Tuesday, May 24, 2016


Observations of  and on  Richard “Buz”  Cooper
In January of this year,  Richard “Buz” Cooper, MD,  a renowned oncologist and health care analyst, died of pancreatic cancer.   Cooper was known for this straight talk.   He believed poverty and delayed treatment for the poor was a major cause for high health costs, not  physicians overuse of care engendered driven by fee-for-service.  
I had the privilege of knowing  Doctor Cooper and wrote the following blogs  on his work.   I have edited them for brevity but sought to retain the essence of the man.

Doctors Don't  Drive Up Costs: Poverty Does

I am a big fan  of Richard “Buz” Cooper, MD, Professor of Medicine and Senior Fellow in the Leonard Davis Institute of Health Economics at the University of Pennsylvania.  

He is a  fine, clear, and direct writer.

He firmly grasps what drives up health costs.  

Recently Dr. Cooper made a presentation before an audience of physician workforce consultants at Merritt Hawkins,  and I could not resist reprinting this piece by Phillip Miller, VP of communications at Merritt Hawkins, the national physician recruiting firm.

Cooper  turns the conventional wisdom of elite policy wonks on its head by saying, in essence, it isn't  “overdoctoring” that drives up costs; it’s sick poor patients who show up in the later stages of their illnesses in economically unstable parts  of the country – like the American South,  remote rural areas, and  inner urban cities.

For  Cooper,  poverty and economic instability is  a short, simple, and reasonable explanation for cost variations across the U.S.

Do Doctors Really Drive Up Health Care Costs?

By Phillip Miller

The “experts” are wrong. They are simply flat wrong.
That’s the only conclusion I believe a reasonable person can draw after reviewing the data and analysis compiled by Richard “Buz” Cooper, M.D., an oncologist and an internationally noted authority on physician supply and health care utilization studies.

Dr. Cooper recently presented his case before an audience of physician staffing consultants at Merritt Hawkins.
His topic was current physician workforce trends, including why there are regional variations in both physician supply and in health care costs.

The conventional wisdom is that regional variations in cost are driven by variations in how physicians practice. Health care is provided relatively inexpensively in the upper Midwest, the argument goes, because physicians practice efficiently and keep utilization down.

 In other regions, by contrast, physicians “over-doctor,” driving up costs.

In the run-up to health reform it was repeatedly stated by policy makers and analysts that $700 billion, 30% of all health care spending,  could be saved if physicians would only practice like they do in the upper Midwest and other low cost regions.

Control how physicians practice and you can control healthcare spending, is the underlying basis of much of today’s health care policy.

But as Dr. Cooper clearly shows statistically, doctors don’t practice more efficiently in the Midwest. They practice more efficiently in economically stable parts of the Midwest. They also practice efficiently in economically stable parts of Manhattan, Los Angeles, and just about everywhere else.

Dr. Cooper observes health care costs are 82% of the national average in prosperous parts of New York City. Literally blocks away in less privileged areas, health care costs are three times the national average per capita, even though the hospitals and medical staffs serving patients from both areas are the same.

Places where health care costs are thought to be high, such as much of the Northeast, are actually comparable to the Midwest and other low costs areas when you compare apples to apples, i.e., one economically stable population to another.

Though Dr. Cooper conceded  ample waste and inefficiency in the health care system exists, he argues  economic disparity, not physician practice patterns, drives health care utilization and therefore health care spending.

Poorer people are sicker and cost more to treat than do more economically stable people by a large margin. Therefore, the key to lowering health care costs is to reduce poverty and increase wealth. Standing over the shoulders of physicians telling them how to practice is not the answer.
This seems like a straightforward argument, but it is not widely accepted in health policy circles.  The problem of rising health care costs derived mostly from how physicians practice, or mostly a result of economics? Or is there another driving force?
The principle driver of variation of health costs is economic instability and poverty,  not physician “overdoctoring.”
Some physicians, hospital administrators, and legislators appear to have succumbed to a behavioral bias.

Jason Sutherland, Ph.D., Elliot Fisher, MD, and Jonathan Skinner, Ph.D., Dartmouth Institute for Health Policy and Clinical Practice, “Getting Past Denial – The High Cost of Health Care in the United States, “ New England Journal of Medicine, September 24, 2009

It took me a while to figure out what the Dartmouth authors meant by “Getting Past Denial.” They never say explicitly what they mean. In effect, the Dartmouth policy wonks are saying fee-for-service incentives move doctors to “do more” to maximize profits.

In another article in the same NEJM edition, Arnold Relman, MD, former editor of the New England Journal, says it more directly, “Most doctors are paid on a fee-for-service basis, which is a strong financial incentive for them to maximize the elective services they provide (“Doctors as the Key to Health Care Reform,” NEJM, September 24).
Opines Relman, what we must do to bring down costs and improve quality, is "pay group physicians a salary for providing patients with the best, most cost-effective care, within the limits of a publicly determined budget.

Richard “Buz” Cooper, MD, professor of medicine at the University of Pennsylvania and a senior fellow in the Leonard Davis Institute of Health Economics at Penn. Cooper has directly challenged the Dartmouth premise and Relman.   Cooper  disagrees.   He  doesn’t thin,  regional cost differences in the 30% range stem from overuse of “discretionary resources” by specialists and subspecialists in high spending regions, but are secondary to poverty and higher spending for delayed diagnosis and higher spending on sick patients.  

Cooper maintains levels of sickness, socioeconomic and cultural differences, and cost of doing business in different sections of the country must be taken into account and that Medicare spending is not representative of health care spending as a whole.

Cooper has issued three reports to this affect, one in association.

One, “Physicians and Their Practices Under Health Care Reform: A Report to the President and The Congress,” prepared on behalf of The Physicians’ Foundation, and distributed to members of Congress, the White House, and the media, on September 8, 2009.

Two, “Regional Variation and the Affluent-Poverty Nexus, Journal of the American Medical Association, September 9, 2009

Three, “Wrong Turn on Health Reform, “ Washington Post, September 11, 2009.

30% “Savings”

The differences between the Cooper and Dartmouth and Relman  positions are important.  Peter Orzag, Obama’s budget director, buys  the Dartmouth argument that erasing regional differences could reduce “waste” by 30%, and generate enough savings to cover the uninsured.

You may not be aware of the Cooper-Dartmouth debate because Dartmouth has chosen to cloak its differences with Cooper and followers through euphemistic language and by  not mentioning Cooper by name. This is an academic put-down.

A perfect example of the Dartmouth approach is in full display in a September 24 NEJM article “Getting Past Denial – The High Cost of Health Care in the United States. “

The Dartmouth authors never mention Cooper. Indeed, they never explicitly say what “Getting Past Denial,” means.  One can infer what they mean when they when they talk of overuse of “discretionary resources ” by doctors “who have succumbed to behavioral bias.” I would argue “behavioral bias” effects everyone, wonks as well as practitioners. As George Orwell famously said, “ no one is genuinely free of political bias.”

From their figures and tables, however, what Dartmouth means is clear. After admitting that health status and income may be minor Medicare factors, they move to their statistical "Quintile" argument.

In one figure, “Quintiles of Care Intensity,” a colorful bar graph shows that “regional factors” have 5 to 20 times more impact than health, income, and race on costs in annual per capita regional Medicare spending from the least to most intensive quintiles.

In a table, the Dartmouth triumvirate shows these differences as one moves from intensity quintiles 1 to 5: impatient days per beneficiary, 1.4 to 2.1 days, up 50%; physician visits per beneficiary, 10.7 to 14.5 days, up 35%; MRI use per 100 beneficiaries, 16.6 to 21.9; CT scans per 100 beneifciaries, 46.9 to 61.4, a 31% increase.

The Dartmouth authors conclude, “We should recognize that so much discretionary care is provided in the United States that we would easily expand coverage without increases in taxes or rationing care – as long as we couple coverage expansion and broadly implementing successful reforms in payment and delivery systems.”

Presumably these reforms entail progressing towards integrated salaried group practices operating on a capitated basis without fee-for-service incentives , through they never say so. That would be too direct and impolite. Instead readers are subjected to a high-level hatchet job questioning the integrity and motives of physicians in high-spending Medicare regions
I would like to bring to your attention three reports by Richard “Buz” Cooper, MD, professor of medicine and principal of the Leonard Davis Institute of Health Economics at the University of Pennsylvania.

One, “Physicians and Their Practices Under Health Care Reform: A Report to the President and The Congress,” prepared on behalf of The Physicians’ Foundation, and distributed to members of Congress, the White House, and the media, on September 8, 2009.

Two, “Regional Variation and the Affluent-Poverty Nexus, Journal of the American Medical Association, September 9, 2009.

Three, “Wrong Turn on Health Reform, “ Washington Post, September 11, 2009.

Opportune Time

These reports come at an opportune time in the wake of these events: President Obama’s speech before Congress on September 9; his campaign stops across the country to rally his followers, the first today in Minneapolis; the taxpayer march on Washington today of 100,000 people ; and 10,000 physicians assembling in D.C. the same day to protest Obama health care policies. These events follow the raucous town hall meetings of August.

The Physicians Foundation

I believe Dr. Cooper’s report before Congress. supported by The Physicians Foundation, a 501C3 non-profit organization representing 650,000 practicing physicians in state and local medical societies, lends perspective, context, and rationality to the otherwise emotional debate over health care.

Contents of Three Cooper Reports

Perhaps the objective way to present the contents of Dr. Cooper’s three reports is to use his words summing up their contents.

One, the “Cooper Report,“ to the President and Congress is a 53 page document. Here are Dr. Cooper’s words about its contents with a list of its other authors,

“Our report is intended to inform the discussions of health care reform about the deepening physician shortages, the needs of physicians' practices in a reformed health care system and the effects of poverty and other social determinants on health care utilization and outcomes. Its conclusions are that, without adequate numbers of physicians, the health care system cannot function; without adequate attention to the structure of physician practices, the system cannot function efficiently; and without adequate attention to the pervasive effects of poverty and other social determinants, it cannot function economically.”

“ We hope you will find this to be useful as the critical issues that it addresses are discussed in the months ahead.

Two, Dr. Cooper’s summary of his JAMA article

The affluence-poverty nexus offers a number of insights.

First, it reconfirms the complex interplay between individual and communal dynamics in determining health care utilization and outcomes.

Second, it demonstrates that when total expenditures rather than expenditures from Medicare or any single source are considered, regions with more health care inputs have better aggregate outcomes.

Third, it suggests that while health care reform has the potential to narrow regional differences in wealth and health care resources, a substantial degree of variation is likely to continue for many decades. Fourth, it provides evidence of the high costs borne by the health care system because of poverty and its associated social determinants."

“As the United States confronts difficult fiscal choices, there should be no illusion about the relationship among physician supply, health care spending, and outcomes. Nor should there be uncertainty about how poverty affects health care utilization. The reality is that more is more and that poverty leads to less, and the false assertion that "more is less" should not detract from efforts to ensure that the United States will have an adequate supply of physicians for the future.“

Three, excerpts from the September 11 Washington Post Op-Ed piece.

“President Obama pledged on Wednesday that ‘reducing the waste and inefficiency in Medicare and Medicaid would pay for most’ of his health-care plan. This echoes remarks from Peter Orszag, his director of the Office of Management and Budget, who has claimed that one-third of health-care spending, more than $700 billion, is wasted annually.”

“Those Orszag comments come straight from the Dartmouth Atlas, which announced that the United States could save 30 percent of its health-care expenditures if high-spending regions were more like low-spending ones. But this can't be how we'll pay for reform. The numbers are too good to be true.”

“Orszag has argued that if Medicare spending could be as low in Newark as it is at Mayo, the nation could save billions. But this theory doesn't hold up in practice.

Consider: One-fourth of the folks in Newark live in poverty, compared with less than 10 percent of those in Rochester. And national surveys show that poor people consume more health-care resources -- 50 to 75 percent more than average.

They are sicker and they stay sicker, despite the best efforts of physicians and hospitals. Mayo is a fine institution, but it isn't more cost-effective than other hospitals in its home region, nor are its operations in Jacksonville, Fla., and Phoenix more cost-efficient than other hospitals in those cities. So why would it be more cost-effective in Newark?”

“To really achieve health-care reform, and find a way to pay for it, the president will have to give up on the Dartmouth suggestion and grapple with some painful truths.

First, medical care is inherently variable in different regions of the country -- socio-demographic differences matter.

Second, more is more and less yields less -- the best care is the most comprehensive care, and it costs more. Finally, poverty is expensive -- the greatest "waste" is the necessary use of added resources when coping with patients who are poor. If we want a technologically advanced, socially equitable health-care system, we will have to organize our finances accordingly. There is no quick fix. That's what we should be talking about.

Reece Take

Four of the interrelated central themes in my book Obama, Doctors, and Health Reform are:

One, the next big political health care crisis will be lack of access to doctors. This will be aggravated by 78 million baby boomers entering Medicare in 2011 and a dramatic expansion caused by millions of uninsured citizens entering the market.

Two, the growing doctor shortage, expected to peak at 150,000 to 200, 000 in a decade;

Three, government policies that systematically pay doctors less each year, this year scheduled to be a 20% cut;

Four, doctors declining to accept new Medicare patients because Medicare fees will make it difficult to maintain and sustain practices.

Although incremental reform is essential and necessary, the health system is too complex to reform, re-engineer, and overhaul in one fell swoop. Medicare is not a good model on which to reform health care. For two reasons. It has no cost controls. It is not representative of the system as a whole'

Health Care Waste or Paying for the Sick Poor?,

“As he raced through the U.S. Capitol this fall, Dr. Richard “Buz” Cooper, a 73-year-old University of Pennsylvania medical school professor, didn't mince words. He denounced as “malarkey” a reigning premise of the health care debate -- that one-third of the nation's $2.5 trillion in annual health spending is unnecessary -- and said that the idea came from “a bunch of clowns.”

“The harsh language underscores Cooper's disdain for highly regarded work -- as close to a sacred cow as anything in health care -- developed over two decades by the Dartmouth Atlas of Health Care. The work by Dartmouth Medical School researchers shows huge geographic variations in the amount of care that hospitals and doctors provide, with spending in some areas running three times as much as in others. Dartmouth argues much of the high spending is due to extra procedures and tests that often don't help patients, but bring in more money for doctors and hospitals.”

“The argument has been embraced by President Barack Obama's administration and several lawmakers, who have repeatedly said that the nation could save as much as $700 billion a year -- if only doctors and hospitals in high-spending areas, such as Philadelphia, Los Angeles and Chicago, would end their profligate practices and adopt the thriftier ways of say, the Geisinger Health Systems, based in Danville, Pa. The House has inserted provisions in the health bill that could punish high-spending hospitals in Philadelphia and elsewhere, while rewarding low-spending facilities in places such as Albuquerque, N.M., Madison, Wis., or Portland, Ore.”

The Poverty Factor

“But Cooper and some allies say that would be a disaster and hurt efforts by doctors and hospitals to care for the poor. Cooper says the Dartmouth research doesn't take into account the high cost of helping the impoverished, who often spend more time in hospitals because they don't have people to care for them at home and often return to the hospital when they can't afford needed medications. “

“There is abundant evidence that poverty is strongly associated with poor health status, greater per capita spending, more hospital readmissions and poorer outcomes,” he wrote in an Oct. 24 post on his blog. “It is the single strongest factor in variations in health care and the single greatest contributor to 'excess' spending.”

How much of U.S. health spending is waste?

How much of this spending is poverty-based?

The Dartmouth people says unwarranted waste is 30% of health care.
Cooper says caring for the poor is something hospitals have to bear.

Dartmouth says eliminating excessive regional variation,
Will be the American health system’s economic salvation.

Professor Cooper of Penn says this is unadulterated malarkey,
Dartmouth studies are the work of a statistical sharkey.

But who is right and who is wrong,
You can argue that query all day long.

But when you have a sacred cow to gore,
It helps if you do it to protect the poor.

Richard “Buz” Cooper, MD, now Co-Chair of the Council of Physician and Nurse Shortages at the Leonard Davis Institute of Health Care Economics at the University of Pennsylvania, and formerly Dean of the Medical School at the University of Wisconsin at Milwaukee – gets it – in 2001 he and his colleagues in Wisconsin wrote groundbreaking Health Affairs article “Economic and Demographic Trends Signal an Impending Physician Shortage.”

In it, they pointed out experts misjudged such factors as America’s population explosion, economic growth with discretionary income pouring into health care, desire for access to specialist-oriented technologies, and created unprecedented demand were behind the physician supply deficit.
Cooper said it was simple: as the economy grows, the nation spends more money on health care.

Linda Aiken, PhD, professor of nursing at the University of Pennsylvania and Cooper’s co-chair at the Council of Physician and Nurse Shortage gets it – she says there is a double whammy because of a an accompanying shortage of nurses of an even greater magnitude than the doctor shortage.

Cooper and Aiken believe in the next 15 years, there may be a 150,000 to 200,000 shortfall in doctors, and an 800,000 nursing shortage.
Where Experts Go Awry
How could this be in a nation of policy and health manpower “experts?”

The answer, according to Cooper, is two-fold:

One, the experts simply underestimated the dramatic increase in the U.S. population, our proclivity to spend more on health care, our embrace of new technologies, and the capacity of people in a democracy to get what they want.

Two, the experts had flawed mindsets.

 Experts at the Council of Graduate Medical Education, who determine the numbers of medical students and resident doctors, and government policy wonks have long believed, wrongly, that we have too many doctors, with more doctors we spend too much money, excess health care spending is bad for the economy, we should organize and discipline physicians so we need fewer doctors, not more;

If people would only behave themselves, fewer doctors would be needed; and we make up doctors shortages by substituting physician extenders for doctors.

Instead it turns out, Americans want to see more doctors, not fewer, and health care is good for the economy – a clean industry, a major employer, often the biggest industry in town, and the only growth sector in the economy.

Policy wonks and federal policymakers don't get it. As result of their missed estimates and flawed mindsets, federal wizards neglected the health care human infrastructure by putting caps on the number of medical students and the number of residency slots.

The problem with expert wizardry is that no matter what your scenario – more efficient, higher quality care, and more federal money poured into care; or more health insurance with expanded care; or more preventive counseling, more information technologies, and more comprehensive, coordinated care, you need more doctors.

What Will Not Work

At this point, having existing doctors work harder will not work; nor will persuading patients they should not have access to what they need or cannot afford. Nor will turning over care to nurses, midwives, LPNs or orderlies. Nor will redirecting care so doctors will be paid only within a federal system, in other words, only reimbursing them if they see Medicare and Medicaid patients.

The Problem

Well, what about single payer or Medicare for all? Here is Cooper’s response to that solution.

The problem with Medicare for all is the Federal government runs Medicare. It will sink health care. It is too capricious; it is too politically driven, too bureaucratically onerous. Physicians hate Medicare. They like the reimbursement when it comes, but it carries too much regulation, so much inefficiency– caring for Medicare patients is a terribly inefficient process. The view of the Federal government is that if they are paying the bills, they should make a whole bunch of rules, well, that just doesn’t work.

They spend all their time looking for the rotten apple in the barrel. There are rotten doctors, everybody knows that. But good doctors are exposed to such scrutiny and such arbitrary action; they are scared to death to take care of Medicare patients. So Medicare for all, in my view, is the death of health care in America.

The Answer

The answer? Listen to the people. Lighten up on federal rules. Lift the caps on the number of residency programs and medical schools. Rebuild the nation’s physician and nurse infrastructure.

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