Can we reach a consensus on what we need to do to achieve meaningful health care reform in the U.S.?
This week, I have been mulling over The American Prospect’s May 2008 Special Report: The Path to Universal Health Care At first glance, it might seem that the eight articles in the report take eight different roads to reform. But I’m glad to see agreement on many pivotal points.
Yet there are still major issues that could divide reformers: Should we acknowledge that we won’t be able to cover everyone unless we learn to “control costs”? Should we move directly to a single-payer system? And finally, should we try to move quickly, to cover everyone, or should we aim for incremental progress while sticking, stubbornly, to first principles?
In the months ahead, I think it is crucial that would-be reformers try to hash out their differences on these issues and unite under a single banner. Only then, can we divide opponents who have billions invested in preserving the status quo.
With that in mind, I decided to weave together some of the strongest insights in the Report—focusing on recurring themes—while also addressing the areas where reformers remain divided.
First, as I wrote two weeks ago on TPM Café the high and rising cost of health care may be the greatest obstacle to health care reform. In the American Prospect report, Ezra Klein captures the problem with brilliant simplicity at the very beginning of his piece: “If health insurance were cheap, we could all buy it. If universal health care could get 60 votes in the Senate, we’d all have it. But these two imperative—tthe need to control costs and the need to attract the 60 Senate votes required to overcome a filibuster—point in opposite directions. This is the central paradox of health reform.”
Congressmen are loath to vote for a plan that would rein in spending for two reasons. First, they fear that if they call for “cost-control,” voters will hear “rationing.” Secondly, they know how lobbyists will react to any attempt to cut the waste in our bloated healthcare system. One man’s hazardous waste is another man’s income stream.
Nevertheless, as Klein recognizes, something must be done about runaway
health care inflation: “The most intractable policy problem is not,
fundamentally, the 47 million uninsured or the fact that insurers have
a business model right out of Dickens. It’s cost.”
In her contribution to the Special Report, Dr. Marcia Angell, senior
lecturer on social medicine at the Harvard Medical School and a former
editor-in-chief of The New England Journal of Medicine, agrees with Klein: “Costs are the central problem; universal health care would be easy if money were no object.”
Angell then slices to the heart of why our for-profit health care
system is so expensive: “The U.S. health system is unique in treating
health care as a commodity to be bought and sold in a marketplace. Care
is distributed according to the ability to pay, not according to
medical need. Private insurers compete by avoiding high-risk
individuals, limiting services for those they do cover, and, whenever
possible, shifting costs to other payers or to patients in the form of
high deductibles and co-payments. We have the only health system in the
world based on avoiding sick people.”
In the next paragraph, Angell zeroes in on the essential conflict
between a for-profit system and the goal of having affordable,
sustainable, high quality care for all: “All of this drives up costs to
the overall system, while yielding profits for the various players
within it. In fact, there’s a fundamental illogic to trying to contain costs in a market-based system.
Markets are about expanding, not contracting. Like all businesses,
hospitals want more, not fewer customers –but only as long as they can
pay.”
Whether they are drug-makers, medical device-makers or for-profits
hospitals, U.S. corporations are hooked on growth. (And as I have
written here,
many not-for-profit hospitals have decided that, in order to compete,
they, too, must grow—whether or not their community needs more
bleeding-edge equipment or more beds.)
To be fair, corporations are only responding to shareholders who clamor
for higher earnings, quarter after quarter, year after year. But that
double-digit growth is what is bankrupting our system. As I have said
before, Detroit’s auto-makers cannot afford to keep Genentech’s
shareholders in the style to which they have become accustomed.
Moreover—and this is something that more and more reformers realize—when it comes to healthcare, lower costs and higher quality go hand in hand.
When one Medicare patient goes to the Mayo Clinic’s flagship St. Mary’s
hospital and a second, very similar patient with nearly identical
problems goes to UCLA Medical Center, Medicare winds up paying roughly half as much for the patient at the Mayo Clinic. And no one thinks that that Minnesota’s Mayo Clinic is delivering discount care.
Why is health care less expensive at Mayo? Research reveals that, at
the Clinic, fewer doctors will tend to the patient. And they will tell
each other what they are doing. Mayo is less likely to do unnecessary
tests or procedures and more likely to get the diagnosis right in the
first place. On average, the patient will spend 43 percent fewer days
in the hospital—which gives him less time to develop an infection while
he’s there. Finally, St. Mary’s has no need to try to “grow” its
business. It is the one academic medical center in the U.S. that
doesn’t advertise. Mayo does nicely on word-of-mouth alone.
And St. Mary’s is not unique. The same research demonstrates that the
Cleveland Clinic, to name just one example, also is very
efficient—which means that it offers higher-quality care at a lower
total cost than most hospitals, in large part because it avoids the
unnecessary care that can be hazardous to a patient’s health. And just
as at St. Mary’s, both doctor and patient satisfaction is high.
Nevertheless, at many other medical centers “a combination of newly
available technology and an unchecked demand to use it” drives health
care inflation skyward observes Jonathan Cohn, a senior editor at The New Republic, in his American Prospect piece.
Here, I would add only that the “demand” is usually coming from physicians, not patients. Consider this passage from Complications: A Surgeon’s Notes On An Imperfect Science
where Dr. Atul Gawande describes how doctors are drawn to new
technology at a conference where device-makers display their wares:
“Then he put the device before the camera. It was white and shiny and
lovely. Against any high-minded desire to stick to hard evidence about
whether the technology was actually useful, effective and reliable, we
were all transfixed.”
Patients don’t “demand” the newest devices and medical equipment
because, in most cases, they don’t know about them until their doctors
propose using them.
Meanwhile, “fee-for-service-payments” reward doctors and hospitals to
“do more,” Cohn observes: “While the payment reforms of the 1980s, so
called ‘diagnosis related groups,’ helped mitigate that problem, they
didn’t eliminate it, and patients don’t actually seem to be better off
for the extra attention.”
As we’ve discussed
on Health Beat, in cities like Manhattan, Miami and Los Angeles, where
research shows that patients consistently receive more intensive, more
aggressive and more expensive care, outcomes are no better—often they
are worse.
Nevertheless, hospitals continue to compete for well-insured patients
(and the doctors who treat those patients) by buying the newest, most
expensive equipment—whether or not they need it. In other countries,
where virtually every patient has insurance, hospitals are not
desperately vying for customers who can pay their bills.
This brings me back to Angell’s point that a for-profit health care
system is all about growth—even though more care doesn’t necessarily
mean better care. Indeed, Angell explains that there is as much waste
in government-sponsored Medicare as there is in our private sector
health care system because “Medicare is embedded in our market-based
entrepreneurial private system, and therefore experiences many of the
same inflationary forces, including having to deal with
profit-maximizing hospitals and physicians’ groups. Doctors’ fees are
skewed to reward highly paid specialists for doing as many expensive
tests and procedures as possible”—something I have talked about here on
Health Beat.
“The bottom line,” Angell observes, is that “Medicare inflation is
almost as high as inflation in the private sector and similarly
unsustainable.”
In addition, Angell notes: “Medicare is not what it once was. For the
past eight years, it has been at the mercy of an administration intent
on dismantling and privatizing it. The prescription-drug benefit
enacted in 2003 is an example. It’s a bonanza for the pharmaceutical
industry because it forbids Medicare from using its purchasing power to
get good prices.” Meanwhile “Medicare pays private insurers an average
12 percent more than it would cost traditional Medicare to care for the
same people.” And “ even as public funds are siphoned off to the
private sector, premiums and co-payments have been increased.”
I couldn’t agree more. As we discussed on Health Beat last week,
the “Medicare Advantage” system which funnels Medicare through private
insurers is proving hugely expensive, not only for Medicare and
taxpayers, but for beneficiaries who use it.
Cohn agrees with Angell that Medicare is, in his words, “trapped in a
deeply dysfunctional system—one in which too much money goes to the
wrong uses and not enough goes to the right ones. Unless we want to
simply hack away at the program’s benefits—in effect, undoing one of
the greatest social-policy advances in American history—the best way to
stabilize Medicare is to think even bigger and fix the rest of the
health-care system.”
Cohn sees Medicare reform as part of overall health care reform, and he
lists the fixes that many reformers agree on: reduce unnecessary,
ineffective care; create new scientific institutions (or redirect
existing ones) to compare drugs, devices and treatments and to
establish what “best practices” are based on unbiased, medical
evidence; create an electronic medical record system, to cut down on
errors and improve coordination of care, and finally, use Medicare’s
size and clout to negotiate for lower drug prices.
The latter would not stifle innovation, Cohn argues, because in our
for-profit health care system, “the driving force behind developing new
drugs isn’t a push for the best new treatments science can concoct.
It’s a push for the best new products that the pharmaceutical industry
can market to gullible consumers and compliant doctors, often trivial
variations on existing drugs about to go off-patent.”
While Angell and Cohn agree that Medicare is mired in a dysfunctional
system, Angell has a different solution: scrap Medicare and replace it
with a new, government-sponsored health care system for everyone.
“The only workable solution is a single-payer system . . .” Angell
declares. “There would no longer be a private insurance industry, which
adds little of value yet skims a substantial fraction of the
health-care dollar right off the top. Employers, too, would no longer
be involved in health care. Care would be provided in nonprofit
facilities. The most progressive way to fund such a system would be
through an earmarked income tax, which would be more than offset by
eliminating premiums and out-of-pocket expenses.”
It is a bold proposal, and I love the “sweep clean” simplicity of it.
But unfortunately, most Americans don’t agree with me. As pollster Stan
Greenberg emphasized in an earlier Health Beat post:
for most Americans, “Choice” is “key, key, key.” And this includes
allowing “families, if they choose, to keep the private insurance they
now have.”
I wish Americans didn’t make ‘choice” such a high priority—especially
when so many of the alternatives that the private insurance industry
offers them are, in fact, tawdry “Swiss Cheese policies” filled with
holes that you don’t discover until you try to use the insurance.
Nevertheless, poll after poll shows that Greenberg is right. Americans
who have employer-based insurance don’t want to be told that they have
to give it up.
This is why Yale political scientist Jacob Hacker has proposed a plan
for reform that would let Americans decide whether they want to keep
the private insurance they have now, or choose a public-sector plan
that would be much like Medicare. Both Barack Obama and Hillary Clinton
have adopted versions of this plan.
Angell is not willing to accept Hacker’s strategy. She acknowledges
that “conventional wisdom holds that we need to retain [employer-based
private insurance as an alternative] because many Americans are
satisfied with it. But except for industry spokespeople and politicians
whose campaigns they support, I’ve never met anyone who actually is.
Many people like their doctors, but that is not the same as liking the
system.”
Here, I disagree. When polls show that 80 percent of Americans like
the insurance they have, this does not mean that they like their
insurer. It means that they like having employer-sponsored insurance.
Given a chance to compare that coverage to a public sector plan, they
might even pick the government’s plan.
But voters just will not accept a government edict telling everyone
that they have to give up what they know for an
unknown—government-sponsored, single-payer care. Most people are afraid
of change. They are particularly wary of switching from the devil they
know to one they don’t know. And the last eight years also have not
bolstered their faith in programs run by the federal government.
Congressmen know this. And this explains why they will not vote for
single-payer.
The debate between those who would hold out for single-payer—and those
who think that politically, it’s just not possible—is, I think, the
issue that most divides reformers. My hope is that those who favor a
single-payer system will eventually come round to the notion that if
people are given a chance to choose, government will be able to provide
insurance that provides better coverage for less. I’m convinced that,
with time, Americans will vote with their feet, and single-payer will
become a reality.
Angell calls such a hope “wishful thinking that overlooks the power of
the private health industry, through its huge lobby, to influence the
rules so that it continues to profit while the public system is
undermined.”
Make no mistake, she is entirely right to be worried. Unless private
insurers are tightly regulated, and forced to compete with public
sector insurance on a level playing field, they will design their plans
to pick off the healthiest customers. Ezra Klein shares Angell’s
concerns that private insurers will offer coverage “to healthy, young
firms at advantageous prices,” while “pressuring sicker, older
companies and individuals into the government options. If they succeed,
the risk pool in the public sector plan will grow expensive, the
premiums will grow inordinately pricey, and cost savings won’t be
realized without cutting care, no matter what the government mandates.”
This would turn national health insurance into something like
Medicaid-For-All, “a poor plan” not just for the poor, but for many
middle-aged Americans. Younger Americans who have a very sick child—or
who suffer from a serious chronic disease –might also find that they
would have a hard time getting jobs at firms where private insurers
offered “advantageous prices.”
The only way to avoid such inequality is to insist that private
insurers offer everyone in a given community the same insurance at the
same price. Young and old, sick and healthy, everyone pays the same
price for the same coverage, and no one can be denied insurance because
of pre-existing conditions.
Insurers will not do this voluntarily. But no one can argue that such a
system would “undermine capitalism” or be “un-American.” The fact is
that this is now the law in a number of states; under national health
reform it would become the law nationwide.
Secondly, if insurers are going to compete on a level playing field,
they cannot be allowed to sell bare-bones or high-deductible plans in
an effort to skim the healthiest and wealthiest Americans from the
pool. Hillary Clinton’s plan, for instance, insists that private
insurers must offer coverage that is “equal to what Congressmen receive
under the Federal employees’ plan.”
But “regulating” insurers means going up against the lobbyists. Can we really do that in America?
Yes, I would argue, if the patients, employers, physicians and state
governors who realize that rising costs threaten to wreck our system
pull together. If they unite, they can put enough pressure on Congress
to defeat the special interests who rake in enormous profits—as our
$2.2. trillion health care bill continues spiral.
In the American Prospect Report, Anthony Wright, executive
director of Health Access California makes this point: “powerful
interests killed reform” in California. “A united health-reform base of
consumers, labor, and providers might have overcome such opposition,
but these constituencies were split as well. The lesson Wright draws
from his experience: Get enough support to unite – and then divide the lobbyists who are committed to the status quo.”
In part 2 of this series, I will explore how we might “divide the
lobbyists,” and address two remaining questions that still divide
reformers: First, should we even talk about “controlling costs”—or is
that giving too much ammunition to the opposition? And secondly, can we
hope to achieve universal coverage all at once, or is Robert Kuttner,
co-founder and co-editor of The American Prospect, right when he says:
“Today there are not the votes in Congress to enact a true universal
health-insurance system. Any progress toward universal coverage will
necessarily be incremental”?
Dr. Marcia Angell statements are the most liberal, government is best dribble I have heard in a long time. If you ever want to dismantle the care that physicians in our country strive to give, then replace it with a govt controlled system. Pure hogwash!
If a govt system ever becomes law, you will no longer be getting the best and brightest into the medical profession.
Before Medicare and the insurance industry took control of healthcare, patients loved their doctors and hospitals, and everyone got along, costs were much lower and charity care was given in abundance.
If you want to remove the waste in the system, you need to do the opposite of Dr. Marcia Angell’s comments. We need more high deductible health savings accounts, and some individual and personal responsibility. The government does not care about individuals. It only tries to remain on a budget!
BTW, What has the government ever run efficiently?
Sorry for the rant, but the views expressed by Dr. Marcia Angell really got my goat. The large majority of healthcare today is delivered by private practice doctors, not liberal academia elitists.
Regarding “choice,” George Lakoff and others have made the point that choice of health care coverage is a neoliberal expression of conservative framing. What people really want is choice of their health care professionals and institutions, and the right to choose their specific health care after being informed of their options.
Most polls on choice ask only about choices in coverage. This has led to the current political rhetoric: “…and you can keep the coverage you have, if you want to.”
The question that you never see asked in polls today: “Would you prefer to continue using private insurance plans that restrict your choices of physicians and hospitals, while continuing to make premiums and out-of-pocket expenses less and less affordable, or would you prefer to have free choice of your physicians, hospitals, and choice in the care received, while ensuring that health care is always affordable by using an equitable system of public financing and by identifying and reducing waste through public administration?”
Okay. So the question is somewhat complex for a public poll, but the fundamental principle holds. People want choice in health care, not choices of plans that reduce or eliminate health care choices.
I agree with Don McCanne, I don’t know how recent these polls or surveys were, all I can tell you is in the past 8 years or so I’ve encountered hundreds of working class Americans, none of whom were happy or satisfied with their employer based health insurance. Yes, we want choice in who treats us or where we’re treated, of course.
I’m going to ask again, isn’t the VA system “government-run” healthcare? Dr. Debakey received the Congressional Gold Medal yesterday, and he encouraged Congress to model healthcare after the VA system, one, I believe, he helped create.
Maggie, you are so correct on reformers uniting. I think part of the problem is a lack of solid comprehension, and a lot of the “reformers” aren’t united because they don’t even know each other exists. I myself have asked many questions of “reformers” endorsing one thing or another and I get empty answers, propoganda or rhetoric instead of information. I love your blog and I’m going to send as many reformers as I can find to it. Please, do tell, how do we divide those deep-pocketed lobbyists?
Thanks Maggie, for this thoughtful overview and pointer to current issue of TAP, and hearty thank you! to Lisa and Don for their comments geared to “let’s get going toward workable reforms and the requisite movement-building to achieve them.
I’m a nurse and health reform activist who works with people in moderate and low income urban populations in MA. I cannot begin to describe the urgency of enacting SOCIAL INSURANCE FOR ALL in order to prevent yet another early death or permanent disability that I and other health professionals bear witness to on a regular basis. Where’s the outrage? These extreme events of tens of thousands of preventable deaths and disability annually go hand in hand with immense and preventable suffering that is endured by patients and their families, in addition to driving up costs (One person’s cost is another person’s profit in our market-driven system, I suppose. How immoral is that?).
I, too, believe that we can build the broad political movement required to enact Improved Medicare For All with everybody in and nobody out — health care policy the civilized way!
Finally, I feel obligated to reply to DrSH who rants against the very insightful analysis given by Dr Angell and then SH goes on to say: “The large majority of healthcare today is delivered by private practice doctors, not liberal academia elitists.”.
SH, could you provide data on that statement? Because, in fact, I believe the data would indicate that Registered Nurses are the health professionals who provide “the large majority of healthcare today”. (per US Census data there are 2.4Mil RNs and 819,000 Physicians in the U.S.
http://www.census.gov/Press-Release/www/releases/archives/facts_for_features_special_editions/004491.html
Additionally, the US VA healthcare system is a very effective and financially efficient “government run” program that achieves very good clinical outcomes. (see “Comparing Outcomes: Comparing Systems” by John G. Demakis in Medical Care, Vol. 37, No. 6).
Reformers are invited to our Day of Health Reform Activism in Boston on Monday April 28, 2008. Here’s the Press Release for it:
MEDIA ADVISORY FOR: Monday, April 28, 2008
Contact: Rand Wilson, 617 803-0799
Alanna Sobel, 202 7897751
Bryan Buchanan, 202-789-7783
***GREAT VISUALS***
On 2-Year Anniversary of MA Health Bill Passage,
Activists Rally Against Mandates, For Universal Health Care
Health care activists from around the country and state will hold a forum in Boston on Monday, April 28 to analyze the failures of the individual mandate approach Massachusetts adopted last year through the Chapter 58 health care law.
A morning panel featuring health care professionals, experts and testimony from individuals hurt by the mandate system will highlight the problems of trying to achieve broader access through individual insurance mandates.
Later, hundreds of people are expected to rally for a “Medicare for All” approach to achieving affordable health care reform. The rally will be at 4:30 PM on Boston Common. There will also be special showing for state legislators of Michael Moore’s documentary SiCKO at the Massachusetts State House at 1:30pm.
WHEN: Monday, April 28
WHERE: Forum at 9:00 AM, Marriott Courtyard, 63 R Boston St., South Boston
SiCKO screening at 1:30pm, Massachusetts State House
Rally at 4:30 PM, Boston Common, Parkman Bandstand
Thank YOU Ann…always it’s the nurses, I love nurses. I pasted your announcement and circulated through my email group.
Lisa:
My previous post was a rant and it was meant to be. But it was never a rant against nursing.
You took offense to a statement where no offense was meant. Private practice is where most medical care is given. More care is given in offices, not in hospitals or urban clinics.
Private practice is a private team approach with physicians, nurses and other staff members. It was not meant as an offense to nurses.
But back to the main topic.
Government run entities do not work well for the majority. To bring the healthcare quality and system down to help those who do not know how to access it is the wrong way. We need to bring those people up to the better care, alongside those who get good quality care.
The purpose of government is to give individuals the framework and the motivation to succeed, not to entitle them to food, clothing, shelter and health insurance.
If you want to make healthcare nonprofit, lets make nursing nonprofit as well. Then lets give everyone a free car,. Why not, everyone else has a nice car. Then give them free gasoline, because, hey, everyone needs gasoline for their car! Where does it end???
Socialism does not work, and it does not drive people to do for themselves, but only brainwashes them to expect the govt to give them a handout for everything. That is the worng message to send. It is certainly a message that I do not give to my children. They need to educate themselves and work hard for themselves, and not for a free handout.
The debate needs to distinguish between Healthcare, Healthplans, and Health Insurance.
Healthcare can be accesible to all. If we get rid of third parties influence on this care, the costs would come down enormously. If Medicare ends the price fixing it sets, care would also come down in cost, and access would go up. That is called the free market. The term free is an important word. I do not ever want to give up my freedom of access to medical care based on a government or academic budget.
There are many possible solutions to health care in this country, but a socialistic system run by the government is NOT the answer.
So many people like DrSH rant against single payer systems as socialist medicine without making a single comment about the wasteful, unjust and deceitful practices of private health insurers.
One physician I know remarked when someone asked him if he wanted to have to go to the government to get approvals, “I can at least talk to my Congressman. Have you ever tried to argue with an insurance executive?”
The problem with health care reform seems to me to scare people because the proposed systems seem large and impersonal to most people.
On the single payer issue the California State legislature enacted in Aug 2006 SB 840 by Senator Sheila Kuehl and vetoed by the Gov. It focuses on universal enrollment as well as access and other features promoted by single payer philosophy. It also contains many features that aim to bring informed choice to consumers when they choose their providers under this bill. It contains some interesting ideas on delivering coordinated care in fee for service care.
Why couldn’t some version of this become the default plan and let people vote with their feet?
Doctors in the US are underpaid but the way they compensate for this is by gaming the system and pushing up overall costs. This is a lose-lose situation.
The average income seems to be about $150-200K. This is a nice income, but is not out of line with other professions such as Wall Street lawyers and financial analysts and managers. In my region policemen get about $100K per year.
Doctors are paid too little for their services (look at how much they get for a standard office visit), and thus do things to boost their income. The most recent examples have involved over prescribing drugs that they administer and for which they are compensated. Another area involves ordering excessive tests.
As I’ve said before, the plumber who visits my house gets a higher fee for the visit than does the doctor. I don’t know if it is possible to fix this imbalance, judging from the recent PBS program on health care in other countries, doctors are equally underpaid for their services elsewhere. They make up for it by being very fast. The Japanese doctor sees most patients for five minutes.
A useful trade off might be to offer free medical education in exchange for a contract that covered employment for a number of years. With no education loans to pay off the doctor’s net compensation might even be greater than under the present system.
Having no incentive to over treat would lower costs to the whole system and benefit everyone. (I’ve focused on doctors, but there are similar issues with nurses and others in the health professions.)
If we unpack DoctorSh’s comment — “The large majority of healthcare today is delivered by private practice doctors, not liberal academia elitists” — we find some annoying and tiresome assumptions. One is that “private practice doctors,” of which I am now one, cannot be, in the standard slur, “liberal.” Another is that liberals are, by the nature of their views, “elitist.” This is also false. Finally, academic physicians, which I was for many years, also roll up their sleeves and deliver care at the bedside. So enough with the demagoguery. To me, the fundamental truth in all this is that standard, “free-market” principles (to which all of us should duely genuflect) are unsuited for structuring a health care system.
Dr Sh:
“Lisa:
My previous post was a rant and it was meant to be. But it was never a rant against nursing.
You took offense to a statement where no offense was meant.”
Dr SH, this is as far as I read and maybe as far as I’m going to. I ignored your initial post for obvious reasons. I never made one single comment about it. Nothing, not a word. Are you some sort of cyber-paranormal or something? Well, you’re not. I was not offended by your initial post because that would indicate some sort of emotional reaction based on what you posted. I did not have an emotional reaction of any sort based on your initial post, it wasn’t that powerful, thought-provoking or interesting, positive or negative, it was like reading cardboard.
Thanks for all of your comments!
Doctor SH–
The fact that you say that “the large majority of healthcare today is delivered by private practice doctors” tells me two things:
A–I’ts quite likely you practice somewhere in the Northeast, Florida or possibly Texas and
B–You’re a dinosaur.
On the West coast,in the Northwest, and in many parts of the U.S. more and more doctors are practicing in large group practices like Kaiser Permanente or the Cleveland Clinic. Very low turn-over among docs and patients in NOrthern California tells us that satisfaction with Kaiser is very high.
Moreover, today the vast majority of young doctors coming out of med school have no interest in going into private practice. They do not want the burdens of running a small business. They want to focus on caring for patients.
When you talk about the good old days of medicine, you are referring to a time when doctors were thought of as gods (or at least they thought of themselves as gods) who “generously” dispensed care to the poor–when they felt like it. (That usually did not include African-Americans.)
Financially, they cleaned up because they were able to charge whatever fees they liked.
Many of them were arrogant “lone rangers”–solo practioners (or doctors in very small group practices) who practiced medicine however they liked. They didn’t want anyone “looking over their shoulder” talking about “best practices.”
No one knows how many people the most arrogant lone rangers killed.
My husband just fired an eye doctor who fit this description. He told my husband he needed cataract operations on both eyes.
My husband is rather young to need cataract operations. And I had already begun to mistrust this doctor . . We found a new eye doctor–and discovered that my husband has 20/20 vision in one eye and very good vision in the other eye. (With glasses) No need for operation in either eye.
One can only wonder how many needless operations the first doctor has done. He is very,very busy. How many of those patients ran into needless complications, infections, etc?? (I’m trying to figure out who to report him to.)
You ask: What has govt ever run efficiently?
The VA
Health Care System became very good in the 1990s, though in recent years it has been under-funded.
I’ve written about it here http://www.thehealthcareblog.com/the_health_care_blog/2007/03/policy_in_defen.html.
Please see Chris Johnson’s comment on your use of words like “elitist” and “liberal”.
Angell is highly respected in the healthcare community, even by those who disagree with her.
But to disagree with her, who have to read, not rant.
Try her book, “The Truth About the Drug Companies” which has received rave reviews from Publisher’s Weekly, among others.
Don–
I agree that the emphais on “choice” is a neo-conservative framing. (Though many, many people have now bought into it).
And you are right, what people really want is a choice of doctor and hospital, not a choice of insurer.
But they are also very, very concerned about costs. The 80 percent who say they want to keep the insurance they have are mainly people who have employer-sponosred insurance–with the employer paying more than 50% of the cost.
Among better-paid employees, 15% have employer-sponsored insurane that costs them Nothing. The employer pays 100 percent of the premium.
They rightly suspect that, if we went to single-payer, they would have to pay more than “Nothing” into the pool. Others, whose employer pays more than 50% also suspect that single-payer might cost them more (it probably would if they earn more than $60,000-$75,000) since they would be helping to pay for lower-income people who need subidies.
And they fear that govt-sponsored insurance might not cover everything that their employer-based insurance covers now. (Again, they’re right– their current insurance covers many ineffective over-priced products, while not covering some of the things they need.)
Coming back to “Choice”–Rather than saying that Americans want Choice it might be better to say that Americans who now have insurance fear Change.
Most people fear Change–it means moving from the known to the unknown.
As for your polling question–yep, it’s way too long. In a polling question, people hear maybe one or two key words.
“Keep what you have, or, if you choose” is calming.
“Required” is not.
If we’re going to get real reform, we have to keep people calm, and ease them into it. Give them a choice. Let them mull it over.Let them hear from their neighbor what he is getting under the govt plan. If we tightly regulate private insurers and force them, kicking and screaming, to compete with public-sector insurance on a level playing field, the public-sector insurance will almost certainly offer better coverage at a lower price.
Eventually most people will figure that out–as they have in other countires where they have choice. (For instance, in Germany, people have a choice between less expensive public sector insurance and more expensive private sector insurance which offers more amenities (like private rooms) but no better healthcare (according to doctors who have chosen the public-sector plan for themselves.)
More than half of the most affluent people in Germany (earning over roughly $75,000) choose the public-sector plan–even though they could afford the private sector insurance. This means they may wait longer for elective procedures and they don’t automatically get a private room (unless it’s medically necessary) but they’re quite happy with the care.
Lisa–IN part two of this post, I’ll talk about dividing the lobbyists. You’re quite right that the VA has been very good–though in the past 8 years, funding hasn’t come close to keeping up with the needs of returning solidiers . . (We’ll be putting up a post about this soon.)
On how people feel about their employer-based insurance, see my reply to Don above . .
Ann–
Good to hear from you. Yes, the VA is a good model, and Yes I agree Angell is excellent. I just don’t think anyone can get the votes for single-payer in Congress and hate to see the whole movment go down in flames because too many people inisted that single payer is the only way to go . . .
But everything else Angell says is spot on.
Robert–
You’re right that primary care docs, family docs etc. are underpaid. But there are also a large number of doctors who average, say $800,000 a year and many who earn a million or more.
I agree with you about med school. In most developed countries it is free. We probably can’t afford to do that right now, but we should expand programs that forgive all loans if students choose to go into a specialty where they are needed and then locate someplace where they are needed for at least 3 or 4 years. . .
Chris Johnson: Thanks for your comment. You write: “To me, the fundamental truth in all this is that standard, ‘free-market ‘principles (to which all of us should duely genuflect) are unsuited for structuring a health care system.”
I agree completely. The free market works well for some things–but not for healthcare.
Maggie:
I’m more willing to put up with a few doctors making $1 million per year than with the CEO of an insurance company making 1000 times that – see the former head of United Health.
It also would be useful to know if those with such high earnings are because they are very busy or because they are gaming the system. The only high earning doctor I knew well was an anesthesiologist who burned himself out. Not only did he do a large number of long, complicated surgeries, but he was frequently on call from the local emergency room.
Remember that a starting lawyer in a big name firm now gets about $140,000 per year for being nothing more than a glorified research assistant.
There are gross imbalances in our compensation system, but I don’t think a top down pricing system will work in the US. Putting doctors on salary, perhaps with some performance bonuses, might be more acceptable.
Robert–
We’re not talking about a few doctors who are overpaid for certain procedures –we’re talking about thousands and thousands of doctors.
(By contrast, the insurance industry has consolidated to a point that there just aren’t that many insurance company CEO’s)
Recent data shows neurosurgeons averaging $550,000 to $850,000 base income—plus benefits, bonsues and malpractice insurance paid for by the hospital where they work.
Urologists base income is $400,000 to $500,000–plus benefits, bonsues, malpractivce insurance.
Orthopods–$413,000 to $650,000 — cardiologists, gastroentrologists, etc all are at simillar levels.
And these are just averages. These are the top guys.
Meanwhile, those doctors in the best-paid speciatlies are doing more and more volume in order to make more and more money. This jacks up our entire health care bill because every thime they do an extra surgery (that may not be needed) or put a patient through another round of chemo(who may not benefit) we not only pay for the surgery or the doctor’s appointment, but for the hospital, the rehab, the nursing, the drug.
As Alan Sager and Deborah Socolar point out in “Health Costs Absorb One-Quarter of Economic Growth, 2000-2005,” U.S. physicians receive or control 87 percent of all spending on personal health.
So when it comes ot health care inflation, physicians who over-treat are in the driver’s seat. And over-paying for certain services provides a powerful incentive to overtreat.
Moroever, doctors earning the top salaries have become increasingly entrepreneurial in ways that aren’t always good for patients. The McKinsey Global Institute calculates U.S. physicians earned $160 billion a year in 2003, segmented as follows: $45 billion in fee-for-service income from hospitals with an additional $90 billion in fee-for-service income from outpatient facilities. In addition, physicians earned $25 billion from profits in physician-owned facilities.”
When phsycians own facilties they tend to use them–and sometimes over-use them. A study published in the Journal of the American Medical Association in March takes a look at the rate of coronary by-pass operations in local populations after a physician-owned cardiac hospital is built. It turns out that once physicians opened the doors of their new facility, the number of coronary artery bypass grafts (CABG) as well as angioplasties suddenly shot up by 19.2 percent. Was the population suddenly sicker? We know that, in health care markets, supply creates demand. (“Build the beds and they will come.”) But the research suggests that it wasn’t just the presence of a new facility; when physicians become owners of a surgical center, they are motivated to send many more of their patients for surgery. By contrast, in markets when new cardiac programs open at general hospitals the number of new procedures increased by only 6.5 percent.
We’re not just talking about a waste of dollars; we’re talking about patients being exposed to serious risks when they undergo unnecessary CABGs and angioplasties. . .
Again, it’s not wasted money that bother me as much as the overtreatment . . .
Annd the money could be used to pay pediatricains, family docs etc. more so that they could afford to spend more time with their patients, co-ordinate their care and manage chronic diseases . .
See these two posts:
http://www.healthbeatblog.org/2008/01/turf-wars-docto.html
http://www.healthbeatblog.org/2008/01/who-decides-how.html
basorthopedists earning $4000 to $650,000 in base income radioologists earnign $350,000 to $500,000 base income—plus benefits, bonuses and malpractice insurance (usually paid for by a hospital)
Maggie:
Suppose I grant everything you say, what then?
There has only been one case of the US banning a profitable private enterprise, that was Prohibition. It was a total failure. It led to the rise of organized crime, disregard for the law by average people and widespread corruption. Some of those effects are still being felt to this day. The mob moved from alcohol to drugs and other enterprises when Prohibition was repealed.
So, to rein in the incomes of doctors would require a restructuring of the entire social system. We would be forcing a single class of small businessmen out of business or imposing strict controls on how they operate. I don’t see this happening. That’s why the pols talk about reforming insurance not health care.
The most likely outcome will be some new programs to cover the uninsured, but without the kinds of cost controls you favor.
Look, tobacco is still legal after more than 50 years of evidence about its adverse health effects. If the US can condone selling poison for half a century what is the likelihood that medical practices will be reformed?
By the way there was a program on Radio Netherlands yesterday about French medical care. It said that the French take too many drugs just as in the US and that the national health service is currently running a deficit of about 11 million Euros. Apparently they don’t have a politically viable solution for their problem either.
So what’s your plan?
Robert–
I’m not talking about rolling back doctors incomes across the board. That’s what Medicare and Congress are talking about doing– in June Congress is supposed to vote on reudcing the fees Meidicare pays the average doctor by 10 percent. The current law says that’s waht Congress is supposed to do. And then Congress is supposed to cut fees to doctors by 15 pecent over the next two or three years.
The reason: because otherwise, Medicare is going broke in 7 or 8 ydars and we’ll have to have a steep increase in the FICA taxes taken out of your paycheck.
I doubt they’re cut doctors’ fees across the board; too many doctors would simply stop taking Medicare patients.
But they will have to do something. I’m suggesting cutting the fees for certain services that are now overdone, and raising fees for doctors at the bottom of in the income ladder who pracice preventive medicine.
In order to save the money that Medicare needs to save I don’t focus on cutting doctors incomes. I urge reudcing wasteful ineffective treatments–which will have an impact on all sectors of the health care pie–drug-makers, device-makers, hospials and doctors.
I also think Medicare needs to negotiate for lower prices for drugs and devices, just the way the VA and every other developed country in the world does
Every healthcare system has problems, but France pays half as much, per person as we do, everyone is covered, and the outcomes are significantly better in many areas.
By and large the French are much happier with their health care system than we are. And they pay less.
You don’t see a lot of
French doctors coming here to practice, even though they could make signficantly more . .
There is no perfect system, but we could get a much better bang for our buck, and cover everyone.
Maggie – RE your reply to me: “I just don’t think anyone can get the votes for single-payer in Congress and hate to see the whole movement go down in flames because too many people inisted that single payer is the only way to go . . .”
I’d like to point out to you and to HealthBeatBlog readers that nowhere in my comment do I say Medicare-for-all “is the only way to go”.
I do know that policymaking/ lawmaking includes compromise and think that it behooves us activists to stake out the ideal solution (single payer Medicare-for-all). Why begin your negotiation process with settling for less than what is right, fair, and reasonable?
To those of us who have an intimate understanding of how the U.S. health system works–including how it fails millions of Americans quite miserably–we have a moral obligation to advocate for single payer Medicare-for-all to be discussed as a serious option when the various “solutions” are being debated in the public realm such as here on this blog and in political campaigns, and in Congress.
Would you agree?
Maggie,
We agree that there are huge regional variations in practice patterns and a lot of unnecessary, inappropriate or cost-ineffective treatments throughout the healthcare system. Aside from comparative effectiveness research that may well take years to have any noticeable effect on utilization of healthcare services, I haven’t seen any worthwhile ideas that could be implemented now or that could make it through our political process anytime soon. Single payer advocates talk mainly about saving on administrative costs and providing more preventive care. Administrative savings are likely to be relatively modest and would be a one time only savings, as you have suggested in the past. Preventive care, while it would likely extend lives which is a good thing in itself, is more likely to cost money than save it over the long term. Malpractice reform is unlikely at the federal level given the power of trial lawyers, though experimentation is going on at the state level.
The bottom line, it seems to me, is that doctors, who drive 87% of healthcare spending, and hospitals suffer no adverse financial consequences if they provide too much unnecessary or inappropriate care. Indeed, it is more profitable for them to practice that way. Until we can devise financial and other incentives that reward the best practicers and penalize the high utilizers, we are likely to continue along the current unsustainable path. Since capitation is a tough sell to providers and rationing won’t fly here anytime soon, I think Medicare, Medicaid and private insurers should consider grouping hospitals and doctors into tiers based on quality and cost-effectiveness similar to what we do with drugs now. Patients could be charged lower (or no) co-pays for using the most cost-effective providers, and gain sharing programs could be developed to reward doctors and hospitals for safely driving utilization down without denying appropriate care. Bundled pricing for expensive surgical procedures would also be helpful, I think. It’s all well and good to talk about getting UCLA or MGH to practice more like Mayo or the Cleveland Clinic, but without appropriate financial carrots and sticks, it’s unlikely to happen.
Barry & Ann–
Thanks for your comments.
Ann– I realize you didn’t say single-payer is the only way; and I believe that you are ready to negotaite and compromise as needed. I also understand why you want to start with the ideal and work down from there.
But many single payer advocates (for instance PNHP and the California Nurses) are adamant that single-payer is the only way.
Given the bitter division we have seen among progressivs over Obama vs. Clinton, I am afraid of seeing people dig their heels in on single-payer vs. choice between single payer and private insurance.
If it begins to seem possible that their might be votes in Congress for single payer, I would be the first to embrace it.
But even the majority of Democratic Congressmen are against single-payer–as are the majority of their consituents. Forget about Republicans. And on this issue Independents are nearly as conservative as the Republcians. . . .
So I don’t see how it can happen. And I can see progressives shooting themselves in the foot again (as they have during this presidential campaign) by lining up ono different sides of the issue and fighting with each other rather than with these opposition.
AT this point, I honestly think it is possible (not probable but possible0 that McCain could win the presidency whichever Democratic candidate is nominated. (I don’t mean to offend McCain supporters here, but even most Republicans don’t think he is as strong as some past Republican candidates.)
Liberals were dealt a good hand–three competent candidates that many people liked. It is just incredible that they have played that hand so badly.
Barry–
As we’ve discussed, when it comes to over-treatment there is actually a huge amount of low-hanging fruit. Begin with ineffective spine surgery (AHRQ pointed this out in the late 1990s.) PSA tests and virtually all treatments for early stage prostate cancer (both he American Cancer Society and the National Cancer Society say there is no evidence that they do any good) statins for peopole over 65 and many under 65 who have never had a heart attack–particularly if they are complaniing of side effects. ((IF a patient over 65 complains of side effects associated with statins and his doctor doesn’t even try taking him or her off them for a few months, this could be the basis for a malpractice suit; unncessary by-pass (done too long after the heart attack) angioplasties (when change of diet, exercise and medication should be tried first); extra rounds of chemo that, at best, will give the patient a few additional months.
In some of these cases, a patient might decide that he wants one of these procedures anyway. But since we have no medical evidence of effectiveness–and do know that there are risks–society as a whole should not be paying for these procedures (through private insurance or govt. sponsored insurance) unless a)the evidence changes or b)there is something very unusual about the case.
(For example if your brother died of prostate cancer, there might be an argument that you should get a PSA test to serve as a “marker” of your PSA levels. Exceptions could be made –but only based on medical evidence.
Finally, studies show that if we give patients a chance to participate in “shared decision-making” about elective surgery and elective tests 20% to 40% decide not to go ahead with the test or procedure.
We also don’t have to re-ivent the wheel; we can look at which drugs and tests and procedures other countries don’t cover–and why. This doesn’t mean we have to follow their decisions (in some cases, they decide not to cover something because of cost–we probably could afford to cover it.)
But looking at what other countries don’t cover becuase it’s not considered effective is a good place to start, particularly since other countires make these decisions based on medical evidence rather than campaign contributions and pressure from lobbyists.
Paying doctors and hospitals for efficiency is much more complicated. We can begin to move away from fee-for-service and toward salaries only insfor as doctors move out of solo practice–which will happen with the next generation.
In the meantime, we can give them financial incentives to join large groups that, in turn, affiliate with a hospital or hospital –and then bundle payments.
But as you know this is all very complicated.
The problem with pay for performance is that a) certain types of patients will skew the results and it can be very hard to adjust unless you are dealing with enormous pools of patients and b) when you “pay for performance” you pay only for what you can measure.
Some of the most important aspects of healthcare cannot be measured because mediciine is as much an art as a science. If the patient dies, the question is: “was it a good death?”
Was the doctor compassionate, or did he cut the patient off once he realized that this case will be a failure (and won’t look good on his “report card.”)
Was the patient frightened and in pain?
If the patient surivived the surgery was he then warehoused in a nursing home for the next 6 years or was he able go go home and function? If he wound up in a nursing home, would he have been better off if he had never had the surgery?
What was the psychological effect of bypass surgery? As you probably know, some older men never recover psychologically. They are forever afraid. Their wives report that suddenly, they seem 10 or 15 years older. Is it because they weren’t prepared properly for the surgery? Did they really need the surgery? Or is it simply that some patients are so afraid of death that there really is nothing a doctor can do?
I could go on. But in general, people are, I think, way too anxious to “judge” and “rate” and then “reward” and “punish”
Our goal should be too improve performance all the along the inevitable Bell Curve, first by letting a hospital/doctor group know that they are “outliers” in terms of how much care costs per patient and asking if they can figure out why (for example they may be taking the most difficutl cases, or have poorer patients.) If there is no obvious explanation, than we need collegiality in the form of colleagues from other hospitals who in the same specailty reviewing hte records, visiting the hospital, and trying to figure out what systems could be put in place to improve effiency.
Rather than paying the group less as “punishment”, they might need additional funding to put systems in place — for example, funding to set up a program ot reduce hospital-acquired infections or to improve communication among specailists treating the same patient.
Most doctors very much want to do very a good job. They are competitive, and mortified if they discover they are not doing as well as they should be. They understand what is at stake—and they’re not selling ties.
Financial incentives might work well to get the tie salesmen to sell more ties, but evidence shows that it can undermine the
morale of professionals.
Barry & Ann–
Thanks for your comments.
Ann– I realize you didn’t say single-payer is the only way; and I believe that you are ready to negotaite and compromise as needed. I also understand why you want to start with the ideal and work down from there.
But many single payer advocates (for instance PNHP and the California Nurses) are adamant that single-payer is the only way.
Given the bitter division we have seen among progressivs over Obama vs. Clinton, I am afraid of seeing people dig their heels in on single-payer vs. choice between single payer and private insurance.
If it begins to seem possible that their might be votes in Congress for single payer, I would be the first to embrace it.
But even the majority of Democratic Congressmen are against single-payer–as are the majority of their consituents. Forget about Republicans. And on this issue Independents are nearly as conservative as the Republcians. . . .
So I don’t see how it can happen. And I can see progressives shooting themselves in the foot again (as they have during this presidential campaign) by lining up ono different sides of the issue and fighting with each other rather than with these opposition.
AT this point, I honestly think it is possible (not probable but possible0 that McCain could win the presidency whichever Democratic candidate is nominated. (I don’t mean to offend McCain supporters here, but even most Republicans don’t think he is as strong as some past Republican candidates.)
Liberals were dealt a good hand–three competent candidates that many people liked. It is just incredible that they have played that hand so badly.
Barry–
As we’ve discussed, when it comes to over-treatment there is actually a huge amount of low-hanging fruit. Begin with ineffective spine surgery (AHRQ pointed this out in the late 1990s.) PSA tests and virtually all treatments for early stage prostate cancer (both he American Cancer Society and the National Cancer Society say there is no evidence that they do any good) statins for peopole over 65 and many under 65 who have never had a heart attack–particularly if they are complaniing of side effects. ((IF a patient over 65 complains of side effects associated with statins and his doctor doesn’t even try taking him or her off them for a few months, this could be the basis for a malpractice suit; unncessary by-pass (done too long after the heart attack) angioplasties (when change of diet, exercise and medication should be tried first); extra rounds of chemo that, at best, will give the patient a few additional months.
In some of these cases, a patient might decide that he wants one of these procedures anyway. But since we have no medical evidence of effectiveness–and do know that there are risks–society as a whole should not be paying for these procedures (through private insurance or govt. sponsored insurance) unless a)the evidence changes or b)there is something very unusual about the case.
(For example if your brother died of prostate cancer, there might be an argument that you should get a PSA test to serve as a “marker” of your PSA levels. Exceptions could be made –but only based on medical evidence.
Finally, studies show that if we give patients a chance to participate in “shared decision-making” about elective surgery and elective tests 20% to 40% decide not to go ahead with the test or procedure.
We also don’t have to re-ivent the wheel; we can look at which drugs and tests and procedures other countries don’t cover–and why. This doesn’t mean we have to follow their decisions (in some cases, they decide not to cover something because of cost–we probably could afford to cover it.)
But looking at what other countries don’t cover becuase it’s not considered effective is a good place to start, particularly since other countires make these decisions based on medical evidence rather than campaign contributions and pressure from lobbyists.
Paying doctors and hospitals for efficiency is much more complicated. We can begin to move away from fee-for-service and toward salaries only insfor as doctors move out of solo practice–which will happen with the next generation.
In the meantime, we can give them financial incentives to join large groups that, in turn, affiliate with a hospital or hospital –and then bundle payments.
But as you know this is all very complicated.
The problem with pay for performance is that a) certain types of patients will skew the results and it can be very hard to adjust unless you are dealing with enormous pools of patients and b) when you “pay for performance” you pay only for what you can measure.
Some of the most important aspects of healthcare cannot be measured because mediciine is as much an art as a science. If the patient dies, the question is: “was it a good death?”
Was the doctor compassionate, or did he cut the patient off once he realized that this case will be a failure (and won’t look good on his “report card.”)
Was the patient frightened and in pain?
If the patient surivived the surgery was he then warehoused in a nursing home for the next 6 years or was he able go go home and function? If he wound up in a nursing home, would he have been better off if he had never had the surgery?
What was the psychological effect of bypass surgery? As you probably know, some older men never recover psychologically. They are forever afraid. Their wives report that suddenly, they seem 10 or 15 years older. Is it because they weren’t prepared properly for the surgery? Did they really need the surgery? Or is it simply that some patients are so afraid of death that there really is nothing a doctor can do?
I could go on. But in general, people are, I think, way too anxious to “judge” and “rate” and then “reward” and “punish”
Our goal should be too improve performance all the along the inevitable Bell Curve, first by letting a hospital/doctor group know that they are “outliers” in terms of how much care costs per patient and asking if they can figure out why (for example they may be taking the most difficutl cases, or have poorer patients.) If there is no obvious explanation, than we need collegiality in the form of colleagues from other hospitals who in the same specailty reviewing hte records, visiting the hospital, and trying to figure out what systems could be put in place to improve effiency.
Rather than paying the group less as “punishment”, they might need additional funding to put systems in place — for example, funding to set up a program ot reduce hospital-acquired infections or to improve communication among specailists treating the same patient.
Most doctors very much want to do very a good job. They are competitive, and mortified if they discover they are not doing as well as they should be. They understand what is at stake—and they’re not selling ties.
Financial incentives might work well to get the tie salesmen to sell more ties, but evidence shows that it can undermine the
morale of professionals.
Maggie,
Thanks for the detailed response as always.
Regarding the unnecessary spine surgery, I’m sure you remember that the spine surgeons almost put the AHRQ out of business after those guidelines were published. More to the point, though, if you gave 100 spine surgery charts to independent reviewers without telling them which patients benefitted from the surgery and which didn’t, I’m not sure how much consensus there would be among them as to which specific patients could be identified in advance as not needing the surgery or who would have been better served by some alternative, presumably less expensive, course of treatment.
On the PSA tests and the statin drugs, it would be feasible to identify large classes of people that should not get the drug because it is not cost-effective. While the PSA test is not very expensive, we could refuse to cover it except for patients with a personal or family history of prostate cancer. People who wanted it could pay for it themselves. The same is true for the statin drugs, especially now that generics are readily available.
I certainly agree that shared decision making is a good thing on its face. The more patients can be involved in their own care, the better. For procedures like hip and knee replacement, many people will opt to put those operations off as long as possible.
With respect to extra chemotherapy treatments, there could be other factors at work here besides financial incentives to continue to treat. Even salaried oncologists who work for, say, Mayo or Kaiser might find it hard to tell the patient that there is nothing more that can be done as soon as they actually reach that conclusion because it means conveying a death sentence.
Studying what other countries don’t cover and why is a “no brainer.” We should absolutely do this. It may be that countries like the UK might not cover a specific procedure because it doesn’t meet their QALY metric, but ours, if we had one, would be considerably higher.
I strongly disagree on the financial incentives. Even though it might be complicated, I think it’s doable and can be refined as we learn more and develop more robust data. I would encourage you to take a look at a story linked to a couple of days ago by Fierce Healthcare Finance News at: http://www.healthcarefinancenews.com/story/cms?id=7926. I’ve said before that incentives matter and we need to apply them. I also think that hospitals should follow the example set by Paul Levy, the CEO of BIDMC in Boston, who is posting infection rates and lots of other data on their website to both provide transparency and hold themselves accountable. Leadership from the top also makes a positive difference on issues like this. If I’m the CEO of a hospital that is performing poorly, it is my and my team’s responsibility to seek out and visit other hospitals that are doing better to learn how we can improve. Infection rates might be reduced by strategies as simple as more consistent and thorough hand washing, the use of checklists, and empowering nurses to speak up when the see something wrong without having to worry about retribution from arrogant doctors who don’t like to be challenged.
I think payers, including taxpayers, are running out of patience with doctors and especially hospitals who don’t want to be held accountable and are increasing their prices at rates faster than general inflation each and every year. Their attitude seems to be: we’re just trying to take care of patients. Money is not our concern. Well, the current system is unsustainable, so money, which is a constraining resource, is their concern and should be their concern and the sooner they understand that the better.
Barry–
I was at a health care conference for med students at Mt. Sinai yesterday and a couple of the points that you mention came up.
First, you write: “Even salaried oncologists who work for, say, Mayo or Kaiser might find it hard to tell the patient that there is nothing more that can be done as soon as they actually reach that conclusion because it means conveying a death sentence.”
At the conference, I describe who I admire greatly, who is on the American Board of Oncology.
He doesn’t use chemo on all of his patients, and when he does, if the first round doesn’t have the hoped-for effect, he tells his patients: “I know I can making you sicker (by doing another round) by I also know that I cannot make you well. The thing you need to decide is what you would like to do with the fore-shortened life you have left. Is there something that you would really like to do? Or do you want to spend that time with me and my assistants, going through more rounds of chemo.”
Yes, he is telling them that they are going to die. AT Mt. Sinai, there was widespread agreement that this is the only ethical, honorable thing to do. If you don’t want to tell people they are going to die and that there is nothing we can do, you shouldn’t go into oncology. In fact, you probably shouldn’t become a doctor unless you want to do cosmetic dermatology.
I’ll be writing about a palliative care specialist who spoke at the conference and talked about how patients are tortured –with another round of chemo, painful tubes providing nutrition to people who are clearly dying. The doctors who do these things think that medicine is only about saving lives. It isn’t.
It’s about caring for parients who are dying and helping them face that face.
On the question of financial incentives for performance, she also made the point that these incentives pay only for what can be measured. And it’s very, very dangerous to encourage health care providers to focus on what can be measured when what cannot be measured is at the very center of medicine.
There also has been a lot of reserach done on this issue in industry, showing that pay-for-performance undermines creativity and causes people to focus on the P4P list–which means they neglect other things.
Barry–
I was at a health care conference for med students at Mt. Sinai yesterday and a couple of the points that you mention came up.
First, you write: “Even salaried oncologists who work for, say, Mayo or Kaiser might find it hard to tell the patient that there is nothing more that can be done as soon as they actually reach that conclusion because it means conveying a death sentence.”
At the conference, I describe who I admire greatly, who is on the American Board of Oncology.
He doesn’t use chemo on all of his patients, and when he does, if the first round doesn’t have the hoped-for effect, he tells his patients: “I know I can making you sicker (by doing another round) by I also know that I cannot make you well. The thing you need to decide is what you would like to do with the fore-shortened life you have left. Is there something that you would really like to do? Or do you want to spend that time with me and my assistants, going through more rounds of chemo.”
Yes, he is telling them that they are going to die. AT Mt. Sinai, there was widespread agreement that this is the only ethical, honorable thing to do. If you don’t want to tell people they are going to die and that there is nothing we can do, you shouldn’t go into oncology. In fact, you probably shouldn’t become a doctor unless you want to do cosmetic dermatology.
I’ll be writing about a palliative care specialist who spoke at the conference and talked about how patients are tortured –with another round of chemo, painful tubes providing nutrition to people who are clearly dying. The doctors who do these things think that medicine is only about saving lives. It isn’t.
It’s about caring for parients who are dying and helping them face that face.
On the question of financial incentives for performance, she also made the point that these incentives pay only for what can be measured. And it’s very, very dangerous to encourage health care providers to focus on what can be measured when what cannot be measured is at the very center of medicine.
There also has been a lot of reserach done on this issue in industry, showing that pay-for-performance undermines creativity and causes people to focus on the P4P list–which means they neglect other things.
Maggie,
I think it would be wonderful if the practice approach of the oncologist you described represents the typical standard of care, but I can’t help but think he/she is in the minority. I hear about too many oncologists who are driven by financial incentives to overtreat. I’ve even heard stories about arrogant oncologists who override or ignore living wills that calls for nothing heroic and continue to treat aggressively. I don’t know whether it’s money, ego or they just can’t let go, but whatever it is, it’s wrong.
I can understand your problems with P4P, but I don’t know how we can impact doctors and hospitals who treat too aggressively or ignore evidence based guidelines unless there are adverse financial consequences at some point. Even if we don’t pay them less for what they do, we should be able to develop information systems and financial incentives (like lower co-pays) that would steer patients to the higher quality, more cost-effective providers. If the high utilizers lose enough business, they will be forced to either change their practice patterns or go out of business.
Barry–
You write: “I’ve even heard stories about arrogant oncologists who override or ignore living wills that calls for nothing heroic and continue to treat aggressively.”
This is true. I don’t know whether it’s money, ego or they just can’t let go (probably some combination) but whatever it is, as you say, it’s terribly wrong.
You also write: “I can understand your problems with what I say about P4P, but I don’t know how we can impact doctors and hospitals who treat too aggressively or ignore evidence based guidelines unless there are adverse financial consequences at some point.”
I think that we need to let outliers know that it appears that they are overtreating. (This is what the Medicare Payment Commission advises.)
And then, after a a few years, outliers (who send their patients for that 3rd and 4th round of chemo–and can provide no evidence as to why their patient are different, or their outcomes are better) just shouldn’t be paid by Mecdicare or any public-sector payer.
Meanwhile, physicians who put their patients first should be paid more. I don’t think that applies to oncologists–from the numbers I have seen they are doing okay,
But the money we squander on oncologists who over-treat their patients should be directed to palliative care specialists (who make sure that dying cancer patients are not in pain, and that their choices are respected) and the family doctors who would send their patients for those tests that really do diagnose treatable cancers.
Barry, as always, I love it when our conversations seem to move each of us closer to agreement. (Rather than just digging our heels in and repeating our favorite arugments over and over)
As I’m writing in my next post on the debate among health care reformers, this is what I think needs to happen.
Refomrers need to clarify their differences, hash them out, offer each other their best evidence and arugments, and, one hopes, move closer together.
This is the only way that we will create a wedge that is strong enough and sharp enough to divide those who oppose health care reform.
[url=http://www.verifiedfile.com][img]http://demya.com/images/google.gif[/img][/url]
[b]Promote Your Website, Product & Services on Targeted Forums & Blogs[/b]
We can post your promotional message on millions of forums worldwide. No, this isn’t spam email. It’s penetrating online established communities relative to your website, product or services. Not only does this increase SEO & Web Traffic, but by targeting forums relative to your