41 thoughts on “The World Turns”

1. Two weeks ago I stumbled onto a Boston University Nursing Archives meeting which featured a joint presentation of Drs. Margaret McClure and Muriel Poulin. They did the ground-breaking work about Magnet Hospitals which was published in 1983. They identified the key features which attract and retain nurses in hospitals. Today the ANCC, a subsidiary of the American Nurses Association, has created a voluntary accreditation program for nurse employer patient care organizations to attain “Magnet” status.
   The demographics in the room were telling: silver hair predominated, and there were no minorities other than a few men in the room. McClure’s work had served as my original inspiration to pursue nursing administration in the quest to find and nurture practice environments for nurses which kept nursing practice autonomy, authority and control in the hands of expert clinical nurses instead of being held by employers and non-nurse power holders (physicians, insurers, external regulators, etc.).
   All this to say that McClure and Poulin’s paradigm of the beneficent employer is also a dinosaur. Nursing is a profession which teeters on the brink of catastrophic failure. It has failed to advocate for patient safety, of which it is primarily charged by ethic and statute. It has failed to come to consensus on a single minimal educational entry credential, in spite of overwhelming research evidence which points out that patient mortality and morbidity rates are significantly reduced when nurses providing the care are educated at a minimum of the baccalaureate level, and that only baccalaureate nursing education provides community health nursing education and patient case management skill development.
   But here’s the light: physicians and nurses share very similar incentives for practice – the satisfaction of providing appropriate patient care based on a healthy therapeutic relationship, and the identification of the need to retain autonomy, authority and control over their respective professions’ practice domains.
   Pat S.’ essay is compelling, because no one willingly gives up a leadership and captain role. But if collaboration could be substituted for patient care management control, I think that the way forward might become clearer and more palatable.
   Imagine, if you will, that physicians, nurses (bacc. educated, natch) and other licensed therapists formed professional practice groups using a medical executive organization type model, selected their own members, elected their own respective professional and administrative leaders, and actively engaged with local academic institutions so that members enjoyed joint appointments, enjoyed access to leading research and education, and enjoyed being recognized for their clinical expertise, they could then position themselves to contract with patient care organizations and third party payers directly to provide services across the continuum of care. Not only from cradle to grave, but from home to hospital, to outpatient therapy to public health agency, to hospice and back to home again. Nurses could work on salary across clinical settings, which has been historically problematic since nurses tend to subvert patient safety advocacy for employer loyalty and obedience. Moreover, nurses are so siloed due to shift work structures, that they often do not have any post-education knowledge about nursing problems and challenges faced by colleagues practicing in different clinical areas, care settings or with different patient populations. A salaried model across settings but with a specified patient population would allow for more depth and breadth of clinical expertise and patient care empowerment and case management to be developed and nurtured, while freeing physicians to provide more direct care instead of administrative case management.
   There are just under 3 million licensed registered nurses with about one third educated at the BSN or higher level. Those nurses form the cadre of professionals who will serve as patient educators, nursing educators, patient case managers, primary care mid levels, clinical experts, and administrative nursing leaders. They cost so little that they don’t register on a single Commonwealth Fund or Kaiser Foundation chart of US healthcare expenditures by major category.
   If you exploit medicine and nursing’s commonalities, common interests, and common practice and patient concerns, there are a variety of ways that physicians, nurses and therapists can team to retain their own expertise and practice domain autonomy while synergistically improving patient care by eliminating both gaps and overlaps in service.
   But first physicians and nurses have to talk, and I don’t have the impression that this is happening on any significant level.

2. Interesting post, Pat. Our current paradigm — independent practitioners paid by fee-for-service — evolved in an era (say, post-Civil War and on into the 20th century) in which medicine had little to offer that was useful. Most times back then it was a frill, something those with the money to pay for were free to buy if they wished. One could even argue that those who purchased medical care were more than occasionally worse off than those who went without it. Some hospitals were proprietary facilities, but many began as charity facilities with voluntary physician staffs who were free to bill patients for services if they could pay, and who often donated their services if patients couldn’t pay. In return for that they got the right to use the hospital for their own patients.
   Now times are different. Now we have treatments that work, although not as many as we think we have (see effectiveness research). Now more and more Americans (the majority, I think) regard some form of basic healthcare as a right.
   So now we have to take the old paradigm of medicine as a proprietary business, which evolved in different times with different attitudes, and apply it to the evolving paradigm of medicine, which is one of promoting a social good. I think Pat’s correct — previous ways of operating aren’t the best for our emerging era.

3. I think the idea of joint appointments of nurses to hospital jobs and nursing schools is excellent, and could do a lot to help deal with the current shortage of nurses working in training programs. I have never encountered that, but Radiology Tech trainers often hold joint appointments of that type, in my experience. Doctors, of course, have held this type of joint appointments in clinical and educational settings for year.
   During my years working for and with large multispecialty groups, a very large number of the people in the upper level administrative positions came from the ranks of nurses, techs, and other non-MD health careers. Most of the committees I served on were staffed at least partly by nurses, and nurses were often the source of useful innovations.
   As I said, some places are already moving toward the models I am talking about. In particular, systems where doctors are “just” employees too, rather than independent entities, often seem to encourage greater participation of other employees in decision making.

4. Pat S.,
   You might be right, but then again….
   Whether physicians will be content to give up a lot of their autonomy is an important question, and the case you make is reasonable. But we’re docs here, not lawyers. We want data, not rhetoric. We haven’t seen it yet. We haven’t seen it in this year’s family medicine match results. And just because something “has to” happen does not mean it will. The future plays its own games.
   The large multi-specialty group model has its problems. I was a Kaiser doc for years and hated it. As a family doc I was over-worked ,underpaid, and disrespected. The specialists ran the show. I’m now much more content in a physician-run single-specialty group. How about the cultural differences between FPs and sub-specialists? Doesn’t anybody realize the obvious–that we want to keep our distance from each other? Maybe I’m a “hold out,” but don’t kid yourself, there are tens of thousands like me.
   Another thing. Will this deal be attractive to med students? Will enough smart young people want to go through a minimum of 11 years of education/training only to then enserf themselves to a system that might well be run by a burned-out surgeon with a night-school executive MBA or, even worse, a business slick with the brains, ethics and dedication of a turnip?
   Well, maybe, but the salaries might have to go up a bit.

5. @PatS.: Thank you for not dismissing the collaborative idea out of hand. If you are interested, by looking at the funded investigators at the National Institute of Nursing Research, you can get a feel for nurses who generally do have joint appointments and their practice venues.
   I’m not sure I conveyed the structure well, though, of large scale multi professional (not just clinical specialty) professional practice groups. It would require that physicians, nurses and therapists all become reimbursed via the same mechanisms, whatever those may be (CMS, third party payers, direct contracting, fee for service, etc.) and that they are NOT employees as in the Kaiser or hospitalist extant models.
   My contention is that by using the combined forces of physicians (about 750K, if I recall), nurses (3 million) and other licensed therapists (several hundred thousand), that practice autonomy across the professions can be better leveraged and retained. A four million member PAC/lobbying group of professional (and already scarce) healthcare providers would make a heck of a larger wave and impact than the eroding and fragmented competing interests of the AMA, the ANA, the APA, PNHP, etc.
   How about ALPHA? American Licensed Professionals in Healthcare Alliance? That might send an interesting message to Washington… *grin*
   @ jrossi: You raise valid points. In order for those whose practice is more of a generalist nature, there is an imperative to design practice and reimbursement structures which provide for parity in professional autonomy, reimbursement and control.

6. Annie —
   As of now, most large health care systems, HMO’s, and clinics pay salaries to all their employees, including doctors, often with a productivity or “organizational success” bonus. Most systems except HMO’s bill on a fee for service basis, but then use the income to pay employees and other expenses,as well as providing for reserves.
   Part of the point of this type of system is some redistribution of the wealth, with PCP’s, including NP’s, being paid more than they would earn in independent practice and higher paid specialties being paid a little less.
   What you seem to be thinking of is practices that bill fee for service for nursing as well as MD services, with all the professionals part of the same corporation. That might be an attractive idea, but in this climate I doubt if third party payers, including Medicare, would pay for that unless costs actually decreased. That would involve nurses giving up money to get autonomy, something I am uncertain most nurses would be interested in. Right now, push come to shove the nurses unions, like teacher unions, seem to be mostly willing to sacrifice most other things for money.

7. Pat,
   I hope we won’t have to wait a generation for the older doctors wedded to the old ways to die off while a new generation trained in the new paradigm takes their place.
   One area that you didn’t address in your post is patient attitudes and expectations. In this age of the Internet and social media, it seems that, over time, patients may become even more demanding as an older generation of more passive patients gives way to a new generation that wants to talk about the research they did on their conditions or what they learned in chat rooms and other social media. Some doctors have told me in the past that engaged patients are probably more expensive for the healthcare system than passive patients who go along with whatever the doctor tells them or recommends. Even if we eliminated DTC advertising by drug and device manufacturers, we can’t eliminate the Internet and social media. I would be interested in your take on this.
   With regard to the need for a different paradigm in the way healthcare delivery is organized and practice, I can think of at least five different categories of care that probably call for different approaches one from another. The five categories are as follows:
   1. Well care. In automotive terms, this is the oil change and the maintenance checkup at appropriate intervals – physical exams, routine screenings, etc.
   2. Management of chronic disease. This includes patients with diabetes, hypertension, asthma, heart disease, COPD, etc. The medical home, a large multi-specialty group practice, and a robust electronic medical record system are all important here.
   3. Determining a diagnosis. When a patient presents with symptoms or complaints, the doctor needs to pinpoint the problem. Tests will need to be run, along with taking a history. This is the category where defensive medicine can strongly influence practice patterns while patient expectations and demands could also drive excessive testing to rule out conditions that the patient is unlikely to have.
   4. Treatment after determining the diagnosis. This can range from the proverbial “take two aspirins and call me in the morning” to writing one or more prescriptions to surgery or cancer treatment. For the serious conditions requiring surgery or cancer treatment, Centers of Excellence would likely be appropriate along with shared decision making.
   5. End of life care. Hopefully, palliative care specialists will play a strong and universal role here to at least explain the options available to the patient and the quality of life implications of each. More widespread use of living wills and advance directives with the information stored on a registry easily accessible to doctors and hospitals on an as needed basis would also be helpful.
   Financing and payment incentives are a whole separate discussion.

8. JRossi —
   Here in the Midwest, despite all the things you mention, there is a steady trend toward doctors joining large systems. In my home town, the last independent primary care group standing became part of a large system in 2008. Market forces are driving them into the groups, since most of them are discovering that they can’t operate nearly as well or as profitably as free standing groups. The large systems see PCP’s as the goose that lays the golden egg – the PCP’s have the patients that the systems need. HMO’s are obviously a different story, since they get their patients from the contracts they make with employers and groups, without any contribution from any doctors to bringing in patients, and the reputation of specialist services probably has more to do with buyers choosing their HMO over other options than the reputation of their PCP’s.
   Also, in the Midwest, there are probably more CEO’s and board members of large systems who are former PCP’s than there are specialists. The desire of doctors to “keep our distance from each other” is as strong among specialists as PCP’s, and that includes specialists keeping their distance from other specialties. In fact, in the organizations I have worked in, surgeons fighting with other surgeons is more common than surgeons fighting with PCP’s – they tend to compete more directly for money, facilities, and power. Plus the idea of leaving medical practice for administration is probably more attractive to PCP people than to many specialists because of financial considerations.
   I agree with you that dollars will be a major driving force in how things work out. I also agree that PMP’s need more dollars in order to recruit enough doctors to the fields. It is sort of a bad joke that PCP’s can make more money in the British NHS than here. Someone is going to have to exert some leadership to see that that problem is addressed, leadership that is not “burnt out surgeons.” I think that the only reasonable choice for early leadership is the federal government, through their muscle as the largest payer. Obama is making noises suggesting that he is inclined to do that.
   BTW — I have several friends who work for Kaiser, albeit in the Bay Area and Portland, not LA. They all say that Kaiser was a mess in the late 90’s and early in this decade, and all of them thought about leaving. However, all of them are much more satisfied now under the new leadership. In addition to everything else that has happened, salaries are much more competitive now.

9. Barry –
   The list of tasks for medicine is pretty correct. The difference between the US and most other systems is that here the tasks are divided up among many different specialties, while in most other systems the primary care provider has primary responsibility for all of them – and sometimes nearly sole responsibility for most of them.
   The problem with patients expectations is not being better informed, it is being misinformed. Drug advertising aimed at patients is one big source of that. Popular media eager to get the latest story – often very prematurely – is another. Research careerists interested in enhancing their own reputations, even if it means premature release of information, are a third. Equipment manufacturers and some doctors eager to promote special services for profit are another.
   Well informed patients are great, even if they might disagree with what doctors want to do. It is their right to decide what they want from their care, based on correct information. The recent discussion we had on this blog about screening mammography is an example.
   One of the primary responsibilities of any National Health Care Effectiveness Board will be to publicize the results of their studies to the public, to help patients understand appropriate choices. PCP’s will be the other big source, and health care systems need to be willing to pay PCP’s for the time it takes to educate patients about their choices, including correcting misimpressions due to the sources I listed above. Right now most payment systems in the US won’t do that. Every patient needs a PCP, and every PCP needs to be paid appropriately for their time, including for time spent educating the patient. Good PCP care, including patient education, is the primary tool for saving money on health care.

10. Pat, I too have several primary care friends who work at Kaiser in the Bay Area, Napa-Vallejo-Fairfield-Vacaville sub-region to be exact. Two have become hospitalists because their outpatient primary care practice was similar to the last circle of hell. The others mainly discuss the Kaiser Healthconnect nightmare and how long they have till retirement (Kaiser does have good benefits.) These people are in their late forties and they’re already leaning for the retirement tape.
    Of course docs new to Kaiser like it because their previous practices were even worse. At least they’re getting paid. Do you consider this a ringing endorsement for a primary care practice at large multi-specialty groups? Maybe so, but the medical students that I precept do not.
    Please don’t try to tell me that the Midwest is a medical Shangri-La. My wife is a Wisconsinite–we know all about Aurora Health Care and the sucky groups in Madison. We also worked for a while at St. Luke’s in Duluth. When we quit my “supervisor” was a twenty-something woman with a BA in Health Administration from the College of St. Scholastica. We left there 6 years ago and they haven’t yet replaced us. In fact they’ve lost more docs since then.
    Just say no to big medical groups. Stay small, stay independent, stay free. Freedom or Retirement!
    Of course if other guys want to join big groups that’s their funeral.

11. JRossi —
    Not saying the Midwest is Shangri-La, just saying that independent groups of PCP’s are joining up with health care systems in large numbers.
    For example, in the time since you left St. Luke’s, they have had at least four different primary care groups decide to leave independent practice and become salaried doctors as part of the St. Luke’s system. Since I assume you worked for one of their own free standing clinics, those may be neglected and have suffered in comparison. Elsewhere, Rice Lake Clinic and a couple of the clinics in Eau Claire merged with Marshfield. Ashland Clinic joined SMDC. Most of the groups in Mankato have joined the Mayo Clinic. The hospitals in Des Moines are rolling up the independent groups in their area rapidly in an accelerating competition to see who gets to be the biggest system there. Most of the independent groups in Northwestern Minnesota are now part of either MeritCare or the Dakota Clinic, which itself is now merged with SMDC. Most of the groups in Brainerd have joined a system created by the hospital there, which is in turn part of the SMDC affiliated groups. Allina is in the process of rolling up the private groups in the St. Cloud area. Hibbing has no independent groups left. Ely and International Falls clinics are part of SMDC. Etc., etc., etc.
    Don’t know the exact circumstances that led the independent groups to do that, but they are doing it. Money is a big part of it. So is the ability to negotiate with private insurance payers – which is just another way of saying money. In some cases, ironically, health insurance costs are a factor, since like many small businesses, having a couple of employees of a smaller practice or their dependents develop significant health problems drives premiums sky high. Big systems are pretty good at showing small groups both a carrot and a stick, but out here independent primary care groups are rapidly becoming rare, and specialty groups are starting to be picked up too. Every time I talk with someone I know in medicine in this area it seems like more groups are leaving independent practice and joining large systems.
    I don’t know much about southern Wisconsin and the Madison area, since that is outside the network of my contacts.
    As far as Kaiser, most of the people I know are my age and therefore much closer to retirement, so it may be easier for them to see the bright side; but they are uniformly more positive than a few years back, when they all sounded like you. I don’t doubt that that nice guaranteed benefit retirement plan is a factor, since a lot of people have seen their 401K’s become 201K’s in the last year or so, making a decision to stick it out at Kaiser seem a lot smarter than it might have in the past. Younger doctors may feel differently.

12. Pat S, Thanks for the NE Minnesota update. You hit the nail on the head. We did suffer as the administration sucked up new groups. Of course this is the key problem with doctors debasing themselves to businessmen. The money people sweet-talk you until you sign up, then you find yourself dancing to their tune. I have known a few smart docs to sign up and then bolt to a new situation as soon as allowed, leaving the business types holding the bag as the practice fails for lack of a serf. Warms my heart just to think about it. As you might have sensed, I have some issues with being told what to do by people who have less education and responsibility than I have. And please do not approach me wearing a suit or a tie if you know what’s good for you. Do not use “dialogue” as a verb. But I digress…. Young docs coming up might not have these same issues. We shall see. All I’m really saying is that there is significant possibility that physician enserfment is not a sustainable practice pattern in the long term.
    A better way forward is to pay primary care docs enough so that small single-specialty groups are viable. And forget about the medical home crap. You’re a doc. You know there is only so much we can do to keep people healthy. Moreover, you know full well that the real money is spent on the old sickies who are at death’s door. And you remember the utter failure of capitation in the last decade. The medical home concept is a desperate marketing ploy by PCPs who have been pushed to the wall. Of course it will fail, but before it does it will get them a few years down the line and maybe something else will have turned up by then….

13. JRossi —
    I am more optimistic about “medical homes” if they are done correctly. I know that it is just a buzzword, and we all have seen a lot of buzzwords, but if it means that PCP’s establish a relationship with patients with chronic conditions and spend time TALKING (that currently non-reimbursed activity) with the patients, I think we could do a lot of good for the “big six” conditions that account for a huge amount of costs in the US (congestive failure, coronary artery disease, asthma, chronic lung disease, diabetes, and depression.) Throw in end of life planning and we would have a huge treasure trove of extra money saved by the system.
    SMDC, as you may know from living in Duluth, recently published the results of their high intensity out patient model for congestive failure management. To get in the study, you had to have had at least 3 admissions for CHF in the previous year. They reduced admissions by 80%, ER visits by 75%, improved exercise tolerance by impressive figures, all without spending much of anything except time for 4 NP’s. The SMDC people are tickled about this result and are expanding the program not because they are getting more funding but because the system saved more money in under-reimbursed care related to over-extended hospitalizations and “bounced” patients than the program cost .
    I know that Maggie is bugged by this, but I think the better model for increasing pay for PCP’s is the British one, which is to set targets and to reward attaining those targets. This rewards time spent talking to the patient, not procedures, and, as the SMDC study shows, it works. Brits get better results for diabetes, kidney failure, asthma, and several other conditions by having the PCP get involved with the patient, using frequent contact — one article I saw quoted one GP saying he sees some patients as often as once a week, but was willing to do that since he could increase his income by 50% if he hit the targets.
    If we could pay PCP’s for keeping people out of the hospital and saving money, we would be doing health maintenance for real, not just as a marketing slogan, and saving the system a ton. It seems fair that PCP’s share that money.
    My own father is a congestive failure patient, under management by a “concierge” program at a nationally known medical system in Southern California. They are managing him in the traditional way — sending him home with some instructions and some meds but not seeing him or having any contact unless he decompensates. As a result, he has had four admissions in the last nine months, all related to failure on his part to pay attention to his weight and his salt intake. They admit him, shine him up, send him home, and 2 to 3 months later he is in trouble again. I know that more careful monitoring would probably not extend his life significantly, but it would do two things: make the quality of his life better and make him a lot cheaper to manage. Both those things are worthy goals, but the cardiologists who wear Armani suits when they come in at night don’t seem to think that keeping contact with him or paying nurses to keep in contact with him on a regular basis are worth their time, since the payers don’t pay for it. The payers do pay for the admissions.

14. BTW — the bizspeak buzzword I hate, even worse than “dialogue” as a verb, is “grow” as a synonym for “increase,” as in “we want to grow our profits.” Another one is “partner” as a verb, when they really mean join, cooperate, or merge.

15. Pat,
    I’m with you 100% on copying the UK system of paying PCP’s bonuses for meeting performance metrics, along with giving doctors the ability to exclude a small percentage of patients based on established criteria and circumstances from the panel to be evaluated. The UK demonstrated that it can be done and there is no reason why we can’t do it too, at least once we have decent electronic record systems in place. It’s not just the health of the patient panel that counts but how much resource utilization it took to achieve the result. Some doctors are likely to be more cost-effective than others and should be rewarded accordingly.
    Under our current payment system, however, I see a couple of problems with doctors and hospitals consolidating into large multi-specialty groups. First, as you already indicated, consolidation affords more market power to negotiate higher payments per procedure from insurers. Second, while the PCP may be the golden goose that has the patients that feed the rest of the system, I think PCP’s are likely to find themselves pressured to feed the mother ship with referrals. Their bonus compensation is likely to be a function of their “productivity” in doing this while failure to drive sufficient revenue could bring “money loser” status which will likely be reflected in a low bonus, none at all or even dismissal.
    Payers may be willing to pay more per procedure if, at the end of the day, the multi-specialty group can drive down overall utilization vs. care by doctors practicing solo or in small groups. I think this is likely to require moving from the fee for service payment model to episode pricing for expensive surgical procedures and back to capitation for primary care and the medical management of patients with chronic diseases. The key challenge with capitation is the difficulty in estimating costs for the upcoming year. That’s a significant issue unless the patient population is huge. We will need the electronic records as I noted above and probably improved individual patient risk scoring as well.

16. Pat, An intensive outpt program for CHF is brilliant, absolutely brilliant. Who wins? First and foremost, the patient. CHF is terrible, and I feel for your dad. The doctors also win. We get no pleasure from seeing our pts short of breath and edematous. The cardiologists get no pleasure from it either. Sure, the hospital might lose some money from fewer admission, but who really gives a damn about them anyway? They exist to serve our patients. Plus, most of them have home nursing outfits that would run point on an outpt CHF setup.
    Here’s what you do-easy as pie: Medicare pays an adequate reimbursement to independent docs and to home nurses to intensively manage CHF as an outpt condition. Ditto with the other conditions.

17. I didn’t mean to suggest that the cardiologists were behaving badly or were uncaring. I don’t even think that they are trying to maximize their income by doing what they are doing. They follow the standard wisdom as to how management should work. This is a typical example of the US model for medical care, based on the idea of waiting until a crisis occurs, then intervening with aggressive, high tech management.
    That is great if someone drops a piano on your head, or if you go into respiratory failure because of swine flu. (Ignoring for the time being the failure of US health care to adopt simple basic quality management that avoids the high number of problems related to errors and system failures.)
    However, since the biggest medical problems in modern America are all chronic, incurable conditions, that model fails. Management of the scourges of 21st century health — congestive failure, coronary artery disease, diabetes, asthma, chronic lung disease, and depresson — does not require the bright and shiny stuff we have so much of. The solutions involve drugs that are often cheap and generic, close monitoring of the patient by himself and by providers using low tech means, and establishing a relationship of trust with the patient to encourage them to do what they need to do and avoid patterns that get them in trouble.
    The problem here is that most payers will not pay for this. They discourage the type of thing that works — frequent visits and phone calls, long appointments with a lot of discussion, sometimes giving patients things like accurate scales that they need to keep track of themselves.
    That is where foreign systems gain an advantage over us. They are willing to pay for a lot more low tech stuff to avoid having to pay for more high tech stuff.
    It is ironic that a patient can get better management for the most common cause of hospital admission and re-admission in a small city in a remote and apparently backward and unsophisticated area than in the biggest, most sophisticated, and most expensive health care systems in this country, but there it is. Sometimes bigger and more shiny is not better.
    The really ironic thing is that with this stuff we could do well by doing good. We could save billions of dollars by re-designing our management patterns in this way. If you do the math on the Duluth study, they saved at least $36 million a year in hospital costs for their 1000 patients while spending about $300,000 to pay for the NP’s who did all the work, and a few thousand for the telemetric scales they used. In just Duluth! I wish someone could show me an investment with that kind of yield.

18. Annie, J. Rossi, Pat S.,Chris, Pat S.
    An interesting thread; I thought I’d weigh in on a few comments
    Annie- Everything you say about a collaborative model makes sense, And you’re right, first physicians and nurses need to talk . . . Perhaps we need to create conferences that are designed to make that happen . . .
    But one question, I’m not sure why you don’t want nurses and doctors to be employees in your collaborative model. As someone (I think Pat?) suggests if they all are employees, this puts doctors and nurses on a more equal footing.
    And we do know that some top-down management works to get doctors to collaborate with each other (let alone with other healthcare workers).
    I’m thinking of the VA,
    Geisinger etc.
    I know some very independent doctors don’t like this, but the fact is we do need them to all use the same checklists, etc.
    J. Rossi– I agree that up until now, subspecialists and FPs have had separate cultures and kept to their separate silos. Often they looked down upon each other.
    But if we want to do what is best for patients, that needs to change. In the past, patients had one main doctor–The Doctor– who they relied up for most of their care. If they were hopsitalized The Doctor came to the hospital and oversaw what was happening there.
    These days patients typically see 4 or 5 doctors, and if those doctors are not communicating wtih each other–and collaborating with each other–patients are injured.
    Keeping your distance from each other really isn’t an option any more.
    But I agree with you that the CHF management that Pat outlines is “brilliant.” As you suggest: “Medicare pays an adequate reimbursement to independent docs and to home nurses to intensively manage CHF as an outpt condition.”
    This is what I mean in my comment to Pat below about simply paying for time without trying to measure performance or outcomes.
    Pat S.
    Why can’t primary care physicains simply be paid (and paid decently) for the time they spend talking to patients by phone, e-mail or in person, seeing the CHF patent once a week, etc.–without trying to measure “meeting targets” to decide payment?
    As IHI’s Don Berwick and others have suggeted, when you begin offering individuals financial incentives for performance you can a) undermine profressionalism and b) encourage people to “game”the system and c) dstract them from other things they should be dong for the patient (see below on hospitalizing the frightened, distressed patients rather than sending him home to a frigtened, elderly caregiver.)
    What do I mean by gaming? A doctor who is paid for meeting targets might well spend more time with compliant patients, knowing that outcomes will be good. Meanwhile, he “cuts his losses” by by spending less time with more “difficult” (usually code for “poor”)
    patients, knowing that even if he sees them once a week chances are the outcome won’t be that good beause these patients have so many medical problems, cannot always afford their meds; are depressed, live chaotic lives, etc. etc.
    In other words, doctors begin “cherry-picking” patients rather than giving equal time to and trying equally hard with all pateints. (You never know which ones will surprise you and begin taking better care of themselves if given more encouragement and attention. I think J. Rossi’s idea of visits by home nurses is a very good one.
    Granted, if we pay only for time–without worrying about outcomes– some doctors will spend more time with patients and not achieve the targets that we would like them to hit. Sometimes this won’t be the docto’s fault. Sometimes it will be. .
    The fact is that some doctor are better doctors than others. The majority are “average.”
    We might want to measure outcomes, to try to LEARN how the better doctors achieve those outcomes, and disseminate this information to all doctors, in hopes of moving the entire bell curve to the right.
    Those who want to become better physicias will pay attention. Those who don’t .. . well someone made a mistake when they were admitted to med school. Bribing them isn’t going to make them better docs–they are the ones who wlll game the system.
    Berwick belives that financial incentives for large groups works (i.e. bundling bonsues to a hopsital and all of the doctors invovled in care), but that you’re entering dangerous ground when you begin rewarding (“bribing”) individual professionals to do the right thing. (There are case studies in business showing that these financial carrots
    undermine professionalism–I talk about this in the book))
    In any case, the basic problem today is that PCPs
    and nures are not paid for the time they spend talking to and listening to patients–thus 15 minute appointements. Why not address that directly?
    Rather than setting up a complicated system that tries to a) measure outcomes, b)risk-adjust for different patient populations, and c) discourage “gaming”–let’s just pay them for the time, and assume that most doctors will be doing their best to use it well.
    One final thought,in the medical home model where docs are rewarded for hitting tragets, often good performance means keeping the patient out of the hospital–whatever it takes. It strikes me that
    sometimes that may mean perusading a frightened patient to go home where he or she will be cared for by a firghtened, elderly spouse, when in fact he or she would be better off in a hospital—psychologically more comfortable,and less likely to have a panic attack followed by trouble breathing, etc.
    But then the doctor wouldn’t get his reward. . . Money always has a tendency to create perverse incentives.
    Chris– I agree that the current system was designed for the independent fee-for service practitioner who I call “The Doctor.” Typically, a patient had one doctor who was supposed to know everything (because there wasn’t that much to know.)
    Now, we need a very different system. There is so much more to know, adn this is why medicine must be a team sport.
    Pat–
    Yes, Kaiser did go through a very rough patch as it tried to learn how to compete with increasingly competitive for-profit insurers . Mistakes were made–including setting up an electronic medical record system that they had to ditch.
    But by the time I was writing the book (2003-2006) things had turned around. Doctors working in the Kaiser system seemed pretty happy; turnover was low and they had a waiting list of doctors wanting to work in the system.
    Employers in Northern California told me that if
    they didn’t offer Kaiser, people wouldn’t work for them.
    And I agree that government needs to lead–it has the clout. Luckily at this point we have a government in Washington that understands the problems in our healthcare system and is inclined to put “the public good” first.

19. Pat, You’re preaching to the choir. Disease management systems are an excellent idea. Pay us fairly to implement them, and they will be implemented. My overriding point, however, is that reducing physicians to employee status might not be a wise long-term strategy for the HC system because it might result in profound and chronic physician dissatisfaction and shortages. That has been the thrust of most of my posts on this blog.
    Some posters here are enamored of the idea that if we could just get all the docs and others under one giant tent and have them all pull together, HC would be so much better. And indeed that setup works for some docs. It doesn’t work for me and thousand of others. And of course the big tent idea should recognized for what it is: a leap of faith. It boggles my mind that some who know so little about HC can be so confident about this idea. My view is different. Personal experience tells me that although some docs are willing to put up with living in the big tent, many are not. My talks with freshman medical students tell me they have very little interest in this kind of practice.
    The simple fact is the many of us docs do not trust big employers. They will sweet-talk us, might even pay us big bucks for our practices, but what about 5 or 10 years down the road? I have seen relentless de-professionalization and dis-empowerment in my profession. I have seen it at Kaiser in Northern CA and at St. Luke’s, at SMDC (my neighbor worked in pediatrics there) at Aurora Health Care in Madison (wife’s friend), at Group Health in Madison and in Washington State. I see big-tent primary care docs desperate to get out, hating their jobs. Sure they feel better for a few years after selling out, but then the degradation of enserfment occurs relentlessly.
    On the other hand, I am the co-boss in my practice. It is not perfect, but I kinda like my job and have no intention to retire.

20. just following along on this thread, but have a comment for Maggie.
    I agree with you completely about measurements used to rank “quality” doctors and the cherry picking that would certainly result. Good luck getting someone to work in an underserved area (usually rural or urban) where the patients have a harder time caring for their disease, for all the reasons you cite.
    I’m not sure, however, that moving the incentives to large groups makes a difference. If the large group is going to get more money from payers if certain quality benchmarks are made, the large group will simply incentivize it’s individual physicians to achieve those benchmarks. So your concerns are all in play, they just went through a middle man. Whether it’s the insurer or the large medical group ranking individual physicians or clinics doesn’t really matter.
    This is exactly what my local groups have done, jumping on the quality/P4P bandwagon, and it’s resulted in the incentives you fear, namely docs that work in the “tougher” clinics are wondering if it’s worth it. It’s no fun being told you’re delivering less quality for your patients, and suffering financially compared to your peers. Better to go find the worried well and improve your outcomes.

21. Maggie and JRossi —
    You are arriving at the same point from two sides of the issue.
    There are potential flaws in any system. There are successful elements in any system. People inclined to game a system can game almost any system.
    Some doctors on salary don’t work very hard. Some doctors on fee for service run patients through their practice like an assembly line. Some doctors try to get patients who can max out their income, turn down low pay/slow pay patients, and do more procedures than are warrented. The Brits got worried about doctors gaming their incentive system, and changed the rules to try to stop that.
    But all systems have their successes too. Part of the reason is that despite all the criticism most doctors want to do a good job.
    Right now, in the US the systems that show the best performance statistics are all large integrated systems, from Mayo to Kaiser. But, interestingly enough, in many geographic areas doctors in smaller private practices can and do match the results of the big systems. Part of that, I think, is that the big systems are sometimes where a lot of the doctors were trained, and part of it is that the standards used by the big systems “leak” into the areas around them. The Dartmouth data is most convincing when it shows systems that run against the grain in their areas in terms of effecive care — Mayo Scottsdale, Geisinger, InterMountain — which are more impressive in some ways than Mayo Rochester or Kaiser Oregon, where the whole state shows a pattern of effective care.
    The same is true in foreign models. Britain obviously has only doctors who are on salary, albeit with the performance bonuses already discussed. In France, the system is mixed, with hospital doctors and community doctors seperated fairly rigidly and with hospital doctors on salary and community doctors mostly on fee for service. Japan is all fee for service, Taiwan partly, Germany part and part, etc.
    However, in the US we are talking about not just how we pay doctors, but how we can get doctors to change the way they work, sometimes in fairly large ways. A friend of mine who is an historian has a statement she likes to repeat: “There are a lot of ways to get people to change their behavior and to do something you want, and almost all of them have been tried over time. The most humane, however, is using money.”
    That’s what I am suggesting — give doctors money in ways that are linked to what we want them to do. Withhold money in ways linked to things we don’t want them to do. In order to avoid the type of cherry picking that Maggie is concerned about, adjust the rewards to fit the risk — paying more for patients who are likely to be harder. Insurance companies do that right now, and Ezekial Emmanuel planned to do it for the system he proposed. I am pretty sure that there are fairly gross indeces to be able to do that, since the concept of cherry picking itself assumes that it is easy to seperate the high and low risk patients.
    The biggest advantage that large systems have is their ability to adopt system wide standards of care. However, given the right incentives, I am fairly sure other doctors could adopt too. We just need somebody making the decisions and taking steps to make things happen. That is why I am so in favor of creating government structures to do that.

22. Maggie, By keeping distance I mean not working for the same employer. Of course communication is important. The trick is how to facilitate it within the limitations of HC in this country. I have argued that physician resistance to enserfment is a crucial, and, at least at this blog, under-appreciated limitation. Others of course disagree, and time will tell who is right. But with all due respect, I think your “not an option” comment indicates overconfidence in the ability of the political class to get what it wants on this issue. No one knows how this is going to shake out. Have you read Taleb’s book on Black Swans? It might have some lessons about the future of HC.

23. Pat, You and I mostly agree. I have no problem with trying to change financial incentives to improve care. I have no problems with a national set of practice guidelines for the seven conditions. It is way past time for this. I have no problem with a fair and reasonable single-payer system. Hell, I’m pretty sure it would increase my income. But I’ll be damned if I’ll ever work for medcorp again.
    Physician autonomy is an absolutely huge issue to us. Not having a boss is one of the main attractions of medicine. I know Maggie doesn’t get this, but as a doc, you must. It would be tragic to see improvements in our HC system trip over this obvious stumbling block.

24. I agree that it would be wrong to try to force doctors to join large systems as part of reform. That is a fight we don’t need. As I said earlier, doctors joining large systems seems to be a trend where I am, for a lot of reasons. I am suspicious it may be a trend elsewhere soon, because it allows diversion of money to PCP’s and to inpatient care from the incomes of the highly paid specialties, and protects hospitals and systems from predation by private doctors installing equipment in their own offices, and patients and payers from the costs and risks of self-referral by doctors for questionable tests and procedures. But I don’t think that large groups are a precondition for successful reform, if there is acceptance of the type of practice standards and of payment changes we need, and if the federal government is able to take leadership in that and the private insurers follow.
    I will say one thing: I have worked about half my career as an employee in large systems and half as a partner in smaller independent single specialty groups. While I certainly saw some unpleasant things in the large systems, as well as some poor planning and mistakes, the absolute worst experience I had was at the hands of a hospital CEO when I was a member of a small private group. This woman, who got her position through nepotism because she was the daughter of the most powerful politician in the county, issued dictatorial edicts time after time, ordering doctors to do various things or face loss of hospital privileges. Her worst mistake was to try to force all the doctors in town to join an open panel HMO — this was the late 80’s and that was the flavor of the month in health management at the time. She and the doctors were saved from potential disaster because the HMO went bankrupt, fortunately while we were in the process of negotiation instead of after we joined.
    I do think that consolidation of physicians into large systems will probably happen because of market forces, but don’t think it should be a quid pro quo for reform. The changes we need have to do with changes in practice standards and payment patterns, and have to do with the relationship between providers and payers. With enough power, the federal government can make those changes working with individual doctors, groups, or large systems, and private insurers will follow along because the financial forces will require it.

25. Pat S., J Rossi and pcb
    Pat S.– I cannot agree with the person who told you that “the most humane way to change human behavior is to use money.”
    Money has been used to turn many of our Congressmen (and women) into people who represent corporations, not citizens.
    Money has been traditionally been used to turn women into passive, obedient creatures. (And I’m not talking about prostitutes. I’m talking about wives married to someone who earns far more than they could ever earn, and treasure the lifestyle. They learn never to disagree. Then they self-medicate.)
    When charm and caring is used to influence a woman’s behavior (and she uses the same talents to influence her husband’s behavior) you have a happy couple.
    Money has been used to encourage children to get good grades. They never learn to love learning for its own sake–just for the reward,whether it’s $10 for every “A” or a letter of recommendation for med school. (I saw this countless times in students when I was teaching at Yale)
    When I was raising my own kids, I never paid them for good grades. I tried to teach them not to focus on grades– “Just find subjects and courses that interest you, immerse yourself in them, and the grades will come.”
    I also told them “If you don’t get good grades I won’t be upset”
    And I didn’t–which helped enormously in shifting their focus off grades and onto the subject at hand. Ultimately, they went to great universities.
    I also told them: “Never work for the rewards–in the long run it doesn’t work out. You’ll wind up in a career you hate. Loving your work will give you a much happier life.”
    They are both now immersed in careers that they truly enjoy– though in both cases, what they are doing is hard work. And they are not earning huge salaries. But, to them,their jobs don’t seem like “work.” It’s what they want to do when they wake up in the morning.
    Pat, I totally agree that most doctors want to do the right thing.
    Introducing financial rewars into the equation can, however, corrupt many (not all, but many) people. If there is enough money at stake, many people will “game” the system. (Wall Street was much more honest in the 1950s, when there was far less money on the table.)
    And when offered these financial carrots, many people will focus on “what can be counted” rather than on the many things that matter more–and can’t be counted. (I’m paraphrsing someone–I think it’s Einstein.)
    This is one reason why Dr. Don Berwick, head of the Institue for Healthcare Improvement writes:
    “Our measurements will mislead us if we forget the stories” (the “narrative” of the whole patient and the many immeasureable aspects of care that he did or didnt’ get.)
    Berwick continues: “Just as measurement can pluck the heart from a story,
    accountability can pluck the soul from our intentions.” This next sentence I find most persuasive: “The leader of a hospital] who thinks it is enough to create report cards and contingent awards, misses the biggest and hardest opportunity of leadership itself– to help people discover and celebrate the meaning in their work.”
    He adds: “We’ve got to support the culture and the underlying system that makes healing, not scoring, the objective.”
    Finally, he explains why he objects to giving financial incentives to individual doctors and nurses:
    “I would draw a very dark line between the incentives that apply to organizations, boards, executives and the bottom line of a company, where I do want incentives in place. I want it to be good for an organization i.e. hospital] to be safe, and I want it to be good for an organization to manage chronic disease carefully . . .”
    But at the individual level, Berwick insists, “I don’t trust incentives at all. . .I think that it feels good to be a good doctor and better to be a better doctor. When we begin attaching financial incentives to throughputs and to individual pay, we are playing with fire. The first and most important effect may be to disassociate people from their work.”
    Pat- thanks for bringing up this subject, I should write a post about it.
    And if you haven’t read Berwick’s collection of essays, Escape Fire, I think that you (and many people who read this blog) would appreciate it. A very fine book.
    JRossi–
    Nassim Taleb is a friend. (I wrote one of the first reviews of his book –which I really enjoyed. He used it as a blurb on the back cover. So yes, I know about black swans.
    Undoubtedly health care reform will have unintended consequences. This is one reason why I think it will be a work in progress for many years.
    Some things will work; some things won’t, and then we’ll have to try something else.
    Ultimately health care reform will never be finished.
    But the notion that medicine is a team sport and requires collaboration has been apparent for quite a while. The body of medical knowledge is so vast that no one can know everything, even in his or her own specialty.
    We know patients suffer when docs don’t communicate well with each other– and with nurses.
    And we know, from multi-specialty centers like Mayo,the VA Geisinger, etc. that when doctors all work for one employer in the same place, and are all looking at the same medical record-seeing each other’s notes on that record–communication is much, much easier.
    As a patient, I’ve seen solo-practioners playing phone tag with other doctors, faxing records that somehow never get there, etc. . .
    And doctors certainly need to view nurses, physical therapists,etc. as peers–fellow professionals,with their eye on one ball: the patient.
    Comments like “Pat — I know Maggie doesn’t get this, but as a doc, you must,” is exactly the kind of comment which suggests that doctors belong to a special fraternity that nurses,patients, physical therapists, whoever . . . cannot possibly understand.
    It’s condescending and creates silos in medicine–and on blogs.
    I might just as well say,
    “Pat I know that you understand–and J.Rossi will never “get it”– because and you I share very similar politics.”
    Or “Annie– I know that you undersnd–and J.Rossie will never ‘get it’–becuase we’re women. The boys just never understand these things.”
    Such remarks are exclusionary and divisive.
    pcb–
    I agree that pay-for-performance incentives for indviduals can cause doctors to avoid difficult (often poor) patients.
    But when I talk about a large group, I’m talking about a very large group–a large hopsital and the hundreds and the hundreds of doctors who treat patients both in the hospital and in the three months before they are admitted and in the three months after they leave the hospital.
    In that situation, there’s no need to avoid difficult patients, their effet on outcomes is diluted by the sheer size of the group.
    An when payment for good outcomes is “bundled” for this large group (everyone involved in treating the patient before, during and after hospitalization, this creates a much better spirit of co-operation between doctors and hospitals–and spirit that, all too often, as lacking.
    The hospital has a reason to want to make sure that the patient has an appointment with a doctor for follow-up, and that the doctor has all of the information he needs about the patient’s condiiton, meds, etc

26. Maggie —
    My historian friend’s point was to contrast use of money with use of other types of coercive manipulation. She was thinking of torture, other punishments, exile, execution, imprisonment and the whole list of other things people do to other people to try to make them do what they want.
    I agree with you about all the negative things you say about money. I also never used money as a reward with my kids. But it does work as a way of manipulating behavior.
    It would be nice if everyone would do what they should without any reward or punishment, but as the Marxists found, it just ain’t happening.
    My favorite study about using money to manipulate people was done back in the 60’s by a couple of researchers in reading. They took a group of 10 5th grade boys who were all functioning at least 3 grade levels lower in reading. They started by giving them a nickel every time they did something right, then dropped back to intermittant rewards of nickels, sometimes for every three good things, sometimes every ten, sometimes every 6, and so on.
    At the end of 5 months all the boys were reading at least at a 7th grade level, 2 levels ahead of themselves. The total cost for all ten boys put together: about $65. A fraction of the cost of putting them in summer school, which is where they were all heading.
    Money talks. You know the rest of the saying.

27. Maggie, I am glad you’re familiar with the concept of unintended consequences. My whole point really….
    Berwick’s quote is a mind-blower. If he doesn’t believe in financial incentives, then he is deluded. Appropriate financial incentives are, quite simply, the most important way to influence behavior in HC. Sorry I offended you, but you and I are in different silos and are likely to remain there –unless you can be convinced of your errors.
    Pat, If you’re paid appropriately for your services, you can negotiate with the local hospital from a position of strength or at least equality. This is where we should be heading, not towards enserfment, demoralization, and de-professionalization. We need re-professionalism.

28. I think there is a fundamental disagreement between Maggie and some of her readers, including myself, about the role of money and profits in healthcare. I think the disagreement is largely philosophical at its core.
    I think, as Pat suggests, using money is probably the best way to induce behavior that we want while recognizing that any system can be gamed. The UK approach to rewarding primary care doctors can teach us a lot. Any such system should be transparent with the metrics and overall ratings available to patients. The UK approach offers an opportunity for doctors to exclude some patients under certain circumstances from the panel to be evaluated which should address the problem of a few non-compliant patients skewing the results. As for treating low income patients, if research shows, for example, that managing the care of low income diabetics requires twice as much utilization of healthcare services to achieve the same outcome compared to managing middle income or wealthy diabetics, that should be able to be factored into risk scoring and evaluation.
    As a patient, I suspect most doctors are fully capable of providing decent care. However, I would like to avoid those that fall into the bottom quartile or bottom quintile if possible. These are the docs who go overboard on defensive medicine or are trying to maximize their income under the fee for service payment model or maybe just aren’t very good. At the same time, I once saw a rating of heart surgeons in Boston. There were 54 surgeons evaluated and they were awarded one, two or three stars based on their outcomes with three being the best. In turned out that 52 of the 54 received two stars, 1 got three stars and 1 got one star. I would probably want to avoid the surgeon who got one star but I think I would probably be in good hands with any of the other 53.
    As for the role of profits, I don’t have any problem with it for insurers, for hospitals or for doctors. At the end of the day, all of these entities have to please patients / customers if they expect to stay in business over the long term. Non-profit insurers charge essentially the same premium for similar benefit designs as their for profit competitors. For doctors in private practice, their profit is their income after practice expenses. For hospitals, non-profits control 85% of the beds, but they will all tell you “No margin, no mission.” Presumably, they reinvest their profits back into their mission.
    Payers need to do a better job of structuring incentives to get doctors and hospitals to deliver cost-effective, high value care. If that means paying a reasonable fee to manage people with chronic disease so they can be kept out of the hospital as much as possible, do it. If bundled pricing for expensive surgical procedures makes more sense than paying a separate fee for each service, move in that direction. Capitation is a lot tougher because of the difficulty in accurately estimating costs and the suspicion among patients that care is being withheld to meet a global budget target.
    We need better information on several levels. We need better individual patient risk scoring. We need to provide patients with better information around what services, tests and procedures actually cost before care is given. We need better quality information to help patients avoid the low quality providers. We need unbiased infomediaries akin to Consumer Reports to help patients sort through their options. The bottom line, though, is that money and profits matter. Just paying all doctors a salary and counting on them to do the right thing with no accountability will not get the job done.

29. Just to follow up on my last comment, I should have added that in addition to money and profit, it is extremely important to get the financial incentives right. We haven’t done a very good job of that overall.
    Charlie Baker, CEO of Harvard Pilgrim Healthcare, commented on his most recent blog post at http://www.letstalkhealthcare.org that when Medicare introduced the Resource Based Relative Value Scale (RBRVS) system, about 50% of all doctors were PCP’s. Now it’s closer to 30% PCP’s and 70% specialists. According to Baker, the RBRVS system was originally expected and intended to strengthen primary care. With Medicare effectively setting payment policy for the entire system, this has been yet another failure. But hey, Medicare doesn’t need to make a profit and its administrative costs are low. Given its record, I don’t think CMS should be trusted with any more market power than it already has which is substantial.

30. “We need better information on several levels.”
    That is another advantage of large organizations over small ones. They have the ability to collect data, and the data is more accurate because of the laws of statistics: sample size flattens out the bumps related to random events.
    SMDC was able to do their congestive failure project because they had access to a pile of data about their patients and outcomes. A ten person internal medicine group would have a lot more trouble.
    In the end, of course, the federal government has access to the biggest pool of data of all, through all their health care clients. They need to mine that trove of information and share it, as well as make decisions using it.
    A good EMR system, used properly, will help that job a lot.

31. Barry C, You make several excellent points. Promulgating accepted standards of care for a selected number of important conditions, and then holding docs to that standard, is a very idea. Good for patients, good for docs, good for the HC budget. Pat S’s seven costly conditions are a good place to start. However, one caveat. Some guidelines are not worth the paper they are written on, there are simply too many of them, and they are too long. We on the receiving end need some streamlining and coordination. One central guideline clearing house, with guidelines written in a standard form, would be helpful. I have on my nightstand a community-acquired pneumonia guideline. It’s too long and repetitive and so I probably will never read it.
    Also, I think disseminating information to pt so they can make informed decision looks good on paper but is only sometimes helpful. Patients are often old and sick–in no position to be “empowered.” These are the folks who often cost the system the most. There was a recent post on this blog that gave an excellent summary of the pros and cons of mammography. Way too much for most of my pts. Is prostate CA screening a good idea? Please tell me because I don’t know.
    Of course not all medical issues are so complicated, and I think having pts avoid quacks might be doable if we’re willing to put up with some anti-competition lawsuits from the quacks’ lawyers.

32. jrossi,
    I appreciate your point about the need for streamlined guidelines in a concise, easy to use format. I also agree that elderly, very sick patients may be in no position to be empowered. However, many of us could make effective use of information that covered price, provider quality and treatment options for the conditions we have. Even the very sick elderly often have friends, relatives, and/or adult children who can help them with this. If unbiased, objective infomediaries come on the scene offering help for a reasonable price that would also be useful. I know there is no one size fits all approach here, but there is also no reason why the medical marketplace needs to be so opaque. We can and should do better.

33. Barry C, Sorry to be so terminally skeptical, but, again, the idea of transparency and better information facilitating better choice is a hypothesis, not a fact. Or if it is a fact, please share the references proving that giving pts info about this stuff has a meaningful effect on quality and cost at a macro-level.
    My own experience suggests otherwise. I spent two spectacularly unremunerative years in practice in rural Oregon. My patients were old (60% Medicare), sick, and uneducated, but nice people. My pts’ relatives mostly wanted everything done for them–intubation for respiratory failure in pts with metastatic renal cell CA, that kind of craziness. I of course tried to dissuade them, and sometimes I was successful. If I failed, sometimes the ICU docs were able to dissuade them, sometimes not. Advanced directives, HC powers of attorney? Most of my pts had no interest in that stuff, and I didn’t always push it. Who had the time?
    Maybe the younger, more educated urbanites deal with information better. But then again maybe they’ll want everything done if someone else is footing the bill. If they’re footing a big chunk of the bill, well that’s a different ballgame altogether.

34. jrossi,
    I guess I look at the transparency issue more from the educated urban / suburban perspective. I agree that if patients aren’t financially exposed in a significant way, they will not be as sensitive to the cost of various treatment options as they should be.
    To deal with cost insensitivity on the part of many patients, I would like to see us use existing and future comparative effectiveness research and data to just stop paying for treatments that are not cost-effective or at least expose patients to much higher co-payments for those. An example would be proton beam therapy for prostate cancer as opposed to standard radiation or seed implantation. I also think that executing a living will or advance directive could be at least offered as part of the process of enrolling in Medicare with the information stored in a central registry so doctors and hospitals can easily access it when needed. It should probably even be required upon admission to a skilled nursing facility. When people, especially the elderly, reach end of life status, I would also like to see universal availability of palliative care specialists to at least explain not only the options available to the patient and the family but the quality of life implications of each including side effects and pain.

35. Barry C, Not paying for useless care in a very good idea. The Medicare/ nursing home living will idea is a good one, as long as docs don’t have to get too involved. Sadly, if they do, it often won’t get done. Time is money. The palliative care specialists idea is a tougher nut to crack. Not sure many docs are interested in being the local hospice director.

36. Our current medical system consists of adopting treatment plans which work. If a better way to treat CHF or any other disease is discovered, it will be adopted. This does not require reform of our system. That IS our system.
    Many innovations from lithotripsy of gall stones, to lung resection for COPD seemed promising initially but were abandoned when subsequent evidence failed to confirm early reports.

37. “Our current medical system consists of adopting treatment plans which work. If a better way to treat CHF or any other disease is discovered, it will be adopted. This does not require reform of our system. That IS our system.”
    I am puzzled to see you make that statement. I agree that that is the theory behind our system — and everyone else’s, for that matter. But as you have often pointed out, the reality is different.
    I recall you yourself posting a long criticism of current trends in management of coronary disease, suggesting that the cardiologists running the programs “need adult supervision.”
    You also posted saying that there was heavy overutilization of many high tech management techniques due to doctors’ fear of malpractice litigation.
    We just finished a long discussion about the fact that the suppositions underlying mammographic screening are questionable, and have never been properly tested. You contributed to the viewpoint that the value of mammography screening was uncertain.
    Of course we all know about the thirty years of evidence from the Dartmouth data showing that better ways of treating various problems are routinely ignored in many parts of the country in favor of less effective but more expensive approaches. That has not led to widespread reform; the problem has gotten worse, not better.
    When researchers studying low tech approaches that improve quality try to implement their findings, many doctors complain that they are being burdened by useless paperwork and time wasting trivia.
    The problem with many of the things I have been talking about is that they are not “new.” They are more careful application of old techniques. Having CHF patients watch their salt intake and weight closely is an idea that was around fifty years ago. We are a lot more excited about new drugs, new machines, and new surgeries than about more careful application of old ideas. When the ICU people at Johns Hopkins published research showing that completely draping the patient and using careful sterile technique for central line placement could cause striking reductions in complications of central lines and in ICU time, costs, and even deaths, no one was very excited, and a lot of doctors were annoyed, but the evidence suggests that that should be applied in 100% of cases. What would you guess is the actual compliance? How rapidly is that clearly important idea being adopted?
    It seems to be a lot harder to convince doctors that some old ideas need to be revisited and applied more carefully than it is to sell bright, new, shiny things.
    In medicine, we have been trapped by a model for innovation that we adopted in the late 19th century. There were many innovations in the period of 1880 to 1955 that were so dramatic and so obviously useful that we fell into the bad habit of thinking that we could ignore science, skip over large scale controlled studies, and substitute “common sense.” We didn’t need a large controlled study to see that penicillin was a good idea. Unfortunately, science has shown us that a lot of common sense turns out not to be right, and lot of things that seem obvious are wrong.
    I agree that the model you cite should be the model for medicine. Unfortunately, as you yourself have written, that is often not the case.

38. Pat,
    I agree that the system doesn’t work as it is meant to, at least over the short term. Over the long term, numerous stupid and dangerous procedures have been eliminated from mainstream medical practice. Some have taken longer than others to eraticate. I tried to give examples of the reverse — plausible procedures that should have worked or could have worked — but didn’t.
    With a longer time horizon, it works better than it is given credit for.
    It is not fair to compare how our current system works in practice, with how another system works in theory. The new paradyme is not going to work according to plan anymore than our current one does.
    I don’t know what the answer is, but the heavy hand of arbitrary government power is likely to have unforseen consequences. I think you have pointed out earlier that HMO’s were supposed to empower PCP, and we all know how that innovation ended up.

39. 1.) That was someone else talking about HMO’s and PCP’s, possibly JRossi.
    2.) I am not contrasting our existing system with a theoretical system. I am contrastng our existing system with something like 30 other existing systems, all of which work better than ours. I am also looking at a number of US systems that work better than the system does as a whole. If we are not capable of sifting through the large number of systems that work better and finding a composite solution that we can make work here, then we are not only lagging in health care, we are lagging significantly in management skills.
    The argument that reform of the US health care system is a risky and radical step that would go where no man has ever gone before is just plain silly. We will be driving down a busy highway where everyone else is a mile ahead.

40. I have visited hospitals in some of the enlighted countries you might be refering to. The citizens there may or may not be happy with their system. The doctors certainly are not. Certainly our citizens will not be happy with their system, whether it works or not for enlighted Europeans.
    Other countries don’t have our demand system where a workup you wouldn’t even qualify for in an enlighted country is done in the middle of the night, at great expense. The sum of healthcare expenses and taxes is much much higher in Europe than it is here. Americans are not going to like confiscatory taxes, even for utopian care (or expert endorsed non-care). Europeans don’t have our Queen for a Day Justice system. In no other country on earth, besides ours, can you be destitute, and 80 years old on renal dialisis. You are not comparing apples and oranges, you are comparing apples and Appleton, WI. We cannot have desert, without eating our spinich.
    Before we get to the socialized eutopia in the future, we may pass through a stage of total failure, on our way there, depending on how we do it. Very critical specialists with scarce skill are already barely solvent, the chance for inadvertant crisis through “across the board cuts” is real. It will start in the ER, and the medical care which will be unavailable will be among the most critical, in my view.
    If we are following the English example it will take a generation at least for third world doctors to emigrate here, as it did there.

41. Christopher,
    Your anecdotal experience (talking to some doctors n Europe) doesn’t square with the reseach which shows that, by and large, doctors as well as patients are much happier with the healthcare systems of Europe than doctors are here.
    Last year I atteneded a huge international healthcare confernce in Germany. A couple thousand doctors and hospital administrators, almost all from Europe.
    While they talked about the need for improvement in their systems, there was a universal consensus that the U.S. has the worst healthcare in the developed world.
    No doctor there expressed a desire to make their system more like the U.S. system, and many expressed real pride in their systems– in France, Sweden, Denmark and Germany.

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