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I had to quit my job because of the stress I had to endure was putting me at high risk for a stroke or heart attack and I couldn’t physically keep up anymore
I’m 56 years of age
My job was 32 hours a week
But because of Obama care my insurance was costing me $600 dollars a month for just major medical!
No dental no eye care no life insurance
So by the time I paid my rent, electric, water, sewer, garbage, car insurance, house insurance etc, I had enough money to put gas in the car to get to work and buy ramen noodles and some cheap hot dogs for food!
Over 60% of my net pay went to insurance that covered nothing!
Now I am unemployed with ZERO insurance
Its pretty damn sad when all the damn medicaide and dissabilty cheats are eating steak with perfect teeth and new glasses and are in perfect health while I have to bust my damn ass just to eat ramen noodles wityh bad teeth , basbasd eyes, and life threatening health problems!!

So here I am, no job, no insurance, no hope

Patient’s story as posted on Obamacare stories

The average household income in the United States is $51,000. From that you pay for our food, shelter, children’s education, and movie tickets. Oh, yeah, and $5000 for a health insurance policy. One of the things that Obamacare did was begin to put a cost on our insatiable healthcare consumption. Turns out, that cost is VERY high.

If you are an average American, boy are you ticked off. Half of all Americans spend under $400 a year on healthcare. Pretty much a round of antibiotics for a sinus infection and, for women, a year’s worth of contraception. Not only that but because of high deductibles (to keep the cost down by discouraging consumption) you are paying $5,000 to the insurance company AND paying cash for your sinus infection visit and medicine. Then there are the drug companies and insurance companies that are colluding to raise the prices of formerly cheap antibiotics to get even more of your household income.

About 1% of the people in this country account for about a quarter (27%) of the health care spending. In 2014, this  was about $100,000 per sick person. Those in the top 5% of sick people were responsible for  almost $50,000 in health care costs. These numbers are unchanged since Obama was elected. So what has changed? Before, the costs of these people were hidden. They would get the care for “free” at a safety net hospital who would get money in other ways to pay for it. Or a sick person would use an insurance card then the payment would be denied as a pre-existing condition and the hospital would eat the cost. More likely, the sick person would get on disability, suffer for 2 years, and become Medicare eligible so we the taxpayer would pay. The care still cost money but was hidden in taxes. Insurance companies kept costs low, in other words, by shifting them to the federal government. Now folks under 65 who are sick can pick up an Obamacare policy and get exceptional care. Also on Obamacare stories are ones like this:

Thank you President Obama thanks to your healthcare plan I was able to continue to see specialists, this resulted in a diagnosis of a rare intestinal infection and even more concerning, two stage three colon cancer tumors, one on each side on each side of the colon. This required almost total colon removal from a top notch physician that was able to do my surgery without having to have a bag.

Only problem is, this type of care costs A LOT more than $5,000. .

So, if you bought an Obamacare policy and feel ripped off, let me tell you what your $5000 paid for. It wasn’t eye glasses and dental work for poor people that jacked up your bill. You spent your $5000 on people under 65 with heart disease and lung disease. You purchased them a lot of expensive tests, some time in the hospital, and some expensive drugs. You paid for the person with breast cancer’s $300,000 tab whose $5000 premiums were paid by the cancer treatment facility.  You paid for the person helicoptered in after rolling their car on Interstate 65 while trying to avoid a deer.  You paid for some very expensive medication for people with mental illness to keep them out of a mental hospital.

Did you pay too much? Yes. Other countries can do the same thing better for half as much or less. Perhaps the new adminstration will look at this as an opportunity to further retool our expensive, not very effective care delivery system and reign in some of the profiteering. Or maybe we’ll just continue to blame the poor…

 

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Remember the song, “We’re # 37“? It came out in 2009, the beginning of the debate about the ineffectiveness of the American healthcare system and the need for change. The video went viral, more because of the catchy tune and cute visuals, I’m afraid, than for the message. Here we are 6 years later and even with the Obamazation of health care our system is still last in the industrialized world. We still do not offer access to all of our citizens (witness the 24 states that deny access to the working poor), Our system remains very inefficient with 30% of spending wasted on inefficiency and unnecessary care. We deny people access to measure proven to extend lives and do so in a manner that punishes those of color disproportionately. Worse, we do it in a manner that costs twice as much as other industrialized countries, with most of that money coming from taxpayers.  .

As a part of a class I am taking, I have been reading a lot about change management. This weekend, I read John Kotter’s book Leading Change. In this book he identifies 8 components necessary to change an entrenched system in the business world:

  1. Establishing a Sense of Urgency (people need to sense that the platform is on fire before they jump into the ocean)
  2. Forming a Powerful Guiding Coalition
  3. Creating a Vision
  4. Communicating the Vision
  5. Empowering Others to Act on the Vision
  6. Planning for and Creating Short Term Wins
  7. Consolidating Improvements and Producing Still More Change
  8. Institutionalizing New Approaches

Why are we still last? It appears that we skipped the first step. Most people never use healthcare at all. thus they are unaware that the platform is burning. Or, even if they do, it is for an urgent problem (my throat hurts, I have a cough) and our system is really good at getting folks in and out for self limited problems in a very expensive manner ($111 to tell you “It’s a cold, live with it“). For the 20% who need our system a lot, the system has moved most of the costs to the taxpayer, so the true costs are hidden. Of course, this is after the family has bankrupted themselves but the expression “blood from a turnip” comes to mind.

Turns out that part one of the Obamazation was “getting all people access” and that wasn’t even in Kotter’s book. Part two, “transform the system”, started last week. Sylvia Burwell, secretary of Health and Human Services, announced last week a series of sweeping Medicare payment changes.  In effect, the platform has been set on fire. The changes moving 50% of the money from fee-for-service to quality by 2018 with an interim goal of 30% by 2016. What does this mean?

[The adminstration] plans to tie 85 percent of all Medicare payments to outcomes by the end of 2016 — rising to 90 percent by 2018.

A subset of those payments — 30 percent in 2016 and 50 percent in 2018 — will have to be part of what the government calls “alternative payment models.” These are contracts where groups of doctors and hospitals and pharmacists — a big enough network, essentially, to cover a patients’ whole spectrum of health care needs — get a lump sum of money to take care of a set number of patients.

This, in addition to the 40% of commercial contracts that currently include a value component, means that over half of all dollars in health care will be contingent on quality. Is that smoke I smell?

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med27I write this blog for 3 audiences. Many of these posts are written for the lay audience. Someone will ask me while mowing the grass about ebola or chikungunya fever and I will provide my (not so) learned opinion in blog form. My friends then access my deep thoughts through Facebook so that at the next cocktail party the conversation goes like this:

Friend: I read your post about chikungunya fever

Me: Chick-a-what?

It seems I have a short memory.

Another audience I write for is folks who make policy. I have a small following of people who actually have some influence. When I write about access to care for Medicaid-gap Alabamians (my favorite subject), insurance monopolies, or the fact that a certain legislator is both against Medicaid expansion and for trying to insert a phrase into a law that takes money away from Medicaid and puts it into a client’s pocket that is the audience that I’m writing for. So, after writing a blog like that, a conversation might go:

Person in position of authority: Who is this Perkins character?

Person who actually knows me: Some commie, I suppose.

Lastly, I write for students of family medicine. In my day job, I run a department of family medicine. This means that I am involved with teaching medical students (most of whom will not go into family medicine) and resident physicians (almost all of whom will go into family medicine), seeing underserved patients (who likely do not know they are seeing a family physician), and supervising faculty physicians (ALL of whom know what they do and let me know about it ALL the time). This blog post is for this audience (but all of you others feel free to read as well).

This past week, the president of the American Academy of Family Medicine, Dr Robert Wergin, announced that Family Medicine 2.0 has arrived. Why the reset? As Don Berwick and T.R. Reid point out at the accompanying press conference, we in family medicine have been working on changing the way we do business since 2000. Meanwhile, the rest of the the medical-industrial complex, not so much. In the words of Dr Berwick, the time to change healthcare is NOW.

What we as a specialty have committed to  is this:

  • Give patients the care they need when they are most vulnerable
  • Care for patients regardless of age and health conditions, and work to sustain an enduring and trusting relationship with them
  • Be each patient’s first contact for health concerns. Address all their health concerns, and resolve most of them
  • Help patients with preventing, understanding, and managing illness
  • Navigate the health system with patients, including coordinating with specialists and staying connected with patients before, during, and after time spent in a hospital
  • Set health goals that adapt to each patient’s needs as defined by them
  • With the care team, use data and best science to prioritize and coordinate services most likely to benefit patients’ health
  • Use technology to maintain and enhance access, continuity, and relationships, and to optimize patients’ care and outcomes
So, medical students, you are on notice that you need to leave our rotation knowing that this is who we are. Residents and prospective residents, you will be held to this standard. Patients, this is our promise to you. Faculty, we have some work to do.

New England Journal of Medicine published an article this week entitled “The Four Habits of High Value Health Care Organizations. The habits were described as follows:

  • Specification and planning. To an unusual extent, these organizations specify decisions and activities in advance. Whenever possible, both operational decisions, such as those related to patient flow (admission, discharge, and transfer criteria), and core clinical decisions, such as diagnosis, tests, or treatment selection, are based on explicit criteria.
  • Infrastructure design. High-value health care organizations deliberately design microsystems — including staff, information and clinical technology, physical space, business processes, and policies and procedures that support patient care — to match their defined subpopulations and pathways.
  • Measurement and oversight. For many, measurement of clinical operations is driven by external audiences: payers, regulators, and rating agencies. Although high-value organizations share this reporting obligation, they primarily use measurement for internal process control and performance management. They collect more (and more detailed) measurements than those required for external reporting, selecting those that inform staff about clinical performance.
  • Self-study. Beyond ensuring that their clinical practices are consistent with the most recent science, these organizations also examine positive and negative deviance in their own care and outcomes, seeking new insights and better outcomes for their patients. By contrast, most health care organizations treat clinical knowledge as a property of the individual clinician, “managing” knowledge only by hiring and credentialing competent professional staff.

The Commonwealth Fund published a report 3 years ago on this very same topic. Their main recommendation is as follows:

Payment reform. • Provider payment reform offers the opportunity to stimulate greater organization as well as higher performance. The predominant fee-for-service payment system fuels the fragmentation of our delivery system. We recommend that payers move away from fee-for-service toward bundled payment systems that reward coordinated, high-value care.

What the high value delivery systems have in common is that they are paid to delivery care “better.”  Why do Alabamians not have better care here? In the words of Deep Throat, “Follow the Money.”

I was asked recently to comment on how I felt increasing the emphasis on primary care would benefit the “system.” This is an important question because, as I have pointed out here and here, academic health centers and primary care education have no love between them. My answer was as follows:

Good primary care will not contribute a whole lot to the bottom line … As our primary payor is Medicaid and if the Alabama results are anything like the North Carolina, the Adult inpatient spending is down almost 10%with the bulk being in preventable adult admissions. In other words, the job of the primary care doctor is to keep folks out of the hospital and so by the very nature we in FM will be at odds with many of our colleagues. In short, better care will reduce folks in the hospital.

I then pointed out what I thought was an obvious strategy when faced with evidence that a tidal wave is fast approaching:

Our department [can] jump in front or not but I suspect it will happen either with or without us.

Why is the tidal wave coming? The payment system is unsustainable and is changing FAST. I believe (and everyone at CMS that I have spoken with concurs) that Fee-For-Service medicine is in deep trouble. HealthSprings Medicare Advantage plan is distributing a good bit of physician payment in the way of “shared savings”  (and recently was purchased by Cigna for almost $4 billion). Commonwealth is about to publish a report on outcomes on PCMH projects across the nation. They have found consistently improved care delivery and CMS is listening. Payment reform can be accomplished without a change in the Affordable Care Act and in the case of BC/BS by fiat. My money is on substantial payment change in Alabama Medicaid, Medicare, and BC/BS of Alabama soon.

Perhaps they’ll need primary care after all to help create a focus on quality instead of having the slickest procedures?  While my money is on primary care, don’t know that I’d bet on Academic Health Center transformation just yet.

Primum non nocere

Attributed to Hippocrates (more likely Thomas Sydenham)

During the health care debate, much was made about the ranking of the United States among nations regarding out system’s performance. In fact, we ended up Number 37 in World Health Organization rankings, a fact that was celebrated in song. While many feel that the poor performance of our health care system is the result of an inefficient system that rewards the wrong aspects of care, others argue vociferously that the system is the best in the world but that Americans are somehow sicker than other homo sapiens in ways that are difficult to measure.

An article was published in Health Affairs (subscription required but summarized here) that puts to bed the myth of “sicker” Americans. In this study the survival of folks ages 45-65 in United States was compared to survival in other countries with at least 7 million people and a GDP similar to America. This list included Australia, Austria, Belgium, Canada, France, Germany, Italy, Japan, the Netherlands, Sweden, Switzerland, and the United Kingdom. The study use 1975 as an index year and compared it to 2005. Although I’m not an expert in international comparisons, this one seemed pretty well put together.

The investigators found that between 1975 and 2005, American health care spending increased at a much greater pace than the other countries and Americans were more likely to die prematurely than the citizens of the other countries. This we already knew. What is news is the magnitude of the difference and the aspects of American society that do and do not contribute to the difference.

Population Diversity – As opposed to the deeply held believe that we have to spend so much on health care because of our sickly poor population, it turns out that our diversity does not contribute to our poor health standing.

Smoking Status – Americans actually smoke less than the residents of the comparison nations so it turns out that smoking status does not contribute to our poor health standing.

Obesity – Americans are more overweight than the residents of the other countries. America was proportionally as overweight when compared to the other countries in 1975 as it is today. If it is obesity that is the cause of our excessive health care spending, it should have increased proportionally (not logarithmically) over the past 20 years. Obesity is not the cause of our excessive health care cost.

Traffic Accidents and Homicides – Much was made of the perceived excessive costs of violence in American society during the recent health care debate, in particular among the underclass. The contribution of violence has in fact been stable over the past 20 years (and is relatively low) so these are not the cause of our excessive health care costs.

So what is the cause? The authors of this study speculate that the health care delivery mechanism in this country has become an expensive self-perpetuating system that directly contributes to poor outcomes. This is potentially a consequence of inefficiencies that occur with rising costs and relative underinsurance as well as absolute uninsurance. Excessive spending on individual health care consumption may have led to inadequate investment in public health and education initiatives. Unintended excessive care may lead to fragmentation and an increase in medical errors.  Intended excessive care leading to life-shortening complications is a very real problem. In America the belief that the the “market” must dictate health care purchases may so distort consumption that people are unaware of just how poor the choices that they make actually are. Until they die, that is…

In a companion article summarized on the Commonwealth website, some of the specific reasons for the poor health of Americans as related to our healthcare system were listed:

  • One-third (33%) of U.S. adults went without recommended care, did not see a doctor when sick, or failed to fill prescriptions because of costs, compared with as few as 5 percent of adults in the United Kingdom and 6 percent in the Netherlands.
  • One-fifth (20%) of U.S. adults had major problems paying medical bills, compared with 9 percent or less in all other countries.
  • Thirty-one percent of U.S. adults reported spending a lot of time dealing with insurance paperwork, disputes, having a claim denied by their insurer, or receiving less payment than expected. Only 13 percent of adults in Switzerland, 20 percent in the Netherlands, and 23 percent in Germany—all countries with competitive insurance markets that allow consumers a choice of health plan—reported these concerns.
  • The study found persistent and wide disparities by income within the U.S.—even for those with insurance coverage. Nearly half (46%) of working-age U.S. adults with below-average incomes who were insured all year went without needed care, double the rate reported by above-average-income U.S. adults with insurance.
  • The U.S. lags behind many countries in access to primary care when sick. Only 57 percent of adults in the U.S. saw their doctor the same or next day when they were sick, compared with 70 percent of U.K. adults, 72 percent of Dutch adults, 78 percent of New Zealand adults, and 93 percent of Swiss adults.
  • U.S. , German, and Swiss adults reported the most rapid access to specialists. Eighty percent of U.S. adults, 83 percent of German adults, and 82 percent of Swiss adults waited less than four weeks for a specialist appointment. U.K. (72%) and Dutch (70%) adults also reported prompt specialist access. 

In summary, it isn’t that America has more poor people and poor people are sicker. It’s that our system for the 20 years prior to the passage of the Affordable Care Act became efficient at transferring money into the Medical-Industrial complex at the expense of the health of our citizens. We can only hope that the change occurs rapidly.

Todays Press Register carried an excerpt of an article from Governing Magazine which contrasted the differences in attitude towards health care reform between Alabama and New Mexico. The article made some interesting points which require some context to fully appreciate.

New Mexico has about half as many people as Alabama (2 million to 4.6 million) and is twice as big (120,000 square miles to 54,000 square miles) so is much more rural. Rurality poses a problem for care delivery for both states but Alabama health care is dominated by several largish cities (Birmingham, Mobile, Montgomery, Huntsville, and Tuscaloosa) that each have a medical school or a medical branch campus. Albuquerque is the only city of significant size in New Mexico. The medical education enterprise in Alabama is dominated by the University of Alabama, Birmingham has as its stated mission “The School of Medicine is dedicated to the education of physicians and scientists in all of the disciplines of medicine and biomedical investigation for careers in practice, teaching, and research. Necessary to this educational mission are the provision of outstanding medical care and services and the enhancement of new knowledge through clinical and basic biomedical research.” The medical school in New Mexico ” Our goal is to provide top-notch clinical services to the residents of New Mexico while being recognized as a respected School of Medicine training doctors for New Mexico.”

Both states are in the bottom quartile of state rankings. The difference is in how the state health officers see the role of health insurance refom in their path to becoming a high performing state. In  Alabama,  Commissioner Stekel sees impending doom. Alabama chooses to insure almost all of its children (97%) but relies on the medical schools to care for the poor adults as a by-product of the education process. As a result there are 100,000 diabetics in Alabama who do not get needed preventive services and either die prematurely or suffer significant disability. 250,000 of its citizens use the emergency rooms as their usual source of care. Although most children have insurance under the current system, 150,000 do not have access to primary care because of a shortage of providers to deliver that care. Commissioner Steckel wishes “more modest approach of incentives for small businesses and pooling had been tried instead.”

The Medicaid commissioner of New Mexico sees opportunity. The per capita numbers may look the same (or even a little worse) but New Mexico Medicaid Director Ingram sees ” it as a tremendous boost to the state economy. Those providers, in turn, will have more money to spend in ways that benefit New Mexico’s economy. Ingram points to a study conducted by the advocacy group New Mexico Voices for Children that found that each dollar spent by New Mexico on Medicaid generated $2.90 in federal Medicaid funds, which in turn generated an additional $2 in extra economic activity as the spending rippled through the economy, ultimately creating a combined “multiplier” effect of $4.90.”

Part of why Commissioner Stekel see impending doom where Director Ingraham sees opportunity may be how Academic Medicine fits into the care delivery system. At the University of New Mexico College of Medicine, many programs exist to enhance care delivery and integrate the clinical offerings into the communities. I saw a very impressive presentation of some of their telehealth activities  at the National Rural Health Association meeting in Miami. I hope that we in academic medicine in Alabama will be offered the opportunity to work with Commissioner Steckel to do the same. 

 

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In our (soon-to-be-paperless-but-not-soon-enough) office, we have boxes where messages from patients, abnormal labs, and such are placed by the staff for action by the provider. Because it is not possible for everyone to know where everyone else is at any given time, we have taken to placing paper over the cubby-holes notifying the staff that we will be out until a certain day. If one is going someplace fun, a picture or something else fun is placed on the message as well. As Chairman, my cubby is covered more that most and this past week I used my “Out Reforming Healthcare” message for 3 of the 5 days.

On Tuesday I traveled to Birmingham to meet with the folks from the Patient Centered Primary Care Collaborative and hear Paul Grundy speak to primary care physician leadership as well as Alabama business leadership. His message is always strong and consistent and it is getting more focused.  As a physician who is involved in direct patient care as well as population based care for IBM employees, he is encouraging all employers to stop paying for garbage (his words). From a recent interview:

“40% of the care that’s delivered, according to some folks, is unnecessary and I see it every single day.  I know parts of the country where it costs $17,000 for the last six months of life and others where it’s $127,000 and by the way the patients in the $17,000 category, this particular case in Iowa live longer and are happier with the care than the ones that are in a scenario that is over $150,000.”

He sees transformational change coming and being lead by an empowered primary care workforce. Denmark is being looked at as a model with the number of hospitals reduced by 80%, for example.

On Wednesday I traveled to Montgomery to preside over the Alabama Rural Health Association board of directors meeting. As I have detailed previously, Alabama has an impending crisis regarding the healthcare workforce in rural Alabama. Although this meeting will not make a difference as a stand-alone activity, it is refreshing to get people in a room who are able to agree on a problem, potential solutions, and set in place a strategic planning activity focused in addressing the shortage. In that meeting we committed to focusing resources on FaceBook to recruit young folks interested in rural Alabama (search on FaceBook to find the page yourself), creating a strategic plan to better direct our resources, and finalizing issue briefs on the manpower crisis in rural Alabama health care prior to January 2010. We also committed to doing rather than talking.

Lastly, we went to New Orleans on Thursday to recruit Tulane students into our Family Medicine Residency program. The refreshing thing about this trip (aside from the soft shell crab) was that we spent a lovely evening with students who clearly entered medicine for the “right reasons” and they were committed to Family Medicine. We had a very pleasant visit and hopefully will see them in Mobile during the interview process.

In summary, like Paul Grundy I believe transformational change is coming. I believe it can happen in rural Alabama. The attitude of the students on Thursday confirmed my optimism. It was, however, a long week…

On this Labor Day I sit in one of the richest countries of the world. I make more money than 98% of the American workers. My peer group (American physicians) makes that or above. Yet, when I watched a  physician on a Fox News clip talk about health reform today, I got the impresion he had just come in from panhandling. In addition, the blame-the-patient nature of his proposed solutions made me long for the days when we believed in demons and humors as causes of illness…at least then the individuals were not to be blamed. Rather than blather on, I refer you to the Health Affairs article from 2004 which identifies increases in cost per disease treated as the major contributor to health care cost increases for most diseases. For some diseases such as treatment of depression, that increase in cost leads to improved wellbeing and increased productivity. 

In short, let’s all agree to deliver high quality care and not milk the system as happens in some places. If we redirect the money currently spent, we can give better care to more people for less cost. No where are “tax breaks” mentioned in my medical texts as a treatment option. Regarding my overweight patients, my bet is that between good medical care and changes in the built environment and improved peer influence, people who need to lose weight will. Meanwhile, we physicians need remember (ironically) the “Fat Man’s laws” and stop blaming the patients for a flawed system that is much more our creation than theirs.

Also, physicians who are on television probably shouldn’t claim poverty.

"Bending the curve" from the Commonwealth Fund

"Bending the curve" from the Commonwealth Fund

In late 2007, the Commonwealth Fund published a paper entitled “Bending the Curve“. The point of the paper was that given the current trajectory, health care expenses will exceed our country’s ability to pay, leading to insolvency. Although this has been the worry of policy makers forever (what’s a good amount of money to spend onhealth care? 5% of GDP like England? 12% of GDP like Canada? 16% of GDP like the US?) and previous policy was that health care jobs were to take the place of manufacturing jobs, increasing our GDP. It turns out that there is an optimum amount to spend if the objective is to achieve optimum health with the least cost possible. That amount seems to be less than what we spend.

The report does not mention rationing at all. Many of the concepts in the report were included in HR 3200, which does not mention rationing either. What is mentioned is “medical effectiveness”, improved health information technology, and shared patient decision making. Using these three concepts, physicians can help to bend the curve down, eliminating the need for hard rationing.

Improving information regarding medical effectiveness should lead to a reduction in use of expensive, unproven technology. We Americans have a fascination with technology. In fact, part of the utilization of the emergency room by patients is because of a belief that technology is necessary for effective diagnosis and treatment. Hospitals in rural Alabama hired physicians away from their practice and had them move into the Emergency Department, subsidizing thier salaries, because they knew that would help attract patients into the hospitals who would then be referred into the technology areas (CT scans, MRIs, etc). Unfortunately, the use of this technology has not translated into people doing better (they may feel better having seen their insides but it is an awfully expensive placebo). Most insurances will pay for technology because there is limited evidence to indicate when technology is good (avoiding an unnecessary surgery) or when it is bad (finding something that is likely normal but “might be something bad” causing excessive worry and unnecessary procedures). In fact, some procedures (placement of stents in certain patients) are found to be harmful after years of having been done. Evaluation of all procedures ought to be more rigorous and establishing money with which to do this will ultimately reduce costs.

Improved information technology (already funding through the stimulus package) should help to reduce costs as well. Transferring information by snail mail and fax is the rule in health care rather than the exception now. Electronic transfer of information, with appropriate safeguards, has revolutionized the banking industry (so much so that the regulators unfortunately got lost in the shuffle). Making information easier to transfer will reduce waste and duplication.

Lastly, encouraging shared decision making is probably the most important of the three. As a physician, I get paid for time in a piecework fashion. If I need to have an hour conversation with a patient about prognosis, different treatment options, or longterm care decisions, I have to schedule it outside of my normal patient care hours and do not get paid at the same rate I would for seeing “regular” patients. Yet, this is probably the most important conversation I will ever have with a given patient. It has been my experience that when faced with a disease that is terminal or that there are several different treatment options, what people want most is someone who knows a little about them to help guide them to a decision they will be comfortable with. All too often, we in medicine assume that the patient always want more and wish to cling to every last second of life but often it is the physicians who impart their worldview instead of listening to the patients and their families. Additionally, the primary care physician, the doctor who knows the patient the best, is often not involved in these conversations at all for a number of reasons. Changing the payment structure will go a long way towards inclusion of the primary care doctor in these discussions.

It is the belief of the Commonwealth Fund as well as myself that these measures will “bend the curve” down without hard rationing. We may have a chance to find out.

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