Will Doctors or Patients Bend the Cost Curve?

The American Board of Internal Medicine (ABIM) and nine other professional medical societies announced that doctors should perform 45 tests and procedures less often than currently done because there is no good medical evidence that they add any value. Specifically, a xray or other imaging for low back pain in an otherwise healthy individual or an EKG as part of a routine physical, just add a lot of unnecessary cost to the health care system as a whole and don't provide doctors or patients any meaningful information that would be helpful in improving health or arriving at the right diagnosis and treatment.

The ABIM partnered with Consumer Reports to create a new campaign called Choosing Wisely and are joined also by collaborators like employers (the National Business Group on Health, the Pacific Business Group on Health), hospital safety (the Leapfrog Group), and labor unions (SEIU).  The mission is simply to have doctors and patients deliver and receive care that is medically necessary, based on evidence, avoids harm, and minimizes duplication.

The real question is - will it work? Will doctors follow what their professional societies recommend?

Though Choosing Wisely is a laudable attempt to make medical care better quality, the truth is doctors won't likely follow these guidelines from their medical societies. If it was that easy, we would not have this problem! Even today, it is still a challenge for the medical profession to have all doctors wash their hands correctly every patient every time, get immunized routinely against influenza, or even not to prescribe antibiotics for coughs, colds, and bronchitis due to viruses! What is more disturbing is that doing these basic interventions did not impact a doctor's income. Some on the list of Choosing Wisely, however, will.

Take a look at the recommendations by the American Gastroenterological Association specifically around the need for repeat colonoscopy after a normal one.

Do not repeat colorectal cancer screening (by any method) for 10 years after a high-quality colonoscopy is negative in average-risk individuals.

Yet, if a doctor does fewer colonoscopies, which is the right thing to do, that also means his income will decrease. In the fee for service reimbursement system, doing fewer procedures means fewer things to bill for. As noted in a previous post, a new patient to my practice wanted a repeat colonoscopy 5 years after her prior one because it was recommended by her doctor even though she had no family history and a completely normal test!

Will patients protest if their doctors offer one of the 45 recommended tests, treatments, or procedures highlighted to be avoided? Are they ready for this new world? Perhaps according to the NY Times piece "Do Patients Want More Care or Less"? 

“People are more receptive to conversations about medical interventions having both pros and cons” says Dr. [Michael Barry, president of the Informed Medical Decisions Foundation, a nonprofit group that promotes sound medical thinking]. “Traditionally, newer and more aggressive interventions were often assumed to be better.” But there are hints of a shift, he says: “When patients are fully informed, they tend to be more conservative.”... [he] believes patients are ready to hear the message. He cites popular books like “Overtreated,” by Shannon Brownlee, and “Overdiagnosed: Making People Sick in the Pursuit of Health,” by H. Gilbert Welch. These are among a slew of books in recent years written by health experts on the dangers of the “more is better” attitude about health care.

Yet, we should also be skeptical about this perspective. Research has consistently shown that there is no value for an annual physical or check-up, yet how many people still have one "just to be safe?" Although there is a small number of patients who are empowered and question their doctors about the treatment plan, the fact is most patients expect their doctors to make the best choices on their behalf. If a doctor recommends an antibiotic for a sinus infection or suggests a MRI for low back pain, will a patient really say no? In general, it takes a doctor more time and energy to educate a patient on why an antibiotic or MRI isn't necessary, how an individual's personal experience is different than those of their friends and family who all got antibiotics and MRIs in the past, and to do so in a caring and compassionate way.

If we expect doctors or patients to bend the health care cost curve this way with more education, better communications, and encouraging patients to talk to their doctors about the appropriateness of care, we will fail.

But increasingly there is a trend I am seeing which will bend the cost curve. Patients are increasingly questioning the need for expensive imaging tests not because they want to only get the right care proven by evidence, but because they have high deductibles and copays that require hundreds of dollars.

This would be good news except now instead of having a conversation and an examination with a doctor to determine if a MRI is needed for back pain, more patients are now simply calling in and asking for a MRI. After all, isn't talking and touching a patient and the healing aspect of a doctor patient relationship simply antiquated in a time with technology? It is now taking more time and energy to educate a patient why an office visit actually is more valuable than imaging!

If there is hope to make care more affordable and of even higher quality, then it will be because doctors have shouldered this responsibility. Our commitment won't be the result of our professional organizations rolling out an educational component, or the media highlighting the "waste" in our system, but rather it will be questions each of us will need to answer. Is doing no harm also mean avoiding unnecessary testing? Will we do the right thing even when it is hard? If there should be some optimism, then it should be that the current and next generation of doctors will lead this change.

This spirit and responsibility is best captured by Dr. Bob Wachter, professor and chief of the division of hospital medicine. chief of the medical service at the University of California San Francisco Medical Center, chair-elect for the ABIM and the "father" of the hospitalist movement, in his keynote address to the Society of Hospital Medicine.

“We need to be great team players, but we also need to be great leaders,"

“We need to embrace useful technology, but we can’t be slaves to it … improve systems of care, but welcome personal and group accountability. Strive for a balanced life but remember medicine is more a calling than a job. And think about the patients’ needs before our own. These are core and enduring values even as we move into this new era.”

“We have big targets on us and I think they are appropriate,” said Dr. Wachter. “There are others who should have targets as well, but the main target has to be us. Change is impossible if we don’t embrace change.”

In the end, it will be doctors who can bend the cost curve.

Guaranteed Prediction - Pay More, Get Less - Your Future Health Insurance Plan

Even with healthcare reform, Americans will increasingly be burdened with high deductibles, more financial responsibility, and less satisfaction with their health insurance for the foreseeable future. Why? Because the healthcare system is unable to transform its services in a manner that other industries have done to improve quality and service while decreasing costs. The two biggest culprits are the mentality of healthcare providers and the fee for service reimbursement system.

Doctors and patients haven't altered the way they communicate over the past hundred years. Except for the invention of the telephone, an office visit is unchanged. A doctor and patient converse as the physician scribbles notes in a paper chart. Despite the innovations of cell phones, laptop computers, and other time saving devices, patients still get care through face to face contact even though banking, travel, and business collaboration can be done via the internet, webcams, and sharing of documentation. As Dr. Pauline Chen noted in a recent article, doctors are not willing to use technology to collaborate and to deliver medical care better, more quickly and efficiently. Mostly it is due to culture resistant to change. Partly it is due to lack of reimbursement. Both are unlikely to be addressed or fixed anytime soon.

Yet, patients come to doctors for our medical expertise and insight in order to stay well or get better. They don't care if it is done via the web or in person. If doctors think their problems are safe to handle via technology then they are for it. If doctors feel a particular condition must be handled in the office, then they are willing to do it. After all, aren't we the ones who can make that assessment? They trust us to make the right determination. We must be willing to challenge tradition and training in the face of a rapidly evolving world.

If this country is going to make healthcare more affordable and more accessible, then doctors need to collaborate better. Only doctors can stop the increasing march of medical expenses.

If we as a profession are unwilling to use technology to get the information and expertise to the point of care to get people better sooner, then our country has only two options left to make healthcare affordable. The first is the government to force pricing down as it is done in other countries. Based on the agenda of Medicare, the government is already squeezing costs by dictating pricing which may not be realistic. The second is to force patients to try and figure out which tests, procedures, doctors are best to help them. Research shows they don't want that responsibility and when they do have that burden they skip care. Nevertheless, employers are increasingly moving their employees to less comprehensive consumer driven health plans (CDHP) and high deductible health plans (HDHP) to save money.

It's doctors who aren't willing to do virtual visits. The public is ready and waiting. If we as a profession won't consider using the same technology we use to communicate with family and friends as well as use these very same tools to provide "second opinions" to our loved ones who value our medical expertise to our patients, then how can we say that we are committed to making healthcare accessible and affordable to all Americans?

While there is a small group of enthusiastic entrepreneurial doctors and leading edge healthcare organizations trying to move American medicine into the 21st century, the healthcare system really needs Steve Jobs and Apple to transform healthcare. As it currently exists, the majority of doctors are either unwilling or unable to make the change.

Can Doctors Provide Rational Care or Cave In? H1N1 Experience with Public Health Indicates Latter

As the country discusses providing everyone with health insurance, an even more important conversation is how to slow the rise of healthcare costs. Many studies and research point to the ability of doctors to remove waste by not performing unnecessary tests or procedures and not prescribing the latest medications which are proven to be no better than generic versions. There is a belief that much of this additional cost is due to the fee for service reimbursement system where doctors get paid more to do more.

For example, spending 30 minutes on nutritional counseling, weight loss, and exercise for one patient with hypertension doesn't pay as much as prescribing blood pressure medication for three patients in 10 minutes. In the fee for service environment, volume is key, not necessarily providing the right care or the most rational care. A recent Newsweek opinion piece by an emergency doctor showed how he evaluated a patient appropriately for a recent head injury, discussed the plan with the family, and arranged follow-up with the pediatrician all without getting a CT scan of the head. Result? Patient did fine. No radiation exposure to the brain. No additional cost to the healthcare system, insurer, or family. Everyone benefited.

While the example isn't rare, it also isn't common. Some 30 percent of tests or procedures performed in this country have been suggested to be unnecessary and added no value to improving patients' quality of life or outcomes.

In other words, if we removed the fee for service reimbursement system, then doctors would prescribe only the right care. Not too much or too little, but just right.

Or would they?

Recent articles should make us think twice. The H1N1 virus which has been demonstrated to affect those under age 25 years old and pregnant women disproportionately than the general population now has a vaccine available, albeit in short supply. This limited supply has been given to individuals not deemed at high-risk for adverse outcomes by CDC.

While the issue might be that some public county clinics received more vaccine than others (a systems or distribution problem), the bigger question is whether public county officials and doctors are willing to have honest and frank discussions about a person's need for the vaccine. Unlike doctors in the fee for service environment, these providers don't get paid more to do more. Since compensation isn't an issue, then can they talk through the fear that people have and provide the appropriate care?

Answer? Unfortunately no. Public health officials don't want to be the police and determine who should justifiably get the vaccine and who should be turned away.

In other words, if people want it, then they will get it. If public health officials can't say no appropriately, then can we expect much better for doctors in the future? Even if the fee for service reimbursement structure is removed, unclear if that will ever happen, will doctors provide rational care and advice or cave in when patients demand prescriptions based on television ads or care recommended by celebrities?

As I received my vaccine at a flu clinic, there were nurses asking each individual in line what vaccine did they want. The nurses appropriately advised those not in the high-risk groups that they would only receive the seasonal flu vaccine and not the H1N1 vaccine. There were no fights, outbursts, or fear. Patients understood that they were getting the right care. Not too much and not too little, but just right.

If America is going to solve the affordability issue of healthcare, then doctors will need to lead the way.

Based on the public clinic officials' performance, I'm even less optimistic about the medical profession's ability as a whole. While I have great confidence in my fellow medical school alumni from the University of Connecticut School of Medicine, the colleagues I work with at the Permanente Medical Group as well as the many medical bloggers I've encountered (many who follow me via Facebook or Twitter - thanks everyone!) , I have real concern about many doctors nationwide and specifically on their ability to provide rational care and not to cave in and take the easy way out when making decisions about medical care.

What does this ultimately mean? Without doctors leading the way, the only choice left is government run healthcare. If doctors can't say no based on scientific and medical evidence, then Uncle Sam will say no. Don't say I didn't warn you.

Evidence That Doctors Will Not Support Healthcare Reform

While doctors are interested in covering all Americans with health insurance, universal coverage alone will not resolve the healthcare crisis. One of the major cost drivers in healthcare is due to more imaging tests, use of expensive medications, as well as more medical interventions which actually don't result in better outcomes.

This has been well described in various articles and books.

Despite our perception as physicians, it isn't necessarily defensive medicine and ordering more tests, procedures, and imaging that is driving overall healthcare costs, but is the reimbursement system. It rewards volume over quality and is particularly true for specialties that can increase volume. This is why primary care doctors have not seen increases in compensation and medical students are flocking to other specialties like dermatology, radiology, ophthalmology, among others. Primary care doctors can only increase volume by seeing more patients. Other specialties can improve compensation and volume by doing more surgeries and procedures, which in many instances are questionable if they are truly needed, effective, or even better than non-invasive treatment or watchful observation.

So it comes as no surprise that the New England Journal of Medicine's article - Physician's Beliefs and U.S. Health Care Reform - A National Survey finds doctors agree in abstract with universal coverage, but when asked to make that happen by asking themselves which expensive treatments really work and which are unnecessary that they walk away from the responsibility. Excerpts from the article:

Although physicians tend to agree in the abstract that health care resources should be distributed fairly, they may be unwilling to endorse concrete policies that expand coverage for basic health care by limiting reimbursement for costly interventions. And despite widespread discussions about using cost-effectiveness data or comparative-effectiveness research to guide clinical decisions, physicians may remain skeptical about such practices.3,4 Thus, physicians may not be willing to take on the role that the President and health policy advocates want them to play.

...surgeons, procedural specialists, and those in nonclinical specialties were all significantly less likely than primary care providers to favor reform that expands access to basic health care by reducing reimbursement for expensive drugs and procedures...

First, the President, lawmakers, and reform advocates can vigorously engage physicians in deliberations on health care reform, cognizant that most physicians see it as part of their professional responsibility. However, more controversial elements of reform, such as limiting reimbursement under Medicare (i.e., expanding the ranks of the underinsured), using cost-effectiveness data in treatment decisions, and limiting reimbursements for expensive drugs and procedures — all of which are elements of current reform proposals — may face serious opposition from segments of the medical profession.

In other words, you can't have your cake and eat it too. If we as a nation wish to expand coverage so that it is universal and everyone has health insurance, then we can't have every test, procedure, medication, and intervention that we want. However, that really isn't the right way to look at solving the problem.

The right question to ask is do we as a nation need every expensive test, procedure, medication, and intervention when others that are less costly but just as good work (comparative-effectiveness research - think Penicillin is still used for strep throat and has been around for over 60 years)? If we agree on the latter, then the problem becomes those medical specialties that benefit from more volume will see a pay cut.

When the abstract of universal coverage meets the reality of taking money away from someone's pocketbook, in this case more specialty doctors than primary care doctors, expect the discussion to become vocal and talk to elevate about rationing care rather than providing rational care. Healthcare reform does NOT require rationing.

Did you pass out? Felt dizzy? What you don't say can cost you.

A recent article in the Archives of Internal Medicine titled, "Yield of Diagnostic Tests in Evaluating Syncopal Episodes in Older Patients" found that patients 65 years and older are often given unnecessary tests to determine episodes of syncope which is defined as "sudden, transient loss of consciousness with spontaneous recovery". Researchers found that although the vast majority of patients received EKGs (99 percent) , were admitted to hospital beds with continuous heart monitoring (95 percent), and a significant number (63 percent) received CT scans of the head, these tools only provided doctors to the correct diagnosis 2% of the time. The results of these tests only changed their medical decisions about 5% of the time.

A far better tool was simply checking the patient's postural blood pressure. This means checking the blood pressure of a person laying down and standing up and noticing if there is a difference between the heart rates and blood pressures. This simple procedure which can be performed by doctors, nurses, or medical assistants resulted in diagnosing the correct cause of the syncope in 15% to 21% of cases, which is up to 10 times better than the fancy expensive tests listed previously. This simple procedure changed what doctors did in 18 to 26% of the time, which is 5 times better.

Unfortunately, this relatively simple and inexpensive procedure was only done 38% of the time.

What is particularly disturbing isn't these findings, but rather the fact that this is been known for 20 years. As the authors note:

Perhaps the finding in this study that causes the most concern is the extent to which unhelpful, and presumably unnecessary, testing in the evaluation of syncope continues to be performed despite the compelling evidence against the practice dating back 20 years. The current study complements earlier work by showing the high costs associated with this unnecessary testing. Extrapolating our results nationally, assuming approximately 460 000 hospitalizations per year for syncope, yearly costs associated with the most commonly obtained tests may be nearly $6 billion. Investigators have shown that easy availability of low-risk testing contributes to the overuse of resources. The frequency of syncope and wide availability of low-risk testing make its an important source of revenue for hospitals. Unnecessary testing is a substantial contributor to rising health care costs and has been proposed as a target for cost savings.

So what other tools might doctors use if the expensive tests don't provide clues in the vast majority of cases? It's the secret that good doctors know. It's the secret that medical students are taught even today. It's something you should know.

Getting a good history and doing a good physical exam is far better in determining which tests are the right tests to get to the right diagnosis.

Therefore in the case of syncope, be sure to try to provide your doctors all of the information you can think of. Provide them the FOUR W's, which are reviewed in my book. In brief, they are the what, the where, the when, and the why. If you don't, then it is very likely you'll have lots of tests, told that they are all normal, and you won't get an answer of what is wrong. With increasing out of pocket costs, can you afford to pay for unnecessary expensive tests especially if they don't get you the right answer in 98% of cases?

As this study shows and what good doctors know are that what you say about your symptoms are far more helpful to get the right diagnosis and right treatment than ordering a battery of tests.

Save Money on Medical Costs - 10 Tips from Money Magazine

The July issue of Money magazine article "Beat the rising cost of health care" has a quote from yours truly!

• Finally, ask about alternatives, says Davis Liu, a family doctor and the author of "Stay Healthy, Live Longer, Spend Wisely." For example, your doctor may suggest an MRI to figure out why your back is hurting. But if you push back a bit, she may also tell you that you can first try back exercises for a few weeks and see if the pain goes away on its own. It very often does.

Overall great tips. Without serious healthcare reform, the brutal reality is this. We are already rationing healthcare in this country. It's not based on your age, health, or research. It's based on your ability to pay.

Prevention Won't Save on Health Costs

The Wall Street Journal recently reported that the belief that a focus on preventive health won't save on healthcare costs. In the article, "Prevention Efforts Provide No Panacea on Health Costs" noted that

• The Congressional Budget Office, in a December report, concluded that greater use of preventive care would at best generate modest reductions in costs over 10 years, and might even result in increases.

Saying that prevention will save money is the wrong goal. What prevention does is free up dollars that would have been spent on other treatments and interventions that would have occurred without being proactive and allow them to be spent on improving coverage. As Federal Chairman Ben Bernanke noted in 2008 when addressing the Senate Finance Committee on Healthcare Reform, "that improving access and quality may increase rather than reduce total costs" and the better question may be, "whatever we spend, [are] we are getting our money's worth?"

Without improving prevention, both the insured and uninsured aren't getting their money's worth.

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
best?

• 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.

Medicare Won't Cover Virtual Colonoscopy - the Right Decision

In a clear blow to CT device manufacturers like General Electric, the Centers for Medicare and Medicaid Services (CMS) has decided not to cover virtual colonoscopy, which is a non-invasive way of screening for colon cancer.

It's the right decision. Although virtual colonoscopy was recommended by the American Cancer Society (ACS) as a reasonable alternative to the more invasive flexible sigmoidoscopy and colonoscopy, the issue with virtual colonoscopy is radiation exposure when other ways of screening already exist. Certainly from the perspective of ACS, which is an organization focused on increasing cancer screening and awareness, I understand the reason for adding virtual colonoscopy as an option.

But in the reality of the healthcare crisis and the goal of President Obama to make healthcare more affordable for all, decisions like this are inevitable where someone won't be happy with the outcome, in this case CT device manufacturers. With the announcement earlier this week that hospitals, insurers, doctors, device manufacturers will decrease the rate of health care expenses by 1.5% per year over the next decade, tough decisions will be made. Private insurers often follow CMS decisions, so don't expect to have virtual colonoscopy covered by your insurance company to screen for colon cancer.

The funny thing is this decision by CMS will be one of the easier decisions to make because other, although less comfortable procedures exist to screen for colon cancer. (Note that the preparation for all three procedures is the same. One needs to take a laxative to clear the colon of stool so that colon polyps can be visualized).

The other is that CMS will be using guidelines from the US Preventive Services Task Force in basing decisions. USPSTF bases recommendations on scientific evidence and tends to be the most conservative of any organization, like the American Heart Association, American Cancer Society, and various physician organizations.

CMS left the door open for reconsideration of virtual colonoscopy in the future, which is reasonable. Certainly the technology may evolve where radiation exposure is minimal to justify exposing people of average risk to a modality that potentially could increase other forms of cancer.

Review my March entry - Virtual Colonoscopy - Just Say No.

The entire article from the Associated Press follows:

Tue May 12, 10:18 pm ET
WASHINGTON – Medicare won't pay for the so-called virtual colonoscopy procedure, concluding Tuesday that there's inadequate evidence to support the cheaper, less intrusive alternative to the dreaded colonoscopy.
Some experts had hoped that popularizing the X-ray procedure would boost screening for colon cancer, the country's second leading cancer killer. Screening to spot early cancer or precancerous growths has resulted in fewer deaths over the last two decades.
But in a decision posted on its Web site, the Centers for Medicare and Medicaid Services said that the test does not qualify for Medicare coverage. The memo noted that the procedure is performed on people without symptoms and cannot, in itself, rid a patient of precancerous growths, like a regular colonoscopy can.
Medicare does cover regular colonoscopies, in which a long, thin tube equipped with a small video camera is snaked through the large intestine to view the lining. Any growth can be removed during the procedure.
CT colonography, also known as virtual colonoscopy, is a super X-ray of the colon that is quicker, cheaper and easier on the patient, but involves radiation. Both procedures involve preparation to clean out the bowels.
The Medicare memo notes that the virtual colonoscopy has shown better precision in detecting larger polyps than smaller ones.
There's been some division of opinion in the medical community over the virtual colonoscopy. Some doctors question its utility since, if a polyp is found, a regular colonoscopy would typically have to follow, anyway.
Others support it, saying it can result in early cancer detection. The American Cancer Society recommends it as an alternative to a regular colonoscopy.
A concern for Medicare officials, according to their decision Tuesday, was the effectiveness of the procedure for the Medicare population — people 65 and older — as opposed to younger patients. More data is needed to answer that, Medicare said.
The U.S. Preventive Services Task Force opted last fall not to give its stamp of approval to the virtual colonoscopy, citing the risk of radiation among other factors. Medicare said it took that decision into account in reaching Tuesday's determination, which is final.
Some private insurers cover the virtual procedure but others don't. Colonoscopies cost up to $3,000 while the X-ray test costs $300 to $800.

Improving Healthcare System Won't Save Money

While healthcare reform is gaining momentum (and rightly so), plenty of experts believe that improving the healthcare system will save money.

Don't believe it.

A recent USA Today piece titled, "Do smokers cost society money" suggests that smoking and dying earlier saves the healthcare system and other benefit programs. It may be that healthier individuals living longer, and consequently having the opportunity to have more chronic illnesses like diabetes and cancer, cost more.

From the article -

• Smoking takes years off your life and adds dollars to the cost of health care. Yet nonsmokers cost society money, too — by living longer.
• smokers die some 10 years earlier than nonsmokers, according to the CDC, and those premature deaths provide a savings to Medicare, Social Security, private pensions and other programs.
• A Dutch study published last year in the Public Library of Science Medicine journal said that health care costs for smokers were about $326,000 from age 20 on, compared to about $417,000 for thin and healthy people. The reason: The thin, healthy people lived much longer.

This is something I've always thought was a possibility. It makes some intuitive sense. Back in the 1950s, if a man died of a heart attack that would be the only cost to the healthcare system. Now as people live longer as we know better on what we must do to stay healthy and well, then they have more opportunities to not only become ill, but also injured, as well as need surgery for joint replacements, etc.

The additional wrinkle is that even the smoker now is likely to survive what was a fatal heart attack a generation ago, presumably quit smoking and also develop illnesses that can't be current, but controlled with a dizzying array of medications.

Why is this important? Healthcare reformers keep talking about cost savings to the system which isn't likely. Instead of claiming huge savings, we should be talking on how better to shift costs from expensive medical expenses like emergency room care and hospitalization for an uninsured patient with a heart attack to providing affordable health insurnace to the person to completely avoid the heart attack.

The healthcare system will still cost employers and the government a lot of money. We as a nation shouldn't expect savings from requiring doctors and hospitals to have electronic medical records (which is the right thing to do) or other touted improvements despite what the experts tell us. The irony and curse of our healthcare system is if we are as good at preventing premature death, by definition we are extending life and the likelihood of more healthcare costs for individuals saved. Can't argue with more time with family and friends.

So be cynical about stories that fixing the healthcare system will save money. It won't. What is far more important is given the amount of money we spend can we ensure it is wisely spent so all of us have the potential to live productive healthy lives?

Kiss Healthcare Reform Good-Bye

I think we can safely kiss healthcare reform good-bye. We can thank the financial meltdown for this. With the most storied and large financial institutions like Lehman Brothers and Merrill Lynch folding as banks like Washington Mutual and Wachovia seek suitors like JP Morgan and Wells Fargo to bail them out, our economy has grinded to a halt. Banks don't want to lend money to businesses or consumers, even those with good credit, because they fear the borrowers won't return their money.

Homeowners have burned many banks by being unable to pay their adjustable rate mortgages and walking away from homes which are now worth far less than the loan amount. Certainly many of these homeowners were fooled into thinking they could purchase more than they could afford. Despite who was responsible for the mess, the reality is no one will lend money out which drives the economy.

To foster more lending and hopefully to improve trust between lenders and borrowers, Federal Reserve chairman Ben Bernake and Treasury Secretary Henry Paulson convinced Congress to give them authority to invest $700 to $800 billion to simulate the economy. The federal budget which ended September 30th resulted in a deficit of nearly $500 billion. Next year because of the action taken by the Treasury, the deficit will be far larger. With a predicted price tag of nearly $65 billion to implement Senator Obama's healthcare reform plan (note Senator McCain has not indicated the costs of his plan), it is highly unlikely that even with a presumably Democratic Congress that elected officials will agree to spend even more money despite the healthcare crisis.

The even bigger issue beyond reforming a poor performing healthcare system is what to do about the looming crisis in Medicare . With the first of baby boomers entering Medicare, benefit programs like Social Security and Medicare will dominate the federal budget. Both are underfunded with Medicare being worse of the two. Neither political party, Democratic or Republican, has dared attempted to make the gutsy and necessary changes to make these programs solvent.

What can you expect? Higher healthcare costs, more uninsured, and a general decline in the nation's health. A couple retiring this year must have about $300,000 available for future healthcare costs. With a stock market in freefall, it is clear people have less available than before. As a result they may unfortunately skimp on necessary preventive care and treatments. While decreasing their costs in the short-term, these choices will cause more expensive complicated problems down the road. The country will pay a price for this with a less healthy workforce or populace with increasing diability. In addition, individuals will discover what many have already which is the leading cause of personal bankruptcy is due to medical costs.

What can you do? Educate yourself. Find out how what medications are worth your money, what screening tests you must have, what you must do to stay healthy and well, and when to seek care and utilize the healthcare system. Our government doesn't have the financial resources or the leadership needed to truly overhaul our convoluted, frustrating, and fragmented healthcare system. This is one situation where only the informed and educated individual can make the difference between getting so-so care, which is the current state of affairs, and getting the right care which is what everyone deserves but increasingly will be unable to get.

High Gas Prices Save Lives, Kitchen Countertops Can Kill

Unintentional deaths are the leading cause of death for those under thirty-five with the most common due to motor vehicle accidents. Newspapers around the country noted that high gas prices have decreased the number of traffic deaths. Naturally one could assume that the number of those injured from accidents have probably fallen as well. This means that if healthcare costs should rise less than expected next year could it be because of decreased utilization of emergency rooms and doctor visits because of fewer motor vehicle accidents?

Of course in other news, more people as a result of high fuel costs are biking, taking golf carts, or scooters, as their mode of transportation. Is it possible the number of lives saved may be simply shifting to other ways of getting around? Too early to tell.

Certainly none of us expect our kitchen countertops to kill us, but an article from the NY Times found that inferior types of granite contained high levels of the radioactive substance uranium. Not only is the element radioactive, which in of itself is a concern, but it also emits the carcinogenic gas radon, which has been a risk factor for lung cancer. With homes sealed for energy efficiency, it could make levels even higher. Could this be the reason why many non-smokers are developing lung cancer?

Who would have thought it was more dangerous to be at home in the kitchen rather than on the road?