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.