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Sunday, July 16, 2017

Repeal and Replace Agonies

The Republican attempts to change the ACA into something else are destined to fail. They are destined to fail not necessarily because their ideas are devoid of any merit, but they are destined to fail because they are charged with a series of impossible tasks. The only acceptable outcomes which are politically sellable are ones that must include the following characteristics:

1. All pre-existing conditions must be covered and insurance companies cannot discriminate on the basis of age of illness. To be actuarial sound you need broad participation but you can't force people to buy insurance they do not want to buy.
2. People must be insulated from the costs of care - this means minimal to non-existent copays and deductibles
3. Since health care is a right, all reasonable services need to be covered, including new and innovative treatments, drugs, and procedures
4. Cost of care must be kept in control and increases in costs must not break state or Federal budgets. However, you need to cut costs without cutting expenditures. Cutting expenditures means you will be killing people. This is where the game of political Twister really becomes interesting.

This is an impossible task. They simply cannot succeed. The insurance markets are a complete mess with the prospect of complete breakdown without intervention. However, no intervention is likely to happen without total collapse. The collapse will be used to justify movement to a Federally administered health system.  Everyone will gain coverage by fiat but that is when the next set of challenges will become apparent.

With a single payer which presumably will coopt present insurance markets, the question will be whether it will represent a floor for care or a ceiling. If a Federal "universal" program has ambitions to provide a comprehensive package of services to everyone covered, it is no trivial task to decide what is covered and what is not covered. Who is going to do this? Are we simply going to contract with the current insurance carriers to do what they have been doing? What are the gains that we will see from this approach. We as physicians and patients will end up bargaining with the same people we have been bargaining with all along. How will these parties be incentivized to administer the system. I suspect they will be rewarded for stinting on care. Sound familiar?

I have worked within a Federal single payer system call the VA Health System. The VA system is amazingly comprehensive. In fact, there are days where it appears that there is no service which might be delivered to a veteran which cannot fall broadly into the scope of health care service delivery. Furthermore, there is really no one who is charged with the job of defining what the scope of health care services might be. The end result is a perpetually expanding scope of services all defined as within the scope of their right to health care. If the job of defining scope does not fall upon former insurance companies, it will end up in the hands of Federal employees who will not be empowered to anything other than allow for scope creep.

The point is that a Federally financed universal health insurance program will not be administered by the Federal government. The Feds to no have any experience in dealing with the systems required with the exception of the VA Health System and the only thing less politically sellable than the Republican alternatives to the ACA is to put everyone into the VA health system.

Despite the explosive growth of Medicare costs, the care of patients on Medicare patients has been cross subsidized by patients whose care is covered by private insurance. A movement to Medicare for all will represent a price shock for suppliers of care They will push for acceptance of Medicare for all only if the system allows for patients to purchase supplemental policies that do more than help pay co-pays and deductibles. Care can be delivered for Medicare prices only by paring costs dramatically. With fewer financial resources coming in, health systems will need to figure out how to operate under these conditions. They will figure out how to do less and spend less and justify these actions.

We are already seeing hints of this under the current system. Rural health delivery is disappearing. It is simply too expensive to maintain a comprehensive set of services where the costs to deliver these services are higher. The first services which go away are ones with small or negative margins. There are also massive movement away from using physicians, who are expensive. The move to a single payer would in essence make everything look like rural health. The drive to reduce costs and to do less, especially less of anything low margin, would translate into whole swaths of care services disappearing. If you have a hard time finding something now, it will only get more challenging.

This is actually happening already. A shift to single payer would only accelerate this shift. However, universal state sponsored health plans also exist within the context of private insurance. This happens in France, Germany, and Great Britain. The Universal Plans provide more of a floor than a ceiling. From my understanding (and I may be wrong) the Canadian system historically had few non-state outlets, other than travelling across the southern border and paying cash to the doctors at the Mayo Clinic. A more basic coverage model is clearly possible with non-covered or poorly covered services being available via supplemental insurance. Whether this would look like our current alternatives for Medicare covered patients is uncertain. If more options are made available to non-Medicare patients, these additional choices will ultimately diffuse into the Medicare population. The program may end up to be a Medicare for all program, but I predict that the end result would be a disruption of Medicare as we know it. Giving options to one group will obligate us to provide those options to all.

What do I predict will happen within the next five years?

1. Single payer in the US. It will not likely happen in the current administration unless there is a complete meltdown of the insurance markets.
2. Single payer will result in dramatic changes to the Medicare program
3. The big debate will be how much of a parallel private insurance market will pop up  - the other tier

Sunday, June 4, 2017

Drug Recognition Experts and other snake oil salesman

I saw a story on the local news yesterday where they showed a video clip of three different people all stopped for minor traffic issues and subsequently arrested for being "under the influence" (News Link). The assessment of their compromised state was made by a single policemen using an algorithm of dubious utility.

The news story focuses on a particular Officer Carroll, a decorated Cobb County Officer who is one of the approximately 250 officers in the state of Georgia who has been trained as a Drug Recognition Expert. In the three cases identified in this news story, Officer Carroll's assessment was at odds with the final laboratory evaluation, which did not demonstrate the presence of drugs. The response of the Cobb County police was nothing short of remarkable. They commented -

"Commanders would not let Officer Carroll talk with us, but they stand behind the arrests. The department doubled-down on their assertion that the drug recognition expert is better at detecting marijuana in a driver than scientific tests."
Say what? The gold standard is an poorly validated and subjective test which can be trusted over the actually measurement of a certified lab whose machines and assays use actual positive and negative controls? What drugs are these people on? 

RAPID decision making

I learned about a new tool for decision making. It is called RAPID and it has been credited to Bain and Company Inc.

While I was introduced to this tool's use in committees structure within ate large health organization, it seems potentially even more impactful within clinical environments. In clinical environments teams of care workers participate,  yet roles and responsibilities are generally very ambiguously defined. A patient who presents with a set of complaints such as shortness of breath, decreased visual acuity, and a new onset rash on the background of hypertension, diabetes, anxiety, and history of opioid abuse will undoubtedly require a large care team to address their issues. Within any team charged with addressing these problems there will be a host of overlapping roles which currently are defined on an ad hoc basis at best, and more often than not never defined at all.

One could imagine creating a modified SOAP note or problem list which would include team members charged with making actual decisions and execution of specific plans. Accountability never happens without actual ownership of problems and definition of roles and responsibilities. 

Assessing outcomes in healthcare: Do we need the equivalent of double entry bookkeeping?

We tend not to understand how what is now viewed as mundane was once revolutionary. The simple act of balancing our checkbook is a legacy of a revolutionary and transformational process which was first propagated not much more than 500 years ago. That process is double entry bookkeeping (DEBK). There is some contention as to where DEBK was first used or at least widely used, but there is little contention that is the big picture, it is a relatively newly adopted human practice. Humans have been accumulating and trading for thousands of years. We have been formally accounting using DEBK for only a few hundred years.

What is the big deal about DEBK? It allowed individuals and more importantly larger organizations to organize large amounts of information into relatively compact journals with visual displays which allowed people to accurately assess whether their activities where leaving themselves and their organizations better off after transactions. DEBK is one of the foundations of the modern trading economy and served as a foundation for the growth of wealth and the unprecedented  improvement of the human condition which has happened in the past few hundred years.

Let's move from commerce to healthcare. In the healthcare economy, at the most fundamental level the ultimate goal is to leave patients with more health assets after encounters than they started with. While appearing very simple when boiled down to this principle, setting up the ledgers is not so straight forward. What exactly do the entries look like? What are health assets and what units can they be measured in? What specifically do people value in terms of health?

There is the absence of undesirable symptoms whether pain, anxiety, or fatigue. There is also the presence of particular functionality. Can you walk, run, climb stairs, think clearly, solve problems, or function sufficiently to work and earn a living. This sounds complicated to measure but there are already various patient reported outcomes tools which measure many of these elements.

There are also financial tools which can be used. For any given intervention, financial assets are needed to deploy. There is always a financial and time costs to devoting resources to address health issues. If we are able to measure health assets over time, theoretically we can begin to assess whether a financial commitment to a person results in a good investment.

The barriers to deploying such a project are not insurmountable. One issue we will need to anticipate is how we will execute the conversion of financial resources into health assets. There will be huge variation in terms of the preferences of specific individuals. Some people will want to invest large amounts of money to improve their health asset picture while others will want to invest those resources elsewhere.

Furthermore, improvement of health assets may be best done via investment directed toward activities and services not commonly viewed as health care services. There are currently biases skewed to certain directions of investment driven by health insurance which probably drive inefficient allocation of resources that leave people and populations worse off than if the resources were invested via some alternative approach. However, without the equivalent of DEBK for health assets, the pernicious effects and the asset losses created by these suboptimal investments are hidden and opaque.

For those who repeat the mantra that health care is different, DEBK application into the world of health assets will be a wake up call. Improvement of the human condition requires human activity driven by incentives and systems that allow us to measure whether investments of time, effort, and money actually provide on return on that investment. Do we leave people better than we found them and are the investments we make best applied to where they can best accomplish this goal?

Tuesday, May 9, 2017

Fixing Medical Prices - The history of RBRVS and the RUC

For those who are interested in the mess that is health care financing, this is a must read. It contains the story of how the RBRVS was adopted and how the whole process was co-opted by the AMA and the RUC. While the influence of the House of Medicine may be perceived to be waning in some domains, a small group of people through the RUC has shaped (warped) and continues to shape (warp) the practice of medicine at the most fundamental level.

Monday, May 8, 2017

Case discussions, tumor boards, and phantom consensus

I received referral paperwork (not really paper anymore..) on a patient this week. In the packet of information was a letter which described that the clinical details regarding this particular patient had been presented at a local medical meeting and a particular consensus regarding diagnosis was reached. The "group" thought the Dx was X. Hmmm...How interesting. Just what did this mean?

Was there an actual vote taken regarding the diagnosis and if so, what exactly was the tally? Did this tally reflect an overwhelming majority, a simply majority or perhaps just some form of plurality (45%?, 25%? or other?). I have been to enough of these meetings to know for certain, no vote was taken. The consensus recognized was owned by everyone but really no one.

This phenomena is widespread within medicine. We value clinical discussions and there are a number of traditional venues where difficult cases are presented to various groups of experts and conclusions are drawn. It is a good idea but there are limits to its utility, especially when the desire for input morphs into groupthink where no one ultimately owns the decisions made. Is this process compatible with medicine in the 21st century?

Sunday, May 7, 2017

Health care reform: What problem(s) are we trying to fix?

I feel I am being taken back to when I started blogging, at the beginning of the Obama Administration and at the time of the debates regarding the ACA. Only this time it is role reversal. The Republicans control both houses of Congress and the White House and similarly, they have insufficient numbers to avoid filibuster issues in the Senate.  I started writing this piece before the first House health care bill was withdrawn but I was not able to get back to it until after the second bill made it to the Senate. I have not had a chance to read either one in any great detail. I suspect I am no different from the overwhelming majority of people who feel entirely comfortable to render judgment, either positive or negative.
I understand the urgency which is perceived by Republican leadership, but the urgency is political urgency, not necessarily anything more. Yes, the exchanges are collapsing but from what I can tell, nothing offered in either of the replacement bills will do much to forestall this near term problem.

As far as I can determine, the debate is essentially useless. One side claims it is acting to avoid immediate ACA collapse while the other side claims it is resisting to avoid system collapse which will be induced by reform. The issues are framed as black or white. None of this makes any sense.
We have a dysfunctional system and it has been increasingly dysfunctional for decades. We spend tons of money for low value care. Services which could and should be inexpensive are expensive. We still have substantial numbers of people who are not insured, despite the ACA. Even those with insurance have a hard time accessing services they need. The quality of the services offered is spotty and highly variable. We are going broke trying to keep up with spending.

It is important to address these issues over time. It is also important to prioritize them because not everything can or should be addressed at the same time. Some of the goals are mutually incompatible, at least currently and likely inherently into the indefinite future.

In my mind there are basically two competing immediate priorities. The quality and value issue is tied to both.

1.  No one should be left without adequate resources to meet the needs of their illnesses, no matter what. Included in this is the debate regarding pre-existing conditions and insurance coverage.

2. Health care costs are increasing in an unsustainable fashion and will consume resources which may better invested outside of the health care economy.

The first tends to be talking points from the left and the second is a talking point from the right. They are two very different priority sets. Both sides want value and quality (who can argue wit that?) Making the first priorities are not compatible with making financial sustainability one's priority. It will take infinite resources to entice the last few millions to partake in the insurance market. Furthermore, even in the presence of near universal insurance there will always be circumstances where coverage will not equate to actual care. A good system which provides insurance coverage does not mean a perfect system. One will always be able to find examples of failure, even in a the best system one can deploy at any given point in time.

The current debate is very disheartening because the competing parties frame the discussion in terms of starkly right and wrong alternatives. If they actually believe this starkness is true we are in trouble. I am not sure what to hope for; parties are blind to where they might be wrong, or parties who are simply power hungry and willing to vilify those with contrary views simply to further their own personal ends.
The current system is a mess, for a host of reasons. Culpability goes back generations to decisions made in both political and private sectors. Unwinding this, if it is even possible, will be painful. It is only possible if the biggest contributors to dysfunction can be identified and addressed in a stepwise fashion. However, we cannot even come to an agreement as to what primary dysfunction we need to address. Is it the fact that there are those still out there who cannot garner sufficient benefit from the insurance/healthcare delivery system or is it that the system is financially unsustainable? Focus on the first priority and you worsen the second problem; and vice versa.
Meanwhile, the rhetoric gets more strident and the assumption is that no compromises and trade offs are required. Lobby for what you believe represents prudent fiscal constraint which is required to save future generations from bankruptcy and you get accused of being heartless and an idiot.

However, for any system to work better, there will be financial transfers required. How much is optimal is likely a moving target. They need to be based upon consistent principles, framed is a transparent way, and supported by the best outcomes data we can muster. The only real outcomes data we use is whether politicians can leverage transfers ( or resistance to transfers) into votes. Currently, financial transfers such as those which are required for the ACA, feed the polarization since they come to be either expected by some segments of society or resented by other segments, independently of whether they are good investments.

The bottom line is I don't get how anyone can be especially passionate about our options. Fixing problems which have plagued mankind for millennia does not happen by trying to implement broad political and legal fixes to problems we do not understand and are not able to readily measure success or failure. One set of constituencies measures success by how we spend while the other measures success by how little we spend.

What I am certain of is within the spectrum of solutions offered to fix health care there are ones that may be better or worse, but none that represent right or wrong. Even the better or worse assessments need to be understood within specific time contexts. Some that may be better in the short term could be worse in the longer term, and vice versa. The choices are simply not that starkly right or wrong and to vilify someone who points that out is crazy.