Tuesday, June 21, 2016

The Warriors Lost

The Warriors lost.

Everyone was nervous, and everyone was watching. At the half I drove quickly down to get my wife a burger. There was no one on the road, just after 6 PM on a Sunday. It usually takes me 25-30 minutes round trip, but on Sunday I was back in 15 minutes. I thought, they're up by 7. Is that really it?  Will there really be a parade?

No, that wasn't it at all. J. R. Smith got rid of that notion with a few 3-pointers and then it was grind and grind, miss too many, throw a couple of passes away, and miss the 3's that were the stock in trade. It was sad, that's what it was, it was sad. It was just so sad. Everyone aching, trying, trying to recall the magic, but coming short, or wide.

So, my friends, John, Bob, and Steven all asked me the same question, how do we understand it? How, indeed. There are times when it helps to be from Philadelphia, like Bob and me. Phillies, 1964, no need to say more. That was slower, drip drip drip, morning after morning coming down to eat breakfast at Vanderbilt Hall at med school, auslanders saying, what happened to Shenkin's Phillies?

When the guys get awards, they say it's humbling, to be MVP, or best something. Nah. This is what's humbling. Losing when you are ahead, that's what's humbling.

It was Cuomo pรจre who said that one campaigns in poetry and governs in prose. That's one way to understand it. All year in their campaign the Warriors practiced poetry. Multiple passes, no-look passes, behind the back, and long rainbow arced 3-pointers in droves. Beauty to behold. Lightness and glee, joy and pleasure and appreciation. Thank you, God.

Enter the grim, the grimacing, the driving with shoulders butting out, with pulling and pushing, with non-called fouls off the ball, with getting beat up for no good reason, only for bad reasons. Enter prose. The Warriors pulled on memory, what was it that got us here? Try that, what we used to do, what was it? Couldn't find it, not at the very end, just couldn't find the ease and the poetry, and the shots wouldn't, couldn't drop.

That's one way to understand it, prose and poetry, probably not too bad. Or think about the gods. Not the Christian God, for all its popularity on the Warriors squad – everyone wants God on their side, everyone wants to be rewarded for following a Godly way, everyone is blessed. But thunder and lightening make more sense in basketball, the realm of the Greek gods; Greece, where sports were king. Some gods backed the Warriors – I like to think Zeus was among them, but maybe not – all the Greek gods were problematic, after all (http://io9.gizmodo.com/the-13-biggest-assholes-in-greek-mythology-1454132475.) It had to be a god guiding Steph's 37 footer in OKC. Even Harrison Barnes won a couple with last minute threes. The gods smiled all season long. Was it Zeus behind Draymond in the first half Sunday night? Athena? I like to think Dionysus honored the Warriors in their mindlessness, in their beauty, but then they got carried away, which is what Dionysus does. Better scholars than I can dope out who was on the other side. Some damn god was. Nemesis tailed Curry, and had his opponents hold onto him, hit him, injure him. A whole season of absorbing punishment, unprotected by the refs in the employ of Hera and her minions. Shumpert falls on Curry and it's Curry's foul? Who blinded the zebra? The gods were fighting, and we couldn't see how they influenced play, but we know they did. Someone got Draymond suspended. Someone cursed Barnes. It had to be the gods.

Or, there's always Zen. Kerr said during the long run to 73 and 9, “...maybe all the talk and all the focus on the record has gotten us away from our process and what makes us who we are, what makes us pretty good.” The process, which is all you control. The end result? Hope that the gods will be kind. When the ball leaves your hand, it's out of your control and it's the physics that tells it where to go, and physics is the realm of the gods. Got to trust the process, let it go, don't point – don't aim and point, HB! Don't will the results, will the process.

In the end, it just wears you down. What did they play, 110 games? And it came down tied to the last minute. Which god was it who had the last breath?

Oakland was quiet today. My physical therapy office was quiet. The gym was quiet. Our usual Monday lunch at the Rockridge Cafe found us only the second customers for lunch at 12:15, when usually there are only one or two tables empty. We were quiet. Beauty had lost, prose had won, our community, home of the Warriors, had lost. We were all quiet.

But isn't it great? It's only a game! It's not really life and death, right? Sure, it's basketball, the game of the gods, but it's only a game.

I guess.

Budd Shenkin

Saturday, June 11, 2016

Centralizing and decentralizing health care

I have been working on an article in which I want to say that there are basically two models of health care organization at the poles: the integrated health care delivery model (e.g., Kaiser) and the decentralized system that used to be called derogatorily “the cottage-industry model,” or as I prefer to call it, the Centers of Excellence model. It will be a great article, but great is in the future. Years ago I coined Shenkin's Maxim and shared it with the kids: “A passing paper in the present is better than a great paper in the future.”
That maxim might have limited applicability, as you will recognize, since I have actually worked hard and long to produce some great papers (in my estimation anyway.)  Although, I have to say, I have other papers that haven't seen the light of day that died on the drawing board, maybe because of standards that have been set too high.
So, that's my “reader beware” statement. I'm not giving up working on the paper; I'm currently doing some basic reading on vertical integration of industries. But in the meantime, here is a little work in progress. First a response I wrote to an article, then the author's response, and then my response to his response. I'm hoping that you, the blog reader, enjoy this brief foray into health care organization theory.  Or skip it until my next post on consumer transportation ripoffs.
My response to his article:
You are of course correct that American costs are high.  Much of this comes from high prices rather than high utilization, although the latter happens, too.  We physicians make more than physicians in other countries, by a lot, especially specialists.  But more importantly, hospitals cost a lot more, and procedures cost a lot more.  And pharma is completely out of hand.  The recent trend to increase prices of established drugs is simply terrible.  Pharma companies have absolutely no sense of the general welfare, decorum, or what is "right."  As long as it is legal or almost legal, they will do it, and government stands by.  It would be really nice if there were honest competition in all of health care, which there isn't, especially since government has allowed lots of oligopolies to arise.
He wrote back:
The fear I have is that because of the high costs of healthcare, the reaction may be to limit access to care.  The far better solution would be to introduce price transparency, patient choice and honest competition.  It seems that for elective healthcare, you could have an Amazon type site that would show a variety of providers and prices.  It seems crazy that when a patient goes to the doctor’s office or hospital, the prices are not displayed on the wall like they are at McDonalds.  When a patient asks about prices, the prices have a huge range based on who is paying.  The answer to “how much will this cost” is rarely clear.
A small example is an ambulance ride.  An ambulance ride can often cost  $2,500.  Rather than calling ambulance in a non-critical situation, why not have Uber offer a “medical” ride for $500.  For that matter, my neighbor may be willing to give me a lift for $200.  The ambulance ride has no price transparency or competition.  It is a one size fits all at the highest possible price.  The ambulance ride is typical of how we deliver medical services in this country.

Thankfully doctor pay is sufficiently high to attract high quality individuals to the profession.
And I wrote to him:
I'm with you on competition, and I'm with you on good compensation for doctors to attract the best possible people, and I'm with you on ambulance rides.  (On the other hand, high remuneration doesn't always work -- the administrations of hospitals and insurance companies are bloated beyond belief, and the high compensations has not noticeably resulted in superior performance, at all.  Medicine and higher education share the affliction of administrative bloat.)
In medicine, the bloat is everywhere, but the cost of care would best be ameliorated if we looked to where the really high costs are, which is in big procedures and studies, in hospital care, and in pharma.  How to introduce competition here is very problematic. 
I think there are two basic models of health care organization, the integrated group and a decentralized model I call the "centers of excellence" model.

For the integrated group, as early as the 1960's, Kerr White of Johns Hopkins wrote that corporate health entities should compete the way airlines compete (this was before deregulation).  Alain Enthoven's "managed competition" of the 1970's and 80's was similar.  There are problems with these proposals, corporate as they are, but they have some really good elements.  Kaiser likes this model a lot, and hospitals are energized behind it, as you probably see locally.  I've got a lot of problems with corporatization, but it seemed to make sense at the time.

When these proposals were offered, they deprecated the old decentralized system of doctor's offices and independent hospitals as a superannuated "cottage industry.” They had a point, although much that is valuable in medicine would be lost by corporatization.  With the advent of modern technology for information and communication, however, I think that intelligent decentralization is now possible. 

In a COE system, you and your primary care doctor could together find the best place for this and for that.  Doing the best job for you will always rely primarily on the doctor's professionalism and fiduciary responsibility, but there have to be financial considerations as well.  It's important to have you and your doctor on the same side of the ball, so you can harness his or her expertise and continuing involvement.  Technology should make this possible, with very transparent information on price and quality and with electronic medical records if they were freely inter-operable (which they are not and which both EMR firms and hospital buyers of EMRs don't want them to be), and there will need to be inventive financial arrangements so that both doctors and patients benefit from some frugality, and not just the insurance companies, but at the same time not overburdening patients financially.

One good step toward that goal is what is called "reference pricing."  I don't know if you are familiar with this, but it's where the insurance company will pay a standard rate for a procedure that is set to the second lowest price extant in the area, and if a patient wants a higher priced provider then he or she has to pay for it out of pocket.  Part of the problem there, however, is identifying standard procedures, and equivalent quality.  And the biggest pot of money is in chronic care, probably, rather than standard procedures, and I don't think reference pricing will work there.

So there is much more to be done. Note, however, that the first steps taken by insurance companies has been "narrow networks," which is a heavy-handed and quality-killing approach designed to introduce multiple levels of quality of care to patients according to their ability to pay.

The biggest problem, however, is really political, where the biggest players have immense war chests, and while all are for improvement and rationalization in the system, it's the other parts of the system that need change, not mine.  Pharma - 'nuff said.  Academic medical centers?  Hospitals?  Radiologists?  The constituency for meaningful change is not great.
This calls for government intervention to make the playing field work for the public, but our government is fairly weak and ineffective, and the path is far from clear.  Every good business does what it can to establish a monopoly or oligopoly, and the government has let that happen so much that one despairs.

And I added: “As Kurt Vonnegut observed, 'And so it goes.'”
Budd Shenkin

Thursday, June 9, 2016

Dollar Rent-A-Car Sucks


Regular readers will recall our train adventure last year in Scotland where Scotrail did their best to charge for first class and deliver economy and not refund the difference. It took an intervention by the BBC to get us our money back, and to get Scotrail to change their reimbursement policies. Happy ending, which is unusual in any transportation saga.

This year's episode of transportation ripoffs comes from our trip last week to Los Angeles from Oakland, which we accomplished by Southwest Airlines and Dollar Rent-A-Car, and for the time we spent traveling and waiting and standing in lines, we could have done as well by driving the 385 miles, and I will give that serious consideration when the time arises. Seriously, it's probably a 5 ½ hour car trip, and it took us longer than that door to door going down there, and not much shorter coming back.

Why did it take so long? It wasn't TSA's fault – we got pre-checked and the lines were miniscule, although one does have to leave early to play it safe. The biggest fault was at Dollar, where despite having made the reservation on line and having filled out all the requisite documentation, we still had to stand in a line at LAX for 40 minutes while the groups of young people diddled around with the staff in making their rentals, and the staff had to take a break in the back room after each transaction, and where the technology was so slow that it took about 15 minutes when we finally got to the counter. Dollar really sucks. Next time we'll go Hertz or Alamo, where you arrive at the agency and move straight to the lot to pick up your car. My brother did that with Alamo and it was cheaper, too. We will adjust; there are alternatives.

But here's my consumer complaint that is more like the Scotrail trap of last year. Look at the receipt at the top of this article. You see that the rental rate was $29.73 per day for a total of $59.46. Fine, that's what we contracted for, I think, somewhere near that figure, anyway. And you see that we declined all extra coverage, and that we filled the gas tank before returning the car so we weren't charged for gas – I had to show the receipt for the gas to the Dollar attendant. OK. But what's all that other crap underneath? “Concession fee recovery” for $6.84? What the hell is that? “FF surcharge” for $2.08? “CUST FAC CHG” for $10? What the hell is that? Two taxes, well, OK, they do tax everything for tourists everywhere. But what are all those extras?

Who knows or cares what the extras are? What we care about is the final score. Which is, unbelievably, $89.12!

In other words, the total for renting this car from Dollar is 50% higher than what you get from the basic per day charge.

How is this not fraudulent, I ask you? Why does the web site say only $29.73 a day, and not $29.73 + 50%? How is that not false advertising? How is that not like the small print in a credit card contract or a cell phone contract? Is this truly the “American Way?”

I'm hoping Elizabeth Warren addresses this soon in one of her speeches and refers it to the Consumer Financial Protection Agency, and asks Trump what he would do. Don't you think? I mean, 50%? What do they think this is, a payday loan?

Budd Shenkin

Monday, May 30, 2016

Two Patients

I'm always challenged by primary care pediatrics. It's partially because I'm not really the best pediatrician in the world. I try hard, and I always see a patient in front of me, which tells my ethical self that I have to try as hard as I can, but I constantly think about how much I don't know. And then I don't see so many patients anymore, so I forget what I used to know. That troubles me. I'm hoping to go out without a big bang, quitting seeing patients before I have to. But then, I also know my standards are high, so I'm always troubled more by my downside than happy with my upside.

Still, there are the little triumphs that come from helping someone. That is really the best thing about being a doctor, we get to help people. Sometimes trite is true. A couple of weeks ago I saw a ten year old girl at the 95th percentile for both height and weight – big. With a little bit of a mustache starting, just a little. Her history was a little hard to get because her mother is primarily Spanish speaking, and while I can converse in Spanish some, only some. The patient herself goes both ways linguistically, but she's only 10. Her main problem, it said on the chief complaint part of the appointment, was abdominal pain. But when I looked at what I could find about her history, I found that she had been in the hospital last month for vaginal bleeding – a 10 year old in the hospital for vaginal bleeding? And that she had had a transfusion. Then that she had been discharged on birth control pills starting at a high dose and then tapering. When I talked to the mother and daughter there were other things troubling her, including a rash that appears at times on the arms and is treated well with aloe vera, and alarmingly to them, two instances when she was lying down on the couch and then found herself unable to breathe for five seconds each time. That is, she found she couldn't breathe, stood up, and then finally was able to. She had also been tired a lot, maybe other things, too, but I don't remember them right now. (Not to be profiling, you understand, but years of experience were ringing in my ears “Hispanic teenage female!”)

I'm not great on gynecology, but it's not uncommon for girls just beginning menstruation to have irregular periods, to have some scanty bleeding, and sometimes to have very heavy bleeding. What this poor girl had had was irregular bleeding, but then a month of heavy bleeding. That's what led to the hospitalization. A transfusion? Well, that's very unusual, but it could be just impatient housestaff, or maybe the bleeding really was hemorrhagic. But then what had led her to our office? It was her first visit to us. It turned out that her mother was worried about her and thought that she had better come to someplace where she could have confidence that the care was very competent. It always makes me proud to see that we have a good reputation, but it also makes me anxious to make sure we live up to that.

While I was going through the process of making a first contact with a frightened mother and daughter, getting the history and doing the physical exam for a girl who didn't want to be seen in her sensitive areas and who had on tight jeans, I couldn't help noting how tense they were. Well, who wouldn't be after you had bled irregularly for months and months and then had menorrhagia and had to have a transfusion?! So I mentioned to the patient that I could see she was scared, and a lot of times people have something specific in mind – did she worry that she had cancer? Or what? She just kept shaking her head and wouldn't say anything.

Her mother said that she was terribly worried about the no-breathing. I told her I wasn't, that this didn't sound like anything big to me, but she was adamant. Then I put some words in her mouth and I said, were you afraid she was going to die? She looked at me as though I finally understood and told me yes, that's exactly what she was afraid of. Then I looked back to my left and our 10 year old patient on the exam table was crying.

“Ah,” I said to her, “that's what you're afraid of, too, isn't it?” She started nodding her head with some tears rolling down her cheeks. Yes, she nodded.

“You're afraid there's something really bad wrong with you? Is that it?”

More nodding.

“Good,” I said, “so that's it.” And then I reassured her. I told her that she didn't have anything very serious wrong with her. (Hoping I'm right, as always.) At Children’s they had told her that what had happened “was normal.” That's what she heard, anyway, as they were trying to reassure her. But of course getting hospitalized for heavy vaginal bleeding is not normal. What does a patient think then? That they didn't know what they were talking about? That they were lying to her, that they were withholding the truth? Especially when she is an immigrant from El Salvador and her English is only partial. They were afraid they were being lied to.

Then our patient got down and went over to her mother and put her head on her mother and they held each other. I went out of the room to do something, and when I came back there were smiles. Not that they completely trusted me yet, and the mother asked if they could see a Spanish speaking female doctor. You bet, I said. My Spanish isn't really good enough, and I bet you don't completely trust me yet. The mother smiled. That's OK, I said, let's get you a second opinion. And she'll feel more comfortable with a woman doctor.

They were talking with me more easily at this point. The patient told me she was the last of five children and I said, “Do you know what they call the youngest one?”

She shook her head and wondered. I said, “The princess! Everyone loves the baby!”

She loved it. Both of them were smiling and talking. I put her on birth control pills to regulate her periods and made an appointment with one of my colleagues for next week.

As I say, I'm not the greatest pediatrician of all time, I'm hoping just to be above average and good enough not to hurt anyone and to help some. But I felt pretty good about this one.

Then I went on to the next patient, a 9 year old with fever for three days. As I walked into the room I was confronted with a grandmother missing several teeth, a mother, the patient, and three other kids.

“What's the problem?” I asked.

Anthony, the six year old, looked at the poor little sick girl and trenchantly observed, “She has an anger problem.”

The patient had some vomiting and some diarrhea, didn't look dehydrated, the ears were clear, not much else seemed wrong, so I told them it was probably viral and they wanted some Tylenol which I was happy to prescribe. I laid the patient down on her back and flexed her neck and the grandmother said, “He's testing for meningitis.”

I told her she was pretty smart to know that, and she observed she had had a bunch of kids. I told them to come back in a couple of days if it doesn't get better, or go to the ER. “We sure will,” said the grandmother. I wish I could do more for them, but they were happy. They knew the ropes, they had confidence that if we looked at the 9 month old we would do well by them, and they knew the road map. They didn't feel abandoned or alone or vulnerable. I hoped that the patient would get better in a couple of days, poor little girl, but it was good to see how well she would be cared for.

And it was so nice to see that both these patients had Medicaid and they didn't have to worry, they had a source of good care. That was great.

I do have to wonder, however, when I will quit. I will miss doing good for people. I sure hope I don't wait too long, because as I say, I'm not the world's best pediatrician, and I can always make a mistake. Although I have to say, my circumcisions, of which I have performed a couple of thousand, I think, are only getting better and better.

Budd Shenkin

Thursday, May 26, 2016

Adolescent Health Care -- Analysis and Direction

Adolescents are among my favorite patients.  I remember with some pain my own adolescence each time I see a teenager in the office, and I try all the harder to help the patient before me.  Most of them are just so endearing.

It pains me to think how underserved our American teenagers are by medicine!  It should be much better.  So, here is a little paper I put together.  Maybe it will be a help.  Who knows?  Stranger things have happened.  I guess.  (in 1,680 words.)


Serving adolescents properly with health care has always been difficult. Utilization of adolescent health care services (AHCS) is far below where it should be, to the detriment not only of patients, but to the nation's health as a whole. When we know that illnesses often begin in adolescence, and that they could be avoided – or at least detected early and treated at that time – why are they so underutilized?

An article last year in Pediatrics by Hargreaves et al. cites a survey of adolescents and parents. What were the impediments to seeking health care for the teenagers? The results were interesting. (The article is at: http://pediatrics.aappublications.org/content/136/3/513)

  • 37.2% - unmet need perceived to be of low importance
  • 32.0% - non-financial access problems
  • 22.7% - negative consequences of health care
  • 14.8% - cost

Now, that's pretty amazing. It would seem that beliefs and inconvenience were the major reasons these kids didn't get the care that experts believe they needed. A mere 15% said that the money it would cost to get these services was an impediment.

This is an inconvenient conclusion. We love to solve problems by throwing money at them, but these results would seem to suggest that money isn't the issue. Does that mean we will actually have to think this thing through? What a bother that would be!

My thought is that, yes, we'll have to think it through, but not to worry, at the end we can throw some money at the problem with some hope of success, although not immediate. These things do take time. So here's the way I put it together.

First, I bet that the newness of adolescent medicine (AM) as a concept is part of the difficulty. Instead of simply a way station between childhood and adulthood that must be endured, we now see adolescence as a separate stage of life, with its own epidemiology that features major components such as injuries, suicide, drug and alcohol problems, mental and behavioral disorders, and sexual/reproductive issues. It is only in recent years have we have recognized that primary prevention, early detection, and interventions in these issues can not only be effective in helping the kids in the present time, but can also pay dividends in better health for decades to come. It is also only in recent decades that adolescent medicine (AM) has been seen as a distinct entity to be served by pediatricians, with its own subspecialty professionals as sources of instruction and as providers of care to difficult cases. In other words, it's new. Indeed, when I was in training in pediatrics at UCSF, we were not allowed to see patients after their 13th birthday! That's how new it is.

I also bet that this newness hasn't filtered down to the general populace fully. The families and the patients are not aware that there are issues in adolescence that should be approached medically. Adolescents typically feel invulnerable as their prefrontal cortexes are still myelinating, so they don't want to come in, and families just don't realize the potential value of ACHS. In addition, I'm sure the difficulties of confidentiality and embarrassment dissuade adolescents from accessing the services.

Also, note the 32% of the survey who said there were non-financial access problems. Lots of patients don't think of the pediatrician as someone to turn to for adolescent problems – although this is changing – and many pediatricians don't really like to deal with adolescent problems that much, and there are many places where full fledged pediatric services aren't available.

OK, so that's “beliefs” and “access,” rather than a direct financial barrier, which only 15% cite as the problem. Still, it seems to me as a health care policy analyst who tends often to think in economic terms, that money can still be an important part of the problem. And as a usually liberal Democrat, I think I can see my way clear to throw money at the problem. But if we are going to do that, we will have to diminish the salience of that 15% number.

First of all, I'm not sure that 15% is the right number for people who are deterred by cost. People do a lot of rationalization when they give reasons for acting as they did. It is very difficult for many people to think, “I didn't give my kid enough care because I wanted to save money.” It's more comfortable to think, “I didn't go to the doctor because I didn't think it would help,” or, “I didn't think doctors took care of that,” or, “I figured he would grow out of it.” Those ex post facto explanations still allow a parent to think that he or she was acting as a good parent. So I'm pretty sure that the 15% number is factitiously low.

Second, even though the ACA was supposed to make care “affordable,” we all know that there are still significant financial barriers to care. Well child visits are now free, but many teens and young adults still lack coverage, and for those who have it, high deductibles and high coinsurance are still problems, many policies are not covered by the ACA and have even higher barriers, and coverage of just those conditions often experienced by teens – mental health, behavioral, and sexual/reproductive services – are often under-covered or uncovered.

So, I would contend that direct financial barriers are still a problem, much in excess of the 15% reported who are affected by it.

Indirect effects of insufficient financing are also important. Clinicians are paid poorly for ACHS. It is well known that procedural specialties are more generously paid than the so-called cognitive specialties, which would include providers of ACHS. But even within the cognitive specialists, ACHS services are particularly undervalued. For instance, there are special billing codes for preventive care services – that is, well child visits. It is so, so much harder to see a 14 year old than a 7 year old. Yet the clinician is paid only a few dollars more to see the 14 year old, which is ridiculous. It is just hard to get paid for visits where the clinician does a pelvic exam, or where the clinician delves into a teen's depression, which over 10% of teens have. For payment, then, a case could be made for AHCS being the lowest of the low.

What does this low payment pattern lead to? For one thing, it leads to general pediatricians providing fewer AHCS than they otherwise would. That's just straight economics. If you are paid poorly for a service, you will tend not to encourage patients to patronize you for that service.

Second, well-financed services can use their money to construct attractive and even luxurious physical settings, to employ a host of aides, and to advertise to the public. I challenge anyone to think of AHCS settings and advertising to rival that of cardiac surgery.

Third, practitioners of financially favored fields hold positions of great respect in society. They are revered. It is hard to think of someone in AH being revered for preventing a suicide.

Fourth, physicians in training vie for positions in the fellowships that will grant them not only the ability to do good, but the ability to do well. AH fellowships are subject to much less demand even though there are fewer such positions available. It is hard for someone to choose a fellowship for three years at the end of which one will be qualified to provide services that will earn one less than one could make at the beginning of the fellowship from being a general pediatrician. Specialists in AM are generally not the major purveyors of ACHS; general pediatricians generally do that. But it is the graduates of the AH fellowships who will train the general pediatricians and give them enthusiasm for the field. As it is, however, training in AM for the primary care pediatricians is far from extensive, as training programs continue to concentrate on hospital-based services and specialties. If the financial rewards were more attractive, basic economics tells us that enthusiasm would be greater.

In sum, then, although patients might not cite financial obstacles as the key for their not obtaining services, there is a strong basis for thinking that if the field were better financed, increased utilization would follow.

What to do, then? Here are just a few suggestions, just illustrative, not definitive:

  • Change the focus of health care cost controls when it comes to AHCS. For much of medicine currently, the aim is to cut costs. For AHCS, the aim should be to increase costs. One could double or triple the cost of AHCS and it would have no impact whatsoever in the national health expenditures. Increasing expenditures would establish a better balance of expenditures and result in better health and eventually lower costs, as adult health improved and costs declined as the well-served adolescents age.
  • Change the ACA provisions for AHCS. Make all outpatient visits for teens have no deductible and only minor copays.
  • Equalize physical and mental health payments for teens.
  • Increase the requirements for AH training in all pediatrics residency programs. Introduce business case training in these programs to teach future primary care pediatricians how they can make money in adolescent health.
  • Change the Relative Value Units assigned to teen well visits – I would increase them by at least 50%.
  • Develop a set of standards for health status for adolescents under the care of larger health care institutions, and require that measurements be taken under supervision at regular times, and that the results be published.
  • Institute Pay For Performance measures specific to AH applicable for smaller practices, and require insurers to pay significant amounts to practices who achieve measures in stepped amounts according to percentile.

AH is a lot more important than people realize. There is a lot that can be improved by grants and special programs, I'm sure. But for a long lasting and relatively simple effort, I would support the basics of human economic theory – pay them more, and measure the results.

Budd Shenkin

Friday, May 20, 2016

Innovation and the Hospital Industry

Innovation is so dependent on the structure of an industry!  For instance, this morning I had breakfast with my friend Stu Lovett, a very talented high risk obstetrician and excellent innovative thinker.  Stu has devised a great software program (and invested a lot of his own money in developing it) that would increase the safety of deliveries by enabling clear decision making criteria for handling deliveries.  Hospitals are reluctant to adopt this innovation.  Why?

One, others haven't adopted it yet, so it would be an administrative risk for the first hospital to try it out.  Two, hospitals don't want to take the risk because there isn't that much for them to gain.  After all, they are already insured for bad deliveries, and if they made babies safer, would their business expand?  No, so why do it.  Three, most hospitals are "blame organizations" rather than "achievement organizations."  The incentive for each executive is not to get into trouble, which could cost them their job, rather than to achieve a quality breakthrough, which would not gain them much individually.

It's really a shame.  If there were real competition among hospitals, and if one hospital could eat another's lunch by showing it was safer, then someone would make the try.  But hospitals mostly just cover their territory and if they want to grow, they merge.

Another example of failure of innovation based on industry structure is in the age old health care question, how do we get Emergency Departments to be used only for emergencies, and move the non-emergency cases out of the ED?  I was asked to review an unexciting article for the Yearbook of Pediatrics, excellently edited by Michael Cabana, that showed that indeed, mirabile dictu, EDs are more expensive than other venues.  I used the article to talk about industry structure and innovation.  Here it is, and I hope you enjoy it:

Commentary on Urgent Care and Emergency Department Visits in the Pediatric Population
Montalbano et al., Pediatrics, April 2016

Reviewed for Yearbook of Pediatrics by Budd N. Shenkin, MD, MAPA

“Invent a better mousetrap and the world will beat a path to your door.” Oh, if only it were as true in healthcare as it is in consumer goods!

This article demonstrates that, to no one's surprise, Urgent Care Clinics (UC's) provide less expensive care to patients with mild and non-urgent illnesses than Emergency Departments (ED's), with no apparent loss of quality. One wonders, then, if it should be surprising is that ED's are still handling the bulk of urgent care in the United States. Is this what economists call a “market failure?” where equivalent quality and lower price fail to drive out the more expensive competitor? If so, why has this market failed?

One answer is that it is not in the economic interest of those who would set up and run UC's to do so. Who would the agents of change be? Not hospitals; they would be cutting their own throats. It is easy to set up a UC side by side with an ED, staff it with midlevels supervised by physicians, and divert urgent but non-severe cases from ED to UC at ED triage. The result is less expensive care, true, who experiences the savings? Not the hospital; the hospital experiences primarily decreased revenues, and less profit per patient to subsidize the expensive ED equipment and staffing. Instead, the savings are experienced by insurance companies and patients. Why, then, would a hospital do it?

Although the article does not explore alternative arrangements, private practices and clinics could establish UC's on their own, either by simply extending their hours to evenings and weekends, or cooperating among themselves to set up and staff a UC for out of hours care. This comes at a cost to themselves of convenience, because it means working at less attractive hours or hiring others to do so. There are CPT codes that would be applicable for extra compensation for out of hours care, but the payment is modest, and moreover, many payers choose not to honor those codes. As a result, once again, out of hours care savings redound to the benefit of government, insurance companies and patients, but not sufficiently to practices for them to answer the bell for potential profits.

Perhaps more tellingly, the article calculates that roughly $50 million a year could be saved by Medicaid were UC's to replace ED's for level 1 pediatric cases. While $50 million sounds like a lot of money, how significant would that really be? Total Medicaid spending for the United States in 2014 was about $476 billion. The projected savings to government would thus be .01%. The savings, then (like pediatric care overall in the nation's health care budget) would be “budget dust.” Saving $875 million by seeing all level 1 and level 2 cases would be a more significant .18%, still close to budget dust. By contrast, Medicaid is said to lose $29 billion to fraud, which would be 6%. No wonder government appears not to care much about the apparent ED waste.i

Moreover, one unit's “waste” is another unit's profit. By reducing the acute care income from an ED, the hospital ED would become less profitable. In effect, this extra remuneration for the ER subsidizes the cost of having ready a unit to service the true emergencies that appear there, which in themselves would not be financially worthwhile to serve. It might be true that, were UC's to proliferate, hospitals would be impelled to centralize their true emergency services to one hospital per city, but would that be optimal care? It is not clear that it would be.

Thus, the case for UC's replacing ED's for common acute care appears to be shaky. On the other hand, extending out of hours care at Pediatric Patient Centered Medical Homes appears to be a better choice. True, the savings for Medicaid would still appear to be small. The savings for private insurance might be larger, since private payments are usually higher than Medicaid payments. But even if the economic advantage were small, the improved quality of care and simplified communications conferred by better continuity might impel change. Convenience for the patient could also be enhanced, since waiting times are so much higher in ED's than in an office or many clinics. In addition, since ACOs are ever in search of even small financial advantages, they might encourage pediatric practices to become PPCMHs and to provide the out of hours care that are part of the PPCMH charter. An ACO would also be in a position to make out of hours care financially attractive for a PPCMH, rather than a sacrifice.

If there were to be more research on the economics of replacing routine acute care now performed in the ED, considering the PPCMH might be a better alternative to consider than a UC. The PPCMH is, after all, the American Academy of Pediatrics' preferred solution for transforming the organization of pediatric health care. In sum, despite the small economic advantage of diverting patients from the ED, there is still reason for hope.

iMedicaid Program Integrity:
Improved Guidance Needed to Better Support Efforts to Screen Managed Care Providers
GAO-16-402: Published: Apr 22, 2016. Publicly Released: May 6, 2016.
Accessed at http://www.gao.gov/products/GAO-16-402 on May 9, 2016.

 Budd Shenkin

Tuesday, May 17, 2016

Progress in the World

His contention, which I have seen before in a current economics book, is that recent technological innovations have had less effect on society than did innovations of a century and a century and a half ago. While this argument has some initial appeal, I believe that it is essentially fallacious. He mentions advances such as indoor plumbing, railroads, cars and highways, elements of society that we can't imagine doing without. Yes, these are now essential to us, and there is a huge difference between having enough (toilets), and having more than enough (fancy showers,) but I think the trap Irwin falls into is that of thinking too narrowly.

But first, a little bit on how he is right. Advances in a field often meet the Law of Diminishing Marginal Returns. As an analogy, if you buy a stock at 3, arriving at 6 is a 100% advance, but then a similar gain of 3 points up from 6 is only a 50% advance, and so on. The further you go the less the impact of an equivalent gain. When the United States was a developing economy, we went from horse to train to car, moving from a 3 or 5 mile life experience perimeter to 200 miles – huge – to maybe 1,000 miles to 2,000 – huge, but less so – to intercontinental – still huge, but even less life-altering. From less than enough, to enough, to more than enough. True.

Here is my rebuttal. One, there are other fields of advance to look to in society, so while it might be true for households and transportation, it isn't true for society as a whole. And two, the Law itself is not always true. Readers will not be surprised as I cite, once again, my profession of medicine.

First, society as a whole. Our society is composed of many different sectors. Each one will advance with different start dates and different end dates. It is analogous to the business cycle of leading and lagging sectors of the economy. Transportation and manufacturing started when Irwin says they did. The 19th and 20th centuries had huge advances. Their impact is now slowing down. OK. But medicine started later and is now proceeding faster than ever before. Where the leading sectors faltered in their effects, the lagging sectors have taken over.

Look how impactful medicine has been and will be. In 2011 I had a pituitary adenoma operated on without cutting open my head. Instead, my surgeon used fiber-optics to go in through my nose and sinuses and cut out a tumor the size of a small tomato and I was out of the hospital completely cured in two days. My hormones are easily supplemented by a pill and application of a gel every day. Unlike transportation or home improvements, everyone doesn't see and experience this every day, but to me and thousands like me, it's a pretty big difference in what would have happened just a few decades ago.

Likewise for my friend Bob, who without modern cardiology would be dead as a nail. And what about the millions with hypertension who now go through life normally instead of dying from cerebral hemorrhages the way FDR did, or from heart attacks the way two of our neighbors did when I was a young teenager. And what would Mickey Mantle's knees have looked like with today's orthopedics? Light years differences here, everybody.

Moreover, and here's the second point, it is not at all clear that we are reaching medical nirvana asymptotically. It is not clear that we are going from enough to more than enough. Medicine and other technologies seem not to experience linear advances, but geometric advances, building cumulatively as knowledge expands. In fact, we are on track now to see Star Trek medicine sooner rather than later.

At some point, of course, we will reach an asymptote. Maybe when we conquer aging we will be faced with the dilemma of not enough room for everyone, even more than we are finding that now in the world. Maybe medicine will outrace reaching for satellite civilizations on the Moon and on Mars. Maybe the contradictions will appear at that point. Or, maybe they are appearing already, as medical advances lead to overpopulation right now, as in places like Syria where modern survival statistics and traditional large families combine with drought to produce wars and exodus. Maybe the killer will be the introduction of genetically altered mosquitoes that abolish malaria as the scourge it is, leading to overpopulation and untold hardship and suffering. That will be a horrible asymptote. Who knows where the asymptote will be?

But as of now, I think Irwin is premature in his assessment that progress has found its asymptote. He's right about households and transportation, but wrong about medicine and other technologies. He's probably also wrong about education, which could do a lot better than it has done. He's certainly wrong about the science of the mind. Eventually he will be right, just not now. And then if we last that long, eventually he will be wrong again with the next wave of advancement.

He needs to read some science fiction, probably.

Budd Shenkin