Well, the first details of the long awaited health care plan are now coming out, and the Internet is abuzz with shock and awe about many of its aspects, particularly its high cost, the undermining of private health insurance policies, and the complexity of its administration, manifested in a host of new bureaucratic agencies to bring the joys of government health care into every nook and cranny of your pitiful and meaningless life.
One big-picture aspect of this huge transformation in American health care which seems to be receiving little or no attention is its heavy emphasis on preventive medicine. We have been hearing for some time about how preventive medicine will save substantial sums of money and thereby make the overall health care system far less costly. Of course, such rhetoric has an enormous appeal at a surface level — after all, if you can prevent diseases, you certainly don’t need to spend money to cure them.
Who could argue with this?
But this innocent-sounding, simplistic Trojan horse will prove deadly for American health care, and end up empowering the bureaucrats and politicians who will, in fact, gain the most from this change in direction.
When we talk about preventive medicine, we are generally speaking of two general areas: the screening and early detection of diseases, and lifestyle changes and therapy to reduce long-term medical risk. Screening and early detection of diseases is appealing concept, but devilishly difficult in practice. The idea sounds wonderful: do a simple, inexpensive test; detect the disease earlier, when it is simpler and less expensive to treat; and you will be healthier in the future, requiring far fewer health resources. The problem lies, as I have discussed elsewhere, in the malignant mathematics and sickening statistics of applying medical screening to large populations. Simply put, no screening test is perfect, and all such tests generate both false positives — telling you that you have a disease, when you do not — and false negatives — telling you you’re fine when you really have the disease. Even with an extraordinarily accurate test the problem lies in applying it to large populations. If you have a cancer screening test with a 1% false positive rate (an extraordinarily low number in the screening business), and have a disease which occurs in one patient out of every 10,000, applying the test to 10,000 patients will generate 100 false alarms (false positives) for every patient with the disease. These false positives all require additional testing or procedures to determine whether in fact the abnormal test really means you have the disease. And herein lies the economic trap: you will in fact spend an extraordinary amount of money on patients without the disease for every patient detected who does have the disease. This phenomenon has been well demonstrated in almost every study of screening — to wit: screening actually increases rather than reduces medical costs.
Of course many simple screening tests and procedures are used every day in medicine. When you go to the doctor, your blood pressure is checked, your cholesterol is measured, you stand on the scale and are weighed, and asked whether or not you smoke. If your blood pressure is high, you will likely be started on medication, and it is also likely that you will need to stay on this medication indefinitely. If your cholesterol is elevated, will be encouraged to exercise, make dietary changes, and lose weight (most of which you won’t do), but will also likely will be started on cholesterol-reducing medication, likely for the long-term. Of course, we recognize that this is appropriate for the reduction of risk from high blood pressure or high cholesterol. What may not be recognized, is that many people with high blood pressure or high cholesterol, unrecognized and untreated, may not have significant problems from these disorders for many years, if ever.
Suppose that 100 people with high cholesterol levels take statins, a common treatment for high cholesterol. Of them, about 93 wouldn’t have had heart attacks even if they had not taking the medication. Five people, on the other hand, will have heart attacks despite taking the statin. Only the remaining two out of the original 100 avoided a heart attack by taking the daily pills. In the end, 100 people needed to be treated to avoid two heart attacks during the study period --so, the number of people who must get the treatment for a single person to benefit is 50. This is known as the “number needed to treat” — and is a common way in which health researchers determine the cost and effectiveness of preventive therapy. Ideally, we will get better at selecting those patients at the front end who actually will benefit from taking the drug, and therefore avoid administering it in those who ultimately will not need it. But such health forecasting is far, far from perfect, and there will always be a need to treat patients perceived to be at risk even though time will ultimately find them not to be at risk at all. The human organism in health and disease is far too complex to eliminate this reality.
Problems such as these arise in every aspect of preventive medicine. It also goes without saying that implementing lifestyle changes, such as weight reduction, regular exercise, smoking cessation, and dietary modifications, is largely a fool’s pursuit. We humans love our addictions, and rarely overcome them even when they threaten our health and well-being.
The myth of the economic benefits of preventive medicine dies hard, however, and the pending changes in the health care system are placing a very large bet on this loser’s hand. The systemic manifestation of this crap shoot is the glorification and indemnification of primary care as the solution to all of our health care woes, economic or otherwise. Although the final details of the pending reforms of health care are still far from complete, it is clear that there will be a heavy emphasis on steering patients toward primary care physicians and away from specialists.
Health care bean counters have long known that care delivered by specialists is more expensive then that delivered by primary care physicians. It is the specialist who performs the expensive surgeries, procedures, and diagnostic studies which cost the government and health insurers a substantial percentage of their total outlays. When viewed from an economist’s standpoint, it makes perfect sense to reduce the utilization of more expensive specialty care, and increase the utilization of less costly primary care. Although the details remain to be fleshed out, it appears that there will be a substantial increase in reimbursement to primary care physicians, and reduction in reimbursement to specialists by eliminating higher payments for consultations, procedures, and surgeries. These changes are already beginning to be implemented in Medicare, even prior to passage of any large healthcare reform legislation. There are plans to bundle payments for chronic disease management, paying the primary care physicians who manage them higher rates, most likely on a fixed payment schedule designed to motivate physicians to reduce costs and improve outcomes.
Like most great ideas arising from the government, this is a day late and a dollar short.
The insurance industry came up with this idea over a decade ago, and implemented it in systems extensively, using the tools of capitation (bulk payments to physicians upfront for future care) and the gatekeeper model (having the primary care physician who receives such bulk payments control referrals to specialists, with a strong financial incentive not to send them there).
Many of you may recall how popular these programs were. What you may not have noticed is that virtually all insurers have dropped them.
There were a host of difficulties with this approach to medicine. First of all, it put the physician in a position of conflict of interest, by giving him or her a financial incentive not to order additional tests or make referrals to expensive specialists. While this incentive would obviously reduce unnecessary tests and referrals, it also gave the physician an economic incentive to defer or eliminate such tests and referrals, when in fact they were in the patient’s best interest. Simply put, your doctor made more money if he did not order your CAT scan, even if a CAT scan had a strong medical indication.
These policies led to no small amount of disgruntlement among patients covered under such plans. It became clear that patients could not get to see specialists when they needed them, because their physician or their insurance company refused to allow them. Even when the system worked as ideally designed — preventing referrals for unproven experimental or unnecessary treatments — patients nevertheless demanded these treatments, and often resorted to heart-rending media exposÃ©s on how the evil insurance companies had refused to pay for their experimental treatment for cancer. In one sense, this approach did work as intended: by restricting access to care, particularly specialist referrals and expensive diagnostic testing, HMOs and other similar insurance schemes did in fact reduce substantially the rise in medical costs. But they did so by rationing — and thereby sealed their own fate when this became enormously unpopular among patients, and (of course) exploited by politicians. Although some remnants of this system remain intact, particularly preauthorization for specialist referrals, certain procedures, and diagnostic imaging studies, the coercive restrictions in place during the height of this trend have greatly mitigated. Those restrictions which remain are still the most common source of discontent among patients and physicians, as insurance companies continue to refuse payment for medical services recommended by their physicians, or require onerous paperwork for their authorization.
As you can imagine, primary care physicians, who have been lobbying for higher reimbursement rates for many years (and not unreasonably so) find many aspects of a new financial emphasis on primary care to be attractive.
They should be careful what they wish for.
One of the deadliest traps of bundled payments such as capitation was the problem of medical outliers. Getting a payment every month for your entire patient population, to manage all their care, is a great deal if all your patients are healthy, as they cost you very little, and you get to keep the difference. The problem arises when your practice involves a large number of patients whose care is very expensive. Your lump sum payment begins to look very small when a large number of your patients require costly hospitalization, surgery, expensive medical therapy or drugs — the payment for which is coming out of your own pocket. This reality created an entire consulting industry to analyze patient populations versus capitation rates, with the goal of reducing the physicians exposure to such potentially disastrous financial consequences. Physicians and their consultants got very good at selecting populations of healthier patients — which often excluded those patients who needed medical care the most. Physicians who got burned on this difficult calculus often ended up terminating their relationship with specific insurance carriers, resulting in large numbers of patients abruptly losing their physicians, and forced to hunt around for new physicians who would accept their insurance.
For these and a host of other reasons such insurance models have largely died an ignominious and well-deserved death. but their rotting corpses are being raised to life again. The Undead will walk the earth, this time with even greater powers granted them the federal government.
With private insurers, physicians and physician groups at least have the option of terminating their contracts with insurance carriers whose reimbursements or capitation rates were insufficient to cover the risks of the patient populations they covered. With universal health care, especially one predominantly or exclusively provided by the government, this escape route will no longer be available. The primary care physician who finds his reimbursement improved for managing chronic diseases will also find himself burdened by a blizzard of additional paperwork to document that the “quality” of his care meets government standards — whether such standards are realistic, or even in the patient’s best interest. Furthermore, if such reimbursements do not cover the inevitable increase in management overhead, there will simply be no place else to turn. One cannot fire the federal government when they are the only source of payment for the medical services you provide. The only option available to physicians will be to opt out of medicine altogether — and you may anticipate the increasing numbers of physicians will do exactly this. Universal health insurance is not the same as universal health access — a lesson we are about to learn painfully if we continue down this path. A seat at the Captain’s table on the Titanic seems propitious until the chairs start sliding toward the bow of the sinking ship.
But there is another aspect to this heavy emphasis on primary care which has received virtually no attention. Although certainly not without problems and potential abuses, the simple fact remains that America’s specialist-intensive health care system is in fact the driving force behind its technologically advanced benefits. Simply put, we are not living longer, healthier lives because we have beloved family doctors who hold our hands and listen to our complaints. The huge advances in medicine in the past 50 years have occurred in large part because of the specialization of medicine. The extraordinary complexity of contemporary medicine has made its mastery by any one type of physician utterly impossible. Even the brightest internist or family practice physician cannot be master of all of the complex aspects of cardiology, surgery, oncology, or the management of increasingly-challenging infectious diseases. Certainly good physicians in primary care are well-versed in many of these areas, at some level, but it has long since been unrealistic to expect primary care providers to be masters of such vast and ever increasing knowledge and complexity in the different realms of specialty medicine. This is not to denigrate in any way the importance of primary care physicians, most of whom are highly accomplished at the health maintenance of large numbers of patients — a skill which has contributed greatly to our improved quality of life and longer lifespans. But our system provides the enormous benefits in high quality and longer, healthier lives because the primary care physician has a very deep bench of specialists at his beck and call.
At some point even the most skilled and capable primary care physician will encounter complex, difficult, or intractable problems which he or she simply is not trained or skilled to manage. Specialty care is indeed expensive — and it is expensive in no small part because the patients who need such care have more difficult or complex medical problems, which simply cannot be best treated without the expertise of specialists.
As our system increasingly steers patients away from such specialty care for economic reasons, it will do so at significant cost in a variety of realms. Much of the advanced medical innovation, which has given us longer and better lives, has arisen out of specialty care, and it is inevitable that significant restrictions on such care will blunt and slow such medical advances. But there are costs hidden in such an approach which will also become apparent with such an unbalanced emphasis. When we, through financial coercion, force primary care physicians to assume the care of increasingly complex patients for which they have neither the training nor depth of experience to manage, such care will inevitably end up being inferior in quality — and likely will end up in the long run, being far more costly. Without access to specialty support, primary care physicians tend to fall back on using more expensive medications, diagnostic studies, and therapies, sometimes inappropriately. The unusual skin condition, which can be promptly diagnosed and appropriately treated in a few visits to the dermatologist, may instead be treated with an increasing array of expensive and ineffective therapies or drugs by primary care providers who are unwilling or unable to avail themselves of specialty consultation and treatment. The insurance companies learned this long ago, and it was one of the factors motivating them to dismantle the gatekeeper model.
The enormous push toward primary care and preventive medicine embodied in the currently-envisioned transformation of the health care system being pushed through by Congress will be doomed to fail, brought down by the flawed premises upon which it is based. But it will, in one important regard, prove successful to those who are currently pushing its implementation. The system as currently designed, with its emphasis on primary care and preventive medicine, will not improve quality or reduce costs, but will give government a far greater degree of control over physicians and the nature of the care they provide. Increasingly it will be the government, and not the physician, who dictates what care you will receive, which specialists you will see (if any), and whether the medically appropriate care which you need will meet its financial standards for return on investment. As Obama has promised us, we will all be asked to “take the pain pill” rather than undergo the surgery we need and which will improve our lives.
It likely is too late to stop the perfect storm of health care reform, given the current makeup of our Congress and Administration. Be prepared for a brave new world in medicine.
And don’t be surprised if it is not to your liking.
UPDATE: Massachusetts, in deep do-do from their universal coverage, is treading this same hoary path: Massachussetts Health Plan Pushes for Capitation Megan McArdle spells out the problems nicely. Take-away quote: “This is why ‘paying for health rather than procedures’ never pans out.”