Wednesday, September 25, 2013

Disillusioned with government

There are many reasons and ways to distrust government, God knows.  As a card-carrying liberal, I have always thought of the good things government can do.  But the more I get involved in government programs, the less I trust.

Here is a beautiful example.  What could be more important to kids than vaccines?  Aside from clean water supplies, there have arguably been no measures more important for saving lives.  Public health demands that children be vaccinated.

In this country the great preponderance of vaccines are dispensed by private medical offices.  No problem there – in general, they do a good job.  Enter, government!

The government says, why should patients on Medicaid get vaccinations the way all the private patients do?  Let’s do it our way!  Instead of having local offices purchase the vaccines and charge for them (with overhead included in the charge), let’s buy the vaccines ourselves (it’s called the Vaccines For Children program, or VFC), ship them to the doctors, and have them give the vaccines to the Medicaid kids.  And since the offices don’t pay for these vaccines, let’s not pay them anything except for administering the vaccines – let them order, receive, inventory, refrigerate, etc. for free.  In other words, if an office agrees to see Medicaid children, let’s make sure they lose money on the deal, because they will have to pay for their overhead out of their own pockets.  That’s their reward.

But wait, you say you’re not satisfied, you say you want more for your money – tell ya’ what I’m gonna do!  Not only will you get no payment for overhead, but if you somehow drop a dose on the floor, you will have to pay us the cost of that vaccine.

And that’s not all.  In addition, we will dictate how you will store your vaccine; it can only be in approved refrigerators and freezers, which you have to buy out of your own pocket.

And even that’s not all.  Some states (hello, Connecticut) will also supply “free” vaccines for even those kids covered by private insurance, so the practices can lose overhead on those kids also!

And then, let’s regulate some more.  Let’s make sure that if a practice has a shortage of a certain vaccine for the VFC program, you can’t borrow from your private stock to vaccinate a kid and replace it later, or vice-versa, no matter how good your record keeping.

And there’s even more – let’s mandate that all vaccines have to be stored separately according to who purchased it.  Here is what Graham Barden, terrific public spirited pediatrician from North Carolina has to say:

Just when you thought the CDC's requests could not get crazier.  The CDC thinks it is reasonable to have separate VFC, Private, S-CHIP, 317, State supplied vaccine. Five complete sets of vaccines. The bean counters want to make sure no one can say they are not counting beans!  Paperwork is now the measure of our success.”

As I said, I have always believed in government.  But when I get up close, government doesn’t seem so nice to deal with.

Budd Shenkin

Restrictive Medical Networks

We know that insurance companies are cutting costs by narrowing networks for physicians and for hospitals, or “tiered networks.”  Our problem is this conjunction that flows off the tongue, "physicians and hospitals."
To be more concrete, here is how it works for a primary care practice.  You as a primary care practice receive a contract proposal from Blue Shield, say.  You can sign up for network, A, B, C, or D.  If you sign up for Network A, all your charges will be paid for at 70% of the Medicare base price.  Patients who sign up for Network A, which costs the insurance company somewhat less because the fees paid are lower, will pay a lower premium than for other networks.  If you sign up for Network B, you will be paid say 80% of Medicare – a somewhat higher fee – but the only patients who can come to you will be those who sign up for Network B and pay the higher premium.  And so on.
From the patient’s point of view, it will be a juggling act – sign up for a Network and figure out where you can go.  If you already have a primary care doctor, see which Network you can sign up for and not change doctors.  We have seen by experience that many, many patients will sign up for a cheaper plan and make the doctor switch.
I’m not quite sure how it will work for hospitals.  It might be that patients in Network A will need to go to a hospital that signed up for that network, and thus will receive a lower payment from the insurance company.  Or it may be that the plan will be so-called “reference pricing.”  In this approach the patient can go to any hospital, but the insurance will pay the charge given by the lowest (or maybe second lowest) hospital in the wide area, and the patient needs to pony up the rest if he or she chooses a more expensive hospital. 
Now, there is every reason to restrict choice of hospitals.  This is where the money is, this is where the savings will be, and this is exactly where the excessive charges are.  There is plenty of evidence of great variability of charges with no correlation with quality (as far as quality can be measured, but that measurement is pretty good for hospitals as compared to outpatient quality.)  It's hard to narrow this network because of hospital consolidations and local monopolies that have resulted, but it must be done, somehow. 
On the other hand, there would appear to be no reason at all to restrict access to primary care.  Primary care impacts only minimally on the health care budget.  Good primary care, high quality primary care, is generally cost-saving rather than cost-enhancing.  There is no evidence whatsoever of primary care being excessively priced.
In fact, what might happen is the reemergence of so-called Medicaid mills.  One can save money in primary care by having clinics staffed by midlevel professionals – nurse practitioners and physicians assistants – and restricting access to patients by a variety of means.  Decreased quality of care in Medicaid mills is inevitable.  But because of the limited impact of primary care onto the health care budget, virtually nothing will be gained by this approach and much will be lost.  It is well established in health policy that the United States has too little primary care, not too much, and the restricted network approach will only further exacerbate that deficit.
[Note that I have not discussed specialists here, only primary care and hospitals.  Probably the best approach would be to split specialists into proceduralists and non-proceduralists, and treat the proceduralists like the hospitals, and the non-proceduralists like the primary care docs.  There are a lot more imaginative approaches that could be followed, but this might be a simple first step.]
Anyway, that’s my view.  There will doubtless be lots of confusion and some conflict, but if the insurance companies are in charge, as the ACA puts them, there is every reason to expect difficulties and missteps. 
Budd Shenkin

Wednesday, September 18, 2013

Second Opinions

Paul Levy has another interesting post on the value of second opinions.  He says:

Simon Schurr at Collaborative Medical Technology Corporation suggests in this blog post that current levels of overtreatment and inappropriate care could be reduced by more widespread and judicious use of second opinions.  He points to unnecessary surgeries, overtreatment of back pain, mistreating ovarian cancer, and outdated procedures.

His diagnosis: "The causes of inappropriate care are complex, but often the root is simply lack of knowledge, an honest mistake, or a healthcare provider who simply wants to help a patient when treatment isn’t working. Sometimes, profit-driven decision-making or fear of malpractice claims lead to over-testing and overtreatment."

His solution:  "The best approach may be a combination of well-informed patients asking the right questions and seeking top doctors who stay abreast of the latest research, and rigor in using second opinions."

My response:

Here, here!
Years ago I advocated (in the first ever Sounding Board section in the NEJM) for patient access to medical records, partly reasoning that if medical records got a wider circulation, their quality would improve, because clinicians would know that what they wrote could be seen by others.  Now, EMR serves the same purpose, as does the growth of group practices generally, where you know that your colleagues will sometimes see your patients and read your notes and judge.
Likewise, it's possible that even the knowledge that your patient would likely be seeking a second opinion would be very bracing.  When our pediatric practice seemed to have an excessive number of referrals to specialists for one HMO. I announced that I would be reviewing all referral requests from our group before they went out.  Instantly, the number of requests dropped, just from the knowledge that they would be reviewed.  I then had to send back the referral request for reconsideration by the clinician only rarely; just the existence of the review process did the job -- as expected.
Moreover, if you consider Groopman's How Doctors Think, you immediately are impressed with the desirability of second opinions,  to avoid the cognitive error of anchoring, if nothing else.
Here's another example.  A doctor friend of mine had a father-in-law, I think it was, who was sick for years and years without a diagnosis.  By chance, my friend and his father-in-law were walking around the halls of Dartmouth Medical Center and a doctor friend of my friend saw them, walked up to them, and said to the father-in-law, "You have hemochromatosis!"  He could just tell by the look.  After years without a diagnosis.  A single doctor just can't know everything.
Or, consider this.  Just two days ago I was at our health club and a 76 year old friend came up to me.  He had pneumonia almost a year ago and has never really recovered, he thinks.  For the last few weeks he has felt really, really tired.  He's worried -- as he should be.  He asked me about a second opinion -- from an internist, he specified -- because his regular doctor (who is in fact an internist), who he likes, hasn't pinned down anything.  Is his doctor saying subconsciously to himself that my friend Arthur has just run out his string?  Is he out of ideas?  What?  I don't know.  But I urged Arther to in fact get a set of fresh eyes on him -- take up the case from the beginning!  Why not?  Visits are cheap.
Finally, while we have many specialists in many fields, what we really don't have is a super specialist in internal medicine.  When I did my medical school internal medicine rotation at the Beth Israel we had an attending who was revered for his differential diagnosis acumen (Manny something).  His visits were prized, as various residents sought help, and to stump him.  The Chief Residents sought to emulate him.  But what happened to these Chief Residents when they moved on out of training?  Chief Residency was the best training possible for a job that didn't, and doesn't, exist.  You either go to a recognized specialty, or you go into primary care, which really presents a different set of circumstances than Chief Residency.  (For one thing, primary care puts a premium on prevention, which internists generally do not excel at, nor are they well trained for, etc.)
What we need is an institutional setting for the master internist, someone to turn to, or a set of doctors to turn to, who are really smart.  They wouldn't have to give primary care, and their field would feature breadth, rather than the depth of the recognized specialties.  These would be great for second opinions.
I guess you could do the same thing for surgery, but that's a more complicated issue.

And to reiterate: visits are cheap - it's the procedures that are expensive.

Budd Shenkin

Sunday, September 15, 2013

Monopoly and Medical Care

In every industry as a firm gets larger and conglomerates, it explains to regulators that its size will redound to the benefit of consumers, as they will be able to offer new services, etc.  Usually, it is bull-diggy.  Who wouldn't want a monopoly?

Paul Levy writes a very interesting blog called "Not Running a Hospital."  It used to be called "Running a Hospital" when he was CEO of Beth Israel Deaconess, a Harvard hospital, and he renamed it when he left his job.  Before I discovered this blog, I had heard of him from some Teaching Company tapes on Leadership - how he came into a dysfunctional Board at the Beth Israel and laid down the rules and turned the institution around.

Anyway, here is his latest blog and my response:

Posted: 13 Sep 2013 06:22 AM PDT
Just when you think you've seen the limits of market power, creativity emerges.  Julie Donnelly at the Boston Business Journal reports:

Partners HealthCare aims to drive new members to its newly acquired health insurer, Neighborhood Health Plan, by cutting off access to some doctors within new health plans offered under ObamaCare.

Neighborhood Health Plan is one of 10 insurers that has been certified to offer subsidized and un-subsidized ObamaCare plans through the state’s Health Connector.

But what Neighborhood Health Plan has is exclusive access to primary-care doctors at Brigham and Women’s Hospital and Massachusetts General Hospital.

Now that Partners, the parent organization of the Brigham and Mass General, owns a piece of the insurance pie, they have decided to offer access to their primary care doctors only to those members who choose Neighborhood Health Plan.

This is likely to drive new business to Neighborhood Health Plan from Boston-area patients who want to keep or begin a relationship with a primary-care doctor at one of the two most prestigious hospitals in the state.
This is a departure from Partners’ strategy in the past. Before its purchase of Neighborhood Health Plan, Partners’ offered access to its doctors to all of the health plans within the state-subsidized health plans that were launched under Massachusetts' own statewide health reform.

And I wrote in rsponse:

Paul, this new thrust by Partners' seems really important. 

I get how pissed off you are at them, probably buttressed by a holier-than-thou sanctimonious and hypocritical attitude -- I was at HMS, so I get that.  
But I'm wondering how this fits in with Kaiser?  And maybe Apple -- closed networks, both. And ACO's.  All talk about the importance of integration - the Oliver Williamson (Nobel Prize, economics) idea that incorporating functions within one company can be more efficient than a market.  Don't get me wrong, I'm with you in smelling monopoly, and as a former primary care doctor with an independent company, I never wanted to be incorporated and thus controlled by an exclusive relationship with a single payer.  I thought it was better for patients, and better for our practice, for us to be independent and have multiple avenues of ingress for patients.  And I had no question that an exclusive relationship would spell decreased payments for us in primary care.
But the ultimate problem with our current medical care system is hospitals and hospital costs.  Kaiser cuts them down because everyone there benefits from decreased hospital costs.  Although they are unionized, and that's a problem.  (Interestingly, when you go into an exam room, the medical assistant is wearing a large, prominent pin that says SEIU!!)  So one could say that to get control of the system they need a completely integrated company.  In this case, of course, one could say that it is not a small upstart company competing with the behemoths, but the latter solidifying their position.  In that case, we rely on government and anti-trust, but we know that's not going to work at this stage of the game. 
Anyway, I would encourage you to keep writing about this, as deep as possible.

Budd Shenkin

Saturday, September 14, 2013

Obama and Putin - Let's Be Optimists!

So, Obama has waged a “feckless” (my word) and confused foreign policy, Putin has “bested him,” and the US looks inward, the world has no cop, the Russians are back in play in the Middle East where they have been aching to arrive again as a Big Power, they say.

As my roommate Peter Kelley from Aroostook County, Maine, used to say, “Bull-diggy.”  Instead, it is time for optimism.

Let’s get away from American “primacy.”  We’re big, we’re powerful – but we’re not the only ones in the world.  We are a settled country, where the government has a monopoly on violence, which is what a non-failed state is.  OK.  We think we have the best government there has ever been – OK, that’s defensible, although not airtight, and as far as I know, it’s true.  Putin is ridiculous when he talks about democracy, and about everyone’s not having achieved it fully, implying that he and Russia have, I guess, although that’s not certain from his editorial.

The Russian government wanted to come over and lobby the House of Representatives!!  How hard to believe is that??  Why isn’t anyone saying anything about that, I wonder?  Putin publishes in the New York Times – lots of holes in his argument, but still!

The fact is, and has long been, that settled governments have a lot of common interests, overwhelming common interests, against disruptive forces like terrorism (did Putin chuckle an “I told you so” when the Chechens hit Boston?), and against their combined assault on the commons of the earth’s environment.

We have to pay attention to human rights, OK – but it’s better than it used to be.  Jews can still emigrate, can’t they?  China has lifted tens of millions out of poverty.  But still – we have a lot in common, and if we don’t get all absolutist on the human rights thing, the civil liberties (which I treasure), if we concentrate on a more public health point of view, a collective good point of view, we can celebrate a coming together, ice-flow breaking up of American-Russian cooperation.

I get pissed off at Obama, true.  But along with millions of others I got pissed off at Nixon, but in retrospect, policy-wise, he was very good in so many ways.  He relied on Pat Moynihan domestically, and although he was terrible on Chile – thanks, Henry – if he had just had a different personality, he would have been pretty good overall.  And my being pissed off at Obama isn’t even near the ballpark of being pissed off at Nixon, not even at the hotdog stand outside the stadium, or even paying off some kid to watch my car when I’m a few blocks away at the game, not near.  So, let’s just call it a general disappointment that will fade with time and with appreciation of the real achievements of the Obama Administration (excepting Eric Holder and his outlawing of investigative journalism when it concerns the Feds.)  But that’s just personal, not business.

Why not let Putin into the game and work together?  It’s not like we’re doing so great on our own.  Why not let him keep Syria in his pocket (do we really have much of a choice, really?)  Does it really hurt us?  What’s Putin’s position on Israel?  I don’t think he’s against it; I bet he is willing to see a successful so-called Peace Process.  Does he want to construct a new Warsaw Pact in the Middle East?  Don’t think so.  Does he want Iran to have the Bomb?  Don’t think so.  Does he want countries to adopt a Communist form or government?  Don’t think so.  I mean really, even if Russians are mean sons of bitches, where is the threat?  Am I just so blind?  Will the Russians construct a new operating system and outlaw Microsoft?  Will they overtake Google?  Where is the competition?  Oil?  Oil?  We’re all on our way to conservation and home-brewing from shale.  Maybe I’m blind.

So, I’ve thought from the start that Kerry will go down as a remarkable Secretary of State, far surpassing Hillary, who really was a competent presence, but nothing remarkable.  Smart, but not innovative, nor probably very flexible.  Could it still be Kerry for President?  I think that ship has sailed and hit the rocks.  But, could it be a new era, and a Nobel?  Could be.

I’m going far, far into euphoric optimism here, buying a stock as it emerges shakily from a very long base.  It’s really too early to tell.  That’s why this essay will simply stay on the blog, not read by many, and if it really becomes true bulldiggy, who will remember?

But I say, let them work together.  Let’s not forget that Fox News and the war-mongers of the Right, always there, will yell and scream.  David Talbot thinks that it was Kennedy’s opposition to the war-mongers that got him killed (Brothers, 2007, Free Press).  Eisenhower identified the Military-Industrial Complex, and it was only in late drafts of the speech that he amended that term from his initial one, “Military-Industrial-Congressional Complex.”  So, we will hear a lot from the House, whose members’ districts still thrive on the military, dispersed strategically throughout the US.  There are interests, there are viewpoints, there is violence always as a threat.  Personally, I would double Obama’s security detail.

But I’m optimistic.

Budd Shenkin

Monday, September 2, 2013

Syria, Intervention, America's Role

I am no fan of Obama, although I voted for him twice; each time, there was essentially no competition, as indeed there hasn’t been for my whole adult life, in which I have never voted Republican for President.  Just the Supreme Court could tip the scales, but in truth the scales were already way over to the left to begin with.  So, like so many of us, I can vote consistently and be consistently rather lukewarm.

But that said, I think Obama is doing pretty much the right thing right now on Syria.  Whether he has done the right thing up to now, I’m not sure, since he seems to have painted himself into a corner with his Red Line statements.  But even that might be OK.  To give a preview of my analysis, I think it might be more important what Obama and the Americans say, rather than what they do.

Two Roles

First of all, let’s distinguish two roles: fighting on the side of the rebels (Role 1), and enforcing the moral and international legal norm of not using chemical weapons (Role 2). 

The first issue has been debated for two years, and is complicated by our history of terribly mistaken enmeshing wars in Iraq and Afganistan, by the history of the Middle East and our escalating unpopularity there; and by the lack of cohesion of a rebel side, well known religious extremist growing preponderance therein, and the lack of democratic sensibility in the region as made clear by the Arab Spring and its lack of democratic flowers.  As a result of all this and more, the Americans have decided to stay out, citing especially the Law of Unintended Consequences and the lack of immediate American security interests.

The second issue has come up in the Syrian conflict once before under obfuscatory circumstances, but now in the last few weeks much more directly and unavoidably.  There is an international treaty, to which I think Syria is not a signatory, against the use of chemical weapons.  Even if not a signatory, the internationally recognized norm is that such weapons should not be used.  War brings out strange quasi-religious beliefs, it seems, that one kind of death is unlike another – fire bombing of some German cities, Dresden for one, caused much more destruction and loss of life than Hiroshima and Nagasaki, but nuclear bombs are verboten and conventional bombing isn’t.  It’s OK to kill one kind of human – combatants – but not another – non-combatants.  Go figure.

Nonetheless, if there is such a norm, how is it to be enforced?  Who shall enforce it?  Is there really such a thing as a world-wide consensus?  If so, is it represented in the United Nations, or some other supra-national organization?  Or can one nation, the United States, claim moral infallibility and be the enforcer?

I said that it might be most important what America says, rather than what it does.  Distinguishing these two roles is what I meant.  Do we enter the arena at all, and if we do, is it to finally engage in the former conflict as combatants, or is it in the role of enforcer of the international norm?

The Tragedy of American Unexceptionalism

Given the decline of hopes for first the League of Nations and then the UN, some in the “free world” hoped that America would lead.  There was at least some surface validity, it seemed, to American exceptionalism, that we were outside the stark geopolitical arena of interests, that we had a sense of human rights and the just society that we would support anywhere as friends of the court.  Make the world safe for democracy.  The socialists had a competing view but as time went on Stalin did his bit to destroy that myth as geopolitical nationalism became the obvious goal, and as the Soviet Union as a just (and efficient) society became an untenable concept, even to Susan Sontag (far into the Brezhnev era, as I recall – but I digress into a personal bĂȘte noir.) 

America was given a pass on its claims for a while, despite United Fruit and the oil companies and the Negro Problem, probably because people could come here from throughout the world and be accepted and do well, and it just seemed like a good place to live and grow up.  After the depredations of the Dulles brothers, Vietnam accelerated the decline of that view of America, and the Iraq deception and Abu Ghraib and other torture and Guantanamo and now unfettered NSA snooping have put the cap on it.  There is no longer any moral high ground left for America in the world’s view.

America is the world’s only military superpower.  People have said, don’t underestimate the evil in the world (true), and how much worse it would be if America were not the world’s cop.  No doubt true.  The problem is, how are you the world’s cop if you have lost the legitimacy you once had?  America could once assemble a powerful coalition of the willing – see Iraq I.  The neoconservatives put the end to that with chimerical coalitions in Iraq and Afganistan.  It appears with Syria all we’re left with is France, the original colonial power there.  Not enough.

Making the Distinction

So, we don’t wade into Syria in the first instance.  Eventually, after what should be called war crime after war crime, the Assad regime uses chemical weapons.  There is skepticism on the evidence, fueled by blowback from Bush-Cheney deception, much of which will not be made public because it rests on surveillance that even Snowden appears not to have revealed, but which I expect to be compelling very soon, nonetheless.  How do you believably declare that you are going to intervene in Role 2 (referee), and not in Role 1 (combatant)?  How can you intervene in Role 2, but not have an effect on Role 1 – that is, how can you penalize the Syrian government for a low blow but not tilt the outcome of the match?

The answer is, you can say what your motivations are, but you can’t fulfill only Role 2 without weighing in on Role 1 as well.  A boxing referee awards points to the opponents for a low blow, which tilts the outcome.  If there is more than a low blow – the boxing equivalent of use of nuclear weapons, perhaps doping the opponent – then the match is declared over and the winner anointed.  If Assad used a nuke the world would be obligated to step in militarily with whatever we had.  With chemical weapons first instance, award points.

This is where I think rhetoric makes the difference, and is the most important thing.  Why are we going in and awarding points?  As the referee.  What kind of points?  Bombing the remaining functioning airfields to hamper the Iranian and Russian resupplies.  Does it help the rebels?  Yes.  Is it decisive?  No.

It would be nice if we could just declare Bashar a war criminal and turn him over to The Hague.  Unfortunately, that is what we have tried to do with Omar al Bashir of Sudan, and look what effect that has had?  As I understand it, mostly a travel ban.  That’s not enough points to award; ask South Sudan.  So, intervention it is for Bashar.

The Usefulness of Consulting Congress

Open discussion and joint decision making is derided by the world that is not used to democracy – interestingly, that derision of “weakness” tells us a lot of what we need to know about the ease of introducing democracy to the world without a parliamentary tradition.  But it will be best for us to do so; it is in our national interest.

The discussion will inevitably give a very complicated but descriptive narration to our motivation.  McCain and Graham want us to fulfill Role 1.  Others want us to fulfill Role 0.  It will be up to Obama to give voice to, and the Congress as a whole to endorse, Role 2.  Maybe it can be done, maybe it can’t.  Maybe it will help others in the world to join us, maybe it won’t.  Maybe it will disappoint everyone from the Saudi’s to the Scandinavians (where are they, by the way, those arbiters of decency?).  But at least it will be us.  This is the way we ought to do things.  If Congress fails, so be it.  That will lead to further discussion and evolution of our institutions.  We need to clarify where we are and how we function, and this whole process should further that need.

Geopolitical Effects

It seems everyone wants us in there for their own purposes.  Assad probably wants us in there so he can rally support of the anti-Americans; ditto the Iranians and Russians.  Even if the declared purpose of America is as referee, few in the non-Western world will see it that way.  But at some point you just have to say, WTF.  Look and learn.

The Israeli’s are probably disappointed; they, too, want a dictator on their side.  The Egyptian military wants us to keep out; they fear the anti-Americanism that will result, and the al Queda predominance of the rebel forces.  The rebels want us in, they want the points.  I bet the Russians want us out, because it will be hard for them to profit from our entry, and they want to keep Assad on their side – “human rights” and “Russia” cannot be uttered believably in the same sentence.  The Chinese probably want us bogged down and they benefit from Anti-Americanism as they buy up African land.  No one wishes an empire well, it seems – what did we bring the world except prosperity and human rights?  (I exaggerate, but can’t help myself from echoing the great scene in Life of Brian as the opposition sects decry the effect of Pax Romana.)

But to all of this, I think you just have to say to the rest of the world, deal with it.  We’re awarding the rebels points, whoever they are.  If it becomes clear in the future that we can really make a credible contribution to peace, prosperity, and human rights in Syria, we will.  But for right now, we’re just awarding points. 

Budd Shenkin