Thursday, July 3, 2014

The screening pelvic examination: not annual, not ever

The Dispute Over Annual Pelvic Exams, an editorial in the New York Times July 3, 2014, highlights an issue about which I have written before, including Primary Care Contributes More than Money...., June 2, 2013 and President Bush's stent: inappropriate screening and care for the rich, nothing for the poor, September 7, 2013. The Times has also had articles on the same subject, notably Questioning the pelvic exam, by Jane BrodyApril 29, 2013. The impetus was a recent guideline recommendation from the American College of Physicians (ACP), the specialty society for internal medicine physicians, that recommended against doing this test on an annual basis.[1]

This examination is not to be confused  with the Pap smear screening test for cervical cancer (although it regularly is). The Pap smear involves obtaining cells for cytological examination from the cervix by means of a spatula and/or small brush. The Pap smear is not perfect, but it is probably the best of the cancer screening tests available to us; the US Preventive Services Task Force (USPSTF) recommends them in women 21-65 years of age every 3 years. The pelvic exam, the part where the doctor puts her/his hands inside a woman and feels around, is often done in conjunction with the collection of the Pap, thus the basis for the confusion among many women. It is not recommended by USPSTF at all, at any frequency[2], but the American College of Obstetricians and Gynecologists (ACOG) recommends it on an annual basis.

I have long been a teacher of family medicine, and for many years have told my students and residents that there was no indication for this examination, at any frequency, for screening. I do this despite the fact that I know they are taught to do so on their OB-Gyn clerkships and rotations, and not because I believe I am more experienced in providing women’s reproductive health care than are the OB-Gyns. I can, however, read the evidence. By definition screening occurs in asymptomatic people; should a woman present with symptoms referable to the pelvic region (for example, pain, bleeding or discharge) the examination may be indicated. However, in the absence of symptoms it is a screening test, and should not be done because there is nothing that it can screen for. Years ago, an argument for doing it was screening for ovarian cancer, but many studies have demonstrated that it is not effective for this purpose, because by the time an ovarian cancer can be felt by the examiner, it is very far gone. These are essentially the same reasons that USPSTF and ACP recommend against it.

And, yet, ACOG, as noted, continues to recommend it (”Annual pelvic examination of patients 21 years of age or older is recommended by the College.”). The Times editorial notes that
…the gynecologists group argues that the “clinical experiences” of gynecologists, while not “evidence-based,” demonstrate that annual pelvic exams are useful in detecting problems like incontinence and sexual dysfunction and in establishing a dialogue with patients about a wide range of health issues.

This defense ranges from the indefensible (that it is not evidence based) to the absurd (that it is the way to find problems like incontinence and sexual dysfunction). If a woman has incontinence or sexual dysfunction, she knows it and the way to discover it is not by a pelvic exam, but by asking her. Clearly, the same is true of “establishing a dialogue with patients about a wide range of health issues.” I strongly doubt that most women would feel that having the doctor put his/her hands inside her vagina is the best way to open such a dialogue!

Why, then, would ACOG continue to recommend it? Long ago, when I was in medical school and residency, almost all OB-Gyns were men, and lack of empathy could be a possibility, but this is far from the case now or in recent decades. There is also the fact that such an examination, as a procedure, is reimbursed at a much higher rate than simply talking to a patient. This is true also for family physicians and other primary care providers (such as general internists, which explains the ACP’s interest in the issue), but for OB-Gyns it is a much greater percentage of their practice and thus their income. It is hard to break with tradition, to change the way that you have always been taught, and it is probably harder when there is a concrete disincentive (loss of income) for changing.

But women, and all people, need to be able to trust that their doctors are recommending and doing procedures, particularly invasive and uncomfortable procedures like the pelvic examination, only when they are indicated by the evidence. They need to have confidence that those physicians are not motivated, consciously or not, by a conflict of interest (e.g., financial gain). One step is for physicians to honestly look at the evidence, and avoid prioritizing their anecdotal experience over that evidence.

More profoundly, however, our society, our health care system, needs to eliminate perverse incentives for doing “more” even when it is not indicated, still less when it is also unpleasant for the patient (like a pelvic exam), and least of all when it is also dangerous (as other procedures are). Physicians should be paid for maintaining and increasing the health of their patients, not for “doing things”. If talking to the patient about “a wide range of health issues”, including but not limited to incontinence and sexual dysfunction, is the right way to find out about these problems, and if it takes a long time, then this is what needs to be reimbursed, not a procedure.

We are currently a long way from this sort of reimbursement, for spending the time needed to provide the best health care for a person. It is good that ACP has added its voice to recommending against screening pelvic examinations, but it is unsurprising that doctors do what they are paid to do. We need system change.

[1] Qaseem A, et al, “Screening Pelvic Examination in Adult Women: A Clinical Practice Guideline From the American College of Physicians”, Annals of Internal Medicine 2014;161(1):67-72. doi:10.7326/M14-0701.

Thursday, May 22, 2014

Treatments that don't cure the disease; we are spending money on the wrong things

In “Heralded treatments often fail to live up to their promise” (Kansas City Star, May 17, 2014), Alan Bavley, writing with Scott Canon, continues to demonstrate that he is one of the excellent health journalists – excellent journalists – in the US, along with Elisabeth Rosenthal of the New York Times. The common practice in the news media (and, thanks to a typo, “medica”) is to hype the new, exciting, dramatic, expensive, and hard to believe even though you want to. In politics, we often see the media acting as flaks for the government, the rich, and the powerful (sometimes, of course, these can be in conflict). Bavley and Rosenthal  and their ilk actually do investigative journalism, trying to the best of their ability to find out the truth rather than to reprint press releases.

The article begins with a review of a surgical procedure that was designed to control high blood pressure (hypertension) without drugs, by cutting some of the nerves to the kidneys. It made sense, it was seen as a big breakthrough (“The potential benefit was huge,” said a cardiologist). Unfortunately, when actually subjected to appropriate scientific study, it didn’t work. Or, rather, it worked just as well as placebo, a sham surgical procedure. The same cardiologist remarks ““This could be considered the biggest disappointment in cardiology of this century, but “the medical community went about it right.” 

Science worked. Unfortunately, the authors add,
“If only that were always the case. A combination of industry marketing, overly eager doctors, demanding patients and news media ready to cheer on anything that sounds like a breakthrough is popularizing many drugs, surgeries and other treatments long before they’re adequately tested. Far too often, they’re ultimately proved ineffective, no better than older, cheaper therapies, or even hazardous. Billions of dollars are wasted and tens of millions of patients are put at risk”

Yup. They go on to cite the Vioxx scandal, in which Merck concealed evidence of its biggest-selling drug causing an increase in heart disease. But that was taken off the market; many other unproven (or worse, proven to be ineffective) treatments are not. They talk about arthroscopic knee surgery, still often being done for conditions for which it has been shown to be no more effective than a sham procedure. They discuss surgical robots, costing upwards of $1.5 million, and proton-beam radiation treatments (those babies, the machines, really cost a lot!) for which the evidence of effectiveness compared to more standard and much cheaper treatment is mixed, at best. But hey, if you’re a hospital, and the competition has robots and proton-beam accelerators, who’s going to come to you if you don’t have one? Poor people? Heaven forfend!

And it is all about getting the advantage on the competition to make more money. A good argument can, and should, be made that competition in hospitals helps no one. That if there were an expensive item that there were an actual medical need for one of in the community, there should be one, not one at every hospital. But that would presume that the goal of the health system was to increase the health of the American people at the lowest effective cost. It isn’t. It’s to make money. If I can get your patients to come to me instead, it is seen as a victory (from a competitive business sense). It is really a loss for the health of our people and the pocketbooks of us all.

It is particularly depressing because that money is not buying us health. If you still harbored the belief that “we have the best health care system in the world”, it’s time to acknowledge that you are wrong (although we forgive you given the hype!). We should all know how expensive our health care system is, that we spend way more than any of the other developed countries (members of the Organization for Economic Cooperation and Development, OECD). The attached graph, from Steven Woolf, MD, PhD, who was a plenary speaker at the recent Society of Teachers of Family Medicine Annual Conference, shows a comparison of spending and life expectancy for the OECD countries. That’s the US way off to the right, spending more than anyone by far, but having a life expectancy close to the Czech Republic. Better than Mexico, Poland, Slovakia, Hungary and Turkey, but at enormously greater cost!

Woolf was the lead author of the Institute of Medicine’s (IOM) recent report “Shorter Lives, Poorer Health” , which presents depressing, but unfortunately accurate, data on our health status. We are among the “leaders” in death rates from communicable and non-communicable diseases and from injuries. Only for a few causes are our death rates better than the average. Our life expectancy at birth is worse than any of the 17 comparison countries for men, and second worst for women. Our probability of survival to age 50 is lower than any of 21 comparison countries. At any age until 75, we are never better than 15 out of 17 in terms of life expectancy. We do have better survival rates once we reach age 75, but there is no information on how much of that is keeping people alive despite poor quality of life.

Want more? In case you think it is only the minority populations (although that would be part of our population), non-Hispanic whites rank no higher than 16 of 17 at any age below 55. And the only portion of our population for whom mortality rates have risen is non-Hispanic whites with less than 12 years of education. From 2005-2009, the US had the highest infant mortality rate of the 17 countries and the 31st highest in the OECD. Non-Hispanic whites and mothers with 16+ years of education also have higher infant mortality rates than those in other countries. Among the 17 peer countries, mortality from transport accidents decreased by 42% in the OECD between 1995 and 2009, but by only 11% in the US. The same trends hold for child and adolescent health – and ill-health and mortality.

And then there are the areas where we really shine, particularly health issues related to guns.
  • In 2007, 69% of US homicides (73% of homicides before age 50) involved firearms, compared with 26% in peer countries.
  • A 2003 study found that the US homicide rate was 7 times higher (the rate of firearm homicides was 20 times higher) than in 22 OECD countries.
  • Although US suicide rates were lower than in those countries, firearm suicide rates were 6 times higher.

We have the highest child poverty rates in the OECD, our preschool enrollment is below most countries, and the ratio of social services spending to medical spending is below almost all other OECD countries.

This is insanity. We are spending enormous amounts of money, but we are spending it so that our hospitals can compete with each other, so that we can deliver the most expensive and high-tech care whether it benefits people’s health or not, and we then do not have any money left to do the things that would really enhance health: expanding education, creating jobs, decreasing poverty, ensuring that people had homes and enough to eat.

Not to mention the guns.

Thursday, May 1, 2014

Quality health outcomes depend upon the Social Determinants of Health

On the heels of the publication by the Center for Medicare and Medicaid Services (CMS) of how much money Medicare paid to individual physicians (discussed on this blog in Medicare payments to doctors: the big issue is the underpayment for primary care, April 9, 2014), we have revelations of inequity in Federal payments to health providers. A panel of the National Quality Forum (NQF), convened by the Administration to look at this issue, has determined  that payments for “quality of care” to hospitals under the Affordable Care Act (ACA) tend to reward those hospitals caring for higher-income patients and penalize those who care for the poor (Robert Pear, “Health law’s pay policy is skewed, panel finds”, New York Times, April 27, 2014). This cannot be the way we want to go, and thankfully that is the conclusion reached by the panel. It is, however, the NQF that developed these 600 or so quality indicators, and has not recommended adjusting them for the socioeconomic status of the patients that a hospital cares for (although it does adjust for severity of illness).

What is happening is that the measures of quality of care are largely not measures of what is done for patients in the hospital, but how they do after – are they readmitted shortly after discharge, are the diseases for which they are being cared for under better control or not, do they get follow-up care. The fact is that for a variety of reasons including money, education, transportation, and competing demands, poor people do not do as well as better-off people, even controlling for the quality of care that they receive when they are hospitalized. A number of panel members comment on this in the Times article, including NQF president Christine Cassel, who says “Factors far outside the control of a doctor or hospital — patients’ income, housing, education, even race — can significantly affect patient health, health care and providers’ performance scores,” and panel member Steven H. Lipstein, CEO of BJC HealthCare in St. Louis who adds “The administration’s current policy on adjustments for socioeconomic status are quite inadvertently exacerbating disparities in access to medical care for poor people who live in isolated neighborhoods. I’m sure that’s not what President Obama intended with the Affordable Care Act.”

These comments are true, but the thrust of the NQF’s comments was the unfairness to the hospitals. This is important as far as it goes – it is outrageous to pay extra money for “quality of care” to hospitals that care for the privileged and penalize those that care for the underserved. Many of the members of the panel and other commenters quoted by Mr. Pear focus on academic teaching hospitals, which indeed care for a disproportionate share of poor people; however, public hospitals (in those areas where they exist) are even more affected. But what is more important is how this issue illustrates the power of what are called the “social determinants of health”, the situation that people live in before they access medical care, and after they are discharged, have on health outcomes.

Health advocate and policy expert Kip Sullivan is more pointed in his comments on Don McCanne’s “Quote of the Day” for April 28, 2014. “The notion that doctors and hospitals are screwing up and will behave if they are subjected to punishment and reward by third parties is not new. The Code of Hammurabi (1750 BC) subjected Mesopotamian doctors to a combination of reward (more shekels) and punishment (cutting off of doctors' hands)…But even Hammurabi didn’t recommend punishing the patients.”  If hospitals that care for poor people are effectively financially penalized for doing so, they will (at best) be further financially challenged in providing that care, and at worst will do their best to not care for the poor to the extent that they can.

Why would the NQF and the Department of Health and Human Services (HHS) take such a position, one that seems both unfair and even mean? One might be tempted to suggest that rewarding the “haves” and punishing the “have nots” is what is usually done by government policy, but we would hope that, given its rhetoric on health care – and the creation of the ACA in the first place – the Obama administration would not be guilty of such intent. We get some better idea from Kate Goodrich, the director of quality measurement programs at the federal Centers for Medicare and Medicaid Services, who is quoted in Mr. Pear’s article as saying “We do not want to hold hospitals to different standards of care simply because they treat a large number of low-socioeconomic-status patients. Our position has always been not to risk-adjust for socioeconomic status within our measures because of concern about masking disparities, and potentially rewarding providers who provide a lower level of care for minorities or poor patients.”

Now, this sounds almost noble, like a values-based response to critics such as those on the NQF’s panel. However, the clear and obvious flaw in such logic is that hospitals have the power to change the lives of these patients in such a way as to decrease their risk for poor outcomes to be equal to, or better, than, those of higher socioeconomic status. They don’t, and to the extent that they could do more work in the community to help this situation, it would cost more money, so it is absurd that they be financially penalized. Dollars spent by government on health care should first and foremost be required to be spent on health, not on making money for providers (doctors or hospitals) who can by virtue of their location (and possibly other strategies) avoid taking care of the neediest. Hospitals should be judged and reimbursed on the quality of care that they deliver, equitably and without prejudice with regard to socioeconomic status, but cannot reasonably be judged on outcomes which depend on factors far outside the control of those hospitals.

The real issue is that people who are poor have a lot more to contend with than the services delivered as health care. It is not uncommon for our hospital to be treating a person with a bone infection made worse by their diabetes who needs 6 weeks of IV antibiotics. This can be delivered by a home health care agency, and most insurance will pay for it. But it becomes a problem if the person does not have insurance. And is even more complicated when they do not have a home. These people stay in the hospital, at exorbitant cost, for the whole duration of treatment. But would our quality measures be better if we only cared for those with homes and insurance? Would the hospital make more? Of course, as Mr. Sullivan points out, while the hospitals lose financially, ultimately it is the patients who suffer.

The social determinants of health are well-portrayed in the “cliff analogy” developed by Dr. Camara Jones and her colleagues,[1] and discussed in my blog of September 12, 2010, “Social Determinants, Personal Responsibility, and Health System Outcomes”. The care given by hospitals occurs at the bottom of the cliff, after people have fallen, but their risk, both before arriving at the hospital and in returning home, is that they are living so close to the cliff face; their housing is poor, their neighborhoods are dangerous and polluted, their schools do not educate, and food is often scarce and not nutritious.  In their study comparing health costs in the US and Europe, Elizabeth Bradley and colleagues discovered that while the US spends far more on “health care”, if you add in basic social service spending, the difference decreases, but that the US spends most of its combined health-and-social-service spending on medical care.[2] (Discussed in a New York Times op-ed, “To fix health care, help the poor” by Bradley and Lauren Taylor, and in my blog “To improve health the US must spend more on social services”, November 18, 2011.)

It is understandable that, given the political climate in Washington and state capitals and the flak that they took for ACA, the Obama administration does not want to put major effort into addressing the social determinants of health by developing programs to meet the core needs of poor people in our country, to prevent them from getting sick, to give them access to meaningful post-hospital care, to have health workers in communities, punish polluters, decrease crime, and limit health risks. Understandable, but not OK. And in the meantime, on this narrower issue, it obviously requires adjusting for socioeconomic risks for hospitals caring for the poor when their quality incentive payments are calculated.

But sometime soon we are going to have to address the core problems.

[1] Jones CP, Jones CY, Perry GS, “Addressing the social determinants of children’s health: a cliff analogy”, Journal of Health Care for the Poor and Underserved, 2009Nov;20(4):supplement pp 1-12. DOI: 10.1353/hpu.0.0228. Slides available on line at
[2] Bradley EH, Elkins BR, Herrin J, Elbel B.,Health and social services expenditures: associations with health outcomes, BMJ Qual Saf. 2011 Oct;20(10):826-31. Epub 2011 Mar 29

Tuesday, April 22, 2014

Index to Medicine and Social Justice Blog, Year 5, Dec 2012-Nov 2013

Primary Care

Dec 23, 2012: Does AAMC have an answer for the primary care shortage? No.

Feb 8, 2013: Creating more family doctors: should we shorten medical school? How?

Mar 19, 2013: Can you be "too strong" for family medicine?

Jun 2, 2013: Primary Care Contributes More than Money....

Oct 13, 2013: The role of Primary Care in improving health: In the US and around the world

Oct 26, 2013: Why do students not choose primary care?


Health Reform

Feb 2, 2013: Kansas, Medicaid expansion, and human rights

Apr 21, 2013: Payments for surgical complications: With a scalpel or a meat ax?

May 5, 2013: Medicaid Expansion: Do we care for people or not?

May 26, 2013: Medicaid expansion will leave out many of the poorest: What is wrong with this picture?

Jun 16, 2013: "Call the Midwife": If Britain could afford to create a National Health Service after WWII, we can now!

Jul 21, 2013: Changes in the RUC: None.. How come we let a bunch of self-interested doctors decide what they get paid?

Aug 4, 2013: Why poor people choose ERs: we need a system designed to meet everyone’s needs

Sep 29, 2013: What can we really expect from ObamaCare? A lot, actually.

Nov 17, 2013: Dead Man Walking: People still die from lack of health insurance


Health Research and Evidence

Dec 8, 2013: More on mammography: just because you don't like the results doesn't make research junk science

Jan 12, 2013: Mental Illness and Guns: A public health perspective

Jan 19, 2013: Weight and class: who is obese and why should we care?

Jan 26, 2013: The flu is a virus!

Apr 7, 2013: Research on disparities/inequities, in practices and communities needs much greater funding

Apr 14, 2013: Premature babies and informed consent: we need to do it right

Sep 7, 2013: President Bush's stent: inappropriate screening and care for the rich, nothing for the poor


Medical Education

Feb 8, 2013: Creating more family doctors: should we shorten medical school? How?

Mar 19, 2013: Can you be "too strong" for family medicine?

Jul 7, 2013: Why don't graduate medical education programs produce the doctors America needs?

Oct 26, 2013: Why do students not choose primary care?

Nov 3, 2013: Should Medical School last 3 years? If so, which 3?

The Health System and Social Justice

May 19, 2013: Keeping immigrants and all of us healthy is a social task

Jun 16, 2013: "Call the Midwife": If Britain could afford to create a National Health Service after WWII, we can now!

Jun 22, 2013: Moving to Recovery By Design (guesy post by Robert Bowman, MD)

Jan 5, 2013: When is the doctor not needed? And who should take their place?

Feb 16, 2013: Creating team based care: are non-physician providers more effectively used in primary or subspecialty care?

Feb 23, 2013: Corruption and Scandal in the NHS: What happens when you introduce private incentives to public services

Mar 2, 2013: Squeezing the needy: a truly flawed financing system for healthcare

Jul 14, 2013: The State of US Health: improved over 20 years, but not nearly enough

Jul 28, 2013: The high cost of US health care: it's not the colonoscopies, it's the profit

Aug 4, 2013: Why poor people choose ERs: we need a system designed to meet everyone’s needs

Aug 10, 2013: Insufficient outrage: is health care about helping people or enriching providers?

Aug 17, 2013: Status Syndrome: an important determinant of health (guest post by Linda French, MD)

Sep 7, 2013: President Bush's stent: inappropriate screening and care for the rich, nothing for the poor

Oct 6, 2013: Critical access hospitals: Worth subsidizing to help save rural America

Nov 10, 2013: Does quality of care vary by insurance status? Even Medicare? Is that OK?

Nov 17, 2013: Dead Man Walking: People still die from lack of health insurance

Nov 23, 2013: Outliers, Hotspotting, and the Social Determinants of Health

Providers, Values, and Health

Aug 10, 2013: Insufficient outrage: is health care about helping people or enriching providers?

Aug 25, 2013: Physicians' role in controlling health costs: do no financial harm

Sep 1, 2013: Rand Paul on health policy: small brain and no heart

Sep 15, 2013: Competition vs. Coordination in health care: remember the patient!

Sep 22, 2013: Controlling the cost of health care by doing the right thing

Oct 20, 2013: The cost of medical care: bundling tests and blaming the victim

Nov 10, 2013: Does quality of care vary by insurance status? Even Medicare? Is that OK?



Apr 26, 2013: Matthew Freeman Lecture and Awards, 2013

Wednesday, April 9, 2014

Medicare payments to doctors: the big issue is the underpayment for primary care

The Center for Medicare and Medicaid Services (CMS) just published how much money individual doctors get paid from Medicare. This initial version is without names, but undoubtedly the names will eventually be revealed. Enough information is available for Reed Abelson and Sarah Cohen, who wrote the article for the New York Times on April 9, 2014Sliver of Medicare Doctors Get Big Share of Payouts”,   to identify many of the specialties and locations. About ¼ of all Medicare payments, the article tells us, go to about 2% of all doctors. “In 2012, 100 doctors received a total of $610 million, ranging from a Florida ophthalmologist who was paid $21 million by Medicare to dozens of doctors, eye and cancer specialists chief among them, who received more than $4 million each that year.” The largest amount of money was accounted for by office visits, $12B, but this was for 214M visits, with an average reimbursement of $57, in contrast to the Florida ophthalmologist, or to the “Fewer than 1,000 radiation oncologists, for example, received payments totaling $1.1 billion.”

Much of the discussion in the article, and in the comments attached, relates to why so few doctors get so much of the $77B Medicare pays out each year. There are, obviously, concerns about fraud; not only is Medicare seemingly fixated on looking for fraud everywhere but there is good evidence that it has occurred, at least historically. For example a highly paid (by Medicare) Florida ophthalmologist is apparently linked to a previous Medicare fraud scandal in which there was some implication of New Jersey Senator Robert Menendez. “The Office of Inspector General for the Department of Health and Human Services, which serves as a federal watchdog on fraud and abuse for the agency, released a report in December recommending greater scrutiny of those physicians who were Medicare’s highest billers.” I would have to say that this is a much wiser, fairer, and probably more productive strategy than simply trying to find largely unintentional errors in coding for outpatient visits, or checking each hospital admission to see if it could have been an “observation”, which is reimbursed less because it is considered outpatient status, as is done by Medicare’s Recovery Audit Contractors (RACs, or as I have called them, bounty hunters). Also, as I have previously discussed, these efforts are harmful to the patient in a direct financial way; as an “outpatient”, a Medicare recipient in the hospital has much higher out-of-pocket costs than if they are admitted as an inpatient. This is, of course, why CMS wishes to limit some stays, but if a person medically needs to be in the hospital, Medicare should pay for a hospitalization, and not play these games that not only financially penalize the hospital and doctors but more importantly the patient.

The other big area discussed is whether, if not exactly fraud, there is substantial difference in practice (e.g., getting CTs before each procedure, using more expensive drugs, etc.) that some specialists who are highly reimbursed by Medicare are doing more of than others. In addition, the question is “are they doing more procedures” or doing procedures with less strict indications? It is worth looking at; there is no guarantee that, even if some doctors are doing more procedures, having looser criteria for them, using more expensive drugs and tests, that this is not the better way to practice, but there is no guarantee that it is the better way to practice. If some doctors are outliers in their specialty, and their practice characteristics “happen” to end up making them a LOT more money than others, then this is certainly a reasonable basis on which to look more closely at how they are practicing, and what is the evidence basis of appropriate practice.

A third issue is that many of the recipients of the most money from Medicare, particularly oncologists (cancer doctors) and ophthalmologists are using very expensive drugs, which they have to buy first and which Medicare reimburses them for. Thus, this skews their reimbursement upward even though the money (or most of it) does not go to the doctor, but rather to the pharmaceutical company. The article refers to a drug called ranibizumab, injected into the eye by ophthalmologists monthly for age-related macular degeneration. It is very expensive, as are many drugs which are made through recombinant DNA (a lot end in “-ab”) used by oncologists, neurologists, rheumatologists, and gastroenterologists as well. One comment notes that he as a physician only makes 3% on the drug. While it can be argued that this is a significant markup (for example, making $3000 on a $100,000 drug), and that this doesn’t include the doctor’s fee for administering it (substantial), it is unfair to count the full cost of the drug as income for the doctor. Of course, it is income for someone (the pharmaceutical company) which suggests there needs to be substantial investigation into pricing of these drugs. And, of course, if a physician is found to be using a lot of a drug where he (or she) makes a 3% markup rather than prescribing an equally effective drug (if there is one) where there is no markup profit, this would be a bad thing.

However, the most important thing revealed by this data, I believe, is the enormously skewed reimbursement by specialty. It is an excellent window into the incredible differences in reimbursement for different specialties, with the ophthalmologists, radiation oncologists, etc. making huge incomes while primary care doctors (and nurse practitioners) are making $57 for an office visit. This is major. The fact that Medicare pays so fantastically much more for procedures (and, as a note, it is likely that all of the doctors, including the 202 family doctors in the highest-paid 2%, are getting it for doing a lot of procedures) leads to private insurers paying similarly more. And makes these specialties very attractive to medical students because they are lucrative (and often, though not in the case of many surgical specialties, involve fewer hours of work). Which leads to fewer primary care doctors, and a dramatic shortage in this country.

Medicare could change this. It could dramatically, not a little bit, change the reimbursement for cognitive visits to be closer to the payment for these procedures. If it did, so would private insurers. If the income of primary care doctors was 70% of that of specialists (instead of say, 30%) data from Altarum researchers and from Canada suggest that the influence of income on specialty choice would largely disappear. More students would enter primary care, and in time we would begin to see a physician workforce that would be closer to what this country needs, about 50% doctors actually practicing primary care.

It is fine if CMS and the OIG look at these highest billing doctors to make sure that they are not committing overt fraud. It is also fine to look at them and see if they are using criteria for procedures that are not supported by current evidence, or doing too many other tests, or taking kickbacks. It is also a good idea to look at the cost of drugs, especially the portion going to the drug company, as well as the markup for physicians, and to re-present the data excluding that portion of the money the doctor does not get (goes to the pharmaceutical company) from their income.

But the most important result of this report should be to be shocked at the way Medicare enables the continued practice of reimbursing for procedures at such high levels, and to kickstart a complete revision of the Medicare fee schedule to bring reimbursement for different specialties into better balance.
That would be a great outcome!

Thursday, March 27, 2014

Perception of problems in the health care system: will the mighty fall or is there a chance to save it for all of us?

[This is a particularly long post, but I haven't posted for some time. I have been working on a book, and if it ever comes together, this will be part of it.]

There are a lot of problems with our health care system in the US. Undoubtedly, there are problems with all health care systems, but ours has the distinction of being – by far – the most expensive in the world, and yielding health outcomes that are shocking low, especially for the cost. Our outcomes are much worse than those in comparable advanced capitalist democracies, and often follow behind other generally less wealthy countries. There are those who persist in saying “the US has the best healthcare in the world” but to the extent that they are not completely ignorant, or, worse, purposely dissembling for political reasons, they are talking about a narrow portion of health care. First of all, medical care. Second of all, medical care that is accessible, and therefore only for some individuals. Thirdly, mostly rescue care – high intensity, highly-specialized, high-tech, high-cost interventions for individuals with some conditions.

Even within these parameters, the claim is not entirely true. Many of the interventions that are available do not actually prolong life or the quality of life. They exist as goods which can be purchased by those with sufficient resources and sufficient motivation (presumably, ill health that is not responding to other treatment) but do not always (or even most of the time) create benefit that is “patient-important” – elimination of unnecessary death, or increased quality of life. For overall health care, even those with money, access, and insurance do not always get higher quality care; frequently, they have things done to them both diagnostically and therapeutically which they are led to believe may be of benefit to them, but often is not. In fact, these interventions can lead to further interventions, at greater cost in both dollars and discomfort or morbidity to the person, as abnormalities that turn out to be unimportant are chased down. Sometimes, these interventions, available mostly to the best off of us, are actually harmful. The costs are so high, we are seeing a new enterprise, “medical tourism”, in which Americans who need or want more-or-less elective surgery travel to other parts of the world, where the outcomes are as good and the cost is often (even with airfare and hotel!) less than the deductible would be in this country.

When we look at population health, rather than the individual health issues of people in the middle and upper class, the problems are even starker. By virtually every measure, health status in the US lags beyond other wealthy countries, and many less wealthy, in markers such as infant mortality, years of life lost to treatable conditions, disability adjusted life years, and even age of death. Our “between groups” contrasts are very stark in the US, mirroring those of many developing economies, not other “first world” countries. The fortunate among us may get the “best” care for some conditions at the expense (both financial and personal) of over-intervention, but many of us get what is frankly poor care or no care at all.

Finally, most of the negative determinants of health are outside of and before interaction with the medical care, or even any aspect of the health care, system. They are the social determinants of health, the economic status of your family (and of your family of origin; wealthy people born poor, while admirable “Horatio Alger” role models, have worse health status as a group than wealthy people born rich). They include housing, food, education, warmth, discrimination, environmental pollution (much worse in poor communities than in wealthier) and a host of other negative impacts that, in Dr. Camara Jones’ analogy[1], put you closer to the cliff face, more likely to fall off and then be at the mercy of whatever the medical care system does or does not provide.

However, even when people acknowledge that these disparities, inequalities and inequities exist, and that our health system is sorely lacking, there is not agreement on what the most important problems actually are. Even when we eliminate overtly political posturing and consider only the honestly conceived beliefs of different players in the system, there is lack of consensus because there are many different perspectives from which to view the elephant of health care. In addition to the differences in perspective, there are differences in incentives, in the fact that what may be good for some part of the system is bad for others. Physicians and other individual providers, hospitals and health systems, politicians, policy makers and pundit – and of course patients – have different perspectives. And, certainly, there is plenty of blame to go around, and no shortage of others that any of us can point fingers at as the “real” problem.

For a physician who is interested in caring for patients, the regulatory burdens can be the real problem. Days are spent with less and less time providing care to patients, and more and more completing the record (and the evidence is that, whatever the benefits, electronic health records take more time to complete), filling out forms, complying with regulations. Increasingly employed by hospitals and health systems, they are driven to “be productive”, which in a fee-for-service system translates into “see more patients and spend less time with each”.  The number of people who need care is increasing, not just from the one-time bolus of people getting health coverage under ACA, but more from the increase and aging of the population. There are exceptions, systems where care is capitated, where physicians and other providers (especially those in primary care) are organized into teams and paid on the basis of providing comprehensive care for populations rather than for face-to-face encounters, but these are far from the norm. From the perspective of these providers, most of the efforts to increase access have increased their workload, decreased their job satisfaction, and, possibly most important, decreased their sense that they are providing quality health care to their patients.

For hospitals and health systems, which have built enormous physical plants and infrastructures based upon “product lines” that are highly reimbursed (and, more important, have a high return on investment, or high reimbursement-to-cost-of-providing-the-service ratio), the challenge is also regulation, but in a different way, and of changing what is reimbursed. Like physicians, hospitals would like the public to think that they are in the business of delivering quality health care, but the emphasis, whether for-profit or non-profit, is often on the business part. Hospitals and health systems are sometimes run by physicians or other health providers (often with MBA degrees) but are frequently run by accountants. They may do well by their metrics, making (or not losing) money, but this may be a result of providing a particular market segment, or product line, or service to a particular (insured) patient population, rather than providing the most-need healthcare to those who need it most. If policy changes begin to financially reward doing something different than the hospitals have been doing (for example, keeping people out of the hospital) they can restructure, acquire ambulatory practices, fight it and hope it will go away, or go bankrupt. They can adopt collaborative arrangements with their physicians, and sometimes restrict referrals to keep them within the system. Changes in policies and regulations are very challenging, because there is such an enormous capital investment.

Policy makers, politicians, and pundits have different challenges. Politicians want to be re-elected, and so need to satisfy voters, or at least likely voters, or at least those with the most money who will finance their campaigns. Pundits have few restrictions other than their beliefs. Policy makers, who may be politicians or work for them, or may have been or later become pundits, have to implement goals. But sometimes the goals are in conflict. To restrict the potentially inappropriate admission of patients by hospitals in order to collect more money from Medicare, puts policies and practices into place which encourage classifying patients as outpatients (“observation” status). But this then does not eliminate the cost; it both decreases the reimbursement of the hospital and increases the amount that the patient, the Medicare beneficiary, has to pay out of pocket.

Of course, there is the patient, who is ostensibly the focus of all the attention, for whom the entire health system exists, but who is usually the least powerful player in the entire equation. More important, there is not a patient, there are many people with different sets of needs and preferences. Yes, most would like to stay healthy if they are, or get healthy if they can. They may be willing to put a lot of work into it or may have a more passive approach, wanting to be made healthy. They may have very different understandings of health, and different degrees of belief in and trust in physicians or other providers, and indeed in science. Even if they want to trust science and medicine, they are very likely to be confused by the complex way in which new medical knowledge is developed and found to be accurate, scarcely in a linear “this is good for everyone, this is bad for everyone” manner. Their lives may be very busy and have little time to spend at the doctor, or they may see visits to the doctor as one of the more positive and fulfilling experiences that they have. They may “know” what is wrong and what is to be done, and find the doctor to be just a particularly uncooperative store clerk who will not provide them with it, even when the doctor believes that it would be of little or no use, unnecessary and expensive, or even dangerous. They may have the sense of invulnerability that often accompanies youth, or the frailty and fear of old age. They may have cultural beliefs that make it difficult or impossible to understand or accept medical recommendations, and lead to frustration in interactions with the medical system. Even positive developments, such as the “Patient-centered Medical Home” (PCMH), are challenged by the fact that not all patients are the same, and what makes one comfortable, at ease, and feel healed may be a negative for another.

In his sensitive and thoughtful essay on the Health Affairs blog, Matthew Anderson provides us with 9 questions that he has about the PCMH, in the form in which he finds himself working and in the projections for the future.[2] He is certainly not opposed to a conversion of practice to being more patient-centered and less provider-centered, but raises questions about the degree to which the processes that have been put in place in the name of PCMH have actually done this, and whether they have increased or decreased not just his satisfaction as a provider but the quality of care that is provided to patients. Dr. Anderson is neither a Luddite nor a malcontent, but rather is trying to raise his eyes above instrument panel at which he is working to see if the direction in which the ship is sailing is the one we want to go in. He is, above all, focused on the values that we are trying to achieve, and concerned that our over-emphasis on the process, on the plan we have put in place rather than the goal, will not get us where we want to go.

In his book “How the Mighty Fall”[3] business professor Jim Collins puts forward 5 stages of decline in once-great companies. Stage 1 is “Hubris born of success”, Stage 2 is “Undisciplined pursuit of more”, Stage 3 is “Denial of Risk and Peril, Stage 4 is “Grasping for Salvation”, and Stage 5 is “Capitulation to irrelevance or death”. Which stage is your organization in?

Luckily, Collins’ work suggests that turnarounds can happen even in Stage 4. The key is staying true to the key principles and practices of our work. Dr. Anderson’s 9 questions can be a start to guiding us.

[1] Jones CJ, et al., “Addressing the social determinants of children’s health: a cliff analogy”, J Health Care Poor Underserved. 2009;20(4 Suppl):1-12. doi: 10.1353/hpu.0.0228.
[2] Anderson, M, “Nine questions about my new medical home”, Health Affairs blog, March 17 , 2014.
[3] Collins J. How the might fall: and why some companies never give in. Collins Business Essentials. New York. 2009.

Wednesday, February 19, 2014

Integrating health systems must be to improve quality, not increase cost

The February 13, 2014 article in the New York Times by Elisabeth Rosenthal, “Apprehensive, many doctors shift to jobs with salaries”, more or less just presents the facts. It notes that the medical placement firm, Merritt Hawkins, says that 64% of jobs this year are salaried as opposed to 11% in 2004, and that it expects it to go up to 75% in the next two years. She cites AMA figures that “…about 60 percent of family doctors and pediatricians, 50 percent of surgeons and 25 percent of surgical subspecialists — such as ophthalmologists and ear, nose and throat surgeons — are employees rather than independent.” In some places it is more dramatic; in Kansas City, there are no longer any cardiologists (a type of internal medicine subspecialist) who are not employed by hospital systems, and oncologists (cancer specialists) are not far behind.

So, is this a good thing? The article suggests yes, but maybe not entirely. It states that “Health economists are nearly unanimous that the United States should move away from fee-for-service payments to doctors, the traditional system where private physicians are paid for each procedure and test,” and I agree, and that “When hospitals gather the right mix of salaried front-line doctors and specialists under one roof, it can yield cost-efficient and coordinated patient care. The Kaiser system in California and Intermountain Healthcare in Utah are considered models for how this can work,” with which I also agree. However, not all health systems are Kaiser or Intermountain Healthcare. The article continues: “But many of the new salaried arrangements have evolved from hospitals looking for new revenues, and could have the opposite effect. For example, when doctors’ practices are bought by a hospital, a colonoscopy or stress test performed in the office can suddenly cost far more because a hospital ‘facility fee’ is tacked on.”

Rosenthal has written about facility fees before, as has Alan Bavley of the Kansas City Star in his “Doctors, Inc.” series (“’Facility fees’ add billions to medical bills”, Dec 29, 2013), and I have commented on it in Changing the structure of health care delivery systems: to benefit the patient, the providers, or the insurers?, January 14, 2014. The new arrangements promise more money, or at least stable incomes, to physicians, and continue to pay the currently-most-highly-paid specialists the most money, with primary care doctors getting less. This is not because hospital systems have anything against primary care, but rather that they are following the money, and these acquisitions have occurred precisely while we are still under fee-for-service reimbursement in most locations. If cardiology or orthopedic or radiologic or neurosurgical procedures bring in great amounts of money to the hospital (“technical fees”) the hospitals like this, and are willing to share some of that money with the doctors to ensure that they keep their patients in their hospital or health system. Primary care does not generate such largesse. Relatively intelligent systems recognize that they need a locked-in “primary care base” to create referrals to their subspecialists, but will pay as little as they can, and demand “high productivity” (which could be seen as “patient churning”), and it is not just primary care: “many doctors on salary are offered bonuses tied to how much billing they generate, which could encourage physicians to order more X-rays and tests.”

Bloomberg News has a more direct take on this phenomenon, stating firmly in an article by Shannon Brownlee and Vikas Saini that “Bigger hospitals mean higher prices, not better care”, February 18, 2014. They cite data from sources such as the Dartmouth Atlas of Health Care, a recent article in Health Affairs[1] which demonstrated that “On average, higher-priced hospitals are bigger, but offer no better quality of care,” and a variety of lawsuits by public agencies (such as the Massachusetts Attorney General) to demonstrate that hospital acquisitions are about market share and control of practices and, ultimately, about money, not quality. “If you think of value as some combination of needed services delivered for the right price, large hospitals are no better than small hospitals on both counts.” As I have written about before, doctors control a lot of costs in the health system, by choosing the tests that they order, deciding whether to admit to the hospital or not, and where they refer. By employing the physicians, hospitals can not only control the latter, but can set criteria requiring physicians to abide by hospital policies on the others. The doctors then become, in the words of this article,  “…another cog in the corporate machine, and many physicians have told us they feel they must skew their medical judgment to keep their jobs.”

This is the nonsense that occurs when things are done piecemeal. Intermountain Health Care and Kaiser are not perfect, but they have used their status as integrated health systems to control costs and increase efficiencies. To the extent that they are also the insurer, it is in their interest to do so. Efforts by the federal government to have others emulate these models through the creation of Accountable Care Organizations (ACOs), without changing the manner of reimbursement, are bound to fail. As Paul Baladian is credited with saying “every system is perfectly designed to get the results that it gets.” If we are getting a system in which hospitals are buying up physician practices so that they can charge insurers, from Medicare to Blue Cross, more; if we are getting a system in which medical decisions are being made in the best financial interests of hospitals rather than the best health interests of patients; if we are getting a system in which we continue to favor some patient over others based upon their income, insurance status, or their type of disease (middle-aged well-insured person who needs a single joint replacement = “good”, older person with multiple chronic medical conditions and “just” Medicare or worse yet uninsured because they are under 65 or undocumented = “bad”), it is because we have perfectly designed it to be so.

Brownlee and Saini offer some suggestions for solutions. They suggest that Medicare expand its “Advance Payment Model,” a program that provides capital to small or rural physician groups, and also particularly about forming multispecialty Accountable Care Organizations driven by primary care.

“Until we give primary-care groups control over what happens to patients, large hospital systems and specialist-dominated groups -- those with greatest access to capital -- will be able to keep raising prices, even as they issue press releases about their plans to control costs and improve care.”

Sounds like a good idea to me. Combine that with a single-payer system that covers everyone, “everybody in, nobody out!” and we may be able to reverse the trend toward higher profit at the expense of lower quality.

[1] White C, Rechovsky JD, Bond AM, “Understanding Differences Between High- And Low-Price Hospitals: Implications For Efforts To Rein In Costs”, Health Affairs, January 2014 10.1377/hlthaff.2013.0747.

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