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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.