Monday, April 26, 2010

Answer to Question #2-What Physician Practices Drive Up Health Care Costs?

Various experts using different methods have determined that we Americans presently spend about $700 billion on inappropriate non-beneficial care and that this excess spending is primarily due to physician practices. What do you believe are the factors causing physicians to practice this way and how would you address these issues?
A. There are multiple studies and estimates by experts leading to the conclusion that about $700 billion dollars per year are spent on unnecessary, inappropriate care in the United States.

1) The Dartmouth Atlas of Health Care

Peter Orzag (former head of the Congressional Budget Office, presently Director of The Office of Management and Budget) using this data is quoted by Trapp D., “…estimated that up to $700 billion of the nation’s $2.3 trillion in annual health care spending does not improve outcomes”.(1)

Kenneth I. Shine , former President of the Institute of Medicine of The National Academies of Science in an editorial responded to an earlier version of this map saying, “….as much as 30% of health care costs might be eliminated without adversely affecting health care outcomes.” (2)

Arthur Garson and Carolyn L. Engelhard said in their book, “We do waste a lot of dollars on medical care, but this “one-half” estimate is based on an over-zealous interpretation of the data: the number is more likely one-third.”(3) This one-third estimate exceeds $700 billion per year.

2) McKinsey & Co. December 2008 demonstrated by a different method that compared to other countries the U.S. wastes about $700 billion yearly on health care.

B. Dr. Arnold S. Relman former editor of the New England Journal of Medicine wrote, “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 United States spends on medical care.”(4)

C. There are several factors causing physicians to practice in this way.
1) Doctors feel compelled to practice defensive medicine – the Massachusetts Medical Society has studied the cost of the yearly amount (2008) spent on defensive medicine in an attempt to minimize lawsuits. The study revealed that in Massachusetts a conservative estimate was $1.4 billion.(5)
2) Unrealistic demands by physicians placed on patients/families, in the name of patient autonomy, to make sophisticated and frequently non-beneficial and expensive medical decisions. These practices are well described by Dr. Atul Gawande in his book Complications.(6)
3) The present structure of advanced directives causes confusion and unrealistic expectations.(7)
4) Congress’s control of Medicare reimbursement rates under the influence of intense lobbying has resulted in the underfunding of primary care and overspending on technology and drugs.
5) Drug and device companies are now allowed to advertise to the public.

D. To address these problems I suggest the following actions:
1) Congress should amend The Patient Self Determination Act and related acts to contain the phrase, “within the bounds of good medical practice”.
2) Congress stipulates the use of a hospital admission form (below) for all Medicare patients. This form would enable patients to clarify their medical preferences with guidance as to medical feasibility along with an appeal mechanism in case of conflict.
3) The scope of peer review expanded to include consistent, uniform, organized oversight by senior physicians and nurses with knowledge and experience in the practice of medicine and patient/family support to ensure that only beneficial care was being delivered.
4) Internal medicine sub-specialists should provide primary care for their patients who do not have a primary care physician.

1. Trapp D. Obama budget sets stage for reform of Health care system, Medicare pay, American Medical News. March 16, 2009 page 4
2. Shine KI. Annals of Internal Medicine. 2003; 138:347-8. PMID: 12585834
3. Garson A, Engelhard CL. Health Care Half Truths: Too many myths, not enough reality. N.Y., N.Y. Rowman & Littlefield Publishers, 2007, Page 17
4. Relman AS. Doctors as the key to health care reform. New England Journal of Medicine 2009:361: 1225-1227 PMID 19776404
5. (accessed April 20, 2010)
6. Gawande A. Complications: A surgeon’s notes on an imperfect science. N.Y., N.Y. Henry Holt & Company, 2002,Page 208
7. Fisher KA, Rockwell LE, Scott M. In Defiance of Death: Exposing the Real Costs of End-of-Life Care. Westport, Connecticut , Praeger 2008, Page 11

Monday, April 5, 2010

Answer to Question #1 - What is medical consumerism and what factors do you believe exacerbate this issue?

One of the factors keeping us from reaching our goal of universal coverage at a price we can afford is medical consumerism, defined here as the public having unrealistic expectations and demands. There are several reasons for medical consumerism in the U.S. and the blurring of the lines of authority between the patient and the medical team.

A) The concept of patient autonomy is problematical as its limits have not been defined.
B) Many Americans believe that a few hours at a web site is sufficient to adequately learn about a medical subject without understanding the complexities involved.
C) Drug and device advertising to the public promotes the newest most expensive drug/device as superior and your doctor is unaware of this marvelous advance. In reality direct advertising is an attempt by these companies to convince the public that their product is the newest and best when usually older and cheaper drugs/devices are just as effective.(1)
D) Hospitals and doctors have adopted a customer oriented business model to maximize revenue.
E) There are unresolved ambiguities caused by the Patient Self Determination Act (1990) which created the legal framework for advanced directives.(2) Many ethicists and physicians have noted that advanced directives have the potential of turning the physician into a technician following instructions no matter how inappropriate.(3) Questions arise about the limits of therapy in the absence of an advanced directive. Although passed in 1990, these concerns are yet to be addressed by Congress.
F) Physicians practice defensive medicine because of the widespread fear of lawsuits. Our legal history is replete with cases that have demonstrated to the physician community that logic and rationality are secondary to patients’/families’ requests and desires. Two examples of this are the cases of Baby K and Helga Wanglie.

1) In the Baby K case an anencephalic baby (no cerebral cortex – no possibility for consciousness or human activity) was born by caesarian section in 1992. Although the physicians, hospital ethics committee, the court appointed guardian and the child’s father recognized the futility of further care, the child’s mother insisted on continuing care along with mechanical ventilation (breathing tube connected to a machine) if needed and pursued legal action. The trial court misinterpreted the Emergency Medical Treatment and Active Labor Act (EMTLA)(4), by not considering the child as an integrated entity, but rather as a respiratory case. Professor Annas, Chair Department of Health Law, Bioethics & Human Rights at Boston University made several cogent statements about this case:
1) Knowing in advance that the fetus was anencephalic ,before delivery the physicians should have discussed with the mother that they would not use mechanical ventilation after birth.
2) The trial judge misinterpreted the intent of Congress in writing the law.
3) Congress mistakenly did not include wording such as, “within the bounds of good medical practice”.
4) We should be treating patients in light of what is best for them and not as objects to meet the needs of others.
5) To avoid medicine becoming a consumer product like toothpaste and in the process becoming unsustainably expensive, physicians will have to set standards for medical practice and follow them;(5) to this date this has not happened.

2) In the Helga Wanglie case, an 86 y/o women was in a persistent vegetative state for a year in an intensive care unit. The physicians concluded that in this case there was no chance of recovery and that hospice would be better for the patient. Her husband objected and sought relief from the courts, which found in favor of the husband; however, Helga died a few days after the verdict. (6)
What is needed to address medical consumerism and resolve the ambiguities between patient and doctor? I suggest:

1) Congress should amend the Patient Self Determination Act, The Americans with Disabilities Act and the EMTLA to contain the phrase, “within the bounds of good medical practice”. This would facilitate physicians developing and adhering to practice standards.
2) An advance directive should be completed at each hospital admission with guidance from physicians as to what is feasible in light of the patients overall condition, with seasoned physicians and a nurse available to adjudicate conflicts.
1. Angell M. The Truth About the Drug Companies: How They Deceive Us and What to Do About It. Random House N.Y. N.Y. 2004 ISBN: 978-0-375-50846-2
2. The Patient Self-Determination Act (PSDA) was passed by the U.S. Congress in 1990 as an amendment to the Omnibus Budget Reconciliation Act of 1990.
3. Perkins HS. Controlling death: the false promise of advance directives. Annals of Internal Medicine 2007; 147: 51-57 (PMID 17606961)
4. 42 U.S.C. 1395 dd (1994) (amended 1997)
5. 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)
6. Angell M. The case of Helga Wanglie; a new kind of “right to die” case. New England Journal of Medicine 1991; 325: 511-512 (PMID 1852185)