Below, a guest post written by HealthBeat reader Jim Jaffe, a long-time Congressional staffer , who now describes himself as a Washington Observer. Here he makes the argument that, contrary to what you may have heard, we are not suffering from a shortage of doctors. (This post originally appeared on Huffington Post)

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There's a popular story circulating suggesting that America suffers from a shortage of medical care and the doctors who provide it.

The narrative basically goes like this. Many people fail to get care they'd benefit from because of inadequate insurance and a shortage of physicians that is becoming particularly acute for Medicare participants, largely because low reimbursement rates are convincing a significant number of doctors to stop participating in the program. This results in a shortage of timely care that feeds increasingly crowded hospital emergency rooms filled with people who are extremely sick.

This story is totally untrue. It is a dense package of misinformation that not only distorts the political debate, but undermines reform efforts to create a more efficient system. So it's worth deconstructing.
A few years ago the Kaiser Foundation compared public attitudes toward care with the views of experts, who believe that up to 30 percent of today's care is unnecessary. That perception was a foundation of the health reform debate — that squeezing out waste could make the system more affordable. The public didn't buy it — and still doesn't, with two thirds saying Americans aren't now getting the treatments they need. Not surprisingly, all the evidence suggests the experts are right.

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Can doctors and other health care providers be the driving force in achieving cost-effective health care? In their commentary in the New England Journal of Medicine, Stanford professors Victor Fuchs and Arnold Milstein, call this the “$640 billion question.” That figure represents the savings to the national health care bill if all U.S. physicians and health care organizations could follow the example of individual providers who already deliver high-quality care at a cost roughly 20% lower than the average.

The authors ask “Why don’t cost-effective models diffuse rapidly in health care, as they do in other industries?” The answer, according to Fuchs and Milstein, is that a long list of stakeholders has interests that are effectively blocking the “diffusion of cost-effective care.” These include drug and medical device-makers who tout their new, more expensive products as always better than older (and cheaper) alternatives; insurance companies with high administrative costs; employers who offer just one or two benefit plans to workers; legislators who accept donations from health industry insiders, academic health centers that tolerate cost inefficiency as the price of training residents; and others whose vested interests keep them from fully embracing cost-effective care.

The media is also to blame, write the authors, by publishing articles that tout miracle cures and treatments to boost newsstand sales and failing to convey risk/benefit information accurately.

Trying to cut health care costs has often been compared to squeezing a balloon; pinch the air out of one end and it will fill up the other. Or as the Canadian economist Robert G. Evans recently told a Group Health audience, “look carefully at so-called ‘waste’ in the U.S. health care system. ‘Nothing is ever wasted… Every dollar ‘always goes somewhere, which is what makes it so difficult to bend the (cost) curve.’ In other words, one person’s waste is another person’s income.”

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You’ve heard the news: If Republicans will consider tax increases, President Obama is willing to raise the eligibility age for Medicare, from 65 to 67. Instead of Medicare for all, we would have Medicare for fewer.

This is such a bad idea that I would like to believe that the President was bluffing. Over at Hot Air, blogger Allahpundit suggests that “Obama has been floating these ‘grand bargain’ packages involving . . . entitlement reforms. . . knowing that the GOP will reject them on tax grounds and fall back to a smaller package of spending cuts only, which O will sign. Then he can turn around and sell himself next year not only as the guy who approved $2.5 trillion in cuts or whatever, but as the adult in the room who was willing to tackle entitlements before Republicans backed out of the deal to protect the rich.”

Maybe, but I don’t think the President is quite that Machiavellian (though sometimes I wish he were.) On the other hand, it’s hard to imagine that he thinks that raising the bar for Medicare is a clever idea. Lifting the eligibility age to 67 only shifts costs while punishing those who need Medicare most: low-income and middle-income Americans.

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Below, a transcript of a column by George Lundberg, M.D., Editor-at-Large of MedPage Today that does a very neat job of summing up why healthy people should not be tested for disease unless they are experiencing symptoms or have good reason to believe that they are “at risk.”  Put simply, the math is against you.

Dr. Lundberg serves as president of the Lundberg Institute, and is a consulting professor of pathology and health research policy at Stanford University School of Medicine. (Full disclosure: I’m on the Advisory Board of the Lundberg Institute.)

Lundberg co-authored this piece with Dr. Clifton Meador. (If you’ve seen the film version of Money-Driven Medicine, you will remember Meador as the doctor who takes you on a tour of Nashville.) They promise a sequel on “false diagnosis” next Monday.

You will find the audio version of the column here.

Hello and Welcome. I'm Dr. George Lundberg speaking for myself and lead author Dr. Clifton Meador of Nashville, Tenn., in this At Large at MedPage Today.

Over the past several decades, there has been a shift in the kinds of patients seeking medical care.

The progression has been from sick to early sick to well to worried well to worried sick.
The reasons are beyond the scope of this article. There is a subtle and hidden, but potentially very damaging, factor operating in the diagnostic process when large numbers of well people seek medical attention in a system designed to care for the sick. This factor is the prevalence of disease.

The accuracy of the diagnostic process is ruled by strict arithmetic.

Specificity and sensitivity of the test itself and the prevalence (or pretest probability) of the disease in the population being tested control the accuracy of the process.

Pretest probability means the percent of people being tested who have the disease in question.
A pretest probability of 2% means that 20 people out of 1,000 have the disease. Obviously, 980 people do not have the disease.

At 2% prevalence, using a test with 95% specificity and 95% sensitivity, the rate of false positives will be 72%.

So, 5% of 980 well people will generate 49 false positive tests while 95% of 20 people with the disease will yield 19 true positives.

1,000 people; 49 "wild goose chases," and only 19 geese caught.

Trouble, especially for the 49.

When the prevalence of a disease decreases, the rate of false positives increases.

Even with a very specific and sensitive test, if the pretest probability in the population is low, there will be more false positives than true positives.

False positives lead to one of two things — one, they must be tracked down with additional tests, which are costly and will generate more false positives. Often this leads to unnecessary biopsies and anxiety. This is part of the sad story of mammograms and PSA testing. Or, two, the false positive test result becomes a label of a nonexistent disease and the person carries the burden of a disease he or she does not have. The amount of false diagnoses of any disease, other than heart disease in children, is unknown and generally unstudied.

It is pure arithmetic.

The increase of well people seeking medical care lowers the prevalence of all diseases and increases the rates of false diagnoses.

Beware of this current active Great American Medical Tragedy.

That's our opinion. We are lead author Dr. Clifton Meador of the Meharry Vanderbilt Alliance and Dr. George Lundberg, At Large for MedPage Today

Below, a post that caught my eye on Kevin M.D. 

Kevin M.D. is a blog that I have long admired–extremely intelligent, timely and written from a physician’s point of view.  (Full disclosure: from time to time, Kevin cross-posts pieces from HealthBeat)

What Dr. Jan Gurley (who writes for Reporting on Health, a USC Annenberg School of Journalism online community for journalists and thinkers), has as to say about our “new, laughably flawed, multi-million-dollar ‘client satisfaction’ industry,”  strikes me as both provocative and a fair warning: Inevitably, health care reform will attract profiteers. As Gurley puts it:  “We’re letting anyone and everyone game the system.”                      ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~                    

Why Popularity Based Payment for Doctors is Not the Answer

by Jan Gurley, MD

Perhaps you remember Sam, the chronic inebriate whose story I shared to discuss the pitfalls of basing doctor pay on patient satisfaction surveys.

Looking at his discharge papers, I wondered who helped Sam fill his survey out, and how much their “help” affected the results.

After all, millions upon millions of dollars are already now at stake for hospitals. And individual doctors’ Medicare payments are expected to be based on their satisfaction scores, as early as the year 2015.

Surely these surveys are validated and standardized, right? Surely there is policing to prevent “helping” people fill them out? You might be surprised by the answers to those questions.

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Low-income people with Medicaid coverage go to the doctor more regularly, have reduced financial stress and generally report feeling happier and healthier than their uninsured cohorts who must depend on safety net services like free clinics or emergency rooms to access care—or forgo it altogether. This may seem obvious, but until the release today of what one expert calls an “historic” working paper published on the website of the National Bureau of Economic Research, there was little evidence to back up the oft-stated benefits of extending affordable coverage to the uninsured.

James Smith, an economist at the RAND Corporation, told the New York Times “It’s obviously a really important paper…It is going to be a classic.”

The study grew out of an unusual state lottery conducted in Oregon in 2008 that added 10,000 additional low-income, uninsured adults (living at 100% of the poverty line) to its Medicaid program—Oregon Health Plan Standard. In 2002, at its peak, OHP Standard had 110,000 people enrolled. But facing budget shortfalls, the state capped enrollment in 2004 and by 2008, only 19,000 adults remained—the rest lost to attrition. That’s when Oregon received a federal waiver to hold the computerized lottery to expand the plan. A total of about 90,000 people applied for the 10,000 openings.

As a side benefit, the lottery system set up the perfect conditions for conducting the “gold standard” of scientific research; a randomized controlled trial. With funding coming primarily from the National Institute on Aging, researchers spent a year collecting data from hospital records, mail surveys and other sources. They compared outcomes in those low-income adults randomly selected to receive Medicaid coverage to outcomes in the applicants who remained uninsured.

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It was only a matter of time. Eventually, Medicare would refuse to continue paying drug-makers whatever they choose to charge.  Now, it appears that this is happening.  (Kudos to Igor Volksky over at Think Progress Health.)

In 2006 when the Bush administration expanded Medicare to cover prescription drugs, it included a gift to drug companies that specifically prohibited the government from directly negotiating on drug prices.

Four years later, when health care reformers were trying to push a politically prickly piece of health reform legislation through a deeply divided  Congress, they didn’t try to reverse that provision. It just wasn’t the time to try to take on Pharma. Too many legislators are beholden to the industry for campaign contributions. As it was, the Affordable Care Act barely made it through Congress.

Nevertheless, some liberals groused that the administration had made a “deal” with Pharma.  As I wrote at the time, I very much doubted that the president had pledged that Medicare would never, ever ask for lower drug prices. I also assumed that sometime between the spring of 2010, and the beginning of 2014, reformers would revisit the issue. The Affordable Care Act was, and is, a work-in progress.

Then, in April, as Naomi reported here on HealthBeat, President Obama put the idea of letting Medicare using its clout to secure lower drug prices “back on the table.” 

“During a speech at George Washington University, President Obama revealed that one of the ways he plans on cutting Medicare costs will be to cut government spending on prescription drugs by $200 billion over the next ten years.”  With this statement, Naomi observed, “Obama seems to suggest that he wants Medicare to . . . start negotiating prices directly with pharmaceutical companies, something the Veterans Administration, for one, has been doing for years.”  (And, I would add, with great success.)

                 Pharma Becomes Part of the Mix in Debt Negotiations

Late this afternoon, Igor Volsky reported that the president has now opened the door to slicing Medicare’s drug bill. 

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While negotiating with Republicans, President Obama has made it clear that he is not willing to cut services to Medicare patients. But he will consider trimming payments to nursing homes.  

Wait a minute—doesn’t that mean fewer services for nursing home patients? Not necessarily.

                  Fat Profit Margins

Over the past ten years, investment groups have been gobbling up nursing homes. By 2008, over 67 percent were operating “for profit.”  And insofar as that is their mission, they have succeeded, handily. The Medicare Payment Advisory Commission’s (MedPAC’s), March 2011 report to Congress notes that “In 2009, the average Medicare [profit] margin for freestanding Skilled Nursing Facilities (SNFs) was 18.1 percent.  . . We examined relatively efficient SNFs,” the report adds, “and found that it is possible to have costs well below average, above-average quality, and more than adequate Medicare margins.”

In other words, there is money to be saved within the nursing home sector without undermining patient care.

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Conservatives call it the “malpractice crisis.” Public Citizen, a liberal non-profit consumer organization based in Washington D.C., calls it “The Great Medical Malpractice Hoax.”

No doubt you have read that ambulance-chasing lawyers have escalated their assault on health care providers, and that as a result, malpractice insurance premiums have been levitating, along with malpractice suits, further hiking the cost of medical care.

Various solutions have been floated, including “caps” on compensation for pain and suffering; “health courts” where expert judges replace juries; immunity for doctors who follow “best practice guidelines;” and “full disclosure” policies which urge doctors and hospitals to move quickly to disclose errors, apologize, and offer compensation.

In the end, the best solutions would make malpractice reform part of heath care reform. Our malpractice system should be redesigned to reduce medical mistakes, fully compensate patients who are injured by human error, reward doctors and hospitals that disclose errors, and penalize those that try to "cover up." When it comes to the cost of malpractice, reform should slash the exorbitant administrative costs built into an adversarial process that moves at a snail’s pace, while subjecting both plaintiffs and defendants to what a recent report from the American Enterprise Institute rightly describes as “inhumane.”

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“Empowered patients” and “patient-centered care” are key goals of the current health reform legislation. The idea is to get patients and their families intimately involved in making decisions about treatment and encouraging them to play a more proactive role in the course of their own medical care. In order to do this, patients must have access to up-to-date and evidence-backed information about the comparative risks and benefits associated with many interventions or diagnostic tests. Patient advocates call this the "quantitative imperative" and insist that access to such unbiased information is absolutely necessary to ensure truly shared decision-making.

But in a recent article in The Hastings Center Report, Peter H. Schwartz, an investigator at Indiana University’s Center for Bioethics, challenges this imperative. He raises the question of whether for some patients, there is such a thing as too much information. For individuals with a poor grasp of probability and mathematical concepts, argues Schwartz, quantitative risk and benefit information could actually be confusing and unhelpful; ultimately leading them to make irrational decisions about care. Mandating that all patients receive this information, he believes, is “deeply flawed” from an ethical perspective.

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