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Can Effective Health Care Reform Occur In This Geographically Varied Country?

There is a romantic view of America as a homogeneous nation – a nation that is flat. But the real America has high peaks of affluence and deep valleys of poverty and a varied landscape of health care spending. It is a hilly terrain of income inequality.

The Affordable Care Act was based on homogeneity. Not only would its provisions be disseminated equally, but smoothing the peaks and valleys of health care utilization would liberate the funds necessary to finance it. Under reform, Newark would come to resemble Grand Junction CO, and Mayo would be the model for Manhattan. No longer would Los Angeles, home to the nation’s largest concentration of poverty, consume more resources than Green Bay, WI, where poverty is infrequent. Regional variation in income and poverty could be ignored all together. The problem is “practice variation,” and health care reform will fix that.

Of course, the US  is not homogeneous, and poverty cannot be ignored. In fact, Read more »

*This blog post was originally published at PHYSICIANS and HEALTH CARE REFORM Commentaries and Controversies*

Middle Ground For Healthcare Reform

Partisan rancor was one of the signatures of the recent healthcare reform debate. Can middle ground actually be sought? That’s a question that Eric Segall asks in a recent AOL News op-ed. As is the case in Washington, both sides are to blame. Read more »

*This blog post was originally published at*

Dr. Richard Bukata On Healthcare Reform

In an effort to get the word out about their new EM Physicians’ blog ( ) 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:


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*

KevinMD Addresses Crowd At National Press Club About Primary Care Crisis

The following are my prepared remarks at Health Care Reform: Putting Patients First, held at the National Press Club in Washington, DC, on July 17th, 2009.

President Obama recently declared that, “We are not a nation that accepts nearly 46 million uninsured men, women, and children.” And indeed, finding a way to provide universal health coverage to every American is one of the focal points in today’s health care debate. There are a variety of ways we can achieve this, ranging from a Medicare for all, single payer system to requiring everyone to purchase health insurance. But no solution can work unless we first deal with the shortage of primary care doctors.

After all, what good is having health insurance if you can’t find a doctor to see you?

As a primary care physician in Nashua, New Hampshire, a city that borders the state of Massachusetts, I have had the luxury of closely observing that state’s health reform efforts. And to their credit, Massachusetts currently enjoys near-universal health coverage, in part because of the mandate requiring every resident to obtain health insurance. Many policy experts are predicting that a national plan will closely emulate the Massachusetts model, so it’s worth noting any potential consequences.

Since reform began in 2006, the Massachusetts health care system has been inundated with almost half a million new, previously uninsured, patients, and the demand for medical services has rapidly outpaced physician supply. The wait to see a new primary care doctor is almost 2 months, leading patients to use the emergency room more often for routine visits. In fact, since the universal coverage law was passed, Massachusetts emergency rooms have reported a 7 percent increase in volume, which markedly inflates costs when you consider that treating simple conditions in the ER can be exponentially more expensive than an office visit. It’s no wonder that the plan has placed significant fiscal strain on the state’s budget, which is struggling to contain soaring health spending.

This affects hospitals like Boston Medical Center, which primarily serves the city’s poor. The state’s mandatory health insurance law is causing the medical center, according to a front page story in last Sunday’s Boston Globe, to brace “for dramatic financial losses, which some fear will force it to slash programs and jeopardize care for thousands of poverty-stricken families.”

Furthermore, consider the words of family physician Kate Atkinson, who practices in Amherst, Massachusetts. She had decided to temporarily accept new patients, as 18 doctors in her area had recently closed their practices or moved away.

“There were so many people waiting to get in, it was like opening the floodgates,” she says. “Most of these patients hadn’t seen the doctor in a long time so they had a lot of complicated problems. We literally have 10 calls a day from patients crying and begging.”

She closed her practice to new patients 6 weeks later.

I witness this phenomenon myself every day, with patients from Massachusetts routinely crossing the border to New Hampshire looking for a new primary care doctor.  These are people with chronic conditions like heart disease, diabetes, depression, and high blood pressure – all who need a regular physician to follow them.

And keep in mind that Massachusetts has the highest density of doctors per capita in the country. What do you think will happen to states that do not have a comparable supply of physicians?

Moving away from Massachusetts, let’s look at two other examples where universal coverage was promised before ensuring adequate primary care access. One would be our military veterans, who are guaranteed health care through the Department of Veterans Affairs, also known as the VA. Earlier this decade, the wait to see a primary care doctor in the VA routinely exceeded 50 days in various parts of the country. Although that number has improved, a recent report by the Office of the Inspector General concluded that more than a third of veterans still waited a month or more to see a doctor. And with tens of thousands returning home from Iraq and Afghanistan straining an already overburdened VA health system, it’s no wonder that my practice in Nashua, New Hampshire sees a fair amount of veterans who are unable to obtain timely care from their local VA clinic up north in Manchester, or from down in Boston.

Next, consider the care Native Americans receive via the Indian Health Service. Despite having guaranteed health care coverage, President Obama himself cites Indian reservations in South Dakota that have some of the lowest life expectancies in the Western Hemisphere. American Indians are twice as likely to die from diabetes when compared to whites, 60 percent more likely to have a stroke, 30 percent more likely to have high blood pressure and 20 percent more likely to have heart disease. Although each of these conditions can be treated or prevented with timely primary care, according to a 2005 Government Accountability Office report, patient waits within the Indian Health Service for routine women’s care and general physicals lasted anywhere between two and six months.

It is encouraging that the President and members of Congress recognize the threat that the primary care shortage poses to their health reform efforts. But some of the solutions being discussed, such as reducing medical school debt, increasing funding to the National Health Service Corps, and training more mid-level providers like nurse practitioners and physician assistants, fall woefully short. None will have any immediate impact, which will be especially critical if there’s a distinct possibility that already overwhelmed primary care doctors will be responsible for almost 50 million additional, newly insured, patients overnight.

Instead, we need to value primary care, and make it central to our health system. Rather than being encouraged to squeeze in appointments and rush through office visits, doctors need to be incentivized to practice patient-focused primary care, including, managing chronic diseases, providing preventive medicine guidance, and taking the time to counsel patients.

There’s no question that we need to find a way to provide health coverage for every American. But we must do so in a responsible manner, and that starts with ensuring that we have a strong primary care system first.

*This blog post was originally published at*

A Nurse’s Perspective On Healthcare Reform

AnacinWell, apparently they call a nurse!

Either that or Nurse Nellie caused the headache.

But we know that nurses never cause doctors to have headaches, so that can’t be what’s happening.


Trust me, there have been a few doctors over the years that have given me major headaches and I have no doubt that I have been the impetus behind a few MD migraines myself!


The guy in the Anacin ad must be doing what I’ve been doing for the last two days.

Trying to get a grip on healthcare reform.

That alone is enough to give you a migraine.

There is so much information and conjecture and opinion and debate, it is difficult to know where to start.

Who gets covered? What gets covered? Who pays? Who decides the charges? Who decides the fees? Who has an agenda: political, financial or otherwise? Private or public plan?

And the most important question of all: Who is fighting for what is best for the patient?

Because, when all is said and done, WE are “the patient”.


Okay, so I’ve come up with some foundations; these are things that I feel must be at the heart of any health care reform debate:

1.   Every citizen must have health care coverage.

2.  Every citizen needs to own their health care coverage.

3.  There should be a choice between private and public plans.

4.  Every citizen must be able to choose between a private or a public plan and switch between as necessary.

5.  Each plan must cover basic health care: physicals, screening, immunizations, well care.

6.  Each plan must cover chronic or catastrophic illnesses. (Diabetes, asthma, MS, cancer – just a few examples)

7. After basic health care and chronic/catastrophic illness, each citizen should be able to choose how they want to be covered. I have heard this called the “cafeteria plan”.


Gee, I don’t ask for much, do I?

We don’t have to invent the wheel here. Other countries have gone before us; there are models of universal coverage we can study.

The operative word here is “study”. Take what is good, understand what does not work and use that knowledge to form a unique form of universal health care that meets the needs of the citizens of the United States.


Probably the easiest way to tackle health care is from a personal angle.

I just found out what my COBRA payment would be if I left my job tomorrow.

I’m hoping my jaw heals before I go to work on Thursday.

But that’s a topic for the next post.

*This blog post was originally published at Emergiblog*

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