The Emperor Remains Unclothed

I guess I shouldn’t be surprised when two of the architects of the health care reform act write an op-ed that continues in the deception that the law would deliver access, choice, and lower costs.  But that is what Ezekiel Emanuel and Jeffrey Liebman offer in their New York Times article, “Cut Medicare, Help Patients.”

The authors start by saying some things that make a lot of sense.  They point out that it would be smart to “eliminate spending on medical test, treatments and procedures that don’t work — or that cost significantly more than other treatments while delivering no better health outcomes . . . [and that} can be made without shortchanging patients.”

But they quickly give up that fight:  “The sad truth is, Washington is never going to do a good job of making smart cuts to Medicare.  Elected officials hate being blamed for directly restricting access to medical treatments — even when those treatments are proven to be worthless.”

So then they revert to their underlying bias, er, theology:  “The responsibility for ending unnecessary medical spending needs to be placed in the hands of doctors and hospitals.  This can happen only if we change our fee-for-service payment system.”

How much damage is being done and how much time is being lost by our society by a religious belief in a payment scheme that has not been proven and that has many inherent difficulties?  As I have noted, not the least of the difficulties with capitation is indeciding the transfer payments among the different medical specialists.

And then to add salt to the wound, they say:

“These seeds of a solution lie in the accountable care organizations, medical homes and bundled payment reforms that were authorized by last year’s Affordable Care Act.”

As I have discussed, the ACO framework prescribed by Congress is inherently flawed because Congress could not and will not limit patient choice.  An ACO cannot manage patient care if there is a PPO structure in place, allowing patients to shift care not a non-ACO provider at will.  Meanwhile, the ACO framework also has risks of market concentration that are drawing the attention of federal antitrust regulators.

This whole discussion is incredibly painful to watch, especially when Emanuel (or was it his brother?) admitted privately during the Congressional debate on the ACA that the costs of providing universal insurance access were well above those that were being publicly projected, and that, ultimately, the US would be forced to pass a value added tax to cover the health benefits that were the result of the law.  What’s the chance of that during this political environment?

On this blog, I have talked about things that can work and that are within the power of Medicare to implement.  The most powerful would be to change the relative fees paid to primary care and other cognitive specialists, compared to proceduralists.  Giving a primary care doctor the ability to spend more than 18 minutes with a patient could change the nature of those doctors from having a triage function to allowing proper management of care.

Medicare can also engage in real clinical transparency, insisting on the publication of real-time information about infections and other important aspects of quality and safety as one of its Conditions for Participation.

But, we must also find fault with the nation’s doctors and hospital administrators who fail to lead process improvement in their institutions, even in the face of documented quality and safety enhancements and cost savings in exemplary hospitals.  Medical schools, too, have systematically failed to teach young doctors about the science of improving care delivery.

I have often asked the question, “What does it take?”, suggesting that a failure to proceed with such changes and to engage in full-hearted transparency is unethical behavior — in the most fundamental sense — on the part of the medical community.  As long as the medical profession fails to demonstrate its own ability to improve results and lower costs and engage in patient-driven care, you can count on officials in Washington and in other jurisdictions to offer prescriptions that simply will not work.  The resulting resentment and anger on the part of the profession then feeds a negative vicious cycle.

Time’s a-wasting, folks.  Let me make this very personal, and perhaps uncomfortable to some of my readers.  As e-Patient Dave likes to say, “Patient is not a third person word.”  We will all be patients some day.  What kind of system do you want in place when you are in the lying in the bed rather standing next to it, or when a loved-one is there?  Chances are that it is not the system that you are helping to run right now.  You can rationalize your inaction and compartmentalize your thinking all you want, but a failure by you — if you are a medical or administrative professional — to demand and lead improvement is, in fact, a deadly decision.

Paul Levy is the former President and CEO of Beth Israel Deconess Medical Center in Boston. For the past five years he blogged about his experiences in an online journal, Running a Hospital. He now writes as an advocate for patient-centered care, eliminating preventable harm, transparency of clinical outcomes, and front-line driven process improvement at Not Running a Hospital.

33 replies »

  1. Why are we lied to? Example you can elect to change plans once each year without regard to health concerns. Well that may be true for Medicare subsidised plans but you cannot with medicare supplement plans.
    They set that up so politions could lie with a straight face.

  2. Hospitals are indeed highy inefficient. They expend more resources on JCAHO (noe “TJC”) compliance and risk management than on care. Ergo the inefficiency is not all their own faullt. Ours is not run by anyone who knows how to make a profit. All the low hanging fruit is gone.

    Nursing management in general is full of people who live the Peter Principle every day.

  3. Repeatedly Mr. Levy makes the case for process improvement in hospitals and nobody takes exception with it or mentions it in the comments. Is that because everybody agrees that hospitals are terribly inefficient places where operations and patient throughput must be improved? If so, why isn’t more attention being paid to this? Why aren’t more hospitals doing it well?

    It seems to me that widespread implementation of process improvement could save tens of billions per decade, make EHRs better, and support quality initiatives, yet everyone ignores it. Why?

    It seems to me if you are going to reform the delivery of health care, you start by overhauling hospitals. They consume the greatest single slice of the health care dollar so they should be as efficient as possible. The best part is we don’t need government to dictate what efficiency is. Hospitals can do it now and see an immediate return.

    Where are the other evangelicals on hospital efficiency?

  4. I agree with almost everything you said about physician compensation, and apparently I am misunderstood and did not express myself well.

    US physicians even at the lower end are well paid, and that is one of the reasons that there are still more applicants then med school spots (I think the current ratio is much lower if I recall correctly; I just looked briefly at numbers and it appears there are 43 K applicants – with multiple applications – for 18 K spots). The other countries with lower physician income have public financing of medical education – if you know of a country with high med school tuition AND low physician income, let me know.

    I know that private physicians in many countries, at least in Germany, Austria and GB are quite affluent. My opinion is that under current conditions in the US, physcian income around 150- 200 K seems reasonable to me, and some extremely trained and selective specialists maybe at 50-100% higher than that. What is killing us are the many, many “rainmakers” bringing their income north of 500 K with unneeded stenting, back sx etc.

    I second that US physicians tend to be, ON AVERAGE, more money centered than, ON AVERAGE, their European counterparts (I trained in Europe myself). The only way to fight this would be to dampen income, esp. peak income, while making medical school free or easily reimbursable (e.g. for service in underserved areas). But this change would take a generation of physicians. The fee schedule currently incentivizing needless procedures could – theoretically – be adjusted quickly.

  5. But still, you’re using the current bad behavior of private insurers to criticize the PPACA for provisions that it doesn’t include. I’m not a fan of everything in the bill, but I don’t find your argument logical.

  6. My mistake, I misread the writer of the above rebuttal question, sorry pcp. But, as a physician, I hope you have some idea what I am talking about with the intrusions in place with authorizations now. I know what to write to facilitate not only approvals, but get it done rather quickly to minimize delays in care. Unfortunately, thanks to the advice of a lawyer who had a family member deal with consequences from a delay.

    Medically necessary, let’s watch an insurer risk overruling that should a negative outcome result in an authorization being denied or significantly delayed. And do it per paper trail, phone calls cannot be documented!

  7. Now this is a question that asks something in a respectful manner.

    Whether or not it is in the legislation to create national formularies really is moot as we still do not know all the specifics of the bill, and you having read it does not guarantee the wording can be skewed later to create such an element. With the pending panel to oversee clinical matters, do you really think it absurd such a panel would come to a conclusion to limit medication access? And the fact there are already such formularies in the VA system, and states per their specific MA programs and correctional facilities, the ground work is in place to implement it nationally.

    I am curious, Mr G, have you ever needed a prescription your treating physician wrote to be told at the pharmacy you could not get until some faceless administrator, in an office you never set foot in, decided you could not receive until your doctor explained an alleged valid need to said faceless disrupter?

    Imagine it was for an antibiotic to treat a fairly aggressive bacterial infection. Could you wait 24 hours to have the approval completed?

    Would you want to risk finding out? Do you think a government bureaucrat really cares if you get the meds in time? Do you think your doctor appreciates being told his/her decision making is under scrutiny by someone who is not a peer equivalent to delay the care intervention?

    If you answer yes to any of the above questions, I wish you well in future care pursuits. But, thank you for asking a rebuttal with some respect and alleged interest in response.

  8. Big deal, working with physicians does not entitle you to be an abusive, antagonistic jerk to certain commenters who do not engage you first. I have no interest in your opinion and this is my last direct comment to you, sir, unless you have something to say that is insightful and respectful, not inciteful and disrespectful. I have an opinion and the right to voice my displeasure with the intent that is PPACA.

    If you are just being a devil’s advocate, go annoy someone else.

    And, your continued defense of what Pelosi basically said in just “pass the bill and we’ll get to the specifics later” makes you an accomplice by your repetitive retorts to my interpretation. I’ll be done here when there are no more posts that give the impression of defending PPACA or attacking physicians for issues undeserving of the scorn or abuse.

    Talk to your physician buddies about what I offer, I’ll bet some of them might actually agree with the basic premise of my distain of the legislation and attacks.

    That is, if you really do engage with doctors on some professional level.

    Have a nice life, sir!

  9. I thought you were done here.

    I read every draft of the legislation as it progressed through Congress, btw. Not a big fan of it.

    BTW, I work with physicians every day.

  10. “I think we need to decide what a solid benefits package is, calculate the costs at Medicare rates, including negotiated prices for goods, and figure out how much we need to collect in taxes to cover the costs for everybody”

    Your right Margalit, Medicare has worked out so great why not expand it to everyone! 40 trillion in uncollected taxes is nothing, I bet if we promise enough we could easily reach what ever number is after a trillion.

    How can you make a proposal like that with such a huge disconnect from present day reality. You know our entire healthcare crisis right now is the difference between tax revenue and the cost of the solid benefit package they promised to a quarter of the population. How does making more broken promises even begin to solve anything?

    “Let everybody compete on how much more they can give patients for the fixed dollar amount allotted.”

    Everyone but the government, their inefficient wasteful portion is guaranteed?

  11. “Contrary to Obama I think we need to cover everyone then worry about the quality of the coverage.”

    You mean we need to have everybody pay a premium to private insurers and figure out later what they receive in return?

    I think we need to decide what a solid benefits package is, calculate the costs at Medicare rates, including negotiated prices for goods, and figure out how much we need to collect in taxes to cover the costs for everybody, including current Medicaid beneficiaries, and quit this shell game.

    Patients will get less, doctors will get less, hospitals will get less, pharma will get a lot less and private insurers will get only what they can sell above and beyond that solid package.
    Let everybody compete on how much more they can give patients for the fixed dollar amount allotted. Obviously some systems/hospitals/doctors are better at this than others – this is the only Darwinism necessary, if we resist the temptation to build one colossus after the other.

    ACOs will not get us there, trowing patients in front of the tanks to fight providers will not get us there and feel good platitudes about magical care coordination will not get us there either.

  12. Can you show us where in the PPACA it mandates the creation of national formularies? I’m not sure how your displeasure with the private insurers requiring pre-auths is an argument against the bill.

  13. “And while aligning entitlement age to that of Social Security wouldn’t reduce total health care costs, it certainly would help cut the deficit.”

    It would shift the cost to the private market, mainly employer sponsored plans. Granted Liberals would love this as it would give them years of stories on how Mediccare controls cost better then private insurance but its counter productive.

    Medicare has a huge advantage with its ability to dictate reimbursement. The same individual covered primary under private insurance will cost more solely because of this reason. If the goal is to reduce the rate of uninsured drving up the cost of private insurance isn;t going to help. If we reversed the Medicare secondary payor laws and allowed private insurance to pay secondary, acting as the gap plan it would drastically lower their cost. That in turn would make it considerably more attractive to younger uninsured workers. Under PPACA those insureds will be costing the government money from their exchange subsidy.

    Overall providers would be the ones losing in this. They would see their compensation from older workers decline but possibly an increase from currently uninsured workers. The government and employers would probably wash out.

    Contrary to Obama I think we need to cover everyone then worry about the quality of the coverage.

  14. I’m as little persuaded of the wisdom of Emanuel and Liebman’s NYT comments as Paul Levy. ACOs have too much potential for morphing into monopolistic provider “fortresses”. Medical homes have yet to demonstrate real cost savings (the Group Health experiment’s estimate of savings fails to achieve statistical significance). Savings from bundled payments have to be considered more optimistic than real—at least in the hands of CMS.

    Unfortunately, I’m not seeing real solutions in Paul Levy’s post, either. Yes, it would be nice if some provider behavior changed, but where are the incentives? And will increasing payments for PCPs really reduce overall spending—or just make for more well-to-do docs?

    I keep going back to the 1999 bipartisan Medicare Commission’s draft recommendations, which actually proposed incentives for controlling costs. Switching to a premium support structure (but a less extreme version than that proposed by Paul Ryan earlier this year) would encourage beneficiaries to choose less costly coverage. Giving “traditional” Medicare the flexibility to contract selectively would cut costs and simultaneously put more competitive pressure on Medicare Advantage plans (which in 1999 didn’t receive the big federal subsidies of recent years). And while aligning entitlement age to that of Social Security wouldn’t reduce total health care costs, it certainly would help cut the deficit.

    It’s becoming clear that we can’t wait to find out if the expensive experiments built into the Affordable Care Act cut costs. Let’s try a little competitive Darwinism instead.

  15. With the economy the way it is and probably going to be worse? Your insensitivity and sheer arrogance to dismiss the concerns of physicians who see this legislation as an entrenched disruption to the practice of medicine reveals your interests. Plus the fact how many people could pay for consierge care even before the bottom dropped out in ’08, what is your next smug reply directed to the public who need advocates? What, they should turn to you?

    Hey, you and your buddy Nancy can read the bill now that it is law!

    Isn’t there another thread or commenter more interested in your opinions?

  16. M as H: this isn’t just about money, it is about telling doctors what will be the standards of care and there will be little if any negotiation to offer interventions that match with the patient’s individual needs/limitations. I don’t know about you, but I am beyond sick and tired of authorization forms to allow patients to get prescriptions I have written that meet the standard of care I was trained to provide. This will increase logarithmically apart, from the development of national formularies that will basically make generic drugs the only options unless the patient has been hospitalized repeatedly after failing this cost focused agenda. That is, if the patient survives this politically and financially driven care agenda.

    You want to see the future of what the public will be subjected to if PPACA stays in place? Go to your nearest correctional facility and ask to see their formulary for medication access for more common illnesses, then compare it to your usual practice style. It will be frightening, especially when you find out what needs to be done to access more updated treatment options.

    You think the earthquake on the east coast got attention of the public yesterday? It will take a figurative equivalent of increases in morbidity and mortality outcomes to get the public to notice the consequences.

  17. your seriously underestimating our government. After they drive all the other jobs overseas or out of existance your only choice is going to be Medical Care, food service, or work for the government. All of a sudden being a PCP for $60,000 a year doesn’t look so bad does it.

  18. My PAs make 100-120K per year plus benefits. No one is going to medical school to earn less than 250k per year. And please remember we are talking about seriously devalued dollars. In a few more years we will need docs to get 500k per year just to stay even.

    The number of doctors was limited by the federal gov’t limit on residency slots by the Graduate Medical Education Commission circa 1980. Just like supporting Iraq in the 1980’s and fighting them in the 2000’s, now you want the feds to create more docs when they worked hard to restrict them.

    Too late. Anyone dumb enough to go into primary care today as a doc is crazy.

  19. With all these talks about ACO why have I not seen a single article discussing the HMO Act of 1973, the last time reformers swore FFS was the porblem and bundeled payments would solve everything.

    “Elected officials hate being blamed for directly restricting access to medical treatments — even when those treatments are proven to be worthless.”

    Those behind the HMO Act of 1973 clearly stated their goal was to create a federally controlled buffer zone between then and the public. They could fund the Federally Regualted HMOs at a level they see fit and leave it to the HMOs to ration care and take the blame.

    How many times are we going to allow cowardly politicians to play these games?

  20. Rbaer, I disagree. There are many, many more people who want to go to medical school than there are slots available for them. This choke point is actually one of the problems in our system that leads to higher costs, because it restricts the supply of physicians artificially. If you look at other nations that have much lower physician incomes than ours, they actually have more physicians per capita.

    When I talk about lowering physician incomes, I absolutely agree with Paul Levy that one way or another we need to recalibrate payments so that specialists do not get paid twice as much as primary care. I would not lower primary care incomes at all if I had a magic wand, but only specialist income, and I would lower that by maybe 30% on average, depending on specialty. That would be more consistent with the relative value provided and encourage more people to go into primary care than the specialties.

    Remember, the reason we have a crazy ratio like 10:1 of med school students going into the specialties is because of the relative pay ratio. In absolute terms, primary care still pays very, very well. If you don’t see that, you have been living in a bubble and looking only at the top 1% of earners, not the median income.

    I agree our medical education system should be reformed to reduce or eliminate debt. This would have benefits not only for the physicians themselves, but also reduce their sense of financial entitlement and the money-focused mentality that has been taking over the system, due in part to the need to earn their way out of their debt hole when they first get out of residency.

    If I recall, right now there are something like 20 to 100 applications for every spot in average to good medical schools. We consider a college selective if it has four applicants for every spot.

  21. I strongly believe that spending can be drastically reduced with minimal impact on the healthcare system.
    We wish to thing that above all this is a logistics problem but sadly it is all about maximizing profits and a fundamental rejection of any kind of change.

  22. ” As long as the medical profession fails to demonstrate its own ability to improve results and lower costs and engage in patient-driven care, you can count on officials in Washington and in other jurisdictions to offer prescriptions that simply will not work. The resulting resentment and anger on the part of the profession then feeds a negative vicious cycle.”

    That seems nonsensical to me. Physician decisions are individual decisions based on medical, logistical, financial, medicolegal and patient satisfaction/expectation considerations. Change these parameters, and you can make these decisions more cost effective.

    @Jonathan “No one is forcing physicians to make $150,000 to $400,000 a year.” By talking about financial incentives, you will hardly find enough qualified people making the effort to go through/finance medical school and work for less then what you indicate. If you would write “No one is forcing physicians to make 500,000 a year instead of 200K”, I would find your position more realistic …. but in the ends, financial incentives (in this case by FFS) matter. It’s like saying: we don’t need environmental protection or gas taxes, no one is forcing people to drive SUVs”. Simply demanding desired behavior usualli is not enough.

  23. The only mention of fee-for-service in the NYT article makes no sense to me. Supposedly under FFS doctors and hospitals have to spend money on improvements to care and receive less money when care is improved. How is this not true under a capitated system?
    Money has to be spend to redesign the care process and the goal of this redesign is to lower costs. Lower costs means lower revenue for doctors and hospitals. There is no way around this.

    And how is capitation supposed to allow more time with patients? Wouldn’t the incentive now be to have as many capitated patients as possible? The only difference would be that there will be an incentive to see them less often.

    This entire FFS witch-hunt is largely based on faith. Faith that physicians should be salaried employees of large health systems. It’s hard to argue with religion.

  24. What is this “allowed” that Paul and Patrick are talking about? Physicians are allowed to spend more than 15-18 minutes with their patients. In fact, many good ones do right now, with the current payment rates.

    No one is forcing physicians to make $150,000 to $400,000 a year. They could “allow” themselves to spend more time with patients and make a bit less. Of course, they won’t until economic forces require it.

  25. I thought you were done here.

    “whatever autonomy and independence remains between patient and physician.”

    Go cash-only concierge. You have that freedom.

  26. As I have said repeatedly at this site and other places involving this debate about the place of PPACA, everyone has played a role in the decay of health care and access by all to it, but it is just lame and pathetic how so many point the finger of sole blame at physicians.

    There is coming a time when the majority of doctors are going to call you all on this crusade to try to crucify the profession, and you as the needing public who will, in the end, need us to keep your pathetic and useless lives while still campaigning to end ours will deely regret our decision to walk out when this need is the most.

    It is equally a shame and pathetic doctors can’t see the writing on the wall this ugly and ill meaning legislation will do to medicine if it fulfills it’s destiny. Hospitals, the AMA, hell, even the AARP are as a collective mirroring that of Neville Chamberlain and what he did to his country of England in World War II.

    And all these organizations deserve each other as the politicians they foolishly supported screw them now as the legislation is being exposed for what it is.

    Face it, I know I am right that a driving force to the ultimate intrusion into the health care arrangement is to end whatever autonomy and independence remains between patient and physician. I just hope I get to see some of the loudest proponents of this garbage get screwed by it before they die, should PPACA survive the judicial challenge that hopefully occurs by early 2012.

    History does repeat itself. I just hope to not be close by when the proverbial bombs start falling on the morons who champion this false cause of hope!

  27. “Giving a primary care doctor the ability to spend more than 18 minutes with a patient could change the nature of those doctors from having a triage function to allowing proper management of care.”

    I agree that we could lower costs by allowing primary care physicians more time with each patient, particularly those with more complex problems. However, we also need to change how we deal with malpractice litigation, otherwise primary care physicians will continue to defensively refer cases to specialists, and defensively order tests, that are otherwise unnecessary.