Health Care Reform: Not Soon

Two recent blog articles are articulate in their pessimism on the possibilities for health reform. First was Brian Klepper's piece in The Health Care Blog about politics, economics, transparency and the lack of action on quality. In places the comments are better than the article.

Then Matthew Holt argues at Spot-On that the rising numbers of middle-class uninsured may become a significant political voice.

Richard Reece at medinnovationblog offers up three concepts currently floating around. I don't think any would work... but who am I to say. He's inviting comments on his blog.

The Stigma of Breastfeeding?

Women's Health News has this problem with public places that do not allow public breastfeeding, or as in this case, insist on the use of a blanket.

I think breast feeding should be allowed in public, but also recognize a breast-feeding mafia at the margin that can make the entire world feel inadequate if it is not aligned to the needs of a nursing mother. Human beings do, in fact, pursue other activities. The use of a blanket or a sheet may be appropriate in certain settings. Hockey games, for example. A lawyer's office, judge's chambers or a church pew at Sunday service for example.

We have several thousand clients who breastfeed. In fact, of our women in a position to nurse, over 70% succeed for at least a few weeks. More than half are still breastfeeding at 3 months. These numbers, while shameful in England, are excellent for this country.

The Stigma of Obesity

Med Journal Watch interviewed Linda Bacon on obesity.

Her major thesis is that mortality and obesity are not necessarily causative. The misperceptions about obesity have led to an unnecessary medicalization and the creation of a new problem; the stigma of being fat.

Indeed she is right that mortality varies with weight along with multiple other factors. The literature has led epidemiologists to conclude that obesity is not an INDEPENDENT risk factor for heart disease. It remains a marker. Dr. Bacon's emphasis on "Health at Every Size" is a much more motivational message for patients.

On the other hand, some of the arguments in the interview don't hold water. She argues that obesity has not increased because skinny people weigh about the same as they did 15 years ago and the mid-range of the population has only gained a few pounds. Unfortunately the epidemiology also indicates that the prevalence has increased for every level of extra poundage: overweight (BMI 25-30), obese (BMI >30) and morbid (BMI >40).

It's gotten so bad that the general perception of what constitutes a healthy weight has changed. I had just finished telling one mother that her child was really obese (at age 3 he weighed the same as a seven-year old), but on my way to lunch another mother was telling her, "It's not true. He's too skinny. Look at my kids. They're fine and he's so much thinner than they are..."

Motivation and normalization are important aspects of dealing with an individual patient, but I'm not a fan of sugar-coating the status. Calling it a rose doesn't make it any less a thistle.

Residents' Work Schedules

Dr. Val looks to Labor Day as a reason to think of residents and the long hours they work. She's right, some of these folks are ridiculously overworked and it can get dangerous. Over My Med Body finally had his first night on call. It's pretty accurate in its craziness.

But there are arguments on the other side.

It should be noted that the length of time spent in the hospital has important benefits. Originally, the idea was much more than having cheap labor to benefit hospitals and attending physicians. The benefit to the learner was the opportunity to observe a patient's evolution for a continuous and prolonged period of time. A patient with diabetic keto-acidosis usually turns around in about 24 hours. You can see an elderly gentleman with pneumonia get better before your eyes in 2 or 3 days. I'll never forget my frail renal failure patient who presented for the first time in pulmonary edema. I stayed up with her all night and learned more than I ever could have going to bed. An acute appendicitis may take a few hours to diagnose and treat and a couple of days for the patient to recover. It is valuable to watch the process.

In the old days, it took a couple of days; now the patient would be discharged in 18 hours. There was a time when there was sufficient leasure in the medical teaching environment that a resident could stop and think and consider what they have been observing. I believe this process is important. In fact, without it, I would argue very little learning has occurred.

Today things have changed. Admissions are short and care is fragmented as patients are transferred through various service units: ER to ICU to step-down to regular ward... and it was still an "observation, "too short to be considered a full admission by Medicare standards.

It is a rare resident who actually choses to follow the patient past their immediate care responsibilities. When was the last time you saw the ICU resident on a med-surg unit? I know it happens, but it is the exception that confirms the rule.

The head cardiologist at my residency was musing one day that when he was chief resident, the nurses would call to let him know about someone having an MI on the ward. He would usually acknowledge it and go back to bed. There was nothing to be done in those days.

I don't think working forty eight hours straight is the problem. More likely the fact that those 48 hours have become as grueling and punishing as an ultra-marathon. The fact is that medical interventions have become much more intense than ever before and no patient lounges around the hospital waiting to get better. The cost-containment pressures on the health care system have made the job insane. I would rather residents spent the hours, but sharply reduced the number of patients they followed. At least they would realize some of the original benefits of spending long hours in the hospital.

Physicians, Money and the Markets

Two stories caught my eye this morning. The first one was the publication of MGMA's physician salary survey. It turns out primary care docs (PCP) salaries declined in real terms, but specialists did better. Is it any wonder we have trouble recruiting PCP's? At least with NP and PA salaries rising faster that primary care, there will be less competition with family docs, internists and pediatricians since the costs are converging.

The other story was the NYTimes report of interest-free loans for certain procedures, such as laser eye surgery and tooth implants.

I wonder, if PCP's did the same, could we use these loans to develop investment-grade derivatives?

Quality Improvement Without Resources

The objectives of health care reform are improved access, quality and cost. Improvements always cost something and have to show up on the financials. It is almost a syllogism that quality improvement must affect the bottom line.

But health care executives are notorious for their conservatism. I once read that 40% of the under performance in the health industry is due to the unnecessary conservatism of leadership [but I never found a reference...]

So if there is an expense contemplated, whither the ROI? Every ROI calculation represents a hypothetical, built on careful and rigorous analysis of the market opportunity and competitive landscape (yes, I am being sarcastic). No wonder a lot Board members with fiduciary oversight respond to quality improvement efforts skeptically. Not only is the ROI calculation a hypothetical with very little concrete assurance of success, it is also set out in the future. In competition for capital, what in the world is the incentive to do this?

Health care organizations are complex and instituting a culture and mindset conducive to quality improvement takes a time. It has taken me two years just for my physicians to trust that I am not going to let some over-reaching administrator manipulate the data to tear them down. Now I think we're ready for a bigger change, but the resources aren't there for that kind of investment. Lean techniques? Six Sigma? I can't convince a cash-strapped community clinic to spend resources up front to maybe squeeze 15% in process efficiencies.

That is the problem with putting cost reductions ahead of quality. Bottom line: quality costs, the savings may come later.

Health Care Crisis Has No Easy Solution

Two blog posts today are realistic about the difficulties in America's health insurance crisis.

Colorado Health Insurance Insider points to unrealistic expectations:

It’s frustrating to hear so many people complain about the current system, and yet still be so resistant to dramatic change in the status quo. There is no easy way out here. It seems like people are waiting for Santa Claus. That somehow we’re going to be able to set up a system where everyone is covered by ultra-comprehensive private health insurance, with lots of options for carriers, and no government monitoring or intervention (Big Brother = Bad). That we’ll continue paying the taxes we already pay, but not the high-dollar health insurance premiums. That pre-existing conditions will all be covered, and we’ll all have a choice of whatever doctors and hospitals we want to use. That is not going to happen. [...]

Some [ideas] call for universal single-payer coverage for all citizens, others call for mandatory private insurance for everyone, and many options propose a combination of private and government-sponsored coverage. But none of them are free. However we fix it, we’ll have to pay for it. As long as med school costs hundreds of thousands of dollars, doctors are not going to start working for $20/hour. Cutting-edge research and development in medicine is not cheap. If we’re going to provide access to health care for everyone, the money will have to come from somewhere.

The Health Care Blog pins our hopes on the non-health care businesses of America getting together and keeping the special interests and partisanship out of it. This post explains

Reform is a complicated topic, particularly because the discussion tends to be so narrowly defined around its objectives: access, quality and cost. But an equally important issue is that American health care is fundamentally about power and money. Achieving reform requires a real understanding of the power dynamics involved.

I'm not sure that keeping powerful special interests at bay will work, just because money rarely sits idely by while others talk about controlling its destiny. But one thing I would hasten to underline is that the health care system does not work for the humble office-based physician these days. They are important stakeholders and the key to keeping costs down, but are not well-represented at the table. The relationships that take years to build between primary physicians and patients are not commodities, but rather, the source of trust which has drained out of the health care system.

WSJ's Poor Reporting on Obesity

The WSJ Health Blog is running a post on Mississippi's State Health Officer's work to reduce the state's obesity rate, the worst int he country. The blog adopts a kind of cynical, tongue-in-cheek,"check out this Southern simpleton" kind of approach. Too bad Elva Ramirez didn't Google the subject of obesity interventions.

Mississippi has several interventions under way, but the data shows neither clinical nor public health interventions work very well.

Obesity is subject to health disparities by race and by economic status and these effects appear to be independent. The worst off are First Nations and Latinos, whose obesity-related mortality is higher. It also turns out inner city African-American neighborhoods have more fast-food restaurants than wealthy "white" areas and are exposed more heavily to high-fat food advertising. One of the most interesting associations (not a causal relationship, for those of you who are still awake) is the effect of infrastructure. The accessibility of sidewalks and safe areas to walk, stores within walking distance, public transportation and exercise facilities or parks can all impact obesity rates in a any given environment. This is frequently referred to as the built environment.

So the NIH is supporting a program to investigate how the built environment influences obesity. Obesity experts have approached our facility with a proposal to participate in a couple of grants and they tell me that the two areas which will likely yield the best future outcomes are interventions that empower patients and interventions that alter the built environment.

But that's just an opinion.

Hungary and the Greeks

I thought Greece had problems with "under the table" payments. I found this link to a Bloomberg article about the Hungarian health system (via Kevin, MD).

I think there is a lesson in this story; physicians are entrepreneurial and like any other segment of the population, will try to get away with what they can. If public policy is to make a serious effort to achieve a public health goal, it must make sure the proper resources are made available and that natural incentives are not ignored.

Every time I hear someone complain about how unethical someone is, how unjust society can be, how cruel life is... I must wonder why things are as they are, rather than as they "should." The thinker of the "should" is at fault for not having understood the landscape well.

Now if I could only understand the general criminality of our politicians...

Clinical Medicine, Business and Policy: A New Measure for the Value of Interventions

In medicine, we just want to do the best for our patient.

In business, we want to make sure our efforts are financially sustainable and help us attain our mission.

In policy we want accountability for the health care dollar and an impact in measurable outcomes.


It's too bad these three worlds don't talk very much.

There is a tool of clinical epidemiology called the NNT, or Number Needed to Treat. It provides a cost-effectiveness perspective for some of our clinical interventions. My favorite example is the one that demonstrates an NNT of 4 smoking interventions to one cardiovascular life saved, as opposed to 400 cholesterol interventions for one cardiovascular mortality.

Scott MacStravic in The World Health Care Blog posted this carefully thought-out article on NNS. NNS is Number Needed to Succeed, which can be used instead of ROI in a health management program. ROI numbers are usually basically made up since the economic inputs are rarely clear, but an NNS suggests how many people you need to achieve program goals in order for the intervention to be worthwhile.

It's a great example of what I think The Physician Executive is about, despite the policy protestations that have grabbed my attention lately.

US Health Rankings Are Accurate

I must rail against propaganda, irrespective of the source. Unfortunately it reminds me of a friend who told me arguing on the internet was as useful as a certain part of the anatomy... well, never mind the bar-room jokes. Too bad the level of discussion is frequently at bar-room level as well.

What has me going this time? The recent publication of the world's health care systems showing the US ranks poorly has generated a lot of discussion and commentary. But the discussion has been the same old thing, worthy of the discussion surrounding crystal power's contribution to the health of the nation. Talk about "woo."

Why is the US ranked so low?

The data is weighted according to a certain set of assumptions using the crudest top level public health measures of the health of a population. Everyone who has ever looked at crude health statistics since public health was born near the Broad Street Pump in 1854 has used overall mortality, life expectancy at birth and infant mortality. All the hot air protesting the use of these measures does not acknowledge that some of the brightest medical minds of the past couple of centuries have adopted these as the best available data for quickly assessing the health of a large population.

I have also never quite been comfortable with the inferences drawn from such data, but how can you argue the same side as the propagandists?

The condition of the young disproportionately affects life expectancy, which has two effects:

1. The elderly don't count. One dead one-year old is equal to nearly 80 elderly people dying a year before their population's average life expectancy. It's hard to justify spending health care resources when there is such little impact on the top level number. [I know mortality and life-expectancy are adjusted for population age distribution, but the general point still holds if not the specific number.]
2. Small changes in the distribution of mortality in certain sub-populations can have large effects on the top number. This relates to the equity of distribution of health resources in the population

Infant mortality is a very sensitive measure of the security of food sources and sanitation in any population. Of course, it has nothing to do with medical care, but certainly reflects the health status of the country.

Equity in health is important for several reasons:

1. Poverty is the most important contributor to health status. Socioeconomic status at birth is the best predictor of health status, job, education, future wealth, and life expectancy. This occurs through a variety of biological and social processes that are not well understood. In the absence of an intervention, a vicious cycle takes place which reduces the opportunity for the disadvantaged to rise into the mainstream.
   
2. Marie-Antoinette said it wasn't before she lost her head. [This is what I call conservative self-interest.]
   
3. I believe it is a predicate of the human condition that we must help one another. Cruelty is generally an aberration, and the US is full of the most compassionate people I have ever known. Why should the country itself appear cruel and selfish?

Equity in ranking health systems may be overstated. Innovation is important as is overall economic performance. Health care contributes a small amount to the health of the population and probably to economic output as well. At some point, the law of diminishing returns makes health care a greater burden than it is worth. When business complain about the cost of health insurance, we are approaching that level.

Correcting minor disparities in children could dramatically influence the ranking at low cost. Primary care, vaccines and nutritional supplementation for low-income individuals are not so expensive. The problems are that primary care is only as credible as access to secondary and tertiary levels of care, should they be needed. In people's minds, it's easy to create a sense of entitlement. I am also genuinely concerned that after 10 years of SCHIP, I have yet to see an impact on population level life expectancy and mortality. I am also amazed at how dramatically the numbers change following adjustment for accidental and violent death.

Maybe health status really is a manifestation of wealth. It makes a case for adjusting the methodology of the rankings. Or else, just take them with a grain of salt. It probably doesn't have much to do with medical care as we usually think of it, outside of public health and policy circles.

Either way, the rankings are accurate. The interpretation has been all over the place!

The Politicization of Quality

I just came across this post by Merril Goozner of GoozNews which demonstrates my previous statement that policy is driven by money, politics and power. The most costly earmark in the S-CHIP reauthorization bill in front of the House is for a quality program that is unsupported by the evidence and could potentially kill people instead.

A pharmaceutical company has apparently bought off a Yale physician to speak out and influence Congress into funding an important quality initiative. Renal failure patients are frequently anemic and although current guidelines suggest a lower level of hemoglobin, the physician testified that a higher number was appropriate. That may be, for some patients, but there is no mortality data to support this course of action and a critical assessment of the literature trumps expert opinion, every time. [This is assuming that the guidelines are evidence-based, but I admit, that can be a pretty significant leap, without reviewing them myself in detail.]

Bottom line, Congress attempted to legislate huge sums of money to a quality initiative unsupported by the scientific evidence and could potentially harm people if dialysis facilities overshot the recommended hemoglobin. In addition, the company that stands to benefit the most is Amgen, purveyor of an injectable treatment to raise hemoglobin in dialysis patients.

Wow! If I had known this was going to happen I would never have sold my Amgen stock!!!

The Utlilization of Evidence: A Dangerous Problem with Regulation

I support Evidence-Based Medicine (EBM) and government regulation in heath care.

I support Evidence-Based Medicine because the literature is growing exponentially and impossible to keep up with, especially for generalists. The critical thinking skills required of physicians (and others) to understand the studies and to prioritize their importance, are actually difficult to to develop and painstaking to practice. Even when I don't find myself interpreting the data the same as my colleagues, the framework is useful for understanding the controversies.

I support government regulation in health care because intervention is usually required to create a sustainable competitive market. This is basic tenet of capitalism and the belly-achers are usually the greatest mercantilists, reaping benefits out of proportion to their effort and then running away, with no concern for the well-being of the people and markets they have plundered. We are talking about the difference between profiting and profiteering.

It seems that government is always reacting to the margin of dishonest and profiteering players, to regulate in order to prevent abuse. However solutions are not well-thought out. By now, I hope the reader realizes I am talking about the CMS decision not to pay for complications.

How can anybody object to that! I mean, who wants complications! We want free care and the people paying the providers... they shouldn't pay for anything if we don't do well. The landscape is that complaining about the rules is such that everyone who objects sounds like a strident, little school child throwing a schoolyard tantrum.

The contradictions are painful: hospitals and physicians are required to adhere to the best evidence, but government can act with no evidence. What's is wrong with the CMS decision? Ahh, let me count the ways...

1. The intervention here is provide a financial incentive to spur the adoption of actionable quality data gathering that results in an improvement in outcomes.
   
2. Any intervention must be based on the reasonable expectation of getting the effect you want. Being punitive, the chain of incentive--> data --> hospital system change --> improved outcome is abrogated at step one.
3. There are alternatives to complete non-payment for a complication; how about a 50% reduction associated with a 25% end-year supplemental reward for the 100 hospitals showing the best results, or the most improvement. Small steps
   
4. A disincentive (non-payment) is not the same things as an incentive.
5. Budget constraints provide clear motivation for calling non-rational thought processes evidence based.
   

Lucian Leape's editorial in the Boston Globe last week was hard to digest and impossible to understand. His writings are required reading in Public Health and had a lot to do with my choice of focusing on management and performance improvement in my mid-career change. But the editorial smacks of impatience and a disregard for process. I am most disappointed (painfully so) by the lack of scientific rigor from one of the icons of the health quality movement. I somehow exepectd more. How the mighty fall!

I am now more convinced than ever that policy is driven by money, politics and power, but I would have hoped someone would at least pay lip service to the science.



NB: I am not a hospital administrator and having nothing to gain or lose from the new set of regulations.

Transparency: The Real Issue With US Health Care

OK, it's not the only issue...

Last week, a court in Arizona, upheld a decision that… well, I’m not sure I understand the details. Let’s just say that what hospitals call “usual and customary” charges stand as the real retail price, even though nobody on the planet would pay that price.

A CRS report [warning: long pdf document] found:

The dispersion of prices for similar health care procedures is high, which suggests that these markets are not working well with respect to price outcomes, as would be expected in ordinary competitive markets. In addition, prices paid by different types of payers vary dramatically. On average, patients without insurance or who pay their own bills pay much more relative to what private insurers, Medicare, and Medicaid pay. Despite these complications, greater price transparency, such as accessibly posted prices, might lead to more efficient outcomes and lower prices. Some markets where lifting advertising restrictions led to lower prices also involved complicated products such as eye care, suggesting that the complex nature of health care may not be a barrier to benefits from price transparency.

Without price transparency, no consumer can make reasoned decisions about the value of price paid versus service received. All proponents of health care reform will fall flat without it.

A lot of consumer resources will be required. Some patients come to me for a visit and don’t realize that for every problem they discuss and for every progressive bit of thoroughness, my chargeable code changes. Unexpected findings occur, as do complications over which I have no control. Additional charges may always apply, but patients serve to know what those charges could be.

For example, if we charge $70 for a Pap test, an abnormal result could trigger a laboratory protocol to run an additional test for Human Papilloma Virus. That’s $150 more. Plus every visit is $50 - $250 depending on widely published criteria.

As a safety clinic, our prices are widely disseminated: $135 up front, sliding to $30 on presentation of proof of income or acceptable documentation from a local social service organization. We charge the same price for all levels of care, which given the complexity of the population we serve, is a pretty good deal.

Other patients might look at a list of CT scan prices like a cafeteria menu; “I’ll have a head CT with a side of spinal MRI.” The physician’s role as the counselor and perhaps final arbiter of clinical appropriateness would have to be clear.

Proft Versus Not-For-Profit Hospitals

Kevin, MD’s Blog Power 8 ranked a post by RangelMD as #1. I am grateful and honored to be on the list at all, but I don’t get the logic in RangelMD’s post, which I think is trying to make the case that charity hospitals are not doing their job.

My problem: I’m not sure what a charity hospital is in the US. I work at a safety-net clinic, but there are a million qualifiers, to avoid the public perception that we’re a “free clinic”. That is the kiss of death. The expectation of non-payment is not tenable anywhere in the world.

I think by "charity hospital" RangelMD means hospitals with not-for profit status (NFPH), which is not the same thing as charity; it represents a tax status. The privilege of not having to pay taxes comes with a responsibility to the community. Nobody said anything about treating everybody for free.

On the other hand, maybe we are talking about government-operated hospitals (GOH). Does that mean we have a beef with the VA? Or maybe it's just the local County hospitals. But these are County Hospitals in name, they are not necessarily funded or operated by a local government.

Since I'm confused about which type of hospital has caused RangelMD's frustration, let’s talk about cherry picking for a minute. There was a time when most hospitals in the US were GOH or NFPH. That really is sort of anti-capitalistic, so appropriately, private or investor-owned for-profit hospitals were encouraged to come into the market. It turns out, without regulation; for-profit hospitals (FPH) could refuse to care for any non-paying patient, conceivably allowing people to die on their doorsteps. Enter EMTALA, a law that requires an evaluation before turning a patient away. Think of it as a US hospital anti-dumping law. There is a prohibition against transferring (i.e. dumping) patients who are medically unstable.

A few hospitals see a sufficient numbers of government subsidized patients to have their Medicare rates raised to provide the kind of advantage RangelMD supposes for all charity hospitals. These hospitals are known as disproportionate share hospitals and are tracked specifically by CMS. These supplemental payments, implemented during the Reagan administration, assist hospitals that would not survive otherwise. According to the complicated formula, their status as DISH hospitals would be in jeopardy if their non-reimbursed care dropped below about 10%. But the formula focuses on Medicaid and Medicare, not “free care.”

This is America. We don’t do “free.”

Given the financial incentives built into health care today, FPHs compete IN THE SAME MARKET as NFPHs. Is RangelMD suggesting that FPHs can take the moral high-road when turning patients away? Or is he just frustrated that there are so many uninsured that cannot pay their way? It is the most frustrating thing about the US health care system.

There are plenty of ways that FPHs can segment the market, most obviously by location. Private hospitals cherry-pick, no matter what you do and what regulation exists is put in place to level out the playing field. So that means you’re just not allowed to complain about the few patients that find their way to your door. If NFPHs start placing obstacles in the way, it is because the market and structural incentives support this behavior.

The literature on the behavior of profit versus not-for-profit is interesting and yields sometimes contradictory information. It seems that FPHs may be more efficient, but when they enter any given market, the local NFPHs may see their costs rise and start behaving more like the FPH. The alternative is bankruptcy or sale. See Prince George’s County Hospital, Greater Southeast in DC, Martin Luther King Jr.-Harbor Hospital, Bayonne, Auburn Memorial, and Samaritan in Kentucky …

RangelMD's frustration is common in ER's across the country. That is because the health care system does not work for the people trying to provide the quality of care being requested.

The Prognostication of Death

My wife sent me an opinion piece from the New York Times by a Harvard physician-sociologist named Christakis, who seems to feel that the art of prognosis is something that should be developed as a medical skill. I beg to differ. Physicians are being pulled in an amazing number of directions by various societal interests. This additional one, does not help.

Every society needs someone to fulfill the role of healer. A technological society is no different, but the proliferation of potential roles requires some discrimination in the choice. When I was in medical school, I was taught specifically to refuse to offer prognostic information beyond the most basic survival statistics. The reason? “You’re not God,” I was told. "What if you're wrong?" Being off by a week would not only diminish your stature in the eyes of the patient and family, but would also make you the butt of the famous jokes that starts with "The doctor gave me six months to live..."

I later discovered that there are an awful lot of disease-specific survival data available. They are certainly not indexed under "prognosis." There is also a large amount of quality-of-life information for survivors of some diseases.

It seems that this is really the job of actuaries and insurance people. Physicians should not always be expected to provide the grimmest of the grim news. To some extent, physicians are purveyors of hope, not experts in communicating complicated statistical survival data.

Whose financial interests are aligned with the prognostication of death and adverse outcomes? Leave it to them, not doctors!

Semantics, Statistics and Lies

I am usually the evidence-based medicine guy at whatever practice I have been. I used to teach some basics of clinical epidemiology to residents, but the problem is that it often makes the eyes glaze over. Most people don't want to know about all the analysis and the numbers that go into your "knowledge", they just want what you know. While precepting, I can't tell you the number of residents who would plead with me at a patient review to just give them the answer. "It depends," and the explanation just wouldn't cut it.

But I found this post at Med Journal Watch which does a terrific job explaining the semantic and statistical problems with a headline about "Overweight surgery."

Now who would like to hear about positive and negative predictive value?

Underfunded, undervalued

Funny that people complain about how hard it is to get a good doctor. Sometimes it is important to ask why things are as they are, rather than complain about why they are not better.

I remember a conversation with an internist a couple of years back, who was complaining about how her family physician was so useless…it takes forever for the office to get back to her, appointments are a bear to get, refills take forever and it’s like getting teeth pulled to get him to call her back.

If a primary care doc is running all day trying to get patients through, then I assume he’s busy. That’s good thing. I’ve never waited for reservations at a bad restaurant. A good rule of thumb is that the better doctors’ offices are more crowded.

I know some physicians who have also had the business sense to build incredible systems that can get 30 patients or more in and out daily and still do a good job at it. Not everyone has the administrative skills to do that, even if they are excellent doctors. If the doctor doesn’t spend enough time to listen, the question must turn to what they’re paid for.

Generally, I view phone calls as a waste of time, because they frequently represent an inappropriate service to deliver by phone. Some advice can be safely dispensed at a distance, but nothing is certain without a proper examination. Oh, and that’s what usually what physicians are paid for. They are not paid to dispense advice, provide basic health education, prescribe medication without an assessment, complete forms for patients who haven’t been seen in two years and coordinate referrals for patients who bypassed them entirely and went straight to the specialist. They are paid by the visit, where an examination frequently takes place.

Our physicians at a facility for low-income individuals are allocated fully 20% of their time to do unremunerated administrative functions, only some of which ethically seems appropriate. We stretch the rules in recognition of our patients’ socioeconomic constraints and only because we receive sufficient grant income to support the loss. In private practice… fuggedaboudit. The only reason to do it, it to preserve goodwill, which doesn’t really pay the bills. (This only applies to traditional fee-for-service environments. More about capitation some other time, because that’s a whole different ball of wax.)

Why do physicians with very busy offices have to be so busy? I mean, are they just greedy, churning people like so many little factory widgets? I suspect, while there are some bad apples in the barrel, the majority are skating trying to cover their overhead, payroll, malpractice and hopefully come close to the national average of $150,000 in income. Remember the big bucks are usually reserved for cardiologists, neurosurgeons and other proceduralists, without which no health system would have credibility. What’s the use of preventive services if there is no available curative services should prevention fail?

My friend, the internist completed her rant by saying there was no value to primary care since her family doctor couldn’t provide the service she required.

I wondered out loud if that was the way the world always worked, “Underfund the service you need so that it can’t do the job and then decide it has not value.”

Playing Politics With Health Care

CMS is reducing physician payments by 10% and cutting reimbursements to hospitals by refusing to pay for so-called medical errors.

The former is justified because physicians make too much money and the latter is an overdue method of rewarding quality.

Forgive me if I sound skeptical. This is an election year full of political maneuvering and dealing with the fallout of the war in Iraq.

The same with SCHIP. Reauthorization of the most effective program that came out of the Clinton administration is hung up in Congress. We are told that states have misappropriated federal funds committed to low-income children to cover adults, middle income kids, kids with insurance, illegals and all kinds of other misbehavior. On the other hand, we can fix the whole problem if we tax smokers.

The Health Affairs blog identifies the hot spots and a Washington Post editorial identifies the politics behind the issues. The blogosphere is abuzz with the left decrying conservative insensitivity, the right screaming that "socialized medicine is coming, socialized medicine is coming..." and congressional representatives aligning along ideological lines.

Meanwhile 60% of eligible children are not enrolled in state SCHIP programs.

So forgive me if I'm skeptical...


I don't care which side of the aisle you sit, but this is simply classic politics at work. The truth is there's a war on; we have to defend ourselves from terrorists abroad. It's unfortunate that the Bush administration has succeeded to make US troops abroad a magnet for suicide bombers, so that pesky Al Quaida won't bother us here at home. The only people acknowledging success in the war effort are the spin meisters. We have a huge federal deficit, the currency has been dropping and we have to balance the budget to avoid macroeconomic consequences. So how can the administration limit the budget deficit without getting hurt in a build-up to the 2008 elections? [Aug 23, 7AM: Bloomberg published an article this morning describing some of the currency battles the administration is fighting.]

Health care costs money, but if you don't pay for it up front, the costs don't just disappear; they become less visible. The more uninsured in America, the more hospitals have to deal with unreimbursed care. While it is true that many die quickly, thereby sparing congress the need to justify the expense of care, others run up unimaginable bills. I have taken care of many critically-ill, uninsured, low-income individuals over the year in ER and ICU. Our politicians know that hospitals have an "accounts receivable" line in their budgets and another for "adjustments." While we're worrying about how to pay for health care for the uninsured in America, let's not forget how we're paying for it now.

So the conservatives are having a field day with the issue and the liberals are feeling ambushed. Get a grip! This is a matter of priorities and a lack of willingness to use the instrument of government to help those in need.

We had enough money to cover a Medicare expansion. We don't have the money to cover low-income Americans. I guess we know who votes, don't we?

Your tomato was grown in...

The Washington Post has an article on a new American trend about the sourcing of food. Food is one of the foundations of health, along with water, shelter and a decent occupation. Besides, I love food so much, I should have called my blog something else, but The Fat Doctor was taken.

The Women, Infants and Children (WIC) program started offering food vouchers to farmers' markets recently. The idea is to get more fresh food into low-income diets. I recently went to restaurant that went so far as identifying the various farms across the country their game originated. That's what the French call terroir, which probably accounts for my liking raw milk cheese from Normandy.

Let's not get snooty here; it makes sense to handle the food, meet the farmer and make decisions about your food quality first-hand. Faceless grocery chains are certainly less expensive, especially when the food comes from overseas where labor is even cheaper than illegals working on domestic farms! But for those who can afford it, it is a nice way to support your local community.

And depending on the season, the farmers' market prices will blow the socks off your local grocery chain.

Is it any healthier? Well, there is data that suggests improved access to farmers' markets may increase the amount fo fresh produce consumed by low-income families. Other than that, it's just a matter of personal preference and market behavior.

I like this trend.

Health Care: The Blind Men and the Elephant

In health care, management and policy are a couple of steps removed from patient care. Physicians and other health care workers have insights that sometimes fall on deaf ears. But this is the era of Babel in health care; I don't believe we have a common language yet, so we can actually understand what each of us are saying.

Health policy is a large enough field that, as in medicine, specialties are starting to emerge. When I speak with health policy types and health economists, they often see the world through the glasses of their area of interest. I know of an economist who specializes in transplant allocation. Another health economist is a state secretary of health (how rare is it that government hires a real specialist for any post, instead of a politician?) Some people are dedicated to providing care for the poor, other would like to preserve choices and options, which are usually relevant to the wealthiest and most privileged.

These different perspectives yield emphasis by turns on primary care or specialties, ambulatory or hospital care, cognitive versus procedural practitioners... Health wonks are like blind men trying to figure out what an elephant looks like.

Biological organisms are not mechanical, and this has an impact in various aspects of the health system. I recall an Operations Manager who couldn't understand why the clinical staff didn't follow medical guidelines the same way his computer staff created patient files. (This represents the mis-application of Six-Sigma to the wrong level of outcomes.) One of the most dynamic classroom discussion I experienced was when a bunch of mid-career professionals tossed around my assertion that "protocols" and "guidelines" are not the same thing. We settled on protocols for processes and guidelines for diagnosis or treatment. It's too bad that medicine cannot be based entirely on empirical evidence, as an epidemiologist (I think) commenter to this blog asserts.

The complexity of people as biological and social organisms leaves us with so many unknowns, I am amazed at how much information we have that is actually actionable. But health care remains governed by careful judgment informed by some data, to help navigate the unknowns.

Experience can be a fickle teacher. So much of our perceptions are shaped by personal experiences, and then confirmed by the consequent bias. If we have a bad experience a physician, we are looking for confirmation in any trace of behavior of every subsequent interaction. So outliers can begin to distort our opinion of things: the greedy doctor, the uncaring insurance company, the bean-counting administrator, the abusive patient or the ignorant bureaucrat... These people exist for sure, but the vast majority are working stiffs who show up for work and try to do the best they can before getting home to their families and an over-leveraged mortgage.

In all this, it is the emotional context of health care that is the most ignored. The fear and despair that physicians and nurses see is forgotten in epidemiologists' regressions, economists' differentials and executives' spreadsheets. No, the golden age of medicine is gone and good riddance, but something else this way comes and we don't yet know what it looks like. Let's just make sure it works for the middle: the normal patients, health care workers and administrators who show up every day and stay for every shift, no matter how terrible the things they see.

Deliver a Dead Baby

At Ten out of Ten there is a story of an emergency physician who delivered a dead premature baby.

It got me thinking about all these people who think that doctors make too much money, and comments about all docs driving Mercedes Benz.

Personally, I know I'm well paid for what I do, but I could be paid better. I'm not sure how much I'm worth, but I'll let the market decide. I also know my plumber cleared more than half my docs last year. I also heard of a college drop-out who reported nearly a million dollars in income a couple of years ago brokering loans, probably to people who can't afford them today.

Maybe the scariest thing is when we, as physicians, cut ourselves off from our emotions and just keep going. I have done the same as this ER doc, twice having held a lifeless 20+ weeker in the palm of my hand, trying to understand the emotions the mother was going through on the other side of the sheet. Like this ER doc, I too finished my shift.

Sometimes, people who are close to me feel I am distant when they are sick. No matter how I feel inside, the exterior is calm, perhaps too calm, but I will get through my shift, or my day, or whatever.

God, I'm glad I'm doing administration more and more.

Pain and Narcotics: Physicians in the Crossfire

Associated Press reports an increase in the use of narcotics across the United States.

Narcotic use has nearly doubled over the last decade, but illegal diversion is now landing physicians in jail! A recent New York Times Magazine article shed light on the case of one physician who went to jail for 30 years for what some people suspect may have been poor-record keeping. Some jurors commented that he should have known the drugs were being diverted because the doses were excessive.

Unfortunately this flies in the face of medical and scientific knowledge that the effective dose of a narcotic can be affected by physiologic habituation. The quantity of drugs the jailed physician prescribed were well within medical standards for people who have developed resistance to the effects of narcotics. That is the real definition of addiction, or habituation technically, that the former dose no longer works and progressively higher doses are required. A dose that can kill a horse may not be enough for someone who has been taking narcotics for years.

Perhaps patients' expectations play a role. The narcotics may control the condition somewhat, but no patient with a chronic pain syndrome should live with the expectation of ever being entirely pain free. This is a difficult message for physicians to deliver to a patient who believes they cannot live with their condition.

When patients get insufficient medication, they will often look for another doctor, and so they become doctor-shopping drug-seekers. We see this most clearly with sickle cell patients who quickly learn how to get pain relief. A few even learn how easy it is to abuse the system, since there is no objective way of verifying the patient's level of pain.

When I was in medical school, Dr. Ronald Melzack, one of the foremost pain theorists to ever walk the earth, was encouraging the use of narcotics for chronic non-cancer pain. I'm not sure he was aware of the depths to which a drug addict will go to get their drug of choice, even in the context of genuine pain. I was uncomfortable then, and the passing of time may be proving me right.

It is difficult to find the full-text of a medical journal online, but a quick search yielded a review that outlines the state of the art for non-cancer pain. I would draw the reader's attention to reference number 34 (which is actually mis-attributed in the text) and the following excerpt:

Unfortunately, as with the non-narcotic pharmacologic treatments, a review of the literature gives no evidence of scientifically designed, controlled, double blind studies with follow-up demonstrating narcotic medication as being consistently reliable in providing relief of chronic SCI pain. Generally, both proponents and opponents of long term opioid use in central neuropathic pain have submitted anecdotal data in support of their respective viewpoints.

Although this article is nearly ten years old, my understanding is that the data are still lacking.

There is no denying that a minority of individuals consciously and intentionally go to doctors for the express purpose of obtaining drugs to sell on the underground market. There is also no doubt that some physicians document their patient visits poorly. But we have created a nation of drug-seeking junkies since patients don't trust doctors and doctors no longer trust patients, especially when it comes to the prescribing of pain medications. Now the very act of asking for a pain medication is enough to raise suspicions.

How does management weigh in? Well, first, we are concerned about patient satisfaction. A few month ago, my CEO marched into my office concerned about a patient complaint. The patient had stated the physician was uncaring, refused a prescription and did not listen. I refused to discipline the physician, since the request was for narctoics. I recently had a conversation with another medical director who felt his young doctors were being unnecessarily prickly about prescribing for pain. I don't have enough information to comment, but I suggest a lot of caution.

No narcotics can be prescribed in the US without a DEA number in the physician's name. No employer should ever question the appropriateness of a refusal to prescribe under a DEA number. Moreover employers should take precautions to ensure that the doctors' DEA numbers are not used indiscriminately by other staff within the company.

Part of my job is protecting my physicians and the organization from litigation and/or investigation. We have instituted policies that will make it very difficult for patients to get prescriptions for narcotic pain relievers, and virtually impossible for a new patient whose doctor doesn't contact one of our physicians first, to validate the situation.

It's really too bad, because this leaves a lot of people in pain. The truth is the drugs don't help patients as much as they think. The truth is the interactions between patients and physicians around pain have deteriorated to the point that some doctors may just refuse to prescribe. The truth is the DEA is sending good doctors to jail along with the bad (108 prosecutions in the past 4 years, according to the AP.)

I do not see a way out of this conundrum.

Blogger's Public Physician Complaint

This situation, which I found via Kevin, MD, is seriously frightening for all. Rather than take her complaint through channels, a woman took her physician complaint to the entire Internet.

It sounds like something went wrong in the communications. It is quite possible that everything was done properly from a medical perspective. It is also possible that there was some anxiety that the nurses and the physician could have handled better. It sounds like the "laying-on of hands" may have been neglected. There is no way of knowing what else happened in the ER that night.

We only hear one side of the story. The physician subjected to this painful public debasement may have been either libeled or appropriately chastised and we can never know.

If a physician responded publicly to such a post, it would be a violation of privacy rules.

Physicians and managers would do well to remember that the goal is to nurture trusting long-term relationships between patients and physicians. ER's are probably not the best place to rely on such relationships.

Medical Errors and Medicare

According to the NY Times, Medicare is no longer paying to treat preventable medical errors in hospitals. This includes injuries and infections acquired in-hospital.

Now the US may go down as the first country in history and in the world that establishes this level of accountability for outcomes.

Medpundit has weighed in to be skeptical that not paying for things can improve care.
The Antidote has summarized the intent of the initiative and pointed out (in the last sentence) that it has not been studied rigorously.

I am quite certain there will be many more comments.

While I understand the value of increasing medical accountability, there must still be recognition that all outcomes, including hospital-acquired infections, have multifactorial causation. So what about a catheter-related infection in someone whose immune system is suppressed from medication. What if the infection was acquired outside the hospital, but became evident in-hospital? What if the patient didn't follow directions? What about the visitors?

Not to be stupid about it, but there is a reason the doctor gets paid, even if the patient dies. The service is provided but the outcome cannot be guaranteed.

I remember a patient who came in for a "flu shot" because they'd been horribly sick for a week. We made sure nothing else was going on and determined that he was actually recovering from a viral infection, probably not even influenza.

My advice was to go home, do liquids and the occasional cold remedy but he wanted a shot to make him feel betetr. When I explained that no such treatment existed and the only cure was time, he looked me straight in the eye and bald-faced asked for his money back!

Remember this new Medicare rule hasn't even been released yet, so it's too early to know, but I think there is no way of operationalizing it. There are just too many factors to consider and I doubt anyone at Health and Human Services can keep up with an algorithm of more than 5a couple of steps. It just looks like a bone-headed attempt by a bureaucracy desperate to placate consumer groups, who in turn, have unreasonable expectations of what health care can realistically deliver.

There is no rule that intelligent people can't find a way around. For every rule, there is necessarily a countermeasure. The NY Times article included commentary that suggests documentation of the presence or absence of infections at admission will become a priority. If you can prove someone was admitted with an infection, you'll get paid for the admission. This means that all patients will probably get blood and urine cultures on admission. A misguided rule can bankrupt the country in microbiology tests alone.

The other appalling aspect of this rule is that it does not respect the single most important principle of quality data: NEVER use your data punitively. Despite every temptation to do so, the risk is that you may provide an incentive for people to fiddle with or otherwise manipulate their data. Of course, nobody would actually fudge something as important as infection rates or medication errors. However, if someone did, my response would be, "What did you expect?"

Water flows downhill.

With all due respect to Paul Levy at Beth Israel Deaconess Medical Center, who is uncommonly open with performance data, I don't believe any hospital, possibly even BIDMC, will share quality data again if quality data is used so indiscriminately.

This country desperately needs transparency and a well-thought out response to quality incentives. So far, I don't see it. But the rule is scheduled to be published next week, so we'll see.

The Physical Exam

I was always taught that the physical examination was the most important part of the patient visit. Dr. Rob at Musings of a Distractible Mind just pointed out the diagnostic value of the "laying on of hands". But my teachers, back in the day, used to emphasize how reassuring it was to the patient.

I am always pleasantly surprised by my patients when they say I had done a more complete exam than they'd had for years.

Really? But with high blood pressure, diabetes and heart disease, you must be in the office every other month?

Why do I have to justify NOT doing an echocardiogram when it has all the features (new, soft, disappears on lying down, no radiation) of a benign murmur? Why did my service chief give me a congratulatory call a few years ago for picking up an abdominal aneurysm when a resident overlooked it (it was obvious)? Why do I find lymph nodes in the posterior chain that nobody else seems to look for? Some of my former teachers believed I was barely adequate at physical diagnosis. I have trouble taking compliments now.

Physical examination provides diagnostic accuracy and reduces the cost of unnecessary testing. More importantly it increases the patient's confidence and enhances the relationship.


But why listen when you can order a scan?

Cause of poor quality and adverse events

We talk about costs and poor quality and errors.... We have knee jerk regulatory responses to make sure that bridges don't crash, mines don't collapse and doctors do their jobs.

The sad part is that no regulation can replace a conscience and the satisfaction of a job well-done. Panda Bear, in an article about moonlighting residents, makes a comment about office-based specialists dumping to ER's. True enough, this does happen. Ed Silverman at Pharmalot in an article entitled "Death by medicine; how to kill the elderly," comments on a story about an elderly gentleman in Australia who ended up in hospital because of a dozen medications he probably didn't need. I call that "polypharmacy" and include it as a diagnosis on my problem lists. That's what I was taught to do 25 years ago during my training. It's a real clinical problem and isn't going away. It is also the result of physicians not doing their jobs.

To be fair, there are a lot of pressures on the office practitioner: poor reimbursement, unreasonable expectations, non-compliant patients, paperwork and regulation... Policy makers and managers need to remember their jobs too. It is to make sure these physicians have an environment where they can reasonably do what they do.

If only we all got along. If only we all took our jobs seriously and realized the depth of the repercussions of slacking off, cutting corners and being generally expedient.

Karl Rove and The Destruction of Medicare

There are some great policy reviews in the blogosphere. I'm not really sure who my audience is yet, but I'm assuming it will be close to my target of physicians, health care executive and the more motivated and educated general reader. Policy specialists may come as well, but for those who are trolling for solid policy opinions and analysis, there are a number of policy blogs that are constantly challenging me to examine my assumptions and my logic.

So I thought I would link to an analysis of Karl Rove's contribution to Part D. Yes, he may be the most important reason Medicare is not solvent on an accrual basis, and Part D is aggravating the situation. The fact that pharmaceutical companies rise and fall depending on which party is leading in the polls can only be called one thing... corruption!



Oh and keep following the links. There's so much great stuff out there that I will be adding to my favorites, as this blog matures...

Physicians Make Money!!!

If this fellow is right, that encouraging physicians to act like entrepreneurs increases health costs, it must mean that physicians are uncommonly successful being entrepreneurs.

Maybe that's what happens when smart people are incentivized with monetary rewards. They succeed.

But on the other hand the NY Times thinks that doctors are well paid. I am sure there are many primary care docs struggling to keep up with the plumber next door, but instead, I'll offer an endocrinologist and a PhD.

Just say no to cold medicine

Dr. Val, one of my favorite bloggers, is providing some info in support of cold medicine for infants! Oh no! I hate the idea.

This was in response to a NY Times article describing potential upcoming FDA warnings.

Most parents feel they need to give an infant something because that's what people do. If you're sick, you take medicine.

The best principle when it comes to self-limited illnesses is take nothing. In the balance between risk and benefit, there is little value to take a medicine which may make you feel better for a short period. As low as the risk may be, it is not a zero-risk proposition. There have been overdoses, miscalculations, reactions, allergies and just plain side effects. Decongestants in children with undetected heart conditions can be fatal. There are better ways to find out there was a problem.

Cold medicines do not make a cold go away any faster, but patients seem to use them with religious regularity. There are patients with chronic illnesses who can't remember to take their own medicine regularly but feed their kids some God-awful irrational cocktail of pharmaceutical products every 4 hours.

If these medicines reduce the severity of symptoms in the short run, there is little or no supporting evidence in the literature. I would hypothesize that symptoms last longer as a consequence of secretions drying out and being hard to clear. But there's no evidence either way. So why take an action which is unproven, probably unnecessary and possibly hurtful?

Remember, I work with low-income individuals. The dollar impact of wasting money on a cold remedy is significant in itself.

What's worse, disagreeing with Val, or agreeing with the NY Times?

Finding a match in your doctor.

CNN had an article on how to fire your doctor.

I agree. Sometimes it's about chemistry. Some patients and I are like oil and vinegar, others like fire and gasoline. I have always invited these patients to seek care elsewhere with no hard feelings.

Somewhere in the corporate transition, this message got lost. My previous employer almost had a hissy fit.

The alternative is an unhappy patient who doesn't trust their doctor, who doesn't really like their patient but is seeing them begrudgingly out of some kind of moral obligation.

If that isn't a recipe for a lawsuit, I don't know what is.

Each physician-patient relationship is different. You are looking for a match. This applies to the patient, but is also good practice for the organization.

How to Schedule Appointments in Clinic

My point exactly. What a great little summary of the problems of scheduling. Add the fact that patients have needs that vary from 5 minutes to over an hour and a day can get pretty crazy.

Worry, Government, Health Care and Ultimately... Health

I passed a church some time ago and saw a sign that said "WORRY IS THE THIEF OF JOY". It got me thinking, in the middle of this harried and frustrating week, about how worry is often the thief of health. There are too many ways to be unwell; spiritually, psychologically, socially and of course, medically.

My cousin, who happens to be a priest, looks after people's spiritual health. One day we were talking about what our days were like. It slowly dawned on both of us; in a lot of ways we do the same thing. Hey, I do primary care, so I 'm not in the OR using technology. When faithful people are in distress, they may go to their clergy for advice and guidance. The conversation is often enough for them to feel better. Others prefer to lock themselves in their room and contemplate for a few hours and then be able to move on. They can function better, interact with people with less friction, and generally 'be' better.

Patients who come to the clinic also feel unwell. It seems that as medicine becomes a corporate machine, there is a growing expectation of cut-and dry diagnosis, investigation and treatment. There is an expectation of a health outcome as a product that can be pre-packaged and mass produced. I suppose that may be a reasonable expectation for some disease states, as far as we are able to understand them. If you have a problem with a heart valve, there is a cut-and-dry surgical method to repair it.

But what about the fact that a significant proportion of visits to doctors do not yield a firm diagnosis. In short, half the visits to primary care offices are for vague non-specific symptoms. There is no organic pathology.

Health has many definitions. The scientific approach to medicine which emerged to dominance in the 20th century tends to focus on health as an "absence of disease". It sounds like a reasonable definition, but there are too many who are unwell, know they are sick in some way but no disease entity can explain their condition. People have headaches all the time, but they don't have a tumor, an aneurysm or even migraines.

The alternate definition is the one from the World Health Organization that states: “Health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.” It is so broad that the medical world doesn't really know what to do with it. This definition is most appropriate for public health and policy makers.

It is a political definition of health. If you use it, then the people who ensure clean water and good sanitation in your community are rightly thought of as health workers. Without sanitation workers, thousands would die of stool-transmitted bowel infections, just as in many 3rd world countries today. By this broad definition of health, keeping people well requires many things unrelated to doctors or the things health-care workers do.

At its most basic, a healthy life requires a secure food source and reliable shelter from the elements. If this seems trite, just try to imagine not having either. Most of us take food and shelter for granted. This is a testament to the effectiveness of our society that it can provide these as well as it does.Make no mistake, the standard of level achievable by the American middle class is the great success of this country.

Sanitation and clean water go hand in hand.

A good job with a satisfying purpose and a steady source of revenue are also very important.

Our connections to people, individual relationships and a sense of belonging to a community are also important parts of feeling good. Where else will we find support when we are stressed and twisted out of shape by the world at large? Nothing gives a human being a sense of purpose as much as family. This applies for most families, despite our minor pathologies and dysfunctions.

Literacy is also critical to well-being; no one gets a great job without knowing to read and write. Moreover, if you can't read the instructions or your pill vial, you're out of luck. Sanitation, literacy, employment, quality shelter and secure food and water are not often considered to be in the purview of medicine as it has been conceived in the last century. This is the world of public health and health policy and it has huge impact in the world of primary care. In the absence of the essentials, where do you think people will go. Usually an internist or pediatrician for diarrhea, work-related back pain, depression, weight problems...

If you were running a community health center, I bet you'd be pretty hard pressed to convince the local County Council to emphasize housing and education as a HEALTH priority! There are no funding streams available for physicians and nurses who want to improve the social well-being of their patients.

When health is redefined as well-being, we recognize that government plays a role in many aspects of our lives. Government apparently has a role in making our lives better. It works to make sure we are secure from foreign threat and ravaging hordes of Vikings threatening to burn our homes. The government provides a framework by which we can purchase homes or otherwise obtain shelter, either though mortgage assistance or emergency shelter in the case of disaster. In addition the rule of law, enforced by the government, secures our property. A regulatory backdrop allows us to have better functioning markets and a transportation infrastructure exists to drive our economic success and helps us secure jobs through this activity. We get together in other ways as well, building sewers, schools and other infrastructural elements that improves our lot collectively.

When it comes to health care, we have trouble seeing it as an infrastructural building block of a nation. At least half of health outcomes are the result of individual choices and the health of one's neighbor is not generally recognized as something which improves one's own life.

Once we have gotten past the major infrastructural domains that have an impact on health, the following interventions have been shown to have the most significant effect on health. These are pretty basic items, but we usually recognize them as health-related. Programs to address these issues are usually funded through public health departments.

• One of the most basic tenets in staying healthy is: do not smoke. That alone saves more lives than all the rest of medicine’s contributions.
  
• Wear a seat-belt and don't drink and drive. Every year nearly as many Americans are killed on the roads than died in the entire Viet Nam war.
  
• Physical activity and recreation are important. Staying socially active is critical, but then again so is keeping physically active. Most of our jobs do not give us the opportunity to move our bodies as they did in the days of manual labor. It was back-breaking work and caused a lot of problems due to overuse. Now we find that the opposite – sitting in an office for twelve hours a day – is no less destructive. We need to use our spare time doing something physical, such as swimming, walking, or going to the gym.
  
• A balanced diet is important to keep vitamins and nutrients up, also to avoid too much fat, carbs and the risk of obesity.
  
• Many diseases are preventable by vaccine and these need to be kept up. Good prenatal care and care for small children carry a huge bang for the effort.

"Bang for the buck" is a method by which government one can be held accountable for health care expenditures. But it is more difficult to measure well-being than health status in narrow terms. Data is more important than determining the validity of the measure.

It is easier to measure the rates of antibiotic administration that to tell if that really makes a difference in the scheme of things. We have to drive, so we won't look at accident mortality as a measure of health. We decide that we have the best health care system in the world because you can swallow a pill and get screened for cancer, but we won't worry that 99.9% of the population has no access to expensive new technological interventions. We won't worry about the social and spiritual well-being of our neighbors, since they made bad choices for which we are not responsible.

Instead we will worry about our accumulation of material things and getting through our to-do list, avoiding people less well-off and becoming more socially isolated ourselves to the point that we cannot recognize that there are poor people amongst us. We will worry about maintaining our status and worry about our assets and worry about getting mugged and bridges collapsing and the ding on the passenger side of the SUV and the price of of gas and getting a promotion and getting to the PTA on time and renewing the tags on the car and stopping at the supermarket and taking the kids to ballet and softball and...

We don't have time for a 30 minute walk. We don't have space in our crowded lives to contemplate or just to be present for half an hour. We don't even have time to listen to our neighbors for all the criticizing of their poor choices. There is no well-being, there is no joy. And we think we're healthy?

One of Dostoevsky's Brothers Karamazov pointed out that "in truth we are each responsible to all for all, it's only that men don't know this. If they knew it, the world would be a paradise at once."

Medical v Management

Medinnovations posted an interesting article on physician entrepreneurs taking back the health care system.

I couldn't disagree, but I am so skeptical.

Physicians frequently find themselves at odds with management with neither side realizing what a valuable skill set they bring to the table. I spent a lifetime developing my medical skills and more recently recognized what a good manager could do. This is why I went back to school. But I am also left with the realization that by the time my mid-career transition produces as good a manager as I am a physician, it will be time to retire.

Physicians reporting to physicians, but with the business acumen to give up some autonomy to physicians with greater business skills... they don't teach you how to let go in med school.

Entrepreneurial skills are rare, even in business school. It takes a very unusual personality to be a successful entrepreneur. Moreover, Dr. Reece is suggesting that physicians become entrepreneurial with consumer-driven health care. As far as I can understand the idea, that takes a pretty sophisticated consumer. Forgive me if I'm skeptical, but working with a low-income population, I don't see a lot of people who can properly make the types of decisions required by this type of health care.

JCAHO Under Fire

This story boggles my mind. Maybe it is because I have spent so much time on our own JCAHO accreditation efforts over the past couple of years, it makes me wonder how on earth Congress could remove it as an accreditation body.

I guess time will tell.

Envelopes and the Greek Medical Business

If you think we have problems in the US, you should try Greece.

There had been talk of a socialized system several years and a couple of prime ministers ago. There seems to be a modicum of a centrally funded, insurance-based system now. However, the WHO's description of Hellenic healthcare tells me it still runs the old-fashioned way:

[Informal payments] are especially prominent in the case of in-patient care, and are made to doctors, mainly surgeons, in public but also in private hospitals. These payments are also made in the case of outpatient care. The rationale is to jump the queue or to secure better quality services and greater personal attention by the doctor. Unofficial payments are considered to be a major problem in the Greek health care system. It is estimated that about half the total private expenditure on health care involves informal payments. There is no really reliable estimate of the size of the unofficial market, partly because it is so widespread, and partly because of the complexity of the Greek health care system.

Almost 60% of total out-of-pocket payments (official and unofficial) are made to doctors and dentists, 20% go toward pharmaceuticals, with the rest being mainly expenditures on private diagnostic centres and private clinics. Out-of-pocket payments (both official and unofficial) represent roughly 6% of household income (1990 figures).

So these informal payments are made under the table, usually cash stuffed into an envelope and they are fairly common, even in the out patient arena. Traditions die hard, and the tradition of the "fakelaki" (the Greek word for envelope) is alive and well. I believe these payments are outlawed in the government-run clinics, but common prejudices take effect: Greeks are nearly Italian in their disregard for authority and let's face it, doctors can't be any good if they works for the government! You and I may know it's not true, but there's no accounting for consumer decisions.

My suspicion is that the lowest risk way of buying a stake in Greek Healthcare is to buy a stake in an envelope factory.


Aide, gela!

Phone Call Volume in a Medical Center

There are few nuisances that medical offices deal with more poorly than the enormous volume of calls coming into the doctors. The problem grows exponentially when you are dealing with a large group or outpatient medical center.

Someone is always out and the patient can't wait. The phone staff just don't have the skills or knowledge required to properly channel the call without a clinician's input. Sometimes the nurses realize they need to be very careful about what they say or do, so the call keeps going round and round until the doctor gets back from the OR, conference or vacation.

One thing for sure, we don't want to be paying my docs as much as we do, to be wasting time on unremunerated service. On the other hand, what happens by phone before and after the visit are essential business functions that impact the bottom line.

The fact that the majority of the calls can be handled by ancillary staff is not reassuring when you're looking a the budget and trying to justify hiring additional staff. Moreover, the patients sometimes miss the mark... Ya, only sometimes, although I empathize with physicians who feel it is more frequent. I just got a call this evening from a patient who wanted to know what to do about her arm hurting. Well, can you make an appointment and maybe an examination will help?

How many times do I need to listen to the nurses' frustration with the message, "Hi, it's me. I am running out of pills. Can you call them in for me?" Sure, a name, date of birth, dose... anything would help.

We ran a quick study at my former job and learned that 45% of the calls were for medication, about 10% of which were inappropriate (antibiotics, narcotics or patient had not been seen in years). About a third of the calls were repeats, usually a pharmacy's second or third call.

Our intervention was to ask patients to have their pharmacy fax the request.

We also learned that we had a lot of calls following up on referral requests. Again we found that many of the patients had not been evaluated: "I'm having surgery tomorrow, I know I haven't been seen, but I need a referral." Please understand, we had a file on some of these patients. The others had our names on an insurance card and nobody (not even the consultant) ever thought that they needed to see a PCP before getting a referral. Educating the patient, without offending them can be a tricky balance.

Some of our problems were exacerbated by being a residency. By final year, residents were in clinic as often as 4 days a week some months. But only once a week in first year and forget about it during the ICU rotation, for example. Some patients were just too uncomfortable seeing a different person at each visit and the staff making appointments never really got used to the idea of continuity. What I found most interesting was that we saw 100 patients a day, but received 200 calls a day on the patient lines and another 200 represented staff and direct dial to certain extensions.

How can you get twice as many calls as the number of patients you see in a given day?

Well, I suggest using a punch-by-numbers menu system that elderly patients can't navigate. They'll just keep calling until the get a human on the line. Depend on voice mail, so that unintelligible messages go unanswered. Voice mail is a terrific way of getting partial messages, cut-off phone numbers and incomplete information. Most importantly, make sure that people's concerns are not completely addressed at the time of the call, so they have to call back... and call back... and call back.

At my current job, we get 19,000 calls a month, compared with 2,000 encounters. This ratio is because we are counting every phone call to the main switch as well as direct dial. We are often confused with a county agency and we run the Women, Infants and Children program. Our brand new technology has allowed us to identify that we have some obsessive repeat callers who hang up and call back repeatedly until someone answers.

One way or another, to answer this volume of calls, you would need 3 people answering calls all day for about an average of 5 minutes apiece. This number is reasonable according to a sister clinic with an established call center in another part of the state. Now that we have the staff to have all the calls the first time, I suspect that we will see call volume drop off. But I think we may be able to schedule more effectively and maximize use of our facilities. Only time will tell.

Running a tight shop means making sure resources are properly deployed to achieve the right goals. In this case, the improvement will fall to the bottom line due to better patient flow.

A Cato Moment

TCS Daily has an intelligent post attacking Universal Health Care written by a Cato Institute scholar. Arnold King points out that the argument over Universal Insurance is merely a distraction from the main issues. Important points:

1. Health insurance is not really insurance. It merely serves to insulate people from the cost of their medicine.
2. Health care is already heavily subsidized by the federal government through tax policy. We are already paying for it.
   
3. The plight of the uninsured is exaggerated.
4. There is a licensing cartel that artificially raises prices.
5. The cost-effectiveness of treatments should be final determinant of what should be paid.

These are my responses:

1. Agreed. Herein lies the crux of the matter. My auto insurance actually pays for a car rental if my care is undriveable due to an accident. Will I get a Kia or Caddy? Unfortunately, we don't think of health care that way.
2. Indeed and I doubt we will be a able to go back. Rather than trying to raise taxes by creating tax neutrality for health care subsidies (i.e. employer-paid premiums), we could find ways to limit the entire cost to government. This would involve acknowledging we have a significant government contribution and the willingness to try things that hold those dollars more accountable than they have been.
3. I work with the uninsured, so my view is biased by the fact that I daily hear a story which convinces me the plight of the uninsured has not been told. Some of my patients are -- or rather were -- professionals, including a pair of lawyers who have spiraled out of control due to factors beyond their control. One is a school teacher whose health is declining to the point that she may no longer be able to remain gainfully employed! I know an engineer, who is self-employed, but not yet eligible for Medicare. These people need more resources than I have to provide. Who cares about tax neutrality, when there is an economic impact at the level of productivity that is so obvious in the field? Why is it that it that so few attempts have even been made to measure the economic impact of health care access?
4. Yes, there is a licensing cartel in the US which has been replicated in most of the world. Flexner in 1910 was partially responsible for creating it. It was created in response to the proliferation of quacks and snake oil salesmen in the Wild and Woolly US of the turn of the century. This idea is a non-starter; don't distract me. My disclaimer is my profile.
   
5. Although proof of cost-effectiveness should be the final arbiter of what should be paid, there are two important caveats. First, one of the fundamental precepts of Evidence-Based Medicine is that the data rarely provides conclusive proof for the clinical actions we all take for granted... and consider the standard of care. You can't pick and chose. Second, innovation depends on the introduction of new technologies and procedures, for which there is, by definition, no evidence. We cannot afford to wait decades until FDA or some new commission approves a procedure. On a viciously sarcastic note, even the wealthy would rather pay for a procedure that has been tested on more than a few poorer people!

I don't think we need to throw more money at the health care system, but that we should identify individuals who need a little more help navigating. Right now costs are being shifted dysfunctionally and the result is that our health care system ranks poorly in international ranking schemes. Our health care system can be improved and justified from a "conservative" point of view.

Healthcare 100 Debut

Debut at 314 on the Healthcare 100!

Not bad for a two-week old blog. Thanks to all who have been visiting. Maybe I should start promoting in earnest.

Update at 11:00 AM: Actually, it's 316 now. Just in a couple of hours... wow!

Kevin, MD needs to go back to school

Kevin, MD is at it again: Irrational one-sided attacks on something he calls socialized medicine with no definitions or evidence of understanding the economic and business principles underlying health care. Management is the bridge between practice and policy and unfortunately, physicians seem to believe their degrees give them an intuitive understanding of everything. The sad part is, of course, that physicians are exceedingly intelligent people who usually have a good understanding of their limitations, at least in their medical practice. Timely referral is based on knowing what you can and cannot do. Neither policy nor management is his forte. Apparently he does not know the difference between universal coverage and socialized medicine.

My guess is the practice isn't going well and they need someone to blame. I will suggest, entirely serving of course, they need a good physician manager.


My diatribe is based on a minor comment that:

"No one really knows whether preventive medicine will save money in the long run, let alone free up the billions of dollars a year needed to help pay for universal health insurance. In fact, studies have shown that preventive care — be it cancer screening, smoking cessation or plain old checkups — usually ends up costing money. It makes people healthier, but it’s not free."

Kevin provides a link to the New York Times article from last week that did an uncommonly good job explaining various candidates' approaches to funding health care reform. However there are a couple of traps that the article glossed over and a decidedly unacademic Kevin missed entirely.

First, the NYT appears to be debunking the popular notion that there is a lot of money to be saved by practicing preventive medicine. Indeed, the literature has time and again shown that while prevention may be effective (and sometimes it isn't) it is rarely cost-effective on a population basis.

It may only cost a few bucks to look for occult blood as part of colon cancer screening, but to do this in millions of people raises the societal cost astronomically. For blood or X-ray screening, the costs are even higher. Stay tuned to MRI's and breast cancer: it seems to work well for early detection, but we're talking over a $1000 a pop! That translates to over $100 Billion dollars a year for a screening program. Nobody is ever going to suggest we do that, no matter if data started to suggest that MRI is the best breast diagnostic tool around (data which does not yet exist.)

Technology also has serious limitations. Unlike mechanical devices, like cars, where diagnostics tend to be pretty accurate, biological organisms are a little more complex. For every test result there is a significant error rate. For some tests which physicians think are reliable, I have done some calculations and found that over 50% of positive results were actually wrong (low prevalence conditions with average specificity tests yield low positive predictive value.) The stool cards I described above are an example of a screening test with a high error rate, which is why further investigation is always needed to follow-up.

PSA is one my favorite tests to pick on; there isn't a single medical organization that says men should have a PSA every year; only that it should be offered to all men and done for high risk people (based on family history or African heritage). The calculus of risk involves balancing the cost of thirty needless investigation out of every one hundred men tested against preventing a single case of the prostate cancer.

You don't have to be a bean-counter to do this type of calculation and the information is useful in daily practice.

The NYT article refers to prevention, which in my mind means screening and early treatment. But, on the other hand, the article goes on to talk about diabetes care. This is chronic disease management, an entirely different activity with a different set of calculations. In chronic disease management, we are concerned about the intensity of resources required to achieve a positive health outcome.

The major determinant of diabetes outcomes is patient behavior, which is difficult to change and dependent on multiple factors outside the delivery of health care. There is a lot of money to be saved, but interventions fail to obtain the desired outcome more often than we like. Most outcome studies use proxy outcomes as often as possible for reasons of practicality and cost. There is some evidence that having a usual source of care does, in fact, lead to better outcomes. This is the argument for universal access to a primary care home.

Universal access is not socialized medicine. Single payer systems are usually socialized, but I can imagine situations where they don't have to be. Universal health care has the potential to save money assuming that there is sufficient chronic disease for which having a "medical home" can improve outcomes. Universal health care does not have to be an entitlement; it can be a defined benefit along the lines of Oregon's above or below the line.

My suggestion to Kevin and others throwing their two cents into the health care reform debate is as follows: define what you're talking about, stick to common definitions and don't muddle the things you're discussing. The NYT started with a discussion of prevention, but moved into chronic disease management. Kevin jumped in and confused universal coverage with socialized medicine.

Jeez, no wonder this county can't get it's act together! People are arguing about different things and think they're talking about a single topic.