Thursday, December 11, 2008

To Our Health!

"Now, some may ask how, at this moment of economic challenge, we can afford to invest in reforming our health care system. Well, I ask a different question – I ask how we can afford not to." [Barack Obama, today.]

On the occasion of Barack Obama's rollout of his health policy team, and given that, according to a couple of pieces of paper I have around here somewhere, I'm a doctor, this seems a good time to spout off -- yet again -- on the state of health care in the US. What it really boils down to is this: we need to reduce cost and raise quality. As long as the discussion is only about paperwork, ie, single payer vs current insurers, electronic vs paper records; and as long as the only real efforts to control costs are in reducing payments to providers, we'll be getting nowhere. As usual.

I've written about why I favor single-payer, and have acknowledged that among physicians I'm in a distinct minority. I've said pretty much all I know about that aspect of it. Moreover: as controversial as it is, it's really only nibbling around the edges. Solutions --REAL solutions -- will come from fundamentally changing the nature of care itself, and how we provide it. And if you think addressing insurance is complicated and daunting, you ain't seen nothin' yet! If we were ever to get to the nitty gritty, we'd hear screams of bloody murder from providers and patients alike!! If and when you hear the noise, you'll know we're almost there.

As I try to elucidate, two things might become apparent: 1) I can only talk about my personal "style" (for lack of a better word), and 2) I probably don't know what I'm talking about. Specifics, anyway. But I think I'm right, looking down from a few miles up.

Inevitably, quality of care delivered differs wildly from provider to provider. It should be no surprise, of course; there are good teachers and bad, competent lawyers and lousy ones (insert malpractice comment here), engineers and architects and scientists and machinists who vary greatly one from the other. To the extent that quality control and outcome assessment have been instituted, it's been pretty superficial. And pathetic. Surgeons, for example, (a subject with which I have particular familiarity) are "judged" on whether preoperative antibiotics are given within an hour of surgery cut-time. (The criterion used to be the opposite; or, at least, in days of yore I was taught that antibiotics should be given at least an hour before, in order to allow time for equilibration within tissues.) They're assessed for application of anti-clotting techniques (pressure devices and drugs), and for proper recording of various patient data, not the least of which is assurance that the operation and patient match up. Worthy and important, all of it, without doubt. But pennies on the dollar.

To save real money, it's necessary to get doctors to agree to practice evaluation. Or, at minimum, to be open to self-assessment based on data from others. Tough stuff. Here's the part where it becomes personal horn-tooting: practically every operation I did, I did faster and cheaper than my peers, with as good or better outcomes. And for those who might find taking my word for it a bit of a stretch, let's just assume it's true that one might be able to find ways to rank surgeons on those criteria. (I speak here of surgeons; but I have no doubt it can and must be applied to all specialties. Especially critical care!!) And having done so, that it could be possible to look at the "best" and find out what separates them from the "worst." Technically. Methodologically. Behaviorally. Finally, assuming such information could be amassed, imagine that surgeons could be "encouraged" to adopt the good methods and toss out the bad. It would require, since doctors are in many ways like humans, a combination of carrot and stick: rewards for adopting cost-effective methods, penalties for being out of range. And reasonable (easier said than done) criteria on which to make such assessments.

Over the objections of many surgeons, and until those voices eventually prevailed, a large insurer in my area used to publish data comparing average total hospital cost of a given operation among all the surgeons in the state. For every one listed, I was near or at the top (or is it bottom?) -- meaning my total costs were very low. It stemmed from being efficient in the OR, and from efforts that made the postoperative stay as short as possible. There's no point in going into detail here; but there are very specific items to which I could point: choice and conduct of operation, and things I did in the recovery period that affected length of stay. (Not the least of which was willingness to make hospital rounds two or more times a day!) (Nor, might I add, was I kicking people out before they were ready!!) For every operation there are specific choices and efforts to be made, the adoption of which would save gazillions of health care dollars.

It's not just doctors that would have to climb on board: patients would have to face reality as well. My favorite example: laparoscopic surgery. It's sexy, it's the latest thing, it's hyped like the newest iPod. But for many operations, it greatly increases cost, while adding nothing to outcome. (Here's where good data are needed: studies comparing, for example, laparoscopic colon resection to open techniques generally use numbers that are nothing like mine: my routine colon resection patients were in the hospital four days or less, whereas the numbers to which laparoscopy are compared are of patients in for closer to a week! Time in the OR -- very expensive, hourly -- is way less for a properly done open operation. Equipment cost differences: staggering!) Patients would have to accept the data as well.

Which gets us to the hardest part of all: when we're at the point of getting truly serious about health care costs, we'll have to bring the "R" word into the conversation.


Call it something else: prioritizing. But until we look at the enormous amounts of money spent in the final days of life, and until we're willing to make hard choices and take difficult -- maybe impossible -- stands on who gets what, and when, we'll just be dancing around the fire.



  1. Thanks for your insight. Suggestion: Keep writing on this subject. It is too important not to. Look beyond the profession to impact on business, states, and individuals in terms of flexibility and freeing up the engine of the economy strapped with health care costs. Submit to the HuffPost with your ideas. I am a single payer guy too, but despair of ever achieving the administrative savings available there. There has to be some sanity somewhere, sometime.

  2. OK, I just went to a doctor, something I rarely do. I timed it. I saw this doctor for exactly 6 minutes. No procedures were done, except that a nurse or assistant took my temp and Blood pressure, at which the doctor was not present. For 6 MINUTES with the doctor I was charged $160. THIS IS RIDICULOUS! That's $1600 per HOUR! No wonder doctors don't want single-payer....they're raping us!

  3. Bravo! Right on the money! I can't understand why anyone would want to do a colon resection laparoscopically. I assume you are doing it for colon cancer. I would think you would want to see and feel around for more of the same. Much less time done openly than with a laparoscope.
    End of life issues are going to have to change. I pray very hard that my 89 year old Dad just doesn't wake up one morning. I still remember having to hang blood on a 95 year old cancer patient. I kept thinking "What if an 18 year old needs this blood." And don't get me started on tube feeding Alzheimer's and PVS patients.

  4. We have rationing, albeit covert. It all comes down to your ability to pay.

    IMHO, everybody should get off the stick and fill out a living will and health care power of attorney (both are statutory documents in my state). Be responsible and make your wishes known to your loved ones. I do not want to end up like Terri Schiavo. When it's my time, it's my time, and all I would like is it to be as painless and peaceful as possible.

  5. anonymous: I don't want to get into the tired old "doctors make too much money" stuff in this thread. But I assume you have no insurance: if so, you're in the only category that would actually pay the billed amount. By law, doctors can't discount people, because that's seen as medicare fraud (if you charge anyone any less than you charge medicare, that's fraud). But there's NO payer -- blue cross, medicare, etc -- that pays the doctor anywhere NEAR that $160. And the doctor is barred from collecting the difference.

    Your situation is worth discussing because it's another aspect of the tragedy of the uninsured. But, in my opinion anyway, most doctors are NOT making too much money; not any more. Physician reimbursement, per se, is no longer a very big part of the problem, except to the extent that it's gotten so low for some categories that there aren't enough people interested in doing it for a living.

  6. Been lurking - is it OK to comment?

    I'm not so sure you're in the minority anymore re: physicians' stance on single payer. Check the WSJ Health Blog comments and the PNHP website for stats. It's all good, I think.

    Second re: end of life care.

    Maggie Mahar at the Health Beat Blog has been going to town and writing superb evidence-based posts about the MA experiment and costs at end of life.

    The Dallas Morning News' Lee Hancock just published a five part (with many added attractions - videos, timelines and reporter/photog essays) series on end of life care across the spectrum from all out ICU to hospice and home deaths absent healthcare support. It's very well done.

    Finally - no one is talking about the elephant (no, not the one that left the enormous pile 'o poo) in the room: the absence of professional nursing in the healthcare reform discussions.

    To that end, I submitted an idea to the Obama Transition team site which prominently features baccalaureate prepared nurses as lynchpins in a primary/preventive/public universal healthcare system reform model. It capitalizes on nursing's undervalued strengths, and it features a connect between public health infrastructure and preventive/primary care - and this would include end-of-life care. It also addresses physician and nurse shortages and practice autonomy and authority around primary care.

    I'd really appreciate people giving it a read and critiquing it as it can be modified.

    Dr Rich at the Covert Rationing Blog has also been hitting them out of the park - he's in your corner, too Dr. Schwab.

    The Country Doc Report - your neighbor, I think, has been reporting about rural patients self-treating and foregoing healthcare due to costs.

    Just thought you'd like to know that others are with you on this.

  7. Figuring out how to create an administrative infrastrcture that allows for rationing in a way that is responsive, humane, accountable, transparent, and cost effective has been one of the major stumbling blocks to acceptance of a single payer system. It is a wedge issue, one that creates an opportunity for instinctive fear to be used as a barrier to the acceptance of the idea of single payer healthcare. By associating the idea of rationing with the fear of big, impersonal, unresponsive big government, it's easy to get people to oppose single payer systems.

    There are reasonable answers. But people seem to be unable to listen because the it takes more time and effort to understand than a "sound bite". Creation of an administrative infrastructure that is locally responsive, accountable, and transparent requires using existing social agencies at the local level and giving them new roles and rescources through which they could determine which optional health care benefits could be added to locally to a core benefits package that applies to everyone. This would allow local variations to respond to need, and remove the fear of disenfranchisement that a central bureaucracy creates.

  8. Great start to a potentially very contentious conversation. I'm an obstetrician/gynecologist in a major southern city forced to watch colleagues not only perform lenghthy, expensive laparoscopic surgery, but now adding the absurdity of the kajillion dollar Da Vinci robot to further showboat(they aren't using 6-0 prolene or performing radical prostatectomies, I assure you).

    I, too, favor a single payer system, but,then, I voted for Obama, which made me the pariah of the doctor's lounge. We can howl about the greed of trial lawyers and the horribly expensive inefficiecies of the insurance industry, with some degree of well-earned righteous indignation. However, when my practice switched to high deductible/HSA health insurance, I don't think either of those whipping boys made my MRI cost over $3,000. Radiologists care to comment?

  9. John D: I just submitted a commentary to the local paper in response to a laudatory article about the arrival of a Da Vinci device in our hospital. It'll be interesting to see if they publish it, since it gently shot down the idea that this was a great advance...

  10. Here in canada we are increasibgly having to send emergencies accross the border to the USA because we deplete our system by applying ever more expensive technology .Much of the investigation and treatment is a cover your ass response to fear of lawsuits.
    Triage / rationing is inevitable - it could be greatly mitigated by adressing the legal fear issue , where in my view most waste arises .

  11. We could avoid having to do the rationing in a single payer health care system if we would stop rationing education. Make affordable schooling in Medicine available and the jobs available to fill on graduation and people will fill them.

  12. As usual, you're right on the mark, Sid.

    As a former OR RN, I've seen my fair share of Surgeons who want to use all the new 'toys' and those who prefer the 'old stand-bys'.

    Appendectomies come to mind.

    A basic, open appy pretty much equates a back table pack, a minor instrument set and suture. One Circulator and one Tech. Quick set up time and quick skin to skin procedure. Less bio hazard waste, less anesthesia time and less cost all around.

    Laparoscopic appys? Two monitor systems, gas, graspers, staplers, etc....and an additional Tech (camera holder). Longer set up time, more cost, more waste and longer Op time. Etc.

    Seeing an open appy on the schedule and I was doing the happy Snoopy Dance. =)

    Also, Congratulations on being included in the Blog Round Up on!

  13. Kristi: interesting aspect of the appy thing: I always did them open. If routine, it took 15 minutes skin to skin. I started with, and usually maintained, a very small incision. Post op discomfort seemed not much different from a lap appy: in fact I sent a few home the same day. For the reasons you mention, it was WAY cheaper, and WAY less demanding on resources. And yet I often felt uncomfortable explaining to patients why I preferred it; when you find yourself trying to talk a patient into something when they started off wanting something else, it's unpleasant, and even -- in theory anyway -- has medicolegal implications. Was I just an old, out-of-it guy, they may have wondered?

    Fortunately there was never an occasion where the patient had any regrets...


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