Doctors are the biggest driver of health care costs

There are many reasons to be dismayed by the error-filled and managerially incompetent rollout of the federal health insurance exchanges that are in many ways the linchpin of President Obama's Affordable Care Act. I sympathize with commentators who have called for the resignation of Department of Health and Human Services Secretary Kathleen Sebelius. It's hard to imagine Franklin Roosevelt not firing someone in his Cabinet had Social Security stumbled this badly out of the gate, or Lyndon Johnson not causing officials' heads to roll if the launch of Medicare and Medicaid had been so mangled.

Still, I believe that throwing the baby (the ACA) out with the bathwater (government officials) would be a huge mistake. Health care costs will continue to rise with or without the law's implementation, consuming an ever greater chunk of the struggling U.S. economy and causing government budgets to run into the red regardless of any future grand bargains on taxes and spending. The status quo stinks, and doing nothing is not an option.

Some of my physician colleagues have argued that the major problem in medicine today is that restrictive insurance companies and armies of utilization reviewers have curtailed our independence. Return decision-making power to doctors, they argue, and the system will run more efficiently. When surveyed recently about who had "major responsibility" to control health care costs, U.S. doctors called out trial lawyers, insurance companies, hospitals, drug and device manufacturers, and patients. Only one in three pointed the finger at themselves.

In an editorial in the New England Journal of Medicine, family physician Cheryl Bettigole takes the opposite point of view. Observing how a $20 to $30 Pap smear can be transformed into a battery of tests (some unnecessary) that cost hundreds or even a thousand dollars, she argues that physicians have the primary responsibility to protect patients from financial harm and be good stewards of health care resources:

So how do all these tests come to be ordered for healthy women who come in only for an annual gynecology exam? The answer is that someone ... checked off all those boxes on the order form. When I was in training, our attendings would ask a standard quiz question: “What is the biggest driver of health care costs in the hospital?” Answer: the physician's pen. A mouse or a keyboard, rather than a pen, now drives the spending, but we physicians and our staff are responsible for ordering these unnecessary tests and hence responsible for the huge bills our patients are receiving.

Yes, the U.S. health care non-system provides physicians with numerous incentives to "do the wrong thing" in patient care. The more services we provide, the more money we make. Pharmaceutical representatives persuade us to prescribe expensive new brand-name drugs instead of more affordable (and often, more effective) generics. Indecipherable medical bills and insurance statements prevent patients from knowing how much their care costs until they've already received it. But these challenges should not be excuses for inaction on the part of practicing physicians or those in training. As Dr. Bettigole writes:

We need to teach medical students and residents to see [good financial stewardship] as an important aspect of their responsibility to their patients. Furthermore, we need to advocate for a system in which information about the cost and benefit of diagnostic tests is readily available to patients and providers at the point of care. If we fail to do so, we risk not only our patients' pocketbooks but also the gains we have made against cervical cancer and many other conditions. We contribute to spiraling health care costs and are doing real harm.

Shining Knights and heroic family doctors

Not long ago, I attended the Shining Knight Gala, a fundraising dinner that benefited the trauma surgery and injury prevention programs at Virginia Commonwealth University Medical Center. The highlight of the evening was the dramatic presentation of the story of a young man who had suffered severe, life-threatening injuries in a car accident and, through the skill and dedication of first responders and the VCU trauma and rehabilitation professionals, was stabilized and over several months gradually restored to health. In recognition of their extraordinary efforts, all of the clinicians involved in this young man's care were awarded the "Order of the Shining Knight." As fire fighters, emergency medical technicians, emergency room physicians and nurses, trauma surgeons, and rehabilitation specialists trooped on to the stage to shake Virginia Governor Bob McDonnell's hand and pose for photos with their award (while their patient looked on happily from a nearby table), it was impossible not to be deeply moved.

It struck me later that there is no primary care analogy for what I witnessed that evening. General internists will not have the satisfaction of being recognized for the patients who didn't have heart attacks or strokes because of the blood pressure medications or aspirin they prescribed; family physicians and pediatricians won't be given awards of merit for all the children they "saved" from measles, mumps, polio, and a host of other vaccine-preventable diseases. While primary care physicians certainly provide acute care services for a variety of ailments, the greatest impact of our work is ultimately unmeasurable: all of the poor health outcomes that might have happened, but didn't.

Does this mean that there are no heroic family doctors? Far from it, but recognizing our behind-the-scenes efforts - and reinforcing the appeal of the primary care specialties to medical students - is certainly more challenging. But I'm cautiously optimistic that the past few years' Residency Match results, which showed modest increases in the numbers of U.S. graduates choosing residency programs in family medicine, general internal medicine and pediatrics, represent a turning of the corner. With the millions of people expected to gain health insurance over the next year, this country will need every primary care clinician it can get.

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This post originally appeared on Common Sense Family Doctor on April 1, 2010. I am re-posting it in belated recognition of National Primary Care Week, which Georgetown is celebrating with a series of Family Medicine Interest Group events led by several outstanding physician colleagues.

Rethinking the war on drugs

A few years ago, I served for several weeks on a grand jury for the Superior Court of the District of Columbia. Mine was designated a RIP (Rapid Indictment Protocol) jury, assigned to efficiently hand down indictments for small drug-related offenses. These cases usually involved undercover officers posing as customers making purchases from street dealers, or uniformed police stopping suspicious vehicles and searching them for drugs. Although rarely we heard testimony about defendants caught with thousands of dollars of contraband, the vast majority of offenses were possession of small amounts of marijuana, heroin, or cocaine for "personal use." Many of the latter defendants had multiple such offenses, which had resulted in probation, "stay away" orders (court orders to avoid certain neighborhoods where drugs were highly trafficked), or brief stints in jail. Few, if any, had received medical treatment for their addictions.

After a few weeks of hearing these cases, my fellow jurors and I grew increasingly frustrated with this state of affairs. We felt like cogs in a bureaucratic machine, fulfilling a required service but making little difference in anyone's lives. A young man or woman caught using drugs would inevitably return to the street, violate the terms of his or her probation or "stay away" order, and be dragged before our grand jury again for a new indictment. We openly challenged the assistant district's attorneys about the futility of the process. They would just shrug their shoulders and tell us that was the way things were, and it wasn't our job to come up with a better strategy for dealing with illegal drug use. True enough, but then again, whose job was it?

An article by Michael Specter in the October 17, 2011 issue of the New Yorker reported on the recent experience of Portugal in decriminalizing personal drug use. To an American physician accustomed to our endless war on drugs, what Portuguese authorities did was hard to imagine: "For people caught with no more than a ten-day supply of marijuana, heroin, ecstasy, cocaine, or crystal methamphetamine - anything, really - there would be no arrests, no prosecutions, no prison sentences. Dealers are still sent to prison, or fined, or both, but, for the past decade, Portugal has treated drug abuse solely as a public-health issue." Rather than being paraded before grand juries for ritual convictions, people caught using drugs in Portugal are instead summoned before a 3-person panel (a judge, doctor, and psychologist or social worker) and assigned to counseling and medical treatment for their addictions.

Did this new policy result in an explosion in the number of Portuguese drug users, no longer cowed by the prospect of criminal prosecution? Hardly. In the words of a chief police inspector who initially resisted the change in tactics:

In the last years before the law, consumers were arrested by police. ... They were fingerprinted and made statements and took mug photos and were presented to court. And always, always, always released. It was a waste of everyone's time. It didn't stop drug use or slow down the dealers. So the idea that somehow people are getting away with what they did not get away with before is silly.

A public health approach to the consequences of illegal drug use in the U.S. might include increasing support for needle exchange programs, which have been banned from receiving federal funding for years but have been repeatedly shown to reduce rates of HIV transmission in controlled studies. Unfortunately, our inherent discomfort with such "permissive" interventions often gets in the way of recognizing the evidence that our current punitive approach to drug use is more harmful than beneficial to drug users and society in general. As Specter concludes:

It is common in the U.S. to judge drug addiction morally rather than medically, and most policy flows from that approach. ... Yet one has only to look at the American health-care system to be reminded that neither science nor evidence necessarily drives public-policy decisions. ... While it would make no sense to base American policy [toward drug use] on a decade-long Portuguese experiment, it seems even more foolish to ignore results that call so clearly for an increased focus on treatment, not jail time.

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A slightly different version of this post first appeared on Common Sense Family Doctor on November 8, 2011.

Upcoming Event: Affordable Care Act 101

This Thursday, October 10th, from 3-4 PM Eastern, I will be participating as an invited panelist in a Google Hangout sponsored by Voto Latino. Please join me and representatives from the National Hispanic Medical Association, National Council of La Raza, Young Invincibles, and Enroll America as we discuss the implications of the Affordable Care Act for the health and health care of Latino Americans.

Learning from primary care in Canada and Europe

What can family medicine in the U.S. learn from the organization of primary care in other Western countries? In this month's Georgetown University Health Policy Seminar, we explored two recent studies that shed light on successes and challenges of primary care reforms in Ontario, Canada and the European Union.

Starting in 2000, policymakers in Ontario implemented a primary care reform strategy based on five national objectives, which are strikingly similar to many proposed U.S. reforms: "1) increasing access to primary care organizations that would provide a defined set of services to a defined population; 2) increasing emphasis on health promotion, disease and injury prevention, and chronic disease management; 3) expanding all-day, every-day access to essential services; 4) establishing interdisciplinary primary care teams; and 5) facilitating coordination and integration with other health services." As a result, an almost entirely fee-for-service primary care system was gradually replaced with a mixture of salary-based, capitation-based, and blended fee-for-service payment models by 2012. Far from being demoralized by the rapid changes, Ontario primary care physicians actually reported increasing satisfaction during this transition period.

Another study in the same issue of Health Affairs analyzed associations between the strength of primary care systems in 31 European countries, national health expenditures, and measures of population health. The study found that countries with more robust primary care had lower hospitalization rates and less socioeconomic inequality in self-rated health, in addition to better chronic disease outcomes. However, these advantages came at the cost of higher baseline health care spending, though spending growth appeared to be slower in countries with a comprehensive primary care bedrock.

What lessons should U.S. policymakers take home from this research?

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This post first appeared on The Health Policy Exchange.

I oppose Obamacare; I support the Affordable Care Act

Tomorrow, more than three years after being signed into law, and more than a year after surviving a Supreme Court challenge, the Affordable Care Act, more commonly known as Obamacare, finally begins to fulfill its promise. Most of this country has long since taken sides, despite appalling gaps in popular understanding of what the law means, what it does, and what it doesn't do.

Let me admit that I've never had particularly warm feelings toward President Obama. I think his foreign policy is a mess. The trillions in debt that the U.S. has run up over the past 5 years will hurt my generation and future generations, and if Republicans can be faulted for their fantasy that the federal budget can be balanced exclusively through spending cuts, Obama has sustained the Democratic fairy tale that raising taxes on "millionaires and billionaires" is all that is necessary to pay the skyrocketing bills. On multiple occasions during my time in government, the President had no qualms about squashing science and scientists for political convenience. He is a perpetual campaigner, preferring theatrical gestures to the backstage grunt work of governing. And for all of his rhetorical gifts when preaching to the choir, he's been one of the least effective persuaders-in-chief to have held the office.

And so, naturally, I oppose Obamacare. I oppose a government takeover of health care that includes morally repugnant death panels staffed by faceless bureaucrats who will decide whose grandparents live or die and make it impossible for clinicians to provide compassionate end-of-life care. I oppose the provision in Obamacare that says that in order for some of the 50 million uninsured Americans to obtain health insurance, an equal or greater number must forfeit their existing plans or be laid off from their jobs. I oppose the discarding of personal responsibility for one's health in Obamacare. I oppose Obamacare's expansion of the nanny-state that will regulate the most private aspects of people's lives.

It's a good thing that Obamacare, constructed on a foundation of health reform scare stories, doesn't exist and never will.

Instead, the Affordable Care Act (which I support) is based on a similar law in Massachusetts that was signed by a Republican governor and openly supported by the administration of George W. Bush. It achieves the bulk of health insurance expansion by leveling the playing field for self-employed persons and employees of small businesses who, until now, didn't have a fraction of the premium negotiating power of large corporations that pool risk and provide benefits regardless of health status. The ACA discourages irresponsible health care "free riders" and provides support for people of modest means to purchase private health insurance in regulated open marketplaces. It tells insurers that in exchange for new customers, they can no longer discriminate against the old and sick and make their profits off the young and healthy. Finally, the ACA rewards physicians and hospitals for care quality and good outcomes, rather than paying for pricey tests and procedures that may or may not improve health.

The ACA has flaws. Since it doesn't do much to narrow the income discrepancy between different types of physicians, it may overwhelm the capacity of primary care as millions of uninsured patients look for family doctors for the first time. The ACA's provisions to discourage overuse of unnecessary medical services are limited and probably inadequate to the scope of the problem. But it's worth noting that these problems all predated the law. We don't have enough family physicians and other primary care clinicians, specialists make too much money in comparison, and overdiagnosis and overtreatment are already rampant today. That the ACA takes on these issues at all is a small victory of sorts.

It's interesting to consider the counterfactual exercise of what might have happened if Mitt Romney had captured the 2008 Republican Presidential nomination and then narrowly defeated Hillary Clinton, who was the odds-on favorite for the Democratic nomination in that year. No doubt affordable health care would have been an important focus of that hypothetical contest, with Romney successfully linking Clinton to her husband's failed 1994 reform plan that makes right-wing objections to the ACA look insignificant by comparison. Once elected, a President Romney would have felt compelled to advance national health reform, and would have naturally modeled his proposals on his Massachusetts plan. We might have ended up with a conservative law that looked much like the Affordable Care Act, only this time criticized by the left for being too administratively complex and not generous enough in providing coverage for all.

A farfetched scenario, you say? Perhaps. But it underlines the need for people of all political persuasions to set aside the overheated rhetoric about Obama and Obamacare and focus on making the ACA work, starting tomorrow.

Guest Post: Why clinical questions are only a starting point

Dr. Robert Bowman is a Professor of Family Medicine at A.T. Still University School of Osteopathic Medicine in Arizona. He blogs at Basic Health Access and Clinician Specific Medical Education.

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People come to family physicians with some indication or faith that we can help them. As the learned “high priests” of medicine, we can answer their questions in various ways. The following 5 ways that Christians perceive that God answers prayers also provide a framework for how we address clinical questions.

"No, I love you too much."

Daily we see patients who already have answers to their questions. They come to us for many reasons. One reason is so that we can confirm their impression. If we do so wrongly, we contribute to their problem. We also know that what some people are asking is wrong. For this and for other presentations, we have to say “No, I love you too much.” This can be difficult for physicians who want to please all of their patients or improve their “patient satisfaction” scores.

"Yes, but you will have to wait."

We gather information and then do exams, tests or sometimes treatments. Haste can help answer a clinical question, but a hasty answer can be wrong. Hundreds of hasty diagnoses or treatments have been proven wrong in later years. For 20 years we were pushing an unproven test for prostate cancer screening when we should have been saying: “You will have to wait.”

Those on the front lines of care recognize that some diseases and conditions go away. Patience is needed. When people come in with fever, chills, and headache within 24 to 48 hours, chances are that this will resolve with little consequence. Deciding who can wait or not is a clinical decision, but one that does not necessarily lead to a diagnosis. We fail to measure much of clinical decision making. Those who measure immediately will find many clinical questions unanswered. This is about the patient, physician, interaction, the state of the science, and limitations in each of these areas. Immediate diagnosis and treatment can be wrong and harmful – but sometimes delays can be harmful. Outside players (legal, payers, practice pressures, daily situations) exert influences that can impede optimal decisions and care.

"Yes, but not what you expected."

This is always a tough situation as people have already moved their minds down one path. It takes time and effort on our part to erase this path so that they can move down another. Our treatments often do not work and some are harmful. Even with correct diagnosis and treatment, some patients find that our treatments are too inconvenient or expensive to continue and may or may not tell us.

"Yes, and here’s more."

Family physicians have more to offer than just diagnosis and treatment. Because of our tens of thousands of patient care experiences, we have experienced the impacts upon others and how they responded and what helped. The context of neighborhood, family, and individual past experiences is a rich database. Teaching of medical students and residents adds to the reflection, discussion, learning, and management. Ideally we have experienced the disease and condition and can speak with regard to practical matters, with evidence as a foundation. It helps to have access to pharmacists, behavioral professionals, and nurse educators who can step in and connect patients to needed care. But adding more can be difficult with financial margins so thin, with penalties for serving patients in settings where margins are thin, with fast rising costs of delivery, and with stagnant reimbursement. 

"Yes, and I thought you would never ask."

This is what we tend to focus on too much. People come in and we make the diagnosis and treatment together and have great agreement and all are pleased about expectation, diagnosis, treatment, and outcome. We like to measure this outcome since it is easy to measure. Much of what we do in family medicine, though, is in the first four answers rather than this last one. Saying no, getting people to wait patiently, or redirecting wrong impressions is often more important to individual outcomes than is the clinical question. Unfortunately, current designs for training and practice support make responding "Yes, and here is more" difficult unless we personally sacrifice to provide more care.

Family physicians generally do not experience the immediate rewards of diagnosing an inflamed appendix with confirmation during removal at surgery. But we do see the negative consequences of focusing on short-term outcomes at the expense of long term approaches to health, where the "clinical question" may only be a convenient starting point.