Wednesday, June 10, 2009

It's the physicians, stupid!

Rarely does a magazine article grab the attention of policymakers, like Dr. Atul Gawande's piece in the New Yorker Magazine on "The Cost Conundrum: What a Texas town can teach us about health care." The article, adorned with a photo of a physician wearing an ATM machine, examines the community of McAllen, Texas, which has the dubious claim of having the second most expensive health care in the nation (Miami, Florida, which has much higher labor and cost of living expenses, takes first place). President Obama has reportedly referenced the article in discussions with congressional leaders. Citing the same, Steve Pearlstein writes that "the central challenge of health reform, then, is to make sure doctors have the scientific evidence about what works and what doesn't -- and then to change the way they work and realign their financial incentives so that this evidence guides their practice."

Why all of the interest in McAllen? Because, as Dr. Gawande writes, "Medicare spent fifteen thousand dollars per enrollee here, almost twice the national average. The income per capita is twelve thousand dollars. In other words, Medicare spends three thousand dollars more per person here than the average person earns." He concludes that the higher spending is a consequence of a prevailing medical culture fueled by money:

"Beyond the basics, however, many physicians are remarkably oblivious to the financial implications of their decisions. They see their patients. They make their recommendations. They send out the bills. And, as long as the numbers come out all right at the end of each month, they put the money out of their minds.

Others think of the money as a means of improving what they do. They think about how to use the insurance money to maybe install electronic health records with colleagues, or provide easier phone and e-mail access, or offer expanded hours. They hire an extra nurse to monitor diabetic patients more closely, and to make sure that patients don't miss their mammograms and pap smears and colonoscopies.

Then there are the physicians who see their practice primarily as a revenue stream. They instruct their secretary to have patients who call with follow-up questions schedule an appointment, because insurers don't pay for phone calls, only office visits. They consider providing Botox injections for cash. They take a Doppler ultrasound course, buy a machine, and start doing their patients' scans themselves, so that the insurance payments go to them rather than to the hospital. They figure out ways to increase their high-margin work and decrease their low-margin work. This is a business, after all.

In every community, you'll find a mixture of these views among physicians, but one or another tends to predominate. McAllen seems simply to be the community at one extreme."

Gawande writes that the debate in Washington largely misses the mark. "Whom do we want in charge of managing the full complexity of medical care?" he writes. "We can turn to insurers (whether public or private), which have proved repeatedly that they can't do it. Or we can turn to the local medical communities, which have proved that they can. But we have to choose someone - because, in much of the country, no one is in charge. And the result is the most wasteful and the least sustainable health-care system in the world."

If it is true that culture largely drives practice, it will be exceedingly difficult to change. History is full of examples where Washington has passed laws to change entrenched cultural behaviors that are not considered to be in the public interest, without much success unless there is buy-in by those who they want to change.

I believe it will require an unprecedented degree of leadership within the medical profession itself to get every physician to accept the idea that they need to be just stewards of resources, as the ACP-endorsed charter on professionalism demands:

"While meeting the needs of individual patients, physicians are required to provide health care that is based on the wise and cost-effective management of limited clinical resources. They should be committed to working with other physicians, hospitals, and payers to develop guidelines for cost-effective care. The physician's professional responsibility for appropriate allocation of resources requires scrupulous avoidance of superfluous tests and procedures. The provision of unnecessary services not only exposes one's patients to avoidable harm and expense but also diminishes the resources available for others."

Without such physician leadership, Washington almost assuredly will fail in its effort to control costs.

Today's question: Do you agree that there is a culture in medicine that leads to excess health care spending? If so, what should the profession do to change it?


Jay Larson MD said...

It has been said that the most expensive medical device is a physician's pen. Yes, we do have a culture that leads to expensive treatment. We like the latest and greatness. Weither it is excessive, we just don't have the data as the newer treatments may be more effective. Caparative effectiveness research will help to resolve this issue.

2 commentaries in JAMA are worth reading about this issue.

Gizmo Idolatry. Bruce Leff, MD and Thomas Finucane, MD. JAMA April 16, 2008. Volume 299 #15. Pages 1830-1832

Medical Professionalism in a Commercialized Health Care Market.
Arnold Relman, MD. JAMA December 12, 2007. Volume 298 #22. Pages 2669-2670

Steve Lucas said...

While still in my 30's a doctor went to great lengths to explain how much better my health needs would be served with a complete physical and blood draw every 90 days. Failing, he blocked the door, and in a raised voice told me I was taking food off his children's table because I had insurance that would pay for the above test and office visits.

Sadly this has been repeated a number of times, with both doctors and nurses blocking the door, usually telling me I am going to die without these test, me squaring my shoulders telling them to move, and finally a statement in the line of, "but you have insurance'"

My personal belief is that for all too many doctors it has become all about the money. I feel part of the blame lays at the feet of the drug industry. Often a drug rep is the one consistent person in a doctor's life offering advice on business as well as prescribing habits. Thus this corporate culture has been adopted by many practices. One doctor told me they had turned all of their prescribing over to their drug reps. Another told me they only trusted drug reps and peer review articles, often prepared by the drug companies, with the appropriate amount of spin.

Change is beginning to happen with the new limitations being placed on drug reps and the decisions of some practices to simply eliminate rep calls.

Real change will only take place with a change in the payment system. Moving from a check the box system, to one based on patient interaction. We do need to look at the overall payment system as distortions have occurred on the high end. In an effort to achieve the financial rewards of some specialist, generalist have focused on simply ramping up their practices over that of patient need. Add some unrealistic expectations of medical income, and lifestyle, and you have a recipe for a dysfunctional practice.

While many fine doctors work endless hours for their patients, many more are simply caught up in a never ending game of getting ahead. Family and friends place pressure on them to earn a "doctor's" income or live the "doctor" lifestyle. Moving a person with both a desire to help and desire to always learn onto a treadmill of constantly trying to maximize income.

While not scientific, I have found those most interested in the business side of medicine, also do not participate in any blogs. It appears they do not want to open themselves up to the scrutiny of their peers, or are afraid they will find a condemnation of their practice styles.

Steve Lucas

DrJHO7 said...

So Steve, what I'm hearing is, in order to be considered a fine doctor, I need to work endless hours for my patients, and even though I run my own private practice (small business), I shouldn't be concerned with the important aspects of running that business?

You have a distorted view of our medical profession. If what you say is true about your encounters with some physicians, then you have clearly run into some rotten eggs. That's bad luck. They exist in every profession.

As a physician, I have regular contact with hundreds of physicians locally, throughout our country, and from several other nations, and I can tell you that well more than 95% of them are hard working, intelligent, highly motivated, caring people who strive to provide excellent care for their patients, frequently putting the needs of patients before the needs of their families, and most of whom were never in it "for the money" - and if they were, they picked the wrong profession.

Next time you need a physician: choose a physician who has the FACP designation after his/her medical degree. Your luck should improve.

Steve Lucas said...


"You have a distorted view of our medical profession. If what you say is true about your encounters with some physicians"

I am a little surprised by this dismissive personal attack. Taken in context with your first paragraph I guess I am to assume that I am simply not qualified to speak to the business and marketing aspects of a modern medical practice. At no time did I state doctors should not take an interest in the business aspect of their practices, only that undue influence was being exerted by the drug, and by extension, device industry.

So lets see, with undergraduate and graduate degrees in business, and as a long time private investor, I cannot understand a medical practice. Running a high volume, low margin business in my mid-twenties I cannot understand a medical practice. Having taken an undergraduate class taught by a sales manager for a drug wholesaler, many decades ago, has given me no insight into the drug industry over time. Speaking with doctors socially has given me no insight into their practice methods.

Being a long time commentator, on a number of medical blogs, has not given me experience with the current issues dealing with business, ethics and the modern medical practice.

First, my experience is valid because it is my experience, you were not there.

Second, if you read some of my past post on this blog you will find that I have posted a belief that doctors do need time for family, and proper time to think about the patients they serve.

Thirdly, I have found doctors often speak about their desire to practice medicine in one fashion and do just the opposite. One doctor I know speaks about serving the needs of low income families. This same doctor breaks down children's immunizations into individual dosages to increase income, is quite angry about loosing drug rep outings, and wants to know "Who is going to buy our pens?"

I am glad your experience has been positive. You are truly fortunate to have the ability to interact with such a broad range of motivated individuals. My decades of experience shows a very different result.

You may want to check out The Wall Street Journal Health Blog, Health Care Renewal, and Cafe Pharma for some insights on the negative side of medicine.

Steve Lucas

Jim Webster MD, MACP said...

Dr. Larson is absolutely on target and those are two of my favorite references which all physicians should read. What if through our professional organizations such as ACP, the profession really got together and reformed health care? Form physician directed multispecialty groups affiliated with hospitals, get rid of fee for service and go to closed budgets and focus on evidence based medicine, quality and patient safety. The savings would be enormous, patients and doctors would all benefit, only the insurance co's and PI malpractice lawyers would lose. Ah well I can dream.
Jim Webster, MD, Ms, Macp

Jim Webster MD, MACP said...

Dr. Larson is correct and those a re two of my favorite references! The reality is that physicians are indeed in charge of health costs, individually and collectively. What if all the professional medical organizations got together and really reformed health care? Get rid of fee for service and go for closed end budgets, quality, evidence based medicine and patient safety. Everyone would be better off and the savings would fund universal coverage. Only the insurance industry and PI malpractice attorneys would lose out.
Jim Webster, MD, MS, MACP