Archive for category Population Health

Physician Shortage — no end in sight

The above chart is from data just released from the National Resident Matching Program.  This is about doctors who completed medical school and now according to their preferences are matched with training programs in various specialties.  This is for the first year of residency, but it should be noted physicians may branch out to other specialties later in training.  Internal medicine is a good example since those physicians branch out to later be general internists, hospitalists, cardiologists, pulmonologists, gastroenterologists, diabetologists, and nephrologists among others.

The point of this chart is to show how the shortfall in US physicians is being filled by foreign physicians.   The foreign physicians are good doctors, in fact, some of the best in the countries they come from.

The obvious question is WHAT IS WRONG WITH THE US PHYSICIAN TRAINING PROGRAM?  It obviously is not keeping up with demand.  Thousands of US students desperately want to go to medical school, but there is no place for them.  Certainly, cost is a definite issue — many who would like to go to medical school just can’t secure the funding or don’t want to go into debt for hundreds of thousands of dollars.  So, the inadequacy of US medical training is resolved from afar.

Other countries, like the UK, solve this problem by offering aspiring doctors the funds to go to medical school in exchange for becoming a specified type of doctor and practicing (for a number of years) in a specified location.  It seems to work.

Attracting good doctors from other parts of the world sounds attractive but it’s not so nice for those other countries losing the doctors.  The US has a significant physician shortage which is getting worse.  Since the US does not have a healthcare system it is not possible to respond to the shortage.  The free market system fills the lucrative specialties in the nice locations leaving the non-urban communities to go without or hopefully attract a foreign medical doctor.  In many rural communities there are no US trained physicians.

US healthcare quality is at the bottom of industrialized countries.   Access to healthcare declines in large part due to a shortage of providers.  Since there is no organized healthcare system no resolution is in sight.  It’s staggering to realize even Cuba has more doctors per capita than the US.  The discussion and legislation so hotly debated currently seems oblivious to the shortage of physicians for which insurance is no solution.


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US Healthcare Diagram — results are what count

us-healthcareThe U.S. healthcare system is going to change or at least be updated in the coming years.  So, when congress tinkers with the system what might be good changes and what might be bad changes?  That is the $3 trillion dollar question!  It would be fair to say most people and most congressmen do not understand U.S. healthcare — the prevailing notion is overwhelming complexity and way too much cost.  However, this blog is going to make the case the key to understanding and the key to making changes is to keep your eyes on the results.

What results?  It’s not complicated, it has to do with measurements.  Consumer Reports and J.D.Power know we want to buy value.  And, value in this case is the reasonable cost for wellness, longevity and successful treatment of disease.  That’s it, three things.  Whatever changes or tinkering are contemplated we just need to know those three things will be getting better and simultaneously costing less.  Politicians have a really bad habit of saying the changes they propose will do the job.  Nobody can predict what will work — there are always unintended consequences — so, any proposal must include a dedication to measuring the outcomes we want — if the change does not work it needs to be discarded as soon as possible.  And, discarding what does not work can’t wait for the next election and should not wait until tomorrow.  Simply, we want results, and we want the data as proof.  On a hopeful note, if something works, keep doing it.

The above diagram describes U.S. healthcare.  It is more simple than the systems in other countries.  The system is linear — people, illness and unlimited money on the left side pass to the results on the right side.  This is a flow diagram of the system.  The complexity can be hidden by thinking in terms of the five boxes.  Later, some of the complexity will be discussed.  First, consider the boxes:

  1. Money to pay for the system.   The money people earn is paid to the health care system.  Money is money — it does not matter if the money comes by way of taxes, insurance or cash.  Funds that do not come from insurance come from the other sources.  This is the cost of U.S. healthcare which is about $3 trillion.  Don’t pay the money, you don’t get healthcare.
  2. The healthcare providers.  Traditionally we only think of doctors, hospitals and drugs.  We often overlook the other things in the box.  Things we don’t like, things healthcare providers would like to see in another box.  These other things are hugely expensive and fully under the control of the healthcare providers.  Unnecessary treatment is perhaps one of the worst — treatment or tests that are not needed.  For example, an EKG done as part of a yearly exam on a healthy person.  Profit is in this category.  Clearly, no profit, no healthcare system.  But, profit beyond what is needed is just waste for the system — it is money that leaves the system and does not come back.   Inefficiency comes in many forms.  Failing to prevent diseases early, only to spend more money later is supremely inefficient.  Corruption is a problem in every human endeavor.  Errors turn huge amounts of money into waste.  The money spent on medical liability suits is just the tip of the iceberg.  Money spent to prevent errors is minuscule compared to the money spent on drug marketing.
  3. Who gets healthcare?  Everybody.  The aggregate need for healthcare is fairly stable for the system.  But, for an individual the need is hugely variable — an auto accident is not predictable.  And, when disease strikes most of us can not afford the cost without insurance.  Statistics show 50% of Americans do not have access to $4oo for an emergency.  The very people who don’t have emergency funds are the very people who do not want to purchase health insurance.  Sadly, those people end up in bankruptcy while the system grudgingly provides the care.  Now that more people have insurance those without may find less compassion from the providers.  Many feel there are freeloaders in the system — people who do not contribute.  Does a birth defect, mental illness or low IQ make people freeloaders — that’s an ethical question which is beyond the scope of this discussion.
  4. Waste.  In monetary terms this about $1.5 trillion dollars per year with a huge death toll in the US.  A hospital acquired infection is very expensive and kills many of those affected.  The high profile infections from spinal injections are just the tip of the iceberg, again.  Re-hospitalization for an unresolved health problem is another example.  Paying $800 for a $10 epinephrine injector is another example.
  5. The results.  We want those good results.  Not just for cancer patients, not just for heart attack victims, not just for you, but for me too.   We don’t want promises, we want results.  In this age of smart phones and millions of apps there is no excuse for failing to have the data to prove the system is working in our hands every day.  We want the results today, not after several years of scrubbing the data in some moldy university.  We all must keep our eyes on the results and hold our elected officials accountable.

Complexity.   Medicine is a science and by its nature is very complex.  Open heart surgery is a good example — there are few people who understand the issues involved.  But, the system, from the patient’s view does not need to be complex.  In one country the cost of hospitalization is $400/day — the people there know exactly how much the illness will cost.  In another country, the prices of office visits are posted in the waiting room — it does not matter what insurance company you might have.   In another country all the providers use the same medical record system — not a big deal to move or see a consultant.  We seem to tolerate the complexity of our system and think it should be as difficult to understand as heart surgery.

The US pays about twice what other countries do for similar or better care.  There is enough money in our system now.   Our problem seems to be in the area of wasted money and effort.  It seems unlikely that just reducing payments to providers will reduce errors and wasted money — this supply-side economics does not get to the real problem.  More than likely, lower payment to providers will only result in lower income for them and perhaps more errors and unnecessary services.  But, if it works, do it.

Back to the initial warning.  Keep you eyes on the results of the system and the cost.  Whether any economic hypothesis proves correct is irrelevant.  What matters is the system must move in the right direction, always.

There is a lot to recommend the quality improvement method called “Plan – Do – Study -Act” or PDSA.  The idea is to plan a change to a system of care,  do the plan, make measurements to study the results then act to change the system to get better results.  This is an ongoing process.  Congress seems to be mired in a system of management which is one hundred years out of date — if anything, that’s what needs to change first.

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Medical Care and Control Theory

sweatshopPiecework maximizes human productivity.  Make more things, get more money.  Garment workers and physicians both have been paid under this system — it’s great if the payment per piece is high but miserable if the price is low.  Because piecework itself is no guarantee of quality inspectors were invented to reject low quality products.  Thus, the little piece of paper in your new shirt pocket “Inspector 23”.

What if you went to a doctor’s office and had to be inspected before the doctor was paid?  You had to have that little piece of paper “Inspector 23” to submit an insurance claim. That’s never going to happen but you get the idea.   The doctor is paid by the number of services but the service should meet a quality standard.

This example is just the tip of the iceberg.  Medicine is discovering process control without much input from the well established engineering field of process control.  It’s sad, and perhaps a little arrogant on the part of medical administrators and law makers, to ignore the extensive work on process control.  People do not like to be considered as little boxes in a system diagram — understandable — but a failure to think in this way is wasting trillions of dollars.  The time for change has arrived.

PieceworkThe black box of medical care is what happens with the doctor-patient interaction.  1) A patient enters the office, operating room or x-ray office then health care happens then 2) the patient leaves.  As it stands now the physician is paid by the number of services performed so the possible process control at points 1 and 2 are wide open.  Nothing is measured, nothing is controlled, and quality is not guaranteed.

Control Theory

Now, consider modern process control with 5 control points, a measurement point and feedback to control the input to the black box of health care.  What is in the black box?  Perhaps just one health care provider.  Or perhaps many health care providers. Instead of a black box it might be a grey box with lots of individual elements.

Parallel SystemPerhaps the box contains whole specialties or perhaps many hospitals within an accountable care organization across many states.

At the highest level of abstraction the feedback loop is intended to minimize cost but at the lowest level the feedback loop is intended to maximize quality.  To make sure throughput is maintained the providers need to be paid by the number of services performed but the flow of patients is choked off if quality is not adequate.

This is rocket science.  But, as Einstein says, a system “should only be as complex as needed”.  Health care is very complicated and at the present the garment industry is not the model the world should be using.  Simplistic ideas of supply and demand are not adequate to make a rocket fly nor to control cost in a health care system.

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Improve ACA — so says USA Today

peopletowerKelly Kennedy of USA Today published the story “Finding Consensus on How to Improve the ACA” 2/28/14.

Here is the list:

  1. Pay doctors more
  2. Let the government pay subsidies to families not covered by the employee’s health insurance.
  3. Get rid of fee-for-service payments
  4. Smooth the transition from Medicaid to subsidized health insurance
  5. Transparent pricing

There are obviously some problems with this “consensus”.  To begin with, who is part of the consensus?  And who benefits from the 5 suggestions?  On the face the ideas seem OK but where is overall cost reduction — the real crux of our health care problem?

So, to address each point:

  1. Pay doctors more — if the payment is not tied to reducing health care costs and increasing quality then it is money down the drain.
  2. Covering families — seems simple enough but why should business be exempt from doing what they have traditionally done?  Employer insurance needs to cover the whole family — that’s simple.
  3. Get rid of fee-for-service.  Yes that payment method  is a problem but there must be an incentive for health care providers to provide a high volume of work and an incentive to do quality work.  The simple solution is to pay a health care system (an accountable care organization) to provide care for a large group of people for a yearly fee.  The organization must meet quality and budget constraints as opposed to our current “the sky is the limit” fee model.
  4. Smooth the the transition away from Medicaid.  At this point Medicaid is less expensive than standard indemnity plans — why think about a change?  If the person enters the workforce the employer just pays the cost — simple.  Changing providers is not easy but if quality is uniformly better there would not be such concern.
  5. Transparent pricing.  This is presented to suggest people could decide on what tests and treatments to buy if only they knew the prices — patients have never had the knowledge to make that decision and never will.  The transparency of pricing should be the price for ALL the healthcare a person needs per year.  Market forces may be helpful on the macro level (like for a healthcare system) but there is no free market for healthcare on the micro level — imagine a person being asked  to choose between various methods of treating diabetes or the best way to remove an appendix (the decision is either random or biased by what the very person asking the question tells them).

The U.S. is experiencing something its citizens have not witnessed before:  the transition away from population healthcare decisions being made behind closed doors at insurance companies to those decisions being made in the political arena.  Other countries experience this all the time — just look at newspaper headlines in the UK or France over the past 20 years!

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Lung Cancer Screening — questionable

spot on ct

Recently published guidelines for lung cancer screening (USPSTF) lack sufficient consideration of side effects and give no consideration to cost.  Insurance companies, so far, don’t pay for it and the American Lung Association has many questions about the basis for the recommendations.

Is CT screening really helpful to people at risk for lung cancer?  Is screening driven by profit motives for hospitals and radiologists?  The latter question may seem harsh but the well documented price gouging by radiology on other CT tests forces the question.

The data are clear: chest CT scans can detect early lung cancer soon enough to allow successful surgical removal.   But, the devil is in the details.

Can the US healthcare system afford this screening — what health services should be eliminated to pay for this very expensive endeavor (like childhood immunizations)?  Can patients who eventually are found not to have lung cancer (the vast majority of those screened) afford the test and the side effects of the invasive tests screening causes?

The recommendation seems premature.  The formation of national guidelines without adequate considerations of cost is hard to believe given our national problem with excessive health care cost.

Many other countries consider the cost of a test or treatment needed to give a person a “quality year of life”.  How much is that year worth? a billion dollars, a million dollars, a thousand dollars, all your money, all the money you wanted your kids to inherit?  Tough questions, especially if you are not a billionaire.  Well, experts on national health care say that dollar figure should not exceed $50,000.

Whether you believe the $50,000 number or not, at least we need to know exactly what such screening will cost.  We purchase healthcare — we don’t get it by magic.

So, what are patients and health care provider to do?  At this point: follow the recommendations and hope less costly and less invasive means are discovered.  Here is what the American Lung Association advises:

The best way to prevent lung cancer is to never smoke or stop smoking now.

  • Q: Who is a good candidate for lung cancer screening?
  • A: The National Lung Screening Trial (NLST) criteria are:
    • a current or former smoker (former smokers having quit within the past 15 years)
    • and in the age group from 55 to 74 years
    • and with a smoking history of at least 30 pack-years (1 pack/day for 30 years, 2 packs per day for 15 years, etc.)
    • and no history of lung cancer
  • There is no evidence at this time that other high-risk groups should be screened. Patients with lung disease, particularly COPD should be evaluated by a pulmonologist regarding the advisability of CT screening in the context of the severity of their disease.
  • At this time, only Low Dose CT scans are recommended for screening. Chest X-rays are not recommended for screening.

Beyond the question of cost is the question of who pays.  Should smokers as a group pay for the screening or perhaps cigarette makers?  Given the lackadaisical attitude of congress about the risks of smoking, ostensibly representing US citizens, perhaps we should all gladly pay for the screening through insurance.

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Patient Centered Care — not a political statement


Patient NON-CENTERED care is a physician looking at a computer rather than the patient, not letting the patient have a minute to express what they are concerned about or not making follow up appointments for diabetes.  Patient centered care is better care.

computer doctor

The International Alliance of Patients’ Organizations (IAPO) has listed the  “Five Principles”  of patient centered care.  The list includes:

  1. Respect
  2. Choice and empowerment
  3. Patient involvement in health policy
  4. Access and support
  5. Information

Four cultural phenomena  are at the root of the patient-centered movement.

  1. Doctors are not always right and communicate poorly.
  2. One third of US citizens are illiterate about health issues.
  3. The Internet has exposed items 1 and 2.
  4. People are wary of the government changing the healthcare system

The slippery slope for many patients starts when doctors tell patients what to do, patients don’t know enough to ask questions, treatment is given , advice is not followed and the outcome is not what the patient wanted.

Patient-centered care may be the solution.  Focus on the provider-patient interaction, improve provider-patient communication, educate the patient about the problems at hand,  and let the patient have a larger say in their own health care.

There is a political side to patient-centered care which is the battle between the public good and the patient’s wishes.  There is plenty of work to be done at the point of interaction between the provider and the patient.   Worry over fluoride in the water,  organic vegetables and workplace dangers are different topics, important, but not patient-centered care.

The insinuation fee-for-service medicine is somehow more patient-centered than other health-care systems is not logical.  No matter what health care system is in place the notions of good communication, patient education and patient autonomy remain critically important.

Patients will suffer the consequences of their decisions.   So, providers should never agree to bad medical care.    The purpose of patient-centered care is not to “give the patient what they want”.  But, rather  to listen to the voice of the patient,  communicate the best evidence-based guidelines and be a partner with the patient to make good decisions.

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Population vs. Patient Care — art no more


The U.S. has always been concerned about population health but mostly in terms of clean water, safe food, and safe medications.  Outside those areas the art of medicine was left to doctors.   There have been lots of medical discoveries in the past 20 years.  But, one quiet discovery may be the most important:  medical care is not art.  It may be industry or business or paint-by-numbers but it is not art.  There are rules and there are expected outcomes.  And, most importantly, the rules can be applied to populations.   For example, there are necessary vaccinations, unacceptable blood pressure levels, excessive weight ranges, best ways to remove gall bladders, and the correct frequency for pap smears.   There is a glimmer of hope that a focus on population health management will reverse the trend of rising health care cost.

An article from the University of Rochester Medical Center is a very nice perspective on population health.   They see the future of health care in systems of buildings, information technology, and organization of primary care.  The theoretical underpinning is reliability, interchangeable parts and operational efficiency.  The tools are there for controlling cost.  But, those tools currently are used to increase profits,  somewhat like letting the fox guard the chickens.

Patient-centered care  emphasizes efficiency and satisfaction at the point of care which mirrors our cultural view of individual importance.  In some respects this is consumerism or “give the patient what they want”.  Quality is the byword and standards for such care have been outlined by the National Committee for Quality Assurance (NCQA).  Important aspects of care include evidence-based guidelines, access to care, timely appointments, after-hours care, coordination of specialty care, continuity of care with one provider, cultural sensitivity, and good record keeping.  All laudable goals but mostly unconcerned with cost.

Each country must find its own path to good quality low-cost health care.  Our neighbor to the South, Cuba, is an interesting case.  The Cuban medical system now has twice the number of doctors per person as in the U.S.  so Cubans have better access to care than we do.  They even have lower drug costs because the government manufactures low-cost medicines.  The path they took is not likely the one the U.S. will follow since Cuba has poor sanitation, high poverty, 70% of employment is by the government and doctors are only paid $20 per month.

The cost of care must always be considered.  The population health advocates assume good systems and management will lower cost.  The patient-centered advocates assume quality care is less expensive care.  The path the U.S. needs to follow should include a blend of both, plus guaranteed (not theoretical) cost containment.  The cold hard fact is our health systems must be trimmed, our provider workforce must be expanded with less expensive providers, and new drugs must cost less.  This is a hard pill to swallow but we just need to take our medicine.

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