Private Profit and the Public's Health: Which is More Important?

Health care is pretty complicated, and insurance coverage is even harder to understand.This is the message that comes through clearly from the interviews being done by Dr. Paul Gordon and recorded on his blog, https://bikelisteningtour.wordpress.com. Dr. Gordon is taking a unique sabbatical, riding his bicycle across the country from Washington (DC) to Washington (state), interviewing regular people, mostly in cafés and such, about their take on Obamacare. 

The economic status of these people varies from poor to pretty well-off (but none really wealthy), from well insured to uninsured. Their political perspectives range from “everyone should be covered” to “benefits just make people lazy”. Three recent quotes: ‘People use Medicaid as a crutch’, ‘You can’t penalize someone for not having health insurance when it’s so expensive and the economy is doing so poorly’, ‘Here’s my take on it – everyone should have insurance’. What they share with each other, and with most of us, is a general lack of understanding of how Obamacare works (or doesn’t) and why. The flaws in Obamacare are the result of the political tradeoffs that allowed insurance companies to continue to have control and make huge profits, but this is often not clear to most people.

Here is something that is easy to understand, however: when you call “911” as you have been trained to do in an emergency, and they don’t come. Or they don’t come for a long time. Or they come with inadequate supplies. Who do you get angry with when you, or your loved one, dies? The government? They are surely in part at fault, even though they probably contracted the service out, to save money, probably because voters want to pay less tax. But there is another reason, explained in an excellent special article in the New York Times, “When you dial 911 and Wall St. answers” (June 26, 2016). The piece, by Danielle Ivory, Ben Protess, and Kitty Bennett, details how many city services, including ambulance services, are provided by companies that are owned by “private equity firms”. These are companies whose investment capital comes from wealthy individuals and particularly from pension funds, unlike banks whose money comes from depositors. They are even lessregulated than banks, and thus more able to pursue their core mission, making profit:

Unlike other for-profit companies, which often have years of experience making a product or offering a service, private equity is primarily skilled in making money. And in many of these businesses, The Times found, private equity firms applied a sophisticated moneymaking playbook: a mix of cost cuts, price increases, lobbying and litigation.

Whoa. This is starting to get complicated again. Banks vs. “private equity” vs. just plain old for-profit businesses? They are really just different forms of for-profit, and provide a stepwise progression, from public services operated by government for the benefit of the people, to private companies that are contracted by government to do a service but might care about doing it well, to having those companies owned by banks who really just want to make a profit, to having them owned by private equity companies who care about nothing but making a profit. The photo accompanying the Times article is of Lynn Tilton, owner of Patriarch Partners (an ironic name, given that she is a woman), which owned the emergency services company TransCare that served many East Coast communities. TransCare went bankrupt, leaving those communities without emergency medical services. Ms. Tilton’s picture is accompanied by the quote from her reality television stint “It’s only men I strip and flip.” As a poster child, she could become the Martin Shkreli of ripping off necessary public services the way he was of ripping off consumers of life-saving drugs.

“The business of America,” Calvin Coolidge is often paraphrased as saying, “is business.” This perspective, that it is not about doing things that are best for the American people, is based in a belief that capitalism – “business” – will, through the magic of the market, eventually meet those needs. OK, maybe not those of people at the margins, people too poor to buy, so maybe we need a safety net. But most people. A similar statement appeared today in the print edition of the Kansas City Star from KC Mayor Sly James, discussing the controversy over replacing the terminals at Kansas City International Airport with one big, new terminal. Surveys consistently show that the large majority of Kansas Citians (84% in this article, “Regarding KCI’s future, city ponders a new flight path”) like the current arrangement, with short security lines and easy access in and out from one story terminals, but the airlines and big businesses do not. In the large-type quote accompanying his picture in the print edition (but, along with the photo, left out of the online edition), Mayor James said “The people of this city need to be convinced of what I believe is a basic reality, that this airport is about a lot more than ‘how fast can you get out of your car and get to your gate?’” Right. Business interests first. Take that, 84% of Kansas Citians!

Because they most obviously involve life and death, emergency medical services and firefighting (yes, firefighting too has been contracted out to companies owned by private equity firms!) get the greatest play in the Times article, but many other services (like water!) are in the same situation: controlled by companies whose goal is to make a profit rather than to provide effective service for people. This is what happens when municipalities are starved of funds because people vote to cut taxes.

Whether it is health insurance or emergency medical services or municipal water, the system becomes very complicated and hard to understand when it is trying to meet conflicting agendas. When the need for people to receive critical, health-producing service (fire and police protection, clean water, garbage collection, ambulances) is compromised by provisions built into contracts (or the law) for companies (insurance companies, banks, private equity firms) to make profit. I guess it is fine if these services can be effectively and reliably provided by for-profit companies, but when their pursuit of profit through “a mix of cost cuts, price increases, lobbying and litigation” conflict with actually providing services, there is a big problem. In the case of emergency medical services, the problem was that “…many newly insured Americans turned out to be on Medicaid, according to the Kaiser Family Foundation. Medicaid restrictssome of the most aggressive billing tactics.”

A variety of other difficult to understand strategies are also employed at the macro level to place the interests of wealthy corporations above those of the people. These include the unlimited political contributions permitted by the Supreme Court’s Citizen’s United decision, incredible gerrymandering of congressional districts so that we have states where the majority of voters vote for Democrats but most districts are solidly Republican (see the New York Times Book Review “Where votes go to die”, June 26, 2016), and the provisions of the Trans-Pacific Partnership (TPP) that prevent national governments from regulating multi-national corporations.

We could solve this if there was a single, over-arching principle, always codified into law, that the interests of the people as a whole always trumps the profit potential of corporations. I vote for that.

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Serving others or self-serving? All generations have both kinds of people

The current generation of young adults, commonly called “millennials”, is often criticized for being self-centered, “spoiled”, the product of “helicopter parents”, showing the signs of having grown up in a culture where “everyone was a winner”. On the other hand, studies also show them to be the most socially conscious, idealistic, and optimistic generation in a long time (despite the evidence that things are not going so well for them, and little reason to think they’ll improve soon). They, as a group, have become politically involved, shocking the established political order with their enthusiasm for the presidential candidacy of an old Jewish socialist from New York City via Vermont, making Sen. Sanders a viable contender

This generation includes most medical students, as well as most residents, so I get to see them a lot. I can say that there are many in this group who are committed, hard-working, idealistic and self-sacrificing. And there are a lot who are not. In short, they are people. Yes, there are those who, for whatever reasons in their personality or upbringing, are “all about me”, argue their grades, have no time for giving to others, seem to have no sense of the collective good, and sometimes make me wonder why they want to be doctors. But you know what? We had those people back in my generation. I was in college in the 1960s, and not pre-med, and there were pre-meds around who had the reputation as narrow, grade-grubbing, and not socially involved. There were also pre-meds who were very involved in the major struggles of the day, anti-war, civil rights, racism. I was in a post-baccalaureate premedical program in the early 1970s, when the Vietnam War, with its extension into Cambodia, was peaking. Many of my fellow students, going to night classes after working all day, could not be seen as privileged, but many, including veterans, were active in those movements. And many were not.

I was in medical school in the mid-1970s, and there were many who were all about themselves and their futures. And many whose futures turned out to be very distinguished and productive. There was also a lot of social involvement. Chicago had a number of medical schools, and students knew each other across schools, even sometimes roomed together. When a physician researcher at one school was discovered to be doing research that targeted poor black women, students there protested; when he planned to leave for a job at another school, students there made an issue of it. I was involved in some of these struggles, and some in medical school. When, at a forum of the whole school to discuss the impact of our 3-year curriculum, the Chairman of Surgery announced he thought our 3^rd-year medical students were ill-prepared because he had heard some of them asking nurses for advice on skills such as starting an IV (“in my day, we would never have asked nurses for advice!”), I stood up and spoke on how we were glad to not be like that, that we wanted to be able to learn from anyone. Maybe not my smartest hour (the chair of another department tried to get my year-old grade in his clerkship changed), but I bring it up because there appeared to be generational differences then, as now. I am not an expert on generational trends (for this I recommend the outstanding book by Paul Taylor, “The Next America”[1]), but looking back I also remember senior faculty who were very supportive of progressive efforts; I think that then, as now, it is people who are different, not really generations.

Our current and recent medical students at KU created and continue to staff and work hard for the Jaydoc Student-run Free Clinic, which provides care for folks with little or no money or insurance in the evenings; succeeding classes, if not generations, have expanded the scope and impact of the clinic. Students frequently volunteer for, and self-fund, trips to provide care in poorer countries – and even sometimes in our own, for those left out of our non-system of health care. (These trips are generically called “mission trips” even when there is no explicit evangelical religious component; however, many are indeed organized by religious organizations, and personed by students, doctors and others motivated by their religious beliefs. I may not be a big fan of religious evangelism, but I am a big fan of people doing good work!) Many of our students are active in the community, in local as well as national programs. They regularly volunteer for the school-based health clinic at a local high school, named the Bulldoc for the school’s teams, the Bulldogs, by the high school’s students (post-milennials?). The clinic itself was created by a collaboration between the school, school district, community groups (particularly pastors), medical school faculty, and students – in particular one medical student, without whose efforts it would never have come to pass.

When I was young, and even in earlier generations, many students, like other people, worked for the interests of others as well as themselves. Many do so now. Others, it is sad (to me) to say, are indeed self-absorbed, and all about themselves. Like other people, like doctors – and nurses and accountants and steelworkers and retail clerks and unemployed people. We can only laud those whose work demonstrates the “better angels” of human nature, and hope that narrow, selfish behaviors will extinguish.

To those who are in medical school, I want to say “No, it is not about you. It is about the people for whom you will be caring. And let’s not forget what ‘caring’ means.” Sometimes I actually do. Maybe we should all say, or at least think, that more often.

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[1]Taylor, P and the Pew Research Center, “The Next America: Boomers, Millennials, and the Looming Generational Showdown”, 2014.

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The US health and social service system is evil

I have often written about how our health system is “deeply flawed”, but I realize that there are many ways in which this is a grand understatement. I initially intended to call this piece “health insurance companies are evil”, but realized that this singled out but one player. I mean, insurance companies are at least as evil as other parts of the health and social services sector, but naming only one part both does a disservice to that part, which is acting rationally in relationship to the other aspects of the system, and tends to forgive the others.

The thing wrong with our health system is that it is a mess; there are dozens or hundreds of ways to have health insurance coverage, or not, and each costs a different amount and covers different conditions, for different percentages, with different amounts of coinsurance and co-payment and deductibles. A single-payer health system, where everyone is covered with the same benefits for the same care (all that is needed, none that is not) and payments tiered to income, is the only rational and effective way to make sure that we have the possibility of quality health care. There can be no quality without equity. While I will not spend more time here making this case, because I and others have previously done so extensively, I will refer to it.

What is evil is how the system affects our actual people. However, people are not really ever seriously considered in “health reform” (or social service “reform”). Yes, people’s suffering sometimes gets mentioned by political candidates, who note that some people are paying too much or are not getting care. Indeed, this has been a big theme of Republican candidates who are critical of Obamacare, but whose only plans are ones which will make it a lot worse for most people. Actually making the system work for people is never really on the table, because when the political negotiations begin, the big players (insurance companies, providers, drug companies, device manufacturers, etc.) enter the picture.

Let’s get right down to it: people in the US, even those who are citizens, just do not get the coverage and services to which they are fully entitled, not to mention the coverage and services that they actually need. You have to sign up for Medicare, pay for Part B (which is what covers everything except inpatient hospitalization, including doctors’ fees), choose and pay for a Part D plan. If you are lucky enough to be able to afford one, you have to look through a maze of possible Medicare supplement plans and hope you chose correctly, given the multiple variables of your health status, the benefits profile, where you live, your actuarial as well as self-perceived probability of getting ill, and what you can afford. Even Social Security, a benefit that you have paid into for your entire working life, requires you to sign up and show you are eligible. This is nonsense; there is no reason it should be this way. We start with a non-system that does not cover everyone, provides inadequate coverage for those who do have it, and makes it difficult to sign up, presenting numerous obstacles which allow people to fall through the cracks.

Actually, this is more than nonsense; to the extent that people pay the price of inability to navigate the system with their health, it is evil. It would work, and be much simpler, if everyone, when they retire, got Medicare. And if Medicare covered everything for everyone wherever they live. Why not just make sure everyone gets Social Security? Why make it the responsibility of the person to demonstrate that they not only are truly eligible but that they can get through a jungle of options, often confusingly computer based, when they are getting to the end of their careers? Of course, if we had a single payer system, everyone would be in and there would be no change when you retired or became 65; you’d already be in a system in which everything you need and nothing you don’t need is fully covered.

Actually, in a good system you’d be better than “fully covered”. You’d be covered appropriately; you would, whoever you are, get the care that you need, but you would not be eligible for coverage for things that you don’t. We would have a health system that provided necessary, appropriate, and proven diagnosis and treatment for people, rather than emphasizing the provision of services which were most profitable to the providers. Insurers would not do their best to risk-select, would not be able to charge more for some people than others (and they can under Obamacare; they have to cover you even with a pre-existing condition, but can charge more), and would not even have to be for-profit. I favor a single-payer health care system such as Canada’s, a (fully-funded) Medicare for all, as does Sen. Sanders. But there are other reasonable alternatives; Switzerland, for example, has, instead of a single payer, multiple insurance companies. But these companies have to cover everyone, provide the same benefits, charge the same price, and be non-profit.

Critics of Sen. Sanders often say that a Medicare-for-All system would bankrupt us. This is also nonsense.  It presumes the built-in profit for insurance companies. It presumes that we would continue to pay the most of the most complex and high-tech procedures, and let providers (via the complex system of the RUC --  Changes in the RUC: None…How come we let a bunch of self-interested doctors decide what they get paid?, July 21, 2013, which essentially sets the Medicare rates on which all other payments are based) set the rates for their own procedures. The evidence is in every other wealthy country, all of which spend much, much less on health care and have much, much better outcomes. They also provide much better social services, not only for the needy and the poor, but for everyone. Retirees get their pensions. And they keep their health care.

The system works in these other countries; that is, if your interest is in ensuring that everyone gets the health care they need, the pension benefits to which they are entitled. If your interest is in maximizing the income of (some) providers and the profit for insurance and drug companies, then they don’t work as well. So I guess our system is not necessarily evil, it depends upon your values.

But, then, I would argue that the values on which the system is de facto based, though, are evil ones.

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Good Enough for Government Work: Quality, Cost, and Gaming the System

The entire text of the "Good Enough for Government Work: Quality, Cost, and Gaming the System", the 23rd Odegaard Lecture from the 27th Primary Health Care Acces Conference, is available now as a Google Doc at this link: https://docs.google.com/document/d/17oc3H5qHxA8eoYEwiQ5s5hUulvzo1JaSWldsu41nSDU/edit

The link will continue to be available on the right side of this blog page.

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Good enough for government work: Quality, Cost, and Gaming the System (Part 4 of 4)

This is the fourth and final part of the 23rd Charles Odegaard Lecture, "Good enough for government work:Quality, cost and gaming the system. I will put the entire talk up as an attachment soon.

Is this really true? Aren’t some of our costs “our fault”, or at least “their fault”, that is other people? What about those folks who are “gaming the system”, by holding out on buying insurance until they get sick? Aren’t they driving up costs? Insurers like Aetna and Anthem make the accusation that people are misusing Special Enrollment Periods (SEPs) for this purpose. This is debunked by the evidence, cited by Michael Hiltzik of the Los Angeles Times, but even if they were, they’re poor people trying to get by! Wondering if they can put off buying health insurance so that they can pay the rent! Who is really in a position to develop and implement strategies to “game the system”? 

Unsurprisingly, as Hiltzik also reports, it is the insurance companies (as well as big health system providers) who are masters of these strategies. Besides, if we have concern about “buying to use” behavior, the best answer is to get rid of the jumble of insurance companies and enrollment periods and have one national health insurance plan that has, in the words of the recently deceased Quentin Young, “everybody in, nobody out”.

The most amazing thing about all of this, the way in which the system is gamed, is the way it transfers public money intended to provide healthcare for people into private pockets far in excess of the cost of providing that care. Himmelstein and Woolhandler provide us with data that shows that we already pay for a national health system, with over 50% of “health” costs being borne by government, far over 60% if we count the loss of revenue from employer contributions to insurance being tax deductible, but we still don’t come close to covering everyone, because our system is so inefficient, and so much boodle is being raked off.

Nowadays, when we hear the phrase “good enough for government work”, we tend to think of something that is poor quality, or only just meets the minimum standards set by government. The Urban Dictionary defines the phrase as “Probably not the best, but what the hell, at least we got the job done to minimally acceptable standards.” And, yet, when this phrase first came about it was a compliment; it meant that the government set minimum standards of quality that had to be met, and if you had someone (say a contractor) doing work that was “good enough for the government” it meant that it met those standards of quality, that they weren’t ripping you off by doing shoddy work. What we have now is our publicly-funded health system being cannibalized by profiteers, and enabled by a government that often seems to care more about cost than quality.

Charles Odegaard, the medieval historian and former University of Washington president after whom this lectureship is named was, and I quote from the Coastal Research website, “an impassioned proponent of the idea that every school within a university should be engaged in the advancement of society in the communities and regions that surrounded it. As a result of Dr Odegaard’s leadership, UW became a leader in the decentralization of medical education, including the unprecedented commitment to training physicians from and in the surrounding states of Alaska, Montana, Idaho and Wyoming.” [1]

There are great positives to decentralization, whether for education of doctors or for administration of social programs. It can decrease the cost of large, unresponsive central bureaucracies, and put control in local areas that are more knowledgeable about and responsive to the needs of their populations. There are, also, risks. Sometimes control at the local level is more about maintaining the power of one sector of the community at the expense of others; one just has to look at localities and states in the South in the Civil Rights era defying integration (or, perhaps, many states and localities more recently). More to the point of this talk, there is the risk that smaller, more decentralized activities can be more easily underfunded. Think about the deinstitutionalization of people with severe and persistent mental illness toward the end of the 20^thcentury. When I was in medical school, I was taught that 1 in 3 hospital beds was occupied by someone with schizophrenia. That is certainly not true today, because of deinstitutionalization. And so we do not have the horror of people with mental illness warehoused in enormous facilities, but we also do not have anywhere near the degree of community-based mental health services that would allow them to live successfully in the community. We have people with mental illness living on heating grates and under bridges and, according to a June 2015 article by Matt Ford in The Atlantic, our nation’s largest mental hospital is a jail (absolutely believable to anyone who has ever worked in one).[2]. It is only ok to decentralize when we can assure that necessary programs will be maintained and will be well funded. We have long since privatized the health care in most prisons, and there is a (to me) disturbing movement to privatizing prisons altogether. Cost, again, trumps quality. Especially, of course, if the prisoners are mostly “not us”. Seeing a trend?

So…is it possible to have quality and still reduce costs? Of course. Our system is not only financially inefficient, and the victim of massive skimming by the private companies, but it is one which is geared to care for individual patients rather than populations; where there is not rational allocation of resources to the areas where they will do the most good, but rather decisions made for each individual, often where the provider has a financial incentive to do more. Oregon’s CCOs, a kind of state-sponsored but decentralized (there are 15 in the state) ACO designed only for Medicaid patients, have provided some movement in this direction, but they are limited because they are, in fact, only for Medicaid patients. This permits skimming, as we see in recent data that shows that the places long touted for their efficiency and low cost for Medicare, like Grand Junction CO and Rochester MN, are among the most expensive for private insurance. The same characteristics, integrated health systems which control most of the care in a community, that allow them to be efficient with fixed Medicare funds, also allow them to raise the rates for private insurance. Gaming the system.

We could have a good health care system. It needs to be built upon quality, and quality has to be based on consensus, and has to apply to everyone, rich and poor, young or old. It cannot be segmented into different versions of quality for privately insured, Medicare, Medicaid, and uninsured people. The “how-to” is not hard; other countries have shown us how. The money is not hard, we are already spending excessive amounts. What we need is the will. 

 http://coastalresearch.org/2015/08/joshua-freeman-md-to-be-charles-odegaard-lecturer-at-27th-national-conference/

[2] (http://www.theatlantic.com/politics/archive/2015/06/americas-largest-mental-hospital-is-a-jail/395012/

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“Good enough for Government Work”: Quality, cost, and gaming the system, Part 3 (of 4 parts)

This is part three of the Charles Odegaard Lecture, delivered at the 27th National Conference on Primary Health Care Access, April 6, 2016

The VA is an example of how quality can be and is compromised when public sector funding is cut. In the area of public health, it can have an even greater impact, and no fewer apologists. When, under cost-cutting mandates from the state of Michigan the city of Flint changed its water supply from treated Lake Huron water to the industrially-polluted Flint River, the complaints of citizens were ignored. When concerned health care providers, like Dr. Mona Hanna-Atisha (pictured), raised warnings about rising lead levels in the children of that city, she was attacked and vilified. But she was right and they were wrong, or, perhaps worse, lying. Poisoning our children to save money. If individual health care is jeopardized when those responsible are being rewarded for cost-cutting, we can do a truly impressive job of harm when we destroy the public health infrastructure. And let us not forget that a major reason this was able to happen was Racism; that they were not “our” children, at least not those of the state authorities.

We need more emphasis on quality. Indeed, quality, not cost-cutting, needs to be our primary metric. Spending less should only be acceptable when quality is not negatively impacted. I realize that this is also subject to interpretation; “quality” has almost as many different interpretations as “waste”, and is frequently (if, hopefully, usually unconsciously) associated with “what benefits me”. I am talking about health care that is of benefit to most people, and is considered basic – keeping patients clean and out of their own filth, feeding them, treating the diseases that we know how to treat, doing surgery when it is of clear benefit, not having excessive waits for specialty care that compromise outcomes. And, most importantly, not providing financial incentives for limiting care. From a cost-cutting point of view, money is fungible, whether it comes from ‘cutting the fat’ or cutting needed care; but from a healthcare point of view, there is a big difference. (I refer to healthcare here as “caring for people’s health”, not the industry of the same name!)

This is the big issue, and it is amazing to me that it sometimes seems like such a mystery. If most of our incentives are to cut costs, to keep our jobs or to make bonuses or to keep our agency functioning, costs will be cut. Even when those cuts negatively affect quality, in real and dramatic ways. The argument for privatization goes something like “the private sector can do it better because, motivated by the opportunity to make profit, they will discover efficiencies that government employees do not, and run a ‘leaner ship’”. The problem is that, while there may be some examples of this happening, what usually happens is that costs are cut by cutting services, and making off with the profit, or bonus. The ship is made lean by cannibalizing its parts, and the only thing which is certain to be maintained in fine working order is the lifeboat in which the parties responsible hope to escape in while the rest sinks. This scenario is repeated over and over again, whether services are actually provided by private and for-profit organizations (think drug companies, insurance companies, nursing homes, and increasingly hospitals) or whether “private sector incentives” are built into publicly provided services, as in England at Mid-Staffordshire, or, increasingly, in the US in Medicare.

Profit may not be a great incentive to provide better health care, and is an uncertain to very poor guarantee of quality, but it is an excellent incentive to generating profit. Think of drug companies like Turing and its former CEO, Martin Shkreli, the poster child for unfettered greed, and his 5000% increase in the price of pyrimethamine, or of Valeant, the Canadian pharmaceutical company that recently doubled the price of secobarbital, an 80 year old barbiturate, in anticipation of California’s assisted suicide law. Think of the increase in price of colchicine, a drug that was used (in its plant form) to treat gout in ancient Egypt 3500 years ago, from 10 cents to $5 a pill when the FDA “encouraged” its manufacturer to conduct new studies and banned the generic (finally reversed last year, with generic colchicine again available.) Think of the insurance companies whose profit was baked into the ACA, making it costly and still not covering everyone. The ACP has recently called for government controls on drug pricing. The fact is that you can’t count on private for-profits to provide quality, unless you really trust Martin Shkreli.

Interestingly, in contrast to the Triple Aim advocates, critics of Sen. Bernie Sanders’ proposal for National Health Insurance system, Medicare for All, assert his math must be wrong, that we couldn’t both save money and deliver quality health care to everyone. (The Chicago Tribune editorial endorsing no one in the Democratic primary says: “Sanders first amused Americans who know their fiscal math with proposals for free college tuition, expanded Social Security, $1 trillion in infrastructure spending, "Medicare for all" .... The nonpartisan Committee for a Responsible Federal Budget calculates that his economic plans would push the top federal tax rate to about 77 percent”).[1](By the way, they really mean the topmarginal federal tax rate, which was, for the record, 90% when I took civics in junior high.) I don’t know if they are disingenuous or purposely befogging the issue, since it is clear that every other developed country delivers care to all its people for, usually, 1/3-1/2 of what we spend per capita in the US, with much better outcomes by most or nearly all measures.

So why are cost estimates in the US so high, when other developed countries do it for so much less? A great deal of it is that profit is built into the system. When we read about the problems of our system, we hear from insurers, who think providers charge too much, and providers, who think insurers pays too little, and each with an army to try to get what it wants. It is not because we care too much about patients. In Canada, there is a single payer national health insurance program (called “Medicare”) where the government pays the bills for largely privately-delivered care. The fact that it is private delivered is part of why their costs have risen second only to ours, but there is some central control. In Switzerland, there are multiple payers, insurance companies that are, however, forced to charge the same amount and provide the same basket of services, and be non-profit. How do they compete then? Why, on service to their patients! What an incredible idea! If you call your company to complain and can’t get through, you switch to another! As long as our system is predicated on building in excessive profit for providers, insurers, and drug companies, it will be fantastically expensive, albeit a full-employment program for those people trained to try to get bills paid and, on the other side, to deny payment. And it will be about cutting costs, not improving quality.

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[1] http://www.chicagotribune.com/news/opinion/editorials/ct-marco-rubio-tribune-endorsement-clinton-sanders-0310-md-20160309-story.html

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“Good enough for Government Work”: Quality, cost, and gaming the system, Part 2 (of 4 parts)

This is part two of the Charles Odegaard Lecture, delivered at the 27th National Conference on Primary Health Care Access, April 6, 2016

We have all heard the business mantra “do more with less”, which, on the face of it, is either absurd or, perhaps, a very cynical indictment of how much is currently being “wasted”, waste being differently defined depending upon the point the user wishes to make. I, for example, would consider “waste” to be money designated as “health care dollars” going to excessive profits for private corporations rather than actually being spent delivering health care; others, perhaps in the insurance industry, might consider “waste” to be an excessive “medical loss ratio”, their quaint term for the money that they actually have to spend delivering health care and don’t get to pocket. Politicians, of course, are more malleable; “waste” is whatever is being spent on what they don’t like, provided of course, it doesn’t get them into trouble with their constituents (like the VA scandal), in which case switching definitions is always an option.

What might be waste in the provision of health care? One is providing, and charging for, services that are unnecessary or possibly even harmful. A current example is the performance of pelvic examinations (as distinct from collecting Pap smears) in asymptomatic women (without pain, discharge, or bleeding) just to see what we can find. The American College of Physicians (ACP), the internists’ group, recommends against them. ACOG, the American College of Obstetricians and Gynecologists, recommends doing them, or at least leaving it up to the physician. Guess which group stands to lose more financially? ACOG’s position includes the statement that “…the College continues to firmly believe in the clinical value of pelvic examinations, through which gynecologists can recognize issues such as incontinence and sexual dysfunction. While not evidence-based, the use of pelvic exams is supported by the clinical experiences of gynecologists treating their patients.”![1]Hm. Maybe the best way to discover issues like incontinence or sexual dysfunction is not to put one’s hands inside a woman, but, perhaps, to ask her!

The US Preventive Services Task Force (USPSTF), of course, makes no recommendations on whether to do a particular exam or procedure, as its recommendations are for or against screening for particular diseases (with, in that context, exams or procedures discussed). It recommends against (“D” recommendation) screening for ovarian cancer, a major “benefit” cited by some ob-gyns, because it is inadequately sensitive and specific and doesn’t save lives. In a recent survey of ACOG members, the “potential benefits” of pelvic examination in asymptomatic women were cited, but not the costs – in dollars or to patients in terms of discomfort and morbidity. 

This is relevant here because when costs, both potential for harm as well as dollars, are not considered, everything could be potentially of benefit. Another recent study showing mild benefit from the use of the diabetes drug pioglitazone to prevent strokes or TIAs in people who have previously had them shows some benefit, but at the cost of an increase in the number of fractures requiring surgery or hospitalization; the editorialist in Journal Watch General Medicine emphasizes the benefit rather than the risk of harm, but is a neurologist, not an orthopedist. Should we do an MRI on everyone every week, just to see what we can find? Certainly there could be some things found! What about CT scans for screening for lung cancer (USPSTF “B” rating)? The best study, from the US, shows absolute risk reduction for death in 6.5 years of 0.33%; some smaller recent studies from Italy and Denmark show no benefit for mortality, and even in the US the frequency being recommended is moving to less than annually.  Should we be on track to weekly MRIs?

So, I just wanted to be clear that it is not true that I am for anything that could improve quality whatever the cost. That is ridiculous. But there is a baseline of quality which not only can, but regularly is, compromised when there is a potential for financial benefit from doing so. 

More recently, and wildly popular in health care, is the Triple Aim. The idea is to improve quality, improve patient satisfaction, and cut costs, all at once. It is difficult to find anyone, regardless of political affiliation or medical specialty, politician, provider, or consumer advocate, who doesn’t think that this is a good idea. To some degree, even I think this is a good idea, but I also believe that, like a lot of good ideas, the devil is in the details, the proof is in the pudding, where the rubber meets the road, or whichever is your favorite saying. While I am certain that many well-meaning pundits and providers, such as the leaders of family medicine, the experts at the Institute for Healthcare Improvement (IHI) and others are serious about improving quality, the reality, as M. Gregg Bloche notes in his NEJM piece (see Part 1, ref #3), is that almost all of the rewards are for cost-cutting. Yes, ACA has given us some modest revenue enhancements for meeting quality goals, although in general they are either very broad or very precise, and in either case poor measures of actual quality, and thus of limited impact. But almost all of the rewards, on either side of the Atlantic, in the NHS, or the VA, or for the ACOs created by the ACA, are for reducing costs. And it is almost always in the public sector that the impact is the greatest.

For example, outside the VA, we have our RACs, the bounty hunters licensed by Medicare to come into hospitals to find “fraud and abuse”. This usually manifests as discovering that some Medicare patients have been “admitted” to the hospital, rather than placed on “observation” status, which costs Medicare less. We have been well-socialized by our institutions, prompted by Medicare, into ensuring that we have reason to believe a patient will be in for “two midnights” (a bizarre conception with regard to health, much easier to achieve when a patient is admitted at 11pm than at 1am!), but how many of us realize that it is our patients who pay, literally with dollars? The excess cost is because “observation” is officially outpatient and paid by Medicare Part B, which requires much higher co-pays than the Medicare Part A that covers admissions. I have to admit that it was only relatively recently, when I heard a cousin being admonished by a friend to “make sure that your mom is admitted, not put on observation, or she’ll go bankrupt”, that I realized this.

[part 3 next week: The VA, the private and public sector, and the profit motive]

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[1] http://www.acog.org/About-ACOG/News-Room/Practice-Advisories/ACOG-Practice-Advisory-on-Annual-Pelvic-Examination-Recommendations

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