Sure, it came out on April 10th, but the April Fools’ Edition of Health Wonk Review hosted by Billy Wynne at the Healthcare Lighthouse Blog is nothing to joke about. Give it a look!
Well, the cat is out of the bag now. All this time we’ve been told that Internal Medicine is a dying art, you can’t make a living at it, payments to physicians are too low, etc. Now the New York Times is telling me that Internal Medicine is fifth on the list of best-paid doctors! How can this be?
Here’s what has happened: Medicare has released the names and specialties of all the doctors it has paid in 2012. That’s a lot of data. It’s, well, Big Data. It’s data on two things: 1) doctors; 2) money. The healthcare reform debate in a nutshell. So this will likely get a lot of press. I haven’t seen the actual numbers yet, and I’m told it will take many weeks to go through all of it. Since nobody pays me to write, I’ll have to keep my day job, and thus will have to leave the number crunching to others.
Thankfully, the New York Times has come to my rescue. (http://www.nytimes.com/2014/04/09/business/sliver-of-medicare-doctors-get-big-share-of-payouts.html?hp&_r=0). According to the NYT, 880,000 practitioners and 77 billion dollars are covered in the report. Twenty-five percent of that 77 billion seems to have gone to two percent of doctors: those in opthalmology, oncology, and cardiology. Internal medicine is right behind, wouldn’t you know. The article actually has a chart that they named “The best-paid 2 percent of doctors”. Yep. Those family doctors are really raking it in.
The paper singles out a specific opthalmology procedure as a prominent, and, it implies, therefore suspect, reason for big payouts. In fact, the paper had to be asked (nicely) not to release the names of the actual doctors with the highest billing records, or to contact them, until all the data is released to the public. I suspect a couple of eye-doctors are going to have a really bad day today. The opthalmology data is a good illustration of how Big Data can be Limited Data. And how it can be interpreted a number of ways. The NYT is implying that because eye doctors’ billing is so high, and so much higher than other specialties, there must be some something criminal going on. Either eye doctors are committing fraud, or they are doing unnecessary procedures, or they are using drugs that are too expensive. The doctors must be wrong.
But the data doesn’t say that at all. All it says it that Medicare, which sets it’s reimbursement rates at levels mandated by Congress, not doctors, pays more money to treat people with eye diseases than it does other diseases. That’s it. It says nothing about a doctor’s practice at all. Nothing.
Let’s take a couple of examples. Opthalmology is a sub-specialized field. A doctor who does cataracts doesn’t do Lasik, or he does Lasik but he doesn’t handle macular degeneration, etc. A lot of specialties are getting like this. Now, say a few doctors have specialized in this one procedure the NYT is all upset about. Other doctors send their patients to these guys. All of their practices becomes doing this procedure. Because it’s their specialty. So they bill Medicare for the procedure. Medicare pays out what it decided to pay for this procedure. How is this the doctor’s fault? (By the way, funny story. There’s a Lasik advertisement on the internet page with this article.)
Another example. Say you are an oncologist. You treat a lot of blood cancers, leukemia and such. Other doctors send you their patients if they have leukemia. There are a lot of types of leukemia, many of which are very expensive to treat and some which actually become chronic. You bill Medicare for your treatments. Medicare pays back what it decided to pay for these treatments. It costs a lot to treat leukemia. That’s what the data says. That’s all it says. It says nothing about quality of care, patient population, number of patients, or disease complexity. It says nothing about variability in office visit time or the level of co-existing disease in a specific doctor’s patient population.
I am all for transparency. I think having this data out there is fine, as long as we understand what we are getting. And I’m not sure we do. Specific doctors are going to be targeted for a lot of scrutiny because of this report. Maybe they deserve to, maybe they don’t. Fraud and over-treatment do exist. But this data is far from telling the whole story.
While the Obama Administration is still permitting people who experienced technical difficulties with the healthcare.gov website to sign-up for coverage until April 15th, the initial open enrollment period for the health insurance marketplaces ended on March 31st. As we now know, more than 7 million people signed up for coverage between October 1 and the end of March. Plenty of people are talking about whether or not this is a victory for the White House. Will this help Democrats in the midterm elections? Is the GOP still on track to take control of the Senate because of how much so many Americans dislike the ACA? There are plenty of angles from which to view the situation, but what I think gets lost in this whole discussion is the magnitude of a number like 7 million. So, in the spirit of trying to help that sink in for you, consider the following:
- If you had 7 million pennies, it would be worth $70,000.
- If you were able to stack all of those pennies up, they would reach more than 6.7 miles into the sky, despite each being merely 1.55 millimeters thick.
- If you had $7 million, you could buy your own brand new Learjet.
- If you traveled 7 million miles in that Learjet (laws of physics notwithstanding), you could fly to the moon and back nearly 15 times.
- If you built a colony on the moon and wanted to populate it with 7 million Americans, you could easily accommodate the entire population of both Los Angeles and Chicago.
The point is, 7 million is a really, really big number. And behind that really, really big number are people who now have health insurance–many of them for the first time in a long time–if ever. It bears repeating that we’re still just getting started, despite being 5 years into the ACA. It will take time for all of this to sort itself out, and it will happen even as everything around it in health care is changing. But we shouldn’t lose sight of the enormity of 7 million people signing up for health insurance. For those who support the ACA, this should be viewed as a step in the right direction, with a healthy respect for the fact that this is far short of the goal of universal coverage. For those who oppose the ACA, this should be viewed as an indication that, even if the policy to fix it is unpalatable, the problem itself is very large. Calls to repeal the ACA without putting something in its place will mean that these 7 million will be left in the lurch.
The kerfuffle over the “doc fix” took a truly courageous turn yesterday in the United States House of Representatives. I will review the general idea of the doc fix but Todd Zwilich today on NPR’s The Takeway gave a fantastic and hilarious take on the history of this money hole, also known as the SGR. In 1997 Congress passed the balanced budget act, which required them to at least appear to be balancing the federal budget. But they couldn’t really so the found a big expenditure, medicare, and did a sort of retro-accounting move. They decided that sometime in the future, say, 2014, the medicare payment system would have to be reset and doctors would take a pay cut of, say, 24%. The took the 24% and added it to the budget for 1997 and wallah! Balanced budget. Todd Zwilich calls this “the worst kind of shell game accounting” that Congress has ever come up with. Tom Coburn (R, Oklahoma), who is a doctor himself, calls the whole thing “funny money”.
OK, so partisanship being what it is, the big push to “fix” the SGR, which is a bipartisan initiative, is going nowhere because the Rs and the Ds can’t decide on how to get the $180 billion it would take. So they needed to pass a patch, a 1-2 year measure to postpone this big pay cut. John Fleming (R, Louisiana), also an MD, acknowledged that “no one wanted to vote for it, and no one wanted to vote against it.” So what did they do, these poor congressmen, so that no one had to come down on either side, thus endangering their chances for re-election? I’ll paraphrase Zwilich:
Eric Cantor (R, Virginia), the House Majority Leader, literally ran out of an office, onto the floor of the House, up to Steny Hoyer (D, Maryland), had a quick conversation, and presto! The bill was passed, without anyone having to soil their hands by voting for it. When the Representatives got to the floor themselves, they were surprised to find the whole thing over with. Now, I have no idea what murky vagaries of House Rules makes this possible, but I do know that our brave congressmen at least had the grace to look slightly embarrassed.
Now the bill (to pass the one year patch, in case I’ve lost you) goes to the Senate. The Senate must vote on it by Monday, which is when the last patch expires. Docs, don’t make your boat payment quite yet. Unless Senators are braver than Representatives, or have the same murky rules, you might be 24% in the hole by Tuesday.
Today is the deadline for open enrollment under the Affordable Care Act. All the reports I’ve heard have suggested that Americans are excellent procrastinators. After the dust settles, we’ll see how many people enrolled in a private insurance plan or Medicaid through the exchanges. Then we can hear both sides argue over whether it has been a success or a failure. It should be fun.
In the meantime, Chris Fleming, who maintains the Health Affairs blog, hosted the latest version of the Health Wonk Review. Wright on Health’s own Shirie Gale was featured this time around. Her post is great, as are all the others. Go check it out here.
My parents have always made their own bread, a skill I have never been able to master. The other day my dad was showing off this beautiful loaf of bread he had made, and I asked him how he did it. He said “I don’t know. I followed the recipe and then added more flour until it looked right.” Huh. So the recipe was wrong? “Well, not really. It just needed more flour.”
As I was reading our dear leader Brad Wright’s policy wonk piece from March 12 I clicked on John Goodman’s piece on personalized medicine and it occurred to me that my father’s approach to bread baking is a good analogy for how doctors confront protocols and guidelines. Goodman has a great blog, by the way, over at the National Center for Policy Analysis.
Let’s start with the recipe itself. You think you want to make, say, a pie. You don’t know what kind of pie, just “pie”. But you’re an experienced baker, you’ve been baking for 20 years. You look in the index and find the directions for “pie”. You follow the directions exactly. You end up with something that looks like pie. But it’s not quite right, it doesn’t fit exactly. There’s no filling. You haven’t decided how to personalize the pie, make it yours. According to our analogy, the baker is the doctor. He’s very experienced, and has been practicing medicine for a long time. He sees a patient whom he decides has, say, diabetes. He looks in the index of his protocol manual, as he has been told to do by the administrators of his EMR, and follows the directions for “diabetes” exactly. But the patient doesn’t get better. The doctor hasn’t found out what kind of person his patient with diabetes is, so he can tailor the recommendations to the patient, that is, he can personalize it.
To extend the analogy, say this baker makes his pie according to the directions but because of his experience, knows a few ingredients are missing, so he adds them. Like my dad, an experienced bread-maker, adding flour. The results are much better, and he is able to charge more for his superior bread. But the doctor does this for his diabetes patient, and the patient’s insurance company calls him saying it won’t pay for the added items. They aren’t in the recipe.
Now someone comes to the baker and says: “Baker I ate your pie and I got sick. What did you put in it?” The baker replies that he followed the recipe, but when pressed admits he added a few things, but nothing that could make the pie-eater sick. The pie-eater doesn’t believe him but the worst that he does is no longer buy pie from the baker. The patient comes to the doctor and says: “Doctor I did what you said but I got sick. What did you do?” The doctor says he followed protocol, but when pressed admits he added a few things, but only things that would improve the patient’s care. Doctor is sued for 10 million dollars. Conversely, a person buys a pie and says to the baker: “This pie tastes terrible. What happened?” And the baker answers that someone got sick from a pie he made with additions, even though it wasn’t his fault, so now he just follows the recipe. The patient says to the doctor: “This treatment isn’t working for me, what happened?” And the doctor says: “I got sued for personalizing care, so now I just follow protocol.”
Tired of this analogy? Me too. Here is the problem with cook-book medicine. You’ll come out with something that looks like quality care, but doesn’t really satisfy anyone. It’s nice to have guidelines, so you know in general how things are done by other doctors and experts in the field, but if you don’t have the freedom to use judgement gained by experience to adjust care to the patient at hand, the end product doesn’t work. I guess my point in all this is that quality care cannot be legislated and measured with strict guidelines. Quality health care is like good pie; you know it when you see it, and you leave it to the professionals.
I moved around a lot when I was really young, but for the most part, I grew up in southeast Georgia–that’s the place that I’ll always identify as home. So, the last few years, first in Rhode Island, and now in Iowa, have taken some getting used to weather-wise. This year, winter has been especially brutal. But as I write this, I am sitting in my house with the windows open. Sure, it is supposed to snow tomorrow, but today it got up to 60 degrees. We have moved our clocks forward, leading to longer sunlit evenings, and I feel the promise of Spring approaching. For now, though, it’s mud season. All of the snow that has blanketed the ground since December has finally melted–quickly–leading to a sloppy mess. To be frank, the world of health policy is not that different. Things can change quickly, and they can certainly get messy. Thus, this mud season edition of the Health Wonk Review is presented with the understanding that while things might be a bit of a mess right now, there is hope on the horizon.
As the snow melts, we’re also nearing the end of open enrollment under the ACA. The latest numbers suggest that the Obama Administration is going to miss its target. I suppose the problem with setting goals is that you can fail to meet them. Louise at the Colorado Health Insurance Insider suggests that it might have been more efficient to spread open enrollment across the whole year. As long as that policy doesn’t extend to frozen precipitation, I’m intrigued.
Likewise, much ado–replete with mudslinging–has been made of Obamacare’s early going: Are enough people signing up? Are they the right types of people in the right proportions? Is it working? These are all excellent questions, but as Joe Paduda points out at Managed Care Matters, they aren’t the most important questions. Those, he contends, are what is happening to health plan prices and quality, and he is encouraged by what he sees at this early stage.
In that spirit, perhaps it will help if health care providers heed the advice of the Healthcare Talent Transformation blog’s Jonena Relth, who urges them to rediscover the adrenaline rush they first felt when they began treating patients. By encouraging use of portals and other patient-engaging technologies, she believes that our nation’s health care system can be the best in the world. On his Health Policy Blog, John Goodman also advocates for personalized medicine over protocols.
When it comes to Obamacare, there’s a lot to wade through, but our bloggers are on it. Hank Stern of InsureBlog examines the disturbing story of a vet caught up in an Obamacare tragedy and asks: What does a 1944 French existentialist play have to do with health care in modern America? Anthony Wright of the Health Access Blog takes a close look at President Obama’s appearance on Zach Galifianakis’ “Between Two Ferns” and in the process of fact-checking the video, dismantles the myth of the “young invincibles.” Also not afraid to fact-check is Linda Bergthold who, writing for healthinsurance.org, explains why rumors about the threat of Obamacare to your employer-sponsored health plan shouldn’t be keeping you up at night.
When the snow piles up, you need a shovel. When the disinformation around the ACA piles up, you need Maggie Mahar to help set the record straight. In “How a CBS Video About an Obamacare ‘Victim’ Misled Millions,” Maggie finds that neither the woman being interviewed, nor the reporters and producers involved in creating the piece seemed to understand some basic elements of the ACA thanks to the fog of disinformation that reform’s opponents have generated. It’s a terrific read–even if a bit unsettling.
Seemingly like the arrival of Spring, implementation of the ACA has also been delayed on more than one occasion. Delay of the employer mandate has gotten a lot of attention, but now there’s a push to delay the individual mandate too. At the Healthcare Lighthouse, Billy Wynne discusses how the House’s decision to pair the bipartisan doc fix policy with delay of the individual mandate is a death knell for permanent SGR repeal in the near term. Also on the subject of payment reform, the Health Affairs blog presents a post from Suzanne Delbanco, executive director of Catalyst for Payment Reform. Suzanne looks at the track record and potential of pay-for-performance and finds that the evidence on whether pay-for-performance models improve quality and affordability is mixed at best.
Mud season is typically referred to in New England (although trust me when I say it applies to the Midwest!), so it’s worth looking at the state that was doing Obamacare before Obama was President: Massachusetts. At the Health Business Blog, David Williams is running a series of interviews about health policy with all of the Massachusetts gubernatorial candidates. He shares with us his interview with well-known health quality advocate and gubernatorial candidate Don Berwick, who says as Governor, he’d pursue a single-payer system and work to implement the Triple Aim.
As we slog along, let’s not forget about other health care providers, like dentists and the hygienists that assist them. As the ACA is implemented, we’re hearing a lot about the use of midlevel providers to meet increases in demand, while helping to control costs. Well, the Healthcare Economist, Jason Shafrin, finds that this principle holds true in dental care as well. When hygienists’ scope of practice is limited, meaning dentists are left to do some less advanced tasks such as cleanings, the net result is approximately a 12% increase in many dental care costs.
The muck and mire is especially thick when you look at conflicts of interest in health care, as our good friend Roy Poses does regularly at the Health Care Renewal blog. This time around, he’s writing about a policy that actually condones keeping conflicts of interest a secret and the implications this may have had in a separate controversial case. Read both of his posts here and here. And, while we’re at it, Tom Lynch of Workers’ Comp Insider tells us all about a hospital that has been bribing politicians and providing doctors with kickbacks for referring patients for surgery.
Finally, for those of you still stuck inside for a few more weeks, I highly recommend checking out a new resource from Jared Rhoads. Healthpolicy.tv is a source for the most interesting health policy videos from around the web. Perhaps most importantly, it aims to elevate the debate by including views from all across the political spectrum. See? I told you that mud season foreshadowed better days ahead. Well, that’s it for this edition of the Health Wonk Review. Next up to host is Chris Fleming at the Health Affairs blog.