Tuesday, August 23, 2011

The emperor remains unclothed

I guess I shouldn’t be surprised when two of the architects of the health care reform act write an op-ed that continues in the deception that the law would deliver access, choice, and lower costs.  But that is what Ezekiel Emanuel and Jeffrey Liebman offer in their New York Times article, “Cut Medicare, Help Patients.”

The authors start by saying some things that make a lot of sense.  They point out that it would be smart to “eliminate spending on medical test, treatments and procedures that don’t work -- or that cost significantly more than other treatments while delivering no better health outcomes . . . [and that} can be made without shortchanging patients.”

But they quickly give up that fight:  “The sad truth is, Washington is never going to do a good job of making smart cuts to Medicare.  Elected officials hate being blamed for directly restricting access to medical treatments -- even when those treatments are proven to be worthless.”

So then they revert to their underlying bias, er, theology:  “The responsibility for ending unnecessary medical spending needs to be placed in the hands of doctors and hospitals.  This can happen only if we change our fee-for-service payment system.”

How much damage is being done and how much time is being lost by our society by a religious belief in a payment scheme that has not been proven and that has many inherent difficulties?  As I have noted, not the least of the difficulties with capitation is in deciding the transfer payments among the different medical specialists.

And then to add salt to the wound, they say:

“These seeds of a solution lie in the accountable care organizations, medical homes and bundled payment reforms that were authorized by last year’s Affordable Care Act.”

As I have discussed, the ACO framework prescribed by Congress is inherently flawed because Congress could not and will not limit patient choice.  An ACO cannot manage patient care if there is a PPO structure in place, allowing patients to shift care not a non-ACO provider at will.  Meanwhile, the ACO framework also has risks of market concentration that are drawing the attention of federal antitrust regulators.

This whole discussion is incredibly painful to watch, especially when Emanuel (or was it his brother?) admitted privately during the Congressional debate on the ACA that the costs of providing universal insurance access were well above those that were being publicly projected, and that, ultimately, the US would be forced to pass a value added tax to cover the health benefits that were the result of the law.  What’s the chance of that during this political environment?

On this blog, I have talked about things that can work and that are within the power of Medicare to implement.  The most powerful would be to change the relative fees paid to primary care and other cognitive specialists, compared to proceduralists.  Giving a primary care doctor the ability to spend more than 18 minutes with a patient could change the nature of those doctors from having a triage function to allowing proper management of care.

Medicare can also engage in real clinical transparency, insisting on the publication of real-time information about infections and other important aspects of quality and safety as one of its Conditions for Participation.

But, we must also find fault with the nation’s doctors and hospital administrators who fail to lead process improvement in their institutions, even in the face of documented quality and safety enhancements and cost savings in exemplary hospitals.  Medical schools, too, have systematically failed to teach young doctors about the science of improving care delivery.

I have often asked the question, “What does it take?”, suggesting that a failure to proceed with such changes and to engage in full-hearted transparency is unethical behavior -- in the most fundamental sense -- on the part of the medical community.  As long as the medical profession fails to demonstrate its own ability to improve results and lower costs and engage in patient-driven care, you can count on officials in Washington and in other jurisdictions to offer prescriptions that simply will not work.  The resulting resentment and anger on the part of the profession then feeds a negative vicious cycle.

Time’s a-wasting, folks.  Let me make this very personal, and perhaps uncomfortable to some of my readers.  As e-Patient Dave likes to say, “Patient is not a third person word.”  We will all be patients some day.  What kind of system do you want in place when you are in the lying in the bed rather standing next to it, or when a loved-one is there?  Chances are that it is not the system that you are helping to run right now.  You can rationalize your inaction and compartmentalize your thinking all you want, but a failure by you -- if you are a medical or administrative professional -- to demand and lead improvement is, in fact, a deadly decision.


Anonymous said...

It's funny you should mention patients not being a third person word. In a recent Medscape physician forum, a surgeon asked the question as to whether patients can do simple things (like removing their own stitches) to save $$.
The discussion turned into a diatribe by several physicians who had been patients themselves for serious conditions, railing against the incompetence of current medical care. I wonder if those physicians subsequently made any changes where they practiced.

nonlocal MD

Margalit Gur-Arie said...

Selective choice of comments from The Health Care Blog:

The only mention of fee-for-service in the NYT article makes no sense to me. Supposedly under FFS doctors and hospitals have to spend money on improvements to care and receive less money when care is improved. How is this not true under a capitated system?

Money has to be spend to redesign the care process and the goal of this redesign is to lower costs. Lower costs means lower revenue for doctors and hospitals. There is no way around this.

And how is capitation supposed to allow more time with patients? Wouldn’t the incentive now be to have as many capitated patients as possible? The only difference would be that there will be an incentive to see them less often.

This entire FFS witch-hunt is largely based on faith. Faith that physicians should be salaried employees of large health systems. It’s hard to argue with religion.

Jonathan and Patrick said...

A couple more comments from The Health Care Blog:

Patrick Mac says:

“Giving a primary care doctor the ability to spend more than 18 minutes with a patient could change the nature of those doctors from having a triage function to allowing proper management of care.”

I agree that we could lower costs by allowing primary care physicians more time with each patient, particularly those with more complex problems. However, we also need to change how we deal with malpractice litigation, otherwise primary care physicians will continue to defensively refer cases to specialists, and defensively order tests, that are otherwise unnecessary.

Jonathan H says:

What is this “allowed” that Paul and Patrick are talking about? Physicians are allowed to spend more than 15-18 minutes with their patients. In fact, many good ones do right now, with the current payment rates.

No one is forcing physicians to make $150,000 to $400,000 a year. They could “allow” themselves to spend more time with patients and make a bit less. Of course, they won’t until economic forces require it.

Jonathan Fenton said...

May I comment as someone who is now retired from practise as an orthopedic surgeon and who is now involved in medical administration and who has worked in the UK as well as in Canada?
I think your comments are well advised and it would seem to me that both in the US and in Canada Tort reform would be a major step towards cutting the costs of treatment.
I also agree that more financial weight should be placed on the cognitive rather than the procedural sevices provided by physicians.
I don't think the thorny subject of FFS versus salaried positions will ever be resolved and that probably there will always be a mixture of the two.
Jonathan H puts it well when he says that a physician can "allow" themselves to spend more time with patients. Personally that to me was one of the joys of practise.
Lastly I would recommend the papers by Augusto Sarmiento "Thoughts on the future of the orthopedic profession" and "Is Socrates dying" which address, more elegantly than I am able to, some of the above concerns of the future of medecine in both our countries.

EMS Man said...

The unfortunate truth is that the Affordable Healthcare Act was pushed through as a band-aid to a healthcare finance disaster for the next generation to deal with.

Why hasn't a true policing body been developed, like the SEC, to ensure that the back-room deals no longer happen? It doesn't matter whether it is poor outcomes, lack of improvement, unwillingness to remove outdated/ overly expensive procedures that serve no greater good, hand shake deals between providers and insurers, ignorance / flat denial of best practices or lack of data-sharing. All of these poor business practices, yes healthcare is a business, have lead us into the quagmire that we are finding ourselves struggling in today.

The more you struggle, the deeper we sink. This time though, no one will be there to rescue us so we must do it ourselves with calm thinking and a mutual respect of all aspects of the healthcare continuum from patient access to how payment will be distributed.

Anonymous said...

I was heartened to just read this:


I believe clinicians are finally recognizing the bias and questionable motives of their own colleagues, and the 'omerta' vow of old may be breaking down. This, when all is said and done and when applied to many other gray areas of treatment, may be their potentially most valuable contribution to the matter of which you speak.

nonlocal MD