Monday, August 17, 2009

Meanwhile, back here in Boston

Let's shift attention briefly from from the national arena discussed below to the local scene.

I am always inspired when I read articles by Don Berwick and Atul Gawande. In addition to substantive wisdom, they have a fluid and persuasive style. Such is the case in an August 12 op-ed authored by the two of them and Elliott Fisher and Mark McClellen in the New York Times. They rightfully point out that, if medical systems across the country adopted reasonable steps in the use of evidence-based medicine, quality and safety, collaboration and efficiency, the current national debate about how to afford universal coverage would disappear.

This is not a new message for these authors, but there is little evidence to date that it has been internalized by doctors and administrators throughout the country, especially here in Boston. To put it in medical terms, we know what medication needs to be taken, but the patient is not being compliant with the prescription.

My friends at Blue Cross Blue Shield of MA believe that a change in the payment system, from fee-for-service payments to a capitated system, is a primary way to help solve this problem, and they are supported in this view by the recently convened Payment Reform Commission. They may be correct that it would be helpful, but only if there is sufficient state regulation of rates to counterbalance the market power of the state's dominant health care system and to get its disproportionate reimbursement rates under control.

But I think the advocates for capitation would be among the first to admit that the other opportunities mentioned by Berwick et al are not dependent on changes in reimbursement rates. In fact, the op-ed makes that point, noting that lower-than-average costs have been achieved even in some communities that do not have a capitated form of reimbursement.

Here in Boston, competition among hospitals has driven costs up, not down. The hospitals' drive for market share combined with doctors' desire for the latest prestigious machine, lab, or building leads to a medical arms race in this city. Efforts at collaboration or rationalization of services among the academic medical centers -- even those in the same system -- routinely fail. Closure or consolidation of ailing hospitals is very difficult and unusual, in that financial rescue is often offered by a state Legislature concerned with constituency issues. And, as noted above, contrary to other parts of the country where there is a dominant provider concerned with lowering costs, the one in Massachusetts has used its market power to raise costs in a manner that has not been effectively challenged by the insurers or their subscribers.

So, for the next article, I'd like to see these authors or someone else address the on-the-ground problems of the Boston metropolitan service area. Is it possible to take the broad themes from the op-ed and bring them back home and advise this group of patients how to take their medicine? Or is there something about this organism that suggests a different diagnosis and treatment plan?


Michael Kirsch, M.D. said...

Can't speak to your situation in Boston, but medical costs here in Cleveland are extremely high, despite the plaudits bestowed on the Cleveland Clinic by our president. We have an unneeded concentration of technology here. How many gamma knives does one city really need? Defensive medicine is embedded in physicians' culture as northeast Ohio has been one of the nation's most legally vulnerable regions, although this has eased with tort reform legislation. The Gawande, et al essay is, of course, idealistic. All we have to do to solve health care is for all of the stakeholders to set aside their personal interests to serve the greater good. This might work in Shangri La, but not here.

Anonymous said...

Hear, hear. I notice that none of the invited standout hospital systems in the op-ed were from very large metropolitan areas; is there some significance to that? Also, the statement:

"In Sacramento, a decade of fierce competition among four rival health systems brought about elimination of unneeded beds, adoption of new electronic systems for patient data and a race to raise quality."

may also provide some insight. Where there is a dominant hospital system, complacency within it often ensues.
This was brought home to me when two elderly relatives were recently admitted to what is supposed to be the flagship hospital in the dominant hospital system in Northern Va. The place was incredibly dysfunctional.

As your example of InterMountain Healthcare indicates, dominance can be good - but it is often bad.
Your legislature needs to pay more attention to that rather than keeping open failing hospitals.


Dan B said...

Is there a good resource that explains the pro/con arguments for salaried physicians vs independent consultant physicians affiliated with the hospital?

Anonymous said...

It seems no surprise that the Payment Reform Commission would come to the same conclusion as BCBSMA as the head of the commission, Sarah Islin, was Andrew Dryfus's (the defacto COO of BCBSMA) chief of staff.

It seems that a very answerable question would be how much of medical trend in the last 3 years has been driven by utilization? The answer would surprise you. Its about 20-25%. Therefore, the current expense increases are mostly due to cost per unit, which is something that capitation is not the best method for control, unless you are a provider that likes going out of business.

Anonymous said...

Dunno, Dan. Others?

Keith said...

It seems the problem tends to lie with the insurance industry to a large degree, in that they seem to offer excessive payments to certain providers in a given market not based on quality, but on market leverage and prestige. I see many situations where they continue to pay excessive prices to these dominant systems despite many good quality options at lower costs. Instead of passing on this excess cost to the consumer to discourage the use of these higher cost providers, they tend to insulate them absorbing this cost differential or attempting to extract it from providers who don't have the same bargaining leverage. Until insurers start paying for quality instead of name brand, we will continue to see dominant, but costly medical systems running up the cost of health care.

Anonymous said...

For Dan B., here are a few random citations from Google: (the best IMO)


Glenn Laffel, MD, PhD said...

Part of the Massachusetts capitation plan, as I understand it, is to empower PCPs to oversee all aspects of care for their patients.

This approach contrasts with the current system in which patients are, all too often, released into the cost-undisciplined tertiary care systems that dominate the eastern part of the Bay State.

If we can find enough PCPs to implement a capitated system...a big if, this approach might just work, especially if PCPs can be empowered by evidence-based guidelines at the point of care.

Electronic health records enable this in theory, but to date, most EHRs have been cost-prohibitive for PCPs.

Recently, Web-based EHRs have become available. They are less expensive to implement, and in the case of Practice Fusion, the EHR is entirely free.

Such tools offer hope that PCPs can finally take control of the care system on behalf of their patients, and assure that referrals and expensive tests and procedures are done only when supported by the evidence.

Glenn Laffel MD, PhD
Sr. VP Clinical Affairs
Practice Fusion
Free, Web-based EHR

76 Degrees in San Diego said...

So, let me see if I get Massachusetts, the players are supposed to be equal....but some are "more equal" than others....I have heard about this before...sounds like "Monopoly" (they play this in China, I hear)

Engineer on Medicare said...

Let's hear from the medical care managers. If you could take the infrastructure and resources that exist, and could change all of the rules and processes by fiat, what would you do to make the health care system better serve the country?

First, what are your standards and requirements? What would be your objectives in terms of health care quality and availability?

What is your cost objective as a percentage of GDP?

What aspects of health care would you ration, and on what basis? There won't be death panels, but rationing will mean that some will not get care that has some probability of extending live. What is the mechanism for making those decisions and will it depend on who is getting the care and the abiloity to pay. Is every medically appropraite candidate going to get the implantable derfibrillator that Dick Cheney got, or will that sort of thing reserved for some who are more equal than others?

What are your objectives regarding uniformity and quality of care throughout the country? How much inequality of care do you consider acceptable across the socioeconomic spectrum?

Then, how would you re-form the system to meet those requirements efficiently? What would be the structure of the system, the relationships and the responsibilities? What would be the involvement of government and private enterprise?

How would the cost be shared by users and by the government?

If nobody can describe and reach consensus on requirements, the process will be driven by large numbers of people all fighting for their piece of the pie without regard to the best interests of society.

Hal Andrews said...


One of the real problems in the national discussion is what is considered detailed analysis of markets or systems that should be the models of reform.

As we have demonstrated, an analysis of markets based on 2005 Medicare data does not tell the real story about high-value markets. Two of the markets highlighted by Dr. Gawande et al. are in the 90th percentile, but two are below the 50th percentile, and the rest are fairly average.

As you and I have discussed, the situation in Boston is easy to diagnose and completely irrelevant to the national discussion. You and Charlie Baker, among others, know the reality of the situation, and you also know that does you no favors.

Anonymous said...

Engineer on Medicare;
I wonder if you are aware (I am sure you must be) that you are already subject to rationing? My elderly mother was recently admitted/discharged to/from the hospital, and the entire discussion of her pre- and post-discharge care centered around what Medicare would, or would not, pay for. Medicare decides what treatments it will pay for, and what it will hot. How is that not already rationing?

nonlocal MD

Dan B said...

Thanks nonlocal,
Looking through your references it seems Mayo should not be used as a typical case simply because it is an atypical environment and might not be an indicator of how other hospitals and physician groups would work.
It does seem like a difficult research question to look at in the traditional medical model and would likely involve a very fun IRB process to answer effectively.

Engineer on Medicare said...

I know that Medicare pays for only limited time in nursing home care, and limits some testing. I am fairly agressive about reporting symptpoms to my primary at every 6-month visit, which includes blood work because I am on a statin and have also had problems maintaining adequate level of K. My experience has been that if I take care to describe symptoms and if I ask for explanations from my primary, then things get done and I don't get a bill beyond what Medicare pays. There are times when I think they order too much.

I have Medicare Supplement F through an affinity group (NRA) which is reasonable cost and I have no copayments or balance billing beyond what they cover. When my primary and the local cardiac department were flailing around on some cardiac issues I personally called a well-know cardiac department in Boston, told them who my primary was, and was seen by a well-respected specialist in 6 weeks. The result was that the local people had not made a proper interpretation of the stress-echo test and the report of valve damage was incorrect. When I had blood in my urine I called the urology department where I had been seen and got a complete workup and resolution of the problem; and had the result sent to my primary.

I can't recall a single case in 6 years on Medicare where I felt that treatment was not covered if I fully described the symptoms and pressed the issue with my primary, and I have had no billing for things not covered.

Anonymous said...

Engineer on Medicare;

You sound like a good steward of your own care, which is critical. However, you may just not yet have been sick enough or hospitalized (where they want to throw you out now, ready or not).
Here is an example of a recent Medicare (CMS) decision which could be considered "rationing" by some:

The CMS noted in its memo, “The evidence is inadequate to conclude that CT colonography is an appropriate colorectal cancer screening test…. CT colonography for colorectal cancer screening remains noncovered.”

This term (CT colonography) refers to the "virtual colonoscopy" which is touted by some as an improvement on actual colonoscopy for the detection of colon polyps/cancer.

Personally, I agree with CMS' decision that this procedure does not add anything to the detection of colon polyps/cancer. But others might disagree. So you see, these kinds of decisions are already being made, and all this nonsense about "death panels" and denial of health care under the new bill is just that - nonsense. Rationing already exists; we just don't use that word.


Michael Kirsch, M.D. said...

I'm a gastroenterologist who doesn't feel that virtual colonography (this is the correct term) is a weak competitor against traditional colonscopy. With the former test, the patient still enjoys the pleasure of a full colonic clean out. However, if a lesion is seen, or suspected, the patient may likely look forward to a second colonic catharsis in preparation for a colonoscopy. Gastroenterologist will be more concerned CT colonography can be performed without laxatives. Of course, by then colonoscopy may already be obsolete.

Engineer on Medicare said...

RE: Virtual colonoscopy note above.

I have had two colonoscopys, the regular kind. Both were without sedative per my request. Engineers like to see what is going on. One polyp was detected and removed in the first; three in the second five years later (this year). I watched the display throughout the procedure and I doubt that the virtual colonoscopy could do a better job of detection. I expect that there is a possibility that the virtual colonoscopy would detect something outside the area that can be seen by the endoscope, if the radiologist is looking for it.

The real down-side of the virtual kind is that if there are polyps to remove it is necessary to go through the whole process again. I can't imagine making that choice for myself.

I don't consider denial of virtual colonoscopy in the absence of medically significant reasons to be rationing. I consider it rationing when a patient is denied a medically effective treatment that has a reasonable probability, in the opinion of the physician and the patient, of positively affecting the medical outcome of treatment of the patient.

Michael Kirsch, M.D. said...

Typo in my comment above. I DO feel that virtual colonography is a weak competitor against colonsocopy. Two additional caveats with the CAT scan approach. (1) Radiation exposure
(2) Finding 'lesions' outside the colon, as suggested in above comment. Such findings on CAT scan are often miniscule and trivial, but they are reported anyway by radiologist who are protecting themselves. Then, patients are subjected to more expense and anxiety chasing down these abnormalities with more tests, consultations, etc. More on this issue in particular under Radiology Quality category of

Anonymous said...

Thanks for clarifying.

Anonymous said...

Dr. Kirsch;

yes, thanks for clarifying! I ran across an interesting discussion of the politics surrounding CMS' decision here:

It describes the mobilization of special interest groups against this decision:
"Radiologist groups and manufacturers of CT equipment, among others, launched a write-in campaign (during the public comment period), conducted congressional briefings, and persuaded 56 members of the U. S. House of Representatives to sign letters urging the CMS to reconsider."
And it ends with;
"We applaud this landmark decision, and we hope that the agency remains firm in its evidence-based approach and extends its application as health care reform proceeds."

nonlocal MD

Barry Carol said...

I think a big part of the healthcare cost conundrum that doesn’t get talked about much is unreasonable patient demands and expectations.

Patients demand prescriptions for drugs that they see advertised on TV. Doctors practice defensive medicine because they perceive that many patients will be quick to sue if they have a bad medical outcome, including a failure to diagnose their disease or condition, even if the doctor followed evidenced based protocols and otherwise applied sound judgment. Patients often give high marks to doctors who order lots of tests whether they are needed or not. They think the doctor is being “thorough.” Patients and their families often want / demand that everything possible be done in end of life situations even if the prognosis is poor and the costs are high. What the heck. Someone else is paying. Finally, even if an insurer like Harvard Pilgrim offers a policy that covers all the hospitals in Boston except for the high cost Partners system in exchange for a lower premium, relatively few people are interested in buying it. As I understand it, these dynamics are much different in other countries. Maybe if we want to understand why our healthcare costs are so high, we should all just look in the mirror.

Michael Kirsch, M.D. said...

Excellent points in the above comments.

Anonymous said...


You are starting to sound like a doctor!! (: I like the saying in another blog I read, the Happy Hospitalist: