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Government Policy

The Challenge with Accountable Care

Noted business professor Clayton Christensen and colleagues discuss the challenge that new health regulations face in the context of physician and patient behaviors that may remain unchanged.

The article, “Christensen, Flier and Vijayaraghavan: The Coming Failure of Accountable Care,”  hints at the major challenge in engaging stakeholders in meaningful change, when custom, economic drivers, and human nature do not reinforce the changes enacted. Perhaps we will end up with a two-tier system, not based upon economics, but based upon compliance and attitude.

The Everett Clinic, as described in the article, has told Medicare patients that they must change to Medicare Advantage – which promotes preventive care and disease management – or seek care elsewhere, in the old fee-for-service model.

The article states that Accountable Care Organizations (ACO’s) are on the hook for patients who don’t comply with recommended treatment or lifestyle changes. In other words, there is a misalignment of interests.

In the old fee-for-service model, hospitals and physicians are paid more for caring for the sick, including those whose problems are of their own making based on lifestyle decisions and avoidance of preventative measures. A system that has one-sided economic sanctions against physicians based upon patient outcomes may induce doctors and even hospitals to deny non-emergent access to certain patients in favor of those who engage in healthier behaviors. The ethics of such care denial have been challenged in this article. Ultimately, the development of ACO’s may limit care access to those who need it the most.

America’s Health Care System: It is Not a Jobs Program

In a New York Times op-ed article, “We Can Be Healthy and Rich,” Ezekiel Emanuel writes about the impact of the health care system on our larger economy and points out that there are many vested interests in the status quo of high health spending.

These high health costs are not geared toward the public good, but rather the economic impact of the massive spending.

He rightly states:

“Health care is about keeping people healthy or fixing them up when they get sick. It is not a jobs program.”

According to the Council of Economic Advisers, reducing health care costs by just 1 percentage point every year would lead to a 4 percent increase in G.D.P. by 2030. In today’s dollars, that would mean an extra $600 billion for our economy and an extra $7,000 for the average family.

Various comments by readers illustrate many views on his article and a number of additional perspectives.

Gag Law Prohibits Doctors from Doing their Job and Protecting Patients

Physicians have multiple roles. In addition to treating illness and injury, they have a public health duty to address risk factors in individuals and society that contribute to morbidity and mortality.

Responsible gun owners know how to behave around guns, including proper storage and use. In the same way that responsible parents use car seats and seat belts for their young passengers, responsible parents who are gun owners must secure their weapons to avoid accidental misuse.

A recent Slate article, “Pediatricians vs. the NRA,” demonstrates the ability of the NRA to successfully introduce legislation that suppresses a physicians ability to do their jobs and to exercise their free speech rights.

The “Privacy of Firearm Owners” law passed in Florida in 2011 prohibits doctors from “making written inquiry or asking questions concerning the ownership of a firearm or ammunition by the patient or by a family member of the patient.”

Fortunately, the law is under attack and being challenged. Hopefully, it is also being ignored by many physicians who understand that there are bigger issues at play here – and that those who write such laws should be confronted with the obligation of enforcing it by trial and punishment. There are times when civil disobedience may be called for. This would appear to be one of them.

Risks and “Dangers” of Marijuana Legalization?

Overall evidence for dangers of marijuana do not support continued criminalization.

Steadily it appears that its use will be permitted, though there remains a disconnect between state laws liberalizing possession and growing, vs. federal standards that at least as written, continue to criminalize use and distribution.

As the matter evolves, we should not be naïve to the potential risk of users abusing and developing an addiction to marijuana and its potential impact on cognition, and youth, especially when not used in “moderation.”

A New York Times article, “Legalizing of Marijuana Raises Health Concerns,” states:

“While marijuana can be addictive, scientists generally agree that fewer than 10 percent of marijuana smokers become dependent on the drug, compared with 15 percent for alcohol, 23 percent for heroin and 32 percent for tobacco.

Marijuana does contain carcinogens, including tar and other toxins similar to those found in tobacco, but people generally do not smoke marijuana in the same amounts as cigarettes. Still, legalization takes health consumers into murky territory. Even though marijuana is the most commonly used illegal drug in the United States, questions about its health effects remain.”

Sounds like the same risks, more or less, of many other legal substances, consumed in excess or misused, including alcohol, prescription drugs, and/or firearms. Whether society should outlaw substances and products that can be used with little risk or high damage is a question that is increasingly being answered at the ballot box.

Hospital & Doctors Fined for Overtreatment

An Ohio hospital and group of physicians settled an agreement with the U.S. Justice Department last Friday over accusations that some of the procedures were costly and medically unnecessary.

What is likely remarkable about this medical group being investigated, charged, and fined is not the overtreatment –  but that they got caught and held to account.

The New York Times article quotes a U.S. attorney on the matter:

“…Besides the cost to Medicare, “performing medically unnecessary cardiac procedures puts patients’ lives at risk,” said Steven M. Dettelbach, the United States attorney for the Northern District of Ohio, which was involved in the investigation.

“Patient health and taxpayer dollars have to come before greed,” he said.

The few facts presented here are certainly egregious in the falsification of complaints. Also, a statistical analysis demonstrated a significantly higher incidence of angioplasties, at four times the national average. But it should raise the question about how often unnecessary procedures are performed based upon the economic self-interests of the system, not the genuine health of patients?

Our fee for service system handsomely rewards treatment over watching and waiting, or conservative care. The hospital’s minimizing notwithstanding, each patient subjected to a procedure without medical necessity was subject to anxiety, pain, and some medical risk, without a corresponding benefit. This is wrong!

The message to all is, follow the money – how does your doctor and hospital get paid? Are they driven by mission and ethics first and foremost, or are they driven by maximizing cash flow and profit?

And consider a second opinion from someone unrelated to those recommending a specific procedure or intervention. Consider the benefits of systems of care, such as integrated organizations, where physicians do not have an incentive to treat. Research the recommended procedure for indications and degree of debate on necessity, and ask a lot of questions.

Connecticut Shooting Differs in Newsworthiness and Degree, Not Substance

By Brian L. Grant MD

Many of us were in a sad mood on December 14, the day of the Connecticut shootings. But further reflection lead me to the unfortunate conclusion that beyond the fact that the carnage in one spot was mainly children and the number in this single incident was high, this was a typical day in America.

According to the Center for Disease Control and Prevention (CDC), we had 31,347 (10.2 per 100,000) deaths by firearm in the U.S. in 2009. That is an average of 86 per day. Of these about 64% are actually suicide, and a small number are accidental.

In the same year, motor vehicle accidents took the lives of 34,485 (11.2 per 100,000 or about 94 per day). Only a few more than were killed with guns. Cars serve a vital purpose and there is unfortunately collateral damage when they collide. Guns are for killing.

Related statistics from Wikipedia describe firearm deaths across many countries in the world.

Our rate per population of gun deaths in the U.S. is roughly 40 times that of the UK and twice that of Canada. Both countries, along with much of Europe, have significant limits on guns. We can’t identify who might engage in slaughter ahead of time without locking up all of us. What we can do is make those predisposed to harm others less lethal by making it a lot tougher to get a gun and limit the types of guns available. This might include limiting access to military and police only on guns capable of shooting many shots rapidly.

As a non-expert on the technical aspects of firearms, I would defer details to those better informed regarding guns and ammunition that ought not be in civilian hands. No hunter or person protecting their home will be meaningfully limited in their purpose by such restrictions. But it might change our landscape regarding gun violence.

We have attempted in this blog to address irrational behavior in a number of areas including the obesity epidemic and our dysfunctional health care system. The recent tragedy may have the positive outcome of shocking society and political leaders into a careful review of the status quo, based upon data and not rhetoric, and hopefully without “shooting” the messengers, as is the habit by those who don’t like what they see or hear.

In the aftermath of the shooting, outspoken gun opponents such as Mayor Bloomberg of New York are being attacked for their opinions, at least as much as their opinions are being challenged.

The political force represented by gun proponents, embodied by the National Rifle Association (NRA), is formidable. Politicians are scared of being on their bad side. Perhaps now more than a few of us, including politicians, will finally say enough and make rational decisions based upon careful analysis. This should include reviewing laws and gun cultures of other countries where freedom seems to coexist with safety and more restrictive gun laws. How many might have the courage to publicly take on the extreme positions of the NRA? Could their political dominance come to an end? Can caring and decent gun owners take it upon themselves to move beyond rhetoric to consider that change may be in order?

It is truly hoped that responsible gun owners will separate themselves from the extremists who see limits on guns at virtually any level as impingement on their freedom and our nation’s values.

One person’s freedom is another person’s burden, or even death, when an innocent is shot with a gun that should not have been available. Competing interests deserve to be heard. We should not be proud of our national record of gun deaths.

For every person who defends themself with firearms reasonably, how many have abused their power and taken a life that could have been preserved? How many murders are the result of open and basically unrestricted commerce in guns? How many suicides would have not taken place if limits were in place? How many people would be served in a positive way by a change, including lives saved?

Indeed, how many actual additional deaths of innocent victims of criminals with guns, as claimed by proponents, would take place? Do international comparisons have relevance, or are we Americans so special and unique that we have nothing to learn from countries like Australia, France, Canada, and Chile, among others? Should we instead emulate Brazil and El Salvador? Even the Mexican drug cartels get their weapons to commit mayhem from north of the border.

We require cars to have all sorts of safety features that have reduced mortality. We license drivers and cars. We have police watching our driving and enforcing driving laws daily. What reasonable limits on access and types of guns and ammunition would balance safety with ownership?

Our constitution has been amended many times including establishing the right to bear arms, allow women to vote, and  abolish slavery. What would our founding fathers say about modern weaponry including semi-automatic rifles and their place in the hands of ordinary citizens? Can the constitution stand as it is with respect to guns while allowing meaningful laws to be imposed? The constitution is silent on types of weapons and the government should be allowed to regulate as they already do, and are hired by us to do.

Let me briefly put to rest the concept that we can prevent many firearm deaths by better mental health assessment. The majority of mentally ill are not violent and unless one chooses to define violence as mental illness, the majority of those who shoot others are not mentally ill. The proximate cause of gun deaths are bullets and guns, not mental illness. Other countries with their share of troubled people and criminals have fewer deaths because violence is enacted in less lethal ways, such as with knives or fists.

We had a sad day. Let us hope that we will honor the memory of all victims of violence in the U.S. with meaningful change consistent with both our respect for liberty and for human life.

Great News for the US: Evidence of Trending Down in Childhood Obesity

While still early, recent studies show evidence that childhood obesity is reversing in some cities.

This is tremendous news for all. The small percentage suggests a reversal of a longstanding trend.

If true, it demonstrates that awareness, education, and intervention helps. The culprits include ignorance, indifference, and the pushing on society of empty calories, especially those in sugary beverages.

Nationally, about 17 percent of children under 20 are obese, or about 12.5 million people, according to the Centers for Disease Control and Prevention, which defines childhood obesity as a body mass index at or above the 95th percentile for children of the same age and sex. That rate, which has tripled since 1980, has leveled off in recent years but has remained at historical highs, and public health experts warn that it could bring long-term health risks. Read More…

Eliminating destructive food options in schools, providing healthier snacks in stores, and reducing intake overall can make a difference.

Just because something is tough does not make it undoable. These statistics mean that some kids are doing a lot better and likely feel great about it, not only physically, but emotionally.

Let’s hope this is not a fluke as we have a long ways to go as a society.

Now With the Elections Over, We Can Focus on Health Care – A View from the Trenches

By Brian L. Grant, MD

Pundits are debating the meaning of the recent election results. I believe that to some degree the election is a mandate to continue to address our out-of-control health care system and an endorsement by the  electorate to continue to develop and deploy the Affordable Care Act – aka ObamaCare.

Coming at health care as a physician, patient, employer, taxpayer and medical director of a company whose business it is to review medical claims for appropriateness of treatment and utilization – I believe I have both skin in the game and a deep perspective on the problems we face.

Long ago during residency, during my medical rotation, I concluded that so much of care was of little value in providing quality or quantity of life to those whose days were numbered. Those providing the treatment were unable or unwilling to ask the tough questions that would limit care in hopeless situations. Governed by good intentions, physicians were and still are largely expected to treat with little moderation. This decision is supported by the economic rewards of treatment, encouragement by the hospitals they work in, and a fear that denying treatment or moderating the testing provided might expose them to litigation.

I wondered how many people would choose the care received if the system were somehow different, such as their paying directly for care of having the money available for some other use. I continue to ask this question today, while recognizing that many would abuse this choice, denying necessary preventive care to themselves or their children if given the option of diverting their health care spending to another cause.

But absent external controls on utilization and consumption – overuse and unnecessary care is common, and according to some, represents some 750 billion dollars annually, or about 25% of our health spend! This would suggest that we stand to gain far more from curbing spending and utilization than we do from discounting it.

And since patients and their families are largely shielded via insurance from the economic impact of treatment, they lack interest or incentive in invoking the economic self-interest that governs all of us in our non-medical personal spending behaviors, when we are not spending directly for our care.

Third party payments also mean that the costs of treatment are not responsive to competition, since everything is expected to be paid for at whatever price may be charged. Third party surrogates including insurance carriers, bill reviewers, and companies such as MCN whose work aims to control excessive and unnecessary costs are attacked by stakeholders including patients, providers, drug manufacturers, device manufacturers and hospitals when limits or denials are suggested or imposed.

As an employer, I have experienced annual increases well into the double digits in proposed premiums for our staff, only curbed by increasing co-payments, deductibles and some of the premium increases to the employees. This means less income for staff as their personal health spend increases – a trend common across the economy. The rate of increase has appeared to curb a bit over the past two years, perhaps in response to the reforms underway that improve the structure of the system by spreading risks to a wider population of insured individuals.

I grudgingly accept the need to provide coverage for employees, all the while wondering why this is the case. Staff do not receive company-paid housing, food or education; they get a paycheck to pay for some, and we all pay taxes to pay for other universal needs such as education. Why is healthcare a unique outlier by being tied to employment? How do we as a society rationally defend employer-based health-care given the outcome? The consequences are well-known.

They include most notably the lack of paid insurance for dependents and spouses under most employer plans,  total lack of coverage for many working people whose jobs don’t provide coverage, the unemployed, students, and those who are self-employed and either can’t afford care or choose to gamble by not buying coverage. Since hospitals do not turn away patients needing emergency care, those without coverage are either forced into economically dire straits if they have any money left over to pay, or the rest of us pay for their care via cost-shifting by these institutions to those who can and do pay. This results in higher premiums for those with insurance and the employers paying for them.

In a nation that extols the virtues of small business and entrepreneurs, how many men and women who might take the risk to strike out on their own are deterred from doing so because they can’t afford the high cost of individual health care, especially if they or a member of their family has preexisting risk that makes insurance unavailable or unaffordable. One would think that those who claim to champion a creative economy would insist upon health care being available and affordable to all. Yet by and large this was and is not the case.

As a patient and physician, I have had the opportunity to consume and provide care and see hospital bills that were extraordinary in their complexity and impenetrability, including excesses in line item charges, and inclusion of items that were not necessary in a particular case but dispensed to all patients admitted as standing orders. If you have the occasion to be hospitalized, call and ask for the multi-page actual bill submitted to your carrier rather than the several line summary they send you describing what was billed, what was paid, what was discounted and what you owe as a balance. It will be an eye-opener!

As a taxpayer I am aware of the massive multi-trillion dollar size of the US system, representing about 18% of our GDP or around a third more than those of other industrialized nations that have better public health metrics including infant mortality and life-spans. This excess spending decreases our national productivity and imposes burdens on all, and riches on a few.

Reasonable people can and should debate the details and the specifics; but like defense spending, entitlements and other massive expenses – health-care should be debated and addressed with data, not ideology! Those who believe that continuing the system with minor alterations are advocating the structural equivalent to putting lipstick on a pig. Concluding that this will somehow lead to meaningful change is either naive or willfully deceptive.

I struggle with the concept of personal freedom vs. personal responsibility, the role of government and who should pay for choices. Others do as well. Thus the debates on public health and safety, lifestyles, chronic illness and self-determined behaviors and how much the government should regulate what we do, how we consume and who should pay for these choices. Many entries in MCNTalk have addressed these topics that include obesity, tobacco, vaccinations, and those who question if and how these should be regulated and who should pay. Again one can debate the details and the ideology, but we can’t escape the expensive outcomes for individuals and society.

Democracy is a participatory sport in a game with real consequences for all. We wish our legislators well, thank them for their service and will be there loudly exercising our freedom along with them in the coming years.

Making ObamaCare Work: Will States Meet their Nov. 16th Deadline?

After Tuesday’s election, it seems years of uncertainty over President Obama’s health care law have finally been put to rest — at least for now.

While several states have already submitted the framework for their health insurance exchange program, others waited for the election results and are now scrambling to meet the November 16th deadline next week. Many states have asked for more time.

Under the Affordable Care Act (ACA), every state is required to submit a blueprint of their own health insurance exchange or participate in a federal-state partnership. If states do not establish their own exchanges by the deadline, the federal government is prepared to step in and assign a federal exchange or a federal-state partnership model.

But the early bird gets the worm. States like Illinois, Nevada, Oregon, South Dakota, Tennessee, and Washington who have already taken the initiative to create their own framework have already received over $181 million in grants from the government to help establish their exchanges.

The New York Times article, “With Obama Re-Elected, States Scramble Over Health Law,” says that the success of the ACA depends greatly on the individual states as they decide whether to build online insurance exchanges, where individuals and small businesses can shop for health plans, and whether to expand their Medicaid programs to reach many more low-income people. Read More…

“There is still a tremendous amount of disinformation out there,” said Jeff Goldsmith, a health industry analyst based in Virginia. “If you actually are going to implement this law, people need to know what’s in it — not just the puppies-and-ice-cream parts, but ‘Here are the broader social changes intended and how they can help you.’ ”

President Obama faces many crucial decisions in the coming months about how best to appeal to those who are for and against the ACA if it is to succeed.

Will the administration, for example, try to address the concerns of insurers, employers and some consumer groups who worry that the law’s requirements could increase premiums? Or will it insist on the stringent standards favored by liberal policy advocates inside and outside the government?

Mayor Bloomberg Talks Politics, Obesity, and Taking on Controversial Issues

In an exclusive interview with Mayor Bloomberg, the Atlantic Magazine editor-in-chief provides a unique look into the mind of New York’s 108th mayor.

While recognizing that Bloomberg is best-known for his success as a high power businessman and controversial politician, the magazine asserts that there may be more to him than most give him credit for.

 

“You could look a little further and see a more interesting pattern: a man who turned getting shunted off the fast track at Salomon Brothers – into an opportunity, creating an entirely new approach to getting traders the data they needed…

Then took the billions he made and chose not to embark on a lifelong vacation but to step into the least-forgiving political arena in the country; and who has since governed New York assertively, putting himself in the vanguard of a generation of mayors who, at a time when the federal government is paralyzed, are testing new approaches to education, transportation, and public health. You begin to see a guy, in sum, who thinks for himself, but not only of himself.”

Throughout the interview, Bloomberg provides an exceptionally clear and honest perspective on the various issues and decisions he has confronted as mayor. He addresses everything from obesity to campaign money, explaining that in government you must do what is in the best interest of the public, even if it means low approval ratings.

Mayor Bloomberg’s stance on obesity:

“Obesity is the only public-health issue that is growing in importance. This is the first disease that has gone from a rich person’s disease to a poor person’s disease. Generally, it would go in the other direction. For the first time in the history of the world, this year, more people will die from the effects of too much food than from starvation.

And there’s one other answer to the question as to why. And that is—whether it is in my foundation [Bloomberg Philanthropies] or here [as mayor]—I like to take on those things that other people either are unwilling to take on for political reasons, or unwilling to take on because it’s just too complex, or they just don’t care.”

Whether you agree with Bloomberg’s position and approach as a politician and businessman, the interview is nonetheless intriguing to read and understand his point of view. Read the full interview here…

“Leadership is about doing what you think is right and then building a constituency behind it. It is not doing a poll and following from the back. If you want to criticize the political process—and it’s probably true throughout history, and certainly not just in the United States—I think it’s fair to say, in business or in government, an awful lot of leaders follow the polls.

And that’s not the way to win. I happen to think it’s not ethical, or right, and not your obligation. But I don’t even think it’s good business or politics, because people aren’t good at describing what is in their own interest … What leaders should do is make decisions as to what they think is in the public interest based on the best advice that they can get, and then try and build a constituency and bring it along,” Bloomberg said in the interview.