Good Healthcare is a Symphony

Good health care is like a fine symphony.  Different professionals and different skills must work in concert to create a result that is much bigger than the individual components.    Here are two versions of a well-known anecdote in the classical music world that has been repeated in many versions over the years.  It tells the story of an efficiency expert enlisted to investigate a symphony orchestra.

Version 1

 He reported: "I found hidden unemployment. At least seven employees played the very same movements, on violins, throughout an entire piece.  On the other hand, the employees in the wind and percussion sections sat through extended periods of a concert without moving a muscle or playing a thing. I also discovered there were entire parts that musicians played over and over, for no reason.  Most of the employees appear to be unskilled as the management has to employ a man, full-time, to wave his arms around and signal to them what to play, when to stop, at what speed, and even at what volume.”

All of this, forced the efficiency expert to come to the conclusion an orchestra is a wasteful institution; it is neither efficient nor profitable; its output may be categorized as "arty and impractical".

Version 2 – A specific report on Schubert’s Unfinished Symphony

1. For a considerable period, the oboe players had nothing to do. Their number should be reduced and their work spread over the whole orchestra, avoiding peaks of inactivity.
2. All 12 violins were playing identical notes. This seems to be unneeded duplication, and the staff of this section should be cut. If a volume of sound is really required, this could be accomplished with the use of an amplifier.
3. Much effort was involved in playing the 16th notes. This appears to be an excessive refinement, and it is recommended that all notes be rounded up to the nearest 8th note. If this were done, it would be possible to use para-professionals instead of experienced musicians.
4. No useful purpose is served by repeating with horns the passage that has already been handled by strings. If all such redundant passages were eliminated then the concert could be reduced from two hours to twenty minutes.
5. The symphony had two movements. If Mr. Schubert didn't achieve his musical goals by the end of the first movement, then he should have stopped there.

In light of the above, one can only conclude that had Mr. Schubert given attention to these matters, he probably would have had time to finish the symphony.

Why do I relate these stories in a discussion of health care?  

In many ways, the move to managed care has been told by these anecdotes.  In the move to make health care more affordable, which is a wonderful goal as it increases access to health care, we have tried to make individual doctor visits more efficient and we have succeeded.  Unfortunately, much of the richness of the physician leading a team and coordinating an effort with the goal of creating a wonderful result greater than the individual pieces has been lost in the process.  As physicians are not rewarded for coordination and in many ways are even discouraged financially from working together the doctors become nothing more than technical experts in their own scientific fields.  Even family physicians who are supposed to be the paradigms of ongoing coordinated care, are unable to do all that needs to be done to assist, coordinate and support those traveling through the complex medical system.  Instead they are expected and trained to see large numbers of patients per day with “simple” illnesses and to triage those who are sicker to specialists. 

But in our complex medical world, there are no simple illnesses.  Every illness has emotional, financial, and social factors.  The mother with small children and limited income who has asthma and needs a chest x-ray and pulmonary function tests needs to understand how to pay any copayments and be able to afford those co-payments, needs a way to schedule the tests, needs a person to watch her children while she goes for the test, and needs help understanding the risks and benefits of the medications that she will have to purchase and take.  She needs someone to help her find the way to communicate all this to her family, who depend on her, and needs help dealing with the stress and fear that accompanies it.  Yet we now have no concert master or conductor.  The primary care doctor has no time, and is not paid to do all this.

I am enough of a traditionalist to believe that a good physician should make the best “conductor” of this symphony although I also know that strong health professionals trained in other disciplines such as nursing, psychology and social work can also play that type of role. It is less a matter of formal degrees and more a matter of communication and coordination skills and resources.  In the best of all possible worlds, a doctor would team with a professional communicator/coordinator/supporter (in Accolade terms a Health Assistant) to give the patient the best chance of having health care that resonates as a fine symphony.  A doctor would then be able to still be relatively efficient while giving the patient everything he or she needs. 

We need both scientific medicine and a symphony like beauty and elegance in the delivery of that medicine.  Until that happens, managed care, of which I am a part, will capture efficiency at the expense of truly caring for those in need.  Here at Accolade, we are committed to providing the humanity that everyone needs in a way that creates cost savings while enhancing the important element of caring.  

The Cost of Hope

 “The Cost of Hope” by Amanda Bennett is billed as “the story of a marriage, a family and the quest for life”.  This excellent book describes Amanda Bennett’s journey through life together with her husband who died of cancer after a long illness.  While Amanda Bennett, a well-known journalist, in part focused the book on many of the problems of high costs and poor communication that confronts families when someone they love is sick, I read it more as a love story than a commentary on health policy.  It is a moving tale of the support she gave her husband and he gave her, when he was faced with a rare cancer with no curative therapy.    It is above all a book about life and a book about the true love that drives people to acts of heroism when faced with disaster. 

When I read this book, I think of all the people I come across professionally who go to work, raise families, and help those closest to them with challenges that the rest of us can only pray to avoid.  The mother of the two year old child who has been sick since age 6 months with a rare illness who lives in a small town in the south and whose husband earns a wage that is not much more than the poverty level comes to mind as one example.  She does not work outside of the home in order to care for her child and has become an expert on this unusual disease, knowing much more than most physicians.  She travels long distances for his doctor’s appointments and communicates with experts around the country via email.  She is also an expert on state, local and federal regulations having to do with care of children, disability issues and other resources.  This woman is a true hero.  Or the business executive I know who has put her career on hold while she cares for her sick, elderly mother who suffers from constant pain.  She is a fierce advocate for her mother, using all of her business skills and her negotiation skills to make sure that the health professionals coordinate and communicate with each other and that her mother never gets caught in the bureaucratic nightmare that Medicare can be. 

When we talk about health care costs, health care policy and health care delivery, we are really talking about people often fighting for their lives, supported by the heroes who love them.  We talk about people showing courage in the face of illness and adversity.  We are talking about individuals and their families finding their way through a complex system of medical opinions which are often contradictory, insurance policies which are often incomprehensible and laws and regulations designed for population and budgetary reasons and not the care of the individual.  We see people taking their and their loved one’s illnesses as a chance to elevate themselves beyond the illness and into a type of nobility of sacrifice and focus. 

Amanda Bennett captures this and by telling her and her family’s story, moves the discussion of health care, which is often mired in partisan political attacks from all sides of the political spectrum into the deeply personal story it is for all of us. 

At Accolade, we are truly fortunate to have found another way of helping people and also addressing some of the cost and quality problems that are part of health care.  We are privileged to be helpers and observers of the heroism of people and their families and to find ways to cheerlead those heroes while also assisting them in their quest for quality care with a strong dose of humanity.  There truly is no better way to make a living and I am thankful every day for what we at Accolade all do. 

Process and Thought Reprinted from Google Plus post

Process and Thought
The big news today is the announcement by the Supreme Court of their decision on the Affordable Care Act (ACA) or ObamaCare as it is referred to.  I write this before knowing the result of that decision and while certainly important, whatever the decision is a person in need will still need a thinking, caring professional to care for them and be with them when they are in need.  For me, the more interesting story this week is the story of two children in Tacoma, Washington who were severely sunburned when a school official would not let them use sun block when they were on a school outing.  The school officials were following a law and a process dictated by that law that did not allow the use of sun block by children without a written prescription by a physician. The school officials in question, by following the policy and process in place insisted they had done nothing wrong.  At the same time, the children were subject to severe sunburn that, in the case of one of the children, was dangerous in that the child had a form of albinism and extreme sun sensitivity.

  Whatever the decision made, our health care is influenced and defined by laws, policies, procedures and statutes. While the laws may change, their presence is a constant.  While laws and procedures are usually put into place with the best of intentions, the consequences of those laws are often unexpected and may be counter to the intent of the “rule makers” whether they are legislators or managers.

The fact is that laws, procedures and statues all can have unintended consequences.  The state legislators in Washington State truly thought they were protecting children from possible allergic reactions to elements of sunblock when they passed that law.  The school officials truly felt that they were being good education professionals by following the law.

 In a recent web first article in Health Affairs, Mary Naylor of the University of Pennsylvania and her co-authors looked at some aspects of the Affordable Care Act (ACA) that are designed to improve transitional care and prevent readmission to the hospital.  The authors found that the incentives built into the act to encourage hospitals to lower readmissions, could instead encourage them to limit access to people with multiple illnesses who are at most risk for readmissions.  The authors also pointed out that the bundled payments that are part of the national pilot program do not include long term care so that the health systems involved could withhold services and “push” them into long term care to create improved finances.  A third part of the ACA calls for community based care transition programs however access to these programs require a hospitalization and often people can be very ill with multiple illnesses but not require hospitalization.  Thus many of those in need would not be eligible unless they were hospitalized which could increase hospitalizations as caring physicians admitted people to help them gain access to the program elements.

The fact is that health care is broad and involves more than just isolated illnesses, insurance contracts and laws.  Health is psychological, social and spiritual. A specific illness or issue is rarely found in isolation but is part of a person who has a unique set of genetic material and unique biologic characteristics often including other illnesses.   Health is a family affair that affects people beyond the patient. Thus no rules, laws or procedures can address every possible person and every possible issue. Thought and judgment are needed by all health professionals and not only rules, policies and procedures.  No matter what the rule or law, a school official should never allow a child to be in danger from the sun, and a health professional should never let a law dictate an intervention that can cause harm or prevent an intervention that can help one in need.  

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Unintended Consequences Of Steps To Cut Readmissions And Reform Payment May Threaten Care Of Vulnerable Older Adults »

Abstract The US health care system is characterized by fragmentation and misaligned incentives, which creates challenges for both providers and recipients. These challenges are magnified for older adu...

ACA and the Supreme Court Reprinted from my Google Plus post

ACA and the Supreme Court
Many people have asked my opinion of the Supreme Court decision concerning the constitutionality of the Affordable Care Act.  While I am flattered to be asked, I am also a little confused as my knowledge and experience is in health and not in constitutional law.  So rather than even try to comment on that decision, I will share some of my thoughts on the ACA now that it is clearly the law of the land. 
 
The ACA is a complex, multifaceted piece of legislation that is over 2,000 pages long.  That fact has been well discussed.  Another aspect of that complexity is that a law is only a starting point.  It is the start of a process that results in the Executive branch of government writing the procedures, requirements and other details of how that law will actually be carried out.  It is said that for every page of legislation that is written, about 100 pages of policies and requirements need to be written in order for the law to be carried out.  Thus, we now have hard working, and well-meaning Federal employees developing these details which could easily total 200,000 pages even as the debate goes on.  Until they are written and then followed, we will not truly understand the full impact of all the different pieces of the law as passed.  That, in general, does worry me. 

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) was passed as a way to better ensure that people’s privacy was protected while in the health care system.  For many, it has been translated into forms that people sign without understanding what they are signing and has led to less communication with family members even though communication is critical when you or a loved one is ill.  The intent of the law was, and remains, wonderful.  The way it is carried out by health care professionals and facilities and by the government agencies that must police it, protects the health industry and make the bureaucrats jobs easier, but does not necessarily help the patient’s privacy.  I do not blame the health professionals or the federal employees.  They are following the logical steps to implement and enforce a law.  The law just places health professionals and facilities in a very difficult place in which they must prove that they are doing what is required and places federal employees in an equally difficult position of having to prove to Congress that they are effectively making sure that the law is in place and working.  Thus the goals become the process rather than the problem of privacy that the law was designed to address. 

That is the lens I have on when I read and review the ACA.  There are wonderful aspects to this law, many of them involved in insurance reform.  As someone who has been in the health insurance industry in one form or another for many years, I am thrilled to see the end of pre-existing condition limitations.  I am also thrilled by the end of lifetime maximums for large, catastrophic situations.  I am more bothered by some of the parts of the legislation that potentially interfere between a doctor and a patient.  In medicine, standards are critical and accountability of health professionals is also critical however the individual variability in patient care is so great, that accountability cannot and should not get in the way of the relationship that must form between a doctor, a patient, and often a family.  The Independent Payment Advisory Board is a 15 member board of experts who will decide on Medicare spending without oversight, including without Congressional oversight.  This worries me.  While I believe it would be well meaning and would focus on the population’s needs, it would not see the individuals behind the population statistics.  Experts are never experts in the care of individuals that they do not know and do not see.  They base their pronouncements on studies, statistics, and academic debates.  If you or a family member is sick, you want your care to be informed by experts but carried out by a caring professional who knows you and your desires and needs.  In many ways, when we pass laws that attempt to define very specifically how individuals should be medically treated, we enter into a dangerous place as the actual practice of medicine, and the care of those in need, is rarely specific and is filled with judgment calls that are different from person to person. 

I have spent a good part of my career trying to reconcile the shades of gray that are medicine to the black and white of laws and finances.  After doing this for more than twenty years, I have finally come to the conclusion that they can never be completely reconciled and instead must live together in a shaky balance.  Laws and finances are needed but there must always be room for deviation when an individual need does not fit the law or the circumstance.  This does not mean breaking a law but it does mean understanding when a law may not apply.  The ACA contains detailed provisions that can potentially be harmful to an individual’s care when it attempts to create false clarity in health decision making.  More often, the decisions are based on different balancing of the risk and benefits (and yes – costs) and are influenced by family, culture, religion, and other individual factors that no board can ever take into account. 

Another aspect of a law that is this big and this expansive is the unintended consequences.  I do worry that as the Advisory Board cuts Medicare spending, that fees for physicians will go down dramatically.  We already have a situation in which doctors are spending far too little time with patients to give the type of quality of care that is often needed.  When unit fees for medical services go down, physicians react in the very human way of increasing their volume of services.  This is not a defense of doctors receiving large sums of money nor is it an indictment of physician greed.  It is an acknowledgment that doctors are also people who have their own needs and desires.  They are usually caring smart people and we have to be careful not to put impediments in their path.  As incomes for physicians go down, and the satisfaction with the career goes down due to less time spent with each patient, the quality of people choosing medicine as a career may also go down.  This is but one example of a potential unintended consequence.  In a recent Health Affairs article, authors from the University of Pennsylvania discussed three other examples from the ACA of parts of the law that may not turn out as desired.  I discussed that in a piece I posted just before the Supreme Court decision. 

So we have taken a complex system and possibly made it more complex with ACA while also improving some aspects of the health insurance industry.  The fact that we will be covering more people is a strong plus.  The challenge is that we need caring, independent professionals who are not focused on the population but on each of us as individuals to diagnose and treat our ailments and care for us..   I fear that the law as written may be a step backward in that very personal aspect of care. 

Understanding the Actuaries: Financial Projections in Health Reform

 

Health Reform will likely become law this weekend.  Many have stated that the recent financial projections from the Congressional Budget Office (CBO) that show the reform package saving money in the first ten years, and reducing the debt in the following ten years gave the wavering moderate Democrats enough political protection to vote for the bill and put it over the top.  The CBO is a very credible agency that is charged by Congress with making actuarial financial projections based on the assumptions that Congress gives it, as well as the specific wording of a bill using accepted standards of actuarial analysis.  The best way to understand actuarial science is through two old jokes.  (My take on this is influenced by my own background as a physician who was a Principle of an Actuarial Firm.)

Jokes About Actuaries

Joke #1 – Three people are trapped in a deep ditch.  They are an engineer, a builder, and an actuary.  The engineer is very upset and says “We will never get out.  There is nothing I can design to allow us to escape!”  The builder then says, “I have no lumber or tools so we will never be able to get out.”  The actuary is sitting at the bottom of the pit smiling.  He say, “Don’t worry.  I will get us out of here.  All we have to do is first assume a ladder.”

Joke #2 – A businessman has to make some financial projections for his company and does not know whether to hire a mathematician, an accountant or an actuary so he decides to interview all three in order to decide.  He first calls in the mathematician and he asks, ‘How much is 2 plus 2?”.  The mathematician answers “4”.  He next calls in the accountant and he asks “How much is 2 plus 2?”.  The accountant answers “That depends on whether we are talking about a cash basis or an accrued basis and whether it is pre tax or post tax.”  The businessman then calls in the actuary and asks “How much is 2 plus 2?”.  The actuary answers  “How much do you want it to be?”  The actuary is promptly hired.

It Is All About the Assumptions

In my professional life, I have spent a great deal of time helping actuaries by defining assumptions based on medical and epidemiological facts.  Those assumptions often dramatically change projections.  In the case of the current health reform package, the leadership of the Congress has developed assumptions that are designed to create a more favorable financial projection.  Thus, at the eleventh hour, the health care bill was modified to also include reform of education loans which has nothing to do with health care.  What that did do, since the CBO assesses the financial impact of the bill, is it included any savings in the education loan reform as being credited towards health reform.  Perhaps the most troubling assumption of the many that were used is the assumption that cuts in Medicare will occur even though there are no concrete proposals to cut costs in that program.  I have written previously about the fact that there is a companion bill which prevents a lowering of Medicare fees to physicians.  The bill assumes that costs will be cut by the following mechanisms:

Proposed Strategies for Reducing Health Care Spending.*

Establish insurance exchanges.

Reduce excessive Medicare payments.

Shift from a volume-based to a value-based payment system in Medicare.

Tax generous insurance plans.

Empower an independent Medicare advisory board.

Address and reduce fraud and abuse within the Medicare program.

Enact malpractice reform.

Invest in information technology and comparative-effectiveness research.

Invest in prevention.

*Adapted from Cutler.4

While Professor Cutler in his Wall Street Journal Op Ed piece outlines optimistically that these components will save money, experience states that each of these efforts will have consequences and political battles that will likely subvert the goals of creating savings.  Many of these strategies can also be put into place without the added expense of increasing coverage dramatically as this bill does and even without new legislation.  The unasked question is why, if they are able to be done, have they not been done already!  The assumptions that create the savings are based on all of these strategies being done in a non-political way that is only designed to save money.  That is rarely the reality.  We are also already investing in information technology and we are already supposed to be reducing fraud and abuse in Medicare yet costs are still rising. 

The History of Congressional Estimates in Health

This habit of creating assumptions that are overly optimistic did not start with this bill.  In 1965, the House Ways and Means Committee estimated that the hospital insurance portion of the Medicare program, Part A, would cost about $9 billion annually by 1990.  Actual Part A spending in 1990 was $67 billion.  In 1967, the House Ways and Means Committee predicted that the new Medicare program, launched the previous year, would cost about $12 billion in 1990.  Actual Medicare spending in 1990 was $110 billion—off by nearly a factor of 10.  Each time these estimates were prepared by actuaries working from assumptions from Congress.  One could go on and on.  It is safe to say that the estimate of the current health reform costing just under a trillion dollars is likely to be very low.

Who Cares?

Perhaps we should not care.  Perhaps the good coming out of the bill is so important that the high costs which every thinking person should recognize should not even be a factor in our assessment of the new law to be.  That may be the case but at the very least, we all deserved a bit more openness and honesty about the costs during the course of the debate.  A recent article in the New England Journal of Medicine put the health reform debate in the context of our national debt.  In the article, Michael E. Chernew, Ph.D., Katherine Baicker, Ph.D., and John Hsu, M.D., M.B.A., looked at our national debt and saw some danger lurking in creating a new national entitlement to increase that debt.  We are currently in debt to a point of danger to our national welfare and security.  Compared to other countries, our debt as a percentage of our Gross Domestic Product (GDP) is seen in this chart.

While the United States was once the example of fiscal strength and prudence, we are now rapidly becoming a profligate spender of other people’s money to a degree greater than Turkey and Spain.

The Answer

I don’t have one.  I only know that I am happy to see certain parts of the health reform bill become law.  I also know that the likely cost of the health reform bill is probably at least double the current CBO estimates (and I am being very conservative).  I am just fearful of the financial future of our country.  Just remember that actuaries are always slaves to the assumptions that they are given.  Unfortunately, if we are stuck in a financial hole, we can’t assume a ladder. 

The Fight for Health Reform

My Own Malaise

One would think that with my expertise and profession, I would be listening to the discussions about the President’s health care proposal with tremendous interest.  Instead, I find myself avoiding the news reports about the proposed legislation.  Rather than a discussion of health care, I see an exercise in raw political power that frankly, leaves me cold.  From the left of the political spectrum, I see almost rabid desire to put into place the basis for a government healthcare system based on a universal “right” of health care that is divorced from any cost discussion, being paid by taxes, presumably only on evil rich people who are defined as anyone who does not work directly for the government or in academe.  On the right we hear about the evils of any government assistance for people truly in need as a slippery slope towards communism.  We seem to have lost any middle in this argument.  Thus I feel only depression and malaise at the way the “end game” on health reform is being played.  The Congressional leadership has decided that the left is in charge so they will move ahead steamrolling those who disagree.  Those on the right appear to be accepting the inevitable while also taking political advantage of the issue for the next election cycle.  I just have deep disappointment in our government leaders who seem more intent on winning at any cost than on finding solutions for the country. 

Lowering Health Care Costs as a False Goal

The goals of health reform are supposedly twofold: increasing coverage of those who are uninsured and lowering costs.  The current legislation is totally focused on coverage for those uninsured and is actually likely to increase costs radically above any CBO estimate despite that being trumpeted as a goal.  The CBO, by law, is required to base cost estimates on only those facts and assumptions that the Congress supplies.  The Congress has created false assumptions that Medicare will show decreases in cost without any plan to decrease costs.  In health care, the only way to decrease costs is to lower payment to providers, namely physicians, hospitals, and other health care professionals and organizations, and/or lower the volume of services which is most easily accomplished by eliminating certain services as benefits.  Lowering payments to physicians is not specified in the bill but there is a fee reduction of 21% currently scheduled, however that has already been reversed by a separate bill passed by the Senate.  This separate bill is a companion to health reform that is not in the CBO calculations and it actually guarantees that physician fees will not be lowered.  Since this is separate legislation it avoids inclusion in the calculation of costs related to health reform.  Recently a bill did pass the Senate maintaining physician salaries for the short term at least.  The AMA memo to their members about that bill read as follows:

AMA renews call for permanent reform of Medicare payment formula for America’s seniors and the physicians that care for them

For immediate release:
March 10, 2010

Statement attributable to:
J. James Rohack, MD
President, American Medical Association

“Today, the U.S. Senate voted to again delay this year’s steep 21 percent Medicare physician payment cut to October 1, pushing the problem off into the near future.  If the House adopts this Senate bill, America’s seniors and their physicians will be left in limbo, and access to health care for Medicare patients will continue to be in grave danger.  Physicians cannot keep their practice doors open to all Medicare patients without clear direction from Congress on Medicare payment rates. Already, Medicare payment rates are far below the costs of providing patient care, and physicians are left wondering how they can continue to run a medical practice if Congress does not inject security and stability into the Medicare program.

“Short-term actions are the wrong answer to a long-term problem.  These band-aid fixes have only served to increase the size of the cuts and the cost of reform. The longer Congress delays, the higher the cost to the American taxpayer.  It’s time to fix the formula and ensure that seniors can count on Medicare now and for years to come.”

If the AMA is unsuccessful, we will then be in a position in which physicians will be earning significantly less for serving Medicare patients.  Physicians in response, will either stop accepting Medicare, or shift costs to commercial insurers.  The logical next step would be an outcry by the public to either raise the rates paid to physicians or force physicians to accept lower fees and lower incomes.  If they are forced to accept lower incomes, there may be many who would be happy with that turn of events however it will create a problem of the best and the brightest deciding to go into other fields that are more lucrative.  That could be a loss to all of us.  That is currently a problem in England with the medical profession lacking new young British physicians.  If the AMA is successful, we then face the problem of ever increasing health care costs unless rationing is put in place. 

Rationing means limiting the services rendered, however the current bill actually adds services by mandating certain benefits that are not the norm right now.  Under the bill, a Federal Board will determine which benefits should be mandated.  While many people worry about the rationing of care leading to fewer services, the other side of that coin is the Federal Board increasing coverage for those services that have powerful politics behind them, even if they are not medically helpful.  Thus we will likely see different groups lobbying for coverage of their pet area increasing the volume of services and increasing costs while other services are rationed to lower costs.  We already know that in states that mandate in vitro fertilization for infertility, now only do those costs directly related to in vitro services increase but the number of sick newborns also increase and that increases neonatal intensive care costs dramatically.  Will costs of mandates such as that be offset by rationing of dialysis for the elderly for example?  We just don’t know.

There are answers to this conundrum however those answers, such as health savings accounts and other vehicles which results in informed decisions by patients leading to self rationing are rejected out of hand by this current legislation.

What is the Real Goal?

If the bill is likely to increase costs then what is the real goal and how will it be achieved?  Certainly the social goal of universal coverage is laudatory however it appears to go beyond that.  Two lead opinion pieces in the most recent American Journal of Public Health suggest the long term political goals of this legislation.  In “Selling the Obama Plan: Mistakes, Misunderstanding, and Other Misdemeanors”, Howard Waitzkin of the University of New Mexico waxes eloquent about how everyone loves Medicare and how all that needs to happen is for Medicare to be the only insurer for the entire population.  He does ignore the fact that Medicare is running out of money as it has virtually no controls for cost in place.  The only way the costs would be controlled would again be lower payments to providers and rationing.  While Dr. Waitzkin expresses unhappiness with the current proposal as not going far enough, he also sees the single payer system as being put into place in the long run.  For him, that is a sign of optimism and for me, it is a tremendous fear as it will signficantly decrease medical innovation and our cultural emphasis on care for the individual.  In some ways, Dr. Vincente Navarro of Johns Hopkins University goes even further in his companion article “Consequences of the Privatized Funding of Medical Care and of the Privatized Electoral Process”.  According to Dr. Navarro, Obama’s biggest mistake thus far is that he has not gone far enough in general and has thus “antagonized the left by excluding single-payer”.  Dr. Navarro then goes on to say that this is all a problem created by a privatized electoral system.   Thus it is more government control in health care and even in electoral politics that is the ultimate goal for Dr. Navarro. 

The Audacity of Hope

The audacity of my hope is that even if this bill passes, the effects will be modulated by future legislation by new representatives in coming years.  This bill is phased in over years so I can only hope that any damage done by it can be overturned in the next few years.  This bill does have positive aspects  such as the elimination of pre existing condition provisions and we should in some way focus on the good that can come out of the legislation.  In the meantime, I just stay in my malaise.  It is probably why I could never be in politics.  It just depresses me.

Inspiration Needed

I have been remiss in updating this blog recently, and partly it has been my tendency to wait until I see something that truly inspires me or at least amuses me enough to write about.  There has certainly been nothing in the health care debate that is either inspiring or amusing and there have not been any blockbuster scientific studies that I have read that have really caused me to sit up and take notice.  But I did receive an email from a faithful reader who asked me whether I thought it would be likely for former President Bill Clinton to have had the same care under the health care reform approaches being put forth by our Congress.  That inspired me.

What Happened to Bill?

For those of you who have not been reading the news, President Clinton has stents placed in two of his coronary arteries this past week after having chest pain.  He is a patient with known coronary artery disease who underwent bypass surgery in 2004.  According to new reports, he developed chest pain and was taken to the hospital where the procedure was done.  He was discharged twenty four hours later in good spirits and presumably in good health.  Had he not had the procedure, one can confidently predict he would have had a heart attack.

Was His Care Different and Would Reform Have Made it Different?

The short answer is that I do not believe that his care was any different than anyone else’s care at Columbia Presbyterian Hospital in New York except that I believe that the attending physician, and not the physician in training, preformed the procedure and that is often not the case in a teaching hospital such as Presbyterian.  I also don’t believe that any of the health proposals on the table would have made an immediate difference in the care he received.  Over time the proposals did put into place mechanisms that could change this approach based on cost/benefit/risk analysis.

So far, the Blog isn’t even Interesting let along Inspiring!

Yet the question made me think about other factors.  President Clinton does have excellent care and has a physician who he can call, hear he has chest pain, know him well enough to understand the possibility of a heart attack, and immediately arrange for the needed, correct care.  That is the part that seems to be to be different under today’s health care and could even get more different in a number of the proposals being made.  In today’s world of medicine for the average person, their contact with the doctor is very short and relatively impersonal.  There is no time taken to really know a patient when you are seeing twenty to thirty patients a day.  Of course there is a small number of people who the average doctors knows well, and a small number of doctors who know all their patients well, but those exceptions are on the tail end of this bell curve.  That is bad now and could conceivably get worse as we move towards a world in which physicians are incented and even rewarded for doing their work quickly and as close to a median norm as they can be. 

Personal Attention as a Vice or a Virtue

While we need to foster more evidence based medicine, more use of electronic information systems and more normative behavior among doctors, we also have to remember that medicine ultimately is personal and caring.  While I want my doctor to know the right thing to do in a situation and I want him to stick with practice guidelines and best practice standards, I also want him or her to understand that best practices are all based on statistical probabilities and that there are always people who are not in the center of the probability curve but two  standard deviations away.  A good doctor will have the judgment to ignore best practice when a patient who does not fit the norm appears.  I fear that the virtue of following “best practice” will turn out to be great for 80 – 90% of patients and potentially deadly for the rest.  Best practice medicine can easily become lowest common denominator medicine.  The present proposals, and even many of today’s approaches make the virtues of following the cookbook of best practice so overwhelming that it becomes a vice.  The moment that a physician is afraid to do the right thing for a patient because it doesn’t fit the normative notion of “best practice”. is the moment our system becomes dangerous for some of us.

Back to Bill

I don’t believe that will ever be a problem for our former President.  I have not been able to determine if President Clinton was told to call 911 and get an ambulance and then be first seen in the emergency room although I doubt it even though every protocol I know for the “best practice” of dealing with acute chest pain in a person with known coronary artery disease would call for that approach.  Under our new incentives, will his physicians be punished with lower payments or even black marks against him or her for licensure or future contracting?  Under a new system, will President Clinton have been required to first have a stress test before going straight to the angiography suite as the costs of angiography are grappled with?  I don’t know the answers and only hope that my family’s care will always be the kind of personal care that the President received.

One Last Word

I love getting questions as they do inspire me so please send them.