Foreign Doctors—A Question of Equity

Consider these two facts:

• Close to 25 percent of U.S. doctors are foreign-born.
• Each year, developing nations spend $500 million to educate health care workers who leave to work in North America, Western Europe and South Asia.  As the most recent issue of the Journal of the American Medical Association (October 24-31) puts it:  “developing nations are subsidizing healthcare in wealthier nations.”

According to JAMA, “These unchecked flows of health workers leave regions with the greatest health care needs with the fewest workers .  .  . 37% of the world’s health care workers live in the Americas, predominantly in the United States and Canada, yet these countries carry only 10% of the global disease burden. In contrast, Africa is home to only 3% of the world’s healthcare workers, yet it has 24% of the global burden of disease.”

On the other hand, according to the American Medical Association, some 35 million Americans live in areas where there are not enough doctors. Nationwide, primary care doctors are in short supply, in large part because they are paid so much less than specialists. Medical students who know that they will graduate with tens of thousands of dollars in loans say that they don’t feel that they can afford to become internists or family doctors.

Moreover, the Kaiser Family Foundation reports that “the nationwide physician shortage is affecting rural and inner-city residents the most,” and following 9/11, “restrictions put in place on foreign doctors who want to practice in the U.S.” have made the situation worse.

Patients Managing Chronic Diseases: Not Your Average Consumer

In his new book, Health Care Reform Now!, Kaiser Permanente President George Halverson points out that when you look at the 10 percent of patients running up 70 percent of the U.S. health care bill, you find that most are suffering from one of five chronic diseases: diabetes, congestive heart failure, coronary artery disease, asthma and depression.

These diseases can be expensive because if they are not monitored properly, they can quickly lead to avoidable hospitalizations—and, in the case of diabetes, avoidable amputations.  One of the most pressing questions health care reformers face today is this: How can we better manage these very expensive diseases—and how can the patient participate in self-management?

Recently, Maggie handed me a Bulletin on Aging and Health from the National Bureau of Economic Research, which includes a synopsis of a paper (penned by James P. Smith of the RAND Corporation) which focuses on one of these chronic diseases—diabetes. Smith’s goal is to explore the relationship among diabetes, socioeconomic status, and the patient’s ability to self-manage treatment.

Of particular interest is Smith’s emphasis on education—which, he concludes, is a major factor in determining first, whether a patient is likely to suffer from diabetes, and secondly whether he or she can successfully self-manage. It’s this second point that I want to address, in part because it provides a good example of how a consumer-based approach to medicine distorts the complexities of health care. 

Hospitals & Nurses: Behind the Scenes

Recently I’ve begun reading allnurses.com, a website that offers an eye-opening window on conditions in U.S. hospitals.  (I found the site when allnurses reprinted my post about the nursing shortage).

Clearly nurses and doctors know more than virtually anyone else about what is going on in our hospitals, but they also realize that they risk reprisals if they speak out. When I was writing Money-Driven Medicine, I was surprised by how many physicians returned my phone calls. The great majority did not know me; I expected responses from perhaps 20 percent. Instead four out of five called back. To a man and a woman, they were most passionate about what many saw as the declining quality of healthcare. “We want someone to know what is going on,” explained one prominent Manhattan physician as he described how much care had deteriorated in many of New York City’s major hospitals. “But please don’t use my name,” he added. “You have to promise me that. In this business, the politics are so rough--it would be the end of my career.”

Nurses are in an even more vulnerable position. I could not find any who were willing to be interviewed. I e-mailed quite a few, promising anonymity, but not one responded.

On allnurses.com, however, nurses speak freely, knowing that their identities are protected and that their audience is composed of other nurses.  Here is what I have learned from some of the polls and forums on the site:

Shared Decision Making

In my last post, I talked about the uncertainties of medicine, and suggested that the relationship between doctor and patient must be built on trust.  (See “A Transaction Based On Trust”). I argued that this is why the consumer-driven model of medicine doesn’t work. It assumes that the doctor is a retailer selling his services and that as his customer the consumer must demand the best quality care at the lowest price. Immediately the relationship between buyer and seller begins to sound adversarial, just as it is in the commercial marketplace where “caveat emptor” always applies. 

But the health care market is not like other market places, and the doctor is not a retailer. He or she is a professional who has taken a pledge to put the patient’s interests ahead of his own interests.  For the transaction to go forward, the patient has to believe this. Who would go under the knife, or submit to any painful or invasive procedure if he didn’t trust the doctor? 

At the end of that post, I asked, “But what about the uncertainty of medicine. Does this mean that the patient must simply trust that his doctor has “the right answer?”

Not at all. The relationship between patient and doctor must be based on mutual trust. Just as the patient trusts the doctor to act as a professional, the doctor needs to trust the patient enough to be open with him about the uncertainties of the patient’s condition and the pros and cons of the treatments that they are considering.

Sometimes—but not always—the doctor must tell the patient: “In this particular case I can’t be sure what the best treatment would be. But here are the options and here are the risks and benefits of each.”    

Disease Mongering By Way of Restless Legs

Yesterday during lunch I saw an ad for Mirapex, a “prescription medicine used in the treatment of moderate to severe primary restless legs syndrome (RLS).” The fact that there was such thing as a restless leg syndrome seemed odd to me, so I did some sleuthing. (Maggie, who has in fact discussed RLS over at the Health Care Blog, has some great thoughts on the issue as well.)

 RLS is a “medical condition that is described as an urge to move the legs”—simple enough. The Mirapex website offers a list of question designed to help you diagnose yourself:

• Do you feel a strong desire to move your legs from time to time, often when they make you uncomfortable?
• Do those sensations in your legs occur or get stronger when you are inactive?
• Does moving around or stretching help ease those uncomfortable sensations in your legs?
• Do those uncomfortable sensations feel their worst at night?

Boehringer Ingelheim Pharmaceuticals, the manufacturer of Mirapex, is considerate enough to translate these symptoms into layman’s terms:

People often use words like "burning," "creeping," "crawling," "aching," "tingling," and/or "tugging" to try and describe their symptoms. Many people with restless legs syndrome have difficulty explaining the odd sensations they feel, even when talking to their doctor.

So far it seems that I may have RLS if my (1) legs get uncomfortable after sitting for a while and (2) I have trouble articulating this sensation. By these criteria, most anyone who has uttered the phrase “my leg feels weird” qualifies as an RLS sufferer.

A Transaction Based on Trust

The consumer of health care is unlike any other consumer, and the product he purchases is unlike any other product. This is something that those who embrace “consumer-driven medicine” choose to ignore.

Advocates like Harvard Business Professor Regina Herzlinger insist that if we just
put the consumer in the driver’s seat, giving him both  transparent pricing and a little “skin in the game,” the consumer  could put a lid on health care prices while demanding the best quality care.  Herzlinger is particularly hopeful that the baby-boomers, a group she describes as “the most manipulative, the most narcissistic and the most effective generation this country has ever seen,” can do the job. (Why one would want such a group setting priorities for our health care is beyond my understanding; I’ll return to this point in a later post.)

Last week I spoke at the Massachusetts’ Medical Society’s Leadership Forum on the rising cost of care.  In two earlier posts (here and here) I’ve described what other speakers had to say about how and why Massachusetts is running into trouble trying to fund its experiment in universal care.

In my speech, I explained why I don’t think that “consumer-driven medicine” is the answer. I don’t believe the “consumer” can rein in healthcare spending.  As an alternative, I proposed a “patient-centered” model of health care which depends on patient and doctor, working together.

Begin with the flaws in the consumer-driven model. First, it assumes that the patient has the same power that a buyer has in the commercial marketplace. But in truth, the patient does not have nearly as much leverage as other consumers.

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The Dangers of a "Zagat Guide" to Physicians

Yesterday WellPoint announced that as of early 2008, a “new online tool” “will allow consumers to share their physician experiences with others” a la Zagat surveys. Zagat in fact is partnering with WellPoint on this initiative, and the format of ratings will be similar to other Zagat products, where customer anecdotes accompany ratings of different criteria on a 30 point scale. The rated criteria for doctors will be trust, communication, availability, and environment. Measurements of quality of care and health outcomes are not included in this rating system, an omission that Jane Sarasohn-Kahn points out over at HealthPopuli.

Jane is kinder toward this announcement than I am. Neglecting crucial information about quality misses the point about medicine—that it is devoted to improving health. As Jerry Flanagan of the Foundation for Taxpayer and Consumer Rights told USA Today yesterday, “the fact that a doctor might have a friendly administrator at the front desk is meaningless if they have a high medical-error rate.” It’s a bit like having car ratings only address color scheme and seat comfort: these are nice facts to know, but at the end of the day you want a car that you can rely on, a consistent performer that does its job and does it well.

Universal Coverage –Why Massachusetts is the Last Place to Begin the Experiment

At the Massachusetts Medical Society’s 8th Annual Leadership Forum last Wednesday, Dr. Steven Schroeder, former head of the Robert Wood Johnson Foundation and Distinguished Professor of Health and Health Care at the University of California, San Francisco, told a provocative story about a poll that asked patients in the U.S. `Canada,  Australia, New Zealand and the U.K the following question:

“If your personal doctor told you that you had an incurable and fatal disease, would you accept that diagnosis or seek a second opinion?

• In the U.S.           91 percent of patients said they would seek a second opinion.
• In Canada            80 percent                    “        “       “       “     “     “           “ 
• In Australia          71 percent                  “        “   
• In New Zealand     51 percent
• In the U.K.           28 percent 

“You have to love the British,” Schroeder commented. “You can just hear an Englishman saying ‘Well, Luv, it’s been a good life, hasn’t it? Now let’s make a pot of tea and discuss the funeral arrangements.”

At the other end of the spectrum, we find the Americans who, Schroeder noted, “are the only people in the world who expect to live ‘in perpetuity’.”

Today, I would like to suggest that our expectations as patients help to explain why we spend roughly twice as much per person on health care as most developed countries—even when, overall, it’s not clear that our healthcare is better. In fact, in some areas outcomes are worse.

We Can’t Fund SCHIP, But We Can Save Merck

Today, Bloomberg trumpeted the good news:  “Merck Profit Gains on Cancer Vaccine, Diabetes Pill.”

“Merck & Co., the third-largest U.S. drugmaker, reported a 63 percent gain in earnings,” Bloomberg reported, a victory made doubly by the fact that Merck has seen some rough times. “Competition from generics and the withdrawal of the pain pill Vioxx in 2004 over heart risks have pulled net income down 39 percent since 2001,” the story explained. Indeed, Vioxx gave Merck a black eye, and it’s still battling lawsuits in the courts. But Gardasil, Merck’s new vaccine to prevent cervical cancer, is turning out to be just the blockbuster the company needed. “Gardasil, introduced a year ago [already] has sales of $418 million”

Those of you familiar with my views on Gardasil may want to skip the below section, as it is pulled from an August post. I promise I won’t do this often, but this is an important subject and it’s example of how, if drug manufacturers and their lobbyists work quickly enough, they can sell their story to politicians and to the public before skeptics in the scientific community have a chance to weigh in. Remember the drug industry saying: “It’s important to sell a new drug while it’s still effective” (i.e. before people know too much about it).

On August 27, I wrote:

Earlier this month the FDA announced that the direct-to-consumer ads Merck has been using peddle its new cervical cancer vaccine, Gardasil, are “half-true . . .information currently being advertised could mislead the public.”