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10 things predicted by the Simpson’s before they became “a thing”

There is a running gag over several years in “The Simpsons” television show about series of movies which included an action hero named “McBain.” Loosely based on a combination of Bruce Willis and Arnold Schwarzenegger, in the movies McBain’s nemesis is Senator Mendoza from some unnamed Central or South American 1980s drug cartel country. In one of the most “haunting” scenes, McBain’s long-term partner is shot as he is outlining his plans for retirement. In fact,he actually takes a bullet intended for McBain while showing a picture of his recently purchased retirement boat, aptly named ” Live-4-ever.”  McBain is shown holding the body of his fallen comrade, crying out “MEEEENNNDDOOZZAAA!!!!”

Federally Qualified Health Centers (FQHCs) have been around since the 1960s. They were modeled on a South African system for effective care delivery to the disenfranchised. One of the first was started not too far from me in Mound Bayou, Mississippi.

The health center model that emerged targeted the roots of poverty by combining the resources of local communities with federal funds to establish neighborhood clinics in both rural and urban areas around America. It was a formula that not only empowered communities to establish and direct health services at the local level via consumer-majority governing boards, but also generated compelling proof that affordable and accessible healthcare produced compounding benefits.

Over the years the federal funding has been generous, though much of the funding comes from patient generated revenue (money for seeing patients).  The Centers are also eligible for grant money for facility development, staffing increases, and offsets for seeing the uninsured among other things. The funding streams vary quite a bit from state to state, with those in Alabama being more heavily reliant on federal grants and less so on patient care. Legislators loved them because they put money in local, impoverished areas. Republicans in particular loved them because of the “block grant” nature of the funding. The local folks were best able, so the saying went, to determine where the money could best be spent.

One of the goals of the  Affordable Care Act was to move the money from direct funding programs into programs where the money followed the patient. It was hoped that this would give patients incentives to seek more effective care. It clearly would cut down on shenanigans such as this criminal case in Birmingham where the CEO bought a building, leased it back to the FQHC, videotaped his assistant in compromising positions, and made off with $14 million of federal money. As outlined in an article today, this money was money NOT used to deliver care to homeless individuals, poor folks, and others in need for whom it was intended. In fact, though they were receiving money to care for the homeless, they created barriers of transportation and distance to keep the poor, sick folks away. This money then made its way to the CEO’s pocket.

The ACA, as designed, would allow all the poor, including the homeless, to use Medicaid for their healthcare needs. This would allow a patient to identify the best care for his or her situation. We, in Alabama, have chosen not to accept the law as designed. Instead we have allowed it to be implemented  in a manner inconsistent with the design. We allow those in charge of implementing the law at the state level as well as those in charge of local care delivery to siphon money off. Then, when the system fails, we shake our fists at the clouds and blame Obama.

 

“…the moral test of government is how that government treats those who are in the dawn of life, the children; those who are in the twilight of life, the elderly; those who are in the shadows of life; the sick, the needy and the handicapped. “ ~ Last Speech of Hubert H. Humphrey

When people think of Qbamacare, they think of the insurance aspect. A lot of the law, however, was  designed to deal with a health care system in crisis. No aspect of our healthcare system was more in crisis than the care of our seriously mentally ill. One reason is a lack of private insurance (many folks with serious mental illness can’t hold down steady jobs, which is how America distributes its private health care dollars). Secondly, if these folks had coverage it tended to be Medicaid, and Medicaid is known to be a poor payer, so poor that many general med-surg hospitals closed their in-patient psychiatric units in an effort to limit their “exposure.” Thirdly, through a quirk in the Medicaid enabling legislation, freestanding psychiatric hospitals were not allowed to bill Medicaid for services even if the folks were admitted to their hospital. (50 years ago, state and local hospitals provided such care, and Congress did not want to shift that expense to a federal program.)

The Obamacare act was designed to right many wrongs, and included was a effort to fix this problem. In a section called the Medicaid Emergence Funding Demonstration Act, it provided funding to freestanding psychiatric hospitals to:

provide $75 million to the new demonstration to determine whether it will improve access to psychiatric treatment, lower costs, and reduce crowding in general hospital emergency departments (EDs). At the end of the 3-year trial period, the CMS will make recommendations to the US Congress about the feasibility of offering the program nationwide.

Alabama applied for and received funding to do just this and the community mental health center in Mobile (Alta Pointe) took the money and opened many more beds to help relieve the congestion. The next thing that happened following the demonstration in Alabama? The slicing of the state mental health budget by 25% and the closing of acute crisis beds at several state hospitals. Thanks Obama!

The difference between Obamacare and other programs was the inclusion of evaluation and outcome measures in these pilots. This particular program is being looked at and so far has been found wanting.

So what’s the status? CMS reported on MEPD progress at the end of one year in a mandated report to Congress (see CMS Report To Congress On The Evaluation Of The Medicaid Emergency Psychiatric Demonstration). CMS’ endorsement was tepid – it stated it did not have enough data to recommend expanding the demonstration, but that it supported allowing the demonstration to continue through the end of its authorization in 2015.

At a year, though overall hospital costs were down, length of stay was the same, as was the rate of discharge to the home environment. In other words, the care by the measures agreed upon was the same. Anecdotally, though many benefited, in Alabama care delivery was not improved. In the words of a spokesperson from the Alabama Hospital Association:

“Most of the hospitals feel that the number of patients in departments continues to increase and the length of time it takes to get people into beds is increasing,” Blackmon said.

The national evaluators apparently felt that there were more comprehensive ways to provide care, so this program will likely not be reported favorably to congress and will end.

Which brings us to yesterday’s news story. Alta Pointe, which opened a hospital in response and is now the effective state facility of the seriously mental ill in Alabama (though with little state money), has been using this “demonstration” funding to provide services previously paid for by the state. Now that the demonstration is going away, they will likely close their 100 beds, leaving only 34 crisis beds for approximately 2,000,000 people. Congress has an opportunity to pass a stand alone to continue the program but, given the outcome and the mood in congress, this is unlikely. Alabama has the opportunity to replace the money with state dollars. Given that they are looking to cut half a billion from existing programs and didn’t budget for this expense, not likely either. Don’t think the citizens of lower Alabama are in the mood to pony up an extra $2,000,000 annually in donations, either.

In the words of one al.com commenter:

Let’s look for Al.com’s isolated sob stories to make our hearts heavy and give in to another tax hike. Nonsense. Cut the programs. Cut the departments. Cut the government in half.

So what will happen? Fortunately, space under the bridges is available and serves the dual purpose of allowing the non-afflicted to get to where they want to go. If it gets too cold, those with serious mental illness can commit crimes. Alabamians are always willing to pay for jail cells..

So last week I talked about how physicians make money not just off of seeing patients but also off of the “mark-up” for medications given in the office. I was asked by the editorial writer at al.com what I really thought and here is what I said:

1) This is only one payer although these are the most expensive patients for the most part. In Alabama, physicians make most of their money form BC/BS so this is only a part of the picture

2) The number is not the take home pay. Think of it as an inventory that they sold. Having said that, physicians take home a lot of money. Orthopedists took home over $400,000 on average in 2012. Even he lowest paid took home $175,000. To do that, though, they shave a little off of everything on that list.

3) There’s a lot on that list that physicians sell that doesn’t make the patients healthier. Next time you as a patient are offered a steroid shot for your cold, question whether or not it is necessary or might it contribute to the chance you will get diabetes. Doctors are doing a lot of stuff to people because people expect it and because insurance pays for it. Under the new insurance plans a lot more little stuff that doesn’t work like steroids for colds will be paid for out of the patient’s pocket. Having a doctor you trust might allow you to ask “is this really necessary?” In fact, you might even be able to ask it via e-mail.

THEN I was asked to put it into layman’s terms and (with A LOT of help from others) we came up with “The tomato version of Medicare spending.” I  will suggest that you go here to read it if you want a neat explanation or ever went to the store hungry for a tomato sandwich and ended up with heirloom tomatoes, foccacia, Maytag blue cheese, and a bill for $200 and wondered “why did I do that?”

crime_writing_comic-scaled500Wayne Tarrance: How about you get down on your knees and kiss my ass for not indicting you as a co-conspirator right now, you chickenshit little Harvard cocksucker?

Mitch McDeere: I haven’t done anything, and you know it!

Wayne Tarrance: Who gives a f**k? I’m a federal agent! You know what that means, you lowlife motherf**ker? It means you’ve got no rights, your life is mine! I could kick your teeth down your throat and yank ’em out your a**hole, and I’m not even violating your civil rights!

From The Firm, a novel by John Grisham. In it Mitch McDeere graduates from law school and takes a job for a lot of money with a prestigious law firm, then discovers that they (and by extension he) are working for the mob. The discovery is courtesy of Federal Agent Tarrance.

We have 77 students in our medical school class. They chose their “senior advisors” this week. These are the people who will guide our students through the complex career choicces leading to a  a residency. There are specialties to chose, audition rotations to plan, and interviews to schedule. We had 3 select family medicine as their potential specialty. This is as opposed to 13 choosing surgery, 9 choosing psychiatry and 9 choosing medicine-pediatrics. Not what we want to see out of our class and, as only 4 chose family medicine from last year’s class, we have been doing some departmental soul searching.

As opposed to the other clinical rotations at our school, we send our students out with physicians in practice. We tell ourselves that this pulls them out of our safety-net hospital environment and teaches them what the real world is like. We also interview our students after their clinical rotation in family medicine. What we are discovering is that this exposure to the “real world” is turning them away from primary care in general and family medicine in particular. The most painful was the student who said “I can see myself doing Family, but I think I am going to do psychiatry. Family doctors don’t know their patients.” On the psychiatry rotation, we have found out, they see 3 patients a day, Monday through Friday. As students they really get to know these patients. It seems that the life of a psychiatrist seeing 3 patients a day has a certain appeal.

The federal government has released the payment information on physicians who took Medicare in 2012 (found in a searchable database here). Turns out, the Internal Medicine faculty member in our institution most engaged in teaching medical students took care of 32 Medicare patients in the hospital in 2012 and oversaw 100 outpatient visits. The psychiatry attending admitted 16 inpatients who stayed about 4 days apiece. Although they take care of other types of patients (these are only the ones over 65), they probably both had a lot of time to interact with students.

One of the community family physicians we send our students to had about $100,000 in Medicare payments in 2012 and the following numbers:

  • 815 office visits at $39.33
  • 179 less intensive office visits at $26
  • 89 more intensive office visits at $56
  • 66 hospitalized patients who were in the hospital an average of 4 days. He (or she) made $143 for the initial visit, $52 for the other hospital days.
  • Gave 264 steroid shots at 18 cents apiece.

These numbers are what goes to the practice, not home with the physician at the end of the day. Half of that, as our students are no doubt told, goes into paying the people required to generate the bill to get paid by Medicare.

Had the students spent time with the busiest community psychiatrist in town (based on $157,000 in Medicare payments), they would have seen a doctor with almost 660 hospital visits, over 200 nursing home patient visits and who supervised 300 medication visits with the medication given by a therapist. With the busiest community oncologist ($1.7 million)? Over 40,000 injections of levoleukovorin.

In The Firm, Mitch realizes, too late, that “the law” he learns in law school is not the law he signed a contract to practice at his new law firm. I’m afraid that in our Family Medicine clinical rotation we are providing a dose of unwanted reality to the students. They are seeing that the business of medicine is a lot about running people through as fast as you can in hopes of getting the insurance company’s $20 (or, in the case of triamcinalone, $0.18). As a consequence, the students are voting with their feet into other specialties only to find, once out, that to make the big money you have to sell a lot of antibiotic and steroid injections no matter the specialty.

I’m afraid that unless the payment structure changes, chasing $20 bills is what the real practice of medicine is about. Maybe to increase interest in family medicine we just need to do a better job of hiding this inconvenient truth from our students until they go into practice. As Mitch McDeere found out, it’s not like you can leave.

 

imagesThe physicians had a special relationship back in the pre-forties. They were respected by the entire community; the were looked upon as gods in their own rank.

Chandler Bramlett at age 74, as quoted in Health Care in Mobile: An Oral History of the 1940s

The Alabama Academy of Family Physicians flew me to Washington DC last week to represent the interests of family docs to our congressional delegation. I have been up to the Hill several times representing the interests of my rural colleagues, but this was the first time I was exclusively representing physicians. When you are representing all of rural Alabama’s health care needs, people tend to give you a lot of respect. When you are representing the economic interests of a group of people who, although relatively underpaid, still make in the top 3% of Americans and the top 1% of Alabamians, respect is not nearly as forthcoming.

I had the privilege of having John Waits as the other half of the small Alabama delegation. John is a family physician in Centreville, Alabama, who has established an FQHC and is in the process of using the Teaching Health Center mechanism to bring family medicine training to his small town with the first class starting this year.

The five-year, $230 million Teaching Health Center Graduate Medical Education (THCGME) program is designed to boost the number of primary care residents trained in teaching health centers (THCs), which are community-based ambulatory care centers that operate a primary care residency program.

Unlike Medicare GME funding, which goes mostly to hospitals, THCGME funding goes directly to community-based sites. The funding is tied to specific health care workforce goals, and THCs must report annually on the types of primary care training programs offered, the number of resident positions, and the number of residency graduates who care for vulnerable populations in underserved areas.

That’s the good news. The bad news:

One area of concern, however, is the funding uncertainty for the future of the program…. The THCGME program is funded only through 2015, which creates a challenge for the THCs…. Unless Congress provides additional funding for 2016 and beyond, THCs may have residents in the middle of their training without THCGME payments to support them.

It was this message we chose to bring to our delegation, asking them to help us make a difference.

We were doing OK with our message except for two little roadblocks. The first, especially problematic for our deeply Red delegation, is how the program got its start. It was included in the Affordable Care Act. Given that we were there on a Wednesday and the vote scheduled for Thursday was REPEAL OBAMACARE (which won 229-195 on a partisan vote), no one in our delegation could see a way to supporting a part of a law which was described this way by one physician congressman:  “Obamacare is terminally sick and we need to call the time of death.”

The second obstacle was, well, the physician congressmen. While Alabama has no physician members, our delegation tended to defer health issue specifics to a group referred to as the “Doc Caucus.” Formally known as the Republican Doctors Caucus, it was formed by Republican House physician members and includes all 15 GOP physician members as well as a psychologist, two dentists, and three nurses. Their issues (from their website) include: Repeal ObamaCare and end federal government’s involvement in healthcare; Encourage (but not mandate) state based high risk pools; Encourage (but not mandate) adoption of Electronic Health Records; Tort reform; Medicare and Medicaid reform (through competition and the repeal of the IPAB); Allow health insurance to be purchased across state lines (not through the exchanges in ObamaCare); Transparency of quality data (different than what was in ObamaCare or outlined by Dr Berwick while he was at CMS); Fix the sustainable growth rate.

Rather than move backwards, I would encourage them to listen to one of their former colleagues, Bill Frist, and consider using the Affordable Care Act to effect change by fixing the payment system:

“We are convinced that reforming our nation’s health care system to prioritize quality and value over volume will not only improve health outcomes and the patient experience, but also constrain costs and produce systemwide savings.”

“Care is organized around what the patient needs, not around what is expedient for an individual provider,” says the report. “Information, such as lab tests, referrals, notes and updated medication lists, is shared seamlessly among health care professionals without the need for patients to intervene.”

Maybe the American public should get to be the gods for a change.

 

 

 

The clinical term is “air hunger.” This is not as descriptive as “drowning on the inside”which is what folks say it feels like after they have been made symptom-free. When you see folks initially, they are wide eyed, gasping for breath, with a panic in their face that must be the reflection of Death.

The human body is marvelously designed, but when things go wrong, things go very wrong. Having a failing heart is one of those “very wrong” experiences. Pumping about 5 liters (1 1/2 gallons) out into the body every minute, the heart must collect 5 liters from the body, pump 5 liters into the lungs, and then collect 5 liters from the lungs every minute. If you only collect 4 liters from the lungs, after about 5 minutes your lungs will be filled up with a gallon of water. The clinical term is heart failure but the sensation is very similar to drowning.

The heart is fed by 2 main arteries, one of which splits into about 3 more. Heart failure is a disease that occurs not all at once but generally following the blockage of several of those arteries over time. Most people already know that  heavy smoking contributes to heart failure. Not dying of your heart attack all at once is also helpful, as it gives the heart failure time to take hold. The 911 system, which works best for heart attack victims, may actually have contributed to the increase in heart failure in the US.

This brings us to Vice President Cheney. As you may or may not be aware, he had a heart transplant yesterday. We were all made aware of his long history of heart disease, beginning at age 37 and fueled by family history and a 3 pack-per-day cigarette habit. After his initial blockage, he had multiple interventions (some of which have been proven to do more harm than good) culminating in the use of a Left Ventricular Assist Device as a bridge for these 20 months until a donor heart was located. The bill for the transplant is likely to come in at just under $1,000,000, likely putting the former Vice President in the top 1% of health care utilizers for the third year in a row.

Although this procedure is covered by Medicare, it is unusual for older Medicare recipients to get one. The outcomes are no different in 60-year-olds than they are in 70-year-olds, but some feel that hearts taken from accident victims and such (a scarce resource) should be reserved for younger people. Some, such as the Arizona legislature, are against public funding for certain organ transplants, at least for the poor.

Almost 300,000 die of congestive heart failure annually, many of whom are Medicare eligible. It is my hope that this starts a conversation around the wise use of resources. Can we and should we use public resources more wisely? In discussing a related issue involving heart failure, the AMA Journal of Ethics had this to say:

We implanted almost 200,000 cardiac defibrillators (ICDs) at $40,000 each with the intention of preventing fatal cardiac arrhythmias. Does it matter that 81 percent of them never fired over a 5-year period, at which time a battery would have to be replaced for $20,000 [9]? Does that represent a wasteful use of health resources? We have a test that can identify with 98.7 percent accuracy who among these potential ICD recipients will not have a fatal arrhythmia over the next 2 years. We could save $2 billion per year by using that test. But getting it wrong 1.3 percent of the time represents 800 lives that would be lost each year. How should we assess that outcome, morally speaking? Does that represent a morally objectionable “pricing of human life”?

Perhaps Vice President Cheney had a rare medical condition that made him one of the 300 people to qualify for a Medicare-funded transplant after the age of 70. Perhaps he elected to spend several million dollars of his own money after opting out of Medicare and he was able to use a heart unfit for a younger man.  I hope he will be forthcoming about the details of this process. If so, when I counsel my older patients who have intractable heart failure,  we might be able to frame the conversation as follows:  “What would Dick Do?”

Don Berwick left CMS last week. When he was appointed, he was vilified  because he used the word “rationing” in polite company. So vilified, in fact, that he was never able to gain the needed 60 votes in the Senate or confirmation and was appointed via the recess route. As a consequence, his appointment expired after a calendar year and it was for this reason that he stepped down.

Dr Berwick was never known for his shy, retiring demeanor and now that he is no longer in government service he is once again “telling it like it is.” He was awarded the Picker award at the Institute or Healthcare Improvement annual meeting and in his address he seemingly called out his opponents:

The true rationers are those who impede improvement, who stand in the way of change, and who thereby force choices that we can avoid through better care. It boggles my mind that the same people who cry ‘foul’ about rationing an instant later argue to reduce health care benefits for the needy, to defund crucial programs of care and prevention, and to shift thousands of dollars of annual costs to people — elders, the poor, the disabled –who are least able to bear them,” he said, according to a copy of his remarks.

Dr Berwick points out that the country is at a crossroads. If we attempt to reduce our country’s health care responsibilities through indiscriminate cutting, his concern (as is mine) is that the cutting will begin at the “voiceless and the poor” but won’t stop there. Soon, as a consequence of lower benefits, less access, increased payment burden for necessary services, and delays in care delivery, our country’s health care quality will further decay and the cost will remain high. Dr Berwick identifies six domains that our health care system has failed us:

  • Overtreatment – the waste that comes from subjecting people to care that cannot possibly help them – care rooted in outmoded habits, supply-driven behaviors, and ignoring science.
  • Failures of Coordination- the waste that comes when people – especially people with chronic illness – fall through the slats. They get lost, forgotten, confused. The result: complications, decays in functional status, hospital readmissions, and dependency.
  • Failures of Reliability – the waste that comes with poor execution of what we know to do. The result: safety hazards and worse outcomes.
  • Administrative Complexity – the waste that comes when we create our own rules that force people to do things that make no sense – that converts valuable nursing time into meaningless charting rituals or limited physician time into nonsensical and complex billing procedures.
  • Pricing Failures – the waste that comes as prices migrate far from the actual costs of production plus fair profits.
  • Fraud and Abuse – the waste that comes as thieves steal what is not theirs, and also from the blunt procedures of inspection and regulation that infect everyone because of the misbehaviors of a very few.

How do we avoid this undesirable fate? Dr Berwick refers to the Affordable Care Act as a “majestic law” and feels that if we work effectively we can save $1,000,000,000 in health care costs. He outlines 5 prinicples all of us in healthcare should follow:

  • Put the patient first. Every single deed – every single change – should protect, preserve, and enhance the well-being of the people who need us. That way – and only that way – we will know waste when we see it.
  • Among patients, put the poor and disadvantaged first – those in the beginning, the end, and the shadows of life. Let us meet the moral test.
  • Start at scale. There is no more time left for timidity. Pilots will not suffice.
  • Return the money. This is the hardest principle of them all. Success will not be in our hands unless and until the parties burdened by health care costs feel that burden to be lighter. It is crucial that the employers and wage-earners and unions and states and taxpayers – those who actually pay the health care bill – see that bill fall.
  • Act locally. The moment has arrived for every state, community, organization, and profession to act. We need mobilization – nothing less.

It is not going to be easy work. As Dr Berwick points out, the “pace of change is majestic.” We now have the framework for health care improvement. Leadership will now not come from the top but will come from those of us in the trenches. Let’s get to work!

I was asked to prepare for a discussion on what the role of primary care in our Academic Health Center should be. This will happen tomorrow. I have spent the better of 2 days trying to decide exactly what that role is.

I’ve decided to begin with the definition that the American Academy of Family Physicians uses:

  • Primary care providers offer a wide range of services including diagnosis and treatment of acute and chronic illnesses, disease prevention services and patient education.
  • A primary care practice serves as the patient’s first point of entry into the health care system.
  • A primary care practice is the continuing access point for all needed health care services

I decided to start here because I don’t know that my bosses have ever thought of primary care as other than another service line.

I plan to emphasize the second bullet point. We, like many other Academic Health Centers, have not taken the role of the primary care doctor in “entry into the health center” seriously. That has resulted in under-utilization of some of our specialty services and when I have conversations about care delivery they tend to go along these lines:

Surgeon: Why don’t you send me more patients.

Me: Only so many people need their gallbladders out.

Surgeon: You need to work harder.

I plan to spend the bulk of my time, though. not on where we’ve been but on where we are going.

My plan is to make the following points and let the discussion ensue:

  • Although the Affordable Care Act (Obamacare to some in the audience) will increase the number of “covered lives” through the exchanges, increased Medicaid coverage, and allowing parents to keep their children on their insurance policy, there will be less money in health care in aggregate. There is no way we can justify spending over 17% of the gross domestic product on health care, especially given the outcomes the system produces.
  • The Affordable Care Act has made system based approaches workable. Accountable Care Organizations and other forms of shared savings are being developed thanks to changes in CMS and in particular the Center for Medicare and Medicaid Innovation
  • Good primary care decreases costs and improves care.  The way that primary care doctors are going to be paid is going to be different, though. We are not going to be paid on fee-for-service but instead on managing chronic illness and keeping people out of the hospital.

Decreasing costs is not necessarily a good thing for an Academic Health Center. AHCs tend to rely on high margin services to offset training costs.It may be that we decide not to invest in primary care, relying instead on traditional appeals to “local medical doctors” and developing high margin profit lines. If we elect to develop primary care, it will need to be with an eye to improving care, increasing quality and improving safety. I hope we don’t do it with an eye to putting patients into my specialty colleagues’ exam rooms.

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.

There is an interesting article in the New York Times (found here) about sleep deprivation and physicians-in-training. A new set of work rules for doctors in training (residents) took effect on July 1st of this year. There was one rather odd requirements  where the 1st year resident can work up to 16 hours but must then get 10 hours off, causing those of us involved with training to do a little head scratching about how to make that work. Did that mean residents come in 2 hours later every day? Talk about a screwed up circadian rhythm.

The article in the Times pointed out that despite severe reductions in work hours over the past 10 years, care related errors have not decreased and have in fact increased. The implication was that perhaps the hours, themselves, were not to blame. The comments accompanying the article were predictable. Many were from older doctors (likely my age) relating how they were able to resurrect folks from the dead but only after working for 35 hours straight. Some were from physicians who are currently in training (and thus only know the work-limited training model) talking either talking about how they would never learn resurrection without being allowed to work 30 hours straight or conversely how they disbelieved the older doctors stories. I trained in a time and setting where the hours were unlimited. I do not recall any specific abilities granted me by virtue of working long hours. I do recall being bone-tired after a day in the office, a night of working to fix some very sick people, followed by a day in the office. I certainly never felt I was doing my best at hour number 36.

The real story is not about one young woman (Libby Zion) who died in New York and her dad’s efforts to affix blame and correct a common sense problem (working for 36 hours straight can never be good). It is about system change:

But all of these hospital reforms ignore what may be the biggest problem in physician training today: the yawning chasm between what most doctors learn during the 80 hours a week they spend training in hospitals and what they actually do after leaving their residencies. Defenders of the old-school way argue that the demands of medical practice justify the brutal hours. But after their residencies, most doctors practice in outpatient settings and work regular daytime hours as members of large groups. They treat chronic problems that need weeks or months of periodic outpatient follow-up, not high-intensity hospital-based care lasting only a few days.

The old method of physician training is dead. We used to think we could put physicians in training and really sick poor people in the same building, and poor people would get at least some care and learners would get training. It was this model that Medicare put money into in the 1960s. This evolved into a different model. In the current model some (if not all in some teaching hospitals) of the inexpensive trainee labor is re-purposed to provide help for physicians providing complex care for paying patients. As we ratchet back the inexpensive labor, changes are going to have to happen.

As I have discussed here and here and as Dr Sanghavi discusses much more eloquently, the current training system does not prepare learners for practice and now is shown to contribute to fragmented, error prone care. It is time to re-think the entire process. In the words of the man who sets policy:

“For people who came out of the old training system, it may be hard to imagine one that works better,” says Donald Berwick, the director of the Centers for Medicare and Medicaid Services and former president of the Institute for Healthcare Improvement. “The point is, it’s all about design and coming up with optimizing models.”

Poor people need care other than in the hospital provided by over-tired trainees. Trainees need to learn about care delivery in settings that prepare them for a future of error free practice. Hospitals need to wean themselves from cheap labor provided in the name of training.

Also, I kind of think the resurrection stories were exaggerated.

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