Can Price Shopping Improve Health Care? Do Pigs Fly?

In a recent Time magazine article Could Price Shopping Could Costs and Improve Health Care, the author suggests as many others have done in the past that forcing patients to more like customers and comparison shop will drive healthcare costs down.

Nothing could be further from the truth.

The theory of consumer driven healthcare goes that if there was more information about the costs of doctors, hospitals, imaging tests, and procedures that people would hunt around to find the best deal, stimulate competition, and drive pricing downward.

Proponents always point to the example of how LASIK eye surgeries have gotten less expensive because of price transparency and increased competition as more eye doctors enter the market in what used to be a very expensive procedure.

But that is always the only example that they give.

They fail to demonstrate how price transparency alone results in decreased costs. Look at elective plastic surgery, which like the LASIK example, has doctors providing a service which isn't medically necessary. Shop around. Get pricing. Has plastic surgery gotten less expensive like LASIK surgery? Of course not. Why?

In the past, LASIK eye surgery required the very skilled hands of an ophthalmologist. Over many years, however, understanding precisely who made a good candidate and the optimal surgical technique to be used become more clear. Consequently the procedure became standardized. As a result, these days LASIK surgery is typically performed by an machine that is essentially automated under the supervision of an ophthalmologist. Because of this standardization and precision, LASIK surgeries are done more reliably and quickly for those who are good candidates. For those of us who have conditions that don't fit into this neat workflow, we will still need to rely on the human doctor's expertise and experience. In those situations, the pricing won't be inexpensive.

It isn't price transparency alone that will drive costs down, but the standardization of treatments for a particular ailment. Specific treatments for bladder infections (urinary tract infections), sore throat, like strep throat or mono, pink eye (conjunctivitis) are fairly clear cut and straight forward. This is why walk-in clinics like Minute Clinic can drive costs downward using less expensive physician assistants and nurse practitioners, rather than doctors. For sore throat, the workflow is pretty obvious (and available at www.familydoctors.org).

Note how they avoid back pain and chest pain. It may be for liability issues, but also because the amount of precision needed isn't quite there. Once medical science can determine which tests or interventions can reliably differentiate a symptom or problem into a specific treatment will costs come down. This is probably why plastic surgery won't quite ever become a commodity like LASIK surgery. How would you like to have a standardized nose job or face lift?

Proponents of consumer driven healthcare also believe that having patients pay more of their healthcare expensive or "having more skin in the game", will also drive costs down over the long-term. The thinking goes that if people understood the high costs of having a chronic illness like diabetes or heart disease that they would choose healthy behaviors. They should appreciate that preventive interventions like cancer screenings were less expensive than dealing with a cancer diagnoses and subsequent treatment. Getting a simple vaccination to prevent influenza or pneumonia would be far better in preventing emergency room visits or hospitalizations. People would begin to make rational choices and opt for less costly therapies today to put off very expensive theoretical losses in the future.

Odds this will occur? Highly unlikely.

Simply look at how the American consumer fared when given financial responsibility to make decisions presumably for their best interest, retirement planning, to determine how successful the public might be in embarking on consumer driven healthcare.

Starting in the 1970s, employers started to shift employees from pension plans (defined benefit plans) to 401(k) plans (defined contribution plans), where employees would have more financial responsibility and have "more skin in the game" in determining how much to save and how to invest for retirement. The thinking was that employees, looking out for their best interest, would do research and demonstrate the rational behavior needed to ensure that they retired with a nest egg that suited their needs. After all, who would have more motivation to save for retirement than the individual himself?

Did it work out as planned?

A recent article from CNN Money found that 43 percent of Americans have less than $10,000 saved for retirement. More importantly "the gap between what Americans have saved and what they'd need for retirement is forcing workers to prolong their working years."

In other words, the American consumer isn't doing well to save for retirement even though it is in his best interest. At least in retirement planning, consumers have the option of delaying retirement and working longer.

Consumers as patients, however, won't have that luxury of putting off medical care if they suddenly become ill. It is very likely a large number of Americans instead of losing weight and controlling blood pressure will have a devastating heart attack that requires open heart surgery. Colon cancers will be detected at later incurable stages requiring very expensive chemotherapy for months rather than having been removed years earlier with less costly colonoscopies. It is very likely in consumer driven healthcare, much like defined contribution retirement plans, that the consumer or patient hasn't saved enough to pay for these very expensive future therapies or treatments.

As a graduate of the Wharton School of Business, however, I wouldn't do my education justice if I completely dismissed the concept of efficient markets, consumerism, and competition. If consumer driven healthcare is to work, it will require a few elements, which unfortunately the American healthcare system at this time is ill equipped to deliver on.

I will discuss these crucial elements in a future post.

Wanted - Primary Care Doctors ASAP.

In a few years, every American will be required to have health insurance. As a result, the 32 million people currently uninsured will seek out a personal physician. This role typically is filled by a primary care doctor, like an internist or a family physician.

While passage of the health insurance reform bill affirmed the belief that having health insurance is a right rather than a privilege, the legislation falls short on building a healthcare system capable of absorbing the newly insured. Universal healthcare coverage is not the same as providing universal access to medical care. Having an insurance card doesn't guarantee that individuals can actually get care.

One doesn't need to look any further than the Commonwealth of Massachusetts to see what problems lay ahead. In 2006, the state required everyone to have health insurance. It was believed that having universal coverage would have slowed healthcare costs. Expensive emergency room visits would be averted as newly insured individuals would have a personal doctor who could address the problems sooner and at less cost.

Unfortunately, that scenario never occurred. According to the state medical society over half of internists and about 40 percent of family physicians were not accepting new patients. So the newly insured still didn't have a personal doctor to call upon even though Massachusetts has the most primary care doctors per capita than any other state. Insurance coverage does not mean access to medical care.

If a manageable patient panel per full time primary care doctor is about 2000 patients, then the nation would need an additional 16,000 doctors to care for the newly insured. With some evidence that the nation is expected to be short about 40,000 primary care doctors over the next decade, one should wonder if we are training enough doctors to fill the gap.

The answer is no. With the 2010 residency match, US trained medical students have indicated that primary care is not what they want to do. Of the roughly 2300 positions in family medicine residency programs, only 45 percent were filled by students attending American medical schools. While the American Academy of Family Physicians proclaimed the 2010 Match as the most successful ever with 91% of residency positions filled, the sad reality is obtaining this rate required eliminating 600 positions over a decade. In 1999, there were over 3200 family medicine positions available for medical students to match into.

Internal medicine numbers are better, but won't address the primary care crisis either. Though nearly 5000 students are training in internal medicine, the trend has been to use the three year residency program as a prerequisite for more lucrative medical subspecialties like cardiology, pulmonary, or oncology, to name a few. While in 1998, 54 percent of internal medicine residents planned on becoming primary care doctors after training, by 2003, the number fell to only 27 percent.

Solving the primary care crisis can't be done with ancillary clinicians. As Americans are paying more for healthcare, I don't believe that they would willingly choose to have primary care done by nurse practitioners or physician assistants. That is not to say that there are not plenty of excellent clinicians out there, but adding these physician extenders won't bend the healthcare cost curve. Their costs often are comparable even as their knowledge base is less.

Though the healthcare reform legislation tries to maintain the primary care workforce via increased income for primary care doctors providing Medicaid services as well as increase the numbers with grants for more primary care training and loan repayment for doctors working in underserved communities, the reality is medical students won't be signing up. The specialty's relatively low pay, absence of work-life balance, and low prestige compared to other medical fields doesn't resonate with today's students.

That's too bad because the nation and the public needs more primary care doctors than ever. Not only can primary care doctors decrease costs, but also the amount of time wasted getting to the right specialists. One health plan that focused on using primary care physicians to coordinate care discovered use of specialists fell by 14 percent, emergency room use decreased by 16 percent, and prescriptions declined by 11 percent. When patients self-referred to specialists, about 60 percent went to the wrong specialist. More troubling is that on average $1500 was spent on various tests and diagnostic services over an 11 month period before patients were told that the specialist could not help them.

So having a personal doctor is important and can save you time and money, but more importantly get you feeling better sooner. Too bad the nation won't have enough to go around. Hurry and find a primary care doctor you like and trust because it is possible later on you might find yourself without this indispensable advisor and guide for many years to come. Result to you and implications for the nation? Spending more time and money and not getting any healthier.

Want a crystal ball on how this legislation will affect the country? See what Massachusetts does next.

Is healthcare a right or a privilege?

Is healthcare a right or a privilege?

Depending on how you view this determines how you feel about the recent healthcare reform which was signed by President Obama.

As a doctor, I firmly believe that having healthcare is a right.

As a nation, we agree that individuals should be accountable for their actions. People often argue that those who are reckless with their bodies by ingesting chemicals via cigarettes or drug use and who subsequently develop cancers shouldn't be subsidized by others insurance premiums as the latter group works hard at staying healthy by exercising, maintaining an acceptable weight, and eating generous portions of fruits and vegetables. Some how it isn't fair.

Unfortunately life and good health aren't quite that easy or predictable.

Children who haven't had time to abuse their bodies do develop cancers, type 1 diabetes requiring insulin, or are born with genetic problems, like cystic fibrosis, that require expensive medical therapies that potentially are lifelong. Once diagnosed, these children are now plagued with the "pre-existing" label and unable to get health insurance. Over the past many years, the leading cause of personal bankruptcy for individuals and families is due to medical expenses. As a parent with an ill child could you simply walk away?

Non-smokers do develop lung cancer (note Dana Reeves, Christopher Reeves' wife). Individuals without a family history do get afflicted with other aliments. Healthy people do get heart attacks.

In other words, life happens. Good health can require a little luck as well. While individually one can decrease risk by not smoking, eating healthy foods, losing weight, and exercising, it isn't a sure thing. Bad things can happen to good people.

About 1 in 10 Americans or thirty-two million citizens, roughly the entire population of Canada, don't have health insurance . As a country, is it acceptable for us to walk away from them?

Even today, Americans believe in the American dream - work hard and you can be successful. The wild card is that having good health can be a finicky thing. Do everything right and you could or a family member could be stricken with a serious illness. Prior to healthcare reform, this situation not only could bankrupt you but your family.

Let's be clear. The legislation isn't perfect. It isn't so much true healthcare reform, but health insurance reform. The program phases in over a number of years. It doesn't address healthcare delivery or costs, which will likely occur in 2011. Nevertheless, it is an important start.

Despite the heated rhetoric from both parties, Americans are still a society that welcomes diversity, provides compassion and help to fellow human beings, believes in justice, fairness, and the opportunity to succeed with dogged hard work. This healthcare reform legislation, though far from ideal, is a good first step to ensure the American dream can still exist for current and generations to come.

The truth about prostate cancer screening

Earlier this month, the American Cancer Society revised its recommendation for men regarding prostate cancer screening based on the latest research. Specifically ACS wanted men to ask their doctors about the limitations of PSA blood testing and digital rectal exams and their inability to improve survival.

Based on the National Cancer Institute's Prostate, Lung, Colorectal, and Ovarian screening trial and the European Randomized Study of Screening for Prostate Cancer, there was no evidence that screening with PSA made a difference in decreasing death from prostate cancer after a follow-up of seven years. While the European study showed a slight decrease in mortality with screening, this did not occur until about after nine years of follow-up. In other words, if this testing is helpful perhaps it will take until a ten year follow-up, before a decrease in prostate cancer rate is seen. Time will tell as the PLCO screening trial is still ongoing.

For now the American Cancer Society (ACS) recommends that men who are average risk (no family history or are not African American) should have a discussion with their doctors at age 50 about the limitations of PSA and rectal exams to find prostate cancer. If patients are unable to make a decision, then ACS suggests that doctors to the following:

After this discussion, those men who want to be screened should be tested with the prostate specific antigen (PSA) blood test. The digital rectal exam (DRE) may also be done as a part of screening.

• If, after this discussion, a man is unable to decide if testing is right for him, the screening decision can be made by the health care provider, who should take into account the patient’s general health preferences and values.
• Men who choose to be tested who have a PSA of less than 2.5 ng/ml, may only need to be retested every 2 years.
• Screening should be done yearly for men whose PSA level is 2.5 ng/ml or higher.

What to make of all of this? Medical research is constantly evolving. The more scientists investigate and study what works and what doesn't then the more precise doctors can figure out what must be done to keep you healthy. Despite public service announcements, prostate cancer screening has always been more controversial than screenings for other cancers because it wasn't clear that early detection made a difference. Certainly the most recent findings do nothing to change that sentiment.

For ACS, an organization focused on improving Americans' awareness to screen for cancer, to essentially tell men not to get prostate cancer screening demonstrates how unconvincing the evidence is that testing allows men to live longer. Another important learning is that patients need to understand that we still have a long way to go until we, doctors, have the tools to make precise diagnoses on which individual has an aggressive form of prostate cancer that requires medical intervention before becoming deadly and which others cancers are too small or slow growing to make a difference in a man's life.

Based on the latest evidence it is possible that with screening you might be diagnosed with prostate cancer, receive treatment that may include surgery or radiation which can result in impotence or urinary incontinence, as you and your doctor believe you've done the right thing to keep your self well. It is equally likely, however, that all of the interventions, treatments, pain, and complications you subjected yourself to made absolutely no difference.

So before you get a panel of blood work for a physical, ask your doctor if prostate cancer screening is proven to save lives. If he says yes, then you might want to print this out and ask him to explain the PLCO findings because you don't want to do more if it makes no difference it allowing to you live longer and healthier.

Navy Investigates Murtha's Death - CNN's Elizabeth Cohen Reports Unhelpful Advice

Nine days after my post wondering if the late Rep. John Murtha's death after an elective gallbladder surgery was a result of a preventable medical error, CNN and the Washington Post report that the Navy is now opening an investigation.

"The review is being conducted to determine if Murtha died due to a preventable surgical error and whether any action against those who performed the surgery is potentially warranted." according to the CNN article.

While this is good news, what I found rather disappointing was CNN's senior medical correspondent Elizabeth Cohen thoughts on how Murtha might have acted differently to avoid this unforseen outcome.

"You really have to be an aware and empowered patient because in those two days it's likely that he likely felt something that he felt some discomfort or felt a bit ill and, of course, we aren't trying to blame the patient but if you feel anything at all strange following a surgery you have to go back to that surgeon."

While I suspect she is trying to be helpful, the advice she offers isn't particularly meaningful. Who doesn't feel a little discomfort, feel strange, or a bit ill after having surgery? What other past life experience provides a reference point on whether this post-operative recovery will turn out fine or be completely disastrous?

The reason she would say such a thing is because our healthcare system is not as good as it must be in preventing medical errors and eliminating missed opportunities for prevention and screenings. Patients don't want to constantly worry about being an "aware and empowered patient". They don't want to be burdened with the responsibility of being vigilant for bad outcomes. They would rather can focus on healing and getting better.

Our healthcare system must continue to focus on improving patient safety.

So, in the end, was Murtha's death preventable? While I don't have any specifics of his case, my sense is that unfortunately his death was the result of a known risk and surgical complication and not due to gross incompetence or negligence. Let's be frank the Navy's review of Murtha's death is only because of his status as a very visible Congressman. Had this occurred to someone else, I doubt a death after gallbladder surgery would have received this level of scrutiny.

If this review is done objectively, then I don't expect anyone to be reprimanded or fired.

His death, however, does serve as important reminder. Only have surgery if it is absolutely necessary.

Could Rep. John Murtha Have Died from a Medical Error or Omission?

While the news reports that Representative John Murtha of Pennsylvania died after complications from gallbladder surgery, the question no one is asking is whether his death was a preventable one or simply an unfortunate outcome. According to the Washington Post, Murtha had elective laproscopic gallbladder surgery performed at the Bethesda Naval Hospital and fell ill shortly afterwards from an infection related to his surgery.

He was hospitalized to Virginia Hospital Center in Arlington, Virginia, to treat the post-operative infection. His care was being monitored in the intensive care unit (ICU), a sign which suggests that not only was the infection becoming widespread but also that vital organ systems were shutting down.

Was his death preventable or simply unavoidable? One reference notes that when gallbladder surgery is performed electively that "the mortality rates are very low. (Even in the elderly, mortality rates are only 0.7 - 2%.)" Perhaps Murtha was one of the unlucky 2 out of 100 to have died from this elective surgery.

It is also equally likely that he died of a medical error or omission. As Dr. Atul Gawande notes in his newest book - The Checklist Manifesto - a simple list helped prevent less than optimal surgical outcomes. One item on the list is whether or not IV antibiotics were given at the time the surgeon begins the opening incision. You would think this would be obvious, yet in the operating room, there is a surgical team which as a group is responsible for the patient's care. Do they work as a highly functioning team? Are there clear lines of communications between the surgeon, anesthesiologist, nurses, and surgical techs? Sadly, communications are not as clear as they need to be. As Gawande notes, a simple two minute checklist not only forced communications (something as basic as an introduction to the surgical team - "Hi, I'm Dr. Gawande general surgeon") but also verified that critical tasks were completed. As a result, the checklist decreased the complication rates by 36 percent and death rate by half. Disappointingly only 20 percent of American hospitals have adopted these types of checklists.

The Leapfrog Group rates hospitals on their processes to keep patients safe. Bethesda Naval Hospital being a government institution isn't listed and is not part of the survey. (Leapfrog Group was founded by large employers, who purchase health insurance, to evaluate the care their employees receive from hospitals).

Virginia Hospital Center, where Murtha was hospitalized, didn't submit any information either even though it is listed in the Leapfrog Group database. Specifically, Virginia Hospital Center declined to respond to the survey on how they are doing to keep medical errors from occurring. Questions include whether there is adequate ICU staffing, processes to reduce ICU infections, and steps to prevent harm. Gawande notes in his earlier New Yorker piece that even intensive care units errors of omission and missed opportunities happen which can be avoided with checklists.

In other words due to lack of transparent information, both hospitals are black boxes - Bethesda Naval Center because it is a government run hospital and Virginia Hospital Center because it didn't submit any data. There is a good chance that Murtha's death was possibly avoidable. This doesn't mean that doctors aren't working hard or trying to do their best. I believe that getting medical care must be as safe as it is humanly possible. Having witnessing near misses in medical care with my family and understanding what it takes to make patient safety as routine as other highly reliable organizations, I recognize that there is still much to do.

In the mean time, what does this mean for you? Surgery is never routine. If you need to have an operation, check out the hospital and how it rates to keep you safe at The Leapfrog Group. Not listed there? See if you can get surgery at a hospital that is recognized by Leapfrog.

Vitamins - Scientific Breakthrough or Marketing Hype? The Truth.

Some patients love their vitamins spending hundreds to thousands of dollars annually. At times, they will even forgo proven medical therapy. As more Americans go without health insurance coverage while others face higher office visits and copays, increasing number of patients are seeking alternative natural therapies instead of medical care. Are vitamins really the scientific breakthrough and secret that doctors refuse to recommend or are they simply marketing hype? As any medical school student will tell you, the correct answer to any question is: it depends.

For certain groups, pregnant women, patients with macular degeneration, and vegetarians, vitamins and minerals may be recommended as research finds them helpful. Prenatal vitamins have more folic acid which has been found to decrease the risk of neural tube defects in the fetus. Vegetarians may need to supplement their diet with vitamin B12, iron, and vitamin D, which are absent in their food choices.

Patients with history of gastric bypass should be on a multivitamin that contains iron and vitamin B12. The surgery, which is used to cause weight loss in morbidly obese patients, can bypass part of the digestive tract responsible for absorbing these nutrients.

Women of all ages should take calcium and vitamin D to improve bone density to decrease their future risk of osteoporosis. This means at least 1000 mg of Calcium daily and Vitamin D 800 to 1000 international units (IU) per day. Women over 50 should be taking 1500 mg of calcium day. A common misconception is that a multivitamin has enough calcium. It doesn't!A typical multivitamin has about 45 mg of calcium (a glass of milk is about 300 mg).

Aside from these individuals, the result of us with a balanced diet should get the right amount of vitamins and minerals. You don't need the large mega-dose vitamin packs found at your local warehouse store or nutritional shop. Not only are they expensive but also unproven.

If you still feel like you can't get through life without taking vitamins, then at least be aware of the following:

Limit the amount of fat soluable vitamins that you ingest, specifically vitamins A, D, E, and K. Unlike water soluable vitamins which excess amounts are excreted by the kidneys, fat soluable vitamins can build up levels in the body.

Vitamin A - toxic levels begin at ingesting more than 50,000 IU daily. Upper limit of tolerable intake (what is considered the upper limit of normal but still safe) is 10,000 IU. Recommended daily allowance is 3,000 IU.

Vitamin D - upper limit is 2,000 IU. The current daily allowance is 600 IU. A new recommendation is expected in May 2010 by the Food and Nutrition Board. Vitamin D is obtained by the skin via sunlight exposure. With people indoors more often than generations ago and possibly the increased use of sunscreen, doctors are seeing more cases of vitamin D deficiency. Your doctor may prescribe a weekly dosage of 50,000 IU weekly for 3 months to replace. Low levels of vitamin D can cause muscle pains, so if a constant problem, ask your doctor to check your levels. (Cod liver oil, incidentally, is rich in vitamin D and is probably why growing up in Canada I had a lot of it during the winter. Ick.)

Vitamin E - recommended dosage is 22.4 IU with the upper limit of tolerable intake no more than 1500 IU. Some research suggested that there was increased mortality for those individuals taking more than 400 IU per day. Because of its antioxidant properties, researchers thought taking more was better. It wasn't.

Vitamin K - found in green leafy vegetables, it is the only fat soluable vitamin where there is no defined upper limit for toxicity. Overdose of vitamin K is rare.

Am I against vitamins? Of course not. For some patients in fact they are recommended. What I am against is, however, having individuals spend their hard earned money for therapies that aren't proven. Note that the FDA, under current legislation since 1994, has no oversight over nutritional supplements.

This is why all vitamin package inserts have the following statement:

* These statements have not been evaluated by the Food and Drug Administration. This product is not intended to diagnose, treat, cure, or prevent any disease.

Want to live well? A better insurance policy than vitamins is to not smoke, perform regular physical activity, take in five servings of fruits and vegetables, and possibly drinking alcohol in moderation (as a doctor I can't recommend that, but if you drink already, it might be o). Researchers found individuals who did all four behaviors added 14 years to their lives. Why don't more of us these activities? They all take some effort. Swallowing vitamins are quicker and easier.

If I still haven't convinced you not to take unnecessary vitamins, then at least check with your doctor before stopping your medical therapies or adding supplements that can interfere with your treatment.

Finally, please avoid colon or total body cleanses. Sounds natural and healthy, but again aren't required. A product found at a large nutritional chain's special "anti-oxidant" formulation basically consists of fruits, vegetables, and fiber. You can do that yourself for a lot less and it probably tastes better too.