Cell 2 Soul: The Humane Health Care Blog

The Fake Freedom of American Health Care

By Anu Partanen
NY Times, March 19, 2017

"The trouble with a free-market approach is that health care is an immensely complicated and expensive industry, in which the individual rarely has much actual market power.  

The point of universal coverage is to pool risk, for the maximum benefit of the individual when he or she needs care. And the point of having the government manage this complicated service is not to take freedom away from the individual. The point is the opposite: to give people more freedom.

I wish we were free to assume that our doctors get paid a salary to look after our best interests, not to profit by generating billable tests and procedures."

Excerpts from an amazing op-ed in the NY Times. It pretty well says it all in a pleasant "nordic" way.

Less Medicine, More Health

7 Assumptions That Drive Too Much Medical Care 

by H. Gilbert Welch

(The following is taken from the book's introduction)

The central problem with healthcare is that too much medical care has too little value, too many people are being made to worry about diseases they don't have an are only at a low risk to get. Too many people are being tested and exposed to all the harmful effects of the testing process: the anxiety of false alarms and the vulnerability caused by ambiguous findings, not to mention the complications of diagnostic procedures.

Too many people are being given treatments they don't need or can't benefit from. Treatment interventions can have substantial physical harms such as medication reactions, surgical complications, even death

It's not lawyers who are the problem; it's economics. Physicians are paid more to do more and insurance, not the patient, foots the bill. Paying physicians a fee every time they provide a service encourages them to order more tests and procedures. Because patients are shielded from the costs by a third-party, they have little incentive to scrutinize the value of the services.

To complicate this more, the general public harbors assumptions about medical care that encourages overuse. Assumptions like the following are extant: it's always better to fix the problem, sooner is always better or it never hurts to get more information. These assumptions flow directly from information provided to the public from many sources (doctors, drug and device makers, the media, the Internet). The public winds up with assumptions that lead to an excessively optimistic view of medical care. That leads them to seek too much care.

This book is about challenging these assumptions – and helping all of us to avoid too much medical care. As a society, we have overstated the benefits of medical care and underplayed its harms. It is possible that in many cases less medicine would be better for our health.

Less Medicine, More Health gives a few simple strategies to avoid too much medical care.

What Walsh wants from medical care is a system that excels in the care and treatment of acutely ill and injured persons. This, in his opinion, is the most important activity of medical care, but is not what most medical care is about. Much of medical care doesn't reliably lead to better health.

Overkill by Atul Gawande

The New Yorker, May 11, 2015  Free Full Text.

This is a long, but invaluable, introduction to the topics of over-diagnosis and over-treatment.  The Lown Institute has impressively addressed this topic for the past three years or so and a cadre of physician scientist and clinicians around the world have been interested in subject as well.  In his polished way, Gawande covers the issue for the lay and professional reader.  He asks:  What can we do about the avalanche of unnecessary medical care that is harming patients physically and financially.

Download Excerpts from Gawande's Overkill

 

Who Is My Doctor?

Leana Wen, the new health commissioner of Baltimore, Maryland gave an instructive TED talk  entitled “Who Is My Doctor,” and has famously said, I believe that medicine has maintained its mystique for far too long, and it’s time to open the veil of secrecy and have patients and providers alike participate as equal partners. I believe that patients have to be part of every discussion that takes place in healthcare, from research to system design to medical care.

Physicians need to recognize that we are here to serve the sick. The practice of medicine should not be a means to enrich one’s self at the expense of patients, their insurers of Big PhARMA.  Unfortunately, many physicians are entrepreneurs who have learned to game the system.  Two of the most common ways to do this are by performing unnecessary tests or procedures and by climbing in bed with Big PhARMA.

Recently, the New York Times had an article about unnecessary cardiac procedures and revealed that a Florida cardiologist was paid $18 million by Medicare in 2012, making him the top-billing cardiologist in the country. Over-diagnosis and over-treatment are not problems unique to cardiologists.  Many primary care physicians and diverse specialists have figured out how to game the system at the expense of patients or providers.

Over-diagnosis and over-treatment allow many physicians to make considerable sums from unnecessary tests and procedures.  Actinic keratoses are a source of income for many dermatologists; in addition, innocuous skin cancers are often over-treated by unscrupulous or ignorant providers.

We looked at the billing practices of the six dermatologists in a county of a New England state. All served a similar population of patients. The table shows that in 2012 one practitioner billed Medicare for 20,004 cryosurgeries compared to 214 of these procedures by another dermatologist.  The highest billing  dermatologist in this group collected $940,000 from Medicare for this subset of patients alone.  Medicare is only one insurer for these doctors’ patients.

Bedding Down With Big Pharma is another way that physicians supplement their income.  Some physicians make a tidy sum from giving talks for pharmaceutical firms.  This often takes place at so-called CME meetings.  Two websites  are helpful for tracking these physicians: Dollars for Docs and Open Payments.  Not all companies participate with this reporting. 

As an example, I am aware that in my specialty, dermatology, there are a number of doctors who make over $100,000 a year from Big Pharma (and this is in addition to their regular income from teaching and patient care).  One New York  dermatologist was paid $93,000 just for talks given to other dermatologists in 2013.  These, so-called “key opinion- or thought- leaders” push expensive new medications when older, much cheaper medications would be appropriate. You can look up your doctor at Dollars for Docs or Open Payments.

The akamai patient can research her or his physician at the websites provided below.  These are not perfect resources but they are helpful places to start.

So, perhaps it is time for you to ask, “Who Is My Doctor” and to check up on your favorite providers.

Resources:

1.  Medicare payments to U.S. physicians:  Use this form to find a doctor or other medical professional among the more than 800,000 health care providers that received payments in 2012 from Medicare Part B, which covers doctor visits, tests and other treatments.

2. Dollars for Docs (Propublica): In recent years, drug companies have started releasing details of the payments they make to doctors and other health professionals for promotional talks, research and consulting. As of 2013, 17 companies published the information, most because of legal settlements. Use this tool to search for payments.

3. Open Payments is a federal program that annually collects and makes information public about financial relationships between the health care industry, physicians, and teaching hospitals. The Centers for Medicare & Medicaid Services (CMS) collects information from manufacturers of drugs and devices about payments and other transfers of value they make to physicians and teaching hospitals. These payments and other transfers of value can be for many purposes, like research, consulting, travel, and gifts. CMS will be making this data publicly available each reporting year.

Steven Brill's Bitter Pill

There is a tsunami media blitz about Steven Brill's new book, America's Bitter Pill.  Is it because the book is really great or is it about marketing?  We will know in a few weeks.

Steven Brill has also recently published an important article in Time magazine on the same subject.  Both are called America’s Bitter Pill. 

See:  Zephyr Teachout’s book review of America’s Bitter Pill in the NY Times (1.9.15)
Time Magazine article:  you need to have a subscription to read it online
NPR interview with Teri Gross (35 minutes)
The Bill by Malcolm Gladwell (review of the Brill book). New Yorker January 12, 2015 (Full Text Online)  Gladwell, ever the contrarian, is less enamoured with Brill and his book than the others.

Excerpt from Terry Gross’ Interview of Steven Brill

“It's hard to understand why you get 36 different first-class envelopes with 36 different pieces of paper from the same insurance company on the same day. That tells you something about the efficiency of the health care industry right there. But then, as you open each envelope, they're as completely unintelligible to me as they are to you, as they are to everyone listening. But better yet, they're also as unintelligible, apparently, to the people who write them.

I got to do what is probably a reporter's dream ... which is I took one of those explanations of benefits, which said, "Amount billed: zero. Amount insurance company paid: zero." And the third column said, "Amount you owe: $154." So it makes no sense.

But here's what I got to do: I had scheduled, as part of the reporting for my book, an interview with the CEO of United Healthcare, the largest health insurance company in the United States — and my health insurance company, as it turns out. I went out to Minnesota to interview him and asked him all kinds of questions about what he thought the impact of the Obama health reform was likely to be. And at the end, I took that explanation of benefits out of my suit pocket and said, "I'm wondering if you could do me a favor, could you explain this to me?" ... "How can I owe $154 if nothing was billed?" He looks at it ... and looks up at me and says, "I could sit here all day and I couldn't explain that to you. I have no idea why they sent this to you."

Summation of NPR Interview:

GROSS: So we started our conversation by talking about your experiences as a patient and the bills that you got when you had open-heart surgery. So now being an expert on the history of Obamacare, on billing practices and on being a patient, if you could make one change what would it be?

BRILL: Well, it would be three.  You take the people who provide the kind of care that I saw firsthand in my own situation, and you put them in charge. You let them expand. You let major hospital systems expand, and you let them provide their own insurance. I'd rather buy my insurance from New York Presbyterian Hospital in New York or Yale New Haven because that's a brand I trust. And then you regulate them like crazy to make sure that they live up to their promises, and you control their profits. And at the same time, you regulate the cost of drugs, and you provide significant malpractice reform.

The NPR piece is a great interview and compliments the Time article.  The latter is not available online at this point.

There is a lot of important information in these resources.  If you are busy with many other things, start with Zephyr Teachout’s book review (online) and the Time magazine article that your local library will have.  I wonder, though, is this "a tale told by an idiot, full of sound and fury and signifying nothing?  Or is this "divinest sense?"

 

 

 

The Right Care Declaration

A Message from Vikas Saini and Shannon Brownlee of the Lown Institute:

The Declaration of Principles of the Right Care Alliance.

“The Right Care Alliance is a movement of clinicians, patient advocates, community leaders, and patients who see that overtesting, overdiagnosis, and overtreatment are endemic to modern health care – they are built into the culture of modern medicine. We see overuse as the flip side of the coin of undertreatment and lack of access, and a major cause of harm to patients."

They came to “understand the power and importance of coming together, to share our concern about practices that harm patients, and our belief in the moral necessity of working together to reduce overuse”

With colleagues, Vikas and Shannon created The Declaration of Principles of the Right Care Alliance.  Please read it and consider joining this Alliance by signing this declaration.  It will demonstrate your solidarity with the movement to assure all of us compassionate, safe and appropriate care.

 

The Shame of American Health Care

Even as Americans struggle with the changes required by health care reform, an international survey released last week by the Commonwealth Fund, a research organization, shows why change is so necessary.

The report found that by virtually all measures of cost, access to care and ease of dealing with insurance problems, Americans fared poorly compared with people in other advanced countries.

See full editorial.  Read and weep!

Our Moral Stain

"When it comes to health care, most liberals are committed above all to ensuring that every American has insurance. In their view, the greatest achievement of the health care reform act is to finally erase the moral stain of the United States' being the only major developed country without universal coverage. But we also hold the questionable distinction of having the world's most expensive health care system - what about cost control?

This is a fine opinion piece by a thoughtful academic physician.  Reading it made me think, "We have met the enemy and it is us."  As a physician, I particpate in the scandalous cost of health care every day.  All of us do unnecessary tests.  All of us prescribe expensive meds when cheaper ones would work.  All of us do more procedures than needed because that's where our reimbursement comes from.  It's one thing to recognize this in the quiet of one's home -- it's another reality in the clinic.

Emanuel's essay is a good springboard for thought.  See: Download What We Give Up for Health Care

 Image is from CartoonStock.com

Health Care Quality in the U.S.

June 24, 2010

According to new annual report from the Commonwealth Fund, a private foundation that focuses on health care, the U.S. health system presents a rather dismal picture in terms of overall quality of health care.

The analysis comparing the nations spending and health outcomes with seven other industrialized nations, found that despite outspending the other competitors, the Americans are getting less for their money and are languishing behind in common health issues.

The Commonwealth Fund's president, Karen Davis, stated, "On many measures of health system performance, the U.S. has a long way to go to perform as well as other countries that spend far less than we do on healthcare, yet cover everyone.

"It is disappointing, but not surprising, that despite our significant investment in health care, the U.S. continues to lag behind other countries.”

America scored poorly in most of the five key areas of health service in comparison to the other six competitors despite the country’s healthcare system being the most expensive in the world.

The rankings of the 7 countries
The Commonwealth Fund report was based on a survey of both patients and primary care doctors for the years 2007, 2008 and 2009 in Australia, Canada, Germany, the Netherlands, New Zealand and the United Kingdom.

The focus of the report was five essential measures of health care- access to care, equity, quality, efficiency and the ability to live long, healthy, productive lives.

The overall winner was Netherlands scoring the highest in the list. The country topped in access and in equity, and ranked second in quality of care.
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The Dutch were closely followed by UK and Australia while Canada ranked sixth and America fared the worst in the list.
                                                                                                                                                                                                                                                             
US healthcare system the most expensive in the world
The United States scored poorly in most of the five key areas of health service despite the country’s healthcare system being the most expensive in the world.

The other six countries spend approximately half that of the United States yet are able to provide better universal care to its citizens.

In 2007, the nation spent $7290 per person which was more than double that of Canada, three times more than New Zealand and also much higher compared to the $3800 per person, spent in the Netherlands.

Some specific findings In areas of providing safe care, the United States ranks last and second last on coordinated care.

Patients with a chronic condition in the nation are most likely to be given the wrong medication and the wrong dose and delays in being informed about abnormal test results.

Another major problem is efficiency. The nation also ranks last on spending on administrative costs, use of information technology, duplicate medical testing and re-hospitalization.

In addition, the nation fared the worst in infant mortality and healthy life expectancy among older adults.

A large number of Americans go without care because of the cost. The report pointed out that the United States was the only country on the list that does not give all citizens healthcare coverage.

The authors of the report stated, "For all countries, responses indicate room for improvement. Yet, the other six countries spend considerably less on health care per person and as a percent of gross domestic product than does the United States.

“These findings indicate that, from the perspectives of both physicians and patients, the US health care system could do much better in achieving value for the nation's substantial investment in health."

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Marginal Notes: A Socratic dialog on health care reform (VI)

Toward the evening of a long day, the philosopher Socrates finally makes his way to the home of Hippocrates, the father of medicine.  >>more

The final in a series of Socratic dialogs on health care reform.  Apropos of these discussions, interested readers may wish to peruse previous conversations with Aeschylus, Plato, Aesculapius, Apothos, and Litigius.

 

Brian T. Maurer has practiced pediatrics as a Physician Assistant for thirty years.  His "Marginal Notes" column appears periodically in the Cell2Soul Blog. The title "Marginal Notes" is taken from a quote by Henry David Thoreau: "I love a broad margin to my life."