Friday, September 24, 2010


We live in a time when optimism is in short supply. Large majorities of voters believe the country is on the wrong track. We don't trust insurance companies, Wall Street, or the news media, and we especially don't trust the government. The Pew Research Center characterizes it as "a perfect storm of conditions associated with distrust of government - a dismal economy, an unhappy public, bitter partisan-based backlash, and epic discontent with Congress and elected officials." But ratings "are just as low for the impact of large corporations (25% positive) and banks and other financial institutions (22%). And the marks are only slightly more positive for the national news media (31%) labor unions (32%) and the entertainment industry (33%)."

It was refreshing, then, for me to hear a committed public servant today tell the ACP's Board of Governors that "optimism is the crucial resource" in improving the American health care system. The public servant is Dr. Don Berwick, the administrator of the agency (CMS) that runs Medicare and Medicaid and that is responsible for much of the implementation of the Affordable Care Act.

Dr. Berwick described his vision of CMS as an agency that supports innovation by the private sector - "we have to do this together." He spoke of "partnerships" with physicians, nurses, hospitals, pharmacists and patients to design systems to achieve the "triple aim" of better care, better health, and lower per capita costs. (To learn more about Berwick's triple aim, see this Health Affairs blog from April 20.)

He said that top-down mandates from the federal government won't work. Instead, he spoke of an unparalleled opportunity for physicians to be leaders in designing systems to improve care and the heath of the population, and to reduce health care costs. Cost reductions, he argued, can be achieved "without ever harming a single hair on the patient’s head," if we commit to eliminating treatments that have no benefit to the patient. He sees the government playing a supporting role by providing funding and re-aligning incentives to support innovation at the community-level. His optimism is ground in the many examples where physicians have been leaders in building better systems to reduce fragmentation, improve patient safety, and reduce costs.

But Dr. Berwick also suggested that there needs to be an authentic commitment by all involved to creating a better health care system and that those who instead want to repackage the status quo will not serve the public interest. He praised ACP for its leadership in proposing ways to reduce ineffective care while improving the care of patients and the overall health of the population. ACP's Board of Governors reacted very positively to Dr. Berwick's remarks, with many of the governors offering ideas on how to achieve his triple aim.

Now, I anticipate that given the intense levels of distrust of government, some who read this blog will react to my description of Dr. Berwick's remarks dismissively. You'll probably tell me that ACP is being taken in by yet another "bureaucrat" who heads an agency that, in the minds of many physicians, exemplifies big and unresponsive government - even though this goes against the grain of everything that Dr. Berwick has said and written about how change must come from the bottom-up.

The question in my mind really isn't whether we can or should "trust" the government to do the right thing, even when led by good people like Dr. Berwick, but whether we have confidence in ourselves. Confidence that the can-do spirit that has made America such a great country still lives. Confidence in our own capacity to build a health care system that achieves Dr. Berwick's triple aim of better care, better health, and lower costs. If we can regain such confidence in ourselves, then there is every reason to be optimistic about the future of American health care.

Today's question: How optimistic are you that we can build a better health care system that achieves Dr. Berwick's triple aim?

Thursday, September 23, 2010

The Muddle-Minded Middle

Today, on the sixth month anniversary of health care reform becoming law, a new Associated Press poll shows that much of the public still doesn't understand it:

"Many who wanted the health care system to be overhauled don't realize that some provisions they cared about actually did make it in. And about a quarter of supporters don't understand that something hardly anyone wanted didn't make it: They mistakenly say the law will set up panels of bureaucrats to make decisions about people's care - what critics labeled 'death panels.'"

More than half of voters believe that the Affordable Care Act will result in most people paying higher taxes this year - when, in fact, only people who use tanning salons will see a tax increase in 2010, a tax championed by the American Academy of Dermatology. (The fact is some 17 million employees of small businesses could benefit from a health premium tax credit, according to a new analysis by economists at the Commonwealth Fund. The credit will offset as much as 35% of premium expenses from 2010 to 2013 and as much as half the cost in 2014 incurred by some small businesses - resulting in a $40 billion tax cut to eligible firms with fewer than 50 employees.)

On 19 "True or False" questions asked by the pollsters, sizable minorities got the answers wrong, according to AP, and two-thirds were not confident in their answers on eight out of nine core provisions. When presented with more and correct information, most Republican voters remain strongly opposed. But the level of support increases among independents and Democrats as they get more accurate information.

The Obama administration is intensifying its efforts to explain the law and tout its benefits, many of which go into effect today. Still, the AP says that the public's continued lack of knowledge is a "dismal verdict for the Obama administration's campaign to win over public opinion."

I am under no illusion that people with strong philosophical, ideological, or partisan objections to the law will be persuaded by more or better information. As I have said many times before, there is a principled argument to be made against the ACA - many people sincerely believe that it costs too much, and gives the government too big a role - which I respect, even though I see things differently. But it bugs me when people make judgments based on misinformation that is demonstrably false - and when such falsehoods (like the death panels) are intentionally spread by some critics.

To help improve public understanding, the American College of Physicians has partnered with AARP to produce a patient/consumer friendly brochure that explains, in simple language, why and how changes were made by the law and the date the changes go into effect. ACP encourages its members to consider making copies of the brochure for their patients, but it is also available for direct download by the public.

ACP has also updated "An Internist's Practical Guide to Health System Reform", which provides a comprehensive, understandable description of the key provisions of the law - by topic area and date of implementation - in an easily searchable form. Readers can scan the table of contents, pick a topic of interest to them, and use their computer's cursor to read a concise, stand-alone description.

Neither the AARP/ACP consumer brochure nor the guide for internists are intended as advocacy pieces - they do not call on readers to take any action in the political arena. They don't reference the ACP's views. They just provide the facts, as simply as possible.

And even though much of the public seems locked into their views, I suspect that there is a muddled middle that would welcome accurate information about what the law will and will not do. More and better information could also lead to a more informed public debate. Wouldn't it be nice if the argument was over the respective roles of the government and private sector in providing affordable health care, instead of being over imaginary death panels and 2010 tax increases and other figments that don't square with the facts?

Today's questions: What is your reaction to the AP poll's finding that large numbers of Americans give the wrong answers on basic facts about the Affordable Care Act? Will you be using the new resources from ACP (the practical guide for internists and the ACP/AARP brochure for patients/consumers)?

Wednesday, September 15, 2010

Has primary care been "oversold"?

Citing a new study by the Dartmouth Atlas, the Wall Street Journal’s health blog provocatively asks "Has the notion of 'access' to primary care been oversold?"

The Dartmouth researchers found "that there is no simple relationship between the supply of physicians and access to primary care." That is, they found that having a greater supply of primary care physicians in a community doesn't mean that the community necessarily has better access to primary care. Some areas of the country with fewer primary care physicians per population do better on access than other areas with more primary care physicians.

The researchers also report that the numbers of family physicians is more positively associated with better access than the numbers of internists, although they call the association "not strong." Although both general internists and family physicians are counted as primary care clinicians, in [regions] with a higher supply of family physicians, beneficiaries were more likely to have at least one annual primary care visit.. In [regions] with a higher supply of general internists, fewer beneficiaries had a primary care visit on average."

The study also suggests that the availability of primary care doesn't always lead to better outcomes:

"For example, leg amputation is a serious complication of diabetes and peripheral vascular disease. A broad array of factors go into a patient’s risk of amputation, including obesity, smoking, poverty, and poor control of blood sugar, and preventing amputation requires diligent attention from both the patient and clinician. One might assume that, at a regional level, access to a primary care clinician would be a predictor of the risk of amputation. Yet ... improving this outcome of peripheral vascular disease is much more complicated than simply ensuring access to primary care; there is no relationship between having at least one annual visit with a primary care clinician and the rate of leg amputation."

So does this mean that ACP and others who have for years have argued that primary care is positively associated with better outcomes, access and lower costs have had it all wrong? I don't think so. There are scores of studies that show that primary care is associated with better outcomes and lower costs of care.

And a careful reading of the Dartmouth study shows that the researchers share the belief that primary care is the "backbone" of health care, that "primary care physicians can play a crucial role in ensuring that patients get high-quality care" and that "primary ... care that does a good job of managing chronic disease can prevent hospitalizations."

What's the story, then? The main point of the Dartmouth study isn't that primary care doesn't matter - it does - but that it is much more than a numbers game.

Dartmouth suggests "that primary care is most effective when it is embedded within a health care system that allows the coordination of primary care services with those delivered by specialists and hospitals." This is one reason why ACP has been so insistent on championing the concept of the Patient-Centered Medical Home, which has as a central purpose facilitating coordination of care through a well-organized primary care practice that has relationships with teams of nurses, physician assistants and other specialists.

My answer to the Wall Street Journal health blog question - has primary care been oversold? - is an emphatic, heck no! But the study does remind us that as much as we need to ensure a sufficient supply of primary care physicians, we also need to learn how to organize primary care to achieve the best results, such as through Patient-Centered Medical Homes. My concern is that policy-makers may instead simplistically point to the Dartmouth study as a reason not to invest more in training and retaining primary care physicians.

Today's questions: What is your reaction to the Dartmouth study? And how would you answer the Wall Street Journal blog's question: has access to primary care been oversold?

Thursday, September 9, 2010

What is the real impact of medical malpractice?

It is an article of faith among many physicians that the threat of malpractice suits is behind rising health care costs. "How can we be expected to 'bend the cost curve' when we are under constant threat of being sued?" said one internist to me at last week's ACP South Dakota chapter meeting.

There is no question physicians are under a constant threat of being sued. A new AMA study finds that by age 55, 61% of physicians have been sued at least once. For general internal medicine physicians, it was 58.3%; for IM subspecialists, 57.6%; for general surgeons, a whopping 89.8% percent.

One might expect that physicians in states that have caps on non-economic damages would be less worried. Not so, according to another new study by the Center for Studying Health System Change. The Center found that "Even in states with economic damage caps in malpractice suits, physicians remain highly concerned about being sued, suggesting that many popular tort reform proposals may do little to deter the practice of defensive medicine that contributes to unnecessary health spending." The authors raise the possibility "that physicians' level of concern reflects a common tendency to overestimate the likelihood of 'dread risks'--rare but devastating outcomes--not an accurate assessment of actual risk ... Whether justified or not, physicians' liability fears are a policy problem because defensive medicine raises health care costs and potentially subjects patients to unnecessary care."

But how much does defensive medicine really contribute to health care costs? Kaiser Health News reports on a new Health Affairs study that finds that the cost is tens of billions per year--but not as much as many believe. "The total cost of medical malpractice-related costs to the health care system, including defensive medicine, is about $55.6 billion per year, or about 2.4 percent of annual health care spending. Defensive medicine is about 80 percent of that total, the researchers found."

The finding that the costs of defensive medicine are a relatively small contributor to costs does not mean the system shouldn’t be reformed, say the authors. "We're spending a very large amount of money every year on a system that's deeply flawed," said Michelle Melo of the Harvard School of Public Health. "Many injured patients never get compensated at all, and many patients sue who are not really victims of medical negligence."

My own view is that it is almost impossible to get a reliable estimate of how much defensive medicine costs the United States in dollars and cents. But when physicians worry constantly about being sued, when most end up getting sued at least once during their career, when patients who are victims of negligence never see any compensation, while others who weren’t harmed by negligence bring suits that aren’t warranted, when patients are exposed to unnecessary procedures because of physicians’ concerns about being sued, when the amount of an award depends more on where you live, the whims of a particular jury, and the quality of your legal representation--not the merits of the case, and when the U.S. spends "a very large sum of money on a system that is deeply flawed"--well, the system is broken, and must be fixed. I also think we need to broaden our thinking beyond the question of to cap or not to cap, since even in states with caps physicians worry about being sued. Caps, after all, limit how much is paid out if a physician is found to be negligent under a flawed tort system, but they don't keep such unwarranted cases out of the tort system in the first place. We need to consider ideas like health courts, no-fault, and other alternatives to the adversarial, confidence-sapping, unpredictable and unfair (to both doctors and patients) medical liability roulette created by our current tort system.

Today's question: What is your reaction to the new studies on medical liability reform?