If you’ve been following some of my previous posts on the insanity of the U.S. health care system, such as the Maze series, you will recall the looming ogre in payment “reform” called pay for performance. Medicare, and the me-too sycophants in the insurance industry, have been promoting and implementing a payment system which nominally will pay more for care which meets certain quality standards. This concept is based on a host of unproven assumptions — the most egregious of which are the unspoken assumptions that much care delivered is substandard, and that trivial increases in reimbursement will correct shortcomings in quality (which are vastly more likely to be due to system complexity than individual error or incompetence). Nevertheless, this lumbering freight train is rumbling down the rails toward our health heroine Nell, lashed to the tracks by Snidely Whiplash, your dastardly federal and private insurance bureaucrat.

Today’s Wall Street Journal (subscription required) reports on a JAMA study of just how well this system works. In a pilot project funded by Medicare, the stunning results are in: it doesn’t. Color me shocked:

Researchers at Duke University, examining heart-attack treatment at 500 hospitals, found that hospitals that received financial incentives to follow treatment guidelines didn’t improve their practices significantly more than hospitals that got no financial benefit.

The federal Centers for Medicare and Medicaid Services launched the pay-for-performance pilot in 2003. Participating hospitals provided the CMS with performance information for five conditions, including heart attack. Hospitals in the two highest performance levels for a condition received a bonus.

In the Duke study, published in this week’s Journal of the American Medical Association, 54 of the hospitals were participants in the CMS pilot and received the financial incentives. The other 446 “control” hospitals didn’t get such payments.

The findings showed that “the pay-for-performance program was not associated with a significant incremental improvement in quality of care or outcomes for acute myocardial infarction,” or heart attack, Duke cardiologist Eric D. Peterson and colleagues wrote in the journal article.

Of course, the usual special pleading is immediately evident: perhaps the carrots weren’t juicy enough (like that will ever happen, in a system which is economically hemorrhaging), or the sticks weren’t nasty enough (now you’re talkin’! Keep beating that dead horse, and surely it will run faster):

It’s possible the financial penalties for not complying weren’t sufficient. “Those with the poorest performance risked future financial penalty,” researchers said, but didn’t actually pay such a penalty. Bonuses for complying with performance standards totaled $17.6 million to a total of 123 hospitals in the first year and 115 hospitals in the second year.

“One read on this is that the carrots have to be bigger,” Duke’s Dr. Peterson said. Hospital officials involved in the Medicare pilot project said this winter in a conference call with reporters that financial incentives were small relative to their budgets.

Now that the data is in, you can be sure that our bureaucrats will rethink their foolish ways — or not:

Still, the findings raise the question of what the Medicare system will do next. A Medicare spokesman said the agency hadn’t seen the study and so couldn’t comment on it.

Nice. Medicare, who funded the study, hasn’t seen the results. Never let the facts get in the way of a bureaucrat on a mission — it just confuses them.

A recent post over at the Advice Goddess regarding access to health care caught my eye. Like many such posts, there was a brisk repartee in the comment section on the topic of fixing our daunting health care access problems. Many of the comments were knowledgeable and informative; some, as is always the case, were idiotic or pedantic. One comment in particular, however, caught my eye, posted by a fellow from the liberal side of the political spectrum. It was a rather lengthy screed, which is excerpted here only in part:

I notice that people who enjoy making reflexive attacks on any and every possible change in the current system have this one thing in common: They love to mock the idea of preventive medicine. …

One other point that isn’t being made by the right wing: The number of students accepted by American medical schools was increased substantially about a third of a century ago (partly by the opening of more campuses by state schools), and then was held static. Some attribute this freeze to pressure from the medical lobby (it creates an artificial scarcity of doctors). We should increase entry level spots in medical schools by fifty percent or so (i.e.: what we did in the ’70s etc), and open many more spaces in nursing schools. Curiously, the federal government could cover the tuition of every medical student in the country for a small fraction of what we spend on medical care in total, and it would solve some serious problems for the rest of us by taking the financial bind off the entry level physician…

Of course none of this is all that hard to figure out. The major paradigm shift occurs if you stop thinking about medical care as the exercise of market place free enterprise in which doctors compete to make the most money, and instead view it as a public necessity.

Now, my intent is not to beat up the poor fellow; he is, after all, a liberal, and therefore possessed of a profoundly misguided understanding of human nature and motivation, and a strong inherent (and incoherent) proclivity for finding in government the solution to every imaginable problem. He is more to be pitied than censured. But his comment prompted me to begin thinking about some of the more common medical myths; those axiomatic convictions which seem to drive every discussion about healthcare policy, and show up in virtually every comment section on a health policy-related post. This particular gentleman’s comment mentions at least two such myths, and therefore provides lush green fodder for a rambling rumination on my part.

So here you have it: Some of my very favorite medical myths, time-tested truisms redolent with pertinence and pathos, but replete with error.
Continue reading “My Favorite Medical Myths” →

A recent article in the Wall Street Journal (subscription required) addressed an interesting new phenomenon in medical practice: the micro-practice. Physicians, weary of being forced to see large volumes of patients because of HMO requirements or financial pressures, coupled with high practice overhead and burgeoning paperwork, are striking out in a very different direction. Some physicians — especially in primary care — are opening small offices without office staff, seeing far fewer patients with much lower overhead, using technology to bridge the gap. As of now, these practices are quite rare, and represent a significant risk to the physician, generally resulting in substantial reduction in income. Nevertheless, it allows these physicians to practice a simpler form of medicine, spending far greater time with patients, having more free time for themselves, and returning to some of the priorities which brought them into medicine in the first place.

Now, I am skeptical that this particular model for medicine will gain wide acceptance. Nevertheless, I believe it represents a trend toward alternative practice models outside the standard framework of large-volume, federal and third-party insurance-driven enterprises. Another similar trend, also small in numbers, is the so-called boutique practice, where patients pay cash, often subscribing on an annual basis to a practice which then provides full services, including appointments on demand, greater access to the physician by phone, routine preventive care, longer appointment times, and other amenities.

I expect to see an increasing divergence in healthcare along similar lines. One analogy would be the box-store versus the boutique. The box store is large, has everything you might need at low prices, provides little in the way of services or amenities — think, Costco or Home Depot-healthcare. For those unwilling to partake of such Wal-Mart style health care, and who have the means to seek alternatives, there will be health care services provided with excellent service and benefits not available in the box store, such as plenty of time with the physician and short waits in the waiting room.

When talking about the social economics of providing health care, it is useful to think of it as a triangle: at one point is quality, and a second point, affordability, and a third point, access. There’s only one problem with this unlovely triangle: one can only have two of the three points at one time. Hence, if you have widespread access to health care which is very high quality, it will not be affordable; if you have broad access and affordability, quality — perhaps not necessarily medical quality, but service quality and access to more expensive or optional medical services — must be constrained. We are currently seeing in large measure the third side of the triangle: we are providing very high quality healthcare, which while expensive, is still relatively affordable — but the cost we are paying is limited access. There is simply no way to have all three points of the triangle.

There is a huge and growing access problem in American health care today, with tens of millions of Americans without insurance, and many more — especially those at or below the poverty level on Medicaid — who cannot find access to physicians because of their own limited financial resources, or the inability of physicians to accept reimbursement from federal programs which pay below the costs to provide the services. The pressure to resolve this dilemma at the political level is very large, and some form of universal coverage seems inevitable in the relatively near future.

In order to provide such broad-based coverage, however, the necessary limit on financial resources — whether federally financed, or paid for through employer-funded or personal-based insurance — must by nature result in a reduction in quality. This is not to say that substandard medicine will be practiced, although there is an increased risk of this; more importantly, there will be significant restrictions in access to optional, high cost technology, and an inevitable decline in service. Universal health care coverage, while critically important, will invariably lead to long waits for an appointment, very little time with the physician, seeing a different doctor at each visit, and having to wade through many levels of support staff to communicate with your doctor. This is already becoming far too common even under our current system due to intense cost-cutting pressures.

While such a universal coverage arrangement may prove very functional from the standpoint of providing basic care for large numbers of people, it will not prove satisfactory to many Americans who have become accustomed to a far more personal and consumer-driven model of health care delivery. There will, therefore, be strong financial incentives to provide alternatives to box-store medicine — and in fact, we are already beginning to see this.

The best contemporary examples of this alternative system of boutique medical care can be seen today in plastic surgery clinics, LASIK eye centers, and the growing trend toward high-end specialty hospitals catering only to orthopedics or other subspecialty care. While social engineers tend to decry such two-tiered healthcare systems, in fact, these alternatives respond far better to true market forces then does the lumbering dinosaur of federally-funded or third-party insurance-controlled health care. Plastic surgery clinics compete on price, service, and quality for a facelift, tummy-tucks, or a breast augmentation; high-end clinics charging more must be a higher standard of quality as well as provide extraordinary service. Consider the dramatic decrease in cost for elective corrective eye surgery with LASIK: prices have dropped dramatically over the past few years as high-volume LASIK clinics compete for patients. Hospitals, faced with a drain of better-paying patients toward specialty hospitals which provide a higher quality of service and a more satisfying patient experience must now re-examine their own quality issues, and are pressured to provide nicer facilities, better food, more nurses per patient, and other service-oriented improvements.

Beware of those — especially of the political persuasion — who promise unlimited, high-quality health care which is affordable. It does not, and cannot exist. We clearly need to address coverage for those in need of health care who cannot currently afford it, for health care, while not a right, is most certainly a very large part of our quality of life and well-being. The boutique model of health care service will not address this problem, in spite of the pipe dreams of libertarians who believe that free market solutions can solve all problems. This two-pronged approach may well provide a uniquely American solution to the worldwide dilemma of providing high-quality care, excellent service and access, and affordability Virtually all countries providing socialized, government-funded health care are struggling with the box-store problem. Poor service, long waits for care and “elective” surgery (like heart bypass and cancer surgery), and spiraling costs are the rule. But we in America have become accustomed to the highest quality of health care in the world, delivered quickly — for those who can afford it.

Perhaps it is time we abandon a utopian vision for health care, and settle on something, though imperfect, which may end up working quite well in the American healthcare system. It may well come from the ground up rather than from the top down.