A Dialogue on Health Care

Q: If health insurance is something one can buy, why not let people buy what insurance they want?

A: To call it insurance is a misleading misnomer. Since sickness befalls everyone sooner or later, unlike house fires or auto accidents, we are not protecting ourselves against an event which usually affects other people. The term insurance enables us to avoid facing up to the reality that as a society, we expect to provide health care for everyone.

This expectation in turn leads to concepts (in ancient Greece, we called them buzz words) like Right or Entitlement. Whatever we call it, it is true that Emergency Rooms are prohibited from “dumping” or “turfing” a patient to another facility if for any reason, like inability to pay, they wish to; they must at least stabilize the patient’s condition before any transfer.

Q: But aren’t people responsible for their health or health care?

A: In a perfect world, all babies would be born healthy to hard working caring parents who buy top notch insurance, abstain from tobacco and toxic substances, drive Volvos, and never make youthful mistakes. They would work and play in safe environments. They would find a team of error -free doctors, nurses, and medical suppliers to render judicious treatment.

In the actual world, children become afflicted by conditions that science has not yet found answers for. An astounding percentage of patients do not take medications as they are prescribed. Children of immigrants do not choose their parents. Some people are injured or made ill by the carelessness of others. In historic example, Dorothea Dix sorted the mentally ill from the criminals at the East Cambridge jail, arguing persuasively that the mentally ill should be treated, not punished. Every generation relearns the folly of blaming sick people for their ailments.

Q: We have 330 million people in this country, and spend over 15% of our GDP on health care. If we have to provide health care for everyone – not just in the Emergency Room – won’t that lead to rationing, as Governor Palin famously charged?

A: You raise an important question. We can easily agree that there is some upper limit on what we can afford to spend on health care. We may even agree that we have passed that limit. Rationing is another one of those buzz words. What we now have is de facto rationing. By which I mean irrational, inequitable, and wasteful distribution, accomplished without naming it as such. Studies show that between 18,000 and 35,000 deaths occur because the person lacked health insurance.

You know, of course, that other countries spend much less, as percent of GDP, on health care than we do. Moreover, in Canada, for example, polls indicate that they are more satisfied with their health care than we are, anecdotal evidence to the contrary.

Q: So what are the challenges and choices in this cost issue?

A: First, the challenges, as they are not lightly to be dismissed. Modern medicine is a technological marvel, churning out designer drugs, new and smaller spare parts and organs, fueled by public expectation of continuous progress, and big time lobbying. Far be it from me to suggest that we are reaching a technological plateau, when the risks of a new treatment are equal to the benefits.

The very event of dying has become another challenge. We have the means of supporting life, sometimes under circumstances that seem futile to me (but I confess not yet to have walked in those slippers). Elasticity of demand is a concept known to economists and practiced by doctors and their patients. This takes two forms. One, if a treatment exists, we should apply it. Two, more is better (this one is most obvious in some misapplications of psychotherapy). Thus, elasticity of demand results in what one of my colleagues (D.W.Boardman) called “acute remunerative medical mischief.”

Now as to choices – I hesitate to call them solutions. They fall into three categories, according to a recent New England Journal of Medicine article: reduce labor costs, reduce services, and/or increase productivity. (There are some who hope that major savings can be gained by “reducing fraud and abuse.” Granting that it does occur, studies suggest that the savings to be expected may make headlines, as crimes, but as a percent of the health care total, that it is a small number, 1-2% is my guesstimate. We can agree that unnecessary treatment is wasteful and perhaps even harmful. There have been two efforts to reduce unnecessary treatment. One is by HMO’s, whose doctors agree to be guided by the limits imposed by their peers, all of whom share in the risk that the HMO will go broke. This approach has proven to be helpful, but has not yielded a plateau (bending the curve is the buzz word) but rather a notch in the curve, after which the curve resumes it relentless upward trajectory.

The latest effort along these lines is that of establishing panels of distinguished experts who will examine the available scientific evidence about a treatment or procedure – colonoscopy and Prostate Specific Antigen , for examples – and recommend whether or not they are useful – and should be paid for by taxpayers’ money. To describe this admittedly imperfect mechanism as rationing, while correct, does not further the dialogue.

We spoke of the costly business of dying, which, remember, is a huge source of revenue to doctors, hospitals, and medical supply companies. It is encouraging to see a lively interest in end of life directives (do you have one?) and the newly established specialty of Palliative Care. Both are steps toward a humanistic, patient- and family-centered approach to the end of life.

Q: I forgot to ask, how is health care paid for now?

A: Again, a perspicacious question. In 1935, around the time that Blue Cross was getting started in Texas, the federal government began providing a system for the health care of merchant seamen, their widows and children. 65 years later, when I retired, my community general hospital in a prosperous Boston suburb got 42% of its revenue from the federal government. By a series of steps, the federal government has become the largest provider and purchaser and payer for health care in the world. As you know, this money comes from taxes, premiums, the general fund, and borrowing. State and local governments – also tax supported – have their own health care expenses.

This care is mediated by various organizations: Medicare, Medicaid, private insurance, some for profit, some not, and the Veterans Administration. To illustrated the complexity (dare I say cumbersomeness?) of all this, my former community hospital had dozens of clerks lodged in a former General Radio factory building, conducting billing activities on behalf of the hospital and its patients – with dozens of insurance companies and governmental agencies.

Many of these companies compete with each other for members, whom they call “customer.”  We can call this complex system a free market, but it is the rare person who reads all the fine print, calls up for missing information, and makes choices that optimize the quality and cost of his or her insurance. As we learned from the recent trouble with mortgages, not all market places are as transparent as one might wish. And this illusion of an efficient free market is expensive. As David Himmelstein and Steffie Woolhandler have estimated, a single payer system would reduce the overhead costs of health care by an amount between 30 and 50%.

Single payer is, of course, a sensible way to deliver health care. What is rarely mentioned in this connection is that there would be a one-time jump in unemployment. Thousands of copy writers, coordinators, billing clerks, lobbyists, and middle managers would be out of work.

Q: Quit your dreaming and tell me where all this money goes?

A: You have hit the nail again. Under the fee for service system, every office visit, test, pill, operation, hospital day, emergency visit, and procedure generates a charge, to be paid for by insurance at pre-negotiated rates, or from a free care pool (don’t ask).

When it became obvious that the fee for service mode was driving costs through the roof (say, the 1970s) states and foundations cast about for alternatives – which is how we got to HMOs. The M in HMO means Management, controlling access to provide quality care (or risk losing patients) at lower cost (or risk losing large purchasers, like Raytheon, Gillette, or the Commonwealth of Massachusetts). As we said, HMOs were effective at first, and are still very popular, but they have not caused a leveling off of the cost of care, and have produced varieties of plans within each HMO which in my opinion makes them less managed and more like the insurance companies they were supposed to replace. This is especially true in New Hampshire, I believe.

We are about to embark on the latest attempt to address costs. Doctors and hospitals form organizations, called Accountable Care Organizations (ACOs). An ACO will provide all the necessary (key word) health care for a group of patients, who may be members of Blue Cross or Medicare, or other. The ACO will receive a federally specified X dollars per patient per month (pppm). You can see that there are risks in this kind of arrangement. The ACO may run out of money; it may drive patients away, or attract a group of very sick (expensive) patients. We can hope that such a plan will encourage doctors toward preventive activities, efficiency, and fair distribution of the money among hospitals, specialists, and primary care doctors.

Q: Sounds pretty promising, but don’t we have a maldistribution of health resources? Where are the primary care doctors going to come from?

A: It is a pleasure to discuss these matters with one who follows the issues so closely.

The popularity of various careers fluctuates with the times. After Sputnik, we had a surge of engineers. Until about 2008, Wall Street was the mecca for the best and brightest. About 10 years ago, one quarter of the graduates of Harvard Medical School’s graduating class went straight into some form of business: McKinsey, a drug company, venture capital. Likewise, there are surges of popularity within medicine. We have gone from the avuncular Marcus Welby to the aggressive Ben Casey, to the brilliant but deeply flawed House. Where are the every day, underpaid, overworked primary care docs?

There are, in my opinion, three motivations for doctors: money, power (usually thought of as autonomy), and altruism – the desire to cure disease and relieve suffering as an end in itself.

As for money, most doctors finish their training around age 30, carrying over 100 thousand dollars in debt. They and their wives have long pent-up consumer desires. Most doctors earn comfortable incomes, some very high incomes. Primary care doctors and pediatricians do not. One of my colleagues offered primary care in Acton Massachusetts for a number of years. When she left that practice, she detailed in an article in the New England Journal of Medicine how she could not live on the money she was making and provide quality care that she believed her patients needed. She took a job at a VA hospital, preparing them for accreditation by the JCOHA.

Regarding power, physicians have ceased to be God-like authorities, captains of the ship, unquestioned by patients and families – as they once thought they were, rightly or not. Health care has become very complicated, and without special talent or training, physicians are not per se good managers. Every doctor I know attests to a diminution in the control he has over his practice.

Altruism is an enduring motivation for being a doctor. But unless he is preparing for sainthood, he or she needs a decent income and acceptable control over his or her practice. Lacking those elements, he or she feels like a sucker, taken advantage of.

Primary care is further challenged by the progression of specialization.  At my former hospital, the day arrived when one of the steadiest, capable family doctors was told he could no longer deliver babies – after 30 years of doing so.

Specialists usually see patients by referral, meaning that someone else has concluded that the patient’s problem falls in that specialist’s area of expertise. Primary care doctors by definition are the first doctors a new patient sees. That means that he or she has to know all of medicine. I have often been told matter-of-factly that primary care is the most difficult kind of practice there is. It is even more difficult in communities that have changing populations, few resources, and lack of social cohesion. The advent of hospitalists, whatever the gains in efficiency or even quality of hospital care, means that the primary care doctor’s visit to his hospitalized patient is an unreimbursed, impotent, social call, done to preserve the illusion of continuity of care.

Women now constitute half of medical school graduates. One would hope that the supply of PCPs would surge. Well, it has not. Women may well be nurturing dispensers of TLC, but women doctors are not saints, nor fools, and feel empowered. So what do they do?  They do office psychiatry, ophthalmology, dermatology – or, if they want the big bucks, they charge into previously male dominated surgical specialties. Or take a primary care job minus night and weekend call, so they can at least see their kids.

The generally constructive empowerment of patients has alas been joined by the legal profession to produce an explosion of malpractice litigation. The consequences extend beyond the increased premiums that doctors pay, to an unpleasant constant worry that today’s cooperative patient may be tomorrow’s adversary. Add to this the significant cost of defensive medical practice – tests that would be unnecessary if the doctor were not afraid of being sued for not doing the test. These costs are well documented in the medical literature.

Is there good news regarding primary care practice? Group practices are virtually necessary; they offer not only shared overhead, but also non-competitive peer review, reasonable hours, and mutual support. This is an important cultural shift, away from the model of the solo practitioner, available 24/7.

We need to find a good name for the people we now refer to variously as nurse practitioners, physician assistants, and in mental health, case managers. These jobs require post college education, are professional, time- intensive, require good communication skills with patients and the others involved with the patient’s care. Doctors are well advised to learn to work comfortably and efficiently with them, on terms of mutual respect.

Q: Are the medical schools helping? Sounds like they need to change.

A: Of course. About 60 years ago, Dr. Sidney Burwell, the Dean of Harvard Medical School, was welcoming the first year students. He said, “In four years, you will graduate, and half of what we taught you will be proven wrong – only we do not know which half.” There are encouraging signs that medical schools know how to change, and are addressing the imbalances of health care.

The process by which medical students become clinicians is humbling, hardening, and one hopes, maturing. Overall, it is a wondrous miraculous thing. Every doctor can recall with gratitude the patients who contributed to his education. Doctors pass through the stages of life as imperfectly as everyone else, a journey that is well captured in Sinclair Lewis’s novel, Arrowsmith.

In retrospect, I can suggest two improvements. The first may be called the denial of chronic disease. We were taught to make correct, prompt diagnoses, and to expect to find a curative treatment. Field trips to chronic disease hospitals focused on demonstrating particular syndromes, often associated with pioneering Russian pathologists (Korsakov, Creutzfeldt-Jacob). We did not learn how a diabetic can get along without a foot, or what dementia looks like in the patient’s home. Any discussion of chronic disease leads back to primary care, because frequently the specialist refers the patient back with a note listing diagnosis, treatment recommendations and a concluding sentence, Thank you for asking me to see this interesting patient.”

Doctors expect themselves to perform perfectly, error-free, day in and day out. This attitude is reinforced by a central educational activity known variously as M&M (which stands for Mortality and Morbidity) or simply, Death Rounds. These are dramatic occasions at which the attending physician reports on a patient who has died in the hospital, or had some regrettable outcome. While there is a subtext which says, “You screwed up, doc, in such and such ways,” colleagues treat one another with gentleness and respect in these discussions whose primary intent is educational. I have rarely heard a comment, on the other hand, to the effect that “Your patient had a good death.”

Recently doctors have begun to tell their patients promptly when they made a mistake. We owe Dr. Lucian Leape a great debt for demonstrating beyond doubt that errors occur in a very high percentage of hospital patients. He cites the airlines’ use of checklists, shared responsibility, and redundant backup systems as successful examples of error reduction.

Q. Given these challenging complexities, are there other opportunities for constructive action?

A.  In broad outlines, our goals are widely shared among our citizens.

1. A single payer, capitated nationwide system that establishes a floor of basic standards for good health care from prenatal to terminal, for everyone. There is scant evidence that this arrangement will diminish anyone’s health; what it will do is hurt major sections of the medical/hospital/supply system in the pocket book.

2. Revise incentives for health care workers by a) empowering nurse practitioners, physician assistants, and case managers, and b) establishing better balance among the incomes of PCPs vis à vis specialists.

3. Eliminate, with firm safeguards, payment for those treatments and procedures for which there is no justification in science. We know there are imperfections in scientific work (it is done by humans) and in its application to health care payments (which is subject to various pressures). But I do not think we can go back to the days of snake oil and leeches. Also, I think Groopman and colleague (recent New England Journal of Medicine) mistakenly link science to the industrialization – and in their view, the dehumanization ? of medicine. There is plenty of room for good judgment and compassion, at the points where good science is lacking, and in its humane presentation where it is not lacking.

4. The competent care given to a patient with one or more chronic diseases is under appreciated. Patients’ length and quality of life can be enhanced by attention to the often mundane details that to them, make important differences. We have come a long way, but advocacy groups (like NAMI) and Congress are ahead of medical schools on this point.

5. The reality that some illnesses cannot be fixed immediately has gained acceptance in the last thirty years or so. The emergence of palliative care (‘care not cure’) is a hopeful sign. Palliative care is different from hospice. Both share the acknowledgement of limitations. Widespread public acceptance will be achieved as each person deals with it across the span of his or her life. It may seem to go against our national ethos (can do). But massive suffering and expense will be avoided when we support one another when we are ready to say, “I’ve had enough.” Perhaps we can take heart from the comment attributed to Winston Churchill: “Americans always do the right thing, but only after they have tried everything else.”

Q. That sounds inspiring, but how are we going to get it done?

A. Now we enter the area of politics in a democratic republic. I admit to ignorance, naivete, and inexperience. But as citizens, we must try.

Bear in mind that the medical-industrial complex is now almost three times the percent of GDP as the military industrial complex. Moreover, we have cause to celebrate impressive results- in diagnostic testing, some cancer treatments, joint replacement, cataract surgery, antibiotics, vaccines, and statins – for examples. These activities are highly organized, intelligent, profitable, and politically sophisticated.

To achieve a public that acts as a rational consumer is, I think, a tough job. Patient advocates help, brochures from disinterested sources help, the internet often helps. No doubt the patient (aka consumer) is the person most interested in his own health. But people are anxious, and anxiety interferes with good information gathering. Patients want to trust the person who is going to treat them. The details can be maddeningly obscure and prolix. We do a lot to educate the public: some advertising is helpful, some generates wasteful expense.

A single payer system and science-based choices will go a long way toward supporting good choices. Patients will always be able to exercise the right to refuse treatment (there are exceptions that require a court order). But we should discourage them from demanding – and getting – ineffective, wasteful treatment.

For the past century, changes have come in increments, each of which seems monumental at the time. Commercial health insurance, benefits for veterans, Medicare, and Medicaid are examples. Currently, electronic medical records are being implemented, not without flaws, complications, and added expense. The gains are speed, fewer errors, and portability with privacy.

At times we turn to what I call a Royal Commission to settle an important question. This works well when the issue lends itself to a well designed study, expert statistical analysis, and massive amounts of data. In the 1960s, Thorazine was conclusively shown to be an effective treatment for acute psychoses using such a study. When the Flexner report came out (1910), it had a great impact on medical education. By contrast, Mrs. Clinton’s effort to assemble a group that would result in health care reform failed, at the time. Whether the current federal legislation will take effect is still in doubt.

The best we can do is pay attention to each crisis as it arises, while keeping the long view in mind.

 

Exeter, NH 11/12/11                                        John Merrifield