Road To Hellth

Feb
24

Will the Ignorant Be Around Even Longer Than the Poor?

For ye have the poor with you always, and whensoever ye will ye may do them good…

– Mark 14:7

We’ll be the first to admit that there are many, many people who are more observant, eloquent and articulate than we are. Many of those people are physicians. So when one of them speaks up on an important subject that does not normally receive a great deal of attention in the conventional media, it is only right that we try to draw some attention to what they have to say.

This is certainly the case with a comment written by Dr. Edward A. Cutler that we recently read on a physician networking website. It was written in response to a post that expressed the utter frustration felt by a doctor who was taking care of a Medicaid patient who was clearly abusing this publicly funded healthcare system for the poor. Here’s how Dr. Cutler, a pediatrician, responded:

“There are two kinds of Medicaid patients. There are those who need Medicaid and other benefits to get minimal health care, and there are those who simply game the system to get others to pay for their needs while they pay for their wants.

This afternoon I saw Robert, a 19 year-old boy, to re-evaluate his ADHD and to refill his medications. He is home schooled in ECOT, “the electronic classroom of tomorrow,” but he is nowhere near graduating from high school. His parents can barely read or write.

Robert was playing a video game, and I asked him to show it to me. It was so complicated I could not figure it out.

He asked me if I had a Play Station 3, and I replied, “No.” He had one.

He asked me if I had cable TV with hundreds of stations and HBO. I said I did not; he said he did.

He wore better clothes than I have.

He has lived in the same house in The Bottoms for most of his life. His family has section 8 housing and pays about $100 per month to rent it, and gets subsidized utilities, and food stamps. The family of four receives more than $30,000 per year from SSI.

I have lived in the same house in The Bottoms for 30 years. The Bank of America has foreclosed and will not let m pay it off and will probably sell it on Friday. I pay hundreds of dollars per month for property taxes, water, sewer, electricity, and gas.

Robert eats steak, burgers, and a lot of fast food. Often I eat porridge, potatoes, and eggs because they are inexpensive and nutritious.

I asked Robert why his brother, Michael, did not show up for his appointment.

“He had to work,” Robert told me.

“What kind of work does he do?” I asked.

“He is getting $400 tonight for removing some trash from a basement.”

The members of this family let us pay for their needs; they pay for their wants, and they pay plenty.

My next patient was different. Sadie, an eight year-old girl arrived with her father one hour early. Father said they had to walk 4 miles to get here (and it was a cold day) and didn’t know how long it would take and didn’t want to be late.

Their clothes were obviously from the thrift shop, adequate but not stylish.

I asked what they were going to eat for dinner, and they said beans and cornbread.

“Could you schedule next month’s appointment on a Tuesday instead of Monday?” father asked after I gave them a Monday appointment. That way I’ll be able to sell my blood on Monday, and we’ll have the money to take the bus.”

Our challenge is to eliminate freeloaders like the first family without hurting those like the second.”

In terms of Dr. Cutler’s message itself, we really have nothing to add. He is as right as the Earth is round, water is wet and the Sun is bright. However we would like to comment about why his thoughts are so unusual in public discussion, so powerful and so important.

Just about every clinician can tell you stories about patients who might as well be stand-ins for Robert and Sadie. One of the blessings and curses of life as a physician or nurse is that one gets an unadulterated view of people as they really are, warts and all (no pun intended). Quite frankly, this sort of personal, real-life contact is one of the most important things that differentiates those who would be wise from the vast majority of administrators, politicians, academics and the sort of people who would wage class warfare by invoking the sanctity of the “poor” over the greed of the “rich”. If you deal with enough of them, one inevitably comes to realize that the innate behavior of homo sapiens is perfectly immune to petty distinctions such as race, gender, income level or social status. The rich have no monopoly on greed and selfishness, just as the poor have no corner on the market for either hard work or laziness.

These are the sorts of details that never seem to make it into position papers, scholarly books and political discourse, mostly because the people writing them have never actually had to work with whole segments of the population such as the poor, the sick, the addicted, those in private industry. It’s why one can make calculated, meaningless statements like “the rich need to pay their fair share”, while “the poor are just trying to make a living”. “The rich” – especially if you define them as households making over $200,000 per year are no more a homogenous group than “the poor” if you define them as those having an apparent income of $22,350 for a family of four. These things say nothing about the behavior or character or deservedness of the individuals involved any more than the color of their skin.

The heterogeneity that exists within arbitrary groups of people – and conversely the consistency of human behavior across social divides – is typically what dooms most of the well-intended social policies that are broadly intended to benefit those who are perceived to be in need of assistance. This is because the vast majority of these policies assume that the occupants of this group or that are equally needy, and that individual attitudes and behaviors are somehow irrelevant to the desired outcomes. Nowhere is this truer than in healthcare, where individual attitudes and behaviors are often the single most important deciding determinant of who gets sick and who stays well – of which patients incur large costs, and which one utilize care cost-effectively.

One result is that many of society’s efforts are completely unappreciated, and therefore wasted. If individuals do not appreciate or value the resources that they are given, those resources will be squandered. This is especially the case if those resources belong(ed) to other people and frittering them away carries no personal penalty.

A simple example can be seen at a large medical clinic of our acquaintance. As a result of long experience, all of their Medicaid patients are always scheduled at the end of each day? Why? Because 70% of them fail to show up for their appointments; appointments that others would have taken gladly. Management would like to charge a no-show fee in order to motivate patients to keep their appointments, but Medicaid forbids this because the patients are “poor”. But since the no-shows have wasted appointments others could have used, new patients (Medicaid patients included) must wait 2-3 months before they can be seen.

So month after month, some poor people are depriving other poor, sick, and even desperate people of healthcare. Technically this is not a crime, but shouldn’t it be? If the patients who are waiting to be seen suffer a heart attack, or die of their uncontrolled asthma, or wait too long before their cancer is diagnosed, who really killed them? Was it the unthinking, uncaring people who used up all of the appointments without keeping them, or the people in state government and Medicaid who decreed that there should be no consequences for depriving others of the care they needed?

This is problem with governing from an ivory tower, or even running a political campaign from one. All of those nice, stereotyping generalizations one makes to establish policy from the far right or the far left simply don’t survive their first encounter the messy reality of human nature. Not in medicine. Not in anything. People who try to make policy that way may or may not be well-intentioned, but they are certainly ignorant. Even worse, we let them keep trying it over and over and over again.

Dr. Cutler’s challenge to all of us is to resist the urge to think of how to fix groups, and concentrate on fixing individuals. This means holding people accountable for their actions as individuals. Oh sure, it’s not as easy as blithely throwing other people’s time and money at a problem. But in the long run, it’s the only thing that’s ever going to work.

[Ed. note: Many thanks to Dr. Cutler for allowing us to reprint his comments here.]

Categories : Clinical Care, Economics, Ethics, Healthcare Policy, Personal Responsibility, Political Hellth, Politics, The Practice of Medicine

Apr
26

Patients, Consumers, and the Krugman Commentary

by Dr. Doug Perednia

Just before Easter weekend, Paul Krugman – the Nobel Prize-winning economist employed as a commentator by The New York Times – published a piece entitled “Patients Are Not Consumers”. We were so struck by the implications of this commentary that we intended to respond right away, but were unavoidably delayed. As a result many others have already weighed in with their own commentaries. A tip of the hat to Megan McArdle at The Atlantic, Jeffrey Grossman at JG, Caesarea, Steven Spear at The High Velocity Edge, Aaron Carroll at The Incidental Economist and others. But even after reading these we believe that the necessary analysis of Mr. Krugman’s commentary is still not complete. Moreover, we believe that Mr. Krugman’s piece is, in the broad scope of things, even more important than even he might have realized. More about that in a bit.

So let’s go ahead and visit the entire Krugman piece, and see if we can tease out the critical points.

“Last week, The New York Times reported on congressional backlash against the Independent Payment Advisory Board (IPAB), a key part of efforts to rein in health care costs.

But something struck me as I looked at Republican arguments against the board, which hinge on the notion that what we really need to do is to “make government health care programs more responsive to consumer choice.”

How did it become normal to refer to medical patients as “consumers”? The relationship between patient and doctor used to be considered something special. Now politicians and supposed reformers talk about the act of receiving care as if it were no different from buying a car. What has gone wrong with us?”

These three short paragraphs contain two separate thoughts. The first is that it is somehow morally, ethically or socially reprehensible to think of patients, i.e, people who are ill, as being “consumers”. Coming from an economist like Mr. Krugman, this seems a bit bizarre. As Megan McArdle correctly observes:

“I found it very odd to see Paul Krugman complaining that “patients are not consumers” as if “consumer” were some sort of horrible, low-status role that should never taint the sacred realm of health care. In my economics classes, “consumer” was not a value judgement; it was a descriptor. A consumer is someone who consumes, just as a producer is someone who produces and a distributor is someone who distributes… Patients consume health care resources. Providers provide them. And the system through which labor and resources are allocated in our society remains money–an arrangement that I’m pretty sure that Paul Krugman doesn’t want to change.”

On its face it’s clearly ridiculous not to consider patients “consumers”, so to be fair Mr. Krugman must be using this language to mean something else. The obvious implication then is that, although patients are “consumers” in the technical sense, they are also something more than that by virtue of their illness and vulnerability. Perhaps something to be especially protected; to be given more options, opportunities and consideration than the average person might be. This must be it because of Mr. Krugman’s next observation that: “The relationship between patient and doctor used to be considered something special.” And indeed it was, and should be. The historic purpose of the physician-patient relationship is to educate patients about their disease and guide them through the sometimes tough decisions that have to be made. And, one might add, to specifically serve as an advocate for the patient when offering those choices and fighting, if necessary, with the patient’s insurer.

Just as clearly, Mr. Krugman believes that treating patients as people who must make consumption decisions for themselves based partly upon financial considerations is a bad idea. There are two possible reasons for this. The first is that they are vulnerable and somehow at risk for making bad decisions by virtue of their education, mental capacity or debilitating condition – thereby harming themselves. The second is that they are likely to make bad decisions that will harm society or others. Apparently both possibilities are of concern to Mr. Krugman, starting with the second one:

“About that advisory board: We have to do something about health care costs. We can’t maintain a system in which Medicare essentially pays for anything a doctor recommends. That’s especially true when that approach is combined with a system that gives doctors and hospitals a financial incentive to engage in excessive care.

Hence the advisory board, whose creation was mandated by last year’s health reform. The board, composed of health care experts, would be given a target rate of growth in Medicare spending. To keep spending at or below this target, the board would submit “fast-track” recommendations for cost control that would go into effect automatically unless overruled by Congress.

Before you start yelling about “death panels,” bear in mind that we’re not talking about limits on what health care you’re allowed to buy with your own money. We’re talking only about what will be paid with taxpayers’ money.”

Ah. So the most important problem here is that patients will make decisions that are too costly, in part because they are given bad advice by doctors and hospitals who stand to benefit by urging them to choose more expensive options. One should note that patients will be particularly indifferent to the cost of their care if these decisions have few or no financial consequences for them personally. This is the case with Medicare Part D (whose “doughnut hole” was closed by ObamaCare), Medicaid, high-end insurance of the type given to many state and federal workers and union members, and many Medicare Advantage plans.

But let’s pause here. We would be terribly negligent if we did not mention one out-and-out error or misconception that Mr. Krugman mentions in the last paragraph quoted. The one about bearing in mind that “we’re not talking about limits on what health care you’re allowed to buy with your own money” when it comes to the decisions of the IPAB. In fact, we are. And the fact that many of our political and economic leaders do not appear to know this is both discouraging and a bit frightening.

The vast majority of healthcare providers who take care of Medicare patients do so “on assignment”. This means that the clinician or other vendor agrees to take whatever Medicare will pay as payment in full for whatever goods and services are provided to the patient. It is illegal for these providers to bill Medicare patients for any additional amounts, or in fact to charge patients anything for any good or service that Medicare itself covers as a benefit. So what happens when a cost control organization such as the Independent Payment Advisory Board decides that they are going to cut costs by reducing the amount that they are going to pay clinicians for a specific healthcare good or service? Well, if the reimbursement becomes so low that it is no longer economically feasible for the clinician to provide the service, (s)he has no choice but to tell the patient “sorry, I can’t do that for you”. Can the patient then respond by using their own hard-earned dollars to pay that provider enough to cover the true cost of the service? Nope. That would be illegal for any provider accepting assignment. The patient’s money simply cannot be spent to purchase that service from that provider. Medicare says so, and by manipulating prices the IPAB can effectively force many patients to forgo tests and treatments that they might otherwise desire and be willing to purchase with their own money. Most Americans should know this, but they don’t. Even a Nobel Prize winner like Mr. Krugman apparently doesn’t.

But let’s go on. Back to Mr. Krugman’s original commentary:

“Now, what House Republicans propose is that the government simply push the problem of rising health care costs on to seniors; that is, that we replace Medicare with vouchers that can be applied to private insurance, and that we count on seniors and insurance companies to work it out somehow. This, they claim, would be superior to expert review because it would open health care to the wonders of “consumer choice.” What’s wrong with this idea (aside from the grossly inadequate value of the proposed vouchers)? One answer is that it wouldn’t work.

“Consumer-based” medicine has been a bust everywhere it has been tried. Medicare Advantage was supposed to save money; it ended up costing substantially more than traditional Medicare. America has the most “consumer-driven” health care system in the advanced world. It also has by far the highest costs yet provides a quality of care no better than far cheaper systems in other countries.

But the fact that Republicans are demanding that we stake our health on a failed approach is only part of what’s wrong. As I said earlier, there’s something wrong with the whole notion of patients as “consumers” and health care as simply a financial transaction.

Medical care, after all, is an area in which crucial decisions must be made. Yet making such decisions intelligently requires a vast amount of specialized knowledge.

Furthermore, those decisions often must be made under conditions in which the patient is incapacitated, under severe stress or needs action immediately, with no time for discussion, let alone comparison shopping.”

Here again in this selection, there are two separate ideas at work. The first is that “consumer-based medicine” has actually been tried in the U.S. (and presumably elsewhere, although the author does not say where else “everywhere” might be), and did not work. The second is the assertion that we mentioned previously that patients are incapable of making sound decisions about what which tests and treatments to select because they are rushed, incapacitated, ignorant or otherwise debilitated. What Mr. Krugman really appears to be saying is not that patients are not consumers, but rather that they are lousy consumers. Let’s look at both of these ideas; they are actually quite inter-related.

First let’s dispose of the time and incapacity issue. It is a fact that the vast majority of healthcare goods and services are provided to patients (and their families) who are not mentally incapacitated or in an emergency situation, but instead seeking care for a problem that is not life-threatening, and often chronic in nature. And where the patient herself is debilitated, their family generally isn’t. So one should be hard-pressed to argue that severe stress or incapacity is the deciding factor (or even a deciding factor) in the majority of healthcare decisions made by patients and families in their capacity as consumers. So what else could account for their poor and costly decision-making performance?

Well, to be a good, cost-effective consumer there are several pre-conditions. The first one, as we mentioned previously, is that you absolutely must have your own financial skin in the game. As an economist, Mr. Krugman should know this better than anyone. How do we know? Real world experience and common sense. You’re a normal person. right? Let’s say that we give you the option of getting whatever clothes you might need at either Target or Nieman-Marcus, all expenses paid. You won’t have to contribute a dime. Are you going to make any attempt to shop at Target, unless it’s substantially more convenient to do so? Of course not. If you have no personal financial liability, the actual cost of the clothes you choose will be immaterial to you. Why should healthcare be any different?

What else does a consumer need in order to “be in charge”? Three things: accurate prices, information about quality and performance, and “control”, (i.e., the ability to make the final decision about which course of action to take). How do those stack up in the healthcare system we’ve known, and the one promised by the Affordable Care Act law?

Prices are the signals that the market sends to consumers and producers that tell them, other things equal, how eager they should be to buy or sell a given product or service. If you don’t have accurate pricing, you’re not going to be in a position to judge the value of that good or service to you as an individual. Yet it is practically impossible for any American patient to determine, in advance, the actual amount that both they and the insurance company will have to pay for nearly anything that is covered by insurance. Just try it. Their doctor won’t know. There are so many combinations of coverage and co-pays and deductibles and write-offs that she’s not in any position to tell you. Think your insurance company will tell you? Try it. Call them today and tell them you need a lumbar discectomy, and ask how much it will cost both you and them. You’ll be on the phone for hours, and will almost certainly never find out.

So patients don’t have the price information they need to be good consumers. How about information about the quality and performance of various different alternative treatments? This is where a good doctor-patient relationship would come in handy. Ideally your doctor will explain to you the purpose, nature, risks, benefits and alternatives for all of the different options that exist for your condition in a completely objective fashion. He’d then answer any questions you might have and help you decide which alternative is best for you in your particular circumstances.

Unfortunately this is not the American healthcare system that we know, nor is it the one mandated by the ObamaCare law. Clinicians in the U.S. are paid by the procedure, and the prices of those procedures are essentially fixed by the government. So one potential source of bias is that doctors are given an incentive to recommend those tests and treatments they themselves perform and that the government has deemed to be most profitable. But the problem hardly stops there. Since the late 1980s, the government has decided that simply talking to patients will be one of the worst-paid and lowest margin services clinicians can offer. As a direct result, talking and counseling time is a scarce commodity. Still worse, insurance companies (including Medicare and Medicaid), have the final say about whether a given healthcare good or service will be paid for. It is well established that doctors are reluctant to offer tests or treatments that they know are unlikely to be approved. Therefore the information given to patients is highly likely to be skewed and incomplete. And that’s well before we get to the issue of it being nearly impossible to find out which specific clinician or hospital is likely to be the best for a given patient’s particular medical condition. The net result is patients are highly unlikely to have access to the unbiased and complete information that they are likely to need to make good consumption decisions.

This brings us to the final pre-condition for effective consumer choice: control. As we’ve mentioned already, insurers are always the ones to have the final say about the options a given patient will have – and in the case of Medicare it may be impossible for them to spend their own hard-earned money to obtain the care that might be best for them. This level of powerlessness is rarely encountered in any other aspect of the economy. In healthcare it is an artifact of the system that the government and private insurers have been allowed, by law, to create.

Knowing all of this, let’s now return to Mr. Krugman’s dual claims that “consumer-driven healthcare” does not work, and that patients make lousy consumers. What are we to make of them?

The first conclusion can only be that “consumer-driven” healthcare has never been tried in the United States on any large scale – especially for Medicare patients. In fact, the only place where one might argue that American healthcare really is consumer-driven is in elective and cosmetic medicine, where patients pay cash for the goods and services rendered. Contrary to Mr. Krugman’s assertion, the experience here has been quite promising. Over the past ten years the real cost of cosmetic and elective procedures such as Lasik eye surgery, Botox, and laser treatments of the skin have steadily declined. Prices are readily available, plenty of time is taken to explain things and clinicians and facilities market themselves based upon experience, convenience and a wide range of amenities. In contrast, everywhere that insurance and government regulations have come between clinicians and patients the essential components of true “consumer choice” have been uniformly absent and prices have risen relentlessly.

The second conclusion is that perhaps Mr. Krugman is right about patients being lousy consumers, but it’s hardly their fault. How are they supposed to make good and enlightened decisions if the healthcare system in general (and Medicare in particular), universally and systematically denies them the tools to do so? Given the dysfunctional history of Medicare’s own rules and regulations to date, how is anyone supposed to have any faith that a new supremely powerful and self-funding IPAB is going to partner with the existing bureaucracy to make things better rather than even worse for individual patients?

We’ve spent a lot of digital ink on this analysis for good reason. The relevance and importance of Mr. Krugman’s commentary goes well beyond his own credibility and that of The New York Times. Many of the assertions that he’s made, and the arguments he uses, are that same ones that led to the creation of the IPAB by Congress and the Obama Administration. If our political and economic leaders don’t understand the fundamentally flawed nature of the Mr. Krugman’s facts and analysis, our nation’s entire healthcare policy has been built on economic and medical quicksand. The passage of the Affordable Care Act legislation ensures that inherently defective healthcare policies will be the law of the land for the foreseeable future. The implications are truly chilling.

Which brings us to Mr. Krugman’s final paragraph:

“The idea that all this can be reduced to money — that doctors are just “providers” selling services to health care “consumers” — is, well, sickening. And the prevalence of this kind of language is a sign that something has gone very wrong not just with this discussion, but with our society’s values.”

We’d like to restate this paragraph in light of all that we’ve learned in this post:

The idea that this can all be reduced to money – that doctors are not neutral parties working solely on the behalf of patients, but paid agents acting according to a set of insurance and government-mandated incentives, rules and regulations about what healthcare patients may or may not know or be permitted access to in their capacity as self-interested consumers – is, well, sickening. And the long history of support that so many of our economic and political leaders have lent to this situation is a sign that something has gone very wrong not just with this discussion, but with our society’s values.

What do you think? Your comments are welcome.

Categories : Liar Liar Pants on Fire Awards, Overhauling Healthcare, Personal Responsibility, Political Hellth, PPACA, Uncategorized

Sep
23

Should Everyone Have a Healthcare Nanny?

by Dr. Doug Perednia

It’s actually a serious question.

Let’s define a healthcare nanny as someone who calls you to tell you that you didn’t take your medicine, or that you didn’t get your prescription filled. They’ll also call you if you haven’t scheduled your routine follow-up appointment or gotten those screening tests that your age and sex suggests that you might want to have. Your nanny will scold you when haven’t been exercising enough, or when you eat too much. And, of course, (s)he’ll weigh in any other aspect of medical compliance that might come up. Just had an operation? Remember to change that dressing and walk around three times a day.

Now before you read on, please carefully consider your own answer to the following question: “Would you want a healthcare nanny?”

And if you’ve answered yes to that question, then here’s another one for you: “How much are you willing to pay for that privilege?” A dollar per week? Ten dollars per week? A hundred?

Now, how much are you willing to pay to ensure that everyone else in America has a healthcare nanny?

This question comes up as a result of an astonishing increase in the number and variety of organizations asking your doctor to either take on the role of healthcare nanny, or pay someone on his/her staff to do so. A large part of the justification behind forcing doctors and patients out of small private medical practices and into so-called “medical homes” and accountable care organizations (ACOs) involves their proposed use of intensive “communication” and “coordination of care”. A large part of this is inevitably going to involve the use of healthcare nannies (or their equivalent) to make sure that patients do what they’re told, when they’re told to do it.

Let’s take a couple of examples. First, take a look at these two letters sent to a physician by CVS Caremark, a large national pharmacy.

CVS Caremark Letters

The basic message is:

We did not fill/refill your patient’s medication as expected;
Therefore your patient may be non-compliant with their medication;
Therefore you should call them and do whatever is necessary to bring them back into line.

On the face of it this may seem like quite a reasonable thing for CVS Caremark to do. In fact, from one perspective it appears to be a valuable public service. Everyone wants patients to get well and save money by staying out of the hospital. If you don’t buy and take your medications, you might get sick and up in the emergency room. No one can accuse CVS Caremark of having anything but good intentions in launching and maintaining this program.

Here’s a second example from Medco Health Solutions, the largest mail-order pharmacy in the country. In this case a physician is being told that he/she should be sure to obtain a routine eye examination on a diabetic patient. As the letter explains, diabetes-associated eye disease is one of the leading causes of acquired blindness in the U.S.

MedCo Letter

The message here is:

Somebody told us that your patient has diabetes. This means that they should get regular eye check-ups;
As far as we here at the mail-order pharmacy know, this particular patient hasn’t had an eye exam lately;
Therefore you should immediately check their records. If they have not had an eye exam lately, you should contact them and do whatever is necessary to get them in for an eye exam..

Here again it would be hard to fault Medco for wanting to help prevent blindness. clearly, good intentions are everywhere. Which leads one to wonder, “Hey, shouldn’t everyone be doing this sort of thing? In fact, why the heck aren’t all of those other lazy, loutish pharmacies doing the same thing? And if some is good, more is better. Presumably they should be joined by every other medical supplier, insurance company and government agency on the planet. After all, what could go wrong?”

Well, if you’re a regular reader of this blog you already know that the Road to Hellth is almost always paved with good intentions. Healthcare nannyism is no exception. And, as usual, the devil is in the details.

Detail #1: Nagging is only useful if your data is correct. Much of the information used to create alerts like these is inevitably going to be wrong. Patients routinely move, change vendors, and change insurers – all while trying to maintain a few remnants of medical privacy. Third parties such as pharmacies and health insurers base their alerts on purchasing or claims information. Their databases are typically incomplete, always delayed by 60-180 days, and often loaded with incorrect information. “Garbage in, garbage out,” as they say in the computer business,.

In the case of the first “non-compliance alert”, the patient had indeed had the prescription filled, but at a different pharmacy. Of course there was no way for CVS to know that, (and if they did, one might wonder how and why they knew.)

In the case of the Medco letter, the patient had already had a recent eye exam. Which raises the question, “why should the pharmacy that mails them their drugs pretend to know anything about what other medical care they’ve been receiving?” Did someone hand them this patient’s records? If so, why? Is it really any of Medco’s business?

The cumulative impact of all these alerts is substantial. Even computer-generated letters cost money to send and receive. Each one generates administrative overhead to produce, send, open, evaluate and process – overhead that is completely uncompensated by the existing healthcare system. Sending alerts that are incorrect or unnecessary is like “crying wolf”. It makes taking care of patients harder rather than easier.

Detail #2: Who’s you nanny? Now place yourself in the shoes of your typical busy, beleaguered physician who has just had a whole stack of these things placed on his desk. CVS is worried about this. Medco is worried about that. You’ve just gotten a bunch of notices from various insurance companies telling you that you may be over- or under-utilizing medical tests compared to your “peers”. The fax machine beeps. Mrs. Jones may or may not have filled her prescription for the medication you prescribed.

Is this really your problem? Are you a doctor, or a nanny?

Following up on alerts like these can be expensive. Let’s say that you ask your medical assistant to call Mrs. Jones. It takes her 15 minutes to bring up her record, dial the number, speak to her on the phone and record the results. At a typical hourly rate that call cost your office at least $5.00, regardless of whether the information was accurate. How much are you paid for being so fastidious? Nothing. The entire cost is going to either come out of your own pocket, or be passed on (directly or indirectly) to all of your other patients. Now multiply this by anywhere from 10-20 alerts per day, five days a week, and it adds up to $20,000 in additional expense per year. Multiply by say, 500,000 doctors, and you can easily spend $10 billion a year just by responding to this stuff.

Even Mary Poppins would think twice before generating that kind of nanny expense.

What’s the payoff? It’s very hard to tell. There is a substantial body of evidence that patient reminders do increase compliance with drug monitoring, reduce the number of appointment no-shows, and increases immunization rates. But do these types of nanny messages actually save anyone any money or improve health status? No one seems to to know. I’ve been unable to find any scientifically valid evidence one way or another. And even if there were, how would that benefit compare with spending the same amount of money on longer office appointments, more medicine or lower insurance premiums?

Which brings us back to the question we asked you to consider. Do you even want a healthcare nanny? Would knowing that it’s going to increase the cost of your health insurance premiums change your mind? To what extent should people be taking responsibility for their own reminders, appointments and medication refills? And most importantly, what cost are you willing to bear to hire and keep healthcare nannies for others?

We can expect to see a lot more of dedicated healthcare nannies under Obamacare, although you’ll never see this particular expense broken out anywhere. Part of the theory behind “medical homes” and “accountable care organizations” (and it’s only a theory – none of this stuff has ever been widely implemented let alone well studied), is that close, continual contact between patients and their clinical keepers will produce better medical results and save buckets of money.

Maybe it does, maybe it doesn’t. But you can be sure that more and more people will be watching to see if your medicine go down.

Categories : Personal Responsibility

Jun
15

Is Healthcare a Right Only If Someone Else Pays for It?

by Dr. Doug Perednia

The caption on this poster reads:"PRIORITIES - When Weighing Important Decisions, Go With Your Gut."

Not long ago, Nicholas Kristof published a moderately disturbing column entitled “Moonshine or the Kids”.

The topic of the piece is his experience with one particular family in the Congo Republic. I’ll let him pick it up from there:

“Here in this Congolese village of Mont-Belo, we met a bright fourth grader, Jovali Obamza, who is about to be expelled from school because his family is three months behind in paying fees. (In theory, public school is free in the Congo Republic. In fact, every single school we visited charges fees.)

We asked to see Jovali’s parents. The dad, Georges Obamza, who weaves straw stools that he sells for $1 each, is unmistakably very poor. He said that the family is eight months behind on its $6-a-month rent and is in danger of being evicted, with nowhere to go.

The Obamzas have no mosquito net, even though they have already lost two of their eight children to malaria. They say they just can’t afford the $6 cost of a net. Nor can they afford the $2.50-a-month tuition for each of their three school-age kids.

‘It’s hard to get the money to send the kids to school,’ Mr. Obamza explained, a bit embarrassed.

But Mr. Obamza and his wife, Valerie, do have cellphones and say they spend a combined $10 a month on call time.

In addition, Mr. Obamza goes drinking several times a week at a village bar, spending about $1 an evening on moonshine. By his calculation, that adds up to about $12 a month — almost as much as the family rent and school fees combined.

I asked Mr. Obamza why he prioritizes alcohol over educating his kids. He looked pained.

Other villagers said that Mr. Obamza drinks less than the average man in the village (women drink far less). Many other men drink every evening, they said, and also spend money on cigarettes.

‘If possible, I drink every day,’ Fulbert Mfouna, a 43-year-old whose children have also had to drop out or repeat grades for lack of school fees, said forthrightly. His eldest son, Jude, is still in first grade after repeating for five years because of nonpayment of fees. Meanwhile, Mr. Mfouna acknowledged spending $2 a day on alcohol and cigarettes.”

You might inclined, as I was, to conclude that these are just a couple of rotten apples in the basket of life, but you’d be wrong. As Mr. Kristof points out, people in extremely poor countries frequently spend much larger percentages of their income on alcohol and tobacco than they do for goods and services that many of us would perceive as being more worthwhile. As evidence, he cites a study by MIT economists Abhijit Banerjee and Esther Dulfo on how the poor spend their money around the world.

As the MIT folks discovered, people were very consistent about spending a substantial portion of their money on addictive intoxicants, festivals, soft drinks and prostitution.

“The extremely poor in rural areas spent 4.1 percent of their budget on tobacco and alcohol in Papua New Guinea, 5.0 percent in Udaipur, India; 6.0 percent in Indonesia and 8.1 percent in Mexico; though in Guatemala, Nicaragua, and Peru, no more than 1 percent of the budget gets spent on these goods (possibly because they prefer other intoxicants).

Perhaps more surprisingly, it is apparent that spending on festivals is an important part of the budget for many extremely poor households. In Udaipur, over the course of the previous year, more than 99 percent of the extremely poor households spent money on a wedding, a funeral, or a religious festival. The median household spent 10 percent of its annual budget on festivals. In South Africa, 90 percent of the households living under $1 per day spent money on festivals. In Pakistan, Indonesia, and Cote d’Ivoire, more than 50 percent did likewise. Only in some Latin American countries in our sample─ Panama, Guatemala, Nicaragua─ are festivals not a notable part of the yearly expenditure for a significant fraction of the households.”

In contrast education spending is only about 2% of the average budget, although in fairness most children do have access to public schools. (Of course many of those are of questionable quality.) Although healthcare spending is not specifically broken out, the health problems of these populations are legion. Many are caused by malnutrition, even though the people in question could have purchased food with the money they spent on alcohol, tobacco and festivals. Not surprisingly diarrhea, anemia and vision problems are quite common, although reported levels of stress are actually much lower than in the United States.

The authors of this study were reluctant to credit these problems to “addiction” spending per se, and more inclined to cite a strong desire for entertainment. (Perhaps alcohol and tobacco should themselves be considered to be a form of entertainment. They clearly are a means of escapism.)

“Provided that eating more would increase their productivity, it is unlikely that the low levels of good consumption can explained by a simple lack of self control (the poor cannot simply resist temptations to spend on other things, and don’t have enough left to eat): As we noted above, they also spend surprisingly large amounts on entertainment ― be it televisions, weddings, or festivals. All of these involve spending a large amount at one time, which implies some saving unless they happen to be especially credit-worthy. In other words, many poor people save money that they could have eaten today in order to spend more on entertainment in the future, which does not immediately fit the idea of their lacking self-control.”

All of which got me to thinking. People around the world are much more similar than they are different. Anyone who spends time in an ER, clinic or hospital in the U.S. can tell you that they see plenty of people who will happily spend their available cash on liquor, cigarettes, cell phones, cable television car toys, long before they would even remotely consider buying their own medications, paying their medical bills or getting their children vaccinated. Most of these same folks will also insist that access to healthcare is a right, and that other people need to pay for the healthcare goods and services that they themselves wish to receive.

It’s one thing to starve yourself to death in order to buy a sixpack, but does everyone really have the right to demand that others supply them with healthcare while they’re still spending their own money on entertainment, alcohol and tobacco? Is it somehow a violation of human rights to ask that these expenditures stop before healthcare assistance will be provided?

If healthcare is supposedly a “right” like food, clothing and shelter, why is there a limit to the food, clothing and shelter that society is obligated to provide, but not the amount of healthcare? Why the heck is healthcare a more righteous right than the others in this regard?

Why do people value healthcare and education so little relative to entertainment and intoxication? Is this something that we teach our children, or is it simply part of human nature?

All of these questions come up in the context of the recent healthcare reform law that was passed by Congress and signed into law by President Obama. Provisions in that law dramatically expand and subsidize access to insurance through Medicaid, and appear to remove all caps on spending for individual cases. The net effect is to dramatically expand healthcare as an entitlement, regardless of personal behavior.

Is it right and proper that we take resources from one person to subsidize another, even if the person being subsidized is blowing what little money they have on drugs, sex and rock and roll? Can we require the subsidized person to spend every penny they have on food, clothing, shelter, healthcare and other necessities before we give them large quantities of healthcare services? If not, that that make the ability to spend one’s own money on alcohol, tobacco and prostitution a protected liberty, just like freedom of speech and assembly?

Here’s another way of looking at the problem. Many people, including President Obama, claim that access to healthcare in America is a fundamental human right. The dictionary refines a right as something that “belongs fundamentally to all persons”. The implication is that you don’t have to do anything to qualify for whatever benefit that a right may provide. So presumably you shouldn’t have to spend a penny of your own money to get access to healthcare, and one is perfectly entitled to spend all of one’s income on alcohol, tobacco, porn, gambling and video games before heading to the ER for free care?

Maybe it’s the puritanical upbringing talking, but I’m having trouble convincing myself that this is okay.

Someone help me here. There must be some relatively simple, rational and understandable rules that most Americans would agree on with respect to these things.

Let’s close with a spectacular piece of insight into the way the world really works.

“Don’t tell me where your priorities are. Show me where you spend your money and I’ll tell you what they are.”

– James W. Frick

Categories : Personal Responsibility

Mar
16

A Healthcare Rorschach Test

by Dr. Doug Perednia

I recently received an e-mail asking me to comment on a letter to the editor written by Dr. Roger Starner Jones. Dr. Jones’ letter was published in the August 29^th edition of Jackson, Mississippi’s newspaper, the Clarion Ledger. I have reprinted it below. I had not seen this letter before, but Dr. Jones does exist and his piece has received a considerable amount of comment in various places on the Internet.

Dr. Roger Starner Jones

Dear Sirs:

During my last night’s shift in the ER, I had the pleasure of evaluating a patient with a shiny new gold tooth, multiple elaborate tattoos, a very expensive brand of tennis shoes and a new cellular telephone equipped with her favorite R&B; tune for a ring tone.

Glancing over the chart, one could not help noticing her payer status: Medicaid.

She smokes more than one costly pack of cigarettes every day and, somehow, still has money to buy beer. And our President expects me to pay for this woman’s health care?

Our nation’s health care crisis is not a shortage of quality hospitals, doctors or nurses. It is a crisis of culture – a culture in which it is perfectly acceptable to spend money on vices while refusing to take care of one’s self or, heaven forbid, purchase health insurance.

A culture that thinks I can do whatever I want to because someone else will always take care of me.

Life is really not that hard. Most of us reap what we sow.

Starner Jones, MD
Jackson, MS

One of the most intriguing aspects of this letter is that it appears to function as a Rorshach test for those reading and commenting upon it. Conservatives believe that it is a clear and moving indictment of a welfare state mentality. Liberals interpret it as a racist and mean-spirited story that is probably made up, and unfairly attacks the poor. When it comes to what this story says about healthcare, opinions are just as varied. Some are offended by the sense of entitlement attributed to the patient, while others see a callous fat-cat doctor working in a healthcare system that is both unaffordable and mistreats its patient participants. It’s amazing that all of those commenting were reading the same story. How can one reconcile all of these perspectives?

To begin with, some of them don’t need to be reconciled. If his story is true as told (or even if it’s not), there is no reason to believe that Dr. Jones is a racist. The type of person he describes exists in all races, creeds and colors. I have seen them as patients many times, and so has every other doctor. There is no need to invent them. If you do not believe this, then you really do need to spend some time as an observer in a busy emergency room or clinic.

With that objection addressed, it’s easy to understand Dr. Jones’ frustration. People make poor, irresponsible and self-centered decisions all of the time. Many of these involve how they spend their money. They buy things they don’t need and can’t afford – often maxing out their credit cards and paying ridiculous rates of interest in the process. They prefer (and even insist upon) instant gratification. Saving for the future or for a rainy day is a foreign concept. And many Americans clearly make consumption decisions based upon advertising and social pressure. Indeed, the real question is why Dr. Jones – or anyone – should expect this large segment of the population to be any more rational and forward thinking about their healthcare decisions than about anything else? Planning for illness is the ultimate in foresight. Almost no one thinks about their health until they’re sick – especially when they’re young.

Let’s not kid ourselves. To the extent that both our healthcare system and our society as a whole promotes these behaviors, they are both broken.

It just so happened that Dr. Jones wrote about a healthcare-related example, but you can recognize the same basic problem anywhere you’d care to look. Because Americans don’t save, we are no longer in a position to supply our own business capital. If we need money, it must be borrowed from overseas. Because we do a poor job of educating ourselves, many of our product development and software engineers, scientists, (and even doctors) are recruited from India, China and elsewhere. Because we’re unwilling to hold banks and individuals accountable for the quality of mortgages they jointly create, our society has been willing to see wealth destroyed on a scale so large that the average person cannot possibly comprehend it.

Perhaps most disturbing is that our political system – the system that we rely upon for economic, social and military leadership – is emblematic of the problem as a whole. Short-term thinking. Buying votes with the taxpayers’ own money. Deficit spending during an economic expansion. Raising taxes on business in the middle of a severe recession. Creating (and passing!) a massive healthcare “reform” bill that is based upon faulty assumptions, political pork, poor economic choices and a complete absence of medical perspective; these are but different manifestations of the same attitude that walked into Dr. Jones’ emergency room that day. Unfortunately, what might be merely offensive in an individual is potentially catastrophic when backed by the sovereign power of a nation.

Which brings us back to the Rorschach test.

It should not matter whether you are liberal, conservative, or somewhere in-between. If we cannot look at Dr. Jones’ patient in a larger context and see that our country is very much in a crisis of culture, then we are either blind or unwilling to accept reality. Either possibility is a terrible danger to any country, especially a democracy.

From the perspective of many patients and providers, many aspects of our healthcare system really are in shambles. We are truly on The Road to Hellth. And there is no question that our healthcare system can be redesigned to minimize many of its present defects. This includes providing better incentives for people to think about their own health and financial choices proactively and responsibly. But we simply cannot stop there. It will hardly matter if we design and implement the perfect healthcare system, only to have it undermined by personal and political cultural values that corrupt everything they touch.

Categories : Personal Responsibility

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Is Healthcare a Right Only If Someone Else Pays for It?

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