So, ridiculed, the AAFP has backed down, and No Free Lunch is now in the AAFP meeting.
So there’s a bunch of rabble-rouser docs who are actually trying to enforce the often mouthed concept that doctors shouldn’t take freebies from pharma companies. They’re called No Free Lunch
And of course, given the actual views of mainstream doctors who believe that life was better when the pharma companies had no restrictions on the graft they could send their way, they are being banned by specialty societies from doing things like handing out the specialty societies own guidelines on gift-receiving to its members, and of course from buying a booth at the oh-so-well incorruptible AAFP’s convention. Jim Edwards at Brandweek has more. But let’s not be too surprised.
So here’s another podcast recorded at the tail end of last week with me chatting with surgeon, talk radio host and "free-market" advocating surgeon Eric Novack. This one focuses on why health care costs so much and why we can’t stop physicians behaving badly. We discuss evidence-based medicine, managed care, capitation, end of life care, practice variation, and defensive medicine — and it’s still incredibly civilized. Don’t worry — we’ll keep having these talks until we really start laying into each other!
Here’s the MP3 to download (this one’s a little over 30 minutes listening time). Enjoy and please tell me what you think
Once again there’s something very important in a WSJ/Harris poll which concentrates on the people that, when I was at Harris, were called the "Trade up players". These are the people with enough discretionary income to buy themselves a better class of service from their providers. As I know many of you don’t have WSJ access, I’ve quoted most all of the results.
"Do you have health insurance? It could be from an employer, that you purchase yourself or from a government program like Medicare or Medicaid?"
Base: All Adults
* * *
"Which one of these statements best describes you?"
Base: Adults with health insurance
* * *
"Whether or not you have done so in the past, how willing would you be to go to a doctor who doesn’t take your health insurance if he or she was highly recommended by a source that you trust?"
"How willing would you be to pay the full cost of a doctor’s visit – rather than use your health insurance – if you . . .?"
The important issue is that pretty uniformly, those with incomes over 50K, which is a little over average household income and around US median income, are willing to spend more money to get a better class of service. Obviously this means a couple of things
a) If you are marketing a health care service to wealthier Americans there is a willingness to pay for it. Of course that’s a well known fact to chiropractors, orthodontists, and cosmetic surgeons. But it might mean that other physicians and providers might start to think about providing better access and customer service, for a small fee (and I don’t mean insisting on $20,000 for concierge service). This is the Nordstroms approach, and one that health care providers should be thinking about emulating (and one that some are).
b) This willingness to pay is a minority effect — it’s a big minority and may be a majority in the case of referrals from someone the patient trusts. But for most of these services more people are unwilling to pay extra, and of course large majorities of those with lower incomes, even those with health insurance, do not want to pay extra.
This tells me that continued bifurcation is likely to be the case when people seek health services that they have to pay out of pocket for, with roughly double the number who want to "trade up" skimping on "extras". Why does this matter? Because in our brave new consumer world, cash may be an increasingly important way that patients pay for health care, especially for "minor" care out of their HSAs. So this correlates with much other data about user fees at the point of care–they tend to prevent lower income people from getting care (including often needed care).
Like it or not, we are slowly heading towards this future. Unless, that is, you live in Rochester New York.
Meanwhile, (and this is a bit of a throwaway for Ron) the Kaiser Network Health Policy Report notes that the CBO is out with a study showing that "Uninsured workers are unlikely to purchase individual health insurance, regardless of whether they receive tax credits or other subsidies to help cover the cost of premiums, according to a report released on Friday by the Congressional Budget Office". Proving to my mind once again that high deductible health plans are not going to solve the uninsurance problem and that voluntary universal health care is a myth.
This one I find hilarious and gives me great deal of personal satisfaction. The pro-American health care system, "it’s the finest on earth crowd" goes on and on about how terrible the Canadian system is and how all the doctors are leaving. In fact it was that sentiment especially from the wonderful, but confused, Sydney Smith over at Medpundit that inspired my "Oh Canada" tome. (Actually I re-read "Oh Canada" the other day and it’s a pretty damn good piece of analysis if I say so myself).
Syd was basically saying that all the doctors were leaving cos they hated the clinical restrictions of the single payer system and wanted to move to the glorious homeland of free-choice medical practice and CABGs for 97 year olds. I showed pretty conclusively using actual real life data that a) very few doctors were leaving Canada for the US, and that b) if they were leaving it wasn’t that surprising as they get paid about twice as much by sneaking below the 49th parallel.
Well now we have more actual statistics and real data that shows that more Canadian doctors are heading back to Canada than are leaving — and this was in 2004 when hockey was on strike so there was no real reason to go to Canada! The numbers are:
Canada has seen more doctors returning than leaving for the first time in 30 years, a report by the Canadian Institute for Health Information (CIHI) shows. The report, released Wednesday, says that between 2000 and 2004,the number of physicians leaving Canada declined by 38 percent. In 2004, 317 physicians returned to Canada and 262 left. That was a drop from 2000, when 420 doctors left the country and a significant decrease from the peak of 771 physicians who moved abroad in 1994.
I’m looking forward to the barrage of articles from the know-it all alleged "free-market" crowd who get spoon-fed rubbish by Frasier, PRI, Manhattan et al offering their apologies to the Canadians and admitting that their system is better than the one down here. After all the alleged rush of Canadian doctors to the US was absolute proof in their mind that the reverse was true.
I’m waiting, I’m waiting….
This week things are starting to get a little serious regarding physicians’ Medicare reimbursement. The AMA is gearing up for a fight, trying to avoid a scheduled 4.3% cut in Medicare reimbursement. Meanwhile a survey of California doctors suggested that they would stop taking new patients at the lowered rates. Much of this is just bargaining rhetoric, but CMS is determined to start Medicare down the pay-for-performance road, and has already begun to initiate this process by paying hospitals for reporting quality measures (even though it’s less than 0.5% of their Medicare revenue).
Meanwhile Republican house rep Nancy Johnson is pushing a pay-for-performance bill which would change how physicians get paid. Anytime you put doctors, money, and quality and performance requirements in a sentence together, be prepared for at the least a vigorous debate. Medicare is still the big Kahuna, and where it goes other payers will follow — if they’re not moving there already.
Eric Novack is an orthopedic surgeon who went to medical school in liberal San Francisco, but is now practicing in the red state of Arizona. Eric has been sparring with me and others in the comments on THCB, and also has his own weekly radio show. It’s on a station called "960 The Patriot" — and you can guess that it’s line up is a little different than San Francisco’s 960 The Quake, which is our local Air America affiliate. Eric’s weekly show is very well done, and I recommend that you head over there to take a listen to his archived shows. Some of you might perceive a bias in his guest line-up, and Eric has strong opinions on policy, many of which I do not share. But I’m very hopeful that by encouraging Eric to write for the blog, (and we are also planning some podcast conversations in the near future), we can get to some of the heart of the issues about which we disagree. For his first post, Eric starts simply, with an idea to get physicians to provide more uncompensated care.
Congress passed a law in 1986 called Emergency Medical Treatment and Active Labor Act" or EMTALA. EMTALA has a variety of provisions but can be simply stated that persons who come to emergency departments cannot be turned away because of an inability to pay. This applies to the hospital emergency department (ED), the emergency room physicians, and the specialists and internal medicine doctors "on-call" for the emergency department. "Emergency" for the purposes of the emergency room is anyone who comes to the hospital– the hospital cannot say– "it is just a cold, so we will not treat you". If someone breaks a leg and an orthopedic surgeon is on call to cover the ED, the surgeon must take care of the problem and the patient including the operation and all appropriate follow-up care.
One of the many problems is that all of this uncompensated care falls back on the doctors– remember that many hospitals are non-profit or have received federal funds that require them to provide a certain amount of uncompensated care.
Let me give an example, (any similarity to any real patient of mine is coincidental…). I am on call for "Arizona Hospital". Bill Jones is brought to the hospital after a fall from his ladder at home, where he was taking down his Christmas lights (it is never too late, is it?). I am called by the ED because Mr. Jones has broken his femur (thigh bone). I see the patient in the ED, he is admitted, and I operate on him at midnight. I finish surgery, the paperwork, and head home around 2:30 AM. I then see Mr. J for the next 3 days after clinic. After discharge, Mr. J comes to the clinic regularly over the next several months for checks and x-rays and advice and guidance. Total charges for all the work, time, expertise, and liability risk is $5000.
Mr. Jones has his own landscaping business. He has no insurance. He never pays a bill. I cannot abandon his care– it is unethical and against the law (abandonment). I get tired of this happening and stop taking call at the hospital. Losers in this scenario–the physician, the hospital (less coverage), and future patients–insured or not- who would benefit from my expertise.
Here is a partial solution– but first, a brief preamble. Health care system transformation will need to be incremental, not revolutionary– otherwise, the kind of horse-trading and compromises that resulted in the bloated, inefficient, restrictive system of Medicare result.
Here’s the partial solution. Guess what happens at the end of the year when I file my taxes? Can I deduct the $5000 in bad debt as a "business loss"? No. By simply allowing physicians to credit bad medical debt from their income (like other businesses can with losses related to products, etc.), physicians would be have a huge incentive to provide a certain amount of care to the poor. It needs to be a credit and not a deduction as a deduction would return only 35 cents on the dollar at best. So, there it is– tax relief to the providers of care for the amount of "free care" provided.
No new bureaucracy. Incentives, not punishment
For some more info on EMTALA see this lawyer’s site.
And in just one tiny example of physician entrepreneurship, the LA Times reports on a new bill to close a loophole in California Workers’ Comp law. The Workers Comp problem is one of those perennial problems here in California, where we have too many doctors and too many lawyers, and they are able to hone their skills in separating the insurers from their money. It was "fixed" by Pete Wilson in the early 1990s, and then "fixed" again last year by Arnie. The latest round seems to have done some good, but one little loophole has been exploited allegedly to the tune of $250m.
The loophole is that pharmacy prices for drugs were capped in the law, but prices for those drugs dispensed directly by doctors were not. Well you know what’s coming next. Physicians were enticed by some wholesalers to start prescribing and dispensing drugs, and their mark-ups are a factor of three to ten what the pharmacies can charge. And it’s all paid for by the insurers. Here are some pricing examples from a Rand study quoted in the LA Times.
Pharmacy price vs. Doctor’s office priceSoma $44.68 vs $396.98Prozac $14.81 vs $131.82Darvocet $12.65 vs $58.31Acetaminophen/Hydrocodone $12.81 vs $58.31
Even the unions are opposed to this, as they correctly see this type of lilly-gilding as being the kind of thing that might lead to another round of attacks on employee benefits. The employers are of course siding with them.
But it does just show you that in American health care, if there’s a way to bill an extra buck or two, physicians are as quick as anyone else to figure out how. I don’t need to tell you the California Medical Association’s position on the bill…..
Why is there a nursing shortage in south Florida? Apparently it’s because the doctors are very badly behaved, sometimes.
The South Florida Hospital and Healthcare Association, seeking to recruit more nurses from other areas, organized focus groups of nurses who had moved here in the past two years and asked them what they didn’t like about South Florida. ”The No. 1 issue was physician abuse,” says Linda Quick, president of the group. ”Sometimes it was omission — the doctors didn’t engage them in the treatment process. But they also indicated there was hollering, yelling, sarcasm. They indicated it was a particular problem here,” compared to other places they had worked.
As ever Florida is just a strange place. We know their practice patterns are out of whack, we know that health care fraud and corruption is a greater problem there than elsewhere, and we know they can’t arrange elections …and left us with the hopeless bunch of clowns running the show now in charge.
I still think they should tow the whole state into the Caribbean and leave it there.
Neil Love, M.D. reports from a survey of breast cancer oncologists based in
academic medical centers and community based, private practice oncologists. The
academic center-based oncologists do not derive personal profit from the
administration of infusion chemotherapy, while the community-based oncologists do
derive personal profit from infusion chemotherapy, while deriving no profit from
prescribing oral-dosed chemotherapy.
The results of the survey show that for first line chemotherapy of metastatic
breast cancer, 84-88% of the academic center-based oncologists prescribed an
oral dose drug (capecitabine), while only 13% prescribed infusion drugs, and
none of them prescribed the expensive, highly remunerative drug docetaxel.
In contrast, among the community-based oncologists, only 18% prescribed the
oral dose drug (capecitabine), while 75% prescribed infusion drugs, and 29%
prescribed the expensive, highly remunerative drug docetaxel. The existence of
this profit motive in drug selection has been one of the major factors working
against the individualization of cancer chemotherapy based on testing the cancer
This is not to imply that the academic center-based oncologists are without
their fair share of collective guilt. They were misguided in not recognizing
that they were trying to mate notoriously heterogeneous diseases into
one-size-fits-all treatments. They devoted 100% of their clinical trials
resources into trying to identify the best treatment for the average patient, in
the face of evidence that this approach was non-productive. However, such
unsuccessful experiments will never be viewed as such by the thousands of people
whose careers are supported by these experiments.
Henderson, et al, entered 3,100 breast cancer patients in a prospective,
randomized study to compare cyclophosphamide/doxorubicin alone versus
cyclophosphamide/doxorubicin plus Taxol (in the adjuvant, pre-metastatic
setting). The results were microscopically positive, at best, and cannot begin
to justify the enormous financial and human resources expended (while making no
effort at all to test and improve methods to individualize treatment).
But these results changed the face of the adjuvant chemotherapy of breast
Cyclophosphamide+Doxorubicin+Taxol became standard of care. Taxol recently
went off patent. Now the thrust is to identify on-patent therapy which is
microscopically better in clinical trials of one-size-fits-all treatment.
Already, the community-based oncologists are migrating to
Cyclophosphamide+Doxorubicin+Docetaxel (expensive/remunerative) so what was the
purpose of doing that 3,100 patient prospective, randomized Henderson study?