Is fee for service really the culprit for health care costs?

Fee for service is said to be a major cause of the high health care costs that we are told must be brought under control to save the economy.Dr. Donald J. Boudreaux,Chair of the Economics Department at George Mason University, argues that is not correct.Rather a major cause is the fact that much of medical care is paid for with someone else's money. Go here to read his entire commentary.

Comment writer asks retired doc about single payer

This post is a reply to a comment made on one of my earlier postings that inquired about the single payer option for U.S.health care or at least what were my thoughts.

I believe the major issue is whether the single payer system that we may eventually end up with allows a parallel system of private care as is the case in Great Britain or if government forbids people to spend their own (or insurance) money for services not provided by the single payer government plan, as is the case in Canada. In the later arrangement the patient's life and health is literally in the hands of the government and without the private option there is no practical appeal to the edicts of the bureaucracy that control the expenditures of the single payer system. Of course, in Canada not infrequently folks go south for health care that is denied or so delayed that it is for practical purposes denied. Also, recently there is an interesting and encouraging move to some elements of private care becoming available in Canada (see here). As the U.S. seemingly is moving to more government involvement in health care, there seem to be a directionally opposite move in Canada where they have had years to see how well or badly their hyper-egalitarian health care system works in the real world.

We have had Medicare since 1965 and it is not going away.The best we can hope for after the re-working of the medical care system comes to pass is for the people to be able to purchase health care denied by the government system without having to travel overseas. ( Maybe the private care movement in Canada will be mature enough by then so we can go there for care.)

An interesting twist on this general topic is the suggestion made in a WSJ October 2008 editorial to "allow"seniors to opt out of Medicare entirely, not just Part B.See here for a discussion of how that might be good for some and harming none, something economists seem to refer to as Pareto Optimal.Currently if someone wants to opt out of Part A he will loose Social security benefits.

I did not realize that until recently.Here is the rule in the words of the government:

"Individuals entitled to monthly benefits which confer eligibility for HI ( hospital insurance,Part A of Medicare) may not waive HI entitlement. The only way to avoid HI entitlement is through withdrawal of the monthly benefit application. Withdrawal requires repayments of all RSDI and HI benefit payments."
h/t to Junkfood Science)

This was not the way the Medicare law was written. You have to wonder what prompted the SS administration to add on this rule. Why would they object to someone opting out of Part A? It would only be a saving for Social Security.

The terms one tier and two tier are sometimes used to distinguish between the systems exemplified by the British and the Canadian systems. One Tier would be Canada and two tier would be Great Britain. In this article in the Archives of Internal Medicine there is a discussion about the ethics of the two systems. Interestingly, one of the authors who supported a two tier system from a practical and ethical point of view is Dr. Ezekiel Emanuel who is the brother of Rohm Emanuel.I hope Rohm will give some thought to his brother's views.

National Demonstration Project for Medical homes-some early observations and concerns

Medscape has a republished a report from the National Demonstration Project regarding the Medical Home concept that appeared in the Annals of Family Medicine in June 2009. See here. The full name for Medical Homes in this context is "Patient-centered Medical Home" or PCMH.The authors examined how the transition of a number of traditional family practices to the PCMH model was working out.

There is much to discuss in regard to the report in particular how difficult a transition is from "regular" practice to the medical home type practice can be but my attention become focused on this paragraph.Bolding is mine.

"Transformation to the PCMH Requires Personal Transformation of Physicians

Transformation to a PCMH requires not only implementing new, sophisticated office systems, but also adopting substantially different approaches to patient care. Such a fundamental shift nearly always challenges doctors to reexamine their identity as a physician. For example, transformation involves a move from physician-centered care to a team approach in which care is shared among other adequately prepared office staff.^[25] To function in this team-based environment, physicians need facilitative leadership skills instead of the more common authoritarian ones. A PCMH requires expanding the clinical focus from 1 patient at a time to a proactive, population-based approach, especially for chronic care and preventive services.^[26,27] In addition, physician-patient relationships need to shift toward a style of working in relationship-centered partnerships to achieve patients' goals rather than merely adhering to clinical guidelines.^[28-30]"

The report is hardly a glowing endorsement of the program at least from the view point of a physician considering taking that road. Not only does the report indicate the costs are greater than anticipated,the transitions take longer than anticipated and the entire process is difficult but the physician may have reexamine his identity as a physician. Does this involve pushing into the background the long standing venerable duty of the doctor to the individual patient? "A PCMH requires expanding the clinical focus from 1 patient at a time to a proactive, population-based approach.."

Does this mean that the physician's strong fiduciary duty to the patient may have to be balanced with more concern for the collective.Trust in the physician commitment to the welfare of the individual patient has been the durable glue of the doctor-patient relationship. One wonders how group meetings and a "population based" approach will collide with the duty-to-the-patient ethic that most practicing physician were inoculated with in the medical training.(I realize that inculcation process has weakened more than a little bit in recent years but still is a strong element in the physician sense of professional identity.)

I wonder if NPs who lead medical homes will have to have that same identity metamorphosis.Earlier I blogged about new Medical Homes funded by a House bill that will allow NPs to independently lead these homes. The American College of Physicians has endorsed this bill, a move that both DrRich and I have critically blogged about.See here and here.

The review indicates that three years is not long enough to transform to this type practice and that the current funding and reimbursements may not be adequate. I find it hard to understand why any internist or family practice doctor ( this study involved family practice physicians) would willingly enter into this experiment considering it to be a more than 3 years process and it having significant likelihood of financial insolvency and may involve taking part in workshops to help you retool your ethical compass so it points to the new correct position in the context of the New Professionalism.

Everyone go read Dr. Wes's Open Letter to patients

Go here.His satire elegantly captures so much of what is happening and is threatening to happen.Those of you who still get up everyday and practice medicine should consider handing it out to your patients.

Ignoring history-doomed to repeat it ?

President Obama recently spoke to the American Medical Association and offered in part some reassurances that the public choice option would not lead to a single payer and his Secretary of HHS assured NPR listeners that their plan is not a Trojan horse with a single payer lurking inside.Various administration spokesmen have promised a plan that will increase coverage, save money and improve quality of care.

Sometimes insight may be gained by sitting back and reflecting on some recent (1965) past history.Here is food for thought from the Medicare bill.

I quote from section 1801:

"Nothing in this tittle shall be construed to authorize any federal official or employee to exercise any supervision or control over the practice of medicine..."

So how has that worked out?

American College Physicians (ACP) endorses house bill that allows NP lead Medical Homes

Note this is a republication of an earlier version with a new headline and some introductory remarks..As pointed out by Bob Doherty in a comment to my earlier posting ( I am not sure that comment will survive this editing but that reflects my lack of mastery with blogger rather than an intent to silence his criticism) that the earlier headline was "demonstrably wrong". It said " The American college of Physicians endorses independent NP practices." To avoid misleading anyone I should have said what the current headline says namely that ACP has endorsed a house bill that does allow NP lead medical home practices.The ACP does not endorse NP lead practices in general only in the context of what is outlined in the house bill, ie in the context of the medical home practices.. Although my earlier headline is arguably technically accurate, it could be misleading and I hope my correction will satisfy Mr. Doherty's concerns. Judging from comments on Bob Doherty's blog I am not the only internist who has serious concerns about the issue of ACP going along with this element of the House bill and the ACP's support for what they do support is bad enough without me implying they are endorsing something worse. So here is the rest of the posting without any changes.

The American College of Physicians is endorsing a bill before the house that would enable NPs to practice independently in the context of the ACP sponsored "Medical Home". Further they seemingly welcome the opportunity to take part in a contest using certain quality measures to see who is the better provider.The bill,HR2350,can be read in all of vagueness and details yet to worked out here.

Go here to read what the ACP's man in Washington, Bob Doherty, has to say about how real practicing internists should enthusiastically get on board and strive to follow the appropriate quality driven guidelines to prove to the world that an internist provides better medical care that a RN with an extra two years Master degree that qualifies him as a NP.

Doherty says that the leaders of the ACP are endorsing this proposal because they are so pleased with the other elements of the bill, which include more training slots for general internists and some very modest increases in reimbursements from CMS and it furthers promotion of their highly touted Medical Home proposal. With these and other elements in the bill they are willing to endorse it even though the NP provision "goes past" what they had previously supported.

Doherty argues that if internists really were confident in their superior training they would welcome the opportunity to show they are better than folks with significantly less medical training. They should relish the opportunity to play a game even those it will likely be with rules that not disclosed (those devils in the details will be worked out later) and are likely to be written by folks who may well have an agenda which would be well served by either a victory for NPs or even a tie, which would also be a victory for the NPs . Go to the proposed bill and see if you can find what will be the rules of the comparison game between doctors and nurses.They are to be worked out later. So we should agree to a contest with rules to be worked out later?

Go here to read from the virtual pen of DrRich of the situation facing the general internist and his views of this "capitulation" of the ACP in his commentary that laments the now official nature of the death of the general internists even if the bill is not passed. (With the current state of the Republican party left toothless since the last election just about any democratic sponsored bill will be passed.) By virtue of their current stand the ACP has already stipulated that NPs are for practical purposes equivalent to internists.HR 2350 may set up more general internal medicine training programs but as DrRich points out what medical students with any modicum of cognitive function left would choose to enter a field of medicine that its professional organization has publicly stated that its members are equivalent to other health care providers with much less training. What does that about what the ACP thinks of an internist training and worth? What good will the Medical Home be to internists or the ACP when its Medical Home becomes a NP run organization?

The assertion that internists will prevail in a head to head who-gives -the- best- care contest seems to me to be naive or hypocritical. Does anyone really believe that such a comparison would be based on anything other than the usual "quality" measurements of compliance with easy to account guidelines and/or coarse grained outcomes too crude to show a difference in the short run.

If you think that it is not possible for this development be spun as a good news-bad news story read the second related commentary by DrRich. Go here for that. He suggests that this ACP capitulation could be taken as a opportunity for internists to get out of this "primary care" farce and become retainer docs leaving what primary care has become to a few internists who may just want to run the clock out and the NPs and whatever level of provider that the NP lead practices may devolve into.

This type of internist he and I trained to be may find professional satisfaction in a retainer practice ( at least before medical "reform" deems that to be illegal) or by becoming a hospitalist . The primary care environment that the internist turned officist now faces is-for many of us-not worth doing.

For those who worry about government managed CER,MedPAC may be your real worry.

From the WSJ we read about the entity that may be the group that really will pull the budget strings for Medicare and have major influence on what the third party payers pay ( if there are any left after medical care reform kick in).MedPac is not a well known word. What is it anyway? Here is what it is in their own words from their website.


The Medicare Payment Advisory Commission (MedPAC) is an independent Congressional agency established by the Balanced Budget Act of 1997 (P.L. 105-33) to advise the U.S. Congress on issues affecting the Medicare program. The Commission's statutory mandate is quite broad: In addition to advising the Congress on payments to private health plans participating in Medicare and providers in Medicare's traditional fee-for-service program, MedPAC is also tasked with analyzing access to care, quality of care, and other issues affecting Medicare.

By the way, the strange sequence of capital and lower case letters in MedPAC is necessary because MEDPAC is something else entirely.It is the PAC of the Minnesota Medical Society.

Here are the current players in MedPAC. They are appointed by the director of the GAO who is the Comptroller General, who is appointed by the president subject to congressional approval.

So far, their pronouncements have been advisory but a recently proposed bill will elevate their expressed wisdom to fiat. The commission will become a government agency whose decisions regarding Medicare payments will largely be determinative.(Congress will have to work out exactly how determinative it will be, i.e. how difficult it will be for Congress to over ride their decisions).

This is being heralded by some as a way to take politics out of governmental medical payment decisions. Let's see how that won't be political. The members are appointed by a presidential appointee. Their decisions will determine how billions of dollars will be spent. Explain to me how all of the major players (drug companies,hospitals,medical equipment manufacturers, physician associations) will not do all they can to influence both the choice of those who will populate the agency and their decisions. Lobbying is not directed to just elected members of Congress. Explain to me again how investing that much power in an agency will not be the one of the best opportunities for regulatory capture ever.

The term "regulatory capture" is of fairly recent origin, but the concept is not new. Here is what President Woodrow Wilson said in 1913.

"If the government is to tell big business men how to run their business, then don't you see that big business men have to get closer to the government even than they are now? Don't you see that they must capture the government, in order not to be restrained too much by it? Must capture the government? They have already captured it."

Must reading for all internists-DrRichs' take on the bill purported to save internal medicine

DrRich's blog entries typically are insightful and entertaining. This one goes way beyond his usual very high standards.Go here to read his reply to Bob Doherty's recent blog entry," Do internists have confidence in their own training when compared to NPs?"

DrRich writes about the death of internal medicine now being official.I sadly have to agree with him about the ACP supported bill before Congress which he discusses in the context of the current state of primary care in general and internists in particular.

CMS's "never events"-so much for reason and let the unintended consequences begin

Aggravated DocSurg offers cogent comments about the seeming lack of logic or common sense in their program of denying payments for so called "never -events". In particular he discusses deep vein thrombosis (DVT). In the recent issue of the NEJM we find an excellent commentary about an even more absurd requirement of this new set of CMS rules,this one involving falls in the hospital.

For those who advocate a "Medicare for all" approach for the United States, I suggest they read what Medicare itself says about the inclusion of falls in their never-events policy.Here is a sample as quoted from the NEJM commentary which explains clearly that CMS is making a requirement for some things that cannot be done.

"There is no evidence that hospital falls "can be consistently and effectively prevented through the application of evidence-based guidelines." The authors of the CMS rule acknowledge this fact. In the final rule, as recorded in the Federal Register on August 22, 2007, they note that "although we have not identified specific prevention guidelines for the conditions . . . we believe these types of injuries and trauma should not occur in the hospital and we look forward to working with CDC and the public in identifying research that has or will occur that will assist hospitals in following the appropriate steps to prevent these conditions from occurring after admission." Although clinical trial results suggest that certain strategies may reduce the risk of falling in community settings, fall prevention in the hospital has been much less studied. What little evidence is available is not encouraging. A recent systematic review suggested that, at best, about 20% of hospital falls can be prevented.¹ Moreover, no intervention has yet been shown to reduce the risk of serious injury, the outcome of clinical relevance."

If one follows all the best evidence driven rules and suggestions for how to prevent DVTs, DVTs will still occur. Under the best circumstances of the very best randomized clinical trials which involve meticulous attention to detail , and applications of the very best preventive measures, DVTs still occur. The incidence is not zero. Furthermore, in regard to falls , CMS recognizes as indicated in the quote above that there are no evidence based guidelines but hospitals and physicians have to obtain a zero incidence rate anyway.We don't know how you will do it but you have to do it.

I have been impressed by Thomas Sowell's approach to try and understand some of the actions of governmental agencies that appear to lack in common sense, or appear to be irrational or just plain silly. He says look at the incentives and constraints they face and the feedback or lack thereof to which they are subject. Here, however, it is difficult to understand how anyone (even a committee) could devise and publish for all to see something that is absurd. OK I 'll try and think about their incentives etc. If their aim was to save money and to dress up their work orders in the current jargon of safety and quality, maybe their plan makes sense to them, but for the rest of the world -not so much . If you make rules that are apparently subject to no appeal,your rules don't have to make sense.