The Uncertain Future of Primary Medical Care
David Mechanic, PhD
Annals Of Internal Medicine
7 July 2009 | Volume 151 Issue 1 | Pages 66-67
The United States needs a strong primary medical care capacity as we engage the challenges of health care reform, expand insurance coverage, and constrain medical costs without sacrificing quality. Research over decades has repeatedly demonstrated that primary care services that provide continuing access to care are associated with superior population health outcomes . Nonetheless, the future of U.S. primary care is uncertain, many clinicians report high levels of frustration and dissatisfaction, and careers in primary care are increasingly unattractive to new medical graduates.
Linzer and colleagues studied 422 family practitioners and general internists in 119 ambulatory clinics. They report high levels of unhappiness about time pressure and practice pace, little sense of control over work conditions, and deficient organizational culture. Other data indicate substantial deficiencies on measures of quality outcomes and neglect of care processes.
Three themes persist across time, place, and practice arrangements . First, primary care physicians persistently report time pressures and insufficient time for patients, but practice disorganization substantially limits their ability to cope . Second, primary care physicians dislike intrusions on their clinical autonomy by managers and are particularly dissatisfied when their remuneration depends on successfully constraining the clinical choices they can offer their patients . Finally, physicians want remuneration to meet their expectations and reflect the intensity of their efforts . Each of these themes will be important as we consider different ways of restructuring medical care and improving standards of care and cost-effectiveness.
Average encounter time has increased substantially over the decades (8). The data do not support the claim that primary care visits are shorter , with an average time of around 15 minutes . However, the perception of time pressure is realistic because more competing treatments have become available; more preventive interventions are demanded; patients have become better informed, more assertive, and more insistent on explanations; and demands for documentation and other bureaucratic requirements have increased. Direct-to-consumer advertising has also increased physician stress because patients ask for advertised drugs, which requires physicians to either spend more time on explanation to divert demands or to prescribe drugs unnecessarily .
Studies consistently find that primary care physicians are more satisfied when they have fewer patients and can maintain a less hurried practice pace, but physicians who adopt this practice style usually don't achieve their target income. Some find lower income an acceptable trade-off for a more enjoyable practice style, whereas others seek to have their cake and eat it too by organizing concierge practices that achieve higher incomes through enrollment fees. Such personal solutions exacerbate health care disparities and increase the challenge of achieving universal access.
Maintaining the fast pace needed to achieve target incomes contributes to physician dissatisfaction and difficulties in providing comprehensive, integrated care. Cost constraints make increased remuneration for primary care unlikely unless income is redistributed from specialists to generalists, which the advantaged class understandably resists. Nevertheless, many clinicians, managers, and policy makers are becoming more interested in moving away from payment for each billable unit and toward coverage of episodes of illness or partial capitation that combines a base payment for managing care for each enrolled patient with fee-for-service and other performance and productivity incentives. Whether these changes will reduce income disparities between segments of the profession is ultimately a political issue.
Linzer and colleagues' findings indicate that, whatever the conditions of remuneration, reduction of chaos in the practice environment and development of more supportive organizational cultures are required to make primary care careers more manageable and satisfactory. Physicians need to be provided with the technical and professional team support that facilitates high-quality care and provides a greater sense of control over one's work.
When quality initiatives, such as evidence-based decision making, implementation of clinical effectiveness research, pay for performance, and electronic health records, are taken in isolation, some perceive them as exacerbating workload and reducing discretionary judgment. But taken together and integrated into effective practice arrangements, they facilitate higher-quality care and greater physician control. Evidence-based standards are essential guides, but health systems must protect physician discretion in decision making when patient circumstances justify it, as in Kaiser Permanente group practices . The key is not rigid adherence, but accountability to colleagues for the reasonableness of one's decisions.
Because physicians have different preferences for how they practice, different models will coexist. Kaiser Permanente and the U.S. Department of Veterans Affairs provide successful models for reorganization of patient care functions. In these systems, primary care physicians have a more defined role, working in teams with hospitalists, nurse practitioners, and other relevant personnel. Care coordination within the team takes time, but sharing workload and responsibilities facilitates high-quality care and often leads to increased physician satisfaction. The patient-centered medical home is popular in part because the conceptual model includes a management fee for the coordination and integration of care, an incentive that is so often lacking. Although many advocate the patient-centered medical home model, its implementation, effectiveness, and capacity to control costs remain uncertain .
Most primary care practices are small and will probably remain so for the foreseeable future . Some primary care physicians, using electronic health records and new forms of communication with patients (including e-mail and group visits), practice to their satisfaction in small or even solitary practices . Many more primary care physicians are likely to join with nurse practitioners and physician assistants to seek ways to manage workload more comfortably.
Electronic health records and an interoperable information technology framework are critical for implementing the coordination, integration, and continuity central to primary care. Although the start-up effort and learning curve may initially slow practice pace and increase workload, electronic health records help physicians manage care and workload effectively and contribute to professional satisfaction. They make possible virtual integration, even in small practices, and address many of the strains of contemporary care, including monitoring and coordinating (19), avoiding duplication and error, and facilitating transparency and accountability. Effective information technology is a core feature that helps build a constructive practice culture and a renewal of medical professionalism .
The future of primary care remains uncertain, and much depends on payment policies and incentives for developing workable frameworks for team efforts and professional responsibility. Primary care as an indispensable set of functions will persist in some form, because most patients want a primary care physician. The challenge is to organize 1-on-1 care as part of an integrated system that serves the needs of both patients and physicians, enhances quality, and keeps costs within reason.
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David Mechanic, PhD, Institute for Health, Health Care Policy and Aging Research, Rutgers, The State University of New Jersey, 30 College Avenue, New Brunswick, NJ 08901; e-mail, mechanic@rci.rutgers.edu.
Monday, July 13, 2009
Sunday, July 12, 2009
Healthcare Fever
Sonia Sotamayor will be he soap opera du jour this week and will displace he health care debate.
This "time out" should allow up to reconsider some of the isssues and proposed solutions.
In a series of Op Ed presentations in the New York Times this morning the debate concerning some of the issues is played out.
Taxes for health care benefits is a contentious topic. Liberals believe that it is a God given salary increase that must be given by an employer as long as it is not taxed to the employee.
The origins of our health insurance system exist from World War II wage price controls. Unions unable to get wage increases accepted health benefits in lieu of them.
The conservative view point allows for taxation of these benefits, arguing that the individual taxed would then become a more discrimminating purchaser of health care and more appropriate in the use of expensive interventions.
Both points are presented below
July 12, 2009
Op-Ed Contributor
Don't Tax Health Benefits.
By ROGER HICKEY
AMERICANS are demanding health care reform that guarantees them quality, affordable insurance, reduces the burden of health costs on employers and individuals and provides backup coverage through a public health insurance option.
But the suggestion that we pay for these needed reforms by taxing the health benefits that millions of us get through our employers is very unpopular — Americans fear that it could undo the one part of our health care system that now works (sort of). And we worry about new tax burdens on people who have worked hard to get and keep decent health coverage. If Democrats want to avoid a serious reaction against their important reform efforts, they should heed these concerns.
America’s health insurance system has evolved over the decades since World War II, when companies began offering health insurance — untaxed as income by government policy. Today, around 160 million of us get our health insurance from employers. And in these difficult times, millions of workers have repeatedly given up wage increases in order to keep their health benefits.
John McCain, when he was running for president last year, proposed taxing all employer-provided health benefits. Were we to do that, some 20 million Americans would lose employment-based health insurance, according to some estimates. And many employers would stop contributing to group health insurance — forcing their workers into the more expensive individual insurance market.
While many health experts acknowledge that taxing all benefits would cause chaos, some share the conservative view that a lot of people are getting “too much” insurance coverage from their employers and are pushing to get new revenues by taxing plans that are more expensive than average. But several recent studies find that it is almost impossible to design a tax that doesn’t overburden workers in firms with older or low-income employees or companies in regions with higher-than-average insurance premiums.
The Communications Workers of America looked at one proposal (to tax all employer-paid health benefits worth over $13,000 for a family) and found a typical member of its union in Pennsylvania with a working spouse and one child would pay $3,165 more in taxes in the first year, and $27,949 more over eight years. The issue is heating up. The Senate majority leader, Harry Reid, has told colleagues that they should not tax health benefits. But the debate continues.
It is dangerous for politicians to focus the government’s taxing power on the hard-won benefits of middle-class families. Fair and progressive income and wealth taxes are a better way to pay for health reform — and keep workers feeling as though they have a positive stake in achieving good health care for all.
Roger Hickey is a co-director of the Institute for America’s Future and a member of the steering committee of the Health Care for America Now coalition.
July 12, 2009
Op-Ed Contributor
A Loophole Worth Closing
By JONATHAN GRUBER
POLLS show most Americans are in favor of universal health care. But how will we pay for it? There is an obvious place to look for the money: the tax exclusion for employer-sponsored insurance.
When my employer pays me in cash wages, I am taxed. Not taxed is the $10,000 per year that my employer spends on my health insurance, and this leaves me with an effective tax break of about $4,000. Over all, this break costs the federal government $250 billion per year in forgone revenue.
This is more than we would need to cover every American who now lacks health insurance. Ending the exclusion would provide a progressive source of financing for universal coverage, since higher-income taxpayers would contribute most of the revenues. It would stop discrimination against those who can’t obtain insurance through their employers and therefore have to pay with after-tax dollars. And it would end a policy of providing a bigger tax break the more one spends on health insurance, which drives overspending on medical care.
Some worry that without this “tax bribe,” employers would no longer offer health insurance, and sicker and older people would not be treated as fairly on their own as they are in employer groups. This is not an issue for medium and large employers, which have continued to offer health insurance as the value of this tax bribe has gone up and down through the years. Small employers might reduce coverage, but this blow would be softened if the policy helped finance a universal plan in which all Americans would get group rates.
Removing the exclusion need not mean an across-the-board tax increase. We might consider merely capping the dollar amount of employer-sponsored health insurance that is excluded from income taxation. Individuals would include in their income taxes the amount of premiums over and above, say, the average cost of employer-sponsored insurance. A typical middle-class employee with premiums of $1,000 a year higher than the average would pay only about $150 in extra taxes, yet such a policy would raise $500 billion in federal revenues over the next decade. This policy would provide strong incentives to purchase insurance more efficiently, since the highest-cost plans would be taxed but lower-cost plans would not. To ensure that the cap was not unfair to employees with relatively high insurance costs, employers could be allowed to compute an adjustment in the cap based on their location or their workers’ ages.
Closing this tax loophole would fix a fundamental flaw in our health care system. Even just capping it would provide the revenues to take us much of the way to universal coverage, without raising taxes on those who purchase average cost insurance.
Jonathan Gruber is a professor of economics at the Massachusetts Institute of Technology.
Medical malpractice is a topic that rapidly arouses physician passions. Most find that such actions are frivolous and the cause of excessive testing breeding a cover your ass culture.
The articles below both written by lawyers argue that medical malpractice has in fact had salutory benefits.
Mr. Baker argues that some of the safety practices adopted in medical institutions are in fact fall outs from a malpractice explosion.
Michelle Mello was one of the authors of the original Harvard Liability Study which purported that malpractice was more prevalent that liability action and injuries due to medical error more prevalent than believed.
Thoufh she does not suggest a cap on payments she does suggest defense by the practice of evidence based medicine. Mr. Baker also supports this though less vigorously.
The sixty four million dollar question who creates the evidence? After all evidence is based on the opinions of experts and every palintiff and defense malpractice lawyer knows such experts are not exactly an endangered species
July 12, 2009
Op-Ed Contributor
Liability = Responsibility
By TOM BAKER
OUR medical liability system needs reform. But anyone who thinks that limiting liability would reduce health care costs is fooling himself. Preventable medical injuries, not patient compensation, are what ring up extra costs for additional treatment. This means taxpayers, employers and everyone else who buys health insurance — all of us — have a big stake in patient safety.
Eighty percent of malpractice claims involve significant disability or death, a 2006 analysis of medical malpractice claims conducted by the Harvard School of Public Health shows, and the amount of compensation patients receive strongly depends on the merits of their claims. Most people injured by medical malpractice do not bring legal claims, earlier studies by the same researchers have found.
On the other hand, medical liability has improved patient safety — by leading hospitals to hire risk managers, for example, and spurring anesthesiologists to improve their safety standards and practices. Even medical societies’ efforts to attack the liability system have helped, by inspiring the research that has documented the surprising extent of preventable injuries in hospitals. That research helped start the patient safety movement.
When it comes to rising medical costs, liability is a symptom, not the disease. Getting rid of liability might save money for hospitals and some high-risk specialists, but it would cost society more by taking away one of the few hard-wired patient safety incentives.
Besides, there’s a better answer for doctors worried about high malpractice insurance premiums.
Critics point to defensive medicine as the hidden burden that liability imposes on health care. Yet research shows that while the fear of liability changes doctors’ behavior, that isn’t necessarily a burden. Some defensive medicine is, like defensive driving, good practice. Too often, we can’t distinguish between treatments that are necessary and those that are wasteful. Better research on what works and what doesn’t — evidence-based medicine — will help. And it will address the more general challenge of avoiding costly but unnecessary care.
Just as we need evidence-based medicine, we also need evidence-based medical liability reform. The research shows, overwhelmingly, that the real problem is too much malpractice, not too many malpractice lawsuits. So medical providers should be required to disclose injuries, provide quicker compensation to deserving patients and — here’s the answer for doctors worried about their premiums — shift the responsibility for buying malpractice insurance to hospitals and other large medical institutions. Evidence-based liability reform would give these institutions the incentive they need to cut back on the most wasteful aspect of American health care: preventable medical injuries.
Tom Baker, a professor at the University of Pennsylvania Law School, is the author of “The Medical Malpractice Myth.”
July 12, 2009
Op-Ed Contributors
The Cap Doesn’t Fit
By MICHELLE MELLO and AMITABH CHANDRA
DOCTORS are battered by the medical malpractice system. They complain, with reason, about unpredictable jury awards, escalating insurance premiums, the emotional toll of litigation and the cost to their reputations of being labeled “negligent” because of outcomes beyond their control.
Patients, too, often feel victimized by the system, enduring an average wait of five years for compensation for their injuries, and suffering the same emotional exhaustion from the drawn-out legal battle. The public gets stuck with a large part of the bill. When doctors practice “defensive medicine” to minimize their legal risk, we all pay for it.
Doctors tend to believe capping damages on malpractice awards would solve their troubles. But the best evidence shows that although caps modestly constrain the growth of insurance premiums, they don’t reduce the number of claims or address any of the fundamental pathologies of the system.
Two kinds of reforms are especially promising. First, in areas where we have reliable scientific evidence about what constitutes optimal clinical care, we should enable doctors to defend themselves against malpractice claims by simply showing that they adhered to evidence-based practice guidelines. An emergency room doctor, for example, could invoke well-accepted guidelines to explain his decision to refuse to order a stress test for a patient with chest pain that appeared not to be due to coronary disease.
This would address doctors’ complaints that malpractice suits often succeed even when care was not negligent, and also reduce incentives to practice defensive medicine and encourage doctors to adopt evidence-based practices.
Second, certain medical injuries should be pulled out of the court system and be handled by an alternative process in which the patient needn’t prove negligence. Severe birth injuries are a good place to start, for they can occur even with exceptional care. We should route these claims into a birth injury fund administered by the Department of Health and Human Services or a state-level counterpart, which would assign fair compensation on a no-fault basis.
Florida and Virginia have operated birth injury funds for nearly a quarter-century, and though not perfect, they have done a commendable job of balancing the needs of health care providers and patients. Doctors can buy into the program, avoiding lawsuits for severe neurological birth injuries, for under $6,000 per year (hospitals for about $50 per birth).
Our proposal would not do away with that hobgoblin of the malpractice system, the negligence standard, but it would curb its worst mischief.
Michelle Mello is a professor of public health and Amitabh Chandra is a professor of public policy at Harvard.
The third debate is one over Medicare costs. I found his one especially interesting.
Background:Mr. Obama has exerted his "regulatory authority" to allow the Medicare Payment Commission (MedPAC) to dictate payment policy rather than suggest it and leave its enactment to the regulatory whims of a fractitious Congress.
Nancy Kane is a member of the MedPAC and she publically argues that Medicare payments to hospitals not be cut. She believes that such cost constraints would result in higher out patient costs, an area that is rising far more rapidly than the costs of hospitals.
Interestingly, she argues that a solution is a bundling of payments for hospitals and physicians for episodes of care. There is some validity to her arguments. Though hospital costs are largely opaque to patients and physicians, the latter are responsible for generating them. The most expensive medical instrument is the physician's pen and the illegibility of the product makes an understanding of costs difficult.
It would be interesting to determine who will control the purse strings the physician or the hospital.
Paul Ginsburg a noted health economist argues that cutting hospital costs is necessary. He buttresses his arguments with references to high quality hospitals which have lower costs than those with higher costs and worse outcomes.
As the debate proceeds August will be a warm month in Washington.
July 12, 2009
Op-Ed Contributor
Keep Hospitals Whole
By NANCY KANE
ONE way that the Obama administration proposes to pay for universal coverage is by cutting Medicare payments to hospitals. True, at 35 percent of 2007 Medicare spending, hospitals represent the largest provider group, but they are not necessarily the most rational target for draconian payment cuts. Cutting payments to specific provider types is not the answer. When payments go down in one area, they end up increasing elsewhere. For instance, Medicare has more constraints for inpatient payments than for outpatient, home health care or skilled nursing care.
As a result, per beneficiary inpatient costs grew only 18 percent from 2002 to 2007, while outpatient costs increased 47 percent and skilled nursing and home health costs each rose more than 50 percent. These differences partly reflect the trend of hospitals discharging Medicare patients “quicker and sicker” so that they go from a tightly controlled inpatient payment system to a less constrained one. Another problem is that the more Medicare restricts payments to hospitals, the more hospitals ask of their privately insured patients.
Real, sustainable containment of medical costs will require an approach in which one government agency at the state or federal level sets uniform rates for all payers, public and private. Also, units of payment like doctor visits and lab tests need to be packaged into a single amount that covers all services related to that spell of illness, so that constraints on one part of the system do not create explosive cost growth in another. An all-payer feature would limit the ability of providers to raise private sector rates to make up for public sector constraints on rates. An integrated payment unit across all providers involved with treating an illness or medical condition would also encourage better coordination of care for patients with multiple chronic diseases.
Integrated payment units might start as bundled payments for services by all providers delivered during a hospitalization and a post-acute stay. Such payment units would encourage individual provider types like hospitals, skilled nursing facilities and primary-care doctors to come together in “accountable care organizations” that take responsibility for the cost and quality of all medical services.
The Medicare program’s long-term viability, as well as hopes for universal coverage, rest on our ability to get payment reform right.
Nancy Kane is a professor of management at the Harvard School of Public Health and a commissioner on the Medicare Payment Advisory Commission.
July 12, 2009
Op-Ed Contributor
Cut Medicare With a Scalpel
By PAUL B. GINSBURG
THE deal struck by the Obama administration and the hospital industry to reduce the growth of annual Medicare payment increases by about $100 billion over 10 years deserves scrutiny. In the weeks before the deal, the hospital industry predictably screamed foul at proposals to rein in the growth of those payments, pointing out that 58 percent of hospitals lost money treating Medicare patients in 2007.
But what about the 42 percent of hospitals that didn’t lose money? Is the problem that Medicare is a stingy payer? Or that too many hospitals have grown cavalier about controlling costs and have the market power to demand higher payment rates from private insurers to stay in the black regardless of Medicare rates?
A report in March by the Medicare Payment Advisory Commission makes a good case for the latter, suggesting there is room to trim the fat from Medicare payments without hitting bone in many hospitals.
According to the commission, high payments by private insurers — which exceeded hospitals’ actual costs by 32 percent in 2007 — resulted in overall hospital profit/surplus margins of 6 percent in 2007, the highest since 1997. The commission points to hospital consolidation and consumer and employer pressure on insurers to offer a broad choice of hospitals as tilting the balance of power toward hospitals in price negotiations.
But not all hospitals can increase fees for private insurers, especially not hospitals that treat a relatively large number of Medicaid patients. Not surprisingly, many of these hospitals did a much better job of holding their costs down.
The commission found that nonprofit hospitals facing the least financial pressure, those with high non-Medicare profits, spent more per unit of service. Nonprofit hospitals facing the most financial pressure, those with little income outside Medicare, controlled their costs better.
Worried that financial pressures might lead to lower quality of care, the Medicare commission also examined how hospitals that did a good job of controlling costs compared on measures like mortality rates and readmissions. These hospitals typically had higher quality and lower costs, and will likely be the ones hit hardest by across-the board reductions.
The recent deal between Mr. Obama and the hospital industry can hardly be called “health reform.” What is clear, however, is that hospital market power, left unchecked, will pose a formidable obstacle to the president’s promise to make health care more affordable.
Paul B. Ginburg is the president of the Center for Studying Health System Change, a policy research organization
This "time out" should allow up to reconsider some of the isssues and proposed solutions.
In a series of Op Ed presentations in the New York Times this morning the debate concerning some of the issues is played out.
Taxes for health care benefits is a contentious topic. Liberals believe that it is a God given salary increase that must be given by an employer as long as it is not taxed to the employee.
The origins of our health insurance system exist from World War II wage price controls. Unions unable to get wage increases accepted health benefits in lieu of them.
The conservative view point allows for taxation of these benefits, arguing that the individual taxed would then become a more discrimminating purchaser of health care and more appropriate in the use of expensive interventions.
Both points are presented below
July 12, 2009
Op-Ed Contributor
Don't Tax Health Benefits.
By ROGER HICKEY
AMERICANS are demanding health care reform that guarantees them quality, affordable insurance, reduces the burden of health costs on employers and individuals and provides backup coverage through a public health insurance option.
But the suggestion that we pay for these needed reforms by taxing the health benefits that millions of us get through our employers is very unpopular — Americans fear that it could undo the one part of our health care system that now works (sort of). And we worry about new tax burdens on people who have worked hard to get and keep decent health coverage. If Democrats want to avoid a serious reaction against their important reform efforts, they should heed these concerns.
America’s health insurance system has evolved over the decades since World War II, when companies began offering health insurance — untaxed as income by government policy. Today, around 160 million of us get our health insurance from employers. And in these difficult times, millions of workers have repeatedly given up wage increases in order to keep their health benefits.
John McCain, when he was running for president last year, proposed taxing all employer-provided health benefits. Were we to do that, some 20 million Americans would lose employment-based health insurance, according to some estimates. And many employers would stop contributing to group health insurance — forcing their workers into the more expensive individual insurance market.
While many health experts acknowledge that taxing all benefits would cause chaos, some share the conservative view that a lot of people are getting “too much” insurance coverage from their employers and are pushing to get new revenues by taxing plans that are more expensive than average. But several recent studies find that it is almost impossible to design a tax that doesn’t overburden workers in firms with older or low-income employees or companies in regions with higher-than-average insurance premiums.
The Communications Workers of America looked at one proposal (to tax all employer-paid health benefits worth over $13,000 for a family) and found a typical member of its union in Pennsylvania with a working spouse and one child would pay $3,165 more in taxes in the first year, and $27,949 more over eight years. The issue is heating up. The Senate majority leader, Harry Reid, has told colleagues that they should not tax health benefits. But the debate continues.
It is dangerous for politicians to focus the government’s taxing power on the hard-won benefits of middle-class families. Fair and progressive income and wealth taxes are a better way to pay for health reform — and keep workers feeling as though they have a positive stake in achieving good health care for all.
Roger Hickey is a co-director of the Institute for America’s Future and a member of the steering committee of the Health Care for America Now coalition.
July 12, 2009
Op-Ed Contributor
A Loophole Worth Closing
By JONATHAN GRUBER
POLLS show most Americans are in favor of universal health care. But how will we pay for it? There is an obvious place to look for the money: the tax exclusion for employer-sponsored insurance.
When my employer pays me in cash wages, I am taxed. Not taxed is the $10,000 per year that my employer spends on my health insurance, and this leaves me with an effective tax break of about $4,000. Over all, this break costs the federal government $250 billion per year in forgone revenue.
This is more than we would need to cover every American who now lacks health insurance. Ending the exclusion would provide a progressive source of financing for universal coverage, since higher-income taxpayers would contribute most of the revenues. It would stop discrimination against those who can’t obtain insurance through their employers and therefore have to pay with after-tax dollars. And it would end a policy of providing a bigger tax break the more one spends on health insurance, which drives overspending on medical care.
Some worry that without this “tax bribe,” employers would no longer offer health insurance, and sicker and older people would not be treated as fairly on their own as they are in employer groups. This is not an issue for medium and large employers, which have continued to offer health insurance as the value of this tax bribe has gone up and down through the years. Small employers might reduce coverage, but this blow would be softened if the policy helped finance a universal plan in which all Americans would get group rates.
Removing the exclusion need not mean an across-the-board tax increase. We might consider merely capping the dollar amount of employer-sponsored health insurance that is excluded from income taxation. Individuals would include in their income taxes the amount of premiums over and above, say, the average cost of employer-sponsored insurance. A typical middle-class employee with premiums of $1,000 a year higher than the average would pay only about $150 in extra taxes, yet such a policy would raise $500 billion in federal revenues over the next decade. This policy would provide strong incentives to purchase insurance more efficiently, since the highest-cost plans would be taxed but lower-cost plans would not. To ensure that the cap was not unfair to employees with relatively high insurance costs, employers could be allowed to compute an adjustment in the cap based on their location or their workers’ ages.
Closing this tax loophole would fix a fundamental flaw in our health care system. Even just capping it would provide the revenues to take us much of the way to universal coverage, without raising taxes on those who purchase average cost insurance.
Jonathan Gruber is a professor of economics at the Massachusetts Institute of Technology.
Medical malpractice is a topic that rapidly arouses physician passions. Most find that such actions are frivolous and the cause of excessive testing breeding a cover your ass culture.
The articles below both written by lawyers argue that medical malpractice has in fact had salutory benefits.
Mr. Baker argues that some of the safety practices adopted in medical institutions are in fact fall outs from a malpractice explosion.
Michelle Mello was one of the authors of the original Harvard Liability Study which purported that malpractice was more prevalent that liability action and injuries due to medical error more prevalent than believed.
Thoufh she does not suggest a cap on payments she does suggest defense by the practice of evidence based medicine. Mr. Baker also supports this though less vigorously.
The sixty four million dollar question who creates the evidence? After all evidence is based on the opinions of experts and every palintiff and defense malpractice lawyer knows such experts are not exactly an endangered species
July 12, 2009
Op-Ed Contributor
Liability = Responsibility
By TOM BAKER
OUR medical liability system needs reform. But anyone who thinks that limiting liability would reduce health care costs is fooling himself. Preventable medical injuries, not patient compensation, are what ring up extra costs for additional treatment. This means taxpayers, employers and everyone else who buys health insurance — all of us — have a big stake in patient safety.
Eighty percent of malpractice claims involve significant disability or death, a 2006 analysis of medical malpractice claims conducted by the Harvard School of Public Health shows, and the amount of compensation patients receive strongly depends on the merits of their claims. Most people injured by medical malpractice do not bring legal claims, earlier studies by the same researchers have found.
On the other hand, medical liability has improved patient safety — by leading hospitals to hire risk managers, for example, and spurring anesthesiologists to improve their safety standards and practices. Even medical societies’ efforts to attack the liability system have helped, by inspiring the research that has documented the surprising extent of preventable injuries in hospitals. That research helped start the patient safety movement.
When it comes to rising medical costs, liability is a symptom, not the disease. Getting rid of liability might save money for hospitals and some high-risk specialists, but it would cost society more by taking away one of the few hard-wired patient safety incentives.
Besides, there’s a better answer for doctors worried about high malpractice insurance premiums.
Critics point to defensive medicine as the hidden burden that liability imposes on health care. Yet research shows that while the fear of liability changes doctors’ behavior, that isn’t necessarily a burden. Some defensive medicine is, like defensive driving, good practice. Too often, we can’t distinguish between treatments that are necessary and those that are wasteful. Better research on what works and what doesn’t — evidence-based medicine — will help. And it will address the more general challenge of avoiding costly but unnecessary care.
Just as we need evidence-based medicine, we also need evidence-based medical liability reform. The research shows, overwhelmingly, that the real problem is too much malpractice, not too many malpractice lawsuits. So medical providers should be required to disclose injuries, provide quicker compensation to deserving patients and — here’s the answer for doctors worried about their premiums — shift the responsibility for buying malpractice insurance to hospitals and other large medical institutions. Evidence-based liability reform would give these institutions the incentive they need to cut back on the most wasteful aspect of American health care: preventable medical injuries.
Tom Baker, a professor at the University of Pennsylvania Law School, is the author of “The Medical Malpractice Myth.”
July 12, 2009
Op-Ed Contributors
The Cap Doesn’t Fit
By MICHELLE MELLO and AMITABH CHANDRA
DOCTORS are battered by the medical malpractice system. They complain, with reason, about unpredictable jury awards, escalating insurance premiums, the emotional toll of litigation and the cost to their reputations of being labeled “negligent” because of outcomes beyond their control.
Patients, too, often feel victimized by the system, enduring an average wait of five years for compensation for their injuries, and suffering the same emotional exhaustion from the drawn-out legal battle. The public gets stuck with a large part of the bill. When doctors practice “defensive medicine” to minimize their legal risk, we all pay for it.
Doctors tend to believe capping damages on malpractice awards would solve their troubles. But the best evidence shows that although caps modestly constrain the growth of insurance premiums, they don’t reduce the number of claims or address any of the fundamental pathologies of the system.
Two kinds of reforms are especially promising. First, in areas where we have reliable scientific evidence about what constitutes optimal clinical care, we should enable doctors to defend themselves against malpractice claims by simply showing that they adhered to evidence-based practice guidelines. An emergency room doctor, for example, could invoke well-accepted guidelines to explain his decision to refuse to order a stress test for a patient with chest pain that appeared not to be due to coronary disease.
This would address doctors’ complaints that malpractice suits often succeed even when care was not negligent, and also reduce incentives to practice defensive medicine and encourage doctors to adopt evidence-based practices.
Second, certain medical injuries should be pulled out of the court system and be handled by an alternative process in which the patient needn’t prove negligence. Severe birth injuries are a good place to start, for they can occur even with exceptional care. We should route these claims into a birth injury fund administered by the Department of Health and Human Services or a state-level counterpart, which would assign fair compensation on a no-fault basis.
Florida and Virginia have operated birth injury funds for nearly a quarter-century, and though not perfect, they have done a commendable job of balancing the needs of health care providers and patients. Doctors can buy into the program, avoiding lawsuits for severe neurological birth injuries, for under $6,000 per year (hospitals for about $50 per birth).
Our proposal would not do away with that hobgoblin of the malpractice system, the negligence standard, but it would curb its worst mischief.
Michelle Mello is a professor of public health and Amitabh Chandra is a professor of public policy at Harvard.
The third debate is one over Medicare costs. I found his one especially interesting.
Background:Mr. Obama has exerted his "regulatory authority" to allow the Medicare Payment Commission (MedPAC) to dictate payment policy rather than suggest it and leave its enactment to the regulatory whims of a fractitious Congress.
Nancy Kane is a member of the MedPAC and she publically argues that Medicare payments to hospitals not be cut. She believes that such cost constraints would result in higher out patient costs, an area that is rising far more rapidly than the costs of hospitals.
Interestingly, she argues that a solution is a bundling of payments for hospitals and physicians for episodes of care. There is some validity to her arguments. Though hospital costs are largely opaque to patients and physicians, the latter are responsible for generating them. The most expensive medical instrument is the physician's pen and the illegibility of the product makes an understanding of costs difficult.
It would be interesting to determine who will control the purse strings the physician or the hospital.
Paul Ginsburg a noted health economist argues that cutting hospital costs is necessary. He buttresses his arguments with references to high quality hospitals which have lower costs than those with higher costs and worse outcomes.
As the debate proceeds August will be a warm month in Washington.
July 12, 2009
Op-Ed Contributor
Keep Hospitals Whole
By NANCY KANE
ONE way that the Obama administration proposes to pay for universal coverage is by cutting Medicare payments to hospitals. True, at 35 percent of 2007 Medicare spending, hospitals represent the largest provider group, but they are not necessarily the most rational target for draconian payment cuts. Cutting payments to specific provider types is not the answer. When payments go down in one area, they end up increasing elsewhere. For instance, Medicare has more constraints for inpatient payments than for outpatient, home health care or skilled nursing care.
As a result, per beneficiary inpatient costs grew only 18 percent from 2002 to 2007, while outpatient costs increased 47 percent and skilled nursing and home health costs each rose more than 50 percent. These differences partly reflect the trend of hospitals discharging Medicare patients “quicker and sicker” so that they go from a tightly controlled inpatient payment system to a less constrained one. Another problem is that the more Medicare restricts payments to hospitals, the more hospitals ask of their privately insured patients.
Real, sustainable containment of medical costs will require an approach in which one government agency at the state or federal level sets uniform rates for all payers, public and private. Also, units of payment like doctor visits and lab tests need to be packaged into a single amount that covers all services related to that spell of illness, so that constraints on one part of the system do not create explosive cost growth in another. An all-payer feature would limit the ability of providers to raise private sector rates to make up for public sector constraints on rates. An integrated payment unit across all providers involved with treating an illness or medical condition would also encourage better coordination of care for patients with multiple chronic diseases.
Integrated payment units might start as bundled payments for services by all providers delivered during a hospitalization and a post-acute stay. Such payment units would encourage individual provider types like hospitals, skilled nursing facilities and primary-care doctors to come together in “accountable care organizations” that take responsibility for the cost and quality of all medical services.
The Medicare program’s long-term viability, as well as hopes for universal coverage, rest on our ability to get payment reform right.
Nancy Kane is a professor of management at the Harvard School of Public Health and a commissioner on the Medicare Payment Advisory Commission.
July 12, 2009
Op-Ed Contributor
Cut Medicare With a Scalpel
By PAUL B. GINSBURG
THE deal struck by the Obama administration and the hospital industry to reduce the growth of annual Medicare payment increases by about $100 billion over 10 years deserves scrutiny. In the weeks before the deal, the hospital industry predictably screamed foul at proposals to rein in the growth of those payments, pointing out that 58 percent of hospitals lost money treating Medicare patients in 2007.
But what about the 42 percent of hospitals that didn’t lose money? Is the problem that Medicare is a stingy payer? Or that too many hospitals have grown cavalier about controlling costs and have the market power to demand higher payment rates from private insurers to stay in the black regardless of Medicare rates?
A report in March by the Medicare Payment Advisory Commission makes a good case for the latter, suggesting there is room to trim the fat from Medicare payments without hitting bone in many hospitals.
According to the commission, high payments by private insurers — which exceeded hospitals’ actual costs by 32 percent in 2007 — resulted in overall hospital profit/surplus margins of 6 percent in 2007, the highest since 1997. The commission points to hospital consolidation and consumer and employer pressure on insurers to offer a broad choice of hospitals as tilting the balance of power toward hospitals in price negotiations.
But not all hospitals can increase fees for private insurers, especially not hospitals that treat a relatively large number of Medicaid patients. Not surprisingly, many of these hospitals did a much better job of holding their costs down.
The commission found that nonprofit hospitals facing the least financial pressure, those with high non-Medicare profits, spent more per unit of service. Nonprofit hospitals facing the most financial pressure, those with little income outside Medicare, controlled their costs better.
Worried that financial pressures might lead to lower quality of care, the Medicare commission also examined how hospitals that did a good job of controlling costs compared on measures like mortality rates and readmissions. These hospitals typically had higher quality and lower costs, and will likely be the ones hit hardest by across-the board reductions.
The recent deal between Mr. Obama and the hospital industry can hardly be called “health reform.” What is clear, however, is that hospital market power, left unchecked, will pose a formidable obstacle to the president’s promise to make health care more affordable.
Paul B. Ginburg is the president of the Center for Studying Health System Change, a policy research organization
Saturday, July 11, 2009
Primary Care (Physician)???????
The ACP Advocate Blog by Bob Doherty
Are doctors and non-physicians speaking the same language when they define primary care?
I know I am showing my age, but the White House roundtable on primary care that ACP President-elect, Fred Ralston, and I attended last week reminded me of the "What's my line?" quiz show from my childhood. The show featured a contestant in an unusual occupation that was kept secret from a panel of celebrities. Each of the celebrities would try to guess the contestant's occupation, by asking "yes or no" questions that the contestant was required to answer truthfully.
The White House's primary care roundtable included community pharmacists, nurse-midwives, nurse-practitioners, physician assistants, psychologists, an oral hygienist, and two physicians, Dr. Ralston and a pediatrician working in a community health center. Each described themselves as primary care providers. But had they been subjected to "What's my line?" style questioning, I think it would be become evident that their lines (roles) were very different from each other.
The optometrist said that he was the "primary care provider" for patients with eye disease. The community pharmacists said they are the first contact for patients filling their prescriptions and uniquely qualified to provide medication management. The psychologist said she provided primary care mental health services to children and adolescents. The nurse-midwives said they were primary care providers for many women, not only during childbirth but throughout their lives. The PAs said that they were primary care clinicians in a physician-led team. The nurse-practitioners said that they were primary care providers for patients of all ages and conditions, and in some communities, they were the only primary care providers. The oral hygienist said she provided primary care for the mouth! Dr. Ralston described his role as a primary care (general) internist caring for a patient population, principally made up of elderly patients with multiple chronic diseases.
As the conversation continued, it struck me that the language that each of the non-physician professions used to describe primary care was quite different. The pharmacists and optometrists placed the emphasis on being "first contact" providers and the specialized skill they can bring to those contacts. The physician assistants made it clear that they believe that they play an increasingly important role in primary care, but not outside of a physician-led team. The psychologist had a regular relationship with her patients, but on mental health issues, not the entire range of her patient's health care needs. Only the NPs and nurse-midwives stated that they provide comprehensive primary and preventive care to their patients.
The Institute of Medicine describes primary care as "the provision of integrated, accessible healthservices by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community." [Emphasis added] ACP also notes that the hallmarks of primary care are "first contact care, continuity of care, comprehensive care, and coordinated care" of the whole person.
Many of the professions represented at the White House's primary care roundtable have important supporting roles within their areas of expertise, but they are not trained to address "a large majority of personal health care needs" or provide comprehensive and coordinated care of the whole person. That is, they simply are not primary care clinicians as the IOM (and ACP) would define it. Advanced practice nurses in some states might meet the IOM's definition, but their skills and training are complimentary--not equivalent--to those of primary care physicians, a topic that ACP discussed at length in our position paper on NPs and primary care. PAs meet the definition, but only when teamed with a physician.
I don't think there was anything wrong with the White House reaching out to different professions. Much of the discussion focused on common ground issues, like the need for coordinated teams that recognized the different skills that each profession can contribute, and for workforce policies to ensure we have enough professionals--physicians, nurses, PAs, and others--with the necessary skills.
But it is important that policymakers not lose sight that primary care is not something anyone can do. It requires an internist or other highly trained clinician who accepts personal responsibility and accountability for addressing a large majority of personal health care needs and developing a sustained partnership with patients, with an emphasis on coordinated, comprehensive and continuous care.
Today's question: Do you think primary care means the same thing to the different health professions?
Are doctors and non-physicians speaking the same language when they define primary care?
I know I am showing my age, but the White House roundtable on primary care that ACP President-elect, Fred Ralston, and I attended last week reminded me of the "What's my line?" quiz show from my childhood. The show featured a contestant in an unusual occupation that was kept secret from a panel of celebrities. Each of the celebrities would try to guess the contestant's occupation, by asking "yes or no" questions that the contestant was required to answer truthfully.
The White House's primary care roundtable included community pharmacists, nurse-midwives, nurse-practitioners, physician assistants, psychologists, an oral hygienist, and two physicians, Dr. Ralston and a pediatrician working in a community health center. Each described themselves as primary care providers. But had they been subjected to "What's my line?" style questioning, I think it would be become evident that their lines (roles) were very different from each other.
The optometrist said that he was the "primary care provider" for patients with eye disease. The community pharmacists said they are the first contact for patients filling their prescriptions and uniquely qualified to provide medication management. The psychologist said she provided primary care mental health services to children and adolescents. The nurse-midwives said they were primary care providers for many women, not only during childbirth but throughout their lives. The PAs said that they were primary care clinicians in a physician-led team. The nurse-practitioners said that they were primary care providers for patients of all ages and conditions, and in some communities, they were the only primary care providers. The oral hygienist said she provided primary care for the mouth! Dr. Ralston described his role as a primary care (general) internist caring for a patient population, principally made up of elderly patients with multiple chronic diseases.
As the conversation continued, it struck me that the language that each of the non-physician professions used to describe primary care was quite different. The pharmacists and optometrists placed the emphasis on being "first contact" providers and the specialized skill they can bring to those contacts. The physician assistants made it clear that they believe that they play an increasingly important role in primary care, but not outside of a physician-led team. The psychologist had a regular relationship with her patients, but on mental health issues, not the entire range of her patient's health care needs. Only the NPs and nurse-midwives stated that they provide comprehensive primary and preventive care to their patients.
The Institute of Medicine describes primary care as "the provision of integrated, accessible healthservices by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community." [Emphasis added] ACP also notes that the hallmarks of primary care are "first contact care, continuity of care, comprehensive care, and coordinated care" of the whole person.
Many of the professions represented at the White House's primary care roundtable have important supporting roles within their areas of expertise, but they are not trained to address "a large majority of personal health care needs" or provide comprehensive and coordinated care of the whole person. That is, they simply are not primary care clinicians as the IOM (and ACP) would define it. Advanced practice nurses in some states might meet the IOM's definition, but their skills and training are complimentary--not equivalent--to those of primary care physicians, a topic that ACP discussed at length in our position paper on NPs and primary care. PAs meet the definition, but only when teamed with a physician.
I don't think there was anything wrong with the White House reaching out to different professions. Much of the discussion focused on common ground issues, like the need for coordinated teams that recognized the different skills that each profession can contribute, and for workforce policies to ensure we have enough professionals--physicians, nurses, PAs, and others--with the necessary skills.
But it is important that policymakers not lose sight that primary care is not something anyone can do. It requires an internist or other highly trained clinician who accepts personal responsibility and accountability for addressing a large majority of personal health care needs and developing a sustained partnership with patients, with an emphasis on coordinated, comprehensive and continuous care.
Today's question: Do you think primary care means the same thing to the different health professions?
Looking up North?
The posting below is proof that a public funded health care entity can exist and be complemented by private enterprise
The Changing Face of Canadian Health Care
By Evan Falchuk
Many Americans look to Canada, as an example of a government-run health care system that works.
But is that really what it is?
Health care in Canada is funded mostly publicly, but is provided mostly privately. That is, most care is delivered by privately run hospitals and medical clinics, with fees paid for by the various provincial governments.
Americans often call this system “single payer,” but it’s really not true. There are many other payers.
For example, if you’re injured on the job, your care is paid by a workers compensation insurance plan funded by employer premiums. Millions of Canadians also have supplementary health insurance policies, typically called “extended health care” coverage, which cover things not paid for by the government, like prescription drugs and other medical services. There is also a growing market for full medical insurance plans, and critical illness plans to provide cash to offset the out of pocket burdens of medical cost. As much as 30% of Canadian health care expenses are funded through these non-government payers.
However paid for, supply (and funding) for health care has not been able to keep up with increasing demand. The result has been well-documented: long waits for health care services. Waiting is a normal part of the Canadian health care experience, with provincial governments publishing information on wait times and working to fix them. The Canadian Supreme Court admonished the provincial governments in 2005, saying “access to a wait list is not access to health care.”
And so an interesting dynamic has emerged.
Canadians are justifiably proud of their extraordinary health care system, and care deeply about preserving its core principles. But they also care deeply about looking after each other, and are as creative and innovative as any people on the planet. As wait times have grown, so has a burgeoning private market.
Hospitals running diagnostic imaging equipment like MRIs are only paid by the government to run during certain hours of the day. So creative hospitals decided to run the same machines during the overnight hours, charging patients (rather than the government) a fee for the service, which could be provided on an expedited basis. While politically controversial, it made it possible to serve more patients without the need for additional government funding.
These types of ideas have grown, extending now to stand-alone diagnostic centers. A couple of days ago, I visited one, Mayfair Diagnostics, in Calgary. This center was created by a group of physicians, who, like others I have met, knew they couldn’t change the system, but could improve the part in which they work. So they bought leading imaging equipment and opened up centers that cater to self-pay patients, as well as those funded through other sources. They actively promote themselves as a way to get needed medical insight only a couple of days – as opposed to the 6-8 week average wait patients would otherwise face. Doctors working in this center also work in hospitals serving government-sponsored patients, making the Mayfair center and others like it a supplement to the government system. And at a price of $650 for an MRI, it’s inexpensive by U.S. standards.
Other kinds of private centers have opened up as well. Some operate almost as membership-only medical practices, offering much of what might be considered primary care. Others provide even more comprehensive services, making most aspects of ambulatory care available on a privately-paid basis. For certain specialties like orthopedics, some even offer complete hospital surgical services.
The Canadian system remains very different from the American one. Canadians do not want their system transformed into anything that reflects American “rugged individualism.” And yet the natural human desire to look after oneself and ones family poses dilemmas. When a loved one is sick, all the abstract ideas melt away, and you think – how can I do everything I can to get help, now.
We’re all entitled to that kind of help — Americans, Canadians, whatever.
The ways Canadians are trying to make sure everyone gets that help are slowly changing the face of Canadian health care.
The Changing Face of Canadian Health Care
By Evan Falchuk
Many Americans look to Canada, as an example of a government-run health care system that works.
But is that really what it is?
Health care in Canada is funded mostly publicly, but is provided mostly privately. That is, most care is delivered by privately run hospitals and medical clinics, with fees paid for by the various provincial governments.
Americans often call this system “single payer,” but it’s really not true. There are many other payers.
For example, if you’re injured on the job, your care is paid by a workers compensation insurance plan funded by employer premiums. Millions of Canadians also have supplementary health insurance policies, typically called “extended health care” coverage, which cover things not paid for by the government, like prescription drugs and other medical services. There is also a growing market for full medical insurance plans, and critical illness plans to provide cash to offset the out of pocket burdens of medical cost. As much as 30% of Canadian health care expenses are funded through these non-government payers.
However paid for, supply (and funding) for health care has not been able to keep up with increasing demand. The result has been well-documented: long waits for health care services. Waiting is a normal part of the Canadian health care experience, with provincial governments publishing information on wait times and working to fix them. The Canadian Supreme Court admonished the provincial governments in 2005, saying “access to a wait list is not access to health care.”
And so an interesting dynamic has emerged.
Canadians are justifiably proud of their extraordinary health care system, and care deeply about preserving its core principles. But they also care deeply about looking after each other, and are as creative and innovative as any people on the planet. As wait times have grown, so has a burgeoning private market.
Hospitals running diagnostic imaging equipment like MRIs are only paid by the government to run during certain hours of the day. So creative hospitals decided to run the same machines during the overnight hours, charging patients (rather than the government) a fee for the service, which could be provided on an expedited basis. While politically controversial, it made it possible to serve more patients without the need for additional government funding.
These types of ideas have grown, extending now to stand-alone diagnostic centers. A couple of days ago, I visited one, Mayfair Diagnostics, in Calgary. This center was created by a group of physicians, who, like others I have met, knew they couldn’t change the system, but could improve the part in which they work. So they bought leading imaging equipment and opened up centers that cater to self-pay patients, as well as those funded through other sources. They actively promote themselves as a way to get needed medical insight only a couple of days – as opposed to the 6-8 week average wait patients would otherwise face. Doctors working in this center also work in hospitals serving government-sponsored patients, making the Mayfair center and others like it a supplement to the government system. And at a price of $650 for an MRI, it’s inexpensive by U.S. standards.
Other kinds of private centers have opened up as well. Some operate almost as membership-only medical practices, offering much of what might be considered primary care. Others provide even more comprehensive services, making most aspects of ambulatory care available on a privately-paid basis. For certain specialties like orthopedics, some even offer complete hospital surgical services.
The Canadian system remains very different from the American one. Canadians do not want their system transformed into anything that reflects American “rugged individualism.” And yet the natural human desire to look after oneself and ones family poses dilemmas. When a loved one is sick, all the abstract ideas melt away, and you think – how can I do everything I can to get help, now.
We’re all entitled to that kind of help — Americans, Canadians, whatever.
The ways Canadians are trying to make sure everyone gets that help are slowly changing the face of Canadian health care.
The Physician may be a Patient
July 9, 2009
Doctor and Patient
When Doctors Make Mistakes
By PAULINE W. CHEN, M.D.
I met Ed (not his real name) during internship, the year after we both graduated from medical school. Built like a competitive wrestler, Ed was an Ivy League college graduate and one of his medical school’s top students, a 27-year-old who wanted nothing more than to become a general surgeon. Like me, he was enamored with the fearlessness that seemed to characterize the specialty. At a dinner during our first month on the job, Ed told the rest of us, “I love that nothing scares a general surgeon.” A dreamy look passed over his well-chiseled face as he continued, “They can take care of it all.”
Ed was determined to be that kind of surgeon and applied his intelligence and good nature to the huge workload we always had at hand. One night when I was on call I found Ed, who was supposed to have gone home for the night, in a patient’s room. A small mound of discarded alcohol swabs, blood-stained gauze pads and used test tubes stood by his side as the patient, an older woman, laughed and encouraged him on. When Ed saw me, he smiled sheepishly. “I never learned to draw blood in medical school,” he said. “It takes me a few tries.” The patient patted Ed’s hand and nodded as he continued, “If I can’t draw blood, how am I ever going to be able to operate?”
But several months later, I learned that Ed had gotten in trouble one night for not responding to a nurse’s page about a critically ill patient. “He must have been overwhelmed,” I thought, remembering that only a few nights earlier I had likewise forgotten a nurse’s request after several trauma patients rolled into the emergency room and I never returned to the wards as promised. I silently vowed to do better the next time and now hoped that Ed would do the same.
But a couple of weeks later, I heard that Ed overslept and missed morning rounds. A month later he was publicly reprimanded for examining and placing undue pressure on a patient’s freshly sewn incision. And a month after that, he was placed on probation because he had pulled a surgical tube out of a patient when it should have stayed put.
Suddenly it seemed as if Ed, the promising young surgeon, had disappeared into a vicious cycle of errors and mishaps and couldn’t pull himself out.
But Ed, the friend, had gone missing, too. He stopped smiling when we passed one another in the halls and refused to meet up with the rest of us for meals. “I’ve got to read,” he would say, his face stony. “I’ve got to study.” He still roamed the wards at all hours, but now he was like a man possessed. With his list of patients crumpled in one hand and a pen in the other, Ed studied patient charts and reports for hours, furiously jotting notes down on his list.
Despite his efforts, Ed continued to stumble. He soon developed a reputation for being testy, not only with other doctors and nurses but with patients. He argued, lost his temper and was too rough during procedures. One afternoon I heard Ed’s voice bellowing from a patient’s room: “But I never said that to you! Why did you have to tell the senior doctor that? You got me into trouble!”
Ed finally gave up on becoming a surgeon. In trying to understand what had happened to our once aspiring colleague, the other young doctors and I talked about how stress is inevitable and surmised that those who collapsed under the pressure were probably better suited to other lines of work. We speculated that Ed lacked a certain sense of humility.
But all of our ruminations finally boiled down to this: each of us was only one misstep away from that lonely and vicious cycle of errors that could unexpectedly and irrevocably spiral out of control.
In the years since, I have worked with other doctors who have had similar experiences. And while the discussions at disciplinary meetings and at morbidity and mortality conferences tend to focus (and rightly so) on the effects of these physicians’ errors on patients, there is rarely any time devoted to how such errors affect doctors and their subsequent interactions with patients.
I called Dr. Colin P. West recently, a practicing general internist and the associate director of the internal medicine residency training program at the Mayo Clinic in Rochester, Minn. About three years ago, Dr. West and his colleagues published an article in The Journal of the American Medical Association on the effect of errors on physicians-in-training and on the outcomes of their future patients. The researchers found that self-perceived errors not only increased the risk of burnout and depression but also adversely affected subsequent patient care. Over time, young doctors who believed they had made errors in the past felt less and less empathy toward their patients, which then led to an even greater risk of subsequent errors.
“What we are learning is that there’s clearly a cost for doctors and patients,” Dr. West said. “There’s probably a certain amount of stress that’s constructive, but when you deal with it for too long and take it too far, that’s when work suffers.”
While doctors should strive for as few errors as possible, “you can’t go through training without making an error unless you are not taking care of patients,” Dr. West said. “And if you are really invested in the care of patients, there’s a personal cost when things don’t go well.”
That cost can extend to patients. Doctors who are depressed are as much as two times more likely to make subsequent errors than doctors who are not. “From the point of view of the patient,” Dr. West observed, “it’s important whether the doctor treating you is experiencing symptoms of depression or burnout.”
And while Dr. West’s research focuses on doctors-in-training, he added, “I don’t think that as a practicing physician you ever stop thinking about how you could have done better, even sometimes with those events you probably couldn’t have prevented.”
Greater support for doctors from both the training process and patients could help to improve patient outcomes and strengthen the patient-doctor relationship. “In 21st century medicine, there’s no reason for a patient to accept suboptimal care,” Dr. West said. “At the same time, patients need to balance their expectations against the reality of the physician experience. And the medical establishment needs to do a better job of helping patients understand what physician lives are really like.”
“This doesn’t mean that physicians need to be coddled,” Dr. West continued, “but they need to be supported from within and by patients. They need to be supported in developing those relationships that help them to flourish. The reward is a stronger physician-patient bond. And that leads to more effective health care for everybody.”
Join the discussion on the Well blog: "For Doctors, the Personal Toll of Mistakes"
Friday, July 10, 2009
Brilliant
This is an op ed from the New York Times and is critical for health care reform
July 6, 2009
Op-Ed Contributor
Health Care’s Infectious Losses
By PAUL O’NEILL
Pittsburgh
HEALTH care reform seems to be on the way, whether we want it or not. So I have been asking questions about the various proposals. Here is a sampling.
•
Which of the reform proposals will eliminate the millions of infections acquired at hospitals every year?
•
Which of the proposals will eliminate the annual toll of 300 million medication errors?
•
Which of the proposals will eliminate pneumonia caused by ventilators?
•
Which of the proposals will eliminate falls that injure hospital patients?
•
Which of the proposals will capture even a fraction of the roughly $1 trillion of annual “waste” that is associated with the kinds of process failures that these questions imply?
So far, the answer to each question is “none.”
Let’s consider that $1 trillion of waste. If we could capture all of it, the savings over 10 years would be five times what President Obama has said he will extract from insurance companies over the same period. The president’s vision of bringing down health care inflation by 1.5 percent a year over the next decade would not be a victory, but a capitulation to the enormous waste in the delivery of medical care.
The president says he likes audacious goals. Here is one: ask medical providers to eliminate all hospital-acquired infections within two years. This is hardly pie in the sky: doctors and administrators already know how to do it. It requires scrupulous adherence to simple but profoundly important practices like hand-washing, proper preparation of surgical sites and assiduous care and maintenance of central lines and urinary catheters. With these small steps, we would no longer have the suffering and death associated with infections acquired in hospitals and we would save tens of billions of dollars every year — money we should have in hand before new health-care entitlements are enacted.
What policymakers tend to forget is that only the people who do the work can make this happen. Legislation can’t do it, regulation can’t do it, infection-control committees can’t do it, financial incentives and disincentives can’t do it. But excellence is possible, and it has been demonstrated.
Where it works, the common denominators are strong leadership and a committed work force. Among those doctors showing the way are Brent James at Intermountain Health in Utah, Gary Kaplan at Virginia Mason Clinic in Seattle and Richard Shannon at the University of Pennsylvania, who have helped bring infection rates down drastically at their own hospitals and at others.
Hospitals and medical schools have great impetus to increase the ranks of such doctors: these improvements in patient care don’t cost money, they save money. And they represent only the tip of the iceberg in opportunities for improving outcomes and reducing costs at the same time.
A next step would be for the government to finance a prompt, detailed and hard-headed study of every example of error, infection and other waste in five major medical centers. Such data would give policymakers and caregivers a clearer picture of the possibilities for cost-saving improvements.
It would also help if reporters and pundits became more informed about the opportunities for improvement, so they could help educate the public and improve the level of the reform debates. As for members of Congress, perhaps it would help them to understand the problem if we assembled the data, by House district, on hospital-acquired infections, medication errors and other waste indicators. They are more likely to push for the right sort of change when they realize that people they know and represent are being hurt or killed by practices we know how to stop.
In the end, any health care reform that does not address the pervasive waste and the associated burden of needless suffering for patients and staff alike will give us little to celebrate.
Paul O’Neill was the secretary of the Treasury from 2001 to 2002
Is Reduction in Physician Fees Rationing of Care?
President Obama is prepared to cut spending for Medicare and Medicaid. Doctors and hospitals will be paid less for services provided under Medicare.
Is that an example of rationing in action?
A radiologist, may argue:
"The proposed fee schedule for 2010 for radiologists and cardiologists is 21% less than this year! Instead of being reimbursed 36.00 per RVU, CMS proposes to reimburse at 28.00 per RVU. These reductions are the first signs of removing economic incentives for medical practice.
Please give us your thoughts about capping the number of work units and how this will put RATIONING on steroids?
There will be few radiologists and cardiologists working after they hit the magical cap number."
Let us be clear about who is rationing what here.
When Medicare reduces its payments to doctors, it rations money to them. It does not directly ration the health care the doctors might render patients.
If physicians refuse to treat patients at the lower fees, it is they who ration health care, even if the incentive to do so came from Medicare.
While I doubt that the payments to radiologists and cardiologists actually will be cut by 21 percent soon — more on that next time — let us suppose it were so. Would there then be “few radiologists and cardiologists working” after such a fee cut?
Presumably, the afflicted physicians would withhold their services only from Medicare and Medicaid patients, assuming that private insurers pay more. But could most radiologists and cardiologists actually earn an adequate livelihood only from privately insured patients? I have my doubts.
Like everyone else, radiologists and cardiologists certainly can claim to be sorely underpaid relative to the extraordinarily high compensation of bankers and corporate executives, which appears to have little correlation with contributions to society. But relative to their colleagues in internal medicine, pediatrics and family practice, radiologists and cardiologists actually are very well paid.
There are a number of sources on physician income (see, for example, this). All of them suggest that the median annual net income of radiologists and of cardiologists (around $400,000) is more than twice that of family practitioners, internists and pediatricians (less than $200,000). The median is a statistic such that half of physicians earn as much as the median or more, and the other half as much or less.
So even if Medicare cut fees of radiologists and cardiologists by 21 percent, the income of these specialists would still exceed that of their colleagues in primary care by 60 percent or more.
Would that be a reason to quit medical practice? After all, doctors are not bankers. They do not work merely for pecuniary gain, but derive non monetary, psychic rewards from their jobs.
Cold hearted as it may seem, economists judge a profession’s income as adequate if it attracts enough young people into the profession. For the last half-century that has been so in American medicine. The constraint on the number of American-trained physicians has never been an inadequate supply of eager and qualified American applicants to American medical schools. Instead, it has been a deliberate constraint on the number of American medical-school slots.
For reasons that elude me, United States policy makers and the medical establishment have for decades preferred to deny thousands of eager and qualified American youngsters the opportunity to study medicine and have then met the resulting shortage of physicians by importing foreign-trained physicians from other countries.
But while there is no overall shortage of qualified young Americans eager to study medicine, there is now a nationwide lament over a shortage of American medical-school graduates willing to enter the primary-care specialties. For that reason Medicare may soon substantially increase the fees for primary-care physicians, assuming private insurers will swiftly follow suit, as usual.
The only question then is whether such fee increases will come at the expense of taxpayers or from other parts of the health care sector, perhaps even the more highly paid medical specialties, including radiology and cardiology. That is a political call.
United States taxpayers have been too stingy vis à vis the medical profession.
I shall also describe a highly ritualistic and entertaining form of Kabuki theater staged annually in Washington in conjunction with the year’s Medicare fee update.
Act I in the play is always the announcement of a 20-percent cut in the fees Medicare pays physicians.
That “cut” actually ends up as a increase of 1 to 2 percent and an annual increase in Medicare spending per Medicare beneficiary on physician services of 5 to 6 percent.
It will be so again this year.
Is that an example of rationing in action?
A radiologist, may argue:
"The proposed fee schedule for 2010 for radiologists and cardiologists is 21% less than this year! Instead of being reimbursed 36.00 per RVU, CMS proposes to reimburse at 28.00 per RVU. These reductions are the first signs of removing economic incentives for medical practice.
Please give us your thoughts about capping the number of work units and how this will put RATIONING on steroids?
There will be few radiologists and cardiologists working after they hit the magical cap number."
Let us be clear about who is rationing what here.
When Medicare reduces its payments to doctors, it rations money to them. It does not directly ration the health care the doctors might render patients.
If physicians refuse to treat patients at the lower fees, it is they who ration health care, even if the incentive to do so came from Medicare.
While I doubt that the payments to radiologists and cardiologists actually will be cut by 21 percent soon — more on that next time — let us suppose it were so. Would there then be “few radiologists and cardiologists working” after such a fee cut?
Presumably, the afflicted physicians would withhold their services only from Medicare and Medicaid patients, assuming that private insurers pay more. But could most radiologists and cardiologists actually earn an adequate livelihood only from privately insured patients? I have my doubts.
Like everyone else, radiologists and cardiologists certainly can claim to be sorely underpaid relative to the extraordinarily high compensation of bankers and corporate executives, which appears to have little correlation with contributions to society. But relative to their colleagues in internal medicine, pediatrics and family practice, radiologists and cardiologists actually are very well paid.
There are a number of sources on physician income (see, for example, this). All of them suggest that the median annual net income of radiologists and of cardiologists (around $400,000) is more than twice that of family practitioners, internists and pediatricians (less than $200,000). The median is a statistic such that half of physicians earn as much as the median or more, and the other half as much or less.
So even if Medicare cut fees of radiologists and cardiologists by 21 percent, the income of these specialists would still exceed that of their colleagues in primary care by 60 percent or more.
Would that be a reason to quit medical practice? After all, doctors are not bankers. They do not work merely for pecuniary gain, but derive non monetary, psychic rewards from their jobs.
Cold hearted as it may seem, economists judge a profession’s income as adequate if it attracts enough young people into the profession. For the last half-century that has been so in American medicine. The constraint on the number of American-trained physicians has never been an inadequate supply of eager and qualified American applicants to American medical schools. Instead, it has been a deliberate constraint on the number of American medical-school slots.
For reasons that elude me, United States policy makers and the medical establishment have for decades preferred to deny thousands of eager and qualified American youngsters the opportunity to study medicine and have then met the resulting shortage of physicians by importing foreign-trained physicians from other countries.
But while there is no overall shortage of qualified young Americans eager to study medicine, there is now a nationwide lament over a shortage of American medical-school graduates willing to enter the primary-care specialties. For that reason Medicare may soon substantially increase the fees for primary-care physicians, assuming private insurers will swiftly follow suit, as usual.
The only question then is whether such fee increases will come at the expense of taxpayers or from other parts of the health care sector, perhaps even the more highly paid medical specialties, including radiology and cardiology. That is a political call.
United States taxpayers have been too stingy vis à vis the medical profession.
I shall also describe a highly ritualistic and entertaining form of Kabuki theater staged annually in Washington in conjunction with the year’s Medicare fee update.
Act I in the play is always the announcement of a 20-percent cut in the fees Medicare pays physicians.
That “cut” actually ends up as a increase of 1 to 2 percent and an annual increase in Medicare spending per Medicare beneficiary on physician services of 5 to 6 percent.
It will be so again this year.
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