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Defensive Medicine: Fear Of Law Suit Or Fear Of Being Wrong?

September 28th, 2009 by Shadowfax in Better Health Network, Health Policy, Opinion
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A thoughtful and (dare I say it) balanced look at medical malpractice in today’s NYT:

Malpractice System Breeds More Waste in Medicine – NYTimes.com

The debate over medical malpractice can often seem theological. On one side are those conservatives and doctors who have no doubt that frivolous lawsuits and Democratic politicians beholden to trial lawyers are the reasons American health care is so expensive. On the other side are those liberals who see malpractice reform as another Republican conspiracy to shift attention from the real problem. […]
The direct costs of malpractice lawsuits — jury awards, settlements and the like — are such a minuscule part of health spending that they barely merit discussion, economists say. But that doesn’t mean the malpractice system is working.

The fear of lawsuits among doctors does seem to lead to a noticeable amount of wasteful treatment. Amitabh Chandra — a Harvard economist whose research is cited by both the American Medical Association and the trial lawyers’ association — says $60 billion a year, or about 3 percent of overall medical spending, is a reasonable upper-end estimate. If a new policy could eliminate close to that much waste without causing other problems, it would be a no-brainer.

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*This blog post was originally published at Movin' Meat*

How Many Uninsured Are There?

September 22nd, 2009 by Shadowfax in Better Health Network, Health Policy, Opinion
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*This blog post was originally published at Movin' Meat*

Is Physician Income At The Root Of Healthcare Inflation?

September 14th, 2009 by Shadowfax in Better Health Network, Health Policy
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Ezra Klein – The Provider Problem

Medicare keeps costs down somewhat better than private insurers, though not as well as private insurers did in the ’90s, and they do it by paying providers less money. Providers hate them for it, and that’s why doctors and hospitals and drug companies and device manufacturers have been so aggressive in opposing a public plan able to use Medicare rates. It’s also why Medicare’s growth rate is totally unsustainable — Congress keeps delaying the cuts in doctor’s payments that the Medicare law requires.

Ezra has an interesting post in which he posits that the problem in health care economics is that the rate of inflation of health care persistently exceeds the general rate of inflation.  Fine; I do not think anybody is in disagreement on that point any more.  He goes a bit further, wrongly, I think, in implying that the solution is just to pay doctors less.

The background here is that in the late ’90s, Congress decided to impose a cap on how much medicare expenses for physician services could increase in any given year, using a complicated formula called the Sustainable Growth Rate, which was indexed to GDP growth.  I should note that for some reason, Congress decided not to cap the increase in expense on hospital services, but to let the growth of Medicare Part A accelerate unrestrained.  (The hospital industry must’ve had better lobbyists.)

The SGR ran into trouble immediately, and required pay cuts for physicians, and Congress repeatedly caved and canceled the pay cuts.  So, Medicare Part B grows year over year, at a rate ahead of that of inflation, and the logic seems simple: we need to pay physicians less!

But that ignores the fact that much of physician’s revenue does not go to that physician’s income.  Most doctors (ER docs being an exception) have offices to maintain, nurses and assistants to pay, healthcare premiums for this employees, in addition to the malpractice insurance and billing expenses.   Medicine is not a low-overhead game any more!  My gut feeling was that physician income has been stagnant-to-declining over the last decade.

So I went to the Bureau of Labor Statistics and I manually pulled the data on physician income over the 1999-2008 timeframe, and the inflation rate for the same time span and saw that I was more or less right:

Note that for the first six years, physician income was less than inflation, and 2006-7 was only a little bit above the overall inflation rate.  Also note that for two years physician income was actually negative.   2008 was the only year in which physician income increased faster than inflation.

A note as to methodology: the BLS tracks doctor’s income by specialty, not as a single profession.  I pulled the data for General Internal Medicine, Family Practice, and Surgery, and averaged them.  Including surgery, unsurprisingly, greatly improved the income figures.  Internists’ and Family docs’ income lagged inflation every year but 2008.  This was not weighted, either — there are many more Internists and FPs than surgeons, while I weighted them equally.  (Also, the BLS changed data collection methods in 2002, creating a spurious increase of 33% that year, so I threw out that year and interpolated for the above graph.)  This is not a rigorous analysis, but it gets the point across that individual physician income has not been the driver of overall healthcare inflation. If anything, I think these methods tend to understate the degree to which physician income has stagnated during this period.

So why have global physician expenditures gone up so fast during the last ten years when physicians are, by and large, not seeing the increase in their bottom lines?  Several reasons, I think:

• As overhead costs increase, doctors squeeze more work into the day just to keep up with rising expenses.
• As the baby boomers age, and as lifespans continue to increase, patients are older & sicker, and physicians appropriately provide more intense care to this needier population.
• As new technologies, procedures and therapies are developed, physicians employ them more, generally at increased cost.
• For Medicare in particular, the graying of America simply means there are more people enrolled in Medicare.

So while doctors are providing more services, the increases are in low margin services or the increases are consumed by increased practice expenses.   I am sure there are more factors as well.

So, Ezra’s suggestion that simply paying doctors less (i.e. implementing the SGR-mandated cuts) would have some effect on reducing the global expense for physician services, it would do little to change the trendline towards increasing costs.  Put another way, it would lower the setpoint of the curve without changing its slope.  It would also, incidentally, have a dramatic effect on physician compensation, since the other costs of a medical practice are fairly inelastic, and the lost revenue would come directly out of doctor’s salaries.

I don’t have a solution to the costs problem, and I am not sure anybody else does either.  Cutting hospitals’ reimbursement would have terrible effects; hospitals are under tremendous economic stresses as it is, and I know most hospitals have razor-thin profit/surplus margins.  Medical devices are expensive, but they are so critical to the improvements in health care that I do not think anybody has the stomach to cut them.  Pharma probably should be cut, but their lobby has defended them very well.  There’s no good answer.

But it is overly simplistic to think that doctors’ compensation is at the root of the runaway costs problem.

*This blog post was originally published at Movin' Meat*

When Alternative Medicine Kills

September 7th, 2009 by Shadowfax in Better Health Network, Quackery Exposed, True Stories
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I saw one of the most disturbing things of my career recently — and that is really saying something.

This was a young woman, barely out of her teens, who presented with a tumor in her distal femur, by the knee.  This was not a new diagnosis — it had first been noted in January or so, and diagnosed as a Primary B-Cell Lymphoma.   By now, the tumor was absolutely huge, and she came to the ER in agonizing pain.   Her physical exam was just amazing.  The poor thing’s knee (or more precisely, the area just above the knee) was entirely consumed by this massive, hard, immobile mass about the size of a soccer ball.  She could not move the knee; it was frozen in a mid-flexed position.  She hadn’t been able to walk for months.  The lower leg was swollen and red due to blood clots, and the worst of the pain she was having seemed due to compression of the nerves passing behind the knee.  It was like something you see out of the third world, or historic medical textbooks.  I have never seen its like before.

So we got her pain managed, of course, and I sat down to talk to her and her family.

What I learned was even more amazing.  The patient had been seen by the finest oncologists in the region upon diagnosis.  They had all recommended the standard treatment of a combined regimen of chemotherapy and radiation.  She had, however, steadfastly refused this treatment.  She preferred, she said, the “Gerson Protocol.”  This is, she continued, “a way for the body to heal itself with a combination of detoxification and boosting the immune system.”

In a less grave situation I might have laughed and asked “So how’s that working for ya?”  As it was, the tears from her only partially-controlled pain took any humor out of the situation.  She was very frustrated that the Gerson therapy wasn’t working yet, but she did not perceive this as a failure of the treatment.  Her theory was that the severity of her uncontrolled pain was keeping her immune system suppressed and preventing it from working.  If, she hoped, she could just get her pain under control, she would finally start to get better.

I spent a lot of time with this young lady.  Listening as well as explaining.  She was dead set against chemo, which to her mind was equated with the “toxins” which had caused her cancer in the first place.  She wrote off the oncologists as pushing chemo “because that’s all they know how to do, and it never works.”  She had, in fact, burnt all the bridges with the various oncologists who had treated her, and was now left with only a pain specialist and a primary care doctor trying to do what little they could for her. She was equally frustrated by doctors in general, who “won’t do anything to help me.”

I could see why she felt that way; when a patient refuses the only possible effective treatment, there is not really much we can do to help her.

I did what I could.  I talked to both her doctors, and I called a new oncologist.  The oncologist, a wonderful man, promised to make time to see her in his clinic, even fully forewarned of the “baggage” she would be bringing with her.  She was happy to receive the referral, though I warned her that the new oncologist would be recommending more-or-less standard treatments.  Ultimately, she went home and I was left to reflect on the futility of the situation and the absolute wickedness of the charlatans and hucksters out there who promote this sort of thinking.   From the late Dr Gerson, to his modern-day counterparts Andrew Wakefield and Jenny McCarthy.

Most woo is harmless — but that’s because most woo is directed at chronic, ill-defined, or otherwise incurable conditions.  Think chronic fatigue or fibromyalgia.  Wave a magnet at somebody, get them to do a lot of enemas and go on a special diet, and you get to write a book and go on Oprah and collect a lot of money.  If the subjects of the “magical thinking medicine” think they are better from the intervention, then so much the better.

But the really pernicious thing about allowing fantasy medical theories and treatments into the mainstream is that when they gain enough credence among the masses, they will tend to be used in place of real medical treatments that work.  Like vaccines.  Even the anti-vaxxers have a limited and indirect harm — of the many thousands of children who go unvaccinated, only a very few get measles and even fewer die.  It’s a real harm, but one which is easy to miss if you’re not affected personally.  But when woo supplants real medicine against lethal diseases that actually have effective treatments, the harm is so much more severe and so apparent that it cannot be left unrecognized.  Because of the practitioners of “alternative” medical treatments who irresponsibly and dishonestly teach people to distrust medicine and embrace unscientific treatments, this young woman is enduring incalculable pain, and may well lose her life.

It’s sad, and it’s an outrage.

*This blog post was originally published at Movin' Meat*

Medicare & Private Health Insurance: Monkey See, Monkey Do

September 3rd, 2009 by Shadowfax in Better Health Network, Health Policy, True Stories, Uncategorized
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File this under utterly predictable:

Aetna tightens payment policies on hospital errors – Modern Healthcare (sub req)

Aetna has established new, tighter policies dictating when it will and will not reimburse for medical care related to errors made by providers.

Under the policies, Aetna has broken errors into two categories: “never events”—three events involving surgery: wrong patient, wrong site and wrong procedure—and 25 serious reportable events as defined by the National Quality Forum. Providers will not be reimbursed for a case involving one of the three never events, under the new payment policy. Of the 25 events, eight will be reviewed by Aetna to determine whether reimbursement should be withheld. The rest of the events will also be reviewed under Aetna’s new policy, but they will not be considered eligible for adjustments to reimbursement, the spokeswoman said.

This of course follows on the heels of Medicare’s decision not to pay for such events. The good news is that, as far as I can tell, Aetna has not extended the policy as far as Medicare has. Medicare, you may recall, also decided not to pay for certain (arguably) preventable conditions, such as foley-catheter-associated urinary tract infections, and surgical wound infections. Aetna, at least for the moment, is limiting its policy to the more black-and-white “never events” as defined by the National Quality Forum: items such as wrong-patient surgery or death due to contaminated medications.

I mention this not to rail against these standards or against the notion of incentivizing hospitals financially to avoid errors, but to highlight how rapidly and directly Medicare policies are aped by private insurers to the point that they become industry standards.

*This blog post was originally published at Movin' Meat*