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When the Office of Economic Opportunity, which was funding Geiger’s clinic (the first community health center in Moundville, Mississippi funded by Lyndon Johnson’s Great Society) , found out, they were furious — and sent an official down to Mississippi to inform Geiger that they expected their dollars to be used for medical care. To which Geiger famously replied: “The last time I checked my textbooks, the specific therapy for malnutrition was food.” [Excerpt from “Wellness is More than Not Being Sick” by Rebecca Onie, Chapter 18 in Creating Good Work: The World’s Leading Social Entrepreneurs Show How to Build A Healthy Economy edited by Ron Schultz]

When Dr Jack Geiger got to Moundville in 1964, he found conditions to be reminiscent of those he had seen in South Africa, and not in a good way. The staff of the community health center, who supposed they were going to be dealing with TB, cancer, and other medical problems instead found themselves overwhelmed by the social problems that undermined health in the region, such as hunger and unemployment. In a way that was prescient,  members of the community were included for the first time in decisions about their health and the future of the area through inclusion on the board and the clinic staff.

These medical folks soon found themselves engaged in food security, developing safe drinking water, and economic development, The clinic developed a farm cooperative to allow community members to grow food for themselves and earn additional money from selling produce to others. They not only saw patients in their offices but went into people’s homes to focus efforts on how to prevent illness. In the days of Jim Crow, they were considered a significant threat to the status quo.

Today, the Delta Health Center has a Facebook presence. The community health movement has spread to almost every part of the country. It is not unusual for the local Center to provide services to all, regardless of ability to pay. However, it isn’t enough. Just as Dr. Geiger saw that food was the treatment for malnutrition, we now know that chronic illness, cancer, and premature death are caused as much by poverty and genetic predisposition as by bad luck. The zip code you are born in predicts whether you will live an additional decade and what that experience will be like. The next Dr. Geiger will need to get into the weeds a bit more.

The Center for Health Innovation at CMS has put together a blueprint to get to the next step. Called Accountable Communities, it envisions health professionals hooking folks up with food, pest control, legal services, and other resources needed to help them overcome the tyranny of the zip code. Health Affairs has outlined what resources we as care providers need to overcome that tyranny:

1) Health Systems Need To Commit To Real Clinical Integration Of Social Needs – If we are going to anticipate the “rising risk” patient, we as care providers need to know something not only about the “really sick” but about all folks in the community and their anticipated needs. Some insurance plans are capturing this on all of their covered folks but doing a terrible job of sharing with other members of the health care team. We need to all know who is suffering so we can match people with resources.

2. Commit To Developing A Workforce That Is Truly Focused On Addressing Social Needs – It will take more and different types of care providers to help folks to not get sick in the first place. What should our outreach strategy be? Do we develop community health workers? Do we recruit volunteers? While it takes a village, more importantly it takes way more than just doctors. Once a need is identified, we need case workers engaged in hooking folks up with services such as food pantries, financial planners, pest control specialists, and legal aid.

3. Commit To Giving That Workforce The Information They Need To Do Their Jobs Well– Community resource availability is an ever-changing picture. Static information sources (books, pamphlets, etc) are rapidly out of date. Medical personnel often are unaware of what the community has to offer. Whose job is it to hook up community agencies with sick people?
4. Commit To Follow Up – For folks at risk of getting sick, repeated contact to help them become motivated to change is the key, even when they don’t want to think about their health. Who makes this contact? Do we aggressively pursue those who feel they don’t need services but clearly do?
5. Commit To Collecting And Analyzing Data – This is a lot of data on people. Target knows when a person is pregnant, often before the baby-daddy does. Do we use this data for the forces of good? If so, who does and how do they use it?
The Great Society didn’t make us great but it sure helped this county. Although still poor, the health markers in Bolivar county are better than 11 other Mississippi counties. For rural Mississippi, that is saying something. Maybe through Accountable Communities we can all take that a step to disassociating illness and poverty.



barbara-smaller-it-s-fine-to-discover-cures-but-remember-chronic-conditions-are-our-br-new-yorker-cartoon (1)Forever there has been a power struggle between the medical school faculty and physicians in the community. For those of you who are versed in House of God, the book about medical care in the early 1970s, attendings and residents at the House as well as the students who went to BMS (Best Medical School) would reference care delivered by LMDs. This term referred to “Local Medical Doctors,” known uniformly for taking crappy care of patients who were then transferred to the “House”  where life-saving intervention would occur. The protagonist soon realized that there was more to medical care then doing stuff to people, culminating in realizing the truth in Fat Man’s Rule 13 (THE DELIVERY OF GOOD MEDICAL CARE IS TO DO AS MUCH NOTHING AS POSSIBLE). In the 1970s, the reality is that physicians on medical school faculty tended to earn less, a LOT less, that the LMDs, may have adding to the tension.

Somewhere about 20 years ago, LMDs traded their label for another that was even more pejorative – PCP. The Primary Care Provider concept was created in part to reduce the confusion around training requirements of physicians (Family Medicine, Internal Medicine, Pediatrics) and non-physicians (Physicians Assistant, Advanced Practice Nurse) who might provide primary care to a given patient. Patients don’t use the term, PCPs find the term demeaning, and the term doesn’t really reflect the complexity of care delivery that happens in the primary care office. Teaching hospitals, though, became Academic Health Centers and were distinguished in part by their lack of PCPs as well as their lack of desire to train them. The Academic Health Center was home to Specialists.

It is now almost 40 years since House of God was published. Obamacare is the law of the land and  the law encourages the use of primary care. This is in part because the work of Barbara Starfield demonstrated that health care is just better when people have access to primary care, and in part because a lot of work was done to demonstrate that specific models which incorporate primary care lead to better health outcomes. Programs like the Massachusetts Blue Cross Alternative Quality Contract and truly integrated systems like Kaiser and Health Partners  led to better outcomes. The work on Patient Centered Medical Home initiatives led to this specific type of primary care being incorporated in the law as well. Good primary care, so the saying goes, will keep you healthy. If you happen to get sick, it will help keep your costs down by keeping you out of the hospital. If you happen to go to the hospital, it’ll keep you from being harmed and help maintain quality care.

This week, the Houses of God are fighting back against the LMDs. The University Healthsystem Consortium (the trade organization for Academic Health Centers) put out a video entitled Through the looking glass: a new perspective on population management. Their video tells us the following in convenient cartoon form: 1) Most people just randomly become ill so don’t need a specific LMDs but instead need access to a CVS with a nameless Pee Cee Peee (their pronunciation) sitting and waiting for you to show up (and perhaps willing to give you a Z-pak “to prevent pneumonia”).  Oh, yeah, and prevention is too expensive so let’s blow off trying to get people Pap smears and mammograms and focus on treatment. 2) If you are chronically ill or sick with a serious illness, you don’t need a Pee Cee Pee at all but a House of God led team of folks. According to the video, they are sitting on the steps of the House just waiting for you to show up. 3) If you suffer from an early chronic illness you might want a Pee Cee Pee, but only get one who has the number to a specialty hotline, just in case you need one of the specialists at the House. You know how those Pee Cee Pees are.

The UHC’s vision is a dystopian one where patients are taking ambulances to the Academic Health Center for their not-well-controlled diabetes because the local House of God is 2 hours away and the Pee Cee Pee is unqualified to administer insulin. The evidence they cite for the effectiveness of this model is dated and incorrect. I can only hope that the Academic Medical Centers and their research arm, UHC Research Institute (TM), have a better plan for survival before the next “House of God” is written without them.

As if in follow-up to my previous discussion about the obese healthy care delivery system as well as a follow-up to Escape Fire and the Time Magazine article on health care costs (conventional wisdom says read the article, ignore the conclusions), I was forwarded this link to a story in the Daily Beast about why Cleveland Clinic is the wrong model. In the article, Meg McArdle points out all the good thing that Cleveland Clinic can do, but then points out:

Last spring, I interviewed Charles Bosk, a sociologist who specializes in studying the way that doctors and medical systems handle error. “Atul Gawande answers the wrong question,” he told me. “It’s not whether checklists are effective. Anybody who has made it through third grade, and/or made it through the supermarket with or without a list, knows that checklists work. What you need is to ask is, ‘What would motivate professionals to use checklists?’ ” Checklists invert the normal doctor/nurse hierarchy, giving nurses the authority to, say, step in and stop the procedure of inserting a central line. That’s tough for many doctors to swallow. And hard for nurses to do, unless the culture ensures that they genuinely shouldn’t fear later retaliation.

When I asked Cosgrove [the CEO of the Cleveland Clinic] if other hospitals could really emulate the Cleveland Clinic, he said “yes, other people can do it. One of the things that is beginning to drive this is the patient satisfaction scores that is now becoming part of the pay for hospitals.”

But he also said “both the incentives and the culture matter. They’re inexorably tied. We’ve gone through a very major cultural renaissance if you will to begin to tie everything together.” And he clearly recognizes that on the culture front, the Cleveland Clinic is something special.

In both the Time article and the movie, the Cleveland Clinic is held up as a model. To be successful, the docs at the clinic have suppressed their egos to improve care. Are they really the only health professionals in the US willing to do such? I certainly hope not.



Found while preparing a talk for the Internal Medicine department on Accountable Care Organizations

Eventually, effective ACOs will hand-pick specialists to become integrated into their provider networks — clinically, technologically, operationally and financially — and those specialists will participate fully in the care model, says Terry Spoleti, president of Glenridge HealthCare Solutions. Specialists working in communities dominated by ACOs will need to perform well or they will lose access to patients, she says.

“There will certainly be winners and losers as specialists compete for referrals based on cost, quality and service,” Spoleti says. “In ACO and population health organizations, utilization will decline, so a smaller pool of specialists will need to serve a broader population.”

Emphasis added,

After a long day yesterday of Mardi Gras-ing that concluded at 1 am, the effects of a viral illness, and the lingering effects from travel, I am not up for too much heavy thought. Instead, I will call your attention to several items that have recently caught my attention:

  • I think that Atul Gwande is probably one of the best “thinkers” in medicine today. I picked up his books Better and The Checklist Manifesto while in DC. I cannot recommend them highly enough.
  • While in DC I had several staffers of our deeply red delegation say “You know that Congressman ____ is against ObamaCare, but can you share with me what you feel is working.” I made them aware of my belief that with or without the ACA, the horse was out of the barn in terms of reorganizing care. I wish that I had read this article by Elliot Fisher before my visit, in particular this passage which would have given me much more authority:

Outside of Medicare, almost 100 provider organizations are already working with private health plans toward contracts containing the core elements of the ACO model: payment tied to improving patient care across the continuum and reducing overall spending growth. Other ACO-related initiatives are emerging at the regional or state level (e.g., Vermont) or through state Medicaid programs (e.g., New Jersey and Texas). At least 12 states have enacted legislation to facilitate accountable care reforms.

  • Lastly, I am going to weigh in on the Making Catholics Pay For Pills/Hating Planned Parenthood/Hating The Susan Komen Foundation controversy only briefly enough to point out that prior to modernization of childbirth, 1 in every 150 births ended in the death of the mother. As the average woman likely had 4 to 6 pregnancies in the 1920s, probably 1 out of every 20 women died in childbed. Today, that number is 8 in 100,000 births in a large part due to antibiotics and C-sections, but also due to pregnancy spacing afforded by contraceptive technology and many fewer pregnancies in older women. The average woman (thanks to pregnancy planning) has under 2 pregnancies so the absolute decline in deaths due to childbirth is about 10000%. The reduction in breast cancer deaths despite A LOT of attention has only been about 20% at best. Maybe God is trying to tell us something.

I ask a question of medical students in a class that I teach:

“List the biggest public health achievements of the past 10 years.”

The WalMart $4 formulary  makes it every time. WalMart claims to have saved patients over $3 billion by providing high quality, low cost generic medications to the American public. In fact, Walmart estimated that 30% of its $4 generic patients in 2007 were uninsured. I use this resource a lot for my patients and they are grateful for it.

However, based on an NPR report today, I thought I might find myself in competition with WalMart myself:

In the same week in late October that Wal-Mart said it would stop offering health insurance benefits to new part-time employees, the retailer sent out a request for partners to help it “dramatically … lower the cost of healthcare … by becoming the largest provider of primary healthcare services in the nation.”

On Tuesday, Wal-Mart spokeswoman Tara Raddohl confirmed the proposal. She declined to elaborate on specifics, calling it simply an effort to determine “strategic next steps.”

The 14-page request, which you can read here, asks firms to spell out their expertise in a wide variety of areas, including managing and monitoring patients with chronic, costly health conditions. Partners are to be selected in January.

Analysts said Wal-Mart is likely positioning itself to boost store traffic, possibly by expanding the number of its in-store medical clinics and the services they offer.

The speculation is that WalMart might even be taking it a step further:

In-store medical clinics, such as those offered by Walmart and other retailers, could also be players in another effort in the health law: encouraging collaborations of doctors and hospitals who want to win financial rewards for streamlining care and lowering costs. Such collaborations, known as “accountable care organizations,” might contract with in-store medical clinics, says Paul Howard, a senior fellow with the Manhattan Institute for Policy Research. He has studied retail clinics, some of which have recently expanded to offer services beyond simple tests and vaccinations, such as helping monitor patients with diabetes or high blood pressure.

NPR later published a semi-retraction:

Updated at 2:52 p.m. ET: Wal-Mart issued a statement Wednesday saying its request for partners to provide primary care services was “overwritten and incorrect.” The firm is “not building a national, integrated low-cost primary health care platform,” according to the statement by Dr. John Agwunobi, a senior vice president for health and wellness at the retailer).

It was fun to speculate on the effect of a true primary care presence in WalMart. According to one source “Their traffic has been declining for over two years and they’ve been losing market share.  If you get someone in the door, you can also sell them milk and a shotgun.”  I don’t know that aren’t going to  be unexpected consequences. It may not be the same in other primary care offices, but our waiting room commonly has people in it who are SICK! They are bleeding, febrile, and I suspect not very fun to be around. Do you really want to stand next to the person with influenza in Line 3? I will also add that no patient has ever ask me if I sell shotguns.

I discussed the slowing of health care delivery inflation here. The New York Times published an op-ed by Zeke Emanuel and Jeffery Leibman that further illustrates how maintaining the  Affordable Care Act is necessary to continue bending the cost curve. Using several examples of expensive, marginally effective therapy, they point out that much of the cost of Medicare is based on income maximization on the part of care providers as they function in this fee-for-service world. Their critique of the anti-ACA alternatives as a method of cost control are as follows:

  • Meat-cleaver cuts hack spending indiscriminately. Cuts that fail to distinguish between high-value and low-value medical care would do more harm than good.
  • Cost-shifting cuts don’t actually reduce health care spending; they just shift costs from the government to the private sector. … raising the eligibility age [for Medicare] would reduce government spending on Medicare, it would shift the costs to individuals and businesses. It would also increase the number of uninsured 65- and 66-year-olds, leading to worse health outcomes and making it harder for older Americans to find work.
  • Penny-wise, pound-foolish cuts reduce current spending by a little but raise future costs by a lot. Raising co-payments for office visits and medications is a good example. Research shows that when older adults are charged higher co-payments, they reduce their primary care visits and use of prescription drugs. But the research also shows that forgoing this outpatient care leads to an increase in expensive hospitalizations.

They point out that already in place in the ACA are provisions that incentivize improved care delivery at reduced cost. They close with the following

The seeds of a solution lie in the accountable care organizations, medical homes and bundled payment reforms that were authorized by last year’s Affordable Care Act. Accountable care organizations are groups of health care providers and hospitals that work together to treat patients. Medical homes coordinate primary care services. And bundled payments consolidate the many costs of an episode of care, like a hospitalization, into a single payment, incentivizing efficient delivery of tests and treatments. All of these reforms allow payments to be based primarily on the number of patients cared for and the quality of that care rather than on the volume of services provided.

Why is our health care system so messed up? It would seem that the efficient delivery of health care could be accomplished with much less stress, muss, and bother. We have a defined population (Americans), we have measurable outcomes (infant mortality,  chronic illness care markers, cost of care, cost in last 6 months of life, etc), we have a defined delivery system run by a set of professionals who are licensed (physicians), and we have a physical infrastructure already in place (hospitals, offices, long term care facilities, etc). What’s the problem? To quote a post from the blog naked capitalism, in a post about the financial mess:

[O]pacity, leverage, and moral hazard are not accidental byproducts of otherwise salutary innovations; they are the direct intent of the innovations. No one at the major capital markets firms was celebrated for creating markets to connect borrowers and savers transparently and with low risk. After all, efficient markets produce minimal profits. They were instead rewarded for making sure no one, the regulators, the press, the community at large, could see and understand what they were doing.

In the words of health care analyst Paul BataldenEvery system is perfectly designed to achieve exactly the results it gets.” There is a lot of money in the current system, thus a lot of folks who want to keep the status quo.

Medicare, with the least opaque payment structure, is the most recent delivery payment vehicle to come under scrutiny by the pundits. A very efficient, though open ended system of paying for care through a fee-for-service model has been the hallmark of this program from the start. Congressman Paul Ryan has set his budget-cutting sights on this program (as I discussed here). This program, interestingly, is the one program where defined population (ALL Americans over 65), measurable outcomes, and existing resources would allow us to easily transition to more efficient, less expensive care.

The Affordable Care Act created a myriad of changes to the delivery system. It created incentives to improve the delivery of care, improvements to the delivery of information to those who pay the bills, and provided information that allows patients to become wiser care consumers. Surprisingly enough, it may now be working for Medicare, even before the provisions take effect:

While our elected representatives wrangle over slicing entitlements, virtually no one seems to be paying attention to an eye-popping fact: Medicare reimbursements are no longer accelerating at a break-neck pace. The new numbers should be factored into any discussion about healthcare spending:  From 2000 through 2009, Medicare’s outlays climbed by an average of 9.7 percent a year. By contrast, since the beginning of 2010, Medicare spending has been rising by less than 4 percent a year. On this,  both Standard Poor’s Index Committee and the Congressional Budget Office (CBO) agree. (S&P tracks healthcare spending with the help of Milliman Inc., an independent actuarial and consulting firm.)

Why? As pointed out previously, systems are designed to achieve the results they get:

Zeke Emanuel, an oncologist and former special adviser for health policy to White House Office of Management and Budget director Peter Orszag, is certain that this is what is happening.  When I spoke to him last week, Emanuel, said:  “This is not mere chance: this is directly related to the initiation of health care reform.”  It is  not the result of reform, Emmanuel emphasized.  The reform measures that will rein in Medicare inflation have not yet been implemented.  But, he explained, providers are “anticipating the Affordable Care Act kicking in.”  They can’t wait until the end of 2013: “They have to act today.  Everywhere I go,” Emanuel, added, “medical schools and hospitals are asking me, ‘How can we cut our costs by 10 to 15 percent?’”

Combine a change in incentives with increased transparency regarding insurance and perhaps we can continue achieving different results.

It seems that only a year ago we were being entertained by some with tales of Medicare cuts, death panels, and the need for someone to save us from a government takeover of medicine. Now, a year later it turns out that government took health care over some time ago (as seen here); it is important for those of us under 55 to accept our Medicare cuts gracefully;  and while there are no death panels yet, there maybe cuts that may lead to increased deaths (but not how you think).

Assuming Congress doesn’t learn to do better in sandbox, come December

Cuts to Medicare would be capped at 2 percent of current Medicare spending, or roughly $11 billion a year for a 10-year savings of approximately $130 billion, said Eric Zimmerman, a Washington attorney and lobbyist for the hospital industry. Details of how the cuts would be carried out remain to be seen, but Zimmerman says it could mean a flat 2 percent reduction in payments to Medicare providers, including doctors, hospitals, nursing homes, and private insurers that offer plans with Medicare benefits.

Doctors and hospitals are alarmed, they state. What alarms me even more is that the system (the one in which the USA is ranked number 72 in overall health, 37 in overall system performance, and 1 in cost) would achieve only a slight savings (2%) in one program (Medicare) through across the board cuts.

When fees were cut by Medicare for ophthalmology in the 1990s, the effects were as follows:

10% reduction in the fee for a cataract extraction will cause ophthalmologists to supply about 5% more non-cataract services. … The suggests that physicians behave more like profit-maximizing firms than target income seekers.

Or, put another way

Physicians with apparent incentives to induce demand appear to manipulate the mix of services provided in order to increase the effective Medicare fee.

In other words, there are those in leadership positions who think we should repeal the Affordable Care Act and that by simply cutting Medicare fees across the board we can cut costs. If this happens without changing the structure of care or the incentives, the evidence suggests that doctors will simply rearrange the game so that they’re providing more services (illustrated here and here). Excess care leads to excess death. So, maybe rationing and death panels are the least of our worries…

Personally, I find that the most objectionable feature of the conservative attitude is its propensity to reject well-substantiated new knowledge because it dislikes some of the consequences which seem to follow from it – or, to put it bluntly, its obscurantism. I will not deny that scientists as much as others are given to fads and fashions and that we have much reason to be cautious in accepting the conclusions that they draw from their latest theories. But the reasons for our reluctance must themselves be rational and must be kept separate from our regret that the new theories upset our cherished beliefs.

Fredrick Hayek

To follow-up on my previous post, we seem to find ourselves in a position where the overwhelming evidence is that we do not live in the country with the best health care in the world, only the most expensive (with a thanks to Barbara Starfield, who passed away this week, for steadfastly pointing this out). The previous point I was trying to make was that there is a role for regulation in various aspects of our life and health care seems to be one of them. Poorly regulated health care delivery has led to excess capacity in the cities, diminished capacity in rural and underserved areas, and care that is excessive and expensive overall. It has also led to poor general health (see We’re #37 for an in-depth analysis). It was reading comments from another health care blog that reminded me of another potential cause of poor care delivery that regulation must change.

The Dartmouth Atlas Study has looked at variations in health care for over 20 years. The study began, very simply, because investigators began asking “Why are certain rates of surgery so much higher in one place than in another (geographically proximate) place even though human beings don’t vary that much?”  What they have found are some dirty little secrets about our care system:

Regarding the supply of care

Simply put, in regions where there are more hospital beds per capita, patients will be more likely to be admitted to the hospital. In regions where there are more intensive care unit beds, more patients will be cared for in the ICU. More specialists will result in more visits to specialists. And the more CT scanners are available, the more CT scans patients will receive.

In regions where there are relatively fewer medical resources, patients get less care; however, there is no evidence that these patients are worse off than their counterparts in high-resourced, high-spending regions. Patients do not experience improved survival or better quality of life if they live in regions with more care. In fact, the care they receive appears to be worse.

Regarding physicians role in the demand for care

We see dramatic variations in rates of surgical treatment for other conditions where multiple treatment options are possible, such as chronic angina (coronary bypass or angioplasty), low back pain (disc surgery or spinal fusion), arthritis of the knee or hip (joint replacement), and early stage cancer of the prostate (prostatectomy). Such extreme variation arises because patients commonly delegate decision-making to physicians, under the assumption that doctors can accurately understand patients’ values and recommend the correct treatment for them. Yet studies show that when patients are fully informed about their options, they often choose very differently from their physicians.

Regarding the type pf doctor we train

Increasing the number of physicians will make our health care system worse, not better. First, unfettered growth is likely to exacerbate regional inequities in supply and spending; our research has shown that physicians generally do not choose to practice where the need is greatest. Second, expansion of graduate medical education would most likely further undermine primary care and reinforce trends toward a fragmented, specialist-oriented health care system. Current reimbursement systems strongly favor procedure-oriented specialties, and training programs would almost certainly respond to these incentives. Third, workforce expansion will be expensive. If outcomes and patients’ perception of access improved as supply increased, then we could debate whether an expansion of training offers better value than investments in preventive care, disease management, or broader insurance coverage, which have known benefits. Instead, the costs of expansion will limit the resources available for necessary reform efforts without any evidence-based promise of a benefit.

In short, the evidence is clear. The bastardization of the market has brought us not only poorly organized and distributed care, but extreme excesses of useless care. I am willing to pay for my share of necessary medical care to ensure that if I incur an illness others will pay for me. I am also willing to support a public system that rewards physicians for delivering care of proven high quality. I am increasingly unwilling to support a system that rewards excesses in the manner that ours does. If we must maintain specialists pay at current levels, let’s stop training the excess and pay the current ones not to deliver excessive care like we did for tobacco growers not so long ago. At least then we will have healthier Americans.