Category: practice variation

Health Beat: The AMA Would Make Health Care Unaffordable for Many Americans

Health Beat: The AMA Would Make Health Care Unaffordable for Many Americans:

“The American Medical Association has announced its opposition to a public-sector health plan that would compete with private insurers. Why? Because the AMA fears that Medicare E (for everyone) might not pay some specialists as handsomely as private insurers do now.

“Why do private insurers pay more? Because they can pass the cost along to you and I in the form of higher premiums. Medicare E has no one to pass costs on to—except taxpayers. And taxpayers will already be helping to subsidize those who cannot afford insurance.

“Everyone agrees that primary care physicians are underpaid. Democrats in both the House and the Senate propose raising their fees, as does the Medicare Payment Advisory Commission (MedPac)—the group that might take over setting fees for Medicare. Moreover, the House, the Senate, President Obama and MedPac have made it clear that they do not favor the across-the-board-cuts called for under the sustainable growth rate (SGR) formula. Congress has consistently refused to make those cuts and President Obama did not include them in the 2010 budget that he originally sent to Congress. On that score, the AMA has nothing to worry about.

“Protecting Excessive Fees for Some Specialists’ Services

“So what does the AMA fear? That either MedPac or Medicare will trim fees for certain specialists’ services. Keep in mind that Medicare’s fee schedule has traditionally been set –and adjusted on a regular basis, by the RUC– a committee dominated by specialists.( Private insurers then follow that fee schedule, usually paying somewhat more for each service.) I have described this group in the past: They meet behind closed doors. No minutes are kept of their meetings. They rarely suggest lowering fees—even though as technology advances, some services become easier to perform. MedPac has pointed out that a less biased group should be involved in determining fees—perhaps physicians who work on salary, and are not affected by Medicare’s fee schedule.

“There is good reason to suspect that the RUC has over-rated the value of some services.. MedPac has suggested taking a look at particularly lucrative tests or treatments that are being done in large volume. Often, this may mean that patients who don’t need the service are receiving it; if the procedure isn’t necessary, then, by definition, they are being exposed to risks without benefits. And in fact, experience shows that when high fees are trimmed, volume falls, suggesting that rich fees were, in fact, driving overtreatment.”

There is more here about using medicare to “bend the curve,” or reduce over-utilization, improve use of preventive services, as well as a discussion of how a Public Plan might besubsidezed, etc. well worth reading, particularly about subsidization.

I would only add that the title falls a bit short: The AMA, or rather, conservative physicians, are hardly the only group fighting significant change. The Health Insurance industry, despite conciliatroy noise, will be the big guns or long knives as this goes forward. And behind them will be Pharma, other device and equipment manufacturers, probably home health servicers, ambulatory care centers, and, for purely ideological reasons, all conservatives.

The High Concentration of U.S. Health Care Expenditures

The High Concentration of U.S. Health Care Expenditures:

“Half of the population spends little or nothing on health care, while 5 percent of the population spends almost half of the total amount. Examining the distribution of health care expenses among the U.S. population sheds light on areas where changes in policy might bring about the greatest savings.

“Select to download print version (PDF File, 785 KB). “

Indeed, well run micro-systems that exist at Mayo, Cleveland, Geisinger, Virginia-Mason and others show us it’s possible.

Annals of Medicine: The Cost Conundrum: Reporting & Essays: The New Yorker

Annals of Medicine: The Cost Conundrum: Reporting & Essays: The New Yorker:

A damning look by Atul Gawande at the way we pay for medical care in America. The final three paragraphs of this must read article.

“Something even more worrisome is going on as well. In the war over the culture of medicine—the war over whether our country’s anchor model will be Mayo or McAllen—the Mayo model is losing. In the sharpest economic downturn that our health system has faced in half a century, many people in medicine don’t see why they should do the hard work of organizing themselves in ways that reduce waste and improve quality if it means sacrificing revenue.

“In El Paso, the for-profit health-care executive told me, a few leading physicians recently followed McAllen’s lead and opened their own centers for surgery and imaging. When I was in Tulsa a few months ago, a fellow-surgeon explained how he had made up for lost revenue by shifting his operations for well-insured patients to a specialty hospital that he partially owned while keeping his poor and uninsured patients at a nonprofit hospital in town. Even in Grand Junction, Michael Pramenko told me, “some of the doctors are beginning to complain about ‘leaving money on the table.’ ”

“As America struggles to extend health-care coverage while curbing health-care costs, we face a decision that is more important than whether we have a public-insurance option, more important than whether we will have a single-payer system in the long run or a mixture of public and private insurance, as we do now. The decision is whether we are going to reward the leaders who are trying to build a new generation of Mayos and Grand Junctions. If we don’t, McAllen won’t be an outlier. It will be our future.”

I went to the Dartmouth Atlas web site myself and found this interesting tid-bit:



I think it fits in well with the ethos described in Gawande’s article.

It is much easier to continue aggressive treatment rather than spend time having an honest discussion about the benefits and burdens of continuing treatment.


Thanks to whoever put the link up on the Howard Dean Webinar tonight!



UPDATE: This recent Archives of Internal Medicine article is particularly apporpriate:
http://archinte.ama-assn.org/cgi/content/short/169/10/954

This also, perversely, can make the hospital statistics in mortality look good, as well. As an intensivist, I can get almost ANYONE out of the the ICU and subsequently out of the hospital if I ignore the true outcome for the patient and the family: additional suffering, minimal prolongation of a life at its end, and so on.

My colleagues who do practice best EOL practices know that our ICU and hospital mortality numbers suffer, but I have no doubt that having honest discussions with my patients and families is the right thing to do. You may have heard this for your patients, “Thanks for the straight talk, Doc,” or “Nobody talked to me about my prognosis before.”

Of course, this is not new information, but we still need to do better as physicians:http://www.chestjournal.org/content/128/1/465.full?ck=nck

Arch Intern Med — Abstract: Discussions With Physicians About Hospice Among Patients With Metastatic Lung Cancer, May 25, 2009, Huskamp et al. 169 (10): 954

Arch Intern Med — Abstract: Discussions With Physicians About Hospice Among Patients With Metastatic Lung Cancer, May 25, 2009, Huskamp et al. 169 (10): 954:

“Background Many terminally ill patients enroll in hospice only in the final days before death or not at all. Discussing hospice with a health care provider could increase awareness of hospice and possibly result in earlier use.

“Methods We used data on 1517 patients diagnosed as having stage IV lung cancer from a multiregional study. We estimated logistic regression models for the probability that a patient discussed hospice with a physician or other health care provider before an interview 4 to 7 months after diagnosis as reported by either the patient or surrogate or documented in the medical record.

“Results Half (53%) of the patients had discussed hospice with a provider. Patients who were black, Hispanic, non-English speaking, married or living with a partner, Medicaid beneficiaries, or had received chemotherapy were less likely to have discussed hospice. Only 53% of individuals who died within 2 months after the interview had discussed hospice, and rates were lower among those who lived longer. Patients who reported that they expected to live less than 2 years had much higher rates of discussion than those expecting to live longer. Patients reporting the most severe pain or dyspnea were no more likely to have discussed hospice than those reporting less severe or no symptoms. A third of patients who reported discussing do-not-resuscitate preferences with a physician had also discussed hospice.

“Conclusions Many patients diagnosed as having metastatic lung cancer had not discussed hospice with a provider within 4 to 7 months after diagnosis. Increased communication with physicians could address patients’ lack of awareness about hospice and misunderstandings about prognosis.”

First, having these conversations with patients is the right thing to do for a multitude of reasons, not the least of which is our duty to help our patients weigh the benefits and burdens of medical treatment. The reduction of unwarranted suffering is hard to over estimate.

Second, imagine the economic impact of doing the right thing. No rationing, just having the appropriate conversations with our terminally ill patients.

Dartmouth Atlas of Health Care: Regional Disparity in Medicare Spending – Interactives – Quality/Equality newsroom – Quality/Equality – RWJF

Dartmouth Atlas of Health Care: Regional Disparity in Medicare Spending – Interactives – Quality/Equality newsroom – Quality/Equality – RWJF

The above link takes youto the interactive map that is kind of cool to look at and comare a few regions to see where yours falls.

The actual NEJM article is here. And here is the substantive part of the article (for me, anyway):

What’s going on? It is highly unlikely that these differences in growth could be explained by differences in health. Marked regional differences in spending remain after careful adjustment for health, and there is no evidence that health is decaying more rapidly in Miami than in Salem.

The variations allow us to rule out two overly simplistic explanations for spending growth. First, “technology” is clearly an insufficient explanation: residents of all U.S. regions have access to the same technology, and it is implausible that physicians in the regions with slower spending growth are consciously denying their patients needed care. Indeed, evidence suggests that the quality of care and health outcomes are better in lower-spending regions and that there have been no greater gains in survival in regions with greater spending growth.1 Second, it is difficult to blame regional differences entirely on the current payment system, since all our evidence on regional growth comes from populations in the fee-for-service system. Other research has emphasized the role of managed care in moderating the growth of costs,2 but this story cannot explain the rapid growth in Miami, where roughly half of Medicare enrollees are covered by Medicare Advantage plans.

The causes must therefore lie in how physicians and others respond to the vailability of technology, capital, and other resources in the context of the fee-for-service payment system. A recent study by researchers in our group provides further insight.3 Using clinical vignettes to present standardized patient care scenarios to physicians throughout the country, the researchers found that physicians in high- and low-spending regions were about equally likely to recommend specific clinical
interventions when the supporting evidence was strong. Those in higher-spending
regions, however, were much more likely than those in lower-spending regions to
recommend discretionary services, such as referral to a subspecialist for typical gastroesophageal reflux or stable angina or, in another vignette, hospital admission for an 85-year-old patient with an exacerbation of end-stage congestive heart failure. And they were three times as likely to admit the latter patient directly to an intensive care unit and 30% less likely to discuss palliative care with the patient and family. Differences in the propensity to intervene in such gray areas of decision making were highly correlated with regional differences in per capita spending.

The Evidence Gap – British Balance Benefit vs. Cost of Latest Drugs – NYTimes.com

The Evidence Gap – British Balance Benefit vs. Cost of Latest Drugs – NYTimes.com

“RUISLIP, England — When Bruce Hardy’s kidney cancer spread to his lung, his doctor recommended an expensive new pill from Pfizer. But Mr. Hardy is British, and the British health authorities refused to buy the medicine. His wife has been distraught.

“Everybody should be allowed to have as much life as they can,” Joy Hardy said in the couple’s modest home outside London.

“If the Hardys lived in the United States or just about any European country other than Britain, Mr. Hardy would most likely get the drug, although he might have to pay part of the cost. A clinical trial showed that the pill, called Sutent, delays cancer progression for six months at an estimated treatment cost of $54,000.

“But at that price, Mr. Hardy’s life is not worth prolonging, according to a British government agency, the National Institute for Health and Clinical Excellence. The institute, known as NICE, has decided that Britain, except in rare cases, can afford only £15,000, or about $22,750, to save six months of a citizen’s life.

“British authorities, after a storm of protest, are reconsidering their decision on the cancer drug and others.

“For years, Britain was almost alone in using evidence of cost-effectiveness to decide what to pay for. But skyrocketing prices for drugs and medical devices have led a growing number of countries to ask the hardest of questions: How much is life worth? For many, NICE has the answer. “

What a great piece. I’ve been hearing more and more about NICE lately, with this being the most visible publication on it.

As I’ve said elsewhere under the “Rationing” label, I would much rather have a fair, national or regional, system of objective analysis by scientists deciding on what care we offer to patients than the current method. The current method being everything for everyone all the time until we can peel the oncologists (sorry, guys! Others of us are guilty, too!) off the patient. Our current method also includes allowing Lilly to lobby for new reimbursement codes to pay for Xigris, or Zimmer to get Medicare to pay twice as much for a “women’s” TKR and assorted other pieces of free market capitalism.

But the US’ favorite method of rationing care, of course, is by income. Don’t have it, don’t get it.

Practice variation links

Some tidying up of older but still interesting info about regional variation in healthcare:

The Dartmouth Atlas study in Acrobat:
http://www.dartmouthatlas.org/atlases/2006_Atlas_Exec_Summary.pdf

And an op-ed piece from Dr. Goodman about utilization/variation:
http://www.nytimes.com/2006/07/10/opinion/10goodman.html?ex=1156046400&en=2960abf359ef20a7&ei=5070

An article about ‘off the chart’ utilization of angioplasties in Elyria, Ohio:
http://www.nytimes.com/2006/08/18/business/18stent.html?hp&ex=1155960000&en=b81be5f43f98a99b&ei=5094&partner=homepage

And a lecture Jack Wennberg talking about Atlas:
http://www.dartmouthatlas.org/atlases/NYAM_Lecture.pdf

Cheers,
Chris