Physicians

POLICY/HOSPITALS/PHYSICIANS: Wennberg found wearing concrete boots at bottom of Lake Michigan

No, not really. But Wennberg’s disciples at Dartmouth are coming out with so many uncomfortable facts for the medical-industrial complex that it’s hard to keep count. Starting by introducing the notion of practice variation 30 years ago, the group is now turbo-charging its research production, and basically all of it is bad news for anyone pretending that “American health care is the best in the world”. To paraphrase Uwe Reinhardt, how can the American healthcare not be as good as American health care?

In just the last couple of years not only has the Dartmouth crowd found that care delivered in areas with fewer doctors, and using less advanced technology, leads to better outcomes at lower costs, but they’ve also found that academic medical centers vary threefold in their efficiency of inputs (and costs) to get the same outputs, and most recently that hospital system and location is a better indicator of resource use than population acuity.

And, for the medical establishment, the news gets worse. For the last five or so years, those of us who think that we’ve already got plenty of doctors per head, as we doubled the number in medical school in the 1970s and 1980s and are still waiting for the smaller generations trained in the 1960s to retire, have been drowned out by hysteria from the medical establishment about an impending “physician shortage”. That is of course code for the taxpayer (via Medicare which funds most medical education) to support the creation of new physician residency slots, creating more specialists, who’ll then start applying more medical technology to all of us, which will contribute to more flat of the curve medicine. But I won’t give you a potted Fuchs/Enthoven class here (although you can search around plenty in THCB if you want more).

Today in Health Affairs (or you can read the potted version in Forbes), Dartmouth researcher David Goodman and his team (including Wennberg) cry bullshit on the “we need more doctors” meme. While the big academic centers which get the money from training them would love to have more residents, by examining one type of intensive medical process — caring for patients at the end of life in ICUs — Goodman et al shows pretty logically that many major academic centers use far too many physician resources. In other words we could provide equally good (or probably better) care while using many many fewer physician “inputs”. Hence overall we need fewer physicians, more efficiently used.

Of course any English surgeon, whose workloads and consequently surgical speed massively exceed those of their American counterparts, could have told you that. And my father frequently did every time he came back from a “fact-finding” trip over here. And when Goodman et al invoke the most famous name in American medicine, it’s pretty hard to argue with their conclusions:

"We have benchmarks. We have academic medical centers which are highly successful in terms of the care they provide, and we need to start looking to those places as our examples," Goodman said. "We need to study them and understand them and emulate them. The Mayo Clinic has been studied very extensively and is fairly well-understood," he continued. "We should be at a point where we can emulate some of those systems."

Mayo of course has fantastic outcomes at relatively low cost. In this study it used 8.9 physician full-time equivalents per 1,000 patients in the six months before death, while at the other end of the spectrum New York University Medical Center had 28.3. Of course the system-wide implications of all of the Dartmouth research are too awful for the medical establishment to contemplate, because they in the end mean 20 of the 28.3 doctors at NYU going away – and there are enough cab drivers in New York City as it is. And it’s not just New York city doctors that suffer when you extrapolate:

Applying the Rochester standard to the nation’s elderly, the United States has an excess of physician input; it needs 30,163 fewer FTE inputs than were allocated in 2000. Indeed, the current rate of supply growth along with excess capacity is sufficient to accommodate the 56 percent increase (in the number of elderly-MH add) predicted for 2020, with 49,917 physicians to spare.

All this research of course reminds organized medicine, and the industries that feed off its members prescribing more and more technology without caring about the cost, of something Lenin said back in 1923 about “Better fewer but better”. And you know how the American medical establishment hates them commies. On the other hand, it also invites memories similar to what Maggie Thatcher did to the British steel-workers in 1980 — she basically fired 70% of the workforce, but the amount of steel produced stayed the same. Are they going to call Maggie a commie? I think not, but you may have noticed lots of major industries taking the same approach.

So this research will stay ignored. We spend too much on high-tech medicine, we have too many specialists doing too many heroic procedures, and everyone’s very happy about that. Until that is that we notice that we have a health care system that does a shitty job of basic primary care, doesn’t cover 45 million people and costs way too much.

But if word somehow sneaks out that the two sides of that equation might per chance be related, then the pillars of the medical establishment might choose to move to other tactics. And perhaps the Dartmouth crowd might find themselves wearing concrete boots and hanging with Jimmy Hoffa instead.

CODA: And in a quick reminder that doctors are doctors whatever their
passport cover says, this article explains how spending more on health care in
Canada has not
shortened waiting times

In the five years up to 2002-03, the number of angioplasties (to open
arteries) and bypass surgeries increased 51 per cent, the number of joint
replacements rose 30 per cent, and cataract surgeries 32 per cent. But demand
for care seems to have increased just as much, and it’s not just because the
population is aging. "We’ve got way more activity beyond what the demographics
would dictate," said CIHI Chairman Graham Scott:More research is needed
to understand the phenomenon, he said but new technology is probably a factor.
If there are new tools available, such as MRIs, doctors are likely to use them.
If techniques for a certain kind of surgery improve, the procedure will become
more popular.

Duh! They don’t need more research. When the NHS was introduced in
the UK in 1948, the politicians thought that demand would fall after the initial
rush from those who hadn’t had coverage before wound down. But it didn’t. 50
years of data tells us that in health care supply creates its own demand, and
the way to deal with that is to restrict supply.

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Categories: Physicians

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52 replies »

  1. In addition to revealing much about health care costs, the question of end-of-life care in the U.S. has its own, unique problems. Nicholas Christakis’s column in the BMJ summarized some of these (http://christakis.med.harvard.edu/pdfs/BMJ_080809_Terminal_Illness.pdf) from a sociological perspective. In a study we recently did, we found that U.S. physicians have particularly poorly calibrated beliefs over their patients’ chances of survival. American physicians systematically over-estimated their terminally-ill patients’ time left to live. This systematic bias in prognosis may be at work when we observe extraordinary high supply of care in the U.S.

  2. Quite provocative … Great! Let me take a stab at your points.
    > When a patient becomes gravely ill and the spending goes through the roof…there is no end point until the patient dies or the family withdraws care…Could healthcare spending be cut in half if there were ethics committees established to review such cases allowing care to be withdrawn earlier even against the wishes of the families?
    Hmmm. How might this play out? A committee says “Pull the plug” and the patient dies? It seems this could save big bucks, but there are some tough ethical problems. Rather, instead of pulling the plug, upon the committee concluding there’s nothing more the hospital can do, compassionate home (hospice) care is provided? We then have to think about how to deal with the economic impact on hospitals that depend on end-of-life care for a significant part of their revenue.
    > if we head down the path of a single payer system corruption and waste will be a given
    Unless there is strong evidence that a single payer system is the only way to provide universal coverage, I agree that we should look to other models.
    > I do also have experience with the Kaiser based system and feel that system works well
    Kaiser, etc. can be classified as “integrated care,” which the literature says can be an effective model. “Selective diversification” is a similar model recently proposed. I discuss these models and others in a post about redirecting competion.
    > There needs to be free market forces driving the change.
    Might the solution to the debate between Tom and you be found through policy that disrupts the current healthcare system by putting constraints on the many dysfunctional processes responsible for the healthcare crisis, while enabling rational competition in a market operating within the bounds of social responsibility?
    > We need to bring the payers [patients and employers] back into the foreground and they will demand changes to the current system. Until this happens, the insurers and hospitals will continue to rape the system.
    To avoid miscommunication, I suggest we use the commone standardized definitions for these terms: “payers” = insurers, “purchasers” = employers, and “consumers” = patients/public.
    I agree that having consumers and purchasers push for change is necessary. Purchasers are already having an impact, and I believe their pressure on politicians to lower healthcare costs is what initiated the HHS National Health Information Network initiative. Reaching out to consumers is also vital. So, developing a model that both these groups will stand behind is key, imo.
    About who’s raping the system: I can’t place blame on any one group. It seems to me that the negative side of human nature is responsible for corrupting the political and economic systems, upon which our healthcare system is built. It’s all tied together.
    Steve
    http://stevebeller.blogspot.com/

  3. The problem with healthcare spending also lies in the fact we are dealing with humans rather than objects. When a patient becomes gravely ill and the spending goes through the roof (I believe 90% of the healthcare dollar is spent in the last 30 days of life or something like that??), there is no end point until the patient dies or the family withdraws care (which is usually a rare early event). Now let us look at what happens with a car when it ends up in a wreck. Often an insurance adjuster weighs the cost of repair v replacement and at a certain level of damage will declare the car a “total loss”. Could healthcare spending be cut in half if there were ethics committees established to review such cases allowing care to be withdrawn earlier even against the wishes of the families? This may seem grim but these are the hard decisions that need to be made in the future if healthcare costs are to be controlled. I don’t think society is willing to accept this today. Any thoughts on this?
    Unfortunately, I believe if we head down the path of a single payer system corruption and waste will be a given. Does anyone have any experience with TRICARE? I do and it may be the proving ground/blueprint for universal/socialized healthcare (Hillary Care) if it is ever enacted. I do also have experience with the Kaiser based system and feel that system works well from the limited experience I had with it.
    Again I think Darwinian forces will be allowed to play out if healthcare is opened to the free market. It is often difficult and nearly impossible to regulate closed markets into forward evolution and improvement. There needs to be free market forces driving the change. Unfortunately, that is what is lacking today in healthcare. Hospitals and insurers often have monopolies in communities and alot of the cost and dollar transfer is hidden from the payer (patients and employers). We need to bring the payers back into the forground and they will demand chages to the current system. Until this happens the insurers and hospitals will continue to rape the system.
    I apologize to Mr Leith for calling him a liberal. My mistake.

  4. > It is true that patients can die unnecessarily, remaining very pleased with their docs. Don’t believe them about clinical efficacy and efficiency.
    And, a la Dr. House, they can dislike their docs, but get phenomenal care. Of course, being highly satisfied with a doc that gives you great care is what we strive to do.
    Also note that I’m not discounting the importance of subjective measures – e.g., patient self-report of physical pain and emotional distress – as vital clinical indicators.
    > Your list of five is where I hope things are headed, but we will get there by way of a very crooked (in both senses of the term) path. … Radical transformation is what we are all called to … we have governments in the meantime.
    Crooked in the way of adjusting direction to accommodate new knowledge, innovation and occurrences is inevitable since that’s the nature of development/evolution.
    Crooked in the way of corrupt political and business manipulation for personal material gain and power, at the expense of the public, I suggest, need not be inevitable despite out shameful history. It gets back to how people’s focus and beliefs reflect our priorities, the models we follow, and the processes we execute. This is where radical transformation is needed. Being a spiritual man (though not necessarily religious in the traditional sense), I share your conviction that such transformation of self and societies is our “fundamental purpose” in life. But (a) with the priorities, models and processes currently valued in country (and others) that are diametrically opposed to this kind of positive social development, and (b) with our government sharing that same mind-set — with all this, I’m leery of putting much hope in a political solution, although I understand your point.
    I hope we all can discuss how to enable the leadership we so badly need to have a meaningful impact on driving our country’s transformation to social responsibility, without being forced into corruption itself (I don’t want to revert to negative Machiavellian tactics). It would be ideal if ALL stakeholders win: public, providers, purchasers, AND payers.
    A few initial questions I pose for discussion:
    What (new) business, political, and healthcare delivery models and strategies are needed?
    Where should we focus our efforts to encourage widespread dialogue and pilot studies?
    How can blogs have the greatest positive affect? What about other media?
    Should positive change be driven by healthcare providers, consumers, employers, or insurers? All of them?
    Would it be best to form international alliances?
    Steve
    http://stevebeller.blogspot.com/

  5. > But I doubt their usefulness as reliable indicators of
    > clinical efficacy and efficiency
    Oh yes! It is true that patients can die unnecessarily, remaining very pleased with their docs. Don’t believe them about clinical efficacy and efficiency.
    Your list of five is where I hope things are headed, but we will get there by way of a very crooked (in both senses of the term) path. Great leadership will be required at every level from the coffee shop to the boardrooms to the White House. Maybe blogs will play a small part .
    Radical transformation is what we are all called to, but as St. Paul pointed out, we have governments in the meantime.
    t

  6. > Insurance, either by contract or social, is the only reasonable way to finance the risk of serious illness. … The policy “rely on markets” is a non-policy that relies only upon third party enforcement of contracts and tort laws to work. … As soon as you say “policy” you have said “there can be no efficient market: we must intervene for the common good.”
    I don’t know what others think, Tom, but if our goal is delivery of quality care for all, I find your argument sound: Without altruistic intervention (aka socially-responsible policy), there is no reasonable way to achieve this goal — unless, possibly, if humanity radically transformed itself … but there’s no sense in waiting.
    I suggest, therefore, we focus on defining a consumer-centric economic policy that:
    a) Enables providers to compete in a sensible manner in a way that benefits the consumer and society
    b) Encourages innovation and efficiency
    c) Supports continually improving care quality
    d) Provides quality care for all
    e) Promotes wellness, public health, and preparedness.
    > Patient satisfaction scores are far from useless.
    Actually, I agree that patient satisfaction can be a useful indicator of certain things such as convenience and staff friendliness, which can affect quality. But I doubt their usefulness as reliable indicators of clinical efficacy and efficiency — See Connolly, C. (February 16, 2006) Vital Evidence: Taking Patients’ Word May Be Ill-Advised at http://www.washingtonpost.com/wp-dyn/content/article/2006/02/15/AR2006021502362.html. Anyway, my statement reflects our foolish tendency in the past to use a few process metrics and assessment of patient feelings to measure care quality, in lieu of clinical outcomes; I failed to adjust my remarks accordingly and stand corrected.
    Steve
    http://stevebeller.blogspot.com/

  7. > 2. The problem of price sensitivity when large
    > expenditures will be made. Please elaborate, Tom.
    I am talking about what happens after a patient gets seriously ill and insurance kicks-in. Once that happens, the patient is almost completely price insensitive. And this is the condition under which the great bulk of healthcare spending occurs, which means there will not be an efficient market in medical services for the sort of services that pare provided for serious illness. Insurance, either by contract or social, is the only reasonable way to finance the risk of serious illness.
    > If by “reasonable alternatives” you mean
    > alternate healthcare delivery, competition
    Primarily these. Financing models don’t matter so much in this discussion, its the delivery I’m focused on. The alternatives to medical treatment are usually suffer, or die, or both. Although there are a few who do, most people do not consider these choices reasonable. The alternative to some particular medical treatment may or may not exist (think masectomy vs. lumpectomy). And there may or may not be alternate providers — in vast expanses of the country there is only one hospital within an 30 minutes of one’s home. When there is more than one, it is two. When there are more than two, they are often organized into “systems” that do not compete among their own members, at least not on price. When there are a few systems, that’s another kind of oligopoly, and they will not compete on price either. They may engage in first-class price discrimination, but that is not price competition. Individual physicians do not compete on price, and have long considered it unethical. It is certainly for them undesirable.
    I failed to mention legal barriers to entry in the market: licensure of doctors and nurses, Certificate of Need laws, physicians controlling medical education through state boards, and so-forth. This damps down considerably competition.
    Efficient markets in consumer goods exist when something like “breakfast cereal” is the good in question. From that point, the markets are less and less efficient.
    > useless patient satisfaction scores
    Patients ought to be treated respectfully and we ought to keep our service promises to them. They ought to have more than technical perfection, especially in faith-oriented systems and facilities. Satisfaction surveys get at these sorts of questions, and are quite valuable in pinpointing training and process problems. Patient satisfaction scores are far from useless. They suffer especially from selection bias, but this is well understood.
    > who are able to influence policy
    From this, I think the gig is up for you. The policy “rely on markets” is a non-policy that relies only upon third party enforcement of contracts and tort laws to work. Some people (radical Libertarians) deny the need for a government even for these. As soon as you say “policy” you have said “there can be no efficient market: we must intervene for the common good.”
    I hope this has been sufficiently high-level for surgeons .
    t

  8. Wonderful debate about possible futures, which seems to boil down to Tom’s challenge that in order to show that an efficient market can exist you will both have to overcome the information problems (including the ability for patients to understand), the problem of price sensitivity when large expenditures will be made, and the problem of a lack of reasonable alternatives..
    Yes, these are some of our greatest challenges to solving the healthcare crisis, along with issues including the limitations of current practice guidelines and quality improvement programs, the shortcomings of today’s HIT systems, and problems with proposed incentive and coverage programs.
    In our white paper (due out in a couple of weeks), we present a blueprint for an innovative HIT system that will help deal with some of these problems, and we outline key issues and propose potential drivers for handling many of the other barriers. But for now, I hope we can clarify and discuss each of Tom’s points:
    1. Information problems, i.e., the inability of consumers to distinguish among levels of quality because they lack adequate knowledge of the relative cost and degree of defect (underuse, overuse, and misuse) of healthcare resources, so they cannot select providers based on the quality/value of their care.
    Well, moves to inform the public of hospital performance has already begun. For example, the New York State Department of Health launched a Web site in January 2006 that compares the performance of hospital regional hospitals by region using process and risk-adjusted outcome measures for common health conditions, as well as the number of common medical and surgical procedures performed annually. These “report cards” are designed, according to State officials, to raise quality by applying competitive market pressures. And in February, the Massachusetts Health Quality Partners group, a coalition of 150 medical groups, posted efficacy data on its web site — measuring the reliability with which patients receive tests and treatments known to improve outcomes — in order to encourage consumers to search for high-quality providers and guide physicians looking to improve their performance.
    While these report cards push hospitals to focus on quality improvement, the data are open to misinterpretation, very limited in scope, and may not help providers improve their care quality. This is because the quality measures in use today tend to be based on immature, imprecise, static practice guidelines, and useless patient satisfaction scores , instead of the valid, precise, evolving quality metrics and evidence-based practice guideline outcomes that can only come from the kind of wide-spread, collaborative, interdisciplinary quality improvement efforts we’re proposing.
    Providers who are proactive in developing and using guidelines in a way that shows the public they are learning organizations truly dedicated to delivering the ever-increasing care quality are the ones most likely to gain competitive advantage.
    2. The problem of price sensitivity when large expenditures will be made. Please elaborate, Tom. Are you talking about the difficulty computing “actual” costs, the problem calculating care “value,” issues related to risk-sharing and amortization, defining “acceptable” profit margins, or what?
    3. The problem of a lack of reasonable alternatives. If by “reasonable alternatives” you mean alternate healthcare delivery, competition, and payment models, then dialogues like the ones we’re having will emerge (and are emerging) innovative models (approaches/strategies). These new models should be subject to intense scrutiny by knowledgeable people from multiple disciplines, their assumptions should be critically examined and challenged, alternate views should be discussed, pilot projects studied, etc. This will require collaborative networks of open-minded, critical thinkers who are able to influence policy and serve as leaders guiding the direction of healthcare into the future.

    Steve is … getting buried too much in the details.
    I am extremely detail oriented and apologize to anyone frustrated by the minutiae of my posts. With the devil hiding in the details, and with so many opportunities for misunderstanding, I tend to focus on examining the small parts and then try to construct a holistic view and conclusions from the aggregate. [And when wearing my software programming hat, I must focus on the smallest details or risk a buggy product … but that’s another story.] Anyway, thanks for the pointer, pgbMD, and for putting up with me and engaging in this discussion!
    Steve

  9. OK, well maybe Steve sort of agrees with you when he “questions” my prediction that efficient markets can never exist in healthcare.
    But in order to show that an efficient market can exist you will both have to overcome the information problems (including the ability for patients to understand), the problem of price sensitivity when large expenditures will be made, and the problem of a lack of reasonable alternatives.
    t

  10. > Wrong again Mr T. Their consumption will go down
    > significantly for unnecessary care and minimally for
    > necessary care.
    The best study on the topic (the famous RAND Health Insurance Experiment) confirms that people do respond to prices. But it says also that patients do not know enough to refuse unnecessary/inappropriate care: inappropriate antibiotic use and inappropriate hospitalizations(!) did not change a whit under plans with high co-pays. Patients in the higher out-of-pocket plans also exhibited a greater tendency to have uncontrolled hypertension. Other studies (Lurie) suggest that both these effects are more pronounced among the poor.
    There are no studies I know of that look comprehensively at spending and health status under conditions where patients pay out of pocket. The best study (RAND) confirms that people do respond to price, but it only looked at low-cost expenditures, and looked narrowly at health status, and only over about five years.
    Fees apparently will chip away at office visits of clearly questionable value, but that’s not where the costs are. And when it is not so clear cut, we will have erred on the side of cheapness: patients don’t know the difference between the flu and meningitis any better than they know whether or not they should have an antibiotic or a proton-pump inhibitor.
    You are thinking wishfully and ignoring the realities of healthcare.
    > Wrong for a second time (PhD Steve agrees with me
    > on this one!!). When will you liberals stop…
    I think this is the first time in my life I have been called a liberal.
    Steve does not agree with you. You claim an efficient market for medical services can exist.
    He has not claimed this. He claims that when providers are subjected (by whom, pray tell?) to reporting requirements sufficient to discriminate differences in quality, patients will choose the better ones, and might pay them more. He rightly wants to engage people in making their healthcare choices through education, but he has not claimed that an efficient market will as a result develop, or that “consumer choice” will “fix healthcare” — i.e. lead to a state we might expect of an approximately ideal competitive market, as we have in haircuts or wheat or clothing. And especially not without regulation. He does not agree with you.
    He does not agree with me either. Steve thinks sufficient information can be developed and made understandable to a population that won’t read a newspaper. I’m pretty sure it can’t be, even if the obfuscatory tendencies of the medical profession could be completely overcome.
    In Steve’s defense, if all medical services were delivered through Kaiser-style organizations and we could get satisfactory transparency of quality and price at the organizational level, individuals might be able to make rational choices. But Americans have shown they have no interest in organizatons like this.
    Further, doing this, we would be creating in each region an oligopoly that does not face competition. We have had industries like this before. Remember the US cars in the 1970’s? Wanna go back to pre-Toyota days?
    Even if prices are transparent, “big” costs will always be insured, and patients will be price insensitive at that point, so all the transparency in the world will not drive choices (if any are reasonably available) when big expenditures are going to be made. Price sensitivity is another required condition for an efficient market to exist.
    Reasonably available alternaties: This figures in at a couple levels: buy treatment or endure pain; buy from GM or Dodge.
    Poor transparency of price and quality, poor price sensitivity with respect to large expenditures, poor availability of reasonable alternatives: this is why I do not think there can ever be in a general way an efficient market in healthcare. None of the requisites are there now, and I do not think they can be.
    > Three strikes and you are out. When
    > Nighthawk is finally eaten
    I have no idea why you mentioned this. I think we are in complete agreement about the process of disintermediation. I helped in a small way to enable it. Maybe you were just on a roll and got carried away.
    t

  11. Sorry lost my quotes with the previous post.
    >Yes their consumption will go down, right along with their health status. They will consume less unnecessary care, and also less necessary care
    Wrong again Mr T. Their consumption will go down significantly for unnecessary care and minimally for necessary care. The necessary care they will seek out. I think even W figured that one out, so it should be easy for a smart lad like yourself. In the totally inefficient TRICARE system (which may be the pancea for Mr T) b/c their were no co-pays and nothing (very minimal) out of pocket the patients came in to the hospital for any reason. Even to get off work!!
    >the conditions that make markets efficient do not and cannot exist in healthcare
    Wrong for a second time (PhD Steve agrees with me on this one!!). When will you liberals stop using this bogus talking point. Next you will be saying that the conditions for market force efficiency don’t exsist in _______. Just fill in the blank for whatever industry you guys will next try to socialize.
    >When I asked whether films would be read in India, I was told no, never! The licensure laws will make it impossible. They certainly do not want a free market. But only because they aren’t real doctors, right?
    Three strikes and you are out. When Nighthawk is finally eaten by a larger company they will look to turn a higher profit and start the outsourcing. Just a matter of time. Remember licensure is essentially controlled by the congress and as the medicare/caid/etc costs continue to rise this will be easy prey to save some $$. Radiologists will be the first to be outsourced due to their 100% reliance on technology and the fact the images can be beamed around the world in a heartbeat.
    I agree with much of what PhD Steve is saying but I think he is getting buried too much in the details. He would never make a good surgeon.
    Great discussions. 🙂

  12. Wrong again Mr T. Their consumption will go down significantly for unnecessary care and minimally for necessary care. The necessary care they will seek out. I think even W figured that one out, so it should be easy for a smart lad like yourself. In the totally inefficient TRICARE system (which may be the pancea for Mr T) b/c their were no co-pays and nothing (very minimal) out of pocket the patients came in to the hospital for any reason. Even to get off work!!

    Wrong for a second time (PhD Steve agrees with me on this one!!). When will you liberals stop using this bogus talking point. Next you will be saying that the conditions for market force efficiency don’t exsist in _______. Just fill in the blank for whatever industry you guys will next try to socialize.

    Three strikes and you are out. When Nighthawk is finally eaten by a larger company they will look to turn a higher profit and start the outsourcing. Just a matter of time. Remember licensure is essentially controlled by the congress and as the medicare/caid/etc costs continue to rise this will be easy prey to save some $$. Radiologists will be the first to be outsourced due to their 100% reliance on technology and the fact the images can be beamed around the world in a heartbeat.
    I agree with much of what PhD Steve is saying but I think he is getting buried too much in the details. He would never make a good surgeon.
    Great discussions. 🙂

  13. Great conversation!
    > But how do you measure quality of care?
    They have thus far focused too much for my taste on process

    The two classes of measures used for quality improvement are care process and outcome measures. Process measures are used to evaluate compliance with guidelines, and outcomes measures are used to evaluate the value of the guidelines; but watch out for the possible pitfalls.[i]
    Care Process Measures
    Process measures of care quality assess whether providers follow predefined procedures for specific patient types, with specific health problems and needs. These procedures are treatments, interventions, prescriptions, etc., which are supported by scientific evidence, or which have limited scientific support, but practitioners can justify their use. The procedures are incorporated into practice guidelines setting particular standards of care, and they become part of a patient’s plan of care. There are many practice guidelines using care process measures.[ii]
    Care Outcome Measures
    Outcomes measures of care assess the clinical results of an episode of care for particular patient types. These measures may include symptom alleviation, quality of life improvement, length of stay, mortality rates, etc. Care outcomes can also include such measures as patient satisfaction and access to care, total cost of care, etc. There are numerous care outcome measures available, which can be used to evaluate the value of the particular guidelines[iii] and new ones are created regularly. These measures may include symptom alleviation, quality of life improvement, length of stay, mortality rates, cost, risk, etc. They provide feedback for improving quality by helping refine them over time by identifying procedures and systems that work well, and by providing insights into areas where there are opportunities for improvement.
    Potential Pitfalls of Quality Measurement
    No mater what quality measures are used, there are complex issues to be resolved, such as:
    • At what point is there sufficient confidence in an evidence-based practice guideline that there is no longer any need to spend time or money on the continuous evaluation of its reliable and validity?
    • When is a definition of quality too narrow, e.g., by focusing on cost or symptom reduction, but not considering prevention, recurrence, coordination and continuity of care, or the patient-physician relationship?
    • How do you measure quality when resources are scarce and optimal care for the community may require less than “the best” care for its individual members (e.g., delegating office nurses to perform certain activities that physicians used to do)?
    • What is the best way to measure quality if outcomes are more strongly affected by patient compliance than by physician orders? This may occur, for example, if certain providers have personalities that trigger greater patient compliance, and visa versa.
    • Is it poor quality care if a provider follows the recommended practice guideline, but the patient is atypical and responds poorly?[iv]
    > A giant percentage of what helps patients take care of themselves is the immeasurable quality of the conversation and the perceived care and compassion that a doctor gives the patients.
    Providers possess qualities that cannot be readily measure, but which affect the outcomes of practice guidelines, and should therefore by addressed. According to a Stanford School of Medicine Dean’s newsletter, “We can and must, of course, not lose sight of educating our students and trainees to learn, to listen, to reach out and to connect to their patients. Some have called this the ‘art-of-medicine’ others ‘bedside manner’. From my perspective, it is the fundamental underpinning of what makes a great physician. Exceptional scientific knowledge, along with a critical and analytic approach to clinical care that is evidence based and data-driven is essential. But unless these skills are coupled with a caring and compassionate manner, the value of the patient encounter is diminished. Importantly the patient feels less well served and perception of the physician as a ‘healer’ is altered.”[v]
    > Tom’s complex medical history is a piece of cake for their evidence-based algorithms and his care is rendered, at least in the doctor’s mind, even before the doctor comes in and spends 6 minutes to examine him.
    To be useful, guidelines should be specific enough to have different versions for patients with the same clinical problems depending on their clinician, hospital, location, available resources, patient characteristics and preferences, etc. And they should be accompanied by consumer versions in lay language and be widely publicized and available to inform patients and the public about what their clinicians should be doing.[vi]
    They should also be constantly evaluated and revised based on research and sharing of anecdotal observations and lessons learned via a continuous quality improvement process.
    As practice guidelines are developed and validated, they should be made available to all stakeholder by storing them in electronic libraries, along with any instructional and reference materials needed to learn about and understand the guidelines, and to use them effectively. The guidelines should be:
    • Modified and refined on a continual basis in light of new research findings, so they evolve based on new scientific evidence.
    • Tailored to the needs of each stakeholder. For example, consumers would have access to guidelines written in a simplified, non-technical way they can comprehend, while providers would receive technical clinical information.
    • Accessible by all stakeholders quickly and easily, through web sites and specially designed software tools.
    In addition, there needs to be a very efficient and effective way to disseminate updated clinical knowledge to providers. Since practice guidelines can change rapidly with evolving clinical trials, after-market surveillance, and new classes of drugs and procedures, a technology must be used that actively delivers (“pushes”) the new and refined guidelines to all clinicians immediately.
    > bringing down healthcare costs must involve the open marketplace and exposing the consumer directly to the REAL cost of healthcare not just a small co-pay.
    Transparency of costs, pricing, and incentives would expose the consumer to important information, although even this can be difficult:
    “Assessing the unit costs of each of a large number of services requires major effort to gather information on direct inputs, such as labor, space, supplies, and equipment, and sophisticated formulas to allocate indirect costs, such as general management. Although estimating unit costs can be relatively easy for services in which a purchased input constitutes a large share of the cost, such as drugs or devices, estimating the costs of most services is far more difficult because the most important inputs produce numerous distinct services. …Providers have limited incentives to devote the resources to set charges that accurately reflect relative costs because a large part of their revenue is not directly influenced by their own charge structure. Any one provider’s charge schedule has negligible impact on calculation of prospective payment rates by insurers. Even when private payers negotiate discounts from charges for each hospital, little is gained from a structure that more accurately reflects costs.” Ginsburg & Grossman (2005)
    But even when transparency of cost can be calculated accurately, there must be corresponding transparency of clinical outcomes in order to compute a quality/value metric. And as we’ve been discussing, quality is also a difficult thing to measure.
    I’m glad we’re discussing these issues and have confidence we can implement effective solutions if we maintain a consumer-centric focus.
    > … they [MBAs] failed to recognize that the conditions that make markets efficient do not and cannot exist in healthcare. … failed to find the best care for the buck because they are so poorly equipped to understand what’s required, much less what’s best for the buck. And the literature on practice variation says that docs don’t really know either.
    The only thing in this statement I question is the prediction that efficient markets can never exist in healthcare. If the current healthcare system remains unchanged, then you’re certainly correct. But what can change to make the market more efficient?
    One idea in the literature is to redirect competition:
    Healthcare market forces in America over the past decade have transitioned from managed care and capitation to integrated delivery (integration of health insurance with provider systems) to a vision in which providers compete to improve care quality (better outcomes at lower costs) and consumers choose more efficient providers. There is now debate on whether competition should be redirected by (a) eliminating provider networks and encouraging informed, financially responsible consumers to choose the best provider for each condition; (b) encourage integrated delivery systems with incentives for teams of professionals to provide coordinated, efficient, evidence-based care, supported by state-of-the-art information technology; or (c) basing selection of particular healthcare services on local population needs and core competencies of the providers. See Redirect Competition for more.
    > [Healthcare consumers] will consume less unnecessary care, and also less necessary care.
    This is one of the criticisms leveled at HSAs. Much depends, imo, on defining “necessity,” along with “quality/value”in terms consumers can understand and appreciate. Yet another worthwhile thing for our country to focus on.

    [i] For examples of quality measures incorporating both process and clinical outcome measures, see the Doctor’s Office Quality – Information Technology (DOQ-IT) site at http://www.doqit.org/dcs/ContentServer?cid=1111783079915&pagename=DOQIT%2FDOQITPage%2FPageTemplate&c=DOQITPage
    [ii] For examples of clinical guidelines with care processes measures, see http://www.guideline.gov/browse/guideline_index.aspx and http://www.ahrq.gov/clinic/cpgonline.htm.
    [iii] For examples of care outcome measures for hospitals, see JCAHO’s ORYX measures at http://jcaho.org/pms/core+measures/information+on+final+specifications.htm
    [iv] Donabedian, A. (2005). Evaluating the Quality of Medical Care. The Milbank Quarterly 83, 691–729. Available at http://www.milbank.org/quarterly/830416donabedian.pdf
    [v]The Dean’s Newsletter – Stanford School of Medicine. (November 10, 2003) Available at http://deansnewsletter.stanford.edu/archive/11_10_03.htm%5Bvi%5D Woolf, S. H., et al. (1999) Potential benefits, limitations, and harms of clinical guidelines. BMJ 318 (20). Available at http://bmj.bmjjournals.com/cgi/reprint/318/7182/527.pdf
    Steve
    http://stevebeller.blogspot.com/

  14. > But how do you measure quality of care?
    There is a growing body of literature on it. The measurements will not be perfect, and will never capture every aspect of a consultative relationship. Maybe you will want to get involved to make them better. They have thus far focused too much for my taste on process. Which is what you are complaining about.
    > Once this is done consumtion will go down dramatically
    > and the consumer will seek the best care for the buck.
    > It don’t take an MBA to figure that one out.
    Yes their consumption will go down, right along with their health status. They will consume less unnecessary care, and also less necessary care.
    MBAs are the ones who did figure that one out. Except they did not pay attention in their boring, difficult economics courses, what with all that algebra, and they failed to recognize that the conditions that make markets efficient do not and cannot exist in healthcare. But this does not matter to the MBAs — anything that reduces the medical loss ratio for the insurance company is a Good Thing, and will get them their bonuses. Dubya’s an MBA. Harvard. Hmmmm. That explains a lot — Harvard does everything with cases. Probably don’t actually teach any economics. Thanks for the tip.
    Anyhow, the Harvard MBAs went ahead, and consumers may have sought, but failed to find the best care for the buck because they are so poorly equipped to understand what’s required, much less what’s best for the buck. And the literature on practice variation says that docs don’t really know either.
    > Check out the company Nighthawk.
    I personally helped to drive the adoption of the enabling technology (DICOM) when I worked in the Electronic Radiology Lab at Washington University. When I asked whether films would be read in India, I was told no, never! The licensure laws will make it impossible. They certainly do not want a free market. But only because they aren’t real doctors, right?
    t

  15. > I’ve got no problem accepting “what the market will
    > bear” if it was actually a free market.
    I don’t know what you want me to say. Healthcare is not a free market, and it is far from being an efficient market, but there is a price the market will bear nevertheless. It seems to me you will have a problem. Note that I am not particularly an advocate of any of this — its just what I see happening. If you want that little spreadsheet, send me your e-mail address.
    t
    t

  16. Tom,
    How can you argue that we should just accept what the market will bear when healthcare is not a free market? Doctors salaries are not decided by open competition in a free market, they are decided by bureaucrats in Washington DC who run Medicare. Medicare already controls 50% of all healthcare dollars spent in the USA, and by 2020 it will be close to 80%. We are already close to a de facto semi-socialized medical model.
    I’ve got no problem accepting “what the market will bear” if it was actually a free market.

  17. Well I guess you guys are coming around (except t the economist) to the fact that bringing down healthcare costs must involve the open marketplace and exposing the consumer directly to the REAL cost of healthcare not just a small co-pay. Once this is done consumtion will go down dramatically and the consumer will seek the best care for the buck. It don’t take an MBA to figure that one out.
    Free market healthcare is the only solution to the problem. The current administration sort of realizes this and thus the HSA. The insurers realize this and thus increasing the co-pay is their only solution although a poor one.
    Can’t go the way of Canada or Europe unless we want to go bankrupt like they are.
    By the way outsourcing physicians has begun. Radiologists will be likely looking for new jobs within 10 years. Check out the company Nighthawk. It won’t be long before most imaging is read overnight by some Indian radiologist and the report beamed back with a smile the next morning. Luckily for me and Dr Hinson, I don’t think this can happen to any significant degree within the surgical fields or Primary Care. I guess in some way we are protected b/c we are real doctors that establish a doctor-patient relationship. Just for disclosure I do own some Nighthawk stock and it was recently highlighted on Jimmy Cramers show.

  18. I do not disagree that to make my proposal fit in with the natural forces of the market process, consumers would need to evaluate the quality of the services they’re given. But how do you measure quality of care? Doing so is much more like evaluating the quality of artists in aa art history book than the quality of contractors in the Yellow Pages.
    Uncle Bob goes to see Dr. Jones. Dr. Jones finished med school in the 60s and has practice in town for 25 years. He says hello to the doctor at Susie’s Rise and Shine every morning. He sees Dr. Jones twice a year. His diabetes is mostly controlled, though not as well as it could be. He’s not on an aspirin a day. But when he sees Dr. Jones, they talk about family and old friends and he trusts Dr. Bob and believes that he has him on all the right meds and rarely, if ever misses a dose.
    Uncle Tom had a fallout with Dr. Jones several years ago when Dr. Jones’ brother began to date Tom’s ex-wife. Tom has to drive into the big city to see a doctor. It doesn’t matter which doctor he sees, they’re all Ivy League trained and sit on the editorial board of the NEJM. Tom’s complex medical history is a piece of cake for their evidence-based algorhythms and his care is rendered, at least in the doctor’s mind, even before the doctor comes in and spends 6 minutes to examine him. He’s given instructions he does not understand, and prescriptions for medicines he cannot afford, and will not take. He leaves frustrated, but the doctor documents the care he received and submits 32 separate G codes to Medicare, which are translated by a roomful of 1975 IBM card punching computers and interpreted to be consistent with “quality care.”
    Uncle Tom dies of a heart attack.
    Bean counters will never understand that, when it comes to primary care medicine, a giant percentage of what helps patients take care of themselves is the immeasurable quality of the conversation and the perceived care and compassion that a doctor gives the patients.
    Marcus Welby can give you the wrong medicine altogether, and you’ll get better. Dr. House might give you the medicine associated with the best t-scores only to see your health deteriorate.

  19. Well, I tried to send Medical Student a spreadsheet with a very simple-minded operating budget and volume estimates to play with, but his e-mail address is evidently bogus.
    t

  20. Med Student says:
    > You give me a salary expectation of 100k take
    > home, and cost of living/inflation adjustments,
    > for a 50 hour work week, with malpractice insurance
    > covered by the federal government, and I’ll be fat
    > and happy.
    I’ll bet you would. If you were in a big enough group, you might expect to work a hours like this. Solo, you will work a about 35 hours/week seeing patients, and then you will have to do the work of a CEO, meet regulatory requirements, do customer service, etc. But that’s if you can realize an average of $220/hour for 35 hours/week. You’ll get two weeks off per year.
    I have never, ever gotten cost of living/inflation adjustments. This is a union concept. For professionals of any stripe, our compensation depends on our performance and on market conditions. That’s all. Our education and hard work do not matter. I have a great deal of both, and I know 😉
    Malpractice insurance is part of practice overhead. I do not advocate the feds paying it under any circumstance. If things work out the way I think they ought, a primary care doc will pull enough billing to cover reasonable overheads and pay himself between $100 — $150K. But the overheads will be his to manage.
    I have sent you a spreadsheet with a very simple-minded operating budget and volume estimates you can play with.
    Best,
    t

  21. Well, Tom, I said I’m not an economist … I didn’t say I’m ignorant of economics. Nevertheless, no one can be authority in every area, I agree that continual learning is a good thing, and it is our good fortune that subject matter experts like you and others here are participating in this forum!
    I’m also convinced that a collaborative approach to problem-solving and decision-making is often the best way to spark the kind of innovation, creative ideas, and productive dialogue that leads to the wisest solutions … especially if the participants have a wide diversity of experiences, knowledge, and conflicting viewpoints. Blogs such as THCB, Healthvoices, and others are a great vehicle for this.
    I’m also a believer in “using the mirror,” i.e., hold up a vision of the ideal situation and asks questions and examine why it isn’t a reality and what must happen for it to be; and if the ideal unreachable, then determine the best path to follow to make the situation ever better, and make necessary adjustments to the direction along the way as new knowledge emerges and events occur.
    It’s obvious that healthcare is incredibly more complex than other industries for many reasons, some of which you point out. I’ve claimed, and to assert, that key to any valid proposal to solving the healthcare crisis is: (a) gaining and disseminating knowledge of the most cost-effective, personalized interventions that keep people well (prevention & maintenance) and make people well (diagnosis & treatment) and (b) a system that enables and encourages consumers and providers to implement those interventions in an efficient and effective manner. If everyone received those interventions in an optimal way, I contend, there would be no healthcare crisis! Of course, this is idealistic. So, we should our focus energies on defining the path that would bring us ever closer to this ideal, then invest heavily on moving closer to making it a reality.
    Since both reducing costs and increasing efficacy (i.e., improving care quality/value) are imperative, we must focus finding ways establish economic/payment/funding policies that support scientific/knowledge/quality-improvement processes. If they don’t, we’ll be repeating the mistakes of the past. And this is a complex endeavor since there are numerous interacting variables that impede and drive such an effort, e.g.:
    • Impediments from a human nature perspective include ignorance, fear, inertia, self-deception, greed, ego, conflicts of interest, etc.
    • Drivers from a human nature perspective include quest for knowledge, compassion, curiosity, innovation, collaboration, talent, awareness of the healthcare crisis and desire to fix it, etc.
    • Impediments from a healthcare systems perspective include an irrational payment system, lack of transparency, misdirected competition, lack of leadership, adversarial relationships between payers and providers, the knowledge void, low use of clinical decision support systems, low fidelity, continuity of care problems, practice variations, “low status” of PCPs, etc.
    • Drivers from a healthcare systems perspective include wellness programs, quality improvement programs, evidence-based practice guidelines, health IT systems, Advanced Medical Home model, personalized care, incentive programs, RHIOs, integrated delivery systems, etc.
    • Impediments from a health sciences perspective include lack of funding, limitations of evidence, time and expense establishing practice guidelines, information overload, uncoordinated research efforts, politicization of research, etc.
    • Drivers from a health sciences perspective include our country’s recent focus on healthcare quality, better IT systems, collaborative efforts (largely abroad), growing awareness that science is a vehicle for bridging the knowledge void, etc.
    Since our whacky payment system is inextricably tied to dozens of other factors, I’m glad were examining it in the context of the bigger picture.
    Discussing monetary issues such as acceptable income levels, a “price-regulator-in-chief,” sensible ways of competition, paying for universal care, etc. are certainly important and I’m eager to share my thoughts, ask questions, research, and learn.
    Equally important is dealing with the challenges of knowledge-building, continuous quality improvement, development of next generation health information technologies, and the systemic change needed to drive them – which, I admit, are closer to my heart than debating economic theory.
    I believe that finding solutions to all this takes a diverse community collaborating openly and honestly with open minds, critical thinking, and a broad, balanced perspective; people who develop wise policies by focusing on resolving very complex issues that often seem intractable. I just don’t want a repeat of the past, where discussions focused on monetary issues to the exclusion of quality issues, resulting in the implementation of short-sighted, ineffective, fiscal-only strategies that made matters worse. We have a tendency to do this in our country.
    Steve
    http://stevebeller.blogspot.com/

  22. As a med student, I would gladly go into primary care for 100k salary take home.
    I go to one of the best med schools in the country, and I’m about the only one considering primary care. The perception is that specialist pay is much better, PCPs are not respected or valued, and that
    Somebody suggested that US doctors salaries should be reduced to what the guys in europe make. If you reduced our salaries to what they get, they would come out far ahead of us because they dont spend tens of thousands of dollars on malpractice insurance or experience the same kind of lawsuit risk we face.
    You give me a salary expectation of 100k take home, and cost of living/inflation adjustments, for a 50 hour work week, with malpractice insurance covered by the federal government, and I’ll be fat and happy. I dont think thats too much to ask for undergoing 4 years of college, 4 years of med school, 3 years of residency, and a system in which the government directly controls the salaries of an entire profession. Even firemen and policemen dont operate that kind of national pay scale, cities and counties compete for their services.
    If you are going to give us socialized medicine with the same salaries that european doctors get, then at least give us the same malpractice protections that they get.

  23. Steve, you make sense under a number of impossible assumptions. There will never be anything resembling an ideal (competitive) market in medical services because it isn’t snack foods or even automobiles.
    Supply is restricted by the suppliers with the help of licensure laws. Every service provided is a bit of a one-off, not so much as some of the doctors claim, but they have a point — direct comparisons are impossible. Many outcomes are heavily dependent on the cooperation of the patients, which is why most quality programs have focused on processes rather than outcomes. Even price and outcome transparency as complete as we can make it will not begin to approach the level of simplicity needed by 75% of the “customers”, maybe more. Everyone knows how a potato chip should taste, but only an expert knows what to expect from a medical intervention, and only imperfectly even so. If you don’t like the car you bought, you can sell it and get another one. Medicine is not like this. Conflicts of interest, real and potential, are rampant. For anything at all serious or complex (read “expensive”) magnify all the preceding by 100 and add in the necessary financing mechanisms. Even if we returned to indemnity insurance, paid to the patient, he is still more or less price-insensitive at this point, and market mechanisms by definition are defeated.
    Since there can’t be an efficient market, someone will have to be the regulator. You really should learn some economics — microeconomics and price theory would help you a lot. Then some game theory if you’re still interested. Can’t do public policy or business strategy without it.
    t

  24. I’m no economist, but Dr. Hinson’s proposal seems like a natural market process to me. The trick would be to enable consumers to evaluate care value, which would require transparency in cost and outcomes. That is, patients would need access to valid, reliable data about the cost and benefit of different services rendered to different types of patients by different providers, so each patient can choose the provider most likely to deliver the greatest value to him/her.
    And since providers would want to gain competitive advantage by delivering the greatest value, there would have to be a way to enable them to continually improve the quality of their care or risk losing patients.
    It seems to me, therefore, that such knowledge on both ends is required to make this system work in a way that helps fix the healthcare system; like when automobile crash tests give objective feedback to the public and manufacturers resulting in better cars and increased sales to the makers of those cars.
    Then, as an increasing number of providers deliver the same value as the best performing providers — through dissemination and implementation of high-quality standards (e.g., evidence-based practice guidelines) — competition would be increasingly based on cost alone, which would require increased efficiency while maintaining the same level of efficacy. Am I making any sense?
    And as far as Tom’s proposal – with the Bass Curve and prices falling in line with new care standard – I’d like to know more since I’m having trouble with the “price-regulator-in-chief” concept. What would have to happen in the healthcare system for the relationship between the Bass Curve and price points to become a natural and fast process as in other industries? That is, how would the system have to be transformed in order for providers delivering the greatest value to receive the greatest “profit” and prices to fall as those high-value services become standards, without the need of a price regulator?
    It’s starting to appear as though the two proposals above are not in conflict. Am I missing something?
    Steve
    http://stevebeller.blogspot.com

  25. You can do that. Go all cash. No credit cards even. And never Medicare or Medicaid. There is a lot to be said for this. Where you live and work, you could probably do it. Go for it.
    t

  26. How about this instead? I decide what it costs me to provide a particular service, and then I charge that to the person I am providing the service to? If I charge too much, or do not provide an adequate service, then no one will come to see me. If I do a good job, and their is value to the service, then everyone is happy. Why should there be ANYTHING ELSE involved?

  27. > This is closely related to Tom’s issue of
    > “real global fee,” which is interesting,
    > but paying everyone the same rate appears
    > to ignore the issue of “value,” i.e., how
    > to get the biggest “bang for the buck.”
    > Knowledge of how to get the best care for
    > least cost is imperative, but requires
    > reconstructing our current healthcare
    > system so it focuses on bridging the
    > ”knowledge void”.
    In the short term it sorta does ingore the issue of “value”, but this serves a purpose in disseminating information and driving adoption.
    They who figure out how to cure a patient at least as well, but less expensively benefit by receiving what you might call an “excess payment” if you have a cost-plus mentality. If you have an intrinsic value mentality, the payment isn’t excess at all: the smarter docs make more profit just like smarter automobile manufacturers do.
    But just like in every other industry, this does not go on forever — you can’t rest on your laurels. The technology spreads (and it is not necessarily capital-embodied technology) and begins to move up the Bass Curve to become the new Standard of Care, the price should come down. In an ideal market, this would happen naturally, and fast. In medicine, the price-regulator-in-chief will have to take care of it.\
    t

  28. While HSA and P4P have some potential, they are far from perfect (see HSA Debate and P4P Debate).
    And as to Dr. pgbMD’s comment “…give the American public some respect and credit and stop being so condescending. They are smarter than you think” – While I agree, I think the issue is less about the intellect of the public and more about informing the public. To make wise decisions about where and when to seek help for a health-related problem, and about what treatments are best for a particular person – judgments that are fundamental to HSA and P4P – people have to be well informed. Unfortunately, valid and reliable information for making such determinations simply don’t exist and it will take major systemic reform to emerge and disseminate this knowledge in useful form, which is something, I say, we should be focusing on doing.
    This is closely related to Tom’s issue of “real global fee,” which is interesting, but paying everyone the same rate appears to ignore the issue of “value,” i.e., how to get the biggest “bang for the buck.” Knowledge of how to get the best care for least cost is imperative, but requires reconstructing our current healthcare system so it focuses on bridging the ”knowledge void”.
    In other words, no fiscal-focused strategies can solve the healthcare crisis by themselves because the crisis is as much a knowledge problem as a money problem, and the two are inextricably connected.
    Aligning income with social benefit is unrealistic without a major shift of human consciousness; and that’s unlikely to happen until things get even worse. Bringing the incomes of PCPs, therapists, social workers, teachers, etc. more in line with lawyers, lobbyists, professional athletes, entertainers, CEOs, etc. requires a fundamental transformation in the focus and beliefs of our society; a transformation from happiness, self-worth and life-purpose:
    (a) being linked to one possessions, creature comforts, economic might and physical intimidation
    … to …
    (b) being the result of one’s proactive membership in the larger “human community” and doing what one can to improve the well-being of all people through social change emerging from self-awareness, compassion, critical thinking, innovation, quest of knowledge, conservation of natural resources, protection of the planet, acceptance of different cultures and customs, etc.
    I’m hoping this transformation will take place before it’s too late, but we cannot sit by waiting for it to happen.
    Back to the “value” concept — I equate healthcare value with healthcare quality by defining quality as safe, effective, efficient, affordable, timely, and available care.
    What is doable near term, and has the potential to transform the system long term, is taking steps to optimize healthcare value/quality. Consider the following strategy:
    1. Giving the greatest income to providers who deliver the most cost-effective care, treat the most difficult patients, and get the best outcomes – i.e., produce the greatest value/quality
    2. And, at the same time, doing what’s necessary to enable all providers to deliver higher-value/quality care to all patients. Factors increasing care value/quality are likely to be practitioner experience, knowledge and skills; the use of effective information technologies and decision-support tools; implementation of effective quality-improvement and wellness programs; use of cost-effective evidence-based treatment protocols and medical equipment; having enough time and resources to execute and coordinate effective plans of care; efficient administrative operations (cutting the red-tape); bedside manner and accurate intuition; etc.
    Two of the biggest challenges to implementing such a value/quality-based system are:
    1. Establishing and using valid and reliable ways to measure and reward “value/quality” and
    2. Creating a system that enables all providers to increase the value/quality of their services.
    Dealing with these challenges requires many changes to our current healthcare system, and, I contend, this is where we should be focusing our efforts and spending our money.
    Steve
    http://stevebeller.blogspot.com

  29. I left a word out of “global fee” — I mean a “real global fee”, one that includes the hospital expenses. This will serve to align everyone’s interests.
    Dr. Hinson, who says a surgeon should make more than a PCP or that a school teacher ought to make more than a baseball player? On what principle of equity or freedom? I have tried to argue that PCPs ought to average about 4 patients/hour at about $55 (realized) per each. If they control their practice expense, they will net $100 — $150K per year working reasonable hours.
    I do not begrudge anyone anything except maybe economic rents flowing from licensure laws: I am only thinking about what I see going on. And as I have said before, if The Guild won’t fix it then someone else will, and it won’t be pretty. It looks to me like Michael Moore will have his way, and the someone else will be the government. I am enough the libertarian that this is very far from what I consider ideal, but unless something drastic happens soon, I do not see how it can be stopped.
    t

  30. What everyone needs to recognize is that that you can not legislate or dictate change via governmental intervention. The government is grossly inefficient and wasteful. I saw it first hand while in the military working with TRICARE. What a scam that was. You sould have seen the rush for the door at 3:00pm by every civil servant working in the hospital. What a disgrace.
    The reason healthcare is in the mess it is in right now is because of too much government red tape/involvement and the third party payer system. HSAs are a good start to solving the problem. Just like the Libs are against school vouchers, they were/are against HSAs. It is amazing how smart the consumer is when given a choice and when they are spending their own money!! You P4P people need to give the American public some respect and credit and stop being so condescending. They are smarter than you think! 🙂

  31. Here’s my attempt to summarize the main points we’re making and pose a few questions:
    1. We all seem to agree that our healthcare system fosters insane fiscal relationships between providers, payers, purchasers and patients, which leads to waste, red tape, and discontent.
    2. Drs. Hinson and pgb make a strong case about how our country’s priorities are screwed up — One’s income is unrelated (and often negatively correlated) to the degree of good one does for society.
    3. A single-payer system is no silver bullet.
    4. Our political system is based on a foundation of corruption, so don’t expect any virtuous solutions from Washington.
    5. Two groups of stakeholders who can drive meaningful systemic change but lack leadership are Consumers and Providers (“The Guild”). Activating consumers to take a stand requires some serious education. As Dr. Rob Lamberts said, “People don’t know what good healthcare is because they don’t know how bad healthcare is. People don’t know how bad healthcare is because they don’t realize how good it could be.” Tom’s suggestion to do it through popular forms of media (e.g., TV, movies) in order to reach the general public makes sense to me. Any thoughts about Michael Moore’s next movie? What is necessary to activate providers to demand rational change in the system in a way that doesn’t put unreasonable economic burden on the consumer? Can there ever be a “clash of the Titans” (Guild vs. CMS) and what would be the likely outcome if there was?
    BTW, I wouldn’t leave out purchasers (employers) as a potential driver for change.
    6. The Oncology reimbursement study confirms my contention that a knowledge void is a big part of our healthcare crisis. If we all knew the most cost-effective interventions (and preventions) for each patient, and had a healthcare system that enabled them to delivered effectively and efficiently, then we wouldn’t have these kinds of problems and we’d be well on our way to solving the healthcare crisis! We should be focusing on much more on the dissemination and implementation of useful scientific knowledge, or we will continue to have serious quality problems and escalating costs due to ignorance, mistakes, and inefficiencies.
    Steve
    http://stevebeller.blogspot.com

  32. A surgeon should make more than an accountant. A cardiologist ought to make more than a plumber. Oh, and an elementary school teacher ought to make more than someone who plays baseball for a living. Our society has a funny way of placing value on services rendered.
    Medicine is unique in that there is a need for the government to intervene and make sure that adequate care is available for those who cannot afford it. If society would rather reimburse Oprah for her TV show than the people teaching our children, than government does indeed need to step in and try to make sure that our schools are adequate. Same could be said about healthcare.
    Primary care physicians are an essential part of the equation. You cannot see doctors for your kidney, for your heart, for your skin, for your abdomen, and expect that all of the treatments and therapies will work together perfectly. Also, there isn’t a specialist to talk to when you think you have heartburn and it turns out that you’re really just suffering from excessive stress.
    I think I make an important impact on the lives of those I take care of. And, for it, I make $30/hr (80 hrs/wk, 50 wks/yr).
    There is another stress, however. To make that $30/hr, I am forced to see more and more people per day, and provide less care for those I do see. I am not able to spend enough time with each patient I see, and knowing that I should be doing even more for everyone, that I should better stay on top of my practice’s chronic medical problems, that I should more actively help manage the bad diseases…this is an even greater stress for me.
    I need a system that will pay me more for doing a better job than I am currently doing, taking into account that to do this, I need to work less and spend more time with each patient. Someone pinch me please.
    I’ve come to think that the only way I can accomplish this is to switch my practice to a free market driven, cash-based practice. Effectively firing a huge percentage of my patients– i.e., those that leave me when I make the switch–and recouping the overhead spent on getting insurance companies to pay me, is the only way I can see pulling something like this off.
    Oh, and don’t talk to me about a Cardiologist, someone who will likely add years to your life, later in your life, making $550K! Would I like some of that as a primary care physician? Sure. But I do not begrudge specialists who make that kind of money. Talk to me instead about what you read on this link–http://www.forbes.com/static/pvp2005/LIRRI3M.html. How can anyone not see that, even prior to a push towards a single payer system, significant health insurance reform is needed. The silent middleman, pumping money into the pockets of our politicians, is the evil underlying our system. Slowing milking it of every last penny and every last bit of humane care.
    United Healthcare recently threatened to cancel the contract of a colleague of mine in Colorado who was billing too many level 4 visits. This doctor takes care of an elderly population and sees 15-18 seniors a day for longer visits, instead of 25-30 people of a mixed population for less complex reasons. As such, he bills more per visit.
    And yet William McGuire, the CEO of UHC, had a salary of $125,000,000.

  33. We already are accepting global fees from CMS and most insurance companies for surgical procedures last time I checked.
    Certainly laywers (and most other top tier professionals) don’t accept global fees. Last time I needed a laywer I kept getting $500/hr bills. My father-in-law is a partner at KPMG (large accounting firm) and all partners make in excess of $850k/yr. Maybe we should go to a single payer system for accounting. Maybe P4P for accounting is in order. Oh I forgot, their profession wasn’t dumb enough to start accepting insurance/HMOs/medicare in the first place so they don’t have that problem.
    Many of my patients are already paying out of pocket for many of my services. I could reduce my office staff by 50% by cutting out accepting insurance and medicare and going to all cash right now, but I feel that that portion of my practice is my payback to society. Medicare and Medicade is the safety net everyone is clamoring about. We already have it.
    HSAs are the begininning of the end of the HMO style of reimbursement that has sucked the life out of our healthcare system over the last 15years. Great way to save in a tax free acoount and also brings the patient back into the fray interms of paying for routine office services. The only people that may get hurt by HSAs are the PCPs when patients think twice about going in for a routine cold.
    The shortage in cardiologists and many other specialty fields that treat older patients is just the tip of the iceberg. I forsee this problem multiplying as the Baby Boomers begin to hit 65yo. This problem is further multipled by the fact that now >50% of med school grads are women. The majority of female doctors don’t want to go into surgical specialties and don’t like the long hours. I have witnessed this personally since I have 2 female partners and they both work only part-time. The cold hard facts are daunting.
    If you are so jealous of those cardiologists then why don’t you go to med school for 4years and then do 7years (for interventional) of cards training! There certainly will be a huge need for good cardiologists in 11years.
    By the way, I recently got an ad in the mail asking me to bat for the NYY and they offered $10mil starting. They must have sent it to the wrong address 😉

  34. Gee, old surgeons retiring — who woulda thought?
    It is well-established that there are many opportunities besides red tape (so-called) to reduce healthcare expense.
    When you are willing to accept a global fee to cover everything when services are rendered like any other profession, then I might start to believe you are committed to a Free Market. I sincerely doubt that your patients pay for much of anything, and so their willingness to pay for facinating toys has not been measured. This is the fundamental disconnect that makes a classical Free Market in helathcare impossible. But there are others.
    While Canadian style socialized medicine can’t happen here (i.e. private pay is illegal), other models could, and doctors (and nurses, and sterilization techs, and housekeepers, and…) would face a single buyer of their services. Even if this is not strictly true, everyone will bargain up from the rates paid by CMS, not down from a fee-schedule.
    Speaking of, I got this in my inbox this morning:
    ============
    New Cardiology Opportunities
    Northern Georgia Cardiology Opportunity
    8 Cardiologists
    1st year negotiable
    2 years to partnership
    near Atlanta
    partners making 550K plus
    ============
    These days are surely coming to a close. We can observe the trend with PCPs, and I cannot imagine it will not spread. I think these guys would still practice for $250K, and if there is one who will not it probably isn’t a great loss to the system. This is the calculation being made: The Guild cannot control supply nearly so well as CMS can control prices. But it will be a Clash of Titans.
    t

  35. Getting the government and red tape out of medicine will be the only answer to drive down costs. I agree with Dr Hinson. A free market is the only way to go. There is a disconnect because of the insurance/medicare middle man. Doctors are moving slowly to cash payments when services are rendered like any other profession. This is the only way out of this big mess. There is something different b/w the “eutopia” of European and Canadian healthcare and the USA and that is the US Constitution. Canadian socialized medicine can’t happen here because of the US Constituion and the right to contract. But that is a mute point since Canadian healthcare is falling apart and “illegal” fee for service hospitals are opening there due to overwhelming demand from the patients.
    As a surgical specialist I am seeing older surgeons leaving/retiring everyday. Soon the breaking point will be reached and I will start charging cash/VISA/Mastercard for my services like any other highly trained professional in this country. Unlike the many self elevating middlemen now sucking the blood out of the US healthcare system my services are the bottom line, don’t come cheap and are not reproduced easily. By the way I do have a “fascination with toys” and believe it or not my patients do too (and they are willing to pay for it)!!!

  36. I am not saying it must happen — I am saying it is happening, that CMS is pushing it (I have to think by design), and that any single-payer scheme will quickly universalize it. Just like in Europe. Matthew and a few others have said it too. There will be no reduction in red tape; in fact an increase, except now there will be only one source of red tape. It is probably a wash on that front, but no improvement. What kills me is that nobody in charge quite wants to admit any of this in plain language.
    I the reason it is happening this way has to do with with leadership, or rather lack thereof, in what I call The Guild. A recent example: the blog article about oncology reimburesements. Who permits this to occur? Primarily other oncologists, and they help each other do it. What would happen if an evil insurance company tried to stop it? What did you call it? Oh yes: there would be “a groundswell of discontent by the public.” Egged on, of course, by the oncologists. But what would happen if oncologists tried to stop it?
    One of my PCP buddies told me about a book you can buy at Amazon that lists every test and procedure a primary care doc can get away with doing when a patient presents with some complaint. No, it isn’t a book of EBM style treatment plans. It is meant to maximize billing and income. The mere existence of this book is an indictment of The Guild.
    All this said, there is plenty of blame to go around, not excluding patients (apologies, Theora). I do not mean to beat up on doctors I don’t know. But there are these recurring patterns…
    With respect to Dr. Hinson’s remark: one thing the HSA scheme could do is somewhat reduce friction in the system for the small expenses. But generally the red tape/documentation requirements will still be there for a bunch of reasons, including UR & P4P. he just won’t have to wait for his money for the visit itself. I feel for Dr. Hinson and my PCP friends on a personal level, but I hope all this motivates them to more activity on a professional level — as leaders in The Guild.
    Steve, I appreciate you want to educate people. So do I, but I think it could be you have a perspective problem. I explain: For more than ten years the great majority of my time was spent at Washington University in St. Louis — either as a student or a staff member. I got quite used to being in a “society” where my gifts in any area were noticably above average only very rarely. I started thinking things like “Well, even I can figure thaaat out!” Then I left this wonderful world and returned to the Real World®. Not to put too fine a point on it, but at the company I iummediately joined, there was one other guy there who was about as bright as I am, but nowhere near as well educated. Just one out of about 35. Maybe you are in the same boat I was in. It warps you until you get jolted out of it.
    If you don’t already, go hang out at a neighborhood bar in a working class neighborhood. Regularly. Or join a car club, or the Knights of Columbus or some kind of organization that the general public joins. The general public that never dreams of college. This is a real education for any aspiring policy wonk: these are the people for whom the policies are made. Their needs, abilities and predjudices must be accounted for.
    Having done all of the above, I have come to think you need television for educating the general public — the two-minute snippet on the local news. Medical dramas. But this kind of thing: not Discovery Channel material. The only people willing to be educated by reading websites or watching The Discovery Channel aren’t the general public. They’re wonks at some level.
    t

  37. The problem as I see it is the disconnect between the person who bills the insurance company, the person who pays for the insurance coverage, and the person who uses the coverage. This unholy triangle, with the insurance company bulging out of the middle of it, is the whole problem.
    To get paid $50 for 15 minutes or work, I (as a solo-practice, primary care physician who is about to be squeezed out of the whole game) have to bill an insurance company who has no incentive to deal with me in a fair way, since I only cost them money and do not pay them money. If they deny a charge (and it is amazing how often this happens), I instruct my patient to call them. But this doesn’t work because now the company can simply say, “I’m sorry, but this is the coverage you have.” (The bill paying employer wants nothing to do with it!) At this point, either I eat the charge, or the patient pays the bill. And the piddly amount is another drop in the river of the corporation’s profits (and the CEO’s pocket (http://www.everybodyinnobodyout.org/FAQ/datCEOs.htm).
    What needs to happen–and what I think will happen once every primary care physician faces the decision to either give up their practice or give up the notion of insurance reimbursement–is for us to, en masse, stop billing insurance and expect payment at the time of service.
    The very idea of this freaks the general public out, because they’ve gone to see their doctor for something like a kidney infection, and subsequently seen the insurance paperwork showing a bill from the lab for $180 for the urine culture that was ordered, and from the hospital for $885 for the renal ultrasound that was ordered. But what they fail to see is the doctor’s bill for only $72, of which only $54 was approved.
    But, really, this makes perfect sense. Seems to me that this is what insurance coverage was meant for. Let it cover the $800 x-ray; let it cover the $3,000 breast biopsy for the abnormal mammogram; let it cover the $212,000 bill for the 4-week premature baby. But do we really need insurance to cover the $55 office visit? I don’t expect my car insurance to cover the $25 oil change! If I did, I guarantee you that it would not take 6 months until all oil changes were $75!
    Primary care physicians would be happy with their $150K (especially if there is the prospect of it actually increasing with cost of living like everyone else’s pay does) if they did not have to work an extra 1-2 hours a day (without pay) in order to deal with the red tape and paperwork that insurance companies cause.
    I’m fine with the idea of P4P and feel that the quality of care that is provided does need to be improved and better standardized, but P4P might just be the proverbial straw that breaks the back of the whole system if the process causes me and my colleagues to have to waste even more time on a day-to-day basis dealing with the health insurance red tape!

  38. I don’t know enough about it to comment on the validity of Charles Murray’s POV, but I don’t see why such a drastic approach is necessary … why providers must be squeezed dry, small/solo practices will have to be demolished, and why payers will be reduced to an administrative services only role. I’m not saying it can’t happen, but I am saying that better alternatives are possible.
    My basic premise is this: The economical delivery of high-quality (safe, effective, efficient, affordable, timely, and available) care, preventative services, and biosurveillance to all people can be accomplished without (noticeable) tax increase and with benefits to all stakeholders, if we collaborated in:
    • Revamping portions of our healthcare system (e.g., redirecting competition, offering rational incentives for QI, increasing fidelity, etc.)
    • Building and using evolving health science knowledgebases and a next generation of HIT tools.
    I’ve started publishing portions of a blueprint of this model on my blog and will offer a comprehensive description in a white paper and wiki by month’s end.
    Targeting resources for consumer education at television news reporters certainly make sense. But our convoluted healthcare system is just too complex to understand with sound bites and 2 minute segments. A series of in-depth reports would help.
    Matt’s blog is a great source of information and ideas, and I even thought about it when constructing my previous post. But what we would need for educating the general public, imo, is more like an online encyclopedia, with an evolving index linking to each main and sub topic, and evergreen content continually being built within the topics, along with threaded discussions. A wiki would probably be a more effective vehicle I’m thinking. I’m saying this because while writing the white paper, I had a heck of time delimitating and organizing all the factors into many dozens of inter-related topics (like a healthcare industry taxonomy).
    In terms of consumer-focused groups that have grass-roots ties, I’ve compiled this list so far: Healthcare-NOW, Center for Medical Consumers, USPRIG, Center for Science in the Public Interest, and Informed Health Online. If anyone know of others, please let me know.
    Steve
    http://stevebeller.blogspot.com/

  39. Steve Beller writes:
    > diminishing compensation to all providers
    > as part of the design of healthcare in the
    > future is simply unacceptable! How much
    > more do providers have to be squeezed?
    Unacceptable to whom? I think the direction is to squeeze providers to the point that they tend to earn on a par with their western European counterparts. Then we can afford more of them. But they will still be in the top 5% of income earners in the USA. I stress that this is how it SEEMS to me, based on what I see coming from the government. The calculation seems to be something like this: we already spend more than anyone else and get less for it. We have a demographic problem and two political problems: access must improve and taxes can’t increase (much). Poorly managed hospitals will close (or get new management), and the solo physician practice will probably disappear because minimum efficient scale is certainly bigger than one, and might be bigger than ten. (Any ideas on this?) Surviving insurance companies will all be ASO processors.
    It is probably true that some very talented people who go into medicine today will choose something else under this scenario. But Charles Murray at least thinks this isn’t all bad. A new set of expectations will percolate through the industry, a new crop of students will enroll in medical school, retirements will happen, and a new sort of equilibrium will form. But in the meantime, things will be very painful.
    You have more faith in the general public than I have. True Democracy as you call it requires also true Virtue or Excellence in the ancient Greek sense at least. Plato didn’t think it could happen, did he? But if attitudes are going to be changed, the educational resource you propose should be targeted at television news reporters. I wonder whether it already exists. Hard to imagine it doesn’t, and Matthew’s blog has some of this flavor already…
    t

  40. It’s wonderful to be engaged in this dialogue with you, Tom. And I, too, would love to hear what others think.
    > more docs want to be PCPs is a necessary condition for shifting to a prevention orientation
    You were clear, Tom. My assumption is that if the status and income of PCPs were more commensurate with consultants/specialists, and if their work conditions improved, then more medical students would WANT to be PCPs. I realize that these discussions are hypothetical and impractical in the context of our current crazy healthcare system, but change — or should I say, paradigm shift — isn’t possible unless disruptive/innovative ideas (and technologies) emerge and are recognized.
    Anyway, diminishing compensation to all providers as part of the design of healthcare in the future is simply unacceptable! How much more do providers have to be squeezed? Our country’s focus and priorities are screwed up. I’d rather focus on answer the question: What can be done to give providers an opportunity to earn more by delivering ever-better care and preventative services, along with better working conditions, without increasing the overall cost of healthcare?
    Your portrayal of the general public mindset seems to boil down to: “Give me whatever I want when I want it without any effort, expense, or inconvenience on my part … or I’ll cry!”
    I can understand why you would say this, but it need not be so. If the general public was aware of what’s really happening in healthcare today in terms they can understand and had an open forum in which to ask questions and learn, the childish attitude you described would be short-lived.
    I suggest such a forum could start out as a blog (or other virtual medium), preferably with financial support from consumer groups with integrity who promote it. It would lay out all the important issues affecting healthcare today in a clear and understandable way – including all proposed solutions/models, their affect on different stakeholder groups (who are the winners and losers), the drivers and impediments to implementing the solutions, etc. – and it would encourage deep dialogue, open-critical-honest debate, sharing a diversity of opinions, appreciation of minority points of view, creative abrasion (friction caused when a heterogeneous group works together to develop creative ideas), continuous learning, etc.
    By enabling people to gain the knowledge they need to understand the complex healthcare system through active or passive participation, we would have educated consumers who could collaborate to push fundamental change. After all, isn’t Democracy (I mean, true Democracy) supposed to that way?
    Steve
    http://stevebeller.blogspot.com/

  41. Matthew,
    On the question of “America isn’t America” I’m completely with you. I painfully refer to healthcare (US or otherwise) as a ‘system’. It isn’t one. It is a wonderul, undefineable flow of marketplace interactions that are, for the sake of discussion, often denoted by localities, regions, and nations.
    Joe,
    My logic was simple. Matthew (nor you) should be able to use the Dartmouth research as a stab against the ‘US Healthcare System’ vis a vis other nations’ which, as you note, involved more government. For one, Matthew points out the silliness of using the nation as a common denominator for comparing health care economies. For the other, the Dartmouth research is limited to intra-American health economies and can’t be used to compare health economies internationally.
    Cheers to both…
    Trapier K. Michael
    http://www.marketplace.md

  42. > … Right?
    No, Steve. “more docs want to be PCPs” is a necessary condition for shifting to a prevention orientation from a restore/rescue orientation, not a consequence of it. At least that was the argument I was making, evidently poorly.
    On a straightforward microeconomic analysis we might THINK that narrowing the compensation gap between PCPs and consultants and giving PCPs a working environment more like the consultant enjoys would result in more interest in primary care. But there is always more to it. (How’s that for an academic answer?)
    And keep in mind we are talking about narrowing the gap between PCP and consultant primarily by reducing the compensation to the consultant faster than we diminish compensation to the PCP. PCP compensation is diminishing already, and the best way to think about it (in my view anyway) is that poor-performing PCPs will see their incomes diminish further than well-performing PCPs. But all of them will diminish. This is apparently by design. So providers will NOT be supportive of the kind of changes we’re discussing here.
    > Any others?
    A boatload, I am sure. One thing I can think of has to do with the definition of “Practice Medicine” and who is allowed to do it. Matthew says 1,000 really smart people read this here blog. I bet half of them know more about this than I do. Maybe someone will chime in.
    > And if payers were convinced that they would
    > actually save money via the PCP + prevention
    > strategy we’re discussing, then wouldn’t they also
    > support it?
    Some were convinced and tried to do more than support it: they tried to implement it. They were called Health Maintenance Organizations. There was a groundswell of discontent by the public. Following good small-d democratic principles, they are essentially illegal now.
    The only thing I really hear coming from the general public goes something like:
    – I want to get whatever I want from whomever I want.
    – I don’t want to pay for it.
    – I don’t even want to think about it, but
    – I want to sue somebody when I am dissatisfied with it.
    – I want Congress to make it happen, but
    – I don’t want Socialized Medicine, whatever it means.
    – I am therefore discontented with the current state
    … and with anything else I have heard about so far.
    Do you think this about covers it?
    > effective patient education includes discussion,
    > demonstration, and active participation.
    I like the “active participation” part. Someone else can start paying my personal trainer, and now I want a Physical Therapist licensed to Practice Medicine, not a merely Certified Fitness Trainer who I just know will kill me some day. The Physical Therapists told me so.
    t

  43. So, Tom, if PCPs could have an income more commensurate with consultants/specialists and would not be diminished by P4P, if maintaining that income requires they see about 4 patients per hour, and if their focus on prevention motivated patients to take better care of themselves, THEN more physicians would become PCPs, patients would get better care, and it would help drive down overall healthcare costs … Right?
    If so, it sounds like a most worthy goal. What changes to our healthcare system would have to occur to achieve that goal?
    One thing you mention is our government’s priorities. Another is patient compliance. A third is payer expectations. The other is providers’ fascination with their toys. Any others?
    So, how do we get governmental priorities to change in a positive direction? Well, it seems to me that there’s a recent groundswell of discontent by the public in our political system. This may point to the need for grass-root pressure. In addition, purchasers are fed up the healthcare costs. And providers would, I bet, would be supportive of the kind of changes we’re discussing here. As such, consumers, purchasers and providers would both benefit from a shift in our country’s political priorities in the direction we’re discussing. Seems like a very powerful force if focused on wise systemic change!
    What would make patient compliance improve? Well, there are convincing studies of the benefit of consumer education, i.e., any combination of learning experiences that influence behavior changes needed to maintain and improve health through changes in knowledge, attitudes and skills. It requires more than simply giving patients written instructions, a pamphlet to read, lists of resources, or a video to watch, however; effective patient education includes discussion, demonstration, and active participation.
    Benefits of patient education include:
    • Improvements in patient satisfaction
    • Better health maintenance and healthcare outcomes
    • Better self-care and adherence to the health care plan and follow-up care
    • More empowered patient decision making
    • Fewer complications
    • Reduced healthcare costs
    • Decrease patient demands on the healthcare system
    • Earlier detection of problems and timelier outpatient intervention
    • Decreasing hospitalizations
    • Reduced absenteeism from school and work
    • Better coping skills.
    And if payers were convinced that they would actually save money via the PCP + prevention strategy we’re discussing, then wouldn’t they also support it?
    Steve
    http://stevebeller.blogspot.com

  44. > I may be being simplistic here
    Yep.
    Physicians avoid primary care because the hours are lousy and the pay is well below what specialists make with decent hours. It seems to me (and others) that the government’s target for PCP salary is about $110K — down quite a way from the income target of about $150K that the PCPs apparently have.
    A friend of mine takes care mostly of older people. He figures he can do a decent job with them if he sees three or four an hour. Some quick back-of-the-envelope calculations tell me that he needs to see 4 patients/hour at $55 each for 1,700 hours/year to make something resembling a $110K “salary”.
    At Medicare’s current reimbursement rates, it is hard enough to make a living, and a fair number of his patients are on Medicaid because he’s one of the few who will accept $12 for 20 minutes’ work because he can’t stand to see somebody go without.
    So, if what you mean by “PCPs were paid” could mean some combination of:
    – reimbursements to consultants fall to narrow the
    income gap with PCPs
    – PCPs become happy at around $110K
    – payer expectations fall to around 4 visits/hour
    – more docs want to be PCPs, abandoning fancy toys
    – reimbursements average $55 15-minute visit
    – people actually take advantage of preventive advice
    – savings from falling reimbursements to consultants
    flow to PCPs, not to other congressional priorities
    then “Preventive Medicine” has a chance. But I think all of the above are necessary conditions. I understand in London I can get odds on just about anything. What do you suppose I’d get shown on this scenario?
    t

  45. Matthew,
    The health care system has been awash with money since the initiation of Medicare and it has become commercialized along with the rest of American Society. No going back or changing that in any meaningful way, so reform will have to look in other directions. Perhaps the time has come to effectively push prevention and retool primary care to lead that charge.
    The National Governors Association launched Healthy America at their winter meeting in February. I was invited to participate by Governor Sanford of South Carolina. There are reports about the meeting over at http://www.fixinghealth.blogspot.com/. Come on over, I could use the help.
    Thanks,
    Marcus

  46. Matthew – it’s always exciting when you get excited.
    Trap – let’s not obfuscate here. the sad truth is there is way too much health care provided, that supply drives demand, and that it is an incredible indictment of the system (?) for the nation that spends the most as a percentage of GDP as well as in real dollars to have 15% of the population uninsured. And there is a lot more government involved in every other health care system that tend to produce much better outcomes with much lower costs.
    I don’t get your logic.

  47. I don’t know that we have too many doctors. Don’t the French have more of them?
    Can you break this down by region and specialty? I think that outside of urban areas like Boston and New York, there’s a real shortage of psychiatrists, and I think that the problem may be about to get worse. I’ve heard that the average age of a psychiatrist is 55; they’re all about to start retiring.

  48. I may be being simplistic here, but (a) if more of those physicians went into primary care, and (b) if PCPs were paid to spend more time with their patients (e.g., as per the American College of Physicians recently introduced “Advanced Medical Home” model), then wouldn’t it put to good use the “surplus of physician inputs,” while promoting better, more cost-effective care?
    Steve
    http://stevebeller.blogspot.com/

  49. Trap, yabutt — America isn’t America. Minesotta or Georgia are not Los Angeles or New York

  50. Let’s be clear, Matthew; the Dartmouth researchers limit their study to the US system alone.
    Thus it’s not right to say their conclusions directly prove US-system-inferiority vis a vis other countries’.
    The very real fact could be that the US system is terribly flawed – because of the free market distortions of public and private third party payment, heavy government regulation, and the ‘command and control’ approach to healthcare characteristic of the professional medical establishment – but it is still the best in the world in many ways. Sad, isn’t it?
    Trapier K. Michael
    http://www.marketplace.md

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