“Consumer-Driven” Health Care vs. “Patient Centered” Care

Your comments on “The Ticking Clock” (below) raise some questions about consumer-driven healthcare that I decided deserve a separate post.

One reader wrote: “We have all been fretting for decades over how to get patients more involved in understanding and buying-in to their health care needs. Consumer-Driven Health Care (CDHC) is the most effective means to that end that has ever come along.”

He added: “Certainly you are right that very often the optimal treatment is unknown or ambiguous. But isn’t that precisely when the patient should be making the final decision? Who else should do it? That does not mean the patient is playing doctor, only that patients will consult with physicians they respect for the best recommendation and will decide on what course of treatment they are most comfortable with. It is, after all, the patient’s life and health that is at stake.”

Another reader responded to my comment that when the patient begins to think of himself as a “consumer” and of the doctor as a “retailer,” this can undermine the trust needed in a doctor-patient relationship. He replied: “As a physician I have to disagree with your comment that ‘Even then, many physicians feel that the consumer vs. seller model undermines the patient doctor relationship.’ If anything it enhances the relationship as only the consumer truly understands their needs and therefore it is best for the consumer to have a good deal of control. Some physicians tend towards protectionism. I also think your opinions regarding the ability of a patient to make [his or her] own decisions [are] a trifle paternalistic, though I can understand how you might have come to that conclusion.”

Let me say first, that I agree with both readers. But I think that what they are describing is not “consumer-driven medicine.” It’s “patient-centered medicine.” There is an enormous difference.

Begin with what “consumer-driven medicine” really means. Here, I’ll
defer to Harvard Business School professor Regina Herzlinger who is
probably the best-known advocate of the consumer-driven model.  (Money magazine has called her the “godmother” of consumer-driven medicine. On her website, she takes credit for inventing the term.)

In her book Market-Driven Medicine Herzlinger defines “smart consumers”
as people who wants “top quality, fast delivery, and excellent
service—all of the time. They do not want to play games. A furniture
retailer notes that American shoppers say, ‘I want it the way I want it
and when I want it—and I want it instantly.’”

This might be a useful (if somewhat obnoxious) stance to take when
purchasing a sofa, but healthcare cannot always be delivered quickly. A
good diagnosis may take time.

Herlzinger believes that health care consumers should demand “convenience, control and choice."

Convenience, she argues, is extremely important. Thus, she believes
that doctors should have office hours on evenings and week-ends. And a
patient never should have to wait in a doctors’ office.

This ignores a few realities: Doctors who get up early to do surgeries
are too tired to work evenings. Those with families would like to see
them on the week-ends—just like everyone else.

As for waiting in a doctor’s office, medicine is unpredictable. I
expect my hairdresser to keep to his schedule because he knows how long
it takes to cut a person’s hair.  A physician, on the other hand, has
no way of knowing which patient will come in complaining of headaches
–and then break down and confess that she has a drinking problem. She
needs counseling and attention that will take more than 20 minutes.

Another patient who suffers from congestive heart failure seems much
more forgetful than he was the last time the doctor saw him. He also
appears to be very nervous. A little careful questioning may reveal
that the patient is aware that he is becoming more forgetful, and that
he is afraid that he has Alzheimer’s.  As the conversation continues,
it becomes apparent that he has finally come face to face with the fact
that his congestive heart failure will ultimately prove fatal. He
probably does not have long to live.

Complicating his schedule further, earlier in the morning, this family
doctor “worked in” a 5-year-old who did not have an appointment—but who
did have a terribly painful ear-ache. The doctor had to explain to the
mother that, no, the child did not need antibiotics, but she did need a
pain-killer. That put him 20 minutes behind schedule at 10 a.m.

Meanwhile, in the waiting room, Regina Herzlinger is tapping her foot.

Control or “mastery” places second on Herzlinger’s list of priorities.
Here she praises “health care activists” such as Janine Jacinto
Sharkey, who told Town and Country magazine  how she
custom-designed the types of incisions that her surgeon used to remover
her breast cancer tumor, faxed questions that arose from her research
about breast cancer to her surgeons, and even selected the classical
music to be played in the operating room. Notes Sharkey: “I’m not the
kind of person to sit there and allow someone else to dictate to me. I
question. I’m involved.”

Uncertainty and Trust

The consumer-driven model assumes that healthcare is a product to be
bought and sold, just like an automobile or a refrigerator.  This just
isn’t the case. First, health care is a service, not a product, and
providing the service is as much an art as a science. This often makes
it very difficult to measure the “value” of health care.  And this is
why there is no Consumer Reports for medicine (or for art).
While Consumer Reports can rate the benefits of various mid-priced
refrigerators, briskly and clearly, in a way that makes comparisons
easy, it is often all but impossible, even for a physician, to be
positive of the relative benefits of a great many medical treatments.

Of course, in certain cases there is little ambiguity. If I break my
arm, my doctor and I both know what needs to be done. “But only about
25 percent to 30 percent of the decisions that doctors make are backed
up by really good medical evidence,” Dr. James Strickler, former dean
of the Dartmouth Medical School once told me. He went on to define “the
art” of being a good physician: “Learning how to make adequate
decisions in the face of inadequate evidence.

Consider the very first step in any treatment—diagnosis. “It is rarely
the case that signs and symptoms are markers of specific diseases,”
observes Carl Schneider in The Practice of Autonomy: Patients, Doctors and Medical Decisions.
“Signs and symptoms often do not appear exactly as described in
textbooks and the full constellation that describes the ‘classic’
presentation of a disease is often not seen.”

Schneider, who is a professor of Law and Internal Medicine at the
University of Michigan, quotes Dr. Eric Cassell who describes Medicine
as a craft “engulfed and infiltrated by uncertainty and practiced in a
sea of doubt.’  As a result,” says Schneider, often “judgments must be
made on the doctor’s personal experience of past cases; the comparison
of the present size, sound or feel of something with what is
remembered; and on what a clinician believes to be the problem, based
sometimes on very scanty evidence.”

In other words, diagnosis is often driven by intuitions that are not easily articulated. Gary Klein, author of Sources of Power: How People Make Decisions
explains: “Intuition depends on the use of experience to recognize key
patterns that indicate the dynamics of the situation.” He gives the
example of nurses in a neonatal intensive care unit who could simply
look at a baby and tell that it was becoming septic, sometimes even
before tests could detect the development. Klein suggests that these
nurses “reacted to a pattern of cues, each one subtle,” that experience
had taught them to associate with a septic infant.

This is medical information that cannot be codified or passed on to a
consumer who does not share the nurses’ experience:  “The problem is
that people who work ‘intuitively’ may not know and thus cannot
accurately explain how they think,” says Schneider. “Because patterns
can be subtle, people often cannot describe what they noticed, or how
they judged a situation as typical or atypical.” In other words, this is medical information that you are not going to find online.

In an Age of Information we often try to pretend that anyone can become
an “expert.” But Schneider explains the difference between how a novice
“sees” a situation and how an expert takes it in. “People trained in
skilled work learn to reason in ways that elide many steps and that
they themselves do not fully realize or understand. . . .Their
experience lets them “see a situation, even a non-routine one, as an
example of a prototype.”  He quotes another study of decision-making by
Ranann Lipshitz: “This happens with little ‘conscious awareness, rapid
rate of data processing, high confidence in answer and low confidence in the method that produced it.’”

“Novices lack this experience. Thus they lack those prototypes,”
Schneider concludes.   “They must work out step by step what experts
see at a glance. The classic illustration of this difference in
reasoning comes from chess. Chess masters look at a board and see
patterns of force and possibility. Beginners see discrete pieces and
ask how many spaces a pawn can move.”

Yet, despite the difference the expert and the rest of us, somehow,
consumers with high-deductible health plans are supposed to be able to
make wise decisions about what is “necessary” care and what isn’t.
Consider the dilemma for parents who are trying to decide whether or
not to take their feverish infant to the ER in the middle of the night.
They have a $4,000 deductible. They know that once they set foot in the
ER the bill will begin to add up: blood tests, a urine sample,
examining the baby, perhaps keeping her over-night for observation. Yet
of course, they would happily spend $4,000—or more—if she really is
seriously ill. But maybe they should wait and call their pediatrician
in the morning. They are smart enough to know that just taking the
baby’s temperature is not a clear marker as to whether she needs help
immediately. What nags at them is the knowledge that they haven’t seen
hundreds of feverish babies and just don’t have the experience to make
a reasonable judgment. 

This is why they shouldn’t have a $4,000 deductible. Their
“consumer-driven plan” is shifting the responsibility for making
medical decisions from the doctor to the patient.

The uncertainty doesn’t end there. Even if they go to the hospital, and
it is obvious to the doctor that the child is very sick, it may not be
at all obvious as to what would be the best treatment. There are just
too many variables, too many unknowns. Every human body is unique. What
worked well with one young patient might be too stressful for another.

This is why “Uncertainty” is, as Dr. Atul Gawande puts it, “the core predicament of medicine. . ."  In Complications: A Surgeon’s Notes on an Imperfect Profession,
Gawande underlines the ambiguity of modern medicine: “Uncertainty is
the thing that makes being a patient so wrenching, being a doctor so
difficult, and being part of the society that pays the bills so vexing
. . .”

I have quoted Gawande before and I quote him again here because I think
his insight is crucial to understanding that medicine is still an art.
Many doctors confide they are certain of what they are doing, that it will work, and why and how
it will work only perhaps one-third of the time.  Often, there is no
“right answer.” A doctor may try one treatment, then another, just to
make a diagnosis. In the past, physicians who presented themselves as
all-knowing hid their doubts. Today, doctors who trust their patients
are honest with them.

This, as Gawande rightly says, is what makes being a patient so
distressing, being a doctor so stressful, and being part of the society
that pays the bills so frustrating. In many cases, there is no way to
measure whether we are getting the best value for our health care
dollars, even in retrospect. The patient might have recovered even if
he or she wasn’t treated. A different treatment might have had fewer
side effects. Over-treatment may have created needless complications.

As Americans, we want to believe that science and technology can
provide “right answers.”  Thus we resist the notion that the best
answer to a great many medical questions is: “it depends.”  Yet,
despite the enormous progress made in the 20th century, medicine is
still a young science. We have barely begun to understand how mind and
body interact.  “With all that we know today about people and diseases
and how to diagnose and treat them, it can be hard to grasp,” Gawande
writes, “how deeply the uncertainty runs.”

This is why the relationship between doctor and patient must be based
on trust.  The healthcare market is different from any other market
because it is so much harder for the purchaser to evaluate what he is
buying.  Adding to his dilemma, unlike other shoppers the patient knows
that he can’t rely on a friend’s experience with the product. While two
consumers may derive pretty much the same value from the same
mid-priced refrigerator, a particular course of treatment can have a
drastically different effect on two people.

Nor can the consumer rely on his own past experience. Three-quarters of
health care dollars are spent on products and services that the patient
has never purchased before and most likely hopes never to purchase
again.

To make the patient’s dilemma even more wickedly difficult, he knows
that there are no warrantees, no guarantees, no returns.  As a consumer
he is in a uniquely vulnerable position: there is a very real
possibility that it could do him more harm than good. This is how the
purchase of healthcare is different from any transaction that takes
place in the commercial marketplace. How could the patient possibly go
forward if he didn’t trust the seller? This is a market where caveat
emptor cannot apply.

I believe that this goes to the heart of the difference between “the
consumer” and “the patient.” When advocates of consumer-driven medicine
talk about the patient as a consumer, the relationship between patient
and doctor often begins to sound adversarial.  It’s up to the consumer
to take responsibility for making sure she gets the “best care
possible” –as if the physician will cut corners unless the patient is
vigilant. In truth, in most markets “caveat emptor” is a good warning.
The buyer cannot trust the seller to put the buyer’s interests first.
So the buyer must demand the best product at the best price.

By contrast, the physician is a professional who has pledged to put his
patient’s interests ahead of his own. The patient must trust in his
doctor’s knowledge and professionalism. Otherwise, the health care
market couldn’t function. Who would submit to a painful, invasive
procedure if he didn’t trust the doctor?

Healthcare economist Victor Fuchs sums up the situation: “The
patient-physician relationship is very different from the one that we
accept in commercial marketplaces because it requires patients and
health professionals to work cooperatively (rather than as adversarial
buyers and sellers). Mutual trust contributes to the efficiency of
production.”

Regina Herzlinger believes that what the health care consumer wants
most is “convenience,” “control” and “choice.” This may be true when
you’re buying eye-glass frames. But the lion’s share of our healthcare
dollars is spent when we are seriously ill. And then, I believe, what
we most yearn for is “competence” and “kindness.” We want choices, but
most of us do not want complete autonomy. We do not want to feel that
our physicians are abandoning us.

Shared Decision-Making

But what about the uncertainty of medicine? Does all of this mean that
the patient must simply trust (or hope) that his doctor has the “right
answer”?

Not at all.  As Fuchs points out, patient and doctor must collaborate,
with the doctor bringing his knowledge and experience to the table,
while the patient contributes her knowledge of herself—what she hopes,
what she fears, what she is willing to wager, and what she is not
willing to risk.

This brings me to “shared decision-making” a formal process that has
been developed at a number of hospitals around the country.
Dartmouth-Hitchcock in Lebanon, New Hampshire led the way in 1999 when
it opened a Center for Shared Decision-Making  where doctors and
decision-making coaches learned to use various decision-making  aids”
to help patients weigh their options. (See their website here).
These aids include pamphlets that spell out the risks and benefits of
various elective tests and procedures as well as videos featuring
patients who describe how they went about making the decision—and
whether they are happy with the outcome.

In August, I wrote
about how this process can help men who have been diagnosed with
early-stage prostate cancer decide whether they want to be treated—or
pursue a strategy called “watchful waiting.”   
The videos and booklets stress that patients have a choice: this
is why we call knee implants, hip implants, most angioplasties,
by-passes, spinal surgery, treatments for early-stage prostate cancer
and a wide variety of tests “elective.”  As the doctors at
Dartmouth emphasize, the patient who decides to undergo one of these
procedures is making a “wager” that the benefits will outweigh the
risks and possible side effects. Some patients are willing to take a
bigger gamble than others.

Patients take these pamphlets and videos home, and often view the
videos more than once, with their families. When they go back to the
doctor, he or she asks questions to test whether the patient fully
understands the benefits and risks. If the patient seems confused, the
doctor explains further until, as one doctor puts it—“Suddenly, the
patient’s face clears—and you know they understand.”

At that point, the doctor begins to ask the patient questions about his
own preferences, fears and priorities. Are there certain side effects
the patient fears more than others? Is he a risk-taker? How does he
feel about uncertainty? Is the breast cancer patient’s first priority
to try to preserve her breast or would she prefer to “get it over with”
by having a mastectomy? The treatment that might be “right” for one
patient will not be right for another.

Here the patient becomes an active participant in the decision-making
process. In the past, we talked about patients giving “informed
consent” before any elective procedure.  At the decision-making center,
patients make an “informed choice” that takes their own values and
temperament into account.

This is not consumer-driven medicine, but it is patient-centered
medicine.  Those who prefer the “consumer” model believe that if
patients have “skin in the game” (i.e. a high-deductible) this
will somehow lead them to make shrewder decisions. Those who advocate
for “shared decision-making” believe that if patients have more knowledge
they will make wiser decisions. This is not about providing
“transparent information.” This is about leveling with patients and
telling them that much of medicine is not transparent —it’s ambiguous.
This is also about giving patients time to absorb this knowledge, mull
over the pros and cons of treatment and, with the help of a
decision-making coach, decide what they want.

“Shared Decision-Making” takes time, and today, physicians are not well
paid for spending time with their patients. We expect them to be “doing
something” to them.  But health policy experts are becoming more aware
that we need to compensate doctors more when they practice “thinking
medicine.” If we do that, we may not have to pay as much for more
aggressive medicine.

Research reveals that if patients share in making the decision, some 20
percent to 40 percent of patients decide not to go ahead with the
elective treatment. Thus many are spared treatments that they didn’t
entirely want, didn’t entirely understand, and might well regret.
Meanwhile, satisfaction among patients who go ahead with the treatment
is higher. The state of Washington already has recognized that “shared
decision-making” could be one answer to malpractice suits. In
Washington, new legislation makes it much, much harder for a patient to
sue if the doctor took him through the formal decision-making process.

30 thoughts on ““Consumer-Driven” Health Care vs. “Patient Centered” Care

  1. I wish Regina Herzlinger would sit this discussion out. As a board member of a major for-profit healthcare provider I don’t see her as having the best interest of the patient in mind. Her board obligations would seem just the reverse: to keep profitability in the forefront.

  2. There seem to be several issues mixed together. Conditions which require immediate attention should be segregated from those which can be scheduled. Hospitals do this explicitly by having an emergency room, family practitioners haven’t worked out a similar scheme. Having a bunch of sick people crammed together in a waiting room is not a good idea under any circumstance.
    Perhaps there needs to be dedicated unscheduled clinics (like the walk in clinics) that work in conjunction with a regular practice. If the walk in traffic is low at some moment the staff can assist with the regular patient load. Those that walk in, know they will wait, those with an appointment go when scheduled. Done right waiting rooms should be mostly empty.
    High deductible policies could have a threshold so that routine care which has a minimal cost isn’t included in the deductible. This might get over the resistance to see a doctor because the fee is going to be $100-250. Of course since there is more coverage being provided the policy premium would have to be adjusted. On the other hand I’ve never understood the need for nuisance fees to visit the doctor. Is collecting $5-25 for an office visit really worth the bother? Is this expected to keep people with “frivolous” ailments away? Some practices (for the wealthy) now charge an annual fee, perhaps some variation of this might work for regular people.
    As for “trust” the problem is that too many doctors are no longer seen as impartial. Even if they have not been explicitly corrupted by the freebies the drug firms give out, they may have been unwittingly influenced. In addition they may have been given unreliable information since many studies seem to use cooked data these days.
    I wonder what the situation is like elsewhere. Do drug reps sit on the doorsteps of doctors in France or Germany?
    As for “trust” just look at how we pick political leaders. The situation is analogous, we don’t know what situation will arise in the future, but we pick a candidate who we think will best be able to cope with it. What else do we have to go on? That’s why elections are more about personality than policy. I think many people don’t want to be part of the decision-making process when seeking treatment. If the doctor can’t make a recommendation asking the patient to do so seems like an abdication of responsibility to them.

  3. You have detailed how and why a sound, ongoing doctor—patient relationship is the foundation of health care. These relationships, mutual trusts, must be or become unconflicted by the dollar bill. This includes removing entrepreneurship for doctors and dollar-based obstruction for patients. Proposed health care policy should be closely examined for its ultimate effect on individual doctor—patient relationships.
    When clear and equal access to sound, ongoing doctor—patient relationships for everyone living in America becomes the new bottom line for our health care system and dollar budgeting becomes subordinate to and supportive of that new bottom line, then good health care reform will evolve. I believe the way to do that is to control the price paid for service and product in advance. Health care pricing by fiat may be a good description of what I am suggesting. This would go way beyond deleting the health insurance industry in favor of a single payer. It would eliminate an open-ended system of billing, i.e., bill as much as you can to obtain the highest profit possible, aka, the free market.
    I think this essay is well done and elaborates a basic tenet of medicine. If a doctor can simply talk with a patient, explain in understandable terms what is going on, share uncertainties with the patient and obtain specialty help to clear up those uncertainties, and help the patient understand that no one has a crystal ball, the most profound decision making becomes greatly simplified.
    R. Garth Kirkwood MD
    doctork@equalhealthcareforall.com
    http://www.equalhealthcareforall.com

  4. Thoughtful post, but 2 related questions (at least) come to mind.
    1. If only “about 25 percent to 30 percent of the decisions that doctors make are backed up by really good medical evidence”, should we be using pooled payments at all in healthcare? What other area with such uncertainty uses pooled payments? Maybe only those processs that are backed by really good medical evidence should be eligible for pooled payments!
    2. If only “about 25 percent to 30 percent of the decisions that doctors make are backed up by really good medical evidence”, then is Fee for service a good way to pay for healthcare when by definition about 70% of these fees would be paying for questionable porcedures??

  5. I sympathize with those who are cautious about the ‘slippery slope’ of prostate cancer diagnosis and treatment, but as one who was asymptomatic when given the PSA test for the first time at age 54, if I had been discouraged from taking the test, I may by now have had a very poor prognosis. Who knows how long I could have gone in happy ignorance that I had this cancer? My very first PSA level was 15, the biopsy revealed a Gleason score of 7, and I would NOT have been a wise candidate for ‘wait and see’.
    My advice is not, however, to rush into treatment, but to go through that patient-centered process to decide what diagnostics and procedures to undergo. Going further, the physician has to be able to handle this well, which in my experience (i.e. being ‘fired’ by the head of Urology at Kaiser Oakland for not ‘trusting him’, ie asking too many questions), means being open to questions, and understanding of the stress patients and their families go through in making these decisions. It’s not enough to have a process in place, and I am wary if the process is mainly put in place to give physicians cover against malpractice suits.

  6. Well thought out and measured essay, Maggie. Very little to quibble with actually. Not too surprising since my partners and I have laid claim to being pioneers in “patient-centered care” in our area of specialty.
    Two brief thoughts. Firstly, on the issue of “30% of care is backed by evidence”, one must remember that this simply means that in that author’s opinion only 30% of the decisions made in a doctor’s office can be backed by appropriate clinical studies (the gold standard being prospective, random, double-blind studies). I think this seriously underestimates the true % of decisions that can be backed by good clinical knowledge. I attended a conference today in which it was noted that there has not been a single study to “prove” that a particular preventative treatment is effective. And yet this treatment has reduced a particular complication of treatment from 3-4% to 0.3%, a full order of magnitude. Since this is a historical comparison rather than a randomized trial this very powerful medical decision, clearly backed by broad clinical experience would inappropriately be lumped in the 70% of non-supported decisions.
    Secondly, I feel that you and many of your colleagues continue to drastically underestimate the effect of defensive medicine on the clinical decision-making process. On the demand side of the medical economic universe there is essentially infinite demand from the doctors ordering tests, etc.; no amount of medicine or medical evaluation is enough if just a little more might be what is necessary to prevent the filing or the losing of a medical malpractice lawsuit. We simply must move beyond our punitive system of malpractice tort (doctors will only do the right thing because we’ll punish them if they don’t) to one that is dedicated to finding the root cause of errors and working to prevent them, while providing care and restitution to the victims of medical misadventure that is not associated with conduct that would generate punitive damages (doctors, as you so eloquently put it, are professionals who take an oath to do the right thing and have and will do so without the need for fear of punishment).
    That would be a wonderful start to re-establishing the primacy of the doctor-patient relationship.

  7. Jack, Garth, Robert, NG,
    Nils,Bingo, Caitmin
    Thank you all for your comments. I agree, this is an interesting thread.
    Jack– You are right about Herzlinger’s conflict of interest.
    Robert– These days, we’re becoming more and more aware of the importance of giving patients a “medical home”–continuity of care from someone who knows them and their medical history.
    For that reason, I don’t patients should be going to a walk-in clinc in an emergency like the child’s ear ache. I think their familly doctor should “work them in.”
    In my hypothetical, the mother might not have listened to a doctor she didn’t know when he told her that the child neededa a pain-killer, not antibiotics. And if the doctor was very busy, he
    might have given in and prescribed unneeded antibiotics.
    I agree that waiting rooms shouldn’t be crowded witih a dozen people. But the best family doctor I’ve ever had always “worked people in” and even took phone calls during the day, while seeing patients.
    He didn’t overbook himself, but typically there would be two people, maybe three, in his waiting room, and I would expect I might wait 25 minutes past my appointed time.
    I might also expect that he would excuse himself and take a phone call during my appt.
    But he never seemed rushed; there was always time for me to ask questions; and when I or my children had an emergency, he took my call or “worked me in” as needed.
    I doubt you’ll find drug reps in doctors’ offices in other countries, though I’m not sure. What I do know is that you won’t find drug ads on radio and TV. They’re banned everywhere except, I think, New Zealand.
    We don’t want people paying an annual fee to a doctor because then they are just insuring themselves. We want them to be buying insurance and paying into a pool that covers everyone. In a given year, you make take out less (in terms of servcies) than you paid in; but in another year, if you are hit by a serious illness, you might take out more than you put it. “Spreading the risk” among a large group of people–that’s the point of insurance.
    Garth– I agree, we need to get the dollar bill out of the doctor/patient relationship–it shouldn’t be a barrier that keeps a patient from seeing a doctor, and it shouldn’t become an incentive to do more than the patient really needs.
    In many other countires there is no payment made at point of service. Everyone pays for healthcare through their taxes, and that tax money covers the full cost. There are no co-pays, no deductibles–and these countries manage to deliver high quality care for roughly half the amount that we spend.
    So even though people don’t have “skin in the game” they don’t seem to “over-use” care. Of course there will always be a few hypochondriacs, but most people really don’t like going to the doctor unless they need to.
    Going to the doctor can be time-consuming (and I really think that if a doctor is practicing medicine as an art, and not rushing patients through, there are going to be times when you have to wait). Going to the doctor can be painful.
    Meanwhile, in these countries doctors are on salary–they are not paid fee-for-service.
    So money changing hands is not part of the encounter between doctor and patient.
    NG–You’re right fee-for-service is not a good way to pay for care.
    Pooling our resources to pay for care is, however, the best way to fairly spread the risk of becoming sick among a large group of people.
    And although doctors lack certainty about perhaps 70 percent of the things they do, it doesn’t mean that they shouldn’t do many of these things.
    In some cases, as Bingo suggests, while we don’t have evidence from a randomized clinical trial that the procedcure works, we have observational evidence that it works for many patients much of the time–even if we don’t know why.
    In other cases, if a patient is suffering, doctors will try one treatment, then another, working in the dark, without certainty, but often the patient will get better. What the doctor doesn’t know is whether the treatment worked or whether the disease ran its course and the body healed itself (which often happens.)
    Here’s another example of working in the dark: seriously depressed patients really are helped by various medications–even though we don’t clearly understand how and have to find the right medication for the right patient by trial and error.
    But these medications are wildly overprescribed to people who aren’t really seriously chronically depressed.
    (Part of the problem is that we can’t clearly define the disease “depression”– though if you’ve ever seen someone who is clinically depressed, you recognize it when you see. And William Styron’s book, Darkness Visible, is a brilliant description of what clinical depression looks and feels like.)
    Nils–
    I think your emphasis on not rushing ahead to treat early-stage prostate cancer is the important point. This is a case where shared decision-makiing is extremely useful because so much depends on the patient’s tolerance for risk and willingness to accept possibly life-changing side-effects.
    And Shared-Decision making is not just a vague “process.”
    An international committee has set up very precise standards for what counts as “shared decision-making.” There are clear steps to the process that I have written about in an
    article here: http://dartmed.dartmouth.edu/fall07/html/choice.php
    For example, the pamphlets and videos used in the process have to be updated every two years. This is expensive, but necessary because what we know in these “grey areas” of medicine is constantly changing.
    In the state of Washington, a doctor would have to meet those standards in order to be
    protected against malpractice suits.
    Bingo–
    I agree that randomized clinical trials do not constitute the only medical evidence. See my comment above to NG.
    But the doctorI was quoting was including those services in his 30 percent. What he really was saying is that he felt confident–with certainty–that what he was doing for a particular patient at a paritcular point in time was correct only about 30 percent of the time.
    Often, the diagnosis is wrong. We know this from autopsies which show how often the patient died of something other than what he was being treated for. And in not a few cases, the treatment for that other supposed problem hastened the progress of the diesase that killed him. (Dr. Atul Gawanade has written about this. He and a group of doctors at Harvard couldn’t believe the numbers on this and so they did the reserach themselves—and found out that diagnosis hasn’t improved much in 50 years.)
    And as Gawande, Schneider and others have explained, often treatment is part of diagnosis. A doctor tries one treatment, and if it doesn’t work, he eliminates that diagnosis and goes on to second one–trying a second treatment.
    Of course there is more ambiguity in some specialities than in others. Psychiatry is
    probably the most complex because there you really have a stand-off: we have only the human mind with which to try to understand the human mind. . . .
    Then there are all of the areas where we are beginning to realize that mind and body seem to come together, influencing each other.
    On malpractice– this is a vexed issue.
    Part of the problem is that people who object to consumers suing companies (or anyone selling a product or service) for ideological reasons (because they want to protect the stock prices of large corporations) hate the plaintiffs’ bar in general. They would like to put attornies who represent consumers of any type out of business.
    And since malpractice attornies are part of the plaintiffs’ bar, they hate
    malpractice attornies.
    These ideologues have done their best to try to persuade Americans that these attornies are lurking everywhere, ready to turn an accident onto an enormous lawsuit that will cause millions and wreck lives.
    And in the processs, they have scared many doctors, creating a greatly exaggerated fear of being sued.
    In fact, your chances, as an individual doctor, of being sued are just not that great–assuming you practice good medicine a keep good records.(Again, this varies by specialty.)
    Here are some numbers:
    “Just 5.2 percent of doctors made two or more malpractice payouts and were responsible for 55 percent of all payouts between 1990 and 2002. Just 1.1 percent of all doctors have made three or more malpractice payouts, amounting to 30 percent of all malpractice payouts.”
    Morever, according to research by the Harvard SChool of Public Health (Note not Harvard Law, the Havard School of Public Health) and published in the New England Journal of Medicine in 2006:
    “the current system works: legitimate claims are being paid, non-legitimate claims are generally not being paid, and “portraits of a malpractice system that is stricken with frivolous litigation are OVERBLOWN.”
    (This, to me is the important point. It’s not that frivolous suits don’t exist but the fear of them is greatly exaggerated–OVERBLOWN.)
    The authors at the Harvard School of Public Health found:
    “Eighty percent of claims involved injuries that caused significant or major disability or death.
    “The profile of non-error claims we observed does not square with the notion of opportunistic trial lawyers pursuing questionable lawsuits in circumstances in which their chances of winning are reasonable and prospective returns in the event of a win are high. Rather, our findings underscore how difficult it may be for plaintiffs and their attorneys to discern what has happened before the initiation of a claim and the acquisition of knowledge that comes from the investigations, consultation with experts, and sharing of information that litigation triggers.”
    “Disputing and paying for errors account for the lion’s share of malpractice costs.”
    “Previous research has established that the great majority of patients who sustain a medical injury as a result of negligence do not sue. … [F]ailure to pay claims involving error adds to a larger phenomenon of underpayment generated by the vast number of negligent injuries that never surface as claims.”
    In other words, more patients should sue.
    Why?
    After all, one might argue doctors are human beings; in the course of a career every doctor is going to make mistakes–maybe a very serious mistake. Suing only encourages overtreatment and defensive medicine.
    And, I realize that just being sued–even if you win– is a horrible, horrible experience.
    But watching a relative die as a result of a hospital error is also a horrible, horrible experience.
    And–this is the important point: lawsuits make patients safer according to another article in the NEJM which points out: that “Litigation Improves Patient Safety:
    the patient’s right to safety can be enforced only by a legal claim against the hospital. … [M]ore liability suits against hospitals may be necessary to motivate hospital boards to take patient safety more seriously.… Anesthesiologists were motivated by litigation to improve patient safety. As a result, this profession implemented 25-years-ago a program to make anesthesia safer for patients and as a result, the risk of death from anesthesia dropped from 1 in 5000 to about 1 in 250,000.”
    The article is right: hospitals do not invest enough in patient safety. Too many hospitals spend money on hotel-like amenities that will bring in well-heeled patients, and too little is invested in reducing infections, improving systems, etc.
    Moreover, studies show that the number of errors and related deaths are higher in U.S. hospitals than in other countries. This is a disgrace.
    It’s also a disgrace that it takes lawsuits to get hospital boards to take errors seriously–but that’s the truth. I recently was at a dinner where the CEO of one of Manhattan’s most prestigious hospitals was at the table. I was giving a talk and mentioned the fact that, given the number of errors in U.S. hopsitals, many doctors will tell you that if you have a loved one in the hospital you should try to make sure that someone is with him or her 24/7, acting as a patient advocate and asking questions–For example: “that medication doesn’t look like the one she was given yesterday, was it changed? ” Etc. ETc.
    The Ceo of this hospital
    blew up. “That’s absolutely Not true. You don’t need someone with you at our hospital!.
    An extremely arrogant man. And in fact, his hospital’s record on errors is not good.
    So, we need lawsuits.
    And the article also is right that Anesthesiologists did a great job of cleaning up their act, setting new standards for safety, and policing themselves. All in response to lawsuits.
    Other specialties need to do the same.
    But they haven’t. According to Harvard’s School of Public Health: “Only 10.7 percent (1,401 of 13,182) of all doctors who made three or more malpractice payouts have been disciplined. Only 16.9 percent (488 of 2,896) of those doctors who made five or more malpractice payouts have been disciplined”
    Should a doctor who has been found guilty of malpractice three times still be practicing? In some cases, the answer may be yes, especially if he is in a specialty like neurosurgery and is known for taking very risky cases.
    But I think a group of neuro-surgeons who do not know him, do not compete with him or collaborate with him should be taking a very, very close look at his records. Is he taking hopeless cases –and putting the patient through an unncessary ordeal– just in the hopes that he can pull it off
    often enough to enhance his
    reputation?
    Is he doing too many surgeries? Is he letting his residents take too much reponsbility in surgery?
    Surely more than 10 percent of those who lose three malpractice suits are in fact negligent, or taking excessive risks, or over-treating.
    Doctors must do a much, much better job of policing their colleagues. If they did, and if hospitals took errors more seriously–and told the truth more often– there would be many fewer suits.
    There is probably something wrong with many (though not all) of the 5 percent of doctors who account for 57 percent of payouts.
    Finally, not long ago I met an attorney who represents hospitals in malpractice suits and she said the biggest problem is gettign them to tell the truth and apologize. And getting doctors to tell the truth.
    Reserach shows that even in countries that have “no fault” malpractice insurance, doctors try to cover up their mistakes. It seems to be part of the macho/ego culture learned in med school. You never admit you screwed up.
    Yet patients are much less likely to sue–and much more likely to drop a suit–if the doctor tells the relatives exactly what happened, says he is very, very sorry –and means it.
    I don’t have numbers on this, but I would bet that doctors who are sued are much more likely to be arrogant, cold people who the patient never liked.
    Caring, compassionate doctors who spent time listening to the patient, answering questions, etc are, I am almost certain, much less likely to be threatened with a suit.
    And they are also probably the ones most likely to say “I sorry”–sincerely.
    This response is so long that I’m gong to turn it into a post !
    Catmin–thank you.

  8. Regarding pay for doctors: I am very much for fee for service. And avoiding payment at the point of service could be very helpful. Deductibles, co-pays, co-insurance, and other business manipulations need to just go away. However, like other parts of the health care reform plan, which I have written, these fees must be: simplified; fair, meaning reasonable-not resentment-inducing; require no major billing effort on the part of the doctor’s office staff; and have quick turn around. The fee itself may be a conflict of interest for some doctors. My view is that this would include a minority of physicians.
    Regarding a salary structure for physicians: Who pays the salary is critical, because the payer MUST NOT INTERFERE with the decision making occurring within the doctor—patient relationship.
    Like a fee for service, the salary structure might be a conflict of interest for some physicians but in a negative sense. Why should I see those extra patients today? Why should I perform that elective surgery? My salary is not going to increase.
    Again, I hope that this would be a minority of physicians. But the reported problems with the Canadian and British systems cause me to question that.
    Doctors need to be paid and paid well in my view. Both payment structures carry potential problems and we have to TRUST that the altruism and sincerity of doctors, a critical part of a sound, ongoing doctor—patient relationship, greatly reduce their strength.
    R. Garth Kirkwood MD
    http://www.equalhealthcareforall.com
    doctork@equalhealthcareforall.com

  9. Garth–
    I agree that “who pays the salary is critical.”
    But at multispecialty clinics like Intermountain, the Mayo Clinic and the Cleveland Clinci, clinic run by doctors is paying the salaries.
    This is ideal.
    And at these clinics, it seems pretty clear that doctors do a very, very good job, even though an extra surgery, or an extra procedure won’t boost their income.
    I believe that most docotors really are professionals–and put their patients’ interests first.
    And particuarly today, when bright young doctors and med students know that they could probablly make more money in corpoate America or on Wall Street–with many fewer years of education, stress, debt and effort . . . Yet they still choose medicine.
    These are people who, I think, are going to be professionals. I trust them to do their best, even though they are on salary rather than fee-for-service.

  10. A couple of random thoughts. Great string of posts.
    On FFS vs salary, I have friends at Cleveland Clinic and Mayo. They are both exceptional institutions, and there is a culture there that is not reproducible elsewhere (think US telling Iraq, “start a democracy, here is how you do it”). Prima facie, you wont get docs to behave in other systems like you would at the two above.
    As far as cross cultural comparisons to UK, Canada, or elsewhere, to me at least, interesting, but never fruitful. Great PBS show last month, http://www.pbs.org/wgbh/pages/frontline/sickaroundtheworld/
    and you will see that as societies, we are inherently different and will respond to difft carrots and sticks. Thought it was telling that in Singapore, folks dont even think twice about privacy issues for data collection. Here, in US, totally different ballgame. No need for copays, deductibles, etc., because they have different mindsets. Kaiser has great podcast when show was unveiled–great listen.
    As far as malpractice, be careful. When speaking about being sued, winning vs losing, etc., I have many friends who have undergone neither, but have been mentioned in Bill of Particulars, been deposed, waited years, and then discontinued. With this comes bitterness and changes in behavior. They are not counted in the stats, and believe me, more sleepless nights than you could imagine. Maggie, this is not a trifle, and as much as I despise using tort reform as the bogeyman (see Dick Armey WSJ Op-Ed today, oy)–we have bigger fish to fry, I do believe it is more influential than many think.
    Finally, I stole this from some slide set, great speaker and i am embarrassed I cant credit him. Anyway, in speaking about CDHC, and MD vs Consumer decision making, see below. It appeared 2×2 table, CONSUMER VS MD DRIVEN choices were X and Y axis.
    Consumer Driven
    MD Driven
    DISCRETIONARY SPENDING (DIAGNOSTIC RADIOLOGY)
    BENEFIT AND NETWORK INCENTIVE: STRONG
    Not Consumer Drive
    Not MD driven
    MEDICALLY NECESSARY (APPENDECTOMY)
    BENEFIT AND NETWORK INCENTIVE: MILD
    Not Consumer Driven
    MD driven
    SID (CARDIAC DEVICES)
    BENEFIT: MILD
    NETWORK: STRONG
    Consumer Driven
    Not MD driven
    MORAL HAZARD (GENERIC Rx)
    BENEFIT: STRONG
    NETWORK: MILD
    What the breakdowns are, ie, how often issues are in quadrants 1-4 is beyond me, but Herzlinger is certainly in the 4 camp.
    Brad

  11. Ah, Maggie, such a disappointing post, citing so much data that does not remotely address my point about malpractice. Brad F. gets much closer. You see, Maggie, it’s not at all about how much money is paid out in malpractice claims, or how many doctors actually end up paying a claim. Sure, that mattered 15 or 20 years ago. But now it matters if you are actually simply named in a suit, with depositions, publication of your involvement in the suit (but no publication when you are dropped because your involvement in the suit was frivolous), and an increase in your malpractice insurance premium simply because you were named in the suit. The practice of defensive medicine was once all about defending a suit that was launched in an attempt to win the suit. Now it’s all about trying to avoid the suit. And no amount of care, testing, or evaluation is enough if just a little more might be what it takes to avoid that suit. THAT’S what drives up the cost of medical care in the U.S. from defensive medicine, not the rounding error of payments or judgments. You failed to read and analyze my comment; you simply used my comment as an opportunity to regurgitate a pat statement.
    You also missed an opportunity to compare and contrast the American system of punitive malpractice tort with a system that is driven by a philosophy of uncovering the root cause of errors and attempting to then prevent errors/misadventure/harm by addressing the underlying source. It is interesting that you choose to cite the anesthesia example, for anesthesia is unique in its ability to have gotten all of its members on board in an across the board root-cause analysis of risks despite the risk that lawsuits would be launched BECAUSE OF THOSE EFFORTS, resulting in a dramatic, measurable decrease in harmful anesthesia accidents. You imply that it is ONLY through a punitive system that this could occur, and you therefore miss the opportunity to trumpet one of the single-payer systems that you should adore–Sweden, where errors are routinely reported in the overwhelming majority of instances, thereby allowing for the prevention of errors downstream through use of evidence-based analysis.
    You also miss my point about the hazard inherent in an adversarial system where victims of medical misadventure, be it negligence or simply a bad outcome, must prevail in a battle in order to be compensated for the hardship caused by said misadventure. How about the victim of true medical malpractice, something that does occur, albeit rather infrequently? What happens to that individual after they lose at trial, which they often do? And what of the victim of an error for which no blame can be assigned? Or even the victor at trial whose award is sufficient to cover their care BEFORE the attorney’s fees of 30-40%? No, Maggie, you missed an opportunity to more deeply evaluate this issue and seek a more considered solution, in my mind due to pre-existing bias that you choose not to re-examine.
    I have not read your Dr. Gawande. Does he practice medicine of some sort? From whence does he gather his data to come to the conclusion that doctors have some sort of confidence in their diagnosis and treatment, from whatever source, of only 30%? How about some data, data comparable to the “evidence” that underpines “Evidence-based Medicine”? I’m not buyin’ it, Maggie. I can’t imagine any cohort of physicians polled with that question coming up with 70% uncertainty.
    And lastly, as long as I’m here, I challenge you to access an attending physician at the Cleveland Clinic at 5:01 PM on any day of the week, with any question, any clinical need, for any medical or surgical problem whatsoever. For that matter, I challenge any physician interested in referring a patient to the Cleveland Clinic at 5:01 PM on any day of the week to access an attending physician, the keeper of the culture, the driver of the care, for any medical question, any clinical need, or any medical or surgical need whatsoever. You have succumbed to marketing no less powerful or effective than that of any pharmaceutical company. I cannot speak of the Mayo Clinic, but the Cleveland Clinic is “Doctor-Centered Medicine” and a “Doctor-Centered Experience.” Journalists, especially those who request stories about patients harmed by unnecessary surgery, have a professional obligation to do research before reporting or opining.

  12. Bingo and Brad
    Thanks for your comments.
    Bingo– You’re new to this blog, or would know that we’ve written about malpractice before and recognize that just being sued (or named) is a horrible, time-consuming, event that can both demoralize a doctor and hurt his reputation, even though he wins.
    I have written at length about alternatives –expert juries (including doctors, medical ethicists, etc.) and expert judges, required arbitration, etc.
    But here is the problem: the truth is that physicians have done a very ,very poor job of policing themselves. This is in part–but only in part–because they are afraid of being sued by a physicians who they expose as being negligent.
    It is also a “club mentality”–too many doctors identify with other doctors, even if they are negligent.
    I’m going to write another post about malpractice and hospital errors laying out some of the myths and facts.
    We definitely need to reform how we deal with malpractice cases in this country, and I’ll talk about that.
    But a doctor who I respect recently called me to talk about the post I wrote about a doctor telling my friend Tom that he needed cataract operations in both eyes. Toom had scheduled on operation and was about to schedule the other when a second doctor then told Tom that he had 20/20 vision in one eye 20/40 vision in the other eyes, and didn’t need an operation in either eye.
    I have since learned that the operation that was already scheduled was in the 20/20 eye.
    The doctor who called me about this post said Tom shouldn’t try to report the doctor because it would “wreck the doctor’s life.” And the fact that he had 20/20 vision didn’t absolutely rule out need for an operation. A “glare” test and other tests would need to be done. This, he indicated is an area of medicine where there can be a lot of ambiguity.
    I was sympathetic to that argument–no one wants to wreck someone’s life. But on reflection it struck me that since the doctor who called me had not seen Tom’s eyes he had no way of knowing whether this was just a disagreement between two doctors in a grey area of medicine or whehter the first doctor was, indeed, simply trying to pump up his practice.
    Blind loyalty to a fellow doctor made him keeping repeating: “Don’t report him; it will wreck his life.”
    What about the people who will be hurt if this doctor is, indeed, doing unncessary cataract operations? The doctor who called me was much less worried about those potential patients than about someone he identified with as a fellow doctor.
    Re Who is Gawande? Since you are a physician, I’m surprised you’ve never heard of Dr. Atul Gawande. He is a surgeon at Harvard who has written a couple of excellent books, writes regularly for The New Yorker, has written op-eds for the NYT etc.
    He was involved in the recent outcry when the government tried to shut down a very good “checklist” program that was reducing errors in hospitals.
    The studies I cited on autopisies were published in 1998 and 1999 and they showed that autopsies revealed major misdiagnosis in 40 percent of all cases.
    (The 30 percent number is not about autopsies–it has to do with the degree of certainty doctors feel according to the Dean of Dartmouth’s medical schooll as well as 3 decades of reserach by Dartmouth how how little of the medicine practiced in the U.S. is “evidence-based” and how much is driven by supply or custom.)
    Going back to the fact that autopsies showed misdiagnosis in 40 percent of cases: “For example, the attending physician may have been treating a person for heart disease when the real problem was cancer or vice-versa,” former JAMA editor Dr. George Lundberg explains. “And in about one-third of those cases the patient would have been expected to live if proper treatment had been administered.” (You’ll find all of this in Lundberg’s book “Severed Trust.”)
    Many of the misdiagnosis could be traced to mis-placed faith in advanced diagnostic tests.
    Atul Gawande and a group of doctors at Harvard found it hard to believe that diagnosis are still so often wrong—despite the tests. So after reading about the 1998 to 1999 reserach, they ran their own reserach, going back to hoospital records from the 1960s (before CT scans etc. were developed)–and
    comparing them to records
    from the 1980s.
    What they found was, they said, “humbling.” It seems that diagnosis have not improved. “In both decades, physicians missed one-fourth of fatal infections, a third of heart attacks and almost two-thirds of pulmonary emboli in patients who died.”
    In most cases, Gawande points out, it wasn’t the technology that failed. The physician never considered the correct diagnosis in the first place.So he ordered the wrong test. The right test was available, but he never thought of it.” (You’ll find all of this in Gawande’s book, Complications.)
    Gawande rightly stresses the degree of uncertainty in medicine.
    Were the doctors who got the diagnosis wrong negligent? Not necessarily.
    Diseases often don’t present in textbook fashion.
    Should doctors be faulted for missing the diagnosis? In some cases yes, in some case no.
    But the misdiagnosis definitely should be investigated by other doctors in that specialty.
    (I wrote at length about this in my book, Money-Driven Medicine, where a whistle-blowing doc talks eloquently about what needs to be done.)
    Suing the doctor is not the important part.
    Investigating him is. And,
    doctors who are sloppy, or simply not very good should not be practicing medicine –or at least should not be practicing without a lot of supervision.
    Gawande also has written brilliantly about how doctors, like everyone else, live on a bell curve.
    At the extreme right, a small number are excellent.
    At the extreme left, a small number are very poor–and shouldn’t be practicing.
    In the middle, the vast majority are “mediocre.” Unfortunately, the vast majority of doctors are not humble enough to admit just how fallible they are, how much uncertainty they are deal with, and that the majority of them are, by definition “mediocre.” This leads to more errors and too little reporting of mistakes by doctors.
    As to doing research before reporting, as regular readers of this blog know, I do a great deal of reserach. And the
    malpractice case that I’ve passed onto the ddocumentary film-makers was brought to me by a physician how is doing research on patients seriously harmed by being over-medicated by their doctors not once–but repeatedly.
    Based on the reserach and reporting I’ve done, in my book and in other places, physicians have invited me to a keynote speaker at medical conferences (Mass. Medical Society, Texas Medical Society, Mt.Sina Hospital, etc.) Since I am not a physician, I am always very flattered. They invite me because they know my work, and trust that it is based on sound facts, reserach and evidence. I realize you are not familiar with my work, but you really should read more of it before offering somewhat condescending advice.
    There are a great many excellent physicians out there doing reserach on the amount of over-treatment and iatrogenic
    illness in this country (diseases caused by medical treatment.)
    To learn more about what they are doing, I’d
    suggest that you start by going to http://www.dartmouthatlas.org, and read their most recent report, documenting the 3 decades of reserach they have been doing on overtreatment, inappropriate treatment,and the lack of evidence behind so much medical treatment– going back to tonsillectomies.
    As to seeing a salaried doctor at 5:31, there is now quite a bit of medical research showing that, on blanace, outcomes are best at multispeciality centers where doctors work on salary–and leave at 5. (See Dr. Don Berwick and the Institute for Healthcare Improvement)
    Too often, scary medicine is practiced by
    solo practioners or doctors in small practices with no one looking over their shoulder who work as many hours a day as they can, piling up fees for service.
    Younger doctors entering the profession are aware of this. Most want to be on salary. For them, these are also lifestyle issues. As you may have noticed, more and more of your colleagues are women, and they (like many of your male colleagues) went to go home to have a family life with their children.
    Tney are happy to be on salary and to have a regular schedule. Most importantly, medical schools are now running courses in “the handover” so that when the doctor “hands over” the patient to another doctor before going home, the second doctor gets the information that he needs in a form he can use. (Electronic medical records at places like Mayo are, of course, a huge help).
    This is much better than having tired doctors working too many hours.
    Brad–
    I agree with you about Mayo and the Cleveland Clnic being special cultures that are not easily duplicated. For instance, some of Mayo’s other clinics are not as successsful (in terms of outcomes and lower costs) as St. Mary’s in Minnesota.
    Still, outcomes are good.
    (Dartmouth does a comparison of Mayo’s hospitals in its most recent report on http://www.dartmouthatlas.org.)
    But I agreee– the people there and a culture makes these special places. Still, they are not alone: Intermountain, UCSanFrancisco, and Dartmouth itself are all very special places. Very good outcomes, much lower costs.
    The contrast between UCSF and UCLA Medical Center is striking– quality is much higher at UCSF while spending is significantly lower.
    And over the past year, I keep finding excellent sources at UCSF– Dr. Steve Schroeder, a woman who is a leading autism expert in the country (and realizes that it is now being greatly overdiagnosed) . . .
    I think part of it is that extremely talented, like-minded people who put patients first and are willing to talk candidly about medical errors and over-treatment tend to cluster at certain places. . .
    The VA is another example. Though it has been crippled by lack of funding in the last 8 years, doctors who choose to practice at the VA seem to be a self-selecting group of acamdemic physicians who truly enjoy working with vets.
    Finally, Kaiser in Northern California seems to have created a strong culture. Again, this is not true of all of Kaiser. . . In other parts of the country, it hasn’t worked as well. Lots of resistance to the Kaiser model in Texas. Then, again, what does work in Texas, except Austin?
    I’m not sure I agree that Americans are that different from other countries. Though drug-makers, the AMA etc. want to tell us we’re “different”
    and wouldn’t’ be happyp with healthcare in other countres I went to the Frontline link you included and went to the transcript. Here’s what the reporter said at the end: “Well, the fact is these foreign health care ideas aren’t really so foreign to us. For American veterans, health care is just like Britain’s NHS. For seniors on Medicare, we’re Taiwan. For working Americans with insurance, we’re Germany.”
    That sounds about right. And seniors are on the whole very happy with Medicare (though we’re beginning to see the strain caused by rising costs) and many vets are very happy with the VA (though given funding problems there are now really problems with long waits. But in the 1990s, it was great.)
    Too often people who have a vested intersted in the status quo– and a vested intersted in telling us that we are “exceptional” and can’t learn anything from other countries –are really just saying that we’re selfish, incapable of thinking collectively, and of looking out for each other. (See my recent post on “Reform by Focus Group.”)
    I’m not willing to believe this. When it comes to issues like health care, leaders need to appeal to the most generous side of Americans, emphasizing that we’re all in the same boat together.
    As a doctor said to me recently, it doesn’t matter how rich you are, if you go to an American hospital you are just about as likely to have the wrong leg amputated as anyone else. Hospital errors that come with fragmented, unco-orindated, market-driven care affect us all.

  13. Maggie
    Sorry, the reference was from the Kaiser healthcast. See link, response to question that starts on page 26 of trancscript. Again, a nice presentation, Reinhardt and his wife were illuminating as always:
    http://www.kaisernetwork.org/health_cast/hcast_index.cfm?display=detail&hc=2576
    If you watch or listen to the entire broadcast, you will get a flavor of their perceptions and how we might differ from other cultures. As you have referenced in the past, the whole issue of social solidarity is a recurring theme. Unlike here, folks think of how their decisions effect others.
    I have USAA as my autoinsurance. I always like that dividend/refund check in the spring. The less we use as a group, the more we get back. Not apples to apples, but you get the idea. That kind of approach does have its salutary effects.
    Brad

  14. I spent twenty years at Mayo and agree that its culture is unique, in ways both bad and good. From the patient’s perspective, though, they are all good. One thing I always noticed was that Mayo consultants (the official Mayo-ese term for staff physicians) really care about what their colleagues think of them. There is a high degree of peer pressure to be thought well of and respected by those peers. That is a powerful force and works to the patient’s advantage. An interesting manifestation of Mayo’s attitude is dress. People joke about how everyone there, men and women, wears a suit and a simple name tag. The absence of gradations of white coats can make it hard to know the major players from the minor ones, but when the department chair and the intern essentially dress the same it does instill an aspect of egalitarianism on the staff level.
    One key aspect to their system is the extraordinary level of support services for the physicians; I have not found this to be true elsewhere, and it is another thing that is more important to many physicians than high salaries. Mayo did find its Minnesota culture a little difficult to export to their satellites in Florida and Arizona, at least when they started. My own secretary was one of the many support folks sent for a couple of months down to Scottsdale to whip some of the Mayo ethos into the folks at the new facility.
    All that is fine for patients, but from a physician’s standpoint it is a little difficult to be a tall poppy at Mayo, or even a slightly different sort of poppy. So I went on to other things without regrets.

  15. Maggie,
    Several comments on this.
    First, when I think of a patient with a problem that is difficult to diagnose that requires one test after another to figure it out; I think of the TV series “House.” I don’t think those cases account for more than a small percentage of healthcare costs. For people with chronic conditions like heart disease, asthma, diabetes, etc., the doctor can often settle on a course of treatment that he at least has a lot of confidence in and would be well satisfied if he or a family member received that treatment under similar circumstances. As you have written often, those chronic diseases account for the bulk of healthcare costs.
    At the same time, one of the Japanese doctors interviewed on the PBS Frontline series said that most of his patient encounters took five minutes or less which doesn’t seem like very much time to provide consultation, answer questions or do analysis. Yet, the Japanese have the world’s longest life expectancy, and they spend far less than we do on healthcare, both on a per capita basis and as a percentage of GDP. Moreover, I’ve heard U.S. emergency medicine doctors claim that, most of the time; they can figure out a patient’s problem within five minutes, even though they have never met the patient and know little or nothing about his or her medical history.
    As you know, I believe in personal responsibility and I think “skin in the game” and high deductible health plans can work perfectly well, at least for the upper half of the income distribution. In my own case, while I have good insurance and can easily afford my share of the bills, I’m not shy about asking if there is an effective generic drug that can be used instead of a more expensive brand. After a couple of years of good reports from my urologist, I asked if I could stretch my checkups out from every six months to once a year. He said I could and I did. I used to get a colonoscopy every three years because of a family history of colon cancer. Last time, I asked if I could stretch it out to every five year. The answer was yes, and I did. While our parents may have been brought up to view doctors as all knowing and to never question their decisions or recommendations, I think the baby boomers and the following generation will have a different mindset. At least, I hope they do.
    On malpractice, I agree that the medical profession needs to do a better job of weeding out the small number of less competent doctors who account for a disproportionate share of malpractice cases. One medical doctor some time back made the point that the committees that are charged with this task develop a mentality to (1) give the guy a break as anyone can make a mistake, (2) he has a mortgage and a family, so we don’t want to ruin his career and perhaps his life, and (3) we’re afraid he might sue us. There’s got to be a better way. If he were on salary, he could, presumably, more easily be fired.
    Finally, with respect to end of life care, there is a lot more need for gentle honesty, especially with respect to cancer cases. If I had advanced cancer, for example, and was told: if we don’t treat it, I’ll die in six months. If we treat it, I might live for 9 or 10 months, but most of that time will be miserable due to chemo side effects and other factors, I might well opt for hospice or palliative care. More than likely, most patients would just be treated aggressively (and expensively) at places like UCLA because it fills the beds and keeps the specialists busy so the hospital can pay off its bonds. If there are hospitals that have a more patient centered and balanced culture, it would be helpful if there were a mechanism to steer patients in that direction if that’s what they really want.

  16. Herzlinger is a hack who hasn’t done any real research on health care. It flabbergasts me that she is taken with even a grain of salt in the health care community. At least Porter brings some interesting ideas to the table that are worth discussing and his latest book on health care was coherent.

  17. I disagree with you that the clinic itself, (Mayo, Cleveland, Intermountain) or HMOs, or hospitals are the ideal entity to be paying a salary to a doctor, regardless of their registered profit status and regardless of who “runs” the clinic.
    These institutions are independent business fiefdoms and their decisions are made from a business-dollar perspective. Decision making within individual doctor—patient relationships becomes subordinate to the flow of dollars, subordinate to the decisions of business people, who direct these clinics’ operations, whether they have MD behind their names or not. There are millions to billions of dollars at stake depending on the nature of the business entity.
    The entity paying the doctor’s salary becomes the employer. Thus the following relationship occurs: doctor—employer—patient. Business decisions made by these employers can and do have direct effect on the doctor—patient relationship both in an individual sense at that particular institution and in a national sense regarding clear and equal access to same. I believe this is not the best way. The doctor’s allegiance must be to the patient not to the clinic, which pays his/her salary. The doctor—patient relationship is indeed an employee—employer relationship but an unusual one. The employee (doctor) does not do what the employer (patient) says. The doctor retains autonomy and yet works with the patient to come to a decision as to the best way to proceed in each individual case.
    The salary structure, which you have outlined, I believe, is just as or perhaps even more conflicted than fee-for-service.
    If payment to doctors is to occur through salaries, I believe these payments should come from a truly “not-for-profit” single payer. This same single payer should also be directing the payment to hospitals and clinics such that they all become truly “not-for-profit.” And, at the same time, the problems known to exist with the Canadian and British single payer systems must be recognized, understood, and then avoided.
    R. Garth Kirkwood MD
    doctork@equalhealthcareforall.com
    http://www.equalhealthcareforall.com

  18. Maggie:
    Quite a few things to comment on regarding your response. I’ll be brief; I’ve got a day job!
    Surprised I’m not familiar with Dr. Gawande? Come on…low blow! Like I said, I have a day job! 70-80% of my reading is professional, time dedicated to doing my job better. I am aware of the research (but was not instantly recognizing the author), but admittedly have not gone to the source material. I’ll try to find a little time to do so.
    Regarding the cataract case: I’ll bet that the doctor you talked with also said something like: “If Tom had no documented complaints and that the other vision tests like contrast sensitivity, etc. also show excellent vision, then there is probably an issue.” And something like: “It’s necessary to know more about the particulars in order to reasonably initiate the kind of inquiry you have in mind. It is a major thing. An inquiry like that will ruin the doctor’s life, not just stop him from practicing, no matter what the outcome is.” Or something like that.

  19. With regard to the malpractice issue I fear that at least I am guilty of “talking past” you in that I am trying to make a point about MY interest in malpractice tort (that defensive medicine dramatically drives up the cost of care in the U.S.), and not listening to the point that YOU are trying to make (that medical errors and diagnostic uncertainty are the greater issue). Mea culpa.
    Unnecessary care, for whatever reason, exposes a patient to the potential for harm. A complication from the care itself (like a complication from premature cataract surgery, however rare) or a complication from a treatment downstream from an unnecessary test that came up with a false positive, would both be examples of harm to a patient from excessive or unnecessary care. We can agree on this.
    But I will ask you again to bring to bear your considerable intellect, and to tap into your equally considerable network of thinkers, and to consider an alternative to our present system of punitive tort. Our present system discourages the pursuit of the root causes of error. Our present adversarial system exposes patients who have been harmed to the spector of losing a case and being left without resources to overcome the effect of the error.
    Remember, the vast amount of cost associated with defensive medicine does NOT find its way to the bottom line of the doctor in the way of income. To be sure SOME cost associated with unecessary care certainly does end up as income to a doctor (eg. premature cataract surgery), with or without harm to the patient (uncomplicated premature cataract surgery, even though it is still wrong as it was done prematurely).
    I hope this is more like talking TO one another…

  20. And finally “confident only 30% of the time.” Am I correct (after having admitted that I have not read the source material) that Gawanade’s research was on the autopsy correlation with the anti-mortem diagnosis? And were the doctors who were “humbled” rendered thus after being presented the data of a comparison of autopsy data with the anti-mortem diagnoses?
    Would you agree, or would you think that Gawanade would agree that it is in those cases that are most complex, in which the possibility of mis-diagnosis is therefore most possible, that an autopsy takes place? Is this really referable to the majority of medical care rendered in the U.S., so much so that such a sweeping statement as “physicians are only confident in their diagnosis 30% of the time” is truly valid outside of a teaching hospital caring for the very sick? And what data do we have that supports statements such as “only 30% of the care rendered in the U.S. is supported by evidence” that it is effective? I think the example I offered below would NOT fall in the 30% backed by evidence as I understand the definition. Such broad statements on both sides…
    Common things are common, and the confidence in the diagnosis and care of common disorders is correspondingly high, and rightfully so. If the conclusion of this area of Gawanade’s research is a heightened awareness of the uncertainty of our dianostic acumen in the face of complexity, with a resulting increase in physician humility, well, who could argue with that.
    While I am new to this blog, as you accurately point out, I am not new to either medicine or this line of thought. I appreciate having the opportunity to think about, discuss, and work through these complex and important issues with you and your commmenters.

  21. Maggie,
    I didn’t have time last week to give Niko Karvounis’ posting the attention it deserves. Let me correct that here.
    He wrote: “Last week, Georgia passed a law—with the support of Newt Gingrich—that will give insurers $146 million in tax breaks for selling HSA plans.”
    Actually, the law waives the premium tax for HSA plans. Saying this is a tax break for insurers is like saying that a back-to-school sales tax holiday is a “tax break” for clothing manufacturers. No, it is a break for consumers.
    NK: “HDHPs and HSAs also do little for the uninsured, since most families without health insurance are low-income won’t be able to afford health coverage that asks them to pay $4,000 out of pocket before their insurance kicks in.”
    That may be, but these folks cannot afford comprehensive coverage either. In either case, low-income people need to be subsidized. We can subsidize their premiums for high-cost coverage or we can subsidize their direct out-of-pocket spending. The question is which form of spending gets more value?
    NK: “Even though Gruber’s medical bills have never exceeded his deductible, his insurer Blue Cross Blue Shield upped his monthly premium from $337.50 a month to $470.50 in 2007, a 39 percent increase.”
    That particular insurer pooled its HSA experience with all of its other products. Mercer was able to separate out the cost increases for various forms of coverage and found that from 2006 to 2007, CDHPs increased 3.5%, HMOs 7.6%, PPOs 6.1%, and POS 11.2%
    NK: “But with the HSA, the deal is even sweeter: when employees withdraw money from the HSA to cover medical expenses, they still don’t have to pay any taxes on the either the principal or the dividends and capital gains that have compounded over the years.”
    The tax treatment for HSAs is identical to the tax treatment for all employer-sponsored insurance. Money paid in (premiums or HSA deposits) is tax free and money paid out (benefits or medical withdrawals) is tax free
    NK: “In 2005 contributions to HSAs totaled $754 million, more than double the $366 million in withdrawals.”
    That’s why they are called Health SAVINGS Accounts. It is money put aside for future needs.
    NK: “Taxpayers with HSAs earn almost two-and-a-half times as much as the average American, with an average adjusted gross income of $139,000—compared to $57,000 for all other filers.”
    This is from the GAO and deals only with the first year of enrollment (taxes filed in 2005), so it is hardly representative. Further it compares HSA holders to “all tax filers” which includes the uninsured, people on Medicaid, people in the military, the Medicare disabled, and so on. The only meaningful comparison would be between HSA holders and others with private coverage.
    NK: “According to a March Employee Benefits Research Institute/Commonwealth Fund report, 31 percent of households that held these plans had incomes of $100,000 in 2007—up from 22 percent in 2005.”
    What EBRI actually found is if you compare the population with CDHPs (with savings accounts) to people with “comprehensive benefits,” the biggest difference is in education. CDHP enrollees are far more likely to have a graduate degree (24% vs. 9%)or be a college graduate (41% vs. 20%), and far less likely to have a high school education or less (11% vs. 42%). It is not surprising, given the better education, that CDHP enrollees have better incomes, though not by as much as you might think. They are more likely to be in households with incomes over $150K (11% vs. 7%), or between $100K and $150K (20% vs. 14%) and less likely to earn less than $30K (6%vs. 15%) or between $30K and $50K (13% vs. 18%).
    NK: “Indeed, the proportion of U.S. workers covered by employer-based coverage fell from 51.1 percent in 2000 to 48.8 percent in 2006.”
    I don’t know where he gets this from. That latest KFF survey reported that 59% of all workers get coverage from their own firm (with others getting coverage from a spouse’s company)
    Overall, Mr. Karvounis never says what he is for. He apparently doesn’t like any form of cost-sharing, but even without HSAs, PPO deductibles are going up – from $689 per family in 2000 to $1,134 in 2007, according to Mercer. Even the much-beloved Medicare has significant deductibles and coinsurance, and no limit on out-of-pocket exposure. Perhaps he likes HMOs, yet HMOs were roundly rejected by the American people for interfering with their ability to get the services they felt they needed.

  22. Barry, Brad, Chris, Anon, Garth, Bingo, Greg S.–
    This is a very intresting thread. I’m sorry I haven’t gotten back to you, but I’m writing postsand also am travelling on business this week.
    But please do check back–I’ll make time to reply later this week.
    thanks, mm

  23. Barry, Brad, Chris, Anon, Garth, Bingo, Greg S.–
    This is a very intresting thread. I’m sorry I haven’t gotten back to you, but I’m writing postsand also am travelling on business this week.
    But please do check back–I’ll make time to reply later this week.
    thanks, mm

  24. the computer culture not only suggests that we all can be experts on everything, but also, equally dangerously, that we live in a binary world. so the question is posed as either doctors are experts and we should do what they say OR we’re customers who can decide what we want and demand that they provide it because we pay them. fact is that docs know (one hopes) more than patients do about the general problem and patients know more about their specific circumstances. the herzlinger stuff is just silly, a half-step above the challenge to evolution.

  25. the computer culture not only suggests that we all can be experts on everything, but also, equally dangerously, that we live in a binary world. so the question is posed as either doctors are experts and we should do what they say OR we’re customers who can decide what we want and demand that they provide it because we pay them. fact is that docs know (one hopes) more than patients do about the general problem and patients know more about their specific circumstances. the herzlinger stuff is just silly, a half-step above the challenge to evolution.

  26. Greg–
    Thanks for your comments.
    Let’s take your points one by one.
    Niko wrote: “Last week, Georgia passed a law—with the support of Newt Gingrich—that will give insurers $146 million in tax breaks for selling HSA plans.”
    Your comment: “Actually, the law waives the premium tax for HSA plans. Saying this is a tax break for insurers is like saying that a back-to-school sales tax holiday is a “tax break” for clothing manufacturers. No, it is a break for consumers.
    I’m afraid you’re wrong. The much bigger tax break is for insurers. See these three sources:
    1) “The legislation also exempts insurers from paying premium taxes on HSA-linked plans. The measure, H.B. 977, goes into effect Jan. 1, 2009.” http://www.businessinsurance.com/cgi-bin/news.pl?id=12918
    2)“Consumer groups say legislation rolling through the Georgia General Assembly, intended to make health insurance more affordable, would also hand insurers an expensive gift: $146 million in tax breaks over the next five years. That benefit, they say, dwarfs the five-year tax savings to employers ($64.8 million) and individuals ($6.7 million) projected under the bill.” http://www.ajc.com/metro/content/metro/stories/2008/03/27/insurance_0328.html
    3)“The House bill is expected to provider insurers with $146 million annually in tax breaks. Employers are expected to save $64.8 million, and workers are expected to save $6.7 million, according to an independent analysis by the Georgia Budget and Policy Institute.” http://www.medicalnewstoday.com/articles/107015.php
    Niko also explained that: “HDHPs and HSAs also do little for the uninsured, since most families without health insurance are low-income won’t be able to afford health coverage that asks them to pay $4,000 out of pocket before their insurance kicks in.”
    You replied: “That may be, but these folks cannot afford comprehensive coverage either. In either case, low-income people need to be subsidized. We can subsidize their premiums for high-cost coverage or we can subsidize their direct out-of-pocket spending. The question is which form of spending gets more value?”
    You need to read more of our posts. As regular health beat readers know we aren’t arguing for keeping the current system.. We believe in more powerful cost-effectiveness across the board. The point isn’t that our “high-cost” system is good, but that consumer-driven medicine is the wrong way to reform. We’re more ambitious than you assume.
    Niko wrote: “Even though Gruber’s medical bills have never exceeded his deductible, his insurer Blue Cross Blue Shield upped his monthly premium from $337.50 a month to $470.50 in 2007, a 39 percent increase.”
    You replied: “That particular insurer pooled its HSA experience with all of its other products. Mercer was able to separate out the cost increases for various forms of coverage and found that from 2006 to 2007, CDHPs increased 3.5%, HMOs 7.6%, PPOs 6.1%, and POS 11.2%
    Who cares what Mercer did? That doesn’t help Gruber.
    Insuers need to be regulated. One problem with the consumer-driven movement is that it shifts the reponsibility for policing insurers to consumers. They are supposed to be “smart shoppers” and recognize that Mercer is doing a better job of separating cost increases.
    The point is that, for so much more out–of-pocket spending, consumers should be getting a much better break on premiums. Blue Cross Blue Shield needs to be regulated–it shouldn’t be allowed to hike premiums to that degree. It’s called “bait and switch”
    . This example shows that the market is not that efficient; high out-of-pocket payments do not always mean low premiums. But if you listen to consumer-driven rhetoric, you find a chain of assumptions at work: “smart consumers will shop intelligently, competition will lower prices, etc etc.” It’s dogmatic, and it sends the message that consumer-driven care is a silver bullet—that efficient reform will fix everything if we just leave everything to the market. But clearly, that’s not true.
    Look at the U.S. auto market, for instance. A number of years ago inefficient, sometimes unsafe SUV’s took over a large share of the market. The consumers who over-paid for those cars were not making smart decisions. And now they’re left holding the bag–the market value of their SUVs has sunk.
    Markets don’t look forward–they don’t anticipate or plan. If anyone in Detroit had been looking forward (or if anyone in Washington had been looking forward and demanding fuel efficiency) it would have been apparent, in 2000, that global demand for oil was outpacing supply, and that gasoline prices would be rising sharply in this century.
    Going back to health insurance, without a uniform, regulated framework, you can imagine many of these “exceptions” popping up, causing more disparity of coverage and cost. You can’t just say “oh, but Blue Cross Blue Shield did it wrong,” but things will work out—because if it’s done wrong, patients suffer.
    There are a many inefficient enterprises that continue to thrive, in any market. The market is not perfect at thinning the herd. Without proper regulation, this sort of unevenness will continue—at the expense of patients.
    Healthcare is too important to be left to the vagaries of the marketplace.
    Niko wrote “But with the HSA, the deal is even sweeter: when employees withdraw money from the HSA to cover medical expenses, they still don’t have to pay any taxes on the either the principal or the dividends and capital gains that have compounded over the years.”
    You wrote: “The tax treatment for HSAs is identical to the tax treatment for all employer-sponsored insurance. Money paid in (premiums or HSA deposits) is tax free and money paid out (benefits or medical withdrawals) is tax free.”
    No,the situations are not identical. Money paid into employer-sponsored health insurance in the form of premiums is paid into a pool of funds that will then be paid out to help whoever happens to become sick. Money paid into an HSA is paid into an individual’s private account building wealth for that individiual. There is no “public good” to justify the double tax exemption. Society is not being helped.
    The proper comparison is to an IRA, which like an HSA is a savings vehicle for the individual only. When I withdraw money from an IRA I will pay taxes on it. But when I withdraw money from an HSA for medical expenses, I pay no taxes. Moreover, I can let that money compound, tax-free, for years. Finally, the definition of “medical expenses” is very broad and can include improvements to my home. Why should other taxpayers foot the bill for things they can’t afford?
    Niko wrote “In 2005 contributions to HSAs totaled $754 million, more than double the $366 million in withdrawals.”
    You commented “That’s why they are called Health SAVINGS Accounts. It is money put aside for future needs.”
    Exactly–they are savings accounts–like IRAs. They offer a way for an individual to build private wealth. The fact that the amount that the government allows people to shelter from taxes so far exceeds the amount they take out to cover medical needs shows that the HSA was designed to be a tax shelter that would let the wealthy (those who could afford to contribute the max and use other funds for medical expenses) let their money compound, tax-free.
    Will people use HSAs to save for medical expenses or simply to take advantage of the tax shelter? Probably both. I suspect that turning a blind eye to the tax shelter element is just as much about politics or ideology as it is about policy, because the truth is we can never really divine HAS-users’ motivations. What is the “appropriate” ratio of contributions to withdrawals? There is none, because it’s all about saving, and rich people can save as much as they want because they have more discretionary income.
    Niko wrote: “Taxpayers with HSAs earn almost two-and-a-half times as much as the average American, with an average adjusted gross income of $139,000—compared to $57,000 for all other filers.”
    You commented: “This is from the GAO and deals only with the first year of enrollment (taxes filed in 2005), so it is hardly representative. Further it compares HSA holders to “all tax filers” which includes the uninsured, people on Medicaid, people in the military, the Medicare disabled, and so on. The only meaningful comparison would be between HSA holders and others with private coverage.”
    I’m not sure why we should ignore people without private coverage—after all, from our perspective at least, good health care reform shouldn’t exacerbate existing inequalities and disparities in health care and access to services. So it’s worth looking at the full spectrum of coverage. We’re not just concerned with how HSAs compare to those with insurance, but how the introduction of HSAs adds yet another level of nigh-unattainable coverage for the have-nots. We don’t need to make it harder for those at the bottom to get to the top—which is what HSAs do.
    Niko wrote “According to a March Employee Benefits Research Institute/Commonwealth Fund report, 31 percent of households that held these plans had incomes of $100,000 in 2007—up from 22 percent in 2005.”
    You commented “What EBRI actually found is if you compare the population with CDHPs (with savings accounts) to people with “comprehensive benefits,” the biggest difference is in education. CDHP enrollees are far more likely to have a graduate degree (24% vs. 9%)or be a college graduate (41% vs. 20%), and far less likely to have a high school education or less (11% vs. 42%). It is not surprising, given the better education, that CDHP enrollees have better incomes, though not by as much as you might think. They are more likely to be in households with incomes over $150K (11% vs. 7%), or between $100K and $150K (20% vs. 14%) and less likely to earn less than $30K (6%vs. 15%) or between $30K and $50K (13% vs. 18%).”
    You are simply confirming Niko’s point: HSAs favor the privileged.Education and income are correlated. Other people don’t have enough discretionary income to take full advantage of HSAs. Anyone with questions can click the link to the report which Niko included.
    Niko wrote: “Indeed, the proportion of U.S. workers covered by employer-based coverage fell from 51.1 percent in 2000 to 48.8 percent in 2006.”
    You commented “I don’t know where he gets this from. That latest KFF survey reported that 59% of all workers get coverage from their own firm (with others getting coverage from a spouse’s company).
    These numbers come from the Economic POlicy Institute’s latest April 2008 report. http://www.epi.org/content.cfm/bp209.
    You write “Overall, Mr. Karvounis never says what he is for. He apparently doesn’t like any form of cost-sharing, but even without HSAs, PPO deductibles are going up – from $689 per family in 2000 to $1,134 in 2007, according to Mercer. Even the much-beloved Medicare has significant deductibles and coinsurance, and no limit on out-of-pocket exposure. Perhaps he likes HMOs, yet HMOs were roundly rejected by the American people for interfering with their ability to get the services they felt they needed.
    To know what we are for, just read Health Beat. We are not in favor of the current system and we think Medicare needs reform. As many physicians and health experts have pointed out, co-pays at point of treatment become a barrier to care. And as Medicare runs out of money, they’re rising too high too quickly.
    In countries where outcomes and overall health are much better than they are in the U.S. (even if you look only at white Americans,) there are no charges at point of service, and everyone goes for Pap smears, mammograms, etc. As a result, cervical cancer, for example, has been wiped out in Scandanavian countries.
    —–Original Message—–

  27. Barry, Brad, Chris, Anon, Garth, Bingo, Greg S. and Jim,
    Back from my trip.
    Brad– thanks for the link.
    Chris– Very interesting information about Mayo and it rings true. I can imagine how it would not be the best place for all very good doctors–though it’s probably a fantastic place to be early in your career. And everything you say about what it is like for patients squares with what I know.
    They haven’t been as successful in other locations, though quality is still pretty high and costs lower than at many places. In its 2008 report, Dartmouth compared the various Mayo locations–see http://www.dartmouthatlas.org
    Garth– read what Chris has to say about Mayo, where he practiced. (Scroll down just a few comments.)
    Everything I know about Mayo is that it is run for the sake of the patients.
    I agree that at for-profit medical centers and hospitals, the drive for profits can take over. I would prefer to see doctors working, on salary, at not-for-profit
    multi-specialty clinics.
    But mission trumps money at places like Dartmouth, UCSF, Intermountain and in many parts of Kaiser. (Very good people in Northern California and in Colorado.)
    Barry– I agree about agressive care for cancer when reserach shows it will only by some months of low-quality life. . .
    Regarding how many cases are hard to diagnose and know how to treat: Depression is one of the five or six chronic diseases that acccounts for 80 percent of healthcare spending.
    Clinical depression is a terribly debilitating disease, and we’re still working in the dark trying to figure out how to treat it. Some medications work for some people. Talk therapy works for some people. But often, patients relapse.
    Other garden-variety diseases that can be very
    difficult to diagnose or know how to treat are infections from unknown sources, complications experienced by older people who typically are suffering from 3 to 5 chronic illnesses and have symptoms caused by treatments for one disease interacting with treatments from another disease; and mysterious illnesses involving very young children.
    When my daughter was about 2, one morning she became very sleepy: Running around one minute, laying down on the rug the next.
    Realilzing something was wrong, we got her into the car to take her to the hospital. Sitting on my lap, she went limp, couldn’t sit up, didn’t respond when I spoke ot her, and by the time we arrived at the hospital 15 minutes away she was in a deep coma.
    Over the next 24 hours, they did every test they could think of They couldn’t diagnose what was wrong; couldn’t wake her up.
    I just kept talking to her.Eventually, about 24 hours after this occurred, I said “Knock knock” and very sleepily, she opened one eye and murmured “who’s there?”
    They never did figure it out. They warned us that she might have seizures in the future (she never did.)
    My best guess is that she got hold of my mother’s blood pressure medication.
    (My mother was living with us, refused to keep it locked in a medicine cabinet, and occasionally spilled a pill on the floor.)
    I told the doctors about this, and they ran tests looking for traces,but couldnt’ find anything. Still, it seems the most likely explanation. We were with her all the time that morning, so we know she didnt’ fall . . .
    My point is simply that many parents can tell stories like this.
    Regarding deductibles: a high deductible can become a barrier to care.
    Research shows than when there is a deductible, people stop going for mammograms, etc. .
    It may seem to you that this is irresponsible behavior but the fact is, we all wind up paying for it if they develop breast cancer and it isn’t caught early.
    The notion that Japanese doctors spend 5 minutes with patients doens’t square with all of the information I’ve seen showing that the bulk of Japan’s health care dollars are spent on cofnitive medicine–doctors listening to patinets, talking to them, diagnosing and prescribing medication.
    Anon– You wrote ” It flabbergasts me that she (Herzlinger) is taken with even a grain of salt in the health care community. At least Porter brings some interesting ideas to the table that are worth discussing and his latest book on health care was coherent.”
    I heartily agree about both of them. Porter is a highly intelligent man and he gets it right about half the time. He just doesn’t quite understand the messy realities of medicine that make it different from other businesses, and why market solutions don’t work in this case.
    Bingo– You’re right, low blow about Gawande!
    But I do think you would really like his book: “Complications: Surgeon’s Notes on an Imperfect Science.” It’s extremely intelligent, wonderful stories and excellent insights into medicine.
    And yes, the doctor who warned I could ruin Dr. X’s life did say those other things. (And when I see doctor Y I plan to ask him more questions to get more particulars before doing anything.) But the doctor I spoke to on the phone also kept repeating “You’ll ruin his life” in a way that initially made me feel guilty about doing anything . . .
    Jim-== You wrote:
    “the computer culture not only suggests that we all can be experts on everything, but also, equally dangerously, that we live in a binary world. so the question is posed as either doctors are experts and we should do what they say OR we’re customers who can decide what we want and demand that they provide it because we pay them. fact is that docs know (one hopes) more than patients do about the general problem and patients know more about their specific circumstances. the herzlinger stuff is just silly, a half-step above the challenge to evolution.”
    I absolutely agree.

Leave a Reply

Your email address will not be published. Required fields are marked *

You may use these HTML tags and attributes: <a href="" title=""> <abbr title=""> <acronym title=""> <b> <blockquote cite=""> <cite> <code> <del datetime=""> <em> <i> <q cite=""> <strike> <strong>