Bigger is… More Dangerous?

All of the “players” in health care are getting bigger. Consolidation is the name of the game as hospital systems hire more physicians, multi-hospital systems merge, insurers develop their own “captive” provider networks and new hybrid organizations, like CVS/Aetna (and maybe Walmart/Humana) are coming with dizzying frequency. Some of this feels to me like an arms race, with size (and its attendant market power) itself the goal, rather than growth as a means to assemble the right combination of resources at the right scale to improve care.

Even so, I believe scale can improve care. Given where I sit, I don’t suppose that is much of a surprise, but I would go further to say that organizational heft is now necessary to provide high quality care through enhanced and better coordinated access to the right technology, the right providers and the right services, when and where patients need them.

It is in that context that I found a recent opinion piece in JAMA an important read. In it, the authors present a thoughtful theoretical framework for considering the potential downside of the growth of provider organizations. Titled The Risks to Patient Safety from Health System Expansions it includes new threats to patient safety and suggests potential strategies for mitigating them, summarized in this table:

(Click image to enlarge)

It is important to note that the authors do not advocate limiting the size of provider organizations or retreating from the prevalent plans for growth to avoid these risks. Rather, they conclude: “Institutions must actively plan for, monitor, and manage the resulting risks as part of a comprehensive strategy, including sharing data on quality and safety, and sharing oversight of care for the joint patient population.”

Makes sense to me. What do you think?

Not All Doctors Are Physicians

A colleague recently sent me a link to the “American College of Cathopathic Physicians” a new organization whose mission “is to protect the professional autonomy and advocate for a full, broad scope of practice for DNPs as a ‘cathopathic physician’ completely equal in every way to our MD and DO counterparts.”

I was, I admit, so stunned by the statement (and confused by its grammatical errors) that I thought the whole thing might be an elaborate joke. It was only after spending some time exploring the site that I realized that it was for real, and a really bad idea.

Lets start with the absurd circular “reasoning” that the group uses to justify labeling DNPs as “physicians.” According to the site (their quotations are unattributed):

A physician is commonly defined as a “doctor who practices medicine” which is “the art of healing” or “promoting, maintaining, or restoring health through the study, diagnosis, and treatment of disease”. Other organizations, such as the federal government, define a physician as a healthcare professional with “the authority to make independent judgments in the examination, diagnosis, treatment, prevention, and care of the human body”.

It then goes on to advocate for DNPs to have such authority, which in turn it believes would justify calling DNPs physicians. And of course, once you get to call yourself a physician, why wouldn’t you have full independent authority? After all, that’s what it means to be a physician, right? So, basically, if you call yourself a physician, then you are one.

Continue reading Not All Doctors Are Physicians

Strategic Priorities

For each of the last several years, we have held a retreat for the leadership of our medical group. In the early years, we used the meeting to address basic questions about who we were and what we were trying to accomplish. In 2014 we established a series of priorities for our group, which we summarized in what we affectionately called “the flower”:

This road map served us well in the years since, but we decided it was time for a refresh, so at our most recent retreat we revisited our priorities, and came up with this:

Continue reading Strategic Priorities

Data About Patients Should Be Patients’ Data

I think that almost everyone would agree that making good choices requires access to good information. That may be especially true with regard to choices about one’s health, where the stakes are high, the issues are often complicated, and there is a lot of uncertainty. That is why I feel so strongly that promoting patient access to clinical data is the right thing to do, that it drives better care, and that patients will increasingly demand it.

Here is another, more personal, reason why I feel strongly about it.

Best wishes for a happy and healthy New Year.

Only in America

The phrase “only in America” was one I heard frequently as a child. It was often said in a light-hearted manner, sometimes with a faux Eastern European accent, but always with a deep reverence for what my parents believed to be it’s central truth: that the United States was a special place. Its unique blend of opportunity, freedom and compassion had allowed our family to go from poor immigrants to prosperous professionals in 2 generations. What a country!

I thought of that phrase this morning in a darker, ironic sense, as I read about a middle-aged couple in Tennessee who were struggling to figure out how to afford health insurance. The husband is retired, and the wife makes a solid salary at a small company. Yet they found that they were trapped by their circumstances: they were too young for Medicare, earning too much for Medicaid, not offered health insurance by the wife’s employer, and not able to afford the market rate for an individual policy on the ACA exchange. After considerable study they decided that they had two options – they could get a divorce, which would allow the husband to qualify on the basis of his lower income for an insurance subsidy, or the wife could take a substantial pay-cut, which would make them eligible for an exchange subsidy. They chose the latter, and actually appear to have come out ahead, since the subsidy was greater than the after-tax difference in her pay before and after.

What is wrong with this picture? Here are a few things that come to mind:

  • The health insurance “system” is clearly broken if it creates incentives, no matter unintended, to dissolve marriages and earn less
  • There is a huge “complexity tax” that we are all paying to prop up the Rube Goldberg arrangements of the current health insurance marketplace. How much time, effort and anxiety were spent by this couple to figure this out? For those of you fortunate enough to have employer-provided benefits, how much time did it take you to do your benefits enrollment? Did you get it right?
  • All this is playing out while Congress cut taxes on the most fortunate in our society

Only in America.

Looking in the Wrong Place?

It is no secret that there is a lot of waste in healthcare. Even if one leaves aside the most egregious examples such as duplication of tests and patient harm that necessitates more care, we still collectively do a lot of stuff that does not improve health. A recent report in Health Affairs changed my assumptions about what that stuff looks like.

The authors analyzed claims data from an all payer database in Virginia for services provided in 2014. They prospectively defined 44 services that were of “low value” defined as providing no net health benefit in specific clinical circumstances. Their assessments were based on nationally recognized standards, including the “Choose Wisely” campaign of the ABIM, the US Preventive Services Task Force, CMS criteria, and others. They then scoured the database to see how frequently these services were provided, and calculated the aggregate costs associated with them.

Continue reading Looking in the Wrong Place?

Holy (Sacred) Cow!

The headline in the New York Times summarized the initial reaction of the cardiology community – “unbelievable” – but still seemed to understate the ground-shaking implications of a recent study of coronary stenting.

The report of The Objective Randomised Blinded Investigation with Optimal Medical Therapy of Angioplasty in Stable Angina (ORBITA)Trial was published last week in the Lancet. In brief, investigators in the UK (hence “randomised”) enrolled about 200 patients with angina, objective evidence of inducible myocardial ischemia and angiographic and hemodynamic evidence of significant single vessel coronary artery disease. Half the group received a drug eluting stent, with excellent technical results. The other half got a sham angioplasty. Both groups were treated medically. The key finding: “real” stenting produced no measurable benefit in exercise time increment (the primary endpoint) compared with a “placebo procedure.” The study was well done, with true blinding of patients and evaluating physicians, careful selection of endpoints, and sufficient power to support the conclusion. Whoa.

Continue reading Holy (Sacred) Cow!

Happy Birthday Emily

A couple of my recent blog posts have advocated for single-payer financing for health care in the United States as the most effective path to universal coverage and lower cost. This one is more personal, but also ends with the same conclusion.

My daughter Emily is an actor and singer. Like many artists, she gets by with a part-time job (without benefits) and professional gigs. And, until her recent 26th birthday, she had health insurance coverage as my dependent. She now faces the challenge of finding affordable coverage that will not disrupt her established patterns of medical care.

In many ways, she is fortunate. Until the ACA, she would have been booted off my insurance coverage after she graduated college, and would probably have found it impossible to get private insurance because of pre-existing medical conditions. And even now, I can extend her coverage through COBRA for up to 3 years (and can afford to do so) or she can buy insurance (with some help) on the NY State Health Insurance Exchange. So this is not a crisis for us, but it points out another fundamental flaw of how health insurance generally works in the United States – it is, uniquely among other developed countries, tied to employment.

Continue reading Happy Birthday Emily

Growing Sentiment

A couple of months ago, I wrote that I favored transforming our complex hodge-podge of health care financing to a national single-payer system. It now seems as though a majority of physicians in the US  feel the same way, with 42% strongly supporting the idea. This is a remarkable evolution from the days when the American Medical Association vociferously opposed the creation of Medicare and Medicaid in the early 1960s. Why the shift?

The folks who commissioned the poll cite 4 major reasons:

  1. Complexity fatigue. Back in the day, Medicare was seen as a threat to the simple and straightforward fee for service relationship that physicians had with their patients. Doctors resisted the intrusion of the “government into the exam room.” Now, the exam room is crowded with so many players, each with its own rules and demands, that having only the government to deal with would seem like a relief. This certainly rings true to me.
  2. Many feel as if the handwriting is on the wall about movement toward a single payer, so they grudgingly agree that we might as well do it sooner than later. I would say that another way to look at this is that few can articulate another alternative that reduces administrative complexity and expands coverage.
  3. Shifting demographics. Merritt and Hawkins cite a generational shift, with younger physicians more inclined to support a single payer. I don’t have the data they cite to judge the validity of the explanation, but I suspect it is not just about age, but about the changing nature of physician employment. As more and more physicians are employed by health systems or other large organizations, I believe they feel more financially secure, and more insulated from the details of reimbursement which makes them more open to single payer.
  4. Changing assumptions. One of the most remarkable aspects of the recent debacle in Congress over attempts to repeal the ACA is that public opinion has changed in a fundamental way. It now seems that there is a widespread belief that the government does have a legitimate role in guaranteeing access to health care, and physicians agree.

Another sign that physicians’ attitudes are changing: record membership in Physicians for a National Health Program.

I think the time has come. What do you think?

It’s Still a Dog

Back in March, I made some observations about the AHCA, the bill to “repeal and replace” the Affordable Care Act that was ultimately passed by the House of Representatives and both hailed and disparaged by the President. Some of the naked political calculus that facilitated the passage of such a truly despicable bit of legislation was the belief that the Senate would somehow rescue the Republican Party from itself and restore something “beautiful.” Well, it is now pretty clear that the Senate bill – cynically dubbed the “Better Care Reconciliation Act of 2017” – is no better than what the House threw over the fence.

The bill retains essential “features” of the House version: less funding for Medicaid, fewer constraints on bad behavior of insurers, leaner subsidies for the uninsured to buy insurance, and repeal of the mandate to buy insurance for those with neither employer provided insurance or eligibility for Medicaid or Medicare.

I think Paul Krugman explained pretty well why the current plans to dismantle parts of the ACA don’t work. The ACA is based on a few interdependent ideas:

  1. For insurance to be useful, it has to have certain features, like broad benefits and inclusion of people with pre-existing conditions
  2. To avoid the insurance “death spiral,” everybody has to be in the risk pool. Otherwise, only sick people would buy insurance, thereby pushing up the price and making those who are relatively healthier drop coverage, driving up the price further and driving more healthy people away, worsening the problem
  3. To facilitate getting everyone in the risk pool, subsidies are provided to those who can’t afford the premium

Remove any one of these and the system collapses. We are likely to end up with fewer people insured and worse coverage for those who buy insurance. As is true of the House bill, the Senate bill does nothing to address the real challenges facing our healthcare system today – access, quality, and affordability. As the President might say: “sad.”

What do you think?