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.