Friday, July 16, 2010

Milstein- Kevin Debate: Obamacare in Perspective

Preface: I often interview national thought leaders from both sides of the political aisle. Recently I conducted a four part interview with Arnold Milstein, MD, and a West Coast physician leader who founded the Pacific Business Group on Health, the Leapfrog Group, and who is now a professor of Medicine at Stanford. There he will lead an innovation center bringing together the best minds from the Stanford Medical School, Engineering, and Management Schools. In general, Milstein is a proponent of consumer and business empowerment, top-down management of physicians through government regulation, management constraints, and creative new business models focusing on primary care physicians coordinating care.

As my four-part interview rolled out, Kevin, an anonymous blogger weighed in with a series of comments questioning Dr. Milstein’s wisdom and conclusions on how to restructure the system. My guess is that Kevin is an internist from California.
It is important to present both sides of the health reform argument. The latest national polls indicate these margins of opposition against Obama care: CBS 49/36, Public Survey 53/40, and Pew 47/35. Further, 88% of Americans are satisfied with their existing coverage, and only 6% feel health care is the number one major problem facing the U.S. It is the Jeffersonian belief that the people, not the political aristocracy, should rule
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"Since when has central planning improved any system? Farms in Russia or China? As you stated, it is only the hubris of the planners that makes them think with enough rules and regulation they can somehow control things. I have not come to this conclusion without considerable thought but MEDICINE IS DIFFERENT!! It's different than banking and other forms of business in so many ways. It is personal, local, intimate. Just wait, once a critical mass of physicians withdraw from Medicare it will quickly become a tsunami and physicians will start fleeing en masse to free themselves from the intrusive regulation and constant second guessing. I wish they would implement the mandated SGR cuts so I would have a good excuse to do that right now. I think the AMA should take the same stand. They got rolled on HCR so they should stop being the mouse in the government's game of cat and mouse. Let them try to run their system when all the doctors have opted out."
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"I doubt that oversea surgery will ever amount to anything other than a small niche for middle class patients who want more cosmetic surgery than they can afford in the US. However, if you were to try to convince Grandma to travel to Korea for a hip replacement or Junior for a valve replacement, it will only be possible if you offer them a substantial financial reward (or penalty) - there's that patient/consumer accountability again.

As for the A-ICU, I think that is what most patients got from their primary care doctors before MEDPAC/RUC started to systematically destroy it by increasing payments for specialists at the expense of cognitive services. Every internist had an RN and a panel of patients about half the current panel size. Now, the specialists have even better trained NPs and the primary care docs have MAs. Rather than A-ICU calls it E-PC (Enhanced Primary Care) and you have the same thing. Let me take care of your sickest 250 or 300 patients for 60% of what the average dermatologist or radiologist makes and I would easily save you hundreds of thousands of dollars in avoided hospitalization costs. The only model which allows this now is retainer medicine which ironically voids most private insurance contracts and of course is not paid by insurance or Medicare. That is what I always wanted to do. But current RBRVS payment for cognitive services pays twice as much per hour for low-level visits compared to more complex visits. So 60-75% of my practice is healthy people with low-acuity problems who subsidize the time I spend on the sicker Medicare patients. And it's not just me; the Mayo Clinic has said the exact same thing. The fact that the Stanford Professor hasn't figured this out yet is disturbing to me."

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I doubt that oversea surgery will ever amount to anything other than a small niche for middle class patients who want more cosmetic surgery than they can afford in the US. However, if you were to try to convince Grandma to travel to Korea for a hip replacement or Junior for a valve replacement, it will only be possible if you offer them a substantial financial reward (or penalty) - there's that patient/consumer accountability again.

As for the A-ICU, I think that is what most patients got from their primary care doctors before MEDPAC/RUC started to systematically destroy it by increasing payments for specialists at the expense of cognitive services. Every internist had an RN and a panel of patients about half the current panel size. Now, the specialists have even better trained NPs and the primary care docs have MAs. Rather than A-ICU calls it E-PC (Enhanced Primary Care) and you have the same thing. Let me take care of your sickest 250 or 300 patients for 60% of what the average dermatologist or radiologist makes and I would easily save you hundreds of thousands of dollars in avoided hospitalization costs.

The only model which allows this now is retainer medicine which ironically voids most private insurance contracts and of course is not paid by insurance or Medicare. That is what I always wanted to do. But current RBRVS payment for cognitive services pays twice as much per hour for low-level visits compared to more complex visits. So 60-75% of my practice is healthy people with low-acuity problems who subsidize the time I spend on the sicker Medicare patients. And it's not just me; the Mayo Clinic has said the exact same thing. The fact that the Stanford Professor hasn't figured this out yet is disturbing to me.
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Wider bundles that encompass longer time periods than a single patient encounter will shift accountability for quality and total costs more squarely onto the shoulders of doctors and hospitals."

There we go! Shift accountability. How about making the consumers/patients accountable? This has already been tried and failed. Pay doctors fairly and hold them accountable for quality for the pay they receive. I want to deliver quality health care services. But hold me accountable for costs? No way! Not unless I get to be paternalistic when the daughter of an 80 year old with advanced dementia, bedridden insists on "everything" for her Mom including ICU, ventilator and CPR despite numerous conversations about appropriate end of life care. (I guess I should also mention that the patient is an immigrant on Medicare/Medicaid who never worked a day in the United States or paid a single cent in taxes yet has access to all the expensive, unnecessary treatment her daughter can demand).

So the government gives them this entitlement to "everything" and I'm supposed to be the bad guy and say no or take a pay cut? Wow, that's real innovative! I guess we need a Stanford Professor to tell us this time it's different and the genius flowing out of his ivory tower will change human nature.

Perhaps the good Professor should seek the counsel of one of his Stanford colleagues who actually treats patients, Abraham Verghese, MD.

Writing on The Atlantic.com he said:

"What helped create our present mess is a payment system that rewards procedures and expensive diagnostic testing, but does not reward primary care; it has necessarily resulted in a profusion of people and places who do things that are well reimbursed and a dearth of physicians doing primary care. We don't need comparative effectiveness research as much as we need a retooling of the payment system and some caps on spending. Let's pay for what works right now, and stop paying for what's not needed."

Given that he helped create this mess with his MEDPAC activity, I have a feeling he will continue to pursue his failed cost shifting theories.
While I suspect that such research is necessary and may be useful, if the good Professor is going to try to develop a model of care where care is "free" for the patient (consumer) and cost containment is the responsibility of the doctor, insurer, government or some other agency or organization it will fail. Ironically, the single most important policy that has driven patients to cost effective generic drugs, the Medicare Part D "donut hole" was repealed in the HCR bill. Without the donut hole, No one is going to ask to change from expensive Lipitor to generic simvastatin. I believe this is a cynical political "poison pill" added to the bill to prevent wholesale repeal of the bill for fear of taking something away from the AARP set.

The models to control costs and ensure quality are already available, high deductible HSA-linked insurance. I have already seen this model resulting in significant decrease in utilization where I work, the East Bay. The decrease has affected specialists so much they are getting more and bolder with unnecessary testing on Medicare patients (no significant cost to the patient, no prior auth required). Of course it's much more fun to give away care for free and then blame the doctors for over-utilization.

As a member of the MEDPAC, which has systematically destroyed primary care in this country (the midlevel’s haven't stepped up and the physicians are dwindling) I suspect the good Professor's research will result in a great big waste of time and money. Patients get treated by doctors who work in offices and hospitals who expect a decent salary for a 60 hour work week - not by Stanford MEDPAC paper pushing policy researchers. I predict that in 5 years or less most doctors will have abandoned Medicare and private insurance for cash pay and offer enhanced service, more time and higher quality and satisfaction. The PBGH should have figured this out many years ago.

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