August 05, 2013

The Contrived March to Scarcity in Health Care

A recent survey of physicians, conducted by Tilburt and colleagues and published in JAMA, finds that most doctors support measures to improve the quality of care, but are opposed to financial schemes aimed at reducing health care utilization across the board, and physicians do not believe that the responsibility for escalating health care costs lies solely with the medical profession, with 85% opposing the denial of “beneficial but costly services to certain patients because resources should go to other patients that need them more”. While over three quarters of respondents reported being aware of costs of care, and agreed that discouraging use of expensive treatments with limited benefits is a good idea, 78% believe that doctors “should be solely devoted to [their] individual patients’ best interests, even if that is expensive”.  The vast majority of the 2556 respondents to the survey place responsibility for escalating costs of care on multiple entities, such as insurers, hospitals, trial lawyers (i.e. malpractice law), patients, government and physicians themselves, with no single mea culpa directed exclusively at doctors. For some reason, this complex view of the health care industry seems to enrage health reform advocates, and none more so than Dr. Ezekiel Emanuel.

Dr. Emanuel’s reaction to the survey findings, published in the same JAMA issue, begins by establishing the usual and customary sense of urgency. According to Dr. Emanuel, health care costs are responsible for increases in college tuition, crippling levels of student debt, stagnation of workers’ wages, federal deficits and national debt. Although Dr. Emanuel left out unemployment, over dependency on fossil fuels, Detroit’s bankruptcy and the sub-prime mortgage crisis, all of which could be tied back to costs of health care equally well, he did not miss the opportunity to ascribe “the same reason bankers are averse to many aspects of banking reform and transparency in derivatives and other market matters” to physicians opposing his preferred brand of change. Why would a respected scientist need to resort to this type of rhetoric?

Back in September 2012, right before the Presidential elections, Dr. Emanuel and 22 other “leading health-policy experts with diverse perspectives” affixed their names to a grand solution to contain health care costs, published in NEJM and proclaimed to “have the greatest probability of both being implemented and successfully controlling health costs”. Some of those diverse perspectives can be gleaned from the attached disclosures of potential conflicts of interest, or in some cases a surprising lack thereof. The comprehensive solution, which Dr. Emanuel briefly summarizes in his response to the Tilburt survey, includes such staples as transition to large integrated health systems, elimination of fee for service, bundled payments, expanding use of non-physicians and introduction of overt cost considerations into clinical decision making to curtail utilization. The solution had more than the greatest probability of being implemented, since it was already being implemented at the time of the NEJM publication. As to having the greatest probability for successfully controlling costs, it seems that physicians responding to the latest survey partially disagree.

When you look at the heart of the survey results (Table 3), it is very difficult to understand Dr. Emanuel’s fury. The majority of doctors is accepting some responsibility for health care costs, and is supportive of “quality” improvements, and somewhat begrudgingly is even onboard with EMRs. Chronic care management, continuity of care, preventive care, evidence-based practice, transparency of performance data, cost-effectiveness research and most other presumed pillars of the Triple Aim garnered wide support from respondents. Although stating that some of the numbers are not as discouraging as others, in Dr. Emanuel’s opinion, “[n]ot unlike the public, physicians embraced reforms that are sufficiently vague that they may offer only modest improvements but certainly will not transform the health care system”. Well, if quality improvements are “vague” and not transformative enough, what is it that we are missing?

First, the survey indicates that doctors are not buying into the concerted vilification of fee-for-service payments, and since the drive to eliminate fee-for-service is based on nothing more than hope, belief and wishful thinking, the only rebuttal to disagreement is vilification of the opponent and contending that “physicians are lapsing into the well-known, cautious instinctual approaches humans adopt whenever confronted by uncertainty: blame others and persevere with “business as usual.”” If those who desire to abolish private practice in favor of systems based care, which is what fee-for-service elimination is all about, have any supporting data showing how corporate medicine is having beneficial effects on costs and quality of care, this would be a perfect time to share it. But since there is no such data, and experience in other countries shows that fee-for-service has no inflationary effects on costs, and perhaps even the opposite is true, philosophical statements will have to do.

Similarly, physicians oppose the thick web of financial carrots and sticks aimed at reducing utilization in general and inpatient utilization in particular. Considering emerging studies (here and here), it looks like those who actually practice medicine understand that very little utilization is amenable to prevention by physicians. There is now, and always has been, very good data indicating that utilization of services in the U.S. is in most cases lower or comparable to other countries, and the difference in levels of expenditures lies mainly in outrageously inflated unit costs. Unit costs, whether bundled, capitated or calculated as salaries are not under physicians control today, and most certainly are not envisioned to be so, in the reformed corporate system. Disputing the merits of readmission penalties and bundled payments is not the same as “denial of responsibility”. In fact, 85% of survey respondents agree to various degrees that “[t]rying to contain costs is the responsibility of every physician”. Well? Is this not puzzling enough to grant the masses of practicing physicians a fair hearing?

Second, it looks like Dr. Emanuel wants physicians to lead, or be the “captains”, of the “all-hands-on-deck” effort to control costs. It’s not enough to provide high quality care and generally be mindful of costs. Something else obviously needs to be done, something that is too uncomfortable to mention perhaps, but should somehow be implicitly understood. A line in the sand has been drawn by the majority of responding doctors who prefer placing individual patients’ best interests ahead of the scarce resources allocation games people dance around these days. Now, Dr. Emanuel has written extensively on allocation strategies for truly scarce resources, such as transplant organs or hypothetical scarcity of vaccines during an epidemic, but on many occasions he made it abundantly clear that these theories do not apply to money as a resource, and that his vision of health care reform does not include this difficult type of rationing. Thus logic would dictate that refusal to engage in denial of care to certain individuals, on behalf of the greater good, should not be the reason for threatening physicians with the doom and gloom of being marginalized into “just another deckhand”. So what is it then? Is there an absolute truth somewhere that escapes all but a chosen few?

It is possible that Dr. Emanuel simply failed to articulate specific expectations on how doctors should lead the cost containment effort, so it may be helpful to look at an example of a physician more than willing to take the lead in this field. Dr. Saurabh Jha, a UK educated radiologist, in a perspective piece in NEJM describes his yearning to become an all-powerful imaging gatekeeper, emulating his hero, a certain radiologist called “Dr. No” somewhere in the UK, who used to deny all radiology orders without ever laying eyes on a patient. Eerily in sync with Dr. Emanuel’s musical vision of a transformative “symphony”, Dr. Jha is pondering who should “orchestrate the contrived march to scarcity of imaging and judiciously dispense the scarce resources” as “value is being redefined”.  The answer is of course, radiologists, and as Dr. Jha explained in a follow-up interview, this is about increasing relevance (no deckhands here), and preventing commoditization of the profession, because radiologists “can't be as ubiquitous as water and expect to command the price of diamonds”. Unlike the physicians in the Tilburt survey, Dr. Jha seems more than happy to take responsibility for cost management and “contrived” rationing, but expects to be “shielded from liability” for any preventable deaths falling outside his equally contrived thresholds for risk.  I am not sure who is going to pony up the diamonds, but I would venture a guess that plenty of hard cash will be forthcoming for this grand deception of the American people.

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