Monday, December 14, 2009

Cardiopulmonary Resuscitation

In my book, In Defiance of Death: Exposing the Real Costs of End-Of-Life Care, I discussed the uses and abuses of in-hospital cardiopulmonary resuscitation (CPR). This procedure involves attempting to restart the heart after it has stopped beating. I quoted a paper that found only 10.5% of these patients were alive one year later. I mentioned that if we could decrease the number of resuscitations in half, by excluding those patients with known terminal disease, not only would we save dollars, but more importantly we would allow thousands of patients to have a more dignified and peaceful death.

I quoted Dr. Blackhall who, in The New England Journal (1987), discussed the concepts of patient autonomy and physician responsibility. Basically, he said that if the medical assessment is that CPR has even a remote chance of success it should be offered and the patient with autonomy has the right to refuse the procedure. However, if there is no chance of success, physician responsibility would dictate that CPR should not be done regardless of the wishes of the patient/family. In these situations Dr. Blackhall concluded that both patient and physician must understand that modern medicine cannot indefinitely postpone death.

I also pointed out that since the early 1960's CPR is performed in the hospital as the default position unless there is a specific do not resuscitate order (DNR). This frequently leads to confusion, with CPR being attempted in the majority of cases when it is obvious that it would not be successful. This is the reason that a small percentage of patients receiving CPR leave the hospital alive and fewer still are alive a year later. I suggested a new hospital admission form that would make CPR an ordered event and create an updated advanced directive with physician input to ensure medical feasibility. I also suggested an appeal mechanism in cases of misunderstandings or differences in opinion.

So what is the latest data? Are we using CPR more or less wisely? Dr. W.J. Ehlenbach and colleagues recently published results using Medicare data (reimbursement codes) from 1992-2005 in the July 2, 2009 New England Journal of Medicine. They found 18.3% of CPR patients left the hospital alive. There was no increase in the survival rate over this time course. They found an incidence of 2.73 CPR attempts per 1000 Medicare hospital admissions with survival less for men, the most elderly, those with co-existing disease and those admitted from skilled nursing homes. Strikingly they found that the proportion of patients dying in the hospital having undergone CPR actually increased during this time period. Fewer survivors of CPR were discharged home over the course of the study. People of African descent had higher rates of CPR but with less survival.

Is it just CPR that is now being increasingly used more inappropriately, or is it a reflection of the present style of medicine in this country? In my mind there is no doubt that it is a reflection of our present medical culture. There are presently no mechanisms whereby physicians collectively attempt to use our ever-expanding medical arsenal in an individualized rational manner. We presently have a business model in what is fundamentally a non-business enterprise. These are some of the reasons why we spend much more per person than any other country, have millions uninsured and inferior outcomes. Until these and other basic problems (i.e. lack of primary care, the politically driven Medicare payment system) are addressed, I believe our present attempts at health care reform will be unsuccessful.

Friday, December 4, 2009

Patient Knowledge Versus Consumerism

Patient education is a component of good health care. Patients should know how to stay healthy and, if necessary, care for disease processes. However, when health care becomes like any other consumer item, the whole process becomes distorted. Unlike consumer products today’s medicine is extremely complex with real limitations as to what can be accomplished. Ignoring these limitations leads to excessive testing and treatments, i.e. consumerism.

It is advantageous for a patient working with a trusted physician to understand the necessity to control blood pressure, control diabetes, control weight and eliminate harmful habits (tobacco, alcohol, illegal drugs, violence, etc.). Every literate American has access to abundant sources of information regarding health issues. Unfortunately, because of dysfunctional reimbursement policies, driven by Medicare as the nation’s largest insurer, for many patients there is little quality time between physician and patient. It then becomes difficult to develop the healing relationship so important for good health care. Frequently patient education develops into unrealistic beliefs in the power of medicine with inappropriate expectations leading to consumerism. In complex situations in patients with multiple health issues there is no substitute for medical judgment. This can only be obtained with formal training and years of experience.

Indeed it takes more training to take care of seriously ill patients than to fly a jet liner. Yet it is inconceivable that a jet pilot when facing a problem, instead of using his experience and judgment, would have the passengers vote on what to do. However, unlike the pilot, in today’s medical practice it is common for physicians to place the task of medical judgment on the patient/family frequently resulting in irrational care. This often leads to patient suffering and the wasting of valuable resources.

This exaggerated sense of patient autonomy along with the fear of legal action has augmented medical consumerism. This problem has been enhanced by drug and device advertisements directly to the public and by the medical profession’s undue reliance on the legal system to decide what are, in effect, medical questions. Instead of our various medical societies forming referral mechanisms to help decide difficult issues, hospitals and doctors have abdicated this responsibility to the courts with the result being an ever-present fear of legal action.

As long ago as October 16, 1975 Dr. Franz Ingelfinger, then editor of the New England Journal of Medicine, wrote about physicians allowing the legal community to be the referee in difficult medical issues. He wrote:
“Serious questions may also be raised concerning the propriety or usefulness of legal proceedings when essentially medical questions are at issue…..dependence on the lawyer in reaching essentially medical decisions will continue, however, unless organized medicine can develop its own effective system of in-house arbitration…..”

It should be noted that till this day our medical societies have not answered this challenge. Again, in May, 1994 (New England Journal of Medicine) while discussing the Baby K court case, an encephalic baby with no chance of recovery, George J. Annas had a similar message. He commented that for medicine to avoid becoming a consumer commodity and thus unbearably expensive requiring control by payers, physicians will have to set standards and follow them. Again organized medicine did not and has not responded.

A few weeks ago (November 2009) a talented second year resident told me that, in his opinion, American medicine is no longer about treating patients’ problems. It has become a hospitality industry focused on customer satisfaction regardless of the appropriateness of the medical plan.

For health care reform to be successful we have to insist that our medical societies set up procedures so that patients are treated as individuals, each with unique needs. At the same time mechanisms must be established so that we uniformly practice high quality medicine with evidence-based use of resources. We must have expanded peer review so that difficult situations and overuse can be quickly resolved using medical experts.

Friday, November 20, 2009

When will we face the real issues?

An obsession with technology coupled with consumerism has led to the excesses so evident in today’s practice of medicine. An excellent example was recently published by F. Knauf and P.S. Aronson, ESRD As a Window into America’s Cost Crisis in Health Care, Journal American Society of Nephrology 2009; 20:2093-7, which describes how nephrology (kidney) treatments are now being applied far in excess of the original indications.

Kidney dialysis and transplantation first became available in the early 1960s. Because of cost, most people were excluded from these life saving benefits. To meet this public need, the Bureau of the Budget created a committee headed by the highly regarded nephrologist, Carl Gottschalk. This committee submitted their report in 1967 calling for federal funding to make dialysis and transplantation available through Medicare to all Americans. In 1972 this concept was approved by Congress.

The Gottschalk committee proposed that dialysis would be limited to otherwise healthy people mostly under the age of 54 years. Thus it was anticipated that dialysis or transplantation would be appropriate in 1 of 5 patients with ESRD (end stage renal disease). Maintaining these criteria would add about 40 patients/million population to the dialysis and transplantation cohort yearly. But now that number is about 400/million, with patients over the age of 75 the fastest growing sub-group, most with serious co-existing diseases causing an increase in patient suffering, hospitalization rates, and a dramatic increase in costs.

Is this good medicine? Does this liberalization of criteria lead to better medical care? Data clearly demonstrate that older patients who are non-ambulatory or with other co-morbidities frequently die in the hospital rather than in the community while receiving little or no benefit. Another recent paper in the New England Journal of Medicine, 2009:361; 1539-1547, demonstrated that nursing home patients, after one year on dialysis, have a death rate of 58 percent and a significant decrease in an already limited functional status. Instead of the careful and thoughtful use of technology mixed with insight and compassion, we in America seek an inappropriate technological solution no matter how great the evidence that it will not be beneficial. Thus, the only pathway to successful health care reform is to develop mechanisms to alter the present medical culture. The approach should be based on the individual characteristics and needs of each patient.

Unfortunately the present plans for health care reform do not in any way address these basic problems. As stated in a recent (Nov. 16, 2009) op-ed essay in the Washington Post by Robert J. Samuelson,
There is an air of absurdity to what is mistakenly called "health-care reform." Everyone knows that the United States faces massive governmental budget deficits as far as calculators can project, driven heavily by an aging population and uncontrolled health costs. As we recover slowly from a devastating recession, it's widely agreed that, though deficits should not be cut abruptly (lest the economy resume its slump), a prudent society would embark on long-term policies to control health costs, reduce government spending and curb massive future deficits. The administration estimates these at $9 trillion from 2010 to 2019. The president and all his top economic advisers proclaim the same cautionary message. So what do they do? Just the opposite. Their far-reaching overhaul of the health-care system -- which Congress is halfway toward enacting -- would almost certainly make matters worse. It would create new, open-ended medical entitlements that threaten higher deficits and would do little to suppress surging health costs. The disconnect between what President Obama says and what he's doing is so glaring that most people could not abide it. The president, his advisers and allies have no trouble. But reconciling blatantly contradictory objectives requires them to engage in willful self-deception, public dishonesty, or both.

There is no doubt that this country needs health care reform that addresses our aberrant medical culture. There certainly is no sign of that at this time.

Saturday, November 14, 2009

The Health Care Crisis: Lack of Resources or Sick Medical Culture?

Health care in the U. S. consumes 17% of gross domestic product (GDP). That’s $7000/person - about one and one-half times more than the next most expensive nation (Switzerland). Costly health care means costly health care insurance. Businesses that provide health insurance for their employees make up for the ever-rising costs by raising the price of goods and services and laying off workers. We lose jobs and lose our competitive edge in global markets. Those people not covered by employers or those out of work drop their insurance because they simply can’t afford it. That means more and more people added to the tens of millions already without insurance or who are grossly under-insured. And for all that high-cost medical care, our health outcomes in many categories are dismally inferior to other industrialized nations. That is definitely not a good return on the investment!

So, who is responsible for health care delivery? Who decides what procedures and treatments will be done? These decisions play an enormous role in health care costs. In the September 24, 2009 issue of the New England Journal of Medicine, the former editor of that journal, Dr. Arnold S. Relman, writes:
Doctors, in consultation with their patients – not insurance companies, legislators, or government officials – make most of the decisions to use medical resources, thereby determining what the Unites States spends on health care.

This being the case, why are doctors spending so much with such unacceptable results? Multiple sources suggest that about one-third of all health care spending is non-beneficial. Presently doctors deliver disjointed, overly technological, irrational care for several reasons.

1. As documented by the Dartmouth Atlas of Health Care, our major teaching centers, where costs for the same diseases vary from center to center, emphasize specialists delivering expensive technology while de-emphasizing history taking, physical exam and wise use of resources. This has taken place in large part, because Medicare reimbursement emphasizes technology rather than thinking.

2. We have a critical shortage of primary care doctors. This is largely a result of Medicare payment policies. Primary care doctors earn significantly less than specialists while having to see 30-40 patients per day. This makes a meaningful patient-doctor relationship virtually impossible and keeps young doctors from entering primary care.

3. The public is overly demanding and confused because of drug and device advertising and the recent over-emphasis on patient autonomy. They often demand procedures or treatments that are costly, but non-beneficial, and doctors are reluctant to refuse for fear of malpractice suits.

The Massachusetts universal health care experiment is a shining example of what can happen when you throw money at symptoms (millions uninsured) without treating the disease (lack of effective physician oversight). This state now has big problems with access and high costs causing extreme budgetary distress. Sadly, Capitol Hill is headed down the same road.

Sunday, October 4, 2009

Is Fee-For-Service the Reason for Our Excessive Health Care Spending?

The evidence is overwhelming that we, as a nation, do not practice efficient medicine. We spend about twice as much per person as any other country yet have many millions without adequate health care. It is becoming obvious that physician practices are a major component of this excess spending. Many experts refer to the non fee-for-service centers such as The Mayo Clinic, The Cleveland Clinic, The Geisinger Clinic and others as examples of efficiency and state that fee-for-service medicine is the major driving force for our excessively expensive medical care.

I do not doubt that fee-for-service is a component of this problem, but are there other factors that are equally if not more important? After all, The Dartmouth Atlas of Health Care has demonstrated that many areas with large university medical centers with medical staffs on salary spend much larger amounts for the same conditions than the most efficient centers. And where are the big physician profits in medicine, in professional fees, i.e. Medicare part B or in facility fees, i.e. Medicare part A? There is no doubt that the big profits come from ownership and not professional fees. Thus many question the propriety of physicians profiting from facilities to which they refer patients. This has nothing to do with fee-for-service. Other factors include:

1) The mistaken belief by many that limiting non-beneficial care is rationing.
2) A fascination for glitzy buildings and fancy machines, leading to real excess.
3) Public demand heightened by drug and device advertising via the mass media.
4) A Medicare payment system that emphasizes expensive machinery at the expense of person to person patient-physician time.
5) Organized medicine’s inability to articulate to the public:
a) what is rational health care?
b) the importance of history and physical diagnostic skills of physicians, skills that are now being de-emphasized in favor of various expensive tests.
c) lack of a concerted effort to promote a more equitable and realistic tort system.

Thus, although fee-for-service may entice some, if not many, physicians to do something extra, it is only part of a much more complex problem. The culture of intensive peer review at The Mayo Clinic and the other efficient medical centers may indeed be the secret of their success, rather than the lack of fee-for-service.

Wednesday, September 23, 2009

The Validity of the Dartmouth Atlas for Health Care

Some authors have asserted that the waste in our health care system based on the Dartmouth Atlas of Health Care is incorrect. The Dartmouth Atlas uses Medicare data from different regions in the United States comparing the cost of care. The assertion is that if high cost regions spent the same as low cost regions for all patients the savings would amount to about $700 billion per year. Critics question this for many reasons:

1) Medicare data does not include non-Medicare patients for which the results could be quite different.
2) Many expenses for Medicare patients are paid for out-of-pocket and supplemental insurance and thus would not be included in the Dartmouth Data.
3) Medicare reimbursement rates vary by region with some low cost regions receiving high cost region reimbursement because of political influence.
4) Hospitals with more private well-insured patients can more readily cross-subsidize their losses from the Medicare reimbursement schedule and thus are less likely to prescribe more procedures.

So does the Dartmouth Atlas of Health Care using Medicare data reflect on how medicine is practiced for all patients or does it give a false sense of what can be saved by having all regions become low cost? Fortunately there is a completely different assessment of the spending for health care per person in the United States versus many other countries. The McKinsey & Company December 2008 Health Care Report compared the amount spent/person versus gross domestic product. Their conclusion, “The U.S. spends far more on health care than expected even when adjusting for relative wealth”. The estimated excess was about $700 billion. It is to be noted that these other countries have better health outcomes than those in the U.S.

Thus the conclusion is inescapable: doctors in other countries take better care of their patients at significantly less cost. They rely more on history, physical diagnosis and clinical judgment and less on expensive tests. I believe the time has come for physicians in this country to assume their share of the responsibility for our excess health care expenditures.

Tuesday, September 1, 2009

Towards a Rational End-of-Life Policy

We have recently witnessed an intense controversy over end-of-life counseling. Deep inside the Congressional House Health Care Reform Bill was a section paying physicians to have end-of-life discussions with patients at least every five years. To be generous it was meant to be helpful. To be cynical it was an attempt at cost saving. Opponents to the proposed legislation exaggerated its intent using inflammatory rhetoric which made headlines but added little to nothing constructive towards a thoughtful discussion of a very sensitive topic.

The medical advancements available to maintain bodily functions (such as heart beat) beginning in the 1970’s caught our entire society ill-prepared. Two famous cases illustrate this point.

1) In 1975, 21 y/o girl Karen Ann Quinlan suffered anoxic brain damage (not enough oxygen), causing irreversible and complete loss of her cerebral cortex. The cerebral cortex is the humanized part of the brain responsible for consciousness, thinking, awareness, speech, purposeful movement, and all other human traits. She was kept “alive” by artificial means. Karen’s father wanted to remove a breathing machine realizing she was irretrievably lost as a person. He was vigorously opposed by her physicians, the local prosecutor and the New Jersey Attorney General. This opposition was most unfortunate considering Karen’s loss of humanness. Physician opposition to removing the respirator help created the image of physicians as irrational purveyors of technology regardless of the potential for benefit. This does not absolve agents of the state who were also complicit in this irrational use of technology. It took the New Jersey Supreme Court to give the father authority to remove the respirator.

2) A similar crisis arose in 1983 when 25 y/o Nancy Cruzan also suffered anoxic brain damage and irreversible loss of her cerebral cortex because of an automobile accident. She was kept “alive” in a state hospital via artificial nutrition although her parents, realizing recovery was impossible, wanted cessation of all therapy. The conflict which arose between the state and the parents was resolved by the U.S. Supreme Court which in 1990 ruled that a competent person could refuse artificial means to sustain her/his life. A corollary to this is that a competent patient can refuse any or all therapy. Shortly thereafter friends of Nancy testified that she would not have wished this kind of treatment. Life support was removed and she ceased to exist shortly afterwards.

Later, in 1990, Congress, as part of budget legislation, passed the Patient Self Determination Act that became the authority for states to initiate advanced directives. Missing from the act was the phrase, “Within the boundaries of good medical practice”. Thus the imperative of knowing the medical feasibility of any desired treatment was missing.

There is a voice missing from this abbreviated synopsis. What is the opinion of physicians and their medical societies on this issue? Their silence was and still is deafening! Should not the fact that complete and irreversible loss of all human functions enter into the decision process, especially when there is medical certainty that for this individual there is no chance of recovery?

Unfortunately cost considerations are mentioned by some when discussing this issue. However, many more important principles are at hand.

1) It is unethical to have a human body decompose in a hospital bed with absolutely no chance of recovery in the name of medical care.
2) The doctors, doctors-in-training and nurses become desensitized to human suffering perhaps lasting their entire careers if they participate in de-humanizing non-beneficial care!
3) Training young physicians and nurses to have the skills to provide futile care takes away from learning more important humane skills such as tolerance, kindness, empathy and physician-patient communication.
4) Families while experiencing great stress are forced to make decisions regarding the continuation of care in situations where further care is only prolonging death.
5) Advanced directives created at any time in the past and without physician input as to what is feasible are at best problematic and at worse deceiving. I suggest that a new admitting form be routine at every hospitalization to determine patient desires and medical feasibility.

In summary, for this nation to develop a rational end-of-life policy it must be based on human need, realistic expectations and devoid of any financial considerations. It must be policy that if there is any chance of recovery there should be no consideration of cost.

Wednesday, August 12, 2009

Hidden Insight in the Dartmouth Atlas of Health Care

Many quote the Dartmouth Atlas of Health Care ( as suggesting we spend about $700 billion/year on inappropriate non-beneficial care. This approximate number is also supported by the McKinsey Global Institute which demonstrated that other industrial nations spend more per person on health care as their gross domestic product (GDP) increases. They made a graph plotting spending per person on the Y-Axis versus GDP on the X-Axis. The result is a tight curve with all countries bending upward toward the right except for one country that is way above the curve. That country is ours, the United States with excess expenditures of about $700 billion/yr. It should be noted that our results in healthy lives are among the worst.

The Dartmouth map demonstrates that the sites spending the most with no additional benefit, with a few notable exceptions, are our major teaching centers. In the need to perform procedures to generate the necessary cash to cover their considerable overheads, these centers are training our young doctors to do, not to think! It is startling to realize that seats of learning have abandoned their basic principles under their need to tout the latest gadgets to attract patients and meet their needs for funds. Our major medical centers are in a technological arms race with each other. They are in competition for cases that need intensive care units, complex testing and therapies requiring ever increasing expensive technologies. Many great things are accomplished for many patients. However, the ability to discern who will or will not benefit is being lost in many of our great institutions. That is the hidden secret of The Dartmouth Atlas of Health Care.

In the Sunday July 26, 2009 New York Times David Leonhardt wrote, “Even when doctors order costly treatments with serious side effects and little evidence of their being effective, as studies find is common, patients are loath to question the decision. Instead of blaming such treatments for the rising cost of medicine, many people are inclined to blame forces that health economists say are far less important, like greedy insurance companies or onerous malpractice laws”. I believe it would be beneficial if our political leaders would read and reread these words.

Physician fees have to be adjusted on an individual case by case basis. The cardiologist who gets up at 3:00 am to do a cardiac catheterization and stenting for a patient in the midst of a heart attack is doing a fine service saving heart muscle and should be well compensated. The same cardiologist who at 10:30 am is doing the same procedure on a patient with stable mild chest pain (angina) should not be reimbursed because medical therapy has been shown to be equally effective, thus the need to individualize each case.

My suggestion to address this issue of appropriateness is thorough peer review. This review would have as one of their functions, sporadically reviewing cases for the appropriateness of their care. After an initial warning, payment would be withheld for care deemed non-beneficial. Doctors and hospital administrators are smart; they would quickly learn to limit their inappropriate non-beneficial care. Some of the saving could be used to reform the Medicare payment schedule to hospitals so that the massive cost shifting now taking place (see posting The Mayo Clinic: A Model for Appropriate Care, But Can it Survive as Such) need not occur.

Monday, August 3, 2009

The Health Care Debate: the Best and Worst of Our Political Culture

We see unfolding before us the present day political process, trying on the one hand to better our society while at the same time paying off multiple parties to make it happen. The paying off does not stop at the federal trough; it also involves huge amounts of monies paid to various legislator’s campaign funds to secure a favorable outcome for those special interests.

First the good:
1)Many decent hard working people are without health insurance which if illness strikes causes extreme financial and emotional hardship along with delays in obtaining care. Any thoughtful society would want to rectify this situation.

2)We as a nation spend much more per person for health care ($7,000 for every woman, man and child) than any other country yet have multiple millions uninsured with comparatively poor outcomes. Additionally our excessive share of gross domestic product devoted to health care (presently 17%) compared to other nations has caused us to loose global market share causing the loss of high paying manufacturing jobs along with decreased take home pay. There is no doubt that our high health care costs must be addressed.

Now a few examples of the bad:
1)The organized medical community, instead of taking any responsibility for the way physicians practice today with excessive reliance on technology while de-emphasizing history taking, physical diagnostic skills and integrative thinking, support health care reform as long as across the board physician payments are not curtailed. As of now, to decrease Medicare costs every year Congress threatens to make across the board decreases in doctor reimbursement. Every year the medical establishment lobbies against these cuts and in the eleventh hour they are postponed to the following year. Now to gain medical society endorsement the administration has proposed to eliminate this yearly struggle and not decrease doctor reimbursement with the result being medical society support for passage of health care reform. Instead these societies should be offering to seek a mechanism to decrease/eliminate non-beneficial care (now totaling about $700 billion/year) and maintain reimbursement for appropriate care. The idea is that people are not widgets and need evidence based care individualized for every situation. Tailoring the right care for every person should be the mantra for physician societies.

2)We are witnessing a Congressional lobbying bonanza. The New York Times (August 2, 2009) reported that the pharmaceutical industry alone has recently spent $68 million lobbying Congress. Key legislators are having massive contributions to their re-election campaign funds. There are estimates that over 300 lobbyists are at work costing various stake-holders millions per day.

We need oversight in our medical system, not by third party payers, not by accountants, not by government, but by senior medical personnel reviewing cases, resolving conflicts and insulating physicians from the threat of legal action.

We need medical system reform that will immediately decrease costs by eliminating non-beneficial care while providing the framework for delivering excellent care at a reasonable cost regardless of how physicians are reimbursed. We need health care reform that serves our nation and not designed to serve those who lobby the most.

Saturday, August 1, 2009

The Mayo Clinic: A Model for Appropriate Care But Can It Survive As Such?

I believe that a recent Time Magazine article (June 29, 2009) written by Michael Grunwald about health care conveys some truths about our health care system. Mr. Grunwald cites the Mayo Clinic as an example of how very high quality medicine can be delivered at a fraction of the costs compared to other referral centers. I agree with his assessment. Quoting from the article, “Last year, Mayo lost $840 million on $1.7 billion in Medicare work. It compensated by charging private insurers a premium for the Mayo name, but they’re starting to balk. ‘The system pays more money for worse care,’ says Mayo CEO Denis Cortese’. ‘If it doesn’t start paying for value instead of volume, it will destroy the culture of the organizations with the best care. We might have to start doing more procedures just to stay in business’”.

There are some real insights conveyed in these few sentences. One, medicine is primarily the art of using available knowledge and science applied individually to each patient. Every patient is unique with individual characteristics and needs. A thoughtful physician must take into consideration many factors in suggesting the proper therapy for each patient. This kind of medicine is presently practiced at the Mayo Clinic without the additional billions of dollars touted as the cure-all by our political leaders and various pundits. If a physician cannot think conceptually about patients taking into consideration the entire clinical picture all the billions spent on comparative research will not be of value and will not help. Obviously at this time The Mayo Clinic does not need this additional research.

The second point, just imagine losing $840 million on $1.7 billion in Medicare activity and feeling the need to become another procedure mill to stay afloat. Why is it that the Medicare payment system, a government program, financially punishes the good players and rewards the bad? And would not the number one business of government in the Medicare program be to develop a system of care delivery that emphasizes patient by patient decision making (see appropriate care committees) to replicate the present Mayo model? The answer I believe is that our leaders in Washington look at problems globally and not as the accumulation of millions of individual events. Governments need to count widgets to justify payment and do not know how to account for the intangibles like thinking, individuality and human trust. The result is an overabundance of quantifiable widgets at great excess costs and a diminution of value in thinking, communication and personnel satisfaction.

Although during the present discussion about health care reform one hears about paying for outcomes, we hear more about Medicare cuts in reimbursement to hospitals and physicians. But, these proposed cuts are global and not based on the individual needs of each patient. This is especially unfortunate because if we could inject the wisdom displayed by the Mayo Clinic into all of our health care there would be more than enough resources to provide universal coverage. And this would be accomplished at a decreased percentage of gross domestic product devoted to health care rather than the increases intrinsic to the present proposals.

Tuesday, June 23, 2009

What Should Be The Goal Of Health Care Reform?

Until a few months ago the cost of health care and the percent of gross domestic product it consumes was a major concern. Our goods were not competitive on the world market in large part because of health care costs, manufacturing jobs were leaving the country and the standard of living of the middle class was compromised, all in large part because of these costs. Despite these expenditures 47 million citizens are not insured and our outcomes are poor compared with those of other industrial countries.
The reasons for our excessive spending, approximately twice as much per person as any other country, are well known:
1)An insufficient number of primary care physicians and an excess of specialists.
2)Over-reimbursement for technology and under-reimbursement for conceptual thinking and judgment.
3)Approximately $700 billion spent each year on inappropriate non-beneficial care driven in large part by our largest hospitals.
4)Excessive administrative costs in the private sector.
Without addressing these issues as in Massachusetts any attempt at universal coverage will face financial collapse!
Now we as a society are correctly trying to provide coverage for the entire nation, but without seriously addressing our excessive costs. Even the Congressional Budget Office has recently voiced the opinion that the cost control measures being discussed are at best speculative. Now we read that Congress is considering additional taxes that will certainly increase the gross domestic product devoted to health care. Thus our goods and services will be even less competitive in the global marketplace. With an even greater decline in our global competitiveness more high paying skilled jobs leave the country. In terms of social justice, without seriously addressing the known excessive costs in our health care system, as we spend more to provide universal coverage (increased social justice) we loose high paying skilled manufacturing jobs (decreased social justice).
The health care system in our country is incredibly complex and how to fix it seems elusive. However if one uses end-of-life care as a lens to understand the various forces that have created this massive over-spending and poor care one can then address the problems and provide better care for all at significantly less cost.
That is why after forty years of practice I choose to write my book, In Defiance of Death: Exposing the Real Costs of End of Life Care, which demonstrates the many problems inherent in our current system and proposes a set of feasible solutions.
Our goal should be universal coverage with a health care system consuming about 15% of gross domestic product. By focusing on how to fix end-of-life care, establishing appropriate care committees, creating a new hospital admitting form and a Federal Health Care Bank with varied administrative functions, we can achieve this goal.

Tuesday, June 2, 2009

Nothing New Under the Sun: Massachusetts All Over Again

A law signed in April 2006 in Massachusetts created state funded health care for all of its citizens. There was a deliberate decision to first insure the entire population and then once this was established deal with the cost issue. The idea was to offend no one, keep every constituency happy. Then sometime in the future face the music when costs become unbearable.

False arguments were made such as, universal coverage should in of itself lower costs by preventing chronic disease. This is of course absurd; chronic disease is frequently a product of medical care, keeping people alive who years ago would have died because of their illness. As average life span increases, the chronic disease burden increases and so does the cost. Another false argument was that with insurance for all emergency room visits with their large expense would be drastically reduced. But, that has not happened because of the severe shortage in Massachusetts of primary care physicians. Thus when people become ill their only alternative is the emergency room. There was no provision in the Massachusetts law regarding inappropriate non-beneficial care. However, one only has to look at the Dartmouth Atlas of Health Care to see that a large proportion of care in the state is inappropriate and extremely expensive.

So now Massachusetts has a financial crisis that must be addressed and unlike the federal government cannot print money to cover its costs. Will universal coverage in the state survive? Only time will tell.
The news from Washington is:
1) Medicare is facing insolvency in 2017, if changes are not made.
2) Many working families and our industries are now in financial distress because of the escalating costs of health insurance.
3) There is great variation in the Medicare cost of hospitalization throughout the country without commensurate benefits.

But what of the solutions offered – pabulum disguised as reform that does not address the causes of our excessively expensive health care – Massachusetts revisited!

1)A White House conference including representatives of the health industry that makes vague promises to decrease the increase in administrative costs over the long term. No mention of tackling the problem causing excessive administrative costs at this time.
2)Electronic medical records, a good idea for patient care but not a cost saver (see post titled The Electronic Medical Record: Must it Cost Billions to the Tax Payer).
3)A Comparative Effectiveness Institute, a bad idea that also is not a cost saver (see post titled The Federal Urge to Spend: The Comparative Effectiveness Institute).
4)Enhanced wellness – a vague idea involving dramatic changes in life style of most of our citizens – probably not to be seen in our life time.
5)A change in incentives so that doctors will be encouraged to deliver high quality care. A vague concept that sounds good, but says little.

David Brooks in an op-ed piece in the Wall Street Journal (May 15), titled his piece, Fiscal Suicide Ahead, in essence saying the proposed health care cost savings so far considered by the Administration and Congress maybe good ideas, but will not decrease costs. Thus the funds for the entire Obama agenda will not be available with the result being gross overspending and excessive debt.

By not addressing the fundamental problems within our health care system at this time, and the culture that maintains these very excessive costs (see postings How to Change a Health Care Culture of Excess and Steps to Affordable Universal Coverage), the federal government will find itself in a predicament that makes Massachusetts look reasonable.

Wednesday, April 29, 2009

The Federal Urge to Spend: The Comparative Effectiveness Institute

Washington is thinking of spending tens of billions of dollars on a Comparative Effectiveness Institute, based on a concept borrowed from Great Britain (The National Institute for Health and Clinical Excellence). However Great Britain has adequate primary care. We do not. And Great Britain has put a dollar limit on a newer drug or procedure regardless of its potential for benefit for that particular individual, while the U.S. Congress has rightfully ruled that out for our citizens.

The biggest flaw in the need for the Institute is the assumption that American doctors do not know how to practice medicine that delivers value for the dollar, and that information on this subject does not now exist. This idea is categorically false! Physicians know very well from many existing studies when further critical care will not be beneficial, when cardiac catheritization and stenting is not warranted, when multiple transfers from nursing home to hospitals will not benefit the patient and so on. I am not discussing debatable situations, rather situations that are manifestly obvious.

It is not a lack of knowledge underlying the cause for all this inappropriate care. The culprits have been previously discussed on this blog, for instance: perverse financial incentives including excessive reimbursement for technology, inadequate primary care, fear of legal consequences, and lack of national medical standards. If you want to read up on it, get a copy of The Dartmouth Atlas of Health Care: Regional Disparity in Medicine.

On this blog I have proposed multiple steps to more effectively deal with these problems:
1) Through the Federal Health Care Clearing House and Bank, prospectively verify the benefit of newer therapies via funding of their confirmatory research through the National Institutes of Health before they are approved for general use. This information would be generated via well-performed excellent studies reported without bias.
2) Use of my new admitting form that clarifies that only beneficial care can be delivered.
3) Physician review through Appropriate Care Committees to guarantee as much as possible that care will be beneficial and uniform throughout the country.
4) Amendments to the Patient Self Determination Act, the Americans with Disabilities Act and the Emergency Medical and Active Labor Act to include the phrase, “within acceptable medical standards.”

We can provide universal coverage and decrease our percentage of gross domestic product devoted to health care. If other industrial nations throughout the world can it, so can we. And we can do it without spending billions to study this, that, and the other, when the information is already out there. However, the sense from Washington is that we have to spend many billions more before we can reduce spending. I completely disagree!

A congressional budget office 2008 report quoted in the April 7, 2009 Annals of Internal Medicine states that a Comparative Effectiveness Institute in the United States would reduce health care spending by less than one tenth of one percent. There is no doubt in my mind that my plan is far superior. Do you agree?

Tuesday, April 14, 2009

The Electronic Medical Record: Must it Cost Billions to the Tax Payer?

According to a Dow Jones article the U.S. government plans to spend 20 billion dollars in five years to achieve a 12.6 billion dollar savings in ten. It is just me, or is there something bizarre about these numbers? The expenditure estimate is from an interpretation of the latest U.S. government spending plans, the savings estimate from the Congressional Budget Office. These numbers are quite approximate and may vary, but the main point is clear: electronic medical records are a good idea for coordinating patient care, but are not a tool for significant cost savings.

Is there an alternative that will provide the benefits of the electronic medical record and not require spending billions of our government’s dollars? Yes there is, with a little imagination and Congressional action. This plan calls for Congress to create a Federal Health Care Clearing House and Bank (see posting The Bank). The Bank’s first function would be to create a computer based national clearing house for patients’ billing and medical records. Many large information technology corporations (i.e. Google, Microsoft and others) have created comprehensive computer programs that can interact with various other hospital and outpatient data systems. The “Bank” would use standard federal government procedures for bidding and selecting the program/s and site/s for maintaining this medical record and billing system. This medical information would be kept in a central location/s with other sites for backup. The key aspect of this proposal is the centralization for maintaining electronic medical records, thus greatly lowering costs.

The central computer would receive billing and patient records from every hospital and medical entity in the land. All hospitals have most if not all their patient records on computer at this time. The “Bank” would charge the hospital, insurance companies and other medical entities a fee for each transaction. These fees would be calculated to support the computer system and would be quite modest for each entry. Keep in mind that there are millions of hospital-patient interactions and many millions of other medical transactions each year. Doctors would access the central computer, enter their information and would also be charged a much smaller fee. Pharmacy and other services would do the same. Patients would be able to access their own medical record free of charge.

There would be multiple levels of computer security, but with an additional caveat. As access to computer records can be traced more accurately than with paper systems, violators can be determined with greater ease. Congress when creating the “Bank” would also mandate heavy fines for unauthorized access, thus helping to ensure confidentiality.

I believe this is a workable and cost saving idea. I welcome your comments about this concept.

Sunday, March 1, 2009

Steps to Affordable Universal Coverage

As we pursue universal coverage there are some realities to contemplate as we try to provide affordable universal coverage.

1)The U.S., at this time, does not have an adequate health care workforce to deliver excellent universal coverage no matter how much money is spent.

a)The nursing shortage in the United States is acute and getting worse! If one looks at the workforce as a pyramid with nurses at the base, physician assistants/ nurse practitioners as a next layer and physicians at the top, we have a grossly inadequate base. We have to dramatically increase the number of our citizens pursuing a career in nursing.

b)The physician workforce in the United States is woefully lacking in primary care, with now only 1/3 of physicians practicing primary care and 2/3 functioning as specialists. This is an inverse ratio from other developed nations which have much better health care results. Without adequate primary care, chronic conditions cannot be adequately cared for and preventative medicine cannot be delivered. Medicare and its payment system have emphasized procedural and technological medicine which has decimated primary care. Changing economic factors can increase the number of medical students going into primary care but it will take decades by this alone to reverse the aberrant ratio of primary care to specialist doctors. Thus a system is needed at this time so that many of our specialists also practice primary care.

2)We need to change our views about medical care in this country

a)Commercialization – Medicine is not a commercial product. Rather, medicine is a personal experience between an individual patient, each with her/his uniqueness, and a knowledgeable, empathetic, caring physician who has the judgment to be able to meet each patient’s individual needs. Specialists, computerization, modern drugs, devices and procedures are useful when appropriate, but harmful when overused. The overuse of medical facilities, documented by the variability in the cost of care from one area of the nation to another, is in part an unfortunate result of commercialization. Direct to the consumer drug, device and hospital advertising adds to this problem. The influence medical device and drug companies have on our system is pervasive and in many instances abusive. We will have to control the excess commercialization of health care that is now present in our system to be able to provide affordable universal coverage for all our citizens.

b)Consumerism - Many experts have voiced that we, as a nation, must learn that more is not necessarily better in medicine. Yes, the newest may be the correct treatment in some circumstances, but in others the best treatment may be no treatment or an old tried-and-true therapy. The Congress, in its desire to protect the consumer, has passed laws - The Patient Self Determination Act, The Americans with Disabilities Act and The Emergency Medical Treatment & Labor Act, all written without a key phrase, for example, within the boundaries of acceptable medical standards. Unfortunately this oversight has hampered our legal system and promoted consumerism.

Monday, February 16, 2009

A New Style of Hospital Admission Form

There are many reasons why our American health care system is so much more expensive than those in other developed countries, and yet we have inferior results. But, by far the largest single reason is the delivery of non-beneficial care which accounts for about one third of our total health care bill and contributes to a tremendous amount of unnecessary human suffering. Perhaps the most obvious example of our inappropriate care is the prolonged anguish and cost associated with the way we practice end-of-life care. Unfortunately however, the irrationality of how we practice medicine in the United States is not isolated to end of life care. Issues that must be addressed are:
•How can we create an advance directive that is both up to date and rational considering the over-all condition of the individual?
•How can we ensure that the care being given is beneficial and not serving other masters such as cash flow, avoiding legal hassles, the prestige of the hospital, etc.?
•How can we make sure that every patient and family has the right to appeal the medical team’s decision as to what is beneficial?
•How are we to avoid doing cardiopulmonary resuscitation on patients that are far too frail to benefit and who as a result suffer a disfiguring inhumane death?

The answer to these questions is my proposed hospital admission form shown below. The form provides a realistic up-to-the-moment advanced directive while providing an opportunity for the patient/family and the medical team to agree on what will be beneficial care. It also provides the patient/family and the medical team a mechanism to resolve disagreements, the appropriate care committee. This new admission form would also make cardiopulmonary resuscitation an ordered event for those patients who could benefit from it in any way, and not done routinely for the majority of patients for which it is of no value.

Monday, February 9, 2009

The Appropriate Care Committee as a Resource for the Patient

The basic concept behind appropriate care committees is to always act in the patient’s interest. Thoughtful medicine practiced with good judgment supported by the applicable medical evidence is the goal of the appropriate care committee system. Technology, procedures and medicines that do not benefit the individual not only have the potential for complications, but also create economic havoc for our nation. In large part inappropriate care is responsible for the health care crisis we now have in this country. Appropriate care committees allow us to solve this problem while maintaining the flexibility to be able to treat all patients as individuals each with unique circumstances, for instance the case of Joe Franks.

Joe Franks is a 57-year-old gentleman temporarily in a nursing home recovering from a heart attack and moderate congestive heart failure. He has type II diabetes, poorly controlled, and is 80-100 pounds overweight. His diabetes has adversely affected his vision such that recently he lost his cab driving license and is now unemployed and has only very basic health insurance. Joe’s mental status is excellent; he is an avid chess player. His doctor in the nursing home told Joe that if his obesity was controlled and he lost the extra 80-100 pounds of weight his health situation would dramatically improve. Joe told the doctor that he has tried everything, but has been unable to lose weight.

The doctor told Joe about the stomach banding procedure, a relatively simple surgery that restricts stomach size and has been quite successful in promoting weight loss in patients just like him. Joe is excited about this idea and asks the doctor to make a referral to the closest medical center offering this procedure. Immediately after nursing home discharge Joe and his wife traveled to the medical center hoping to arrange for the banding procedure.

Unfortunately the banding clinic told Joe and his wife that he was not a good candidate for the procedure and tried to send the two of them back home. However, Joe’s wife had read about the appropriate care committee system and asked for an appeal. The appropriate care committee nurse was immediately notified about his case. The appropriate care committee nurse arranged for Joe and his wife to stay the night at a nearby hotel to wait the full committee’s (two physicians and the nurse) finding early the next morning.

The committee heard from the clinic doctors who felt Joe was not a reliable patient and was unable to pay the additional fee above that of his basic insurance. The committee also interviewed Joe and his wife before rendering a decision. The committee decided that Joe was an excellent candidate for the procedure and that the clinic must offer it to him.

One year later Joe had lost 95 pounds, his Type II diabetes was cured, his eyesight and heart failure much improved. He was able to reactivate his cab driving license and was proud to again be an active contributing member of his community. He told all the overweight customers in his cab about his experience with gastric banding and how pleased he was with the clinic. After the tenth referral to the clinic because of Joe, the physicians at the clinic put on an appreciation party for Joe and his wife which included an overnight stay in a nearby luxury hotel.

How to Change a Health Care Culture of Excess

We have seen great strides in the decrease of deaths caused by heart disease in the past few decades - better control of elevated blood pressure, still far from ideal, drugs to lower cholesterol and procedures to improve ischemic (not enough blood flow) heart disease.

One of the procedures, cardiac catheritization and stenting, is provided for about a million patients each year at a cost of roughly $60 billion. The question that has recently been posed is, what patients should receive this procedure? The answer, it turns out, is that the procedure should be limited to those with very severe angina (chest pain due to ischemic heart disease), and those with increasing or unstable angina. Drugs alone are quite adequate for the majority of patients who have stable and milder angina.

As a matter of fact, a cardiologist from Miami, Dr. Michael Ozner, has recently published a book, The Great American Heart Hoax, decrying the approximately sixty billion dollar expenditure via overuse of cardiac catheritization and stenting. The science behind the concept that treating the lesions seen on an angiogram is in most cases folly is well documented and accepted by leaders in the field. In spite of this, by far the majority of patients receiving this procedure are in the non-indicated group. Of course cardiology is not the only specialty of excess. Many, if not a majority of medical areas such as end-of-life care, dialysis, orthopedics, oncology etc., combine to create a medical system of inappropriate care with a whopping $600 billion price tag.

Any solution to this problem must be timely, combining medical knowledge with excellent judgment while treating each patient as an individual. This is a task for my local appropriate care committee, salaried and made up of two physicians and a nurse.

For instance: the committee in each hospital would review 50 to 100 charts of patients who had recently undergone catheritization and stenting. Those determined to be unnecessary would require the physicians and the facility (hospital or clinic) to reimburse the third-party payers for these services. This would at the outset require the return of significant amounts of money. This process would be repeated in many areas such as the intensive care units, dialysis, oncology units, etc. The physicians and hospital administrators would quickly learn that inappropriate care is not a good idea. The culture would change overnight and we would have a different medical system.

Monies saved would be more than adequate to properly reimburse primary care and provide universal coverage. No system of saving can be perfect. However, I believe that of the $600 billion spent on inappropriate care, we could save approximately $400 billion. The process would be especially sensitive that any and all care from which a patient could benefit would be encouraged.

Friday, January 16, 2009

Why we Need Appropriate Care Committees: A Case Study

Linda Jones was an 87 year old woman who had been in a nursing home for the past four years. She was admitted to the nursing home by her two daughters because of mental deterioration to the point of being unable to care for her self. Since entering the nursing home she had been transferred to the hospital six times. The first, three years ago, was for pneumonia and while in the hospital her daughters agreed to the placement of a feeding tube. However, her daughters were concerned about her over all well being as she did not recognize them and could not communicate in any meaningful way. She appeared to be unaware of her surroundings and did not respond to her name. Her third child, a son, lived thousands of miles away and was not in contact with his mother or sisters. Linda was returned to the nursing home which was now reimbursed at the much higher Medicare rather than the Medicaid rate. During the past three years Linda was readmitted to the hospital five times, twice for pneumonia and twice for urinary tract infection, each time bumping up the nursing home collections from Medicaid to Medicare. Her last admission to the hospital was for sepsis (bacteria in the blood) possibly from her lungs, urinary tract or the small skin breakdown over her sacrum that the nursing home tried diligently to prevent. In the hospital Linda was placed in the intensive care unit (ICU), intubated (breathing tube) and given other medications.

The ICU doctors told her daughters that Linda was terminal. Her daughters agreed with the doctors that she should not under go cardiopulmonary resuscitation (CPR) and should be transferred to hospice, but wanted to wait for their brother who was about to arrive. Linda, like most Americans, had not executed an advance directive nor designated a durable power of attorney. The son arrived and strongly disagreed with the do not resuscitate order and hospice despite meetings with the ethics committee which had agreed with the ICU doctors. The hospital having had unpleasant and expensive legal experiences in such circumstances took no action. Linda remained in the ICU for another three weeks, had a cardiac arrest and died after one hour of attempted CPR. No autopsy was performed.

Linda’s ordeal is reproduced in one form or another hundreds of thousands of times in American hospitals yearly. The results are: 1) Linda suffered a disfiguring intrusive death that was an assault on her human dignity. 2) The family as a whole (all three children) was faced with decisions they were not prepared to make and were mired in conflict. 3) Doctors and hospitals have become accustomed to, and in many cases financially dependent on, providing non-beneficial care. 4) The resources consumed were enormous.

What would have happened if my admitting form and appropriate care committee system were in place? Upon Linda’s first hospital admission the admitting form would have created a contract between Linda, her family, and the physicians which stated that only beneficial care could be delivered and also would have served as an up-to-date advanced directive. Cardiopulmonary resuscitation would not have been ordered and she would have not had suffered that indignity. Because of her severe and profound dementia the advice of the physician staff likely would have been that after her first hospital admission she should be treated for any complications in the nursing home and if unsuccessful placed in hospice. If conflict arose the appropriate care committee would have been consulted and most likely would have agreed with the physician’s plan, as it was reasonable and humane. With committee concurrence the family would have been told that third party payers would not be responsible for other than nursing home and hospice care. Knowing that, the son would have most likely agreed with the plan and family conflict would have been avoided. Our society would have saved significant resources which could then be devoted to universal coverage and other worthwhile goals.

Thursday, January 8, 2009

The Road to Universal Coverage

1)The U.S. Healthcare Workforce

The U.S., at this time, does not have an adequate healthcare workforce to deliver excellent universal coverage no matter how much money is spent.

a)The nursing shortage in the United States is acute and getting worse! If one looks at the workforce as a pyramid with nurses at the base, physician extenders as a thin next layer, and physicians at the top, we have a grossly inadequate base. We have to dramatically increase the number of young Americans pursuing a career in nursing.

b)The physician workforce in the United States is woefully lacking in primary care. Today, only 1/3 of physicians practice primary care and 2/3 practice as specialists. This is an inverse ratio from other developed nations with much better health care results. Without adequate primary care, chronic conditions cannot be adequately cared for and preventative medicine cannot be delivered. Medicare and its payment system have emphasized procedural and technological medicine which has decimated primary care. Changing economic factors can increase the number of medical students going into primary care, but it will take decades by this method alone to reverse the aberrant ratio of primary care to specialists doctors. We need a system in which many of our specialists also practice primary care.

2) Beneficial Care, A New Admitting Form and Appropriate Care Committees

Medical care must be of high quality and deliver value for the dollar. This means that only beneficial care can be given, using judgment on a case by case basis determined by each patient’s individual overall health situation. This must be done in tandem with expanded coverage or excess costs will quickly bankrupt the system. We need to deal with consumerism and the commercialization of medicine that has become the American healthcare system. There are many examples of excess use of technology - the Courage trial demonstrating overuse of procedures in coronary artery disease, over half a million deaths yearly in intensive care units of patients who belong in hospice, etc, etc, - that must be addressed immediately and for which ample data is presently available. If not done the percent gross domestic product (GDP) devoted to health care in the U.S. will continue to increase. The economic distortions to our economy will continue, regardless if paid for by private means or taxes. We must quickly decrease our percent GDP devoted to healthcare while providing universal coverage, which, with the proper controls (hospital admission form and appropriate care committees) can be immediately achieved, or this laudable goal will cause more economic hardship for our people.

3)A Healthcare Board (synonymous with Health Care Bank)
This board would be fashioned after the Federal Reserve Bank taking the management but not the responsibility of healthcare out of the hands of Congress is an idea whose time has come (see posting on the "Health Care Bank").

Sunday, January 4, 2009

Now It's Your Turn - Tell Us Your Stories

I hope 2009 is a good year for you all.

For the past eleven months I have been presenting ideas about health care reform here on my blog. Many of these postings are accompanied by stories about patients with whom I have had personal knowledge. In my travels, when discussing my book and or my blog, I have found that almost everyone has a story about our healthcare system. Most, but by no means all, have involved end-of-life situations. I suppose this is because these experiences are so intense and personal, and, in so many cases, our end-of-life care is so irrational. In a sense, the irrationality of our end-of-life care is a bell weather example of the irrationality present throughout our entire health care system.

There are, however, many wonderful stories we also need to hear and read. So, I am inviting all of you who visit my blog and are so inclined to summarize in a comment one of your experiences, good or bad, with our health care system. I will respond to each of your postings.