Thursday, December 29, 2011

Ron Paul, Evolution, and Iowa

The latest polls in this week before the Republican caucuses in Iowa show surprising levels of support for the presidential candidacy of Ron Paul. (Frankly, at this point in the fascinating prelude to the "silly season," with polling showing a dizzying sequence of "flavors of the month," I'm not sure we should be surprised by anything.) And so I find myself doing some reading about what Congressman Paul has to say (and has said over the years) about issues of importance to me.

Dr. Paul was an obstetrician/gynecologist before he went into politics. Despite the fact that he has now been in politics for many years (a member of the House as far back as the 70s), he has nevertheless been more than willing to tell people what he really thinks about a broad range of issues. This, for those of you who completely ignore the U.S. political scene, is most unusual.

There was an interesting recent thread on a listserv to which I subscribe, one whose members are interested in emergency care. My colleagues on this list go "off topic" (meaning they discuss things of marginal relevance to emergency care) quite often, which is maddening to some and quite entertaining to others. One of the frequent contributors is an ardent proponent of libertarian political philosophy, and he has taken opportunities to enlighten the rest of us about some of Congressman Paul's views.

Those who are disposed to challenge the libertarian perspective - and who don't much care for Ron Paul - have posted messages about controversial statements made by Dr. Paul over the years. And so a recent thread was launched (perhaps I should say spun, as one would surely find a challenge in the physics of launching a thread) about whether Paul believes in evolution.

It seems the good doctor has some uncertainties about this, and this has led many participants to draw conclusions about his critical thinking skills and about whether all of that education in the sciences was somehow lost on him.

So I did a bit of reading on the Web to find out what the congressman has actually said, and I find myself inclined to agree with him. Not about the soundness of the theory of evolution, but about its place in public discourse in the context of a presidential campaign.

The Republican caucuses in Iowa are strongly influenced by Christian conservatives, and these are people who typically have very definite views about evolution. They tend to believe that evolution and intelligent design are competing theories about how life as we know it came to be and that these theories should be taught side by side in public schools.

Professional educators - particularly those who run public schools - are fiercely opposed to this notion and say it is preposterous to expect teachers to present articles of religious faith alongside scientific theory with some sort of implication that they are equally "plausible" - when, in fact, they represent two entirely separate ways of thinking about life.

So it isn't possible to have a public discussion of evolution and creation and how these ideas relate to each other without getting into the morass that is the highly politicized and emotionally charged controversy surrounding public education and its connection to separation of church and state.

I might like to know what Congressman Paul has to say about that - and I consider it much more important than what he thinks about the theory of evolution. The libertarian position he espouses actually makes his answer to this question pretty straightforward: questions about evolution are strictly a matter of one's personal beliefs and inclination to think in scientific versus spiritual terms, not terribly relevant for a politician, unless one gets into the messy argument over public education, which can be largely avoided by getting the federal government entirely out of the business of public education and giving parents tax credits to let them choose whatever schools they want (or none at all, opting for home schooling).

Yet we will still have public schools (there seems no easy way around that), and so we will have state and local school boards making decisions about curricula. If they decide to include intelligent design, there will be challenges in the federal courts on church-state-separation grounds. Thus it becomes more important to ask Ron Paul how he is going to find Supreme Court appointees who agree with his originalist interpretation of the Constitution. That means what the framers had in mind, which was simply that there should be no official Church of the United States as there was a Church of England - not that religion or religious teaching should be excluded from all spheres of life touched by public dollars. And if he can find some, can he get the Senate to confirm them? Good luck with that, Congressman.

Friday, December 23, 2011

A Lump of Coal from Medicare

If you're 65 or older, or the Social Security Administration has declared you disabled (or if you have chronic kidney failure), you are covered by the federal health insurance program called Medicare. This is a good thing: it has kept many millions of senior citizens from becoming medically indigent.

But there is a growing gap between what Medicare pays to doctors and hospitals for caring for its beneficiaries and what it costs to provide that care. There is also a gap, growing even faster, between what Medicare pays and what commercial health insurance (also known as "real insurance") pays.

This is not because commercial insurers are generous. Rather, it is because the federal government has decided that the way to slow the growth of the Medicare budget is to pay the providers of health care services less (in inflation-adjusted dollars) each year.

A large part of the reason so many hospitals struggle to stay in the black is that many of the services they provide to Medicare beneficiaries are paid for at rates so low as not to cover the cost of providing the care.

It wasn't always this way. In the 1970s Medicare paid hospitals for what they did, with a bit of a margin. This is called a "cost-plus" system of financing. But the feds decided that was much too expensive, and in the 1980s they implemented a new system in which hospitals were paid based on what was wrong with the patient. If they could care for the patient for less than Medicare paid for the patient's diagnosis by being very efficient, they did well. If it cost more than that to get the patient well enough to be discharged, the hospital took a loss. This was supposed to give hospitals an incentive to be more efficient.

But life is full of unintended consequences. If innovations become available that improve the quality of patient care, will hospitals use them? When the system of health care financing pays for the patient's diagnosis, not for the treatment provided, this favors innovations that prove to be cost-efficient, while those that improve quality but increase cost may fall by the wayside.

Fortunately hospitals also get paid for taking care of many patients who have real insurance, so the potentially stifling effect of this system of financing on innovation has been substantially mitigated.

Nevertheless, as our nation's population gets older and sicker, and the proportion of patients covered by Medicare grows inexorably, more and more hospitals will be squeezed harder and harder.

The situation for doctors is just as bad, but the approach has been different. In the Balanced Budget Act of 1997 a new formula was introduced: the Sustainable Growth Rate formula, or SGR. As its name implies, the purpose of the SGR was to keep growth in Medicare expenditures for services provided by doctors within the realm of sustainability.

Each year a complicated calculation tells the folks at the Centers for Medicare and Medicaid Services (CMS) how much growth is permitted in payments to doctors for taking care of Medicare patients. If the allowable growth in expenditures is less than the projected growth in expenditures, CMS must adjust for this by paying doctors less.

While on its face this seems patently unfair, there is a rationale based on a certain school of thought in health care economics. The idea is that physicians have a degree of control over utilization of resources. They have some flexibility in deciding what tests and treatments to order or recommend. So the system is devised to give them an incentive to do less. The less they do for Medicare patients, the slower the growth in Medicare expenditures. The slower the growth, the less likely it is that the projected rate of growth will exceed the sustainable growth rate (SGR). Then, instead of getting paid less every year for what they do, they might even get paid a little more.

There are several obvious problems with this approach. First, it assumes that physicians act as a group, in the interests of the group and all its members. After all, if I am constantly looking for ways to practice more cost-efficient medicine, but my colleagues are not, I will not benefit from a reduction in the rate of growth in expenditures. It is only if we are all singing from the same hymnal (the metaphor seems apt on the eve of Christmas) that we will all reap the benefits of economizing.

Second, it assumes that SGR-driven reductions in payments are a sufficiently powerful incentive to physicians to take a less-is-more approach to patient care, when many other factors are pushing them in the opposite direction. These other factors include a focus on doing what is best for the individual patient, with an emphasis on diagnostic certainty and state-of-the-art testing and treatment; a natural inclination to pursue the best possible health outcomes regardless of cost; and concern about the consequences of missing something by being less than very thorough, including the possibility of ending up a defendant in a medical malpractice lawsuit.

For quite a while now, the projected growth rate has exceeded the SGR more often than not, meaning CMS is supposed to reduce what doctors get paid for what they do for Medicare patients. And, more often than not, Congress has intervened to prevent the cuts. Each time that happens the gap between actual growth and "sustainable" growth gets bigger, and so each year the cuts that would be triggered by the SGR grow larger. On January 1, 2012 it would be 27%, except that Congress is about to enact a two-month reprieve to give itself yet another opportunity to figure out what to do about this absurd system.

Why should you, if you are not in a health profession, care a whit about whether doctors get paid poorly by Medicare? (And believe me, the difference between payments by Medicare and those for services provided to patients with "real insurance" are sometimes eye-popping.)

Think about CMS as an employer. If your employer decided to pay you less every year for doing the same work, while other employers were giving raises at least enough to cover inflation, how long would it take before you started looking around for other opportunities?

Now imagine you are a doctor who takes care of a diverse population of patients. Some have real insurance. Some have Medicare. Some have Medicaid (the publicly financed health insurance for the poor). And some are uninsured. If you want your practice to be a going concern, you have to limit the number of patients who have no insurance and cannot pay. You probably also must limit the number on Medicaid, which generally pays very poorly for services rendered. It is now getting to the point where more and more doctors are realizing they must limit the proportion of their patients who are on Medicare.

They are not sending letters to their Medicare patients telling them to find another doctor. But they (actually their receptionists) are saying no to new Medicare patients. They have no choice. They have practice overhead to cover: mortgage payments on the office, utility bills, staff salaries, purchases and maintenance of equipment. Oh, and they want to maintain their own personal income, too, because they have educational loans to pay off, families to support, children's college tuition to pay or save for, mortgage and car payments - you know, the same stuff the rest of us worry about. They may drive fancier cars or live in bigger houses, but they're a lot like you.

Expecting doctors to practice cost-efficient medicine - to get the biggest bang for the buck when making decisions about tests and treatments for each and every patient they see - is reasonable. Expecting them to take responsibility for "unsustainable" growth in Medicare expenditures, when that growth is rooted in so many factors beyond their control, is not reasonable. And punishing them when growth in expenditures exceed targets that are based on a deeply flawed formula is decidedly unreasonable.

When you or your parents reach the age of 65, it's going to be harder to find a doctor who takes Medicare patients. That's why you should care.

Monday, December 12, 2011

We are the 2%!

False beliefs abound. In few areas of public discussion is this more true than health policy.

One of these false beliefs is that emergency care is terribly expensive, and that we could save a lot of money if we could just somehow see to it that everyone who goes to a hospital emergency department with a problem that is not a true emergency could be re-directed somewhere else.

So ... is that true or false?

As with so many other things, it depends on how you look at it. And, with a complex proposition such as this one, it is important to recognize that it has several interdependent parts.

If you've been a patient in a hospital emergency department (ED) for something that you might have seen your primary care doctor about, if you could get a timely appointment, you surely noticed that the bill was higher than it would have been at the doctor's office. There are, as you may know, two fundamental reasons for that.

First is that the ED has a lot more "fixed costs" (or overhead) that must be covered by revenues. Second is that we have to engage in "cost shifting." We have a lot of patients who do not or cannot pay, and many more whose form of payment (Medicaid, Medicare) does not cover the cost of the care provided. And we have far more of these patients than the typical primary care doctor. So the hospital must bill paying customers more to make up for the ones who pay little or nothing.

Imagine going to McDonald's and finding that the price of a Big Mac had doubled because half of Mickey D's customers weren't paying for their meals, and so the paying customers had to pick up the tab. You might think Ronald didn't know how to run a restaurant, that he couldn't make a burger for a reasonable price. But the cost of making the burger didn't change - just the price he has to charge you to stay in business. That doesn't happen at McDonald's, because they don't give everybody chicken nuggets regardless of ability to pay. In the ED, we do exactly that. We do it partly because we believe in certain principles of social justice and partly because there is a federal statute that says we must.

So the cost is higher after accounting for overhead, and the price difference is even bigger. And if you have private insurance, the insurance company has ways of discouraging you from using the ED when you could go to your doctor's office instead. For example, if you were sick, but not sick enough to be hospitalized, your ED co-pay might be $100, whereas in the office it would have been $10. And yet people go to the ED anyway. There are lots of reasons for that: convenience, resources available in the ED, and perceptions of the quality and comprehensiveness of care are perhaps foremost among them. Even if you could always get into your doctor's office on very short notice, you wouldn't necessarily go there for everything your insurance company thinks, in retrospect, you could have. You had a kidney stone? That didn't require hospitalization, so you couldn't have been all that sick. You could have gone to your doctor's office. Try that some time, and see how well it goes.

But let us imagine that you really could get care in your doctor's office for every illness not serious enough to require hospitalization, and you could get it in a reasonable time frame. Let us further imagine that your doctor's office was actually equipped to distinguish indigestion from a heart attack and serious from trivial causes of abdominal pain. Let us even suppose that your doctor could evaluate and treat minor injuries not requiring a surgical specialist - and could tell which ones do and do not require such specialty consultation.

How much money could we save?

Do you have any idea what percentage of the U.S. health care budget is spent on emergency care? If you read the headline, you know the answer. That's right. Just two cents of every dollar spent on health care in the United States are used to pay for emergency care.

So if we could just get everyone without a life-threatening problem out of my ED, we would slash the health-care budget by ... a lot less than 2%, because nearly all of them would get care somewhere else, and it wouldn't be free wherever that might be.

In the halls of Congress we hear all the time this nonsense about the need to get all the patients without true emergencies out of those expensive emergency departments. And nonsense is exactly what it is.

We are the 2%! Occupy Capitol Hill!

I Think, Therefore I ... Should Turn Off News Reporting on Politics

During a recent debate featuring candidates for the Republican presidential nomination, Newt Gingrich expressed the view that a compassionate, humane approach is called for in dealing with undocumented immigrants who have been in the United States for many years.

Gingrich pointed out that it makes no sense for members of a party so focused on the family to want to deport immigrants who have built lives and families here, thereby breaking up those families.

In observing that doing so is neither humane nor compassionate, Gingrich sounded much more like a centrist or moderate than most people think he is. Of course a review of his statements and actions when he was Speaker of the House during the 1990s reveals that he was definitely capable of taking a centrist approach, as evidenced by the various things that were achieved through the joint efforts of the president and the speaker.

The next day this aspect of the debate was reported by CNN. Call me old fashioned, but I think news reporting is a matter of telling people what happened. Of course a bit of context is helpful, and it is entirely reasonable to include something about reactions to what someone has said.

Suppose one of the other candidates had responded by saying, "Newt! That's amnesty! Don't you remember what happened the last time we did that? The floodgates opened. We cannot do that again."

That would have been something to report, but that didn't happen. And it's too bad, because it would really have been interesting to see how Gingrich, who loves history and champions the importance of studying history to avoid repeating mistakes, would have handled it. No, in fact, none of the other candidates replied in a memorable or effective way.

So, absent anything good in the way of a response to report from the debate itself, CNN turned the matter over to its pundits. And I'd be OK with that, because I am a pundit myself - I have a certificate suitable for framing from the online University of Punditry - and I am usually interested in hearing what other pundits think of the events of the day.

That, however, is not what the pundits did. No, instead, they launched into speculation about how what Gingrich said would be received by voters - particularly conservative Republicans in Iowa. All day - OK, maybe not literally, but it sure seemed so - the pundits droned on about how conservative Republicans in Iowa (they may have mentioned New Hampshire or South Carolina, but Iowa was the focus) would not like what Gingrich had to say.

This statement, the pundits said, was sure to go over poorly with Iowa's conservative Republicans, would likely affect Newt's standing in Iowa polls, and might very well torpedo his chances of a big win in the upcoming Iowa caucuses.

This goes far beyond the proper role of a pundit. The reporter tells us what happened. The pundit provides context and gives us some perspective on the news. It is not the pundit's proper role to tell us what to think about the news.

In other words: Now hear this, all you pundits. You may tell me what you think. Do not tell me what I should think. Do not tell the conservative Republican voters of Iowa what they are expected to think or how they are expected to react.

Surely many of you have noticed that the news networks have gone far beyond reporting and analysis. This is not good journalism. So here is my recommendation. Watch the debates, and then turn the television off. Do your own thinking. If you want to know what to think, don't ask me. I will tell you what I think, but don't adopt my thoughts as your own, if you want to stay out of trouble.