THE BUSINESS OF MEDICINE

Wednesday, October 29th, 2014 2:32 PM by Christopher Gregory

Someone recently accused me of being blindly pro-physician because I didn’t jump into a chorus of condemnations that were being aimed at doctors. Frankly, it didn’t shock me. In the 40 years I’ve worked with physicians, the respect and admiration for members of the medical profession have deteriorated badly.

Admittedly, many physicians are not immune from the siren song of big money, so the public’s anger over a notion of money-driven doctors is understandable. Witness the streams of newly-minted physicians electing to pursue high dollar specialties over primary care. We have maintained a free-for-all payment environment that makes it easy for physicians to generate big bills full of myriad services. Bills today are longer, less transparent and contain bits and pieces of goods and services previously not itemized and charged.

There are well-publicized, troubling stories about doctors who expose patients to unimaginable harms in the pursuit of profits. These are audacious acts of greedy individuals lacking a moral compass. It is unfortunate that these predators exist and give the profession a black eye.

Untold stories garner less attention –  stories about doctors supremely frustrated by impediments to good doctoring. Many of these doctors champion health care that would dial down the hyped obsessions with premature, unnecessary and wasteful care. I work with some of them.

If costs and confusion in our healthcare system are targets, a spotlight should be focused on businesspeople who have seized control of major hospital/health systems and run them like manufacturing companies. Theirs is a domain of maximized profits, efficiencies and peak productivities. In the process, physicians have become cogs in the business machinery. One satirical commentary recently reported about a physician who happened to read a hospital executive business manual focused on “controlling” doctors. Maybe satire? Maybe more truth than satire?

What resonates throughout the healthcare system is a feeling that doctor-patient relationships have been marginalized. Who hasn’t felt that their doctor entered the exam room with a stopwatch? Patients don’t like it – especially older patients who might have a list of ailments to address. Worse, there are doctors with whom patients have never had the briefest of interactions, yet who bill patients vast sums for services delivered while the patient was unconscious. Yes, it happens and there are companies out there that teach doctors how to do just that.

Good doctors want more time for their patients. They don’t want more paperwork (hello ICD-10), efficiency experts running their days or hospital employers leaning on them with production quotas.

Good independent doctors want a fair shake when it comes to insurance reimbursements, not meager amounts compared to large practices with plum contracts. And so important, we need to find ways to allow intuitive primary care physicians to be thorough, comprehensive and paid fairly when treating patients who come to their doctor’s office with a list of medical needs.

Then do we wrest control of our healthcare industry from the profiteering executives who execute business models that penetrate and saturate our neighborhoods and lives leading to cost proliferation? To whom should control be given?

Having advised physicians for a number of years on matters financial/organizational, my first thought would be to avoid turning the wheel over to them to run major systems. Medicine is their forte, not running business empires. Put doctors in charge of patients time and quality care and reimburse them fairly. Most doctors afforded sufficient time with their patients, less bombarded with paperwork and paid rightly for the time and the years of work it took to get there – those will be happy doctors.

Who then? Perhaps somewhere in the fictitious middle lies an evidence-based system that is cost-effectively administered, allows quality doctor patient interactions and pays well.

Maybe that’s what Physicians for a National Health Plan are talking about.

 

 

THE RIGHTCARE ALLIANCE

Friday, October 24th, 2014 2:46 PM by Christopher Gregory

With permission, I am re-posting an open letter written by Dr Vikas Saini. Dr Saini and our colleague Shannon Brownlee at the Lown Institute have launched the RightCare Alliance, which is an action call to members of the medical profession. Physician members of the Alliance have committed to reducing overuse and underuse in our healthcare system while preserving the vital relationship between physician and patient. The funding appeal at the close is an appeal from the Lown Institute, to underwrite the costs incurred for physician engagement meetings around the country. I encourage your support of this worthy cause and the call to our nation’s doctors. 

lown 2

Dear Friend,

Today we are facing an arms race in medicine. It is a race for technology, market power from hospital consolidation and the mass industrialization of patient care. The medical profession, once revered for its marriage between compassion and science, is now encouraged to manage the business of sickness.  

The health care system is on the cusp of a major transformation. New delivery and payment models are being offered up in the hope that they will reduce wasteful spending, improve coordination and remove incentives for delivering unnecessary services. These shifts are necessary but will not lead to better care or better health without attending to the art of healing. 

Instead, pressure on clinicians to improve efficiency will limit time for care, further eroding the doctor patient relationship and robbing health professionals of what they love most, and patients of what they want beyond efficiently delivered medical technology.

There is still time to change the course of medicine. The Lown Institute promises to be the moral compass during this dynamic period of change. We are assembling a national network of impassioned medical students, residents, senior clinicians, patients and community groups who have joined us in building the RightCare Alliance, a movement dedicated to ensuring that human presence is central to scientific ministrations. Members of the RightCare Alliance are creating programs for transforming medicine, by addressing issues of overuse and underuse of our existing healthcare system and working to ensure that the heart of medicine is preserved over the business of healthcare.

We invite you, too, to be part of this growing movement. Together we can create a just, effective and caring healthcare system, sustainable for many decades to come. But we need your support.

Now more than ever, your donation will have impact. A gift of $50, or any amount you are comfortable giving, will help us continue to organize across the country. Please visit our donation page here to contribute.

Thank you for your help in the past, and for your commitment to the Institute’s work in the future. I deeply appreciate your support.  

Sincerely, 

 

Vikas Saini, MD

President

Lown Institute

 

 

 

 

 

FOLLOWING DRS SALTZ AND KANTARJIAN ON 60 MINUTES

Friday, October 10th, 2014 10:42 AM by Christopher Gregory

My previous commentary followed last Sunday’s 60 Minutes interview of two oncologists who spoke out against the pricing of cancer drugs. What these two doctors exposed was the blatant profiteering companies like Sanofi and Novartis are getting away with. Now comes this……

In response to recent reports that the cost of some generic drugs has been unexpectedly rising at a rapid clip, two members of Congress have launched an investigation and asked 14 generic drug makers to provide data about what the lawmakers called the “escalating prices they have been charging” for generic medicines.

A recent analysis, for instance, found that half of all generics sold through retailers became more expensive over the past 12 months. And prices paid by pharmacies more than doubled for one out of 11 generics. In some cases, price hikes exceeded 1,000% and even topped 17,000%.

The reports add to growing concern about the increasing cost of prescription drugs, which has largely been confined to brand-name drugs – such as expensive new treatments for cancer, hepatitis C and certain rare diseases. Outrage erupted earlier this year, for instance, over the Sovaldi treatment for hepatitis C that is sold by Gilead Sciences at a costof $1,000 per pill, or $84,000 for a 12-week regimen.

I asked Dr Bob Kramer, pediatrician and child lung specialist for many years about Albuterol Sulfate, which is used to treat asthma and other lung conditions. The average cost for a bottle of 100 pills was $11 last October, but rose to $434 by this past April. He was shocked. And the antibiotic doxycycline hyclate cost $20 last October for a bottle of 500 tablets, but by April of this year, the price was $1,849, according to their pricing chart. Another example is the per-unit price for a 500 mg capsule of tetracycline, a common antibiotic. It increased from $0.05 cents to $8.59, a more than 17,000 % increase

“It is unacceptable that Americans pay, by far, the highest prices in the world for prescription drugs,” says U.S. Sen. Bernard Sanders (I-Vt.) in a statement. “Generic drugs were meant to help make medications affordable for the millions of Americans who rely on prescriptions to manage their health needs. We’ve got to get to the bottom of these enormous price increases.”

At the bottom of this is a Congress which has prevented the government from negotiating Medicare drug prices. In essence, the current law says that Medicare must pay whatever a drug manufacturer charges, plus a percent cushion. Which of course ripples throughout the pharmaceutical supply chain (i.e., private insurance).

And U.S. Rep. Elijah Cummings, (D-Md.) says “in some cases, these outrageous price hikes are preventing patients from getting the drugs they need.” He cited a report by IMS Institute for Health Informatics showing generics account for 29% of prescription drug spending and 86% of drugs dispensed in the U.S.

Consider the ripple effect of massive price hikes for generic drugs. Faced with the rising costs of generic prescription drugs, health insurers increasingly are turning to tiers and preferred lists on their formularies to keep costs down. Those strategies previously were used only for brand-name and specialty drugs. Experts say those approaches will increase out-of-pocket costs for patients and could make them less likely to adhere to drug regimens. If  generic medications become unaffordable, what might be an expected outcome if a patient stops taking or reduces the recommended dosage of a prescribed medication? Could a patient denied albuterol because of cost end up in the ER due to an asthmatic crisis? 

Can there be any doubt that the financial carnage being imposed on this country by the various health care sectors has reached insane proportions? Lives are subject to the whims of profiteers in all segments.

 

 

IN PRAISE OF 60 MINUTES, THE NEW YORK TIMES, ETC

Monday, October 6th, 2014 12:26 PM by Christopher Gregory

This commentary will address a problem so pernicious, and in so many ways lacking in humanity, that we are being literally dragged into an economic black hole consumed with only one goal – profits all around for a healthcare system that is not close to being a good deal. In order to become more informed, there are news outlets like 60 Minutes, and reporters like the New York Times Elisabeth Rosenthal (Paying Till It Hurts) that should be seen and read by everyone because healthcare touches everyone.

Anyone watching 60 Minutes on Sunday, October 5th, saw jarring revelations from two cancer specialists. Drs Len Saltz at New York Sloan Kettering and Hagop Kantarjian at Houston MD Anderson spoke out about financial carnage when drug manufacturers get away with exorbitant pricing on cancer drugs. These are drugs desperately sought by cancer patients who are, in some instances, being financially destroyed in order to live a little while longer. And remember that the extension of life for a precious little while says nothing about the other glaring price that is often charged – quality of life. The ugliest scenario one could imagine is being financially devastated in order to endure in misery one’s final days.

WHY …. does the 2003 law mandate that Medicare must pay whatever a drug manufacturer decides to charge? As shown on 60 Minutes, the drug Zaltrap’s pricing was pure fiction, limited only by the extent of Sanofi’s audacious belief that they could get away with it. And so individuals pay, employers pay and we the people (government) pay whatever freight corporate greed decides it can get away with.  

This commentary could go on for a mile, documenting the outrages, excesses and wastefulness of our health care system. Anyone who doubts the seriousness or the extent of that – contact me and you will be given directions to reading materials that will wake you up and keep you up.

Here is the problem. As a nation of employer and consumer users and payers for healthcare, we have become devoid of the intestinal fortitude needed to take on the massive “business” of healthcare. Good doctors and good systems dedicated to providing ethical care when needed in the most appropriate ways at costs that will not destroy peoples’ lives have faded into memories. Today, physicians are pawns on the commercial chessboard of a system that will financially destroy our economy if left unchecked. Everywhere you look, our consciousness is saturated by health concerns, lack of informed choices, drug ads and medical vanities that haven’t distinguished this nation in terms of quality metrics.

There is a complete lackadaisical attitude about taking on the beast. Nowhere is this more in evidence than in attitudes among those who could lead. The biggest potential force that exists with sufficient mass to move in opposition against the healthcare bleeding we are experiencing rests with the single largest source of money being spent on healthcare. That is a commitment and a collaborative cause to bring healthcare costs under the control of the people who hold the purse strings – American businesses and the employees that are covered by health care plans.

The buck is being passed. We have asked employers simple questions, e.g., “what was the last innovative thing you did to put a lid on escalating costs?”. Too often, the plans of our employers have been enveloped in a miasma of mediocrity. Too often, health plans have simply pushed more costs onto employees. Too often, employers have succumbed to the entreaties of purveyors of schemes like wellness and prevention plans that promise big payoffs – and spectacularly fail to deliver. (Wellness culture good, wellness plans bad.)

There is a lack of control by the people who should be going catatonic over the costs of health care – the financial people in our nation’s businesses. The bleeding is seen there, and the tourniquets should be applied there. This means getting tough with employee-consumers of healthcare. The mindset that consumers can have it all, have it now and have it where they want it should be finished. Best providers – hospitals, doctors and others should be (and can be) identified. Employees should be given options to use the best identified, or pay a stiff price for being indifferent and spoiled. We need to wrench away the misconception held by 50% of our populace – that more expensive healthcare is better healthcare.

A force like none seen previously needs to emerge. That force needs to be possessed of a single-minded vision to defeat politicians’ agendas, sham government agencies, bad law legacies, obsessed profiteers and spoiled, hypnotized consumers.

Think Canada. Think the UK. Think countries with better healthcare at fractional costs to ours. Think common sense and think no frills, quality healthcare.

IT DOESN’T ADD UP

Friday, October 3rd, 2014 1:30 PM by Christopher Gregory

For our colleagues committed to meaningful changes in our healthcare system, a nagging question persists. When senior corporate management can measure and understand the financial toll that health care costs are taking on their companies, why haven’t there been more vigorous, concerted efforts to push back in areas where genuine, meaningful changes can produce outcomes that are good for employers and their employees?

Each year, when CFOs must account for health care expenses in corporate annual reports,  discussions are held with department(s) responsible for managing employers’ health plans. For a long time, when the numbers have been added up, those conversations should have focused on hard realities, i.e., health care costs too much. To which should be added another contemporary question, “how much more of the cost pie can be passed on to employees before we try to make real changes?”

According to the recent Bank of America poll, CFOs rate health care their #1 concern for the third year running. Yet, when asked to take control of efforts to reduce these costs, they tell us things like – “we have people on it”, or “the timing is not right”.

Tom Emerick managed the WalMart health care plan for 15 years, and has been recognized for genuine innovation and thought leadership in health benefits design, healthcare economics, evidence-based medicine and process improvements. When asked about what should happen to move employers in the right direction, his response was prompt:

 “Health costs are a huge risk to be managed and should no longer be viewed as an HR construct. To truly begin the process of controlling health costs, the following four steps have proven effective:

  1. Transfer benefit design to the finance department;
  2. Inter-company data collaborations and direct contracting with providers have proven useful in some markets;
  3. Use claims data and other resources to determine the highest quality and most cost-effective providers and direct employees to use them; and
  4. Curtail wasteful spending on demonstrably ineffective programs, a step few HR departments can do well”;

Regarding collaboration, Brian Klepper, PhD, CEO of the National Business Coalition says “absolutely right”

In fairness to HR and benefits departments that have a lot on their plates, one sales pitch after another has been made to employers from vendor services promising  remarkable things to reduce health care expenses. It gets wearisome. Take wellness, for example. Wellness in and of itself is a good thing and something which should be the responsibility of individuals (losing weight, quitting smoking, reducing cholesterol and exercising). It’s a culture of wellness that should be pursued. But many wellness plan purveyors promise much, while delivering little by way of savings that can be quantified. Many wellness vendors proclaiming attractive ROIs make a great deal of  money while delivering little. Ample evidence has been presented to demonstrate overblown claims, e.g., the Safeway story, the State of Nebraska and the Rand report to name a few. A big problem with things that don’t work is they can create more expenses and are accorded too much center stage attention by employers, to the exclusion of other steps that can and should be meaningful in reducing costs.

Another challenge for employers is the consulting industry. Too often, as many of my colleagues agree, consultants hold an almost unlimited influence on employer decisions. Really innovative thinking, e.g., collaborative innovation, is not something consultants want to be drawn into.

Claude Lagalante, Senior Director at Truven Health Analytics tells me that data methods available today can definitively and conclusively identify the facts that should be targeted by employers in metropolitan areas like Dallas Fort Worth. If employers commit to working collaboratively, data will identify best hospitals and best doctors in critical areas as the requisite information needed to form narrow, high-performing networks that employers can motivate employees to use. That will save employers and employees money, save employees from receiving excessive, unnecessary and wasteful care, and even save lives.

Yet when these incontrovertible facts are presented to forums of executive leaders (e.g., CFOs), the response from areas around the country (and not just DFW) is, “the timing is not right”, “we can look at this next year” or “we have people on it”.

Dr Bob Kramer is a physician with many years of hindsight and insight into medicine and healthcare as both a physician and a CMO. As a passionate observer of the wrong direction we are taking in our delivery of healthcare, he makes an analogy. He says that attitudes displayed by many senior management executives today is akin to “calling the fire department to report a house fire, and hearing them say they won’t come out for two weeks”.

Hospital systems are building everywhere, freestanding emergency rooms and CareNows are sprouting like mushrooms, hospital system physician influence is now being connected to in-store clinics at CVS, WalMart, Walgreens and most recently Target stores:  retail medicine -so long real doctor-patient relationships. Hardly any independent primary care doctors can be found anywhere (resulting in far greater costs for office calls). Hospital chargemasters are confounding messes, lack of medical cost transparency is contributing to 60% of personal bankruptcies, and physicians are rigging the game and committing heinous acts in pursuit of millions in revenues because they can. Pharmaceutical and device manufacturer conflicts of interest for physicians are everywhere (hello “Sunshine Act”). Government panels have rigged the game for specialists at the expense of primary care medicine which is drying up.

The term “black hole” surely applies to healthcare.

As Brian Klepper says at every opportunity, “the only possible counterweight to the healthcare system today is non-healthcare employers banding together”.

And yet, we hear yawning in the room.

 

SHARED DECISION-MAKING

Thursday, September 25th, 2014 5:47 PM by Christopher Gregory

I would like to thank Dr. Vikas Saini and Shannon Brownlee at the Lown Institute in Boston for an exceptional Lown journal called the Right Care Weekly. Some of the best things I have read, aiming to get us doing the right things for the right reasons in healthcare, have come from Lown and the Right Care Alliance. The Alliance is a committed physician movement which I fervently hope will grow across the nation. The first important Right Care Alliance meeting on the road will take place on October 13, at the University of Colorado Medical Center in Denver.

The article which I reference in part below is one that was just published by the Institute of Medicine, in which Shannon was one of the coauthors. It talks about shared decision making (SDM).

What Is SDM?

For this paper, we consider SDM to be the process of communication, deliberation, and decision making during which:

  • One or more clinicians share with the patient information about relevant testing or treatment options, including the severity and probability of potential harms and benefits and alternatives of these options given the specific nature of the patient’s situation;
  • The patient explores and shares with the clinician(s) his or her preferences regarding these harms, benefits, and potential outcomes; and
  • Through an interactive process of reflection and discussion, the clinician(s) and patient reach a mutual decision about the subsequent treatment or testing plan.

Since research has shown that extemporaneous conversations with clinicians often do not result in the effective exchange of reliable, complete, and balanced information, a structured tool can often enhance information exchange to support the process of SDM.

When Should SDM Be Pursued?

There are a few treatment decisions, such as whether to set a broken arm, for which there is such incontrovertible evidence of benefit and so few downsides, that clinicians and patients would be almost unanimous about what to do. While some have sought to limit the application of SDM to preference-sensitive decisions, this distinction is difficult to define and challenging to apply in practice.

We propose that the default position for every medical decision for which the options or results have health, financial, or quality-of-life implications should be that patients should be informed about their options and given a chance to have their informed choices honored when decisions are made. In particular, since patients must implement (and could in the process revise) many health care decisions—to fill prescriptions, attend visits, self-monitor blood sugars—SDM should be the aim for discrete decisions (such as whether to receive a certain screening test, or which treatment option to pursue for a given diagnosis) and also for ongoing, daily management and lifestyle choices for such chronic conditions as diabetes or high blood pressure.

What Is the Role of Decision Aids?

One way to promote SDM is to provide patients and clinicians with well-designed and structured decision aids, which are tools intended to provide detailed, balanced, evidence-based information about competing treatment options.

A 2014 Cochrane review of 115 randomized trials reported that using patient decision aids can lead to patients who are better informed about their options compared with patients who receive usual care. Decision aids enhance patients’ knowledge and understanding of the harms and benefits of various options, lead to more accurate perceptions of risk, greater comfort with decisions, decisions that align better with patient goals and preferences, and patients using decision aids are less likely to remain undecided (Stacey et al., 2011, 2014). There is also evidence that patients tend to make different choices when they have access to these tools versus usual care, and they are, on balance, more likely to choose less-invasive interventions.

In sum, while patient decision aids can help patients become better informed, and being informed may help patients engage with clinicians, ensuring that patients are informed does not necessarily ensure that patients are invited to “share” in the decision making process, or that their preferences are respected. The best decision aids, therefore, provide information and also encourage patients and clinicians to get on the “same page” with regard to options, evidence, preferences, values, and plans.”

Why Have I Written This Commentary?

For years, I searched for ways by which I can advocate for patients to become better equipped to make decisions about their health care. Too often, physicians rely on their professional gravitas to basically compel patient decisions. Remember Elisabeth Rosenthal’s excellent (and troubling) New York Times article where the surgeon told a patient compromised by excruciating pain “You need surgery, you won’t walk out of the hospital”?

I searched for and found a company that does an excellent job of encouraging patients to become more conversant and better involved in decision making, and then supports patients with information to do just that. That company does not interfere in the doctor patient relationship – they improve it by making conversations and decisions better.

I have spoken with employee benefit managers at major corporations about this. I don’t believe they intend to overlook and minimize the importance of steps designed to make right decisions and better decisions. They just have a great deal of information to process and a lot of people vying for attention, and so I don’t know if the decision making process has become a high priority in agendas about bending the employer’s cost curve. I hope it will.

Studies have shown repeatedly that when quality information is sufficient, decisions about surgery are often changed in favor of medical management that involves much less risk and expense. Back problems are a glaring example of how treatments facilitated by better investigations and questions can eliminate costly and ineffective spinal procedures. At one Fortune 100 company, such an approach reduced back pain-related costs by 50%, while vastly improving patients’ quality of life.

Information is power.

 

HEALTHCARE ECOLOGY 101

Monday, September 8th, 2014 5:28 PM by Christopher Gregory

I happened to read something about nature the other day. The subject was how living things coexist in their spaces: it brought back memories of my college biology courses in ecology. (Perhaps it also offers an explanation for why the human species is going increasingly nuts inside the flying sardine cans the airlines have created).

Here are three terms.

Symbiosis:      This comes from a Greek word simply meaning ‘living together’ and can be used to describe any association between two organisms.
Mutualism:     This can be used to describe an association in which both organisms apparently benefit
Parasitism:     In this association one organism [the parasite] benefits, and the other [the host] is adversely affected [weakened, sickened, damaged etc].

I draw these definitions to your attention, because I have a point to make here about our American healthcare system as compared with others. To do that, I look back to the last commentary I wrote about the UK travelogue of Dr Richard Young.

When you consider the health care systems in most industrialized nations, yes you see challenges just like we have here. But what distinguishes them and their challenges compared with us is that they produce better results at much lower costs. In the UK for example, Dr Young tells us that the British rationale is to spend on quality healthcare without frills, excesses and waste. The Canadians are the same way. Consequently, there are likely far fewer MRIs in these entire nations than there probably are in Chicago. There’s a stiff upper lip when it comes to waste, and there’s strong evidence that the British people are mindful of that as much as the British government is. They just don’t demand as much, and the common sense medicine practiced under the watchful eye of primary care physicians in the British NHS keeps their checkbook pretty well balanced. So the symbiosis of the British healthcare system and the people covered by it can perhaps be defined as a medical-economic mutualism. Each party derives benefits from its association with the other and they live peaceably and healthier in the same space.

Don’t get me wrong. There are many good things about the US health care system: it’s a medical-technological marvel. It’s just that we overdo so much of the good stuff – we do too much of it too soon, waste money on the excessive and unnecessary and push people into the healthcare meat-grinder far too fast. That explains why the term medical bankruptcy is so prevalent here, and nonexistent elsewhere. And we have overspecialized our healthcare system with physicians who are body parts specific, at the expense of the type of quality medicine that the Brits deliver from their general practitioners. We (meaning the AMA, the government, the insurance reimbursement system and spoiled American consumers)) have crippled the best delivery of healthcare we could ever hope to have. All we have to do is wake up and do the right thing by promoting and fostering strong primary care, family medicine as the required first step into the system. Got a headache, bellyache, sore knee? First stop – required – is your family physician, not a neurologist, gastroenterologist or orthopedic surgeon. And be glad you have a family doctor who knows you and all your parts. Raise a ruckus with your elected representatives to pay family doctors better, which will hopefully encourage new doctors to consider the challenges of family medicine. If you can do that, and we can get a hale and hearty primary care system running at peak efficiency – that’s going to create mutualism – good for patients and good for primary care docs. Good for the wallets of a nation, its employers and its people.

The stories come out regularly about surgeons doing too many unnecessary and/or questionable surgeries because they can and because it’s lucrative, e.g., heart procedures, spine procedures, knee replacements … the list goes on. Hospitals and highly profitable freestanding ERs are sprouting up everywhere, hospitals are on a spree buying up physician practices and jacking up office call costs, insurance companies only giving the best reimbursements to mega-groups and freezing out small practices until they can no longer survive. That folks is not a mutualistic healthcare environment. That is a parasitic relationship and look where it weakens and damages – US employers becoming less competitive in world markets, more and more of the nation’s GDP being eaten up by healthcare costs and not spent elsewhere, pharmaceutical companies charging obscene amounts for the latest drugs rolling out and people being wiped out financially.

Can anyone reasonably argue that we have a good thing going? When the broken system makes a lot of money for purveyors,costs a lot and does economic and health damage – that’s parasitism – good for one, bad for the other.

KEEP CALM AND CARRY ON

Monday, September 1st, 2014 10:38 AM by Christopher Gregory

Dr Richard Young of Fort Worth, Texas traveled to the UK to observe firsthand the workings of their healthcare system.  He  wrote an in-depth article that looks at the British National Health Service, or NHS, through the eyes of an American family physician. This is particularly important to us in the U.S. because it offers a glimpse of a far more efficient and effective way to run a nation’s health care system. We should learn a lesson from his observations. Unless we recognize the sheer folly of our own system before it is too late, the most efficient front line of medicine we will ever know in this country will disappear into the morass of the costliest, most overspecialized, profit-obsessed and monumentally wasteful healthcare in the world.

The NHS, which is anchored by their corps of general practitioner primary care physicians (GPs), is a stunningly effective and efficient national healthcare system. They provide care to citizens of the UK at about 50% of the cost of the U.S. For 2011, the Organization for Economic Cooperation and Development reported that British healthcare costs consumed 9.4% of their overall economy (GDP) while the U.S. spent 17.7% of the GDP. That equates to $3,405 per person per year in Britain against $8,508 in the U.S.

As a doctor and a teacher, Dr Young is committed to the preservation and propogation of quality, cost-effective family medicine. I can only surmise, as he saw how healthcare is managed over there,  that maybe he was envious to see the British system in full scale action doing the things he practices and teaches back here at home. When an elderly British patient told him that she didn’t see the need for a diagnostic test at her advanced age and that it was a waste of time and money, I wonder if he felt a “high-five” was in order?

If we hearken back to the beginnings of the ObamaCare saga, which early on included discussions about a government health plan offering to citizens, we might remember the horror stories that were told. Powerful and entrenched healthcare special interests  scared us silly with stories about all manner of Canadian and British health system miseries, and how we would be rationing care away from our grannies (aka, death squads). Dr Young was mindful of those scary tales of long waiting times for surgeries and cancer treatments, so he set out to learn on a more personal level how the British system really works. He talked to people both in and out of the healthcare system and observed doctors working in a hospital and a clinic. He also talked to British patients both inside and outside of NHS facilities. He even went on house calls.

Note During that pre-ObamaCare period of scary stories, I gained some of my own perspectives by talking with Canadian healthcare experts at the University of Manitoba Centre for Health Policy. What I learned from them closely follows what Dr Young has reported about the NHS. While all health care systems face challenges everywhere, the British and Canadian health care systems produce far better results at far less cost. Translation: higher quality with money left over for other needs of a nation.

Dr Young wrote that one of the elements of the NHS that held his fascination for years is how given instances demonstrate that, for the most part, British health policy decisions are not paralyzed by dramatic anecdotes and rhetoric the way they are in the U.S. The ability of UK politicians to mostly behave when debating challenging health care issues shows how different our two nations are culturally. From the WW II Blitz days, the English rally themselves on all manner of paraphernalia with the motto “Keep Calm and Carry On”. When the subject is healthcare, the modern American slogan always seems to be, “I want it my way and I want it all and I want it now.” While behavioralists tell us that stories are more powerful motivators of change than numbers, the English don’t let stories of some young people dying of cervical cancer, or anecdotes about expensive chemotherapy treatments not being covered, or decisions to not provide the most expensive Alzheimer’s drugs force the NHS to change its policies merely to quiet the clamorings of special interest groups.

Dr. Young’s British medical travelogue is not a highly clinical work. Rather, it is an up close and personal observation of care deliverers, care consumers and how a nation’s mindset works reflecting a shared sensibility about financial resources available for citizens health care needs and how to spend them to produce the greatest good. Notions like a preference for the quality of life one has remaining over the mere prolongation of life at all costs and beyond quality time.

They just don’t overdo healthcare in Britain (and Canada) like we do. They don’t go overboard on MRIs, CAT scans and questionable treatments, procedures and drugs that are marginally efficacious. When it comes to decisions about appropriate care, physicians in the UK decide and patient abide – imagine that! There is near zero tolerance for whining, demanding patients and families, and so patients and families don’t whine and demand much. And their numbers show the results – better outcomes there (and in Canada) in many categories of quality and cost. 70% of the citizens in the UK think their NHS is very good or excellent – the highest national opinion number ever recorded.

Here is a striking example that, to me, shows just how differently health care is provided over there and over here. A Dallas television commercial yesterday jogged my thinking about this.

In his travelogue, Dr Young wrote about his visit to a new, modern UK hospital and his time accompanying an internal medicine hospitalist. He went with the physician on his daily rounds in a modern hospital ward consisting of 22 curtained off beds. All new, all modern.

The glitzy local television commercial I watched was for Forest Park Medical Center, a fancy new hospital in an upscale north Dallas suburb. I had to watch closely to discern if this was truly a hospital or the Ritz Carlton I stayed at on my last trip to Washington, DC. There was a very upscale cafeteria (I looked to see if there was a sommelier standing somewhere), staircases like a cruise ship and private fashionably decorated rooms ensuite with guest quarters and hardly a single medical device showing. The only tipoff to this being a hospital was a sick person in a hospital type bed.

The commercial ended with “our patients like it here so much, many don’t want to leave”.

That’s them, that’s us. We are spoiled, extravagant and demanding – they are frugal, prudent and accepting. We spend, they conserve. We build opulent, luxury patient suites, they build efficient places to treat sick people.

They do health care better at around half our cost, and 70 % of the British people think their system is very good or excellent.

Top that.

 

SELL IT AND THEY WILL COME

Tuesday, August 26th, 2014 11:27 AM by Christopher Gregory

Selling healthcare to the American people has spawned an endless stream of marketing hyperbole intended to saturate our brains with the virtues of all kinds of drugs, treatments, doctors and medical facilities. We are goaded into the overdone, unnecessary and costly simply because it is in our faces 24/7. Everywhere we turn, it seems that there are gleaming new hospitals going up, doctors selling treatments on tv, drug ads, and freestanding emergency rooms and urgent care clinics sprouting like mushrooms. Walgreens and CVS will be moving ahead with their own expanded versions of care pronto.

The Dallas Morning News has consistently demonstrated quality, well-researched reporting focused on problems in our healthcare system. This past Sunday, a front page article reported on the extent to which a provider organization has attempted to carve their niche in a highly competitive and costly area of care by employing elegant marketing methods, testimonials and attractive claims.

North American Spine is an aggressively marketed, expanding organization that advertises on Fox & Friends, the internet and through traveling seminars. They proclaim to offer a new procedure that promises “excellent pain relief” to back pain patients.

After a thorough reading of this extensive article I was left to wonder if, behind a gleaming façade of promises, a warning light is flashing the message “buyer beware!”.

Prompting this heightened concern are facts that cannot or should not be overlooked. First, consider a NAS physician founder with a checkered history (including an arrest for possession of cocaine), a suspended medical license and numerous malpractice suits against him (ultimately totaling 40). Next, there are webinars narrated by a NAS cofounder who is a preacher from Mountain Home, Arkansas, proclaiming his PhD from an unaccredited educational institution.

More facts. While often depicting itself as a medical institution (marketing materials showing men and women with white coats and stethoscopes), NAS admits in court filings that it has never provided medical services. NAS is, in fact, a marketing and office services company. The whole image is a façade. Buyer beware.

In fact, NAS refers patients to outside independent physician contractors, most of whom are not board-certified spine surgeons. Rather, the physicians performing these delicate spine procedures are anesthesiologists and pain management specialists. The newspaper report tells of a patient who underwent a very expensive 45 minute surgery at a private surgical center (total $94,000) and came out with lasting pain worse than before surgery. In a lawsuit brought by another NAS patient, the testimony of a consulting board-certified orthopedic surgeon identified a lapse in physician postoperative care that left the patient partially paralyzed and with a loss of bowel and bladder function.

And finally, NAS has claimed that studies confirmed the value of the new procedure, touted as the AccuraScope operation. In fact, the procedure is not new (it has been around for years), NAS admits it did not invent it and AccuraScope is not an instrument – it is a surgical technique. Regarding the so-called studies affirming the AccuraScope procedure’s value, NAS states on its website that “independent, peer-reviewed research is a cornerstone of evidence-based medicine”. The problem with this is that the studies cited on the NAS website are authored by NAS doctors evaluating their own work. Far from independent, totally self-serving.

The message from this newspaper article and countless other stories out there is that we are in the midst of a medical marketing blitzkrieg that is intended to dazzle us with lofty promises, lead us down the garden path and motivate us to seek brutally expensive care and treatments. Consider again the recent study that shows 47% of our citizens believe that the more expensive care is, the better the care.

And yet, the forces out there that can drive change remain silent. Where are the country’s corporate giants who can collectively form enough payer muscle to counterweight organizations that mislead and snare people into treatments that are costing us dearly and in many instances harming people? Where, if not from giant corporate payers, is the answer coming from in response to our healthcare system that does too much, too soon, in the wrong places, by the wrong providers, doing wrong treatments that are too costly and unnecessary?

 

GLUT ECONOMICS

Wednesday, August 13th, 2014 10:39 AM by Christopher Gregory

Today’s commentary wasn’t planned, but a morning report changed my mind. It disturbed me and it should disturb everyone who pays for healthcare – patients, employers and employees alike.

I get a daily journal of what’s happening in Dallas Fort Worth healthcare, and today it was reported that Baylor Scott & White Healthcare will open a new freestanding emergency hospital in the nearby suburb of Colleyville. This facility will be located 5 miles – a 10 minute drive – from the Baylor Scott & White regional medical center in Grapevine. They have a nice big ER there at the Grapevine hospital. 

Baylor Scott & White is the newly created mega-healthcare system that certainly appears intent on becoming the local 900 pound gorilla. Recently it was reported that they are moving into alliances across Texas, as far away as Longview Texas to the east, and Midland Texas to the west. 

In Wisconsin, five major healthcare systems are linking their affiliations – that will cover 90% of individuals in Dairyland.

Dr Richard Young, my friend and a fellow campaigner for saner care, wrote a piece intended for distribution to DFW employers who gathered last year to hear ideas about collaboration smarts. He wrote:

“I’m sure many of you have seen these freestanding emergency rooms popping up all over DFW like mushrooms after a hard rain. Ask yourself this: if you were thinking about opening a healthcare business and you could get paid $1500 in one facility or $100 in another for the same product, which facility would you invest in? This is not a facetious question. It’s exactly the dynamic that is driving the growth of these freestanding ERs, and the urgent care centers before them. A recent article in the (Fort Worth) Star-Telegram about one of the freestanding ER companies stated that the average revenue per visit is $1500, which is completely believable. Another source I know in the ER business told me that it only takes 8 patients per day for these things to break even.”

Within short distances in my own community of Flower Mound and the very next community over, there are four freestanding ERs, a new Texas Health Flower Mound hospital and right across the street from the new hospital, an emergency hospital put up by the nearby competing HCA hospital. Then, I think at last count, there are four walk-in CareNow clinics. And the profusion of new ologist offices along the growing medical corridor in Flower Mound is impressive. This is all within a 10 or so minute drive

There’s a term to describe events when an overactive thyroid-controlled metabolism runs amuck. That term is “thyroid storm”, and it is described as a very serious condition that can be life-threatening. By all stretches of the imagination, do you see this seemingly exponential expansion of facilities, hospital system mergers, and hospital systems gobbling up doctors’ practices like Pac Man as a threatening sign? It feels as though healthcare as gone from overactive to amuck. It’s dangerous and there is a bad moon rising. I recall from a population ecology course in college, that when there are too many bugs in a box, or too many lab rats in a cage, things start to get ugly. Are we there yet? 

That’s why I coined the term “glut economics”, because the glutted health system is feeding more fuel into this healthcare revenue inferno. We hear and read all about the “system” (hospitals and insurance companies mainly) morphing into a new dawn of transparency and accountability. Is that bunk to make us feel ok? Yet all the while, we see insanity like these freestanding operations that are just huge moneymakers and hospitals grabbing up doctor practices to create subservient employees needed to feed more and more patients into the hospital mother ships.

C’mon – isn’t this a little scary?

 

 


Copyright © 2014 DocOnomics Physician Planning Blog. All Rights Reserved.
No computers were harmed in the 0.383 seconds it took to produce this page.

Designed/Developed by Lloyd Armbrust & hot, fresh, coffee.