Learning about end-of-life care

The "death panel" frenzy propounded by Sarah Palin and an army of uninformed and ill-intentioned allies when the administration proposed paying physicians for conversations with their patients about end-of-life care has come to a quiet conclusion.

Medicare  has finally authorized payment for advanced care planning "at the discretion of the beneficiary" in both the outpatient and hospital setting. These discussions require sensitivity, thoughtfulness, and time. Medicare will pay $86 for the first 30 minutes and up to $75 more for 30 additional minutes. The fee is far from lucrative when overhead costs for maintaining an office are taken into consideration, but it recognizes and compensates physicians for a core medical responsibility - collaborating with patients at every phase of life.

The moral of this happy story is that although it took six years, it shows that we are capable of moving beyond disinformation and hysteria and understanding what caring medical practice requires!

(For previous posts about "death panels" see here, here, here and here.)

Public Learning about ACOs

"Culture beats strategy every time" is a truism in management consultation. The Accountable Care Organization concept is excellent strategy, but it won't get anywhere if our health system culture doesn't support it.

This morning I was happy to see a front page article in the New York Times about how Advocate Health Care is developing its ACO. The article is clear and informative. But the amateur medical anthropologist in me was struck by what the language reveals about the cultural context within which ACOs will thrive or crash and burn. In what follows, snippets from the article are in italics, followed by my editorial comments. I've highlighted key phrases - all of the emphases are mine:

On a stormy evening this spring, nurses at Dr. Gary Stuck’s family practice were on the phone with patients with heart ailments, asking them not to shovel snow. The idea was to keep them out of the hospital, and that effort — combined with dozens more like it — is starting to make a difference: across the city, doctors are providing less, but not worse, health care.

In recent years I've been careful to shovel snow slowly and not to overload the shovel. If I was one of Dr. Stuck's patients I would have appreciated a call from the nurse. But note the assumption that less care is likely to be worse. As a physician who practiced for 43 years my default view is that less is better/more is worse. Many of my colleagues think the same way. ACOs won't succeed unless we can nudge the wider public into understanding that "more" does not equal "better" and "less" is often an improvement!

For most health care providers, that would be cause for alarm. But not for Advocate Health Care, based in Oak Brook, Ill., a pioneer in an approach known as “accountable care” that offers financial incentives for doctors and hospitals to cut costs rather than funnel patients through an ever-greater volume of costly medical services. Under the agreement, hospital admissions are down 6 percent. Days spent in the hospital are down nearly 9 percent. The average length of a stay has declined, and many other measures show doctors providing less care, too.

Insofar as the kind of integrated care ACOs are designed to promote is the right way to deliver care, the changed payment structure is removing a barrier to doing the right thing, not "incentivizing" us like rats in a maze. I don't think I'm alone in finding all the talk about "incentivizing physicians" to collaborate with their patients and colleagues offputting. And if I were a naive patient I'd be suspicious of care that my doctor had to be "incentivized" to provide!

“It’s hard to imagine that you could start from scratch and do this and be successful in three years," said Dr. Lee Sacks, Advocate’s chief medical officer, noting that other systems may find it far harder to flip the traditional fee-for-services system on its head. “We had a running head-start going back to 1995.”

The organizations that joined in 1995 to create Advocate have a 100 year history of faith-based health care. As a non-Christian I found the Advocate mission inspiring. I would be proud to practice with colleagues who shared the values Advocate promulgates. I wish the article had taken the following great quote from Dr. Sacks that I found on the Advocate website:

"There is just a special feeling throughout Advocate Health Care. We regularly recognize those who exemplify our values of compassion, equality, excellence, partnership and stewardship, even though many of them would say that they were just doing their job.”

A piece of cheese at the end of a maze isn't what "incentivizes" health professionals - it's the privilege of being part of a caring profession whose values go back for millennia! The admirable clinicians Dr. Sacks is talking about would be stunned to be told that their comportment reflected economic incentives, not personal mission!

In some ways, accountable care resembles earlier efforts to control medical spending, including the health maintenance organizations that proliferated in the 1980s but fell out of favor, in part because they severely limited patients’ choices. But accountable care differs by giving doctors and hospitals a direct financial stake in saving money and a reason to invest in various programs of preventive care rather than relying exclusively on the fees they would normally earn from providing services.

This snippet tip toes towards getting the culture issue right, but it still misses the crucial point. Capitated payments facilitate investment in programs (and not just for prevention) that are not paid for in our cockeyed fee-for-service/widget-rewarding payment system. But that's not what gives doctors a "reason" to invest. The reason is that it's the right thing to do in light of a mission that even many athiest clinicians regard as "sacred."

So far, Advocate has achieved a small but significant savings of about 2 percent below projected costs, Blue Cross Blue Shield said, but it is not clear whether it can continue to make progress. Already, some Advocate hospital chiefs have expressed fears over losing revenue and warned about the threat to their financial performance. Doctors fret that their incomes may suffer. “We’re doing it because it’s the right thing to do for patients,” said Dr. Stuck, the Advocate family physician. “We’re not making more money.”

Dr. Stuck's point about doing the right thing speaks for itself!

“You’re trying to overlay a payment design onto a benefit model that allows a patient to go anywhere he wants,” said Steve Hamman of Blue Cross Blue Shield, noting that patients can undermine the advantages of the new approach if they ignore the advice or insist on unnecessary tests and procedures. “We can talk all we want about provider accountability and how important that is. But there is a measure of patient accountability that is critical as well.”

For readers who aren't familiar with the ins and outs of the ACO concept, this paragraph is referring to the fact that Medicare beneficiaries who are receiving their care from an ACO aren't "locked in" to the ACO network. If Dr. Stuck's patients want to go to the Mayo Clinic they can do so. This is likely to create clinical, economic and ethical challenges for ACOs. What if the Mayo Clinic does knee replacements better than the ACO? Do we have to refer patients "out"? What are the acceptable ways for ACOs to try to keep patients "in network"? And, most important, how do we engage patients and the public in seeing stewardship of shared resources as a societal imperative they share responsibility for?

We Yanks believe in magic bullets. That's why we have so many drugs in our medicine cabinets and drones in the sky. ACOs, alas, will not magically solve our health "system's" problems of quality and cost. The ACO is a good concept, but it won't thrive without a supportive culture. The otherwise excellent article in the New York Times shows how far we have to go to develop the culture we need!

(See here, here, and here for posts that discuss related aspects of the ACO concept.)

Nonprofit Regional Health Plans

As the US health system moves towards the 2014 launching of health exchanges and other components of Obamacare, regional nonprofit health plans are poised to take a distinctively important role.

An article in today's New York Times described the steps Florida Blue, which covers 4 million Floridians - 30 percent of the Florida insurance market - is taking. The  proposal for a "public option" like Medicare for all that would compete with private insurers crashed and burned in the health reform process, but regional nonprofits like Florida Blue are carrying out the function that was envisioned for the public option. Nonprofits can't function without making a margin beyond their expenses, but their structure allows them to be more mission-driven and locally connected than investor-owned plans.

For much of my clinical career I practiced at the nonprofit Harvard Community Health Plan (HCHP) HMO. My late father, who lived in Florida, know how much I respected HCHP, and asked me if he should join an HMO. At that time none of his choices were nonprofits, and I'd read about various scandals in the Florida market. If he'd been living in Massachusetts I would have encouraged him to join HCHP where I and my family got our care, but I advised him against the HMO route in Florida.

Medical care is ultimately local. It works best when clinicians and their organizations are part of the local community. This passage in the article stood out for me:

“Florida Blue has the same problems everyone else has,” said Dr. Michael A. Wasylik, an orthopedic surgeon in Tampa who works with insurers through the Florida Medical Association, but “they have a better trust relationship with doctors.” The local representatives are better able to address doctors’ concerns, he said.

Health reform won't get anywhere without enthusiastic participation from the clinical community. Insurers can facilitate reform, but they can't make it happen. Engagement with the local community, and above all the kind of trust that Dr. Wasylik refers to, are key. If the national for-profit giants can compete successfully with regional nonprofits like Florida Blue, more power to them. But if the narrow margins and need for highly collaborative relationships with the clinical community make Obamacare an undesirable business opportunity, regional nonprofits like Florida Blue will flourish.

Victor Fuchs on health reform

I've never met Victor Fuchs, but I've admired and learned from his writings for years. His article in this week's JAMA on "How and Why US Health Care Differs From That in Other OECD Countries" is a gem. Here's a summary:

US expenditures differ from the average OECD country in three ways:

1. As a percentage of GDP, US expenditures are twice as high.
2. The share of expenditures funded by government in the US is 46%, compared to a 75% average for other OECD countries.
3. The mix of services differs substantially - intense focus on technology vs more basic care.

Here's how Fuchs explains the difference, again in a series of three:

1. The US population has a much more distrustful attitude towards government - a trend with deep historical roots.
2. The US population is much less committed to equal outcomes through redistributive policies.
3. The US political system provides many "choke points" that allow special interests to block or reshape reform efforts.

Finally, Fuchs draws three practical conclusions for future reform efforts:

1.  "[G]overnment's role should be limited to what is necessary, not just desirable."
2. "[P]rovision of basic coverage for all should not require equality for obtaining additional coverage...individuals should be free to purchase more than basic care."
3. "[R]eform should have features that would appeal to some special interests, or to some elements within each special interest group."

Fuchs, who is presumably in his mid 80s (he graduated from NYU in 1947), is giving us the gift of his wisdom. His two page JAMA piece ends this way:

Comprehensive health care reform in the United States is necessary to avoid a financial disaster, but enactment of such reform will require attention to US history, values, and politics."

Fuchs' analysis is relevant for liberal critics of the Affordable Care Act. In the eyes of single payer advocates and other progressives, the ACA is a disappointing flop. But by Fuchs' three practical conclusions, the ACA was the best that could be achieved in 2010. The right approach for progressives is to do all we can to make it work.

Paranoid Style in the ACA Dissent

My wife and I are in Vermont with two of our grandchildren visiting, so I've only just now finished reading the 193 page Supreme Court decision about the ACA.

Throughout the health reform process I've tried to understand the virulent opposition to the ACA in terms other than "stupidity" and "demagoguery." Stupidity is real, as when Senator Breaux's constituent pleaded "don't you let the government get hold of my Medicare." And demaguguery is all too real, as in Sarah Palin's death panel lies and Mitt Romney's sucking up to the Tea Party and running away from his constructive role in Massachusetts health reform. But the dissent written by Justices Scalia, Kennedy, Thomas, and Alito (that's the sequence of their names on the dissent) offers a uniquely clear insight into hatred of the ACA.

I'm not a scholar of constitutional law, but I found Justice Ginsburg's argument that the individual mandate was constitutionally justified under the Commerce Clause persuasive. But I also found Justices Scalia, Kennedy, Thomas, and Alito's argument that the Commerce Clause does not justify the mandate strong in logic.

It may be the psychiatrist in me, but I believe the conclusion the four dissenters reached (and the virulent hatred of the ACA that some of its opponents express) reflect the dissenter's fear of a slippery slope more than the nuances of interpretation of precedents. The dissent has a framework of logic, but the driving force is emotion. I've highlighted the emotional content of three representative excerpts from the dissent:

...to say the failure to grow wheat (which is not an economic activity, or any activity at all) nonetheless affects commerce and therefore can be federally regulated, is to make mere breathing in and out the basis for federal prescription and to extend federal power to virtually all human activity. (p 129)

...If congress can reach out and command even those furthest removed from an interstate market to participate in the market, then the Commerce Clause becomes a font of unlimited power, or in Hamilton's words, "the hideous monster whose devouring jaws spare neither sex nor age, nor high nor low, nor sacred nor profane." (p 134)

But if every person comes within the Commerce Clause power of Congress to regulate by the simple reason that he will one day engage in commerce, the idea of a limited Government power is at an end. (p 138)

The dissenters see the ACA as unleashing a hideous devouring monster. Their outlook reflects what historian Richard Hofstadter called the paranoid style in American politics. Here's the essence of Hofstadter's analysis:

I believe there is a style of mind that is far from new and that is not necessarily right wing. I call it the paranoid style simply because no other word adequately evokes the sense of heated exaggeration, suspiciousness, and conspiratorial fantasy I have in mind. I am not speaking in a clinical sense...It is the use of paranoid modes of expression by more or less normal people that makes the phenomenon significant.

...As a member of the avant-garde who is capable of perceiving the conspiracy before it is fully obvious to an as yet unaroused public, the paranoid is a militant leader. He does not see social conflict as something to be mediated and compromised, in the manner of the working politician. Since what is at stake is always a conflict between absolute good and absolute evil, what is necessary is not compromise but the will to fight things out to a finish. Since the enemy is thought of as being totally evil and totally unappeasable, he must be totally eliminated—if not from the world, at least from the theatre of operations to which the paranoid directs his attention.

The dissenters see the ACA through the lens of the paranoid style. This is what leads them to the crucial slippery slope argument - that if we allow the individual mandate we allow the government unlimited power to coerce us. The end result is the image of the body politic as an infant, being forced to eat broccoli by a controlling mother:

All of us consume food...But the mere fact that we all consume food and are thus, sooner or later, participants in the "market" for food, does not empower the Government to say when and what we will buy. That is essentially what this Act seeks to do with respect to the purchase of health care. (p 139)

The slippery slope argument - from the health insurance mandate to total government control and forced feeding with broccoli - depends on the emotion, not logic. Justice Ginsburg makes a powerful argument that health care, representing more than one sixth of our national economy, is a distinctive case, not just one stop on a slope leading to broccoli. But from the perspective of the paranoid style, giving an inch is giving a mile.

Hofstadter is clear that the paranoid style doesn't mean that the views being asserted are wrong. In my view the dissenters make cogent arguments about Commerce Clause precedents but, again in my view, the arguments don't trump those advanced by Justice Ginsburg. But for those who see the world through the paranoid style lens, the associated emotions add the necessary weight to arguments that in themselves are not decisive. 

The paranoid style isn't a logical conclusion - it's an emotional predisposition. As a result, logic won't alter it. Between now and November we'll see how the Republicans will seek to fan paranoid style flames and how the Democrats will seek to counter it. Stay tuned!

(The full Supreme Court decision is available here. And for a strong argument as to why the health sector is distinctive and the slippery slope argument fails, see health law professors the amicus brief from 104 health lawyers here.)

The Ethics of Choosing Wisely and Practicing Efficiently

This month the American Board of Internal Medicine Foundation (ABIM) joined with nine medical specialty societies, each of which released a list of five tests, procedures or treatments whose use and clinical value were not supported by evidence, as determined by experts from the specialty.

This is a major step for the US health system. We've been phobic about engaging seriously with waste. In the 1990s we asked insurers to do the job, but physicians and patients pushed back against "managed care," and insurers backed off. Now we physicians ourselves are stepping forward. It's about time!

Among the 45 recommendations, the ones that are "absolute" should be relatively easy to discuss with patients, as in this example from cardiology:

Don’t obtain screening exercise electrocardiogram testing in individuals who are asymptomatic and at low risk for coronary heart disease. In asymptomatic individuals at low risk for coronary heart disease (10-year risk <10%) screening for coronary heart disease with exercise electrocardiography does not improve patient outcomes.

There's no waffling here - this form of screening "does not improve patient outcomes." If I were a cardiologist I would say that asking Medicare, Medicaid, or a private insurer to pay for the screening would be unethical. If it is known not to improve outcomes there's no justification for using shared health care funds to pay for it. And I'd feel fully comfortable looking my patient in the eye and explaining why I would not order the test.

The same is true for this "absolute" recommendation:

Don’t obtain imaging studies in patients with non-specific low back pain.
In patients with back pain that cannot be attributed to a specific disease or spinal abnormality following a history and physical examination (e.g., non-specific low back pain), imaging with plain radiography, computed tomography (CT) scan, or magnetic resonance imaging (MRI) does not improve patient outcomes.

But some of the recommendations are "relative," not "absolute," as in these two examples:

Don’t obtain preoperative chest radiography in the absence of a clinical suspicion for intrathoracic pathology.
In the absence of cardiopulmonary symptoms, preoperative chest radiography rarely provides any meaningful changes in management or improved patient outcomes.

Don’t use cancer-directed therapy for solid tumor patients with the following characteristics: (a) low performance status (3 or 4), no benefit from prior evidence-based interventions, not (b) eligible for a clinical trial, and no strong evidence supporting the clinical value of further anticancer treatment.
Studies show that cancer directed treatments are likely to be ineffective for solid tumor patients who meet the above stated criteria...

Suppose a patient with a solid tumor that meets the specified criteria protested - "I understand that further chemotherapy is unlikely to be effective, but I want to try anything with the slightest chance of helping me. Your medical society is recommending rationing! That's not fair!"

The oncologist won't have an easy time responding. The patient is right - the medical society has made a rationing recommendation. In my view, this is a long overdo step forward out of the lala land of make believe infinite resources. But in our political culture, the word "rationing" is avoided as assiduously as the "f" word. Our reflex is to deny that rationing is occurring, not to discuss the rationale for why and how it is being done.

And with regard to the recommendation against a routine chest X-ray, it's only a matter of time until the evening news features a patient whose X-ray picked up an undiagnosed cancer, leading to cancellation of the scheduled surgery and removal of the cancer. The patient will tell us "the X-ray saved my life - are we going to let a rationing decision kill people just to save money?"

I hope the ABIM and the specialty societies are brave enough not to run for cover when the inevitable backlash occurs. They've taken a courageous step on behalf of the health of patients who could be harmed by interventions that wise clinical practice should avoid. And they've pushed us towards open engagement with the question of when interventions that "rarely" produce any benefit should be paid for our of shared insurance funds. We should thank the ABIM and the specialty societies for their contribution to healthier patients and a healthier society!

(Information about the ABIM's "Choosing Wisely" program can be found here.)

Educative Journalism in Massachusetts

Apropos yesterday's post, this editorial from today's Boston Globe is interesting. I've interlaced comments of my own in bold italics:

EVEN BEFORE this year’s grand debate about containing health care costs begins on Beacon Hill, a pointed disagreement has broken out among key players in the state health care arena.

The health plans fear that legislative meddling is opening holes in the very cost-controlling arrangements that a recent law required, while legislators contend they are simply looking out for individuals who might be hurt by policy changes. The editorial makes clear that this is a classic "good vs good" conflict. Constraining costs is an ethical responsibility, since health care costs deplete wages, small business viability, and the state's capacity to fund other public goods. But protecting vulnerable people from unintended impacts of policy decisions is also an ethical responsibility.

There is nothing wrong with trying to minimize disruptions on patients from changes to their insurance plans, but the recent proposal to give certain patients the right to keep receiving treatment at higher-cost hospitals is too broadly written. Until it is clear just how many people would be exempted from policy changes, and how that might add to insurers’ costs, the Legislature should hold off, lest it undermine its own goal of making health care more affordable. If I'd written the editorial I wouldn't have used the phrase "insurers' costs." Those costs are passed through to the businesses and public agencies that purchase insurance. The public doesn't always understand that health plans - especially the regional not-for-profit health plans Massachusetts has - are essentially purchasing agents for the public and private entitites that provide health insurance to their constituents.  

The year before last, the Legislature passed a law requiring insurers to offer limited networks, which restrict plan members to certain hospitals and doctors, and tiered networks, which charge plan members more for using more expensive providers. The moves provided lower-cost insurance options for families and businesses, albeit by limiting patients’ choices of doctors and hospitals. Over the past two years, average annual premium hikes have shrunk from a projected 16.3 percent to 2.3 percent.

But this year, at the behest of Representative Steven Walsh, House chairman of the Joint Committee on Health Care Financing, and other influential legislators, the Legislature passed a budget rider making exceptions for some members of such plans. Walsh says he’s concerned that patients who were undergoing treatment at Children’s Hospital, the Dana-Farber Cancer Institute, and the Floating Hospital under the terms of their previous plans be able to continue their treatments there without bearing large cost increases. He contends that the budget language is crafted to apply to only a relatively small number of patients; he doesn’t, however, have a reliable estimate of just how many.

Although the legislative intentions may well be good, this episode is a cautionary tale.

The insurers, for their part, worry the language would allow a much larger number of patients with chronic conditions to sidestep plan features designed to rein in costs. They also worry that this action sets a bad precedent for future legislative interventions; already, lobbyists for major hospitals are seeking ways to keep their patients while still receiving higher reimbursements from insurers. It will likely now be left to the Patrick administration to work out a compromise.

Although the legislative intentions may well be good, this episode is a cautionary tale. Health care policy is so complex, and with so many moving parts, that it’s best to work out problems beforehand rather than fix them later. In this case, it’s easy to imagine a relatively small number of people with serious illnesses in the midst of rigorous treatment at Children’s, Dana-Farber, or Floating Hospital having a legitimate need to continue seeing the same doctors. I know from research I've done on the appeals process that continuity of care is a common concern for patients and clinicians. When you look at individual situations in detail it's clear that there's a continuum from long term/high complexity treatments in which deep relationships have been created over time to relatively clear cut treatments that could quite reasonably be transferred to another site. The editorial writer(s) recognize this continuum and make a nuanced argument.

But until Walsh and other sponsors can say just how many beneficiaries there are, and be certain that other patients will not be able to use the law to get treatment at their institution of choice without having paid for that option, the Legislature should avoid meddling with a reform that truly has worked.

This is a thoughtful, well-informed editorial. This kind of educative journalism has been an important contributor to the relatively collaborative way in which the state is dealing with the volatile conflicts that any serious health reform effort must tackle.

The Truth about Massachusetts Health Reform

If your view of Massachusetts health reform came from the Republican presidential debates you'd think the program is a catastrophe. That's baloney.

A recent article in Health Affairs shows it's a measured success, a work in progress.

An ongoing annual survey of 3,000 randomly selected households shows that uninsurance among nonelderly adults - the group most vulnerable to being uninsured - is steady at 94-95%, the highest insurance rate in the nation.  Emergency room visits for nonemergency conditions has declined. From 2006, when the reform went into effect, to 2010, self reported "excellent" health status improved from 59.7% to 64. There's been no drop in the rate at which employers offer insurance to employees. Two thirds of the population continue to support the program, though political bashing of "Obamacare" and "Romneycare" has led to an increase of those who are opposed to it from 17% to 27%.

As I see it, the key lesson from Massachusetts health reform is the process by which it launched and is currently handled. Prior to passage of the 2006 law, there were several years of discussions, reports, conferences, committee meetings, and more. From this combination of education, argument and deliberation, what emerged was a consensus that government, employers, and individuals had to share responsibility for making things better. And, at least as important, all that interaction created some trust among the key parties and a culture of civility that is all-too-lacking in the pathetic national non-dialogue on federal reform.

In terms of shared sacrifice: individuals accepted a mandate that we be insured; employers accepted a requirement that they provide insurance or pay into a state pool; and the state accepted responsibility for subsidizing low income folks and for creating a mechanism - the Connector - to administer the new forms of insurance that were made available.

Those leading the reform process decided to defer the most challenging aspects of reform - (1) cost containment and (2) delivery system reform, until almost everyone in the state was insured. The agenda for Massachusetts has now shifted to those two issues.

In 2012, Governor Patrick, a Democrat, is using the same process that Governor Romney, a Republican, used in 2006 - orchestrating broad stakeholder participation, and using the bully pulpit of the state house. Instead of bashing insurers for the health cost trend the Governor is directing insurers to drive hard bargains. This repositions the insurer from being the enemy of the public to being the agent of the public. The fact that more than 90% of the Massachusetts insurance market consists of locally based not-for-profits makes this a viable strategy for the state.

I'm deeply skeptical about the readiness of the U.S. to come to grips with health costs, but I'm guardedly optimistic about Massachusetts. This year rates in the small group market are going up by only 1.8% (see here and here). Fee-for-service is diminishing - 1.2 million folks (20% of the insurance market) are already in programs with global budgets. And from conversation with friends who practice in different hospitals and medical groups I know that the medical community is working on reengineering clinical systems to produce equal or better results at a lower cost.

If the Supreme Court finds the Accountable Care Act constitutional and it becomes clear that the law will stand, it will be easier for other states to do the kind of long term work with messy and difficult problems that Massachusetts is doing. Hysterical tantrums about "Obamacare" are getting tiresome!

(If you're interested in Mitt Romney's role in launching the Massachusetts reform process, see this excellent New Yorker article.)

A Personal Experience with Consumer Directed Health Care

I'm agnostic about how effective Consumer Directed Health Care (CDHC) will turn out to be in prodding us patients into acting like discerning, value-oriented consumers. But I'm a total believer in the goal.

As a psychiatrist whose work is now largely in ethics and health policy, I'm interested in the psychological side of how we not-always-rational human beings respond to policy innovations like CDHC. So when I had a little interaction with my own CDHC plan last week, I paid attention.

In the last couple of weeks a longstanding mild medical problem had acted up such that my primary care physician and I decided that a specialty consultation would be a good idea. As a physician I knew it wasn't a medical emergency, though it had preoccupied me enough so that I didn't do any blog posts between December 1 and December 18.

In terms of CDHC, I knew that I'd met my deductible for 2011, so the sure-to-be-pricey specialty consultation would only cost me a $20 copayment, not an arm and a leg, but only if it took place this year. But I doubted that a "routine" appointment would be available before January at best, when the new deductible would kick in.

I was pretty sure I could get an appointment in 2011 if I said it was "urgent." But from a medical perspective it wasn't urgent, and I didn't want to (a) lie or (b) take away an appointment from someone else for whom it would be truly urgent. But at the same time I was peeved at the idea that the consultation would cost me $20 or several hundred dollars (especially if tests were added on, which they may well be), depending on the vicissitudes of schedule. Since I could afford the difference, even if grudgingly, I determined to take the first non-urgent appointment that was available, expecting it to be in 2012.

Still, it seemed odd that "better service" (an appointment in December) would cost much less than "worse service" (an appointment in January or later). That would be like Amazon offering next day delivery for a lower price than routine delivery!

The personal side of the story has a happy ending - the specialist had time later this week.

But I was interested in the way the financial incentive built into CDHC created a potential artifact. It wasn't a big deal, but these real world behavioral impacts are the kind of thing we need to understand and evaluate in assessing policy innovations.

(For an example of research I did with colleagues on the behavioral impact of CDHC see here. And see here for a blog post about how CDHC can work exactly as hoped for!)

The Reform Medicare Really Needs

Between now and the elections in November 2012 we're going to hear a lot about Medicare vouchers - or, in the prettied up term, "premium support." We're finally at the point where no responsible politician denies the need to curtail Medicare costs. And, in recent weeks, Democrats as well as Republicans have been floating different forms of voucher proposals for reining in Medicare costs. "Guaranteed Choices to Strengthen Medicare and Health Security for All," the hot-off-the-press proposal from Senator Ron Wyden (D-Oregon) and Representative Paul Ryan (R-Wisconsin) will get the most attention.

The Wyden-Ryan proposal opens with an on-target diagnosis of how virulent Medicare politics has led to the morass we're in:

Few issues draw more heated partisan rhetoric than the future of Medicare. Seniors are a reliable and powerful voting bloc, and both Republicans and Democrats are guilty of exploiting Medicare concerns to frighten and entice voters..In fact, the more the national conversation about the future of Medicare deteriorates into partisan attacks that our opponents will “cut Medicare” versus superficial campaign pledges to “make no changes” to a 45-year-old program, the harder it gets to have a serious debate about the best way to ensure that seniors can rely on a strengthened Medicare program for decades to come.

The debate about Wyden-Ryan and other voucher proposals is predictable. Republicans and a few Blue Dog Democrats (foreign readers - "Blue Dogs" are conservative Democrats) will fight for vouchers on the basis of free market theology of choice and competition. Yellow Dog Democrats (foreign readers - "Yellow Dogs" are so loyal they would vote for a yellow dog if it was called a Democrat) will fight to keep fee-for-service Medicare as it is, with tweaks to reduce costs.

Both positions are wrong. They ignore the two most important constituents - Medicare beneficiaries themselves and the improvement-minded clinicians who care for them.

We Medicare beneficiaries (I say "we" even though I'm only a Medicare "eligible," since I still have employer insurance) don't want to mortgage opportunity for future generations to pay for the bloated system we have now. The 77% of us with traditional Medicare like the government-run insurance program. The 23% of us with Medicare Advantage plans are happy with private insurance. But we're not happy with the discoordinated care system in which tests are repeated unnecessarily, doctors don't communicate with each other, we get readmitted to the hospital too quickly, and, at the end of life, too often die surrounded by monitors and tubes in the ICU rather than by our loved ones at home. And our physicians and nurses are frustrated by many of the same things.

To get real Medicare reform three things must happen:

1. Medicare beneficiaries must speak out about improving care and protecting future generations by reducing costs. Politicians imagine that we're all "greedy geezers" like the folks who threaten them in the recent AARP advertisement. Some of us are, but it's a minority. Our political leaders won't get serious until they hear from us - their constituents - about what most of us believe and want.


2. Improvement-minded physicians, nurses, other health professionals, and administrators are the ones who know how to wring the waste, estimated to be as high as 30%, out of the care system. Competition won't do it. Vouchers won't do it. Only motivated health professionals can. If you want to understand why this is so, read Don Berwick's recent address to the Institute of Health Improvement.


3. Medicare needs a budget. Creating a budget by adding up the bills for our care won't do the job. If there's a true budget we can work with out caretakers to do what's needed within fair limits. Most of us are on fixed incomes. We know there's no pie in the sky!

For 35 years I practiced and got my own care at a not for profit HMO where clinicians and patients lived within a budget and made the system work. I'd rather see us use patient-physician collaboration as the basis for Medicare reform rather than hope that financial pressure will turn Medicare beneficiaries into health care shoppers who drive costs down. But quite apart from the prevailing conservative faith-based belief that "skin in the game" will inevitably fuel the needed reforms, it's not irrational to fear that politicians won't have the gumption to create and stick to a true budget for Medicare, or to allow CMS to apply sensible management strategies like centers of excellence instead of unbridled fee-for-service. It's that perspective that leads Democrats like Senator Wyden to take up the voucher concept.

But with or without vouchers, with or without either single payer Medicare or multiple competing insurers, the key ingredients of Medicare reform are (1) strong beneficiary demand for positive change, (2) leadership from improvement-minded clinical leaders, and (3) an overall budget for the program. Without this triad we're just whistling into the wind.

Learning from Massachusetts Health Reform

The Blue Cross Blue Shield Foundation of Massachusetts has just published a report on the first five years of Massachusetts health reform. The report provides valuable lessons about how U.S. society can learn to improve access and set limits on costs. It's crucial for us to understanding the learning curve for health reform. Reforming the health system isn't primarily an intellectual challenge. The difficulties are mainly in our own psyches, and among the different players on the health care chess board.

As I see it, the key aspect of Massachusetts health reform is the process by which it came about. Prior to passage of the 2006 law, there were several years of discussions, reports, conferences, committee meetings, and more. From this combination of education, argument and deliberation, what emerged was a consensus that government, employers, and individuals had to share responsibility for making things better. And, at least as important, all that interaction created some trust among the key parties and a culture of civility that is all-too-lacking in the pathetic national non-dialogue on federal reform. The term "Obamacare" is a symptom of the lack of dialogue and civility.

In terms of shared sacrifice: individuals accepted a mandate that we be insured; employers accepted a requirement that they provide insurance or pay into a state pool; and the state accepted responsibility for subsidizing low income folks and for creating a mechanism - the Connector - to administer the new forms of insurance that were made available.

Massachusetts has reduced its uninsured population to 1.9%, compared to the shameful national average of 16.3%. The cost of the subsidized insurance has gone up 3% per year, significantly lower than the national average. Approval of the 2006 law has remained steady at two thirds of the adult population.

Massachusetts explicitly chose to tackle coverage before squaring off with cost. The five year report documents that coverage is relatively "solved." Now the state is turning its attention to cost.

It looks to me as if we're approaching the cost problem the way we approached coverage - with LOTS of talk. We've had multiple reports, all of which say much the same thing - that providers with market clout get paid high prices without delivering comparably superior outcomes, that the entire system has a great deal of waste, and that cost escalation is strangling the businesses, public agencies, and individuals, who pay for care. As I wrote back in March, Massachusetts is the jawboning capital of the western world (see here).

Wise psychotherapists understand that dealing with the resistance to change is the hard part of the work. Once resistances have been dealt with, things get easier. And the late management guru Tony Athos described Japanese management style in the same way - LOTS of process to bring about consensus and then much smoother implementation than we see with our "process-lite" U.S. approach.

I believe, and hope, that what we're seeing in Massachusetts now with with regard to health care costs is creating the human and social infrastructure we need to get a grip on costs. The next report, five years from now, will reveal whether this is true or not.

(The five year report, written by my former colleague Alan Raymond, is very readable. If you're interested in learning more about Massachusetts health reform, take a look.)

Zeke Emanuel on Health Reform

Zeke Emanuel provides an excellent piece of public education about the potential for improved quality of care and cost savings in a recent New York Times blog post. The piece will be especially informative for folks who don't understand how fragmented the U.S. care system has become and how fee-for-service reimbursement promotes the fragmentation. Emanuel concludes, correctly, that there's substantial potential for improving care for patients with chronic illness, and that these improvements can achieve savings for the health system.

But I think Emanuel makes two mistakes in the piece. Both come from misinterpreting the psychological underpinnings of health reform.

First, after describing very lucidly how bundled payments provide financial support for coordination among caretakers, he explains that "the idea is to force all of a patient's care providers to work together." But "force" is the wrong verb here, and it reflects a mistake medical managers make all too often.

Collaborating with colleagues actually makes practice more enjoyable as well as more effective. Working together in ways that help our patients is intrinsically satisfying. When those in charge assume we clinicians have to be "forced" to do something, we buck them. When they facilitate what good clinicians want to do, we do it with pleasure. The idea of global payments is to "allow" and "support" collaboration, not to "force" it!

Second, Emanuel correctly notes that improved care coordination can produce much more savings than malpractice reform. But apart from the question of how much savings a reduction in defensive medicine might produce, the climate of litigation has a corrosive impact on the psychology of medical care and the doctor-patient relationship. In ethics discussions with medical students, residents, and practicing physicians, the first question is typically - "what does the law say - what happens if I'm sued?"

The spectre of malpractice litigation creates a sense that patients and society are potential enemies. Health reform requires collaboration between doctors, patients, and the wider public. Malpractice reform is crucial not just for whatever money it might save for the health system, but for the potential that reform will reduce the degree to which physicians feel under attack.

Mitt Romney on the Veterans Health System

By temperament I'm an optimist, but Republican pronouncements on health care, like Mitt Romney's proposal for privatizing the Veterans Health system, challenge that stance. Paul Krugman has a powerful op ed on this latest piece of Republican disinformation in today's New York Times.

The Veterans' care system was radically reengineered in the 1990s. It now consistently outperforms the private sector on measures of quality and cost. As Krugman points out, that violates Republican theology. When facts and faith collide, something has to give. Romney isn't dumb, so the differential diagnosis is (1) faith in markets that is so strong he'll deny facts or (2) garden variety political duplicity - (i.e., expeditious lying).

(See this piece in yesterday's Daily Kos for details about the VA program and the Republican knee-jerk assault on public programs.)