Saturday, October 1, 2011

Costs in Medicine - additional evidence.

Yesterday, I said:

So on to a new round of hand wringing about medical costs. What is interesting to me is that what I read coming out of Washington seems to be addressing a system that I am not familiar with. I see all around me reasons that medical costs are high, but none of these are seriously addressed, some not even mentioned.
Some years ago, I asked the outgoing President of the American College of Radiology (our large national organization that deals with legislation) what was the most surprising thing that he had learned in his tenure. His reply was immediate, no thought necessary: he was shocked at how little legislators knew about the things they write legislation on. And so it is.
Today, I see that at least some others are aware of the problem of inexperienced neophytes with political agendas running our health care:

The point is that ObamaCare was meticulously crafted by people who didn’t have a clue how health insurance worked or how people respond to the various economic incentives in health care and insurance.  And we just got another example of my claim with the notice of the probable mothballing of the CLASS Act, yet another actuarially unsound provision in ObamaCare.
The ObamaCare effort was like those utopian planners who have a vision for how an economy should work, and then try to force everyone to conform to that vision.

I am not a fan of the insurance companies, but reality is that currently, they are an indisposable part of our health care. Perhaps the actual goal was to make the insurance companies insolvent. Who knows?  The real point here is that the legislation that became the Affordable Healthcare Act was written by people who truly know little about what they are directing. The result is sadly predictable.  

Friday, September 30, 2011

Costs in Medicine

That is the topic of the national discussion right now. It's everywhere. Several articles online today note that  Obama had promised on the campaign trail that his plan would save everyone money. Skeptics said how, and the answer was a rather diffuse promise to "bend the curve down". No real details on how that would happen.

That, obviously, hasn't happened.

In fact, the Kaiser foundation released data yesterday that costs are at an all time high. Specifically, up 9% from last year.

So on to a new round of hand wringing about medical costs. What is interesting to me is that what I read coming out of Washington seems to be addressing a system that I am not familiar with. I see all around me reasons that medical costs are high, but none of these are seriously addressed, some not even mentioned.

Some years ago, I asked the outgoing President of the American College of Radiology (our large national organization that deals with legislation) what was the most surprising thing that he had learned in his tenure. His reply was immediate, no thought necessary: he was shocked at how little legislators knew about the things they write legislation on. And so it is.

What is my list of unrecognized money sinks in medicine? Here goes(this is in no particular order, because I have not done the work necessary to estimate the magnitude of each of these yet):

1) Malpractice costs: this has seriously warped the decision making process of every physician. This was true when I entered the field, it is much more true now. The insidious thing is that the practice patterns have been in place for so long, that physicians have lost track of the effect it has on them. This is to say that, unfortunately, if malpractice costs were gone tomorrow, cost savings would not start tomorrow; much too much inertia.

2) Hospital competition and profits: Our medium sized town has at least 4 "heart centers". You can get every service known to man in each of these. My hospital has one. The nearest one to us is about 3 miles. The "competition" in medicine is distorted because the patient is not paying. The patient has already paid in the form of insurance premiums, and wants to get the absolute most that they can for their money. The competition, therefore, is to spend more. And, of course, the hospitals get reimbursed on a fee for service model, so the profitable thing is to DO MORE.

Ever wonder why you suddenly see ads on billboards for "wound care centers" and other odd centers that seem to be way off the mainstream of medicine? It is because a smart administrator found an area that the fees had been set relatively high. Therefore, a nice chance to pick off some profit. Do not expect to see an "alcoholic cirrhosis" center anytime soon. Money loser, big time. This also explains the proliferation of breast centers - more later.

Have you also noticed that the decor in most hospitals today is nicer than the nicest home you have ever been in? They want to be sure that it feels luxurious to you, the patient. The cost to do this in a hospital, as opposed to a home, are staggering. Every piece of the construction and decoration of a hospital costs far more than what you would do at home, due to regulations requiring certain quality. A hospital adminstrator would say " I need to spend this to look as nice as the place down the street, otherwise we get a reputation for being "old" and "dirty". We will lose patients.".   He is right, he has nearly no choice on this one. You and I pay for this.

3)Physician self-referral. As a patient, you are recommended to have tests by your physician. Do you know how much he or she makes from this? Often now the physician owns a part of the testing facility and makes money from each referral. This is a very important cause of increased costs, particularly in imaging (CT, MR, Nuclear Medicine). More on this later, but suffice to say that it is intuitive that if a physician makes a profit off of each test he or she does, then there will be  more testing. Ah, you say, but this means I am being better cared for. NO, not at all. I would agree that there is a point (ill defined) up to which you are better cared for, but after that, your outcomes, and life, are worse. This is because any test carries with it the possibility of raising red flags that are not real (false positive results), but must be tended to with more testing. In the worst case (which I have seen) that further testing leads to a serious complication.

A recent review article has gone over all of the available literature on the subject. The papers reviewed had included 76,905,192 individual "episodes of care" (! - there is some statistical power.) The result: as compared to physicians who referred to facilities they did not have ownership in, Physicians who referred to facilities that they had some ownership in ordered 2.48 times as many exams. This is not a 20% increase, this is about a 150% increase. (These results, it should be said, were highly statistically significant). The cost? $3.6 billion per year in unnecessary testing. (JACR vol 8 issue 7 pp 469-476. This may be available to non-ACR members, I am not sure. try>publications)

I need to add here that this is just imaging. This doesn't begin to talk about other ways physicians may self refer, to their own testing facilities that are not imaging. Or to their own treatment centers, such as physical therapy centers.

I want to soften this by also saying that while this is a serious financial and ethical problem, I am also amazed that it is not worse than it is. In other words, many physicians will act against their own interest in recommending that you not have a test.

4) Hospital advertising;  small potatoes, but still, in terms of outcomes, an absolute total waste of money that is paid for out of patient fees.

5) Patient expectations: Here is a big one. Suffice to say for now that much unnecessary work is done at the implied or expressly stated demand of the patient.

6) Middle man profits: this one is hard to quantitate, as it is so diffuse, but I will give it a shot.

7) Insurance company profits: much to say on this, little space.

8) Overtreatement of everyone, but most notably the terminally ill

Not in this list is physician pay. Why not? Isn't it obvious that that is a major cost. Well, if you are a politician trying to win re-eletion, this is a ripe target. But, if you are intelligently attacking a problem, you will be much more nuanced in your thinking. To start, physician pay is roughly 17% of the total expense. Last year, medical costs rose 9%. As a thought experiment, you could cut physician pay to zero, and in two years, would be back to square one, with costs still increasing.

More practically: my income fell last year, as it has for the past 3 or 4. (here, it should be noted that I am working 30% longer hours and producing 60-80% more in those hours than I did 15 years ago. So, the work has substantially increased, and the income has gone down. From your standpoint as a paying patient, I have become much more efficient, and you are getting much more for your dollar).

 It certainly wasn't my individual income that contributed to the 9% increase, and my colleagues are in similar situations. The individual physician has, by and large, seen their income contract. Perhaps the total amount paid physicians is higher, but if so, that would be because of more physicians. We are already seeing a dramatic increase in physicians refusing to see medicare patients because they lose money on every one. This suggests to me that there is no more "savings" to be had from further reducing the amount paid to physicians.

What seems to be always missed in the discussion of physician pay is that it is not what the physician charges the patient that is so expensive: it is what the physician does for the patient that is increasing so rapidly. "Does" in the sense of expenditure events that the physician puts into motion: ordering imaging tests, ordering lab tests and the like.

It has been my observation that as the government ratcheted down physician payments (and the insurance companies followed) that the physicians had to develop ways of staying financially solvent. This involved opening their own testing facilities in many cases. It appears to me that there was a slow change from the physician being exclusively the patient's representative, to being someone who had a conflict of interest. On one hand, being at least in concept responsible for the patient's best interest, to, on the other hand, being interested in reaping more money for their care. I am embarrassed to report to you (but honesty demands that I do report this) that I have heard physicians say "they are MY patients and I deserve whatever profit comes from their care". Important - I have heard this only twice, and it is so striking because it is so far off the ideal. Nevertheless, it was said, and probably represents the feelings of more who were not so ignorant as to actually verbalize the thought.

I believe that physicians were happy with the arrangement that they were paid a good living for acting as their patient's advocates and it was only when the government made it financially impossible to do this and still remain solvent, did they begin to look for other, less ethical ways of keeping the practice afloat financially.

So it seems that the "solution" to high costs that was put in place in the 80's - just pay less - has had major unintended consequences. They began to order more tests that they would benefit from in three ways: 1) protection from malpractice suits 2) The patients are happier because they see their physician being very active ordering tests and reviewing the results of the tests. They feel more cared for and consider him to be a "smart" doctor because he knows what to do! 3) Personal financial gain from referring to facilities from which he derives profit.  This is not unexpected if you intelligently assess the situation.  This all could have been anticipated.

And now, the institutions that pushed us down this path are telling us that physicians and hospitals are not to be trusted, but simply allow them more authority to direct medical care from Washington and all will be well.

Till later,


Thursday, September 29, 2011

So what is Radiology.

It has been surprising to me how little most people know about Radiology, and what Radiologists do. Not infrequently, someone believes that I am engaged in taking x-rays. Nope.

First, start with what we have to do to get here:

Four years of college (for me Chemistry major)
Four years of Medical school.
One year of internship (being a general low-level doctor in all facets of medicine and surgery, functioning with very tight supervision from more experienced doctors)
Four years of residency - this is a radiology residency, where you learn about all forms of medical imaging and become competent in reading x-rays, CT scans, Ultrasound exams, Nuclear Medicine tests, Interventional radiology (used to be called angiography), Mammography, and MRI exams. It is a load. My schedule through those 4 years was to be at the hospital working a full day, then (if not staying all night at the hospital on call) home for dinner, and then 4-5 hours of reading. The stack of books that I supposedly had to know inside and out was about 4 feet tall.

After residency, most all (including me) do a fellowship, where you are a fully certified radiologist but learning one area in great depth. This ranges from 1 to 2 years usually. I finished when I was 31.

And then you are supposedly ready for the real world- academic or private practice. Except, you hit the real world and feel overwhelmed because there is so much you don't know still.

So why Radiology?

Why would anyone choose Radiology. At the time I was in Med School, radiologists had a reputation for being odd little people who lived in the dark that no one ever saw. The rest of the medical world thought of them as necessary hangers-on to the medical world. Not RD's (real docs) as many said. There was some truth to that. To me they appeared to be dull people without much imagination.
Except for one: the Chairman at the University where I went to medical school. Overbrimming with enthusiasm. During a reading session, a favorite game was to turn over the req (requisition - piece of paper that says what the referring doc thinks might be wrong with the patient) and to pull out as much information as you could about a patient just looking at the images. This was intoxicating stuff.

As an example: A simple chest xray. Dr.F asked me to tell him all about the patient. My stab - a female. (duh). His interpretation: woman brought in for an overdose. Alcoholic. How did he know? Woman - easy enough. Overdose: bones were those of a young patient and she was intubated (tube in the trachea).  She came in at midnight. Why do young women come to the ER at midnight and get intubated. Not heart attacks - overdoses. Alcoholic - many rib fractures in various areas of her chest. This happens from people falling off barstools frequently, and is correlated with overdoses.

I was hooked, but - there was more. Dr.F had weekly conferences for medical students. Not many came, 3 or 4 usually, but in these sessions, he would go over cases. It became evident that this man had a good grasp of all of medicine. Radiology requires this - you must know about everything. So - I could become knowledgeable of all aspects of medince - interesting.

The coup de grace was the new modalities. Ultrasound was just starting then and we could actually see babies in the uterus and check to see how they were doing. Revolutionary. One hospital in town had the newest gadget - a CT scanner. Called, at the time, an EMI scanner, for the company that made it. EMI, incidentally was the company that was involved with the Beatles. They had so much money, they had no idea what to do with it. Someone directed them to Geoffery Hounsfield. Hounsfield was an astrophysicist who had worked out ways of localizing radio sources in the sky. He realized that if you shot small beams of xrays through someone, that you could mathematically determine how dense each little piece of the body was. And so we have CT.

When I saw these new modalities, I realized that they were the first time that computers had been applied to medical imaging and that there was much, much more to come. Being a computer programmer at the time, this was also quite interesting.

So, I decided to ignore the stigma that came with what was usually thought of as a radiologist, and take the plunge. Good decision.

New blog

Why a blog? Clearly there is enough chatter in the world. For an overview, see "about me" pane. To expand: I need to have a repository to save all of the items that I encounter daily that later I wish I could find again. Why not let others see this?  So here it is.

As mentioned on the sidebar, I know from talking to friends outside of medicine that they really don't know how medicine functions in actual practice. What they know is an amalgamation of what they see while waiting in the doctor's office, or what they read in the media. Two small windows on medicine.

It used to be that medicine impacted your life when you were ill. Now, however, it affects you everyday. Discussions of the cost of insurance, inability to quit your job, fear of even bankruptcy. All of these things are in our collective consciousness daily. Add to that the litany of "xxx found not to be good for you" and it seems we are saturated with medical or medical-related data daily. And, again, most of it is questionable information at the very best.

My attitude generally toward the information I get in the media is to not believe it, particularly on the subject of medicine. I recommend this to you. Require more proof that "Dr. Z says". Require more proof than even "published in the New England Journal of Medicine" Without an actual count, I would say that most, if not the very large majority of what is presented to us dissolves away as untruth within a very short time. Some findings do stand the test of time, but the cacophony of new information presented as solid truth to us in the media generally (as in most often) will not stand the test of time, and is untrue.