Wednesday, March 28, 2012

Don’t Ask, Don’t Tell

Don’t Ask, Don’t Tell is making a comeback—directed now at doctors, not the military, but this version has nothing to do with sexual orientation and everything to do with the doctor-patient relationship.

Lawmakers across the country are involved in a feeding frenzy to see who can pass the most obnoxious, offensive and intrusive laws to prohibit physicians from asking or telling patients about clinical information that is relevant to their health. They also are going at the physician-patient relationship from the opposite direction, mandating what physicians must ask or tell patients about their medical care—and even what tests and procedures they have to impose on them. Without regard to a physician’s clinical judgment, patient preferences, informed consent, clinical effectiveness, medical necessity, or cost!

To illustrate how ridiculous this has gotten, last June I posted a satirical description of a new Florida law to prohibit doctors from discussing alcohol consumption with their patients.  Actually, the real Florida law prohibits doctors from asking or telling patients about firearms safety—but to make my point, I substituted references to alcohol whenever firearms were referenced in the actual statute, such as:

“An act relating to the privacy of consumers of alcoholic beverages; providing that a licensed medical care practitioner or health care facility may not record information regarding ownership or consumption of alcoholic beverages in a patient's medical record . . .”

I asked “If Florida’s ban [on doctors asking patients about firearms] stands up in court, is it really out of the question that manufacturers and sellers of whiskey, or red meat, or even marijuana, might want to do the same?”

Well, I didn’t think to include fracking (high-pressure chemicals, sand, and water that is blasted into rock to tap into natural gas). Pennsylvania has passed a law so that doctors can get information from mining companies about a patient’s potential exposure to hazardous chemicals related to fracking, but they can’t disclose the information to anyone, including the patient they are treating! Here is the offending section of the PA law:

“If a health professional determines that a medical emergency exists and the specific identity and amount of any chemicals claimed to be a trade secret or confidential proprietary information are necessary for emergency treatment, the vendor, service provider or operator shall immediately disclose the information to the health professional upon a verbal acknowledgment by the health professional that the information may not be used for purposes other than the health needs asserted and that the health professional shall maintain the information as confidential. The vendor, service provider or operator may request, and the health professional shall provide upon request, a written statement of need and a confidentiality agreement from the health professional as soon as circumstances permit, in conformance with regulations promulgated under this chapter.”

Excuse me, but doesn’t this seem fracking ridiculous to you? If I were a patient, and my doctor found out that I had been exposed to specific chemicals that might have harmed my health, shouldn’t I have the right to know about them—and shouldn’t my doctor be obligated to tell me?

To be clear, the American College of Physicians has no policies on fracking. We don’t have policies on access to abortion services, or the right to bear arms (although we do support gun safety screening as part of a preventive risk assessment). On a few occasions, we or our state chapters have taken positions on state laws based on broad policies on the doctor-patient relationship and informed consent. With the national ACP’s support, our Florida chapter has objected to and joined in a lawsuit to successfully block the Florida gun safety gag rule. And ACP’s Virginia chapter recently wrote to its legislature to urge opposition to Virginia’s ultrasound before abortion bill, on the basis that “this legislation represents a dangerous and unprecedented intrusion by the Commonwealth of Virginia into patient privacy and that it encroaches on the doctor-patient relationship . . .” The chapter pointed out that it has no position, individually or collectively, on abortion itself. (An amended version of the bill passed and was signed into law by the governor.)

State lawmakers will offer all kinds of reasons for intruding into the doctor-patient relationship, from protecting business interests, to their ideology, to constitutional rights, to seemingly sincere and principled views on the morality and need for different medical interventions.  But to me, the issue comes down to one thing: the government not telling my doctor what he can say or do or the decisions we make together about my health. 

You would think that at least some of the people who are parading with their “Keep government out of health care” signs today outside the Supreme Court today would be even more concerned about their own states’ efforts to insert government, in the most fundamental and intrusive ways possible, into the relationship between doctors and their patients. They may discover that the real government takeover of medicine is happening in their own state capitols, not Washington. 

Today’s questions:  What do you think of state laws to tell doctors what they can and can’t ask or tell patients or what tests they must perform on them? And why do you think that there is not more of an outcry about such laws from the public, and from many physicians?

Monday, March 26, 2012

What now for health reform?

Today, the American College of Physicians, the nation's second largest physician membership organization and largest specialty society, reminded the public why it is essential that the country not turn its back on reforms to provide all Americans with access to affordable health coverage. The statement, issued the day that the Supreme Court will begin to hear oral arguments about the Affordable Care Act's constitutionality and three days after the second anniversary of it being signed into law, points to the millions of Americans who already have been helped by the law. These include: young adults who are now on their parents' plans, children who can't be turned down because they have a pre-existing condition, seniors who have access to no-cost preventive services and reduced prices on prescription drugs, and fourth year medical students who are getting loan forgiveness or scholarships to practice primary care in underserved areas.

But the biggest changes are yet to come: affordable health insurance for nearly all Americans and 32 million fewer uninsured, to be achieved by offering sliding scale subsidies to help people with incomes up to 400 percent of the poverty level buy competitive private insurance offered through state-run exchanges, expanding Medicaid to pay for the poorest families (paid for almost entirely by the federal government—100 percent in 2014, going down to 90 percent of the cost by 2020—so that it isn't an unfunded mandate on the states), and a ban on insurance companies turning down or overcharging anyone who has a pre-existing condition. Oh, and the requirement that people pay a small (but unenforceable) penalty—the law doesn't allow the government to file charges or liens against people who refuse to pay—if they can afford health insurance but refuse to buy it.

These changes are hardly radical, and they are not "socialized medicine." (Only in the weird world of American partisan politics could subsidizing someone to buy for-profit private insurance be called socialism.)

And they used to have bipartisan support. ACP first proposed a similar set of policies in 2002 with no objections from our more conservative members—in fact, the only objections I recall came from liberal doctors who favored a single payer system! ACP's ideas were then incorporated into a bipartisan bill, the HealthCARE Act, introduced in two consecutive Congresses. Conservative think tanks including the Heritage Foundation until recently advocated a similar set of policies, including the individual insurance requirement that it now says is unconstitutional. 

It was only when these policies became the Affordable Care Act, or "Obamacare," that bipartisan consensus broke down. 

Now, the question is: will the Supreme Court, and the U.S. political process, allow these reforms to remain, or will we go back to the days when the country tolerated 50 million or more uninsured persons and allowed insurance companies to cherry-pick who they choose to insure? 

I don't know what the Supreme Court will rule, and ACP's statement stayed away from the constitutional arguments because the organization's expertise is in evidence-based development of health policy, not constitutional law. But based on its assessment of the most effective ways to expand access to health care, ACP concluded that the key reforms created by the ACA—subsidies, exchanges, Medicaid expansion, and the individual insurance requirement—should be maintained.  

I see no other viable political pathway to achieve ACP's decades-long vision that every American, no matter where they live or work or how rich or poor they are, should have access to affordable coverage for essential health benefits. If the ACA goes, there will not be a "replacement" plan offered by the law's opponents that will come anywhere close to providing coverage to nearly all Americans. (The GOP plans offered to date—health savings accounts, buying insurance across state lines, and medical liability reforms—would not materially reduce the percentage of uninsured Americans, according to the Congressional Budget Office.)

People will disagree on whether universal health insurance coverage is a right, but there didn't use to be much disagreement that it is the right thing to do. As we hear arguments over the next few days about the Commerce Clause, states’ rights, the anti-injunction act, broccoli, and rationing, I hope we don't forget the millions who have been helped by the ACA, and the millions more who will be if it is allowed to stand.

Wednesday, March 21, 2012

Dissecting the Ryan Budget

Try your hand at today’s multiple choice quiz about the budget blueprint released yesterday by Rep. Paul Ryan (R-WI), House Budget Committee chair. The plan:

1.    Dramatically reduces the public debt over the next decade.
2.    Relies on unrealistic and vague assumptions.
3.    Drastically reduces health spending on the poor.
4.    All of the above.

The answer is all of the above—even though the first two statements seem to contradict each other.  How can they both be true?  Well, the Congressional Budget Office says this about the Ryan budget:

“At the end of fiscal year 2011, federal debt held by the public was 68 percent of GDP. The paths for revenues and spending specified by Chairman Ryan and his staff would lead to debt equal to 61 percent of GDP in 2023, 53 percent in 2030, and 10 percent in 2050. That debt would be a much smaller share of GDP . . .”

But here is the kicker: the CBO was relying on the “paths for revenues and spending specified by Chairman Ryan and his staff” in coming up with these estimates—that is, it is taking their word that Congress will come up with the required revenue and spending cuts, and that the policies proposed in the document will work as Rep. Ryan says they will. Or, as CBO itself puts it, “Those calculations do not represent a cost estimate for legislation or an analysis of the effects of any given policies. In particular, CBO has not considered whether the specified paths are consistent with the policy proposals or budget figures released today by Chairman Ryan as part of his proposed budget resolution.

And, as the Washington Post points out in its editorial today, the Ryan budget is “intentionally vague” on how it would achieve the revenue and savings numbers that the CBO was working from:

“THERE IS NO credible path to deficit reduction without a combination of spending cuts and revenue increases. This is the fundamental conclusion of every responsible group that has examined the issue, most prominently the Simpson-Bowles commission, and it is the fundamental failure of the budget blueprint released Tuesday by House Budget Committee Chairman Paul Ryan (R-Wis.).  Instead, and unfortunately, Mr. Ryan’s plan lunges in the opposite direction. He dangles the carrots of lower income and corporate tax rates. He says he would maintain tax revenue and in fact have it grow to 19 percent of the gross domestic product by 2025. Yet he fails to do the hard, and politically treacherous, work of specifying what deductions and credits he would eliminate in order to make all that happen. Does Mr. Ryan propose to eliminate the mortgage interest deduction? The preferential tax treatment of employer-sponsored health insurance? The deduction for charitable donations? Mr. Ryan says he’d leave those pesky details to the tax-writing House Ways and Means Committee, and no wonder: The nonpartisan Tax Policy Center said Mr. Ryan’s plan would reduce revenues by an eye-popping $4.6 trilllion — and that’s on top of the $5.4 trillion cost of making the Bush tax cuts permanent.”

What is much clearer is that the Ryan budget would cut so much out of Medicaid (the program that funds medical care for most of the poor) that it would result in millions more uninsured and underinsured poor Americans, according to an analysis by the Center for Budget and Policy Priorities. (The CBO agrees: “the magnitude of the reduction in spending . . . means that states would need to increase their spending [on Medicaid and the Children’s Health Insurance Program], . . . make considerable cutbacks in them, or both.  Cutbacks might involve reduced eligibility, . . . coverage of fewer services, lower payments to providers, or increased cost-sharing by beneficiaries — all of which would reduce access to care.”)

The Washington Post’s Ezra Klein observes that the reduction in spending on the poor isn’t due to any intent on Rep. Ryan’s part to hurt the poor, but because the GOP’s “overlapping fiscal commitments . . .  leave them few other choices”:

“I don't think Paul Ryan intended to write a budget that concentrated its cuts on the poorest Americans. But there's a reason their budgets turned out so similar: The Republican Party has settled on four overlapping fiscal commitments that leave them with few other choices. The Republican plans we've seen share a few basic premises. First, taxes are too high, and must be cut. Second, defense spending is too low, and should be raised. Third, major changes to entitlement programs should be passed now, but they shouldn't affect the current generation of retirees. That would all be fine, except for the fourth premise, which is that short-term deficits are a serious threat to the country and they need to be swiftly cut. The first three budget premises means that taxes and defense will contribute more to the deficit, and Medicare and Social Security aren't available for quick savings. That leaves programs for the poor as the only major programs available to bear cuts. But now cuts to those programs have to pay for the deficit reduction, the increased defense spending, and the tax cuts. That means the cuts to those programs have to be really, really, really deep. The authors have no other choice.”

The Ryan budget also includes a new version of last year’s Medicare premium support program, but this time, he would allow beneficiaries the option of enrolling in a public Medicare program in addition to the choice of using the government’s allowed contribution to buy private insurance. Under either option, most seniors would pay more for their care, because the government’s allowance would not likely keep pace with the costs of medical care.

Rep. Ryan deserves credit for laying out the fiscal choices facing the country (but not for his vagueness in how he would achieve the revenue and savings estimates). On that score, he has done much more to focus the debate on how to reduce the debt and the choices involved than President Obama and Senate Democrats, who have been quick to criticize while failing to offer their own detailed plans.

But physicians especially should be concerned about the impact of the Ryan budget on health care for the poorest Americans. The American College of Physicians has long advocated that every American, regardless of where they live or work or how much they earn, should have access to affordable health coverage. The Ryan plan, regrettably, violates this concept by taking health care away from those who can least afford it. There are better ways to reduce the public debt than going after health care for the most vulnerable.

Today’s question: What is your reaction to the Ryan budget?

Friday, March 16, 2012

Health care limericks

As long-time followers of this blog know, I hail from a decidedly Irish background. My beloved late Dad, Jack Doherty, was born and raised in Drumshanbo, Ireland, emigrating to the United States with my grandmother at the age of 10. He owned, operated and tended bar at the establishment originally opened by my grandfather, Thomas, for more than 30 years, until he sold the bar in 1978. When I was in college, I worked behind the bar—the third generation of Doherty’s “behind the stick,” as the old-timers would remind me. The bar—then called Doherty’s Bar and Grill (located in Woodside, Queens, New York)—is  still there and operating as a drinking establishment, but under a different name and ethnic clientele, serving a largely Latino population.

So as you can imagine, Saint Patrick’s Day is a big occasion in my family. One of my traditions is to write limericks to honor the occasion. Limericks are a “humorous, witty or nonsensical” poem named after the Irish city, following a prescribed AABBA rhyme scheme.

In honor of the great Saint Patrick, my Dad, Ireland, and Doherty’s Bar, I offer the following limericks to mark the occasion:

The SGR is like Groundhog Day
Something that just won’t go away.
Congress dithers,
Medical care withers,
As doctors turn patients away.

Doctors don’t always agree
With the positions of the A-C-P
My blog posts stir the pot
And make some downright hot
As they write, “You aren’t speaking for ME!”

(Okay, these aren’t going to win any poetry awards, but I hope they introduce a bit of levity into your day.)

Today’s question:  How about taking a turn at writing a health care or political limerick for posting here?

Thursday, March 15, 2012

Will health information technology make medical care MORE expensive?

“Doctors using computers to track tests, like X-rays and magnetic resonance imaging, ordered far more tests than doctors relying on paper records,” reports the New York Times on the findings of a controversial new Health Affairs study.

The study’s authors write that “physicians’ access to computerized imaging results (sometimes, but not necessarily, through an electronic health record) was associated with a 40–70 percent greater likelihood of an imaging test being ordered,” suggesting to them that “electronic access does not decrease test ordering in the office setting and may even increase it, possibly because of system features that are enticements to ordering.” From this, they go on to make the sweeping conclusion that:

“Use of these health information technologies, whatever their other benefits, remains unproven as an effective cost-control strategy with respect to reducing the ordering of unnecessary tests.”

Not so fast, says Dr. Farzad Mostashari, the National Coordinator for Health Information Technology, who issued a response to the Health Affairs article, taking issue with its methodologies and conclusions, which in turn invited a response to his response from the study’s authors. You can read an excellent account of the back-and-forth on this in an American EHR blog post by my ACP colleague, Dr. Michael Barr.

I don’t claim to be an expert on health information technology or on the methodological debate over the Health Affairs research, but my sense is that the study raises an important question—do health information technologies that make it easier to order and then read the results electronically also make it more likely that an unnecessary test will be ordered? I don’t think we definitively know.

But at the same time, there are enough questions about the study and its limitations to reach any sweeping conclusion on the value of health information technologies in reducing costs. Plus, as Dr. Barr points out in his blog post, the world of health information technology is changing rapidly, including the new stage 2 “meaningful use” proposed rules that will encourage adoption of clinical decision support tools, based on evidence-based guidelines on appropriateness, in computerized order entry systems.

Of greater significance than this one study alone is that it adds to a growing body of research and opinion (exaggerated and magnified by news reports and the blogosphere) that suggest that some of the most popular remedies offered to bring down rising health care costs won’t work. Last week, I blogged about the limitations of price competition, transparency, high deductible HSAs, and private contracting in bringing down costs; today, it is heath information technology that at least this one study says won’t deliver the bang for the buck. And my next post will be about studies that raise questions about the value of care coordination in lowering overall spending.

My concern is that the message that could be received by the public and policymakers is that nothing being contemplated today will be effective in bringing down health care costs. So why bother trying? Or let’s just pull the plug on the ones that aren’t working?

Healthy skepticism about the cost control idea of the day is good. More research is good. But at some point, showing the limitations of current cost control interventions and suggesting more studies won’t be enough. Instead, we will have to come up with an American way that will actually work to lower health care costs, or policymakers will end up on the tried and true cost control measures used in other countries: explicit rationing of services, and even more price and capacity controls.

Today’s question: What do you think about the research questioning the value of health information technology in lowering costs?

Friday, March 9, 2012

“Feeling much like a cow on a milking machine”

A reason getting a handle on rising health care costs is so hard is that many of the approaches people hope will work to lower costs turn out to be not terribly effective, and those we know from evidence will work usually involve unpopular trade-offs.

Today’s blog will examine several new analyses that call into question the effectiveness of price competition and transparency in lowering health care costs. (Future posts will examine new studies on the impact on costs of health information technology and care coordination.)

The argument for price competition and transparency is straightforward. Markets do better than government in setting a fair and competitive price for health care services. For price competition to work, there needs to be more transparency in the price of health care services, so that patients can anticipate in advance what they would have to pay and can shop around for the best deal. And patients need to have more “skin in the game”—for instance, through high deductible conventional health plans and health savings accounts.

This all sounds great—in theory. Market-based competition works great for cell phones and tablet computers, driving down costs while steadily increasing capabilities and performance, so it should work for health care, right?

But what if health care is different, and price competition and transparency ends up driving up health care costs?

National Journal's Maggie Fox reports on a new Health Affairs study that found that if consumers are given information only on the cost of treatments, they prefer the more costly medical care. The study involved 1,400 workers, who were offered different doctors and care options. “If they were given details on price alone, the volunteers chose the most expensive choice,” presumably because they associated more expensive care with better care. Providing patients with quality and cost information “moderated” their choices—but the U.S. is a long way from developing a reliable “quality score” for patients to use in selecting a physician or hospital.

High deductible plans in theory should counter the bias for more expensive care, because patients would have a more direct economic interest in selecting a less costly source of care.

But a patient’s first-hand account, posted in ABIM’s Medical Professionalism Blog, shows how difficult it is for patients in high deductible plans to get physicians to reveal their prices or find less expensive care options. The patient, Court Nederveld of Florida, writes

“Hypertension was the trigger that forced medical cost awareness to the forefront. My doctor decided that with my rise in blood pressure, it would be prudent to prescribe a blood pressure medication and order a nuclear stress test. With only a catastrophic insurance policy and a $5,000 deductible, it was imperative for my financial health to know the cost of both the drugs and the procedure up front.”

But he found this was much easier said than done.

Mr. Nederveld researched and sought out a less expensive hypertension drug than the Lotrel recommended by his doctor. He encountered resistance when he tried to get his doctor to reveal in advance the cost of a nuclear stress test or to consider a less expensive conventional stress test. Only after Mr. Nederveld’s persistence did his physician agree to a modest discount in the fee for the nuclear stress test, but even then, it was more than he could afford. He continues:

“Feeling much like a cow on a milking machine, I began to test the theory that medical procedures should be available as a commodity. Using the Internet to begin my search, the only specific criteria required was that the location of the facility performing the test be within a short drive from home. It took very little time to find and confirm a company that would provide a nuclear stress test sans consultation, and would willingly and promptly forward the results to my primary care physician. To verify that all was understood, I informed them that I would have a check for the exact amount they quoted and no further remuneration would be forthcoming. All was as stated and the procedure was done. Total cost was $938.11.” [Compared to his own physician’s “discounted” fee of $1,900 for the test plus an initial $250 consultation fee.]

You might say that Mr. Nederveld’s experience shows that high deductible plans and price competition can work in driving down costs, since he was able to get his nuclear stress test for less. But the enormous obstacles he encountered raise doubts in my mind about how realistic it is to expect that most patients, especially the elderly and those facing life-threatening conditions, will have the time, skills, and persistence needed to get a better deal, when the system is skewed against them and time may be of the essence.

Finally, another study has found that the United States spends more on health care than other countries because U.S. residents pay higher prices for common procedures. The Washington Post’s Ezra Klein blogs about a new Health Affairs study, which found that “in 22 of 23 cases, Americans are paying higher prices [for common procedures] than residents of other developed countries . . .Usually, we’re paying quite a bit more.”

And the reason we pay higher prices, Mr. Klein argues, is that in most countries the government controls or negotiates prices with physicians and other providers, whereas in the U.S. “it’s a free-for-all. Providers largely charge what they can get away with, often offering different prices to different insurers, and an even higher price to the uninsured”—except for Medicare and Medicaid, which regulate the prices charged by physicians and hospitals.

So let’s connect the dots. When patients are given information about the cost of treatments by different doctors, they choose the most expensive ones. When they have more skin in the game because of a high deductible plan, they encounter huge barriers to getting advance information about the cost of care and finding less costly alternatives. And a main reason health care in the United States is more costly than in other countries is that there is less government involvement in setting prices, not too much.

People who argue that getting government out of health care and unleashing the market will lower health care costs start from a good, principled position that seems as American as apple pie. (ACP, for its part, supports greater price and quality transparency, and the option for physicians to privately contract with patients to charge a higher fee than Medicare allows, as long as there are safeguards to protect patients when they have no real choice.) But free-market advocates don’t get to simply ignore evidence that health care is so different from other markets that competition, price transparency and less government regulation might have the opposite effect of driving up prices and costs.

I think that there is a better way of looking at the question of market competition in health care than posing it as an either-or choice of more government or less. Instead, we could acknowledge that government works best when it uses its regulatory authority to make free markets work better (the reason our Founding Fathers gave Congress the constitutional authority to regulate interstate commerce), not to replace free markets.

So, instead of using its regulatory authority to directly set prices, the government could establish the rules of the game: require clinicians to provide accurate pricing, cost and quality data before care is rendered, mandate safeguards to protect patients from being over-charged when they have no real choice of physician, and break up insurance monopsonies that hinder competition. In theory, such regulated competition should work to lower costs, but even so, we can’t rely on theory and blind faith alone. We need solid evidence.

Today’s questions: What is your reaction to the studies that show that price transparency, competition and less government price regulation may increase health care costs? And what does Mr. Nederveld’s experience tell you about the barriers to market competition, even for a patient who knew “it was imperative for my financial health to know the cost of both the drugs and the procedure up front”?

Note: the original post of this blog incorrectly cited the author and source of the article on the study that people prefer more expensive care.  This version has the correct reference.