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Sunday, January 23, 2011

repealing health care reform and rescinding payment for end of life counseling

This last week brought a couple of disappointments.
  1. The House of Representatives passed a bill to repeal the health care reform package: This was expected and "largely symbolic" since the senate will not approve it and the president will not sign it. I think that it is not largely symbolic, but rather largely strategic. It has the psychological effect of making people remain confused about exactly what health benefits they will have, on top of the confusion that already exists due to the complexity of the present bill. Because of confusion and insecurity about the provisions of the health care bill, hospitals and doctors are acting slowly to take advantage of the changes that are scheduled to occur, and so positive changes that would be more likely to make the primarily democrat backed plan look good to American voters will be less evident. As a physician, the stuttering pace of change is frustrating and discombobulating. 
  2. Congress decided that they will not pay for counseling about end-of-life choices for patients with Medicare, despite the recommendation that this be done by the Center for Medicare Services. Speculation is that such payments would lead to more "death panel" rhetoric from Republicans. Payments for counseling on obesity and smoking cessation and healthy diet are now paid for as preventive services, but not discussions with patients about whether they would want to be on life support if their hearts or lungs would fail.  Responsible physicians do have these conversations with patients, but many are very uncomfortable doing this because they believe that it will be depressing and maybe that it will communicate to the patient the false impression that the doctor is expecting the person to die soon. Conversations about end of life care are difficult and emotionally taxing, much more so than discussions of smoking cessation, and really make a difference in how comfortable a person is in dying. They make the lives of family members better at a time when the pain of grief makes talk of details difficult. I personally will not change my practice with regard to learning about a person's end of life preferences because of the fact that I will not be paid for it. Many doctors, though, are hesitant to have such discussions, and this leads to a crisis mentality during a patient's final illness with associated emotional and monetary costs.
 These particular events are not earth shattering, and will eventually come to nothing, as we gradually re-form the health care reform bill to meet our needs, and as physicians gradually come to accept the fact that patients mostly want to be involved in decisions about the medical treatments they receive at the end of their lives. It is hard, though, to watch this wasting of effort and the conflict it produces as we take another step backward in the slow dance toward fixing our health care mess.

Thoughts about civility, love and positive change

Martin Luther King Junior wrote:

"The ultimate weakness of violence
is that it is a descending spiral,
begetting the very thing it seeks to destroy.
Instead of diminishing evil, it multiplies it.
Through violence you may murder the liar,
but you cannot murder the lie, nor establish the truth.
Through violence you murder the hater,
but you do not murder hate.
In fact, violence merely increases hate....
Returning violence for violence multiples violence,
adding deeper darkness to a night already devoid of stars.
Darkness cannot drive out darkness; only light can do that.
Hate cannot drive out hate; only love can do that."

Congresswoman Gabrielle Giffords is now a rehab facility to learn how to walk and talk again and the families of the folks killed in Arizona are trying to put the shreds of their lives back together and to make sense of what happened on January 8th, 2011. The angry rhetoric and reflex blaming is quieting down among politicians and political commentators. Martin Luther King Day has come and gone and the sermons and speeches that attempt to make sense of his life and death are fading again.

Bloggers have pretty much ceased to argue about whether civility is practical, and about who is the least civil and ought to apologize to whom about what.

Things in the world remain pretty scary, as they mostly are most of the time if one chooses to look at them that way. They are a bit scarier than when the economic indices were looking pretty, because we can all hear the wolf howling at the door of the metaphorical drafty cabins that are our lives. The fear turns to anger, as it often does in the movers and shakers of history, and the anger fuels action, which is more comfortable than inaction when things look grim. The action seems important and the anger seems justified, in such dire times. We talk about civility, but frightened and angry people have trouble with patience and respect and empathy and kindness.

The action that is fueled out of the anger that is fueled from fear can fight a battle or repel an attacker, but it can't build a community or create an idea that unites people to do the hard and complex work of nation building.

Martin Luther King Jr. could get away with talking about love because he was a preacher. The rest of us, writers, politicians and such, can barely squeak out the word "civility" without embarrassment. But it is love, not civility, that gets the job done. Anger, hate, blaming and name calling, righteous indignation and insincere apologies are truly and unavoidably human, but they are counterproductive in a situation where creativity and hard work are what is needed.

I'm not entirely sure how we get there from here. On the subject of health care reform, members of congress and the political parties who influence them continue to argue about which side has the best interests of the country in mind, who wants to help the working poor receive medical care, who is spending the money of the American taxpayer and raising debt, who wants to cut services to those who depend on Medicare and Medicaid to fund their medical expenses. But this is not an issue that is well suited to party politics. It is an issue that requires good ideas and an agreement to compromise and try new approaches.

Psychologists have begun to use the concept of deliberately cultivating gratitude as a way of increasing happiness (  Organizational change can be more effective when an approach called "Appreciative Inquiry" is used, re-framing a situation in positive terms and moving in the direction of what is good in contrast to moving away from what is bad (  It is clear to me that, as a country, our focus on what we don't like, don't want and don't feel is acceptable has been partly responsible for the conflict burdened paralysis that we presently see in our government. A paradigm shift in the direction of love and gratitude is what will allow us to move beyond bickering to forging cooperative solutions to problems that we all want to solve.

And on that subject, on this Sunday morning I am exceedingly grateful for the time I have to sit and think and write, for a full stomach and a warm house and for all of the social reformers who have felt strongly enough about what is right to devote their time and words to their respective causes.

Wednesday, January 19, 2011

Is the individual mandate constitutional and, more interestingly, is it a good idea?

Today in the New England Journal of Medicine authors ask the rhetorical question "Can Congress make you buy broccoli?"

We would undoubtedly reject a requirement to buy broccoli, but on the same subject, is it reasonable that the Affordable Care Act requires every American (with few exceptions) to buy health insurance?  Although Congress has required citizens to do various things, including pay taxes to fund Medicare, it has never before required that we buy a product from a private company. 

Why do we need to buy health insurance from private companies? Mainly because providing a federally funded "public option" for health care coverage was so unpopular among conservatives that there is no public option, and so if we must be insured, our options (unless we are old, disabled or very poor) are limited to buying insurance coverage from the existing private insurance companies.

Despite the fact that private insurance lobbies supported the passage of the health care reform bill, they are still showing a remarkable level of dis-ingenuousness as they rapidly increase the costs of private policies while reducing their coverage in order to recoup losses expected when regulations of health insurance go into effect.  These companies will do their very best to continue to increase their profits because that is what they do. Private insurance companies are not driven by ethical considerations. Private insurance companies are driven by the desire to gain market share and pay those they employ and shareholders, in the case of for profit companies, as much money as possible. Requiring people to buy insurance from private companies ensures their ongoing success. I am not sure this is a good idea.

Yes, it is true, that allowing people to remain uninsured means that the cost of medical care will be shared only by those who buy into the system. It will make our affordable care act not affordable. But is this an equivalent evil to mandating that we support an insurance industry that has no vested interest in promoting public health?

A link to the article, with relevant supporting information such as legal precedent is:

Monday, January 3, 2011

Seeing the light: let's use Medicare to change the world

In medicine, third party payers have been partly if not mostly responsible for price inflation and inefficiency. Because an individual does not pay for most of his or her medical care, there is no incentive for that person to insist on fair pricing and excellent service. Because the third party--an insurance company that may be private or government funded--is not actually receiving services, there is no incentive for that payer to insist on quality, and in most cases higher costs can simply be passed on to the insured.

A solution to this problem could be direct payment for services by the patient, but such a transition would be difficult since prices are already so high that services are unaffordable, and we are deeply entrenched in the third party payment system.

So how do we get our third party payers to act as individuals, and insist on good quality and affordable costs? Right now there is a significant pressure on Medicare to reduce its costs, and so Medicare is a very good place to start.

People love their Medicare.  They may complain about it, but the vast majority of folks are very happy to have a large portion of their medical costs taken care of and to be able to count on care when they are sick or in pain. Medicare's costs, though, are going up faster than nearly any other area of government spending, and Medicare pays doctors and hospitals less than private insurance companies, making Medicare-insured patients less desirable to providers and limiting their choices of providers. Often physicians will not accept new Medicare patients and these patients can't even find providers in the communities where they live.

Much of the excessive costs associated with medical care are associated with coding and billing and generally partitioning care into billable units so that providers can submit requests for reimbursement to insurance companies. This focuses providers on the units of care rather than on the care of the patient, is time consuming and counter-productive. The most efficient way to pay for medical care is to pay the provider directly for care of a patient, either by the month or by the year, and have that provider be responsible for the care of that person in the area of their expertise.  A physician who cares for 1000 patients can make a very adequate living, including covering his or her overhead, for $200 per patient per year. Hospital costs can be high, but most patients rarely or never use a hospital, so their costs are quite affordable, per capita, as well.  Pharmacy costs are high, but much of that is due to insurance billing issues and often use of brand name medications where generics would do, and pharmacies could be quite efficient if they were paid to serve a community rather than per prescription.

What if Medicare offered a comprehensive program to pay for primary care, hospital costs, pharmacy costs and specialty costs? A fixed fee could be paid to providers to deliver services including pharmacies and hospitals and even high volume specialists, and in turn the providers would need to give Medicare administrators data about the overall health of the patients they served, but not bills. If this program were to happen nationwide, patients who were out of town on vacation or who moved from community to community could receive care from Medicare providers without difficulty.  Such a program could be started relatively small, as a Medicare option. Medicare would need to fund tertiary care and care outside of the funded providers if it were necessary, which would give Medicare incentive to make sure that health care delivery was effective, that their patients stayed healthy. Providers would have an incentive to keep patients healthy as well, since more health care would not mean more money. Patients would be more likely to see their primary care physician and get to know that person better so there would be more personalized care.

I would love to be a Medicare provider in such a system.  My record keeping focus would be on the health of my patients, rather than on billing issues. I would be paid to keep these patients healthy, and would get a regular salary. My case load would be lower since I would have to treat fewer patients to receive a salary, and I could be more efficient since I would be spending less time with billing issues. I would spend more time with each patient since I would be providing true comprehensive primary care.

Those who worry about socialized medicine could use traditional third party fee for service plans either through Medicare or privately, though the number of people who prefer this option would likely drop. This system would be an option only. It would start small so bugs could be worked out, and certainly there would be bugs. But after bugs were worked out by Medicare, private insurance would begin to offer such plans. Medicare was an innovator when it first came into existence, providing comprehensive medical coverage to a whole class of people who had been struggling to receive care. It has now become a poorly functioning and ruinously expensive program with a need to make changes.

I think this idea will happen. It will  happen under the auspices of the Center for Medicare and Medicaid Innovation, a program developed under the health care reform law to change the way care is delivered and paid for. It will happen because it is really the only way to deliver care that makes sense without entirely scrapping publicly funded health care and the third party payment system. This system will have to learn from the mistakes of previous experiments with capitation and managed care. Lessons could be learned from the successes of health care cooperatives as well. Such things as massage, home visits and health club membership would be included in benefits, since all of these things efficiently contribute to maintaining health. Nevertheless, patients will have to be patient since major change is never easy. If this works it will work because many committed people put their backs into it, and it will happen slowly.

A system like this will be much less costly and will have a significant impact on our economy in both negative and positive ways. The vast number of people involved in the business of billing and paying bills will need different jobs. The number of people employed by the health care sector will eventually shrink.  Money spent on health care mostly stays in the US economy, and if health care is less expensive it will be important to capture that income in some other way.  Freeing up workers to do truly useful work will be a challenge and an opportunity.

Sunday, January 2, 2011

Medicare and the lemming-like desire for more government funded healthcare

This week in my hometown newspaper two articles from the Associated Press were featured, representing some major issues about Medicare’s ongoing viability. The first article presented numbers about how the average person’s Medicare tax contributions compare to their average Medicare expenditures. The most often quoted figure (this data is rapidly achieving viral status) is that an average couple earning $89K a year will contribute $114K to Medicare over their work life and require $355K in expenditures by the end of their lives through Medicare. The second article looked at a poll conducted in November of 2010 in which 1000 US citizens age 18 and older who were asked various questions about their feelings and preferences with regard to Medicare, given that it appears to be unsustainable without significant changes. The actual data can be accessed at this link:

Data from the AP poll showed that this randomly selected group of people had very different opinions about what to do with the need for change in Medicare. The articles that I can access online report the same things, in fact they mostly use the same words to report the same things, and report that most of those interviewed believe that although they don’t want to increase Medicare taxes or increase the age at which Medicare kicks in, they would prefer that to having a reduction in benefits. As far as I can tell, they were not told what these hypothetically reduced benefits would be, so that pretty much nullifies the value of that question, but so it goes.

The vast majority also said that they would like Medicare to cover hearing, vision and dental services. If they had been asked, I wonder if they would also have liked to have the government buy them a new car and decrease the work week to 3 days.

Perhaps they should have been asked “In the best of all possible worlds, would you like to have everything you want and be happy all the time?”

But I digress.

The real question, the interesting question, is why the couple featured above should require $355,000 in Medicare expenses after the age of 65. What changes could be made that would keep medical costs affordable while preserving or improving health and quality of life?

I am not a fan of making one-size-fits-all guidelines to decrease costs. Medical costs are huge, though. Each item we do or order to be done for a patient carries a very large price tag, and there are huge numbers of patients requiring these costly items which means that intelligent tailoring of doctors’ ordering behaviors can have a huge impact on overall costs.

In order to make choices that fit individual patients’ needs, doctors need to spend more time with each patient and need to get to know the patients and their families and social settings better. This means that in order to save money, we need to spend money, educating more doctors and paying them more for encounters that actually get the job done. A doctor bills heftily for an appointment in which he or she hears about a cough and prescribes (incorrectly) an antibiotic. For an appointment that takes twice or 3 times that long, in which a person is counseled about health, a connection is made that involves learning about that person’s situation and health related questions are asked and answered might be billed at 30% more, and might easily avert long term problems or expensive emergency room visits. In short, we doctors need to do a better job, and we need the system that educates and pays us to support that.

One of the things that is a costly part of Medicare benefits is the use of brand name drugs where generics will do, and using drugs at all when no drugs will do. That said, there are some patients who require the newest and fanciest drug due to intolerance of or ineffectiveness of the older drug, and a physician who spends time will help that person make decisions like this more effectively.

Another wickedly expensive thing that we do when under time pressure is to order imaging procedures where a good exam or the passage of time would do just as well in making a diagnosis. A CT (Cat) scan may be billed at $2500, and is associated with a dose of ionizing radiation equal to 300-500 chest x-rays, with associated significant risk of future cancers. Use of this kind of imaging is increasing rapidly, with major negative effects, both on our health and on our economy. And as for saving the busy doctor time, it does not, since these imaging procedures often show some irrelevant and often incorrect finding that requires counseling, reassurance and often repeated imaging tests. A thoughtful doctor who takes time, though, will order imaging tests for the patients who can benefit from them. Tests such as CT scans have expanded our abilities to detect serious conditions at a stage in which treatment is effective and less harmful, but trends such as ordering an abdominal and pelvic CT scan for every case of appendicitis is clearly out of line.

Blood tests are some of the least expensive items that we order, but we order them in profusion, often with no expectation that they will be helpful. People expect them at every physical exam, and there is no useful standardization to allow us to limit their use. They are usually confusing or inappropriately reassuring and are associated with many many millions of dollars of excess spending.

There are so many other ways in which good medicine is less costly. It frustrates me to see Medicare’s rising costs viewed as an unavoidable result of medical progress. It seems as if whoever wrote the questions for this AP survey is part of the conspiracy of ignorance that equates limiting health care expenditures with “reducing benefits.” It is just not true that more medical procedures and unneeded medical procedures are a benefit.