Monday, December 14, 2009

Et Tu, Mayo? Medicare Expansion Won’t Get Us There - Mayo Health Policy Center Blog

Medicare Expansion Won’t Get Us There « Health Policy Blog:

A very disappointing post from the Mayo Health Policy Center:

Proposal Would Not Increase Access to Health Care Services or Control Costs
The current Medicare payment system is financially unsustainable. Any plan to expand Medicare, which is the government’s largest public plan, beyond its current scope does not solve the nation’s health care crisis, but compounds it. We need to fix Medicare by moving it to a system that pays for value – quality health outcomes that are affordable over time – and ensure its success, before bringing more people into a broken system.
Expanding this system to persons 55 to 64 years old would ultimately hurt patients by accelerating the financial ruin of hospitals and doctors across the country. A majority of Medicare providers currently suffer great financial loss under the program. Mayo Clinic alone lost $840 million last year under Medicare. As a result of these types of losses, a growing number of providers have begun to limit the number of Medicare patients in their practices. Despite these provider losses, Medicare has not curbed overall spending, especially after adjusting for benefits covered and the cost shift from Medicare to private insurance. This is clearly an unsustainable model, and one that would be disastrous for our nation’s hospitals, doctors and eventually our patients if expanded to even more beneficiaries."

I simply have to call BS on the figure of how much money Mayo loses to Medicare. We know Mayo is one of the high performing providers and so should be doing far better.

From Ezra Klein:

On March 17th, Glenn Hackbarth, the chairman of MedPAC, testified before the House Ways and Means Committee on this very issue. Hospitals, Hackbarth argued, are inefficient. Their costs are too high. And this was backed up in the data. "MedPAC analysis has identified a set of low-cost hospitals that consistently out-perform other hospitals on a series of quality measures, including mortality and readmissions," Hackbarth explained. "Among this set of hospitals, we found that Medicare payments on average roughly equaled the hospitals’ costs." In less "efficient" hospitals, Medicare's payments were below costs.


Among the major differences between "efficient" and "non-efficient" hospitals was that the less-efficient hospitals were not under financial pressure: They made a lot more money from other sources. As such, they spent a lot more money on things like capital expansion. As example, compare the amount a young journalist spends to the amount a young investment banker spends. The banker requires more income to break even on that lifestyle. His "cost" is higher. But he doesn't need that lifestyle. He doesn't need that "cost." And if that banker is being paid on taxpayer dollars, I don't want him to have that lifestyle. I want him to have what he needs, rather than what he wants. Because I'm paying for it.
And so too with Medicare payments. Indeed, what MedPAC found was that hospitals under "financial pressure" -- hospitals that made less money, in other words -- managed to control their "cost" better. Medicare's payments sufficed for them. And their quality outcomes weren't any worse.

This is a remarkably "retro" viewpoint from Mayo, which has taken progressive stands on cost containment, reducing over utilization of procedures and testing, chronic care management and the like. To hear them call Medicare unsustainable is surprising. While I agree that Medicare payment has to be radically changed in some areas, the only thing unsustainable is our current course!

And, regardless of what Mayo "believes" about government run entities (which they disparage in their piece), government run or strictly regulated systems consistently outperform the US system in France, Germany in many other places. The ACP Policy Committee has recognized this for years and has advocated for a single payer system like France or a hybrid system like Germany's for many years.

And one more thing, wouldn't you rather get paid by those expensive 55-65 year olds who don't have insurance instead of eating it (or eating part of it, and bankrupting families)? I realize the Mayo's catchment area has few uninsured, but consider the rest of the country in making pronouncements!

And the Mayo release has been picked up by Fox News for goodness sake! In a fair and balanced piece on Medicare expansion, of course.

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Physicians on Health Reform, UPDATE!

Update 1/23/12 : the ASA, No. 7 below did not support the HCR Bill, just a Public Option. See the full correction here. My apologies. 

Below are the largest physicians organization, in order, with estimated membership numbers based on their own websites (or other sources when the Web Site didn't have them).

All are YES on reform with Public Option except 11 and 12 as noted below.

1. AMA 240,000
2. ACP 126,ooo (Internists and many medical subspecialists)
3. AAFP 94,000 (Family Practice)
4. ACS 76,000 (surgeons)
5. AOA 67,000 (osteopaths)
6. AAP 60,000 (pediatricians)
7. ACOG 52,000 (ob-gyn)
8. ASA 43,000 (Anesthesiology!)
9. APA 38,000 (psychiatry)
10. ACC 37,000 (cardiology)*

NO: 11. ACR 32,000 (Radiology - Not on Board)*
NO: 12. ACEP 27,000 (Emergency Medicine - Has policy statements, no stand on bills)

13. AGA 17,000 (gastroenterology)

14. It gets a little fuzzy from here on. I think Dermatolgy with 14K is next (they are against a public option), but there are probably organizations that I'm not thinking of that belong in here. Please fill me in and I will update accordingly.

SO, actually, the BIG NEWS is that 10 of the 10 largest physician organizations support health reform with a public option.

[*I had mistakenly put Radiology above Cardiology. But I checked the numbers again today, and these, I think are accurate as they are from the society's websites. PLEASE correct me if you think I've erred.]

State Medical Societies (these are rough estimates):

1. Texas 43,000 Against Senate Bill, member survey: more worried about govt than private insurer interference in medicine.
2. California 35,000. Sent letter of support to AMA
3. NY 30,000. Sent letter of support to AMA
4. PA 20,000. Sent letter of support to AMA on principals, not specifics
5. Florida 19,000. Has set of principles, no specifics
6. Illinois xx,000. For reform, worried about Medicaid expansion (low reimbursement) and no fix for SGR in Senate)

If you'd like to add your state to the list or correct what I have, please do and I will put it up on my blog.

And, of course, don't forget the recent NEJM published surveys of physicians' opinions on reform.

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Wednesday, December 9, 2009

Gawande on what agricultural reform can teach us...

Testing, Testing by Atul Gawande

"America’s agricultural crisis gave rise to deep national frustration. The inefficiency of farms meant low crop yields, high prices, limited choice, and uneven quality. The agricultural system was fragmented and disorganized, and ignored evidence showing how things could be done better. Shallow plowing, no crop rotation, inadequate seedbeds, and other habits sustained by lore and tradition resulted in poor production and soil exhaustion. And lack of co√∂rdination led to local shortages of many crops and overproduction of others.

You might think that the invisible hand of market competition would have solved these problems, that the prospect of higher income from improved practices would have encouraged change. But laissez-faire had not worked. Farmers relied so much on human muscle because it was cheap and didn’t require the long-term investment that animal power and machinery did. The fact that land, too, was cheap encouraged extensive, almost careless cultivation. When the soil became exhausted, farmers simply moved; most tracts of farmland were occupied for five years or less. Those who didn’t move tended to be tenant farmers, who paid rent to their landlords in either cash or crops, which also discouraged long-term investment. And there was a deep-seated fear of risk and the uncertainties of change; many farmers dismissed new ideas as “book farming.”

Another inciteful piece showing how far agriculture came in a few short decades by experimenting and scientifically evaluating methods for improvement and the parallels for us in this centuries health reform debate. How does he come up with these?

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An Interview With Thomas Russell for Health Affairs

Health Affairs Blog link to full interview.

John Iglehart, one of the Founders of Health Affairs posts an interview with surgeon and retiring Executive Director of the American College of Surgeons. There are quite a few pleasantly surprising moments in the interview, which I'll bullet here, but you can go read on your own.

  • Q. I would assume that more than a few surgeons regard such activity as an intrusion into the independent practice of medicine. Is there a generational difference among surgeons in their willingness to cooperate or at least participate in these kinds of initiatives?
    Russell: Absolutely. The younger surgeons have trained in an environment in which they to expect that the quality of care they deliver will be measured and evaluated, so they don’t really have any difficulty participating in these activities. It’s some of the older physicians who entered practice in a more autonomous era who struggle with these new forms of oversight.
  • First, let me say that the surgical community is not homogeneous, and they’re all over the map on reform. The College has a split membership. Some surgeons think that the status quo is just fine and that greater oversight and accountability are unnecessary. They view them as intrusions into the autonomy of a sovereign profession, while others are all in favor of reform.
    There is at least one matter on which I think we mostly agree, and that is the fact that we have to do something to fix our broken payment system. So, the number-one change that I would like to see emerge from the health care reform debate is fundamental, long-term improvement in how physicians are paid, so that they really are being paid for providing cost-effective, high-quality services.
  • Iglehart: Would that mean, according to your vision, an abandonment of the fee-for-service payment model and going to an alternative model, or some kind of a hybrid?
    Russell: I recently addressed a large group of surgeons and asked them whether they are paid a salary, and most of them raised their hands. Throughout the nation, more surgeons are becoming salaried professionals. Most academic surgeons as well as those in integrated delivery systems—such as the Mayo Clinic, Geisinger, Kaiser, and many others, including Veterans Affairs—are on salary. So are doctors who are employed by the VA. I think it’s safe to say that more than 50 percent of the nation’s physicians are paid a salary. And, some of the happiest doctors whom I’ve met are the salaried ones because they don’t have to deal with the hassles of malpractice insurance, including the high premiums they pay, or coding, or any of the other administrative burdens that confront physicians who are in private practice and reimbursed through the complicated fee-for-service system.
  • We also need to look in a very thoughtful, ethical way at rational – I’m not using the word rationing, I’m using the word “rational”–ways to improve end-of-life care.
    In addition, the medical and surgical professions need to develop protocols for the best ways to approach diseases. We need policies about when scans, such as a CTs and MRIs, are indicated, and to make sure they are not unnecessarily repeated by another physician. And we must develop standardized ways of treating diseases so that every health care professional involved in coordinating a patient’s care is addressing the condition in the most cost-effective way that follows the scientific evidence.
  • For instance, I think that the Number One way to help patients avoid frivolous trips to the ER is to educate them about where they should turn to receive appropriate care for nonemergency conditions and to make certain they have access to primary care physicians. [We do a poor job of getting people into PCPs- cmhmd]
  • Here’s how this maldistribution of surgeons has arisen. About 80-90% of medical school graduates who pursue surgery as a specialty begin their residency training in general surgery. After five or six years of residency, and at ages 32 to 34, many pursue additional training in a fellowship that will allow then to focus on just one type of disease or organ that general surgeons treat and operate on. That is to say, they become super-specialized in breast surgery, minimally invasive surgery, bariatric surgery, cardiac surgery, or cancer surgery. So they’re taking themselves out of the pool of professionals who can perform the broad range of general surgery procedures. And, most of this highly specialized surgery is performed in large cities, so these surgeons are not typically accessible to rural patients.
  • Organized medicine and many Republican legislators have long argued in favor of capping awards for noneconomic damages, but I don’t believe the nation will ever reach a consensus on that proposal, although a few states have implemented the limits. I think instead more efforts should be made to educate, in this case surgeons, about how to avoid or better manage risk by staying within their scope of practice. Communication with the patient and his or her family throughout the surgical experience is also key to helping these individuals understand why there was a negative outcome. When a mistake is made, apologize, if you practice in a state that has passed legislation providing legal protections for saying, “I’m sorry.”
    Very important, too, is for the profession to develop evidence-based best practice protocols and for physicians to follow them closely. In my era, we objected to this form of standardization and called it “cookbook medicine.” But, as calls for accountability have increased, lawmakers should consider setting policies that protect physicians who adhere to professionally developed protocols. In these cases, if a patient sues because of a bad outcome, the physician can respond with a legitimate defense: ”Look, I followed the protocol that we all agreed was best practice. I’m sorry for the bad outcome, but a bad outcome does not equal malpractice. [Except for this and people like Bernadine Healy, who should know better -cmhmd]

Thanks to Mr. Iglehart and Dr. Russell for the informative interview.

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