The Clock Is Ticking

Who knows what the Supreme Court will say about the ACA. Strange, isn't it, how something so far from politics as health care will break along predictable political lines in the court, with one swing vote, as usual, being decisive. Whatever they decide, our health care system will remain astoundingly dysfunctional.

While politicians politicate, Medicare is testing new approaches to paying hospitals and docs; namely by paying lump sums for the management of a particular diagnosis/operation. Some say it's working.

If a hospital delivered care for less than the bundled rate, while hitting certain quality metrics, it would keep the difference as profit. But if costs were high and quality was too low, Baptist would lose money. For the first time in their careers, the doctors’ paychecks depended on the quality of the care they provided.

Four surgeons quit in protest.

“I’d describe the reception as lukewarm at best,” Zucker says. “There was a lot of: ‘How could you do this?’ and ‘I’m not going to participate.’ ”

The program launched in June 2009 with a checklist of quality metrics. To earn a bonus, surgeons would, among other things, need to ensure that antibiotics were administered an hour before surgery and halted 24 hours after, reducing the chances of costly complications.

Only three doctors hit the metrics that first month, but their bonuses caught the attention of others. “There was a lot of, ‘Why are those doctors getting more, and I’m not?” Zucker says. Eight doctors got bonus payments in July; two dozen got them in August. Compliance with certain quality metrics steadily climbed from 89 percent to 98 percent in three months.

Two-and-a-half years later, Baptists’ surgeons have earned more than $950,000 in bonuses. Medicare, meanwhile, has netted savings: Its bundled rate is about 5 percent lower than all the fees it used to pay out for the same services.

When I was in training, we were told that pre-op antibiotics had to be given at least an hour before the operation started; the opposite, in other words, of now. The idea was that it took that long to establish effective tissue levels, as opposed to blood levels, of the drug. Whatever. I'm certainly in favor of testing old theories and establishing new procedures based on new data. But that's not my point. The point is that tracking the timing of antibiotic delivery is as easy as it is arbitrary. Fifty-nine minutes: good. Sixty one: fail.

I've seen borderline panic when, for any of several trivial reasons, it looks like knife might not be laid to flesh within the one-hour window. A minute too long, you get dinged. It's pretty stupid, ask me. Does a minute or two make any measurable difference in surgical outcomes? Take a wild guess.

But it's a parameter. And it's simple, binary, yea or nay. Ding or dong. Because it's easy, there it is. It's a hell of a lot harder to compare, say, two patients who had the same part of their colon removed for the same reason: one whose operation takes an hour and who goes home in a couple of days; the other who was in the OR for four hours and went home in over a week. Is it because the second surgeon screwed up? Did s/he take too long because s/he wasn't well-enough trained; did the patient languish because of preventable problems, poor (or, in the case of laparoscopic colon resection, unnecessarily expensive) technique, out-of-date post op management?

Because I knew how to carry out an operation efficiently, because of ways I managed their post op care, my patients were in the OR an hour or two less than other's, went home a couple of days sooner than average, happy. Total costs when I did a colon resection were thousands of dollars less than nearly every other surgeon in the state (it was actually tracked at one time, until other surgeons hollered.) Had there been in place, back then, a system of rewards for such superior care (yeah, go ahead, say it...), not only would I have made out like a ... surgeon who provided superior care, but there'd have been pressure on my colleagues to figure out what I was doing (they could just ask!), and do it, too. A win-win for patients, docs, and hospitals.

But there are factors in every case that are nearly impossible to quantify and compare: the patient's body habitus, the effects of meds they might be on, the amount of inflammation in the area operated, tumor size (if that's what it was about), adherence, circulatory issues, and a lot more. Anesthesiologists categorize patients into five risk groups (six, if you include brain-dead organ donors): the higher, the more they charge. So far there's not a reliable system for doing the same for operative difficulty and postop risk. (There's a code or two for higher degree of difficulty, which theoretically increases the surgeon's reimbursement; but not a hell of a lot. And, far as I know, it doesn't affect "package pricing." I could be wrong about that.)

So what happens when package pricing is in effect? What happens when things are a little tough in the operation? Would some surgeons look for shortcuts so as not to have extra surgical charges on their record? Would patients be pressured to go home a little too soon?

Neither, in my experience, is too likely; and I'm certainly not the first to raise the question. But despite what you might have heard, surgeons are human. And when there's money on the line, when records are kept about individual docs in the form of "economic credentialing," things change. Might surgeons and hospitals tend not to accept patients whose care looked like it'd be too costly? And what would that do to referral hospitals? Would they and their surgeons lose even more money than they are now? How long would it take -- or would it be possible at all -- to get their package price upped to reflect the level of care they're providing?

I greatly admire the Democrats' attempts to make economic sense of it, however flawed; and I absolutely reject the typical R dodge that letting "market forces" take care of it will, in fact, take care of it. It's what's been in play for decades: how's it going?

This is why I think "effectiveness research" is so important, and why it's literally obscene that congressional Rs just voted to eliminate that part of the ACA; the vote is the culmination of stupid, demagogic politicization of something too important to be left to teabaggRs and their imaginary "death panels." Bullshit, codified.

Inefficiencies abound in American health care: systemic ones, economic ones (in the form of allowing health insurers to pocket as profit so much of the money intended for care), and ones related to doctors using various treatment options that have or can or would be shown to be less efficient and less effective than others. Assuming such research were allowed, and assuming the results could be trusted, it'd bring a level of rationality to care that currently exists only sporadically. (My former clinic has received national recognition for being a place where it exists, matter of fact.)

And it would give "cover" to people like me who tried, not always successfully, to convince a patient or family that something they were demanding didn't make sense.

Doctors And Death

I just read an article that's worth reading by everyone. Titled How Doctors Die, it's ultimately about end of life care, futile care, making impossible decisions. And it evokes in me thoughts that I've had many times, in many ways.

The title comes from the writer's (a physician) claim (which he makes no attempt to document, by the way) that doctors tend not to opt for all the extraordinary, expensive, and odds-fighting care they often provide for their patients, preferring to go quietly. I've said many times -- and I hope it's true -- that my plan is to not get sick; and when I do, to have the wherewithal to take things in my own hands and never set foot in a hospital.

From the article:

Almost all medical professionals have seen what we call “futile care” being performed on people. ... All of this occurs in the Intensive Care Unit at a cost of tens of thousands of dollars a day. What it buys is misery we would not inflict on a terrorist. I cannot count the number of times fellow physicians have told me, in words that vary only slightly, “Promise me if you find me like this that you’ll kill me.” They mean it. Some medical personnel wear medallions stamped “NO CODE” to tell physicians not to perform CPR on them. I have even seen it as a tattoo.

Then the article gets to the real point -- unreasonable expectations, impossible choices, insurmountable pressures:

To see how patients play a role, imagine a scenario in which someone has lost consciousness and been admitted to an emergency room. As is so often the case, no one has made a plan for this situation, and shocked and scared family members find themselves caught up in a maze of choices. They’re overwhelmed. When doctors ask if they want “everything” done, they answer yes. Then the nightmare begins. Sometimes, a family really means “do everything,” but often they just mean “do everything that’s reasonable.” The problem is that they may not know what’s reasonable, nor, in their confusion and sorrow, will they ask about it or hear what a physician may be telling them. For their part, doctors told to do “everything” will do it, whether it is reasonable or not.

[...]

But of course it’s not just patients making these things happen. Doctors play an enabling role, too. The trouble is that even doctors who hate to administer futile care must find a way to address the wishes of patients and families. Imagine, once again, the emergency room with those grieving, possibly hysterical, family members. They do not know the doctor. Establishing trust and confidence under such circumstances is a very delicate thing. People are prepared to think the doctor is acting out of base motives, trying to save time, or money, or effort, especially if the doctor is advising against further treatment.

Some doctors are stronger communicators than others, and some doctors are more adamant, but the pressures they all face are similar.

As President Obama has discovered, this is an extraordinarily difficult subject, the perfect platform for political posturing. Ironically, it's the party that most loudly claims to want to cut Medicare spending that has taken the president's reasonable efforts to address this morass as an opportunity for demagoguery. Hard to imagine it addressed seriously. There's global climate change; the political climate shows no sign of cooling.

Mentioned in the article is a patient of the author who'd always made it clear he didn't want extraordinary measures. But then he had a massive stroke and was brought to an ER where no one knew him.

Doctors did everything possible to resuscitate him and put him on life support in the ICU. This was Jack’s worst nightmare. When I arrived at the hospital and took over Jack’s care, I spoke to his wife and to hospital staff, bringing in my office notes with his care preferences. Then I turned off the life support machines and sat with him. He died two hours later.

Even with all his wishes documented, Jack hadn’t died as he’d hoped. The system had intervened. One of the nurses, I later found out, even reported my unplugging of Jack to the authorities as a possible homicide. Nothing came of it, of course; Jack’s wishes had been spelled out explicitly, and he’d left the paperwork to prove it. But the prospect of a police investigation is terrifying for any physician. (Emphasis mine.)

When it came time to withdraw care, I always felt the need to involve the nurses caring for the patient, to ask if any had reservations, and to discuss them. It wasn't as much ass-covering as it was acknowledgment that they'd invested more time and emotion in the patient than I had, and needed to be heard. But, yes, ass-covering was surely on my mind, too.

It shouldn't have to be. It ought to be possible, based on knowledge, compassion, data, patient wishes, and proper education of patients and potential patients, managing expectations, to provide comfort care only when it's the right thing. Not just possible: expected; part of the job; a no-brainer. As it were. Maybe, somewhere, in a society more rational than ours, it can be.

Microcosm

Here's a small but pretty good example -- far from the whole reason, of course -- of why medical care costs so much:

Multidetector CT Should Be Standard of Care for Appendicitis

The symptoms of acute appendicitis are nonspecific, making preoperative diagnosis difficult from clinical findings alone. ... ...To reduce morbidity and mortality risks, it is desirable to have a low perforation rate at appendectomy, but this must be balanced against minimizing the rate of negative findings at appendectomy through appropriate patient selection.

Computed tomography (CT) has been used in an attempt to improve preoperative diagnosis of appendicitis, but there are few high-quality studies of its efficacy for this indication, particularly since the advent of multidetector CT (MDCT). Therefore, the objective of this study by Pickhardt and colleagues was to evaluate the diagnostic performance of MDCT in a large adult cohort with suspected acute appendicitis.

Study Synopsis and Perspective

MDCT is sensitive and specific and should be the standard of care for suspected appendicitis in adults, according to the results of an analysis of MDCT findings reported in the June 21 issue of the Annals of Internal Medicine. (coloring mine.)

"Nonspecific." Funny how things change. Not too many years ago, it was said that appendicitis is a clinical diagnosis, a bedside diagnosis. You listen to the story, do a two-buck lab test, you examine the patient. Carefully. In the majority of cases, it's pretty clear. When it's not, that's when you do more tests. When I was sure, based on the preceding steps, that the patient had appendicitis, I was never wrong (or, at least, it was always something that needed an operation.) (Okay, it's been a long career. I suppose I've forgotten one or two. But no more than the CT scan was wrong. In fact, I operated a couple of times when I wasn't convinced, clinically, got a CT which was interpreted as showing appendicitis, and found nothing.)

But here's the point: I was willing to come to the ER and make the diagnosis. (I was also taught physical diagnosis.) In fact, it pissed me off when I was called after a CT scan had been done. (When I mentioned it, the ER docs invariably said all the other surgeons demanded that one be done before they were called.) As time went on, and CT scans were done more and more routinely, it became more and more uncomfortable for me when I told a patient that I didn't think we needed one. And now, given the legal climate, who in his or her right mind (right mind? A surgeon?) would be willing to forgo ordering a CT when there are articles out there like the above?

In my community a $500 million hospital just opened. (It's gorgeous, and cutting-edge, and I'd bet the cost was way above what they've announced.) There's a dedicated CT scanner in the ER. It can do a scan in around ten seconds. Originally, they took fifteen or twenty minutes.

Last time I checked, a CT scan of abdomen and pelvis cost around $1500 bucks, and it's been a while since I checked.

[Interesting factoid: the above-referenced article was published in a journal for primary docs. Clever, huh?]

A Ration

Here's one of the clearest discussions of rationing of health care, the impossibilities, the need, the politics that I've read in a while.

....We want our doctors to go all-out for our loved ones and ourselves. But as voters and consumers, we send a different message. We pick politicians who promise to cut taxes, and we demand low-cost insurance. We're telling government and the health-care industry to hold the line on health-care costs, even if it means sacrificing clinical benefits. And we put doctors in the middle of this contradiction.

In recent weeks, private insurers have revealed plans for double-digit rate hikes. Our medical bills are already close to a fifth of our national income, on track to reach one-third within 25 years. Soaring Medicare and Medicaid costs are the main reason for nightmarish federal deficit projections over the long term. Yet as Republicans and Democrats battle over the federal budget to the point of threatening a government shutdown, serious health-care spending cuts remain unspeakable.

House Budget Committee Chairman Rep. Paul Ryan, R-Wis., recently proposed to cut Medicare and Medicaid by shifting their costs to poor and middle-class Americans who can't afford them. It's an unconscionable approach, but it at least acknowledges the urgency of gaining control over federal health-care spending. Neither President Obama nor congressional Democrats have put forth plausible proposals for doing so.

I'd disagree with the last sentence: the ACA calls for effectiveness research, which might well go a long way toward controlling unreasonable costs. Rs, of course, have convinced teabaggers that it's another form of death panel; as is the case with pretty much everything teabaggRs believe, the exact opposite is true.

Along similar lines, there's this thoughtful suggestion:

Andrew Sullivan has a proposal to lower health-care costs that actually makes some sense. “If everyone aged 40 or over simply made sure we appointed someone to be our power-of-attorney and instructed that person not to prolong our lives by extraordinary measures if we lost consciousness in a long, fatal illness or simply old age,” he writes, “then we’d immediately make a dent in some way on future healthcare costs. A remarkable proportion of healthcare costs go to the very last days or hours of our lives.”

His idea is voluntary. But I’d make a different suggestion. What if, to be eligible for Medicare, you had to give someone power of attorney and sign a living will? You could tell your attorney, and write in your will, that you want every possible measure employed to keep you alive. You could say cost is no object, and neither is pain or quality of life. You could make whatever choice, and offer whatever instructions, you want. You just have to do it. You have to make the decision.

The Palinites wouldn't be able to get past the "to be eligible part," of course. But, in fact, the suggestion reiterates what's always been true: living wills allow you to choose whatever you want.

Thoughtful people -- the President included -- have put thoughtful ideas on the table. Sadly, any thoughtful idea is necessarily fraught with the non-starter that realism no longer has a place in our politics. So we stumble on toward the darkening horizon, preferring to sling slime at those who actually try. No wonder birtherism, secret-Muslimism, have taken hold: when he took office, President Obama actually thought there'd be a place for give and take discussions, serious ones, about serious problems.

What planet was that guy from??? He sure as hell doesn't sound like one of us.

Scoping The Problem

This is emblematic of a large part of the problem with health care costs, and why it'll be next to impossible to do anything about it.

In roughly the third iteration of my surgical career I've been assisting on cancer operations around once a week. As always it's fun to be in the OR, and a little sad to know I'll never again be standing on the operator's side of the table, nor be anyone's surgeon any more. More than that, though, there's a certain frustration in seeing things that are unnecessarily costly while knowing that even though I'm right, it'll never change.

A while back I helped with a sigmoid colectomy, for colon cancer. Of all the locations in the colon, it's cancers of the sigmoid portion that are the easiest to remove: it's as if the anatomy there was specifically designed for the surgeon. Which is nice, because it's also the most common location for colon cancers to occur. No question I'd have done the operation open, with an incision starting below the belly-button and extending downward; it's the least painful location for any abdominal incision. I'd have taken about forty-five minutes to do the operation, and, most likely, the patient would have been discharged, comfortable and happy on the second or third post op day. (If anyone wants to read a detailed ten-part description of how it's done, written for the lay reader, s/he can start here, and get to each subsequent installment by clicking on "newer post" at the bottom of each, below the comments.)

The operation I assisted was done laparoscopically. It took three hours (operating rooms charge by the minute, not including equipment and set-up charges), and the number of very expensive and non-reusable components was in double digits. After being mobilized using a scope and various costly instruments, the colon was then, in order to complete the removal and prepare the reattachment, partially pulled out through a two-and-a-half inch incision above the umbilicus. In that location it'll be at least as painful as the one I'd have made, despite being a couple of inches smaller. I'm certain the patient will be in the hospital longer than mine would. (In addition, he was asthmatic; two extra hours of inhaling gases is not entirely benign. But any patient would be in that long.)

Finally, there's this: the hookup between the two ends of bowel is high up from the rectum, made with a (very cleverly engineered and cool) circular stapler. For anatomic reasons -- namely, the corkscrew-like nature of the upper rectum and lower sigmoid -- passing the stapler that high is difficult and -- so the surgeon said -- requires using the smallest diameter device. That makes eventual narrowing of the hooked up area much more likely than if a larger diameter stapler had been used. I stapled bowel many times in similar situations, but only when it was low enough in the pelvis that hand-sewing was very difficult or impossible. I always used the largest device, so narrowing was rare; when it happened I could dilate it permanently and painlessly, in my office, using only my finger, with no risk to the patient. Not to mention free of charge. If it occurs in this patient, it'll require colonoscopy, a special ballon, at the cost of several grand, and will occur outside the pelvis where perforation is possible.

All totaled, the operation in question cost, I'm guessing, around ten thousand dollars more than mine would have, not counting the possible future occurrence and treatment of stenosis (narrowing), with no advantage in terms of pain or length of hospitalization. Doing it open would not have been seriously entertained by the surgeon, a young guy (who is, I must add, an excellent surgeon, extremely well-liked by his patients, very good at what he does, exceptionally knowledgeable) who was trained to do it this way. And patients have been even better-trained to want laparoscopic surgery as if it's magical as fairy dust.

Were there ever to be "effectiveness research," I'm certain (if my way were compared to his, which it won't be because hardly anyone does it like I did any more) it'd be obvious that whereas each approach is safe and effective, there's a huge cost differential with no benefit to show for it. You'd think it reasonable, therefore, that payors would be disinclined to keep paying for the operation to be done laparoscopically. But what, then, do you imagine would be the public response?? And how about from the RWS™??!!?? (Unless, of course, if it were under a Republican president)

Much of what we do in health care is consumer-driven -- more than most would acknowledge. People blame doctors for running up charges for more profit, but that's not at all what's going on here. The surgical fee for colon resection is the same whether you do it one way or another. Nor do docs cash in on the equipment they use in ORs. People think they want laparoscopy ("non-invasive," "minimally invasive," "bloodless," are, bluntly, deliberately dishonest terms), just like they used think they wanted lasers. The money to be made is with the suppliers (and, as long as they are paid based on charges instead of globally, with hospitals*) and they spend big bucks convincing people to want their products, and convincing doctors that if they don't adopt the next big thing, patients will go elsewhere. Which is, in fact, true.

As I've written on Surgeonsblog, I love laparoscopic surgery, in the right circumstances. It's fun, and I've done a lot of it. There are several abdominal operations (NOT including gallbladder removal, by the way) that are best done laparoscopically: fundoplication, bariatric surgery, total colectomy (probably), adrenalectomy (maybe), splenectomy (under certain circumstances)...

Realistically, though, like pointing out the disastrous consequences of teabagger policies, this particular argument is me paddling toward a tsunami.

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*It's a pretty interesting subject: time was, hospitals counted on the use of surgical disposables for profit. Because of changes in Medicare reimbursement rules, they no longer could charge processing fees for cleaning and re-sterilizing reusable instruments, or for laundering surgical drapes; but they could charge for the use-once and throw-away (and nearly always non-biodegradable) stuff, and charge a "reasonable" marked-up price. There became, in other words, a perverse (and presumably unintended) disincentive regarding cost-containment. To the extent that hospitals are starting to be reimbursed with global fees (ie, they get x-thousand dollars to care for a colon-resection patient), the opposite has become true. The most efficient surgeon is, theoretically, the most desirable one. Yet so-called "economic credentialling" is almost never done; and when it is, there's generally nothing in it for the surgeon. Meaning people like me, who saved payors thousands of dollars per case, while still getting excellent results, got neither recognition nor monetary reward. Further, on the rare occasions when it does happen (one insurer collected data, identified those of us who were the most cost-effective, and sent us checks!) the other docs scream bloody murder and have all sorts of reasons why their costs are justified. (That insurer stopped after one cycle.) There could be benefit if hospitals were to give more operating time to the more effective surgeons, which, no doubt, would also cause screaming and the gnashing of teeth.

In health care, it's really not hard to identify problems; it's just that it's next to impossible to fix them. And -- dare I repeat myself -- the first serious attempt by a president to give it a shot has been demagogued by the RWS™ as death panels, killing grandma, communism, terrorism, paraphimosis, and Sharia law.

A Chicken In Every Plot

The next senator from Nevada suggests we can solve rising health care costs by paying with chickens. Like the good old days. A Republican dream, if ever there was one. No need for insurance: gecherself some Rhode Island Reds.

Not that I mind the idea of chickens as payment. No vegetarian, I. Given the opportunity to trade my services, I'd be happy to consider it, although for most people who couldn't afford care, I just gave it away. Actually to figure the price of an operation in terms of proffered services -- not simple. Better, I felt, to go freebie. And there are legal issues. Charging a patient less than one charges Medicare is, last time I checked, considered fraudulent, subject to monetary penalties and institutionalization. Ouch. So, either you hide the transaction (tax fraud), or you need a much bigger waiting room. And a greenback/grocery converter. Is there an app for that?

The larger problem is that, as has been pointed out, the cost of office care or even a surgeon's fee for a procedure, is a pretty small slice of the costy pie. I might take six hundred bucks' worth of chickens, especially if the giver would build me a coop, come by once in a while to twist a neck. But the price, say, of an appendectomy really turns on hospital charges; I'm guessing not many of those institutions would accept payment in poultry, or even the installation of an air conditioner.

How many chickens ought I share with my nurse? My receptionist? If I sent some along to my suppliers, would they squawk?

The funny thing is that an all-barter economy is pretty much the thing those right-wingers claim to hate: communism. From each according to his ability, to each according to his need. How strange things get, when the Foxobeckian, the Bachmannopalinized among us begin to confront reality -- even their version of it. Putting forth actual ideas, as opposed simply to screaming about what Obama is doing: harder than it sounds, huh? Which, probably, is why they are so much better at the latter, and so piss-poor at the former.

At every turn, these guys are giving us chicken shit, and asking us to believe it's chicken soup.

Warning: Facts Below

Congressional Republicans, echoed on Fox "news" and by all the RWS™, claim reconciliation has never been used before on something as important as health care. Surprise. They're lying. Unless you believe they actually can't remember.

And, as long as we're talking facts, here, the clip below is worth watching. It will (or should) make you wonder why we're wasting so much time getting reform, or abiding Republican obstructionism and obfuscation. Really:

One Small Step

If anyone here reads Andrew Sullivan's blog, runs across this post, and finds anything familiar in the writing, there could be a reason... Anonymity doesn't do much for blog traffic, but any way to spread the word...

The word, of course, is the extent to which health care reform is aimed at doing things that will be helpful. Even -- especially! -- for those very people who yell and weep and carry guns to meetings, spouting verbatim the insane ravings of Glenn Beck and Sarah Palin while having not the slightest idea what they're really talking about. "Keep government out of Medicare," they say. "Socialism."

The "socialism" trope may be the most laughable (were it actually funny): all of the proposals on the table fall over themselves to maintain the death-grip insurance companies have on us. (Talk about "death panels!" What is it when insurers deny coverage?) None talks about nationalizing the health care delivery system. Not even Medicare is socialism. Single payer -- which in my mind is the only option that makes sense, and which, like Medicare is NOT socialism -- is, clearly, off the table.

There's no possible health care reform package that will satisfy everyone; nor, given the way Congress works, one that will be free of pork-fat, undue complexity, or unexpected consequences that will need to be addressed. Still, what the various iterations seem to have in common are regulations to prevent rescission, to create portability, to remove limits on lifetime coverage, to banish denial for pre-existing conditions. Is it really possible that any of the screamers are against those reforms?

Cost is most certainly an issue, and there is a multitude of ways to address it. Starting, from the doctors' part, with the sort of thing mentioned in that Andrew Sullivan post. Only the surface has been scratched there. And, long after I'm dead, assuming the country still exists, I predict single payer will have come to pass, and people will be glad for it. Even the gun-totin' America lovers.

Signs at the meetings -- ignoring the ones showing Obama as Hitler, a completely ludicrous meme hatched and promoted at Fox "News" (sic) and ingested without chewing by its self-pitying listeners -- point out that Medicare is "bankrupt." While not yet true, it's a point worth considering. To the extent that it hasn't enough money, it's not the fault of Medicare, which spends far less on non-medical expenses than any private insurer. It's because of funding. It's because of the holdover idea from the Reaganomics that you can have what you want without paying taxes.

So, what if everyone were covered by a Medicare-like program, and no one paid premiums; or if there were the sorts of premiums and co-pays associated with Medicare? Currently I pay $14K/year in premiums for me and my wife. Would I be happy to have taxes raised in another area, even, say, by $10K/year? Who wouldn't take that trade? By getting rid of the 30% skim by insurers, that math works right away. And by taking seriously -- instead of demagoging as "death panels" -- the idea of finding cost savings in more efficient care, much more than that will be saved.

And yet, they rave and froth. Getting crazier and scarier. Arguing, in effect, for maintaining a system in which their premiums have likely doubled in the last ten years, which covers them sparingly, cutting them off when they need it most: sick, out of work. And they are ready to draw weapons over a plan to pay for help writing the very instructions that will keep them in charge of their care when they're unable to make decisions for themselves.

Who'd have thought people so in need of health care reform could be whipped into a froth by people who lie so freely and make easily refutable claims? I remain unable to understand. And bereft of hope.
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Ay Yi, Robot

I add to my recent posts on medical cost issues: In our local newspaper (I still have a fondness for ink) there recently appeared a news article profusely exhuberating the arrival in town of a 1.5 million-dollar surgical robotics device. Not a wait-a-minute word among them. The mentioned surgeon is sure to have an instant waiting list; the hospital, another feather in its heady hat.

Here's an opinion piece I submitted to the paper. I'm told it'll be published soon:

In response to a recent article in The Herald, and recognizing the risk that my duddy might be seen as fuddied, I’d like to comment on the arrival of the 1.5 million-dollar robotic surgical device in Everett. Allow me a few drops of cool – if not entirely cold – water.

Years ago, with the arrival of laparoscopic surgery (done through small holes with cameras and special tools), I learned how to remove gallbladders in that new and highly important way. At the time, lasers were used for much of the internal cutting; in fact, the word “laser” was part of the name of the operation: Laser Laparoscopic Cholecystectomy. Exploring the technique in learning labs, we used both laser and traditional electro-surgical machines. I found no advantage for the former, and since lasers cost several tens of thousands of dollars, I asked the instructor (an employee of the laser company) why we should buy one. “Because,” he said with no evident irony, “it’s what patients want. If they hear you’re doing the operation without a laser, they’ll go somewhere else.”

Gathering dust in hallways of hospitals all over the country are lasers bought for the purpose. Virtually nowhere are lasers used in laparoscopic gallbladder surgery any more: they were indeed found to confer no special benefit. Which calls to mind a quote from the recent story: “A lot of patients have been reading about it as the newest and best thing and asking for it…”

Don’t get me wrong. Robotic assist devices have an important role in the future of surgery. In fact, perhaps the greatest potential was not even mentioned in the article: because the robot is in the operating room and the operator is at a separate console, the surgeon doing the work can be, theoretically, anywhere in the world. (Anywhere with a highly reliable broadband connection, that is.) Herr Doktor Emmenthaler, while sitting in his office in Geneva, could remove your tricky brain tumor right here in Everett! In fact, similar things have already been done. Originally, surgical robotics were developed with battlefield surgery in mind. We surgeons could sit safely behind the lines while the poor medics hooked up the machines as the bullets flew.

So what’s my point? Just this: to date, there really isn’t much evidence that outcomes of robotic surgery are significantly better than those of more standard approaches. In fact, some studies have shown no difference other than higher cost with robotics. Specifically, the advantages mentioned in the article – small incisions, magnified views, short stays – are already the norm with, for lack of a cooler term, flesh and blood laparoscopy. So far, much of the excitement is because surgeons (speaking not only for myself!) love new toys and fresh challenges, and because, as the article confirms, hype directed at patients has rarely fallen on deaf ears.

Times are tough, and getting tougher. Ultimately, fixing our struggling economy will require fixing our failing health care system as well. At the heart of it is cost. So far, most of the effort at cost containment has been in cutting reimbursement to providers. Ain’t no more blood in that particular turnip. At some point, we’ll need to take a really hard look at the actual delivery of care. What works, what doesn’t. Which ways to solve a particular problem make the greatest overall economic sense. Most of the cost of an operation is generated in the operating room; an hour there can cost more than a day recovering in the hospital. So it’s not just about sex appeal. It’s about hard numbers, carefully generated. When we get around to that, not everyone will like it.

Funny story: in my career I developed a way of removing gallbladders through a single very small incision, without the tools and troubles of laparoscopy. Like the laparoscopic operation, it was done mostly as an outpatient, with as rapid recovery and return to work, and (trust me on this) fewer complications. Because of the much simpler equipment and shorter operative time, someone saved well over a thousand bucks every time I did it that way. But it never caught on among my peers. The secret will die with me. There’s a lesson in there, somewhere.

The hospital folk might not like it, but it won't be the first time I wrote something that caused their ire. It happens to be an excellent hospital, consistently highly ranked nationally for its heart services, and statewide for pretty much everything else. Given the current realities, they must do what they must do to attract patients, particularly the surgical kind, from whom they have a chance to make a buck or two. If this tack is cynical, it doesn't follow that it's unnecessary: in this ass-backwards era of ineffective cost-management, it's reality. The purchase and publicizing of a million-and-a-half dollar machine of dubious value is seen as appropriate. And until we get around to the hard stuff, maybe it is.

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Heartless

Riding my indoor bike in front of the TV, working on my own heart, I saw that the owner of the Carolina Panthers, age 72, is awaiting a heart transplant. I'm sure he's a nice guy.

Until we have so many extra hearts that they're being thrown away, seventy-two year olds ought not be getting them. Football team owners are among the very wealthy, so I assume he can and/or would pay every nickel himself. Even so, it's not right. Whereas it brings up that age-old question about whether the wealthy ought to get better medical care than the not-so, and whereas I'm not entirely unsympathetic on one level (the level that says rich people get better cars and bigger houses), medical resources are finite, and getting finiter. No matter if he plans to leave a big tip: unless everyone under fifty already has one, he shouldn't get a heart. That's not just rationing: it's morality.

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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.

Rationing.

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.


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