Friday, June 5, 2009

Doctors Critical To Save Healthcare System, But Will They? Doubtful.

Two critical articles over the past few weeks give a good sense of where our healthcare system will be in a decade and it isn't good.

An insightful survey from the Kaiser Family Foundation, NPR, and the Harvard School of Public Health asked the public about key issues currently tossed around the topic of healthcare reform including the use of electronic medical records, coordination of care, and also comparative effectiveness. The report titled The Public and the Health Care Delivery System demonstrates the great disconnect from reality. If we were as good in delivering and coordinating care as the public believes, the United States would be the first among industrialized countries in health quality outcomes like cancer screening, blood pressure and cholesterol control, and infant survival, rather than last.

Books like Overtreated have illustrated quite convincingly that we fail to do basic proven treatments routinely in our country and we often don't provide the least expensive option which is equally as effective as more pricey options.

But the public doesn't think so. Perception is reality regardless of the truth.

From the survey, these questions show that the majority of Americans believe, wrongly I might add, that doctors recommend less expensive therapies which are equally as effective as more expensive ones.

Q28. In the past two years, do you think your doctor has ever recommended an expensive
medical test or treatment for you when a less expensive alternative would work just as
well, or hasn’t this happened?
  • 9 Yes, doctor has recommended expensive treatment when less
  • expensive alternative would work just as well
  • 87 No, this hasn’t happened
  • 4 Don’t know
  • -- Refused

The public wrongly believes that in the majority of cases, the right care and scientific evidence is not available on how to treat certain illnesses, when in fact there is more precision and diagnostic ability.

Q13. When doctors make decisions between different treatment options for a patient, do you
think there is usually CLEAR scientific evidence about which treatment is likely to work
best, or do you think the scientific evidence is not always clear about which will work
  • 23 Usually clear scientific evidence
  • 72 Scientific evidence is not always clear
  • 5 Don’t know
  • * Refused

Doctors often use medications that are "off-label" not approved by the FDA or backed by clinical trials. Although in the case of cancer, this might be acceptable, there are plenty of examples that this is deadly and dangerous. About a decade ago, it was touted that the best chance for survival for a woman with metastatic breast cancer was a bone marrow transplant, that is, wipe out the entire immune system, and transplant a new immune system with stem cells. It worked for blood cancers, like leukemia. Tragically, there was never any evidence and the only one study that showed survival advantage the investigator made up data. Women died unnecessarily from complications of the bone marrow transplant and over time we discovered they did worse, not better, not even as well as those who chose "traditional" chemotherapy and treatment.

Yet, women were clamoring to get the procedure done (thankfully no one does now, I hope...). Who held the line? Insurance companies noting that there was no scientific research. Naturally and understandably people went to the press and insurance companies buckled under mounting pressure that they were denying care. But do doctors really make the right choice for you? For the record, I don't believe in for profit health insurance companies.

Q15. If your doctor recommends an expensive medical treatment, but it has not been proven
to be more effective than other, less expensive treatments, do you think your
insurance company should have to pay for it, or not?
Based on one half of total respondents (N=619)
  • 55 Insurance companies should have to pay for it
  • 38 Insurance companies should not have to pay for it
  • 4 (Vol.) Depends
  • 3 Don’t know
  • * Refused

Doctors can't say no and we can't even provide you the least expensive care which is equally as effective. Why? Part of the reason is how the majority of doctors are reimbursed. The more they do, the more they get paid. Why would they ever say no to you? You might not come back. Also, it's no skin off their back as the costs don't come out of their pocket. Of course, it does increasingly come out of yours. But you aren't equipped to make the right decisions on when to skip and when you need to spend to get better.

Q30. In the past two years, has a doctor denied you a medical test or treatment that you
wanted because they thought it was not medically necessary, or not?
  • 10 Doctor has denied medical test or treatment you wanted
  • 89 Doctor has not denied medical test or treatment you wanted
  • 1 Don’t know
  • * Refused

This last question is the most important. The public feels that doctors try to keep the cost of health care down for the individual, yet from the previous question it is clear that what you want, you get. Fact is we spend more per capita than any other industrialized country in the world and aren't even healthier for it, that is, we die sooner!

23. Do you think your doctor tries to keep the cost of health care down for you, or not?
  • 63 Doctor tries to keep cost of health care down
  • 29 Doctor does not try to keep costs of health care down
  • 1 (Vol.) Don’t have a doctor
  • 7 Don’t know
  • * Refused

The second piece an article by Dr. Atul Gawande in the New Yorker, The Cost Conundrum - What a Texas town can teach us about health care illustrates that it is doctors that dictate the rising costs of healthcare. Until we align and change the delivery system so that they will do more of the right thing, that is recommend the most effective care, not necessarily the most expensive when a least pricey one will work, and when we make doctors accountable for the entire healthcare system not just piecemeal will we have money to cover all Americans and have everyone be healthier.

The type of reform, which Dr. Gawande notes is the most important, would require doctors to say no to patient requests to unproven treatments or the latest heavily marketed medication (can you say Vioxx?). Are we capable of doing that? 89% of the time we can't rather we let insurance companies do that. Will doctors routinely provide treatment based on scientific evidence and based on effectiveness as well as cost rather than relying on drug reps touting their latest products and free samples?

Unfortunately, I tend to agree with Dr. Gawande. I think the country will not have more Mayo Clinics even though it is the right thing to do because frankly the type of reform needed may be too much for our doctors as they now need to have candid but important conversations about effectiveness and cost in a country always fooled into thinking newer is sexier and better, when in medicine that is far from the case.

Excerpts from the article -

It is spring in McAllen, Texas. The morning sun is warm. The streets are lined with palm trees and pickup trucks. McAllen is in Hidalgo County, which has the lowest household income in the country, but it’s a border town, and a thriving foreign-trade zone has kept the unemployment rate below ten per cent. McAllen calls itself the Square Dance Capital of the World. “Lonesome Dove” was set around here.

McAllen has another distinction, too: it is one of the most expensive health-care markets in the country. Only Miami—which has much higher labor and living costs—spends more per person on health care. In 2006, 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.

...Health-care costs ultimately arise from the accumulation of individual decisions doctors make about which services and treatments to write an order for. The most expensive piece of medical equipment, as the saying goes, is a doctor’s pen. And, as a rule, hospital executives don’t own the pen caps. Doctors do.

...The real puzzle of American health care, I realized on the airplane home, is not why McAllen is different from El Paso. It’s why El Paso isn’t like McAllen. Every incentive in the system is an invitation to go the way McAllen has gone. Yet, across the country, large numbers of communities have managed to control their health costs rather than ratchet them up.

I talked to Denis Cortese, the C.E.O. of the Mayo Clinic, which is among the highest-quality, lowest-cost health-care systems in the country.

The core tenet of the Mayo Clinic is “The needs of the patient come first”—not the convenience of the doctors, not their revenues. The doctors and nurses, and even the janitors, sat in meetings almost weekly, working on ideas to make the service and the care better, not to get more money out of patients...

The Mayo Clinic is not an aberration...

This approach has been adopted in other places, too: the Geisinger Health System, in Danville, Pennsylvania; the Marshfield Clinic, in Marshfield, Wisconsin; Intermountain Healthcare, in Salt Lake City; Kaiser Permanente, in Northern California. All of them function on similar principles. All are not-for-profit institutions. And all have produced enviably higher quality and lower costs than the average American town enjoys.

Providing health care is like building a house. The task requires experts, expensive equipment and materials, and a huge amount of coordination. Imagine that, instead of paying a contractor to pull a team together and keep them on track, you paid an electrician for every outlet he recommends, a plumber for every faucet, and a carpenter for every cabinet. Would you be surprised if you got a house with a thousand outlets, faucets, and cabinets, at three times the cost you expected, and the whole thing fell apart a couple of years later? Getting the country’s best electrician on the job (he trained at Harvard, somebody tells you) isn’t going to solve this problem. Nor will changing the person who writes him the check.

This last point is vital... When it comes to making care better and cheaper, changing who pays the doctor will make no more difference than changing who pays the electrician. The lesson of the high-quality, low-cost communities is that someone has to be accountable for the totality of care. Otherwise, you get a system that has no brakes. You get McAllen.

...In the war over the culture of medicine—the war over whether our country’s anchor model will be Mayo or McAllen—the Mayo model is losing. In the sharpest economic downturn that our health system has faced in half a century, many people in medicine don’t see why they should do the hard work of organizing themselves in ways that reduce waste and improve quality if it means sacrificing revenue.

...As America struggles to extend health-care coverage while curbing health-care costs, we face a decision that is more important than whether we have a public-insurance option, more important than whether we will have a single-payer system in the long run or a mixture of public and private insurance, as we do now. The decision is whether we are going to reward the leaders who are trying to build a new generation of Mayos and Grand Junctions. If we don’t, McAllen won’t be an outlier. It will be our future.

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