Saturday, January 30, 2010

A Job for the ACO

In an Op-Ed article in the January 25 issue of The Boston Globe, pediatrician Claudia Gold recited the sad tale of Emily, a patient who was returning for care that she (Dr. Gold) was not able to provide. Emily was returning because her psychiatrist was no longer accepting her insurance.

Dr. Gold used this situation as an example of the need to change the direction of health care. She suggested that the wrong direction in which it is now going could be attributed to “the combination of a health insurance industry wielding huge power and a seriously undervalued system of primary care and mental health care.”

We have family in London, England whom we visit with some frequency. I make it a point to read a local newspaper while there (usually the Daily Telegraph) and often find similar tales of woe relating to the British Health Services.

Friends of ours in the US Foreign Service were recently stationed in Ottawa, Canada and from time to time would send me newspaper articles chronicling the failures of the Canadian health system.

All of this leads me to conclude that there is no system of health care that will meet everyone’s need every time.

That leads me to a second conclusion, which is that every system, however financed, needs a local focus of responsibility. When the system fails and someone “falls through the cracks,” there ought to be someone responsible for making sure that needs are met.

There has been recent talk about creating something called an Accountable Care Organization, or ACO. Maybe looking after people who have been failed by the system is one of the things for which it could be accountable.

Thursday, January 28, 2010

Rights and Consequences

“Americans for Responsible Health Care is dedicated to protecting the right to choose your own doctor, the right to the procedure you need at the time and place of your choice.”

That statement was part of the organization’s full-page ad in the January 21 issue of The Boston Globe thanking the voters of Massachusetts and congratulating Scott Brown on his election to the U.S. Senate.

Statements like that sound good, but they hide some important truths. For example, “the right to choose your own doctor” also means that your insurance company has to pay whatever doctor you choose, regardless of competence or efficiency of practice. It also greatly weakens the hand of anyone negotiating with the doctor on financial or clinical matters.

Claiming the “right to the procedure you need” raises another issue. “Need” is a value judgment and the question is, who will make it? Shall it be left solely to the doctor and the patient without regard to the source of funds to pay for it? The “right to the procedure you need” as defined by the patient and the doctor is arguably one of the causes of the high cost of care.

Then there is the right to get procedures “at the time and place of your choice.” For myself, I would like all the procedures I need to be available in the local village center, a three-minute drive from my house. And I’d like all my appointments to be at 9:00 a.m. Obviously, that is not practical.

If the cost of health care is to be brought under control, and if significant progress is to be made on quality, someone has to be responsible for doing it and accountable for results. It will not do to bind the hands of that someone by imposing “rights” without regard to their consequences.

Thursday, January 21, 2010

Maybe Ben Nelson Did It

The unexpected victory of Massachusetts Republican Scott Brown in the election to fill the US Senate seat vacated by the death of Ted Kennedy was no doubt caused by many factors, but is commonly attributed in large part to a public uprising in opposition to the health care reform legislation being promoted by the Obama administration and the Democratic Congress.

It is not that Massachusetts voters are opposed to expanding health insurance coverage. Massachusetts has enacted its own universal coverage program, which according to the polls continues to enjoy widespread support among the state’s voters.

I suspect that a combination of factors caused people to be concerned about the proposed health care reform bill. It had grown exceedingly complex, approaching 2000 pages in length, so that a public already distrustful of government couldn’t know what was in it and suspicious minds could imagine the worst. The inability to attract a single Republican vote did nothing to inspire confidence. Cutting back the financing of Medicare wasn’t calculated to elicit support from seniors. Then there was the high cost of the proposals at a time of increasing concern about the large and growing national debt. Proponents of the legislation claimed that it would reduce the deficit, but it is doubtful that many people believed them.

People were probably also turned off by the cynical political horse trading that went on in the quest for votes, a process capped off by Democratic Senator Ben Nelson of Nebraska. One element of the Senate’s plan to expand insurance coverage was to enlarge Medicaid. Medicaid is a joint federal-state program with each paying for part of the cost. As the price for his vote, Senator Nelson got a provision in the Senate version that required the federal government to pick up the tab for Nebraska’s share of the enlarged program. So the taxpayers of Massachusetts were going to have the privilege of supporting Medicaid in Nebraska.

It is impossible to know whether that was the tipping point in the Massachusetts election, but it is fun to speculate that it might have been.

Wednesday, January 20, 2010

Is Our Health Care Delivery System “Broken?”

Many critics have concluded that our health care delivery system is “broken.”

A recent reminder of that was an Op-Ed article that appeared last October in My San Antonio. It was authored by Ruth Berggren; physician, UT faculty member, and long-time family friend. The title is “Our health care delivery system is broken.” The article was called to my attention by Ruth’s mother Gretchen, also a physician and long-time friend.

With all due respect to Ruth (currently in Haiti caring for earthquake victims) I do not agree.

For one thing, the pharmaceutical and medical equipment and supply companies seem to be doing very well. Doctors and hospitals, though they complain about inadequate payment levels, do not appear to be in any financial or other serious difficulties.

Most important of all, most Americans, so far as I can tell, are satisfied with the health care they are getting – so much so that President Obama has felt constrained on numerous occasions to assure people that if they like what they have, the reform legislation now under consideration will allow them to keep it.

Actually, this high level of satisfaction may account in large part for the difficulty the Democrats are having in maintaining public support for health reform legislation. Whatever interest people might have in improving things seems to be more than offset by worry that tinkering with the system will make things worse rather than better.

Our system has a number of faults. Too many people find it difficult to get good care because they can’t afford it or for other reasons. Care costs more than it should or needs to. Quality and safety are not what they should be. But characterizing the system as “broken” distorts reality and makes it harder to focus on practical remedies.

Wednesday, January 13, 2010


A recent Associated Press article told the story of a Dover, Delaware pediatrician who had been arrested and charged with more than 50 felonies related to sexual abuse of his patients. The arrest followed a mother’s report to police of the doctor’s abuse of her 2-year old daughter.

The story indicated that there had been complaints about this doctor dating back almost a decade. The state’s medical board suspended his medical license, but not until after he had been arrested.

Police had tried to deal with the matter in 2005, but were told that they could only investigate if there was a formal complaint by a patient or a parent.

Governor Jack Markell was quoted as saying that the system had failed and that there was a need to find out where and how.

What the governor could learn without bothering with a formal investigation is that a health care system that includes independent private practice is unable to deal satisfactorily with this type of situation. In his private office, a physician is effectively accountable only to the state medical board, which can only act if a complaint is filed and then, as a branch of government, has to grant the full panoply of constitutional protections to the person complained against..

Had the doctor been employed by a properly functioning group practice or hospital, chances are the problem would have been dealt with a long time ago. Once his behavior became clear, he would have been called on the carpet, following which he would either have ceased to offend or have been fired.

There is talk these days of developing entities called Accountable Care Organizations (ACOs) of which doctors like the Dover pediatrician would be a part. The ACO would then be ‘accountable’ for all aspects of care, including that of dealing with physician misbehavior.

If Governor Markell wants Delaware to have a system that works, he can promote the development of ACO’s and the requirement that every doctor be part of one.

Tuesday, January 12, 2010

Yes, But

Ben Nelson, Democratic U.S. Senator from Republican Nebraska, has gained considerable notice lately for his vote in favor of the Senate version of health insurance reform. In defense of his vote he has been airing a television ad, in which he predicts that the legislation for which he voted would lower families’ costs, protect Medicare, and reduce the deficit.

The front page feature article of the Sunday, January 10 Omaha World Herald critiqued the ad as follows:

Yes: More than 175 million Americans would pay about the same or less for health insurance premiums than if the bill didn’t pass, partly due to new federal subsidies.

But: The Senate bill includes taxes on high-priced plans and would likely increase premiums for 14 million Americans not in group plans who earn too much for subsidies.

Yes: Solvency of Medicare program would be extended by nine years, to 2026.

But: Much of the plan would be paid for by reducing Medicare payments to hospitals and other providers, which could cause some to go out of business or stop taking Medicare.

Yes: The federal budget deficit would be lowered by more than $130 billion over the 2010-19 time period.

But: Some revenue provisions start immediately while most major spending starts in 2014. The reduction also hinges on Congress breaking past patterns and following through on the Medicare cuts.

Fair commentary, I would say.

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