A Guest Post: What the Doctor Ordered

This post was written by Pat S,  a recently retired physician who practiced in the Midwest for 30 years.  He has worked for both private practices and for large multispecialty groups, spending about half of his career in each setting.

Doctors play a critical role in any potential health care reform.  Although they have very little impact on attempts to broaden access to health care, they are central to efforts to improve the lagging quality of US health care and to address the issue of the cost of medical care in the 21st century.

Our national health care bill now runs over $2.5 trillion a year, consuming 17% of GDP. The cost of health care threatens to overwhelm the economy, and ultimately, as President Obama has noted, undermine any economic recovery. Unless we change the way we practice medicine, the adoption of new policies to improve health care access through universal insurance and improve benefits in both private and public programs will make our financial problem even worse, since greater access will lead to increased spending as new people enter the market for medical services.

If we imagine a long train of carloads of cash from both government and private sources entering the healthcare market, it is doctors who have their hand on the throttle.  Most medical spending occurs because of orders written by doctors: tests ordered by doctors, hospital admissions carried out by doctors, procedures recommended and performed by doctors, and drugs and other treatments prescribed by doctors.  When it comes reducing health care costs and improving the health of most Americans, doctors have greater power than anyone.

The research performed by the Dartmouth Atlas group has documented that lower cost providers actually offer better care than higher cost providers.  The data suggests that if higher cost providers in the Sun Belt and on both coasts were to change their practice patterns to match those of  the Mayo Clinic, Cleveland Clinic, and several other large providers,  we could not only save significant amounts of money, but would have better health care.

However, approaching this problem seems overwhelming, since we are addressing nothing less than the entire culture of medicine in the US.  Resistance to changes by most doctors in higher cost settings probably makes a large scale approach futile. 

Doctors tend to practice in ways that they have been taught during their training, which accounts for a large part of the regional variation.  Oversupply of doctors — especially specialists, hospital beds, surgical units, and diagnostic equipment both in hospitals and clinics and in private doctors’ offices is also critical to the cost differences, since providers tend to engage in practice patterns that fill their schedules and utilize available resources.  Both the Dartmouth data and other focused studies have shown that this increased use of resources (both professional and infrastructure), often leads to worse, not better, results of care.

This is not to say that doctors never amend their practice patterns. They do. But the two biggest drivers of change are information reported in scientific journals and meetings and information conveyed by representatives of drug and equipment companies. 

The role of equipment and drug sales people in promoting the use of more expensive treatments and technology is obvious.  Unfortunately, because of cultural pressures on researchers at many institutions to be part of innovative new approaches, and because of the close financial and professional relationships between many researchers and research institutions and pharmaceutical and equipment companies, a lot of reported research endorses complex, high tech, expensive care. 

There is also strong cultural pressure to publish reports of successful, not unsuccessful, research.  As a friend of mine who works in research at a major center told me, “You get a lot less positive reaction and get a lot fewer grants if you regularly say that things don’t work than by saying that things do.  There have been no Nobel Prizes given for proving that new approaches fail.  No one likes bad news.”

Since it is unlikely that we will see a large scale change in American medical culture to match the characteristics of British, French, or Swedish practitioners–or even to match the practice patterns of institutions like the Mayo Clinic that the Dartmouth data shows give the best health care while containing costs– we need to find another way to create change.

I believe that the best way would be to target specific patterns of practice that research has shown are overused, expensive, and less effective than lower cost approaches.  Rather than trying to solve the problem wholesale, we need a retail approach, building better practice patterns one brick at a time.

The building blocks we need to work with start with patterns of practice that have been addressed by large scale research in both the US and overseas, and have shown clear evidence that changes in practice patterns would result not only in huge savings but also in better results for patients.

A few examples:

1.) Change the way we manage hypertension to conform to results of research, depending primarily on diuretics, low cost generic beta blockers, and low cost generic ACE inhibitors instead of using expensive proprietary drugs that are less effective, have more frequent and significant complications, and cost hundreds to thousands of dollars more for each patient each year.

2.) Change the pattern of management of coronary artery disease for patients who have not just suffered an acute heart attack and do not have symptoms of unstable heart disease.  We need to move away from coronary artery bypass surgery, angioplasty, and stent placement for these patients and rely on less aggressive non-invasive medical management.  Again, this approach is backed by large scale research.  It would be less expensive, safer, and more effective for patients.

3.) Change the pattern of management of back pain not accompanied by significant motor nerve findings or bowel or bladder dysfunction away from MRI imaging and surgery and to conservative management for a period of 3 to 6 months, ordering MRI or surgical consultation only if conservative treatment has failed.   This too is supported by multiple American and European studies, and is safer, just as effective and much, much less expensive.

4.) Change patterns of use of diagnostic imaging.  Areas of overuse of imaging include assessment of chronic headaches without neurological findings, of new knee pain in people over 50 or 55, of non-specific abdominal pain, and several other areas.   Changes should aim to eliminate studies that have extremely low (often less than 1%) yield or that tend to result in findings that are misleading in terms of clinical management.  We also need to eliminate imaging in areas where imaging will not change management, regardless of results, because clinical and lab findings clearly establish appropriate management paths independent of imaging.

5.) Experiment with the use of the “medical home” concept and intensive low tech primary care management of the “big six” chronic illnesses, including asthma, congestive heart failure, coronary artery disease, chronic lung disease, depression, and diabetes, This means paying appropriate fees to primary care doctors, other primary care providers, and nurses to provide close care for the patients..  Evidence from several sources, again both here and abroad , suggests these management patterns could drastically improve quality of care, resulting in lower use of ER’s, hospitals, and ICU’s, saving billions and improving health and quality of life.

6.) Save money by using universal insurance coverage to encourage people to obtain primary care providers for routine care and common mild acute problems, stopping expensive use of ER’s for primary care.  This requires establishing alternatives, especially in low socio-economic areas, partly by changing reimbursement patterns so that Medicaid reimbursements at least match Medicare reimbursement. Financial incentives also are needed to motivate providers to supply the personnel needed to staff community clinics and other alternatives to ER’s both in  poor urban neighborhoods and in poor rural areas.

7.) Implement simple quality improvement steps, including checklists and pre-procedure staff “time out” evaluations, which show promise in reducing errors and complications, saving lives, hospital and ICU time, and preventing medical mistakes.  These techniques have been mainly designed to improve care. However, the research also shows that they save healthcare dollars..  The cost of implementing quality improvements like these would be negligible, but applied across the entire US, huge amounts of money could be saved while effectiveness and safety of care would improve immensely.

8.) Utilize the electronic medical record effectively. This would include requiring national standards for EMR systems that assure that systems are capable of sharing data with systems in other health care settings and with systems manufactured by different venders/ allowing Interoperable systems t can prevent expensive duplication of services and dangerous errors due to lack of information about the patient, while also reducing the overhead costs of billing for services.

9.) Create a program that pays a reasonable fee for comprehensive “end of life” counseling for families and patients, informing people of l
ikely outcomes, the effects of various types of interventions, and what their choices are.  This could help people make the choices that are best for themselves and their loved ones and allow them to discuss alternatives in an informed and comprehensive manner before choices have to be made.  End of life care eats up a significant chunk of our health care dollars, yet results in care that frequently does no real good, lowers quality of life, and is resented by families and patients unhappy with the services.  In many cases, a two hour discussion early in a first admission would save two weeks of poor quality survival in the ICU, as well as carloads of money.

If these steps were adopted and there was compliance by most providers, we would save at least $300 billion to $400 billion a year, and would achieve better, more effective, safer care, and healthier Americans leading better quality lives. 

Although these clearly represent best practice standards, that does not say they should be applied to every patient in every circumstance.  There are legitimate contraindications for some treatments, and legitimate indications for alternative treatment in particular cases The programs must allow doctors and patients the freedom to document these circumstances and deviate from  the guidelines.

However, we need to avoid the common attitude that “my patients should have the more expensive treatment because my patients deserve the best,” or that “research does not apply to me because I am a better surgeon than the people studied in the research, so I should continue to practice the way I always have.”  Although medicine is indeed an art as well as a science, all doctors know that in the large majority of cases following standard practice gives better results.  The exceptions that are publicized in books and articles by doctors and others are exactly that: rare exceptions to general rules that make dramatic reading but do not establish appropriate “best practice” in most cases.

In everyday settings, doctors do best when they follow proven standards.  This, in fact, is the secret of high quality, low cost institutions.  Mayo follows the “Mayo way,” after experience and research establishes that that is the most effective and safest standard of care, and its culture works against individualistic “freestyle” medical practice.

So if most providers followed these standards most of the time Americans could be healthier and lead higher quality lives.  Each one of the standards is just one brick in the wall of rebuilding US health care as a stronger, better system, but together they would make the whole structure stronger. 

Why the Government Needs to Be Involved

Unfortunately, although many doctors and some institutions do follow “best practice” guidelines based on medical research, many do not.  Research indicates that compliance with any of the standards listed here is no more than 60% and in many cases as low as 15%.  Cultural settings, pressure from patients and colleagues, fear of litigation, and confusing information all play a role in this unfortunate situation.

Private insurers and HMO administrators should be interested in implementing standards that would improve quality of care and reduce costs – and many have programs that push in that direction.  But they are handicapped by pressure from patients, employers, health providers, and drug and equipment manufacturers as well as by the competition within the insurance industry itself.  Especially since the late 90’s, when the backlash from the public and the media forced companies to stop attempts at “managed care,” private insurers and HMO’s have found it very difficult to take the lead in controlling costs and improving care.  Part of this was  the companies own fault:  when vying for contracts from employers,  many insurers competed on price, not quality—offering cheaper coverage  not better care. Today, some. insurers and HMO’s are creeping  back into areas of trying to improve standards of care while reducing costs, but competitive forces and public opinion force them to move very slowly and cautiously.

Individual providers, hospitals, and HMO clinical divisions also frequently have problems trying to implement standards on their own.  In a candid private conversation the CEO of a large health care system told me that it would be impossible for his system to institute changes in management of back pain, since those changes would cause patients to leave his system and seek care from other nearby institutions that would be willing to provide early MRI and surgical consultation.

Very large, dominant systems can make changes that save health care dollars and improve  outcomes, and sometimes these changes will filter down into other practices in their geographic area. But unfortunately that is the exception rather than the rule. The Dartmouth Atlas has done a good job of identifying the systems that routinely do set standards for efficient care—proving that it is possible to provide care that is at once less costly and more effective.

In the end, the one institution involved in US health care that does have the power to put these changes in place is the federal government.  Through Medicare, Medicaid, SCHIP, the VA and military health care, public employee insurance programs, the Public Health System and its branches, and the large national scientific organizations like the National Institutes of Health and National Cancer Institute, the government does have the clout. The government now pays more than half of all health care bills in the U.S. (this includes the money federal, state and local governments spend providing care for their employees,) and the government is also the most powerful source of medical research. Development of an optional Federal Insurance Program (Medicare Part E – “E” for everyone) as part of universal care would broaden the government’s reach and increase its  clout in changing the way we practice medicine.

In order to identify and implement appropriate standards of care, a federally run National Health Care Effectiveness Board could provide a way to document and encourage changes, based on information from scientific studies that already exists.  The board also could play a role in collecting and commissioning new studies to provide similar information in other areas of medicine that have not been subjected to careful assessment of clinical effectiveness.

Protection Against the Threat of Malpractice Suits

Many health care providers will be willing to implement these changes in their practices if the government provided them with cover by setting standards and explaining the standards to both providers and the public.  This is partly because most providers really do want to provide the best possible care (and almost all believe they do,) and partly because establishing practice standards could protect against inappropriate lawsuits. 

The most dramatic example of this can be seen in the history of anesthesiology.  In the mid-70’s, anesthesiologists faced the highest malpractice insurance premiums of any specialty – often as high as $100,000 a year (and those are 1975 dollars, remember.)  The Society of Anesthesiology, realizing that this was threatening the viability of many practices, created a national panel which developed a set of specific standards for anesthesia practice. 

They then created a task force of lawyers and academic experts that offered its support to any practitioner who could document that they had followed the standards but was still being sued.  Verdicts against anesthesiologists plunged ,and–since plaintiffs attorneys cannot afford to lose regularly –the number of lawsuits declined sharply  Insurance premiums fell  by 90%. 

More importantly, compl
ications of anesthesia and deaths from anesthesia also declined .The standards not only had the desired result of ending the malpractice crisis in anesthesia, but also made anesthetic management safer and more effective.  This created an impressive win for the patients as well as the doctors.

This effect of practice standards on the malpractice climate could be helped along mightily if states passed legislation to codify the fact that documented proof of following best standards promulgated by federal agencies would serve as a clear and binding defense against charges of malpractice.  This is not to say that patients do not deserve to be compensated when real malpractice occurs, but that the public also  deserve protection from inappropriate and sometimes dangerous procedures, tests, and treatments ordered as “defensive” medicine to try to avoid lawsuits.

But in the end, let me stress, while the government needs to play an important role in creating and documenting standards of care, organizing the effort to improve care and providing “cover” for doctors, hospitals, and insurers, it is doctors who write the orders. They and they alone have the power to reform the quality and cost of our health care system from within.

39 thoughts on “A Guest Post: What the Doctor Ordered

  1. I thought this was an excellent and comprehensive analysis. I would just like to offer a few thoughts.
    First, I strongly agree with the need to develop easy to use, cost-effective interoperable electronic medical records. Such records not only should reduce duplication of testing and adverse drug interactions, especially in hospitals, but they should also provide the infrastructure to facilitate data gathering and analysis to help us understand more quickly and completely what works and what doesn’t.
    Second, regarding protection from litigation if it can be documented that evidence based best practice standards were followed, I agree with this as well. However, I note that the example of the anesthesiologists related to doing procedures as opposed to trying to diagnose a medical problem. As I understand it, part of the problem anesthesiologists faced was that different brands of equipment worked differently such as requiring a valve to be turned to the right on one brand to turn the volume up or down and to the left on another. Standardization of equipment functionality was a big part of the solution. I think a lot of defensive medicine today is driven by fear of suits related to a failure to diagnose a disease or condition even though such suits represent only about 19% of malpractice cases according to Maggie. There is no question, however, that if we expect doctors to help us control costs by following best practices, we need to protect them from inappropriate litigation if they can show that they did so.
    Finally, I was pleased that Pat noted the high costs related to end of life care. A compassionate but honest discussion of options with the patient and the family early in the process should become standard practice in these cases.
    Where we have good data regarding what constitutes best practice, we should promulgate it and incorporate it into payment policy. Where we don’t, we should try to develop it with the help of interoperable electronic medical records.

  2. a wonderful analysis. key is the acknowledgement that physicians have their hands on the throttle. the challenge lies in either slowing down the train or allowing someone else to take responsibility for doing so. one way or another America will find a way to moderate costs. but it still seems an open question as to whether physicians will take the lead here or be an obstacle. equally unclear whether they realize that these are their only options.

  3. Excellent!
    The “more is not better in medicine message” needs to be said over and over and over again.
    And ethical and compassionate rationing toward the end of life would be a huge step forward.
    Be Well,
    Dr. Rick Lippin
    Southampton,Pa

  4. As usual, Barry has some interesting comments.
    I agree that there is considerable difference between the practices of anesthesiologists and that of internists, FP’s, ER doctors, and others dealing with the question of diagnosis with a sick patient in front of them. However, a couple of points.
    First, a lot of what the doctors on the front lines do CAN be addressed by standards. For example, the problems of headaches, back aches, stomach aches, joint aches, fevers, malaise, tiredness, and all the other things that cause patients to present themselves and ask “doctor, what can you do?” As it happens, practice standards can give a lot of guidance about when it is appropriate to get a CT, an MR, what labs are needed, when a consult from a surgeon or other specialist is necessary, and so on, and when it is appropriate to say “take two tylenol and call me in the morning.” In fact, this is exactly where a lot of the effort to create standards has focused in other countries. And, BTW, those efforts don’t always say “spend less, do less.” The British effectiveness board actually directed physicians to get MORE CT’s in acute head trauma than was generally being done in England.
    Second, the changes in anesthesia were not mostly about uniformity in machines. They focused mostly on doing and documenting adequate monitoring of various things happening with patients, eliminating some obviously less safe and effective techniques, and doing a complete job of finding out about the patient’s underlying health — and above all document, document, document. A lot of the standards were really an early example of the “checklist” technique, with the checklists being employed many times throughout the process. In terms of equipment, the standards were important in getting widespread early application of pulse oximetry and of CO2 monitors, which created some costs, but costs that were more than made up by avoiding serious complications of anesthesia. However, that happened several years after the initial positive impact of the standards.
    Finally, the issue with end of life discussion is not whether it should be done, but whether it should be PAID for as a seperate service. My belief, and there is a lot of evidence suggesting this it true, is that it should be paid for and that the relatively small fee will be repayed, sometimes literally a thousand fold, in savings on care that is ineffective and actually unwanted, but gets done anyhow.
    Practice standards cannot be applied to everything, and are not at the root of all malpractice, but they can be applied to a surprising number of things with good effect on quality of care, associated litigation charging poor quality of care, and on costs — really a huge amount of cost.
    They are a much better way of dealing with costs than using the blunt edged approach of across the board cuts in payments, and have the enormous advantage of making things better, not worse.

  5. Excellent suggestions.
    Overuse is so built into the system, It will take a long time to turn this bloated system around. Dr. Pat has identified the major areas of abuse. Patient expectations also drive utilization; no doctor is going to send grandma out of the ER without a CT, if that’s what his lawyer daughter in law is demanding, without tort immunity.
    If it were up to me, I would attack utilization first. EMR sounds like a good idea to the same people that think automated baggage handling would be a good idea in Denver.
    End of life care is the biggest sink hole in the system. In ten years the electricity to heat our children”s schools is going to be cut off to run the respirators of the comatous elderly, at the rate we are going.
    Since we all seem to think Medicare is a success, why don’t we have Medicard for all uninsured, but with the proviso that no malpractice suits can arise for the care, in the absence of actual criminal negligence. See how that works. If that works, then extend the protection to the ER and OB.
    Opps..back on earth, this will not happen. Most policy geniuses don’t think malpractice is a problem. Really. Until they do, we are all pretty much doomed.
    They don’t see the relationship between malpractice protection and curbing end of life care. What better way for an alienated family member to prove his loyalty to dad than suing the hospital that so mistreated him?
    Or the relationship to access, excessive testing, and clogged ER’s.
    We will have to eventually eliminate our current tort system. Why not do it now, before our entire society is broke?

  6. This is a very interesting article on the new stimulus package including healthcare. I was actually very happy to hear about it and also believe in the innovations and upsides as well. But as I was blindsided and I think Obama was as well, the immediate reaction from this was the healthcare stocks dropped dramatically. It is kind of like a downward spiral for our economy. I truly hope that everything pulls together as we all are equal and we should all have decent healthcare as well.
    We should all be able ask a nurse a question from personal health questions to disease management and be able to get a straight answer without getting charged a million dollars

  7. You have touched upon some very good ideas to some of the problems that vex the health care system. We are in need of some serious change and that should be enough of a start.

  8. Pat,
    First, thanks for fleshing out the history of what happened with the anesthesiologists. It’s quite surprising to a non-physician like me that checklists and documentation have not always been part of standard medical practice for surgical procedures.
    It is also gratifying to learn that established best practice standards can be applied to such a wide array of complaints that patients come to family doctors or ER doctors to seek help in treating. I think the general concept of significant legal protection from inappropriate suits against doctors who follow best practice protocols is a critical component of any successful strategy to drive wasteful utilization out of the healthcare system. Unfortunately, the trial lawyers are an even stronger lobby than the physicians, and it’s likely to be extremely difficult to get such reforms through a heavily Democratic Congress and a Democratic administration that collectively accept so much PAC money and bundled contributions from trial lawyers. Aside from myself, virtually all the comments I see on this and other healthcare blogs calling for sensible medical tort reform are from doctors who are on the firing line everyday. Progressives who downplay the need for tort reform cite the relatively low combined payouts for malpractice judgments and / or say that we can’t measure defensive medicine accurately because other motivations from patient expectations to revenue maximization may also be driving utilization.
    On the end of life care issue, I didn’t know that a discussion of options wasn’t paid for as a separate service. It certainly should be, and, as you suggest, it would be a quite modest expense compared to the potentially huge bills that can be generated by a days or weeks long stay in an ICU. I think this is an area where we can learn a lot from other countries in how they define and apply good, sound medical practice.

  9. Great post. But…
    Gotta get real when it comes to the greed generated fraud and abuse that have contributed heavily to the outrageous cost of American health care. There is no segment of the industry that hasn’t had an impact. Take a look at taf.org and the top 20 False Claims settlements of this young century. They are all in health care. Scroll down the long, long list. Health care entities dominate. Enforcement needs to be the rule – not settlements and laughable corporate compliance programs. Take a look at the payoffs to physicians by joint implant manufacturers and the poster-child of what’s wrong with our health care system – Big Pharma! What about physician self referral? How about self referral and anti-trust issues surrounding large health care systems? One of the biggest oxymorons in health care is not-for-profit hospital.
    Why do so many docs love the ambulance chasers? It’s a great reason to justify over utilization of tests and procedures. What is a physician’s ATM called? An MRI.
    How about the impact of 1-800 Ask Lucifer?
    Enough. There is no need to beat a dead horse. Well, one more point. It’s the health care Mafia. What happens when one of the majority of good health care providers “narcs” on one of their colleagues who is cheating the system? They may as well close their doors and move on.
    Change has to come from the real world of health care, not from the pundits, the industry greed mongers and pseudo-academicians that got us to where we are now.
    We must build on the ideology, experience and passion of Dr. Pat S. and move forward with a system that rewards good health care providers, especially physicians (and especially the primary care docs) and punishes charlatans, frauds and cheats.

  10. Spot on as far as it goes. Everything you have said about the roles of doctors and government is absolutely correct, but no one is talking about the third leg of the stool: the role played by patients and their expectations. As long as Americans insist on only “the best” medical care, perceived to include instant MRI and stents and backed up by the threat of litigation for any suboptimal outcome, we’re not going to get anywhere.

  11. An excellent perspective from Dr. Pat — I’d like to call out one point he makes that others have not commented on: “Doctors tend to practice in ways that they have been taught during their training, which accounts for a large part of the regional variation.”
    This is a truly important aspect of health care reform that isn’t discussed much — how will substantive reforms be sustained if our medical professionals (not just physicians, but also nurses and allied health providers) are not trained in new ways?
    The Mayo Clinic Health Policy Center is hosting The National Medical and Health Care Education Reform Symposium April 26-28. The goal of the symposium is to gather stakeholders — educators for all types of providers, government, professional societies, students, patients, etc. together to discuss the issues and, most importantly, to develop a set of prioritized solutions/ideas of how to change medical and health care education to support health care reform. More information can be viewed at http://www.mayoclinic.org/healthpolicycenter/2009-agenda.html. Please consider attending or following along.
    While much of our national attention rightly needs to be focused on creating a sustainable, high-quality health care system, we also need to look ahead and figure out how we will continue to support and improve it over time — and an excellent place to start is with changing how we train our providers.
    Jane Jacobs
    Mayo Clinic Health Policy Center

  12. One thing that never gets discussed explicitly are goals.
    We want to lower costs, by how much? When will we know that we have reached an optimum place? If we cut back on, say, the six most questionable practices have we saved enough so that the rest of the inefficiencies are no longer significant?
    Saying that this should be an ongoing process and that there is no final goal isn’t really an answer either. At some point the incremental savings become not worth pursuing. It costs money to evaluate efficacy and to monitor compliance and this may outweigh the savings.
    A similar lack of specific goals is seen with treatment options. Many treatments have variable outcomes depending upon ill-understood factors about patients. A cancer drug works on one person, but not on another. Do we not try it because we don’t know who will benefit?
    There is only one area where I think we can state a straightforward goal – universal accessibility to health care. When the number of people falling through the cracks is zero we will have reached our goal.
    I’m of the opinion that this should be the first goal, not an incremental one. Massachusetts adopted its health plan with this strategy and managed to sign up most of those not covered quickly. They are now tackling the high costs of medicine in general, but have brought all the health providers and insurers into the program and made them stakeholders. The public will not stand for a return to partial coverage, so cost control is now the only topic of discussion.
    It is just as much of a battle to ask for $5 billion as for $50 billion. Just look at all the opposition to various incremental tax schemes like raising tobacco or gasoline taxes.
    Aim for the Moon and only back down when you have to, not aim for New Jersey and then take one step at a time.
    In spite of what people claims we can afford to cover everyone right now. It’s just a question of priorities – granny or more F22’s? Health care or Afghanistan?

  13. Specifically, we need to invest in a new health system that can tackle the growing problem of chronic disease, which is crippling both our health care system and our economy.
    Of the $2.2 trillion we pour into health care each year, a frightening 75 cents of every dollar goes towards treating patients with chronic illnesses. In Medicaid, this figure is an even more regrettable 83 cents of every dollar; in Medicare, it’s an astounding 96 cents.
    Illnesses such as diabetes, heart disease, and cancer, that in many cases could have been prevented by changes in behavior or could be better managed through early detection and appropriate access to treatment, have risen dramatically over the past three decades, leaving Americans in much worse shape at earlier and earlier ages.
    The rise in obesity is at the root of this increase. With younger and younger Americans suffering from overweight and obesity, the outlook is grim for finding a solution to stem rising health costs short of helping Americans transform their unhealthy behaviors.
    The truth is, we can never expect to improve the affordability of health care until we face the dual crises of obesity and chronic disease. And, until we deal with cost, the chance of extending health care coverage to more Americans is grim.
    Check this out:
    http://blog.nj.com/njv_guest_blog/2009/03/health_care_reform_lets_do_it.html

  14. robertdfeinman —
    1.) Analysis of effectiveness is unlikely to reach a point where it is no longer useful anytime soon, or in fact anytime at all. There are many other things to look at after the top six or seven have been addressed, and researchers, drug manufacturers, and equipment and supply manufacturers keep introducing new things all the time.
    The point is that effectiveness and comparative effectiveness should be a routine part of evaluation of any new and all old medical management techniques. The costs of medical care are so high and the costs of good research are so low — and due to get lower, as Barry points out, if we adopt a good EMR system — that the cost/benefit ratio is always very high.
    2.) Almost all medical management techniques have some degree of variable results, since people are biologic systems with a degree of variability of their own. For example, a very small number of children have serious reactions to childhood immunizations, but no one who remembers when polio regularly killed and crippled thousands or when measles was a leading cause of blindness and deafness would suggest that we not practice large scale immunization. The point is to select the best and most efficient ways of dealing with any medical problem as the basic approach, but realize that there will be failures and there will be patients in whom other approaches are indicated. Those exceptions need to be documented before proceeding on to other less effective options.
    3.) Universal access, including both universal coverage and improvements in coverage to stop obstructions to access, is goal number one. But in order to continue to offer universal access we need to improve effectiveness and reduce costs, otherwise we will destroy our ability to offer universal access or even access for most people.
    Health care already costs between two and three times as much as the most complete accounting of the cost of defense. At the rate that health care costs are growing, we could decide to spend every dime of the defense budget as well as every dime of the hidden costs of defense on health care, and in a few years we would be back in a serious potential shortfall.
    Reducing costs is an important part of reform, since without that reform cannot succeed in the long term.
    Improving effectiveness of health care is also critical to reform, since if large numbers of people are given access to care that actually fails to help them or makes them worse, we have failed as well.
    The approach I am discussing strengthens univeral access by saving money and allowing the programs to continue, and strengthens the quality of medical care by providing care that works.
    Advocates of health care reform like to say that health care is a three legged stool. Access is important, but effectiveness and economic impact are also important. If we forget any of the legs, the whole system will collapse.

  15. Pat S:
    I’d never get anywhere in congress since my skills at getting legislation passed are non-existent. So we need to separate goals from strategy.
    I have no way of judging what strategy will work the best or the fastest, but I look from a moral point of view. If we cover everyone NOW we reduce suffering NOW. If we cover everyone “eventually” then we are allowing an evil to persist that we can avoid.
    I seem to remember hearing numbers in the range of $60 billion per year to cover those currently left out. We certainly can afford that, we have just given twice that to AIG.
    As for the cost of militarism, Joseph Stiglitz has estimated the wars will end up costing $3 trillion, yet there are no discussions of how this affects the health (figurative and literal) of society.
    So, what we are debating is strategy. I said provide full coverage now as Massachusetts has done and then (or simultaneously) work on improving “efficiency”.
    Right the wrong you can fix first. Is this politically feasible? I have no idea, but Massachusetts did it.
    Yesterday the census released its five year survey of business. There are about 16 million people employed in the health field, changing that culture will take a long time, covering people can be done with a single piece of legislation.
    I vote for cutting in the Gordian knot, not incrementalism.

  16. Excellent post. I will copy and save it for future reference. Reforming end of life care would save a lot of money and give most people a better death. But payment reform is crucial. The current payment system results in over-utilization of technology, too many specialists, and not enough generalists. I would add that any chance of reining in costs or improving value for cost will fail with an inadequate supply of generalists.

  17. healthcare advocate —
    We do need to address the costs of chronic disease. The “medical home” and intensive low tech outpatient management of the big six chronic diseases, mentioned in my original post, should be tried as in important potential way of providing better care, better quality of life, and significant cost savings.
    Efforts to address causes of poor health, including obesity, smoking, sedentary habits, and poor diet choices, are important for their own sake. They can help people to live better, longer, higher quality lives.
    However, as was discussed at some length on an earlier thread here, improvement of health habits is not a good way to save money in the overall health system, because longer lived people with healthy habits actually cost more money in the long run, a fact demonstrated in several studies, especially by the Dutch National Health Service.
    The idea that we could save large sums of health care dollars by getting people to have healthier habits is a common one in the US, but, unfortunately, not supported by the best objective evidence.
    We need better health habits to make us more healthy, but in order to save money we need to concentrate on more effective management.

  18. robertdfeinman —
    I understand where you are coming from and don’t disagree. I don’t think anyone involved in health care reform does not think that universal care is an immediate priority. The insurance industry has endorsed mandatory universal coverage, and in his response to Obama’s congressional address Bobby Jindal said that Republicans stand for universal care.
    However, realize that the $3 trillion cost of the war is cost accumulated over all the years the war has been going on and the future years when the debt incurred to fight the war will be paid off. The cost of health care is now $2.5 trillion a year and will shortly be $3 trillion every year. If universal health care is passed the government share of health care costs will rise rapidly to at least 65% of that total. The $60 billion a year estimate of costs for universal care is incredibly optimistic and really is just a campaign slogan. The congressional budget office estimates $180 billion a year, by itself exceeding the costs of the war. That does not count any added costs for the underinsured.
    Remember that 15% of the population is uninsured, and that number again underinsured to the point where they avoid using health care. 15% of the nation’s health costs is $375 billion a year. Costs will be less than that because the people insured will mostly be under 65, but will be higher than the average costs for working age people since uninsured people always cost more for the first few years they have insurance.
    This is not saying that I don’t agree that universal access is of critical importance or that a lot of military spending, especially the Iraq debacle, is wasteful.
    However, if we don’t incorporate plans for saving on health costs in any reform we will find ourselves in the situation that MA is in right now, with costs exceeding available resources.
    Implementing universal access without cost savings is like being a person who bought a big beautiful house with a view of the ocean back in 2005, using a subprime mortgage. If we want to avoid jeopardizing health care not just for the uninsured but for everyone , we need to start immediately with prudent plans to deal with costs. We also need to address the fact that our health care system underperforms in terms of effectiveness, since receiving less effective care can be just as bad as having no access to care at all.

  19. J Rossi —
    Thanks for your comments.
    My comments in the original post were deliberately limited to the role doctors would play in health care reform.
    As you say, there several other cost saving reforms that could be implemented by players other than doctors.
    The idea you discuss of changing the reimbursement system to reduce payments for highly paid specialists and for procedures of various sorts would be one. Some of that would go to direct savings. However, some of this money should go to primary care providers, to pay for things like the medical home approach and end of life counseling. Those would be cost saving in their own right. Once again the government payers would probably have to take the lead, since they have the power to do so, but private insurers would follow happily if costs were reduced.
    Payers, including government payers, should band together to negotiate lower prices for drugs and medical equipment, buying for prices closer to world market costs and our own VA.
    Private insurers should make changes in the system for billing by providers to enhance efficiency and create greater clarity and uniformity, reducing providers cost of collections to the range of Medicare without changing the identity of private insurance systems.
    There are others as well, but each of the three above could save billions each year, additional bricks in the wall of rebuilding health care.

  20. Another great thread–
    thank you all.
    And thank you, Pat S. for responding to comments.
    I have been tied up dealing with the fact that someone has stolen my identity on one of my -mail accounts (Yahoo).
    If anyone here e-mails me on Yahoo and received a message that appeared to be from me– rest assured, I am not stranded in Nigeria.
    This has turned out to be a time-consuming hassle.
    But I will be back tomorrow with comments on this thread (and a new pst or two.)
    Maggie

  21. Mail me if you want this sorted ASAP. I can connect you directly with an insider for yahoo mail issues. Sorry to hear your trouble with yahoo mail

  22. i’m interested in hearing dr. pat s’s opinion on where the cost savings at mayo and cleveland clinic come from.
    my personal observation is that they are procedure and consultation factories. people go there from around the world to see what the specialists have to say, and rightly or wrongly, these typically are not the primary care doctors they are going to visit. when i visit, they seem to be overstaffed with support staff compared to hospitals i have worked with.
    they seem subject to the same inherent conflicts as other hospitals-doing things that raise money to support other efforts that are not able to sustain themselves.
    ie,
    both facilities offer executive physicals which have never been deemed to be effective or cost effective, but do make money. they seem to offer all the newest technology before it is proven to be effective or cost effective.
    both are looking at alternative medicine, which may be reasonable for some but wouldn’t typically be supported under the heading of demonstrated effectiveness.
    a second question is
    where do the dramatic cost savings to offset the expenses mentioned earlier come from? they can’t come just from paying docs less, can they? while they may pay their physicians less than private practice counterparts (or so i have heard), they sure seem to make up for the relatively lower pay with a lot more physicians.
    i’m questioning whether we can truly use those locations as sites of best practices from which to draw upon? i have not heard that the satellite mayo clinics and cleveland clinics have been able to reproduce the same clinical results as the mother ship hospitals. this is not to disparage those hospitals, because i think they are great places to get treatments. rather, i wonder if their cost effectiveness is the result of bookkeeping variations and confusing corporate umbrellas etc which may serve to make them appear cost effective through hidden costs of ownership and perhaps having technology donated and private donations and income from patents and educational courses they provide that would not necessarily be available to everyone.
    because they sure seem to run a lot of or’s and cath labs and have a lot of the fanciest technology when i go to visit them. and have a lot of nurses and hospitality employees. etc etc.
    thank you for your thoughts.

  23. Pat S–thank your for the excellent post and replies to thoughtful comments; I’ve learned a lot that will help me discuss these issues with other clinicians, students, and with all kinds of people who want meaningful effective reform.
    Being a clinical educator at 2 nursing programs, I’m very grateful to Jane Jacobs in MN for the tip about the upcoming conference on health professional education–wish I could attend but I’ll be teaching! (so will try to follow online). As Jane states, the conf. goal is “to develop a set of prioritized solutions/ideas of how to change medical and health care education to support health care reform”. What this actually means is somewhat unclear to me but is nonetheless intriguing. If it’s productive in concrete ways I hope that this conf. might spur others to be convened across the country.
    End-of-life care is one of my top clinical interests along with pain management and I strive to incorporate best-practice policy discussions on these topics in whatever course I’m teaching. There’s such a need for dramatic improvement in these areas that will lead to cost and quality improvements, as has been discussed here. Nurses can provide important leadership for reform in these areas (and in all areas of fundamental health reform), along with our physician colleagues. I’m dedicated to helping make that happen.
    NG–it’s obnoxious for you to post an article link without any description of it or sharing your critique of it, especially when it turns out to be mostly a waste of time. FYI to readers– it’s a blog link to an article written by John Goodman who is a self-described as “the father of health savings accounts”, so you can guess what conclusions his article comes to.
    Maggie and commentors–thanks so much for fostering these discussions; I’ve referred countless people to HealthBeat and can only hope they have the time to digest this rather dense information.
    HealthBeat’s detailed discussions are so valuable b/c they delve into real-time data and clinical issues, and into detailed policy discussions including U.S. politics (in other words, how policies become actual functioning programs–or not).
    to robertdfeinman–I am compelled to tell you and others here a sad fact: The Massachusetts insurance law has fallen far far short of what is being said about it in the mainstream media.
    The facts speak for themselves but are not readily available. But the facts do exist in places like the Commonwealth Connector board meeting minutes and the state budget documents. And some add’l data from a MA state Senator is at this link http://www.bluemassgroup.com/showComment.do?commentId=177949
    Despite the huge new sums we are spending on the “MA Plan”, Massachusetts is NOT covering almost everyone with quality affordable health insurance. Yes, we are covering more people with an insurance policy but many still cannot afford nor access the health care they need. Women are having a harder time affording and accessing care than before the law was passed, according to a major report issued by researcher Dr Susan Sered at Suffolk Univ.
    The state (my state, where our public schools are now facing 10% budget cuts) is now spending almost $1Bil in NEW public dollars this year on the law for subsidized insurance policies and $40Mil for new bureaucracy and marketing (the “Connector” budget).
    Many of the policies have high deductibles (some are $2K for an individual and $4K for a couple or family) and high co-pays. These are facts and constitute very real barriers to needed care.
    MA is facing a $3Bil budget deficit next year and huge cuts have already been made in essential programs such as eliminating most day programs for people with chronic mental illness, diabetes prevention, and other vital cost-effective programs.
    Yes, MA has a “landmark” health insurance law but what is it really accomplishing and at what cost? Please don’t be fooled by some of our politicians self-serving rhetoric; it may keep them in good graces with the state’s insurance industry CEOs but it doesn’t provide a path for meaningful health system reform.

  24. To Ann Malone, RN concerning the link I posted:
    Ann, I do not think posting this link was obnoxious in the least. In fact, I believe the points made in this article will and do describe quite well the coming battleground areas that any reform will have to overcome to get enacted. I did feel the article was written by a conservative believer in the status quo of the current system, but I wanted to see what others felt. Again, do not dismiss this article, as many would like to believe it and will rally around it if it has much merit, IMO.

  25. to NG–I didn’t say the link itself is obnoxious, what I said is the following:
    “it’s obnoxious for you to post an article link without any description of it or sharing your critique of it”
    and I’ll stick to what I said (btw it’s what Maggie Mahar has requested of commentors who post links on her blog, as I recall).
    While we’re on these topics, I’d like to share a nurse’s story that someone just shared w/me. It’s from a recent NYTs piece and is good for stimulating public discussion. It’s very moving, takes me right back to my time working on an oncology unit in Boston, and I agree with all of it except the author’s statement: “no on wants to die”. I strongly disagree. Some people, including patients I worked with at an AIDS Hospice in the early ’90’s who were suffering greatly with no effective treatments wanted to die, and my Grandmother who was 94 years old at the time and suffering from end-stage heart failure said she was ready and wanted to die. Death is a natural part of the life-cycle, is almost always sad, and oft-times tragic when it comes early. But it’s still a natural occurrence for all of us at some point. We owe it to each other to do much better with death and dying in the U.S..
    “A nurses distress over a dying patient” http://well.blogs.nytimes.com/2009/03/18/a-nurses-distress-over-a-dying-patient/?em

  26. The ‘culture’ of medicine is the consequence of many years of low deductible, high and higher premium plans, making both doctor and patient incentive to costs of what they are both doing.
    There is huge inequity in insurance coverage. Some have too much, millions have too little or none. A universal basic benefits package from which people could upgrade, if desired, will change the ‘culture’ of medicine driven by doctors and patients, leaving the insurance companies to facilitate communication rather than decide care or how much gets paid.

  27. anonymous —
    I have first hand experience of how Mayo works, but none on Cleveland Clinic.
    Despite your comment on Mayo that “they sure seem to run a lot of or’s and cath labs and have a lot of the fanciest technology”, it turns out that Mayo actually does fewer caths and fewer procedures per patient than most private hospitals. Remember that when you look at Mayo they are seeing many more patients per day/week/month/year than private hospitals. In fact, in Minnesota Mayo does significantly fewer procedures than much smaller busy places in most large cities, including Minneapolis.
    Mayo has an institutional emphasis on getting patients in and out quickly. A lot of the reason “they seem to be overstaffed with support staff compared to hospitals i have worked with” is because of that emphasis. Historically, Mayo takes great pride in how fast they can return a typed result of an xray exam or lab — typically less than four hours after they are ordered. This speed of service translates into decreased costs elsewhere, since sitting and waiting is a costly passtime in many medical institutions. It is not at all uncommon to hear patients comment that they can fly to Mayo from their home, get a thorough workup, diagnosis, and have treatment initiated, and fly back home several days faster than it takes them to have the same thing done at home.
    In the end, however, the biggest saving at Mayo is what they don’t do. Mayo actually charges more for each individual service than many other centers, but does many fewer of them per patient. The Dartmouth Atlas comments in its last edition that Mayo charges more per service than Mass General, but that cost per patient is significantly less — around 1/3 less.
    The reason that Mayo accomplishes this is that they have carefully thought out protocols covering many patient problems — and the experience to have been able to evaluate these protocols for effectiveness, including in many conditions that are rarities in most institutions. Mayo also has a strong culture of conformity to its standards, with most providers following the same approaches rather than having variation from provider to provider.
    The degree to which the Mayo branches conform to these standards and this culture determines the degree to which they match the performance of the mothership. For example, Mayo Scottsdale — which has become an “elephants’ graveyard” with many experienced senior Rochester staff occupying leadership positions while choosing to spend the last decade or two of their careers there — matches and sometimes even exceeds the efficiency of the main center, despite being located in what is otherwise a very high cost region.
    Other branches have varying efficiency, but still perform more efficiently than other institutions in their areas. The rapid growth of the branches has taxed the ability of Mayo to keep its culture intact at the new clinics, since staff often has no history of connection with Mayo, but Mayo is striving to colonize the “Mayo way” at the new centers.
    In the end, low cost centers, whether Mayo, Geisinger, Marshfield, Kaiser Bay Area and Kaiser Portland, Intermountain, or others, have one characteristic: they do more with less. They have a culture which is ammenable to the habit of following proven standards of practice and resisting less efficient approaches. The standards are sometimes written and explicit, and sometimes unwritten but ingrained, but they all result in better care that costs less.

  28. Thanks to Maggie and everyone else. This has been fun.
    We return now to our regularly scheduled programming.

  29. Ray–
    Thanks very much for your offer to help.
    But I don’t have your e-mail address. (No doubt it’s on the list used to send out updates, but someone else handles that, and without your last name or e-mail, she probably wouldnt’ be able to find it.)
    Could you send your e-mail to me at– Mahar@tcf.org ?
    I still haven’t gotten anything exept automatic replies from Yahoo–which tell me things that don’t work. I can’t even change my password becuase “my yahoo” has disappeared.
    Thanks much, Maggie

  30. thanks pat.
    i can only say that my experience as a referring physician to mayo has not been what you describe. my patients regularly go numerous times for what i consider unnecessary extra visits. when i call to make appointments, the appointments are typically few weeks to months away unless there is an inpatient urgency to the transfer. there is no ability for them to be seen by multiple outpatient specialists on the same day, except by chance.
    communication is excellent, really top notch. discharge note quality is highly variable–and this i think is a critical area for a tertiary referral center, especially when individual doctors who perform consultative services are not named-it becomes a real chore that can take hours to try and track down the unnamed specialists who saw patient x on mar 2, 2007. procedural notes are the best i have ever seen however.
    i’m lucky to be in a facility where i can get labs, consults, and transcription back in a few hours as well, so that doesn’t seem value enhancing to me, more of a baseline that should be expected.
    as to whether they do more or less procedures per patient, i’m curious how the denominators work out.
    are you saying that the cardiologists do less caths per patient the cardiologist sees versus how many patients all physicians see? i am guessing, that a fair number of patients are referred directly for surgery or procedure. i have a hard time believing that if you include those patients, their utilization is lower. i am not sure which is a better metric for comparison to other health systems. i am open to the idea that my observations are wrong.
    i do have more than passing familiarity with some of the other institutions you mention and would disagree with you (respectfully) that they do more with less. sometimes they do more with more, and sometimes they do less with more. (mayo’s costs may be artificially decreased by location or malpractice environment,local competition, or other factors compared to mass general, not because mayo is more efficient at saving money), and again i am suspicious that they get better pricing on technology than would be available to community hospitals. perhaps i have been blessed with only working in really good places though.
    your statement that mayo has an institutional emphasis on getting patients out quickly makes me laugh (respectfully). i have never been in a hospital (more than 18 in my career) that didn’t have a huge commitment to getting patients out quickly, esp in the past 5-8 years. they may not do it as well as mayo (again support staff variations i think) but they emphasize it tremendously.
    thanks for your thoughtful article and post.
    anon 05:20

  31. Everyone–
    Very interesting thread, and Pat S., thank you for responding to readers’ comments.
    Below, my respnoses
    Ann Malone-
    You’ll be interested in the two-part post I just put up that focuses on Massachusetts, why we need a public sector insurance alternative (which Mass.
    doesn’t have) and what we can learn from Mass.
    Some people can’t afford to use their insurance; others can’t afford the insurance; the state is, as you say “making huge cuts in other essential programs” while facing a $3
    billion deficit.
    This is not working out well.
    Mass. needs to cut healthcare spending, and I tend to agree with the report I write about: a public sector plan (Medicare for all) could set a benchmark for cutting costs while providing higher value for patients.
    It would be very hard for a state to launch a public-sector plan, but it should be part of federal national health reform.
    I’m glad you’re enjoying the detailed discussions here and recommeding them to others.
    I agree that we’re developing a very special
    community of intelligent, passionate, yet civil readers.
    Even if readers dont’ comment– and I realize many don’t have the time or the inclination–the rise in the blog traffic tells me that the community is growing.
    Barry and Christopher George–
    I agree with you that much of our end of life care is not only wasteful, but cruel.
    And counseling from palliative care teams could definitely help.
    But we should acknowledge that many families and patients won’t accept the counseling.
    Reader Robert Feinman sent me this from a recent New York Times article:
    “Patients with advanced cancer who used their religious faith to help
    them cope with their disease were more likely to receive intensive and
    aggressive treatment during their last week of life, a new study has found.
    “Intensive life-prolonging care, defined as receipt of mechanical
    ventilation or resuscitation in the last week of life near death, was
    about 3 times more likely to occur in patients with a high level of
    religious coping than in patients with a low level of religious coping.
    The results suggest that a reliance on religion to cope with terminal
    cancer may contribute to aggressive medical care in the last days of
    life, the authors conclude in the March 18 issue of the Journal of the
    American Medical Association.”
    I don’t understand why very religious people who presumably believe in heaven aren’t more anxious to leave this world when they are suffering–and I truly mean that.
    Though Robert suggests that people who are very religious may need religous faith because they are so very afraid of facing death . . .
    In any case, in our culture a large number of religious people do seem to believe that their creator wants them to stay on this earth as long as possible.
    And I do think that makes
    curbing spending on end-of-life care difficult: the notion that one should “fight death” to the very end in so embedded in parts of our culture.
    This doesn’t mean that more pallative care won’t make a huge difference–it’s crucial. It’s just that we should understand that it won’t be be able to reach some families and patients.
    Christopher– I also agree that much of this has to do with family resentments
    masquerading as religious beliefs . . .
    healthcoaching–
    I’m afraid healthcare stocks dropped because Wall Street really doesn’t care whether what Obama is proposing would be good for the nation’s healthcare long-term; Wall
    Street cares only about how his proposals might affect companies’ earnings, short-term.
    “The market” is not ratioal, and it is not particuarly wise. Short-term, the market is simply a place where gamblers place bets on how they think other people will react to today’s news. (I hate to sound cynical, but I wrote about Wall Street for many years. Even over the long-term, the market is not necessarily rational or wise: look at market history from 1982 to 1909. Stocks have been hugely overvalued through much of this time.
    Ken Schields–
    You write: “We must build on the ideology, experience and passion of Dr. Pat S. and move forward with a system that rewards good health care providers.”
    I couldnt’ agree more.
    #1 Dinosaur– I agree that patients are definitely part of the problem.
    I would add that doctors tend to be in the driver’s seat– most patients trust their own doctor and will listen to him/her about what they do and do not need.
    But increasingly, patients with a huge sense of “entitlement” will stamp their feet and demand what they want.
    In those cases, it seems to me that established physicians (who have more than enough patients) should simply suggest that patients who are demanding overtreatment find another doctor.
    Obviously, you don’t want to abandon a very sick patient.
    But I’m thinking of healthy patients–the “worried well.”
    Doctors can’t cut them off without warning, but doctors can meet the patients’ immediate needs, and make it clear they this just isn’t a good match. . .
    Jane
    Yes, changing the way we educate medical students is key to changing the system.
    I look forward to attending your conference at Mayo; after that, I hope to write much more about this under-discussed topic on HealthBeat.
    Robert–
    The problem with Massachusetts’ focus on covering everyone–without cutting costs– is that now, while most of the state’s citizens have insurance, many cannot afford to use it or to buy it (see my most recent two-part post.)
    healthcare advocate: I agree that obesity and chronic disease is an enormous part of the problem: I would add only that much chronic disease
    (diabetes, depression, lung disease, some heart disases) can be traced directly to poverty.
    We need to pay more attention to that factor.
    Pat S.: You make an important point:
    Health care spending is a recurring expense.
    I agree with readers who say that money spent on the war in Iraq was wasted. But that is not an expense that will go on and on, every year,for the next 30 years.
    If we set up a healthcare system where spending continues to rise by 7 percent every year, it will collapse–and in the future, many more Americans will be doing without healthcare.
    AS you write: “Health care already costs between two and three times as much as the most complete accounting of the cost of defense. At the rate that health care costs are growing, we could decide to spend every dime of the defense budget as well as every dime of the hidden costs of defense on health care, and in a few years we would be back in a serious potential shortfall. . .
    “the $3 trillion cost of the war is cost accumulated over all the years the war has been going on and the future years when the debt incurred to fight the war will be paid off. The cost of health care is now $2.5 trillion a year and will shortly be $3 trillion every year. If universal health care is passed the government share of health care costs will rise rapidly to at least 65% of that total. The $60 billion a year estimate of costs for universal care is incredibly optimistic and really is just a campaign slogan. The congressional budget office estimates $180 billion a year, by itself exceeding the costs of the war. That does not count any added costs for the underinsured.”
    (Pat S.: Conceivably you should write a post comparing the cost of heatlhcare reform to the cost of the war . . . underlining the fact that health care costs are recurring costs, growing at 6% to 8% a year.
    And once we set up a system we can’t afford –and then find that it is not sustainable– health
    care reform will be in a world of trouble. The system will blow up. I could easily be another 10 or 15 years before we try again. Or we might just wind up settling for a sharply tiered three -tier system.)
    I’ll be back to respond to the rest of the comments . ..

  32. anonymous —
    I would be the last to argue that Mayo is perfect. As we used to say when I was there, “If the Mayo brothers were so smart, how come they built the clinic in Rochester instead of San Diego?”
    I will grant you that all provider systems are now motivated to move patients along as rapidly as possible, but having worked in both private practice and other multispecialty settings, most places are having a struggle in doing so — I used to sit on a committee addressing exactly that problem at a large health system. At Mayo, it is intrinsic to the system, and has been since the days of Plummer.
    I will also say that in many parts of the country, especially in the upper midwest, the presence, over years, of large numbers of Mayo trained physicians has caused the Mayo way to spread, even to doctors who are Mayo haters but unconsciously follow the culture because it is ingrained.
    The Dartmouth data proves that Mayo, Mayo Scottdale, Intermountain, Cleveland Clinic, Kaiser in the Bay Area and in Oregon, Geisinger, Marshfield, Group Health Puget Sound, and several others outperform and underspend compared with other rivals that are similar large referral institutions or comprehensive care systems, and outperform most providers in the Sun Belt and on the coasts. It is quite clear that this happens because they employ fewer high cost management techniques while at the same time effectively hitting the mark in terms of the results of care.
    Maybe Jane Jacobs can tell us more at her seminar on teaching providers how to work efficiently and effectively. I am interested in seeing Maggie’s comments on the program. Unfortunately, I can’t make the program, since I have to be someplace else. (However, someone should ask Jack Stobo to comment on why UCLA costs so much more for care than UCSF, even though they are part of the same system and operate in areas of similar cost of living. There has to be something to learn there.)

  33. Pat S–
    The question about the difference between UCLA and UCSF is a very good one.
    I think some of it has to do with the different cultures of San Francisco and Los Angeles.
    Los Angleles, like Manhattan is money-driven.
    In SanFrancisco, money is of course very important, but other values sometimes override $$$.
    (Btw, it think it is very fortunate that the Mayo brthers founded the Clnic in Minnesota. I can’t thnk of a state with more enligtened attitudes about collective thinking that go all the way back to many of the people who first settled the state.)
    I can alos say that, when I’m looking for sources in various specialities, I often find them at UCSF–to such a degree that, in my mind,
    I’ve come to think of UCSF
    as “Dartmouth West.”
    There is the same awareness of overtreatment and overdiagnosis (for example diagnosing babies as autistic) the same strong interest in public health) and the same patinet-centered cutlure.
    When I have interviewed people in Los Angeles.–for instance the CEO of Cedar-Sinai (this was a few years ago, many not be the same person today) I was could have been talking to an executive at GE. . . (And GE is not one of my favorite companies. )

  34. Medicine @ home/telemedicine/wiki docs on my iphone, tort reform = spot on.
    Big problem = no business model for preventative health. We don’t get paid to keep you healthy.
    Why have an anonymous author? This gets to another issue that
    privacy (in Health) is a ruse. Where’s the PUBLIC, Netflix-like distribution of doctors… and hospitals?

  35. Improving effectiveness of health care is also critical to reform, since if large numbers of people are given access to care that actually fails to help them or makes them worse, we have failed as well.
    The approach I am discussing strengthens univeral access by saving money and allowing the programs to continue, and strengthens the quality of medical care by providing care that works.
    Prostate Problems

  36. Right the wrong you can fix first. Is this politically feasible? I have no idea, but Massachusetts did it.
    Yesterday the census released its five year survey of business. There are about 16 million people employed in the health field, changing that culture will take a long time, covering people can be done with a single piece of legislation.