Second Thoughts by Physicians and Others on Obamacare

Among mortals second thoughts are wisest.

Euripedes (485-406)

Now that Obamacare is more than three years ago, people have had a chance to consider its various provisions,  and second thoughts are flowing in. Many of these second thoughts are expressed in a special section “An Exam on Doctors Pay” in yesterday’s Wall Street Journal.   I am disappointed such issues as “savings” from Accountable Care Organizations, deep cuts in Medicare pay, and bundled bills were not addressed, but entire section is worth reading.

The Journal runs six pro and con articles by experts on these six “crucial” issues and asks  these questions.

1)      Should physician pay be tied to performance? (

 

      Comment: I think not, since  no one knows yet  how to define performance, and studies to date have been inconclusive).

2)       Will companies stop offering health insurance because of Affordable Care Act?

  Comment:  Some have already, perhaps 10 million, but others may be waiting to turn   coverage over to government).

3)       Would Americans be better off on an organic diet?)

 

        Comment: I doubt it, but one man’s pesticide is another man’s fertilizer,  just as one woman’s wheat staple is another woman’s gluten-free food.)

4)       Should hospital residency programs be expanded to increase the number of physicians? 

 

      Comment: Yes.

5)       Should nurse practitioners be able to treat patients without physician oversight?

 

      Comment:  Yes, under certain circumstances, minor illnesses and routine complaints.

6)       Do the health benefits of neonatal circumcision outweigh the risks?

      Comment: I have no opinion, but “yes expert” says, “The benefits are many, while the risks are few,  and the “no expert” says, “It’s unnecessary, causes pain and reduces pleasure.”

What  interested me most about the WSJ's section was tucked in the back under the “The Best of the Experts” and was called “Insights From Our Expert Panel.” 

 

One question asked there was “In two years, what will doctors say about the Affordable Care Act? Here are their answers.

·         Fred Hassan, Chairman of Bausch & Lomb :  “Most doctors will feel the Act has resulted in decreased reimbursement while making them have to see more patients.  Many will also that ACA has decreased choices for patients while doing for tort reform.”

Comment:  Spot-on.

·         Leah Binder, president and CEO of Leapfrog Group, an organizations representing employer purchasers of health care:   “”Physicians will say they were blindsided by a private-sector phenomenon that completely transformed their practice : high-deductible health plans, the fastest-growing form of health plan. With HDHPs, employees need information on price and quality so they can shop for value.

Comment:  HDHPs are a good thing, but a bad thing.

·         John Sotos, cardiologist, flight surgeon, advisor to the television series, “House”: All true physicians will be applauding the ACA.  A true physician’s first concern is, and must be, the health of his or her patients.  Taxes, nanny-state worries and politics are lower on the list, and do not distinguish a physician from other members of society. Physicians must be physicians first, and taxpayers second.

Comment: Spoken like a true-believer in the goodness of government.

·         Peter Pronovost, anesthesiologist, professor at Johns Hopkins School of Medicine:  ‘Physicians will be frustrated that the ACA and meaningful use incentives have forced health-care systems to spend millions on electronic health records that hurt productivity, provide limited, if any, decision support and do little to improve patient outcomes.”

Comment: EHRs are vastly  overrated as a tool to improve health care and distract from the doctor-patient interaction.

·         Liz Feld, president of Autism Speaks:  Expanding access to health-care coverage was a noble mission.  The country will be sorting through how to afford the ACA;s implementation.

            Comment:  To quote Samuel Johnson(1709-1784), “The road to hell is paved with   
            good intentions.”

Tweet: The June 17 WSJ has a special on doctor pay.  Read it and form your own opinion.  I have mine.

 

The Obamacare Radar Detector

The most essential gift for a good writer is a built-in, shock-proof, shit detector. This the writer’s radar all great writers have it.

Ernest Hemingway (1899-1961),  Interview in Paris Review (1958)

I do not profess to be a great writer.  But I like to believe I have built-in radar for what’s going on beneath the surface  of the healthcare news.

Here are two examples.

·         The biggest threat to Obamacare implementation is the IRS scandal.  It undermines trust in impartial government and  truths it claims to impart.  In today’s Forbes, Grace Marie Turner, founder and president of the Galen Institute, brings this threat to light in “Danger Ahead: Obamacare and the IRS.” She claims Congress has a duty to delay IRS funding to block Obamacare implementation. The IRS, she asserts, will have unprecedented and compromised powers – to collect $1 trillion to fund the law,  distribute another trillions of dollars  in subsidies, enforce compliance of many mandates,  introduce 46 new tax proposals,  collect information on citizens’ income, employment and health status,  and increase and monitor surveillance of their private affairs.  

These activities are beyond the IRS’s normal functions and will require $10 billion in additional funding and 16,500 IRS agents to enforce.  Furthermore, she adds, Sarah Hill Ingram, the top IRS official who oversaw the IRS office that targeted, delayed or stopped the Tea Party and other conservatives efforts from qualifying for tax exempt status,  will run the IRS implementation of Obamacare from the White House.    As Shakespeare said, “Something is rotten in the state of Denmark,” and it has a decidedly fecal smell .  The IRS has forfeited its claim to being politically impartial and should be stripped of its Obamacare enforcement powers.  All of these things empower government while disempowering individuals.

 

·         The other phenomenon going on relating to Obamacare is the movement of consumers and physicians away from traditional healthcare settings. – physicians offices, emergency rooms, and hospitals and their outlets.  Fear of premium “rate shock,” among the 25 million in young, individual, and small group markets triggers this movement.  It is occurring among relatively healthy consumers seeking more convenience, lower costs, and fewer hassles – and among physicians  seeking refuge from  third party straight jackets that drive up overheads and divert attention away from patients.  The alternatives to traditional care include:    retail clinics now offered by all major drugstore chains, generally run by nurse practitioners,  where the average cost is $78 dollars per visit;  worksite clinics, financed by one-third of major employers with over 500 employers; 1200 community health clinics, partially financed by government,  where costs vary from $35 to $300, depending on the nature of the visit; and  9000 urgent care walk-in centers,  which are growing at the rate of 300 per year,  where costs average $118 for each visit; and concierge practices  Among consumers, the appeal of these new settings is lower costs, less waiting, less bureaucracy, and in the case on conciege practices, more unfettered access.   Among physicians the main appeals are professional independence , escape from rules and regulations, and direct pay, which increases cash flow and lowers overhead.  If. as a physician, a consumer, or someone interested in direct pay strategies, you may want to attend a workshop, “Thrive, Not Just Survive," to be held at Hubert Humphrey School of Public Affairs in Minneapolis  on August 10, 2013,.  For more information and to register, call 612-333-4646.

Tweet:   Two Obamacare radar screen sightings: 1) negative IRS impacts on implementation; 2) rise of nontraditional lower-cost healthcare settings.

On the Envy of Other Nations’ Health Systems (And of Obamacare)

Young man, there is America-  which at this day serves as little more than to amuse you with stories of savage men and uncouth manners; yet shall, before you taste of death, show itself equal of the whole of that commerce which now attracts the envy of the world.

Edmund Burke (1729-1797),  Irish statesman and member of English House of Commons

We believe that envy has an appropriate place in health policy, if in this case means health systems struggling to address specific weaknesses by identifying strengths in other systems that they could emulate… More bottom-up flexibility in England and more to-down regional strategies  for the United States would represent progress.

Nick Seddon and Thomas Lee, “ A Strategy for Reform,” New England Journal of Medicine,  June 13, 2013, Reform London and Partners Healthcare System and Harvard Medical School
 

Creating a high-performing health system entails challenges athat are being addressed by other countries.   Incorporation of international evidence-based policy initiatives migh enhance U.S. cost containment efforts.   Germany's bundled payments and Japan's payment adjustments are two of the many options that are tranferable and relevant to the U.S. context.

Gerald Anderson, Amber Willink, and Robin Osborn,  "Reevaluating 'Made in America- Two Cost Containment Ideas from Abroad, " New Englad Journal of Medicine,  June 13, 2013, Commomnwealth Fund and Bloomberg School of Public Health

The Swedish system performs superbly, and my Swedish colleagues cited evidence of that fact with obvious pride. The United States spends more than $8,000 per person on heatlh care , well more than twice what Sweden spends.  Yet health outcomes are far better in Sweden in virtually every dimension.

Robert Frank, economics professor at Cornell, “What Sweden Can Tell Us about Obamacare,” New York Times, June 16, 2013

What will happen, if in the end, Obamacare really works? Of course, you can expect scare stories and Fox News alerts abut higher premiums.  These anecdotes will focus on young health people with no coverage who will have to join the rest of the country in the insurance pool, or pay a fine.  Some employers will also choose to pay the government rather than insure their own workers.  It’s a fascinating moment, akin to the dawn of Social Security and Medicare.

Timothy Egan, “Million-Anecdote Baby, “ New York Times,  July 13, 2013

There you have it – a voice from the past, saying the rest of the world would eventually envy America’s economic might and voices from American  progessives, expressing envy over other nations’ health systems for their lower costs and universality.    How to account these points of view?  Could it be America’s entrepreneurial  freedom-loving culture , relatively low level of regulations, and distrust of big government?  Could it be our  relatively low top income tax rates,  39.6%, versus an average of  over 50% in Europe, which has an addition VAT tax of 19% to 25%.  Or could it be that progessives  are right? That comprehensive benefits for all, which will come at higher costs for the young and American businesses, may be the future?

Tweet:  The world envies U.S. prowess and might: The American left envies other nations’ health systems with their lower costs and universal access.

 

 

 

Measuring and Paying for Performance and Outcomes

Measurement is the first step that leads to control and eventually to improvement.  If you can’t measure something, you can’t understand it.  If you can’t understand it, you can’t control it, And if you can’t control it, you can’t improve it.

Dr. H. James Harrington (born 1929),  Statistician, entrepreneur, and improvement guru

It all sounds so logical, compelling, and scientific.  Compile enough measurement data,  measure physician performance,  measure patient outcomes,  and measures of quality of care will improve. 

In the words of George Halvorson, CEO of Kaiser Permanente,  “"We are on the cusp of the golden age of healthcare delivery,” He went on to explain that the toolkit to improve patient care, "is getting better every day. We have better technology, better connectivity, better databases, and better science. We have better opportunities to interact with patients to help them improve their health.”

This is very persuasive rhetoric, at least until you get the details, namely,   what measurements, what performances, what outcomes, and what rationale? 

Let’s take hospitals first.    The Centers of Medicare and Medicaid (CMS) has seized upon the idea if we could only measure the rate of 30 day readmissions  among American hospitals,  we could improve care before and after discharge.  

How?  Well,  we could give patients more instructions on  what to do once out of the hospital,  we could coordinate the transition to home and rehab facilities.  We could have the hospital take charge of care once patients have left the hospital. And we could punish those hospitals with high readmission rates by lowering their Medicare payments.  

As I see it, there are a couple of problems with this approach, rational and admirable as it may be,  Most discharged patients who are readmitted have serious chronic diseases only temporarily altered by their hospitalization.   Most cash-squeezed hospitals do not have the resources to take care of patients outside the hospital environment.     Patients,  many of them elderly,  return to the environments and behaviors  that caused their illnesses in the first place.

You can use big data to measure these problems, which are well known, but measurement does not necessarily change the realities and dynamics on the ground.

Consider physician performance.  As   Regina Herzlinger, PhD, professor of business administration at Harvard Business School and the “godmother of consumer driven care,” in Who Killed Health Care (McGraw Hill, 2007),  comments, “ Congress is now practicing medicine. Its pay-for-performance (P4P) initiatives enable governments to tell health care providers how to practice medicine. The higher the performance, the higher we pay. The health care system lacks metrics of performance. Despite its name, P4P does not pay for performance – the attainment of improved care at a reasonable price. Instead, it pays for conformance – the adherence to a government-dictated recipe for the provision of health care. The government pays for adherence for its recipes for the process of delivering health care rather than for outcomes.”

And as of a January 26, 2001 report in Reuters, pointed out, “ Paying doctors financial rewards to meet targets for improving the care of patients made no discernible difference to the health or treatment of people with high blood pressure, a study has found.”

“The findings suggest governments and health insurers across the world may be wasting billions of dollars on doctor incentive schemes but getting no improvement in patient care, researchers who conducted the study said.”

“Researchers from Britain, the United States and Canada assessed the impact of incentivised targets on quality of care and health outcomes in around 470,000 British patients with hypertension and found that they had no impact on rates of heart attacks, kidney failure, stroke or death.”

As it turns out,  Medicare and Medicaid, and  medical societies,  can’t yet figure out what clinical outcomes to measure.  Two obvious measure targets are diabetes  and obesity.   You can measure hemoglobin A1C,  which declines  when  patients lose weight, exercise, take their medicine, and eat properly.  All of these activities depend on how patients behave as outpatients,   not necessarily on instructions they receive in doctors’ offices,  Obesity is similar.

Measurements of hemoglobin A1C and body mass indices could serve as signposts of improvement ,  and  teams of primary physicians,  dieticians, nurses, and others visiting homes or in telephone contact could improve outcomes.  But diabetes and obesity are only two clinical conditions and account for a  fraction of chronic diseases requiring improvement.   

Studies to date have shown only modest improvement when doctors are paid for  improvement.  Maybe with big databases , studies of population health,  closer interaction with patients based on information technologies,  these numbers will improve.

Tweet:  Measuring and paying for performance and outcomes promise   to improve healthcare but they have yet to significantly improve results.

 

 

 

 

Is Congress Being Hypocritical about Obamacare?

It’s necessary and only fair for Congress to live under the rules we pass for everybody else.

Senator Chuck Grassley (R-Iowa)

Obamacare Has Federal Workers Panicked.

Charles Hurt,  Headline of article in June 13 Washington Times

What’s good for the goose is good for the gander, except for Congress and their staff who live in Washington, D.C, where the government goose lays golden eggs for government workers. 

These workers,  who include president Obama, vice-president,  Biden, senior government officials, members of the Cabinet,  congressional Representatives, Senators and their staffs,  are covered under the Federal Employees Health Benefit Program (FEHBP), which is not available to ordinary citizens.   Under FEHBP,  the government subsides cover an average of 72% of their premiums.    This benefit may stop on January 1, 2014,  when these employees will be required to sign up for the health exchanges.

Washington politicians complain this provision in the health  law may cause a “brain drain” among staffers, who will no longer be able to live and work in Washington, D.C., the nation’s boom town  with high living expenses, skyrocketing real estate values,  and citizens living the in country’s  top 5 most affluent zip codes.

Word on Capitol Hill is that behind the scenes,  Congress is lobbying to make the nation’s top politicians and their staffs exempt from Obamacare.  It is not fair, they say, for Senators, Representatives and their staffs  to be forced into health exchanges they created.  It is not fair that their health premiums will go up.  It’s  not fair  that what's good for the rest of us is bad for them. It’s just not fair for Washington politicians, who make $174,000 a year, with guaranteed retirement pay no longer how  long they serve, and their staffs, whose average pay is nearly $100,000 to pay for increased premiums coming under Obamacare, especially young staffers who may be shocked by the "rate shock."

I suppose rank,  gained  by  rising to the top of the political pile,  has its privileges.   But that rank smell in the air at the top of the pile,  may be one of  hypocrisy.

Tweet:    Washington politicians, Senators, Representative, and their staffs may be forced to participate in health exchanges on January 1, 2014.

For New Doctors: The New Commencementarians

Commencementarian  – A person accomplished in the practice of new beginnings

I dreamt last night  I gave a commencement talk before graduating medical students. 

Here is what I had to say.

You are about to enter a  brave new medical world convulsed by health reform.   As a person who has tracked health reform  over the last 30 years, here is what  you can expect.

It will be a new world, full of new beginnings.

Consolidation – You can expect to work for an organization,  either as an employee or as its leader. For the most part,  hospitals or “integrated healthcare organizations” will own these organizations.  You will will be expected to comply within the organization’s rules.  You will be expected to comply with government regulations.  You will be expected to be creative in making the organization more efficient,  more patient-oriented,  safer, and more competitive with a larger market share.  By 2015,  these large organizations will own 75% of physician practices,  for only large organizations will have the capital,  resources, and technologies to function  in the new reform environment.

Coordination -  You can expect to hear a lot about “coordination” and to be an integral part of  “coordinated, “ integrated,” and “aligned” organizational activities.  These activities will revolve around providing more comprehensive,  essential,  accountable,  and measurable practices focusing on prevention, genesis,  genomics, and treatment of chronic disease.   You can expect that  “big data” will be used to measure the success of these activities.   As W. Edwards Deming (1900-1993), the father of modern statistics, declaimed, “ In God we trust,  all others bring  data.”  You will be expected to follow protocols, guidelines, and algorithms.   If you are a primary care physician,  you will be expected to lead the clinical team, to be knowledgeable in “population health,” and  to be skilled in health information technologies.

Commentarianism -  If  you belong to  an independent  maverick, entrepreneurial,   risk-taking subgroup,   you will be expected to provide cost-lowering,  convenience-generating,   disruptive-producing ideas  that change practice and the status quo  as we now know it.   If your ideas have mass applications,  your ideas can be expected to attract venture capitalists.   You can expect most of these ideas will involve  information technologies, to lend themselves to finger clicks and flicks of your fellow physicians  and  healthcare entrepreneurs.   Many of these innovations or apps will fall within the realm of telemedicine,  monitoring patients outside the hospital,   creating new  virtual doctor-patient  communications  not requiring  the physical presence of either party, and in new payment mechanisms, such as concierge practices,  cash-only arrangements,   and bundled-payments,  outside the reach of private and government third parties.   

Tweet:   This year’s medical school graduates can expect a Brave New World,  with consolidation,  coordination, and entrepreneurship as main themes.