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Balance of Power

In researching a novel I am writing I have been reading about the history of the treatment of depression.  As often happens, I ran into an historical issue with echoes of the future.

Here’s an interesting paragraph from Howard Kushner’s book American Suicide.

“While asylum superintendents [in the 1840s] were as much captive of bourgeois ideology [the conviction that the insane could be reformed and that the suicidal could be cured] as were other social reformers, they were influenced on a daily basis by more parochial concerns.  Not least of all, these men sought stable employment in the medical profession at a time when, buffed by competing medical sects, medicine promised neither prestige nor a regular income.  A career as an asylum superintendent offered a solution to the contradictions between humanitarian desires to help others and a quest for economic security.  Like most professionals then and now, these asylum physicians saw no conflict between an increase in their professional power and the improvement of the condition of the patients they served.  Indeed, they viewed the former as essential for the latter.”  (Bold letters are my addition.)

Let’s look at that second-to-last sentence.  Professional physicians see no conflict between increases in power and the improvement of patient condition.  Conflict may not be quite the right word.  Maybe correlation is a better one.  Professional physicians see correlation between increases in power and improved patient condition.  Up to a point the statement is historically accurate.  There was no conflict in the eighteenth and early nineteenth centuries because as trained doctors from legitimate medical schools began to have more influence than the untrained barber-surgeons and apothecaries, patient health did get better.  Education and science eventually led to treatments that truly helped people.  This resulted in a medical profession which, unlike that of 1840, had great prestige and good income.

Since those early days of medical professionalization, however, power has shifted.  The turn away from paternalism toward autonomy has shifted the balance.  Regulation, legislation, and an omnipresent media have shifted it further.  Power, which used to be in the hands of doctors, for better or worse, is now in the hands of regulators, administrators, and the patients themselves.  The question is, does the decrease in physician power correlate with a change in the health of patients?

The answer, of course, depends on who you ask.

You could ask Timothy Quill and Howard Brody, who would tell you they doubt extremes of patient power increase the well-being of patients.  In 1996 they wrote the following in the Annals of Internal Medicine: (Ann Intern Med. 1996;125(9):763-769)

“At one extreme end of this [patient autonomy] spectrum is the “independent choice” model of decision making, in which physicians objectively present patients with options and odds but withhold their own experience and recommendations to avoid overly influencing patients. This model confuses the concepts of independence and autonomy and assumes that the physician’s exercise of power and influence inevitably diminishes the patient’s ability to choose freely.”

You could ask the Physician Regulatory Issues Team at CMS, which claims that the power of regulation, in the form of government money, improves the condition of patients:

“Physicians have a special role in our health care system, as they not only care for the health of individual patients, but also help to shape the broad health care delivery system. As the federal Medicare agency, CMS respects the bond of trust between physicians and their patients, and appreciates the need to support physicians in the leadership they provide in service delivery. The Medicare program and physicians share a common mission, the provision of high quality medical care for patients.” (http://www.cms.gov/Outreach-and-Education/Outreach/PRIT/index.html?redirect=/prit/)
You could ask Drs Bell, Wilkes, and Kravitz, who may say that the power of advertising is not improving anyone’s condition.  They found that “A sizable fraction of patients believed they would react negatively if their physician refused to provide a prescription for a drug advertised in the general media.”  The Journal of Family Practice [1999, 48(6):446-452]
You could ask Louis Goodman and Tim Norbeck of Forbes, who would probably say that regulations are not increasing patient health.   “…Physicians are already spending 22 percent of their time interacting with insurers on formularies, claims, billing, credentialing, pre-authorizations, and quality measure data.  The workload can only increase with the new [ICD-10] codes.” http://www.forbes.com/sites/physiciansfoundation/2013/11/05/healthcare-is-turing-into-an-industry-focused-on-compliance-regulation-rather-than-patient-care/

You could ask the people of Florida, where doctors abuse their power of the prescription pad.  They would say that absolutely, regulation has improved the condition of patients.  An article in the New York Times reported that “New laws are also cutting off distribution [of prescription painkillers]. As of July, Florida doctors are barred, with a few exceptions, from dispensing narcotics and addictive medicines in their offices or clinics. As a result, doctors’ purchases of Oxycodone, which reached 32.2 million doses in the first six months of 2010, fell by 97 percent in the same period this year.” http://www.nytimes.com/2011/09/01/us/01drugs.html

Balance of power is important in health care, just as it is in government and marriages.  No one will argue that giving physicians full power to do anything they want is a great idea.  But we need to be careful about how much power we take away.

 
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Posted by on October 9, 2014 in Debates, Legislation, Physicians

 

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Expanding Insurance May Not Mean Long Lines and Trouble Seeing the Doctor

When health reform made it on the agenda in 2008-9, it took almost no time to hear the old familiar line that government-run health care will mean rationing, with crowded waiting rooms and the dreaded prospect of it taking months or years to get seen by the doctor or have an important surgery performed. It didn’t matter when Brits and Canadians chimed in to say “Actually, it’s not like that here at all.” Americans succumbed to the combination of logic and fear. The logic is apparent: If more people have the ability to go to the doctor, and there isn’t suddenly a corresponding increase in doctors, then either doctors are going to have to see more patients in less time (potentially reducing quality), or patients are going to have to wait to be seen (and we don’t like to wait). Given my parenthetical explanations in the preceding sentence, do I even need to elaborate on the fear aspect?

There’s just one important question: Is that really what will happen? This is where the good folks at Harvard who do health policy and health services research are so lucky. In Massachusetts, which basically implemented ObamaCare at the state level years before ObamaCare came into being, we have a nice policy laboratory to investigate this question. That’s precisely what Karen Joynt and colleagues did, as they report in a recent article in Health Services Research.

The very short version of what they did is this: Using Medicare data, they looked to see if people with chronic diseases like diabetes and hypertension had fewer outpatient visits to the doctor after the Massachusetts health reform was enacted, compared to the number of visits they had before the reform. They also looked at some quality metrics in the same way. That is, did the patients get the treatments we know they are supposed to get? And they also looked at health care costs. The cool thing about this is that they were able to use patients in other New England states that didn’t have health reform as controls. That means that their study design is really able to attribute any changes they see in Massachusetts above and beyond what they see elsewhere in New England to the health reform in Massachusetts.

The very short version of what they found is this: There was no decrease in health care visits or health care quality in Massachusetts because of health reform, but there was an increase in costs. Now, there are some limitations to what they did, but the authors acknowledge these nicely. The biggest issue is that Massachusetts had a low rate of uninsured persons to begin with, so their health care system was less flooded with newly insured than other places–like Kentucky–might be thanks to the ACA. The other big issue is that the study only examined the Medicare population age 65 and up, so we have no idea if the under-65 disabled Medicare population and everyone else may have experienced issues getting seen by a doctor. Still, despite these limitations, the study offers a ray of hope that our health care delivery system is responsive enough to adapt to an increase in demand without making us suffer lengthy waits to be seen for outpatient care, and that the ACA may well end up doing more good than harm.

 
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Posted by on September 23, 2014 in "Rationing", Recent Research

 

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Let The Witch Hunt Begin

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.

 

 
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Posted by on April 10, 2014 in Health Care Costs

 

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Doctors: Beware The Doc Fix

Let’s talk about the Doc Fix.  No it doesn’t mean that surgeons will get any less cranky or that your urologist will improve his bedside manner.  What I am talking about in this case is the Sustainable Growth Rate formula. You see, the Center for Medicaid and Medicare Services, or CMS, has to figure out every year how much it’s going to pay for things. The SGR is supposed to ensure that as fees for everything in healthcare go up, the rate of increase does not outpace the growth of GDP. In a complicated middle-man maneuver, CMS sends a report to the Medicare Payment Advisory Commission, which in turn advises Congress on how much medicare spent last year and how much it’s targeted to spend next year.  There is a conversion factor that adjust payments based on how much over or under the target cost was the previous year.  The SGR is that conversion factor, and believe me unless you have the beautiful mind of John Nash you don’t want to know how it’s calculated.  The SGR was formulated in 1997 and, put simply, is a way to control costs.

So the SGR is a formula to control medicare costs.  OK.  So what’s the problem?  The problem is that as healthcare spending has outpaced GDP, every year since 2002 physician reimbursement has gone down.  The SGR demands it, because every year cost is over the target.  And every year Congress, under the heavy lobbying of the AMA, passes short-term overrides to prevent these cuts.  And why is THIS a problem, since everything Congress does these days is emergency short-term fixes?  Money. The gap between what the SGR says we should pay for medicare and what it actually costs is about $300 billion.  The gap will get bigger and bigger.  But what’s the alternative?  Here’s what the Society for Hospital Medicine blog says:

“To earn greater or equal revenue, we will need to achieve prespecified process of care and health outcome targets (VBP or value-based payment) on top of the old reimbursement chassis.  Additionally, participating in alternate payment models (APM’s), e.g., patient-centered medical homes, will garner increased rewards.  A caveat, APM’s work for ambulists, but not for hospitalists—and SHM has responded to CMS with proposals.  The same goes for VBP mismatches.”

What?  I have no idea what most of that means but, as a physician, the phrase “we will need to achieve pre- specified process of care and health outcome targets” strikes fear into my heart and puts ice into my veins.  You see, what Congress is suggesting is that instead of tying medicare payments to GDP, they should link the payments to quality measures or performance-based incentive programs.  That would be great if there were anything like actual meaningful quality measurement metrics.  Quality measurements have to be things that are easily understood numerically.  Number of people counseled on smoking.  Number of flu vaccines.  Number of people getting pre-operative antibiotics.  Number of time-outs before surgery.  Number of people tested for prostate cancer.  These are NOT measure of quality.  They are measures of compliance by physicians who must blindly check boxes in order to ensure that their “quality” matches what a panel of experts say is quality. Not only do quality measures not measure quality, they impose the increasingly onerous documentation requirements physicians face every day.

According to Forbes(http://www.forbes.com/sites/brucejapsen/2013/12/13/in-rare-bipartisan-moves-congress-may-remedy-medicare-doc-fix-in-2014/) the AMA thinks this is a great idea:

“(Thursday’s) strong, bipartisan votes by the Senate Finance and House Ways and Means committees, following similar action last October by the House Energy and Commerce Committee, shows that there is overwhelming, bipartisan support for ending the SGR in a fiscally responsible manner and closing the book on the annual cycle of draconian Medicare physician payment cuts and short-term patches,” said Dr. Ardis Hoven, president of the American Medical Association. “This long-overdue policy change provides the stability that physicians need to pursue delivery innovations that help improve patient care and reduce costs for American taxpayers.”

I suspect Dr. Hoven hasn’t practiced medicine in quite some time.

 
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Posted by on January 7, 2014 in Legislation, Quality

 

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As They Age: Women Know What They Do Not Know

The need for health care varies greatly over a lifespan, with older adults having significantly more health-related needs and costs than younger individuals. Women, in particular, often face a myriad of health problems as they transition through menopause. Sadly, despite the fact that every woman will go through menopause, very little is understood about the physical and mental changes that occur during this period of life. In addition, women may struggle to find pharmaceutical solutions, which can safely provide proven relief without the worry that those available will increase their likelihood of other health and mental complications.

Much is misunderstood about menopause and the changes that are associated with the hormonal fluctuations. This is largely due to the fact this inevitable transition is rarely apart of the conversation, particularly in the context of health care. Further, menopause is expected to be merely “bothersome”; not something one could attribute real health problems to. Although maternity care and issues related to younger women are required in the Affordable Care Act as essential health benefits, nothing of legislative note will improve the knowledge and acceptance of this natural life progression.

Most insurance companies do not even cover basic mediations associated with menopausal symptoms, and conflicting research has women scared about the potential long-term effects associated with hormone replacement therapy. Negative press, little medical literature and low financial assistance often leaves women to suffer through menopause silently, many of whom worry constantly about memory deficits they experience and potential long term changes.

A recent study focused on the memory complaints of midlife women has been receiving a lot of attention. The study, conducted at the University of Illinois- at Chicago (UIC), attempted to determine if women who are experiencing hot flushes during menopause were able to accurately predict their own memory performance.

According to the principal author, Lauren Drogos, “We found that a one-item question: ‘How would you rate your memory in terms of the kinds of problems that you have?’ was the best predictor of verbal memory performance on a list-learning task. We also found that many complaints were related to mood symptoms.”

In the US, the average woman becomes postmenopausal around the age of 51. Common symptoms that occur include hot flushes, sleep disturbances, mood changes and memory problems. However, until recently it was believed that women were unable to accurately describe the current state of their memory and the changes they experience as they progress through menopause.

Despite the difficulty in being taken seriously about the physical and mental challenges that menopause presents, this recent study from Drogos, along with other research, shows that woman are able to accurately describe their current memory abilities. Specifically, a group of sixty-eight women performed a series of memory tests and were then asked, to detail the types of memory problems they were experiencing. The study concluded that women were able to accurately rank themselves on a scale from no memory problems to severe problems.

Using recall of a short story, the deficits seen in memory did not indicate that women were suffering from dementia, nor were they experiencing shortfalls in memory that were impacting daily life. Instead, it was simply indicative that women who experienced memory deficits often recognized the changes occurring.

Previous research focusing on women’s transitions through menopause also found that hot flushes during the nighttime were the best predictors of memory performance in women. This leads researchers within the Women’s Mental Health Research Program at UIC, to believe that sleep disturbances and stress hormones may play integral roles in memory and hot flushes.

The good news for women concerned about the transition through menopause is that the cognitive decline that occurs appears to only be temporary, with performance rebounding early into post-menopause. Further, for those who want to keep both their minds and bodies at peak performance, research indicates that leading a non-sedentary lifestyle, keeping mentally active, and having a healthy diet can be the best preventers of cognitive decline.

 
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Posted by on July 11, 2013 in Good Reading, Medicare, Public Health

 

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Medicare’s Sustainability and Disproportionate Impact on Women

In light of the recent election and the number of monumental decisions elected officials, government agencies, policymakers and health care providers have to make around health care reform, the Medicare program hasn’t been receiving much attention. However, given the sheer number of Americans covered by the program and the fiscal disaster looming for aging citizens, it is important to examine the state of the country’s care for the elderly and disabled.

In the United States, older women rely on the Medicare program disproportionality and significantly more than men. Not only do women make up more than half of the Medicare beneficiaries, they comprise about 70 percent of the oldest (over 85 years old) beneficiaries and are more likely to have multiple chronic conditions as they age. In 2010, the program, which is administered by the Centers for Medicare & Medicaid Services (CMS), covered 47 million elderly (age 65 and over) and disabled beneficiaries. Unfortunately for beneficiaries, the US Government Accountability Office (GAO) has designated Medicare a high-risk program due to its fiscally unsustainable path.

Because women have a greater likelihood of living longer than men, more health care conditions will accumulate and more health care costs accrue. This means that as women age increased cost sharing and out-of-pocket expenses directly impact them more. Therefore, given the importance of Medicare’s cost sharing with seniors, and its quickly dwindling resources, it is important to revisit how vital the program is to the elderly, especially older women.

Facts about older women on Medicare:

  • In 2010, the average American woman over the age of 65 had an annual income of less than $15,072 (compared to male counterparts at $25,704)
  • Women over the age of 80 made up 62% of all individuals with Medicare in 2010
  • In 2011, older women paid an average of $115 for the Medicare Part B premium, plus deductibles that range from $162 to $1132 before their benefits kicked in
  • In 2007, the average American women spent an estimated 18.7 percent of her income on out-of-pocket health care costs, with percentages increasing throughout the recession
  • Nationally, 49% of women with Medicare report having three or more chronic conditions (compared to just 38% of men)
  • Despite cost sharing measures, Medicare does not cover many common and costly health care needs such as eyeglasses, hearing aids and long-term care

Current approaches to prolonging the Medicare program include:

  • Capping provider, hospital, devise and pharmaceutical reimbursement payments at 2012 levels
  • Reducing Medicare reimbursement rates for health care providers to previous levels
  • Raising the age of Medicare eligibility progressively from 65 to 67, or even higher, as people are living and working longer
  • Replace Medicare as it currently functions with a Voucher system (also known as a Premium Support Model)
  • Restructuring beneficiaries cost-sharing
 

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IPAB

Contrary to the title, the IPAB is not a new Apple product. Rather, it is the “Independent Payment Advisory Board” created by the Affordable Care Act to solve the problem of ever-increasing Medicare spending. In people’s worst nightmares, the IPAB is a death panel that will make decisions about how to ration health care for the elderly and disabled. Images of 15 people sitting in a room handing out death sentences flash through the minds of the anti-government crowd. Of course, nothing could be further from the truth, as the IPAB has no authority to limit benefits, increase beneficiaries’ out-of-pocket costs, or otherwise alter the Medicare program in any way that would “ration” care.

So, what can the IPAB actually do to promote slower spending growth in Medicare? They can suggest legislation, that’s what. Legislation that, for example, would reduce or alter the way in which payments are made to providers. It’s debatable if the recommendations from IPAB will work to actually control spending. What’s not up for debate is whether action will be taken, and that’s what I’m most pleased about.

You see, I hear often from family and friends about how Congress “never does anything” and how we should “vote the whole sorry bunch out and start from scratch.” It doesn’t seem to matter which party is in power, either. Congressional disapproval knows no party affiliations. And this isn’t just a trend among my social circle. Americans generally disapprove of the job Congress is doing. The IPAB puts an end to that, and here’s how:

Starting in 2013, the chief actuary of the Centers for Medicare and Medicaid Services (CMS) will report both a projected and a target Medicare growth rate for the next five years. If the projected growth rate exceeds the target growth rate, IPAB is tasked with making recommendations to bring things in line. These recommendations are formally submitted to Congress as proposed legislation. In the past, this is where progress ceased to occur, but no longer.

With the ball in Congress’ court, the options are straightforward. Congress may either enact the legislation recommended by IPAB, introduce and enact its own legislation that achieves the same cost savings as the recommendations from IPAB, or fail to act. If Congress fails to act, however, the secretary of the Department of Health and Human Services must implement IPAB’s recommendations, which cannot be overruled by either the executive or the judicial branches. In short, when Medicare spending increases too rapidly, something will be done to address it, even if Congress fails to act.

 
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Posted by on January 11, 2012 in Congress, Medicare

 

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