The Evil That Men Do-An Open Letter to President Obama

"The evil that men do lives after them; the good is oft interred with their bones". William Shakespeare, Julius Caesar, Act 3, Scene 2

Dear President Obama:

Late in a second term, a President's attention often turns to framing their legacy. I suspect you are no exception and have given this considerable thought. You might wish to be remembered for the Affordable Care Act, even called Obamacare, which brought the US closer to universal healthcare coverage. However, I recall the end of President Clinton's second term a short 16 years ago. During that administration the Federal coffers were full; an unprecedented business boom occurred; and foreign entanglements that might have led to war were avoided. However, most of us do not remember those positives, but recall a White House intern and a certain blue dress. As pointed out by Shakespeare over 400 years ago powerful men are remembered not so much for the good they do but the bad.

Robert McDonald, your Secretary of Veterans Affairs (VA), was brought on board two years ago to deal with concerns about long waiting times for Veterans Administration medical services-concerns and the subsequent lies that were told to cover it up that led you to fire his predecessor, Eric Shinseki. McDonald was talking to reporters in the week leading up to Memorial Day, when attention always turns not just to honoring America's war dead but to whether the government is delivering services it promised living Veterans. The reporters asked McDonald why the VA doesn't publicly report the date when veterans first ask for medical care so as to better measure waiting times (1). His reply:

"The days to an appointment is really not what we should be measuring. What we should be measuring is the veteran's satisfaction. What really counts is: How does the veteran feel about their encounter with the VA? When you go to Disney, do they measure the hours you wait in line?"

Although McDonald later apologized for his remarks, they were offensive to me as a physician who worked in the VA, and I might point out wrong on several fronts. First, Disney does track its wait times. Second, the remark shows a fundamental disconnect between upper echelon management and healthcare. As we pointed out several years ago, satisfaction with healthcare does not mean better healthcare, in fact, it may mean worse care, perhaps because the focus is more on satisfaction than good care (2). Third, McDonald's remark was truly disingenuous. McDonald is concerned about wait times which led you to fire his predecessor. Otherwise, why would the VA lift the supervision requirement for nurse practioners which they did later in the week (3)?

The prolonged wait times occurred because an insufferable VA administration created a hostile work environment for physicians. Many left and the VA was unable to replace them. Although salary is part of this, it is less of a problem than those inside the Beltway believe. The VA abandoned its academic affiliations and created a work environment where physicians seeing patients is largely put in the same category as janitors waxing a floor. Middle level administrators who know nothing about healthcare are now directing physicians on what they should do. The goal has become less about healthcare than the administrators being in charge. The replacement of physicians by nurse practioners is in line with this concept. The goal will not be as much to deliver quality healthcare, a concept that is often nebulous and hard to define, but rather to redefine quality. For example, replacing timely and good care with a measure such as making sure that on each visit the Veteran is reminded to fasten their safety belt (a current requirement), is certainly measurable, cheap and does not require a physician. In most businessmen's minds it matters little whether it does any good or not. It is a measure of someone's concept of quality and the VA will deliver quality as long as it does not cost too much and an administrator can receive a bonus for it. Based on the VA, many physicians are suspicious that this is the long term goal of Obamacare.

So on this Memorial Day, let us remember our Veterans, Mr. President, and consider your legacy. My view is that unless changes are made, your misdirection of healthcare both at the VA and nationally through Obamacare, could be your White House intern in a blue dress.

Richard A. Robbins, MD*

Editor, SWJPCC

References

1. Capital Gazette editorial board. Our say: McDonald gaffe points to a deeper problem. Capital Gazette. May 30, 2016. Available at: HTUhttp://www.capitalgazette.com/opinion/our_say/ph-ac-ce-our-say-0529-20160529-story.htmlUTH (accessed 5/30/16).
2. Robbins RA, Rashke RA. A new paradigm to improve patient outcomes: a tongue-in-cheek look at the cost of patient satisfaction. Southwest J Pulm Crit Care 2012;5:33-5. Available at: HTUhttp://www.swjpcc.com/editorial/2012/7/17/a-new-paradigm-to-improve-patient-outcomes.htmlUTH (accessed 5/30/16).
3. Japsen B. VA would join 21 states already lifting nurse practitioner hurdles. Forbes. May 26,2016. Available at: HTUhttp://www.forbes.com/sites/brucejapsen/2016/05/26/va-would-join-21-states-lifting-nurse-practitioner-hurdles/#2d4e391e9f2cUTH (accessed 5/30/16).

*The views expressed are those of the author and do not necessarily represent the views of the Arizona, New Mexico, Colorado or California Thoracic Societies.

Cite as: Robbins RA. The evil that men do-an open letter to President Obama. Southwest J Pulm Crit Care. 2016 May;12(5):201-2. doi: http://dx.doi.org/10.13175/swjpcc048-16 PDF

Capture Market Share, Raise Prices

Two principles in medical economics central to the Affordable Care Act (ACA) were dealt blows by recently published studies. The first principle is the belief that economies of scale will result in lower prices. The theory is that larger insurers will have lower prices because they are more administratively efficient. The second principle is that provider-owned health plans, usually hospitals, will reduce premiums. The theory is that  by controlling doctors over charging health plans in a fee-for-service model will lower prices.

The first study published in Technology Science found that the largest insurer in each of the states served by HealthCare.gov raised their prices in 2015 by an average of over 10 per cent compared to smaller competitors in the same market (1). Those steeper price hikes for monthly premiums did not seem warranted by the level of health claims which did not significantly differ as a percentage of premiums in 2014.

The second study published by HealthPocket compared the lowest monthly premiums for provider-owned to nonprovider-owned plans within twelve counties across the US (2). The counties analyzed were spread across the eastern, central, and western regions of the U.S. Premiums were based on a 40-year-old, non-smoker profile. Insurance offered by health-care providers such as hospitals, was on average 12% more expensive compared to  traditional insurers. The data were also analyzed by the type of plan under the ACA: bronze, silver and gold. There were too few platinum plans to perform an analysis. Table 1 shows the local results in the three western states analyzed.

Table 1. Monthly premiums for Provider and Non-Provider Health Plans Under the ACA (2).

Silver plans account for two-thirds of plan selections on the ACA marketplaces during the 2015 annual enrollment period (3). Only the premiums for the bronze and silver provider-owned health plans in Arizona cheaper. Both in New Mexico and Utah all the provider-owned health plans and the more frequently selected silver plan in Arizona were all more expensive.

The premises of economies of scale and elimination of the fee-for-service reimbursement are both central to the ACA. Both appear to be myths. The results of these studies illustrate the sobering reality that the best intentions in reforming American healthcare do not necessarily produce the intent imagined. Despite the theoretical promise of reducing expenses by eliminating waste, both studies show an increase in healthcare costs, opposite the direction that traditional economics predict. Both larger companies and provider-owned health plans have a profit motive with numerous conflicts which likely accounts for these increases in premiums. Rather than allowing mergers and focusing on controlling physician behavior as strategies in reducing costs, it is time to focus on the insurers. Their strategy appears to be "capture market share, raise prices" and therefore their profits. This later premise agrees more with the data. Most of us who work in healthcare know this, it is time for those in Washington to pay attention to what is going on rather than their prejudices and political beliefs. 

Richard A. Robbins, MD*

Editor

Southwest Journal of Pulmonary and Critical Care

References 

1. Wang E, Gee G. Larger Issuers, Larger Premium Increases: Health insurance issuer competition post-ACA. Technology Science. 2015081104. August 11, 2015. Available at: http://techscience.org/a/2015081104 (accessed 8/31/15).
2. Colemen K, Gleeson J. Cheapest healthcare provider-owned insurance plans still 12% more expensive than cheapest insurance plans not owned by providers. HealthPocket. August 20, 2015. Available at: https://www.healthpocket.com/healthcare-research/infostat/fee-for-service-and-provider-health-plans#.VeRqLPlVhBd (accessed 8/31/15).
3. Health Insurance Marketplaces 2015 Open Enrollment Period: March Enrollment Report. ASPE Issue Brief. (March 10, 2015).

*The views expressed are those of the author and do not necessarily represent those of the Southwest Journal of Pulmonary and Critical Care, the American Thoracic Society or the Arizona, New Mexico, Colorado or California Thoracic Societies.

Cite as: Robbins RA. Capture market share, raise prices. Southwest J Pulm Crit Care. 2015;11(2):88-9. doi: http://dx.doi.org/10.13175/swjpcc115-15 PDF

Obamacare and Computers-Who Is to Blame?

Count me among the unsympathetic to the recent Center for Medicare and Medicaid (CMS) problems with the rollout of Obamacare, aka the Affordable Care Act. Yesterday, Marilyn Tavenner, the Administrator of CMS, apologized for the troubled rollout of the federal health insurance web site and promised to fix the problems that have prevented many consumers from signing up for coverage (1). Today, Tavenner’s boss, Kathleen Sebelius, Health and Human Services Secretary acknowledged “frustrating” problems that would be fixed “as soon as possible”. She offered an apology for the site’s troubled launch, while also attributing the glitches to private-sector contractors (2). The later is particularly telling.

We have repeatedly heard how the “magic” of the computer can solve problems in health care (3). To this end, CMS created a Medicare Electronic Health Care (EHR) Incentive Program and touted that eligible professionals could receive up to $44,000 over 5 years for full implementation (4). However, CMS estimated the average cost of implementing an EHR over 5 years was $48,000 or a loss of $4,000 assuming the best reimbursement. It is not clear how close these dollar amounts match the actual numbers but a number of private practice physicians have complained that the cost was much more and the reimbursement much less (Robbins RA, unpublished observations). What was most disturbing is the implication that physicians are to blame when EHR implementation is slow or fails to achieve the promised improved care at lower costs (3).

The recent Obamacare rollout problems can be blamed on a variety of issues from too many contractors involved, inadequate testing, poor leadership, etc., but the main fault has been the perception that health information technology (IT) is easy. However, the available evidence suggests that health IT is not “magic”.  In most industries, IT has taken years, often decades to exert its effects (5).  Personally I believe health IT can have a huge beneficial effect on healthcare delivery-but it might take a decade or two. 

A meaningful partnership between clinicians, administrators and payers achieving and rewarding high-value care is needed. To do this physicians need considerable input, and perhaps more importantly, control of any EHR. Second, physicians need to be rewarded for good care which is centered on improved patient outcomes and not endless checklists that do little more than consume time. Failure to do so will result in inefficient and more costly care and not in the improvements Obamacare promised. To paraphrase Cassius from Julius Caesar, the fault is not in our contractors, but in ourselves. It is distressing that political ambition and arrogance may jeopardize the healthcare of millions of Americans.

Richard A. Robbins, MD*

Editor, SWJPCC

References

1. Somashekhar S. Administration official Marilyn Tavenner apologizes for HealthCare.gov problems. Washington Post. October 29, 2013. Available at: http://www.washingtonpost.com/national/health-science/administration-official-marilyn-tavenner-apologizes-for-healthcaregov-problems/2013/10/29/4d2a07ea-40c6-11e3-9c8b-e8deeb3c755b_story.html (accessed 10/30/13).
2. Branigin W, Somashekhar S. Kathleen Sebelius acknowledges “frustrating” problems with health-care web site. Washington Post. October 30, 2013. Available at: http://www.washingtonpost.com/politics/kathleen-sebelius-acknowledges-frustrating-problems-with-health-care-web-site/2013/10/30/8cf36c98-415e-11e3-a751-f032898f2dbc_story.html (accessed 10/30/13).
3. Robbins RA. Getting the best care at the lowest price. Southwest J Pulm Crit Care 2012;5:145-8.
4. http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/index.html?redirect=/ehrincentiveprograms/ (accessed 10/30/13).
5. Jha A. As the debate over Obamacare implementation rages, a success on the IT front. The Health Care Blog. July 12, 2013. Available at: http://thehealthcareblog.com/blog/2013/07/12/as-the-debate-over-obamacare-implementation-rages-a-success-on-the-it-front/ (accessed 10/30/13).

*The views expressed in this editorial are those of the author and do not necessarily represent the views of the Arizona, New Mexico or Colorado Thoracic Societies or the Mayo Clinic.

Reference as: Robbins RA. Obamacare and computers-who is to blame? Southwest J Pulm Crit Care. 2013;7(4):269-70. doi: http://dx.doi.org/10.13175/swjpcc145-13 PDF 

What to Expect from Obamacare

“I predict future happiness for Americans if they can prevent the government from wasting the labors of the people under the pretense of taking care of them.”

-Thomas Jefferson

The Supreme Court decision is in and the election is over. Obamacare, or the Patient Protection and Affordable Care Act (ACA), will become reality, but questions remain on what it will look like. ACA had three goals: 1. Expand coverage to the poor; 2. Control costs; and 3. Improve care. These are all laudable goals but it is unclear if they can be achieved. Experience from Federal-run health systems such as Center for Medicare and Medicaid Services (CMS) and the Veterans Administration (VA) provide some clues as do recent Federal actions and the Massachusetts health care system.

Expand Coverage to the Poor

The US has about 60 million uninsured and one of the ACA goals is to come as close as possible to achieving universal healthcare coverage. In order to do this, the ACA depends heavily on Medicaid, a joint Federal-state health benefits program, to reach the goal of near-universal health care. If every state participated, 17 million uninsured people would gain coverage through Medicaid and the Children's Health Insurance Program between 2014 and 2022, according to the Congressional Budget Office (CBO). These are often the poorest of the poor. The Federal government usually pays for about half to two-thirds of the cost of Medicaid. To encourage states to participate in the ACA, the Federal government upped payment to 100 percent of the cost of covering newly eligible people from 2014-6, after which the share will gradually go down to 90 percent in 2022 and later years.

However, the Supreme Court decision in June, which mostly upheld the ACA, gave states the right to opt out of the Medicaid expansion. At the time of this writing, roughly a third of the states have decided not to participate, a third will participate and a third are undecided (Figure 1).

 

Figure 1. State commitment to expand Medicaid eligibility as of 12/12/12.

Some governors have asked Health and Human Services if they partially expand Medicaid will the Federal Government still pay for the expansion. In response, Health and Human Services Secretary, Kathleen Sebelius, has written a letter to the Nation’s governors saying it is all or nothing. According to the CBO this lack of participation leaves up to 3 million of the poorest Americans without health coverage. Placement of bureaucratic obstacles to discourage eligible persons not to sign up as well as political bickering and their inevitable subsequent lawsuits are likely to further delay care for the eligible. Therefore, it is unclear to what extent the ACA will increase coverage to the poor but it seems unlikely to bring the US any where close to universal healthcare.

Reduce Costs

Clearly medical care costs too much. In order to control the growth in costs it is necessary to know where the growth in spending has occurred. The latest data available is from 2010 and has been the subject of a previous editorial (2). Although there are many categories of health care expenditures, the four largest and their percentages of healthcare expenditures are hospital care (31.4%), physicians (16.1%), pharmaceuticals (10.0%), and net cost of insurance (5.6%). The largest increase in absolute costs was in hospitals which accounted for 39.4% of the increase of the $101.15 billion increase compared to 2009. The largest percentage increase was in net cost of insurance at 8.4% which was much higher than the 3.9% increase overall. Drug costs were not markedly increased at a1.2% increase but the top 12 companies had 310.8 billion in sales and 49.3 billion in profits in 2012 suggesting that the pharmaceutical industry is healthy and profitable (3). Although the Obama Administration often talks tough about reducing costs, especially insurance company costs, it seems unlikely based on their history that there will be a reduction in any of these three categories.

On the other hand, physician salaries have fallen. While the income of dentists, pharmacists, registered nurses, physician assistants, and health care and insurance executives rose by an average 10.2% in 2005-10 compared 2000-4, the income of physicians decreased by 5.8% (4). Although the hourly wage of physicians remains high ($80.00/hr) and remains higher than dentists ($70.64/hr) and lawyers ($54.21/hr), the gap is closing (5-7). This is despite a shortage of physicians (5). Even though the greatest physician need is in primary care physicians, pediatricians, family practioners and general internists remain the lowest paid physicians (8).  

Based on these trends, it seems likely medical costs will continue to rise. However, payments to physicians will probably remain static or decrease. Although the consequences are unclear, the cuts in payment to physicians are not sustainable and will likely drive many physicians, especially primary care physicians, out of private practice. The other consequence may be that some physicians, most likely specialists, may not take insurance with low reimbursement such as Medicare and Medicaid. This would mean that those that can afford to pay out of pocket will receive health care while the poor, the very people the ACA was intended to help, may not. Regardless, it is unlikely that the continual focus on physician reimbursement to control costs will be successful in controlling overall medical expenditures. The 16.1% of healthcare costs attributable to physicians is simply not large enough to reduce the overall costs, especially since physicians have born the brunt of the cuts for the past few years.

The ACA also proposes to reduce costs by paying only for value- and evidence-based care based more for outcomes than procedures. However, this is the approach that has been in place for some time at CMS and has yet to reduce costs. Committees far removed from medical practice have often made poor decisions. For example, patients who need self-catherization were at one time allowed only 4 catheters per month. Some patients had excessive and expensive hospital admissions for urinary tract infections. Presumably the catheters were not properly cleaning their catheter prior to reuse which resulted in the excess hospitalizations. The policy has now been changed to allow up to 200 catheters per month.

Another example is computerized healthcare records. In a January speech, President Obama evoked the promise of new technology: “This will cut waste, eliminate red tape and reduce the need to repeat expensive medical tests," he said. However, rather than reduce costs, the opposite happened. With better documentation, physicians billed at higher levels actually increasing costs (9). Response blaming physicians was swift implying physicians committed fraud (10).

Physicians and their patients may find themselves directed to cheaper care even when evidence points to a better but more expensive alternative. As a personal example, I have congestive heart failure and take carvedilol. My insurance company, Blue Cross and Blue Shield, has denied payment for the carvedilol despite evidence that it is superior to their recommended alternative, metropolol (11). The VA and Medicare have had similar policies in place. The difference in cost is about $1/day. I pay for my carvedilol out-of-pocket because in the COMET trial it reduced mortality from 40% to 34% (11). My judgment was that a 6% increase in survival was worth the extra cost. Patients are likely to find themselves in similar situations where if they want care that is not in the guidelines, they will need to pay for it themselves whether it is evidence-based or not.

Improvement in Care

A clue to how the Obama administration plans to improve care was in the 2010 summer recess appointment of Don Berwick as Administrator of the Centers for Medicare and Medicaid Services. Prior to his appointment he was President and Chief Executive Officer of the Institute of Healthcare Improvement (IHI). IHI was a group who convinced many hospitals to adopt a number of their guidelines. These guidelines had two common themes-most were physician focused and many very weakly evidence-based (12,13). CMS began tying reimbursement and compliance with the guidelines. The financial disincentive to accurately report data induced many hospitals to lie about their data (14). Not surprisingly, compliance improved but there has been little evidence for an accompanying improvement in outcomes (14,15). Witness the recent example of central line associated blood stream infections (CLABSI). Based on hospital self-reported data, CMS announced its program reduced the rate of CLABSI (16). Within a month an article appeared in the New England Journal of Medicine reporting the program did nothing to reduce infections or any other outcomes (17).

However, there may be a glimmer of hope. Although there is a continued reliance on weakly evidence-based surrogate markers, CMS has begun looking at mortality, morbidity, length of stay and readmission rates. These patient-centered outcomes have real meaning to patients as well as affecting costs. This may finally force health care administrators to address real care issues rather than performance of surrogate, weakly evidence based guidelines such as administration of pneumococcal vaccine to adults, telling smokers not to smoke without any follow up and providing discharge instructions.

Conclusions

Overall it appears that the ACA will have minimal impact on its goals of expanding care to the poor, reducing costs or improving care for the foreseeable future. It will likely continue to cost shift reimbursement away from physicians while costs continue to rise. Almost certainly it will be entangled in political bickering, eligibility challenges and lawsuits reducing many of the benefits of the law. However, we can probably be assured that CMS will continue to rely on inaccurately reported data, quickly declare their programs successful and stay their course, despite the programs doing little to nothing for patients. When their programs focus on outcomes such as mortality, morbidity, length of stay and readmission rates, real progress can be made in improving patient care rather than “spinning” dubious results.

Richard A. Robbins, MD*

References

1. Kliff S. White House to states: on Medicaid expansion, it’s all or nothing. Available at http://www.washingtonpost.com/blogs/wonkblog/wp/2012/12/10/white-house-to-states-on-medicaid-expansion-its-all-or-nothing/  (accessed 12-13-12).
2. Robbins RA. Follow the money. Southwest J Pulm Crit Care 2012;4:19-21.
3. Fortune. Available at: http://money.cnn.com/magazines/fortune/fortune500/2012/industries/21/ (accessed 12-13-12).
4. Seabury SA, Jena AB, Chandra A. Trends in the earnings of health care professionals in the United States, 1987-2010. JAMA 2012;308:2083-5.
5. US Bureau of Labor Statistics. Avaiable at: http://www.bls.gov/ooh/healthcare/physicians-and-surgeons.htm (accessed 12-13-12).
6. US Bureau of Labor Statistics. Available at: http://www.bls.gov/ooh/healthcare/dentists.htm (accessed 12-13-12).
7. US Bureau of Labor Statistics. Available at http://www.bls.gov/ooh/legal/lawyers.htm (accessed 12-13-12).
8. Medscape. Physician compensation report 2012. Avaiable at: http://www.medscape.com/sites/public/physician-comp/2012 (accessed 12-13-12).
9. Haig S. Electronic medical records: will they really cut costs? Time 2009. Available at: http://www.time.com/time/health/article/0,8599,1883002,00.html#ixzz2FF0XBf5d (accessed 12-16-12).
10. Carlson J. HHS inspector general's office quizzes providers about EHR use. Modern Healthcare 2012. Available at: http://www.modernhealthcare.com/article/20121023/NEWS/310239946 (accessed 12-13-12).
11. Poole-Wilson PA, Swedberg K, Cleland JG, Di Lenarda A, Hanrath P, Komajda M, Lubsen J, Lutiger B, Metra M, Remme WJ, Torp-Pedersen C, Scherhag A, Skene A; Carvedilol Or Metoprolol European Trial Investigators. Comparison of carvedilol and metoprolol on clinical outcomes in patients with chronic heart failure in the Carvedilol Or Metoprolol European Trial (COMET): randomised controlled trial. Lancet. 2003 ;362:7-13.
12. Padrnos L, Bui T, Pattee JJ, Whitmore EJ, Iqbal M, Lee S, Singarajah CU, Robbins RA. Analysis of overall level of evidence behind the Institute of Healthcare Improvement ventilator-associated pneumonia guidelines. Southwest J Pulm Crit Care 2011;3:40-8.
13. Hurley J, Garciaorr R, Luedy H, Jivcu C, Wissa E, Jewell J, Whiting T, Gerkin R, Singarajah CU, Robbins RA. Correlation of compliance with central line associated blood stream infection guidelines and outcomes: a review of the evidence. Southwest J Pulm Crit Care 2012;4:163-73.
14. Meddings JA, Reichert H, Rogers MA, Saint S, Stephansky J, McMahon LF. Effect of nonpayment for hospital-acquired, catheter-associated urinary tract infection: a statewide analysis. Ann Intern Med 2012;157:305-12.
15. Robbins RA. The emperor has no clothes: the accuracy of hospital performance data. Southwest J Pulm Crit Care 2012;5:203-5.
16. Agency for Healthcare Quality and Research. Available at: http://www.ahrq.gov/qual/clabsiupdate/ (accessed 12-13-12).
17. Lee GM, Kleinman K, Soumerai SB, Tse A, Cole D, Fridkin SK, Horan T, Platt R, Gay C, Kassler W, Goldmann DA, Jernigan J, Jha AK. Effect of nonpayment for preventable infections in U.S. hospitals. N Engl J Med 2012;367:1428-37.

*The views expressed are those of the author and do not necessarily represent those of the Arizona, New Mexico or Colorado Thoracic Societies.

Reference as: Robbins RA. What to expect from Obamacare. Southwest J Pulm Crit Care. 2013;6(1):23-28. PDF