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.