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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Marcus AlexanderSteve Beller, Ph.Dmed studentpgbMDG. Hinson, MD Recent comment authors
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Marcus Alexander
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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.

Steve Beller, Ph.D
Guest

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… Read more »

pgbMD
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pgbMD

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… Read more »

Steve Beller, Ph.D
Guest

> 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… Read more »

Tom Leith
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Tom Leith

> 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… Read more »

Steve Beller, Ph.D.
Guest

> 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… Read more »

Tom Leith
Guest
Tom Leith

> 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… Read more »

Steve Beller, Ph.D.
Guest

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… Read more »

Tom Leith
Guest
Tom Leith

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

Tom Leith
Guest
Tom Leith

> 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… Read more »

pgbMD
Guest
pgbMD

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… Read more »

pgbMD
Guest
pgbMD

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… Read more »

Steve Beller, Ph.D.
Guest

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… Read more »

Tom Leith
Guest
Tom Leith

> 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… Read more »

Tom Leith
Guest
Tom Leith

> 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