September 1st, 2009 by GruntDoc in Better Health Network, Health Policy, Opinion
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In an effort to get the word out about their new EM Physicians’ blog ( em-blog.com ) Dr Bukata has asked to post here to generate some conversation, and some buzz for their blog.
Dr. Bukata has long been a leading light in EM, and it’s my pleasure to present:
THE SECRET TO UNIVERSAL HEALTH COVERAGE – DOCTOR BEHAVIOR
As the debate goes on regarding the Obama initiatives for healthcare reform, the one recurring theme that is heard is – cost. What is universal access to healthcare going to cost and who is going to pay for it? It really is just about money. The fundamental premise is that, if we spend at current rates, it will cost an ungodly amount of money to cover everyone in this country no matter who pays.
Given that we cannot continue to spend at the current rate, yet we want to insure the 40 million people or so who have no insurance (and all of this is supposed to remain budget neutral over time), the logical answer regarding cost must be reducing per capita spending while increasing the number of people covered.
How do we achieve this goal? There is really only one way. The answer is to narrow practice variation. Practice variation between doctors is absolutely huge. The data are compelling. Even small changes in the degree of practice variation have the potential to save hundreds of billions. I refer readers to an article in the New England Journal of Medicine by Elliott Fisher, et al (360:9, 849, February 26, 2009). The article is entitled Slowing the Growth of Health Care Costs – Lessons from Regional Variation. This short paper gives examples derived from the Dartmouth Atlas on Health (which I have referred to in the past and which is absolutely fascinating reading concerning Medicare practice variation nationally) that make it clear that doctors are major determinants of healthcare costs. We order the tests, we order the drugs, we put people in the hospital and we determine where they go in the hospital and, to the chagrin of hospital administrators, we determine how long they stay.
Using Medicare as an example, at our current rate of spending growth in healthcare it is estimated that Medicare will be in the hole by about $660 billion by 2023. If per capita growth could be decreased from the national average of 3.5% to 2.4% (just a measly 1.1%), Medicare would have a $758 billion surplus. Just a measly 1.1%.
Now for some examples. Per capita inflation-adjusted Medicare spending in Miami over the period 1992 to 2006 grew at a rate of 5% annually. In San Francisco it grew at a rate of 2.4% (2.3% in Salem, Oregon). In Manhattan, the total reimbursement rate for noncapitated Medicare enrollees was $12,114 per patient in 2006. In Minneapolis it was $6,705.
It is noted that three regions of the country (Boston, San Francisco and East Long Island) started out with nearly identical per capita spending but their expenditures grew at markedly different rates – 2.4% in San Francisco, 3% in Boston and 4% in East Long Island. Although these differences appear modest, by 2006 per capita spending in East Long Island was $2,500 more annually than in San Francisco – with East Long Island representing about $1 billion dollars more from this region alone.
Are the patients sicker in East Long Island? Hardly. There is no evidence that health is deteriorating faster in Miami than in Salem. So what’s the difference? People point to “technology” as being one of the biggest sources of costs in American healthcare. But “technology” does not account for these regional differences. Residents of all U.S. regions have access to the same technology and it is implausible that physicians in regions with lower expenditures are consciously denying their patients needed care. In fact, Fisher and colleagues note that the evidence suggests that the quality of care and health outcomes are better in lower spending regions.
So what is the answer? It is physician behavior.
It is how physicians respond to the availability of technology, capital and other resources in the context of the fee-for-service payment system. Physicians in the higher cost areas schedule more visits, order more tests, get more consults and admit more patients to the hospital. Medicine does not fit the supply and demand model of modern day capitalism. Normally when there is lots of competition, prices go down. Not in medicine. In medicine payment remains the same and is not sensitive to supply or demand.
And normally when there are a lot of businesses providing the same service, there are fewer customers per business. Not in medicine. Although doctors may have fewer patients in an area saturated with providers, they don’t necessarily have fewer visits because doctors determine the frequency of revisits and the literature indicates there is huge variability in what they consider the appropriate frequency for revisits when given identical patient scenarios. And do patients shop prices to choose medical providers – no way – it is impossible. Bottom line – medicine is largely immune to the laws of supply and demand and other economic drivers.
So what’s the answer? It is simple, yet hard. Doctors in high cost areas need to learn to practice like doctors in low cost areas. Are doctors in low cost areas beating their chests and bemoaning the inability to care for their patients with the latest technology? Not at all. But doctors in high cost areas are largely clueless to the practice patterns of physicians in low cost areas and are likely to whine if asked to tighten their belts and learn to be more cost-effective. The good thing – mathematically, this will result in only half the doctors in the country complaining as they are prodded to emulate the practices of their more cost-effective cousins.
To accomplish this narrowing in practice variation, doctors will need help (and, particularly, motivation). Payers and policymakers will need to get involved to facilitate and stimulate the information transfer between doctors. Based on research by Foster and colleagues, it’s advised that integrated delivery systems that provide strong support to clinicians and team-based care management offer great promise for improving quality and lowering costs.
Given that most physicians practice within local referral networks around one or more hospitals, it is suggested that they could form local integrated delivery systems with little disruption of their practice. Legal barriers to collaboration would need to be removed by policymakers and incentives to create these systems would drive their formation.
Fundamentally, Medicare would need to move away from a solely volume-based payment system (since doctors are the drivers of their volumes) and other forms of payment would need to be incorporated (such as partial capitation, bundled payments or shared savings). Hospitals and doctors lose money when they improve care in ways that result in fewer admissions, and they lose market share when they don’t keep pace in the local “medical arms race” (does everyone need a 64-slice CT?). In the current system there are no rewards for collaboration, coordination or conservative practice. This must change.
The bottom line – much can be done to save money yet provide patients with high quality, technologically advanced care without rationing (or worse yet having some government “board” telling you what to do). There is so much waste in the current system largely resulting from physician practice variation that the opportunities are huge.
And, should they choose, doctors are in a position to take the lead. The AMA and other physician organizations can initiate (well, that may be asking a lot) and support incentives that will facilitate the needed changes outlined above. Unfortunately, organized medicine (almost an oxymoron) is more often than not reactionary. “What are they (payors) making us do now?” That’s the typical response. What’s needed is for physicians to take the leadership role that their patients expect of them. The status quo is not an option. And if doctors won’t act, the payors will – because ultimately, the payors have the power. That is one rule of economics that does apply even to the practice of medicine.
W. Richard Bukata, MD
I respectfully disagree about markets not working in medicine, but have few arguments with the rest.
What say you?
*This blog post was originally published at GruntDoc*
September 1st, 2009 by Happy Hospitalist in Uncategorized
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There appears to be some controversy brewing. The New York Times is reporting that the CDC may recommend just that in an effort to protect the boys against HIV as they become sexually active:
The topic is a delicate one that has already generated controversy, even though a formal draft of the proposed recommendations, due out from the Centers for Disease Control and Prevention by the end of the year, has yet to be released.
The American Academy of Pediatrics is currently neutral. As a result, many state Medicaid programs do not pay for the procedure. But it sounds like that may be changing, with a policy indicating circumcision has health benefits beyond HIV prevention.
Hundreds of commenters wrote into the New York Times today to complain about “child abuse” and “genital mutilation” and one “religious sect’s agenda of control” (i.e. Jews).
I don’t see what the big deal is. Everyone seems to be piercing and tattooing their bodies these days. What’s wrong with a little circumcision?
Perhaps you could mandate the same kind of prevention that schools do with their vaccination requirements. What do you think? Should all boys be circumcised?
*This blog post was originally published at A Happy Hospitalist*
September 1st, 2009 by RamonaBatesMD in Better Health Network, Opinion
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I’m going to wade right in here. I am not a fan of abortions, but neither am I of amputations. Both are sometimes necessary. To me, too often abortion opponents forget the mother. She is a life present before us. Her care should not be forgotten.
I have been listening and reading the discussions over how the abortion coverage may sink health care reform. I think it would be a shame if this one issue does sink reform.
If my understanding of the Hyde Amendment (and it’s amendments over the years) is correct the Federal Government covers the cost of abortions in cases of rape or incest or when the life of the mother is at risk. It does not cover the cost when the health of the mother is at risk:
With these bans, the federal government turns its back on women who need abortions for their health. Women with cancer, diabetes, or heart conditions, or whose pregnancies otherwise threaten their health, are denied coverage for abortions. Only if a woman would otherwise die, or if her pregnancy results from rape or incest, is an abortion covered. The bans thus put many women’s health in jeopardy.
I agree with opponents who do not wish to cover abortions for simply any reason (i.e. the timing for a pregnancy is not good, etc). Abortion should never be used for birth control. That should be done using birth control pills, condoms, abstinence, etc.
Currently, the only abortions available under Medicaid are the ones mentioned above. I think it’s a shame that distinctions can not be made to provide coverage for a woman who’s HEALTH would be negatively affected by her pregnancy. All insurance policies should do so in my opinion.
Opponents of abortion want language that would prohibit any private insurance company that accepts federal funds from offering to policyholders abortions other than those already eligible under Medicaid.
Sources
How Abortion Could Imperil Health-Care Reform by Michael Scherer; Monday, Aug. 24, 2009; Times.com
What is the Hyde Amendment? (July 21, 2004); ACLU
*This blog post was originally published at Suture for a Living*
August 31st, 2009 by Jon LaPook, M.D. in Better Health Network, True Stories
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For years my friends and patients have told me how surprisingly shocking the death of an elderly parent can be. We know it’s inevitable yet the finality is jarring. But knowing and KNOWING are two different things. So her son the doctor reacted just like so many others when my mother died unexpectedly last March at 86 after falling and striking her head. I found it hard to get my arms around the idea that my mother was no longer alive.
I received an outpouring of beautiful condolence letters and contributions but have only written a handful of thank you notes. My undoubtedly over-simplistic armchair psychiatrist explanation is that if I don’t write the notes then maybe she didn’t die. And I’m not alone in my behavior. My 90-year-old father, married to my mother for over 66 years, asked me a few months after her death if it was ok that he was pretending she was still alive. “Absolutely,” I replied. “That’s why God invented denial.”
My mother lived totally in the moment. She’d start to peel an orange and would say “at this moment this orange hasn’t seen the light of day.” Every morning she would look out the window at our breakfast table and say, “Good morning, dogwood tree.” More often than not, whatever she was experiencing was “the best ever.” The best ever sunset was the one she was watching. The best ever salad was the one she ordered at our last lunch alone together a few weeks before she died. Her best ever meal was the one she had just finished. She did not want to waste a single second, as was reflected in a hilarious essay she submitted to the New York Times upon turning 75. It was rejected; so here is the world premiere {link to NYT submission below}.
My wife had the idea to plant a dogwood tree on the top of the beautiful Vermont hill where we had sprinkled my mother’s ashes. Yesterday my family gathered under cloudy skies for the ceremony. One of my two sons sang a beautiful song he had composed using the lyrics of a poem called “Growing” that my mom had written when my three sisters and I were little.
Growing
Goodnight sweet baby and goodbye
I’ll see you as you are no more.
For dusk has settled in the sky
And you have wondrous dreams in store.
As you sleep, a magic hand will touch you
And you’ll grow more wise.
Tomorrow morning you’ll awaken
New and different in my eyes.
This morning my father admitted that he still finds it hard to accept she’s gone and sometimes imagines that “she’s just out shopping.” But we’re both starting to accept that we’ll see her as she was no more. This afternoon I’m going to start writing thank you notes in earnest. Well, maybe tomorrow.
***
Dear Editor:
I just celebrated my 75th birthday, and do you know what? I’m better than ever! Well, I guess you could say I’m stronger than ever. No, not in my muscles, which can be developed and maintained during regular workouts in the gym, but in my mind, which gets a daily ongoing on site workout. I now have the strength of my convictions, something I never had when I was young because in those days I always aimed to please, so that everyone would like me. I have now become much more assertive, more determined, more stubborn, and more aware of the passage of time, and as I calculate how much of it I have left, I have made a firm decision not to waste one moment of it.
With that thought in mind, here are some resolutions I’ve made to myself for the New Year:
1. I will not open unsolicited advertisements in the mail. This includes 10 million dollar lotteries and free trips to the Caribbean. Into the garbage they go!
2. I will not make dinner dates with boring people. This includes people who didn’t used to be boring but are now.
3. I will not put off doing things that I want to do.
4. I will not attend meetings out of a feeling of obligation.
5. I will not play singles rather than doubles in tennis or play an extra hour because I’m afraid to say no.
6. I will not ride when I can walk or walk when I can ride, depending on how I feel at the time.
7. I will not take part in long phone conversations with talkative people who are boring.
8. I will not dress up to go out if I feel like wearing a shirt, sneakers and jeans.
9. I will not shop ’til I drop. I never did and I certainly won’t start now.
10. I will not agree with someone unless I really do. I won’t be afraid to express my opinion.
11. I will hang up instantly on phone solicitors with no apology whatsoever.
12. I will remove the tag from each and every mattress that I own with absolutely no fear of penalty of the law, and when I make the bed I won’t always do hospital corners. Sorry, Mom!
13. I won’t be afraid to break a date if something better comes along.
14. I plan to make a lot of money selling something on Internet. Don’t know what yet.
15. I will not be intimidated by a surly maitre d’ or waiter. I won’t be afraid to send something back if it’s not to my liking, and if the rolls aren’t hot, back they’ll go.
16. I’ll squeeze the toothpaste from the top of the tube–so there!
17. I’ll watch every Seinfeld rerun, all Frasier episodes and all Woody Allen movies.
18. I will wear white before Memorial Day and after Labor Day if I want to.
19. I will always remember that health takes priority over everything, and I will guard it carefully.
20. I will keep smelling the roses and seeing, tasting, touching and hearing the world about me for a long, long time.
Happy New Year!!
Elsa LaPook
August 31st, 2009 by Bongi in Uncategorized
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Occasionally I post something that scores high on my weird sh!tometer (here, here and here). It seems this is such an occasion.
I thought of this incident recently when I was privy to some doctors complaining about stupid referrals. This was the only one I could think of. In reality it was more a moronic patient than a moronic referral.
As usual it was late at night. The casualty officer said he thought the patient had an enterocutaneous fistula (connection between bowel and skin). I asked why someone with something like that would wait for the middle of the night to turn up in casualties when the condition was almost always chronic. He gave a nervous chuckle and agreed. When I started asking about possible disease processes which could give rise to this condition (which pretty much can’t just happen spontaneously) he had no answers. In his voice I could almost hear him saying:
“Come on. I’m tired. It is a stupid thing to come into casualties for at this hour but here she is. Just come down and see her so it is no longer my problem.” I answered before he was forced to actually say these words.
“Ok, I’m on my way.”
The patient was an old Indian lady fully-clad in her robe-like traditional garb. I asked her what the problem was. She was quite a bit less than forthcoming. I asked her to show me the problem if she couldn’t describe it. She lifted her robe. I was not prepared.
She presented a disfigured torso and abdomen. It seems when she was younger she had been severely burned by hot water. Those areas that had been burned were devoid of fat and had skin attached directly to the underlying muscle. Between being young and the present she had become obese. Actually that is only partly accurate. Only the unburned areas had become obese. She had areas of supreme obesity interspersed by a network of amazingly slim. On one of the fat areas, towards her flank was an opening which was oozing pus. The smell was unearthly. I may have gagged a bit. But something was missing.
“Where is your umbilicus?” I asked. She looked sheepishly away. She was determined to not be forthcoming. A more direct approach might work, I decided. I pointed to the suppurating hole almost on her flank and asked:
“Is this your umbilicus?” She nodded. The burn wounds interspersed with severe obesity had dragged her umbilicus to her flank leaving behind a long oozing tunnel. I was annoyed. She knew what the problem was from the beginning. She also knew that it wasn’t something to come into casualties for in the middle of the night. She had been taking us all for a ride. But what could I do? She was there and I had to do something. Something, I decided, would involve double gloving.
I inserted my finger into the oozing hole. As expected, now that I knew what it was, It tracked towards the midline where the umbilicus had been many years before. At its base I felt a tennis ball sized mass of old debris. This time I did gag. This mass I scooped out bit by bit until the umbilicus was something it hadn’t been for years…clean. Annoyance fell away to disgust. I almost couldn’t speak because of my gag response, but I forced myself.
Fortunately all I really had to say was:
“Have you heard of soap?”
*This blog post was originally published at other things amanzi*
