Doctors and Nurses
4 Reasons Why Tort Reform Won't Be Part of Health Reform
Published September 03, 2009 @ 06:45AM PT
I could be wrong, of course. An amendment containing language to reduce the high cost of medical malpractice insurance could be offered from the floor of the House or the Senate. A backroom deal with a moderate Republican in exchange for a small number of votes could yield some additions to the health care bill. But I don’t think it’s likely. Tort reform won’t be in whatever bill emerges out of Congress, and there are four good reasons why.
1.) We’re working through the wrong committees
Nothing gets Congress tied into a snit more than breaking rules of jurisdiction with regards to committee assignments. Take the current situation in the Senate. The Senate Health, Education, Labor and Pensions Committee would have loved to be able to write an entire health care bill themselves. Had they done so, it could have been debated on the Senate floor for three weeks before the August recess. But they had to wait for Senate Finance, because no one else has jurisdiction to write laws concerning Medicare, Medicaid and tax revenue. The only reason the House is further along is because all three committee chairs with jurisdiction on health care were working together from the get go -- that’s the exception, not the rule on complicated bills like this.
We have five committee working on health care in total this year -- and none of them have jurisdiction over tort reform. That’s entirely in the hands of House Judiciary and Senate Judiciary -- and the House committee has a well-earned reputation for being particularly partisan and, at times, nasty (see “Clinton Impeachment Resolution”). The quickest way to kill health care reform dead would be to add two more committees to it. So that’s not going to happen.
2.) You can’t negotiate if you’re not at the table
Reforming medical malpractice as a way of driving down costs in health care isn’t a Democratic Party issue. It’s a Republican Party issue. As I’ve written (and as former Sen. Bill Bradley wrote this weekend), there’s a logical deal here to make health care reform pass with some bipartisan support. But look, for whatever reason, Republicans aren’t at the table to deal. When they talk about tort reform, as Sen. Mike Enzi did this weekend, it’s in the context of a complete alternative to the proposal on the table, not as a deal. When they’re in back rooms with the “gang of six”, we hear about reduced subsidies, about ditching the employer mandate, etc. – it’s all about reducing what’s there, not adding a new element.
And it’s not like there aren’t willing partners. President Obama has been further out front on this than most Democrats, and Max Baucus’ famous white paper on health reform contained a whole section of intriguing ideas on malpractice reform. But the folks at the table ain't dealing. And Democrats aren't going to give way on an issue like malpractice only to have Enzi and Grassley then vote against their own compromise. (And if they do, maybe they should be sued for legislative malpractice).
3.) Tort reform does jack for reducing health care costs
There are many good reasons for fixing medical malpractice. The system we have doesn’t adequately help patients who have legitimately been injured, many of whom never bother filing a claim. It freaks the hell out of doctors who overreact through doing extra, unnecessary tests and procedures -- known as “defensive medicine.” There’s a crazy-quilt of different regulations based on what state and specialty you’re in. It’s a mess.
But reducing health care costs is not a good reason for tort reform. And it won’t at all get a good score from the Congressional Budget Office, which says, “even a reduction of 25 percent to 30 percent in malpractice costs would lower health care costs by only about 0.4 percent to 0.5 percent, and the likely effect on health insurance premiums would be comparably small.” Granted, the CBO is somewhat pessimistic of savings in health care in general, but they’re backed up by the actuarial firm of Towers Perrin, which as Tom Baker says in an interview with the NY Times, pegs “litigation costs and malpractice insurance at 1 to 1.5 percent of total medical costs. That’s a rounding error. Liability isn’t even the tail on the cost dog. It’s the hair on the end of the tail.”
Rewarding Primary Care, But Not Nurse Practitioners
Published August 29, 2009 @ 04:32PM PT
With health care, we keep saying the perfect shouldn't be the enemy of the good. But as good as the bills moving through Congress are when it comes to expanding access, improving quality and giving us tools to finally begin to control costs, there are a few areas where the bills simply whiff. One of the worst is how little money is set aside to both improve the quality of education and increase the numbers of nurse practitioners and physician assistants for a health care system that’s desperate for them.
If we waved a magic wand and covered all the uninsured tomorrow, would we have enough doctors to provide care? The answer is yes and no. For specialists, unquestionably – orthopedic surgeons, radiologists, dermatologists and other specialties are in no short supply. But for primary care, where low reimbursement and high burnout rates have led to only half the available residency slots in primary care being filled each year by American graduates, the answer is no. Filling this gap are nurse practitioners and physician assistants – nurses who have been trained to do as much as 80% of the tasks associated with a primary care physician. At a time when we already have a primary care doctor shortage, having 75,000 PAs and about 140,000 NPs has helped get us through, particularly in high need areas, at community health clinics and in the medical home model of care. Just to mention it, primary care nurses also get paid significantly less than primary care physicians ($81,000 vs. $160,000 as posted on KevinMD), which help brings health care costs down. And a study in Health Affairs suggests patient satisfaction with the level of care given by NPs and PAs is high.
So why is there so little to promote NPs and PAs in health care reform? Let’s look at the House bill. There’s an expansion of the National Health Service Corps for primary care physicians, a new loan program also for primary care doctors, increased rates for primary care in Medicare and especially in the far-too low Medicaid rates. But nothing specifically directed to NPs and PAs. No funding for more of the nursing school instructors that we so desperately need, let alone for the relatively new specialized doctoral-level instructors required. No primary care bonuses to attract skilled nurses to get the extra training required. No money for community health clinics or medical homes using NPs and PAs as a cost-saver. The only time NPs are even mentioned in the House bill is to say they’re not disqualified from working at said medical homes.
Why aren’t we investing in more nurse providers, even just to get us through the current primary care crunch before the programs for physicians in the bills have a chance to work their magic? Difficult to say – but the American Medical Association seems pretty happy with them being left out. In their FAQ on HR 3200, they make clear, “we do not support nurse practitioners practicing independently, without at least regular consultation with a physician.”
It’s a big omission, and it doesn’t quite seem worth it.
(Photo credit thebone on Flickr.)
Why Hospitals Are Loving Health Care Reform
Published August 27, 2009 @ 11:23PM PT
We talk all the time about health care reform from the perspective of doctors, insurance companies, pharmaceutical companies. But hospitals get overlooked. More than that – they're keeping a low profile. When the White House announced its deal with the American Hospital Association, Catholic Health Association, and the Federation of American Hospitals, it didn’t even warrant the President showing up for the photo-op – they used Joe Biden instead. One can be forgiven for not knowing where hospitals stand on the push for comprehensive health care reform.
But the answer is quite simple. They get a lot of money. So yes, they’re for it.
Part of the confusion is so many others are speaking on behalf of hospitals – including, weirdly enough, insurance companies. In their attempt to find examples of how a public health insurance option would be harmful to anything else besides their own profit margins, released a report suggesting that if a public option were based on Medicare rates, every hospital in California would go broke. Sounds like a joke, right? The analysis was disingenuous in the extreme – no version of the public option in current legislation is based on Medicare rates at all. But it gave me a case of whiplash to see Big Insurance sticking up for hospitals when just a few months ago they were throwing them under the bus. In reaction to a Health Care for America Now report tying the consolidation and monopolization of the insurance industry to increased premiums, AHIP lashed out at hospitals: “Studies over many years have shown clearly that rising health care costs are the result of increases in hospital costs, increases in physician expenses, and increases in the cost of pharmaceuticals.”
Confusing, right? But whether hospitals are greedy money leeches causing rising health care costs, or innocent victims of imaginary government-run health care gone mad, the impression is they’d be against the bills moving in Congress.
Except, as evinced by the White House deal, they’re prepared to support reform, even if they haven’t endorsed specific legislation. Bloomberg explains the simple math behind the decision:
Community Health Systems Inc., HCA Inc. and other hospital groups would receive $171 billion over 10 years in reimbursements for the newly insured under legislation to provide medical coverage for all U.S. citizens, the AHA said in a report to industry and lawmakers. The benefit would more than offset $155 billion in proposed cost cuts during the same period that hospitals promised in a deal with the White House.
As much as hospitals may complain about Medicare rates or low rates from HMOs, the fact is that uncompensated care is actually a larger drag. In my own Congressional district, hospitals and providers lose $135 million in uncompensated care each year. Sure, the Obama Administration is asking them to take on some cuts, particular in subsidies that they currently receive for caring for the uninsured – money that they won’t need if the uninsured have quality health care plans. Unmentioned in the Bloomberg article are the other goodies. After all, many of the more aggressive long-term cost-cutting measures actually involve compensating hospitals for something new – a social worker to follow-up with a recently-hospitalized patient to make sure they’re following instructions and preventing costly re-admissions. Medicaid rates - a much sorer spot for hospitals - would be increased under the House bill. And, of course, a national push for Health IT and new residency slots for primary care will benefit hospitals directly.
So don’t listen to the insurance companies. Hospitals are going to be just fine when health care reform gets passed. In fact, they’re quite likely to come out ahead in the game.
(Photo credit: Chealion on Flickr.)
Rationed Care vs. Rational Care
Published August 13, 2009 @ 11:32PM PT
People are fond of thinking that we haven’t figured out how to "bend the curve" of escalating costs within our health care system. Especially among opponents of reform, all you’re hearing is that government is incapable of controlling costs through any other methodology than denying care. Usually when pressed, those same critics have a hard time pointing out how the private sector has ever effectively controlled costs – except, of course, for the denial of care from HMOs. But the actual truth is that we do know how to get better, more cost-effective care… or at least, some of areas of the country already do. We just have to figure out how to share what we know.
That’s the backdrop for today’s article in the NY Times by Drs. Atul Gawande, Donald Berwick, Elliot Fisher and Mark McClellan, as they take up an old and often misunderstood topic. We talk about things like per capita spending or cancer survival rates in the U.S. We even compare our rates to other countries. But health care in the United States is anything but homogenous. So the four doctors took a deeper look at the best-performing regions in terms of controlling costs – areas where they not only spend less now but where the cost growth rate is lower than the rest of the country, yet thet still have above average quality. In short, areas in the U.S. that even without health care reform are “bending the curve.”
What’s the secret?
Well, again and again the answer seems to be “They just looked at the data.” The article is fancifully titled, “10 Steps to Better Health Care,” but it really is one lesson: practice medicine based on the evidence, and give doctors the chance to learn and make better decisions. That goes for the town in Cedar Rapids which tracked the number of CAT Scans performed and realized that ratio was way out-of-whack. That goes for Portland, where they worked collaboratively to study the data on medical errors, as well as for Sacramento, where their big investments were in competition based on the data from electronic records. Like a medical version of the Observer Effect, the act of observing changes the observed. Put numbers in front of doctors and they inevitably learn how to pay attention to the health of their practice, not just the health of their patients. It’s something so simple that it’s amazing we don’t do it already, especially since, as the writers report, “neither the physicians nor the citizens reported feeling that care is ‘rationed.’ Indeed, it’s rational.”
The Congressional Budget Office tends to largely ignore the savings to be derived from electronic records and reorganizing doctors to working collaboratively instead of in fragments. Instead, the CBO favors such actuarial fixes like automatic caps on care and making it more expensive to have "cadiallac" insurance plans through the tax code. These are more predictable than focusing on quality for accountants, I suppose. But to do so ignores the track record not just around the world, but here at home.
Tucked into the health care bills moving in Congress and largely ignored by the CBO and so-called “fiscal conservatives” are provisions to increase investment in Health IT to track data, give extra payments through Medicare for “medical homes,” episodes of care and other models for getting providers to work collaboratively rather than separately, and creating a new Center for Quality Improvement whose mission will be to do the “best practices” surveying that these four doctors did -- and then making sure that information disseminates, especially into the most wasteful and costly regions. I imagine these parts of the bills will continue to get overlooked. They shouldn’t. A New England Journal of Medicine article on regional variation laid out the possibilities: “Reducing annual growth in per capita spending from 3.5% (the national average) to 2.4% (the rate in San Francisco) would leave Medicare with a healthy estimated balance of $758 billion, a cumulative savings of $1.42 trillion.”
We don’t have to ration care, we don’t need to hand-wring that there are no answers, and we don’t have to necessarily reinvent the wheel. But we need to do a much better job of passing on what we already know works.
(Photo credit: southerntabitha on Flickr.)
Don't You Dare Take Away My Useless Placebo!
Published August 07, 2009 @ 10:09PM PT
NPR and the NY Times both ran stories about multiple newly-released studies that call into question the effectiveness of a longstanding treatment for the pain caused by osteoporosis. Not the comparative effectiveness – the effectiveness, period. Within the context of the wild rumors about what investing in comparative effectiveness research will or will not do to the quality of care, the studies couldn’t come at a better time. It’s not just the results themselves that show how badly we need to fund and learn from more of this research. It’s the reactions to that research by doctors and patients that is most revealing – and alarming!
Vertebroplasty was devised as a treatment for back pain caused by fractured vertebrae. Until 15 years ago, the options for treatment were limited to localized pain killers, rest, back braces, that sort of thing. But then, a researcher at the Mayo Clinic became the first American physician to injecting a type of cement into the damaged bone to reinforce it. The procedure is not without its flaws – an infrequent risk is that the cement will leak into the blood and damage vital organs, or that the cement in one or two vertebrae will lead to breaks in others. There’s also the cost -- $1,000 to $2,000 for an MRI, followed by $2,500 to $3,000 for the procedure. Still, it was quick, easy, and popular – patients usually reported relief from the pain, and 73,000 people had the procedure done last year alone. No problem, right?
Well, one big problem. Simultaneous studies in Australia, Great Britain and the U.S. showed that despite its popularity, it was no more effective than a placebo. Patients reported the same amount of pain relief from the procedure that costs thousands of dollars as they did from getting a simple Novocain injection and, in one of the surveys, being told that they were receiving the cement injection, without actually receiving it. As orthopedic surgeon Dr. James Weinstein summarized, “What it said to me is that essentially this is a treatment with no effect, and it probably shouldn't be done any more.” Dr. Rachelle Buchbinder, who participated in the test in Australia, was even starker in her assessment: “It does not work.”
Open and shut, right? After wall, it was confirmed in three different studies – including one designed by Dr. David Kallmes, the radiologist who first attempted the treatment at the Mayo Clinic.
Not so fast. This is American health care. We don’t make decisions based on effectiveness, let alone cost-effectiveness.
After all, vertebroplasty makes over $250 million a year for providers. Dr. Kallmes knew what this meant: “I’m going to be the most reviled radiologist on the planet.” Indeed, NPR writes this intriguing sentence: “The head of the North American Spine Society says the broken vertebrae studies show that both the placebo and cement procedures work.” Placebos work, at root, because we think they work. That’s how the NY Times is able to write about, “One patient in the study, Jeanette Offenhauser, 88, said she was convinced that the cement had helped her severe back pain, even after hearing the results.” But here's the thing, those of you wondering how much patient choice will be affected by this devious display of actual scientific research. Nowhere in the stories does it suggest that this research will become unavailable or even curtailed, or even that that's a possibility for the future. The most the doctors want is to be able to present the options – as in, if it’s a placebo anyway, you may wish to go for the cheaper option, or you should at least know that there’s no real evidence that the more expensive option works better.
As more and more negative ads and unruly shouters shriek about rationing, about denial of care, and about how we shouldn’t consider ever cutting a dime out of Medicare (despite those same people often going on to point how Medicare spending is out of control), it’s hard not to think the placebo effect is alive and well in politics, not just American medicine.
(Photo credit: damclean on Flickr.)
Who's Holding Doctors Back?
Published August 06, 2009 @ 06:27AM PT
We still hear a lot about how health care reform will interfere between a doctor and a patient. We hear that people (government, Obama, Nancy Pelosi, what have you) shouldn't substitute their ideology or opinion in a way that overrules the choices that doctors make. We're told that the government, as empowered in HR 3200 and the Senate Health Education Labor and Pension bill, or in HR 676, the Medicare for All bill, will just get in the way.
Interesting.
This video first made the rounds of the Web this time last week. At the same time, there was a meeting in the Senate of representatives of physician groups which, in aggregate, totaled 450,000 doctors. If you really value your doctor's judgment, you should watch this:
Oh, and that's not all.
HR 3200, the America's Affordable Health Choices Act, has been officially endorsed by the American Academy of Family Physicians, the American College of Obstetricians and Gynecologists, the American College of Physicians, the American College of Surgeons, the American Medical Association, the American Nurses Association, the American Osteopathic Association, the American Psychiatric Association, Doctors for America, the National Medical Association, and the National Physicians Alliance.
I'm not a mathematician, but that's a @#$% lot of doctors.
So who's really interfering with the health care choices made and prescribed by doctors? Who's interfering with their ability to determine what's best for their patients? If you're working against the passage of health care reform this year, isn't the answer -- well -- you?
(Disclaimer: Although my day job involves working with resident physicians, my employer is neither referenced in nor had a role in creating any of the material above. Even were it otherwise, the opinions and views expressed are my own.)
Krugman, Sarcasm and Soylent Green: The Best of the Weekend
Published August 02, 2009 @ 05:53PM PT
Every Sunday, I’ve taken to posting the best of the best – the three must-reads or must-watches that will really help you parse what’s going on. During the presidential campaign, we took to calling the period where the importance of what was covered was in inverse proportion to the frequency with which it was covered “silly season.” This week, the focus seemed to be on – well – beers at the White House. ‘Nuff said.
So here are the three weekend articles you won’t want to miss to remove some of the silliness from your coverage. As we move into August, the misinformation begins to fly. Most of it will be reported as “he says/she says” by the news – two sides of an argument that deserve equal weight. But as these writers show, there’s a big difference. One side is looking to address the problems of our broken health care system, and the other is trying to make it seem as confusing and hopeless as possible.
If there’s a silver lining, it’s that so many great writers are determined not to let the agents of the status quo have the last word.
1.) Paul Krugman – “Health Reform Made Simple”
I’ve lost track of the number of people who have asked why there can’t be a simple 2 page description of what’s going on in health care reform and then, when I start to explain it in as simple terms as I know how, stop me with questions that get both deep and technical. Of course, the deep, technical questions are how it’s supposed to be – participatory democracy should involve meat and not just baby food. But it does point out an interesting fact – it’s easy enough to debate health care reform in a couple of hours or in a 100-page document. It’s tough to debate it in a few minutes and 500 words.
But just as I comforted myself with that notion, Paul Krugman delivers the best and most succinct explanation of health care reform you can imagine. And yes, it’ll take you minutes to read:
The essence is really quite simple: regulation of insurers, so that they can’t cherry-pick only the healthy, and subsidies, so that all Americans can afford insurance. Everything else is about making that core work…
That’s it. Any commentator who whines that he just doesn’t understand it is basically saying that he doesn’t want to understand it.
Read the whole blog post here.
2.) Jonathan Alter, “What’s Not to Like?”
Satire is the art of turning a preposterous argument on its head to demonstrate its truly silly core. With this Newsweek article, subtitled “Reform? Why do we need health-care reform? Everything is just fine the way it is,” Alter undresses what is beginning to become a popular argument of saying the convoluted, wasteful, prohibitively expensive and abusive American health care system doesn’t need fundamental change. It’s an argument so at odds with the experience of most Americans when dealing with an illness or injury that it deserves what Alter gives it – sarcasm:
I had cancer a few years ago. I like the fact that if I lose my job, I won't be able to get any insurance because of my illness. It reminds me of my homeowners' insurance, which gets canceled after a break-in. I like the choice I'd face if, God forbid, the cancer recurs—sell my house to pay for the hundreds of thousands of dollars in treatment, or die. That's what you call a "post-existing condition."
I like the absence of catastrophic insurance today. It meant that my health-insurance plan (one of the better ones, by the way) only covered about 75 percent of the cost of my cutting-edge treatment. That's as it should be—face cancer and shell out huge amounts of money at the same time. Nice…
Speaking of fair, it seems fair to me that cost-cutting bureaucrats at the insurance companies—not doctors—decide what's reimbursable. After all, the insurance companies know best.
Read the whole article on Newsweek's site.
3.) The White Coat Underground, “Health Care Reform – How to Obfuscate, Confuse and Inflame”
I wasn’t following this blog but, after this post, it’s a must have on my RSS reader. PaulMD is an internist in the Great Lakes region, and he knows malarkey when he sees it. The new constant refrain (the new “socialized medicine is bad,” if you will) of those who would like to continue profiting financially and/or politically from the current inefficiencies of our health care system goes something like this: the government will overrule your doctor. The supposed villain is comparative effectiveness research. Well, it just so happens that PaulMD is a doctor. His diagnosis of this fear-mongering argument? It’s baloney:
How does [Betsy McCaughey] justify this unjustifiable conclusion? She doesn't. She simply asserts it. "Comparative effectiveness" is an au courant term used to describe research that looks at medical practices and tried to assess its effects. For example, there are two surgical ways to fix blood flow to the heart muscle: percutaneous coronary interventions (PCIs) such as angioplasty and stenting, and coronary artery bypass grafting (CABG or "heart bypass"). I'm not going to teel you which one is better, because the answer is complicated and still being investigated, but to choose the correct therapy for a patient we must answer a number of questions: which works best in which kind of patient; how long does each last; which has lower complication rates; which leads to longer survival; which leads to longer survival without additional need for a second intervention; which costs more, and over what time period; which makes people feel and function better. These questions and others need to be asked about many of the things we do, and comparative effectiveness research is a reasonable way to approach this.
To ignore these questions because we don't like the answers is so frighteningly ignorant that it's hard to believe an intelligent person could suggest it. Knowing these answers doesn't mean it's time to start making Soylent Green. What we do with the information is where our ethics as individual and as a society are tested. If we find that kidney dialysis in eighty year olds on average does not provide much quality or quantity of life, do we decide to stop covering it? Do we create algorithms for deciding what do offer an individual? Do we make a subjective choice in each case?
(Photo credit: taekwonweirdo on Flickr.)
