Calling Mr. Watson

By Kim Bellard, October 24, 2011

I was going to write something about the recent controversies about the PSA test or Pap test, but the effort by the U.S. Preventive Service Task Force to use documented evidence in determining the value of periodic testing seems almost certain to be overcome by the combination of tradition, emotional responses, and self-interest by impacted parties, so I’ll let that go for another day. 

Instead I’ll turn my attention to one of my favorite topics, the use of technology to improve the delivery of health care services. 

I’m enough of a science-fiction fan to believe that I should be able to get medical advice and consultation whenever and wherever I am, from an appropriate expert (or at least a qualified person with real-time access to any necessary expertise), using real-time biomedical and other readings.  I’m glad to say that this is rapidly moving from science fiction to reality.

Earlier this month, California passed AB 415, the Telehealth Advancement Act.  The bill updates California’s prior telemedicine law, and makes various improvements to allow wider use of telehealth in California.  It allows broader use by more types of providers, removes rules requiring documentation of barriers to in-person visits, and eliminates restrictions on reimbursement for services provided by email or telephone, among other things.  The bill’s proponents claim it should save up to $1.3 billion per year to the state’s Medi-Cal program, much of which comes from electronic home monitoring programs for patients with diabetes or potential heart failure. 

Several studies (e.g., University of Texas Medical Branch and UnitedHealth Group) argue for telehealth’s particular value in care delivery for rural populations, where access to in-person services may be especially problematic.  Again, closer monitoring of patients with chronic conditions is cited as an opportunity for improved care and lower costs. 

Meanwhile, the Mercy health system has announced plans for what it calls the nation’s first “virtual care center”.  It will bring together a variety of existing and planned telehealth programs, such as the Mercy SafeWatch program.  This program is an electronic ICU, monitoring 400 beds in 10 Mercy hospitals to provide around the clock support from specialists and ICU nurses to the bedside practitioners.  Mercy plans to spend $90 million on building the center and another $590 million in technology to support their multiple initiatives. 

Similarly, Washington Health Center, in Washington D.C., announced CodeHeart, a mobile application it developed in conjunction with AT&T.  It allows cardiologists to view video and test results while a critical care patient is in transit, allowing them to better prepare for the patient’s arrival in the emergency room, where time is usually of the essence.

It’s no surprise that telehealth is a hot topic.  Manhattan Research claims that 75% of physicians own an Apple mobile device – iPhone, iPad, or iPod – and 26% of U.S. adults have used their mobile phones for health information and tools.  Mobile is rapidly becoming crucial to telehealth, supplementing prior video-conferencing capabilities.

The barriers to telehealth are no longer technological, since the increased availability of broadband connections and more robust mobile platforms have made possible a wide variety of options.  The real barriers are artifacts of historic practices, especially related to reimbursement and licensing.

Reimbursement for telehealth remains uneven.  Medicare, for example, covers some telehealth services, and is expanding its rules for 2012, but still does not do so uniformly.  For example, it is more favorable to beneficiaries in rural areas than in urban areas, and only covers live interactions, not so-called “store-and-forward” methods used for images and certain other patient information.  Fourteen states require private payors to cover telemedicine, but the rules are not consistent across states, nor do they necessarily speak to reimbursement equivalence. 

Licensing is an issue because health care practitioners are licensed by the state in which they practice.  Telehealth, of course, is not bound by geographic location, but under current laws providers in one state cannot treat patients in another state unless they are licensed in that state.  Practicing in multiple states thus is onerous. 

Both of these issues can be overcome, but it will not be easy.  Most private payors follow Medicare’s lead in reimbursement policies, so if and when Medicare makes progress in how aggressively it wants to use telehealth, the private sector should follow.  The reluctance of payors is understandable; the practice of telehealth is still in a relatively early stage, and many payors are concerned that paying for telehealth could lead to an explosion in costs.  In an ACO world, where ACOs have strong incentives to live within a global budget or budget target, employing the use of cost-effective telehealth services should seem entirely logical.  In a predominantly fee-for-service world, perhaps not, or at least not necessarily. 

As for licensing, state licensing agencies are not surprisingly reluctant to cede oversight.  They can justifiably claim that patients could be at risk by treatment from practitioners over whom they have no control and no assurance of competence.  While valid, we seem to be able to conduct inter-state commerce in other fields without abandoning consumer protection.  It argues for more uniform licensing practices and reporting across the states, lessening any particular state’s concerns.  Indeed, the American Telemedicine Association has launched an initiative – FixLicensure.org – to make licensure more appropriate for 21^st century capabilities and practices, including telemedicine.  E.g., why should my access to the best doctors be subject to my physical location?

Licensure will become even more problematic with the evolution of expert systems or artificial intelligence.  This is starting to become real; take, for example, the recent collaboration between Wellpoint and IBM’s Watson technology.  For readers not familiar with Watson, it is the system that beat the Jeopardy champions of champions.  Wellpoint plans to use Watson to help suggest treatment options and diagnoses to doctors.  With so much medical knowledge, and with that knowledge increasing exponentially, such assistance seems inevitable, not to mention highly desirable.  Still, at what point will that kind of assistance be considered practicing medicine?

History buff may recall the apocryphal story that Alexander Graham Bell uttered, “Mr. Watson, come here – I need you” into the first working proto-telephone, launching the era of electronic voice transmission.  It seems ironic, yet somehow fitting, that Watson may again be critical to launching of another technological revolution.

More, Please

By Kim Bellard, October 2, 2011

Private health plans – everyone’s favorite scapegoat – are getting rolled.  They might as well get used to it.

Kaiser Family Foundation released its annual Kaiser/HRET Health Benefits Survey, which showed that health insurance costs increased 9% for family coverage – over $15,000 per family annually.  This compares to last year’s more promising 3%.  Single coverage was up by an equally daunting 8%.

What struck me was Kaiser’s estimate that health care reform accounted for 1-2 percentage points of the increase.  It’s a good thing for the Administration, then, that the overall increase was as large as it was, so that the effects of health reform couldn’t be blamed for a larger share of the private sector health spending increases.  Whether that proportion is one-ninth or one-third of the total, though, it’s still a lot of money.  Private health insurance expenditures are on the order of $850 billion, so that 1-2% increase is a cool $8.5 - $17 billion hidden tax increase annually.  And it’s only starting. 

Just a few days ago, there were various news reports trumpeting the success of Affordable Care Act (ACA) in getting more young adults coverage, via the requirement to cover dependent children up to age 26.  Both the CDC and Gallop released findings validating the increase in coverage, estimated at some 900,000 more young people with health insurance.  But insuring these young adults has a cost.  The Kaiser study reported 20% of firms have covered young adults due to the law, an estimated 2.3 million adult children.  The difference between the 900,000 and the 2.3 million suggests a majority of those adult children might have obtained coverage on their own rather than through their parent’s insurance.  If I were an employer trying to cover my health insurance costs, I might be kind of mad about that.

Kaiser also reports that the ACA impacts are just starting to be felt.  Seventy-two percent of employers still had “grandfathered” plans, which have not yet been fully subject to ACA requirements.  Among those requirements are coverage for specified preventive care services without deductibles or cost-sharing.  Last month we saw one shoe drop in this regard, when HHS announced the list of services considered preventive for women’s health.  The services include not just birth control, but also, among others, HIV screening and counseling, breastfeeding support and supplies, and domestic violence screening and counseling – all very worthwhile services, but not all ones traditionally seen as either preventive in nature or covered by health insurance.  Then again, the federal government is requiring the private sector to pick up the costs, so serving political or social justice goals becomes part of the equation.  The Wall Street Journal reports that Catholic organizations are, not surprisingly, already upset with the requirements about contraception, and it will be interesting to see how special interests play out against other special interests in achieving ACA’s goals.

It’s going to be very tempting – too tempting – as ACA moves forward, for more special interest groups to lobby to get their services covered at no cost-sharing to the consumers.  No cost-sharing to consumers, of course, doesn’t mean no cost; it all has to get paid for somehow, and it all adds up.  We’ve been down that road with state mandates for health insurance, except that under ACA there are no jurisdictional escape routes for employers or health plans. 

Critics of health insurers, of whom there is no shortage, blame the 9% increase on health insurers trying to make their money before they are required to hit the loss ratio and disclosure requirements of AAPCA.  Those critics might want to note that Kaiser also reports that 60% of covered workers are in self-insured plans, so their argument loses much of its force, as these firms have no incentive to raise their costs any higher than necessary.  Self-insured or not, employers provide the vast majority of private health insurance, and they are struggling to afford it.  They are not an endless piggybank to be used for political purposes. 

The only “good” news about ACA I’ve seen lately is that the Administration is finally being forced to be more honest about the CLASS long term care program.  Skeptics of this program, including me, argued that the program was not structured to be sustainable. It was included as a tribute to Senator Ted Kennedy and as a way to count the program’s initial years’ premiums as revenue in the bill’s cost – rather than reserving them to pay for promised benefits.  Now it appears that HHS may try to not implement the program, having gotten rid of the actuary assigned to work on it and reportedly planning to close down the CLASS Office.   I feel bad for the people who might have benefited from CLASS, but as a taxpayer I’m relieved that we might not have jumped off this particular cliff yet.  

It remains to be seen if the 9% increase in costs is an aberration or the start of an ominous trend.  As the various ACA changes more fully impose direct costs on private health plans, and as providers continue to cost-shift to private payors due to worsening Medicare and Medicaid payment shortfalls, the prospects for holding costs down are grim.

Bad as they are, the cost increases could be worse.  Consumer Reports found that 48% of consumers are skimping on prescription drugs or other forms of medical care, up from 39% last year.  Presumably costs might be higher if patients didn’t “skimp” on health care, which included delaying a doctor’s visit or declining a test.  Of course, this concern about “skimping” on health care should be counterbalanced by questioning whether all of the recommended care was needed.  A recent study found that 42% of primary care physicians think their patients get too much medical care, driven in part by malpractice concerns and ordering tests rather than spending more time with patients (see my previous blog on addressing this).  They thought sub-specialists were even worse in this regard; 61% thought sub-specialists provided too much care.

The fact of the matter is that we still don’t know how to tell what care is needed and what isn’t, and ACA hasn’t helped accomplish that.  Yet.

Perhaps HHS will get the ACO regs right, and ACOs will flourish.  Perhaps EMRs and meaningful use will quickly yield the desired paybacks.  Perhaps the exchanges will be a boon for consumers and health plans alike.  Perhaps, perhaps, perhaps; the big problem with ACA was that it focused primarily on how health insurance is financed, not on making structural changes to how we deliver and pay for health care.  Until we do the latter – health plans, better open your wallets (and by “your wallets,” I mean “spend our money…”)!

A Penny (Or More) For Your Thoughts

By Kim Bellard, September 13, 2011

Let’s start with the non-news: a primary care physician association – in this case, the American Academy of Family Physicians – thinks primary care physicians aren’t being paid enough fairly and wants CMS to change the Medicare payment system.   It would be a surprise if any primary care physician organization argued any other position, and there is a lot of sympathy for the argument that primary care physicians are undervalued compared to specialists.   I’m sympathetic myself.

On the other hand, a new study in Health Affairs asserts that primary care physicians in the U.S. both are paid higher fees than primary care physicians in several other countries and also have higher incomes as a result.  The study, by Laugesen and Glied, further asserts that the higher incomes are simply the function of the higher fees, not due to higher practice costs, higher volumes, or medical school tuitions, as some have theorized.  The study also notes that the same type of gap exists for orthopedists in the U.S. versus in other countries, and that the income gap between U.S. primary care physicians and orthopedists is wider than in other countries. 

The fact of higher physician fees and physician incomes for U.S. physicians compared to their international peers is nothing new, and I’ve blogged about this previously.   With the ongoing and increasing pressures on Medicare and Medicaid spending, we can expect even more pressure on how we pay which physicians.  No one seems to be stepping up to say that they are overpaid.

A few other recent studies give me pause about this topic.  On of the most interesting was a study from Israel that concluded medical history and examination were more important than extra tests, particularly CT scans, in making a diagnosis.  The authors found that added tests only helped in about one-third of the cases, while adding significant costs and exposing patients to additional radiation and its attendant risks (see, for example, this nice summary).  This was in Israel, mind you, and one can only imagine how many more “extra” tests are performed in the U.S., given our culture to always do more and patients’ demand that everything possible be done, regardless of cost-benefit.  It’s nice to have it confirmed empirically that cognitive skills still trump technology most of the time. 

An example that dramatically illustrates this is a recent study about the effectiveness of “brain stents” to prevent strokes.  The study not only found the costly procedure was not more effective, but actually was worse for patients than those treated conservatively with drugs and advice.  Patients with the stents had more strokes and more deaths, to the extent that the study was halted prematurely once the results became clear.  Interestingly, this study is on the heels of another recent study indicating that heart stents were not more effective than medication, yet the number of such stents being performed hadn’t gone down once those results had become widely known.  The U.S. health system just seems to be in love with procedures and testing, not always to be benefit of its patients.

Now, some observers might view the results from Israel and claim that, well, if it was your mother/spouse/child, surely you would want those extra tests as well, just to make sure, since in one of three times they did prove to be useful.  It isn’t easy, after all, to tell which of the three will benefit before the fact.  It’s a valid argument, and this attitude is typical of our health care system, where doing more is usually seen as better.  We don’t seem to have this attitude in all aspects of our life.  If, say, it turned out that police routinely arrested three people to find the one person who was guilty, there would be cries of outrage across the board.  We’d argue indignantly that the police need to take a little more time to be sure they had the right person before making arrests.  We seem to hold our policemen to higher standards than we do our health care practitioners, and I’m not quite sure why.

I enjoy watching the television show House, in which it’s grumpy, damaged lead physician plays Sherlock Holmes with baffling diseases, eventually putting together all the clues to (usually) save the patients’ lives.  Every time I watch it, though, I have two reactions – first, those poor patients, who are put through a bewildering and often painful array of tests and procedures before the Dr. House reaches his miraculous conclusion, and, second, who is paying for all this?  There’s never any real sense that Dr. House and his team ever worry about how much their efforts are costing, and there seems scant concern for what they put the patients through.  All House cares about is getting to the right diagnosis.  It’s great TV but a horrible patient experience.

So here’s my thought.  Let’s pay physicians more for the cognitive work, the so-called Evaluation and Management codes (“E&M”).  All doctors, any doctors, plus nurse practitioners and other physician extenders.  It’s less important which doctors get it than what we incent them to do, and what we should want them to do first and foremost is to use their intellect, training and experience to figure out what is or might be wrong with us.  “First do no harm” and all that.

We should give them not just a token increase but a major one – double, triple, pick a number, but make it a very noticeable one.  I would assert that the health care system won’t go bankrupt – well, more bankrupt – because of too many office visits, even if we start paying for e-visits and telemedicine visits, as we should.  It’s what happens from those office visits that we have to worry about – the prescriptions, the tests, the procedures and treatments that result.  Of course, we’d need to find a way to ensure that those added payments for E&M visits aren’t just additive, but actually help deter other inventions that are not truly necessary.

The pot of money available in health care is, for practical purposes, a zero-sum game.  Pretty soon employees are going to realize that their “employer contributions” for health care is their own money, and pretty soon the federal government is going to have a harder time paying for its health programs using deficit financing.  So whatever we increase in E&M payments will need to come from elsewhere in the existing spending.  For example, could we use “thinking time” as the unit of measure, so that a procedure which takes an hour to perform should get paid the same as seeing patients for an hour?  Alternatively, perhaps many tests and procedures should end up getting paid more like a commodity – more expensive initially as people learn how to do them and as the initial development costs get paid for, then rapidly dropping the price as volume increases and people get used to doing them.  We have a tendency to start out high and never drop payment levels.   Smarter people than me can figure out exactly how to make the offset, although the lobbying opposition will be very intense as every specialty fights to protect its turf.

We all like to think that the patient-physician relationship is sacrosanct.  So why not pay for it like we actually believed that?

Health Insurance is Good For You (?)

Kim Bellard, July 11, 2011

Finally, a study that indicates health insurance is good for you! 

Granted, the study looked at Medicaid, for a low-income population, in a specific state, but in a time when health insurers are commonly castigated as villains, perhaps they can take some comfort in the findings.  Or perhaps not.

A brief recap of the study.  In 2008 Oregon realized it had funds to expand their Medicaid rolls (having substantially dropped them several years earlier).  They knew demand would exceed the number of slots available, so they set up a lottery that allowed potentially eligible consumers to enter; almost 80,000 did.  Researchers realized they finally had a classic study design – populations randomly selected into those who got health insurance and those who remained uninsured.  This appears to be the first such ever done when it comes to health insurance. 

The results from the first year indicate that those with health insurance did appear to benefit.  I won’t recap all the results, but some examples include that the newly insured saw doctors 35% more often, went to the hospital 30% more often, got mammograms 60% more often, and were 25 percentage points more likely to say their health was good or excellent.

Not surprisingly, they also cost 25% more.

The increased utilization may be partly an artifact of the so-called “woodwork” effect, i.e., people tend to use benefits more when they first get them (or, conversely, are about to lose them).  The researchers are continuing to mine the data, looking in particular at longer term impacts on health results.  Those extra doctor or hospital visits may or may not actually be improving health; several of my previous blogs (e.g., here) have discussed some of the overuse and errors that appear to be prevalent in the health care system. 

Earlier studies have tried to quantify the impact of health insurance, or lack thereof, have on health outcomes, such as those by the IOM or Mathematica.  Numbers like 44,000 deaths annually attributable to lack of health insurance have been claimed.  It’s not even only a matter of the uninsured not receiving services; even when they obtain services they may have worse outcomes.  Another recently released study indicates that payor status impacts mortality and morbidity for patients undergoing cardiac value operations, with privately insured patients faring better than either the uninsured or those with Medicaid.  So, any way you cut it, having insurance seems like a good thing. 

Clive Riddle recently posted a blog that reminded us how disproportionate health expenditures are distributed, with 5% of the population accounting for about half of the spending.  The fifty percent of the population with the lowest spending accounted for only 3% of all spending.  And that, for insurance purposes, is good.  Historically, and still true in other sectors, insurance is supposed to protect against unpredictable and catastrophic losses.  Anyone can get hit by lightening, catch a rare virus, or develop cancer.  Protection for the high expenses caused by relatively rare events that are outside of the individual’s control is what insurance does best. 

Insurance doesn’t work well at all when the insureds either already are incurring expenses or know they soon will be; for example, persons with chronic conditions.  People in this situation are basically depending on the other insured people to subsidize their expenses.  The data that Clive cited in his blog also noted the persistence of high spending for persons with chronic conditions; high spenders are no longer primarily one-time catastrophic cases, but more often now involve ongoing situations.  At some point, low cost people may balk at continuing to subsidize higher cost persons who have ongoing expenses; many would argue that this is exactly what is happening already in the individual market.

Don’t get me wrong; I am all in favor of reducing financial barriers to care for low-income people.  I’m all in favor of ensuring that health expenses don’t bankrupt families.  Medicaid has many, many flaws, but in any health care system we’re likely to get there will need to be some kind of special consideration for populations on whom financial burdens of health care fall hardest.  Where I start to scratch my head is how far those special considerations need to apply.

A common perception seems to be that without essentially full or low cost coverage for services, people will not get them.  The antipathy towards high deductible or consumer-directed health plans reflect this, with critics fearful that consumers will not behave responsibly when they are accountable for the initial deductible of a few thousand dollars.  PPACA similarly added requirements for coverage without cost-sharing of various preventive services, on the premise that consumers are too irresponsible to obtain services if they bear any financial burden when obtaining them.

A little Insurance 101 might be helpful.  If 100 people are covered, and one of them is likely to incur a $100 charge, then charging an annual premium of $1 per person (plus an add-on for administrative overhead) suffices.  However, if every person was going to get, say, an annual preventive visit that cost $70, then each person will have to pay a $70 annual premium (plus the add-on for administrative overhead) to pay for that visit.   There is no insurance, simply dollar trading with a mark-up. 

For skeptics who say people are irresponsible and won’t obtain appropriate services if there is cost-sharing for them, then I would argue (and have, here) that we have a far bigger problem.  Rather than waiving any financial involvement from patients, we’d be better off figuring out how to motivate patients to take better care of themselves and how to motivate physicians to ensure their patients are doing so. 

I.e., it’s not the coverage; it’s the behavior.  Coverage is necessary but not sufficient.  Sadly, we’ve built our delivery system and much of our health behavior around what insurance pays for rather than around makes the most sense from a health outcomes standpoint.  Or perhaps we’ve built our coverage around what is easy to pay for rather than what we should pay for.   Either way, it’s a problem.

Do We Really Want Better Health?

By Kim Bellard, June 20, 2011

There are times when I despair about the prospects for improving our health care system.

To illustrate, let me give some examples – two from the physicians’ standpoint, two from the patients’ standpoint – and then see what we might conclude. 

Recently JAMA reported the results of a study by Dr. William Borden and others on the treatment of heart patients with clogged arteries, following up on their 2007 research.  That earlier research indicated that patients receiving drug therapy fared equally well as angioplasty in preventing heart attacks, and so should be tried before performing the more invasive, more costly surgical approach.  The 2007 study was widely reported on, and was expected to reduce the number of patients receiving the surgical approach.  The new research indicates that in the two years after the 2007 results were released, there was virtually no impact in the percentage of patients receiving the drug treatment approach.  Experts cite time being needed to change practice patterns as well as patient demand for the “high tech,” more immediate impact surgical approach as reasons for the modest impact.

All right, maybe that’s not the best example.  Perhaps the original study results simply hadn’t been out long enough to change practice patterns, and most likely switching to the medication approach would have significant revenue impacts on both hospitals and on vascular surgeons that might create resistance to change.  Let’s take a less controversial topic: hand washing.  This is a practice whose clinical benefits have been well known for, what, 150+ years?  Moreover, it is one whose benefits pretty much everyone -- physicians, nurses, other health care workers, and patients -- agree upon.  Despite that, the accepted wisdom is that health care professionals appropriately wash their hands less than fifty percent of the time, with some estimates as low as thirty percent.  One study indicated that the baseline rate of hand hygiene compliance was 26% in ICUs and 36% in non-ICUs…and after a year of feedback these rates increased to 37% and 51%, respectively, which is hardly cause for celebration.  Again, the problem has been well understood for years, with vigorous attempts to highlight best practices in order to improve compliance, yet the problem persists.

Patients have their own blind spots.  Take antibiotic compliance.  Antibiotics were one of the great medical advances of the 20^th century, and remain one of the leading methods of treatment for many conditions.  Unfortunately, the literature is clear that patients often are noncompliant with their prescribed programs, which can reduce their effectiveness significantly.  One study conducted a review of various other studies and found that the mean dose-taking compliance was only 71%.  Compliance was higher in once-daily regimes, falling to 51% if the dose required four daily doses.  Patients are told to take the full course, but forget to take doses or stop once their symptoms diminish.  The failure to complete a course of treatment can cause relapses and is often cited as a reason for increased antibiotic resistance.

Then there is the obesity epidemic in America.  The facts are well known: recent estimates put the incidence of obesity at a third of all adults.  That percentage is double the prevalence thirty years ago.  Obesity, of course, is associated with a number of serious health concerns, including high blood pressure, diabetes, and heart disease.  To make things worse, it is estimated that another third of adults are overweight, meaning that two-thirds of American adults have a weight problem.   The comparable figure for children is an equally startling one-third. 

Sadly, many people do not even have an accurate perception of their weight-related health risk.  A survey by Harris Interactive/HealthDay found that thirty percent of the overweight felt their weight was normal, while 70% of those considered obese thought they were merely overweight.  Interestingly, respondents to the Harris survey cited lack of exercise as the key culprit for being heavier than they should, yet pointed to surgery as the most effective weight loss method, followed by prescription drugs.  Enough said.

In previous blogs I’ve been a strong advocate of the importance of using information to help health care professionals improve their performance and to help consumers make better decisions about their choice of treatments and health care professionals.  With examples like the above, though, it seems that information is necessary but definitely not sufficient.  In each case, the “right” thing to do was fairly well established empirically, widely communicated, yet consumers and even health care professionals continued to make the “wrong” choice.  And by no means are these examples the only ones of their type in health care, or even the most egregious.  Just this week researchers reported that as many as 70,000 Americans may die of heart failure each year because they are not receiving the optimal treatments called for by accepted national guidelines. 

Between medical errors, sub-optimal care, and our own neglect of our health, it’s a wonder anyone survives the health care system.  It’s getting to the point when I’m afraid to read any more studies.

The basic problem is that behaviors are hard to change, even when given information about how that behavior should be changed.  I point to the example of car safety belts.  They were widely installed in most cars by the 1960’s, and were well understand to reduce traffic fatalities significantly, yet by the early 1980’s usage was still as low as 11%.  Today usage is up to 85% (and one could be dismayed it is “only” 85%), but it took a generation to for wearing seat belts to become the norm. 

Information is essential.  Incentives are appropriate.  Neither, even when used in combination, may be enough to change behavior until and unless the individuals in question see the need for change, and the value to themselves in making the change.  We need to do a better job of making that case.

The good news is that we can learn new behaviors when we want to – for example, almost 70% of American’s with mobile phones use them for texting (according to Comscore), a feature that barely existed ten years ago.  If we can make room in our lives for that, certainly there should be room for us to do better at improving our health and demanding better health care.  Or so I hope.

The Two Percent Solution

By Kim Bellard, June 13, 2011

Blue Shield of California recently announced that they would be limiting profits to two percent of revenue.  The move is believed to be one of the first of its kind, and is one of a series of bold positions on health reform that the company and its CEO, Bruce Bodaken, has taken over the years.  The company is even applying the limit retroactively, refunding last year’s profits over that level, some $180 million.

To be fair, Blue Shield of California has had its share of critics over the years, including criticism of recent rate increases or proposed increases and over compensation for its key executives.  The recent announcement has similarly drawn its share of skeptics, some of whom noted that California is currently considering giving the Department of Insurance the ability to reject “excessive” rate increases.  They speculate Blue Shield is trying to head off the increased oversight. 

I won’t presume to speculate on Blue Shield’s motives, and I’ve been in business long enough to know that companies have many accounting options to classify a good deal of money in ways that can help keep it from showing up as profit.  Still, I wish Mr. Bodaken had gone further.  Perhaps he should have called for a “2 percent solution” across the board for health care, or at least for its non-profit constituents. 

People love to pick on health insurers, perhaps because their premiums are one of the more visible costs to consumers in our health care system.  Health insurers often don’t make it easy to defend them, but their level of profits is probably one of the harder aspects to attack.  One economist points out that the health insurance industry ranks only 86^th in profitability, with an average profit of 3.3%.  Profits from drug manufacturers, health information services, home health care companies all dwarf those of health insurers.  Granted, that data is a couple years old, but 3-5% is a typical profit margin for health insurers. 

Contrast this with a more beloved sector of the health care system, non-profit hospitals.  Moody’s estimates that non-profit hospitals made, on average, 2.3% in 2009.  Larger hospitals fared better; the 50 largest hospitals made 3.5% on average.  The IRS took a look at non-profit hospitals a couple years ago, and found an even bigger number.  In their review, non-profit hospitals’ “excess revenues” (total revenues less expenses) averaged 5%.  Rumor has it that some large health systems in my region of the country enjoy 10% margins, and it wouldn’t surprise me if that was less rare than many people would think.  So neither Blue Shield’s 2% limit, nor even their 2010 margin of 3.1%, look out of line.

One wonders if non-profit hospitals will be bold enough to follow Blue Shield’s lead and vow to limit their margins to 2%.  One also wonders if it would make any difference.

More troubling is the kind of practice the Wall Street Journal reported on recently, regarding physician-owned distributorships, or PODs.  Essentially, PODs are a way to give physicians a cut of the revenue from medical devices that they prescribe to, or implant in, their patients.   Not surprisingly, they found, for example, surgeons tended to perform more spinal implants when they were part of such arrangements, and not always for the better health of their patients. 

The Journal has been running a periodic series on various questionable provider billing practices, using Medicare Part B claims data (which, by the way, it had to go to court in order to get access to).  Their article on the potential adverse impact of PODs has now spurred a Senate Finance Committee report and a request for the HHS Inspector General to take a closer look.  Every time I read one of these articles, I’m struck with two equally strong reactions: how much of this kind of chicanery is there, and why the hell isn’t CMS doing more to identify and combat it? 

Physician ownership of other health care entities, which now include ambulatory surgical or imaging centers, pharmacies, and even hospitals (although health reform has put a halt to the latter, at least for now), have been linked to higher utilization (e.g., see Hollingsworth).  Defenders of the practice deny such links, arguing that they actually lead to higher quality or even to lower costs, but, honestly, it must be hard to say that with a straight face. 

Ironically, it seems like the one area where physicians seem to have less desire to own are physician practices themselves, which have seen a sea change in ownership by hospitals.  Less than half of physician practices remain independent.

Maybe ACOs and/or bundled payments will solve this problem, which I would refer to as self-referral had Rep. Stark not already claimed that term (although his efforts obviously have not met with persistent success), but I’m not optimistic.  It just seems like the people figuring out how to make more money from the health care system are smarter than the people writing and enforcing the rules that try to restrict them.  Or they have better lobbyists.

To be fair, I don’t really care all that much about who owns what or even how much their profit margins are.  What I care about with health care is if I receive the right care at a reasonable price…it’s just that both of those remain fairly nebulous concepts.  In health care, more than in any other sector of the economy, I want to have confidence that the people and organizations providing services to me care more about my well-being than they do their own financial well-being.  Those don’t have to be incompatible, but how do I know when they are?

Which leads me back to Mr. Bodaken’s bold effort.  The point is that profit margins may not be the best way to evaluate health plans.  Nor are medical loss ratios.  The proof of the pudding is in the eating, and the proof of health insurance is how expensive it is, relative to the benefits.  From a societal standpoint, we want to ensure that insurers don’t get to lower premiums by unfairly denying claims, providing poor service, or cherry-picking the healthier members.  If a health insurer really achieves lower premiums because they have better deals with providers or manage the health of their members better, why should we care what their profit margin is? 

Profits are not, in themselves, a bad thing, and I don’t understand why some people seem to think they are especially bad in health care.  It’s about demonstrating value.  After all, Apple makes close to 25% on its products, and people seem to love them.  Too bad they are not in health care (yet).  In health care, you’d need to be Sherlock Holmes to figure out what value is and how to know when you are getting it.  The 2% solution won’t do it.

What, Us Measure?

By Kim Bellard, May 18, 2011

I read with some interest an article in the Wall Street Journal outlining Wellpoint’s new approach to hospital payments, in which future payment increases would be tied to performance on 51 quality measures.  As interesting as that is in itself, what fascinated me even more was the reaction of Chip Kahn, the President of the Federation of American Hospitals.  Mr. Kahn did not appear too excited about the approach.  As he told the Journal: “We don’t have good outcomes measures yet.”

I don’t mean to take a shot at Chip Kahn or the Federation.  They are strong advocates for their members.  To its credit, the Federation has actively been involved in quality efforts for many years, including the Hospital Quality Alliance.  But, seriously – we pay hospitals some $800 billion per year, and we don’t have good outcome measures yet?  What are we waiting for?

A recent study by the Beryl Institute, whose mission is to improve the patient experience, indicated that 31% of hospital executives listed quality/patient safely as their organization’s top priority over the next three years, followed by 21% who cited patient experience/satisfaction.  The Beryl Institute seems to view this as good news, and I suppose it is good that no other single priority topped these two, but I have to wonder: so, almost half of respondents did think something else was their top priority?  

“Adverse events” – injuries caused by medical errors -- have been one of the open secrets in the health care system, and a recent study indicated that the problem may be as much as ten times worse than thought – impacting up to one third of hospitalized patients.   With those kinds of problems, if I ran a hospital, I might not want to track outcomes either, or at least not report them.

Wellpoint isn’t alone in targeting hospital quality.  Many health plans have implemented some version of pay-for-performance, although they tend to be paid as incentives rather than core to reimbursement.  Last month CMS announced the final rules for its Value Based Purchasing Program, which begins in 2012.  Medicare will also pay based on performance, initially as incentives but rapidly moving to reductions for hospitals that do not perform well.  The CMS measures are oriented towards process and patient satisfaction indicators, whereas 55% of Wellpoint’s measures are based on health outcomes, 35% on patient safety measures, and 10% on patient satisfaction.

Of course, quality measures are not just a problem for hospital performance.  Hospital quality measures are more evolved than physician quality measures, and both are far ahead of other parts of the health care system.  As Kenneth Kizer, founder of the National Quality Forum (NQF), said: “There are many areas of medicine where there simply are no measures – or there are, but they aren’t as good as they should be.” 

There certainly is no shortage of organizations working on the issue.  In addition to NQF, one could cite The Leapfrog Group, NCQA, CMS, the Physician Consortium for Performance Improvement, and several medical specialty associations, among others.   Still, the sense from the provider community seems to be that we’re not quite there, certainly not to the point where consumers should be making judgments based on the various indicators, nor having reimbursements materially impacted by performance on the measures.  They like the measures to be voluntary, although the recent CMS report on the Physician Reporting Quality System indicate only one in five health care professionals who are eligible to participate actually do – and only slightly more than half of those earned satisfactory scores which merited bonuses. 

It’s too bad, because it appears that the “standard” measures that consumers tend to look at to evaluate physicians, such as education or board certification, don’t appear to actually distinguish quality performance very well, according to a study by Rachel Reid and colleagues.  As the authors concluded:  “Few characteristics of individual physicians were associated with higher performance on measures of quality, and observed associations were small in magnitude. Publicly available characteristics of individual physicians are poor proxies for performance on clinical quality measures.”

Similarly, a study by Lauren Nicholas and colleagues published last fall indicated that the “process” measures currently reported by CMS on its Hospital Compare website don’t correlate with actual patient outcomes, such as mortality rates or surgical complications. 

How in the world did we get to the point of spending so much money on health care without even being able to measure if we’re doing it well?

I’ve complained about the lack of data in health care in previous blogs (such as in Gambling on Health Care), but it still disturbs me.  Maybe when – or if – we get to a world of electronic medical records and fully realized health information exchange we’ll have a better job of getting the right data; that is the point of “meaningful use.”  Still, I go back to another quote from Kenneth Kizer: “Nothing makes a performance measure better than when it starts being used.”  We need to start using the existing measures more now.

Putting performance data out there is half the battle, and I applaud the many people and organizations working to make that happen, hopefully sooner rather than later.  The other half of the battle – and one that, frankly, worries me even more -- is getting people to use it.

Designing the Perfect ACO

By Kim Bellard, May 4, 2011

Accountable Care Organizations (ACOs) are supposed to be the way forward in improving our health care system.  CMS has recently released proposed rules around Medicare ACOs that help detail the requirements, with Medicare getting ready to start making funds available for ACOs as early as 2012.  The private sector is expected to follow in Medicare’s footsteps with their own versions of ACOs.

Since ACOs hold the prospect of being the new delivery system for many or even most Americans, I wanted to propose my own wish list for what I hope will be true of the ACO experience:

• I want to go to an ACO physician knowing something meaningful about him or her.  Not just the standard medical school/board certification/professional designation information, but facts that give me insight into actual (and recent) performance.  I.e., what is the profile of the patients he/she sees?  How well do patients with chronic conditions receive the recommended set of services?  For physicians doing procedures, how many do they do, and what are their outcomes?   Perhaps most importantly, what do patients report about their experiences with this physician?  And not just current patients, but also former patients; e.g., are they former patients due to no continued need, or due to a bad experience?
• I think it is entirely fair that better-performing physicians get paid more, whether by me (via my cost-sharing) and/or by the ACO/insurer.  In fact, I think it is downright dangerous if that does not happen.  If everyone gets paid the same, the more likely it is that everyone performs the same, and I want my physicians striving to be the best.
• I want the physician to have my medical records readily available – not just from prior encounters with him/her, but including all the relevant information from all of my recent encounters with the health care system.  E.g., tests, imaging, prescriptions, reports from other physicians (primary care or specialists).  Presumably this speaks to a unified electronic health record -- permission-based, of course.  He/she needs to know the whole picture, and I don’t want to keep trying to accurately fill out the same or similar forms each time I see a provider.
• I want access to my health records.  Not in the same language and format as the physician sees them, but based on the same information, yet in a consumer-friendly version that helps make my health history understandable and actionable, so I can do my best to maintain and improve my health.  I should be able to provide my own input into the records, some of which would be purely for myself and some of which could provide additional insight for my physician(s).  After all, when it comes to reporting my own health, who better?
• I want the physician to be reminded of any medically indicated actions for me; e.g., am I not refilling my prescriptions, is it time for a preventive test or procedure, were there concerns from prior visits that should be followed up on?   Physicians are generally very smart people, but the data are pretty clear that many patients are not getting all of the recommended services and oversight.  We shouldn’t rely solely on the physician’s memory to help remind them what should be happening, and when, with me.   For that matter, I want to be reminded as well.
• I want to know that the physician is not acting solely on his/her own for my treatment, that there is some effective peer review in the ACO that monitors the care he/she is providing, and actively provides feedback.  It’s not about suspecting the physician is doing a bad job; it’s about instilling an attitude of always wanting to do things better.  Measurement and feedback loops are Quality Improvement 101.  Physicians are notoriously independent, but that is not an attitude that leads to strong QI.
• I want to make sure my physician and I use the most efficient mechanisms to communicate.  Sometimes he/she needs to see me in person and “lay on the hands,” but many issues can be handled through other mechanisms like texting, email or video.  How and where we communicate shouldn’t be driven by insurance reimbursement concerns, but by what is most time-effective and medically appropriate.
• I want my physician to help coordinate any other testing/treatment I need.  E.g., not just refer me to another physician or imaging center, but help arrange the visit.  And I certainly expect that I would not need to tell that referred provider why I am there or to recount my history all over again.  They should have access to my records, know what the plan is for me and their role in it, and when they finish make sure everyone involved has most updated information about me.
• I want to have a single bill.  I understand, although I don’t like, that in our health care system lots of entities seem to come out of the woodwork when there is billing to be done, but an ACO should be able to consolidate all that into a clear, unified bill covering anyone they’ve gotten involved in my care.  I hate getting bills from health care professionals or entities I’ve never heard and/or for services that I wasn’t sure I’d had.  And I don’t want to be billed until they’ve worked everything out with the insurance carrier.
• I want reassurance that the professionals treating me don’t simply get paid by doing more things to me, or get paid the same regardless of how well they treat me.  I don’t think either a fee-for-service or a salaried approach is inherently evil; both need to be coupled by rewards for getting good outcomes and penalties for poor outcomes, which include providing unnecessary or inappropriate care.  To be fair, though, physicians shouldn’t be penalized if I am non-compliant or remain passive about taking active efforts to maintain or improve my health.  Splitting those hairs is going to be tricky.

The good news is that none of these are unachievable even in the current health care system.  One can probably find a few integrated delivery systems that already accomplish many of these goals.  The bad news, of course, is that none are doing all of these, and most consumers don’t have access to a delivery system that does even a majority of them.  That’s assuming we can get agreement on how to accomplish them, particularly measurement of and reporting on physician performance.  We have a long way to go...

Gore Someone Else’s Ox, Please

By Kim Bellard, March 24, 2011

News flash: health care spending is out of control. 

Sadly, this is nothing new.  It’s been “out of control” for decades.  If we are serious about controlling health care spending -- and I’m not sure we are yet -- we may need to think not just about on what services the money is spent but also about to whom it is paid.

The facts are fairly well known.  U.S. national health expenditures were estimated to be $2.5 trillion in 2009, which consumed 17.6% of Gross Domestic Product (GDP).  Another decade and health spending may account for one-fifth of the national economy.  The spending is a source of concern in itself, but it is especially so when compared to other industrialized nations.  We spend over double per capita of the average of the other OECD countries, and the country with the next highest percentage of its economy devoted to health care is France, which looks miserly by comparison at 11%.

The truly scary thing is that, despite our runaway health spending, there is ample data that we are often not getting all the services we should, and that the tens of millions of uninsured do not get as much health care as insured persons do.  Just think how much worse the spending problem might be if those problems were solved.

Last year’s federal health care reform vowed to slow the increase in spending, although the specific mechanisms for this remain murky.  Several states are taking the lead in trying to attack the problem.  For example, the state of Washington is using a Health Technology Assessment Program (HTA) to determine which services the state will cover in its program for state employees, as well as for Medicaid and worker’s compensation.  HTA tries to use effectiveness research to determine which services are cost-effective, and it is the “cost” portion of that which has raised some controversy.   Meanwhile, Arizona has eliminated coverage for several types of transplants as one of its efforts to control Medicaid spending; two patients are reported to have died as a result.   Of course, many other states are following the more typical pattern of simply slashing Medicaid reimbursement rates further.

The problem is a hard one, and it is not at all obvious what the solution might be.  In 2007 the Congressional Research Service did an in-depth study of our health care spending relative to other countries, and the report had some counter-intuitive results.  It’s not that we have too many hospital beds, nor spend too many days in the hospital.  It’s not even that we have too many doctors nor visit them too often.  On all those measures, we rank fairly low compared to other OECD countries, despite spending much more per capita on hospital and physician services.  About the only area where the U.S. seemed to clearly use more services than other OECD countries was in imaging, specifically for CT scanners and MRI…but even then we are lower than Japan, which still manages to spend much less than we do. 

CRS concluded much as Gerry Anderson and his colleagues did a few years earlier in their well known Health Affairs article: “It’s the Prices, Stupid.”  Simply put, we pay much more per unit of service, and health care professionals – at least physicians – earn much more in the U.S. than almost anywhere else. 

Many pundits point to fixing our costly malpractice system, reducing administrative overhead, and generally cutting out “waste” as the way forward.  Indeed, PwC estimated that $1.2 trillion of the $2.4 trillion in spending was wasteful.  As evidenced above in Washington and Arizona, though, “waste” is not so easy to identify.  Reformers are forgetting one key truth: one person’s waste is another person’s income.

Let’s think about spending.  The money spent on health care goes somewhere, to someone.  It doesn’t disappear down a black hole and vanish.  It ends up as revenue for a variety of entities in the complex health system ecosystem, such as doctors, hospitals, pharmacies, nursing homes, home health agencies, labs, imaging centers, and health insurers/administrators.  Controlling health care spending means some of those entities will collect less revenue than they would have collected otherwise, and that’s the rub. 

Maybe we don’t need as many specialists, or maybe don’t need to pay them as much.  Maybe more generic drugs could be used, or maybe we could pay less for brand drugs.  Maybe insurers’ medical loss ratios should be higher, or maybe we could curtail their premium increases.  Maybe spending on diabetes and bariatric surgery would go down if we identified people at risk earlier.  Maybe.  But none of the entities currently receiving the money for any of these examples will be keen to have their revenue go down.

To be sure, reduced revenue does not necessarily mean reduced income/profit.  There certainly are huge inefficiencies in our health care system, and pressure on revenues should, in a capitalism system, result in more efficient competitors.  But those pressures in that capitalism system should also result in some of the affected entities not surviving, and when it comes to health care, we don’t seem too keen on that. 

Competition should spur innovation and better value for consumers, but those are hard to accomplish.  It’s easier for at-risk organizations to fight for the status quo, at least for oneself.  It seems that every type of health care entity has its own trade association which vociferously advocates for its interests, including payment rates and eligibility of its services.  And the threat of reducing services usually alarms current recipients of those services, who are sure they not only need them but are entitled to them.  No one wants to have the dreaded R-word invoked, and yet no health care provider wants to take a pay cut.  It’s the irresistible force of health care demand against the immoveable limit of health care budgets. 

The hard fact is that whenever health care spending finally gets under control, as it inevitably must, there will either be fewer health care providers or those providers will be getting less money – or both.  The danger we face is that the reductions will be arbitrary and/or across the board.  We should be able to do better than that.  There’s nothing inherently wrong with specific health care providers making a lot of money.  One would want health care providers who deliver high quality, effective care to their patients to do well financially.  On the other hand, though, it is ludicrous to be paying the same to providers who are not doing well for their patients, whether that is not delivering appropriate treatment, making medical errors, or simply not getting good results.  It’s even silly to be paying “average” providers the same as high performing ones, yet we do this millions of times every day.  Right now, of course, it’s virtually impossible to tell which providers are which.  Where’s the data, where is the proof, and why don’t they – or we – seem to care?

Reform should mean making sure competition is based on delivering demonstrably better care and services, not on factors like geographic dominance, better lobbyists, or the simple inertia of not wanting to harm “my” doctor/hospital/pharmacy/etc.  Face it: there is going to have to be some goring, so we better make sure it is done to the right metaphorical oxen.

A New way of Looking at Hospitals

by Kim Bellard, February 22, 2011

I’ve been worrying about Accountable Care Organizations (ACOs).

What is there to worry about?  I mean, what could possibly be wrong with entities whose purpose is to be accountable for the cost and quality of care of patients, and who are rewarded for doing a better job of delivering that care?  Aside from the pesky facts that no one is quite sure what an ACO actually is or how to make it effective, the concept is surely what our health care system – and perhaps other nations’ – needs. 

Some skeptics look at ACOs with a jaded view – been there, tried that – thinking back to the PHOs/IPAs of the 1990s or even the original concept of HMOs, especially the staff model HMOs (e.g., Kaiser Permanente or Group Health Cooperative of Puget Sound) that used to dominate the field.  Still, optimists are sure this time it will be different. 

I tend to believe that it will, indeed, be different, but in ways that are the source of my concern.  Of the many changes in health care since we last made a serious run at controlling costs in the 1990s, two are most problematic for ACOs: hospital consolidation and hospital ownership of physicians.  I’ve touched upon those in a previous blog (Saying No to Choice), citing studies of increased hospital market consolidation and estimates that over half of physicians are now employed by hospitals.  Those changes have radically changed the competitive landscape, giving hospital systems much greater negotiating power.  Last November The Center for Studying Health System Change issued a report “Wide Variation in Hospital and Physician Payment Rates Evidence of Provider Market Power” that illustrates even in supposedly competitive markets certain providers can virtually dictate pricing. 

Regulations for ACOs may give providers even more ability to band together, citing the need for increased clinical integration as a rationale.  This may, though, just further open the door to anti-competitive behaviors, and various experts are already raising concerns (see, for example, the recent New York Times article).  If ACOs have the effect of extending hospital control in already non-competitive markets or sub-markets, we may or may not get improved quality of care but it is unlikely we will achieve improved cost control. 

What is different with hospitals than with physician practices or most other health care entities is that it simply is too expensive to build new hospitals in most markets.  I.e., expecting to interject new hospitals into non-competitive marketplaces is not realistic.  In that sense, hospitals enjoy advantages similar to those that the utility, telephone, or cable companies once enjoyed.  In those cases, no one wanted to pay to connect new lines to all the potential customers, so regulators for those industries either regulated pricing or forced competition, such as when AT&T was ordered to allow other long distance carriers to use its lines.  Instead of increasing the number of hospitals, imagine if hospitals were required to lease out beds or entire floors to competitors.  That could go a long way to diminishing the kind of local geographic monopoly many hospitals currently enjoy. 

I think we may have the wrong conceptual model for hospitals.  In a retail analogy, one can view the hospital as a department store – trying to sell as many things to as many kinds of customers as it can.  Within the department store, as with the hospital, there are specialized departments targeted at specific types of customers.  Department stores often have boutique areas featuring well-known designers, and along the same lines some hospitals feature well-known specialists; both strategies aim at further improving market appeal.  Department stores once ruled the retail world; think of the huge, blocks-long Macys, Marshall Fields, or Hudson’s that once lined downtown shopping districts.  They might remind one of the huge, blocks-long urban hospitals that still dominate many cities. 

I would argue that our health care system might be better served if hospitals were less like department stores and more like malls. 

In the mall analogy, the hospital is the “landlord.”  It provides the physical space and shared services, which in the health care world would include not just rooms, light and heat but also a basic level of medical devices as well as electronic connectivity to EHRs and/or billing services.  Their “tenants” would be various ACOs, which lease the space for their patients who need inpatient care and add any differentiated equipment or staff the ACOs deem necessary.  The hospital in this model does not deliver care and does not own practitioners who deliver care, although its “lease” agreement should give the hospital an interest in assuring that their tenants are effectively providing care.  The hospital would want to ensure that it contracts with a wide variety of quality ACOs, so as to be attractive to a wide patient constituency. 

For this new approach to hospitals to work, it may be necessary to separate out the hospital-as-physical plant from hospital-as-intellectual property.  The latter may be the entities that create or partner with ACOs, while the former provides the platform for inpatient care to multiple ACOs.  Innovations developed in specific service lines could help give an ACO a competitive advantage, without locking other ACOs out from other approaches using beds in the same location.  The transition to this new model would not be simple, but hospitals would not be the first industry to have monopoly providers split up to ensure competition, so it could be done.

We still would face the core issue of how to ensure that there are sufficient numbers of ACOs to give consumers meaningful choice, as well as that those ACOs are capable of being responsible for the cost and quality of care.  Multi-specialty physician groups would seem to be one obvious solution, but they are not widely prevalent, nor easy to create or to run.  ACOs are likely to still require capital and management partners, which may include hospitals, and will take some time to develop and mature.  However, I don’t think the challenge of developing effective ACOs is any worse under the proposed approach, and not having the “Big Brother” hospital systems in the picture may actually make the challenge easier.

One alternative to making hospitals compete through a more open model would be to move to a regulated, all-payor hospital rate system, as proposed by Uwe Reinhardt and others.  This approach is certainly an option, although one that was tried in a number of states in the 1970’s and 1980’s but which only survives in Maryland.  The challenge for such systems is how well they can resist the various pressures, political and other, that seek to undermine the neutrality of the approach, especially as state and federal budgets are increasingly strained by Medicare and Medicaid expenditures. 

Personally, I prefer interjecting more competition into the system, but doing so would require a radical change in our concept of what hospitals are and how they compete.  Hospitals have always been essential community institutions, and my guess is that they are going to remain so.   We just need to make sure they don’t become monopolies, whether that is as health systems or as ACOs.  

Quis custodiet ipsos custodes?

by Kim Bellard, February 1, 2011

Don’t worry if your Latin is as rusty as mine; I’ll provide a translation of the title a little later on in case its meaning has not become clear by then.

The New York Times recently got a lot of attention for their story about older physicians, reporting that one-third of U.S. physicians are over 65, and that proportion was expected to rise as baby boomer docs increasingly begin to hit 65.  The Times pointed out that, while many of these older physicians provide excellent care, there are not strong mechanisms in place to assure continued competence of the aging physicians, and, in fact, many older physicians are “grandfathered” (pun unintended, one hopes) from efforts intended to help demonstrate physicians’ continued expertise, like tougher board certification standards.  They contrast the situation for physicians with that of pilots, who not only face mandatory retirement at age 65 but also are required to begin periodic physical and mental tests at the tender young age of forty. 

With all due respect to the Times, the issue is not age (and, by the way, their estimate of one-third of physicians over 65 appears overstated – as best I can tell, one third of physicians are 55 and older, but slightly less than twenty percent are currently over 65).  The issue is competence and demonstration of that competence, regardless of age. 

In 2009 Sidney Wolfe and Kate Resnevic of Public Citizen analyzed data from the Federation of State Medical Boards (FSMB), and found that disciplinary rates per 1000 physicians ranged from .95 in Minnesota to 6.54 in Alaska, with the overall U.S. average at 2.92.  According to their analysis, that latter number has actually been dropping in recent years, over 20% lower than the peak in 2004.  Maybe physicians are getting better, and maybe the doctors are that much worse in Alaska (or in Kentucky or Ohio, the next highest states), but one has to worry about how well problems are being reported. 

Indeed, last year Catherine DesRoches and her colleagues published an article that reported survey results about physicians’ attitudes towards peer reporting.  Only 64% felt a professional obligation to report fellow physicians who were significantly impaired or otherwise incompetent to practice.  Seventeen percent of the surveyed physicians had direct personal knowledge of a physician colleague who was incompetent to practice, although only 67% of those admitted they actually reported that colleague.

The disciplinary actions and the survey results don’t measure quite the same thing, but one has to worry that there is too big a gap between 17% of physicians knowing an incompetent colleague and yet, on average, only 0.3% of physicians with disciplinary actions.   Even if the latter number was the “right” number, the variation of the disciplinary rates between states would still be troubling.

Economist Mark Perry, of the University of Michigan and a visiting scholar at the American Enterprise Institute, has some strong views about the medical profession.  Not pulling any punches, he likens the medical profession to a cartel (see, for example, this blog entry).  He contrasts the number of law schools versus medical schools over the past 100 years.  The former has grown sharply (much to many people’s dismay!), while the latter has dropped even in the face of predictions of looming physician shortages due to population growth and aging of the population (all those baby boomers hitting 65!).  The number of schools is perhaps not the best measure, but the number of students graduating from medical school each year has not changed substantially over the past 30 years (something some blame on federal policies on residency training funding).  The number of physicians per 1000 residents has been increasing over the past several decades, but this is due in large part due to importing physicians from other countries rather than graduating more in the U.S.  Despite this increase, the U.S. still ranks well below the OECD average for practicing physicians per 1000 population.  We just pay physicians much more than other countries (as reported by the Congressional Research Service and others.  But that’s a topic for another blog.

It has always been difficult for consumers to get information on physician performance.  Sites such as Healthgrades or WebMD have some information on physicians, but to date they have still been largely demographic in nature.  The FSMB allows consumers to get some information on individual physician disciplinary actions, at $9.95 per result.  Some specialty associations are developing quality measures aimed at consumer reporting, as are NCQA and others.  Various health plans have been trying to publish data on physician quality, although not without controversy.  Most recently, Medicare launched its Physician Compare site, as it had done some time ago with Hospital Compare; the launch has its critics (see Michael Millenson’s view).  All of this is good – and none of it is enough.

The medical profession takes great pride in its work, and since the medical school scandals of the early 20^th century has fiercely kept control over medical training and oversight.  In medieval days guilds served the purpose of ensuring that trade secrets and practices in specific areas stayed within the members of those guilds.  Both the legal and the medical professions retain many characteristics of those guilds, including having de facto monopolies for their field of expertise.   Whether that is good or bad can be debated, as could how much of a monopoly either actually enjoys, but as consumers we should be able to expect demonstration of that expertise, not just have to take it on faith.   And we should be able to assume that the profession will do a good job of policing its own members and standards.

As can be inferred from my prior blog entries, I am a big believer in the importance of transparency of information and of consumers’ right to get – and obligation to use – information on the services they may receive and the practitioners from whom they may receive them.  We need our health care professionals focusing on improving the quality of care, which already is neither as high nor as uniform as it should be (see, for example, my previous entry “Gambling on Health Care”).  We shouldn’t also need to wonder if the medical profession is properly ensuring that their brethren are adhering to the adage in the Hippocratic oath -- “first, do no harm.” 

Sad to say, one only has to pick up a newspaper to realize these concerns are very real.  It certainly wasn’t the sole responsibility of local physicians to report or of the state Board of Medicine to put a stop to the recently discovered events at the abortion clinic in Philadelphia – some physicians did try, and the city and Health Departments also didn’t do their parts -- but the local medical community and the Board both evidently had some knowledge of the horrors and must bear some of the blame for not doing more to protect those patients.  Who was watching out for them?

About that title.  It has been more decades than I care to admit since I took Latin, but fortunately Wikipedia helped me find the right quotation.  For those of you similarly not fluent, it means “Who will watch the watchers?”  

Saying No to Choice

Kim Bellard, January 6, 2011

I read one of the most astounding articles last week.  It appears that the Ohio Board of Pharmacy doesn’t think much of consumers opting to shop pharmacies.  In rules that went into effective January 1, Ohio consumers will only be permitted to transfer prescriptions once a year, except for transfers within a pharmacy chain using a centralized computer system.

The Board’s rationale is that transfers can result in errors, thus making the new rules a patient safety issue.  They also note that these rules are more consistent with DEA rules on transfers of prescriptions for controlled substances.  Critics of the rule suspect that pharmacists did not like the time and paperwork associated with the transfers, much less the competition brought about by various retailers offering discounts or other incentives for such transfers. 

Consumers can switch pharmacies within the same pharmacy chain or can obtain new prescriptions from their doctors in order to go to a new pharmacy.  Staying within one pharmacy chain may miss the point of the consumer’s desire for a change, while forcing the doctor to write a new prescription simply shifts the burden to the physician, and also makes it more difficult for PBMs and insurers to monitor utilization.  And it’s not just price-conscious consumers who may be impacted; snowbirds, college students, or other individuals who have more than one residence during the year may also be out of luck. 

So much for being consumer-focused.  Rather than focusing on true patient-safety solutions like better ways to electronically enable such transfers, the Board of Pharmacy is just telling consumers “too bad.”  We should keep in mind that pharmacy has long been the envy of the rest of the health care world due to its decades-long ability to get online claims, benefits, and eligibility information.  One would like to think they could solve something like prescription transfers in a more elegant manner.  It strikes me a little like when the mobile phone companies used to tell consumers they’d have to change phone numbers if they switched carriers.  I’m sure there were some record-keeping headaches with transferring phone numbers to a competitor as well, but somehow the phone companies survived once they were forced to allow the transfers.  Telling patients they can’t take their prescriptions elsewhere just seems paternalistic; pharmacists should worry more about why consumers want to take their business elsewhere and then address those reasons.

Can anyone imagine something like this happening in any industry other than health care?  Historically, consumers have consistently rated pharmacists as one of the most trusted type of health care providers, such as in a recent Gallop survey.  It’s hard to see how this action will help pharmacists continue to earn that level of trust.  The Board of Pharmacy comes off more like a Soviet Board of Central Planning, and our health care system once again reveals that it doesn’t quite grasp the concept of consumer-focused. 

Meanwhile, the New York Times reports that drug companies are using coupons and co-payment cards to reduce the effective cost of brand names for consumers (although not to PBMs or insurers).  Consumers have been following the money these past few years, especially since more have copayments or coinsurance that encourage use of less expensive drugs, and the result has been an increase in generic drug use.  No wonder consumers are changing pharmacies.  With the coupons, consumers can get brand names as cheap or cheaper than generic, so from their point-of-view, why not?  It’s not surprising that the drug manufacturers are fighting back to regain market share, nor is it surprising that we have yet another perverse financial incentive for health care consumers. 

One wonders how the Board of Pharmacy will react to the coupons.

Still, perhaps lacking a regulatory option that pharmacists in Ohio had, some health care providers are finding their own way to limit choice.  The past fifteen years have seen waves of consolidation in hospital markets, creating effective or actual monopolies for hospital care in many markets.  According to William Vogt, Ph.D. of the RAND Corporation, 90% of the U.S. lives in “highly concentrated” hospital markets, and that hospital consolidation raises hospital prices.   The Robert Wood Johnson Foundation raised concerns about this back in 2003, noting both the trend and the impact on costs, and the trend hasn’t stopped since then.  It doesn’t even have to be a true monopoly.  Last year the Massachusetts Attorney General found that health insurers paid significantly more to hospitals and physicians with market leverage than can be accounted for by quality of care, severity of illness of patients served, or cost to deliver the care for these institutions.   These “must have” provider systems are able to dictate contractual arrangements with insurers that help assure better financial results for their system, but also help drive up the overall cost of health care and health insurance in those markets. 

Health care reform in 2010 created the specter of even greater consolidation, such as reported by Bloomberg and others.  To have even greater control of the health care delivery system, hospitals are also acquiring physician practices.  As reported by the Wall Street Journal, 55% of practices are now owned by hospitals, up from 30% five years ago.  It doesn’t take too much imagination to envision some markets where, for all intents and purposes, there comes to be only one monolithic health system, including doctors, hospitals, labs, imaging, and other services.  It could make cable service look like a hotbed of competition.

More horizontal and vertical integration may indeed be good in many cases.  Increased clinical integration between providers is going to be necessary to improve care.  The need for increased investments in Health Information Technology (HIT) is likely to be costly and is more affordable for larger organizations.  These reasons certainly provide some solid rationale for more consolidation and integration.   However, the risk is that we’ll get the reduced choice without offsetting improvements in cost-effectiveness and quality.  The goal shouldn’t just be “bigger,” it needs to truly be “better.”

Consumers should have choices in health care, as in anything else.   Reforms in the health care system should encourage competition and consumer choice, and should help make those choices be based on measurably better performance, both clinical and financial.  We should be saying “no” to actions that don’t serve that purpose. 

Gambling on Health Care

by Kim Bellard, November 23, 2010

I heard a speech by Tom Daschle recently, and something he said really struck me: to paraphrase, he pointed out that we can get more performance statistics on virtually every athlete than we can on any physician.  He’s not entirely right, but he’s close enough for this statement to hit home.

My tablemate at the speech suggested to me that fantasy leagues in health care might help solve this problem, which I think is a great idea, but perhaps what we really need to motivate getting more information on health care providers would be to introduce gambling into the health care system.  Oh, wait, cynics might argue that we already have gambling; we call it health insurance, and the bookies are actuaries. 

I’d argue that we have a different and more insidious form of gambling: simply getting care.

The HHS Inspector General recently released a report indicating that 13.5% -- that’s one in seven -- of hospitalized Medicare beneficiaries suffered an adverse event that caused a lasting impact or even death during the month reviewed; some 134,000 patients just in one month.  Worse than that, 15,000 of those patients ended up dying due to their adverse event; just in one month, just for Medicare patients.  An additional 13.5% of the hospitalized beneficiaries suffered events that caused temporary harm.  The researchers determined that 44% of the various events were preventable, and that the adverse events cost Medicare some $4.4 billion annually.  I say again: these deaths, and those costs, are only for Medicare patients. 

Sad to say, but these statistics no longer come as a surprise.  It’s been over ten years since the Institute of Medicine produced their estimates that as many as 98,000 deaths annually are due to medical errors.  The IOM also estimated that medication errors injure 1.5 million people annually.  Various other studies, including Zhan and Miller (2003), come up with similar sorts of numbers for hospital deaths.  I previously blogged about a study reporting on adverse surgical events that should scare anyone facing surgery.  One could conclude that going into a hospital is a crap shoot as to if you’ll be walking out with both legs intact, or walking out at all.

And it’s worse than that.  A study by a study by McGlynn, et. al., indicated it’s also essentially a coin flip as to whether you’ll get the recommended care when going to the doctor’s office.  Similarly, a study by the Urban Institute cautioned that “…patients may be at greater risk of safety problems in the United States than they are elsewhere,” citing issues with surgical and medical errors, issues with safe medication practices, receiving delayed or incorrect test results as examples. 

Given all these problems, one could naively conclude that it is no wonder that medical malpractice costs are high; reimbursing patients harmed by all this problematic care would be expensive.  That would be naïve indeed.  It appears that our malpractice system doesn’t make either patients or health care providers very happy.  Studies suggest that only a very small number of patients suffering actual medical errors even filed claims (see Localio, et. al.), and that as much as 54% of every dollar spent on compensation go to administrative expenses, such as lawyers’ fees and court costs (Studdert, et. al.).  Then there is the shibboleth of defensive medicine, which everyone agrees exists but which is hard to quantify.  Mello, et. al. bravely estimates that defensive medicine accounts for about $46 billion of the estimated $55 billion spent on medical liability, while Jackson Healthcare concluded that the order of magnitude was between $650 billion and $850 billion.  Whatever the number is, we can all agree it is big.  Defensive medicine as a way to reduce malpractice risk is like trying to hit a piñata; not really sure where the target is or what will happen if you do hit it. 

Which leads me back to statistics.  Our current liability system is based on fear and blame.  Documenting and reporting on errors can indeed seem foolhardy in a system that seeks to find deep pockets, not to fix problems or improve care.  It’s no wonder better data doesn’t exist and available data is hard to find.  Reform efforts based around capping liability payments miss the point almost entirely.  We need an entirely different mindset.

We have to start with the data: what happened, what went right, and what went wrong.  We should be looking for patterns, trends, and opportunities – not for culprits. 

We have to recognize that not everything that goes wrong is malpractice.  The notion that we will ever have an error-free health care system is folly, but at least we can get a clearer idea of who is making which errors how often.  Errors need to be tracked, and used to identify processes that can be improved.  Only with that kind of data can true quality improvement efforts happen.

Just as there will always be errors, there will also always be some unexpected medical outcomes.  Those are unfortunate, but they may not be due to any errors and may not be anyone’s fault.  They should be treated and fixed, without recourse to litigation or blame.  However, expecting patients or their insurance to pay for this follow-up care can unduly reward providers in a fee-for-service system, and payment reform should address.

There will still be a small number of situations where a health care provider is practicing in a manner that is not consistent with available medical evidence or best practices, is treating patients while impaired, or otherwise not acting in the patient’s best interests.  These are the situations where liability comes into play, but one would hope in a more transparent environment there would be fewer opportunities for harm to occur.  In theory, the medical profession self-polices itself, disciplining wayward members, but it is hard to imagine how this could ever happen under the current system of haphazard and incomplete reporting. 

Collecting the necessary data, and making it public, should go a long way to ensuring that patients are getting the right kinds of care from the appropriately qualified providers.  If we’re going to gamble with our lives and our well-being, I want to know the odds and I want to make sure I’m getting care from someone who would be on my health care fantasy team.

Prescribing Profits

By Kim Bellard, November 10, 2010

Marcus Welby pushing more expensive drugs on his patients in order to increase his income?  Impossible to imagine!  Of course, Marcus Welby was a family physician not given to costly treatments, and is now almost entirely unknown to anyone under 50, but one has to wonder what’s become of our health system given what some physicians are doing with their prescribing pads. 

The New York Times recently broke a story that Genetech was giving eye doctors “secret rebates” to use the more expensive Lucentis instead of Avastin to treat age-related macular degeneration (AMD).  Ironically, Avastin is also made by Genetech, and has been used for AMD for several years, although it was not designed or approved to treat that condition.  Lucentis can be more than ten times the cost per dose, the bulk of which is usually paid for by Medicare and private insurance.  However, there is yet no data to suggest that Lucentis is more effective than Avastin; even if equally clinically effective, it certainly would be much less cost-effective at its current pricing.  The rebates can reportedly amount to tens of thousands of dollars for a physician practice each quarter.  The Times quoted one retinal specialist as saying “There’s no way to look at that without calling it bribery.” 

Alas, the influence of financial considerations on prescribing costlier care appears not to be an isolated problem.  In 2006 Mirelle Jacobson and colleagues asked the question “Does Reimbursement Influence Chemotherapy treatment for Cancer treatment” in Health Affairs.  The good news is that reimbursement did not appear to impact the initial decision to administer treatment, but the bad news is that physicians who received more generous reimbursement did, in fact, administer more costly drugs. 

Medicare has attempted to address the cancer treatment reimbursement issue – to neither side’s evident satisfaction – and recently United Healthcare has initiated a program of its own.  It announced a pilot program that pays oncologists for the entire treatment program, regardless of the drugs administered.  It deliberately tries to remove – or at least limit the continued growth of – the portion of the physicians’ income based on profits from chemotherapy drugs.  In its coverage of the program, The New York Times quotes an oncologist as saying “A lot of us want to get out of selling drugs.”  Aetna and several other payers are developing their own programs.

Of course, one doesn’t have to work too hard to find studies demonstrating disturbing impacts of other perverse financial incentives within our fee-for-service system.  For example, studies indicate the clear impact of physician ownership of ambulatory surgical centers on number of surgeries performed (see, for example, Hollingsworth or Mitchell.  Similar results exist for imaging.  Then there is the oft-cited New Yorker article by Atul Gawande on the peculiarly high cost of care in McAllen, Texas.  There are both anti-kickback and self-referral (aka Stark) laws to prevent such apparent abuses or conflicts of interests, but one would have to conclude they are not having quite their intended effects. 

So what’s the big deal?  If patients want to buy services from physicians, why should they – or we – care about how much money those physicians might be making on those services?  Isn’t that capitalism?

Yes and no.  I cling to belief in a market-based structure for our health system, with appropriate protections for low-income and other disadvantaged individuals.  I have no problem with people making money in the health care system, and think it is great when individuals and institutions that achieve better results for their patients get more patients and make more money. 

Unfortunately, our system doesn’t make it easy for that to happen the way one might want it to.  The above examples highlight two key missing pieces that are needed for a truly market-based health care system:

• Performance: for the most part, patients don’t have good information on the efficacy or relative performance of the treatments they are “buying” or on the providers from whom they are receiving them.  They certainly can’t be viewed as making informed decisions.  It’s hard to say who to blame more for not caring more about making such information readily available – patients or health care providers – but there can be no real health care reform without that kind of information, comparing treatment options and providers. 
• Other People’s Money: if consumers want to spend their own money on frivolous or overpriced goods, well, that’s their right in a capitalist economy.  Most health care spending, though, is paid for via public or private insurance, which is a little bit of the patient’s own money and a lot of other people’s money.  As a result, they spend it differently, sort of like a college student using his/her parents’ credit card.  We can’t bend the cost curve unless both patients and health care professionals stop thinking of health care spending as other people’s money. 

Let’s get this straight: I think most physicians are good people trying to do a good job for the patient in a hopelessly complex, fragmented, and frustrating health care system.  Nor would I point the finger (at least not singularly) at health insurance companies, pharmaceutical companies, or hospitals, the entities who are most often cited by the public as the culprits.  It is the structure of the system that is failing us, with the various incentives either explicitly or implicitly built into it that don’t reward the best performance. 

Health plans, include Medicare, are working hard on “pay-for-performance” (“P4P”) programs that reward physicians for appropriate performance, particularly in terms of quality and sometimes cost-effectiveness.  Lester and colleagues studied the impact of both addition and subsequent removal of financial incentives on four clinical indicators.  They found that scores did increase with the incentives, but unfortunately fell again once they were removed.  It’s good that physicians improved their performance given targeted financial incentives, but it is troubling that they reduced that clinically appropriate behavior when no longer paid “extra” for it.  Such programs are certainly a start in the right direction, but at this point are still only a small step.

George Bernard Shaw, writing in a different time and about a different health care system, summed the problem very well: “That any sane nation, having observed that you could provide for the supply of bread by giving bakers a pecuniary interest in baking for you, should go on to give a surgeon a pecuniary interest in cutting off your leg, is enough to make one despair of political humanity. But that is precisely what we have done. And the more appalling the mutilation, the more the mutilator is paid.” 

It’s a prescription for disaster.

No to Apple Pie and Free Preventive Care

By Kim Bellard, October 28, 2010

Much has been made about the recently effective provisions of the Patient Protection and Affordable Care Act that require health insurance plans to cover many preventive services without cost-sharing.  Increasing the use of preventive services, and removing financial barriers that might prevent people from using them, are the kinds of things that most people – in both political parties -- seem to automatically approve of.  It’s practically un-American not to favor the idea.

Well, I’m as patriotic as the next person, I love my mom, but I don’t like apple pie and I don’t think free preventive care is necessarily a good idea.

While some studies over the years have found that increased use of certain preventive services is cost-effective, the evidence is neither universal nor entirely clear-cut.   For example, Joshua T. Cohen, PhD. and his colleagues raised this question in an article in The New England Journal of Medicine, and concluded that many preventive measures are not cost-effective.  They urged that care be taken to target cost-effective measures, which the new law purports to do, by focusing on “evidence-based preventive services.”  Still, not everyone is persuaded that even this focus will deliver intended savings; for example, the American Academy of Actuaries raised several good points in their response to the Interim Final Rules promulgated by HHS last summer.  Ambiguity about interpretation, over treatment, and cost-shifting to preventive service coding are cited as examples of potential problems that could have the result of increasing costs.  

I’m not going to try to argue on either side of that particular debate; I’ll leave that for the researchers, actuaries, and other number-crunchers.  My skepticism is whether making access to these services without cost-sharing via health insurance is good public policy. 

In their background on the new preventive care rules, HHS says that Americans only use preventive services at about half the recommended rate, citing a study by McGlynn, et. al.  However, as best I can tell, that study talked about recommended care on a number of fronts, and did not cite financial barriers as the key problem.  The McGlynn study is indeed very troubling, but it left me wondering why physicians were not doing a better job giving their patients recommended care, not why patients were failing to show up for it. 

Preventive care is something that most Americans should be able to afford.  If it is too expensive for at least middle class Americans to pay for directly, then we have an even bigger problem, because paying for it via health insurance is still going to require that middle class to pay for it, along with everything else insurance covers.  I get frustrated when policymakers and pundits seem to think employers and insurance companies pay for health insurance with “their own” money.  These entities aren’t like the federal government, which can print money and/or borrow money from China.  It is a poorly understood truism that insured people pay for insurance; the insurance companies essentially redistribute the money from people who don’t use services to those who do.  Money for employer-based health insurance is coming out of workers’ paychecks; they just don’t always realize it.

That’s the basis of the problem.  We are getting further and further divorced from the cost of health care.  Health care is scary because no one knows if tomorrow they’ll get hit by a bus or feel a cancerous lump, and be faced with bills that are hundreds of thousands or even millions of dollars.  That’s why people have historically bought insurance: to protect against unforeseen and potentially catastrophic expenses.  

Preventive care isn’t like that.  The expenses are not usually huge, nor are they unpredictable.  These should be budgetable expenses, like scheduled maintenance for one’s car.  Yes, there are lower income people for whom even these expenses are unaffordable and who do need financial assistance in paying for them, but removing the apparent financial obligation from everyone as a way to solve that problem is not only overkill but expensive overkill.  Health insurance is not a good vehicle for income redistribution; it is a mechanism to redistribute money to people using services from people not using services.

I also have to wonder: if preventive visits are so important, why aren’t we including dental check-ups or eye exams?  Certainly the same arguments used to justify medical preventive visits should apply here too, especially given the increasingly accepted linkage between oral and overall health.   I say that with a wary eye to the slippery slope we’re already on; whatever preventive services will be covered initially, one has to strongly suspect that it will only be the beginning.  There is not much political will to take away a benefit once given, so services are likely to only be added to the list, not removed if/when new data comes out to challenge the efficacy of the service.  If you don’t agree, just ask Jerry Brown about the wisdom of questioning the efficacy of mammograms…

The oft-used argument is that preventive visits will pay off in the long run, although – as the studies cited above indicate – that is not always the case.  The argument posits that making it “free” now will incent people to obtain the care.  The hidden premise to this argument is that people don’t view preventive care as being of value unless it is free.  I.e., they are not smart enough to take care of themselves and won’t take the right actions for their best long-term health.  Well, in a country with 33% obesity rates and 20% smoking rates, that does appear to be a valid argument – but I’m skeptical that those people are going to be motivated to act in that interest simply by removing cost-sharing for their annual exam either.  

I hate to sound like a Grinch by not supporting “free” preventive visits, but they’re not truly free.  To me, the core issue is how to make people care about taking care of themselves, with part of that including getting appropriate care.  Call me a cynic, call me uninformed, but giving away “free” preventive care seems more like just bread and circuses for the masses compared to the underlying problem of motivating people to be responsible for their health and well-being.

Scary Stuff

by Kim Bellard, October 25, 2010

Two studies were released in the past week that are appropriate harbingers of Halloween.  The Centers for Disease Control announced that one in three adult Americans will have diabetes by 2050.  Earlier in the week, researcher Philip F. Stahel, M.D. and his colleagues published a study in the Annuals of Surgery detailing the disturbing number of wrong site or even wrong patient surgeries.

I’m not sure which study scares me more.

The CDC projections suggest a sharp increase from the current one in ten prevalence of adult diabetes.  An aging population, an increase of minority populations most at risk of developing diabetes, and persons with diabetes living longer are cited as key reasons for the increase.  Diabetes rates have already more than doubled over the last thirty years, and are closely tied to higher health expenditures and adverse health effects on impacted individuals.  Even if actual rates end up only half as bad as the CDC fears, it would still be a train wreck for health care in America.

Dr. Stehel’s study found 27,370 adverse events from January 2002 through June 2008, using a database of 6,000 physicians in Colorado.  These adverse events included 25 wrong patient and 107 wrong site operations, and came despite widely adopted universal protocols developed by the Joint Commission that were intended to avoid such mistakes.  “These happen much more frequent than we think,” Dr. Stehel says. “This is just the tip of the iceberg.” 

Diabetes, of course, can be often controlled through proper diet and exercise.  Its increase has often been tied to the similarly large increases in obesity in America – nearly 34% of adults are now considered obese, double the percentage thirty years ago, while childhood obesity rates have tripled during the same period; 17% of children are now obese.  Increased availability of fast food and lack of adequate exercise are commonly cited as reasons for the increase in obesity.  While many persons with diabetes are often unaware of having it, obesity is harder to not be aware of.  It’s not that people don’t know that they should eat better, get more exercise, and keep control of their weight; it just seems that fewer people are willing to make the necessary efforts to do so. 

Similarly, the universal protocols are supposed to ensure “never events” such as surgery on the wrong patient don’t happen, but “never events” reflect more of a goal than an achieved outcome.  The researchers note that the blame for the mistakes fall across the medical profession.  Dr. Stehel says doctors should take more personal responsibility for their errors.  

For both problems, we don’t need magic bullets; we need the appropriate parties taking responsibility for themselves.  Unfortunately, that is not as easy as it sounds.  No one wants to develop diabetes, and no physician wants to operate in the wrong site/patient.  Yet here we are.

It does seem that somehow personal accountability in health care is getting lost.  Patients too often abdicate their own decision-making for their physician’s judgment and treatment, and physicians often don’t have adequate mechanisms to admit, track and improve on their errors.  Physicians should be able to expect that patients are doing their best to maintain and improve their own health, and patients should be able to expect that physicians are doing the right thing at the right time for the right reasons.  One would have to be something of an optimist to believe that either of those behaviors are always the case. 

Halloween is all about mock scares, with children trick-or-treating in cute costumes (while receiving lots of candy that probably help drive up those childhood obesity rates!).  These studies reveal real boogeymen, things that should frighten us and cause us all to act.  These aren’t the first unsettling revelations about how poorly our health system works at times, despite its high costs.  How many more of these scary stories do we need to see before we get serious about improving it?