This is far too sensible — Universal health coverage as used in France, Belgium can work here. Damn those moderates at the New America Foundation. Perhaps they can merge with the Project for the New American Century instead.

By THOMAS R.LEITH

I am not quite sure what to make of this. In this past Sunday’s (18-Jun-2006) edition of the St. Louis (my fair city) Post Dispatch on Page 1, above the fold, was a story headlined  Is your doctor paid to keep you healthy? Probably Not.

Typically, physicians get paid only when their patients receive care, and more complex care often brings bigger paychecks. At the same time, doctors complain that paltry payments for office visits force them to rush through checkups instead of educating patients about their illnesses, medications and healthy living – all of which might lower future medical bills.

It’s a system that gives doctors little financial incentive to keep patients well. And, experts say, it might be contributing to dangerous, unnecessary care as well as high medical bills.

So, the writer (Mary Jo Feldstein) has got the problem identified. Good. The rest of the story is about three things:

1. Medicare Advantage (“like” an HMO)
2. Disease Management & Care Coordination
3. Essence, a Medicare Advantage plan owned by a big medical group here in St. Louis

The article speaks glowingly about “better quality at a lower cost”, acknowledges in passing that Medicare Advantage beneficiaries all go to doctors chosen by the plan, but then (get this) does not dwell on the restriction of “choice”. This is uncharacteristic of this newspaper. Wow. Oh, and Maggie Mahar’s book gets yet another plug in the article. I thought she’d like to know that.Then on the front page of today’s (22-Jun-2006) WSJ, above the fold is a story (sub req’d) about how the New York State Medicaid department has discovered Disease Management. In a deal struck between the state and Mount Sinai Hospital, their outpatient clinics were designated “Diagnostic and Treatment Centers” which brought higher Medicaid reimbursements. In return Mount Sinai runs a DM program around CHF, and the state’s total Medicaid payments to Mount Sinai Hospital have fallen. But this is evidently OK with the hospital: they have been running at 95% capacity, and would much rather have a bed filled by (say) a commercially-insured ortho patient than by a Medicaid CHF patient. Evidently things are working as expected. The government of New York State has begun to pay docs to keep patients — OK, they’re not healthy. Healthier. Or at least out of the hospital and more functional.So? With attitudes towards the loss of “choice” changing evidently among patients and (significantly) the press, and with a new apparent willingness to pay doctors and allied pros to think and talk to and teach patients, maybe — just maybe the stage is being set for a resurgence of `70s idealistic Managed Care Organizations. Toss in a handful of transparency, shake it up a bit, let it marinate a few years and it could be we have an environment where the Enthoven Plan doesn’t look so revolutionary. Or scary.

Today is Torture day 2006. That’s not an invitation for people to do more of it despite what our current Adminstration thinks. instead it’s UN International Day in Support of Victims of Torture. I’ve supported a London Charity called The Medical Foundation for the Care of Victims of Torture for years, and I invite you to check out their web site. Whatever your political views this is an organization that but for the accident of birth we might all need.

My buddy Laura Locke has a nice article in Time about San Francisco’s Latest Innovation: Universal Health Care. This one’s closer to the George Bush agenda than gay marriage—and I’m pretty sure that we’ll all have accepted gay marriage long before we’ve got to genuine universal health insurance. Essentially it’s about redirecting funds from the City and County back to the city and county health facilities, and making the uninsured pay into a pool. Not a bad start given that a City can’t do much, but it’ll run into trouble, just as I explained a while back when the proposal first came out because it’ll mean small low-wage businesses will have to pay more.

Here’s my follow up to Maggie’s interesting piece and it’s the editorial in FierceHealthcare later today

The non-profit hospital world has been in the news lately, and this week a study of all the studies ever done on the non-profit/for-profit contrast came out in Health Affairs. The story is pretty well known and the study confirmed that non-profit hospitals offer a little more charity care, and have slightly lower costs than for-profits. But then again, there are three factors that make those results a little less than great. First is that location matters and the non-profit category includes a great number of hospitals that are in unfavorable locations, like inner city areas and poor rural counties. Second, the behavior of their for-profit competitors over the years has tended to center on the border between scandalous and criminal. And far too many non-profits have been imitating that behavior, such as New Jersey’s St. Barnabas, which settled with the government for as much as it could afford for apparently over-charging Medicare by over $500m. Third, for-profits have stayed at around 15% of hospital beds for decades and aren’t expanding their market share much. So the main issue is how do hospitals overall behave.

The truth is that whatever the label put on an organization, in an environment where doing more and charging more brings more profit/margin, there will always be institutions and people within them that will fall temptation to taking the easy (and fraudulent) way to more money. Proponents of self-reform may point to the improvements in quality brought about with no financial incentives which were reported by IHI last week, but until we create incentives for organizations to do well by doing the right thing, the label will be largely irrelevant.

By MAGGIE MAHAR

Monday, The New York Times reported that the IRS, Congress and state officials have begun taking a close look at nonprofit hospitals, all asking one charged question: Do they really deserve their tax-exempt status?

Some 16% of U.S. hospitals are for-profit—and they pay taxes. Nonprofits, by contrast, have traditionally been tax-exempt.  But now investigators are asking: “Are they really that different from the
for-profits?  Do they provide enough charity care and community service to justify the break?

The short answer is this: To understand the economics of the hospital industry,  you first need to understand that it is in many ways very much like the real estate industry: what matters most is “Location, Location, Location.”

A hospital located in an affluent area will draw well-insured patients. By definition, then, it will provide less charity care because it well see fewer uninsured patients.

This is why for-profit hospitals tend to provide less charitable care: If you’re a corporation you don’t a build a for-profit hospital in a market where you expect that half of your customers won’t be able to pay.  For-profits don’t close their doors to the poor, but they purposefully try to locate areas where they won’t see as many of them.  As well they should: a for-profit corporation’s first obligation is to generate profits for its shareholders.

Non-profit hospitals, on the other hand, began as charitable institutions—often with a religious affiliation—and to this day, many are located in inner cities or poor rural areas where they serve a large uninsured or underinsured population. Traditionally, nonprofit hospitals have operated with a sense of “mission”—to serve the health needs of their community. This is argument  giving them a break on their taxes.

Yet, it’s  worth noting that all nonprofit hospitals are exempt from corporate income taxes as well as state and local property taxes—wherever they are located. Perversely, that exemption is most valuable to those located in the most affluent areas because their income is higher and their property is worth more. As David A. Hyman and William M. Sage point out in the current issue of Health Affairs:

“All else being equal, a hospital that provides little charity care and is located in a “desirable” location (in terms of property values) will receive a much greater financial benefit when its income and property go untaxed than a hospital that provides lots of charity care and is located in an “undesirable” location. Thus, in important respects, current subsidies are ‘upside down’ in the sense that they are worth the most to institutions that are likely to” [provide the least charity care. ]

This brings us directly to the question Congress and the IRS are posing: should nonprofit hospitals be exempt from taxes based simply on their status as nonprofits, or should tax-exempt status be dependent on what they actually do to serve their community?

Here, it’s important to remember that caring for the poor is not the only way that a hospital can contribute to its community. Under the law, a nonprofit can  receive a federal tax exemption, if it is organized and operated exclusively to promote one of the specific purposes set forth in section 501(c)(3) of the Internal Revenue Code—which includes charitable, religions, educational and scientific ends.

Thus an academic medical center which  loses money educating  medical students while also investing in the expensive technologies that it needs to do important scientific research might well be able to justify its tax exempt status even if it treated only a small number of indigent patients. Some hospitals also provide educational  services in their communities—running support groups for diabetic patients for instance, teaching them how to monitor their disease.

How a nonprofit uses any money left over after covering the costs of operation is also important.

A for-profit might distribute those earnings to its shareholders, or invest in something that would generate greater profits going forward: valet parking, for example, might attract more well-insured patients. But to qualify as a non-profit, Hyman and Sage note, a hospital must:
“retain its net earnings and use them to promote the purposes for which the nonprofit was created. “ In other words, a non-profit must plough any surplus back into its “mission.”

Yet in today’s fiercely competitive market, non-profit hospitals sometimes spend their capital in ways that seem to have little to do with mission—and much to do with struggling to take market share away from neighboring hospitals.

In Money-Driven Medicine: The Real Reason Healthcare Costs So Much ( Harper/Collins, May 2006).  I quote the director of a Phoenix-based health foundation describing how resources are allocated in his hometown as local hospitals chase affluent newcomers moving into the city’s “Valley of the
Sun”:

   
“By expanding and modernizing, acute care hospitals are looking to compete with a recent surge in physician-owned hospitals and specialty surgical centers,” he explains. Acute care hospitals fear that these specialty centers will “skim” lucrative business like heart surgery, leaving the general hospitals with the least profitable businesses—burn units, for example, level 3 trauma units or ERS.
   

Fighting to offset potential losses, the nonprofit acute care hospitals are rushing to add beds in the Sun Valley area where a new young, well-educated and well-insured work force is moving in. The foundation director describes a new facility: “It’s like a luxury hotel.”

Every hospital feels that it  must stake their claim in this newly affluent area, he adds, and “the land-rush mentality doesn’t always take into account planning for the community’s needs . . .  When it comes to breaking down the health needs of the population by age and chronic disease in order to try to decide what mix of ambulatory, inpatient and home health care will be required . . . This,” he observes, “Is not the game that hospital executives are in.”

Meanwhile nationwide, nonprofits like those in Phoenix may be overbuilding—or at least investing their capital in the wrong areas. As they view for well-heeled customers, they may be putting too much emphasis on cosmetics and bleeding-edge unproven technologies, while investing too little in less visible areas like palliative care, or the information technology that could reduce hospital errors.  

In many regions, nonprofit suburban hospitals are trying to take high-margin business away from big city hospitals. “What we have to do to maintain our position in the market is to keep adding services,” a Westchester hospital CEO explained to New York Magazine a couple of years ago. “That’s the whole reason we’re doing liver transplants.”

“Liver transplants”??

Do the residents of Westchester County need a local hospital doing liver transplants? Just how many would the hospital do? Would patients be better off at a high-volume medical center in Manhattan, where the carpeting might not be as nice, but, research shows, “practice makes perfect”?

These questions didn’t seem to come up. Transplants would raise the nonprofit hospital’s image.
 
And when it comes to enhancing a brand name, sometimes nonprofits seem littler different from for-profits. In Money-Driven Medicine, I quote from a 2005 study in the Archives of Internal Medicine which describes how even academic medical centers trawl for customers with ads like “We Do Botox!” or “FDA Approves Deep Brain Stimulation Therapy for Parkinson’s Disease”
The study pointed out that many of the ads (38%) risked “raising false hopes” by thumping the tub for unproven procedures like “deep brain stimulation for Parkinson’s,” while another 28% were advertising cosmetic procedures. Such ad spending has little to with improving the health of the community, much to do with growing market share.

Yet, with the number of uninsured patients and unpaid bills rising, many nonprofit hospitals find themselves caught between a rock and a hard place. If they can’t bring in the patients willing to pay for private rooms with Jacuzzis in the maternity ward–patients who will be impressed by a waterfall in the lobby and chutney for dinner–they won’t have the money they need to keep the trauma unit open–and serve the larger community. “No [profit] Margin, No Mission” is a favorite saying among hospital CEOs.

Moreover, today’s hospitals are increasingly dependent on the bond market to raise capital. At one time, both government and philanthropists contributed a much larger share of the money hospitals needed to survive, but today, hospitals rely on borrowing by issuing bonds. And, quite understandably, a bondholder’s primary concern is not whether or not the hospital is serving its community, but whether or not he will receive the expected return on his investment. Thus, when bond rating agencies like Standard and Poor’s rate hospital bonds, they can’t give points for charitable care.      

Nevertheless, if we are going to give nonprofits enormous tax exemptions, somebody needs to be keeping an eye on how they are spending their capital.

Two years after the Westchester CEO bragged about his new “product line” (liver transplants) The New York Times reported that a state audit of the very same Westchester hospital showed  “mismanagement, sloppy accounting practices and wasteful spending” which “contributed to staggering financial losses.”  The audit also showed that former executives at the hospital were spending lavishly on things like restaurants, hotels and florists—with scant controls or documentation” even while  “the medical center’s finances were deteriorating.”But while some hospitals should lose their tax breaks, we don’t want to throw out the baby with the bath water by doing away with tax exemptions for all  non-profits.  They are different from for-profits-in ways that are essential to our health care system.   

In the most recent issue of Health Affairs Bradford Gray and Mark Schlesinger very carefully analyze some 162 studies comparing the real-world performance of nonprofit and for-profit hospitals, nursing homes and health plans on a  range of issues and discover that, while they may not be as different as one might expect, the fact is that, on average:

“for-profit organizations more aggressively mark up prices over costs and otherwise maximize revenue. This pattern has been documented among community general hospitals, nursing homes, psychiatric hospitals, drug treatment centers, rehabilitation facilities, and health plans.

“Second, nonprofit organizations appear more trustworthy in delivering services, being less likely to make misleading claims, to have complaints lodged against them by patients, and to treat vulnerable patients differently from other clientele.

“Third, nonprofits are typically the incubators of innovation, using philanthropy and cross-subsidies to finance the development of services for which there is not yet a market.

Moreover, while only about one-quarter of non-profit hospitals provide enough uncompensated care to the poor and uninsured to equal  their  tax benefits, “one  study found that the nonprofit hospitals that were the least involved in free or subsidized treatment were the most engaged in other forms of community” service.

The bottom line is that auditing nonprofits is a good idea, though federal investigators should turn to community experts to find out just how much service a nonprofit offers. Local GPs who work in low-cost clinics, for instance, will know how easy or difficult it is for a Medicaid or uninsured patient to get an appointment with a specialist at a hospital clinic.(And will that patient be seen by residents or a combination of teaching faculty and medical students?) Local educators will know which hospitals are making a contribution to health education in the schools.

Because the hospital industry is all about location, these audits must be done on a local basis, with the community weighing in on decisions. The many ways in which a hospital serves its community are not easy to quantify, and they vary, depending on the needs of the community.

At the same time, it is good for non-profit hospitals to know that they are accountable–and that if they forget their mission, they can (and should) lose that tax exemption.

Consumer-driven medicine is seen, by many, as the answer to our health care crisis.
Put the consumer in the driver’s seat, we are told, and patients will drive down costs by insisting on the very best value for their dollars.

The movement goes hand-in-hand with health savings accounts and high-deductible plans: Force the patient to spend his own money, and he will be motivated to comparison-shop.

“When consumers pay directly, innovators respond to their needs—that’s how a market works,” declares Regina  E. Herzlinger, a leading consumer advocate, in Market-Driven Healthcare.  (Writing in 1997, Herzlinger somewhat optimistically held out the American automobile industry as a prime example of an innovative industry that has responded to consumers’ needs. )

What Herzlinger ignores is the “uncertainty” that is intrinsic to health care. In my recent book, Money-Driven Medicine: The Real Reason Health Care Costs So Much I quote Dr. Atul Gawande, who rightly identifies “uncertainty” as the “core predicament” of medicine– “the thing that makes being a patient so wrenching, so difficult, and being part of a society that pays the bills so vexing.”  (Complications: A Surgeon’s Notes On an Imperfect Science).

Consider, for example, a patient who is diagnosed with stage 1 prostate cancer. Chances are his physician will tell him that there are three possible treatments:

  a)”We could just keep an eye on it,” the doctor might say.. “Since you’re 67, and this is a cancer that grows very slowly, it’s quite likely that it will never catch up with you. “We’ll just have you come in every six months so that we can monitor its progress, but hopefully, we’ll never have to do anything.. This course of treatment is called “watchful waiting.”

b) “Alternatively, we could try radiation treatment. This will have side effects that you won’t like. About one half of patients become impotent within 2 years. Some suffer side effects like rectal bleeding. And there is a possibility that the tumor will come back.”

c) “Surgery. This is the most certain remedy. If all of the cancer is removed during surgery (and if course this is always an “if”) —you are probably cured.  But of course you face the risks of surgery—you could lose a lot of blood during surgery. And afterward, you could be impotent or incontinent—or both. Most people don’t suffer severe incontinence, but about a 1/3 while find that they leak urine when they cough or laugh. . . “

Then, if your doctor is very honest, he will tell you—“We can’t be sure, but I think that in your case, ‘a,’ or ‘b’, or ‘c’ is the best course of action.” (Though these days, a doctor who believes strongly in consumer-driven healthcare and patient autonomy may say, “I can’t tell you which treatment is best for you. That’s something you have to decide.” )

Given the ambiguities, how can patients hope to comparison-shop the way they might shop for a computer? 

While Consumer Reports can rate mid-priced refrigerators briskly and clearly, in a way that makes comparisons easy, it is all but impossible, even for physicians, to be positive of the relative benefits of a great many medical procedures. The product is opaque; you can’t compare two treatments the way you might compare two cars.  This is not just because the human body is so complex, but because each body is unique—what worked on one patient may not work on another.

Granted, today both physicians and patients enjoy access to more information than ever before. But, as anyone who has ever been seriously ill knows all too well, the more one learns about a disease and the odds of success with possible treatments, the more ambiguous the situation can become. (And most of our healthcare dollars are spent on serious and chronic illnesses.)
As researchers noted in a 2004 article in Health Affairs, “much of medical practice remains in gray areas . . . and is likely to remain so for quite some time.”

“Outcomes research”–which compares outcomes for similar patients exposed to different treatments, drugs or procedures– is still an infant science. In-depth analysis of outcomes requires long-term, risk-adjusted clinical trials.  It will be many years before we have enough clinical data to create useful guidelines for “best practice” when treating most chronic and serious diseases. (In an excellent article in The New Yorker, Dr. Atul Gawande describes how over a 40-period one physician painstakingly learned how to  establish what appears to be “best practice” for just one disease—cystic fibrosis. )

In the meantime, there is a real danger that quick comparisons of .how patients fare under different regimens will turn into an entrepreneurial industry that produces Instamatic “report cards.”  Such snapshots of medical data can be misleading, warns Mark Fendrick,  a professor of medicine at the University of Michigan. In a letter to Health Affairs, he paraphrases sports announcer Vin Scully: “The utility [of such ‘report cards’ on quality]  resembles  the benefit a drunk derives from a lamppost in the dark, ‘support not illumination.’

Returning to the consumer’s dilemma, to make his situation as a shopper all the more difficult, when it comes to healthcare he knows that there are no warrants or guarantees. The patient cannot return an unsuccessful operation. And if he winds up unhappy with the outcome, he may find himself stuck with something far worse than a bad haircut.

No wonder patients are reluctant to bargain-hunt—even in cases where they can get clear price information to make comparisons. This is not an industry where consumers are going to bring prices down—even when spending their own money.

A sick patient isn’t looking for a bargain, he’s looking for the highest quality. But when it comes to comparing healthcare providers, it’s extraordinarily difficult to measure quality. As one hospital CEO told me, “our patients know whether they like the rooms, the food, the service—but they have no way of knowing whether they are getting the best possible care.”

Even after the fact, the patient can never be sure—would his condition have cleared up on its own if he hadn’t had the operation? Would another, less expensive or less painful treatment or drug have just as good a job, with fewer side effects?

Some pundits claim that mortality rates will tell you how good a hospital or a doctor is. But the truth is, a hospital with high mortality rates may simply be one that takes the most difficult patients. When they are being “graded” on mortality rates, many hospitals have been known to “game” the system by refusing the hardest cases. Adjusting for the difficulty of the cases that a given doctor or hospital takes is a very tricky business.

The consumer-driven movement tries to shift the burden of ensuring quality to the patient—pretending that, by just going online, the resourceful health care shopper can become his own expert, and learn to  choose  the “best” procedures, doctors and hospitals at the best price. A few years ago, a Wall Street Journal article suggested that in this new era of consumer-driven care, “New rating systems around the country are staring to make it possible for people to shop for a hospital the way they shop for mutual funds.” (“Shopping for Hospitals,” May 1, 2002)

Did we learn nothing from the nineties?

Just as most people are not cut out to be their own money managers, the majority are not well suited to becoming their own physicians. In the 21st century we have instant access to a world of information—but information is not knowledge. All of the mutual fund rating systems in the world could not save the small investor if he bought a five-star high-tech fund at the market’s high. And if it is difficult for laymen to avoid the hype while chasing hope on Wall Street, consider the dilemma of a seriously ill patient facing the mysteries of his own mortality.

Patients need to rely on their doctors—doctors who are professionals and will put their patients’ interests ahead of their own financial interests—to give them the best possible advice. Some of that advice will be based on what the doctor has read and learned, some on what he has experienced. Much of that experiential knowledge will be intuitive knowledge that is hard to put into words—knowledge that a patient can’t pick up on the Internet.

Certainly, today’s patient wants to be included in the decision-making process. The days of “Doctor Knows Best” are long gone. Patients want to ask questions, to have their options laid out for them. Often, they want a second opinion.  But while they don’t want to be kept in the dark, once they have been informed, most want their physicians to help guide them toward the course of treatment that the physician has reason to believe (even though he often cannot be certain), will yield the best result.

In an essay questioning the whole idea of consumer-driven medicine, Robert Berenson, a physician and former top Medicare official, quotes health economist Victor Fuchs, noting that Fuchs “understands that the patient/physician relationship is very different from the one we accept in the commercial marketplace because it requires patients and health care professionals to work cooperatively rather than as adversarial buyers and sellers.”

In other industries, “caveat emptor” always applies. The savvy consumer must take care that the seller does not cheat him. He must demand the best product at the best price.

But healthcare is different from other industries. The buyer is not a “consumer”–he is a patient. And the seller is not a businessman marketing a commodity—he is a physician  practicing his profession. Insofar as a patient “shops” for healthcare, he needs to shop— not for the least expensive doctor, nor for the doctor who advertises that he has the highest ratings on  somebody’s rating system– but for a doctor whom he trusts to act as a professional, and put the patient first.

In other words, what we need isn’t “consumer-driven medicine,” but “patient-centered medicine.”