Monday, December 22, 2008

Is This Appropriate Health Care? You Decide.

A 97 year old woman, while in an intensive care unit in a smaller community hospital had written, “Please let me die." Later after transfer to a larger hospital she was on life support and slowly decomposing - literally. This is an example of a modern American tragedy that happens to many thousands yearly.

Because this woman did not have an advanced directive, she was kept “alive” by a reluctant medical community under the authority of a legal guardian and a probate judge. The judge did not seek medical opinion as to the patient’s viability, chances of recovery, damage to her body that would occur as a result of the breathing & feeding tubes, irretrievable lack of consciousness and multi-organ failure. Rather, the judge chose to rule that without a properly executed advanced directive, every conceivable medical treatment must be utilized to keep her heart beating.

Wrapped in legal jargon, most would argue that this was an irrational, cruel and inhumane plan for this 97-year-old person. She had no chance of recovery. Those caring for her felt helpless in the midst of a legal system that is abstract in its reasoning and makes decisions as if medical science does not exist. A well meaning and caring society spends billions of dollars to perpetrate this kind of action upon thousands of dying Americans yearly despite excessive health care costs.

The Patient Self Determination Act passed Nov. 5, 1990, stated that patients have the right to create advanced directives stipulating what they wish done in an end-of-life situation. The act was never intended to mean that those without an advanced directive must undergo care that cannot be of benefit, is disfiguring to their body and draining resources from the rest of society. Quoting from the Philadelphia Inquirer, Nov. 7, 2005, "After three decades of urging Americans to write living wills (they preceded advanced directives), many doctors, lawyers and ethicists concede that these documents have largely failed”. Every case is different and therapy must be individually tailored. Thus it requires knowledge and judgment to treat in an appropriate fashion. This cannot be done in judge's chambers as an abstract exercise in fine points of the law.

The question to be asked is: does this irrationality in medical care apply only to end-of-life situations in American Medicine? Unfortunately, as has been repeatedly documented on this blog and in my book, the answer is a resounding NO! Dialysis, cardiac catheterization with stents, knee surgery, and excessive use of expensive radiological equipment (i.e. proton accelerators) are only a few examples of medical technologies that, when used appropriately, are terrific, but are being overused and thus abused. No wonder there are not adequate funds available to support primary care and universal heath care coverage.

Wednesday, December 10, 2008

The Need for Appropriate Care Committees – A Case Study

The burden of decision making in medicine and especially in end of life situations can be painful. We need to feel confident and supported in these difficult circumstances. No one wants to lose a loved one, yet we all know that life is temporary. We need to be sure that the decision to withdraw temporizing measures is correct. Frequently the family, as the patient advocate, assumes they are fighting for the patient and demands the use of multiple gadgets. The doctors comply although knowing they will be of no value. The family thus assumes that perhaps the doctors believe there is a possibility of cure.We need a system to help guide us through an experience that for many, and reasonably so, is very difficult. Following is a case from my own experience that clearly shows why we need appropriate care committees.

The daughter of a patient in the ICU with no chance of recovery was adamant that we continue care. After we exhausted all possibilities as formulated by the AMA Policy to Discontinue Care Against Family Wishes, care was withdrawn and the patient quickly died. After the funeral the daughter came back to the ICU to thank us. She told us that as long as we were willing to care for her mother maybe we thought she did have a chance to survive. But, by withdrawing care she knew we thought survival was impossible and that took the burden of letting her mother go out of her hands.

Thursday, November 13, 2008

The Election is Over, the Health Care Crisis Still Looms, So Now What?

As the national election drew near, a spate of Perspective articles in the New England Journal of Medicine discussed the problems and possible solutions to providing universal health care coverage. Most begin with the now familiar litany of problems with our present system: greater percentage of gross domestic product (GDP) spent on health care than any other nation yet millions are under and uninsured, poor results when compared to other nations, and an economic burden that is costing jobs while lowering the standard of living of the middle class.
The first four papers were from each of the presidential campaigns and then a rebuttal. The Obama campaign identified many of the problems in our system. Although the excessive costs of our present practice of medicine were discussed, the solutions were superficial and vague. While more uninsured would be covered, the anticipated increase in spending would make these reforms unattainable or so expensive as to cause more chaos to our economy.
The McCain campaign, although recognizing many of the American people’s concerns, offered a solution that is primarily a change in payment scheme. Again the fundamental problems existent with our health care system were not addressed; instead the plan relied on patient dollars to create a savvy consumer able to wisely purchase services, although they are extremely complex with consumerism a major problem driving up costs.
The Obama campaign countered the McCain plan as completely unrealistic and probably causing more harm than good. The McCain campaign responded to the Obama plan as unrealistic and, if enacted, prohibitively expensive. In my opinion both rebuttals were correct.
Following these exchanges, three health policy experts wrote about their ideas for changing the health care system. They argued for control of the growth of health care spending without which any attempt at universal coverage will fail. They stated that a large reason for the increase in costs is new technology and drugs. To deal with this problem they support the creation of an independent well-funded organization fashioned after the British National Institute for Health and Clinical Excellence.
I disagree with this idea for several reasons:
1) We already have a well-funded entity with known scientific excellence – The National Institutes of Health (NIH).
2) Drug and device companies now fund a great deal of research for use in clinical practice, which we know is frequently biased. Therefore, I suggest that Congress enacts legislation requiring all drug and device clinical research monies spent by the companies go through the NIH for experimental design, execution and reporting. This would ensure more valid data.
3) My proposal of the health care “Bank" would then enforce the concept that only therapies of benefit would be funded.
4) My appropriate care committee system would insure that these decisions are tailored to each individual’s needs and not applied in an autocratic manner. These changes would be part of the medical system and thus would not require the creation of another expensive bureaucracy. As mentioned in a previous post, the “Bank” would adequately fund and also enlist specialists to provide primary care, the backbone of any successful health care system and dramatically lacking in our country.
Unfortunately none of the articles dealt with medical advertising to the public (which should be prohibited), the growth of medical consumerism and the overuse of Cardiopulmonary Resuscitation and the flaws in Advanced Directives that have substantially increased health care costs. It seems that no one wishes to tackle our outrageous end-of-life care, the suffering it causes to patients, and its cost to our society. My hospital admission form and the appropriate care committee system would address these problems. We can provide world class care, universal coverage, decrease the percentage of GDP spent on health care and thus greatly enhance our standard of living by adopting my three major proposals (hospital admission form, appropriate care committees and the “Bank”).

Friday, September 19, 2008

Health Care Reform: Time for American Medical Leadership to Start Thinking Ouside the Box. Part Two

Now we'll look at another Perspective article in the New England Journal of Medicine, titled Collective Accountability for Medical Care – Toward Bundled Medicare Payments. It was written by senior members of The Medicare Payment Advisory Commission (Medpac).

Let's be clear upfront that Medicare's underpayment of primary care services has had a devastating effect on the supply of primary care physicians and their services over the past 43 years. The family doctor is disappearing. Only a third of all U.S. physicians are primary care doctors - the reverse ratio of all other countries that spend much less on health care than we do but have far superior results.

The article is a well-written scholarly discussion of a proposal to bundle hospital and physician services for each admission. The authors correctly state that Medicare spending is excessive and unstable and is far from delivering value for the dollar. However, the authors do not address Medpac’s role in causing this situation. They claim that the incentives in a fee-for-service system are the root cause of this problem. Their solution is a bundled payment system, where Medicare would pay a consortium of hospital and physicians a fixed amount for 30 days of care for each hospitalization. The goal of this proposal would be to better coordinate hospital and later outpatient care.

As I see it, this proposal has two major flaws:

1)It in no way addresses inappropriate care. Should the patient have been admitted to the hospital in first place and were the services in the hospital appropriate considering the patient's overall condition? Inappropriate care accounts for about a third of all administered care in the U.S.

2)There is no mention of the critical importance of the primary care physician and the significant adjustments to their reimbursement so that they can spend a minimum of thirty minutes with their patients at each visit and be able to follow their patients once they are admitted to the hospital. However, in Medpac’s submission to Congress in which it discussed bundling of care, an increase to primary care providers was suggested. This increase would be accomplished by an adjustment to the complex formula now being used to insure budget neutrality. When attempted in the past within the present system, this approach has proven inadequate.

Although in the Congressional report it was mentioned that many specialists do provide some primary care services, there was no mention of how dramatic the undersupply of primary care physicians is, nor of their vital role in chronic disease management. There was also no mention that it will take years of significant payment increases to rectify this shortage.

In my opinion, the answer to this problem at this time is to have internal medicine sub-specialists who are consulting on the patient’s major medical problem assume primary care responsibility for that patient if the patient has no primary care doctor. They would be reimbursed at the new higher primary care rates, but not the much higher subspecialty procedural rates for those primary care services.

I believe it is time for Medpac and Congress to admit the obvious-the present system is irrevocably broken and should be replaced with a Federal Reserve type Health Care Bank. The Bank, with expert advice, would adjust physician payments to adequately fund primary care as its first priority, then fund subspecialty and procedural care. This difficult task should take place without political interference. That would be thinking outside the box.

Health Care Reform: Time for American Medical Leadership to Start Thinking Ouside the Box. Part One

A recent Perspective article in the New England Journal of Medicine raises concern that because the federal Food and Drug Administration (FDA) has approved certain drugs, citizens could not sue drug companies in state courts because of the preemption clause in the U.S. constitution which states that federal laws trump state laws. The article, Why Doctors Should Worry About Preemption, was written by three physicians on the Journal staff . Given their positions, they are among the top leaders in the medical community and exert considerable influence.

FDA approval is based on a four phase process with all information supplied by the drug company at a cost to the company of over eight hundred million dollars. There is much debate as to how to improve this process. Aside from this debate, the authors of this article support the concept that after FDA approval, state tort litigation augments drug safety and enhances consumer confidence in the safety of medications and devices.

I disagree and here's why:

1) Legal action does not address the fundamental problem of our drug/device approval process. Presently clinical research to define the efficacy and safety of these commodities are funded, designed and controlled by these companies. The cost of bringing a new drug/device to market is enormous with failure risking the viability of the company. As has been repeatedly shown in the recent past this research is tainted by inappropriate design, withholding of results, and conflicts of interest.

2) Patients have confidence in drugs and devices when prescribed by their physicians even though the safety and efficacy may be proven otherwise somewhere down the road. It takes many years before tort cases reach any helpful conclusion and, by that time, many patients may have been harmed.

3) Allowing drug/devise direct marketing to the public has distorted the public's view of the safety and efficacy of these products, while considerably increasing their cost.

A possible solution to this litany of problems is to have all drug and device clinical research funded by the companies, but through the National Institutes of Health (NIH). This would ensure rigorous design, honest and timely reporting of results. We might then have more high quality information disseminated to the medical community. People with conflicts of interest at the NIH would be excluded from this activity.

Funding by the companies would also be mandated to include follow-up of all products to spot any problems that occur once the drug is available to the mass market. If problems do occur or efficacy is not proven, the FDA could immediately withdraw the product from the market.

Using this system, knowledge from rigorous scientific processes would drive the system, rather than a drawn-out legal process that also has the potential for emotional misadventure, as occurred with the silicon breast implant litigation. I also propose the discontinuance of direct advertising to the public that creates excess demand for newer more expensive products that may have no benefit over older off-patent material.

It is my hope that the leadership of the prestigious New England Journal of Medicine will expand the scope of their view to consider fundamental change to the oversight of this industry rather than a slow, extremely expensive and some times grossly inappropriate legal system. We must use knowledge and science to better treat our patients, not the courtroom.

Tuesday, July 15, 2008

The Healthcare Crisis: Can We Avoid Rationing?

As healthcare costs continue to spiral out of control, the buzz is already starting about having to ration healthcare in the future. It would boil down to providing care to those who would most benefit from it. But shouldn't it be the other way around? That is – providing only beneficial care to every patient and not pulling every expensive technological and procedural rabbit out of the hat in cases where the outcome is basically hopeless.

So what's the answer? Appropriate Care Committees. Can Appropriate Care Committees avoid the specter of healthcare rationing? My answer is a resounding yes! Let's take a look at a few of the things behind the explosion in healthcare costs.

Medicare alone is now spending over $400 billion a year, with expenses growing at an alarming rate. Congress and the President are dismayed, but haven't come up with a plan to prevent the impending financial disaster. One expert after another has said that inappropriate care is the biggest culprit in out-of-control costs - estimated at about $600 billion per year. Medicare is a large source of this problem.

So, how did all this come about. The causes are many and complex. Here are just a few.

• More and more use of expensive technology without evidence of superiority over existing methods takes advantage of lucrative quirks in the Medicare payment schedule. Some examples are proton accelerators for prostate cancer or the use of cardiac stents in patients whose conditions are just as easily managed with medication.
• Device and drug company advertising directly to the public helps promote an increasing sense of consumerism. Patients and their families have a virtual smorgasbord of drugs, devices, and procedures – all attractively packaged in the ads - that they can demand whether they'd be of any benefit or not. And, unfortunately, many physicians are loathe to say no to them.
• Medicare’s chronic under-funding of primary care and over-funding of specialists and subspecialists who perform many unnecessary procedures plays the largest role. The under-funding of primary care has nearly destroyed the old fashioned doctor-patient relationship, so there is a marked decrease in preventative care and poor management of the chronically ill.
• Medicare, in its attempt to save money, under-funds regular hospital bed care causing hospitals to emphasize expensive intensive care units and procedures which results in spending even more dollars.
• Medical societies have been reluctant or unable to enter national dialogues about important medical issues (like the Terry Schiavo case) or help set up a support system for practitioners who wish to practice high quality appropriate medicine but are afraid of lawsuits.

So here we are. Our healthcare system consumes over 17% of the gross domestic product, we spend more per person on healthcare than any other country in the world, but with worse health outcomes, and still have more than 47 million people uninsured.

What will the government do if these runaway costs are not controlled and bring our national economy to the breaking point? Enter talk of rationing. Make no mistake. It's a very real possibility.

How can we avoid rationing and maintain the ability to individualize every case? Appropriate Care Committees - system of committees on the national, state and local levels, created by Congress with the power of law behind them. These independently funded committees of physicians, nurses, and clergy would function to review various cases in hospitals and nursing homes to insure appropriate care and would have the power to withhold funding for inappropriate care. It wouldn't take long for the word to get out that inappropriate care is no longer a cash cow and the tangled billion-dollar web of who-does-what-and-why would quickly unravel and healthcare costs would plummet.

This system would also give the patient the benefit of an impartial opinion regarding appropriateness without any conflicts of interest since they would have no monetary or loyalty connections to a hospital, nursing home or physician. For the same reasons, they would provide support to physicians who want to provide appropriate care, but the patient or the families are demanding something else.

The cost saving of this system, along with changes in administrative structure (see post about the healthcare bank) could well head off the looming financial crisis that could lead to healthcare rationing.

Friday, June 13, 2008

Medicare - America’s Single Payer Healthcare System

Medicare is the single payer system for the approximately 44 million eligible citizens who are 65 years and older. Passed by Congress and signed into law by President Lyndon Johnson in July 1965, it is now in deep financial trouble. This is despite its low administrative overhead which is the proposed great advantage of a single payer system. The lesson to be learned by this experience is that low overhead alone does not guarantee adequate funding if the fundamental flaws in the health care system are not addressed.

There are two fundamental flaws perpetuated by Medicare that have so far escaped correction - the under funding of primary care and the lack of a system to prevent inappropriate care.

1) Since its inception Medicare has under-funded primary care, which has led to the continuous and progressive decline of this specialty. Starting in 1965 Medicare paid what were then the usual and customary fees for physician services. This payment formula emphasized technology and procedures while underpaying primary care. An attempt was made to correct this imbalance by instituting the Resource Based Value System in 1992. This process has also failed to adequately reimburse primary care. The result has been the continued decline of the number of physicians practicing this specialty along with shortened visits and decreased in-hospital follow up. The shortage of primary care physicians has also led to inadequate preventative care for our population. Many authors have stated that if universal coverage would somehow appear tomorrow, with the deplorable state of primary care which is the infrastructure of any nation’s medical system, the health of the nation would not improve. See my posting about the “bank”. We must correct the inadequate reimbursement for primary care.

2) There is no oversight to prevent non-beneficial care. Such unnecessary care consumes approximately one third of Medicare’s budget which translated to our entire medical system equals six hundred billion dollars yearly! See my previous posting on why we need Appropriate Care Committees.

Saturday, June 7, 2008

Overly High Healthcare Administrative Costs And A Solution

Billions of healthcare dollars go to paying the salaries of the folks who have to handle healthcare claims – both from insurance companies and Medicare. There are all kinds of different insurance policies with variations in coverage. That means that healthcare providers have to employ people who are skilled in the complexities of the various plans. In a primary care practice that might be 2 or 3 people. In a large hospital, dozens of people. The insurance companies and Medicare also have many people working for them to ensure payment goes only to covered services. All of that adds up to a lot of money in administrative costs on all sides.

I have a solution. I propose the creation of a separately chartered, independent federal agency – like the Federal Reserve system – that would be a central clearing house for our entire health care industry – public and private. Let’s call it a “Health Bank.” The Health Bank would coordinate and perform many tasks now performed by insurers and healthcare providers. It would not only simplify the system and make it more uniform, it would decrease administrative costs to the tune of billions of dollars a year. At the same time it would maintain our present mix of private and governmental insurers.

The “Bank” would:

1) convene a biannual meeting of all insurance entities to define five standardized insurance packages. The lowest cost, plan 1, would cover all essential appropriate medical services. At the other end of the scale, plan 5 would be more expensive and include extras such as podiatry, massage, health club memberships, plastic surgery, etc. Plans 2, 3&4 would be successive gradations between plans 1&5.
2) determine fees so that primary care and regular hospital and nursing home care would be adequately reimbursed, thus providing for the rebuilding of primary care. It would eliminate the need for hospitals and nursing homes to stress often unnecessary, non-beneficial technological and procedural care to maintain solvency.
3) establish a central computer system through which all billing takes place and through which all insurers are paid. Insurers would compete by coming up with innovative preventative programs such as weight control, diabetes and blood pressure control, home health services for the elderly, etc. along with price competition for the five plans.
4) maintain an electronic medical record system for the entire nation with multi-layered safeguards to insure privacy.
5) require that all hospitals, nursing homes, other health providers and insurance entities (public and private) adjust their computer programs so that all could interface with the bank’s computers.
6) fund The National Institutes of Health (our major national research endeavor) by collecting monies from all insurers, governmental and private, in proportion to the percentage of the population covered by each one. This type of research is an investment for the future and should be funded by all carriers, not just the federal government.
7) fund graduate medical education (residencies & fellowships) through funding from all carriers in proportion to their market share and make payments directly to the educational entities.
8) pay the salaries and staff of the appropriate care committee system (local, state & national). (See post on Appropriate Care Committees)
9) require all drug and device companies to fund their clinical research through The National Institutes of Health which would oversee the experimental design and the results. This would remove the conflicts of interest that exist in the present system. The Health Bank would collect and distribute the funds.
10) be funded by fees paid by all carriers in proportion to their market share. The Health Bank, like the Federal Reserve, would report to Congress on a fixed schedule.

More details of how the Health Bank would work and how it would facilitate universal healthcare coverage are in my book In Defiance of Death: Exposing the Real Costs of End-of-Life Care. You can order the book from Amazon through the link here at the blog.

Friday, May 23, 2008

The Problems with Advance Directives, Inappropriate Care and A Solution

Only about 20% of Americans have executed an advance directive and only about half of these have discussed their wishes with their physician. (1) Without one, most hospitals and nursing homes assume that the patient wishes every conceivable means of medical therapy, even if inappropriate for that particular patient. Another problem with advance directives is that it asks the person to make a decision about what type of care would be wanted at some time in the future. However, one could not possibly know what the clinical situation will be at that time.

My solution is a new style of hospital admission form. The advantages of this form and its benefit to patients, families and our society include:

1. This form would be completed at each hospital and nursing home admission and would serve as a fresh and timely advance directive. The patient/family can make a much more rational decision about which therapies are not wanted. Because admission to a hospital or nursing home is an extremely stressful time for the patient and family, the medical team can facilitate the completion of an up to date advanced directive with the patient/family at that time.

2. During the discussion about the form upon admission to the hospital or nursing
home, the physician can clarify the fact that only beneficial care can be administered but that the patient/family retains the right to refuse any or all offered treatments (if of age and sound mind). This eliminates, as much as possible, the potential of delivering inappropriate care.

3. The form would be adopted by Congress to be used for all Medicare and Medicaid patients and would create a legal framework for the appropriate care committee system. See March 1, 2008 post about Appropriate Care Committees.

4. Using this form would eliminate cardiopulmonary resuscitation (CPR) by default – that is performing CPR whether it would benefit the patient or not. CPR - the restarting of heartbeat and breathing - was first developed in the early 1960s, before Medicare, when the hospital patient population was much younger. So it was reasonable to be automatically initiated whenever there was a cardiac arrest because the patients had a more reasonable chance of survival and recovery. However, the hospital population is now much older and many are in an end-of-life situation. Despite this change in demographics the custom still remains to automatically attempt CPR, even in patients with end-stage disease despite great discomfit to the dying patient. This occurs unless a specific order is written to avoid the procedure. My proposed admission form would correct this problem by making cardiopulmonary resuscitation an ordered event to be used only in the appropriate circumstance. This would save many thousands of patients a great deal of discomfort and preserve billions of dollars of resources.

5. I have copyrighted this form so that I could insure that it be used in a constructive manner.

6. Because of the importance of this form to the reintroduction of rationality to our medical system I am asking all of you who visit my blog to download the introductory letter and the form and fax them to your Congress Person and Senators. Download the letter and the form here.
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Teno J, Lynn J, Wenger N, et al. Advance Directives for Seriously Ill Hospitalized Patients: Effectiveness with the Patient Self Determination Act and the SUPPORT Intervention. SUPPORT Investigators Study to Understand Prognosis and Preferences for Outcomes and Risk of Treatment. Journal of the American Geriatrics Society 1997;45:500-507 (PMID 9100721)

Thursday, April 24, 2008

Can Medical Ethics Taken to the Extreme be Detrimental?

I believe it can. Here’s a recent example.

An 18-month old child with a rare and always fatal disease had been on life support in a Texas hospital for five months. The Texas physicians, with the agreement of the hospital ethics committee wanted to discontinue life support because the child had no chance of recovery. His death was imminent and certain. Texas has a Futility Law that provides for a limited time period before the hospital, with the agreement of the ethics committee, can discontinue all but supportive care. His mother wanted life support continued and with the help of others, appealed to the courts to prevent the Texas Futility Law from being activated in this case. The child died before the judge’s final ruling.

Dr. Robert D. Truog, Professor of Medical Ethics and Anesthesia (pediatrics) Harvard Medical School, wrote about this case in a perspective article in the New England Journal of Medicine. (1) In Dr. Troug’s view, since the child was severely neurologically impaired and could not perceive pain, the doctor’s claim that he was having a painful death was not valid. But what about the indignities suffered by this child with feeding tubes, constant IVs, multiple blood tests and the ventilator tube to keep him breathing? The physician’s concern about the dignity of the child’s death was of little concern to Dr. Troug, the child’s mother and others who joined in the legal battle.

These are extremely unfortunate and painful situations that require delicacy and understanding, but I believe, must be addressed with a sense of reality. If, indeed, the total weight of medical knowledge shows that a patient will not benefit from therapy, then providing such therapies because of patient/family demands, means physicians are not to express or develop judgment, but must rather use their skills as technicians at the bidding of others.

There is no doubt that some form of due process should be in place to insure against human misjudgment and provide fairness to the patient/family. But Dr. Troug’s view that the judicial system is the only source of due process is an extreme view that says honesty and fairness is impossible in a medical setting. I share Dr. Troug’s respect for the need to be fair to minority views, but that fairness does not, in my opinion, extend to family desires that are totally inconsistent with the reality of the situation. This is just the sort of situation that would benefit from a nationwide system of appropriate care committees (See my March 1,2008 post about Appropriate Care Committees for more details.) The courts are not the places to decide medical issues.

Dr. Troug’s conclusion that physicians are incapable of dealing kindly but appropriately with end of life situations along with ill-conceived judicial opinions (2), have had a serious negative impact on American medicine. This has led to over 550,000 deaths in ICUs yearly with its overuse of technology and procedures, lack of spirituality at tremendous cost to our society (3).

In my opinion, physicians must learn how to deal fairly with the many difficult and sometimes tragic situations they confront on a daily basis, but cannot relegate conflict to others, especially to the courts. Doctors must learn to use the profession’s ever increasing treatment options wisely for the benefit of their patients and for our society. A family’s demand for treatment does not relieve the physician of responsibility to deliver care within the confines of medical knowledge and with the best interest of the patient at heart.
1. Troug, RD. Tackling Medical Futility in Texas. New England Journal of Medicine 2007;351:1-3 (PMID 17611201)
2. Annas, GJ. Asking the courts to settle standard of emergency care – the case of Baby K. New England Journal of Medicine 1994;330:1542-1545 (PMID 8164726)
3. Angus, DC, Barnato AE, Linde-Zwirble, WT, et al. Use of intensive care at the end of life in the United States: an epidemiologic study. Critical Care Medicine 2004;32:638-643 (PMID 15090940)

Friday, April 4, 2008

The Health Care Mess - Medical Society Responsibility

The American College of Physicians (ACP) recently presented an elegant model of primary care in the Annals of Internal Medicine. (1) They also made other suggestions that would greatly improve health care in The United States. What they failed to do, however, is discuss why primary care is in such a shambles and what their role should be as a professional organization. Primary care is the backbone of any successful health care program. Patients and their primary care physician – what we used to call the family doctor – can build relationships that bring much better care in the long run. Why? Because the primary care physician knows the patient as a “person” not just a jumble of symptoms and diseases. That’s of the utmost importance when it comes time to make decisions about care, and for a physician to use judgment about what’s appropriate for a particular patient.

Approximately one-third of care is inappropriate to the tune of $600 billion dollars a year. (2) That’s a lot of money that could be directed to primary care, provide universal access and make our health care system less of a burden on our economy. The ACP should take a leading role in addressing the excessive use of technology that frequently does not benefit the patient, particularly patients at the end of their lives. (3) If the primary care system was strong, there would be a vital link between the patient and the hospital that would facilitate much better decisions about what would be in the patient’s best interest.

The plain fact is that hospitals and physicians make more money with expensive procedures whether they help the patient or not. A classic example is using coronary artery stents in patients in whom medications alone are equally efficacious. (5) The growth of specialty hospitals and procedurists is a result – not more physicians practicing primary care. At this time there’s just not enough prestige and money in it.

Most of the overuse of technology and procedures occurs in large teaching hospitals. (4) What kind of message does this send to young physicians in training? Does it teach them to build relationships with their patients? To use their judgment to decide what would benefit a patient the most? Or does it teach them to throw every procedure they can into the mix and bill handsomely for it?

Medicare has attempted to adequately fund primary care. However, because of the excessive funding for specialists and procedures, their efforts have failed. (6) If the American College of Physicians is serious about its goal of excellent primary care for all, then it must take an active role in promoting the appropriate use of our medical resources. Only with a return to a strong primary care system will we see good preventative care and the delivery of appropriate treatment for everyone.
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1. Public Policy Committee of the American College of Physicians, Ginsburg JA, Doherty RB, Ralston JF Jr. et al. Achieving a high-performance health care system with universal access: what the United States can learn from other countries. Annals of Internal Medicine 2008;148:55-75 (PMID 18056654)
2. Garson A Jr., Engelhard CL. Health Care Half Truths; Too Many Myths, Not Enough Reality. New York: Rowan and Littlefield; 2007, Page 17
3. Barnato AE, McClellen ME, Kagay CR, Garber AM. Trends in inpatient treatment intensity among Medicare beneficiaries at the end-of-life. Health Serv Res 2004;39:363-375 (PMID15032959)
4. Fisher ES, Wennberg DE, Stukel TA, Gottlieb DJ, Lucus FL, Pinder EL. The implications of regional variations in Medicare spending, Parts I&II. Annals Intern Med 2003;138:273-298 (PMID 12585825 & 12585826)
5. Mitka M. Cardiologists get wake-up call stents. JAMA 2007;297:1967-1968 (PMID 17488954)
6. Ginsburg PB, Berenson RA. Revising Medicare’s physician fee schedule – much activity, little change. N Engl J Med 2007;356:1201-1203 (PMID 17377156)

Tuesday, March 4, 2008

Appropriate Care Committees

No healthcare system, Universal or otherwise, can be efficient, cost effective, and truly serve the best interests of patients without oversight. I’m talking about consistent, uniform, organized oversight by senior physicians, nurses and clergy rather than bureaucrats and accountants who have no knowledge or experience in the practice of medicine. I’m talking about a system of Appropriate Care Committees organized at the local, state and national level created through Congressional action to put the power of the law behind it.

Organized, well-planned action to create uniform Appropriate Care Committees will shift the decision-making to those who know best. It will also be the key to addressing the issues that have gotten our healthcare system in such a mess in the first place. Issues like ICU over-use, especially in end-of-life situations, coronary artery stent over-use, shuttling nursing home patients back and forth from nursing home to hospital even though they cannot benefit from hospital care and need to be in hospice instead, would all fall under the review of Appropriate Care Committees.

I envision a committee in every hospital and nursing home in the country. This committee would be made up of senior physicians, nurses and clergy. It would have the power to cease payment for care that offers no benefit to the patient, and mediate disagreements between admitting physicians and families over options for care. The family could appeal to the committee which would review the case and make a decision based on medical evidence and the individual needs of the patient. This would be particularly beneficial in end-of-life cases where there is wide spread use of non-beneficial procedures and treatment when hospice would be the most appropriate and humane option.

Senior physicians, nurses and clergy would also staff the statewide committee. It would handle appeals from local committees, and oversee the appropriate care committee system within that state. These appointments would be salaried, therefore committee members would have no financial interest in their decisions, These salaries would be paid for by a consortium of all insurers.

A national committee, also composed of senior physicians, nurses and clergy, would oversee the entire system for the nation. National appointments would be similar to those of The Federal Reserve Bank. State and local committee nominations would follow guidelines established by the national committee in concert with individual state medical societies.

Many physicians would object to the system, thinking that it would interfere with their autonomy and could threaten their income. Many others, however, would embrace it for three reasons:
1. It would reintroduce the primacy of the patient-doctor relationship, especially for the primary care physician. It save more than enough resources so that primary care can be adequately compensated.
2. It would provide back up for the physicians who truly try to do their best for their patients, but now have to concern themselves with legal and economic issues.
3. Most physicians believe the present healthcare system needs reform because of excessive costs, lack of care for millions of our citizens, the public's dissatisfaction with the system and our less than stellar health outcomes compared to other developed nations.

There will be oversight. Make no mistake about that. The question is: do we want oversight from non-medical bureaucrats and accountants who are hundreds of miles away making crucial healthcare decisions about what’s appropriate and what’s not? It’s already happening in fits and spurts with Medicare and some insurers, and it’s a patient’s and physician’s worst nightmare.

Sunday, February 17, 2008

Robbing Peter to Pay Paul-The Fall of Primary Care and the Rise of Technology Medicine

If Peter is the primary care physician then Paul is the obsession we in American medicine have with technology and procedures, which frequently are of no benefit to patients. Technology used wisely can be wonderful, but when used inappropriately is potentially harmful to the patient and wasteful of resources. Perhaps the most painful example of this obsession is in end-of-life care, typified by the recent publication of articles extolling the virtues of end-of-life care administered in the intensive care unit (ICU).(1)

Some of the many reasons why the concept of knowingly providing end-of-life care in the ICU is inappropriate are:

1) Once it has become obvious to the ICU team that an end-of-life situation is at hand, the patient needs symptom control and along with the family, spiritual support. However, ICU care is technology intensive, with an inherent inability to eschew that technology regardless of its appropriateness. This was admitted by the authors of the above quoted article in their response to my letter. (2)

2) Certainly there are much better venues able to provide spiritual support than an intensive care unit with its hustle-bustle and crisis like atmosphere.

3) Energies expended by the medical care team on end-of-life patients in the ICU are not spent on other patients who have the capacity to improve and for which ICUs were developed.

4) The difference in cost between end-of-life care in a regular hospital bed and the ICU is staggering. (3) Some ICU doctors argue that fixed costs (nursing and equipment) in the ICU are such that decreasing the number of patients would not result in savings. (4) However, fixed costs would be decreased if patients who should be in hospice were not admitted to the ICU. Unfortunately hospitals have become mesmerized and addicted to this additional income!

But where is the primary care doctor in this situation, the physician the patient and family has learned to trust over the years and should guide patients during tough times? There is no mention of her/him in the ICU literature and from a national perspective because of severe financial constraints, primary care is in crisis. (5) This ICU scenario is a microcosm of our medical system. Technology is frequently used inappropriately, patients do not receive the care they need, patients who would benefit from more attention do not receive it because of diverted efforts, and the medical system pays exorbitantly for services that cannot accomplish a worthwhile goal. Because of the huge amount of funds going for nonsensical technology and procedures, primary care, the cornerstone of any nation’s health system, withers on the vine. This is a national disaster that must be addressed before our health care system can deliver adequate care to all our population. In future articles, I will discuss a physician based appropriate care committee review system with financial authority on the local, state and national level, to address patients on an individual basis. This would go a long way to solve this problem.
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1. Lautrette A, Darmon M, Megarbane B, et al. A communication strategy and brochure for relatives of patients dying in the ICU. New England Journal of Medicine, 2007;356:469-78. (PMID 17267907)
2. Fisher KA. Communication about dying in the ICU. Letter to the editor. New England Journal of Medicine, 2007;356:2004 (PMID 17506162)
3. Angus DC, Barnato AE, Linde-Zwirbl WT, et al. Use of intensive care at the end-of-life in the United States: an epidemiologic study. Critical Care Medicine, 2004;32:638-43. (PMID 15090940)
4. Luce JM, Rubenfeld GD. Can health care costs be reduced by limiting intensive care at the end-of-life? American Journal of Respiratory Critical Care Medicine, 2002;165:750-4. (PMID 11897638)
5. Public Policy Committee of The American College of Physicians. Achieving a high performance health care system with universal access: what the United States can learn from other countries. Annals of Internal Medicine, 2008;148:55-75 (PMID 18056654)

Thursday, February 7, 2008

Universal Health Care: What’s Wrong with This Picture?

Survey results in a recent article in the New England Journal of Medicine(1) show Democrats and Republican have very different views about our health care system. Democrats are not happy with the system and want universal coverage, even if it means more government involvement and higher spending. Republicans, on the other hand, are more satisfied with our present system and are more concerned with controlling costs. They favor private insurance solutions and tax breaks to decrease the number of uninsured people.

Both sides miss the point. The question is not how to finance our health care system. The question is why do we spend more money per person than other developed country, but still have more than 47 million people uninsured and lower life expectancies? Current health care costs are running around $2 trillion a year – about $7 thousand for every man, woman and child.

The reasons for this are not difficult to understand. Some of our excess costs are attributable to higher prices for medical goods and services and considerably higher administrative costs. But the big problem is our technological and procedural style of medicine, fostered by the reimbursement system of Medicare and other insurers. We pay for procedures and not for clear thinking. There are several reasons for this, and I’ll examine each of them in detail in future posts.

1. Primary care (family doctor, general internist and pediatrician) has been under funded for decades, resulting in an acute shortage of primary care physicians. The old-fashioned doctor/patient relationship that provided critical insights into individual patient care is virtually non-existent.

2. There is no system of physician oversight in either hospitals or nursing homes to make sure that patients are receiving only beneficial care and not care that means a bigger tab to bill the insurance companies or Medicare/Medicaid, without any real advantage for the patient.

3. There are no controls on drug and medical device manufacturers in terms of research validity and funding, lobbying Congress to approve their products for Medicare/Medicaid coverage, or advertising their wares to the public.

4. End-of-life care in large teaching hospitals is more costly, yet the death rates are higher. There is more emphasis on expensive high-tech procedures, whether the patient will benefit or not.

Approximately 17% of gross domestic product now goes to health care. That’s a significant drag on our economy, especially when compared to other countries. There is no question we need universal coverage, but to get it without bringing our economy to its knees we must change the way we practice medicine.
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(1)Blendon RJ, Altman DE, Deane C, Benson JM, Brodie M, Buhr T. Health Care in the 2008 Presidential Primaries. New England Journal of Medicine, 2008;358:414-422 (PMID 18216365)