Wednesday, March 11, 2009

Maybe two out of three?

I heard President Obama speak several days ago about his plans for health care legislation. As I recall, he said he was hoping for three things: (1) a reduction in health care costs; (2) an increase in access for people currently uninsured or under-insured; and (3) maintaining choice for people in their selection of doctors and hospitals.

While I admire his goals and hope for the best, I don't see how all three are possible. The Massachusetts experiment with access, i.e., giving insurance to a much broader group, has actually led to higher costs as people use that access for care. Now, over time, this will hopefully level out, as the value of preventative care spreads, but it could be many, many years before that effect is seen.

On the cost front, the president for now seems to be confusing underlying costs with how much the government chooses to pay. His budget proposal apparently would reduce Medicare payments to doctors and hospitals as a way of building a savings account for greater access. Reductions in appropriations might reduce costs to the federal government, but they do not reduce the underlying costs of care. With 50% of American hospitals operating at a deficit right now, it is hard to imagine how a reduction in federal payments for Medicare patients deals with the cost problem. Costs remaining uncompensated by the federal government would simply be spread to other patients.

Finally, other countries that provide universal access usually take away a great degree of consumer choice in doctors and hospitals. Instead, a parallel private insurance system often emerges, outside of the government plan, to provide such choice -- usually to wealthier people.

So, it seems to me that we could accomplish two-thirds of the Presidents goals, but that it would be difficult to obtain all three -- at least in the foreseeable future.

Your thoughts?


PJ Geraghty said...
This comment has been removed by the author.
PJ Geraghty said...

Whitecoat is one source for this healthcare axiom:

Quick medical care
Free medical care
Quality medical care

Pick any Two

nana said...

If one HAS to pick only 2 or 3, which one would you eliminate Paul? Or, do you have a different creative solution?
By the way, nice comments in Globe today... good job!

BladeDoc said...

Preventative care has never, not once been shown to reduce medical costs. It is probably a good in its own right and it likely can delay the onset of "lifestyle" diseases (HTN, DM, etc). But dying of uncontrolled diabetes at 60 is a lot cheaper than 10 years in the nursing home for dementia at 80.

I am NOT saying that we shouldn't support primary preventative care -- it's likely better for the patient but please look into the actual data before you jump on the "it'll save money" bandwagon. It will not. It mathematically cannot (c.f. smoking which also actually saves lifetime health care costs for similar reasons).

#1 Dinosaur said...

The biggest fallacy in health care is the "Preventive care saves money" canard. It's been shown time and again (when looked at directly, which seldom happens because it seems so "self-evident") that preventive care costs money in the short term. The problem with the long term is that everyone has to die, meaning that eventually everyone will develop one condition or another that will leave them dead. If end-of-life spending can be reined in, then the best case scenario is budget-neutral. In no event does preventive care actually end up "saving" money.

This is not a reason NOT to advocate for preventive care, though. But its purpose needs to be made clear: quality of life, NOT cost containment.

Until Obama and everyone else working on health care reform come to realize this, none of their programs is going to work the way they think it will.

Anonymous said...


I wonder if you could shed some light on the trend in cost growth at BIDMC, other academic medical centers and community hospitals over the last 5-10 years. Specifically, what has the trend been in the total number of employees per licensed bed? Also, if you know of any data regarding employees per bed in Canada and Western Europe, that would be helpful as well. Hospitals seem to be the most significant driver pushing medical cost growth well beyond the general inflation rate. Why is this and what can we do about it?

Anonymous said...

So, Mr. Obama wants to reduce healthcare costs and expand access at the same time. That is two out of three--free and quick. Does he know that it is possible to reduce costs and increase quality at the same time (maybe foregoing the quick)? Look at Mount Auburn Hospital's new Alternative Quality Contract with BC/BS of Massachusetts. If it is a success, it could be a model for the entire nation.

Anonymous said...

Paul - You are exactly right and with Medicare facing a sixty TRILLION dollar shortfall as the baby boomers age into it, well that's a lot of money. Further, the "Medicare for All" crowd refuses to address the fact that the current system of Medicare is totally bankrupt, facing trillions in deficits and as you correctly say, would result in a private insurance market for the wealthy as seen in England. As Massachusetts has shown, providing insurance and access is relatively easy compared to controlling costs. I think the level of technology and patient demand for the latest and greatest make it hard for the U.S. to compare to other countries and their costs relative to GDP. We simply spend a LOT more money on healthcare and based on our aging demographics this will not change anytime soon. Also, reductions in Medicare simply put more pressure on hospitals and providers to collect higher reimbursement for the private insurers they deal with such as BCBS, Tufts and HPHC.... of course the local plans collect their own premiums from businesses so this is just a HUGE cost shift on to businesses and their employees while the economy is already reeling. I would suggest they look at raising the Medicare eligibility, eliminating the drug benefit (Wal Mart offers $4 generics which account for nearly 80% of all prescriptions), means testing Medicare benefits and premiums and really get serious about waste and fraud. As one study showed, if every provider and hospital delivered care like an efficient provider such as the Mayo Clinic, billions of dollars would be saved. There are solutions but cutting provider reimbursements and expanding Medicare are not the way to go.

Unknown said...

We are a non-teaching hospital, and have a lot of medical staff who aren't our employees. So it is hard for us to control what items they want to use, especially regarding some joint implants etc.

We are thinking that given the harder economic times, that physicians will more likely be willing to work on their supply preferences with us.

This alone could greatly reduce our costs. Does anyone else see this in their facilities?

Anonymous said...

I'm a little bit irked by the hoo-rah about having free choice of physicians. Nobody in an HMO, which was last century's great innovation in medical care, has free choice of physicians.

Every private insurance plan throws up endless bureauctratic obstacles to getting to see specialists, testing, etc. I honestly don't see how anything the government could come up with could possibly be any worse than what most insured people have right now.

On the cost front-- speaking as someone whose relative spent 11 days at BI and then 6 weeks in rehab some years ago for a procedure that should have required at most 3 days in hospital and discharge home, because of several instances of completely broken communication among well-meaning BI medical staff, I do have hope that computerizing medical records will eventually make a fairly significant impact on costs.

Anonymous said...

I just read the Globe article - I wish there were more leaders who had the insight and courage to do what you have. The staff at BIDMC are fortunate to have you as their leader.

Anonymous said...

I'm a Medicare customer. I will accept managed care if they give us all the same standard of access and care as Federal Employees and Members of Congress.

I buy supplemental insurance (The F model) and Medicare D. I have had a couple of cases where "specialists" were flailing around and not getting to a resolution, and my Primary was not proactive. In both of those cases I used the flexibility of Medicare to get to a qualified specialist and the problem was resolved.

If there is to be management of access it ought to be that Medicare users should be subject to exactly the same access standards as full time government employees and members of congress.

Anonymous said...

I agree with the earlier arguments about preventive care not saving money to some extent. However, we must look at other data that has not been gathered, at least that I know of. That data would include preventive care for birthcontrol, substance abuse, and malnutrition as a few examples. These conditions effect a large poputlation that are children, or young adults but do not alway kill them. This is a lifetime of healthcare costs that do not always reduce life expectency. If anyone know what percentage of the population could benifit from preventive care it might make a difference is cost savings.
The only other option is to give everyone on their 60th birthday a motorcycle.


Will's Dad said...

I am terrified that this legislation is the first step toward universal health care. It sounds like a swell idea until you experience some sort of catastrophic illness. I have a son 4 years into a battle against cancer and I find myself meeting families who have uprooted themselves from countires with universal care. They have had to come to the US to try and save their children because as bleak as the options seem here at times they are faced with a dumbfounding lack of options as a result of nationalized care. I fear for all of us here in the US..and elsewhere in the world...should this come to pass.

Anonymous said...

I was wondering how much people like the CEO are going to contribute to saving the hospital money. If the CEO is making a million a year can he live off of say 250,000 a year. I could live life like a king for 250,000 and that would be like laying off 100 of those transporters and others you saw so much value in. What about all the other over paid salary people, let them chip in the kings share like Obama had suggested.

Unknown said...

Mr. Levy,

Not really sure if you will ever actually read this or not, nor am I sure this is the most appropriate place to leave this message. However, I wanted to applaud your dedication to your employees. I read an article on your meeting at the Sherman Auditorium and as I am sure you have already been made aware, people are not only impressed, but are sincerely appreciative. Realizing that it takes their cooperation as well, I would still like to commend your thinking outside the box and knowing the right course of action is not always the course most traveled. While I am currently a Law Student and unemployed, I do not necessarily feel the weight of the downed economy. However, my family and friends do. The world would be a better place with a few more Paul Levy's running things.

Mark said...

Dear Mr. Levy,

You've just been awarded my first "Mentch-Of-The-Day" award. See my website

If all CEO's had your chochem, our country could overcome these troubled economic times. Mazal Tov!

Mark Thompson

makeitgood said...

Having just read an article on yahoo news about your meeting with the hospital staff and your willingness to NOT pink slip the "little guys', I really must say that you are a hero. If we celebrate the captain of an airship that champions his plane safely into the river, we CERTAINLY should celebrate YOUR heroics! Beautiful, really beautiful. In fact, I have 2 weeks of vacation time stored up at my own job and knowing how much stress my boss is under, I am going to offer my vacation days up to him for use in keeping an employee who's job is being evaluated. Thank you for the inspiration.

Anonymous said...

I just read about your plans for Boston hospital during this economic downturn. All I can say is "BRAVO". I only hope more people in positions of power follow your lead. You are an inspiration to our nation.

Anonymous said...

I just read the innovative idea you came up with regarding your staff in the lousy economica times Mr. Levy. It left me speechless with wonder at your acumen!

It is people like you who collectively make this Nation the greatest in the World!!

Manoj Narang

Anonymous said...

Dartmouth-Hitchcock Medical Center has an innovative program, the Quality Research Grant Program. It was initially developed as a means to help junior faculty conduct research. The internally-funded program provides $ and research support for any employee who has an idea that can reduce costs and/or improve patient care. One MD resident took the results of his 18-month trial and went on to receive a larger NIH grant to further his study.

We published an article about it:

Ideas for cost reduction are best when they come from clinicians who are familiar with the work. Often simple ideas can create huge savings.

I agree that reducing reimbursements to hospitals and doctors is not a good way to improve care. This is a better way. Obama's plan should include something like it.

Anonymous said...

All three goals can be pursued simultaneously.

My son was injured by malpractice / error during an episode of meningitis. I was unable to stop the malpractice / error despite making all the right arguments about all the evidence to the doctors.

For the past six years, my son has had more therapies than I knew existed. It took him six weeks to learn to walk again. I was haunted by the incident. The healthcare professionals were intelligent and caring. They made several cognitive errors in processing the information. I developed a simple solution for how to organize evidence in a chart that would prevent most errors that are litigated.

Preventing the errors for my son would have SAVED what must be tens of thousands of dollars and probably more. Errors are very expensive.

The problem is that physicians have to learn a different approach to thinking about the evidence. Changing how we think is the most difficult challenge.

DesCartes came up with the idea for Cartesian Coordinates, the X axis and Y axis, when he was sick watching a fly crawl across ceiling tiles. He got a different perspective.

Relativity was solved by a patent clerk who was able to look at the problems of physics from a different perspective.

Most malpractice cases involve hospitalized patients who are injured or killed by a complication listed on the informed consent sheet. The healthcare providers fail to recognize all the warning signs of those complications in the chart when they do rounds because those warning signs are spread throughout fifty to a hundred pages.

I have an incredibly simple way of listing all the warning signs together on one page, in context. I have been a medical malpractice attorney for over 25 years. I stumbled over this while ruminating over my son's injury.

If you are interested, I can explain the idea in thirty seconds.


Lee Tilson

Anonymous said...

Read about you in the Globe earlier. Great job! Thank you for giving a damn.

Anonymous said...

Dear Mr. Levy,

I too read the article in the globe and I think what you did was beyond magnificent. I lost my job late last year because of money and had the company I worked for did what you had done I would not have lost 14 years of service. This is exactly what the President is talking about that many in the press label socialism. If common deceancy is socialism then I'm all for it. Good Job and thank you for helping the hard working people that help to run your hospital.

cmmconsultant said...

Dear Dr. Levy,

Just saw the news about you ä head with a heart"and I follow into your blog. I have a plan to find a group of medical care people to network since my sis in law gave a birth to a pre-mature baby boy about a month ago. Seeing your blog makes me realize that it is possible to find medical professional like yourself. We could make it possible if we follow a leader with a heart. Thanks for sharing.


KayInMaine said...

I just read your prophetic words, Mr. Paul Levy, where you want to save the jobs of the lower wage earners at Beth Israel Hospital by asking those who can afford to give up some of their pay to help those who need it to keep working. Fantastic idea! What a wonderful man you are to think of these workers in a very fragile financial time. Not many in your position would.

I hope this kind of thing goes viral across our country. I'm feeling the pride!

Andy said...

Paul, I think this is the first time reading your blog that I've sensed a lack of optimism from you that our health care system CAN be improved despite the great obstacles... I think we're at the point where any less just won't do, wouldn't you agree?

Without getting too much into the details, doesn't the increased emphasis (and subsequent increased reimbursement) of the primary care system along with a reform of the delivery system (going into ideas from medical home, medical home, bundling, accountable care organizations, etc) provide for the type of changes that over the long haul WILL save money and provide higher quality care?

As to the choice issue.. I think one of the biggest obstacles health reform faces is the realization on the public's behalf, of how bad the current system actually is. It's a huge political error to say we have bad quality health care in this country, because most people believe THIER healthcare is high quality... just everyone else's is bad. Yet we all know how we stack up on everything from HAI to infant mortality.

Now I'm just rambling, but I'd like to talk with you more about this, because you are one of the most optimistic people I know and it's disheartening to hear you say we can't achieve all 3 of Obama's goals. I think changing the delivery system drastically WILL be the key to doing what the MA health reform left out- with just the coverage issues. That's how you get at cost, choice, and quality.

Isn't it interesting that the House Energy and Commerce Committee had it's first health reform hearing this week and it was about the "delivery system"? I think we're on the right track. I'm going to admit, I work there, but let's talk some more and get you on board!

PJ Geraghty said...

Paul is probably not going to post the link to today's Globe article about him, so I will.

Well done, sir!

Anonymous said...

I agree that preventive medicine has never been shown to reduce costs. However, does avoidance of 'preventive' behaviors increase costs? Don't know intuitively that not wearing a seat belt can lead to more serious injuries (more costs)? That smoking, poor diet, and inactivity can put one at a higher risk for a CABG than someone who avoids all three? That those who avoid PSAs after 65 and colonoscopies after 50 are more likely to have advanced (and more costly) cancers when they are finally discovered? Acknowledgment of pure scientific data is honorable, but it should not prevent us from acting in ways that we know are right without the proof in our hands.

Anonymous said...


Since you've ventured into the world of comparative health systems, I want to be sure that you and your blog readers are familiar with the excellent work by the Commonwealth Fund in this area, particularly its studies on how the US health care system compares to those in other resource rich countries, both on macro measures like costs, access and quality, and as reported through surveys of people with chronic conditions. The information most of us get about how the US system compares to others is shallow, often inaccurate, and perpetuates myths about other systems (e.g., there is less choice of providers). No health system is perfect but I think the US has much to learn from other countries about how to do better, and often much better. If anyone is interested in reading the Commonwealth Fund material, here's a link to two reports of note: and

As we debate health reform in the US, I hope we will try to learn from other countries instead of demonizing and denigarting them. EAch country is unique in its cultural, political and social values, so we would never just adopt the system of another country. But there's a lot we can learn and we shouldn't miss the chance.
Nancy Turnbull

Anonymous said...

Thanks, Nancy. I agree. As a general matter, from what I have seen, others countries put a much greater emphasis on primary care (relative to our use of specialists and tertiary care). This has obvious advantages. They also tend to set a national budget for health care that limits overall spending. Often, but not always, this results in a rationing of tertiary care. Often, but not always, this results in a parallel system of private insurance and private pay for the wealthier segments of those societies.

In contrast, we do the opposite. We ration access to primary care by income, and people who don't have coverage do not get sufficient care, until they then are forced to use emergency room services for diseases that probably could have been handled more effectively earlier.

A gross generalization, I know, but I think that's the overall pattern.

Logan said...

Paul, just out of curiosity, it seemed you had a somewhat negative attitude toward the private insurance alternatives available in many universal nations. I may have read that wrong, so I just wanted to clarify. It seems to me a good thing that people still have the opportunity in such places to expand their coverage if they want to spend the money for it. In fact that's the only model that I think America would accept-somehow I can't picture America accepting a command-and-control system without alternatives (that's the most common criticism I hear of the Canadian system as well-at least in Ontario there are no alternatives). We may have come a ways since the Clinton plan, but I'd say most Americans (myself included) would find a hybrid system the most reasonable.

And speaking of socialism, Anon 4:49, let it go with Paul's salary already-some people make more money than others-we're not a communitarian society. Besides, if any hospital CEO is worth $1 million, Paul definitely is.

Anonymous said...

I wonder if they calculate secondary effects.

If the hospitals get less medicare money, they need to cut costs. Notwithstanding your townhall meeeting, in many hospitals that translates to laying off people in housekeeping and other ancillary services. (And not - in most cases - a decrease in CEO salary!)

And so what happens to those people? Social security, unemployment, medicaid, ....

Anonymous said...

Hi Logan,

I wasn't meaning to be negative about it, just to point it out. It is the inevitable result of rationing services under the national system.

Logan said...

Hi Paul,

That's what I thought-thanks for clarifying. Congratulations on the Boston Globe article by the way!

Anonymous said...

Isn't it true that the cost of health care is growing because we are getting better at it? A person that has a heart attack that would have killed them 20 years ago, now has the oppurtunity to develop cancer.

Retired individuals make up a majority of our health care expenses yet have less earning power. Businesswise that is not a cost effective model.

For the record I find those that are older to be invaluable to our society.

florid nightingale said...

Spot on, Paul! Health care costs are the heart of the problem, not the amount the feds are willing to reimburse. If our politicians had the guts, they'd reduce end-of-life expenses for hospitalized elderly (which admittedly would entail some very challenging decision-making) AND they'd examine the appropriateness of high-tech solutions to problems that can be addressed through other means. That is to say, for the ailing diabetic(for instance), perhaps a pancreatic transplant followed by a lifetime of immunosuppression is not what's needed; perhaps it's nursing care, education, lifestyle coaching and support.

I have to disagree with the assertion that preventive care doesn't pay. In the United States, we have not even begun to operationalize prevention. Our care for chronic disease is far inferior to our care for acute illness, which is arguably the best in the world. Only when we try to manage chronic disease as well can we make valid cost comparisons.
- Teresa Goodell,RN,CNS,PhD

e-Patient Dave said...

Sorry I'm late to this party.

1. Not to be a broken record, but where in this set of options is improved patient outcomes? I'm just stunned that in forum after forum people talk about costs and access (genuinely huge issues) but nobody ever seems to talk about whether the freakin' system even works.

Exception: the Whitecoat wisecrack mentions quality.

2. But that wisecrack adds a destructive twist on an old saw from the printing industry. We used to say "Quality, speed, price - pick two." It's been twisted so "price" is now "free." When people talk about prepaid healthcare as if it doesn't cost anything, it's harmful: misleading, declarifying, obfuscating.

A similar thing happened at the Transforming Healthcare evening on 2/26 at the Seaport Hotel. I talked about how much good patient communities can do, and one of the panelists responded that they don't cost anything. Well, tell that to the people who run the servers and write the code ... nothing's free.

The fact that the ACOR network (dozens of cancer communities) does enormous good and would be transformed by $100k doesn't mean it's free. But since it's tinier than a rounding error in the world of billions and trillions, it's overlooked. Where are the priorities, people??

Every option needs to be evaluated for its total cost and how well it works for the patient. Everyone, stop assessing options without considering that!


Anonymous said...

Mr. Levy,
Do you think this "mental model" has any merit ?