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Friday, December 11, 2009

questioning everything: CT scans and cancer, coffee and diabetes

Computerized tomography, otherwise known as CT or Cat scanning, has imaged 70% of non-elderly adults in the last 3 years. The use of this technology has been steadily rising, and we now perform a total of over 19,500 CT scans per day in the US.

CT scans use a computer to organize x-ray data in such a way as to produce pictures that resemble cross sections of the human body, complete with bones, brains and soft tissues, tumors and blood vessels. The pictures are truly marvelous and have revolutionized the way we diagnose disease, allowing us to know many things about the insides of a person without actually cutting them open. We can see if a tumor is present, has spread, if an aneurysm is bursting or if the excruciating pain in a person's belly and back is a kidney stone or pancreatitis. We can tell if a victim of trauma is bleeding internally or if a mysterious fever is caused by a well hidden abscess.

In December's issue of the Archives of Internal Medicine, researchers from the National Cancer Institute and other participating institutions published an article looking at the cancer implications of all of these wonderful CT scans we have been doing. Based on risks of cancer predicted by a study of ionizing radiation done by the National Research Council, the CT scans done in the US in the year 2007 will be responsible for 29,000 cases of cancer, and 15,000 excess deaths. One CT scan of the abdomen and pelvis may be equivalent to 450 or more chest x-rays in terms of radiation exposure (though this varies by procedure and institution.)

CT scans, besides being life saving and revolutionary, are also killing us and eating up our health care budget. The trick is moderation. It is clear to me, from seeing my patients return from visits to emergency rooms or specialists, that we do far more CT scans than are truly necessary to diagnose serious disease. Sometimes an elective CT scan is interesting or reassuring, but just as often the tests done for interest or reassurance end up being confusing and anxiety provoking, as they show the benignly quirky internal makeup of individuals who might have cysts or enlargements of organs, duplicated spleens, liver hemangiomas, missing kidneys.

But moderation is not always a good thing. Take coffee, for instance. Another study reported in the month's Archives of Internal Medicine shows that a person who drinks coffee in large amounts has a significantly lower risk of getting diabetes than a person who drinks coffee moderately or not at all. Many studies have shown this, to varying degrees. The meta-analysis, a statistical combination of many small studies to produce a more robust result, suggests that for every additional cup of coffee you drink in a day, you reduce your risk of diabetes by 7%. Although fewer studies have looked at tea and decaf, they appear to carry the same benefits as real hi-test java. The best outcomes were seen in people who drank at least 6 cups of coffee a day.

Once again we see the limitations of science to address the concerns of the individual: if I drank that much coffee I would certainly die.

Tuesday, December 8, 2009

mammogram screening, take 2

I finally read through the 3 articles in the Annals of Internal Medicine that addressed the new recommendations from the US Preventive Services Task Force (USPSTF) about the recommendations for mammogram screening and breast exams. These have led to angry reactions, mostly based on lack of information and lack of understanding of the science behind the recommendations.

First of all, the USPSTF is far from the only organization to weigh in on screening recommendations. There are organizations such as the American Cancer Society, the American College of Obstetrics and Gynecology and various other official groups from various branches of medicine. The USPSTF is, however, the most evidence based of the groups, the least financially motivated, and the most conservative.

The recommendations of the USPSTF are categorized according to how sure they are that they are right, and changes come after long discussion and detailed evaluation of the research and the opinions of other organizations. In 1996 they were unable to endorse regular mammogram screening for women younger than age 50, but in 2002, based on information from studies done since that time, they extended their recommendations to women starting at age 40. They acknowledged at that time that there were risks associated with mammogram screening and that it was neither sensitive nor specific during that decade.

Yet more studies have become available since that time and the recommendations have gone back to encouraging women to begin mammogram screening at age 50, saying that screening before that time should “take patient context into account, including the patient’s values regarding specific benefits and harms.” They conclude that evidence is insufficient to recommend screening of women 75 years and older, which is solidly in line with recommendations in European countries. They do not, however, recommend against screening in older women.

The decision not to recommend mammograms routinely for women ages 40-49 is based on the fact that mammograms often pick up abnormalities of the breasts which appear suspicious, result in further procedures, and harm women through over treatment and excessive diagnostic testing. Breast cancers are detected in that decade, but the risks of screening all of those unaffected women outweigh the benefits of early detection in the few.

The recommendation that women not be taught breast self examination has engendered the greatest amount of misunderstanding of all. On the face of it, it makes no sense. What harm could self examinations do? Why should a woman not know her own body?

The recommendation is based on two large studies, one in Russia and another in China, evaluating self breast exams in a population that did not get regular mammograms. Women who were taught breast self examination techniques had no benefits in terms of breast cancer survival when compared to women who were not. So this recommendation really addresses the question of whether a physician should spend time specifically teaching women techniques of self breast examination. It does NOT say that doctors should now tell women not to examine their breasts. Perhaps women are just fine at examining their breasts without being harangued by their doctors to do so.

What, you may ask, is the rationale behind getting mammograms every 2 rather than every one year? Studies have shown that as many as 99% of breast cancers are picked up by every other year mammograms, and given known harms of radiation and associated costs of those extra mammograms, were they done every year, 2 year intervals seem like they are the magic number.

But why 2 years? What’s so special about the number 2?

At the Norwegian Institute of Public Health, studies have looked at women who got mammograms every two years for 6 years vs women who got only one mammogram at the end of 6 years. The women who got the mammograms every 2 years had a significantly higher incidence of breast cancer than the ones who got only one mammogram, and this difference persisted in the years that followed. The conclusion that the Norwegian doctors came up with was that the every 2 year screened women had breast cancers discovered which would have gone away if left untreated. American researchers have hotly disputed this interpretation, but their arguments are not compelling.

It is clear to me that the recommendations of the USPSTF to reduce recommended mammogram screening is NOT based on a politically motivated desire to reduce health care spending at the expense of the health of women. It is not yet clear to me what the best recommendations for mammogram screening should be. I intend to continue, as I have, to discuss with patients the pros and cons of mammogram screening and help them make the choices that are best in line with their risks and their values.

Monday, December 7, 2009

missing the safety net

What if you graduated from high school, left home, got a job delivering pizza, and were critically injured in a motor vehicle accident?

What if you had a part time job at a big company, a house, a family and got cancer?

What if you lost your job and your 8 year old daughter got appendicitis?

In the United States there are systems that act as safety nets for situations such as these, but they are not self sufficient and are severely strained in their ability to provide services with the progressive loss in adequate insurance coverage, the floundering economy and the increasingly outrageous costs of various forms of medical care.

If you were the first guy, ejected from your Geo Metro when you were t-boned at an intersection by a drunk driver, you would be taken to an emergency room at any hospital, transported to a trauma center if necessary, and treated until you were on the mend by that hospital. If you were eligible for medicaid or medicare due to the severity of your disability the hospital would eventually be reimbursed for the cost of your care (at least partly), and if you were not eligible, the hospital would attempt to bill you and when you were unable to pay, would eat the cost, part of which would be tax deductible.

If you were the second guy, the doctors who treated you would do so with little hope of being paid, might bill you, and would eventually eat the costs. You might be able to apply for a county emergency payment program to pay for things like surgery and CT scans, but you would eventually be expected to repay these costs. You would apply for public assistance based on disability, but the process of being approved for it would be slow. Your savings would inevitably be used up. You might lose your house.

In the case of the child, we have guaranteed medical insurance available for children through the government, but you do need to apply for it. The child with appendicitis might die or have some other bad outcome due to delay in treatment from lack of insurance. In a perceived emergency, though, treatment through the local emergency room would be assured.

Much of the problem with American health care stems from the escalating costs associated with it. Yet many of these costs, especially those associated with procedures and tests, go to hospitals who are the basis of our safety nets. In cutting costs, it is going to be vital that we pay attention to making sure that hospitals stay solvent. Providing adequate universal insurance will be a project that takes time, probably years. It is this insurance that can support hospitals and allow them to continue to support the communities in which they operate.

An article in the New England Journal of Medicine ( addressed our safety net system, and just how fragile it is. Because some hospitals are located in areas of particularly acute economic and social disaster, they are simultaneously vitally important to a safety net and totally inadequately reimbursed. Allowing hospitals like that to go under threatens the whole fabric of the larger medical system.

Saturday, December 5, 2009

How the conference on affordable health care went

There were nearly 30 people there, at a not much more than 40 bed hospital. This is unprecedented for a not-required noon meeting. There was food, but it wasn’t very good, so they were there for the content (or maybe they though the food would be better.)

The radiologist talked about appropriate use of technology and reducing unnecessary testing. Primary care docs talked about ways to make the computerized medical record systems give information about costs. The pharmacist talked about how to find out good information about drug costs, and we discussed ways to educate docs in the hospital on alternatives to the most expensive medications. We discussed other methods for reducing pharmacy costs which will also have other health benefits (changing medications given by vein to ones given by mouth, for instance.) The hospital CEO was willing to commit to putting into practice a system that would promote cost transparency for providers and patients. We talked about shifting responsibilities for record keeping to nurses in our offices so we would have more time to see patients so they wouldn’t have to go to emergency rooms where the costs are higher and the care is less personalized.

What will come of this is unclear, but the very act of discussing it in an open forum is brand new in my experience.

There is a part in the hippocratic oath about sharing the precepts and learning only with those who have taken the sacred oaths and the sons of other doctors. This may partially underlie a tendency of doctors to be circumspect. For whatever reason the workings of the practice of medicine are not shared easily outside of the profession. Discussing and re-evaluating what we do will go against some pretty basic instincts.

Post conference feedback has been interesting too. As might be imagined, not everybody had their say, and not everybody's issue got discussed. One provider mentioned that she would have liked to problem solve some really pressing issues of access to care. A tech guy mentioned that he had lots of ideas on how to make the hospital staff more efficient by making technology more effective. I am sure that the more we talk, the more issues will come up, and there may need to be smaller conversations and groups of people with similar interests will have to do their own work.

Monday, November 30, 2009

Framing a conference on making health care affordable

Tomorrow will be my first attempt at bringing the health care providers from my community together to discuss how we can change our practices to make health care more affordable.

I approach it with some level of trepidation due to the fact that doctors can be pretty defensive about change. Nevertheless in many one on one conversations I’ve noticed that all of us are to some extent disgusted by how much health care costs, and by the fact that this means that many people don’t have access to good care.

So what will I say to a group of internists, nurses, family practitioners, radiologists, orthpedists and surgeons (if they show up)?

I hope that it won’t be me talking at them, since I already know what I think. But I will have to get the whole thing rolling.

I am co-facilitating this with a radiologist who is motivated to change our doctors’ ordering habits for radiological procedures so they are at least ordering the right tests and not repeating tests unnecessarily.

I intend to say:

I’ve talked to many of you over the last months about the costs of health care. I’ve been doing thinking and research on the subject, and I think that, although we do a god job with our patients, the whole process costs way too much. Some of that is because we order too many tests when we are busy or because we are worried about malpractice, and some of it is because there are so many demands on doctors that we have trouble organizing our efforts. Many of us have adopted computerized medical records, and though they improve the quality of followup and documentation, they are sometimes distracting, and slow us down and focus us away from our patients. Technology and pharmaceuticals have exploded since most of us finished our training, and it is hard to keep track of which medications or procedures are really worth the time and expense.

The result of these factors is that our patients end up going to emergency rooms or quick care offices for things that could be better handled by their primary care doctors, and end up with testing that is expensive, and often unnecessary. We spend much of our time keeping track of preventive medicine recommendations and being glorified record keepers and ineffective nags in the service of smoking cessation, weight loss, colonoscopies, mammograms, pap smears and other preventive strategies.

We have very little knowledge of what the things we order cost our patients, and so they end up with huge bills that often profoundly affect their finances and so their overall social health.

There has been much talk about health care reform, and I have paid attention to a good bit of it. What I see is that legislators have lots of ideas for improving access, though they don’t necessarily agree with each other, but they really do not know how to address reducing costs, which is the basis for most of the debate. In some ways this is good. If legislators make rules to reduce medical costs, they are liable to be rules that don’t make sense from our standpoint. I think reducing costs is something that we, as providers, can do best. There are limitations to what we can do as a small community, but this is our community and it is a place to start.

What I would like to do today is sit together and talk about what we do that is effective in our practices, and what things we see happening, or do ourselves, that contribute to the high cost of health care. I would like for us to come up with some concrete ideas for ways to improve our efficiency, our and our patients’ well being and move medicine in the direction we want to see it take.

We the people who love food too much

We the people who love food too much

Every year we tell the story of pilgrims, coming to a new land to seek religious freedom, nearly wiped out by hunger and disease, and saved due to their resolve and some good advice by native Americans. I will not speculate on how much of that is true, but it is our story. We then tell the story of a meal shared to celebrate and express gratitude for their survival.

The original Thanksgiving feast was probably not much of a spread. We have gone far in the last 200+years to make amends for that. I personally never remember a Thanksgiving celebration when it was possible to fit all of the food I wanted on one plate.

Corn was one of the reasons that our predecessors survived. It grew easily, was forgiving of nasty weather and inadequate soil, and now is our major cash crop. We produce huge amounts of it, and so we make all kinds of stuff out of it, and instead of scrawny pilgrims, we are now round, well fed, and increasingly diabetic.

We continue to be a resolute and industrious people, and have fixed the problem of inadequate food supply, in spades. We make plenty of cheap food, and though starvation is by no means wiped out in the US, more of the poor are injured by access to cheap and abundant corn-based carbohydrates than are from inadequate calories. Like Scarlett O’hara in “Gone with the Wind’, we will “never go hungry again.”

Friday, November 20, 2009

Pap smears and mammograms: what's the story?

If you've been watching the news, you may have seen some historic changes in recommendations about cancer prevention. There have been news releases regarding a change in the recommendations for mammogram screening by the US Preventive Services Task Force (USPSTF). Women in the 40-50 year old age group are now only encouraged to have regular mammograms if they are at increased risk of breast cancer, due to the fact that this test often finds non-existent of unimportant abnormalities in this age group that, on the whole, makes them less, not more, healthy. This will save women thousands of dollars and countless hours of time and energy at a time in their lives when that time and energy is a real gift.

Today I read that the American College of Obstetrics and Gynecology now recommends starting pap smear screening at 21 for most people, and reducing the frequency in that first decade to every 2 years. I have studied evidence based recommendations for pap smears for years, and the formula that makes sense is somewhat more complex than this, but in most cases our standard yearly pap smears are not necessary. This is based on the fact that some of the treatments for abnormal pap smears can make a women less healthy, less fertile, and that the whole process is expensive enough that honing it down to what is truly necessary makes excellent sense.

Cost is certainly not the only issue here, but diversion of significant money from womens' health funding in directions where it does no good hurts all of us. Google tells me that a mammogram costs around $100, and may cost as much as $200, and a pap smear runs about the same price. The cost of these tests in terms of comfort and dignity is not insignificant.

Tuesday, November 17, 2009

cool things we should all want (not)

Three articles in the most recent New England Journal of Medicine describe more new medical technology, and have made me curl my toes in mental conflict.

1. A pacemaker that goes into both the right and left chambers of the heart, rather than just the right side, preserves heart function better, according to ultrasound tests. It is a much trickier (read inaccessible, expensive, desirable) procedure than the standard one, and the patients don’t actually feel any better or act any healthier than with the standard kind of pacemaker.

2. Giving an intravenous iron supplement that I’ve never heard of before (new) (they didn’t test the ones I have heard of before) can improve heart function and health in patients who have congestive heart failure and are iron deficient. How odd that they didn’t evaluate oral iron supplements which have been generic since before I was born and are the standard treatment for iron deficiency. Is it just possible that the new product will be the only product approved for treating congestive heart failure in patients with iron deficiency? Is it just possible that it will cost some jaw dropping amount of money?

3. In people who have heart failure so bad that they would need a heart transplant to survive, but they are not well enough to survive a heart transplant, use of a mechanical pump can prolong their life, and can be used somewhat indefinitely. Only 1/4 of these people will live a year with this technology, and 17% of those treated will have a major stroke. The cost of the technology wasn’t mentioned, and quality of life was not addressed.

We continue to move towards technology that is more expensive, more resource consuming and does not seem to improve quality of life, at least in clinical research. Frequently practice follows close on the heels of research. A good journal still publishes studies like the intravenous iron one that may influence practice without any evaluation of possibly equivalent less expensive and resource intensive alternatives.

Whence my internal conflict? Clinical science occasionally barks up the right tree, and contributes to the health and happiness of people. It also burns money like it is nothing, as if resources were unlimited.

Sunday, November 15, 2009

Sermon to Unitarians on health care reform: Healing America's health care system

(this is really long compared to my usual stuff, but some people may want to read it anyway. It is a compressed synopsis of my many mini-essays that I delivered today at church.)

I love my job. It is possibly the best job that anyone could ever have. I get the chance to meet people of incredible diversity, and participate in decisions that they make about some of the most important aspects of their lives. I hear amazing stories. I get to solve mysteries, or at least try to solve mysteries. I get to interact with other doctors, who are some of the most interesting and committed people I know.

In the years I have practiced medicine I have been impressed often with the compassionate and effective care we can give to people regardless of their ability to pay for it, regardless of their social status, race or nationality.

So when I say that the American health care system is broken, I say it with love, and with the frustration that comes of knowing how good it can be.

The major problem that I see with American health care is that it simply costs too much, which is the reason that we are not providing adequate care for a sizeable proportion of our population. If we can untangle the causes for the high costs of medical care and thus free up resources we can provide care for everyone and start to focus on what is really of value to all of us.

I grew up very close to my two grandmothers who weathered the depression well because they really had very little to lose and were already incredibly thrifty and hard working. Although they were comfortable by the time I knew them, owning their own houses and with plenty of food to eat, they always considered cost and good value in making decisions. So when I began doing my clinical rotations at John’s Hopkins, I sometimes found it difficult to come to grips with testing and treatment that we did that seemed to lead to nothing of value in patients’ lives. I have practiced medicine as if cost matters since I have matured, but certainly not to the extent that my grandmothers would have, if they had been in my place.

As the health care debate has heated up, I began to hear figures related to costs in medicine that were and are increasingly disturbing. Figures like 2.3 trillion dollars spent on health care yearly in the US, and 17% of our GDP going to health care. I looked at a book of facts and figures that came to me by chance a couple of years ago, and saw various health indicators for developed countries that showed us to be merely average, despite our higher per capita spending on health. I asked my friends, other doctors, why they thought we were so expensive, and they all knew. And I knew too. We all know that, for various reasons, we order too many expensive tests, procedures and medications, without considering the costs and the benefits. There are 4 reasons that we do this: we don’t really know what medications and tests cost, we feel that our patients have come to expect this kind of care, we don’t have time to discuss care with our patients, and we think that ordering these medications or tests or procedures will protect us from being sued for malpractice.

One day I sat down and calculated about how much money we might really be wasting on testing and procedures that do nobody any good, and came up with a ballpark figure of 20,000 dollars wasted in a half a day. I’ll tell you the story of a busy doctor on an average morning. The story is entirely fictional, but happens all the time in the US. The costs are approximate, because they vary considerably.

8AM—arrive at the hospital, perform two treadmill tests with nuclear imaging, ordered by physicians for patients at low risk, because of concern about malpractice should they have a heart attack. Each costs $3000, one unnecessary, the other of which could have been done without nuclear imaging at my office for $200.
9AM—see two patients at the hospital. One remains in the hospital because she can no longer live at home and can’t afford to go to any of the extended care facilities that have openings, at a cost of $1000 for the day. The other is there because she wasn’t insured and waited too long to see a doctor for her migraine headache, costing $2500 for her MRI scan of the head and $1200 for her day’s stay at the hospital, and $600 emergency room fees.
9:45—get to the office late because the uninsured patient was news to me, so I didn’t plan on seeing her. See my first patient who has a physical scheduled. She wants “a complete lab workup” even though all of her labs were normal last year and nothing has changed, because her insurance will cover it. She has been having back pain. Since I don’t have time to talk to her about the natural history of back pain I order an MRI scan and physical therapy. Labs: $120, MRI$2500, 8 physical therapy appointments $1000.
10:30—next patient has numbness in his fingers when he is anxious. He can’t afford counseling and I don’t have time to discuss relaxation techniques with him so I refer him to a neurologist. He will see the neurologist 3 times, at a cost of $150 per visit, and she will order a head MRI scan for $2500.
10: 45—next patient has a cough and a stuffy nose for 4 days. I think it is viral, but she is sure she needs antibiotics. I don’t have time to explain the side effects and futility of antibiotics so I prescribe an antibiotic. She says the generic doesn’t work. Cost is $120 for that and $200 for an inhaler which is what I think will work, though if she just waited she wouldn’t need that. Because she smokes and I am worried about being sued if she eventually gets lung cancer, I order a chest x-ray. That is another $200.
11:00—patient comes in for follow-up of his diabetes. It has been in poor control, but since I don’t have time to counsel him on diet and exercise in a way that will probably have an impact, I prescribe a new medication. He is already on generic pills, so I have to prescribe insulin, and because time is an issue, I use the newest insulin delivery system which is easier to explain. This costs $150 and doesn’t make him any happier, plus his risk for complications is just as high because he will continue to gain weight.
11:15—the next patient comes in for follow-up of an abdominal CAT scan I ordered because I didn’t have enough time to counsel the patient on how to avoid constipation which had then given him belly pain. The CAT discovered a cyst on his kidney and a nodule on his adrenal gland. He is beside himself with worry, even though both of these things are usually normal findings. I reassure him that I will get a follow-up CAT scan to make sure they are normal, which will use a better technique and cost $2000 (but I don’t tell him this because I don’t know what it will cost and have no idea what his insurance will pay.) Because he is so worried I don’t have time to see my next patient who has to leave and go to the emergency department with her pneumonia at a cost of $1500.
With over half a million practicing physicians in the US, this may add up to 100s of millions of dollars every day. It has become clear that many of the expensive things we do are the things that don’t make patients healthier or happier, and that costs related to what I think of as stupid care may make up a sizeable portion of our health care budget.

So let’s move away from my personal experience a little bit. Trends in health care spending have changed some, but why have the American people all of a sudden noticed that something is wrong? Our economy took a nosedive about a year ago. Insurance prices finally became too high for individuals and companies to afford them, and the services they provided became inadequate to cover the medical care that people were receiving. People are now commonly bankrupted by paying for medical care, insured or not. We got a new president who started focusing on health care, and began talking about making changes that would allow more people access to it, and about ways to bring the spending on that health care in closer line with most other developed nations. Focus has moved to improving the cost and service provided by the insurance companies, and we have become alarmed by their high profits. But even if their prices come down and profits are reduced, the budget for health care will still be unsupportable.

Because medical care is so expensive now, people who are uninsured have virtually no access to non-emergency care.

So what do we need to do?

We obviously need to allow access to good medical care for everyone. We also need to substantially reduce the cost of that medical care.
If we substantially reduce the cost of medical care, all sorts of options become possible for extending access to everyone. The point that our democratic legislators have failed to emphasize is that if we do not reduce the cost of medical care, extending access to everyone becomes economically unsupportable. The really miraculous thing about this situation is that reducing costs can directly improve the quality of medical care. When we spend money on things that don’t really help people to become healthier, we are also spending time and energy on those things, and that is time and energy that could be spent giving better care.

One way to reduce costs and improve health will be to provide adequate primary care for everyone, so we can take the time that is needed to do what is most valuable to each individual. Patients need to be able to see a provider who knows them and their issues for problems as they arise, rather than having to go to emergency rooms or urgent care offices where costs are much higher and procedures are ordered much less conservatively. When you go in to the emergency room for a condition, the doctor focuses on the many life threatening conditions that you might have, and with no familiarity with you or what makes you tick, will order many blood tests and imaging tests that will be done while you wait. In some situations this is just what should happen, but in most situations you will get way more tests than you actually need.

Allowing everyone access to a primary care doctor will mean changing the way medical care is paid for so that primary care is a more desirable field. When a new doctor finishes medical school, that person is in debt for about $150,000. Going into a medical specialty guarantees a much higher salary than going into primary care, and this has driven a progressive trend away from training physicians in primary care fields. When I graduated from medical school over half of graduates became primary care docs, and now that number is just above 10%. This trend does not allow us to even replace the internists and family doctors who retire, much less increase the work force to take care of the patients who we hope will soon have access to medical care.

Another way to bring down costs is to make them part of the discussion when deciding what should be done to take care of a problem. Procedures are often ordered in place of spending time with a patient. A discussion of costs, risks and benefits would likely reduce the number of procedures done, and make sure that they will actually contribute to a patient’s health. To have such a discussion, doctors and patients need to know what they cost. As odd as it may seem, it is quite difficult to find this information. When I order an antibiotic for a patient or a CAT scan I truly have no idea what the total cost will be or what the patient will end up needing to pay, and that situation is simply unacceptable.

Worries about being sued for malpractice drive doctors to order tests and consultations that are not necessary. We need to have a system of dealing with medical malpractice that is designed to improve quality rather than lead to defensive medicine. The way things are now, very few people who injured due to a medical mishap are compensated, and the process of completing a malpractice case takes years of a patient’s and a doctor’s time, leading to bitterness rather than quality improvement, in most cases.

What can we do, as patients and families of patients? We can look honestly at what we want to get from our medical care. We need to realize that the resources to pay for everything are, in fact, limited. Money we spend for medical care is money we don’t have to spend on food and shelter, education, and having fun with our friends and family. We need to have honest discussions with our health care providers about costs of things and expected benefits. We need to consider ahead of time what we want the end of our lives to look like, whether we want intensive care, and we need to discuss these things with our providers.

Doctors need to look at the way we provide care, and seriously study what procedures and evaluations for common conditions work and which do not, and what methods of treatment give best value. We need to use our substantial clout to open up discussions of costs which are out of line with other countries, such as costs for radiology procedures and medications. We need to take the time with patients to provide the counseling that the patients need, and push for compensation for this that allows them to do this without going broke.

But what about insurance?

Insurance issues dominate much of the discussion of health care reform right now. About 58% of people have private insurance at this time, and about 34% of people have some sort of public plan. We pay insurance companies, by salary deductions, direct billing or through taxes, and they, mostly, pay for our health care. The way they pay for our health care is positively diabolical in its complexity, and separates us from having much direct effect on what things cost. When insurance pays for something, we are usually just relieved, and not very concerned if the cost is outrageous, because the money paid out does not really look like “real money” anymore. So the very fact of being insured contributes to the excessive cost of health care.

Until something can be done to reduce prices for medical care, and this will be a slow process, everyone needs insurance.

I do not have the solution to the proper way to insure everyone. Presently Medicare covers something like 17% of Americans, and in many cases pays half of what private insurance does for many services. It is because there is a mix of public and private insurance that many offices can afford to provide services to everyone. A simple extension of Medicare to cover all of those who can’t afford insurance would strain the ability of offices to provide care, and many of those insured publicly would find themselves without providers. If Medicare were reformed, and payment schedules were changed, this would be a viable option. Health care coops are an interesting idea, and seed money for an expansion of that system would eventually result in improvement in availability of care. Tighter regulation of private insurance companies, requiring that they compete across state lines, be portable from job to job, and cover pre-existing conditions will help, but if medical costs continue to rise, that improvement will be short lived as costs outstrip anyone’s ability to pay.

Many other countries have developed systems that work for them, and if we can be flexible, their ideas could be modified to work for us.

You may notice that I have not yet mentioned evil drug companies. Much like evil insurance companies, evil drug companies do exactly what they were designed to do which is make money. They will continue to make medications that are overpriced and over advertised as long as we continue to pay for them. We will continue to pay for them as long as we are unaware of their costs and alternatives.

So—there is much to think about. In my mind, there is huge balloon of hope at this time in history. Something finally will be done to improve the way health care is delivered, and liberate resources that have gone to buy medical care that makes no one healthier and happier. Doctors are seeing this, and are actively working to improve the way care is delivered, and the rest of us have the power to bring about change we have previously thought of as impossible. A very special thing about this crisis of costs in the US is the opportunity it brings us to focus on what we really want from medical care, rather than continuing with the “business as usual” which has become a very different thing.

Closing Reading: by Rachel Naomi Remen MD

For the past hundred years the goal of health care has been the curing of the body. Restoring the concept of healing to the heart of health care is no small thing. It requires rethinking the assumptions on which medical relationships are based, rethinking the goals of every health care interaction. It will require a revolution.

Tuesday, November 3, 2009

unthinkable thoughts about preventive medicine

Of course it’s true that preventing disease is less painful and less costly than treating disease. Or is it?

Take the recent New York Times article ( addressing mammogram and prostate cancer screening. Apparently over the last 20+ years of screening with mammograms, we have been able to discover many more breast cancers that are small, and might never have been noticed, and probably never would have progressed to the point of hurting anybody. This has given rise to alarming statistics, such as the one that breast cancer incidence has risen 40%.

We have long known that detecting prostate cancer early, especially in older men, finds many cancers that would never have caused any injury and would never have been noticed had we not screened the men. When we find cancer, we usually remove it, and for women with breast cancer this means amputation of a breast or radiation therapy, and often chemotherapy. For men with prostate cancer this means surgery on their very delicate private parts after which they often have trouble with bladder or sexual function.

But even if mammogram screening did detect cancer early, thus protecting women from getting more serious breast cancer, which honestly it sometimes does, is it really less painful and less costly than treating the disease? Mammogram screening, it is estimated, costs about $105,000 per year of life saved if we screen women yearly starting at age 40. Because mammograms are somewhat difficult to interpret, many of those women have breast cancer scares, and all of those women get their breasts painfully smashed flat once a year. Encouraging them to get those mammograms is the job of doctors and nurses who might use that energy to provide other more life affirming activities. The focus on the breast as the seat of cancer, rather than of, say, love or courage, puts women in the position of being at war with their bodies.

Let’s go back to the $105,000 per year of life saved. I certainly love my women friends and relatives enough to believe that a year of their life would be worth $105,000, but isn’t it possible that if we spent that money on something a little different than mammograms, we might be able to buy more than a year of life? I could support a family, for instance, for a year on $105,000.

I do know and love people who have had screening mammograms, found breast cancer, had it cured, and are now healthy. I think some of them might have died had they not had a mammogram. I am not ready to say that women shouldn’t get screening mammograms. It is, however, not necessarily accurate that preventing disease is less costly and less painful than treating it, at least in the case of breast and prostate cancer.

Wednesday, October 28, 2009

relieving suffering and reducing risks

Do patients actually know what they are getting from their doctors, and do they want it?

As I understand it, most patients want from their doctors primarily relief from suffering. And if they can't get relief from suffering, they would like to be heard and they would like to come closer to understanding the cause of their suffering.

When we prescribe cream for a rash, antibiotics for pneumonia or set a broken bone we are really right on the money. When we counsel and comfort we are doing the job we were hired for. When we get into the business of prevention, we are on a bit more shaky ground.

Much of our energy is spent haranguing, wheedling, threatening and assigning tasks. This is all in the service of preventing suffering, which isn't a bad goal when you think about it. We nag patients to take cholesterol pills, we assign them to go to obscure destinations to see specialists, we convince them to have painful and undignified tests like colonoscopies and mammograms. Many patients think that we are doing all of this to make them healthier, but that's not really it. The prevention gig is more of a very complex game of chance. A mammogram does not make a person healthier, in fact very much the opposite. Giving a person an 18 hour case of diarrhea followed by a potentially lethal dose of anesthetic, as is done for a colonoscopy definitely doesn't make a person healthier. Cholesterol drugs lower the risk of heart attack, and maybe strokes, but they don't make a person healthier. Their cholesterol numbers may be lower, but they are not healthier.

Much of this revolves around a rather abstract statistical indicator called the "number needed to treat." For many of the most accepted screening tests and preventive medications, the number needed to treat, which is the number of people who need to get the procedure or medication in order for one to not get the dire event it is meant to prevent, is anywhere for 20 on up to over 100. This means that 20-100 people have to do whatever it is in order for one of them to benefit. I guess you could say that everyone benefits, to the extent that they feel like they are doing the healthy thing, but I would say that's a bit of a stretch.

I don't mean to say that standard preventive medical testing and treatment is wrong, only patients need to understand that their chance of benefiting from these things, in actual fact, is nowhere near universal, and in many cases may be less likely than randomly pulling a one-eyed jack from a deck of cards. Costs, including the cost of loss of dignity and loss of time that could be spent on actual healing, need to be evaluated in this light.

Assuming, say, for treatment of high cholesterol, that the number needed to treat to avoid a heart attack is 20. The drug costs 100 bucks a month, and a person has to take it for 20 years. That's looking like over 20,000 bucks for a 1 in 20 chance of avoiding this dire event. Certainly something to consider. If the treatment costs only 5 bucks a month, the price tag is certainly more tolerable, and that represents the difference between a generic drug and a brand name. A certain number of people who take this drug will have a side effect, as well, and this human cost needs to be part of the equation as well. If the suffering and the money spent by all of the people who take the drug is less than the money and suffering of the one person who gets the benefit, then from a public health standpoint it is good medicine to encourage everyone with high cholesterol to take it. However, 19 out of the 20 people who take the drug are essentially "taking it for the team" and not actually doing any better than if they had avoided it all together. I am not entirely sure that people are aware when they take a drug or have a procedure done to prevent some bad health outcome that they are personally unlikely to notice any good effect.

Tuesday, October 27, 2009

dialysis in the very old

As people age, their kidney function gradually goes down, usually keeping pace with overall needs. In people with longstanding diabetes or high blood pressure, though, sometimes the kidneys fail before the rest of the body does. In this situation, various toxins build up in the blood and such a person gradually becomes weaker and eventually dies.

Enter kidney dialysis.

With a machine that runs the blood through a filter, much as the kidney is a filter, the toxins can be removed from the blood. Unfortunately all of the blood needs to be run through that filter, which is somewhat tricky, and it takes about 4 hours, and needs to be done about 3 times a week.

This is barely tolerable, but better than dying, usually, if you are pretty young, or only have to do it for awhile, as you wait to receive a kidney transplant.

If you are very old, though, dialysis is physically stressful. The heart has to tolerate the movement of blood out of and back into the body, and all of the organs have to tolerate the rapid shifts in electrolytes and blood volume that are part of the process.

Not surprisingly, older folks, those over 80 for instance, don’t have much more in them than the 3 time a week dialysis sessions, and so don’t benefit in terms of energy from being dialysed, other than not actually dying of kidney failure. A study done at Stanford showed that, in fact, most nursing home residents lose their abilities to take care of themselves after starting dialysis, and within the year, almost half of them die anyway. But the over 80 crowd are in fact the fastest growing population of patients getting dialysis in the US.

Dialysis is a big business. It is a procedure and therefore is reimbursed generously by insurance companies. Dialysis centers are popping up like mushrooms, and must have patients to continue to make money. A single dialysis session will be billed at about $1200, sometimes more, and be reimbursed by medicare for maybe half that. Private insurance pays considerably better. No matter how I calculate it, that is considerably over $100,000 a year.

In our small town there were no dialysis facilities available, so everyone who needed to have dialysis needed to travel at least 45 minutes to a dialysis center if they wished to have it done. With much wrangling and organizing, the hospital eventually put in a dialysis center, which seemed like it would probably not be very busy, since there just aren’t that many people living with kidney failure around here. They opened their doors a month ago, and then, as if by some kind of evil magic, there were two dialysis centers, in a town of 20,000 people. The second one is in a mini-mall at the edge of town. Competition is good, when it can bring down cost and increase quality, but costs for these things is based on what insurance will pay, which is static, and quality is pretty well controlled by standardization. Perhaps they will compete on the quality of the cookies they serve in the waiting room? The second dialysis center was started by a specialist who was not the proprietor of the first dialysis center, and figured he could hold on to his share of the patients by building his own.

Now perhaps I shouldn’t be fussing. What harm could it do if two companies want to open up and offer services that don’t really hurt anyone in town, and in fact potentially save lives? What I’m worried about is the large population of over 80 year olds in town who will now most likely experience rather powerful marketing as both of these centers struggle to make ends meet.

These folks and their families will now be faced with the expectation that they should not let nature take its course when their kidneys quit, since dialysis is common and easily accessible. If this made them healthier and happier it would be one thing, but I predict it will not go that way.

Wednesday, October 21, 2009

unthinkable thoughts, hypothetically

Last night I participated as a member of a panel speaking to medical students about issues relating to health care reform. Next to me was a respectable Blue Cross executive from the state capital, next to him a health care economist from the university and then two of my doctor colleagues. Our first starter upper question from the gathered masses was what we thought was the major problem with health care in America. The insurance guy and the economist said that people don’t take good care of themselves and so are in lousy health, and that they ought to take more personal responsibility for being healthier. This is what I keep hearing from Washington DC folks not in medicine, and although it is a truism, is it actually true?

Clearly, from the standpoint of bang for the buck, health and happiness and overall simplicity of delivery, the prevention of illness by avoiding overeating, drinking, smoking and drug addiction is powerfully attractive. Add to that physical activity with all of the associated intrinsic benefits of getting out and about and using one’s body as it was intended, and the recipe is really hard to beat.

But what if the finding in the New England Journal of Medicine last year that cessation of smoking eventually would actually lead to higher health care costs due to the fact that people would live longer is also true for all the rest of the things we do that make us healthier?

That is to say, what if being healthier means we live longer, and use up more health care resources because in America that’s just what happens?

This is a hypothetical question, and the answer might include a suggestion that however healthy we become, it will still be necessary to reduce health care costs.

It is certainly a more attractive idea that being healthier is also less expensive, but then one gets into the question of how to make people make choices that make them healthier.

Studies throughout the last 20 years have shown absolutely pitiful results from doctors counseling patients about lifestyle changes. So, hypothetically again, is it possible that beyond giving relatively casual advice, doctors really shouldn’t be in the business of delivering messages related to lifestyle changes? Would it, perhaps, be more efficient to have public health people do this? Maybe making exercise and healthy food more attractive and available would work better than nagging?

A somewhat different subject, but also nearly unthinkable, is the concept I’ve been rolling around in my mind lately about the source of our willingness to pay excessive prices for procedures and drugs compared to their value to us and their objective value in a global market. Is it possible that the introduction of public insurance, medicare and medicaid, in the last 50 years, has resulted in acceptance of actually generally unaffordable health care costs? On public insurance, in most cases, anything ordered by the doctor is paid for, without a significant bill to the insured. So there is very little reason for these insured people to protest the cost of things. I am absolutely positive that medicare and medicaid have saved lives and livelihoods for the many years they have been in existence, and that if they simply disappeared today havoc and misery would ensue. But is it just possible that they have been a primary player in the creation of our financially extravagant medical care in the US?

A single payer system might have the motivation to act like a patient/consumer would, and have the clout to reduce prices and increase quality, but lacking that how can we get insurance companies to do this? And why do that not act this way?

Insurance companies, when they first started to pay the bills, paid "usual and customary" fees for doctors and for procedures, set by what had been the market forces acting on them. As time went on, insurance companies standardized what they would pay for things, due to a great variation in regional billing, and then billing began to match, or rather slightly exceed, what insurances paid. Billing for these things gradually went up, and insurance payments went up, slightly trailing billing, and here we are. But as technology got better, the cost of x-rays and cat scans should have been able to come down. Procedures could have become cheaper, and drugs that had been around for years could have come down in price.

Saturday, October 17, 2009

Hawaii and the free market

Hooray for Hawaii! Apparently they have managed to get employers to cover just about everyone with adequate health insurance and their health insurance costs and other markers of health care efficiency are marvelous. Could it be the sea air?

So I am brought back to the dilemma that keeps popping up in the health care debate. Can we submit the business of caring for peoples’ health and diseases to market forces and bring down costs? As long as health insurance continues to protect people from exposure to the real costs of things, I don’t see market forces adequately coming into play. Only if health insurance companies actually acted like consumers would that really happen.

Why are medications so incredibly and jaw droppingly expensive? Especially ones for diseases like cancer and transplants and severe diseases? Because people who have those conditions are ALWAYS insured, or else they die, and are not part of the equation. If they don’t start out insured, they become insured when they run out of resources and go on public assistance. So drug companies know that they will be pain the 10 or 20 thousand dollars a year or a course for whatever new and necessary drug is prescribed. If consumers had to pay for drugs that were this expensive, they mostly would not, and prices would have to come down for the pharmaceutical producers to sell their products.

Coming back to Hawaii (which is always pleasant) we see a system that works by covering everyone with health insurance. It reduces costs by keeping the insured out of emergency rooms, cared for by doctors who know them, and by reducing use of procedures because the culture in Hawaii tends to avoid them. But the costs of those procedures and drugs etc. are still amazingly high, and they are successful only in comparison with the rest of our country.

Tuesday, October 13, 2009

Senate finance bill 10/13/09

A bill has passed the senate finance committee, with "bipartisan support", which means one Republican voted for it. The bill is only a tiny part of a health care reform package that will eventually by voted on in the house and the senate.

This tiny piece provides for more affordable universal health insurance, which is good, and will make those of us who have to negotiate for health insurance breathe a little easier. It would put an end to really heinous insurance company antics, such as canceling policies because people are sick. It allows for competition across state lines, stand alone dental insurance, expansion of medicaid and funding help for consumer driven health insurance options.

So it is good. It is not exactly what we need, but it does address some of the issues.

What we really need is still a radical reduction in costs. Although, as a health care consumer, I welcome anything that will bring some relief to those of us who suffer through having to pay for health insurance, I also recognize that those costs are almost completely driven by the cost of the product that is being paid for.

We focus on health insurance costs because, for those of us who are insured but rarely use medical services, that is what hurts most. And it is true that health insurance companies make obscene profits. Nevertheless, even the obscene profits are a drop in the bucket of what we pay for medical care overall. If we are relieved by improvements in the way insurance is administered and paid for, that relief will only be temporary, because the actual costs will continue to be too high. Costs need to come down.

As we breathe a sigh of relief that not all of our income will be used to pay for insurance, we need to stay focused on the work of rethinking what we want from medical care.

Presently, the culture of medicine, despite improvements in communication between doctors and patients over the years, remains hierarchical. Patients are expected to defer to doctors' opinions, and rely on the idea that doctors will truly know what is best for them. And doctors are still trained to think of the cost of care as being irrelevant. We have been trained in medical school to search for truth, find the diagnosis, even if it may have no important influence on outcomes, and damn the cost. Patients, through long association with their doctors, have come to accept this approach as only right and proper. There has been movement in the direction of providing appropriate and cost effective medicine, but it is by no means the rule.

The rethinking of our medical culture is going to take work, and time, and a willingness to change. As much as I would like to believe that legislation can make it happen, that would probably be unwieldy and heavy handed. Other than substantial federal malpractice reform, changes that need to happen need to happen at the level of health care providers and their patients, agreeing to do things differently, in a way that benefits their well being and remains financially sustainable.

Thursday, October 8, 2009

Health Care--a right or a privelege?

Does every American citizen have a right to health care? How about "affordable health care?"

It's tricky, this question of rights. I would like everyone to have enough food, but everyone doesn't have a right to enough food. Or enough sleep. Or love...

Soon after 9/11, Mayor Giuliani of New York City said that every American has a right to freedom from fear. No, I think, they do not.

Traditionally, as a country, we have made laws that prohibit the government taking away our individual self determination, and placing strict controls on the ways in which our self determination can be restricted in cases of law breaking or conflict. We have also developed institutions by which we care for each others' needs, guarding against letting those who are vulnerable die of poverty.

As a health care provider, I balk at the idea that every citizen has a right to what I produce. It's kind of like telling a dairy owner that everyone has a right to cheese. Nevertheless, as a not-abjectly-poor country, it is consistent with other safety nets we have created, to ensure that health care is available to everyone who needs it. In addition to issues of compassion, provision of universal health care makes business sense.

The present system, if it can be called that, provides expensive health care to some people, and is paid for at least partly by expensive insurance which increases the expense of the care by being ridiculously complex. The expensive insurance is paid for by employers, at least in part, and is part of what makes them competitive for good employees. They are cornered into buying the expensive insurance if they wish to do effective business. Our country lives or dies on its ability to be economically successful, which means that a health care system that strangles business, as it is doing, strangles the US of A.

Compassion drives many of us, but it need not drive the push for reform and universal health care. Health care does not need to be a right in order for it to be something that we, as a nation, agree to provide for all of our citizens.

I would love to see legislation that pushes us in the direction of smarter and more efficient health care delivery. But even if we don't get what I want, we need, at the very least, to reform the way in which health care is paid for provide adequate and affordable coverage to everybody.

Thursday, September 24, 2009

Where does the money come from and where does it go?

All water is recycled. The drip from my nose was, at one point, the drip from someone else's nose and so on. And the same goes for money. There is a limited amount of money, as it represents resources, but it doesn't just go away when we spend it. So, with health care dollars, the problem with the 2.3 trillion dollars going to pay for health care isn't exactly that 2.3 trillion dollars, it is where it comes from and where it goes.

An example in point: A friend of mine was just diagnosed with a particularly nasty form of brain cancer, glioblastoma multiforme. It is the most common malignant brain tumor, and it just killed Ted Kennedy. I don't have any idea how it chooses its victims, but it seems clear they have no fault in the process. He has already had 2 MRI scans, brain surgery and 5 days of hospitalization around the brain surgery. He also had an ambulance ride and several doctors' visits. He hasn't got the bill yet, but my guess is that he has just racked up close to $100,000 in medical costs. Everything, so far, has been necessary. But the costs of everything are significantly higher than they would need to be if procedure prices were as low as a competitive market could make them.

So the money comes from my friend, a teacher making maybe $45,000 a year, and his insurance company and it goes to a neurosurgeon, emergency room doctor, 2 hospitals, and indirectly to the makers of various medical equipment and supplies. It also goes to the many administrators who push pens regarding insurance payments. If he is responsible for 10% of the costs, he's already looking at 10K out of pocket.

As he enters the next phase in his treatment, he will spend tens of thousands of dollars over the next 6 weeks getting radiation therapy and then chemotherapy, at an expected cost of $5000 a month, for which he will foot some percentage of the bill. The money will come from him, his insurance company, and go to an oncologist, a radiation oncologist, a hospital that does the radiation, and a drug company that produced and markets his chemotherapy agent. And a bunch of administrators pushing pens in a system more complex than anyone could shake a stick at.

His situation illustrates a problem that will not be solved by doctors getting together and streamlining and making more effective the care they deliver. The care that he is going to need over the however long he has to live is just way too expensive, and his portion of the cost is way too high.

If he happened to roll the jackpot and live a long time, he will exceed his insurance's lifetime max of 2 million dollars in less than 10 years.

It is clear to me that there needs to be significant pressure to bring down the costs of big ticket items, procedures and certain medications, and that the system of insurance coverage needs powerful tweaking, either by regulation, replacement, or effective competition, in order to protect people from financial ruin. Just having a public option won't achieve this, but a public option, with standardization of coverage, and regulation of private insurance companies, could do this.

Sunday, September 20, 2009

Excuse me Mr. Obama--here's the money you were looking for...

Now, like the beginning of a mudslide, there are people, doctor people, writing about why it costs so all fired much to deliver medical care in these United States. There are articles in the New England Journal of Medicine, that staid periodical with the plain white cover, and just this week an article in the Journal of the AMA which explains exactly how the costs of medicine can be curbed, resulting in better care.

The sound of this message is a murmur that is steadily increasing in volume. I'm not entirely sure that anyone in lawmaking positions is hearing it yet. Perhaps when it gets really roaring they will.

I was feeling frustrated by the apparent near inaudibility of this message until today at about 1:30 when, while walking on an old logging road, I realized that it doesn't really have to be heard by law makers. Now, if they did hear it, they could be substantially relieved to know that costs are going to go down, but they don't even have to know that. Perhaps it will just be a pleasant surprise.

It is going to happen that medical care will become more streamlined and more effective, because it is really what everybody wants. And when people start talking about it, it will happen. In talking to doctors of all description, including those who make lots of money from procedures, I've found that virtually everybody is feeling uncomfortable with waste in medicine, and those of us who are in the position to be leaders have started to do things to make change happen.

The next step that I'm going to take is to have a conference at my hospital, most likely a repeating event, in which providers (I hope this will include nurses and therapists) will discuss the things that we do that are costly and don't really help anybody, with the overall goal of sharing thoughts and eventually developing new policies. The radiologist who first got me thinking about all this and I talked about it yesterday, and he will talk to the person who sets these things up this week.

Thursday, September 17, 2009

Senator Baucus' proposal--are health care co ops a bad thing?

I just skimmed the 223 pages of the health care proposal by Senator Baucus, with a focus on the health care cooperative suggestion and the mention of medical malpractice reform.

There are lots of sections in this proposal, and most of them contain good ideas. Achieving all that is in it would be a humongous and monumental amount of work. It also nearly completely misses the boat in terms of cost savings.


The proposal suggests that we establish health care cooperatives as an alternative to presently available insurance plans, that work about like Group Health does now. Group Health is a cooperative based in the northwest which provides full health care services to members for what looks like a reasonable price compared to what most health insurance costs. It provides basic services easily, emergency services competently, and focuses on prevention. It provides good care for serious illnesses of all kinds, and skimps a bit on cutting edge technology and medications. Sometimes members have to wait for services if the providers get busy. The basic idea behind cooperatives from a doctor's point of view is that we get paid a salary to take care of a certain number of patients, and provide those patients all the health care we are qualified to do, and refer out to other providers or services as necessary.

I worked for Group Health from 1989 to 1993 or so, and had a baby while insured with them. The total cost for prenatal care and delivery was $5, which I paid for use of the TV in the delivery room (which I didn't actually watch). As a provider, I was occasionally quite annoyed when I wanted to prescribe a new medication for a patient, and they wouldn't pay for it until I had tried 3 or more ineffective medications with tons of side effects, but no one ever died because of that.

It will be difficult to establish functional health care cooperatives on a large federal scale in time for them to absorb all of the people who need insurance now, but it would be well worth the effort. A cooperative such as Group Health has the ability to mandate cost effective strategies for taking care of patients, and if that began to be part of the way medicine was practiced in the US, it might spread to the fee for service arena, as the overall culture of care changed.

The problem is that it would be slow, but then the strength of it would be that it would be slow.

The changes that need to happen in health care are so large that going too quickly might entirely bust something that is only mostly busted right now.

Still, to get a health care cooperative up and running well will take years, and will be a bumpy road for each individual cooperative, which gives little relief to people who need medical care now.

A public option, if it were identical to medicare, would have the difficulties of medicare, with a set of rules that don't make good sense, and reimbursement that is low enough that many providers opt out of caring for patients insured with it. If we could make a public option plan available and also improve medicare at the same time, with a medical home model, this would be better than cooperatives, but if that can't happen, all would not be lost if we were able to get in motion good, solid, viable health care cooperatives.

There was exactly one paragraph in the bill about malpractice, saying the the "sense of the senate" was that states should take this change in health care delivery as an opportunity to change the liability system so that it actually works. I can see that perhaps the inclusion of broad and powerful malpractice reform in a health care bill might kill it, but I am disappointed nevertheless. Tackling malpractice is vital to reducing costs and there is actual energy and motivation to do it now.

Tuesday, September 15, 2009

What American health care system, exactly?

People throw around the expression "American health care system" like it was something that actually exists. Britain and Canada have health care systems, and in the US of A we have things like Kaiser and Group Health and the VA which are health care systems, but we don't have "A health care system". What we more accurately have is a bunch of professionals who provide services that are sometimes random and sometimes coordinated, having to do with caring for peoples' health and diseases.

Because we don't have a health care system, it is hard to fix it.

Most of our health care is delivered by people who see themselves as individuals delivering a service. In addition to delivering the service, these individuals want to make as much money as they can, consistent with keeping the client happy and healthy. This model does not lend itself well to cost efficiency.

Today our office was provided lunch by a well dressed representative of a medical equipment company. This salesman was sent by his company to show us a device, an inflatable vest, that bumped and vibrated to help patients with lung conditions get rid of their congestion. I can see that it would be helpful, but he said the cost was $15,000, most of it paid by Medicare. So his company had made something that was pretty darned good, but cost as much as a car, and shouldn't. If there were an actual health care system, that system would include the medical equipment company which would be encouraged to produce the fancy doohickey for less money.

If we are to make a bunch of independent providers deliver cost effective health care, we either need to regulate costs, which might work, or allow the market system to push down costs.

Monday, September 7, 2009

What if I had 3 minutes to make my case

What if I had 3 minutes with a health care czar to ask for what I think we need

Okay, the timer is running...

1. Reduce costs of health care by a. reforming the malpractice system at a federal level to reduce malpractice insurance costs and reduce "cover-your-ass" medical spending b. introducing cost transparency, whereby providers and patients know what everything costs and can make informed decisions and c. creating teams of healthcare professionals to identify waste in practice and administration.

2. Insure everybody by expanding medicare to cover those who can't afford insurance, and revamping medicare to encourage a "medical home" model that provides care for patients through primary care providers who know them well. This would include better coverage and compensation for patients and providers who participated in the new medicare program, and education in cost effective and appropriate medicine to providers of care.

Thursday, September 3, 2009

Bedtime story

Once upon a time there was a big country with not very many people living in it. They were farmers, and ranchers and teachers and people who sold things that other people needed. There were doctors, too, who gave advice to the sick, did minor surgery and comforted the dying. The doctors could set bones, bandage wounds and tell people approximately what was wrong with them, but they couldn't do much to fix people who were sick. Eventually the doctors made schools to teach each other what they knew, and educate new doctors who would know a bunch of things right off, rather than having to learn them as they went along. The new well educated doctors were respected because they were able to help people who really needed help, so smart young people wanted to be doctors. In the medical schools the teaching doctors were able to discover new ways to treat the dread diseases that they saw, and so the job of doctoring was associated with more respect. With the respect came good pay. When doctors were actually able to do something for patients the patients were more willing to pay good money for what the doctors had to offer.

Pretty soon the only people who could get into the medical schools to become doctors were the smartest students, and they were often from rich or influential families. A job with good pay and immense respect was hard to beat, so qualifying for it became very competitive. The prospective doctors didn't realize, though, how hard it would be to learn the increasingly huge amount of book facts and practical skills that were taught at the medical schools. The time and effort that were spent educating these students was huge as well, and so the cost of going to these medical schools rose. The young doctors, despite their good families, often were not able to pay for school and went into debt and they were sometimes ill or sad because of how hard they studied.

The ever more effective and fancy procedures that the young doctors learned were very expensive, but they were also the only thing that might stand between a sick and suffering person and death. There was no question. The sick and suffering person had to have them. Since the procedures were so expensive, nobody could really afford to pay for them. Cleverly, the communities of people produced a whole industry that would pay for the medical procedures that people couldn't pay for themselves, using money that was contributed by everybody, even when they weren't sick.

The doctors became more powerful, as a profession. In order to make them accountable to their patients, the communities of people hired lawyers to tell them when they had done wrong, and the lawyers told the doctors that if they didn't behave, they would have to pay lots and lots of money. The doctors then started doing more and more for the sick and not so sick people so that the people would like them and not sic the lawyers on them. But the more things the doctors did to make the people happy, the more money the people spent and eventually all the money in this entire country was spent on the stuff that the doctors did, and there was no money to spend on other things the people needed.

A wise matriarch who lived on top of a mountain saw that the whole thing had gotten utterly and ruinously messed up, and so she did something that was so wise and so creative that all of the happy people who lived in that country spoke of it around their kitchen tables of an evening, for long generations. But I'm not entirely sure what she did. We can, though, write the rest of the story any way we like, so long as the ending comes out happy.

Tuesday, September 1, 2009

What's wrong with spending trillions of dollars on health care

A couple of years ago I decided that the reason that Americans spend so much money on health care is because it is our national pastime. In Brazil they like soccer and Carnival, and in France they like fine wine and good food. In the US, we like our MRI scans, our bypass operations, CAT scans and the whole gory and dramatic process of getting them and discussing them. When we have a spare moment, we talk about going to the doctor and what tests the doctor ordered and what the doctor said. We have other hobbies, true, but we are very interested in things medical.

When I developed this theory of health care as a national pastime, I saw it as interesting and neither particularly good nor bad. It seemed that any national pastime costs money, and the money that is spent on it goes to pay the salaries of the many people who provide the goods and services related to the pastime. Since medical care consumes such a large amount of money, it must support many households whose wage earners make medical equipment, administer to insurance companies, provide direct care etc.

Then came the realization that our nation's health care budget is rising faster than any other segment of that budget, that our national debt is rapidly increasing, and that a rising national debt threatens to wreck our economy. At the same time it has become clear that much of the money spent on health care is spent on unnecessary care, inflated procedure costs and administrative waste. This wasted money does eventually make its way back into the revenue stream, but without creating any product of value.

In the federal budget the biggest expenses are medicare/medicaid, defense and social security (about 20% each). Social security gives us a safety net in retirement and in disabling circumstances. Defense spending, at its best, provides for a structure that keeps the bad guys from messing with us. Medicare provides for maintaining health and treating disease in people who are at the age of retirement, or unable to work. Other budget items include money spent to maintain roads, pay for police and public works, support education. In the ideal world, all of this money not only pays the salaries of citizens, it also creates something we value. Money that is spent on things that are truly waste, if not spent that way, will remain in the revenue stream as disposable income. ( I would argue, on another point entirely, that money spent to build beautiful shiny bombs that are then blown up to destroy people and property in unwinnable wars is money more extravagantly wasted that that spent on a needless CAT scan.)

We come back, again, then, to what is wrong with spending trillions of dollars on health care. I would argue that spending money wisely on health care creates something we value. Spending vast amounts of money on things that don't make anybody healthier or happier is wasted money, and the extent of that waste goes considerably beyond what I can consider a national pastime and becomes more of a self destructive addiction.

Sunday, August 30, 2009

Computers and the medical record

Many of the elected officials who I respect--President Obama, our own Idaho congressman Walt Minnick, and anybody else appropriately fired up about health care reform--say that we will all be better off when the records of our blood tests, medical procedures and office visits are made accessible by computer. It sounds simple and beautiful. Two and a half years after starting to use such computerized medical record keeping system I have a few opinions about how good it is, and what it is really good for.

In a state of unrealistic optimism, many health care reform proponents are saying that electronic medical records will, when combined with Americans adopting healthier lifestyles, save enough money to pay for health care for the presently uninsured. Healthier lifestyles are indeed a money saver, but I'm not exactly sure what transformation is supposed to happen to make us eat less crap and stop smoking.

On the other hand, though, a computerized medical record is not a cost saving device.

Having records kept in a way that is readable, easily communicated, and coordinated with things like recommendations for preventive medicine does make patients' care better. Or it would, if doctors could learn how to use it. Some health care providers take to computers like seals to the ocean, and some find that it just doesn't suit their style. Some run screaming in the other direction. When we launched our computerized medical record keeping system, everyone reduced the number of patients they would see in a day by half, and even with that everyone in my office at some point became so frustrated and hopeless that they cried. After adjusting to the system, which took a year, (yes, a year) we no longer cry, but we still can't see as many patients in a day as we could when we were scrawling notes on paper, and phoning in orders for various things. Because of the stress of adjusting to the new system, several providers left our practice, which resulted in staff cutbacks, service cutbacks, and almost made our business fail.

Now, about 2 1/2 years later, we have recovered. We know how to use our system, and it only crashes occasionally. It helps me remember what I did last time, to know what other docs did at remote locations, to review results, and my notes are always legible. If someone wants a note produced I can do that pronto, and I have instant information about drug interactions, costs and medication allergies. I can ask questions, document answers, and not have to ask the same questions again.

But it's not cheaper. Because I can document all I have done conveniently, I can bill more successfully for what I do, but it all takes time, and so I see less patients and each one costs the insurer, or the individual, more. Overhead for us is probably a bit higher, because, although we no longer have to handle paper charts, we now have to pay many 10s of thousands of dollars yearly on tech support, after the hundreds of thousands of dollars that the software and hardware cost in the first place. The software is also, still, deeply flawed.

Electronic medical records really are the wave of the future. This particular progress is unavoidable, and in the end, a positive step. But, though it is better in so many ways, it is not going to save the billions of dollars that we need to save to balance our federal budget.

Do no harm

After finishing medical school, we all stood together in the big hall where we had been educated for 4 years, and took the hippocratic oath. The only part of the oath that I remember well is "primum, non nocere." Those words recognize that a doctor has the ability to harm as well as help, and needs to have the humility to recognize that.

Today in the New England Journal of Medicine, the most well regarded journal of research and practice for internists, an article appeared that referred to medical harm. I think it may be available to non subscribers at The author looks at the evidence of help and harm from radiological procedures that are done to prevent disease.

The number of CAT scans and heart imaging studies that are done is rapidly increasing, and yet there is no evidence these save lives or improve health in most instances. There are definitely times when they are helpful or appropriate, but most of them may be time and money wasted.

But waste is only part of the picture. Most imaging procedures expose people to radiation, and at this point, with the amount of tests people have been getting, about 2% of cancers may be attributable to radiation from CAT scans. The number of CAT scans performed has quadrupled since 1992, and when I look at the graph, there does not seem to be any evidence of this growth slowing. So the extra CAT scans done today will be responsible for an even larger percentage of cancers in future years.

It is hard to track the harm done by radiation exposure because it happens so many years after the actual procedure, which makes it difficult for doctors or patients to put the harm concept together with the test that's done "just to make sure everything's OK." In order to do no harm, we so strongly need good doctor and patient education about the reasons to do and not to do expensive testing, and more universal understanding that what we pay the big bucks for in medical care is not necessarily what makes us healthier.

Thursday, August 27, 2009

Why do doctors make so much money?

In the discussion of why American health care is so expensive, it is certainly necessary to entertain the question of why doctors salaries are as high as they are. The average American makes $38,000 a year, and the average primary care doctor makes around $150,000 a year. These numbers vary by geographical region, certainly, and the primary care doctors I talk to in my small Idaho town mostly make less than $100,000. But they certainly do command a higher salary than teachers or carpenters or most university professors at our esteemed and underpaid state university. So why is this?

To practice medicine, a doctor has to finish 4 years of university, 4 years of medical school and at least 3 years of residency as an MD in training. In order to get into medical school, they need to be in the top of their university classes, and have finished a set of premedical requirements that is heavy in science and math. Medical school is an order of magnitude harder than university. The first two years are spent trying to memorize a tremendous amount of information on anatomy, physiology, biochemistry and the myriad of diseases of the human body, along with their molecular mechanisms and present treatments. The second 2 years are spent intensively practicing medicine, usually in a hospital setting, under the close supervision of teaching doctors and residents in training. Medical school is long, hard and painful, and is essentially all consuming. After these 4 years an MD degree is awarded and the graduate starts residency. The residency years are paid, but at a lower rate than many jobs. In 1987, in my first year out of Johns Hopkins, I worked about 80 hours a week, was often up all night, caring for desperately sick and wildly complicated patients, and made about $18,000. That was the most money I had ever made in my life and I was very proud. But it wasn't even minimum wage, I don't think. After 3 years of this, the resident becomes a full fledged, employable, and usually indebted doctor. On average, a new doctor will have over $150,000 in educational debt.

So the freshly fledged doctor emerges, blinking, into the sunlight of the real world, with enough debt to have bought a house, exhausted, and jobless. The new job, once obtained, is hard. There are new systems to learn, the pace is faster than in training, and the new guy frequently will be given the extra work that nobody else wants. The hours are long, and many of them unpaid.

Now don't get me wrong. I have no cause to complain. I have the best job in the world and I love it. It was just really hard to get to this point, and I don't think that many qualified people would do it if the salary weren't good.

Wednesday, August 26, 2009

Cost shifting--is that why hospitals charge so much?

If health care costs go down significantly, as providers order less unnecessary tests, and as tests and procedures come down in price due to the incentives of actual competition (OK, I'm making a rather huge and optimistic assumption) hospitals will see less money coming into radiology departments and labs. When there are more primary care doctors available to see patients, and patients seek care earlier in the course of their illnesses, there will be less patients seen in emergency rooms, and hospitals will see that revenue go down.

Or will they?

If we truly get universal healthcare, the amount of uncompensated care that hospitals have to cover will be dramatically reduced or completely eliminated. Right now if an uninsured young man is brought into the emergency after a gunshot wound, that man will get top of the line trauma care, with specialists called in, multiple imaging procedures, needed surgery and medications, and the hospital will simply eat those costs. It is not clear to me how great of a loss of income hospitals will face if there is comprehensive and cost saving health care reform.

At this point our hospital runs in the black, though not far in the black. When I look at the hospitals charges for tests and procedures I see that they are significantly higher than I think they should be, comparing them to the same procedures done at doctors' offices or the same procedures a few years ago. But hospitals spend huge amounts of money on uncompensated care, or poorly compensated care, and high charges for tests and procedures are part of the income that offsets these losses.

For a health care reform solution that saves significant amounts of money to allow hospitals to survive, there must be universal health insurance, and that health insurance must adequately compensate hospitals for their services.

While everything is on the table, medicare and medicaid payments to providers (doctors and hospitals) needs to be on the table as well. I know these payments are barely adequate or inadequate to pay for a doctor's services in the office, and I expect they are also close to inadequate in their payments to hospitals. In order for patients who are insured with a publicly funded plan such as medicare or medicaid to be assured access to care these programs must pay providers for what they do.

Tuesday, August 25, 2009

Cost transparency--what's not to like?

Cost transparency, that is making sure that patients and providers know what everything costs at a time that is relevant for discussing options, is a great idea. The effects of sharing this kind of knowledge would be powerful. Cost could become part of conversations about what is the most appropriate care. A patient could ask if a particular $3000 test would really change their treatment, for instance. If everyone knew, up front, what things were supposed to cost, billing errors and fraud would be much easier to identify. And when things cost way too much, we could start asking why, and begin the process of making these costs competitive.

There are, however, some pretty serious obstacles to making this information available.

I would like a patient to know, before she even sits down with me, how much her visit will cost. Unfortunately, I don't know. The amount of time and complexity of the encounter, including office procedures that might have to happen, will unfold during the visit. Now the patient could have a sheet that gives costs for various things that might happen, but that, too, gets pretty complex. Here is an example. Just recently we raised our rates for office visits. Now a detailed office visit, which may take about 30 minutes and involve research or consultation with other doctors, carries a price tag of $160. That is the price that all insurance companies and uninsured patients see on their bill. Medicare will pay $86, Premera $127 and Blue Cross about $150. Depending on the patient's specific policy, they may have to pay a part of that as a copay, or even be billed for the difference. The uninsured are discounted according to whether they pay at the time of service, and sometimes, at the discretion of the provider, their financial situation.

For costs to be truly transparent, they must be presented in a way that just about anyone can understand, without requiring that person be computer savvy or able to sift through a packet of insurance materials.

Providers of medical goods and services could be required, at the time of service, to provide a list of costs of the most common items that they offer and provide information on costs for less common items quickly at a patient's request. Insurance companies could be required to produce an easily understandable list with information on how much they pay to be available to the patient at the time they received services. This information could be accessed online or by telephone by the provider's staff.

The trick with all of this is to make the information clear, relevant and to avoid adding a layer of complexity to an already complex system. Processes that require more time per patient inevitably make an office less efficient, and thus more expensive, which is exactly what we're trying not to do.

A single-payer health insurance system would make cost transparency a piece of cake, but maintaining truly independent health insurance companies does make the process more challenging.

Why isn't malpractice reform an issue for the democratic party?

Malpractice reform is not traditionally an issue that Democrats support. Why?

I think it is because democrats feel strongly that everyone, no matter how poor or disenfranchised, has a right to his or her day in court.

This is good: we are right to hold on to systems that allow people who have been wronged to be heard. But our tort system does not work in the case of medical injury and malpractice.

Most people with a medical injury never sue for malpractice. Most of their injuries are too small for a lawyer to take the case, and many of the injured don't want to enter into the complex and contentious world of the legal system.

Most cases that go to court are ones in which a person has a very bad and often expensive outcome, in which a lawyer could hope to get an amount of money worth his or her time. Most of these cases have no convincing level of negligence, and so there is no significant benefit for the injured party.

During the time that the case is being prepared, usually a number of years, the injured party must continue to be injured, and so has a powerful motivation not to get his or her life back on track, and not to heal up from whatever bad thing happened. The provider being sued is encouraged by the lawyer representing him or her to feel sure of how good and appropriate the care was, and thus not learn from any mistakes.

I have noticed that in my hospital when something bad happens to a patient, and there is no perceived risk of a malpractice suit being brought, that the whole medical community comes together with meetings and discussions to figure out just what happened, and what can be done to make it never happen again. They will organize educational opportunities, change protocols, talk to patients and families who were involved. If the event has a threat of malpractice, all discussion is hushed.

Doctors live in fear of being called into a malpractice case, which will use up countless hours of their productive life, and leads to bitterness and isolation. The vast majority of doctors will at some point be sued for malpractice, but that doesn't make it any easier on each individual, who is ashamed and shaken.

Bottom line--the malpractice system is horribly ill. It is damaging to everyone who comes in contact with it, and continuing to do it they way we do is a huge missed opportunity for improving health care and reducing unnecessary costs.

To fix the problem, in a way that is substantial and could really work, we need major changes. The whole process of taking care of medical injury and negligence could be taken out of the courts and placed in the hands of a board, consisting of physicians and lay people, with the ability to give no-fault compensation to the injured party, analyze and remedy whatever process led to the injury, and educate and punish, if appropriate, anyone who was negligent.

How to fix it

The problem:
Health care costs too much, insurance costs too much, and people are suffering because of money spent directly in bills or indirectly through taxes. Because of the cost of insurance and health care, too few people have access to it.
Scope of the problem:
Huge. Because of the lack of access, America’s indicators of overall health, including infant mortality and average age at death aren’t as good as most countries we consider our peers. Because of the cost, average Americans’ take-home salaries are significantly lower than they would be and federal and state governments are unable to afford other basic services such as education and other social services.
Causes of the problem:
1. Doctors practice medicine that is not cost effective because of worry about malpractice, and perceived patient expectation that costs are not a consideration where health is concerned.
2. The number of primary care physicians is shrinking because primary care physicians are not paid as well as medical specialists who do procedures. Doctors who do primary care try to do as many procedures as possible because they are paid better for them. Because they are paid poorly, primary care doctors have to see more patients, and so they spend less time with each patient. It takes more time in an appointment to discuss with the patient whether they actually need an expensive procedure or medicine than to simply order the procedure or medicine (examples: MRI or CT scans, x-rays, and antibiotics.) One MRI scan costs about as much as 50 office visits.
3. Even though insurance companies make it difficult for doctors to order tests or expensive medicines, the threat of malpractice is so great that we spend the time it takes to get authorization to do these things, and subsequently have even less time to spend with patients.
4. Almost no stakeholder, not patients or doctors, knows how much anything in medicine costs. The insurance rules and coverage are so complex that costs of procedures, medications, office visits or referrals are not known at the time they are prescribed so cost cannot even enter the equation.
5. Because billing is so complex, and insurance rules are so complex, certainly a huge amount of billing mistakes and fraud happen on a regular basis.
6. The staffs and administrations of insurance companies are very large and expensive and the billing departments of doctors’ offices have to be large and expensive to deal with them. The system is adversarial rather than cooperative and wastes a great deal of money.
7. Medical devices, procedures and medicines are too expensive because the risk of liability reduces competition. iPods have gotten cheaper and better in the last 5 years and MRIs and appendectomies have gotten more expensive.
8. Uninsured and low income patients don’t come in to see a primary care doctor because they can’t afford it. Instead, they get the most expensive kind of care, which is hospital based, when their preventable problems become emergencies.
1. Cost transparency: patients and doctors need to know what everything they do will cost ahead of time. Patients should know the cost of an office visit when they see the doctor and know what their portion of that cost would be. Doctors should know that as well. The same is true for surgeries, scans, lab tests, medications. This will not be practical in every situation. There will be emergencies and unexpected costs, but these things should be the exception not the rule. Doctors will find it much easier to practice cost effective medicine when they actually know what the costs are. This will require a significant change in the way insurance companies operate.
2. Tort reform: doctors practicing cost effective medicine need to be protected from being sued for being responsible about expenditures. Some level of tort reform on a federal level to prevent lawyers from benefiting from huge settlements will help get doctors to do what they already know how to do: take care of patients.
3. Pay adequately for primary care: it takes time and intelligence to counsel patients in such a way that they feel satisfied without unnecessary tests or medications. Surgical specialists will also be more likely to counsel patients rather that doing procedures if they are compensated adequately for the time spent counseling.
4. To alleviate the primary care shortage, consider a program to subsidize medical education for primary care doctors. High educational debt drives graduates into high compensation practices including specialty medicine and primary care in big cities.
5. Educate doctors in cost effective medicine. We are required by our malpractice carriers to take continuing education in risk reduction, and it would be simple to require a certain amount of time for learning about cost effective practice in order to qualify for updating our licenses. A large amount of research has already been done in the field of effective medicine and evidence based practice, such that there are clinical practice guidelines for many common diagnoses. Doctors know these exist, but are usually not familiar with them.
6. Provide adequate insurance to those who can’t afford it, based on the most effective and efficient models available. (Consider Medicare, Group Health, and other countries with good health indicators.)

Bad Ideas:
I have read many proposed solutions to the healthcare crisis, and a few have seemed particularly poorly conceived.
1. Across the board cuts in payments to doctors: if we make less money for each patient we see, we will have to see more patients in a day, and do more procedures in a day to pay off our educational debt, which will make health care less effective and more expensive. Costs for procedures and medical equipment may need to be cut, but that needs to be combined with some significant changes that allow it to be easier for us to do business. Doctors in the US do not make significantly more money, corrected for cost of living and average salary, than doctors in countries whose health care systems are more cost effective. In Moscow, Idaho, primary care physicians make about the same salary as a good accountant does. Medical education takes a minimum of 7 years postgraduate education and is very expensive and competitive. If the practice of medicine doesn’t offer a decent competitive salary, the people who are qualified to go into medicine will do something else, and physicians will leave their practices.
2. Requiring low income patients to shoulder more of their insurance and healthcare costs: In my experience, low income patients have no extra money to spend on insurance or co-pays and simply will not pay these bills. If there is a “public option” insurance offered by the government and patients on minimum wage are told they need to shoulder 15% of the costs and pay 20% of their medical bills, they will either remain uninsured or will fail to pay their portion of bills, and lose their access to their doctors for bad debt.