International Comparisons

A few weeks ago, there was considerable buzz about the poor rankings of the US health care system in the Commonwealth Fund's study. It echoed findings from an earlier WHO study.

Of course, everyone was focused on the US' place in the rankings. Also Canada and Cuba and whatever else Michael Moore was talking about.

I felt the discussion was a misdirected attempt by apologists of the American system who did not understand the nature of public health measures. Equity is important to public health and is an appropriate basis upon which to compare systems internationally. It is not a slight to the quality of your neighborhood hospital. It is a measure of government's ability to undertake its basic responsibilities.

Recent news from Myanmar gave me the notion of looking at the bottom of the rankings. There it was, at 190 of 191 in WHO. Given the concentration of power at the top and complete disregard for pretty much any kind of domestic policy, the country is in meltdown.

Position 191 was held by Sierra Leone in 2000, at the time in the grips of an internecine war. Positions 188 and 189 are the Congo and the Central African Republic, two of the poorest in the world, with Congo also at war. Nigeria is 187, not exactly the poorest in Africa, but rife with class, ethnic and religious strife with an ineffective government that has left the country's infrastructure in a mess.

Isn't it interesting how war and ineffective governance can have such a powerful impact on health systems? In Myanmar's case, it may have been a predictor of unrest. It's not just poverty. The Solomon Islands achieve a ranking of 80 despite a bottom-of-the world $600 a year GDP. Maybe the quality of a county's health system is just a reflection of its government's effectiveness?

Weekend Wishes

One of the fun parts of blogging is sparring with the whacks at Insureblog (oops, I did it again) and calling sloppy work at the Cato Institute. But methinks I may take too much pleasure in shooting from the hip.

Much more pleasurable is the discovery of gentle, elegant writers who give us a window into their lives, their minds and ultimately our own nature.

Maria of intueri has been interviewing for fellowships in NYC. In every post I can smell the city, as immediate as my last visit.

Sid Schwab at Surgeonsblog posted on naming conventions in medicine. It is probably the best post I have read since I began exploring the blogosphere.

I love some of the behind the scenes stories that bring memories of my days in ER, the wards or being a student.

I have also discovered I can have an effect far beyond what I thought was possible, having led Dr. Wes to pull a post. Honestly, I have mixed feelings about this, but I'm a pretty multicultural guy myself, given who I am, how I grew up, who I married and the people I have served. Any time a business can make a concession in the name of multiculturalism and make money at it... all the more power to them. On the other hand, I was pretty harsh and don't feel good about it.

Food for thought. Have a great weekend.

Argument for Big Pharma

Peter Pitts appears to be a very intelligent person. As a former head of the FDA, he knew how to find the money and took off to run the Center for Medicine in the Public Interest, generally recognized as a front for Big Pharma. I like reading his posts, for the same reason I like reading the Cato; I am always looking for good arguments on the side of any position.

So I came across this interesting article suggesting that we need to stop insurance companies from switching people to generics all the time. This was published the same day that Wal-Mart added terbenafine, once $300 a month, to it's $4 generic list.

As a clinician, my frustration is that insurance companies, or more specifically the pharmacy benefit managers, forcing patients to change meds. They insist that a certain medication in a given class is not covered and the patient must change to a different drug in the same class. It's like don't take amoxicillin, you have to take penicillin. Alternatively, the physician can somehow demonstrate or certify an adverse reaction or lack of effect before they authorize going back to the original drug. I already know drug A doesn't work, from experience on the previous insurance. The insurance requires that we try Drug A again, before they reimburse for Drug B, which the patient has been taking for a long time.

I understand the complications of dealing with expanded formularies and the inefficiencies of having to stock so many similar drugs. I also understand the value of the discounts available when you order in bulk.

I just don't think it's a good idea to swap chemical entities because I have a healthy respect for the risks of consuming anything on a regular and ongoing basis. Once you have a functional and safe regimen, it is unwise to change.

Here's the bone I'm going to throw to Big Pharma; sometimes a softer argument makes a greater effect than one so strident, the bias encourages the reader to discard it without a thought.

Asking Questions About Poverty and Health

The NY Times reports that poor New Yorkers are in poorer health. This gap between haves and have-nots, known as Health Disparities, is important to address. Even though there are racial and ethnic overtones important in the context of US history, an additional consideration is how health and poverty interact.

Socio-economic status (of which poverty is a significant component) is an important predictor of health status. Poor health has economic consequences. A vicious cycle beyond someone's control is important to address, since it may not be the consequence of individual choices. The lack of opportunity to climb socio-economically increases the risk of social unrest. (Just as the lack of of an opportunity to fall socio-economically decreases motivation and personal responsibility... ask any Wall Street hedge fund manager.)

I have avoided some of the economic analysis required to measure the pros and cons, in part because I am not an economist, but in part because I am not is someone has framed the health care issue in purely economic terms. Maybe the data is sufficient now to take a stab at it. If so, I would proffer a couple of questions.

1. Does health care coverage improve economic performance or individual productivity?
2. Which component of health care coverage? Somehow I'm not sure hospital and specialty care achieves any purely economic goals, but may be required for credibility.
   
3. How much cheating or consumerist behavior makes the coverage cost-prohibitive?
   

Comments on CMS’ Physician Quality Reporting Initiative

We should never throw out the baby with the bathwater. In other words CMS’ Physician Quality Reporting Initiative (PQRI) sounds like a good idea, but if it is poorly implemented and physicians don't participate, it doesn't make the idea a bad one.

Here is a pro and con analysis of PQRI.

My patients are pretty young so we don't have an interest in participating in any Medicare program. I learn from the 'con' piece that a 1.5% increase is all that's available. In addition there are stumbling blocks on the CMS side. They do not take advantages of EMR capabilities so reporting becomes a big bother for a small practice. The positive article, unsurprisingly is written by a medical executive with responsibility for a 150-physician group in the Midwest. With a high Medicare proportion in the payer mix, economies of scale can make 1.5% pretty significant, especially when one considers the process improvements required to hit your quality targets.

Alert Your Physicians...

Since Medicare decided not to pay for adverse events, especially never-events, hospitals should have been wondering how they were going to establish that these conditions were present on admission.

Ingenix is a consulting company owned by United Healthcare Group that helps prepare hospitals for what's coming. If you're a hospitalist, ER doc or admit patients to hospital, this would suggest that you are about to assume an additional duty: POA (presence on admission) reporting.

Alert physicians that you are going to ask for their cooperation related to POA. Work with physicians on the importance of documentation related to POA and explain why you need this information.

Some hospitals won't realize they need physicians' cooperation until... about mid-February, probably.

Missing the Point on Canada

The Cato Institute is plugging an as-yet unpublished paper comparing the health systems of Canada and the US.

We show that the efficacy of health care systems cannot be usefully evaluated by comparisons of infant mortality and life expectancy.

Well, this is a public health measure and an international standard. It may not reflect every aspect of health care system performance, nor was it ever intended to. This misunderstanding has been the basis of what appears to be an almost systematic campaign of misinformation for the purpose of advancing an ideological agenda.

However, having said that, there is still the following interesting matter:

We also find that Canada has no more abolished the tendency for health status to improve with income than have other countries. Indeed, the health-income gradient is slightly steeper in Canada than it is in the U.S.

That is in fact, a brilliant observation, which, if true, would bear considerable additional attention from non-ideologues. I can't wait to see the original paper to see if there were exclusions, what the specific outcomes were in consideration of health outcomes, and, of course, if this is a trend or actually approached anything resembling statistical significance.

On the issue of cost, about twice as high in the US as in Canada,

Is the U.S. getting sufficient additional benefits to justify these greater expenditures and where should we cut back if cutbacks must be made?

This seems to miss the point, that Canada can achieve its goal of improving specific health care outcomes at less than half the cost of the US. The US is more interested in the unmeasurables of satisfaction and can't achieve a fraction of what our people deserve.

Hiowver, comments may be premature, until the article becomes generally available.

More on the Politics of Breastfeeding

A series of recent events around breastfeeding in public is summarized in this Toronto newspaper article.

It seems vaguely peculiar that one of the most over-sexed societies in the world blushes at the view of a naked breast with a baby's mouth on it. On the other hand media offers overtly sexual images with impunity.

Breast-feeding has taken root in Europe quite awhile ago. The third world, well that's a class issue, so let's not go there.

I suggest we should encourage breast-feeding by making sure women feel comfortable doing so in public. Let's also get hospitals to stop formula supplementation prior to discharge... but that's a story for another day.

Concierge Physicians

Scott Schreve's post on concierge physicians is a pretty good analysis of the pros and cons of this kind of practice. I had not considered the potential for accusations of inappropriate behavior with doctors practicing on their own. I have practiced chaperon medicine since coming to the States, although in Canada, we never felt we needed someone in the room while performing a breast or pelvic exam.

Perhaps, more importantly, there is one important down-side he did not consider that I am thinking about more and more lately. If primary care is in such short supply, concierge physicians divert resources from populations who really need it. It has been difficult recruiting family docs for my community health center. How much more with Medicaid expansions, the potential of a national health plan and just the organic trends of increasing primary care use?

More on Obesity and the Environment

In a previous post on obesity, Chris Rangel expressed skepticism about explaining the obesity epidemic by pointing to external factors, such as the physical environment. While I agree that personal responsibility is important and, as physicians, we sometimes see patients who are their own worst enemies, circumstances play an incredibly important role. We don't completely understand the relationships, but one more study points to the built environment in association with obesity.

Drug Safety Expectations

I am not a big fan of drug companies whose marketing practices can push the envelope of propriety and potentially run counter the public interest. On the other hand, this CNN article highlights how 65 millions prescriptions are filled for drugs that have not been FDA approved. It turns out the drugs in question never went through an FDA approval process because they were grandfathered into the Pharmacopeia at the FDA's inception.

I wonder how much the FDA is responding to an unrealistic public expectation. It sounds like the general public wants drugs that have no known side-effects, no potential downfalls and make everyone as healthy as a lark. Are FDA employees really willing to do their darndest to ensure their own job security by attempting to achieve the impossible? Frankly, I know enough hard-working FDA folks who would probably like to avoid strange, unscientific mandates from some ineffable special interest.

Moreover the article's prime example is quinine, a drug in use for well over a century. Guaifenesin, one of the most benign drugs ever invented, has come under review in an attempt to get all these old drugs under FDA control. The last time I looked, Thompson's proprietary Micromedex ($$, sorry the University dropped the subscription) began its section on this common cough medicine with the sentence "Guaifenesin has no known side effects."

So let's see if I understand the reason for the FDA attacking legacy drugs.

• No drug can ever be shown to be 100% safe.
• Post-marketing (Phase IV) surveillance provides some assurance, more so than all the studies conducted prior to marketing (Phase I - III).
• Drugs that have been in existence for more than a century and have been used in millions of patients (so necessarily we have seen hundreds of rare events) have more safety information available than any drug since penicillin.
• Since we don't have Phase I - III studies on these legacy drugs, we will ignore a century of Phase IV data in the interests of safety.

Hey, my mom's the regulatory expert in the family, not me. Maybe someone can explain it to the rest of us?

ROI From Health Care? A Study on Depression

My discussions with some health care economists have often been limited to the obvious fact that health care investments have not yielded improvements in mortality.

Searching for the economic benefits of health care does not need to be that hard, as another research article shows. The economic benefits of health care are related to quality of life and don't forget: "a happy employee is a productive employee."

But is has been business' historical prerogative to shoot itself in the foot over and over again. See the coming S-CHIP debacle. Can the Republicans be so stupid? A veto will loose the center here.

Public Reporting of Hospital Mortality

Massachusetts seems to be leading the way in public reporting of hospital quality measures. A couple of days ago, Health Care For All and the Massachusetts Coalition for the Prevention of Medical Errors held a conference on the Hospital Standardized Mortality Ratio (HSMR), a measure purported to risk-adjust accurately based on Medicare data.

OK, let's get it out of the way: "but my patients are different..."

The whole idea of publishing HSMR for the purpose of making hospital comparisons can become sticky very quickly. First, there is the assumption that it is possible to make imperfect data available to consumers in the context of asymmetrical information. The data is technical and most consumers are not armed to understand their strengths and weaknesses.

The simplest and most important technical component of mortality rates is the fact that patients are not the same from hospital to hospital. It is difficult for the lay public to understand the adjustments that go into the HSMR and the implications for the quality ratings they will read. But it is certainly not impossible.

The advantages of the HSMR measure is that it relies on mortality, not adverse events or morbidity or costs or anything else. Mortality is a solid end-point, it is well-understood and not likely to be manipulated. Mortality data is also complete and can be cross-checked with other sources of death records.

On the other hand, it appears to be about 80% accurate. What does that mean for the naysayers? Is it accurate enough to make comparisons between various hospitals? The incentive is for a hospital with a minor advantage to be very loud about how much better they are than the cross-town competitor. How easy is it to explain the concept of "significant difference" to the public, or to a marketing executive for that matter? There is plenty of ammunition for the doubters. What I remember from my research into Medicare risk-adjustment a few years ago was that no system could predict more than 50% of the variance in Medicare spending for the subsequent year. Try explaining that one to the general public.

Of course there is a difference between a solid end-point like mortality and one as fluid as Medicare expenditures, but it would appear to me to be enough for hospital and large provider groups to resist.

The reality of most rating systems is that most everyone is in the middle. The real purpose is to identify problems at one end of the bell curve and the truly outstanding at the other end. The major advantage of HSMR is that "what gets measured gets done" and there will undoubtedly be a positive movement in the performance of all hospitals whose performance is measured.

I fall in with Paul Levy on the side of publishing HSMR but the devil is in the details. The explanation of ratings and public education efforts will be the most important elements of any effort to make complicated data safely interpretable by patients without harming the reputation of hospitals, the majority of which make a good faith effort to provide quality care.

International Demographic Trends' Implications For Health

Foreign Policy identifies five major global demographic trends. Is it not interesting how all five have dramatic implications for health?

1. As populations turn gray, birth rates drop. The negative economic implications lead governments to provide incentives for having babies. But maybe OB-GYN isn't the best specialty for medical students to choose?

2. Populations explode in developing economies, areas collectively known as "The South." Contraceptive policy takes the forefront and the US finds itself attacked whether it supports or undermines efforts to distribute contraception in the third world. Either way, populations here are on the rise and migrating to wealthier countries.

3. AIDS decimates sub-Saharan Africa: This has been the single greatest tragedy of our generation, with all due respect to those who died in the September 11 attacks.

4. In China and India, sex selection has created a demographic time bomb: all males, too few females. Since access to this technology is somewhat income dependent, I wonder if anyone has considered the socioeconomic implications of skewed demographics to a class-conscious society.

5. Migration: Related to point 2 above, indicating that the reason we have illegal immigrants in the US is because the world is lined up that way. No wall across the Rio Grande will ever resolve the cost of health care to illegals. By the way, Point 1 above speaks to the economic concerns related to a demographic shift to the elderly. Could illegal immigration be a safety valves to prevent an economic collapse when there is no one left to manually produce anything anymore?

Hospitalists and Better Outcomes

As a generalist, I find it very difficult to acknowledge that specialization leads to better care in every instance. Certainly in some areas, but not all.

However this article from the Archives of Internal Medicine is a well done study that reveals the advantages of hospitalists. I would like to see the same in community hospitals. I suspect the differences would be greater, not less.

Questions About Flu Vaccine

This article in the normally staid and reponsible BBC casts aspersions about flu vaccine.

The problem I see with articles like these is that most people read the headline and internalize it before getting to the most important sentence:

UK policy is constantly under review to take into consideration all available evidence. This study acknowledges that, whilst waiting for an improved evidence base, vaccination with flu vaccine in this group should continue.

This sentence is at the 21 paragraph. A passing statement that this data is, in fact, controversial appears in the 3rd paragraph.

How long before some lunatic fringe blog picks this up?

By the way, has anyone heard that measles vaccine causes autism? Anybody?

Time Spent in Clinic

Everyone complains about how little time physicians spend with them. Sometimes a perception is based in reality and other times it is just that: a perception.

I have observed the patient perceives the physician spent less time if she appeared rushed.

I have read that the average patient contact time in England is under 6 minutes, but that was over a decade ago. The number stuck because around the same time, I ran into another study of changes in face time time in the US over the years. According to that author, it was more than England at the beginning and has increased over time.

One possible explanation for the reason face time has increased but the perception has been that physicians are spending less time with our patients may be that there is more to do and we are more rushed.

I'm sorry I don't have the references, but it's enough to make my point. The details: well, you can't compare times across studies with different methodologies and I am not sure I would trust time estimates if they were not directly observed.

Here is a report of a new study at The Healthcare Economist that suggests there is a greater influence on time spent with patients: payment arrangements. This is a direct observation study analyzed by payment methodology. One consideration is always comparing how similar the different groups were, especially in complexity. As it turns out, as direct observation, the study authors could assess the complexity of patients and seem to have addressed the problem.

If you care about cost, you would increase productivity by continuing managed care incentives. If you want quality, you could encourage salary arrangements. Or you could find a way of incentivizing to maximizing both.

Response to Michael Cannon

I have had trouble responding to Michael Cannon. I knew when I first read his response to my critique of his USA Today Op-Ed (that's a mouthful to follow) that more should be said. He spent most of his time defending incorrect referencing in his Op-Ed, but there was something more. The more I read, the more I perceived a purposeful selection of data in support of an existing position. I am more familiar with the scientific method which requires the writer to follow the data, including contradictory evidence. Mr. Cannon comes from an ideological perspective to which I cannot relate. Perhaps no response is required for ideologues. After all, what is the purpose of the Cato Institute but to purvey a particular ideology?

I have a libertarian streak, but I am no libertarian. These ideas serve as a reminder that there are limits to what government can and should do. There are limitations to the financial resources of any society. I do not believe that there should be a single payer or that everyone is entitled to every possible medical intervention. But as I dig deeper, my understanding is growing of the ideology which shares these principles.

First let me direct some comments directly to Michael's defense of the USA Today Op-Ed:

1. To minimize the number of uninsured is to miss the point that there are vulnerable people in society who need some assistance. The government has a role in improving the quality of life of its citizens by supporting education, defense, law and order, health care and probably other areas as well. To believe the government has no role whatsoever is false, intellectually on the fringe and historically on the road to revolution.
   
2. To suggest that all people covered by Medicaid would be better off with private insurance is as ignorant of the lives of the poor as Mariah Carey talking about poor starving kids and flies and death and stuff. Crowd-out as Michael Cannon describes is another name for cherry-picking. To force low-income individuals who are most likely to cost insurers more money is to keep private insurance more profitable for the insurers.
   
3. Most medical care is not cost-effective, as measured by macro-level indicators. Since leaving Canada I have learned that no country ever became great by trying to be cost-effective, but rather by achieving its goals. Therein lies my objection to raising the issue of medical cost-effectiveness. The most important variable in cost-effectiveness is defining the goal, so as to know if you are being effective in achieving the goal. It would be cost-effective to focus efforts on coverage of the most vulnerable. It would be cost-effective to stop treating the elderly, the disabled and the mentally retarded. Sometimes we do things because we feel it is important as a reflection of the quality of our society. Economic reasons alone are not good enough to make decisions about health care policy, something I was taught by a health economist from Harvard.

There are some very valid notions being floated regarding health reform, not the least of which are reducing payments to hospitals (which account for 50% of the country's health care bill), increasing transparency of pricing and increasing consumer control of their own health care money and benefits. These proposals address many problems in health care today, but not the problems of those who need the greatest assistance. At the risk of sounding like a guild monopolist, physicians are better representatives of patients when they cannot speak for themselves than a policy wonk who's never walked a day in clinic.

The first step in crafting health care policy is articulating a role for government. If you don't believe there is any role for government in health care, then we have nothing more to talk about and we must agree to disagree. If the goal is a responsible approach to improving the well-being of the population through expanded health coverage while simultaneously improving accountability of the tax dollar, then there is a possibility of discussing the relative merits of various approaches.

Illegals and Health Care

I am really torn about this issue; illegal immigrants getting sick in the US. A Federal court in NY has indicated Medicaid funds cannot be used for non-residents (illegals, students and visitors) needing chemotherapy.

First, I am a physician and feel a strong moral obligation to help whomever I can. But I am also a tax-payer and know there are limits to what any society can afford.

Illegal immigration is a political issue and the reasons underlying it are complex, social and economic issues that have gone completely unaddressed by the ridiculous attempts at enforcement. There are individuals who are little more than visitors and have managed to outstay their welcome, despite the benefits they bring to the economy at large.

Once I am in clinic I cannot ask, nor care, about an individuals immigration status. It is unethical and immoral for any physician or health care provider to treat someone solely based on their nationality. Physcians are not even supposed to refuse to care for people who are criminals. If a mass murderer seeks care, as odious as it may feel, I have an obligation to treat the patient as long as there is no imminent threat to myself, my staff or the people in the building.

But where are the limits. Everyone has to get paid somewhere down the line. There is no longer enough margin in private practice or hospital operations to allow charity care for long, complicated and expensive treatments. Directly or indirectly, the states are left holding the bag for a bunch of unremunerated care.

The alternative is to let people die.

I remember one lady who split her time between South America and here, where her daughter had emigrated. Just before returning to the US, she had her mammogram (it was cheaper). A day before she got on the plane, she was told she had bad-looking lesion and probably had cancer. She came to see me in tears.

Without insurance and insufficient funds to cover the treatment, she was truly out of luck. In this state, she could never qualify for any public assistance. Her only options were a local charity or return to South America and do the best she could with what was available to her there.

As a physician, I want to get her the care she needs. That's it. No ifs ands or buts. Keep me out of enforcing a political agenda, even if I sometimes wonder where my tax money is going.

Psychologists Prescribing

Since I have been called a "dirty rotten guild monopolist" on my own blog, I thought I should try to live up to the name.

Psychologists have been trying to get prescribing privileges in various states and they have been consistently shot down. I can understand that psychologists would like to prescribe, given the difficulties of finding psychiatrists and the low regard they have for primary care physicians. But I did take a pharmacology course and prescribe something at least ten times a day (well less, but that's closer to the national average).

If a patient experiences an adverse event, I am in a position to treat or direct the patient accordingly. Enough people dump on me as it is. If it's your adverse event, don't refer the patient back to me. On the other hand, if you think your patient really needs a medication, I'll take your recommendation, if you ask me first.

My opinion; to understand why psychologists would like to prescribe rather than foster the primary care relationships they should be supporting, just follow the money.

Manager Bites Physician, Physician Bites Back

One of the things that spurred me on to management was trying to resolve complaints about doctors. My first taste was dealing with complaints from the front desk staff and the nurses about residents. Over time, I learned some of the principles that I explored more fully in my management degree. Funnily enough, working where I do with fully adult grown-up doctors, you would think there are fewer complaints.

Wrong.

This week I am being asked to deal with a physician who is refusing to see patients from a county program and is refusing to file prescriptions electronically.

Sure, we have the prima donnas, who harbor childhood memories of the respect that physicians used to command. I have very little tolerance for the rose-colored view of a fantasy golden age which probably never existed. They expect everything to go their way, as though they were in private practice. Sorry but you took a job in an employed situation and, although I will do the best to represent you, you are now in an environment where everone else has a say in how things run.

Of course there are those doctors who occasionally get frustrated enough to throw scalpels, verbal or otherwise. Temper tantrums are not acceptable anywhere, especially in my eyes. This behavior makes my job of representing the physicians to management all that much harder. Making my job harder is usually bad when it comes to evaluation time, that should be easy enough to understand.

But these types of doctors are few and far between, although they seem to have a disproportionate impact in shaping management's perceptions of physicians.

So what accounts for the perception by management that physicians are chronic, terrible, whiny complainers? Physicians are 'difficult' and thorny to manage.

Things have certainly changed since physicians have exited private practice, where they could run things as they pleased. Now they are very likely to find themselves in an employed situation and find themselves answering to people whom they regard as less educated, fewer skills, less influence and whose only authority is titular. Everybody has a boss and even the Chairman of the Board answers to a higher power, be it the Code of Federal Regulation or the God of Abraham.

People with busines degrees are acculturated in the context of a complex system with multiple stakeholders where teamwork is important. It's like being a little brother in a family of 10. Physicians are acculturated to write orders and see that they are carried out. It's like being the big brother keeping everyone else in line. Maybe a better analogy is like being the only child, who never had to worry about other brothers and sisters at all.

It turns out my physician got dumped on by a social worker who left a non-verbal child with little documentation for a complete assessment which took over an hour. Moreover the computers have been running slow as molasses so it was impossible to write electronic prescriptions.

In other words, my doc was in the right, but nobody bothered to listen enough to understand the situation. Maybe the problem had not been articulated in a way the manager could hear. This seems like an awful way to treat physicians, but I see it all the time. This is worse when you consider that physicians are the primary source of revenue since they are the only ones at our enterprise that can provide a service and bill for it.

My experience is that, whatever the complaint, the physicians are coming from a very valid point of view, but do not express what they want in sufficiently diplomatic terms. Maybe it is true that physicians are not sufficiently savvy at articulating their needs and demonstrating their importance to the organization, but who is the professional manager here? If management does not pay attention to some of the smartest people in their organizations, they do themselves a disservice. Physicians become disgruntled, disaffected and ultimately disengaged. A disengaged physician does not care any more.

Personally, I'd rather deal with people who are complaining, because it means they still care about their patients and the quality of care they are delivering. Moreover, why would a physician manager want to get caught between physicians who are getting slammed in clinic and managers who are unwilling or incapable of improving their production environment?

Greed, Need and Wants

I had an interesting conversation with a group of parents which, along with Lisa Emrich's articulate description of her situation, got me thinking about the right's objections to expanded health coverage.

The group was parents of disabled children transitioning to adulthood. I learned a lot, for example, social security disability depends on the individual having contributed to social security. It is difficult for a non-verbal child with cerebral palsy to get and hold a job so they can qualify for benefits one day. I also learned that those children who do grow up to be able to hold one of those minimum wage jobs designed for people with disabilities, will lose their benefits quickly and then need significant social resources to navigate the system to requalify. The parents must worry who will navigate the maze of regulation when they are gone one day.

These families also have difficulty finding primary care physicians (PCP) who are willing to care for them under Medicaid managed care. It is clear that with the poor remuneration provided by Mediciad and the complexities of special needs children, it is easier for PCP's to simply say "We don't do that. Let the specialist take care of it." For the first time in my career, I don't see the need for PCP's to get involved, since the managed care company's requirement for a PCP is met by the physician who has known them for 19 years and not by a family physician or internist.

In this case, managed care is cutting off it's nose to satisfy a "no exceptions" policy. As a matter of fact, I was invited to this group after meeting a mother who came to see because the new insurance comany was insisting on a repeat sleep test (done years earlier under a different plan), to justify a replacement unit for an expensive piece of respiratory equipment the child had used for 7 years. She was forced by her insurance to come to me to get a referral from her PCP, someone who had never met her or her child and had no realistic hope of ever knowing this child cum adult with a medical history as long as his career.

Now that I've heard and considered the right's argument that people are greedy or do not take care of themselves and just want someone else to pay the bills, I hope I am forgiven the belief that these self-styled conservatives are really just uneducated grunts who got drunk reading Ayn Rand and watching Fox News late one night.

Lisa said in a comment:

Although I am a believer in taking individual responsibility for your own
physical and financial wellness, I strongly object to the notion that one of
these must be sacrificed for the other. No one should have to be shackled by the
realization that earning $5000 too much in one year will result in an extra
$10,000 expense the following year, or earning $10,000 will result in a $21,000
expense. The alternative would be to forfeit access to the medication, which may
or may not protect quality of life for awhile, in order to maximize financial
gains now which may or may not ensure future economic security.

The best way to make someone behave greedily is to put them in a situation where their needs are not met and then have to justify the things they want.

Counties Building Networks for the Uninsured

Here is a local take on what is happening with the uninsured. Howard and Montgomery County are among the richest counties in one of the richest states in the union. Although the current state administration appears to be willing to expand coverage for the uninsured, the money just isn't in the budget this year.

Local and county governments need to step in to assist their citizens.

By throwing the doors open, Howard County has revealed the extent of the problem, one which can usually only be surmised. Montgomery County's 80,000 uninsured is surely an underestimate, as it appears to take into account only legal residents. Latino groups mark the number much higher, but have good reason to bias the numbers as high as possible.

Deny That The Uninsured Exist

Some people argue that there are not 47 million uninsured in this country because they are not uninsured the entire year. I came across a NACHC report that suggests that more than 56 million are disenfranchised. I suspect even more are poorly insured and vulnerable.


The denial of the existence of the uninsured is puzzling. Presumably and by implication, the uninsured are just good old upper middle class Americans who can afford to COBRA their insurance between jobs and just elect not to. They live in nice suburban neighborhoods and commute past the golf courses and malls, all the way to shiny office towers where they put in an honest day's work and make a value decision on their way home.

Well, maybe this is just a fantasy, but I'm not sure where people come off denying the existence of things they cannot possibly see on their own commutes or social circles. You do not see uninsured Americans if you hang out in Georgetown and don't travel to Southeast, the capital's crime-ridden center of ghetto violence. The uninsured are invisible on the beaches of Florida or on adventure tours of Bryce Canyon or the San Juan Islands.

The fact is many of my insured patients are the same ones that were uninsured two months ago and will be uninsured in a few more months because they got this plan temporarily as they worked their way through school. Or they just couldn't afford their premiums once they got to their new job that was supposed to be a great step up for them. The uninsured, as well as Medicaid patients, tend to bounce on and off the rolls every few months or years. I would argue that financial stability is not usually to be had for 2 to 3 years, so would count anyone who has been uninsured for any period of time over the past several years. Anyone who has ever tried to get off the ground after a fall, knows you are the most off-balance as you're trying to get back on your feet.

Yes, I know SCHIP is being extended to individuals over 300% of poverty, but has anyone noticed that the official federal term is "Federal Poverty Guideline", a term chosen specifically because nothing can strictly define poverty. The US does not have a poverty level, in part because of regional variation in what would be a basic subsistence income.

Living in the Washington metro area, I can assure everyone that 300% of poverty is less than subsistence in these parts.

What does this mean for the uninsured? It means 47 million is an underestimate of the vulnerable population. Yes they deserve access. I'm not sure they deserve everything that medicine possibly has to offer. The practicalities of life is that there are financial limitations to everything and as several commenters have observed on this blog, health care does not necessarily contribute all that much to overall health status as measured by crude population vital statistics. I think this is the law of diminishing returns at work, but is insufficient reason to offer nothing.

Community Health Centers [disclosure: I am the medical director of one] can provide quality health care, usually better than "private" practices for lower cost. A follow-up study, conducted with the Graham Center, a policy think-tank that supports the interests of primary care, points to the economic benefits to be had by assuring access to health care through low-cost, high-quality centers.

The rest of the health consumers out there can make their own decisions where to go and how to spend their dollars. Community Health Centers generally don't turn away patients with insurance.

The Truth About Canada's Medicare

Look, I left Canada, OK? So you can fairly assume I'm not a fan. On the other hand, the rhetoric that circulates in the US and other quarters is the kind of thing that gets my blood boiling. And no, I am not going to discuss Michael Moore's views. What I am going to say is that the system works, albeit not perfectly. I am also going to say that many people are missing the real danger of replicating Canada's system in the United States.

The Canadian system is fully socialized. It is operated and entirely funded by one source, the government. Well, not to be a nit-picker, by ten sources, since provincial jurisdictions are mandated to run the system. Each province collects business and personal taxes for the express purpose of funding a health system for all.

The principle of universality is near and dear to the Canadian heart. It assures that all citizens have access to any program ostensibly intended to improve quality of life for the poor. This means that even milk money (my nickname for a national nutritional subsidy) means that checks were delivered monthly to the wealthiest households in the country. It also means that if you're wealthy enough to skip it, you are not forced to use the system.

The system works well for the majority. Most Canadians prefer the access provided by the Medicare to nothing at all. Of course the system could be improved and there is no place on earth where we don't enjoy complaining about the government.

Physicians are underpaid in Canada and some areas have caps on earnings, so there are not many incentives to work harder or see more patients. Thus there is a shortage and there are queues. When I worked there, my practice was full within six months and I was sometimes tempted to run patients out of the office. I'm a good doctor, but not that good. When demand exceeded what my quarterly cap would be, I would just go on vacation. So it really wasn't all that bad from a lifestyle perspective.

Physicians and hospitals represent a cost, pure and simple. Canada does not look to its health care system to produce innovation, since Canada is not as business oriented as other countries.

Obviously, as any business man knows, systems only have to be good enough to achieve your goals. Canada's health system is good enough to fulfill it's primary public health function. It is good enough to maintain a reasonable supply of physicians. It is good enough that constraints on the supply of physicians and technology serve to keep costs down. It is good enough to raise the tax burden to a level that is apparently tolerable to the various stakeholders.

Yes, Canadians sometimes die wating for care. Americans die due to a total lack of access. Overrall the US ranks worse than Canada.

The American system is cleaner, more luxurious, sexier and more exciting. There was a time there were more CT scanners in San Francisco than the entire country of Canada. It makes practicing medicine more fun, but this is unlikely to be a deciding factor for most physicians who might consider crossing the border. It certainly makes medicine more profitable, which is a factor for some. Readers may be interested in what convinced me to leave Canada.

My opinion about the risks of a Canadian style medical system is related to the general American fear that the government may abuse the rights of individuals. In an all-out political battle between different interest groups, there are fewer checks and balances in Canada than in the United States. The health system is a weapon in such circumstances.

In 1995 the government of Quebec decided to close 11 hospitals in the province. Five were acute care hospitals, three of which were located in the English-speaking part of Montreal, not likely to vote in support of the ruling party's separatist agenda. One of the other acute care-hospitals was a bilingual hospital near the almost universally French capital, Quebec City, and was converted to a long-term care facility.

There is no way to avoid the conclusion that hospitals were closed as a form of political punishment. And it seemed to me that nobody else in the country cared.

The real lessons for Americans is to ensure that health care stays out of government hands, because politics here are more ruthless than in Canada. Can you imagine what would happen to a Democratic-designed health system when Republicans came to power? Just think Medicare Part D; dollars for those best able to amnipulate the political winds.

Universal health coverage can and should be mandated, because it represents a social good. A health system should be funded by all stakeholders, especially those most able to profit from it, hospitals and pharmaceutical companies included. It should be regulated only to the extent necessary to assure a free and competitive market. It should never be left to any government to administer.

Reasons for Health Care Coverage

I have to confess that, although I have a lot of respect for health economists and health policy types, they appear to fall on a bell curve in quality, as in any profession.

For example, my policy professor at MPH school gave me my only B, apparently because I argued a position different from his. On the other hand, a few months ago I met the new state health secretary. He impressed me as smart, soft-spoken and pretty determined fellow.

Health wonks argue that the cost of health coverage is too high, but I do not clearly understand the primary assumption underlying their arguments. What is the purpose of health care coverage anyway?

A few years ago, I was at a cancer conference, where a researcher was demonstrating that annual Paps are no logner necessary (sorry to break it to you, but most groups have not recommended annual Pap universally for years). I suggested that we would still see the patient annually and I was shot down. He said physicals were not necessary and we needed better ways to market our preventive services.

For real!

Dr. Ted Mitchell's USA Weekend column reminds us that the great value of annual checkups is the connection with the patient. Economists argue about the cost, but what they are talking about is technological, procedural medicine. There are many other areas of medicine.

We have commoditized primary care, when it should be the inverse. The technology is a commodity, subject to the general rules of economics. Primary care is a relationship-based service business which has the effect of reducing costs. It represents the ultimate in product differentiation.

Primary care cannot be imposed. It does not work where there is no trust. Primary care reduces reduces health care costs. [After 20 to 30 years of reseacrh, this statement should carry the weight of common knowledge and not be controversial. However, since no one seems to know that primary care reduces cost and improves health status, I would point people to Barbara Starfield's lifetime work, as the most elegant choice.]

Some economists argue that, since health care does not reduce mortality (very difficult to demonstrate, it is the highest bar) we should scrap universal coverage. However, we know that -- for population level crude mortality statistics -- the most improtant medical interventions are 1) the keeping of vital records, 2) immunizations, 3) maternal-child care (under five) and 4) primary care.

All other interventions would require universal access to be able to demonstrate survival advantage on a population basis. Even then, a survival advanatge may be demonstrated on a select group of patients in a controlled trial, but may not reach significance on a population basis. That's why we look to health status as a better measure to justify the expenditures. The rule of diminishing returns means that we have to spend a huge amount of money from where we are to improve health status.

Fact is, it won't cost as much to provide coverage for the poorest in the country, which is the main reason of the US's poor performance in international rankings.

Is health care coverage justified on the basis of mortality rates? Probably not, because of data limitations. Is it justified on the basis of health-related qulaity-of-life? This is a more realistic goal, and may be cost-effective for low-income populations, especially if coverage promotes quality primary care.

The Uninsured: This Is What I Do

Sometimes colleagues in the community ask me what I do. Perhaps they wonder how our company is different from their own medical practice or maybe they want to see if we can be a resource to their patients. This is what I tell them.

I am an executive in a not-for-profit clinic that provides health care for the uninsured and Medicaid patients. We can do this because of our structure which allows us to be better remunerated, donations, and becasue of our links to various other programs which provide many intangible advantages.

At this point, the person I am talking to is usually wrinkling their nose. “What kinds of patients do you see?” they ask.

I tell them our patients are mostly Latino, many African immigrants and a few Asian patients as well. If anyone is still listening by then, I tell them about a 30-year old landscaper (yes, he was a legal immigrant) who felt something pop in his ankle playing soccer a month ago. It had taken him a month to get into clinic, because we are so backed up, so that we could diagnose his ruptured Achilles tendon. Surgery was another 3 months away sicne Orthopedists are in such demand, they don't frequently have to deign to treat "charity" cases.

I may tell them about my Ugandan woman, who asked about finding an obstetrician at her first visit. Her due date was less than a month away. Any benefits of preventive prenatal care had been lost. Thus the baby would not get a good start and the cycle of poverty continues.

I tell them about the patients with atypical depression who cannot get consultations when they have failed three different treatments at my hands or the schizophrenic who managed to lose her coverage and could not afford her medications or the lawyer whose catastrophic health bills put her on the street.

To be fair, about half my patients have adequate coverage for their needs, but not a day goes by that I do not face a person in crisis die to the lack of health coverage.

Clinton, Obama or Paul; let's not lose sight that this is a safety net for those who stumble and need a helping hand.

USA Today Response From Michael Cannon

I am still travelling. My computer crashed and I'm using a little lobby "business center" within ear shot of college footbal on a TV set loud enough for a small, dusty, desert-town desk clerk to hear from the back room.

Minor frustrations aside, I'm having fun. But you can imagine my surprise when Michael Cannon, whose USA Today article I criticized for being dogmatic, loose with data and improperly documented, decided to respond.

I have read the response, but intend to review it in more detail later. Mr. Cannon has certainly made a good faith effort to explain his point of view and we are well on the way to fleshing out areas of disagreement. In fact, at first blush, these disagreements may not be as huge as one would think.

The underwhelming level of dicussion on my initial post serves to underline the fact that this is a very difficult and technical area. Could it be that rhetoric and controversy attract more attention that the substantive dialogue? Well, one of the reasons I like CATO is that they tend to lay out strong arguments for various positions, like these on health care. CATO tends to have a conservative to libertarian bias, which is usually clear and well laid out from the first.

My primary concern is that there remain a large number of vulnerable individuals in the country who need assistance. These people deserve some form of very basic health coverage as part of a national effort to help the most underprivileged of our brethren.

FQHCs and Hospitals Part II: Follow the Money

I have previously pondered why federally qualified health centers (FQHC), designed to provide low-cost high-quality care to underserved individuals and rural areas, don't work with community hospitals more often. I thought their missions would mesh and their natural interests would be aligned. I was wrong.

I recently has some insight into the situation in rural communities. There exists a federal designation known as the critical acces hospital (CAH) for small communities without another hospital center within 25 miles. There are multiple other criteria to be a CAH, but this is probably the most important. Such hospitals exist in a competitive vaccuum and they exist in a commnities where health would suffer significantly due to the lack of access associated with living in a rural agrariran community. We already know that farmers and farmowrkers are the most dangerous occupations in the US. If the hospital were to go under, the communities would face significant hardship.

CAHs are allowed to charge medicare their cost, whatever it may be, plus a reasonable margin. Cost plus reimbursement is a rarity in the US today, and leads to escalating charges for the most basic procedures. Mammographies and colonoscopies are charged at three times the rate the local FQHC can do it.

If the FQHC delivers cost-efficient health care, patients would chose not to go to the local CAH. This jeopardizes the CAH's existence, which in turn is a liability for the FQHC, since physicians would be unable to hospitalize their own patients in their own community.

Partnerships are difficult to establish when the regulatory landscape produces a disincentive to competition and innovation.

Government and Obesity

A city council proposal to limit fast-food restaurants in South LA has attracted some interest in the media but none that I can find in the blogosphere.

How far can government intervention reach into the personal behavior of individuals justified by public health concerns?

I have a libertarian streak that would prefer less government intervention unless absolutely justified by a compelling argument. I am not sure I like the idea of spending my hard-earned tax money in a regulatory effort that is not market-based.

On the other hand, why are fast-food restaurants so concentrated in poor urban neighborhoods? I would not want to see business interests preying on people who don't know better and claiming that they are just satisfying demand. Is this the explanation for high fat super-sized foods masquerading as value? Frequently, healthy alternatives like locally-owned and operated mom and pop businesses get run into the ground once the big marketing machines move in to the neighborhood.

McDonald's indoor playgrounds may be the safest place for low-income single moms to take their kids at the end of late afternoon commute, which just complicates the analysis of pros and cons.

I do not generally believe in legislation or regulation to resolve these kinds of issues, but the observations and realities of life in low-income neighborhoods are sometimes hard to accept.

Ideological review of the ALLHAT study

If you were wealthy and taking the latest and greatest $100 a month anti-hypertensive medication, how would you feel if you found out that an ancient diuretic that cost 4 cents for a six-month supply was superior?

Why, you'd be upset, wouldn't you? You might even find some merit to the manipulative ravings of a pharmaceutical talking head.

Physicians and scientists of all political stripes need to speak out and resist the wanton use of the media to argue scientific points that are so vacant. Rise up and fight! This is identical to the global warming misinformation lobby. You couldn't get this crap published with peer-review!

Today is the Day

For my generation, this day is like the anniversary of the lunar landing was for our parents. You remember nearly everything about a day whose events were so startling, the entire world changed.

My story was that I was at an MGMA conference in Philly on September 10 and nearly got to stay another night when my flight got canceled. Arriving at the airport, I discovered I had been rescheduled on an 8AM flight on September 11, 2001 out of Philadelphia. But I had played hooky and left the conference in time to make an early flight. That is how I narrowly escaped being in the air during the attacks.

I remember running late most of the morning and getting most of my information from a much-too-slow internet connection at work. All day I gathered news between patients and considered driving up to New York to help. I was glued all evening to CNN, until just around midnight when they showed a close-up slow-motion image of the second plane penetrating the surface of the building. By then it had sunk in; there were too few survivors to help.

Dr. Val was in lower Manhattan that day. Her recollections are a moving expression of what many health care staff went through that day.

Health Coverage, Money and the Physician Shortage

Dr. Val left a comment to my last post which, as I composed a response, started getting longer and longer and morphed into a post in its own right.

Just wondering what you think of the physician shortage and what that would mean for a universal coverage system?

Also - PandaBearMD had an interesting story about a patient who came to the ER for mild constipation. He believes that the primary problem with the healthcare system is human stupidity, enabled by malpractice attorneys. :)

As an intern, I once saw a recent immigrant who believed that not having a bowel movement for a day was not normal. He also was accustomed to going to the hospital for all medical care. He turned up in the ER with a chief complaint of constipation.

Yep, it's pretty frustrating. People don't behave in ways that the educated and informed consider smart. Even intelligent people without the help of a malpractice lawyer can behave in a self-destructive manner. We are in a position to help and contribute something positive in people’s lives but often find our time wasted.

It is not an efficient use of our skills and is particularly frustrating if we feel poorly remunerated.

As for the physician shortage, I’m glad you reminded me, Val. Sometimes I’m not too bright. One of the greatest impracticalities of widening coverage for the uninsured is that we don’t have enough docs to take care of all these people. This shortage is especially acute in primary care.

The remarkable shortage of primary care docs extends to certain specialties. Usual market forces of supply and demand do not apply simply in health care. More doctors create more demand. One more reason the mantra of “access, cost and quality” is absurd.

Increase access and you increase cost. There may be savings to be had in reducing inefficiencies and preventing complications, but they can never realistically cover the entire increase. Improving process quality may reduce some additional inefficiency, but health outcome quality derives from patient behavior as well and thus is much more difficult to change with health care delivery interventions.

We need more doctors, especially in primary care, used efficiently (focus on process quality), extending coverage to those in greatest need and the simple acknowledgment that it will cost a lot of money. So why is Medicare cutting physician reimbursement? Well, that's another post, isn't it?

What is the reason to spend so much money covering the unwashed, uneducated, self-destructive mass of humanity?

Because it’s the right thing to do.

Non-Compliant Patients

Fat Doctor wrote a great post about a couple of crazies in the ER.

But then there is another way of looking at it.

Fat Doctor's patients each refused an obvious course of treatment or investigation that does not even remotely approach an area of controversy in medicine. All patients have the right to refuse treatment or investigation. As Fat Doctor herself admits, there is also the little issue of her own obesity, which is generally accepted as a condition associated with unhealthy lifestyles.

I guess the physician's frustration is raised by the question of why someone would seek treatment if they are not willing to accept the recommended treatment. But the fact remains that it is everyone's right not to do the right thing, or what an expert says is the right thing. I've been beating the market lately, not listening to financial advisers. At least this was the case last week; next week may be another story. I'm taking my chances.

But in the case of the market, my adherence or non-adherence to recommendations does not affect everyone else. I gain or lose financially as a consequence of my actions and I am the only one to gain or lose. In health care that is not the case. Moreover, many decisions yield consequences well beyond the capacity of the average person to pay. If a diabetic makes poor diet choices and has a heart attack, someone else pays for the care, either through insurance or the inadequate mechanisms available for uncompensated care.

Also consider that another individual without diabetes, who has always made the right health choices may still get a heart attack.

Saying that it is more likely for an uncontrolled diabetic to suffer a heart attack is not the same thing as saying that the diabetic brought it on herself. Such are the vagaries of chance and genetics and since no genetically perfect human being exists to our knowledge, we should all be living in fear of discovering our unknown weaknesses.

Some ideology might require we reject the notion that people should be sheltered from the consequences of their poor choices. Other ideology would lead the government to insinuate itself into people lives with instruction, education and prerequisites for benefits.

Somewhere in the middle are physicians who morally, ethically and legally obligated to treat everyone in an emergency, regardless of the ability to pay. At least that's how I read the Hippocratic Oath and its contemporary application. Universal coverage would help the country's physicians do what the people need them to do and the doctrine of personal responsibility is insufficient to reject the idea. When we reflect on the causes of heart attacks, cancer and the multitude of killer conditions out there, maybe they are complicated enough that non-compliance is an insufficient reason to condemn a patient.

Parting Thoughts

I will be traveling for the next week, but my trusty laptop and a free Broadband connection will keep me blogging, albeit at a somewhat slower pace.

As a parting thought, I must point out that Holland has undergone a terrific health reform. The Health Economist has a deep, penetrating and positive analysis. My impression is the latest reforms puts the Dutch more in line with Germany, if I understand the semi-private sickness funds correctly. I recognize that a government requirement that everyone purchase health insurance is a problem.

I have to hold my nose since I don't think the government should tell me what to do. It is one of the reasons I left Canada. However, I'm willing to accept the notion because I will share in the collective benefit realized by a reduction in the societal costs associated with uncompensated care.

The obligation to buy health insurance has reduced the number of uninsured slightly in Massachusetts [for an explanation of the is contradictory information being trumpeted by the demagogues of the right, see here.] The reduction is much smaller than I had expected, but the enforcement mechanism is through taxes and we have yet to complete a full fiscal year. Only time will tell.

It heartening to see the Governator has the clarity to build a consensus around the issue. Hospitals are among the most powerful interests in health care, along with the insurance industry, and they appear to be on board. Sure, the docs are important, but let's get real. That's a lot of money in hospitals and insurance...

In the end, I am somewhat heartened by the consumer movement in health care. When the rubber meet the road (in health care, it means the patient has met the doctor) health care has to work in the context of a relationship: the doctor-patient relationship. Without it, throw the whole thing in the waste-basket; nothing will work. I have stories... I have stories. I will share more of them at some point, because I have to keep reminding myself that policy has nothing to do with facts or data or science. It has to do with money, power and stakeholders jockeying for position (also known as politics.)

Let's make sure the patients don't get lost in the shuffle between the powerful and the moneyed.

Health Care Performance or Insurance Performance?

Newsday has published on New York and New Jersey HMO performance. I think? Maybe it was health care providers.

The article discusses performance on measures by which HMO's are generally measured including prices and premiums, but then refers to prophylactic pre-op antibiotics, and Cesarean Section rates.

I may be a little dense, but I thought that health care providers did some of these things. I thought it was a doctor who had to write the order for antibiotics. I thought nurses verified and administered the medication: right drug, right time, right patient and all that. I thought that administrators were responsible for putting in place systems to ensure nobody slipped through the cracks. I'm not sure where a managed care organizations can influence appropriate process except by certifying and credentialing providers and dumping poor performers. Unless they have extra money to provide incentives to hospitals, doctors and nurses, and we know that's not happening.

The few examples of MCO's have the kind of control where they can be judged and measured this way are the staff model MCO's. Even though groups like Kaiser Permanente do not directly own their physician groups, they can certainly influence systems and incentives sufficiently to achieve quality goals better. At least theoretically; my reading of the literature is that it has been mixed.

Maybe that's why we're confusing performance measures that are appropriate for hospitals and staff model HMO's with those that are best for contracting agencies.

It is easy to get confused the wide variety of measures, which will not help physicians who are grumbling about how little quality is measured in quality measures. It also does not help those who feel that transparency is the key to health care reform. With the number of organizations that recommend quality measures proliferating, Scott Schreve's comments about confusion in P4P are exactly right.

Thanks to About Health Transparency for getting me started...

25th Anniversary of the Alma Ata Declaration

My post earlier a couple of weeks ago that touched on the different definitions of health was more timely than I knew. This week is the 25th anniversary of the Alma Ata Declaration, which has guided the WHO and public health officials for the better part of the last quarter century.

My own outlook is somewhat less populist than it was when I was a younger man, and even though I may no longer regard well-being as a human right, I value the Alma Ata Declaration as a framework for understanding health and health care as distinct entities.

Our world is sadly unequal and always will be. However we must always take care to provide the opportunity for social mobility and socio-economic transitions. If health compounds poverty and so on in a vicious cycle, and hope expires, we will be no better than Europe was two centuries ago, on the eve of repeated unrest and conflagration.

USA Today Health Reform Editorial

Dear readers, I need your help.

As you may know, I am a proponent of a non-dogmatic approach to policy debate and would like to see some truly conservative approaches to health care reform. I despise the tools of rhetoric and the use of formal logical fallacies that characterize the current crop of so-called conservatives.

Yesterday (via InsureBlog), USA today published an op-ed by Michael Cannon of the Cato Institute, an organization which I usually find provocative and challenging, but not thoroughly manipulative nor responsible for shoddy scholarship. I reviewed the articles which Mr. Cannon offers as references and have trouble connecting the articles to the point being made. There are also some logical inconsistencies.

Here is a systematic breakdown of what I found:

1. US Census Bureau. Nothing wrong here, the Bureau’s number may very well bear re-examination since all surveys have strengths and weaknesses. There is no such thing as methodological perfection.

2. Agency for Health Research and Quality: “other recent surveys put the number between 19 million and 36 million” for the uninsured. The link takes us to a MEPS survey (Medicare Expenditure Panel Survey is a running survey of medical expenditures using a representative sample of the entire US population) which does not support Mr. Cannon’s statement. The study delves more deeply into the census bureau’s figures by looking at the duration of being uninsured. The census bureau counts people as uninsured if they have been uninsured for any time n the past 12 months. Since the public health concern is identifying a vulnerable population, this is an entirely valid definition. The MEPS survey states “In 2003, 25.4 percent of the population was uninsured at some point during the year, 18.8 percent was uninsured throughout the first half of the year, and 13.6 percent was uninsured for the entire year.” Even math errors on Mr. Cannon’s part does not explain why he is comparing the proportion of American uninsured for the first half, second half and at any time of the year.

3. The next link is used to support the phrase “As many as 20% of the "uninsured" are eligible for government health programs, so in effect they are insured.” This is the most egregious. It comes from data that many who are eligible for Medicaid do not sign up since 20% of those eligible are not signed up for SCHIP. The statement holds true only if all the uninsured are eligible for some kind of government program, which is inconsistent with a seprate implication, presented with no evidence, that so many of the uninsured are illegal. Moreover, it escapes me how someone who is eligible for a program is still covered if they chose not to sign up. How does this address the vulnerability associated with catastrophic health expenditures? Moreover, the study referred to is a sober and numbing methodological comparison of the MEPS and Census surveys, not one of the many studies which have demonstrated repeatedly that under-utilization appears to be the hallmark of programs like SCHIP.

4. Mr. Cannon uses a study by Bundorf and Pauly to support the statement that as many as 75% of the uninsured can afford insurance. The paper is a fascinating and illuminating look at the effect of different definitions of affordability on the population estimate. While 76% is the high end, 31% is the low end of the estimate. Their findings support a statement much different than Mr. Cannon’s, here I quote from Bundorf and Pauly’s conclusion: “Our results demonstrate that lack of “affordability” is an important barrier, but not the only or the major barrier to obtaining coverage for all, or even most, of the uninsured. […]Omitted variables related to health status are potentially of particular importance. If our measures of health status do not capture characteristics of individuals that result in unusually high premiums (potentially due to risk rating of premiums or denials of coverage in the individual market, for example), we may over estimate the affordability of health insurance for high risks. […]Deciding for whom health insurance is affordable is ultimately a normative decision on the part of policymakers and society. We believe that our definitions, however, offer researchers and policymakers a positive empirical framework with which to begin to evaluate this question by basing the definition of affordability on the behavior of other consumers with similar characteristics, rather than an arbitrarily chosen income threshold.” This is very wise, unlike Mr. Cannon’s inexplicable peripatetic diversion.

5. To support the statement that “many economists can find no evidence that it [expanding coverage] is a cost-effective way to improve health” Mr. Cannon uses a non-peer reviewed piece of secondary literature that is actually an interesting review of the literature with respect to causality between insurance and health. The reviewers observe that if the causal chain fails, it may be either health insurance or health care that may not improve the health of the population. That is an established fact, which is not at issue because we are talking about extending health coverage to vulnerable sub-populations. The poor represent the majority of the uninsured unless you believe the prior misinformation. Perhaps the argument against covering the uninsured is being used as an argument against either government run or universal health insurance.

6. A rapid sequence of references challenge the notion that expanding health coverage will not

a. Improve quality: New England Journal article shows that income is more important than race. The study does not address access to which coverage is most relevant.

b. Reduce disparities: Paper argues that reducing poverty is more important to health than improving health care access.

c. Affect life expectancy: A New York Times article about education being related to longevity.

d. Reduce cheating: A Health Affairs analysis of how health care costs for the uninsured are currently distributed. No mention of how not having a program deters cheating on the aforementioned non-existent program, i.e. Mr. Cannon's argument is nearly circular.

7. The Kaiser Family Foundation says that the average family of four spends $11,000 a year. Individuals are pegged at $4,000. What the average cost per employee is, I just don’t know. Using one number without the other is not an honest presentation of the problem and I may be a little dense here… what was the point? Health care is expensive? We know that.

8. Several correct citations regarding the number of people covered by employer-sponsored insurance, rise in health insurance premiums, a White House press release, Rudy Guliani’s campaign website and a CBO letter.

Please review what you can (not everyone has full text access to Bundorf & Pauly) and let me know if I have mis-read any of Mr. Cannon's references. Please note the title of the editorial refers to making Americans care about health care. This is a very promising position. I hunger to hear the argument, but am I just dense, or did he completely skirt around the cost, except a passing mention of average family insurance expenditures? I think there are extremely cogent arguments to be made.

Referral Refusal

I know it is immensely impractical, but I am sometimes tempted to stop doing referrals.

I am a good (at least a decent) family doc, so I know when it's time to get help. I have had progressively more trouble finding a community of referral physicians over the years, given that I have moved twice in my career and have not remained at the same practice location for more than 4 years. [Perhaps moving around like this is the natural effect of the commoditization of primary care?] But I basically try to make sure my patients get the right care at the right time, even if I have to struggle on the phone to find the right person to hand off to.

It's those stupid little pieces of paper I object to. They are so common, many states have Uniform Referral Forms. You have to fill one out before your insurance will accept to pay for the visit to the specialist...

I hate the expectation that I am obliged to fill these out or I am somehow guilty of malpractice. (What do you mean you won't fill one out without seeing me? Your name is on my card!) I hate the parent who lies to get a CT scan for their child (OK, I just told you he still had pain. I still want a scan.) I hate the uninsured who come looking for a referral... (Dude, cash talks! Find someone you like and . The charity I work with only pays when I think you need a specialist. Last I heard, I can start treating acne and if we run into trouble, I'll send you on.)

Of course, there are non-confrontational ways of dealing with some of the more difficult patients (I am ashamed to admit that I yelled at the patient who told me they lied with a straight face...) like putting the referral in the queue you know will take the longest to process. You can put the right words on the referral ('per patient request') that should never get the referral approved...

But insurance companies never question something obvious like that. They question my single-word referral ('snoring') because it doesn't have enough information. Hey, snoring in a five-year old? Sorry, I should have added "persistent, loud, apneas raising with the risk of facial abnormalities". Most doctors know that significant snoring in a 5-year-old is a strong indication for tonsillectomy or at least an upper airway evaluation. I thought the communication was doctor-to-doctor. Silly me.

I don't want to do referrals because if that was the reason for your visit, you missed the fact that it follows my opinion and does not precede it. If you don't value my opinion, I'm not going hungry any time soon without your visit.

But I promise, that when I think you need the higher level of care, I will definitely find the right person for you.

Changing Physician Practice Patterns

The Center for Studying Health System Change (CSHSC) periodically tracks physician practice arrangements. Their reports make great reading, so here are some highlights from the most recent one.

Young physicians have more frequently gone into large group and multi-specialty settings, but now older docs are getting out of the game of 1- and 2-physician practices and finding their way into groups. This trend was most marked amongst specialty and procedural providers who are moving into mid-sized, single-specialty groups.

This makes sense, because in multi-specialty groups, high income earners have to somehow redistribute some income to the primary-care physicians who do not benefit from diagnostics and procedures. In return the specialists benefit from a higher than average referral rate. Since restrictions on referrals from primary care have eased, according to the CSHSC, then the outcome is pretty much as expected: dump the the PCP's and maximize revenues. As a business man, I would do the same.

Policy-makers may pause to ask if this is what they wanted:

Policy makers envision physicians aggregating into large and, preferably, multispecialty practices. Larger practices are more likely to have the financial and administrative resources to collect quality data, implement quality improvement and reporting activities, and implement information technology, while multispecialty practices are better positioned to enhance care coordination. Large practices also may have more employed physicians and more structured physician leadership, which may make it easier to implement these types of activities.

[However] most of the growth so far has been in mid-sized practices, which, although they may be better equipped than solo and two-physician practices, do not yet approach the capabilities envisioned by quality improvement leaders. Moreover, increased consolidation in single-specialty practices raises the potential in some markets that certain specialties can drive up prices in negotiation with health plans. Some market observers also are concerned that if physicians are aggregating into larger practices to provide profitable procedures and ancillary services, the greater ability of physicians to legally self-refer patients under exceptions to self-referral laws could lead to overuse of certain services, further driving up costs of care.

What policy-makers still don't realize is that physicians are central to the health care system and as actors in an economic system, they behave according to normal market rules. Reform has to work for physicians or it just doesn't work. If we got rid of all the physicians in this country and just started over, there would soon be a similar problem with whomever is going to replace them. There is nothing surprising about physicians reacting to the natural economic incentives with which they are presented.

Some natural incentives at work here include administrative burdens that make it uninteresting for solo practitioners to continue practicing without a group. Capital requirements bring individuals together to pool resources. Such resources represent investment and will search for and find a return, i.e. higher charges, higher utilization and greater profitability, as in any other industry. Where the savings are, I don't know.

Primary care physicians are disadvantaged here, since consumers naturally gravitate to providers who can differentiate themselves. There may be reasons to go to a cost-leader like Wal-Mart, but if you think can afford something special, you go to a specialty store. (Personally, my weakness is Williams-Sonoma, I mean why buy pans at Wal-Mart?)

Since health "insurance" is really a subsidy, there is no reason to gravitate to a low-cost provider. Most consumers with insurance have no qualms about "affording" a certain specialist.

The more technological solutions are commoditized, the less profitable they will be and the smaller the incentive to build single specialty profit mills. On the other hand, commoditize primary care and you have a disaster. (One that looks an awful lot like the US healthcare system.)

A little disclaimer, as a primary care physician and a manager, I am likely to benefit from any of these trends. I am centrally positioned. Physicians in employed situations suddenly need people to report to, where none were needed before...

Ron Paul Seems to Hate Politics Too

I hate politics and I hate the shameless schmucks that manipulate data and so-called conservatives who spew demagoguery pitting them against so-called liberals (whose major fault is a touching naivety) to produce distorted policies that serve a few special interests and leave the rest of us out in the cold.

And then I discovered Ron Paul.
That's Dr. Ron Paul.
MD.
Presidential candidate Ron Paul.
Congressman (Rep) Ron Paul. A conservative from Texas.

Easy now, not everyone from Texas is stupid, any more than legacies from Yale.

It turns out Ron Paul is very popular among bloggers and technophiles (perhaps characterized by respect for reason, a middle-of-the-road kind of libertarianism and actual practicality). Yes, he has a health platform, most of which actually makes sense. I actually like his voting record, despite the APHA rating him at 53%. Although a relatively poor rating, it is the highest among Republicans running for President. (I would argue that the APHA's view is too unfriendly to business and will require raising taxes too much.)

I find it interesting that NPR has taken notice, but the conservative mafia are savaging him at every turn. Not real conservatives, you understand, just the goons currently running the GOP. Here is a Fox news article describing the internecine wars, written by an intelligent, tolerant, conservative journalist. This struggle between the GOP leadership and a former Libertarian presidential candidate probably seals the deal; Ron Paul has no chance. But he probably has a better chance of influencing policy than Dr. Dean ever had 4 years ago.

Shag Policy and Sexual Health

Reading a British paper I came across an article on international comparisons of sexual behavior. I find it hard to believe that anyone does studies like this, but then I've lived in the US a long time. We are considerable more prudish than the rest of the world and maybe, just maybe, a little openness about sexuality and we would be healthier.

Sex isn't going to stop, premaritally or otherwise. Using condoms helps. There is no surprise that STD rates in Norway are astronomical along with the rate of unprotected intercourse. Not Germany has the youngest age for onset of sexual activity, a low rate of unprotected intercourse and low STD rates.

The mystery to me is why people in India, who more often wait to have sex with a single partner, bother to use condoms at all.

Car Getting Old: Need Auto Repair Subsidy

So I was talking to a friend who is an actuary for some insurance outfit. I was saying that my car was getting old and I had an $800 service bill last time out. Maybe it was time to buy a new car, but it was still running well, it was just costing me more.

I wondered out loud how much longer I would keep the car if I could be protected from big repair bills. Wouldn’t it be nice if my auto insurance helped me keep my costs down?

The analogy slapped us both across the face at the same time.

Your car insurance could help you find auto shops that charged less (my former insurance company already does this with body shops… did I mention: FORMER insurance company) and maybe even pay a part of my service bills. Of course the cost of the insurance would rise with the car’s age, instead of decline as it currently does.

Problem is, you can’t trade your body in if the price went up to much. You can always trade your car in for a new model if it got too expensive to service or insure.

Problem is, I drive fast and my insurance rates are going up with every fender bender. I’m not sure I’ve seen a credible way to adjust health insurance rates for non-compliance. Except maybe smoking.

Now here’s another interesting idea, if my insurance completely covered the price of fixing little dings and dents, would I park next to the cart rack at the supermarket? Would a human being subconsciously take less care of themselves if their “service costs” were so heavily subsidized?

How much does all this cost? Our current auto insurance costs us about $335 a month for two cars and remember, mine is fast becoming an old clunker. We pay $150 a month for health insurance, but my employer pays a significant share.

The NY Times ran an article about universal coverage, which is more accurate than the word “insurance”, which they use only a couple of times. It contained a better estimate for a quick calculation of the price of a decent low-cost health insurance from the Massachusetts reform.

Before the law was passed, a 37-year-old in Boston, for example, would have had to pay $335 a month for a policy with no coverage for prescription drugs and a $5,000 annual deductible.

Funny how the cost of my auto insurance and a health care subsidy match… Coincidence? I think not!