The Problem Is Profit (At Least in Healthcare)

If the vagaries of the medical system has you frustrated, look no further than today's New York Times opinion page for a little shot of optimism to your system. There you will find some government/academia heavy hitters (Ezekiel Emanuel and Jeffrey Liebman, both former advisers to the Obama administration) explaining how wunnerful healthcare is gonna be due to the impending extinction of health insurance companies. How's that possible, you ask? Well, the details are complicated, but the gist is that due to the changes wrought by the health care bill so stupidly referred to as "Obamacare" by the vast majority of Americans, a new system of apportioning dollars for healthcare will come into being in the next few years. This new system will have organizations known as "accountable care organizations", or ACOs, which "will increase coordination of patient’s care and shift the focus of medicine away from treating sickness and toward keeping people healthy". And, the authors contend, it's going to make everything better.

How that will take place is explained in two terse grafs midway through the article:

Because most physicians and hospitals today are paid on a fee-for-service basis, medical care is organized around treating a specific episode of illness rather than the whole patient. This system encourages overtreatment and leads to mistakes and miscommunication when patients are sent between their primary care doctors, specialists and hospitals. Indeed, under today’s payment system, investments in providing better care are doubly penalized. If a hospital hires a nurse to follow up with patients after they are discharged in order to reduce readmissions — for example, to help patients with diabetes improve blood sugar control — it must pay for the nurse, which is typically not reimbursed by insurance companies or Medicare, and it loses revenue by preventing the readmission.

In contrast, accountable care organizations will typically be paid a fixed amount per patient, along with bonuses for achieving quality targets. The organizations will make money by keeping their patients healthy and out of the hospital and by avoiding unnecessary tests, drugs and procedures. Thus, they will actually have a financial incentive to hire that nurse for follow-ups.

To give some context, a major chunk of Zeke Emanuel's career has been defined by paying attention to the issue of "overutilization"--the overuse of extremely expensive resources by physicians and hospitals--and ACOs appear to constitute a solution to this problem. Stop overutilization, you drive costs down because you stop needless testing. Create incentives to limit spending, you stop overutilization. QED. Thus, the new rules of the healthcare act will massage this new model into place.

Now that all sounds very nice and well, but color me dubious for the most part. I don't dispute Emanuel's contention that we spend too much on healthcare (we spend twice the amount of any other country per capita), and I agree with much of his analysis of the root causes of overutilization. But Emmanuel and Liebman appear to think that the private sector is up to the task of doing this, and on this point I am skeptical. Oh, we'll have changes with this ACO model, I'm pretty confident, but several of them are going to take a system that already has huge problems and make at least some of them worse.

The problem is profit. Healthcare companies are like any other capitalist venture: the bottom line is that they are in business to make money, and make a lot of it. Companies exist to make shareholders wealthy, and they will engage in whatever practices are legal in order to do so. In healthcare, this means, on the whole, that corporations wishing to make money have to increase production (having doctors see more patients, not by having more sick people) and/or reduce costs (either by making people healthier, which is easier said than done, or by decreasing overutilization, or by having cheaper labor than doctors see patients, or just paying doctors less).

I'll let the economists wax eloquent on how this makes the world a better place in theoretical terms, but I want to give you some idea of what this means in the real world. Let's take Your Local Little Hospital. If you go there nowadays, you're as likely as not to be cared for by something called a "hospitalist", which is an internal medicine doctor whose sole job is to care for hospitalized patients, and thus this doctor has no "practice" in the traditional sense of having a group of patients for whom he or she cares for an extended period. These hospitalists often work for either the hospitals themselves, or for corporations involved in the profit business.

If you go to Your Local Little Hospital and your hospitalist works for a corporation, that corporation likely is putting an enormous pressure on Dr. Hospitalist to see as many patients as they possibly can in one day, upwards of 20 to 25 patients. If you have ever spent time in a hospital or been with a loved one or friend, you'll know that face-time with the doc can (one hopes at any rate) be a huge factor in understanding what's going on. Suppose a conversation with a doc takes just five minutes; most people would want more, especially if they're sick, but let's just be conservative for the sake of the numbers to make a point. If that doc spends just five minutes talking with each patient and/or family of the patient, the doc with a census of 25 would spend about two hours each day just doing that task. That leaves the tasks of reviewing data, interpreting the data, writing a note, calling consultants, examining the patient, placing orders, and then reviewing the new data from that day's tests and making plans as necessary. It takes a lot of time to take care of a patient, about an hour each day by my estimation, so you can see what happens when you have 25 patients on your census.

The difference between this world and the one where the hospitalist is employed by Your Local Little Hospital is that the hospital--assuming it is a non-profit hospital--is not driven to quite the same extent by raw money. Of course, even non-profit hospitals need to keep a positive cash flow, but they don't have to worry about creating huge amounts of cash so that their CEO and major shareholders can afford lovely getaway ski chalets. Their only real bottom line is to stay in business, so they can afford to let their hospitalists see, say, 12 to 15 patients a day--considered by most in the biz to be an entirely reasonable number and still do good medicine. That's nearly half the workload of the hypothetical hospitalist in the graf above, and while this is all hypothetical, it really is happening out there right now.

In the brave new world of ACOs, all of these numbers may eventually seem quaint. Here's an op-ed--from the CEO of the Society of Hospital Medicine, mind you--that blithely chirps about "new paradigms" in which a hospitalist can see up to forty patients in a day! I have no understanding of what such a new paradigm could be except for one in which mistakes will be made and families and patients will wonder who the hell is in charge of their care.

So when people write feel-good phrases like "the new system will encourage treatment of the whole patient instead of being organized around treating a specific episode of illness", and that the remedy for such problems is by bringing the magic of market-based solutions to bear on them, I think that such people have learned the high art of euphemism because they either don't understand, or don't care about, the realities of what caring for patients actually means. (Though Zeke Emanuel must--he's a doc himself! What happened to his rhetoric I can only guess.)

I make good money as a doc, but I'll never be CEO-rich doing it, which is fine with me since becoming rich wasn't my priority in going into medicine. Most of the docs I know could be described similarly. But for us, profit wasn't the primary motivation. It's true that most of us make enough for the occasional nice bottle of Cabernet, but for people who want to be rolling in it, being a doc is not the right way to go, as there are easier ways of making a buck. The same should be true, by and large, for the entire biz of healthcare as well.
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Taking the Right (Though Small) Steps in Conflict of Interest

Amidst the braying and screeching of the Republican Presidential candidates in South Carolina came a small news bit that the Obama administration will institute new requirements that drug companies must disclose their payments to physicians for speaking, consulting, and research activities. As noted here, this has been backed in large measure by Republican Senator Chuck Grassley and Democratic Senator Herb Kohl, who have been at the forefront of conflict-of-interest issues in medicine for the past several years.

Two facts in the articles bear repeating: a) that physicians can be mightily influenced by the largesse of drug companies; and b) that "about a quarter of all doctors take some cash payments from drug or device makers and nearly two-thirds accept meals or food gifts" [my emphasis]. As you can find on the ProPublica website in the above link, companies invest millions of dollars in these little gifts. If you think that doctors can go to a fancy dinner sponsored by Drug Company X and not have their subsequent prescription patterns influenced in favor of Drug Company X, then you would wonder why the industry invests such resources in the first place.

Disclosure is a nice gesture, but it is mostly only a gesture. Like the disclosure of nutrition facts for food producers (something that industry likewise fought against tooth and nail), it is utilized only by a very small group of people. Similarly, the vast majority of patients won't have the determination and persistence to track down the disclosure information. And besides, when two-thirds of docs are on the take, what difference does the research make, anyway?

The only legitimate long-term solution is to tighten existing rules about doc-industry relationships. There are a few areas where docs have to work hand-in-hand with industry (surgical subspecialties are the main ones that leap to mind) and would need to be carefully thought out, but otherwise it's really not that difficult to create rules by which docs are supposed to operate with respect to drug companies. We already have such rules for scientific ethics in research; why there can't be a similar arrangement for the daily business of doctoring is quite beyond my understanding. In the meantime, the standards we have now would be regarded as appalling by most people if they understood the situation.
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One Patient, One Hour

If the American principle of voting can best be described as "one man, one vote" (leaving aside that it ain't just men), I'd say there's a similar, though less well defined and understood, principle that applies to hospital medicine: one patient, one hour. That is, to do good medicine in a hospital-based setting, it takes a general internist, on average, about one hour to take care of a patient.

This may come as a surprise to anyone who has been hospitalized and seen a doc for about five minutes each day, but that hour applies to all the tasks required in caring for that patient. A doc's gotta review the vital signs, the med sheets, the nursing notes, the social worker and physical therapist's assessments, look up the daily labs, check the consultants' notes, and then come before the patient, examine them, answer their questions, talk to family members, set up a plan for them, and then write a note in the chart. Of course, individual styles may vary: I tend to enjoy spending time talking with patients and their families, but that slows me down, and I'm not highly efficient to begin with. Moreover, not every patient every day requires an hour, as the patient with uncomplicated cellulitis needs IV antibiotics, not a huge re-evaluation on a daily basis. But based on my experience and discussions with lots of hospital docs, the one-hour-one-patient "rule" is a pretty good predictor of the quality of medicine. Cut that amount substantially, and sooner or later a doc will make a mistake, whether it's an oversight in drug-drug interactions, a missed lab value, or a misunderstanding with a family about prognosis because a meeting between doc and family didn't take place.

So this past weekend, when I took to covering the "floor" patients as part of a moonlighting gig at a local community hospital, I was given a list of 14 patients at 7 am. I wasn't surprised very much when I left the hospital almost exactly 14 hours later. It took about a half-hour to divvy up the patients initially, and I took about ten minutes to wolf down a lunch, but the average time I spent was just under an hour for each patient, and by the time I headed home I felt I had a decent handle on what was going on with them.

Two particulars about this experience bear mention, however.

First is that a "census" of 14 is, based on what the full-time floor docs tell me, on the lower end of the spectrum, with typical numbers in the 18-20 range, sometimes higher. The reason for this is money, money, money. The docs at this particular hospital work for a for-profit company (as do I when I moonlight for them), a company whose stock is publicly traded and for whom profits are by definition their lifeblood. While I'm not making any comments on how the company is run and how they try to maximize profits and simultaneously provide high-quality care, I can give you an idea about the numbers.

In the northeast, where I work and where salaries are a little higher than in other parts of the country, a typical hospitalist (i.e. a hospital-based doc, though more on "doc" anon) costs a company around $250K per year when you add benefits, malpractice insurance, and administrative costs to the salary, which at least where I work is a touch under $200K. When you factor in reimbursements from patient care, all it takes is an accountant to figure out how many staff are needed to see so many patients on average and estimate the census size required for the company to make a profit at a given hospital. Since the company's reason for existence is profits, they are always trying to push the envelope with patient census, and shooting for a census of 20 (or higher!) keeps the company in the black. This article from KevinMD features the musings of a doc who once routinely had to care for forty patients a day--and he casually notes that he currently has a daily census of "maybe around 20".

Now, a non-profit hospital running its own hospitalist program also has a bottom line and still has to think about having its revenue stream cover its costs. But there's one difference, and it's a huge one: the need for profit. I haven't done a lit search to see if there are any articles looking at this, but I'd be willing to bet more than $5 that if you surveyed the average patient census of hospitalists working for non-profit hospitals versus for-profit companies, you would find a statistically significant larger census in the latter group. By how much, I don't know. But what I do know is that if you move an average census above 12-14, and if you ever move it above 18, you simply can't be a decent doctor. It can't be done.

(As this piece notes, two studies have shown that as census numbers increase, face-to-face patient time does not decrease, but the critical behind-the-scenes work of "documentation, writing order, and communicating with nurses and primary care physicians" does. For those interested in reading the primary academic literature on staffing requirements, you can see this article from 1999--it assumed an average census of about ten in making its calculations.)

The second item of note is that, while I was slogging away seeing my patients, I saw a brief verbal altercation between two of the younger hospitalists, neither of whom I knew. I ran this past one of the hospitalists with whom I've worked for many years and he shrugged. "Oh, X is mad because Y just left yesterday at noon and turned her pager off," he said. "Noon?!" I responded. To leave at noon, this doc saw fifteen patients in around five hours. That's twenty minutes per patient--and she was meeting all of these patients for the first time. That means she looked through the chart, reviewed the medications, saw the patient, wrote a note, and (a theoretical conjecture--I doubt it really happened) communicated with family members...all that in less than the length of a sitcom. Which is an appropriate comparison, since all one can do when confronted with such negligence is laugh. My heart goes out to this doc's patients and families. I hope she remains the exception in our profession.
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Is HuffPo Changing Its Science and Medicine Editorial Policy?

Yesterday the Huffington Post ran a fascinating column in its Science section. Seth Mnookin, a science journalist and author of the book The Panic Virus (required reading for anyone looking for an introduction to the flim-flammy methods of the vaccine-causes-autism cult), commented on the role that responsible journalism has to play in educating its readers on science and medicine. "The fact that a specific story is controversial (or that it is promoted by a particularly outspoken celebrity) does not mean it deserves the oxygen it needs to survive", Mnookin wrote.

Such sentiments have been expressed before by Mnookin as well as other journalists and scientists. What made his dispatch so singularly stunning is that HuffPo has heretofore provided an electronic safe harbor for most well-known anti-vaccine cranks for the past several years. The website has granted a platform to an ongoing campaign of misdirection and misinformation about vaccines and its alleged link to autism, of which this article by Robert F. Kennedy Jr. is but one odious example.

As a consequence of this policy, Mnookin has, entirely appropriately, devoted much of his energy in recent years to hammering HuffPo for its irresponsibility and harm-inducing potential. (A terse encapsulation of his thoughts can be found in a brief blog entry where he notes, "Let me state very simply: HuffPo publishes dangerously ignorant dreck", and similar thoughts can be found here and here.) Thus, inviting Mnookin to hold forth on...well, basically anything constitutes a very profound shift in attitude.

Will this lead to wholesale changes at HuffPo? Hard to say. "It'll be interesting to see how this all plays out", says Mnookin, wondering if he was being played by the editors who could then claim that they were being "balanced" in their approach. If they are sincere, a good place to start would be to issue some form of retraction, as Salon did in its removal of a Kennedy-authored vaccine/autism piece, co-published with Rolling Stone, entitled Deadly Immunity. (Rolling Stone removed the story as well, but as noted here, they have not been as forthright in dealing with the criticism of their decision to publish Deadly Immunity as Salon.) We'll see what comes of it.

Also in the same vein, it appears that one of the main peddlers of nonsense about the vaccine-autism link, the now-thoroughly-discredited Andrew Wakefield, has decided to file a libel lawsuit in Texas against the authors of a British Medical Journal article published last year in which Wakefield was described as a "fraud". A similar type of lawsuit filed by Wakefield in the UK in 2005; Wakefield dropped the suit after the judge suggested that Wakefield was using the proceedings "for public relations purposes". As the linked article notes, a new law in Texas is supposed to discourage frivolous libel suits by placing a higher burden on the plaintiff than in years past, so the Wakefield suit should become something of a test case.
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