Alan Greenspan and Retail Clinics

I am struggling with the fiscally conservative approach to health care policy this weekend, since I have just finished reading Greenspan's memoirs and find a number of interesting insights.

Given the apparent anti-competitive stance of my last post on retail clinics, I am feeling a little schizoid.

But the more I think about it, I am more convinced than ever that retail clinics are harmful because they alter the landscape in ways that could be ultimately negative for health outcomes. If there is a need for non-ER, after-hours facilities to provide care for minor medical urgencies, it is partly the result of labor shortages in the face of increasing demand. I'll be blunt; nobody in their right mind will take the lifestyle impairments of 24/7 availability out of their primary care office given the current regulatory burden, liability and low level of remuneration in primary care. There are not enough primary care docs to meet the demand and they are not sufficiently well remunerated to provide the level of care it takes to keep people out of ER. They need more resources, but instead, I see resources going to retail clinics and moreover, benefiting large, profitable pharmacy conglomerates at the expense of primary care.

I am furious at Massachusetts because not every state has a progressive (note I did not say liberal) tradition of protecting the common good and a regulatory structure to support it. It is hard for me to believe that intelligent, well-meaning people with a commitment to public health have such a distorted and short-sighted view of the world that they truly believe they are doing good by allowing retail clinics greater sway. To be honest, I had not previously followed the story and do not now have a full understanding of the arguments in support of retail clinics in Massachusetts, but the result produces a visceral response in me. I am guilty of knee-jerk reaction in this case. Most of my arguments are at Paul Levy's Running a hospital and they do not require repeating here.

One statement in Greenspan's book that I think is relevant for some reason is that "too low a risk-adjusted return implies a waste of resources and productivity." From a macro-economic perspective, I can understand that.

Workers (including physicians), capital and other resources will be distributed according to their risk-tolerance, the risk and return profile of their chosen activity and the depth of their personal resources. Some people take 12 years to finish their neurosurgery training because they perceive that the return on their time and effort (as well as the opportunity cost of deferred income) justifies those resources. The return is measured in dollars and some qualitative sense of their happiness and vocational satisfaction.

Others complete their three or four years of primary care residency and get to the workforce a little faster, expecting to live a somewhat less stressful life and earn a little less for the same effort. But that income cannot be so low that it no longer provides an incentive for working harder. There is a risk that, at some point, reimbursement can become so low as not justify working harder. There is a point, where you just show up for work, do your eight hours and pay the mortgage. Sometimes the headaches of additional patients, hours away from family and satisfying regulatory masters just do not make it worth any effort beyond just staying afloat until retirement.

In the end, you have got to love what you do, enjoy the training environment enough to survive and make an assessment of what you can reasonably accomplish as well as what it is worth in future income and satisfaction.

Those who put in their three to four years to become primary care physicians do not expect the same reimbursement levels as people who have invested a greater part of their lives in training, but as the differential in reimbursement between specialists and primary care grows, two things will happen:
a) more people will gravitate to specialties until primary reimbursement catches up due to the supply-demand equation. There will be shortages as a consequence, frequently manifest by a lack of primary care access.
b) as the demand for primary care grows, primary physicians will simply not be willing to put up with requirements from hospitals, ER's, specialists and even patients that impose greater uncompensated responsibilities and liabilities. In other words, there is no incentive to work harder and longer, to make sure after-hours coverage exists.

Retail clinics provide the opportunity for primary care providers to seek additional revenue, at low risk, low effort and high compensation. It is ultimately good for them. What the heck; if they can compete and do well in the system, all the more power to them.

But wait a minute! Whose system is it? What is the purpose and objective of our system? I did not see the words "to improve the financial health of physicians" in the mission statement of any non-profit in the country, much less that of a progressive state such as Massachusetts.

Surely retail clinics are going to help pharmacies generate prescriptions, revenues and excess profits. It is definitely good for them and probably for the markets and the economy as a whole. But as I perused the Massachusetts Public Health Council Web Site, I did not find that the health of the public's 401K investments was part of their mandate.

I did, however find that the Council is composed of the chair of a University pediatrics department, an infectious disease specialist, an emergency physician, University chancellors, policy wonks and the like. I did not find a single person with academic primary care credentials who could indicate the potential of adverse impact on the primary care workforce. Also the majority of PHC members, necessarily come from the large contiguous urban core of Massachusetts, which is traditionally over-doctored and thus not subject to the same degree of primary care pressure as other parts of the country. Come to think of it, I bypassed Boston in 1996 because their academic primary care presence was just so darned weak. Those who have struggled in the shadow of the center of the American academic medical machine were much braver than I. Boston is simply not representative of the rest of the country, or perhaps even of the the state as a whole.

The thoughtfulness of a group of academics is usually measured from the perspective of their primary research or advocacy priorities, not the search for unintended consequences.

Let's return for a minute to the economics of the situation as an educated non-economist can understand it: "too low a risk-adjusted return implies a waste of resources and productivity." In health policy terms, I would interpret the "return" to refer to the health status of the population as adjusted for their baseline risk determined by age, gender, social and socio-economic status. If we had a good way of measuring the risk-adjusted return of our health investments according to some macro-economic unit (such as a state, for example,) and we found that it was high, we could infer that resources are deployed efficiently and effectively. If the return was low, I think Greenspan would assert that resources are not efficiently distributed amongst various health care activities in a manner consistent with the greatest good.

The return in question is not necessarily a financial one, although dollars could serve as a proxy for health, if one were to consider future health expenses.

Primary care resources are tight, so any distribution into activities that do not provide dividends in measurable indicators of health status will presumably diminish the absolute level of returns in other areas of health care activity. If we were to take diabetes as an example, reduced access to appropriate facilities could potentially result from the diversion of limited resources to retail clinics. We can only imagine the future impact of such a reduction in access on health outcomes for diabetics as well as any number of other chronic diseases.

Retail clinics do not better the health of the population for the amount of resources they consume. They have the potential to reduce congestion in ER's but do not address the underlying lack of a sufficient primary care workforce. Thus, it is possible that ER's will simply become congested with sicker patients over time, because those patients had worse access to primary care and suffered as a consequence. The alternative would have been to provide an incentive to non-profit community health centers (yes, I have a vested interest) to provide longer hours and expand into more areas in the state. I suspect that if they have not been able to do so, it is because they are unable to recruit a sufficient number of primary care providers at their current level of resources. Massachusetts and Boston in particular benefits from some of the highest concentration of federally-qualified community health centers in the country.

Remember, I am a non-economist and just a poor CMO of an FQHC in rural America, hardly able to compete with the best minds Boston has to offer this country. I know it would take several months of work to elevate my argument to the level of academic credibility and formulate a methodology to verify the hypotheses contained therein. But I have read similar arguments before in the academic literature, so I don't think that the Council was entirely ignorant of what we know about primary care and its importance to a health system. For my part, I have to go out and recruit a half-dozen physicians, respond to our local hospitals' needs and do what I believe is best to positively impact the overall health of my community. I hope our authorities let Massachusetts do the tinkering and use our regulatory powers to adjust the competitive environment with an actual health outcome in mind, and not just the health of our hospital emergency rooms.

I'd like to think that's what Alan Greenspan would say.

Retail Clinics Versus Public Hospitals

This morning, two stories caught my eye. KevinMD is pointing to another article on Grady's plight in Atlanta; another public hospital struggling to survive.

The other story was one of several reports on CVS' MinuteClinics being cleared to operate in Massachusetts: WSJ, David Harlow's Health Blawg, White Coat Notes at the Boston Globe, and Paul Levy at Running a hospital.

So hospitals are dying while corporate money mills with very little value-added are thriving. This evening, I spotted another post, reporting that 6 - 8 storefront, limited-service, retail clinics are going to open per day in 2008, over and above the 1000 already in existence.

There is a greater need in one area, but a greater profit to be had in another. Public hospitals fail while retail clinics grow.

I am a great believer in free markets, but fair markets rarely occur naturally. The current conditions are, in fact the result of regulations that provide perverse market incentives. Half the practice of medicine involves NOT PRESCRIBING MEDICATION!!!!

(Sorry, I'm yelling!)

Now, retail giants like CVS, have succeeded in developing vertically integrated style operations in which they control everything from the distribution channel to the provider's incentive. By most informed people's standard, quality is not defined by the highest possible prescriptions per encounter, but that is the natural incentive when a pharmacy chain controls the providers. Bonuses will be paid and employment decisions will be made according to the provider's ability to generate prescriptions.

And a public health authority voted for this? In Boston, with an incredible network of publicly controlled, not-for-profit community health centers? That makes absolutely no sense and without an adequate explanation of their logic, somebody please look for corruption or corporate threats on the face of it. As David Harlow points out, the diversion of resources will ultimately be damaging to the population's health. People need medical homes, not McDocs and McPA's. Nobody is coming to work for me, given that all I have to offer is a more difficult job and lower remuneration.

We must compete on a level playing field. The question is who is getting the more difficult patients and not being adequately remunerated for it. Who is getting easy encounters and getting the dividend of the prescribing revenue?

I can see 50 healthy people with coughs and colds with a good nurse and someone to answer phones and I can do it in 4 hours. In the same amount of time, I can properly do two complete geriatric assessments. The reimbursement differential per encounter cannot possibly cover the differences in resources, so I can't afford to do them properly. I cannot allow my physicians to do complete assessments and so will encourage them to refer out. MinuteClinics didn't worry about pushing those patients to me because they do not provide the service. Will you, dear reader, require me to have a different moral standard than MinuteClinics?

If retail clinics can push certain patients to me, then I can push those patients to someone else.

Health care facility managers segment their markets and subtly poach the patients that represent the best profit margins. Why hire a nurse practitioner with pain management background? Those patients are time-consuming, frustrating and unprofitable. Rheumatologists sometimes deal with elderly patients and time-consuming multiple medical problems, frequently more than they can compensate for in procedural fees from joint injections. In fact, poor people are generally a good bet to represent losses, sometimes even with Medicaid.

In a city like Atlanta, hospitals and ER's adopt the view that the "county hospital's" job is to take "those" people off their more productive hands. Some public/county hospitals do not recognize that this is the kiss of death.

Public and county hospitals must be in a competitive mood in order to recognize that their existence is threatened. Despite not having lived in Atlanta for three years, I am convinced that a major portion of Grady's trouble stems from the mind-set that "they" will never let Grady go under (meaning the counties and the state would always bail Grady out, no matter how much trouble they got into.)

Being sheltered from competition is part of Grady's problem.

Here, in the Great American Desert, I am in a community with three hospitals; one is county-funded (and trying to expand based on a public appropriation), one is critical-access (therefore subsidized by enhanced Medicare and Medicaid payments) and a stand-alone for-profit. It is only the for-profit that is knocking everyone's socks off. The others are trying to protect or expand their federal or local subsidy, rather than competitively expanding product lines, improving service levels or quality-of-care.

So we have contradictory forces regarding competition. In the case of MinuteClinics, competition harms the public health. In the case of public and county hospitals, the lack of competition is at the root of the problem.

In a free market, public and county hospitals must realize that they have to compete for the same kinds of profitable patients that MinuteClinics is after. But MinuteClinics must not be permitted to get away with such an artificially limited scope of service, by which they effectively block access to complicated patients, leaving the costs for others to bear. And damn the consequences that the rest of us who will have an even greater trouble recruiting competent providers to do the slugging in the trenches where it counts.

Did the Press Miss An Important Obesity Article?

One of my pet peeves is how the press handles health news. In the rush to sell more papers and ads, every little piece of old news is treated as a breakthrough even though science is a slow, dogged, methodical pursuit of incremental truths.

In obesity, we have been running through scientific assessments of fad diets for a significant portion of the post-WWII period. Of course, the years have exposed a series of contradictory bits of evidence about weight loss. Does anyone remember the rice diet in the 60's? I was too young, except for some distant family members told me how much they'd gained! Then it was fat reduction in the diet, which I never really saw succeed. Then we had the low-carb diets like Adkins (eat all the fat you want) and South Beach (it's not the quantity, it's the quality of fat and carbohydrate that counts).

In the absence of real-world data (as opposed to controlled, quasi-laboratory environments) that incontrovertibly proves that either carbohydrate and/or fat intake reduction actually do work, I recommend to people to exercise and not exaggerate their intake. This study, although far from perfect, is another small notch in the favor of combined low-carb, low fat, high protein diets. It is too small to constitute proof, but it was certainly long enough at over 1-year follow-up. The concern about high protein intake and an association with renal problems (manifest by proteinuria) remains unanswered.

Fox is reporting on internet hormone sales and the secrets of great sex.

Oops.

2007 Medical Weblog Awards

Well, wouldn't you know, I am now settled in and spoiling for a bit of a blogging dogfight. So I go over to my favorite sparring partners at InsureBlog only to find out that I am a finalist for the 2007 Medical Weblog Awards in two different categories.

I am a co-finalist with Dr. Val and the Happy Hospitalist who have been favorites of mine, in the New Blog category.

I also made the best Health Policies/Ethics Blog category.

I am disappointed that Hank Stern and his comrades from InsureBlog did not make the list. They present controversial and different viewpoints with verve and intelligence. You still have my tip of the hat and plenty enough kudos from other sources. I look forward to the next time we do "combat."

On the other hand I am delighted that both intueri and Surgeonsblog made it in the Literary Blog Category. Whatever you feel, think or do, please take the time to vote.

Is Universal Health Care the Right Thing to Do?

The December issue of Managed Healthcare Executive has, as its cover article, a piece on Massachusetts Connector.

Jon Kingsley is quoted as saying:

"Community rating alone does not ensure value, but must be combined with guaranteed issue, guaranteed renewal and broad if not universal participation so that insurers don't just end up pricing premiums to cover the sick," Kingsdale says.

But Kingsdale knows that health care reform cannot succeed if it fails to control the underlying costs of health care.

If you ask Kingsdale how to reduce the costs of medical care, he has a long list of initiatives in his back pocket. These range from reducing hospital-acquired infections to managing variation in the flow of patients through the emergency rooms or operating rooms, to not paying for botched care, to reforming medical tort liability, to standardizing certain administrative processes, to constraining use of "me-too" brand drugs, to rigorous assessment of the efficacy of new medical devices and technologies.

A reduction in costs has to come from somewhere and it appears that Kingsdale is referring to inefficiencies and waste in the system. It is somehow gratifying, even if only on a self-serving basis, that Kingsdale does not refer to physician and other health staff salaries. Most physicians would be concerned that improvements in outcome come at a cost, often it comes from their hides,in the form of unremunerated committee work or more unjustified interference with their practice independence.

But there is an alternate way, which is to reduce inefficiencies and the costs associated with those inefficiencies. I suspect that physicians are cash-accounting types, as opposed to accrual-accounting; they cannot see assets that they can't use to pay off their debt. It is hard to justify the adoption of technology at an up-front cost, if there is only a promise of future efficiency. There are no billable medical procedures associated with the technologies required to enhance the processes of care.

The performance and process improvement movement has had success in multiple industries explaining, justifying and demonstrating its value. Somehow health care has been more resistant and it is the largest single segment of the US economy, possibly larger than the entire federal government, ex-defense. [At any rate, it's pretty close.] I am not sure if it is the nature of health care, the fragmentation of the industry or physicians themselves that are to blame. It might possibly be that health care has grown so large that competing interests pulling in disparate directions are making it impossible to define a common direction.

Ask ten people about health care and they will give you ten opinions about what it should look like, possibly more than ten opinions if people like me are in the mix! It comes down to large pots of common resources being allocated with a purpose in mind. Allocating to health care is just to vague and allows a mercantilistic profit-motive to take over. [A mercantile profit-motive as described by Milton Friedman is not evil, and allows the common good to be provided by the invisible hand of a complex adaptive system such as our economy. I distinguish a mercantilistic concentration of resources in the hands of a few interests, which no longer reflects a free economy. However, I recognize I have just said a mouthful and mixed ideas from multiple great streams of thought in ways that they were never intended. I do so in the hope that I can clarify the ideology that underlies this post.]

For any large segment of the economy—and healthcare at 16% of the Gross National Product is huge—I only know two ways to allocate and manage resources: effective markets or centralized budgeting. We are trying the former in an effort to enhance competition and choice. I sincerely hope this works. To the extent that we find this wanting, we may be pushed toward the other alternative.

But the article is thin on explaining the reasons to pursue universal health coverage, beyond stating the obvious, that it is the "right thing to do." This is a problem.

We cannot allocate to health care. Health care is not a purpose or a goal. We do not invest in health care unless we expect health care to provide a return on investment, which will be measured in new technologies, market gains and perhaps some tax dividends.

I would rather invest in the health of our workforce, which, it comes to mind, was the original rationale of insuring workers during the wage and price control era of WWII. Well, maybe it was a rationalization rather than a rationale, but it served as a useful framework to analyze success or failure for a time.

Health care may very well be the "right thing to do" but it may be more useful to identify constraints to economic productivity related to health care and address them broadly. For example we know that productivity losses from colds and influenza can amount to several hundred dollars per year. One model I found describes $40 billion dollars in aggregate economic impact of only the non-influenza respiratory infections.

Much of this data comes from the health effectiveness literature and there is certainly a great degree of interest from pharmaceutical companies in this type of data. [Please take your time with this link, it contains a lot fo food for thought, if you have not been exposed to these kinds of economic analyses.] It may make sense for policy-makers to leverage this type of information as a justification for universal health care. Perhaps an economic justification for health care can be built from even partial mitigation of the economic productivity impact of certain diseases or conditions.

A frequent knock on health care is that it is difficult to demonstrate an attributable reduction in mortality or an increase in life expectancy due to the availability of health care. But crude population statistics are a machete, compared to the scalpel of individual condition-specific economic analysis. On the other hand, neither instrument may be appropriate if you are cutting a lawn.

One thing for certain, I don't know that I can argue for or against health care as "the right thing to do" since it is a moral argument. I know how I feel, but bringing you over to my side seems like a futile exercise. A dollar-and-cents argument has to be balanced with a bit of compassion, but can provide the basis of a more productive discussion.

Physicians and Managers

Well, it was my first day on the job at my new community health center in the Great American desert. I came across management that expects the CEO to be hands on and a CEO who is working at 30,000 feet. It remain unclear what the organization needs, but expectations are what they are.

I came across physicians frustrated with a series of ineffectual management teams that they are not giving the current group a chance. I would not have come if I didn't believe the current group was worthwhile, but the docs may have seen too much over the years to believe in their current managers.

When doctors and medical staff are not given the credence and attention they deserve, they become passive-aggressive and actively subversive. That partially explains why I met a physician with angle closure glaucoma taking a sick day two days before a routine screening dilated exam!??!

[Angle closure glaucoma is precipitated and/or exacerbated by the dilating drops. The chronic open-angle form requires annual pressure monitoring and only occasional dilation. In any case, there was plenty of time to set up a screening exam within the required 30 days for a planned preventive service.]

Doctors are sometimes too smart for managers to handle. Managers need to spot BS quickly. In the end, it is the community and the patients that are the priority for both managers and doctors. When the environment has become full of mistrust, reminding both parties of their common mission is the only way out. It's been too short a time, but I see no reason this group cannot pull it out.

Immigration and Health Care Costs

In my drive across the country, I encountered many languages. Coming from a polyglot city like DC, it is easy to be jaded about the American heartland and consider fairly white-bread. This is why it struck me that I encountered so many cultures along the way. I could have said that there were more non-English culture Americans along the way, but then I would be grandstanding.

I did run into a family of Greeks from Turkey along the way, an almost vanished cultural subgroup. Mostly I found myself conversing in my broken Spanish. First was a family from Cuba and we met in the St. Louis arch. Of course the dominant group was Mexican-American, who manned convenience stores, restaurants and hotels the entire length of the country, even in the most white bread areas. I even saw a young black man cleaning a hotel room, a truly unaccustomed site in this country over the last decade, but it was at a National Park, where reasonably affluent young adults work hard in exchange for the adventure of their lives.

All these impressions came on the heels of a radio talking-head saying something to the effect that the trouble with this country was the extent of illegal immigration. He was saying that people seemed to think it was OK to break the law or to simply ignore it in such unprecedented numbers.

So, that would mean that all laws must be vigorously enforced at all times. I’m glad this guy isn’t in charge of the highway administration; I would have been in trouble with speeding especially in some abandoned stretches of road in the West. But the level of policing required to eliminate all speeding in the country would be onerous, certainly it would be cost-prohibitive. Before the ACLU lost its way when the real issues gradually disappeared, they would have gently reminded us that not all laws are meant to be enforced severely given the risk that we could begin to look like a police state; a deplorable condition to be avoided at all costs. Indeed the fathers of this country did proclaim their liberty, or their lives!

If a law requires such severe and absurd efforts like building a wall across a natural resource like the Rio Grande, then I would consider the law worthy of re-evaluation. A law of the land is not a natural law. It is not the Law of Evolution, it is not a Law of God handed down to Moses, or elucidated by Mohammed or revealed by Christ. This country’s laws reflect intelligent people’s best bet on how to secure the greater good.

Our immigration laws are not only ineffectual; they are economically and socially counter-productive.

I caught a CSPAN rerun of Chris Matthews plugging his new book and he suggested that he had a problem with providing government documents to people who were not supposed to be here, i.e. making someone look like they had a status or legitimacy they did not have. That, I can understand. His position reflects serious thinking about how to approach the problem of rapid, undocumented immigration. But stopping immigration altogether is a boneheaded concept. Stopping illegal immigration is unlikely, given the strength of the forces behind migration. In fact, it is the complexity of human migration decisions that makes draconian immigration enforcement so stupid.

It is also economically counter-productive since I am convinced that labor is an asset for any country and does not represent a net burden in services. Some services relate to infrastructure that already exists and incremental increases are not necessarily harmful. Other services such as health care have raised some people’s hackles.

Those people who are up in arms over health care costs to immigrants need to come off it! Immigrants, especially illegals are mostly young, fit and hard-working. They do not come with the express purpose of seeking free health care for themselves or their families, although that may play into their needs after several years if their parents fall ill. There are numerous indications that immigrants, and especially illegals, use less health care and are more likely to pay for it than America’s own native poor. (By native, I mean born in the USA.)

The major burden in most areas is a fertility rate that approaches third world levels, but we’re too busy preaching the ineffectual dogma of abstinence to do anything about it (but that’s another post.) If anyone bothered to do a detailed economic accounting of the costs and benefits, I suspect it would quickly become clear that even illegal immigration is of net economic benefit to this country. Issues related to national security are just more fear-mongering to which I have become inured.

In construction and agriculture alone, this work force represents the ultimate in flexible, mobile work force to do labor of a kind no American would accept to do for any wage. To get native born-American to take up the back-breaking toil which is manual farm labor, we would all be looking at $8 tomatoes and a $20 head of cabbage.

If the problem is that there are too many immigrants, then I say it is the same old xenophobia that has affected people since time immemorial; a mean-spirited, deeply-rooted human fear of all that is unfamiliar. If the problem is only that such immigration is illegal, then I say change the laws. They are too impractical and poorly thought out for my liking. There are better and more intelligent ways to deal with a big incentive for economic migration from our southern neighbors.

The fear of health care costs related to immigration is just one more ideological bone from the political demagogues.

The End of the Year

This is the season of resolutions. Another year over, a new one just begun...

Weight, smoking, exercise... these are the things that people typically resolve to improve. But how often do we hear someone say, my resolution this year is to improve my relationship with my daughter? How often is the resolution to keep in touch with my friends, or reconnect with colleagues from my last job?

In fact, from a purely careerist standpoint, one of the most important things anyone can do, is call one new person a day. This, I heard from a previous chairman who was encouraging me to call researchers and academics for networking. But, boy do I hate cold-calling. As it turns out, my personality is just not conducive to picking up the phone and calling someone to whom I have not been introduced. But I wish it was.

So here we are, shacking up in a motel in the Rockies, hoping the snow will settle down enough to make it back on the road and the thought comes to my mind: given all the communications technology available, I can spend all of New Year's Day on the phone calling up old friends and still not talk to anyone I had talked to in 2007!

The way my mind works, I'll probably create a spreadsheet so I can track how many people I am calling from each of three different categories...

Maybe I'd better just stick to those people who love me.

Happy New Year everyone.

Industry, Beauty and Environment

On our drive across the country, we took a little detour into a West Virginia canyon. The New River Gorge is full of great views and spectacular rapids (including a few class V's that got my former paddler heart palpitating). Winding our way between the New River and Charleston West Virginia, we found ourselves driving through an environment I had not previously been familiar with, although I had gotten inkling over the years.

It is the riverine industrial environment.

I say this tongue in cheek. The roads looked a little muddy, like a mudslide had been recently cleaned up. I did not pay attention to the piles of black gravel by the river banks until we passed what could only be a coal-fired power-generating plant. The smokestack was less than half the height of the mountains in that tight little valley. A fine soot was collecting on roofs, and on cars. Although it was a crystalline clear afternoon, I wondered about the health of people exposed to burning coal. There is a little pocket of northwest Georgia where air quality downstream from a massive power plant. Not surprisingly, "respiratory ailments" are high in the area.

It is perhaps, a truism that ecological degradation and poor health go hand in hand. The reasons why are not as simple even, as a chicken and the egg paradox. The simplest way I have come to understand it is that rich people move away to better areas when an environment starts become unhealthy. But poor people cannot leave, or else their jobs maybe attached to that area. It's not as simple as that, of course, but it's a simple way to think about it.

Of course I know about silicosis in coal miners. I am aware of general lung function deterioration in areas of poor air quality and the notorious London fogs of the late 18 th and early 19th century. I know of the drop of longevity that was the hallmark of the Industrial revolution in Europe and the US.

We all have to make a living; economic production is as much an issue for the poor of these areas, unable to move out due to financial conditions or ties to the land that go far beyond anything I have experienced in my own peripatetic life. Have we sacrificed vast swaths of the American landscape to industrial production? As resilient as Mother Nature is, are some areas no longer fit for habitation? Are some parts of this country too plain, thinly populated and of little biological importance that they can be sacrificed?

Perhaps it is not unreasonable to say that once toxic kinds of industrial activity is underway, people should not live in those areas. Bring them in by truck or bus or train, but do not allow them to live in the vicinity of these environmentally decrepit areas. This is the ‘nanny state’ at its best: allow economic activity, recognize that if social accounting systems reflected all the true social and environmental costs, there could be no profit, therefore no incentive to invest, therefore no jobs for the handful who need them. Government can and should mandate what areas people may not live because of environmental deterioration, but in the interests of creating economic value, can allow that certain parts of the country be destroyed in the interests of industry.

Concentrate industrial activity in the interests of limiting the areas where environmental degradation is a problem.

It is an outrageous idea, but seriously, is the landscape around Evansville, Indiana attractive enough to save for a park?

There are many problems with this idea, like, for example, who would decide? The cost and risks of transportation of raw materials and people are an issue. The only mechanisms of transferring the costs associated with such a radical way of running industry are via government, and I am not a proponent of big government.

But the biggest question may well be why some centers of the industrial economy are located near some of the most picturesque landscapes on the continent? West Virginia is a spectacle of Appalachian beauty and yet its riverbanks are spoiled (in my eyes) by 100-foot mounds of coal. Louisville's riverfront is dominated by highways and infrastructure. Most of the waterfront in Jacksonville, FL is dominated by the port.

Maybe I'm just a sentimentalist tourist, expecting natural beauty in places where the business of human life is more important than the exigencies of beautiful vistas.

The Great American Desert

Posting has become spotty, not due to traveling and the holidays, as much as the fact that this morning, my wife and I begin our 3500 mile coast-to-coast drive. The packing has been intense, shoehorned as it was between jobs and graced by the festivities of the season.

We will spend New Year's on the road and the details of the road trip must be shrouded in the veil of my anonymity, which is becoming more fragile and more difficult to justify as this blogging gig is spilling over into print.

It has been 5 months since this blog began and it is moderately successful. I have surprised myself with how much I had to say. I am more pleasantly surprised by the extent of the positive response. What began as an exercise in self-expression has become a way of clarifying my own convictions, less self-indulgence and more exploration. I am impressed that anyone at all has been interested in what I had to say, and humbled by the quality, sensitivity and intelligence of my readers.

Wish us good luck and know that, even if the missives become less frequent for a time, there are more interesting changes coming in 2008.

See you on the road.

Christmas and Change

Merry Christmas. Christianity was seen by Bertrand Russel as an excuse for mediocrity. I think this perception can arise from Christianity's insistence on the potential for change.

Christianity is (or at least should be) about forgiveness and redemption above all. That means no matter how inadequate we are, how erroneous our ways, how mediocre our performance, there is always the opportunity for improvement. This position can sometimes seem to excuse past mediocrity, perhaps even celebrate it and reward it.

I was an awkward child, and a certain social awkwardness has penetrated into my adult life. But I am getting better. I have made many mistakes and continue making them. But I need to be free of the baggage of past errors in order to progress. For this reason perhaps, Christianity seems so ready and willing to forgive everything, in heaven if not on earth.

There can be no redemption without guilt. There can be no change without mediocrity. They are the catalysts for change.

Have a warm and happy day.

Doctors and Customer Service

Because The Physician Executive is leaving Maryland, headed to the Great American Desert, he has been spending an inordinate amount of time talking to other companies' customer service experts. When a customer calls to cancel their service, they usually are shuffled off to some of the better folks at handling customer service issues.

My response to this experience is to wonder how, for a service economy, you can't get any. Service, that is. Maybe health care is not doing so badly after all.

Gas and electric handled my departure with grace. Dish Networks offered options that didn't make sense and made me feel like a heel. Verizon (as usual) transferred me to four different people before they hung up on me when I expressed some frustration with the process. After going through three more people and a total of 1 1/2 hours on the phone, I finally understood that they intended to extract as much money from me as possible with lame justifications of service contracts for internet service, which now apparently renew annually instead of just expiring after the one-year term.

And we worry about transparency in health care?
We feel we are not getting good outcomes?
We worry that physicians do not provide adequate customer service?

Of course, there are lapses in any industry as large as this. No single company could hope to go through even a year without a significant lapse in customer service. I know there are stories out there... But overall, my impression is that physicians, nurses, pharmacists and all other allied health staff are generally professional. Do not forget that it is frequently a physician's job to refuse care; as in narcotics, excessive testing and unnecessary treatments. Somehow we manage to convince most of our patients that there is a better way.

We use the principles of shared decision-making, patient-centered care and self-management to come to reasonably satisfactory solutions. Using the parlance of customer service, the customer's experience is necessarily negative to begin with, since many clients are sick, afraid and upset due to their illness or condition. As an industry, we generally manage to treat people with compassion, caring and a modicum of dignity.

We drop the ball sometimes, especially in hospitals where the urgency of care sometimes leads to a neglect of personal propriety. When we need access to someone's neck veins in a hurry, we don't worry about what body parts are really naked. Privacy has always been an issue around the break room (and HIPAA is inadequate to the challenge). We have trouble dealing with drug-seekers and malingerers, who represent a betrayal of the compassion and skill with which we approach sick people (i.e. difficult patients are difficult.)

Apart from the odd scalpel-throwing surgeon or consultant-on-a-soapbox, I can't think of too many instances of internal customer catastrophes. In other words, we even manage to treat each other with some respect the vast majority of the time.

Customer service skills (or bedside manner, as it used to be called) are distributed as a bell curve in any random population; some do better than others. But overall, as a profession, as a group of professions and as an industry, don't we really do better than folks like Verizon and the cable company? On a risk-adjusted basis (adjusting for the fact that most patients are grumpy about even having to be a patient) we may, in fact, be stellar.

Not every problem needs fixing. Sometimes, no matter where you sit on the bell curve, your eyes are fixed on improvement. But little by little, we raise expectations and diminish our ability to provide any return on investment or effort.

We can lose sight of the fact that, compared to the level of service received in retail, business services, financial services, hospitality, IT and others, health care does reasonably well. We can lose sight that the law of diminishing returns dictates that significant improvements from here will be prohibitively expensive and pack only a small punch. Sometimes, the emphasis on customer service can belittle a worthy industry and its workforce.

Personally, I think we are doing well, and our weaknesses come to rise from the expectations that grow as a consequence of our success.

A Marketing Tool for Physicians and Policy Makers

Back when I got my management degree, albeit at a school of public health, I noticed how many approaches to understanding management involved divisions by four. The two-by-two matrix seems an easy way of characterizing the world and the approach has made many a career.

Take for example the service process matrix and the BCG matrix; even a SWOT analysis can be interpreted as a 2x2 box.

It always seemed to me to be an extension of the dualism that affects early human intellectual development, but aside from the obvious fact that two dualistic axes is better than one, splitting the world into two is a useful didactic tool.

So why should health care be any different? The Harvard Business Review reports on a study that divides health consumers into four, along financial and health spectrums. One thing I love about this type of exercise are the colorful descriptives that creative types can come up with.

• The first group is characterized as Healthy Worriers who have nothing to worry about but their growing inability to pay for future health care. This is probably the largest segment in the US.
  
• The Healthy, Wealthy and Wise have the resources not only to take care of their future illnesses, they are also motivated to maximize their current functioning, a different take on health.
• The Unfit and Happy don't recognize their risks and the significance of their actual health status. They mistrust the health system and justified or not, probably represent the bane of most physicians and providers.
  
• The Hapless Heavyweights. This is my segment, unhealthy and impotent to change anything, they need external support and motivation to lose weight, quite smoking, take their pills and actually show up for their next appointment. Come to think of it, a significant proportion of public health activities are focused on this group.
  

I suspect that the movement of consumer-directed health care was conceived to help the Health Worriers, but it seems to appeal the most to the Unfit and Happy. A parallel may be drawn to the rise of discount brokers in the 90's and the rise of do-it-yourself investing.

Mistrustful of the lack of apparent value in bad broker's advice over the years, I started finding information on the nascent web and making my own decisions. I found inexpensive sources of information, inexpensive trading platforms and made a small fortune. I also underestimated my risk and took a bath when the market collapsed. I have since rebuilt my portfolio by seeking out the professional advice I once eschewed, but continuing to use the internet to find that information. I still rely on my own judgment of Lehman or Prudential's research, but I have also learned where the holes are and use Google as my best overall financial adviser.

So in health care, some patients, mistrustful of the apparent lack of value in physician services, seek their own information and make their own health care decisions. Impaired by a lack of experience and perspective, they make errors and suffer health consequences. Eventually, this group learns how to use professional opinion and improve their decision-making, continuing to use alternative information resources to make better purchasing decisions.

But one way or another, efforts to reform the health care system tend to address the concerns of one or another of these groups. It rarely encompasses all groups. Not everyone was ready for discount trading in the 90's, not everyone is ready for consumer-directed health care today. Improving conditions for Hapless Heavyweights is decried as "nanny-state" interventionism by the Healthy Worrier. Reducing anxiety for the Healthy Worrier is met with accusations of freeloading from the Healthy, Wealthy and Wise.

And so on. The California debate will probably demonstrate these schisms yet again, but this HBR article may help us understand the market a little better.

Segment and conquer.

Billing Fraud Incentivized By Coding

I'm not sure what to make of this post at "Every Patient's Advocate." It follows up on a Steven Cole OpEd in the Dallas News, in which he points out that doctors prescribe medicines and order tests just to justify higher reimbursing billing codes.

There are certainly some medicolegal reasons for ordering tests and prescribing medications, many of which can be addressed by working on the communication skills of physicians.

But billing?

Poppycock!

The codes in question are 99213 and 99214. The principle is that you're pretty poorly remunerated for these visits, so you may as well capture what you've already done; document up to the code appropriate for the complexity of your patient.

Studies show that most primary care physicians underbill 99214. This is an established patient code; new patients have a higher documentation requirement and physicians tend to overbill the equivalent codes.

Get that; physicians underbill the one and overbill the other because the documentation requirements are different and they generally do not make the effort to learn all the details of billing. Physicians do not generally consider documentation and billing important parts of their calling.

So that must be why they prescribe drugs and order tests to get paid more... Yaaaaaa, riiiiiight!

Well, Dr. Cole is an allergist. I don't know how his colleagues behave, but I certainly know about primary care physicians. It's not what he describes. But even if we were to accept the notion that physicians practice patterns are affected by reimbursement rules, then all I have to say is "the trouble with incentives is that they work."

The CPT coding system was devised to distribute resources according to the effort required. Somebody underestimated the effort required by primary care and most especially the degree of risk assumed in primary care. But fraud is not worth it at our compensation rates. Physicians are smart enough to figure out whatever stupid system of regulations is thrown at them. Don't blame the physicians, blame the inadequacy of the regulation.

And as far as patient advocates are concerned, you have just shown me yet another ugly aspect of consumerism in medicine. Throw your efforts at improving the medicolegal environment, increasing transparency of the charges, and use primary care docs as your best advocates to guard against the worst that American medicine brings to bear.

We Need Votes

MedGadget is running the 2007 Medical Blog Awards. I think I'll nominate myself, but it would be so much cooler if you did.

Change in Health Care: Government or Corporate?

There is a great phrase I hear frequently on financial news programs. Usually it is from the mouth of a CEO, like Lily's new chief being interviewed this morning, and it goes something like this, "We will continue to drive change."

It sounds like a sports athlete coached to use canned sound bites like "our goal is to play hard and come together like a team."

The question that comes to mind listening to CEOs, who have become true celebrities in the last decade or so, is whether driving change has anything to do with playing like a team.

Change is not something capital can typically accomplish. Most often, the "change" is a fundamental change in the environment or the landscape. In a more Buddhist vein, I would suggest that change occurs in the river. Corporations/capital is like a canoe in the river. If the stream goes one way and the company goes another, someone's going to get wet.

Companies do not drive change. They navigate change something like shooting rapids.

Of course, some companies catalyze change. Microsoft was successful because the product they offered fundamentally changed the way America ran their businesses. But companies rarely, if ever, actually drive change.

I may have confidence in the power of markets, certainly as opposed to central planning of economies or government regulation. This approach tends to reflect a knee-jerk response to a perceived problem, thereby not accounting for the inevitable unforeseen consequence. You can't take just one noodle out of a bowl of sloppy spaghetti without making a mess.

On the other hand, I am losing confidence in the ability of capital to innovate (it would rather diminish risk), to drive change (the status quo always reflects less risk) or to self-regulate (there is altogether too much corporate influence in US governance, don't you think Dick?)

Change is much needed in health care. Will it come from well-meaning activists who would use the levers of government and probably make things worse? Will it come from capital whose interests, like pigs at a trough, compete for a limited amount of feed? I don't think capital can do it especially because the interests of pharmaceuticals and devices, hospitals, insurance, specialties and primary care are typically at odds with each other. And they resist change.

I hope activists who would use government as an instrument will remember to use the markets to their advantage and not to over-regulate. Government can work, just not the way folks are talking now.

The Meaning of Life

With all due respect to one of my former colleagues (who shall remain nameless), we recently got into a discussion regarding my future work plans.

She told me that she did not believe in God or an afterlife and figured what she was going to do with the last few years of her work life and into retirement was based on an accounting of what she valued. It's from zero to 10, she said, there's nothing after.

Of course, I do not wish to contradict anyone's beliefs because I do believe in God and an afterlife. The literality and inerrancy of the Bible are just sad remnants of a humanity that forgets meaning is in the eye of the beholder.

What occurred to me is that, in ethics as in life, there could be very little difference on our decisions based on our belief in God. Those who would believe feel they have to justify their life to God in faith and actions that reflect the faith. "What have you done with your life, dude?" is the question I am preparing for. If I didn't believe in God I would still want to maximize the value of my life. As an atheist, what standard would I use to measure myself?

Even though the "value" could be centered differently according to which ethic I prefer, a Christian or an atheist one, there remains the very concept of ethics. Embedded in the very need for the word to exist is a notion that there is a greater good than that which can be defined by the individual. Even if one was sufficiently egotistical to believe that their set of values was all that mattered to the entirety of creation, it remains that these ethics are all that matter to them.

I wonder if it isn't possible to perceive a kind of spirituality in atheism, that Christians are often too blinkered to see. I suppose I might say the same for Jews and Muslims, since my point is that spirituality transcends religion and may well exist as long as we speak of ethics.

The existence of the concept of ethics represents to me a basic human need to see a finger of creation behind the random events which make up our lives. I conceive God in the traditional Christian "person", but even if I didn't, I would still feel the need to justify my life to myself or even to a random Brownian universe. The process is the same, the name differs, as does the lord, the prophet or the energy.

St. Catherine of Siena, a mad-as-a-hatter nun if ever there was one, expressed this wisdom to the Pope once in her own defense.

It didn't fly and she had to recant to avoid excommunication. How sad the world of religion, rather than the full spirituality which we need, atheist or not, to make sense of this random world. Perhaps this is why St. John Chrysostom wrote about the gift of tears which affects those who discern the state and health of the human condition.

Chronic Pain, Malingering and the Difficult Patient

There have been some recent storms in medical blogdom over physicians refusing to prescribe pain medication. It seems some patients, especially someone named 'Anonymous Anonymous,' have taken exception, vomited vitriol and demonstrated that action and reaction are most visible at the point of conflict.

Consider the following:

Scalpel or Sword original Letter From a Chronic Pain Sufferer and a response in the Angry Migraineur.
White Coat on The Great Pain Debate and an observation in Disturbing Conversation.
Dr. Val's November post critical of physicians.
Consider understanding posts by a nurse and an English EMT

Let's call these people difficult patients; crazy or not, we need to deal with them. Here are a couple of great articles on the Difficult Patient in AFP, FPM and Medical Economics. There is a difference between the malingering patient (the one who storms out of the ER to get a heroine fix at her sister's) and the somatizer (often an unhappy middle-aged woman with abdominal pain migraines and a high depression score, but no insight).

We all know and hate the malingerer. In fact, it can even be fun to catch them in the act and watch them as they play up their dignity and indignation, as they slink out knowing not to mess with you again. But the somatizer is a type of difficult patient who we sometimes lump in with the malingerer. This person, I have some sympathy for, although rarely the patience to deal with effectively. They will counteract your every action, negate all help and have probably been their own worse enemy since long before you ever met. Sometimes all you can do is make your suggestion, smile and say you're sorry for what they're going through. Sometimes that's all their looking for, a sympathetic ear.

I even wonder about the people with real disease, such as sickle cell, who come in with marginal crises on occasion, planting yet another seed of doubt to infect my interactions with other patients.

Yes, our jobs are difficult all around, and ER physicians have reason to be frustrated by certain aspects of their jobs. But we need to learn to deal with the fact that about every 7th patient encounter (15% estimate quoted int he Med Ec article) will raise our blood pressure with some kind of manipulation, lack of insight or just plain dysfunction on the part of a patient.

No, we don't have to prescribe narcotics in inappropriate settings. Indeed we should prescribe narcotics as little as possible.

No, we don't have to argue with patients who are in need of deeper emotional care than their insight allows them to recognize.

No, we don't have to treat these people GOMER's ("Get Out Of My Emergency Room") even as we show them the door.

But we can upgrade our skills. I for one, need better strategies to remain calm, especially when I know I'm being manipulated.

And if you're a patient who is tempted to flame me, read this:

There is a reason you need a prescription. There is a reason you need to see us. Don't forget, many of us have pain too. We don't let it stop us. We do want to treat it well. There are alternatives to medications. But the expectation of a painless existence is no longer a credible or reasonable expectation for you. Work with us and do not put yourself in the position of being lumped in with the malingerers.

Granny Can't Die [UPDATED]

Have you ever thought about how we die in America?

I guess there are occasions that a certain latent anger disturbs my usually inscrutable internal peace. Such as this earlier post, for example...

An off-line commenter (nobhilltreehouse) chastised me, saying the following:

Comes across callously and jaundices other posts. I know what you mean but I would have preferred: '"cause these days a dignified death comes with an all expenses unpaid trip to the ICU, replete with tubes, moving parts and tubes ad infinitum" or something like that.

Indeed, it comes across callously and for that, I apologize. Most especially, I am sorry because it deflects attention from an idea worthy of it's own post: how poorly we die in America and how much it ends up costing us.

In fact, my experiences with medical technology have highlighted for me the difficulty of deciding when medical heroics are futile. I really should know better.

I once felt the speed of the losing elderly family members as a blessing in disguise, a kind of nostrum against grief. A couple of years ago I lost a friend to cancer, in part because I couldn't convince her to undergo chemotherapy rather than the naturopathic remedies she preferred. Later I stared at that fearsome suffering we dread and found that technology can diminish as well as create it. For all the suffering, there are people in my life today who wouldn't be there otherwise.

This New Yorker article describes a medical miracle, such as those that frequently grace our televisions achievements that are actually mundane and unimpressive. But consider this amazing story of a 3-year old girl that fell into a frozen Austrian lake and disappeared under ice for over half an hour and was demonstrably brain dead early in the weeks-long efforts to save her life and then rehabilitate her. She is now a normal 5-year old.

Our ICU's are choked with people whose survival prospects are somewhat slimmer, to say the least. The Happy Hospitalist described a man with lung cancer and emphysema/chronic bronchitis who was receiving significant medical care. Would it be reasonable to undertake an effort as complex and resource-intensive as would be necessary to save this man if he had drowned under a frozen Austrian lake? I wouldn't want to be the one trying to say 'no.'

The story of the young Austrian girl carries with it a touch of the magical which is hard to separate from the cold scientific reality of day. But who is to judge? I am far enough away from my days in the ICU to shake my head with the same sense of awe my father, a physician who trained in the 1920's, had as he heard about my experiences in medical school.

I have pointed out in the past that the need for health care is an emotional one. The clinical economic term of "health care purchasing decision" does not speak to the panic a parent would feel if their child slipped into an icy tomb. That panic is no different if it is one's father; cancer and COPD and having lived a full life are pleasantries for the wake, not useful in the moment.

My close personal knowledge of the emotional aspects of health care decisions makes my apparent callousness and cynicism all the more inexplicable. Physicians do not make life and death decisions; typically it is the families that do so.

They need guidance on alternatives to heroic treatments and how realistic it is to expect recovery, so they can weigh it against the granny's wishes and her suffering while under treatment. An army of well-paid counselors and ethicists would cost us less than what we are spending on end-of-life care that I would judge as futile from my comfortable and sometimes jaded perspective. Presumably, a hospitalist and a critical care specialist would have a more aggressive perspective than mine. I would certainly seek out their advice and counsel to make up for my more recently acquired ignorance of the capabilities of a well-trained ICU team.

The problem is that specialists in intensive care can be unnecessarily optimistic at times. They hate losing a patient as much as anyone else. Consider also that their training is focused on saving lives, not letting them go. Our perceptions can shift according to who we're speaking with. If a family member is ill and you have a well-trained, compassionate physician, you will hear a lot about the possibilities that sound as miraculous as an Austrian child who died for several hours, but nobody gave up. Even talking about the risks and the expenses sound like so much fine print disclaimers on a credit card application that no one ever reads.

Problem is that it is expensive. Nobody should have to face the emotional agony of making a life and death decision based on money. Thus health care consumers expect all efforts to be made for our families. This impulse is so strong that we sometimes even make heroic efforts to save the lives of patients with living wills that explicitly limit such efforts. Thus, the bulk of Medicare expenditures are "wasted" on the last year of life.

It is end-of life care, after all. An economist may well define this care as expensive with no discernible return (but I doubt they would slip up so badly). If we define quality as "right care, right time, right person" then we must also define the "right perspective." That would be the perspective of the patient and the family.

This is where individual values are at odds with societal ones and there is no happy medium. Somewhere in the debate over paying for uncompensated care, we need to recognize that patients must get accustomed to being told that they cannot have care they perceive as necessary, because the odds are not good. And anyone who says 'no' is likely to get strung up and shot by a frantic, grieving family member who feels wronged.

UPDATE: Same day, similar thoughts, different blog. Actually, it looks like Panda Bear posted on the same subject yesterday before me, but we must have been working in parallel.

In addition, yesterday's Globe & Mail highlights the conflict between the abilities of medical technology and a cherished Orthodox Jewish value of never giving up hope, no matter how grim or how much it costs. Some may view this point of view as completely untenable from a resource perspective, but it is as old as Maimonides. It is the story of Samuel Golubchuk, a Winnipeg man whose family prevented withdrawal of life support by appealing to Manitoba court. The legal issues in Canada are related to the need for consent to actually remove someone from life support.

Think It Out Loud

Jerome Groopman's book How Doctors Think is doing really well and is on Amazon's Best of 2007 list.

I came across this article in one of my literature scans and thought about how we use the technique of "thinking aloud" in teaching residents. Clinical reasoning can only be taught if the learner's reasoning is made explicit for the purpose of evaluation, reinforcement and occasionally correction.

So how would patients respond if they were included in the "think aloud" exercise? I have been both criticized and praised for the fact that I tend to share my thinking with the patient. In fact, I usually get in trouble for taking up too much time. Joint decision-making and evidence-based medicine take a lot of time in practice, so one must wonder if it is possible to invest time sharing our reasoning and still churn 20 - 30 patients a day.

An article from Health Services Management Research would suggest otherwise. I think I'll just order another CT scan! Yes, this is how cutting Medicare reimbursement to cognitive specialists could increase health care costs.

Pay us for thinking and involving the patients in decision-making and maybe we won't just refer, test and follow-up in two weeks.

Health Wonk Review Closes Out 2007

HealthBlawg presents the latest Health Wonk Review, an end-of-year, Happy Holidays wonkfest. It is heavy on politics, given current action on the hill and approaching primaries. Rob Laszewski's Huckabee analysis is most welcome (that man frightens me).

The Happy Hospitalist: Why is Health Care So Expensive?

Health care is expensive. Making use of people's expertise and motivating them to take on responsibility and risk is expensive. Having a workforce belonging to a licensed healing class is expensive, whether you call them doctors, nurses or PA's. The more educated, the greater the number of years in training and the greater the debt, the more expensive they will be.

The Happy Hospitalist shows us some reasons he has uncovered for health care being expensive:
The Happy Hospitalist: This Is What Chronic Illness looks like

Happy, you missed one: dying in America is expensive, 'cause granny just can't die!

Mass Customization in Health Care

Mass customization is a concept which, more than any other in the business world, has the potential of reaching physicians.

Attempts to improve health care quality and performance have relied on ideas imported from the business world, most specifically from manufacturing. Mass customization comes from that environment, but is also increasingly applied in the service industry.

The first system that I came across was Six Sigma. The attempt to reduce a defect rate to 1 in a million or 1 in ten million provoked ridicule among my physician colleagues in class. Eventually it sinks in that the defects in question are process defects: charts, weights, temperatures, getting medications given at the right time. It had little to do with what we physicians recognized as our jobs. Instead, Six Sigma referred to everything that went on around our jobs, enabling or obstructing our efforts.We were thinking health outcomes, they were talking process outcomes.

This is how a group of skeptical physicians and a diverse group health professionals, including pharmacists, nurses, program managers, administrators and epidemiologists, all got on the same page. I would never have imagined something like this was possible until I saw it for myself in my Master's class.

After all, if you think about the complexity of flying planes, and applied the same rigor as a pre-flight checklist to medicine, it would be a miracle if any metaphorical flight would ever take off. Flying planes is not as complicated or as filled with uncertainties as providing health care.

Years after my MPH, I recalled how the physicians, including myself, came around and thought there was an important lesson to be had. Physicians can become so insular as to reject the contributions of very smart people from outside health care, "because they just don't understand."

Well, personally, I'm a "lumper". I see more similarities in things than differences. All the while I try to respect the differences between people and their experiences, deep down inside, I know the differences are only superficial. Medicine is like any other industry, except that we deal with more uncertainty and do so almost automatically, by virtue of our training.

As an aside, I believe that this ability to handle uncertainty that should be our greatest strength and selling point, but somehow physicians manage to stumble over it. It seems that we become vulnerable to uncertainty when the link between what we do and health outcomes is questioned. However that is a property of the battlefield terrain, not of the soldiers that tread fearlessly on to battle on it. But enough of the battle analogy; let's move on to cars.

Later in my career, I came across the Toyota Manufacturing Process, also know as the Lean Methodology. This is rising in popularity in health care today. One of the first principles is that we don't know anything. None of the people at Toyota knew anything about building a car and decided to break the process down to its quantum bits and figure it out.

I don't think physicians would object to someone approaching them with that attitude. In addition, the physician would have to accept that they know nothing about all those little bits of process that surrounds everything they do (i.e the paperwork).

Physicians inherently recognize the amount of resources wasted, spinning wheels, waiting and delaying because there is always something that prevents them from getting done what needs to be done. As an intern, I used the age-old techniques of schmoozing and being nice to people to get scans done on my patients at the drop of a hat. My length of stay was the envy of many a supervising resident, who then proceeded to give me a hard time about why I couldn't get a nuclear scan for one patient (when I had reservations) but could get anything on anyone at any time.

I was just schmoozing and found efficiencies beyond the imagination of my supervising residents. And that was eighty years ago when there was very little we could do for patients compared to today. [OK, I'm not that old, but I am thinning out lately.]

"Lean" aims to make the system surrounding the actual delivery of care (in a physician's eyes) as waste-free and seamless and possible. I think the docs would buy into this one, but would hold back over the fact that they will remind us how their patients are different.

Everyone who has ever had to manage physicians is smirking right now. Riiiiight. Every doctor's patients are different.

Mass customization addresses that concern. Every patient is different and gets to choose from their incoherent Chinese menu of options under a physician's guidance. Every physician has their preference in treatment or test. Erythromycin or penicillin can be a gut call. Stress echo or PET scan should not be. Sometimes, the preference is just too expensive to be tolerated.

But every patient is different, or at least different enough to feel that their specific concerns are being addressed. Physicians generally do that very well, though probably not as well as the legion of customer-service-savvy alternate medicine providers like chiropractors and naturopaths. Going through a hospital or large clinic should not be an alienating, frightening crap-shoot. Will the nurse be nice? Will the radiologist know how to read the film? Does the surgeon know right from left?

Every patient is unique and must be treated that way. The systems the patients travel through are not unique and need to be smoothed out, made predictable for both the patient and the physicians who ultimately will provide the revenue stream for the entity. All of this depends on obsessive attention to processes that physicians do not traditionally view as their purview. But if we are forced to take a minute prior to a procedure to make sure we have the right patient and the right equipment for the right procedure, we will get safety right each and every time. Also efficiency will rise as the incidence of screw-ups (defects) declines.

That means more money, lower costs and better outcomes.

Literate Medical Blog Posts

Sitting in Denver is called catch-up time. All things considered, there were a lot of interesting articles along the way and a few reached the level of this weekly award's criteria: well-written, good/atmospheric vignette or clear brief essay.

My selections for the top 3 this week:

1. james gaulte @ retired doc's thoughts on The Good Doctor Worries About His Patient
2. Bob Wachter @ Wachter's World on Adventures in Bizarro Land: My Don Imus Interview
3. Val Jones @ The Voice of Reason on Breast Augmentation: Mixed Emotions

How about insuring providers instead of patients?

The Economist's take on the US health care debate makes the assumption that the lack of universal coverage is an anomaly for so wealthy a country. The concerns about mandates is prominent, especially given the general lack of information as yet about the success or failure of the Massachusetts plan, which relies so heavily on the individual mandate.

Maybe a scaled-down employer mandate would work with the government contributing to the rest? It's not really the patients we really want to insure. It's the doctors, hospitals and labs. Right now, uncompensated care is disproportionately affecting all our costs. Maybe this would be a better place for a government bail-out.

The Economist adopts a position of detached bemusement.

Dr. Greenspan and the health insurance debate

I am stuck at the Denver airport in the snow. Our plane was delayed for two hours at the gate in Baltimore which means we missed our connection. Now, it's getting dark and the flurries are threatening a good old fashioned blizzard. We're still scheduled to get out of here by 6:30 this evening.

One good side of airport delays is the opportunity to read more print text than I have in the past three months (the totality of which has been a slim book by an Egyptian Jesuit). I finally got into Greenspan's Age of Turbulence. It's a surprisingly easy read (especially if you've listened to his congressional testimony) and came across a notable quote:

The existence of a democratic society governed by the rule of law implies a lack of unanimity on almost every aspect of the public agenda. Compromise on public issues is the price of civilization, not an abrogation of principle.

The current debate on universal health coverage [note, I did not say government controlled, single payer or insurance] has left me flummoxed by the lack of consistency and logic on both sides of the debate. It is good to be reminded that market-based solutions and a responsible approach to health care costs are important in an effort to increase wealth and the fairness of its distribution. If I have previously had trouble articulating the purpose of health care coverage, Dr. Greenspan has shown me the words and reminded me how the process is really a rugby scrum of competing interests pulling and pushing in different directions (image stolen from James Gaulte, as promised).

At least I finally found free internet in Denver.

Medicare Reimbursement, Physicians, Hospitals and Your 401K

Wow! Is there any reason to believe that between physicians and business interests, physicians will ever get it together enough to win?

I have been looking at the Medicare payments reduction of 10% with dismay, knowing full well that an increasing number of physicians are dumping Medicare. I always thought the major problem would be in rural areas where physicians dedicated to their communities cannot survive without the dominant insurer. Rural practitioners are folding their practices into large hospital-run groups or merging with FQHC's. A large reduction in Medicare payments would force a significant proportion of rural practitioners out of business or into groups.

But it took a GoozNews article for the light to go on! President Bush has threatened to veto any plan that cuts Medicare Advantage payments (Democrats take note, you can probably tie our fearless leader up in court for the duration of the next presidential term if you can figure out where the payments went). As long as Medicare Advantage plans are strong, physicians simply don't have a choice. Any physicians who tries to contract with a managed care company will be told "take them all or take nothing at all." Those physicians who can afford to drop Medicare cannot afford to be entirely cut out of the insurance market.

Actually, they can, but it is frightening to consider a cash-only model when you've been processing insurance for eons. Certainly the large groups have to eat the decreased reimbursement.

Take Goozner's analysis the next step and it becomes obvious that if you can't cut deeper into physician reimbursement and you won't touch Medicare Advantage, then the only place the money can come from is hospital reimbursement. This will hurt the cities, not the rural areas, because rural hospitals benefit from cost-based reimbursement. Inner city hospitals have had to become more efficient or close. On the other hand, rural hospitals have benefited from more money and many have milked it for all it's worth. The perversity is that semi-rural critical access hospitals un suburban and urbanizing areas stand to benefit the most, while inner city poor people's hospitals like Grady suffer.

In other words, the goal of improving the population's health does not receive much attention. The goal of protecting the health insurance industry's profits appears close to being accomplished, at least for the next fiscal year. I know where I'm putting my 401K money.

Cavalcade of Risk

This biweekly collection of matters related to risk, including insurance of the health type, is a fascinating window into a world outside medicine, which mysteriously and ineffably alters how medicine is practiced. As such, I recommend this week's Cavalcade at Joe Paduda's ever-opinionated, erudite and intelligent blog. I particularly like Lisa Emrich's take on Montel and big pharma.

Pharmacy Wars

So what happens when a retail pharmacy chain and pharmacy benefits manager merge? [PBM's are used by your managed care company to handle the pharmacy benefits side of the insurance.]

A war breaks out between retail chains, that's what.

CVS and Caremark are among the largest retail pharmacy chains and PBM's respectively. they also became one company in March of this year. So Walgreen's terminated their agreement over poor reimbursement. Nice try CVS/Caremark.

Physicians (and payors) take heed. Nobody told you to accept poor reimbursement. Reject the contracts and see what happens.

[UPDATE 12/5/07 1:45 PM: This is what happens.]

Canada and Health Care

I've been approached recently by a couple of Canadian mags about my American experience. It got me thinking about Canada's contributions and got me reading some Canadian content online.

I came across this article. It seems that Canada's scientific contributions have accelerated of late, despite a highly socialized system and government-run health care. Highly accretive societies like the US can quickly forget that some of their greatest heroes are "foreigners." So in the spirit of international cooperation and the remembrance of our common human nature, may I remind my adoptive fellow Americans that Neil Young and Bryan Adams are as Canadian as insulin and blood testing for cancer.