PHYSICIANS and HEALTH CARE REFORM Commentaries and Controversies

On the 71st anniversary of “The Wizard of Oz,” Peter Orszag, the wizard of health care reform, returned to the pages of the NEJM, this time to tell the wonderfulness of his Affordable Care Act. One of its great features is that it will penalize hospitals with excessive readmission rates, easily avoidable by simply assuring that patients have a physician visit quickly upon discharge since, according to a paper that he quotes from a recent JAMA, early follow-up reduces readmissions. So I read the paper and summarized it in the bar graph below. What it shows is that there is no difference in readmissions among hospitals in the three highest quartiles of follow-up visits, despite a substantial decline in follow-up among them. Only the lowest quartile of hospitals has more readmissions. Also, there’s no difference in the percent of blacks at the hospitals in the three highest quartiles for follow-up. Only the lowest quartile has more blacks – by double. So there’s no gradient that links follow-up to readmissions, but there is a distinctive quality about the hospitals with more readmisions – more blacks, which really means more poverty. Follow the yellow brick road. It leads to poverty. Penalizing hospitals that take care of the poor and therefore have more readmissions certainly will not help.

Solutions to problems are generally sought from within the problems themselves. Two recent examples are health care and finance. In both cases, the solutions are believed to be better-structured and regulated systems. In blogs, articles and speeches, I have stressed that, while there are myriad ways that health care can be improved, the real solutions to high health care spending lie outside of health care. Poverty and its associated manifestations are at the core of the health care spending crisis. The high costs of caring for the poor will continue to overwhelm the system, no matter how it is structured and improved. Rather than looking for solutions through changes in process and regulation, the major solutions to health care’s excessive spending reside in areas such as K-12 education, neighborhood safety and the creation of jobs that can lift low-income families from the cycle of poverty.  Simply stated, the US does not and will not have the resources to provide equitable care for those among us who confront inequitable circumstances in every other aspect of their lives.

Now Raghuram Rajan, a distinguished professor of finance at the University of Chicago and former chief economist at the IMF, has come to the same conclusion about our financial system. In his new book, Fault Lines: How Hidden Fractures Still Threaten the World Economy, he describes how cheap credit was a mistaken remedy for the consequences of poverty. In addressing its financial future, the US will have to place greater emphasis on educating its young and creating a safety net for its poor.

Neither cheap credit for those who are too poor to pay it back nor costly health care for those whose poverty creates the demand for more, nor even more primary care physicians to treat their woes, can hold our society together. Commenting in the BMJ on similar circumstances in England, Iona Heath said, “It has been much too easy and much too convenient for governments to locate the task of lessening health inequalities within their health services, as if a brief contact with the health service could compensate for a lifetime of disadvantage and deprivation, with the resulting almost inevitable attenuation of opportunity and hope.” Here, as there, the fault lines of income inequality are the nation’s greatest challenge.

Reed Abelson and Gardiner Harris, whose previous NY Times article characterized the Dartmouth Atlas as “shaky,” have responded to the rebuttal of their work by Dartmouth researchers, Elliott Fisher and Jonathan Skinner. Carefully and deliberately, they have shown how the Dartmouth team has pursued a consistent pattern of exaggeration and fabrication. It is this same pattern of deception that I described in papers in Health Affairs here and here, in the Washington Post, in letters to Congress here and here and in blog postings here and here and here and here and here and here and here and here and here and here and more.  I pointed out that “The 30% Solution is a Treacherous Prescription for Health Care Reform.”

Over the past 18 months, I have referred to the Dartmouth group’s pattern of deception as “Dartmouth doubletalk,”  “twisted truths,” “malarkey“ and “voodoo statistics.” It should never have reached this point. In a letter to John Wennberg three years ago citing several such examples, I said, “I can find no way to characterize these statements as anything other than a deceptive misrepresentation of the data and intentional perversion of the truth. I don’t think it’s worth having them contaminate the enormous body of important work that has flowed from your enterprise. It would be so much better if you and your colleagues would rectify the misconceptions that have been created.” He chose not to, and his colleagues chose to progressively elevate the level of deception. I proceeded to publish the facts as I saw them, and now the New York Times has done the same.

Sadly, the Dartmouth Atlas and its misrepresentations by Dartmouth researchers have misled health care reform. Saddest of all, they have diverted attention from the policy needs that exist because of the high health care costs of poverty. The road back to truth and coherent policy will be long and difficult, but we must now begin.

The infamous Dartmouth Atlas publishes maps that purport to report an association between increased Medicare spending and the wasteful overuse of supply sensitive services (top figure, below). But Brown and O’Connor, from the same research unit at Dartmouth, have published a very similar map, which they interpret as showing an association between increased deaths from heart disease and socioeconomic factors (bottom figure). So which is it: more deaths (and therefore more health care spending) due to socioeconomic factors, or more spending in many of the same areas because of the avarice of physicians?

I know that the Dartmouth Atlas crowd won’t listen to reason from me. They even had the audacity to say that almost none of the variation in their Medicare map is due to poverty (shame on them!). But I hope they will listen to their colleagues, Jeremiah Brown and Gerald O’Connor, whose June 10^th paper in the NEJM gets it right. People are sicker where they are poorer, and it costs more to care for them.

On June 3^rd, NYT writers Reed Abelson and Gardiner Harris bravely published the truth about the Dartmouth Atlas - its use of data is shaky. Writing in the Washington Post last September, I called the Atlas the “Wrong Map for Health Care Reform.” Other than two pathetic rebuttals, one from the perpetrators of the Dartmouth hoax (Fisher and Skinner) and the other from its spinmeister (Gwande), the NYT has yet to publish objective commentary. Given the gullibility of its editorial page, which bought into Dartmouth doubletalk right from the start, it may never do so. And so, my brief response to the NYT follows:

To the Editor:

Abelson and Harris’s critical analysis of the Dartmouth Atlas unmasks the fact that it cannot be taken as a measure of expenditures in relation to quality, and therefore as a measure of value. Yet we are left to wonder, why are expenditures higher in some geographic regions than in others? The answer is that the Atlas’s geography is the geography of poverty. In some cases, poverty encompasses entire regions of the Atlas, particularly in the south, but more often poverty is concentrated within “poverty zones,” such as south Bronx, north Philadelphia or Watts, where it is masked within the Atlas’s units of analysis by the surrounding affluence. Health care expenditures per capita in such poverty zones are double those of their affluent neighbors, and such spending is not masked. As phrased by a colleague, “one persons affluence off-sets ten people’s poverty, but one poor-person’s health care spending in not off-set by even ten who are affluent.” The same pattern applies to expenditures within particular hospitals. Mayo is wrongly thought to be “efficient,” because its per patient expenditures are lower, but no lower than other hospitals in regions where population density is low and poverty rates are even lower. In contrast, hospitals in Los Angeles, which bear the burden of almost two million poor people, are wrongly viewed as “wasteful.” The lesson is that, while much can be done to improve our health care system, all efforts pale in comparison to addressing the higher expenditures required in caring for the poor.

Quality and value are important. But are they best achieved through professionalism or regulation? In 1996, Donald Berwick co-authored an important book, “New Rules,” which set forth the manifesto for how and why health care was to regulated. The following statements, grouped into paragraphs, are from that book.

 BERWICK:  “Physician control of knowledge has allowed practitioners to shape both the demand for medical technology and its supply. One motivation for doing so may have been that the monopoly of knowledge and the inhibition of the patient’s role furthered the profession’s own economic interests. Another, and more probable explanation is that the espoused ethic of medicine eliminated all influences on the healing relationship except for the physician’s commitment to the patient.

Today, this isolated relationship in no longer tenable or possible.  No longer is the physician, paternalistically committed to the patient, the driving force in medical care. Health care has become an industry, with numerous loci of authority well beyond the doctor’s office. Traditional medical ethics, based on the doctor-patient dyad, must be reformulated to fit the new mold of the delivery of health care. The relationship of the patient to the doctor is less important. In these circumstances, the need for regulation is greater, not less.

Regulating for improved medical care involves designing appropriate rules invested with authority. Their primary function is to constrain decentralized, individualized decision making. Strict regulations reduce the autonomy of health care professionals and thereby improve safety.” 

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The American Academy of Family Practice published a series of eight papers about the National Demonstration Project (NDP) of the Patient Centered Medical Home (PCMH). The first thing you should know is that, like the Group Health and Ontario medical homes, described earlier on my blog, these homes were for middle class folks – 20% had graduate degrees, more than double the national average. As the authors note, the practices chosen included few low-income and minority patients. So, like the others, poor people need not apply.

Most of the papers in this series are about how the medical homes struggled to implement the various things that constitute a medical home. The critical paper is the one that looked at outcomes. Here’s its conclusion:  After slightly more than 2 years, there were no significant improvements in patient-rated outcomes, including the 4 pillars of primary care (easy access to first-contact care, comprehensive care, coordination of care, and personal relationship over time), global practice experience, patient empowerment, and self-rated health status, although there were small improvements in condition-specific quality of care, as measured from charts.

In simple terms, the medical homes did not achieve their intended results (i.e., the model failed). But it wasn’t their fault. The family practice folks tell us that, without fundamental transformation of the health care landscape, including higher reimbursement and additional clinicians (to allow smaller patient panels), medical homes will face a daunting uphill climb.  

So, the medical home model failed, but not because it was a bad idea. The AAFP tells us that it failed because primary care physicians need to take care of fewer patients, which would mean that we need more of them. But what we really need is a model that requires fewer of them (see No One Home in the Medical Home). In such a model, generalist physicians would redefine their roles as caregivers for patients with chronic illness and multisystem disease and as the identifiable physician-of-record for larger panels of patients, who would receive most of their routine care from midlevel practitioners. If primary care physicians focused on those segments of care that demand their level of training and knowledge, and if they were properly compensated for doing so, we not only will need fewer of them, we’ll get what we need because a discipline will exist that medical students will want to enter. Let’s try for that next time.

One final thing. Why is Health Care Reform reforming the system so that it serves minorities more poorly? Echoing Dartmouth’s malarkey, Orszag has fostered a bill that calls the extra costs of treating poor people “waste and inefficiency,” and in the name of “value,” penalizes providers who care for the poor. And the medical home model that it promotes excludes poor people (never mind that the model doesn’t work). I’m getting a little tired of defending the poor against an administration that was supposed to help them.

In a recent blog posting, I described Group Health’s medical home for 8,000 patients. It proved to be a boon for primary care physicians, who were able to reduce the size of their patient panels, see fewer patients per day, refer more patients to specialists and maintain or increase their incomes. Patients liked it, too. And Group Health was happy because expenditures per patient were 2% lower. But poor patients had trouble getting through the front door of the medical home, so based on demographic differences alone, expenditures should have been lower by 10% or more. Nonetheless, they declared victory.

Now news filters south from Ontario’s eight year experiment with medical homes for 8,000,000 patients, and the news is similar. Participation is skewed to healthier and wealthier patients, who, in the absence of risk adjustment, yield profitable capitation for primary care physicians.  Incomes have soared an average of 25%. But while better service was promised, it hasn’t been delivered, at least not for the medical needy and not after hours. Indeed, patients who have sought such extra care (which is charged to the medical home) have been removed from the roster, further improving the risk profile of those who remained.

The conclusion reached by Glazier and Redelmeier, whose JAMA commentary I have drawn upon, is that Ontario’s medical homes were laudable in their innovation and scope and successful in increasing primary care physicians’ incomes. However, the result has been gaps for vulnerable groups and suboptimal access for those most in need. And once again, the urban poor have been left out in the cold.

Health care reform is in love with medical homes, and in theory, there’s a lot to love. But before we rush head-long into a new care model, with too few physicians to do it, we’d better look carefully at what has occurred elsewhere and think about how we might build homes for all of our citizens, not just the healthiest and wealthiest ones.

The power of Tony Judt’s new book, “Ill Fares the Land,” is in his assertive exposition of the corrosive effects of income inequality – a problem that is greater in the US than in any other Western democracy. “Poverty,” he says, “is an abstraction, even for the poor. But the symptoms of collective impoverishment are all about us.” Not only in crimes committed, which are actually decreasing, but in gated communities and the incarceration of young black males, both of which erode our social fabric.

Nowhere are the effects of income inequality more evident than in health. Judt cites Wilkinson and Pickett’s recent book, “The Spirit Level,” which chronicles the relationships between poverty and ill health. And ill health begets health care spending, so it should not be surprising that the added health care costs associated with poverty account for as much as one-third of health care spending in dense urban centers. Indeed, more than any other factor, poverty explains the geographic variation in health care that was so widely discussed but never properly diagnosed during health care reform. Judt has made the diagnosis for the US, as Sir Michael Marmot did recently for England, where the problem is similar but half as great.

Here, there and everywhere, the solution will require more than just health insurance. It will require the kind of social reorientation that Judt calls for. 

Richard Cooper
Philadelphia

The writer is a professor of medicine at the University of Pennsylvania

Group Health recently published two papers, one in Health Affairs and the other in JAMA, both extolling the virtues of its Medical Home. These follow a brief report last fall in the NEJM and a lengthy description in the American Journal of Managed Care. In addition, Group Health’s Medical Home has been promoted by the Commonwealth Fund and others, and it is praised in an editorial in the current issue of Lancet. The big news is that costs for patients in their Medical Home were a full 2% lower than in conventional practices, hardly a great success – it wasn’t even statistically significant.  But was even this small difference due to the Medical Home, or was it  because Medical Home patients were less likely to consume care?

Group Health’s answer is that the 7,000 patients in their Medical Home were the same as the 200,000 controls, because the burden of disease, as measured by Diagnostic Cost Groups (DvCGs), was similar in the two groups. But while the DxCG system adjusts for diagnoses, age and sex, it does not adjust for sociodemographic factors, the strongest determinant of utilization. Nor does it appear to have accounted for health status. The chart below, from data in the AJ Managed Care publication, shows just how different these two groups are. Sadly, these data were not included in papers in the NEJM, JAMA or Health Affairs, which are read more widely.

Anyone should be able use fewer resources caring for patients who are more highly educated (and presumably higher income), who are more often white and whose baseline health status is better. Indeed, it’s remarkable that the DxCGs could have been so similar, since health status was so much better among Medical Home patients. What’s most amazing is that this more favorable group consumed only 2% less resources. I would have expected at least 20% less.

But even if Group Health’s model of care were valid, it’s important to recognize the practical limitations in generalizing from it. It took eight physicians to constitute the six FTE physicians who provided Medical Home care, and these physicians had patient panels that were almost 25% smaller per FTE than in Group Health’s usual practices. Nonetheless, Medical Home patients were more frequently referred to specialists (and that was statistically significant). With eight Medical Home physicians providing the same care as four full-time physicians working in the usual practices, it’s not surprisingly that those in the Medical Home had less stress. Patients were more satisfied, too. But there are not 25% more primary care physicians available to allow all of the primary care physicians in America to reduce their panels, particularly with many working part-time. And when there are too few, the poor come in last (see:  No One is Home in the Medical Home).

Beyond these basic concerns, I’m left with two nagging questions. Why, if the Medical Home is patient-centered, did it start with 9,200 patients in 2006, decline to 8,094 by the end of 2007 and fall further to 7,018 by the end of 2009, a loss of 24% of the patients in less than three years? Not too “continuous, comprehensive and coordinated ” for them. But more important in terms of study design, where did these 2,000 patients go? And why? And how much does their care cost? And why aren’t those costs in the final calculations?

And one last question. How can Group Health be a model for the nation when, according to its Service Area Maps, it accepts commercially-insured patients from eighteen counties (top panel) but Medicaid patients from only three (bottom panel)?

If we want high-performance primary care, it will have to be delivered in high-performance systems that use scarce physician resources more efficiently. Panel size will have to be increased, not decreased, as physicians defer more care to others. And physician satisfaction will have to increase not because of less stress but because physicians are rewarded for exercising the complex knowledge that they worked so hard to attain.

Most of all, if we want to decrease health care spending, we will have to recognize that the major remedial costs are associated with the added care that is provided to low-income patients. It’s time to stop talking about wasteful Medical Homes for college grads and start talking about safe neighborhoods, high-quality schools and workable systems of care  for a diverse and needy nation.