28 May 2012

Memorial Day

Another Memorial Day and we are still at war. Hoping this will be the last one where I can say that.

24 May 2012

Are healthcare providers profiteering?

Andrew Sullivan fumes over the fact that the price of healthcare continues to go up despite the fact that utilization is not, and concludes that healthcare providers (generally hospitals and doctors) are "rent -seeking." The allegation here is that doctors and hospitals are jacking up the prices for services simply because they can, because they (we) enjoy a monopoly on the provision of healthcare and are able to set rates as we see fit.

There is a grain of truth to this logic which makes it an appealing argument. Part of my job is to fight with insurance company executives for the highest possible reimbursement. It's always, as the euphemism goes, a "spirited discussion." Sometimes I win and get more money, sometimes not. In my state, and in my experience, there's been a balanced power dynamic where neither the payers nor the providers enjoy significant leverage over the other. There are, however, many states where payers have de facto rate-setting power, and there are some markets in which certain providers, due to their size or cachet, are able to drive these negotiations towards outsized reimbursements.

But what of Andrew's central allegation? Is this, as the puts it, "The Great Healthcare Rip-off"?

I don't think so, at least not in the sense that we are using whatever leverage we enjoy to create outsized profits. Healthcare is a low-profit business. According to the AHA's Trends in Hospital Financing, the typical hospital's operating margin hovers between 2-4%, and about a third of hospitals run a negative operating margin in any given year.

hosp margin

Point is, that if hospitals do have price-fixing capabilities, they're certainly not using them to pad the bottom line. At least, not very effectively.

Similarly, physicians' income does not seem to be positively affected by this market power. Last time I looked at the raw data was in 2008, when I found that for the previous decade physicians' income had been flat-to-declining compared to inflation. I haven't seen any evidence that that trend has changed, and a quick glance at BLS data doesn't seem to show a spike in doctors' income.

So again, across the industry, I don't see evidence of profiteering. If anything, healthcare providers are just frantically trying to offset the losses from the economic downturn and reductions in public insurance reimbursements.

So why is US healthcare so damn expensive?  I can't add anything rigorous to Aaron Carroll and Austin Frakt's extensive analysis of this issue from a couple of years ago, so I won't even try. But I will add one anecdote in the way of explanation.

The DaVinci robot. It's the coolest, got-to-have medical gadget of the decade. It does minimally invasive surgeries, particularly pelvic surgeries like prostate removal. And it is awesome. Check out this video of Swedish Hospital neurosurgeon Dr James Porter as he makes a paper airplane the size of a penny with the DaVinci:

As a gadget guy, I get the allure of such a toy, and the promise is exceptional. All the other hospitals in our area got these, at a cost of a couple of million dollars each, and the urologists at our hospital demanded that our facility purchase one also. If we didn't, they worried, we would be at a competitive disadvantage and would lose cases to regional rivals. Despite the relatively lower case volume and lack of a business case for the investment, they got their wish and we have the gadget too.

So the medical market is dysfunctional in a unique way: competition increases costs.  This turns the laws of economics on it head, since in most other industry, increased competition drives prices down, not up. See: Walmart.

The kicker is that the outcomes for the robotic surgery do not seem to be any better than the traditional method of doing the procedure.*

Which brings us to the other big reason that US healthcare is so damn expensive. Physicians continue, over and over, to do procedures like DaVinci prostatectomies, like knee arthroscopies, like lumbar diskectomies, like coronary stenting for stable angina, like MRIs for low back pain, and many more, despite the fact that they have not been proven to be more effective or in some cases have been proven to be ineffective or harmful!

Of course, it's hard to convince someone that a procedure doesn't work when their income depends on their not understanding that fact.

So, returning to Andrew's thesis -- is American healthcare a "rip-off"? Yes, in the sense that the market is broken and full of perverse incentives and inefficiencies, and yes in the simple sense that we pay twice as much as the rest of the world and get no more value from that extra investment. But no, not in the sense that physicians and hospitals are deliberately maximizing their monopoly powers to realize excess value.

*Disclaimer: yes, I know the data is conflicting, and am very skeptical of the industry supported data showing benefit, given the huge profits the device manufacturers are making. Suffice it to say the technology is controversial, and that the enthusiasm for its adoption far exceeds any reasonable demonstrated cost-benefit ratio. 

21 May 2012

A weekend with grandmaster

I had the pleasure this past weekend to work with Grandmaster Fusei Kise and his son, Kaicho Isao Kise at a karate seminar here in the NW.

Grandmaster is a remarkable person, to put it mildly and with a great degree of understatement. He survived the Battle of Okinawa as a young child and endured much deprivation in the years to follow. He chose to dedicate his life to the study and preservation of the traditional Okinawan martial arts as a young man and continues to do so. He has been a 10th degree black belt for 25 years! He is, it seems, as old as the hills and as enduring. He is pushing 80, but still as tough as nails. Standing a diminutive 5'0", he can toss young men about like rag dolls, despite the fact that they have 12 inches of height, 60 lbs, and 50 less years of age on them. And his bones are so dense that blocking his punches feels like smashing your forearms into a cement wall.

Age is beginning to take a little toll on him: his kicks are no longer any higher than his waist, and workouts of longer than two hours are taxing. Still, I can only hope to be in as good shape when I am 80.

We also benefitted from a great degree of personal instruction from Kaicho. The man is amazing with the fluidity and precision of his movements, and his discerning eye which will spot (and correct) a student's most subtle flaws — a slight misalignment of this hips, say, or a strike which arcs in an inaccurate angle. The legend is that in all his years of competition in karate tournaments he was never once deducted a point, except one time when he forgot his belt. When he enrolled in tournaments, the other competitors would drop out. Having the opportunity to observe him up close, I believe it.

This weekend we worked on kata (traditional forms) and some sport kata (forms adapted for tournaments), as well as fighting drills and tuite (standing grappling techniques) and time with traditional martial arts weapons. This in addition to a great deal of conditioning work and body toughening.

We shared a lot of sweat and bruises. Sometimes it seems as if nothing in the words is as funny as watching a close friend writhing in pain as Grandmaster demonstrates a particularly agonizing maneuver on him. And a few minutes later, it is your turn to experience the pain as you become the tackling dummy. Afterwards, you rub your wrists or neck or wherever the technique was performed, and all you can do is laugh. But it's a gift as well: once you've had a joint lock performed on you, you will never forget how it works and how to apply it yourself.

A weekend of karate — inspiration from the great masters and comradeship with our fellow students. Good times.

And if you see me walking funny in the ER tonight, you'll know why.

18 May 2012

The E stands for "Emergency"

Beating A Dead Horse

I can't believe we are still having this conversation. Really, it kind of makes me sick. I've been beating this dead horse for five years now, but I guess it's worth saying again.


Sorry to shout.

I'd like to thank Aaron Carroll & Sarah Kliff, who recently made the point (again) over at the Washington Post's Wonkblog:
The emergency room is not health insurance

and on CNN:
Why emergency rooms don't close the health care gap

And I'd like to expand on their points a little bit.

What the ER does (because federal law says we have to):

  • Examine every patient who walks or rolls through our doors.
  • Screen for life-threatening disease or other conditions which present an imminent threat to health and bodily function.
  • Provide necessary stabilizing care for the above.

What the ER does (because we are nice people and like helping patients):

  • Treat minor injuries and acute but not life threatening illnesses.
  • Treat exacerbations or decompensations of chronic illnesses.

What the ER does not do:

  • Provide comprehensive, integrated, longitudinal health care.
  • Provide screening and health maintenance services.
  • Manage chronic illnesses.
  • Provide guaranteed access to subspecialty care.

So, if you come in because you are pooping blood and it's serious enough that something needs to be done to stop the bleeding, you're in luck! We can do that. But if, say, you come in because you're tired and I notice that you are slightly anemic with a very low-grade lower GI bleed from your as-yet-undiagnosed colon cancer, well, that's unfortunate. Because I will be sympathetic, and I will tell you that you need to go get a GI doctor somewhere to agree to scope you, and good luck with that if you are not insured. Maybe you live in a county with a hospital for the indigent who can do that for you in six months, if you've the fortitude to stick with it through the byzantine process it will take for you to get into their clinic. Hopefully, they'll diagnose you before it metastasizes. But I'm going to give you a piece of paper and send you home. Regretfully, I should add. I care, but I can't give you the care you need in the ER.

Alternatively, if you come in with an acutely blocked and inflamed gallbladder, I can get you to the OR for a surgeon to take it out before you get septic from it. Yay us! If, however, you have the seventh attack of excruciating pain from an uncomplicated gall bladder attack, that's a pity. I can make you feel better and send you home with a piece of paper. Maybe you'll get lucky and it'll get bad enough that someone has to take care of it.

Further, if you come in with a hangnail and I notice that your blood pressure is sky-high, I may be able to give you a short-term prescription for a blood pressure medication. But I can't manage it forever through the ER (though some patients try), and unless you get into a family doctor's office to get it taken care of properly, I'll see you again in a few years when you have your heart attack/stroke.

So, Thank You, Sarah and Aaron, for making this important point yet again. Let us all scream it from the rooftops. The ER is for Emergencies. That's what the "E" stands for. We're a backstop — the option of last resort, the societal safety net. We are not the venue for universal health care, and I wish that for once and for all that policy makers (largely the conservative sort) would get that through their heads.

17 May 2012

Is the ER biased against uninsured kids?


This study was flagged widely in the press recently. It's a good study, based on my cursory review, that addresses an important point:

Insurance Status and the Care of Children in the Emergency Department (full text link)
Usual disclaimers about the validity of the underlying database apply, but overall I can't disagree with their findings. Privately insured kids who go to the ER are more likely to receive diagnostic tests or interventions than those who are uninsured or on public insurance (i.e. Medicaid/SCHIP). The study authors, wisely, refrain from making sweeping statements about the cause of such disparity. Which doesn't prevent the media from leaping to conclusions, and going right for the salacious ones:

Study: Privately Insured Kids Get More Care In ED 
Emergency departments are required to treat everyone who comes through the doors, but that doesn’t mean they treat everyone the same way. 
Insurance coverage may play a major role in the kind of care a young patient receives, according to a study published in the most recent edition of The Journal of Pediatrics.

No, no, no, no a thousand times, no. The implication here is that the ER discriminates inappropriately, either undertreating indigent children or overtreating insured children. This is not what the study says. It is, I hasten to add, a valid question, worthy of research. Bias based on socioeconomic status is a real factor in medicine, well documented, and should be looked into. But if you look at the very abstract of the study in question, it concludes: "It is unclear whether these patterns represent appropriate utilization."

The problem is that the database does not allow the researchers to account for the different characteristics of two very different populations presenting to the ER. The acuity of the uninsured children is much lower, generally (in fact, the paper affirms that the triage acuity of the uninsured group was significantly lower). In large part this is because the access to primary care for kids on Medicaid is very poor-to-nonexistent, so they substitute the ER for a PCP, visiting with very minor illnesses and well child exams at a far higher rate than privately insured kids. So you would expect a lower rate of testing in the underinsured group, because they are not the same as the privately insured kids, who have good access to pediatricians, and tend to come into the ER when they are sicker and more in need of tests.

To properly evaluate whether insurance status leads to inappropriate disparities in treatment, it would be necessary to acuity-match the two populations. The one element in the cited study that roughly does so is in the comparison of the care provided to admitted children, and in that subgroup, there was no difference in the amount of tests provided. This is not surprising, since the admitted kids are by definition the sickest and most likely to require tests and interventions. More important, if you are looking for disparities in how kids are treated, is to compare matched groups of discharged children with comparable presenting complaints. but this study, due to the limitations in the data source, cannot do that.

The study authors are remiss, in my opinion, in under-recognizing the actual acuity differences in the two groups. That they chose to headline their own study with the disparity in treatment with barely a mention of the patient-specific factors is leading and invites readers to draw conclusions which are not warranted.

16 May 2012

Isaac is bleeding

I always thought the story of Abraham and the binding of Isaac was one of the creepiest and most horrifying stories of the many creepy and horrifying stories in the Bible. I mean, think about it. At the behest of some supposed supernatural being, Abraham is prepared to truss his child like an animal and slit his throat:

Abraham took the wood for the burnt offering and placed it on his son Isaac, and he himself carried the fire and the knife. As the two of them went on together, Isaac spoke up and said to his father Abraham, “Father?”
“Yes, my son?” Abraham replied.
“The fire and wood are here,” Isaac said, “but where is the lamb for the burnt offering?”
Abraham answered, “God himself will provide the lamb for the burnt offering, my son.” And the two of them went on together.
When they reached the place God had told him about, Abraham built an altar there and arranged the wood on it. He bound his son Isaac and laid him on the altar, on top of the wood. Then he reached out his hand and took the knife to slay his son.
That's messed up. The fact that it was God's funny little joke and Isaac wasn't murdered doesn't really redeem the story.

I think this is so repugnant because it runs counter to humanity's deepest instinct, to love and care for our children. It's appalling to consider that abstract notions regarding the dictates of a probably nonexistent deity can over-ride this fundamental human impulse, to put the life and welfare of your child above all else.

I was musing on this after a recent case I saw in the ER. A young man, barely old enough to drink, well, went out and got drunk, as young men do. He was involved in a dispute of some sort involving drugs and was administered some street justice. He came in to me quite ill indeed. He had stab wounds to the chest and abdomen, as well as an actively bleeding deep cut to the left arm extending up over the deltoid and into zone 3 of the neck. The paramedics reported a large amount of blood loss at the scene, and his arm wound was still bleeding heavily on arrival.

The resuscitation went very well, considering the injuries. He was intubated and thoracostomied in a jiffy, and I tacked together that big arm wound in a temporizing fashion to stanch the blood loss. But clearly, he was going to need to get to the OR pretty soon. His hematocrit dropped dramatically after fluid resuscitation and he was showing signs of shock so we began to prepare for transfusion.

It was around that time that his parents showed up and informed us that the patient was a Jehovah's Witness and would not accept blood products under any circumstances. Even if that meant his death. They were adamant on this point even after I explained that we were not in hypothetical territory any more — that his injuries were quite life-threatening and the blood loss might be the factor that caused him to die. They were firm and well-prepared and even showed us a piece of paper signed by the patient, fairly recently, expressly refusing blood transfusions.

Now I will parenthetically note that this young man was not so observant a Jehovah's Witness that he wouldn't go out and get drunk and use drugs, so I wonder whether he would have been willing to rescind that refusal were it his own life on the line. But he couldn't speak for himself, so I was bound to obey the parents and his expressed wishes.

As it happened, he got lucky. He had a very rough course in the OR and post op. He definitely would have been at less risk and probably would have suffered less disability had he been transfused. Thanks to a very skilled OR team and our hospital's exceptional blood-conservation program, he pulled through.

The parallel between this case and the Genesis story is pretty apparent, I should think. They're both equally abhorrent. I'm more appalled by my experience, actually, since a) it really happened and wasn't some myth of dubious factual provenance and b) the parents who were willing to allow their son to die did so in the context of modern education, societal mores, and with all the tools of moderns medicine at their disposal. Yet they valued some abstract, imaginary fantasy of the afterlife and their idiosyncratic reading of scripture over the real, actual living, breathing son whom they had loved and nurtured for two decades. That's just sick, and it made me feel sick to be complicit in their withholding of care to their son.

Yes, I understand the legal and ethical obligations I am under as a physician, and I obeyed their wishes. But I do not respect them; in fact I hold them in the deepest contempt.