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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Medical interventions we shouldn't be getting: issues of cost, health, and equity

Many of us are concerned about the cost of medical care, particularly in the US. We are also concerned about the care that we, ourselves or our families and friends receive. We want the diagnostic tests and treatments we get to be likely to benefit us and to not cause us harm. Or, if there is chance that we may be harmed, that the probability and degree of benefit exceeds the probability and degree of harm. Sometimes there can be a tension here: we want to spend lesson health care globally (and certainly less on the portion that just goes into the pockets of big corporations, like pharmaceutical companies and device manufacturer, insurers and huge health provider networks), but don’t want to scrimp on things that may benefit us. Especially when we are well-insured and not paying for it directly out of our pocket.

Fortunately, there are many times when these two different interests come together, when tests or treatments that are costly are also of no benefit to us, and may cause us harm. The problem is that sometimes our doctors recommend them to us anyway, or, frankly, we ask for them (because we’ve read about it on the Internet or seen an ad on TV or because a doctor recommended it for our Cousin Shirley who had the same thing, or at least something that sounded a little the same). How can we, as patients, know when our doctors are recommending a test or treatment that is not indicated for us, will not benefit us, may even cause us harm? How do we know when we are appropriately advocating for ourselves as opposed to asking for something inappropriate? It is not easy, but we can try.

One answer is NOT to reject all medical recommendations for diagnosis or treatment, to assume that something “natural” is always right. Medicine can do a lot; it can treat a lot of illnesses that can cause you to suffer or die prematurely. There are many tests that are proven useful or valuable for making diagnoses. Another is to not reject things simply because they cost money (difficult when you don’t have much and they cost a lot), but also not to ask to have them because you havemoney (or insurance). To a great extent it is asking your doctor questions, asking about the degree of benefit, hoping that they are up to date, trying to question what the likely benefit is from another test or treatment, especially if costly. It also, sadly, means understanding if the doctor themselves, or a company they work for, stands to make profit on the test or treatment, since this creates a conflict of interest (but certainly does not mean that it always or usually isn’t appropriate).

There is an entire medical literature on medical overuse, and your doctor should be familiar with it, or at least the most egregious overuses that are in her/his field. A recent article in JAMA Internal Medicine , “Update on Medical Practices That Should Be Questioned in 2015”, by Morgan et al., reviews some of these.[1]The authors reviewed the literature on articles published in 2014, and came up with 104 that at least one of the 3 thought was very important, and 33 that all agreed were very important. The article reports on the “Top 10”, because this is a nice, round number and because it seems to be a manageable number of things for doctors to remember. Just these 10 represent a lot of excess tests and excess expense.

I will summarize some of these 10 (the ones I feel are most relevant; you can find them all in the article), both to remind doctors and other health care providers who might not have seen it, and because other readers may have had these tests recommended. Before doing so, it is important to review the difference between a screening test, done on the general population (or a subset of it) who don’t have any symptoms, and a diagnostic test, which may be the same test done on someone with symptoms related to what that test tests for. Frequently a test is useful for diagnosis for someone with symptoms but in someone without may not only be of little use, but find “false positives” that end up leading to more testing with more cost and greater risk.

• There Is No Benefit to Screening for Asymptomatic Carotid Stenosis.  None, for screening. Ultrasound or other tests may be of value for people with TIAs or other symptoms.
• Screening Pelvic Examinations Are Inaccurate in Asymptomatic Women and Are Associated With Harms That Exceed Clinical Benefits. Again, none, for screening. You can’t screen for ovarian cancer. I have been trying to convince my residents of this for years, despite their being often taught otherwise by OB-Gyns. This is the part where the provider puts his/her hands inside. It is NOT the same as a Pap smear, which is recommended for screening.
• Head Computed Tomography Is Often Ordered but Is Rarely Helpful. Often finds clinically insignificant abnormalities. Also, often repeated with no added benefit. (“A retrospective cohort analysis reviewed 130 patients admitted for any cause at least 7 times during a 1-year period to a tertiary care center. Patients received a mean of almost 7 CT scans, including 3 head CT scans. More than one-third (36%) of head CT scans were ordered to evaluate for altered mental status. Only 4% (7/127) of head CTs had clinically significant findings that resulted in a change in management.”)
• Thyroid Cancer Is Massively Overdiagnosed, Leading to Concrete Harms.  Study is from S. Korea, where they screen for it.
• There Is No Benefit to Paracetamol (Acetaminophen) for Acute Low Back Pain. “The median times to recovery were 17 days in both of the paracetamol groups and 16 days in the placebo group.” This does not mean we should be using opioids, though. In fact, when we give opioids for good reasons, like postoperative pain…
• Postoperative Opioid Use Continues Past the Postoperative Period.

Some overuse comes because practices once felt to be appropriate, but now shown not to be, are being taught to trainees, who either don’t know or are loathe to disagree with their instructors. Some comes, consciously or not, from the potential for providers to make money. Another recent JAMA Internal Medicine[2]study looked at family medicine and internal medicine residents who saw “secret shoppers”, standardized patients who were requesting inappropriate imaging. About 25% of the time the tests were ordered, which could be seen as either bad or good (75% of the time they weren’t). The study also showed no difference between those residents who got significant feedback and those who didn’t, and similar (and generally good) techniques of communicating to the patients why these were not indicated. An interesting wrinkle is that some of the tests chosen (MRI or CT for new-onset uncomplicated low back pain) were imaging studies not recommended by the American Academy of Family Physicians and American College of Physicians (Internal Medicine) as part of the “Choosing Wisely” campaign, but are not recommended against by the  American Academy of Orthopaedic Surgeonsin their “Choosing Wisely recommendations. Of course, orthopedists stand to benefit from doing surgery on these patients. (By the way, among the recommendations of the AAFP is not doing screening pelvic examinations!)

What is the social justice issue here? After all, tests and treatments that are not indicated should not be done on anyone, regardless of financial or insurance status, racial or ethnic characteristics. Indeed, one could argue that those with more money or better insurance would be the most likely recipients of extra tests. But poorer, or less well-insured, people often don’t get the tests and treatments that they actually need (which has often been discussed in this blog; see for example Dead Man Walking: People still die from lack of health insurance, November 17, 2013), while tests and treatments are overused for others. This creates the (accurate) perception of a two-class health care system, and the (sometimes, perhaps, less accurate) perception that the disadvantaged are, in addition to not getting care they need, are not getting discretionary care that benefits the wealthy. Also, the more money spent globally on unnecessary medical care, the less available for necessary non-medical initiatives (housing, food, education) that would actually create better health.

A single payer system would not in itself achieve this goal, but it would create far more equity in the allocation of healthcare dollars, and at least eliminate the profit motive that might impact the recommendations of some providers and healthcare institutions.

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[1] Morgan DJ, Dhruva SS, Wright SM, Korenstein D, Update on Medical Practices That Should Be Questioned in 2015, JAMA Intern Med. 2015 Dec 1;175(12):1960-4. doi: 10.1001/jamainternmed.2015.5614.

[2] Fenton JJ, Kravitz RL, Jerant A, et al., Promoting Patient-Centered Counseling to Reduce Use of Low-Value Diagnostic Tests: A Randomized Clinical Trial, JAMA Intern Med. Published online December 07, 2015. doi:10.1001/jamainternmed.2015.6840

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