Congratulations to all the newly minted and matched doctors! Now that the dust from the celebrations of your feats have settled, there is no time like the present to address the shortage of doctors in the United States. No matter what stage of training you are currently in, you have probably heard that there is a "shortage of trained physicians", especially primary care doctors, in the context of our rapidly aging population - it's all over the news. What I would like to hear more about is the untapped supply of trained physicians available for immediate and excellent patient care: foreign medical graduates and foreign physicians.
American vs. Foreign Medical Schools
If you look at the residency match statistics, the medical school graduates most likely to match are those from American medical schools. Why is this the case? Do students who go to the Caribbean or abroad necessarily not as "well-trained" as those in the US? Absolutely not. We all come out of medical school with a similar base of knowledge. Although students at some medical schools may have more on-the-job responsibility and training than at other schools, there is no evidence that this has any impact on quality of patient care. We become better doctors based on accumulated experience over the years during residency and beyond, so the notion that local and international graduates provide different outcomes is ridiculous. Good doctoring is a matter of perseverance, patience, humility and teamwork - and I have seen this from graduates of medical schools all over the place.
It floors me to hear fellow graduates assess the quality of a residency program by the number of "FMGs" that train there - this reeks of elitism and is not founded in any actual science. No studies have shown different outcomes outcomes in patients depending on the medical school of origin of the residents. The first such study showed no mortality difference between international and domestic graduates, but such studies are very difficult to conduct as numerous physicians, especially at academic centers and residency programs, play a role in the care of each patient.
I consider myself fortunate to have been trained at an excellent medical school - getting into medical school is tough and getting more difficult every year. However, the excellent physicians I have worked with thus far hail from everywhere ranging from the top of the US New & World Report rankings to the bottom, to around the world. What makes them good is their dedication to each of their patients and their hard work.
Foreign Physicians in the United States
As described in this New York Times article, the road to becoming a fully-fledged physician in the US for doctors who have practiced for years in other countries is formidable. I have met innumerable excellent physicians, who have practiced abroad as surgeons, internists, anesthesiologists, ophthalmologists, radiologists and neurologists. These doctors move to the United States and are forced to either pick new careers, or repeat at least three years of residency training in order to continue practicing their trade. Many of these individuals often end up in rural residency programs, since many American graduates tend to shy away from primary care and rural settings.
Why is this the case? Are medical schools and hospitals in other countries inferior to ours? Absolutely not. The language of medicine is universal. To believe that our educational and training capacity are somehow superior reeks of American exceptionalism. There are excellent hospitals in developed and developing nations. Furthermore, these individuals have what may American residents lack: experience. Experience, not regurgitative assessments in examinations, is the vehicle through which doctors learn their trade and become great physicians. If we compare our healthcare outcomes (mortality rates, efficiency, management of chronic disease) to those in many other countries, and then magnify this comparison to efficacy and complication rates in individual top hospitals in different countries, the differences are minimal.
This article on KevinMD.com cites communication as a barrier to higher utilization of foreign physicians. However, does this automatically obligate repeating residency? I propose an abbreviated program (not more than a year) that ensures physicians from foreign countries have the appropriate English speaking capability and can practice up-to-date, evidence-based care - anything more than this is a waste of valuable time that can be spent caring for more patients.
I am happy that we are opening more medical schools to care for our rapidly aging and growing patient population. However, I believe we are doing our patients a disservice by inadequately utilizing FMGs and international doctors, an often very competent and experienced pool of available physicians. If we are going to promote the supremacy of "evidence-based medicine", I would like to see studies of differential outcomes before baseless elitism and American exceptionalism in the way we treat these physicians.
Monday, April 7, 2014
Thursday, March 20, 2014
Reflections on Healthcare Economics: The Costs of Defensive Medicine
Physicians frequently cite defensive medicine (i.e., ordering extra tests, imaging, studies to fend off potential lawsuits) as a contributor to soaring health costs. Though the jury is still out on the extent of the costs of all this extra, often unnecessary, work up, it is undeniable that a significant proportion of physicians frequently consider the legal implications of their medical decision-making.
Brief background and statistics: Surveys of physicians have shown that significant proportions (80-90%) report practicing defensive medicine. Estimates of how much this practice contributes to healthcare costs vary widely, since the subjectivity of defensive medicine makes it very difficult to measure retrospectively. Most experts believe anywhere between 1-2% of total health spending is attributable to defensive medicine, but this is extremely challenging to calculate. If one ignores the costs of defensive medicine and focuses on the liability system, the costs amount to a puny 1.5% of healthcare spending. A recent prospective study attempting to quantify the incidence and cost of defensive medicine in Orthopedic Surgery revealed that defensive practices accounted for 19.1% of orders (x-rays, MRIs) and 34.7% of the cost.
The controversy arises from the fact that many health policy experts do not believe that tort law reform will result in the dramatic cost reductions that physicians often predict. They point to states where capped damages have not necessarily resulted in reductions in cost. Furthermore, there is a concern that patients who are victims of gross negligence may suffer from inadequate compensation in states with capped damages.
This line of thinking would suggest that tort reform may not be the most urgent priority for our legislators. We have yet to tackle increasing coverage, changing reimbursement, improving quality, etc. So why do physicians advocate for tort law reform?
Although the contribution to the total may seem minimal, 1-2% of billions of dollars is not insignificant. Furthermore, with the coming changes to the healthcare system that reward efficient provision of healthcare (i.e. not ordering unnecessary tests, imaging and procedures), it will be important to reduce the practice of defensive medicine. Consider a scenario:
Imagine that you are an emergency medicine physician about to see a 50-year-old patient who experienced a witnessed fainting episode - his wife tells you he was standing up from sitting down on a hot day and fell backwards onto their sofa and was briefly unresponsive before regaining consciousness. He is otherwise healthy and has no other medical problems. He denies any other recent symptoms, medications, travel, or sick contacts. His vital signs and physical exam are totally within normal limits. Would you order a head CT scan? Or would you order a chest x-ray and cardiac injury markers routinely in young patients presenting with uncomplicated chest pain?
These scenarios often result in divergent answers from different clinicians. Some practitioners would want to be sure they are not missing something dangerous (like an intracranial hemorrhage or myocardial infarction, respectively). Others would be reassured by the benign presentation of these patients and hold off on ordering further testing. This spectrum exists across every clinical decision because of differing appetites for risk from clinician to clinician. This is a phenomenon influenced by many factors, such as level of training/experience, clinical context, the patient seen just before this one, and even the state of being in an active lawsuit! For example, my clinical experience may drive me to "want to be sure" and order the extra test, whereas my attending may feel comfortable without the extra testing. Miller et al show that clinicians with a recent malpractice suit are more likely to order tests for defensive reasons. Atul Gawande describes studies where the EKG diagnosis determined by a clinician is influenced by the diagnosis of the previous EKG. Experience can also be a relative handicap - if the first two patients you prescribe blood thinners to happen to end up with fatal gastrointestinal or intracranial hemorrhage, you may hesitate prior to prescribing the same medication to the third patient. This is the challenge of different risk appetites in different clinicians for different clinical situations.
Take this already complex situation and add the caveat of bundled payments that reward "efficient" practice. Will a doctor in the hypothetical clinical scenario described above forego the head CT scan if he or she knew that their paycheck may be affected? It depends. Personally, I would rather take the hit on my paycheck rather than risk malpractice claims that can destroy reputations and instill years of anxiety and distraction associated with litigation.
To me, the strongest indication for tort law reform is to better enable clinicians to practice efficient medicine in the bundled payments model. Physicians will be more likely to only order the necessary testing/imaging if the persistent paranoia of litigation is attenuated, as articulated in this article in Journal of General Internal Medicine.
How can we address this issue going forward?
There are many potential solutions:
1) Litigation for gross negligence: Some states (e.g., Georgia) have attempted to move towards medical malpractice only for gross negligence. This means that all reasonable, well-trained clinicians would be expected to make certain decisions, order certain tests, and prescribe certain medications in a given clinical situation. Physicians not adhering to this standard and making decisions that harm patients are viewed as practicing in a "grossly negligent" fashion. An example of gross negligence is the physician that fails to order cardiac enzymes and an EKG in a male patient with a cardiac history and diabetes who presented with "crushing" sub-sternal chest pain radiating down the left arm. Interestingly, in Georgia and Texas, two states with recent tort law reform, mortality rates have remained the same or declined. Although this is a crude measure of patient safety, there is no evidence that patient safety has been sacrificed.
2) Capped damages: Some people have proposed that capping damages in medical malpractice claims can potentially reduce frivolous claims. However, in some places where this has been enacted, health care costs have not come down. Furthermore, there are concerns that patients with legitimate claims may not receive adequate compensation.
3) "Safe harbor": Similar to the gross negligence concept, the "Safe Harbor" model proposed by the Center for American Progress recommends the definition of national evidence-based guidelines and utilization of clinical-decision support systems. These would define the actions a trained and reasonable physician would be expected to take in a given clinical situation. Patients (and their lawyers) would have to establish that these clinical standards were not met when presenting a claim. This would reduce a problem faced currently: the fact that there are wide variations in practice from one health system to another. We have begun to address the issue - under the Choosing Widely initiative, 35 specialties released standard recommendations on common testing modalities and imaging. This effort is laudable and should be expanded to national standards for most common clinical situations - the challenge will be in nationwide implementation.
4) Non-adversarial medical malpractice compensation: It is now widely accepted that individual blame is counter-productive when a medical error occurs and patient safety is compromised. Most experts recognize and advocate that medical errors occur due to systemic failures in the provision of healthcare (errors occurring in the "Swiss cheese model"). This concept is described in "To err is human" and has revolutionized the way hospital systems address and improve patient safety. While there is evidence that fear of lawsuits affects medical-decision making, there is no evidence for reduced rates of medical error with the current litigious atmosphere. For this reason, some have proposed different ways of addressing fair compensation when a medical error occurs. One option is a "workers' compensation" type of board (under the Patient Compensation System) where patients can take grievances, instead of having physicians going to court. Such a board would provide a means for compensation, physicians would still pay malpractice premiums, and there would be a venue for addressing negligence and suspension of licensure for egregiously gross negligence.
Tort law reform will not be the panacea of health care cost reduction. However, it is clear that physicians' decisions are affected by fear of litigation. There is no evidence, however, that the threat of litigation has improved patient safety. The new paradigms focusing on the systemic causes of medical error provide more promising means of improving patient safety. Until the fear of litigation is attenuated, it may be difficult to achieve rapid gains in cost reduction under the bundled payments model.
“No matter what measures are taken, doctors will sometimes falter, and it isn't reasonable to ask that we achieve perfection. What is reasonable is to ask that we never cease to aim for it.”
― Atul Gawande, Complications: A Surgeon's Notes on an Imperfect Science
Brief background and statistics: Surveys of physicians have shown that significant proportions (80-90%) report practicing defensive medicine. Estimates of how much this practice contributes to healthcare costs vary widely, since the subjectivity of defensive medicine makes it very difficult to measure retrospectively. Most experts believe anywhere between 1-2% of total health spending is attributable to defensive medicine, but this is extremely challenging to calculate. If one ignores the costs of defensive medicine and focuses on the liability system, the costs amount to a puny 1.5% of healthcare spending. A recent prospective study attempting to quantify the incidence and cost of defensive medicine in Orthopedic Surgery revealed that defensive practices accounted for 19.1% of orders (x-rays, MRIs) and 34.7% of the cost.
The controversy arises from the fact that many health policy experts do not believe that tort law reform will result in the dramatic cost reductions that physicians often predict. They point to states where capped damages have not necessarily resulted in reductions in cost. Furthermore, there is a concern that patients who are victims of gross negligence may suffer from inadequate compensation in states with capped damages.
This line of thinking would suggest that tort reform may not be the most urgent priority for our legislators. We have yet to tackle increasing coverage, changing reimbursement, improving quality, etc. So why do physicians advocate for tort law reform?
Although the contribution to the total may seem minimal, 1-2% of billions of dollars is not insignificant. Furthermore, with the coming changes to the healthcare system that reward efficient provision of healthcare (i.e. not ordering unnecessary tests, imaging and procedures), it will be important to reduce the practice of defensive medicine. Consider a scenario:
Imagine that you are an emergency medicine physician about to see a 50-year-old patient who experienced a witnessed fainting episode - his wife tells you he was standing up from sitting down on a hot day and fell backwards onto their sofa and was briefly unresponsive before regaining consciousness. He is otherwise healthy and has no other medical problems. He denies any other recent symptoms, medications, travel, or sick contacts. His vital signs and physical exam are totally within normal limits. Would you order a head CT scan? Or would you order a chest x-ray and cardiac injury markers routinely in young patients presenting with uncomplicated chest pain?
These scenarios often result in divergent answers from different clinicians. Some practitioners would want to be sure they are not missing something dangerous (like an intracranial hemorrhage or myocardial infarction, respectively). Others would be reassured by the benign presentation of these patients and hold off on ordering further testing. This spectrum exists across every clinical decision because of differing appetites for risk from clinician to clinician. This is a phenomenon influenced by many factors, such as level of training/experience, clinical context, the patient seen just before this one, and even the state of being in an active lawsuit! For example, my clinical experience may drive me to "want to be sure" and order the extra test, whereas my attending may feel comfortable without the extra testing. Miller et al show that clinicians with a recent malpractice suit are more likely to order tests for defensive reasons. Atul Gawande describes studies where the EKG diagnosis determined by a clinician is influenced by the diagnosis of the previous EKG. Experience can also be a relative handicap - if the first two patients you prescribe blood thinners to happen to end up with fatal gastrointestinal or intracranial hemorrhage, you may hesitate prior to prescribing the same medication to the third patient. This is the challenge of different risk appetites in different clinicians for different clinical situations.
Take this already complex situation and add the caveat of bundled payments that reward "efficient" practice. Will a doctor in the hypothetical clinical scenario described above forego the head CT scan if he or she knew that their paycheck may be affected? It depends. Personally, I would rather take the hit on my paycheck rather than risk malpractice claims that can destroy reputations and instill years of anxiety and distraction associated with litigation.
To me, the strongest indication for tort law reform is to better enable clinicians to practice efficient medicine in the bundled payments model. Physicians will be more likely to only order the necessary testing/imaging if the persistent paranoia of litigation is attenuated, as articulated in this article in Journal of General Internal Medicine.
How can we address this issue going forward?
There are many potential solutions:
1) Litigation for gross negligence: Some states (e.g., Georgia) have attempted to move towards medical malpractice only for gross negligence. This means that all reasonable, well-trained clinicians would be expected to make certain decisions, order certain tests, and prescribe certain medications in a given clinical situation. Physicians not adhering to this standard and making decisions that harm patients are viewed as practicing in a "grossly negligent" fashion. An example of gross negligence is the physician that fails to order cardiac enzymes and an EKG in a male patient with a cardiac history and diabetes who presented with "crushing" sub-sternal chest pain radiating down the left arm. Interestingly, in Georgia and Texas, two states with recent tort law reform, mortality rates have remained the same or declined. Although this is a crude measure of patient safety, there is no evidence that patient safety has been sacrificed.
2) Capped damages: Some people have proposed that capping damages in medical malpractice claims can potentially reduce frivolous claims. However, in some places where this has been enacted, health care costs have not come down. Furthermore, there are concerns that patients with legitimate claims may not receive adequate compensation.
3) "Safe harbor": Similar to the gross negligence concept, the "Safe Harbor" model proposed by the Center for American Progress recommends the definition of national evidence-based guidelines and utilization of clinical-decision support systems. These would define the actions a trained and reasonable physician would be expected to take in a given clinical situation. Patients (and their lawyers) would have to establish that these clinical standards were not met when presenting a claim. This would reduce a problem faced currently: the fact that there are wide variations in practice from one health system to another. We have begun to address the issue - under the Choosing Widely initiative, 35 specialties released standard recommendations on common testing modalities and imaging. This effort is laudable and should be expanded to national standards for most common clinical situations - the challenge will be in nationwide implementation.
4) Non-adversarial medical malpractice compensation: It is now widely accepted that individual blame is counter-productive when a medical error occurs and patient safety is compromised. Most experts recognize and advocate that medical errors occur due to systemic failures in the provision of healthcare (errors occurring in the "Swiss cheese model"). This concept is described in "To err is human" and has revolutionized the way hospital systems address and improve patient safety. While there is evidence that fear of lawsuits affects medical-decision making, there is no evidence for reduced rates of medical error with the current litigious atmosphere. For this reason, some have proposed different ways of addressing fair compensation when a medical error occurs. One option is a "workers' compensation" type of board (under the Patient Compensation System) where patients can take grievances, instead of having physicians going to court. Such a board would provide a means for compensation, physicians would still pay malpractice premiums, and there would be a venue for addressing negligence and suspension of licensure for egregiously gross negligence.
Tort law reform will not be the panacea of health care cost reduction. However, it is clear that physicians' decisions are affected by fear of litigation. There is no evidence, however, that the threat of litigation has improved patient safety. The new paradigms focusing on the systemic causes of medical error provide more promising means of improving patient safety. Until the fear of litigation is attenuated, it may be difficult to achieve rapid gains in cost reduction under the bundled payments model.
“No matter what measures are taken, doctors will sometimes falter, and it isn't reasonable to ask that we achieve perfection. What is reasonable is to ask that we never cease to aim for it.”
― Atul Gawande, Complications: A Surgeon's Notes on an Imperfect Science
Tuesday, March 4, 2014
What Makes a "Good Doctor"?
What makes a good doctor? Is it the ability to memorize countless facts, associations, studies and clinical trials? Up-to-date evidence-based patient care? Being a good listener? Consistent stamina and test-taking skills during recurrent, long, and drawn out exams? Or is it simply the silent and willing forfeiture of one's life to the care of others? In my experience, the following qualities are what make a good physician - this is what I want in a physician when I inevitably require one:
1) Perseverance
It drives me insane when people equate becoming a physician with intelligence. While the road to MD/DO degrees involves countless and never-ending tests and the accumulation of volumes of knowledge, this does not endow upon our profession the characteristic of intelligence. On the contrary, the road takes immense perseverance - it is challenging to sit and study for test after test, year after after. As long as an individual has this characteristic, they can become a physician. It does not take the epic intellect that people often believe is a pre-requisite for entering the profession.
It takes perseverance to wake up daily at 4:30 AM, get in to work by 6:30 AM for 12-16 hours of work a day. Every minute of these working hours is completely filled by talking to patients and families, calling consultants, rounding, writing notes, placing orders, admitting new patients, discharging others, and teaching students, all the while being interrupted incessantly every few minutes for another task that demands instant attention. Notice that most of these activities do not involve the intellectual exercises of diagnostic reasoning and treatment planning. None of this even involves the regurgitation of memorized facts. Some of the best doctors I know perform these activities without any complaining or whining - they effectively perform the day-to-day routines that comprise patient care.
2) Patience
It takes forever to go through medical training - 4 years of undergraduate, 4+ years of medical school, 3-7 years of residency and 1-3 years of fellowship. This means that most of us do not have our first salaried jobs (research jobs do not count) until our late 20s at the earliest. This involves many significant opportunity costs, including skewed personal finances, strained social lives, and the wholehearted consumption of all free time to the pursuit of professional goals.
Though I have no regrets and am immensely thankful for the opportunity to care for patients, I sometimes wonder: if I had chosen one of my other passions:
- Where would I be living? (Home in NYC, obviously)
- How many countries would I have been to? (Probably > 40)
- Where would I be working? How much would I be making? How positive would my net worth be? (anything is better than the current abyss of red ink/negative yardage)
- Would I be an actor? A hip hop choreographer? A singer? A consultant? A trader? (probably an actor/singer/dancer)
- How many more significant family events would I have been able to attend?
Though I have no regrets and am immensely thankful for the opportunity to care for patients, I sometimes wonder: if I had chosen one of my other passions:
- Where would I be living? (Home in NYC, obviously)
- How many countries would I have been to? (Probably > 40)
- Where would I be working? How much would I be making? How positive would my net worth be? (anything is better than the current abyss of red ink/negative yardage)
- Would I be an actor? A hip hop choreographer? A singer? A consultant? A trader? (probably an actor/singer/dancer)
- How many more significant family events would I have been able to attend?
3) Teamwork
Medicine has always been a team game. With the recent changes to duty hours and the dramatic increase in the number of handoffs and cross coverage, this has become truer than ever. Being a good team member is critical in providing effective patient care and making a stressful work environment more enjoyable. What does this entail? It involves the skills of being a leader, follower, facilitator, and teacher; good team members play all of these roles simultaneously - I have been fortunate to be a part of many such teams during my career. Studies have shown the importance of teamwork within High Reliability Organizations (HROs) in high-risk work environments where errors can have huge consequences but occur infrequently; this is the ideal that we should seek in the provision of healthcare.
The best doctors remember that the most important team member is the patient. Patients are the most important determinants of the ultimate outcomes. This means that we do our part to enable patients to take ownership of their care by providing appropriate education and ensuring we convey the importance of follow up and compliance.
4) Humility
While it takes perseverance and patience to become a doctor, I believe the most important trait in a practicing physician is humility. We practice an art that is filled with uncertainty. No two patients are similar; no matter how many studies are done, each patient will have idiosyncrasies that deviate from the patients studied in the cardinal trials. Furthermore, we often work with incomplete information; a differential diagnosis is an amalgamation of competing probabilities that vary with the unique characteristics of each patient, how they tell their story, and the accumulated experience of the physician.
Finally, human beings are fallible and physicians are no different. Dr. Atul Gawande beautifully articulates this in his book "Complications". Medical decision-making is heavily influenced by internal and external factors, such as fatigue, misleading cues in a patient's history, the diagnosis associated with the patient seen immediately prior to a given patient, and how pressed a physician is for time. A physician's memory is similarly affected by these factors. This is what makes medicine challenging. Given these factors, I do not want the perfect physician to be my doctor; I want one who acknowledges the uncertainties in clinical practice and as well as his/her own limits and potential for fallibility. I want the doctor that does not rely on imperfect memory and chooses to look things up when doubts arise.
Fallibility is influenced by intrinsic as well as extrinsic factors - inexperience is the most common internal factor in young trainees. Inexperience can be rectified, but the extrinsic factors that we cannot control are more frightening. This is especially true for surgical fields: operative success and complication rates provide excellent statistics on the track record and experience of a given surgeon. However, how can we predict whether the next case is unsuccessful or is complicated by adverse outcomes? If/when I need surgery, I plan to seek what I feel are the most important factors in surgical outcomes: experience and confidence in the face of the routine as well as the unexpected.
---
Given the uncertainty that often shrouds our work, I believe there is no room in medicine for arrogance, for that would imply greater control over the unknowns that is realistically possible. I hope that I will be able to practice throughout my career with unending perseverance, patience, teamwork, and humility.
Medicine has always been a team game. With the recent changes to duty hours and the dramatic increase in the number of handoffs and cross coverage, this has become truer than ever. Being a good team member is critical in providing effective patient care and making a stressful work environment more enjoyable. What does this entail? It involves the skills of being a leader, follower, facilitator, and teacher; good team members play all of these roles simultaneously - I have been fortunate to be a part of many such teams during my career. Studies have shown the importance of teamwork within High Reliability Organizations (HROs) in high-risk work environments where errors can have huge consequences but occur infrequently; this is the ideal that we should seek in the provision of healthcare.
The best doctors remember that the most important team member is the patient. Patients are the most important determinants of the ultimate outcomes. This means that we do our part to enable patients to take ownership of their care by providing appropriate education and ensuring we convey the importance of follow up and compliance.
4) Humility
While it takes perseverance and patience to become a doctor, I believe the most important trait in a practicing physician is humility. We practice an art that is filled with uncertainty. No two patients are similar; no matter how many studies are done, each patient will have idiosyncrasies that deviate from the patients studied in the cardinal trials. Furthermore, we often work with incomplete information; a differential diagnosis is an amalgamation of competing probabilities that vary with the unique characteristics of each patient, how they tell their story, and the accumulated experience of the physician.
Finally, human beings are fallible and physicians are no different. Dr. Atul Gawande beautifully articulates this in his book "Complications". Medical decision-making is heavily influenced by internal and external factors, such as fatigue, misleading cues in a patient's history, the diagnosis associated with the patient seen immediately prior to a given patient, and how pressed a physician is for time. A physician's memory is similarly affected by these factors. This is what makes medicine challenging. Given these factors, I do not want the perfect physician to be my doctor; I want one who acknowledges the uncertainties in clinical practice and as well as his/her own limits and potential for fallibility. I want the doctor that does not rely on imperfect memory and chooses to look things up when doubts arise.
Fallibility is influenced by intrinsic as well as extrinsic factors - inexperience is the most common internal factor in young trainees. Inexperience can be rectified, but the extrinsic factors that we cannot control are more frightening. This is especially true for surgical fields: operative success and complication rates provide excellent statistics on the track record and experience of a given surgeon. However, how can we predict whether the next case is unsuccessful or is complicated by adverse outcomes? If/when I need surgery, I plan to seek what I feel are the most important factors in surgical outcomes: experience and confidence in the face of the routine as well as the unexpected.
---
Given the uncertainty that often shrouds our work, I believe there is no room in medicine for arrogance, for that would imply greater control over the unknowns that is realistically possible. I hope that I will be able to practice throughout my career with unending perseverance, patience, teamwork, and humility.
Monday, February 17, 2014
Incentivizing Good Health Habits
Some of the most expensive contributors to the cost of healthcare are chronic medical conditions and health behaviors, such as diabetes, obesity, and smoking. For example, the estimated costs of obesity and smoking in the US are $254 billion and $96 billion, respectively. These estimates obviously do not encompass the opportunity cost in lost productivity, as it is quite difficult to calculate with accuracy.
Given these immense costs, many policy experts and physicians have advocated incentivizing good health habits, such as weight loss and smoking cessation. If research shows increased risk of adverse health outcomes that cost individuals and the system more, should individuals who "choose" less healthy lifestyles not pay more in terms of premiums, copays, and deductibles? Or conversely, should people who are or become "healthier" over time be rewarded by lower payments? (Sort of like the "Vanishing Deductible" concept popularized by Nationwide)
Given nondiscrimination laws enshrined in the Health Insurance Portability and Accountability Act (HIPAA), employers and insurance companies opt for the latter, by offering individuals discounts if the engage in healthy habits, such as maintaining a healthy BMI or abstaining from smoking. However, as this great article in the New England Journal of Medicine illustrates, this approach is fraught with potential ethical hurdles. The authors argue that the approach may end up being unintentionally discriminatory to individuals on the lower end of the socioeconomic spectrum who may not have the means to exercise or eat healthy or individuals who try, but fail, to lose weight.
This is an extremely important point. Exercise and healthy eating are often challenging for individuals living from paycheck to paycheck, or those who live in neighborhoods where healthy food options are limited or gym memberships are prohibitively expensive. After struggling to lose weight myself, I appreciate the numerous barriers to developing healthy habits. Insurance schemes that reward weight loss should absolutely take into account socioeconomic background and a patient's ability to exercise and eat healthy, or we may effectively be punishing people for failing to achieve something they may not have the ability to accomplish. As physicians, our job is to consider these limiting factors before simply advising patients that they "really should lose some weight". We need to work with patients to come up with strategies to live healthier lives, even within the limits of socioeconomic status.
Given these immense costs, many policy experts and physicians have advocated incentivizing good health habits, such as weight loss and smoking cessation. If research shows increased risk of adverse health outcomes that cost individuals and the system more, should individuals who "choose" less healthy lifestyles not pay more in terms of premiums, copays, and deductibles? Or conversely, should people who are or become "healthier" over time be rewarded by lower payments? (Sort of like the "Vanishing Deductible" concept popularized by Nationwide)
Given nondiscrimination laws enshrined in the Health Insurance Portability and Accountability Act (HIPAA), employers and insurance companies opt for the latter, by offering individuals discounts if the engage in healthy habits, such as maintaining a healthy BMI or abstaining from smoking. However, as this great article in the New England Journal of Medicine illustrates, this approach is fraught with potential ethical hurdles. The authors argue that the approach may end up being unintentionally discriminatory to individuals on the lower end of the socioeconomic spectrum who may not have the means to exercise or eat healthy or individuals who try, but fail, to lose weight.
This is an extremely important point. Exercise and healthy eating are often challenging for individuals living from paycheck to paycheck, or those who live in neighborhoods where healthy food options are limited or gym memberships are prohibitively expensive. After struggling to lose weight myself, I appreciate the numerous barriers to developing healthy habits. Insurance schemes that reward weight loss should absolutely take into account socioeconomic background and a patient's ability to exercise and eat healthy, or we may effectively be punishing people for failing to achieve something they may not have the ability to accomplish. As physicians, our job is to consider these limiting factors before simply advising patients that they "really should lose some weight". We need to work with patients to come up with strategies to live healthier lives, even within the limits of socioeconomic status.
The potential for punitive incentivization is especially true for weight loss - most diets do not work and people often gain back much of what they have lost. True, lasting weight loss comes not from fad diets, but from revamped habits of exercise, portion control, and limiting culinary indulgences.
I disagree with the authors on the application of incentives to quit smoking. Irrespective of socioeconomic status, quitting smoking does not require a gym or access to healthy foods. Smoking essentially amounts to a life-shortening and unnecessary expense for all those who partake. While it is imperative to have access to smoking cessation aids, quitting must start with education about the harmful effects of tobacco smoke, from coronary artery disease and strokes to several types of cancer. For the lower end of the socioeconomic spectrum, it even makes economic sense to drop a habit that costs greater than $7 a day. As long as patients are provided with the appropriate education, counseling and resources, and yet fail to reduce tobacco use in a given time frame, shouldn't their premiums be higher?
Several companies already do this in some form. From an actuarial perspective, this model is based on risk calculation and makes complete sense, incentivizing the patient to lower their risk or face direct penalties, similar to how getting a ticket for reckless driving results in higher insurance premiums. Importantly, this tactic has the potential to wield significant influence in health insurance, where currently people have no financial incentive to stay healthy because their premiums are based on pooled risk of many people. Directly aligning how much a patient pays for insurance with their dedication to keeping themselves healthy could reduce costs for the individual as well as for society. However, this approach will need to be refined to avoid discrimination as well. For example, insurance companies will have to be more liberal in covering medications and patches that help people quit. If not, we will run into the same problem with people at the lower end of the socioeconomic spectrum being less successful with smoking cessation given the relative higher out of pocket costs they would face as part of a smoking cessation program.
Several companies already do this in some form. From an actuarial perspective, this model is based on risk calculation and makes complete sense, incentivizing the patient to lower their risk or face direct penalties, similar to how getting a ticket for reckless driving results in higher insurance premiums. Importantly, this tactic has the potential to wield significant influence in health insurance, where currently people have no financial incentive to stay healthy because their premiums are based on pooled risk of many people. Directly aligning how much a patient pays for insurance with their dedication to keeping themselves healthy could reduce costs for the individual as well as for society. However, this approach will need to be refined to avoid discrimination as well. For example, insurance companies will have to be more liberal in covering medications and patches that help people quit. If not, we will run into the same problem with people at the lower end of the socioeconomic spectrum being less successful with smoking cessation given the relative higher out of pocket costs they would face as part of a smoking cessation program.
Incentive programs are easy to talk about, but will likely face some difficulty with implementation. In addition to the aforementioned potential for discrimination, there will always be individuals who try to game the systems. This is no different than athletes who game the anti-doping rules in professional sports or professionals who abstain from drug abuse prior to pre-employment drug tests. However, this is a small price to pay if we end up with a more healthy population that costs less to care for.
Interesting thought: instead of all these incentive programs affecting premiums/deductibles/copays, what if insurance companies (or employers) just paid people in cash for meeting certain health targets? This concept is similar to several anti-poverty programs (such as Brazil's Bolsa Familia) that provide financial support to poor families only if they vaccinate or send their children to school, for example. This benefits the family as well as society as a whole, which now has healthier and potentially more productive members of society joining the ranks. Why not pay people to maintain a low BMI or quit smoking? Given the thousands it costs to care for a patient after they have a heart attack fueled by smoking and obesity, it may make more economic sense to pay patients to reduce their risk factors. If insurance companies do this, it would not cost the taxpayers anything either, avoiding any fiscal congressional acrimony. This has been tried in a limited scale before, with little success: John Cawley reports a study of wellness programs that included 2,635 individuals across the country that failed to result in meaningful weight loss and struggled with commitment to the program. As he explains, this may have resulted from the parameter that was being measured (e.g. weight loss that may not have accounted for weight gain in the form of muscle) or inadequate incentives (the financial reward was not high enough to change behavior). It is possible that if applied more broadly by insurance companies or perhaps in specific populations (e.g. lower end of the socioeconomic spectrum), this program can result in meaningful changes to health outcomes and cost, but more studies are clearly needed.
Regardless of how we end up incentivizing good health habits, we must remember to avoid making our patients feel ashamed. At the end of the day, all behaviors are habits that are immensely difficult to change in a short time span. We must acknowledge this difficulty and provide positive feedback and instructive guidance, working with our patients to come up with personalized solutions to lose weight and quit smoking. I like to tell my patients of my own experience with weight loss and emphasize the positivity in small victories: even one pound lost in a week or one less cigarette smoked a day are steps in the right direction. I certainly hope that in addition to constructive counseling and guidance, financial incentives leave us with a healthier population that is less expensive to care for.
Sunday, February 9, 2014
Reflections on Healthcare Economics: Inadequate Insurance Coverage and the Emergency Medical Treatment and Active Labor Act (EMTALA)
Everyone should know by now that over 47 million Americans were uninsured in 2012. As a medical student, I knew that this well-known statistic contributes to healthcare costs, but my experiences during residency has opened my eyes to exactly how.
First off, insurance companies generally work with hospital systems and standalone practices (which are becoming less common over time), to predetermine rates for the provision of medical care. For being included in a insurance company's list of "in-network" providers, these hospitals provide discounted rates for a given healthcare commodity. This benefits both parties, as hospitals get preferred access to the patients on the insurer's books, while insurer's pay discounted rates for their customers' care. Patients would also obviously benefit from lower costs, as this may mean lower deductibles and copays.
Therefore, when an uninsured individuals goes to an Emergency Room and gets admitted to the hospital, they receive bills that are significantly higher than they would if they had been insured. This is especially more difficult at the lower end of the socioeconomic spectrum: about 38% of the uninsured include people under the Federal poverty line. The average cost of a hospitalization in 2010 was almost $10,000. The average night spent in the hospital in the United States is over $1,500, but this number varies widely from state to state and in different types of hospitals. Imagine the impact of such a bill for a family making less than $23,050 who do not have health insurance! This highlights the potential cost-saving benefits to individuals and the system as a whole of expanding coverage, whether it is with an individual mandate or not.
Working in the ER early in my first year of residency revealed some of the implications of the Emergency Medical Treatment & Labor Act (EMTALA). EMTALA was passed in 1986 by Congress with good intentions: any person that requires emergency medical treatment can receive it at any ER without any questions asked about their ability to pay for care. First of all, physicians should ideally never consider a patient's socioeconomic status and ability to pay for care. However, from a cost perspective, the impact of this law has been atrocious - millions of people who do not have insurance have utilized the ER for all of their healthcare needs. The practice of defensive medicine in the ER alone has served to amplify the effects of millions of people using the ER as their primary care physician for even trivial chief complaints and medical conditions (more on this later). Hospitals often have to front these costs; about 55% of the costs of caring for the uninsured are not reimbursed.
How can we overcome this challenge? First of all, more people need to be covered with some type of insurance plan. This is the goal of the individual mandate that has caused so much political controversy. However, from a cost modeling standpoint, if more healthy, young, otherwise uninsured individuals join the market, it should spread the risks undertaken by insurance companies now obligated to cover people with pre-existing illnesses. Unfortunately, at this point in time, enrollment of these healthy individuals is far below what is needed to make this feasible. It is believed that the penalty of failure to enroll is too low to incentivize enough individuals to sign up.
Certain populations, especially those in less wealthy parts of the country and in big cities, will still have plenty of uninsured patients even after broader implementation of the individual mandate. Therefore, whenever an uninsured patient has an interaction with the healthcare system, whether it be in the ER, the clinic, or the inpatient setting, every effort should be made to encourage and assist patients in seeking out an insurance plans; this is where case managers can potentially make a huge impact. Hospitals benefit from this too - the reimbursement for a future hospitalization for a patient at high-risk for readmission (such as one with CHF or COPD, for example) will be higher if that patient presents with insurance.
There have been been instances during my training where I have seen patients have longer hospital stays because they have no health insurance. For example, if a patient presents with something as life threatening as a blood clot in the lung, known as a pulmonary embolism, and this patient cannot afford an outpatient anticoagulation regimen that could hasten discharge (bridging with Lovenox), then as physicians, we are obligated to keep the patient in the hospital to bridge with heparin. Situations like this still happen frequently, but I hope the incidence drops over the next few years.
The ACA applies to US citizens as well as naturalized citizens, but does not apply to undocumented immigrants. Almost 20% of the 47 million uninsured are undocumented. This is a travesty, as many of these patients also utilize the ER, and are essentially left out of the healthcare overhaul. Furthermore, these individuals often suffer from the same chronic illnesses (heart disease, diabetes, obesity) that cost our healthcare system billions of dollars. When they present to the emergency room for care, it is often because of the catastrophic consequences of these illnesses (myocardial infarctions, strokes, etc.) that add significantly to cost and negatively affect the balance sheets of hospitals. I have taken care of plenty of such patients. Ideally, we should allow undocumented immigrants to purchase health insurance from exchanges - but that would be politically tricky, as people against immigration reform would consider this legitimization of what they consider their "illegal" status. I hope that the immigration reforms currently being consider in Congress considers the provision of health care to undocumented immigrants, since addressing this issue is something both sides of the aisle can agree on - cutting the cost of healthcare overall.
First off, insurance companies generally work with hospital systems and standalone practices (which are becoming less common over time), to predetermine rates for the provision of medical care. For being included in a insurance company's list of "in-network" providers, these hospitals provide discounted rates for a given healthcare commodity. This benefits both parties, as hospitals get preferred access to the patients on the insurer's books, while insurer's pay discounted rates for their customers' care. Patients would also obviously benefit from lower costs, as this may mean lower deductibles and copays.
Therefore, when an uninsured individuals goes to an Emergency Room and gets admitted to the hospital, they receive bills that are significantly higher than they would if they had been insured. This is especially more difficult at the lower end of the socioeconomic spectrum: about 38% of the uninsured include people under the Federal poverty line. The average cost of a hospitalization in 2010 was almost $10,000. The average night spent in the hospital in the United States is over $1,500, but this number varies widely from state to state and in different types of hospitals. Imagine the impact of such a bill for a family making less than $23,050 who do not have health insurance! This highlights the potential cost-saving benefits to individuals and the system as a whole of expanding coverage, whether it is with an individual mandate or not.
Working in the ER early in my first year of residency revealed some of the implications of the Emergency Medical Treatment & Labor Act (EMTALA). EMTALA was passed in 1986 by Congress with good intentions: any person that requires emergency medical treatment can receive it at any ER without any questions asked about their ability to pay for care. First of all, physicians should ideally never consider a patient's socioeconomic status and ability to pay for care. However, from a cost perspective, the impact of this law has been atrocious - millions of people who do not have insurance have utilized the ER for all of their healthcare needs. The practice of defensive medicine in the ER alone has served to amplify the effects of millions of people using the ER as their primary care physician for even trivial chief complaints and medical conditions (more on this later). Hospitals often have to front these costs; about 55% of the costs of caring for the uninsured are not reimbursed.
How can we overcome this challenge? First of all, more people need to be covered with some type of insurance plan. This is the goal of the individual mandate that has caused so much political controversy. However, from a cost modeling standpoint, if more healthy, young, otherwise uninsured individuals join the market, it should spread the risks undertaken by insurance companies now obligated to cover people with pre-existing illnesses. Unfortunately, at this point in time, enrollment of these healthy individuals is far below what is needed to make this feasible. It is believed that the penalty of failure to enroll is too low to incentivize enough individuals to sign up.
Certain populations, especially those in less wealthy parts of the country and in big cities, will still have plenty of uninsured patients even after broader implementation of the individual mandate. Therefore, whenever an uninsured patient has an interaction with the healthcare system, whether it be in the ER, the clinic, or the inpatient setting, every effort should be made to encourage and assist patients in seeking out an insurance plans; this is where case managers can potentially make a huge impact. Hospitals benefit from this too - the reimbursement for a future hospitalization for a patient at high-risk for readmission (such as one with CHF or COPD, for example) will be higher if that patient presents with insurance.
There have been been instances during my training where I have seen patients have longer hospital stays because they have no health insurance. For example, if a patient presents with something as life threatening as a blood clot in the lung, known as a pulmonary embolism, and this patient cannot afford an outpatient anticoagulation regimen that could hasten discharge (bridging with Lovenox), then as physicians, we are obligated to keep the patient in the hospital to bridge with heparin. Situations like this still happen frequently, but I hope the incidence drops over the next few years.
The ACA applies to US citizens as well as naturalized citizens, but does not apply to undocumented immigrants. Almost 20% of the 47 million uninsured are undocumented. This is a travesty, as many of these patients also utilize the ER, and are essentially left out of the healthcare overhaul. Furthermore, these individuals often suffer from the same chronic illnesses (heart disease, diabetes, obesity) that cost our healthcare system billions of dollars. When they present to the emergency room for care, it is often because of the catastrophic consequences of these illnesses (myocardial infarctions, strokes, etc.) that add significantly to cost and negatively affect the balance sheets of hospitals. I have taken care of plenty of such patients. Ideally, we should allow undocumented immigrants to purchase health insurance from exchanges - but that would be politically tricky, as people against immigration reform would consider this legitimization of what they consider their "illegal" status. I hope that the immigration reforms currently being consider in Congress considers the provision of health care to undocumented immigrants, since addressing this issue is something both sides of the aisle can agree on - cutting the cost of healthcare overall.
Wednesday, January 29, 2014
Reflections on Healthcare Economics: The Skewed Incentives of a Third-Party Payer System
The provision and consumption of medical care are strange economic beasts - they defy traditional paradigms of economic behavior.* This is partly related to the fact that we treat our health and well-being differently from other traditional commodities. Traditional supply/demand economic paradigms imply a consumer who understands the utility of what they are purchasing. In medicine, however, clinical knowledge is largely in the hands of the physician and the patient cannot be expected to have a thorough understanding of what their money is buying. It is also affected by the extensively skewed incentives in the healthcare market, which have contributed to the acceleration of costs. The fact that there has been a third-party (i.e. health insurance company) paying for healthcare has removed some of the usual expected downward pressures of rising cost associated with consumption of commodities. This means that physicians (who have been paid per procedure and test ordered) and patients (who want the best, most comprehensive possible care) have both been shielded from the rising costs of healthcare.
From a patient's perspective, after paying his/her premiums and deductible, any further testing and procedures are effectively "free" in that the insurance company bears the costs thereafter. Why should a given patient not get the most "bang for their buck" and order any tests/procedures that the physician recommends? It's been the same headache he/she has had for years, but why not just get that MRI "just to be sure"?
From a physician's perspective, there are numerous motives for ordering extra tests/procedures. The first involves the potential ethical/moral pitfalls of a model that has compensated physicians based on the number of procedures/tests ordered (fee-for-service). Of course, our goal is always that we perform the most efficient medicine and do no harm. However, the revelations of Medicare fraud have highlighted the potential for this model to go awry.
The second motive involves the fact that most physicians are risk-averse and medicine is a field fraught with uncertainty. If an extra test/imaging/procedure can enhance the probability of our diagnostic confidence even slightly, we often feel compelled to act. This is especially true when the extra cost is not borne by the ordering physician or a given patient, but rather by the insurance company.
The third is our fear of litigation and indulgence in defensive medicine as a protective measure; this goes hand in hand in with our often risk averse tendencies and desire for increased confidence in our diagnoses (more on this later). Throughout medical school, we learn these extensive physical exam maneuvers and classical presenting signs and symptoms. And yet, invariably, we often order the advanced imaging study. For example, if a patient presents with a cough and a doctor is confident the lungs are clear on exam and not affected, why should he or she order an x-ray? Because it increases our diagnostic confidence and also serves the double purpose as protective data in litigation.
There are models that may address the skewed incentives for both the patient and the physician. For patients, one interesting and potentially revolutionizing idea involves broader implementation of Health Savings Accounts (HSA). This basically a unique savings account where a patient can save their own money to spend on healthcare costs. The idea is that patients will treat healthcare consumption more like a traditional commodity. For example, a patient who has mild symptoms (like the common cold) would theoretically be less likely to seek medical attention and go to the hospital/clinic only if symptoms become severe, resulting in more judicious expenditure.
More recently, the goal for physicians has been to shift away from a fee-for-service compensation model to one that encourages more responsible ordering of testing and diagnostic studies. In the new paradigm, payments are bundled for a given healthcare encounter. For example, if I am admitted to the hospital for pneumonia, the hospital will receive a fixed sum for my hospitalization, as determined by the expected cost of a hospital stay for this diagnosis. This is expected to bring down how much hospital and doctors get paid. However, on the bright side, doctors will be expected to be more efficient in reaching a diagnosis and order only what is necessary to treat a given patient's illness, since any further testing may not be help the patient and will reduce a hospital/clinics margins.
One interesting aspect of the new Centers for Medicare and Medicaid Services (CMS) compensation schemes that I have personally experienced is the new regime for readmission. Basically, if a patient originally admitted with a diagnosis of congestive heart failure, pneumonia, or COPD exacerbation (conditions often with a high-risk of re-admission) is re-admitted with the same diagnosis within 30 days of discharge, the hospital has to bear the cost of the second admission. This is effectively CMS telling us to take better care of our patients. I have noticed several positives resulting from this systemic change. First off, patients are now consistently scheduled to follow-up soon after discharge (often within days). I notice my colleagues spending more time at discharge discussing with patients why they were hospitalized and what they can do to take better personal care. More immediate outpatient follow-up for patients with recent hospitalizations as well as better patient education are definitely positive outcomes.
A concern with the "more efficient" practice of medicine is the possibility that, as we move away from the often broad nets we now set in the search for diagnoses, we may miss other diagnoses. For example, in the aforementioned patient with the cough, a chest x-ray may show evidence of lung cancer as an incidental finding. However, in the bundled payment compensation model, there may be circumstances that the chest x-ray is avoided. While the patient may have their cough effectively treated by the efficient clinician, he/she would not have the benefit of an earlier cancer diagnosis that would be incidentally found on an x-ray.
Given that human life and well-being are at stake, healthcare will never fully behave like traditional commodities and classical supply/demand curves. However, I am hopeful that addressing the skewed incentives and shifting cost to the primary parties (doctors and patients) that matter most in the transaction will help reduce costs in the long run.
*Caveat: even traditional economics may not fully explain human behavior, even in the consumption of non-healthcare related goods and services. See this great article by Derek Thompson in The Atlantic.
From a patient's perspective, after paying his/her premiums and deductible, any further testing and procedures are effectively "free" in that the insurance company bears the costs thereafter. Why should a given patient not get the most "bang for their buck" and order any tests/procedures that the physician recommends? It's been the same headache he/she has had for years, but why not just get that MRI "just to be sure"?
From a physician's perspective, there are numerous motives for ordering extra tests/procedures. The first involves the potential ethical/moral pitfalls of a model that has compensated physicians based on the number of procedures/tests ordered (fee-for-service). Of course, our goal is always that we perform the most efficient medicine and do no harm. However, the revelations of Medicare fraud have highlighted the potential for this model to go awry.
The second motive involves the fact that most physicians are risk-averse and medicine is a field fraught with uncertainty. If an extra test/imaging/procedure can enhance the probability of our diagnostic confidence even slightly, we often feel compelled to act. This is especially true when the extra cost is not borne by the ordering physician or a given patient, but rather by the insurance company.
The third is our fear of litigation and indulgence in defensive medicine as a protective measure; this goes hand in hand in with our often risk averse tendencies and desire for increased confidence in our diagnoses (more on this later). Throughout medical school, we learn these extensive physical exam maneuvers and classical presenting signs and symptoms. And yet, invariably, we often order the advanced imaging study. For example, if a patient presents with a cough and a doctor is confident the lungs are clear on exam and not affected, why should he or she order an x-ray? Because it increases our diagnostic confidence and also serves the double purpose as protective data in litigation.
There are models that may address the skewed incentives for both the patient and the physician. For patients, one interesting and potentially revolutionizing idea involves broader implementation of Health Savings Accounts (HSA). This basically a unique savings account where a patient can save their own money to spend on healthcare costs. The idea is that patients will treat healthcare consumption more like a traditional commodity. For example, a patient who has mild symptoms (like the common cold) would theoretically be less likely to seek medical attention and go to the hospital/clinic only if symptoms become severe, resulting in more judicious expenditure.
More recently, the goal for physicians has been to shift away from a fee-for-service compensation model to one that encourages more responsible ordering of testing and diagnostic studies. In the new paradigm, payments are bundled for a given healthcare encounter. For example, if I am admitted to the hospital for pneumonia, the hospital will receive a fixed sum for my hospitalization, as determined by the expected cost of a hospital stay for this diagnosis. This is expected to bring down how much hospital and doctors get paid. However, on the bright side, doctors will be expected to be more efficient in reaching a diagnosis and order only what is necessary to treat a given patient's illness, since any further testing may not be help the patient and will reduce a hospital/clinics margins.
One interesting aspect of the new Centers for Medicare and Medicaid Services (CMS) compensation schemes that I have personally experienced is the new regime for readmission. Basically, if a patient originally admitted with a diagnosis of congestive heart failure, pneumonia, or COPD exacerbation (conditions often with a high-risk of re-admission) is re-admitted with the same diagnosis within 30 days of discharge, the hospital has to bear the cost of the second admission. This is effectively CMS telling us to take better care of our patients. I have noticed several positives resulting from this systemic change. First off, patients are now consistently scheduled to follow-up soon after discharge (often within days). I notice my colleagues spending more time at discharge discussing with patients why they were hospitalized and what they can do to take better personal care. More immediate outpatient follow-up for patients with recent hospitalizations as well as better patient education are definitely positive outcomes.
A concern with the "more efficient" practice of medicine is the possibility that, as we move away from the often broad nets we now set in the search for diagnoses, we may miss other diagnoses. For example, in the aforementioned patient with the cough, a chest x-ray may show evidence of lung cancer as an incidental finding. However, in the bundled payment compensation model, there may be circumstances that the chest x-ray is avoided. While the patient may have their cough effectively treated by the efficient clinician, he/she would not have the benefit of an earlier cancer diagnosis that would be incidentally found on an x-ray.
Given that human life and well-being are at stake, healthcare will never fully behave like traditional commodities and classical supply/demand curves. However, I am hopeful that addressing the skewed incentives and shifting cost to the primary parties (doctors and patients) that matter most in the transaction will help reduce costs in the long run.
*Caveat: even traditional economics may not fully explain human behavior, even in the consumption of non-healthcare related goods and services. See this great article by Derek Thompson in The Atlantic.
Sunday, January 26, 2014
Reflections on Healthcare Economics
In addition to the recent highly publicized rollout of the individual mandate provision of the Affordable Care Act, there has been an extensive amount of press coverage of the contribution of physician salaries to the cost of healthcare in the United States. For example, in a recent New York Times article (Click Here), Ms. Elisabeth Rosenthal highlights some examples of the often exorbitant costs incurred by patients pursuing specialty care for seemingly minor procedures. She presents evidence in the form of "median annual compensation rates" for several specialties and the unfortunate experience of a patient, who apparently had very little say in the choice of expensive, and likely unnecessary procedure options. While I agree that every physician should ALWAYS communicate the various treatment options, including risks, benefits, alternatives, and his/her professional recommendation for a patient's unique circumstance, a fixation on physicians' salaries as a major contributor to healthcare cost is incomplete and short-sighted.
Several factors must be taken into consideration and each individually addressed with at least incremental and ideally monumental changes. Over the next few weeks, I will be briefly expanding upon the following areas that experts believe are ripe for reform, with some reflections from personal experiences:
1) The Skewed Incentives of a Third-Party Payer System
2) Inadequate Insurance Coverage and the Emergency Medical Treatment and Active Labor Act (EMTALA)
3) Tort Law and the Costs of Defensive Medicine
4) Escalating Medical Education Costs
5) Tackling the Shortage of Physicians
6) Evidence-Based Medicine vs. Economic Use of Medicine and Procedures
7) The Opacity of Healthcare Pricing
Stay tuned..
#scrublife
Several factors must be taken into consideration and each individually addressed with at least incremental and ideally monumental changes. Over the next few weeks, I will be briefly expanding upon the following areas that experts believe are ripe for reform, with some reflections from personal experiences:
1) The Skewed Incentives of a Third-Party Payer System
2) Inadequate Insurance Coverage and the Emergency Medical Treatment and Active Labor Act (EMTALA)
3) Tort Law and the Costs of Defensive Medicine
4) Escalating Medical Education Costs
5) Tackling the Shortage of Physicians
6) Evidence-Based Medicine vs. Economic Use of Medicine and Procedures
7) The Opacity of Healthcare Pricing
Stay tuned..
#scrublife
Subscribe to:
Posts (Atom)