Random Thoughts from a Restless Mind

I have been pretty generous in sharing my thoughts about some of the ills of our American Healthcare system, especially with regard to the barriers erected between physicians and patients. I find the various proposals now before our legislative bodies in Washington to be rather curious, even offensive. Since when does the United States of America adopt wholesale an economic solution from another country? Especially another country that is in some way otherwise riding the considerable coattails of the U.S. economy?

The “baby with the bathwater” approach in the halls of our Capitol and the editorial offices of our leading media outlets (WSJ excepted) is about as wrong-headed as you can get.  What we need is an AMERICAN solution to the challenges that we presently face with the economics of healthcare in the U.S., using our present system as the foundation.

Not surprisingly, I have some thoughts!

1) Malpractice tort reform. See my thoughts in “Tort Reform = Healthcare Reform”. Effective reform will dramatically reduce the scourge of defensive medicine with its attendant costs and risks to patients. Defensive medicine represents 15-25% of all medical costs in the U.S. That’s 15-25% of $2 Trillion. Do the math.

2) Tax Reform #1: Remove the tax deduction for employer-offered health insurance. Provide a 100% TAX CREDIT to the lowest 60% of wage earners for the purchase of health insurance. Provide a progressive TAX DEDUCTION for the upper 40% of wage earners.

Tax Reform #2: Remove the tax deduction for advertising as a business expense for Hospitals. If we are concerned about unnecessary increased utilization of medical resources why are we allowing advertising by hospitals? For that matter, remove the tax-exempt status of any hospital or  provider that advertises. How is it appropriate to allow a hospital system to advertise to increase revenue, deduct that advertising as an expense, and still be not-for-profit? If it looks like a business, acts like a business, and sounds like a business, tax it like a business.

3) Insurance Reform #1: Reverse all of the for-profit conversions of previously not-for-profit health insurance companies. Who was the genius who thought THIS was a good idea? I don’t remember insurance premium increase that were quite so massive when all of the Blue Cross/Blue Shield plans were not-for-profit, do you? And while there were $Million execs in the non-profits I don’t recall any $10, $20, or $100 Million execs. Removing the need to answer to the stock market will create companies that will compete quite nicely with the for-profit companies without the horror of a government run system. Let the equivalent of NGO’s compete with the United Healthcares of the world.

Insurance Reform #2: Remove state-level coverage mandates and create a minimum federal set of mandates for comprehensive insurance policies. A REAL minimum. REAL medically necessary items. No Viagra or artificial  insemination coverage. Allow cross-state competition for the business. Real competition always drives prices lower.

Insurance Reform #3: Mandate high-deductible catastrophic health insurance for all. Real insurance, the kind that protects against a life-altering financial death sentence, not the pre-paid service plans that we now call health insurance. See Tax Reform #1 to see how it can be covered.

Insurance Reform #4: Allow insurance companies (Medicare and Medicaid included) to discriminate IN FAVOR OF people who make healthy lifestyle choices (eg. no nicotine, no DUI, etc.). We are all so afraid of the stick that we refuse to allow any use of the Carrot.

4) Freedom of Speech/Restraint of Trade Reform #1: Abolish, once again, direct-to-consumer pharmaceutical advertising. There was a quantum leap in the utilization of all sorts of medications immediately following the 1997 rulings that allowed DTC pharmaceutical marketing. If it is so obvious that our ever-increasing levels of spending on medical care is a threat to the very existence of our fair Union, then DTC drug marketing is a version of yelling “FIRE” in a crowded theater.

Freedom of Speech/Restraint of Trade Reform #2: Begin a return to the professionalism of yesterday by prohibiting all forms of advertising by, or for, physicians. The AMA gets a lot of criticism, most of it well-deserved in my opinion, but the court and FTC rulings that prohibited the AMA from censoring physicians who advertised was a seminal event in the de-professionalism of doctoring and medicine. Doctors and other medical advertising was, is, and always will be wrong. While we’re at it, do the same thing for lawyers and the practice of law.

5) Public Health. Finally, and most importantly, go to the true root of whatever “Crisis” we may have here in the United States, be it a “Healthcare Crisis” or a “Healthcare Finance Crisis” or what have you. We as a people are not healthy; certainly not as healthy as we ought to be. We are not healthy because of some wrong-headed previous Public Health decisions (simple-carbohydrate based diets, abolition of school phys-ed programs, tort-fearing closures of playgrounds, etc.). We are not healthy because our ability to treat the diseases that result  from poor lifestyle choices (cigarette smoking, alcohol abuse, preventable accidents, etc.) is SO GOOD that we are able to keep more and  more unhealthy people alive longer and longer, paying ever more to do so along the way.

This is where true leadership can make a difference. Remember JFK and the President’s Council on Fitness? I do. 8 pull-ups in the fifth grade for me. Sweden identified saturated fats from whole-milk products as a significant cause of heart diesease in the 70’s; a full court Public Health press for low-fat dairy brought about a dramatic decrease in cardiac deaths in the 80’s. Polio, measles, smallpox and whooping cough were once the leading killers of children in the U.S. but are now historical footnotes due to Public Health initiatives.

We lead the world in per capita alcohol related accidents and deaths, losing young lives by the thousands each year. We have ever more increasing numbers of truly obese citizens who go on to suffer the diseases caused by that obesity, and we pay ever more for their diabetes, hypertension, strokes and heart attacks. These lifestyle choices are root causes for our increased expenditures on Healthcare, much more so than all of the targets of Beltway demagoguery like insurance company expense ratios and pharmaceutical company profit margins. A solution to this issue, more than all of numbers 1 through 4 combined or any other proposal yet floated, is the true crux of the solution to any “Crisis” we may be facing. Everything else is only there to buy time. Time to get healthy.

There are no votes to be had in making Americans healthier. Nothing but hard work on every side of the equation. Who will stand up and do the hard work? Who will lead?

Who will have the guts to not only say that the Emperor is naked,  but also drunk and fat and puffing away our economy.

In any discussion or debate about a “Big Idea” the quality of the discourse depends in part on the accuracy and specificity of the definition of terms, as well as the amount of agreement among the participants as to the actual question or idea that is under consideration. When the discussion is proceeding with the goal of establishing a solution to a “Big Problem” or crisis, it is also useful to have performed a root cause analysis of the crisis so that one can assess whether the “Grand Solution”  is targeted at the true problem or simply aimed at a symptom of that problem (hey…I’m a doctor…I can’t help myself with the medical analogies). In short, in order to avoid the all too common trap of “talking past one another”, participants in this type of discussion must agree on premise and definition before embarking on the journey.

Unless, of course, the participants are politicians, government bureaucrats, or other creatures who feed with them and upon their offerings.

We are being bombarded with articles, speeches, broadcasts, and Tweets about the “Health Care Crisis” in America. In my reading there seems to be at least a dozen separate discussions occurring under this heading, mostly due to the fact that the above two rules about premises and definitions are being ignored, either inadvertently or willfully. So why don’t I offer up a couple of definitions that will allow us to explore the root cause of this so-called “Health Care Crisis”? Who knows? Perhaps a solution might arise.

Loosely defined terms allow a type of linguistic abuse in “Big Idea” discussions; this abuse usually involves some sort of secondary gain (money, power, legacy). The more loose the definitions the more abuse made possible. What is meant by “Health Care” and what should the definition really be? At present “Health Care” when combined with the term “Crisis”,  means the cost of providing health care. “Health Care” is properly defined as the provision of medical care, cognitive, diagnostic, and procedural, that actively prevents or cures disease.  I think anyone who has been paying attention would agree that we might very well have a “Health Care COST Crisis” in America right now. It’s really expensive to provide  health care to  everyone who needs it in America.

Do we have a “Health Care Crisis” in America? Are our hospitals, our doctors and our nurses providing inadequate or bad care? Pundits, politicians, and plain old people on the street point to the fact that the United States does NOT have the highest life expectancy among developed countries and say that the answer must be “yes”. They point out the regional discrepancies in treatment protocols and health care expenditures and say that this is proof that healthcare providers are not providing the best care possible. I would argue just the opposite. The actual “Health Care” that is provided in the United States is superior to that provided anywhere else in the world. I will show in a minute that this is actually part of the “Cost” problem.

These same people  then point to the fact that, at any one time, some 47 million Americans are without “Health Coverage”, what we call health insurance, and that this lack of financial coverage preventing them from gaining access to health care is causing  preventable deaths. These preventable deaths explain the lower life expectancy of Americans in comparison with, say, Swedes. It turns out that this, too, is a canard. A red herring. Americans without “Health Care Coverage” do in fact have access to health care, and access to “Health Care Coverage” or health insurance does not appear to affect life expectancy.

No matter how you slice it this discussion or debate comes right down to the most basic definition, which then establishes the most basic root cause of the problem. We do, indeed, have a “Health Care Cost Crisis” right now in America, but it all stems from the undeniable fact that we have a “HEALTH CRISIS”, and it’s getting worse. Our people are more and more unhealthy and our phenomenal ability to care for their diseases is allowing them to live unhealthy lives longer. This  allows us to spend more money on keeping them alive.

The Eight Americas Study published in the People’s Library of Science examined life expectancy in America and the factors that influence it. (http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.0030260) The population of the United States was divided into 8 cohorts based on age, race, county of residence, race-adjusted income, and cumulative homicide rate. Cause of death was recorded and variables such as whether or not the individual had health insurance were tabulated. The difference between the longest lived cohort  and the shortest-lived is 35 years! The results are as surprising as they are counter-intuitive. While income is a weak factor underlying this difference neither “Health Care Coverage” nor access to health care is a factor.

“The eight Americas analysis indicates that ten million Americans with the best health have achieved one of the highest levels of life expectancy on record, 3 yrs. better than Japan for females and 4 yrs. better than Iceland for males. At the same time, tens of millions of Americans are experiencing levels of health that are more typical of middle-income or low-income developing countries… The health disparities among the eight Americas cannot be explained by single causes of death such as homicide or HIV. Nor are the largest sources of disparity in children and the elderly. The mortality disparities are most concentrated in young and middle-aged males and females, AND ARE A RESULT OF A NUMBER OF CHRONIC DISEASES AND INJURIES WITH WELL-ESTABLISHED RISK FACTORS.” (emphasis added)

Yes, we have a Health Crisis in the United States. It is a crisis born of preventable injuries and disease (vehicular accidents, alcohol-related homicide, diabetes, heart disease) with actionable underlying causes and risk factors (alcohol abuse, tobacco use, obesity). We have aided and abetted this Health Crisis because we do NOT have a Health Care Crisis; it is precisely our ability to treat many of these diseases that keeps many unhealthy Americans alive. We bear the financial consequences of this Health Crisis as a nation.

The solution to this problem becomes rather clear once we have the appropriate definition of the problem and once we identify the underlying cause of the problem. It appears that we cannot afford to pay for all of the health care that will be necessary to keep Americans alive if we continue to go on with things as they are; we have a “Health Care Cost” problem. The root cause of our financial problem is that a large percentage of Americans are not healthy; we have a “Health Crisis” and this is largely due to problems that can be prevented. No amount of “Health Care Reform” that involves changes in how we pay or who ultimately pays for healthcare will solve our “Health Care Cost Crisis” unless we solve the underlying problem of unhealthy Americans. The solution to this problem is a PUBLIC HEALTH  strategy that will improve the health of Americans, and it is here that funding and reform should occur.

Now, when this inevitably  fails to occur because there is no near term secondary gain to be had  we can have a discussion about the “Leadership Crisis” in America.

I’m a big Game Theory guy. I think you can explain the actions of the participants in any structured activity or enterprise by looking at the rules of the game. When you look backwards in time you discover that the “players” almost always made choices that represented rational self-interest. This is especially true in games played using Zero Sum rules: someone wins only if someone else loses. How the game is set up, what the rules are in the beginning, determines who “plays to win” and who plays “not to lose”. Unfortunately, it is impossible to forecast all of the outcomes of a Zero Sum game before play starts because it is impossible to forecast who and why each player plays the way they do.

The Medical Malpractice Tort system in the United States is a Zero Sum game.

There is a significant amount of medical care provided in the U.S. that does not have any significant positive effect on medical outcomes. This care has been broadly termed “Unnecessary Care” and it is rightly cited as a major contributor to the systemic healthcare economic crisis now facing the U.S. Unnecessary Care is also a part of the systemic issue of poor health in the U.S. Every time a patient receives care that does not contribute to better health she is exposed to potential complications of that care, and every dollar spent on Unnecessary Care is a dollar that won’t be spent on care that delivers better health.

“Defensive Medicine” is a form of Unnecessary Care. The best working definition that I know for Defensive Medicine is medical care of any sort that is ordered or performed solely to prevent either the filing or the loss of a medical malpractice lawsuit. Defensive Medicine is typically extra care layered onto reasonable, effective ,necessary medical care to provide cover in the event that a bad or unexpected outcome occurs. Various extimates exist regarding the extent of Defensive Medicine. Anywhere from 15-25% of all medical expenses are said to be some form of Defensive Medicine. That’s 15-25% of a $2 Trillion part of the U.S. economy. $300-500 Billion. As I will show below, most of this money does NOT show up as revenue for the doctor who is playing defense.

How can this be? Why would doctors do this? Well, let’s return to Game Theory for a moment. The Medical Malpractice Tort system in the United States is a Zero-Sum Game. Someone has to lose in order for someone to win. It is a punitive system, one meant to punish the doctor or hospital that committed malpractice. The financial and psychological costs of being sued are so severe for a doctor that nothing is too much to do to prevent being named in a lawsuit (simply receiving a letter stating that a suit is being considered typically results in an increase in malpractice insurance premiums). Doctors therefore play this particular game “not to lose.”

Patients, on the other hand, seemingly have very little to lose under the rules of the American medical tort and medical insurance systems. They are largely insulated from the cost of all of their care by what we call “medical insurance” (which is actually a pre-paid service contract), and a contingency fee system that allows them to bring suit without any personal financial cost, win or lose.

So how does this work? Let’s use an example of a very common medical complaint, and an all too common story of the medical care associated with that complaint. Let’s look at a patient with a really common type of headache, the migraine headache. Every doctor takes care of patients who complain of headaches. Some, like me, more than others, at least in terms of actually working to diagnose and treat the headache (not a lot of orthopedic surgeons working too hard on headaches, to pick on my “bony Brethren” again).

A patient, well known to her primary care doctor, comes into the office with a history that is bang-on, straight out out of the textbook for a Classic Migraine Headache (there really is just such a diagnosis). It’s a really severe headache and she’s really suffering. she’s scared, because it hurts so much. Her doctor, a “middle of the Bell Curve” American PCP, which is to say in the top 5% of PCP’s world-wide, makes the diagnosis. Classic Migraine. Given the history the likelihood that this is the correct diagnosis is in excess of 99%. Less than one our to every 100 patients who present with this history will have anything other than a Classic Migraine. Fee for the visit: $75.

But it’s a really bad headache, and headache is one of those things that can turn out really badly if the diagnosis is missed. She had some visual symptoms before the headache, some wavy lines in her vision–Classic Migraines have a prodrome or a warning sign. It still feels like it’s a Classic Migraine, but just in case better send her to an ophthalmologist (this is how eye doctors get to be headache doctors). She really has a bad headache so a CT scan can’t hurt, and you never know, so let’s have her see a neurologist, too; they’re REALLY the headache experts.

The CT scan is normal (fee: $500; chances of correct diagnosis now 99.9%). The ophthalmologist finds a normal exam and agrees with the diagnosis (fee $125; 99.91%). The neurologist agrees with the diagnosis, too (fee $250; 99.991%) but she spends her entire professional life treating nothing but the rarest and most complex types of headaches. She can name the next 29 diagnoses on the list of the top 30, as well as numbers 71-100, off the top of her head. She suggests an MRI, “just to be on the safe side; just to be sure.” The MRI will cost $750 and a negative test will increase the accuracy of the diagnosis by another factor of 10 to 99.9991% (anyone else notice how little the ophthalmologist added?!).

But…but…but…this is MADNESS! Why would they DO this? Why do the doctors keep ordering tests? And for Heaven’s sake, why does the patient keep going for these consultations and these tests? Well, let’s return to the rules of this Zero-Sum Game, shall we? The patient is insulated from the cost of all of this medical care by the nature of our “health insurance” system in the U.S. and therefore has no reason to question the suggestions of ANY of her doctors. The doctors, fearing a lawsuit if they miss even the rarest of problems, have no reason NOT to order more care. There simply is no amount of care that is enough when you are trying “not to lose” if a little more care might prevent a lawsuit. One should note that the additional care, the Defensive Medicine, the Unnecessary Care that is ordered by each physician, does not result in income to that physician; contrary to common belief, Defensive Medicine does not produce income to the doctor practicing defensively.

How do we begin to change the way we pay for healthcare in the United States? I say we start by changing at least some of the rules. Start by changing the Medical Malpractice Tort “Game” from a Zero Sum game to a NON-Zero Sum Game and gradually remove the perceived need for doctors to practice Defensive Medicine. This will also allow for more complete reporting of medical errors and misadventures, which will in turn allow for a more complete “root cause analysis” of these problems leading to better medical care and better health.

Let doctors stop playing “not to lose”. Medical Malpractice Tort Reform EQUALS healthcare reform.

As the cost of providing health care in the U.S. has risen we have been bombarded with new terms and new ideas as “experts” attempt to solve our “Health Care Crisis”. In truth doctors, nurses, and other health care providers in the United States are dramatically better at treating and curing diseases than their counterparts anywhere else in the world. We really don’t have a “Health Care Crisis” in the U.S. What we have is a “Health Crisis” (our people are not as healthy as they could or should be) and a “Health Care Cost Crisis” (treating all of this poor  health is very expensive).

Major challenges exist when we begin to tackle this “Health Care Cost Crisis” (I think I’ll just call it the Cost Crisis hereafter). How do we reign in the cost of providing this international “best in class” medical care? How do we do so without creating either rationing of disease care, or the appearance of rationing? Regardless of the direction that our health care system may take, how do we prevent the politicization of a process that should be driven by those who are in the trenches providing that health care?

There is another term that is now ubiquitous in my world as a physician, one that is cropping up more and more in the non-medical media: Outcome Based Medicine (OBM). OBM is a rather loosely defined term which essentially boils down to medical care that has been proven to work. Pretty simple, huh? Unfortunately, OBM is getting rather fuzzy around the edges as it is used (or ignored as we will see) to achieve economic or political goals in addition to achieving the best possible medical outcomes. You know, stuff like a longer, better, healthier life.

The very first prospective (forward, not backward, looking), randomized (some folks were treated and some were in a control, or un-treated group), double-blind (neither the doctors treating nor the patients being treated knew which group was which) was actually an ophthalmology study. The Diabetic Retinopathy Study or DRS was published in the late 1970’s. It showed that using laser treatment to the retina of those patients with severe diabetic retinopathy saved more vision than doing nothing. Outcome-Based Medicine proven in a clinical trial.

Subsequent medical trials have proven the beneficial effect of innumerable medicines, surgeries, and treatments.  Other trials have been launched to provide a head-to-head comparison of competing treatments. Right now there is a trial in ophthalmology evaluating the effectiveness of two medicines, made by the same company, in the treatment of the most devastating type of macular degeneration. Macular degeneration (AMD) is a potentially blinding disease of the elderly which will become more and more common as our population ages. One very expensive medicine has been approved for the treatment of AMD and the other, inexpensive medicine has been approved for other uses and adapted by retinal specialists because it works. The hope underlying this study is that the doctors treating AMD will be allowed to generate a conclusion about which medicine works on which people in what circumstances in order to provide guidance on the most cost-effective EFFECTIVE treatment of AMD without the interference of politicians, bureaucrats, or accountants for the company that makes the medicines.

Which brings us to Pre-Admission Testing (PAT) and OBM, and an example of why I am fearful of the abuses that may befall this process. PAT is a process that some patients are asked to undergo prior to having anesthesia for surgery. The one and only reason to undergo PAT is to determine if there is any medical or health condition that will make the anesthesia more dangerous, to help prepare the anesthesiologist in the quest to prevent anesthesia complications. There is NO OTHER REASON to do PAT.

I am an ophthalmologist, an eye surgeon. I operate on people to save, restore, or enhance their vision. Many of these people receive anesthesia as part of their OR experience. After more than 10 years in which my OR patients were simply screened with a phone call by anesthesia I was recently informed that all of my patients receiving any anesthesia in the OR would now require PAT. Why? Essentially because the hospital said so. “That’s how the in-patient division does it so that’s how the out-patient has to.” The Joint Commission said that Medicare wants it.” ” Why do you care? It’s no more work for you.” And other such non-answers.

Well…I DO care. PAT is expensive, even though no one ends up paying for the physical exam part. EKG’s and lab work cost money. Patients and their families must take off work, go to a hospital or clinic, endure needles and disrobing. All for something that doesn’t matter. All for something that doesn’t contribute to better medical or health outcomes. Because you see, there WAS a study that looked at that EXACT question. Does routine PAT have any effect on the outcome of cataract surgery done on an out-patient basis? (Schein, et al. NEJM January 2000, Vol. 342, No. 3, 168-175).Turns out the answer is “NO”.

18,000 patients undergoing cataract surgery were split into two groups, one undergoing PAT and the other receiving no PAT. There was no difference between the two groups in intra-operative or post-operative events. There were no differences between the groups in complications. The firmly stated conclusion: Routine medical testing before cataract surgery does not measurably increase the safety of the surgery. PAT, in 2000 costing roughly $200-250 Million /year, before cataract surgery is a WASTE OF MONEY.

OBM at its very best. Ignored. Ignored by the hospitals who get paid to do the tests (although free-standing surgery centers typically do not do PAT). Ignored by Medicare, because we all know there’s lots of free cash floating around in the Medicare till just looking for a place to be spent. Ignored by the bureaucratic minions who skitter and twitter about the OR with their checklists and their rules and their regs. Who pays? Well, every patient  or family member who has to miss work or make a co-pay, and of course you and me through our taxes.

In the end Outcome-Based Medicine is only as good as the people who are reading and reacting to the results of the studies. When good research (my goodness…18,000 patients! The New England Journal of Medicine!) is ignored in a situation where there is little political capital on the line, what hope is there for us when someone sees votes (nationalized health care?) or real money (cholesterol and heart disease?) on the line?

What do you think THAT outcome will be?