem they were discharged for, or complications of that problem. Managing this issue will require the ACO to have not only financial relationships with primary care doctors, but often with long-term care facilities as this is where patients are discharged to – and return to the hospital from.

Fisher, McClellan, and Safran, in their New England Journal of Medicine article “Building the Path to Accountable Care”  (December 29, 2011; may require subscription)[1], identify five “challenges” to implementing ACOs with suggestions for how to overcome them. The challenges are providing timely and useful data, overcoming transition costs, gaining consumer support, learning what works and using that knowledge to inform policy and practice, and clarifying the path forward. Their suggested approaches to solving them are largely based upon what is being done in existing integrated health systems (such as Kaiser and Geisinger). This makes sense, as these systems were the model for ACOs and are often relatively cost effective, but it will require major restructuring for other such systems to develop in ways that can work as well. The authors do not address a major challenge for ACOs, which is that every patient will be identified with a particular ACO (based on the physician from whom they receive the majority of their primary care) and that ACO will be held financially responsible for that patient’s costs, but that the patient will be free to receive service from outside that ACO. This is a political decision, intended to avoid the criticism that the ACO program is just “managed care” in new clothes by ensuring that the program will not “restrict” people. Of course, it is a huge flaw. If a patient is not happy with the care they receive from members of their “identified” ACO, whether that is for “good” reasons (denying unnecessary, excess, risky procedures, hospitalizations, etc.) or “bad” reasons (less than the best quality), the patient can go elsewhere and receive that service from someone else. And if Medicare deems it unnecessary or excessive, it is the “identified” ACO that will receive the financial penalty, not those providing the service.

The authors’ final challenge, the vaguely worded “clarifying the path forward”, is about future changes, including (from their table) “Create meaningful alternatives to fee for service for all providers.” This is a good idea, and not a new one. It means that rather than have the provider (hospital or doctor) paid for each particular service, the payment is tied to something else. Most simply, it could be a global fee for providing care to a patient, as the capitated payments in traditional HMOs. This allows practices to budget their resources, and also allows patients to get care in the way they need it. If a doctor is being paid a set amount in advance, there is no financial incentive for them to require a person to have to take off from work, travel, park, and wait to be seen when that person has a question that can be answered by phone or email. You would only have to be seen in person if either you or the doctor thought that there was a reason to do so. The disincentive under the current fee-for-service system is that the doctor doesn’t get paid unless you are seen in person. In addition, the ACA law envisions paying more for higher quality (or less for lower quality). So why were these “meaningful alternatives” not included in ACA? Again, political, and the question is “what will change the politics in the future?”

In another NEJM “Perspective”, “Achieving accountable care – “it’s not about the bike” (published online on December 28, 2011), Walker and McKethan argue that it is the skills and competencies of providers, rather than the structure of the systems, that will determine the success of ACOs. Their metaphor is from Lance Armstrong’s memoir, in which Armstrong acknowledges the importance of having a great bike but says that “Although advanced equipment is very important, winning depends more on athletes' riding skills, physical conditioning, and race-day effort.” Cute, but obvious; any athlete with enough money (and all top cyclists have backers with enough money) can buy the best bike, but it is his or her skill and dedication that leads to victory – or not. Is it, however, a good metaphor for medical care? “If an ACO were a bicycle,” Walker and McKethan write, “its wheels, spokes, and gears would be the criteria used by payers such as Medicare to determine providers' eligibility, the methods used to assign patients to a given ACO, and the manner in which financial bonuses are calculated.” They then go on to discuss at some length what ACOs will need to do to “…compel and equip the athletes riding them…” (meaning providers) to do what is necessary, for “…accountable care will depend on a care team's identification of and action on the specific needs and preferences of the individual patient, deploying the most relevant, tailored interventions and supportive services to address patients' specific needs, circumstances, and preferences.”

Sound good? It is an appropriate metaphor in that structure alone will not guarantee success, but it loses strength after that. ACOs are not bicycles, and providers are not athletes. Most important, “success” in the arena of healthcare should not be about “winning”, about “beating” the other “competitors”, but about development structures, methods, practices, and reimbursement procedures in which everyone receives the best, most appropriate care. In which we all win.

And that is going to be one of the big challenges, because neither of these commentaries addresses the fact that not everyone in our country is going to be part of an ACO, and not everyone in our country has health coverage. Those people who do have coverage have found their premiums, co-pays, and deductibles increasing and their benefits diminishing.  ACOs are (at least initially) a program for Medicare recipients, but all we hear from Congress and pundits is that “Medicare costs too much” and that these costs need to be scaled back, so unquestionably the emphasis of programs like ACOs will be on reducing cost.

I have often noted that much of the excess cost in this country is from providing unnecessary, or even harmful, care, and so there is not necessarily a conflict between saving money and increasing quality. But people are different, with different diseases and needs and wants, so there will need to be flexibility. And those who are most disenfranchised will remain outside the pale.

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[1]Fisher ES, McClellan MB, Safran DG, “Building a path to accountable care”, N Engl J Med 29Dec2011;365:2445-2447

Cui bono? Is healthcare financing about funding providers or caring for patients?

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In a recent blog, GME funding must be targeted to Primary Care, December 10, 2011, I wrote about the fact that the financial interests of hospitals lead them to choose to support residency training positions which are not necessarily (or often, or usually) in those specialties that the nation most needs. I urged that funding from the government for graduate medical education (primarily through supplements to Medicare and Medicaid) include mandates as to the proportions of trainees in different specialties, with a strong emphasis on training more primary care physicians. This is only one area, however, in which the financial incentives to hospitals, and indeed all health providers including physicians, do not always jibe with the healthcare needs of our population.

A recent spate of news articles has discussed changes in the organization and financing of healthcare services. The New York Times recently covered the conflict between the governor of the state of New York, Andrew Cuomo, and the mayor of New York City, regarding the potential conversion of Emblem Health to a for-profit company (Bloomberg Predicts Fair Deal if Health Insurer Gets For-Profit Status, by Thomas Kaplan, December 23, 2011). Cuomo wants it because it could bring as much as $1B in tax revenue to state coffers; Bloomberg is concerned because Emblem is the insurer of the majority of municipal employees and he expects such a move will drive premiums up. But, as the title of the article suggests, he thinks they can work it out. Between them. For the benefit of both the city and state governments. Not, however, for the people insured by Emblem. Emblem was created by a merger of Group Health Insurance (GHI) and Health Insurance Plan (HIP) of Greater New York, two early not-for-profit HMOs, or managed care organizations. Except they were created before either term, HMO or managed care, existed. Back in the 1950s, these were consumer cooperatives, where it was recognized that by cutting out the (for-profit) insurance company middleman, people could have more care for the same money, or the same care for less money. No wonder the majority of city employees enrolled.

Over time, rebranded by the Reagan administration with the new name of “HMO” or managed care, became the de facto standard for US health care coverage. Why Republicans could buy into this vaguely populist or socialist concept was that the new HMOs would increasingly be owned by for-profit insurance companies, which they could literally buy into as shareholders. The savings that came from managing care would now accrue to the insurer, not the patient-owner-members. Many of the long-standing HMOs of the early period (e.g., Los Angeles’ Ross-Loos) were purchased by insurance companies, but there were a few holdouts that remained consumer cooperatives (e.g., Group Health of Seattle and the groups that became Emblem). And then, as we remember, came the consumer backlash against HMOs in the late 1990s, with people furious at the restrictions these organizations put on their access to health care. The mistake, however, was thinking that the problem was the organization of care with requirements for only approved therapies, relatively “closed panels” of doctors and hospitals, and capitated payments. The problem was that they were, and are, mostly owned by for-profit corporations, which increase their profits every time care is denied. This is a very different incentive than when the owners are the patients themselves through a cooperative.

As time went on, even the non-profit HMOs and other non-profit groups like the Blue Cross / Blue Shields that are not part of the for-profit Anthem/Wellpoint, have had to act like for-profits to compete. The advantages have all been for the insurers, which remain very profitable, not for the patients, who find both many of the same restrictions they bridled at in the past, and, in addition, increasing premiums, co-payments, and deductibles. If Emblem becomes for-profit, Michael Bloomberg may be able to work a deal where the city government is spared a major premium increase, but the city workers who are insured by Emblem will not be so lucky. In a typically excellent “Quote of the Day”, Don McCanne, MD, discusses the fact that the National Business Group for Health (NBGH) is predicting major increases in deductibles for all employees. As reported in an article in the Nashville Tennesseean, “High deductible plans on the rise”, by Tom Wilemon, December 27, 2011, “Helen Darling, its [NBGH] president, predicts that by 2016 the majority of all health plans will have high deductibles.” McCanne notes correctly that the members of NBGH are the nation’s largest corporations, mostly Fortune 500 companies, which have historically had the best health insurance coverage for their employees. If these deductibles – the amount a family has to pay out-of-pocket before any insurance coverage kicks in – rise to $1500 a year, it will be much worse for those working for smaller, less prosperous companies.

McCanne also comments on reports from the AMA that Highmark, the large Western Pennsylvania Blue Cross / Blue Shield affiliate, will be purchasing its own health system, where it will be able to profit on both ends, or, at least not pay as much for care. He observes that this will enhance its financial status, but not benefit patients, who will be preferentially locked into care at West Penn. The greatest complaints are from the competing University of Pittsburgh Health System, which believes it will Iose patient revenue from such an arrangement. So the conflict here is between the benefit for one health system versus another. It is not benefit for state versus city government as in the Emblem case, but it is still not about the health of the people. It continues to be about how the money from healthcare is distributed among the various players, including as insurance companies, hospitals and doctors.

My hospital, the University of Kansas Hospital (UKH), has done very well financially. In the most recent “Book of Lists” sent to subscribers to the Kansas City Business Journal (not on line; a copy will cost you $65, or $169.95 for immediate download!), it had the greatest revenue in the Kansas City area, at over $2.5B, more than $1B ahead of #2. The physicians who staff the hospital, faculty of the University of Kansas Medical Center, are seeking a restructuring of the current affiliation agreement to share more of that revenue with the doctors. As one of them, I do not disagree with the concept that the physicians, whose work generates much of the revenue, should share more equally, but, as with West Penn and University of Pittsburgh, this is about who gets what, not about how to provide better healthcare for less money to more people.

Health industry consulting groups, such as the Advisory Board, warn hospitals that there will be major cuts to their income resulting from federal budget cuts and programs such as pay-for-performance (P4P) and “value based purchasing” (this is “value” in the economic sense, that is cheaper, rather than having anything to do with “values”, such as caring for the sick!) Hospitals like UKH worry about whether their up-to-this-point successful strategy of investing in the highest-profit “product lines” such as heart disease and cancer will continue to work in the changing reimbursement system. They sense a pressure, as do physicians, to enter into “health systems”, collaborations, to maximize efficiency and profit (or at least not make much less than they are). There is a certain irony in pressures to re-create the managed care era.

But, because that “re-creation” is still about how hospitals, doctors, and insurers can make money, not about how we can provide the best health care for the most people, it is re-arranging deck chairs on the Titanic. If, when, we hit that proverbial iceberg and the ship goes down, many people will be hurt. Sure, just as on the Titanic, it will be the poor people on the lowest decks who get hit the worst. Then, the middle class. And even some of the rich, and some of the officers will go down. But, if you are a betting person, you bet on the most privileged being the most likely to survive; you would have been right in on the 1912 sinking of the boat, and you’d be right 100 years later in health care.

One day maybe we will develop a health policy that engenders behaviors that are about providing the best health to all of our people.
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"How Doctors Die"; post on Zocalo Public Square by Ken Murray

I would like to call your attention to a superb post on "Zocalo Public Square" by Dr. Ken Murray, "How Doctors Die." It addresses what doctors want for themselves when they are dying, which is generally much LESS intervention.

I would suggest that if patients knew that doctors felt this way, rather than that we were trying to "deny" something to them or their relatives, it might be much more effective.