June 24th, 2009 by EvanFalchukJD in Better Health Network
2 Comments »
Steven Pearlstein actually wrote that in the Washington Post on Wednesday, right after (another) long rant against physicians. At the end, he offers doctors an olive branch. Or maybe its an offer he thinks doctors can’t refuse:
The choice for doctors now is quite clear: They can agree to give up a modest amount of autonomy and income, embrace more collaboration in the way they practice medicine and take their rightful place at the center of a reform effort that will allow them to focus more on patient care. Or they can continue to blame everyone else and remain — stubbornly — a part of the problem.
After reading Pearlstein’s columns, I’m still sure not why he has such a problem with doctors. I am beginning to think it’s because he just misunderstands them.
Pearlstein is convinced that doctors go into medicine for the same reasons investment bankers go to Wall Street: to make money.
Docs seem to take it as a given that physicians in the United States should earn twice as much as doctors in the rest of the world — and five times more than their patients, on average. Mention these facts and you are guaranteed to get a lecture about the crushing debt burden that young docs face upon completion of their medical training. Offer to trade free medical education for a 20 percent reduction in physician fees, and you won’t find many takers.
Pearlstein has no source for these claims, but let’s assume they’re true, and do the math. The government says that there are 633,000 doctors in the United States, and they earned median salaries between $135,000 and $320,000 a year. If we take a number in the middle — say $200,000 — that means that American doctors earn about $125 billion a year. A big number, but total health care expenses in the United States are over $2 trillion, which means doctors represent about 5% of the total. Can physician salaries really be driving our health care problems?
It seems unlikely. But Pearlstein is desperate for it to be true, so he keeps trying to discount all of the other possible causes of our problems as examples of conspiracies or arrogance or sloppiness:
For example, medical malpractice litigation is a problem…
But one of the reasons malpractice suits are still necessary is because doctors have transformed local professional review boards, which are supposed to protect patients, into nothing more than mutual protection societies
The “infelixible bureaucratic processes” that insurers impose are a problem….
But given that there is overwhelming evidence that doctors tend to order up tests, perform surgeries and prescribe treatments whose costs far outweigh the benefits, you can hardly blame the insurers.
We think it is good to have “clever and creative” doctors…..
but . . . we could all have better health at a lower cost if docs were less inclined toward the medical equivalent of the diving catch and simply were more disciplined about kneeling down for routine ground balls.
Doctors should be applauded for embracing evidence-based medicine…
however, practicing physicians still think that nothing should interfere with the sacred right of doctors and patients to make all medical decisions, even when they are wrong.
Pearlstein’s views on how doctors think are fundamentally flawed. He thinks of them like stock brokers, pushing questionable stock to make commissions for themselves. He’s thought of all the different ways doctors are abusing the system to their own advantage, but he doesn’t seem to have thought that maybe, possibly, he’s wrong.
So, yes, some doctors abuse the privilege of being asked to help their patients. But the overwhelming majority don’t. They want to spend as much time as they can with their patients, collecting information, thinking about their problem, and offering good, sound advice. They are bothered by the involvement of the insurance company or the government or the plaintiff’s lawyer not because they believe they have a “sacred right” to total independence. Or because they think the way to fix health care is to give them “free rein to treat their patients . . . run the hospitals and set their own fees.”
No, it is because these things actually interfere with the doctor’s ability to think, process and decide with their patient on the right things to do.
Pearlstein and other would-be reformers of our health care system need to reconsider their assumptions on what motivates doctors. Maybe it’s something Pearlstein should ask some of his friends about.
*This blog post was originally published at See First Blog*
June 14th, 2009 by EvanFalchukJD in Better Health Network, Health Policy
4 Comments »
Everyone is reading Atul Gawande’s article in the New Yorker about health care costs. But I think most people misunderstand Gawande’s major point.
Everyone’s At It
The conventional wisdom on Gawande’s piece is this: our problems are caused by bad incentives in our health care system. They encourage doctors to overprescribe care. McAllen, Texas is the poster child of this problem. If we can change the economic incentives, doctors will behave better. They will follow medical evidence, not their bottom lines, and from this will emerge a rational, affordable system.
This isn’t what Gawande is saying.
Gawande went to McAllen expecting to see a microcosm of the American health care system. As expected, he found excessive, even abusive spending, and a culture that encouraged both. But he also found that in nearby El Paso, Texas, medicine wasn’t practiced this way, nor in most other places in the country. And so he came up with a surprising insight. Yes, McAllen is a reflection of what can happen based on the incentives in the system. But if every incentive works this way, why is McAllen such an outlier?
Gawande concluded it had to do with the “culture” of medicine in each community. Most doctors go into medicine to help patients. In Gawande’s visit to McAllen, he heard stories that money had become more important than quality care. What Gawande realized was how important this question of “culture” was to how McAllen became McAllen. It made him think of places that had a completely different culture, like the Mayo Clinic.
The doctors of the Mayo Clinic decided, some decades ago, to put medicine first:
The core tenet of the Mayo Clinic is “The needs of the patient come first” — not the convenience of the doctors, not their revenues. The doctors and the nurses, and even the janitors, sat in meetings almost weekly, working on ideas to make the service and the care better, not to get more money out of patients. . . . Mayo promoted leaders who focused first on what was best for patients, and then on how to make this financially feasible.
Gawande couldn’t believe how much time doctors at the Mayo clinic spent with each patient, and how readily they could interact with colleagues on difficult problems. While it is true, the Mayo Clinic has financial arrangements that make this easier, it is the culture of patient care that dominates, not questions of pay:
No one there actually intends to do fewer expensive scans and procedures than is done elsewhere in the country. The aim is to raise quality and to help doctors and other staff members work as a team. But almost by happenstance, the result has been lower costs.
“When doctors put their heads together in a room, when they share expertise, you get more thinking and less testing,” [Denis] Cortes [CEO of the Mayo Clinic] told me
And this is where Gawande is being misunderstood.
The “cost conundrum” that Gawande talks about is not about how to cut costs, or how to change who pays for health care and how much. It’s deeper than that. Gawande’s point is that we have been fixated for so long on the question of money in health care that we are starting to forget about medicine. By focusing on ever more clever ways to pay doctors, we have systematically undervalued everything that makes for high quality medicine. Things like time with your patient, thinking about his or her problems, consulting with colleagues, and coming up with sound advice.
We discount what he calls the “astonishing” accomplishments of the Mayo Clinic on this score. And instead of designing health care reform around ways to help more hospitals become like the Mayo Clinic, we choose instead to think about money, to focus our attention on how to cut costs in places like McAllen.
Politically, it makes sense – it’s convenient to have a poster child like McAllen to explain why one reform plan or another should become law. But the pity is that in this important time of reform we’re not talking about trying to put the needs of the patients first – to put medicine back in the center of health care. The pity is that in spite of the fact that everyone’s reading Gawande’s article, his most important insight is being misunderstood.
If we continue to be focused on money over medicine, we will lose the “war over the culture of medicine – the war over whether our country’s anchor model with be Mayo or McAllen.”
*This blog post was originally published at See First Blog*
June 10th, 2009 by EvanFalchukJD in Better Health Network
3 Comments »
Did you know that doctors are paid too much, wrongly complain about medical school debt, and falsely believe there is a medical malpractice crisis?
Did you know that doctors are hopelessly conflicted sellers of medical care, motivated by the search for extra income?
Well, then you haven’t read the Washington Post’s Steven Pearlstein’s work on health care reform.
“It’s the doctors, stupid,” he begins his column today. At once, he recycles the tiredest of political phrases and tells his readers exactly what he thinks of them. But it’s not the column that is most telling, it’s the live web discussion that followed. I participated in it, and can share with you the highlights. It’s a revealing insight into the thinking of a mainstream DC columnist.
To save you the trouble, here’s a summary of Pearlstein’s views: Doctors learn a craft that they owe to the rest of us as a public good. But instead of doing this, they take advantage of knowledge to make as much money as they can. They do it willfully – like an insider-trading stock broker – but they also do it because they just aren’t all that competent at what they do.
Think I’m making this up? Read:
On medical school debt:
I think we allow doctors to make too much of their debt. . . In major metropolitan areas, that debt looks pretty small when compared to the lifetime earnings that doctors accumulate in private practice over many years. They more than make up for their investment, as it were. But they use this debt to justify their elevated incomes for the next 30 years — and make no mistake about it, doctors in the U.S. do make ALOT more than docs elsewhere, on average. . . . My suggestion is that we socialize the cost of medical education, that is have the government pay for it, in exchange for a couple of years of community service. That way, we get the community service and we eliminate the No. 1 reason given by docs to justify getting paid more than docs everywhere else.
According to the Bureau of Labor Statistics, a freshly minted family care doctor has a median wage of less than $140,000 a year. According to the AMA, these same doctors have, on average, about $140,000 in educational debt. Thirty years seems about how long it would take to pay off that debt, and you can forget about buying a house, a car, or paying for your own kids’ school under those circumstances. I’m sure many medical students would love the Joel Fleischman plan, but we should do that because maybe it will help more people become doctors, not because we think doctors are exaggerating the impact of debt equal to 100% of your gross pay.
On how our system ought to allocate medical resources:
There is no reason why people can’t travel an hour to a big hospital to have a baby, for example, in a big modern maternity ward that does lots of deliveries and has enough volume to be able to afford all the latest equipment in case something goes wrong. I mean how many times in your life do you have a baby that you can’t drive an hour to have it done, rather than insisting that every community hospital have its own maternity ward. It’s just one example of the inefficiency built into the system by people — that would be you and me — who insist on things that, in the end, don’t have ANY impact on the quality of care. In fact they have negative impact.
I don’t know if Pearlstein has ever had a baby before, but just being an hour away from a hospital is unthinkable for most expectant moms in the weeks prior to delivery. And what is someone to do who lives an hour away and has a complication during the pregnancy? Pearlstein’s prescription seems to be that they should eat cake.
On the freedom of patients to choose their medical care:
The emphasis on being able to choose your own doctor in every instance is another, as if most of us have a clue as to who are the best docs and who aren’t. These are the kinds of irrational things we need to try to work out of the system, because they wind up being very costly.
Yes, for goodness’ sake, let’s get rid of the irrational desire of a sick person to want to pick their own doctor. Even Senator Kennedy’s “American Choices Act” guarantees the right of patients to choose their own doctor. I don’t know where Pearlstein is on the political spectrum with this view, except perhaps a certain territory between China and South Korea.
On how doctors are hopelessly conflicted in giving medical advice by their desire to make money:
But first we need the evidence to show that it isn’t a good idea. Then, once we have the evidence the doc has to follow the protocol and explain to the family why it’s not a good idea and not merely blame the big, bad insurance company for being so heartless–which, by the way, a lot of docs do, so they can look like the good guys. Of course they’d love to do the surgery in many cases because they’d like the business and the extra income, so they are hopelessly conflicted. . . . .
[B]uying medical care is not like buying lawn furniture. . . in medical care you rely to an extraordinary extent on the advice of the doctors (i.e. the sellers). And its also not an area where you are inclined to be very price-sensitive — is anyone going to go the the Wal-Mart of surgeons if they think their life may depend on it. . . . But it is NOT true that a well-informed consumner will always make the right choice about medical options — they still need the advice of doctors, who under the current system have a very noticeable conflict of interest.
I’m actually not sure that Pearlstein has even been inside of a Wal-Mart. Because they consistently have high quality merchandise at the lowest prices. In fact, if more hospitals worked like Wal-Mart the problems that plague our health care system today probably wouldn’t exist.
Responding to a commenter who said that the notion that defensive medicine is a large expense is “totally false:”
Indeed. But doctors don’t believe this, no matter what evidence you present them.
Yes, evidence is like kryptonite to doctors.
I asked Pearlstein if a doctor ran over his dog or something. He didn’t directly respond, simply saying “Maybe you should talk to Atul [Gawande].”
Now that’s the only sensible thing he said.
June 10th, 2009 by EvanFalchukJD in Better Health Network, Health Policy
1 Comment »
The OSHA-ization of health care quality continues.
A research group and a consulting firm have been hired by the state of Massachusetts to head up a new initiative to publish cost and quality information on Massachusetts doctors. But the quality measures they will use are the same old ones we have seen for a long time. They mean very little to most patients, and even less to doctors as a measure of how good their work may be.
To understand what I mean, look at what is being measured.
For the category “Adult Diagnostic and Preventative Care,” there are only four quality measures. They are:
- rates of colorectal screening tests
- the number of patients in an insured population who lowered their blood pressure in a given year
- correct imaging test use for lower back pain
- rates of use of a spirometry test for COPD
The good news is Massachusetts doctors do better than the national average on these measures. The bad news is it’s hard to say what that means as far as how good any doctor is who is measured this way.
Maybe it’s better in women’s health. There, the four quality measures are:
- rates of breast cancer screening for women 40-69
- rates of cervical cancer screening for women 21-64
- rates of chlamydia screening for women 16-20
- rates of chlamydia screening for women 21-25
Hmm. So if I am a 30 year-old woman trying to figure out how good my doctor is, the only thing that is being measured is whether he does a cervical cancer screening on me or not. How about pediatrics?
- rates of well visits
- correct antibiotic use for upper respiratory infections
- follow-up with children starting medications for ADHD
I could go on, but there’s a pattern. All of these “quality” measures are crunching medical billing data and styling it as a quality metric. And so every metric is going to be focused on things that are easily measurable by a review of those bills.
But there’s a more disturbing pattern. The information is simply not valuable to consumers. Worse, I think it is deeply misleading. A medical group that does chlamydia screenings on 100% of its patients may be good or bad – or it just may be smart enough to know that if they do the state of Massachusetts will rate them with five gold stars. But consumers won’t be able to tell the difference. All they will know is that practice A is “high quality,” while practice B isn’t. Some doctors are starting to sound the alarm about this.
And this is the larger point. Our health care is organized in a way that systematically undervalues the thinking, processing and deciding aspects of medicine- the things that really matter to you when you’re a patient who is sick trying to get help. Our system treats medicine as an assembly-line process amenable to assembly-line metrics. But it’s not.
Doctors, like others in professions requiring judgment and reflection, need time to think, and ought to be judged by how well they do that. Since the leading cause of misdiagnosis is a failure of synthesis – a failure by the doctor to put together available information in a way that leads them to the right conclusion – our system ought to be built around helping make sure this happens each and every time.
So, instead of a web site where you could see how often a medical practice does chlamydia screenings, imagine you could find out how often doctors at a hospital got their patients the right diagnosis and treatment? Now that would be a useful way to measure quality.
*This blog post was originally published at See First Blog*
June 4th, 2009 by EvanFalchukJD in Better Health Network
No Comments »
Preventable disease is a terrible burden, made all the more tragic by the fact that it can be avoided.
Policymakers in Washington take this a step further, claiming that we can save huge amounts of money by systematic programs to prevent disease and encourage wellness. The document explaining the Republicans’ new “Patient Choice Act” says that wellness and disease prevention can save trillions of dollars (.pdf). President Obama seems to agree, saying these programs like these can create “serious savings” that represent “huge amounts of money in the long term.”
There’s one problem: study after study says it’s not true.
Earlier this year, the prestigious journal Health Affairs published a study on this topic. The author reviewed the results of nearly 600 studies (abstract at link, full article requires subscription) on the cost-effectiveness of various prevention programs. The findings are overwhelming – less than 20% of these programs saved money, while more than 80% actually added more to medical costs than they saved. How can this be?
It isn’t that complicated when you think about it. Take high blood pressure. If every American with high blood pressure took blood pressure medication, we would have lower rates of heart disease and stroke, and of course, eliminate the costs associated with those avoided conditions. But as the study points out:
the accumulated costs of treating hypertension are nonetheless greater than the savings, because many people, not all of whom would ever suffer heart disease or stroke, must take medication for many years.
Studies have shown similar results for other chronic diseases, like diabetes and asthma. There is also important data showing that even screening programs for cervical, breast and colon cancer cost more than they save.
Does this mean we shouldn’t do these things? Of course not. For each life that is touched by avoiding a chronic disease, finding a tumor early on, staying out of the hospital, there is enormous value. But the value is not financial. It’s something we do because it’s right, and it’s inherently good. There are no formulas to measure this.
Health care is very expensive, and the burden of that cost affects us all. But to talk seriously about this problem we need to confront an inconvenient truth: there is more to health care than just dollars and cents.
*This blog post was originally published at See First Blog*
