Patient-Centered and Doctor-Centered Care

These days it’s fashionable to say that if you give patients enough reliable information, they will become equal to doctors. What’s wrong, say these same people, is that doctors are overly authoratiative and have their own interests, not the patient’s interest, at heart.

In other words, what we need is more “patient-centered care.”To a certain extent, I agree with this. I agree patients should be given as much information as possible. I agree their options should be spelled out. I agree patients, informed through Internet search engines, are a good thing. I agree patients spending their own money and knowing what things costs, would save the system a lot of money.

The Institute of Medicine spelled out the essential ten elements of patient-centered care in 2001 in Crossing The Quality Chasm. These elements are,

1. Care is based on continuous healing relationships. This is the basic idea behind the medical home with primary care physicians offering continuous, comprehensive, coordinated care.

2. Care is customized according to patient needs and values. What the patient wants, not what the doctor wants, should reign supreme. Sounds good, but not always possible to fulfill.

3. The patient is the source of control, meaning the patient not the doctor should control care. This strikes me as a little naïve. Most patients want doctors to tell them the right thing to do, as I did recently, when as a patient, the doctor told me he was going to place a stent in my plugged coronary artery.

4. Knowledge is shared and information flows freely. Agree. Information should not remain stagnant in medical record.

5. Decision-making if evidence-based. This can become a little silly since much of medicine is an Art, based on experience and training, without retrospective “scientific evidence” of precisely what might happen.

6. Safety is a system property, meaning every hospital and every doctor’s office ought to have to check off a list of what might go wrong before making a decision, or “taking off”, like an airline pilot. This may be useful before major surgery or other dangerous clinical intervention, but it’s hard to apply when you’re seeing 30 patients a day.

7. Transparency is necessary. In short, medicine both in costs and consequences is often too “secretive.” I agree, but absolute transparency is seldom possible in most human exchanges.

8. Needs are anticipated. Agree. As much as possible, doctors should manage and satisfy patient expectations.

9. Waste is continually decreased. Of course. Cut to the heart of the matter, rather than assiduously document every detail and follow every rule or regulation.

10. Cooperation among clinicians is a priority. I would argue this already exists, although there are those who say “fragmentation,” i.e. specialization, is rampant.

What is being suggested here is a kind of 21 century clinical utopia with a personal generalist primary care physician overseeing the complete spectrum of care. There is a danger, though, of the perfect crowding out the good. Not all of us will be able to have the equivalence of a medical education, and not all of can be generals. Most of us need solitude, privacy, space, and, specialization for special needs. On the other hand, society needs less atomization and more anticipation of human needs. It’s striking the right balance that will make the difference.

Health plans - Private Health Plans in Trouble

The nation’s 1500 private health plans are in deepening trouble for these reasons.

• Membership is dropping at the rate of 2% to 3% each quarter across the board for the Blues, Anthem, Wellpoint, United, Aetna, Tufts, Harvard Pilgrim, and other plans, large and small.

• Profits are declining.


• The recession is causing employers to drop health plans.

• The day of raising premiums to compensate for dropping membership is over.

• The Obama administration's reform policies of play-or-pay and a National Insurance Exchange featuring a public plan competing with private plans threatens private plans because private plans with their overhead can’t compete with a low-cost government plan.


• Hospitals and physicians are fed up with mounting accounts receivable (58 days and 38 days respectively from charge to receipt of payment), largely due to their perception that the plans are holding onto the "float" (new electronic processing systems should make it possible to shorten payment delays to 7 days.)


• Polls indicate the public would welcome a competing public plan and do not believe the private plans justifications for their high costs.

With regard to the latter, voters overwhelmingly support choice of private or public health insurance plan. A new poll conducted by Lake Research Partners on behalf of Health Care for America Now (HCAN), a private plan opponent, found “intense and widespread voter support” for choice of a public health plan as part of comprehensive, national health care reform.

For example, 62% of voters believe a public plan will spend less on profits and administration and force private insurers to compete while only 28% of voters believe the attack that a public plan would be a “big, government bureaucracy.” 60% believe that if private insurers are really more efficient than government, then they won’t have any trouble competing with a public plan. Only 23% believe a public plan would have an unfair advantage over private plans.

Other Key Findings:

• 61% think a public health insurance plan will be better able to control health care costs by using its purchasing power to drive competition. Only 25% believe a public plan will shift higher costs onto the privately insured.

• 61% agree that millions of people are already losing their coverage every year, and a choice of private or public health insurance plans will make sure that Americans always have quality, affordable care. Only 27% believe the claim that a public plan will cause millions of people to be dumped from their private coverage.

• Two thirds (66%) agree that a public plan will provide a choice with a standard, comprehensive package of benefits and a wide choice of doctors. Only 26% believe a public plan will force people into lower quality care including rationing and long waits.

Personally I find the voters’ views naïve and an exercise in wishful and uniformed thinking. Nevertheless, their current views have political power and deepen the health plans’troubles.

Costs - Listen Closely to Health Reform Debate

Listen closely to the health reform debate, and you’d think it boils down a contest between government and private enterprise.

Government focuses on Medicare, collectivism, comprehensive coverage catastrophic protection, and health care as a right. The private sector harps on markets, individualism, choice, personal responsibility, and patients’ rights. You gain the impression there’s no middle ground – that never the twain shall meet.

Maybe the time has come for government and private efforts to stop fighting and combine the two approaches. We’ve now had 44 years of Medicare, 43 years of Medicaid, 35 years of managed care, and 50 years or so of private care (using 1959 as a target date because that’s when health costs began to escalate).

I don’t include consumer-driven care, dating back to December 2003, when Congress made HSAs and high deductible plans widely available. That’s too short a time frame to make an impact but enough time for 6 million Americans to sign up for HSAs.

Whatever time frame you take, the results have been dismal. We’re spending 16% of the GNP of health care, twice what any other country spends, and 16% of us remain uninsured.

The reason for this sorry state of affairs?

Bob Herbold, retired Chief Operating Officer of Microsoft and a member of the Board of Trustees of the Heritage Foundation and the Board of Overseers of the Hoover Foundation, says in Real Clear Politics it’s because nobody in the U.S. has any interest in controlling costs.

He says.

Physicians, for example, have little incentive for keeping their rates low. Actually, doctors are eager to try all kinds of remedies and procedures on an individual because cost is not an issue; either the patient has insurance or some government program can usually be tapped. As for the very poor, they often just go to a hospital emergency room and get free care.

The insurance company is in the same situation. The more the system is used, the greater the opportunity that insurers have to make additional profits. The same is true for hospitals. They like patient flow because it means revenues and profits.
The individual loves to get all those tests and fancy new drugs from their doctors to try to get over their illness as soon as possible. And all kinds of state-of-the-art technology is used to quickly figure out what may be wrong with an individual.

Herbold’s solution? Consider the Singapore health care model, which covers everyone and costs only 3.7% of the GNP and which mixes universal coverage and private enterprise by making individuals responsible for their health and for medical care spending.

Each Singaporean has a mandatory savings program, a "Medisave" account. Individuals are required to pay a small percentage of income each month into that account, and employers contribute. The government subsidizes unemployed individuals. Singaporeans also engage in a "Medishield" program, a national catastrophic illness insurance plan. Premiums for the Medishield program are small, and are paid for out of an individual's Medisave account.

When individuals in Singapore go to a physician, they select the doctor based on cost and quality. Physicians compete for the patient's business. Individuals select carefully since it's their Medisave account money that pays for the chosen physician.
Individuals can use Medisave accounts only for medical use. These accounts grow steadily over time because the government invests these funds for the individual in a safe and modestly performing investment fund.

What's important here is that the money is not the government's. It's the individual's money and, at retirement age, people actually have access to these funds. That's why individuals use the funds wisely.

I'm a realist. I don't believe the Obama administration will consider transitioning from Medicare to Medisave. Going from government dependency to consumer-responsibility, even if government subsidized and even if it makes economic sense and even if consumers are well informed, is simply too great an emotional and political switch. To trust doctors and ordinary citizens and to pit them against the collective wisdom of Washington isn't in the political cards.

Safety - Attack of Doctors; Hippocratic Oath

April 30, 2009, Investor's Business Daily

Prelude: What follows in an article by Betty McCaughey. McCaughey is a patient advocate and founder of the Committee to Reduce Infection Deaths. She is also a fellow at the Hudson Institute and a former lieutenant governor of New York State. Her point of view directly counters policy makers in the Obama Administration, who believes the government should reserve the right to override doctors’ decisions based on computer evidence of effectiveness.

Patients count on their doctor to do whatever is possible to treat their illness. That is the promise doctors make by taking the Hippocratic Oath.

But President Obama's advisers are looking to save money by interfering with that oath and controlling your doctor's decisions.

Ezekiel Emanuel sees the Hippocratic Oath as one factor driving "overuse" of medical care. He is a policy adviser in the Office of Management and Budget (OMB) and a brother of Rahm Emanuel, the president's chief of staff.

Dr. Emanuel argues that "peer recognition goes to the most thorough and aggressive physicians." He has lamented that doctors regard the "Hippocratic Oath's admonition to 'use my power to help the patient to the best of my ability and judgment' as an imperative to do everything for the patient regardless of the cost or effects on others."

Of course, that is what patients hope their doctor will do.

But President Barack Obama is pledging to rein in the nation's health care spending. The framework for influencing your doctor's decisions was included in the stimulus package, also known as the American Recovery and Reinvestment Act of 2009.

The legislation sets a goal that every individual's treatments will be recorded by computer, and your doctor will be guided by electronically delivered protocols on "appropriate" and "cost-effective" care.

Heading the new system is Dr. David Blumenthal, a Harvard Medical School professor, named national coordinator of health information technology. His writings show he favors limits on how much health care people can get.

"Government controls are a proven strategy for controlling health care expenditures," he argued in the New England Journal of Medicine (NEJM) in March 2001.
Blumenthal conceded there are disadvantages:

"Longer waits for elective procedures and reduced availability of new and expensive treatments and devices."

Yet he called it "debatable" whether the faster care Americans currently have is worth the higher cost.

Now that Blumenthal is in charge, he sees problems ahead.

"If electronic health records are to save money," he writes, doctors will have to take "advantage of embedded clinical decision support" (a euphemism for computers instructing doctors what to do).

"If requirements are set too high, many physicians and hospitals will rebel - petitioning Congress to change the law or just resigning themselves to ... accepting penalties," he wrote in NEJM early this month.

The public applauded the new requirement for electronic records, not foreseeing that it would put faceless bureaucrats in charge of your care.

Patient views - Rising Expectations of the "Near Old" as an Obstacle to Cutting Health Costs

The Revolution of Rising Expectations

Harland Cleveland, title of speech

New drugs ease pain, reduce depression, manage hypertension, control cholesterol, improve sexual function, and generally make life livable for millions of Americans. New technologies quite tremors, replace failed joints, keep diseased hearts beating, and hunt down errant cancer cells. New scanning procedures allow physicians to view the body through incredible imaging technology that much likes magic as science. Every single one of these new and wonder care improvements costs money, and most cost a lot of money.

George Halvorson, George Isham, MD, Epidemic of Care, Jossey-Bass, 2003

Critics of American health costs complain we spend 30% of Medicare dollars on the last illness. What they don't say is: we spend even more restoring function to the “near old.” Someone has grandly divided aging into the very young old (55), young old (65), middle old (75), and old old (85). But most of us naturally think of ourselves as the “near old,” meaning not old yet. As the saying goes, you're only as old as you feel.

We “near old” have high and rising expectations of what health care can do for us. This is America, and we expect quick access to those life-style and youth-restoring half-way technologies that make us feel and function as the near-young again.

I often ponder the rising expectations of aging America as I walk, talk, and balk at the aging process with my male friends each morning at our coffee clutch. All of us are over 60, all of us think of ourselves as high functioning seniors. All of us have experienced American medical care's wonders, and all of us expect to continue to have prompt access to these wonders.

There are 10 of us. As an exercise, I’ve jotted down what wonders the 10 of us have experienced and are experiencing.
• Currently taking statins 8/10

• On hypertensive medications 6/10

• Stent, coronary bypass, 6/10
pacemarker, or other device

• Cataract surgery 3/10

• Drug for hypertension 5/10

• Invasive surgery 8/10

• Joint replacement 3/10

Summary

Growing old and infirm used to be very hard. It means faltering parts and a Medicare card. Now, thanks to Medicare and medical technology, along with replacement parts comes a new psychology. When you’re going like sixty again you don't feel like part of the fading old Guard. The rising expectations of the near old for quick access to the wonders of modern technology will make it hard to cut costs as part of the health reform effort. This is America, the land of equal opportunity, and a shot at the best.

Physician payment -Congressional SGR (Sustainable Growth Rate) Formula and AMA's RUC (Relative Value Update Committee) Stack Deck Against Primary Care

A large, widening gap exists between the incomes of primary care physicians and many specialists. This disparity is important because noncompetitive primary incomes discourage medical school graduates from choosing primary care careers.

The Resource-Based Relative Value Scale, designed to reduce inequality between fees for office visits and payment for procedures, failed to prevent the widening primary care-specialty income gap for 4 reasons: 1) the volume of diagnostic and imaging procedures has increased far more rapidly than the volume of office visits, which benefits specialist who perform these procedures; 2) the process of updating fees every 5 years is heavily influenced the Relative Value Update Committee, which is composed mainly of specialists; 3) Medicare’s SGR formula for controlling physician payments penalizes primary care physicians; and 4) private insurers tend to pay for procedures, but not for office visits, at higher levels than those paid by Medicare. Payment reform is essential to guarantee a healthy primary care base to the U.S. health system.

Thomas Bodenheimer, MD, Robert Berenson MD, and Paul Rudolf, MD, “The Primary Care –Specialty Income Gap: Why It Matters, Annals of Internal Medicine, 2007; 146, 301-306

This year it’s the same old story. Medicare pay cuts for doctors are imminent. Congress will step in at the last minute to block the cuts.

But this year differa because the Obama administration knows health reform is not possible without more primary care doctors and other specialists (general surgeons, ER doctors, and other specialists). Surveys indicate doctors are unhappy and are refusing to accept new Medicare and Medicaid patients in record numbers because of low reimbursement and bureaucratic regulations taking time away from patient care.

The threatened pay cuts are due to the SGR (Sustainable Growth Rate) formula, adopted by Congress in 1997, which has called for physician pay cuts every year for the last ten years, and coding actions of the AMA/Specialty RVS Update Committee, formed in 1991, which favors specialists over primary care doctors.

This year’s SGR says doctors will receive a 21% Medicare pay cut on January 1, 2010. That will not happen, and the Obama administration knows it. The Obama team and Congress, on the other hand, seem reluctant to change the historically unworkable and inflexible SGR, which, if implemented would cause more doctors not to accept new Medicare and Medicaid patients. Congress, on its part, seems reluctant to enlarge the payment pie for doctors by saying it is “budget neutral,“ a euphemistic phrase which means if we enlarge the slice of the pie for primary care, we will have to reduce the slice for specialists.

This thinking has set up a potential food fight between primary care doctors, 300,000strong, and the Alliance for Specialty Medicine, comprised of 11 national medical societies representing 200,000 specialists. The AMA, the American College of Physicians, and the American College of Surgeons say the solution is simply enlarging the pie, but Obama and the Democratic Congress has suddenly become sensitive about the $6.5 trillion it has proposed to save the economy and the staggeringly large and mounting national debt.

Medicare is considering drastic alternatives, such as ending fee-for-service and replacing it with capped payments for bundled hospital-physician procedures, not paying for doctors and hospitals for individual visits and procedures but for episodes of care, rewarding doctors for joining into “accountable” multispecialty groups, refusing to pay for “avoidable” complications, standardizing payment through the country to stamp out “unwarranted practice variations,” and setting up pay for performance and comparative effectiveness programs requiring doctors to install and use “certified” EHRS for “meaningful purposes.” What that means nobody seems to know.

As you consider ramifications of SGR and RUC, remember they’re designed to save a buck. Yes, SGR and RUC may lack flexibility, but they’re fundamentally escapes from hard reality. It takes doctors to give care. That SRG and RUC can’t duck.