Monthly Archives: April 2009

In his new book about Lincoln as a writer, Fred Kaplan describes Lincoln’s disdain for the “linguistic dishonesty” of leaders of the Confederacy, who attempted to divide the nation with “a barrage of verbal propaganda that corrupted the relationship between language and truth.” Strong words, but not unlike the verbal propaganda that has been used to create a schism between primary care physicians and specialists and that is impeding solutions to the nation’s physician shortage.

We are told that patients in areas with more primary care physicians and fewer specialists spend less on health care but receive better quality care, use fewer hospital and outpatient services, incur lower end-of-life expenditures and achieve better health status. They even have lower mortality from cancer, heart disease and stroke, decreased infant and maternal mortality, decreased all-cause mortality and increased life spans. All quite remarkable. And while one can find a kernel of “statistical truth” in some of these studies, it generally disappears once race and poverty are considered. And when these are considered, the associations apply to family physicians but not general internists or pediatricians, who practice in the same manner, a curious anomaly that results from the preference for family practice in states along the northern tier. Indeed, the superior outcomes have everything to do with the merits of Minnesota over Mississippi and nothing to do with the merits of primary care. 

But what about the old saw that primary care physicians can deliver specialty care better and cheaper than specialists?  Greenfield, who led these studies in the 1990s, acknowledges that they lacked adequate risk adjustment, and subsequent studies have shown that specialty care generally yields better outcomes, particularly for patients at greater risk, although with greater costs.  But these conclusions run headlong into the Dartmouth’s Atlas, where outcomes in “regions” with more specialists and more spending are said to be no better and sometimes worse. Yet even a casual inspection of the Dartmouth map shows that the “region” with the most spending is a scattered collection of America’s densest urban centers, while the “region” with the least encompasses the vast northern tier, from Alaska to Maine (see “The 30% Solution”). Yet these two vastly dissimilar areas have equivalent outcomes.

Even more curious are the statistical gyrations used by members of the Dartmouth group in claiming that “states where more physicians are general practitioners have higher-quality care and lower costs, whereas states where more physicians are specialists have lower-quality care and higher costs.” While widely cited, these claims are simply false (see “Less is Less-Mississippi” March 26^th). States with more specialists actually have higher quality care. Mississippi and Nevada, where quality is low, do not have an abundance of specialists, as portrayed, but the fewest in the nation. 

Take note. Obama has arrived from the land of Lincoln with the clear message that language and truth must be reunited. And Lincoln would probably add something about what happens when a profession is divided against itself. Primary care physicians don’t need to be advertised as better “specialists” than specialists, nor as the fountain of long life, and falsely denigrating specialty care doesn’t make primary care physicians more valuable. Patients know their value already. And experts know that health care is better when primary care physicians and specialists work together and best when there are more of both. The tasks at hand are to end the “verbal propaganda” that divides disciplines and concentrate on expanding physicians supply overall so that future generations will have access to the technologically advanced, socially equitable care that they will want and deserve. 

For references, contact cooperra@wharton.upenn.edu

 I had the pleasure of participating in the American College of Physician’s International Forum. The question posed to the Forum was, “what is the future of Internal Medicine?” Physicians from other nations described the more traditional roles of Internists as consultants to primary care providers and physicians for patients with multiple co-morbidities. But the ACP sees Internists as custodians of the “Medical Home,” a broad and inclusive model of care that is more conceptual than practical and only minimally tested among adult populations. Yet even if it proves to be valid, it faces the reality that there won’t be enough Internists, or Family Physicians, to make it happen.

This lack isn’t simply because Internists and FPs aren’t paid enough, although they aren’t. It’s because there won’t be enough physicians overall. There already are too few general surgeons and too few urologists, and the oncologists project a 40% shortfall within ten years. Faced with shortages like these, physicians will have to gravitate to roles that only physicians can play, while most of what goes on in a Medical Home is undertaken by Nurse Practitioners and others.

But the problem for Internists goes even deeper. With the demand for hospitalists and internal medicine subspecialists growing steadily, it is unlikely that there will be enough Internists even for the absolutely essential roles of serving as consultants and providing care to patients with multiple infirmities. The reason is unambiguous. Too few doctors are being trained, and that is because Medicare capped its support for residency training in 1996, while population and the economy have continued to grow.

Some see this as good – it’s a form or rationing. But it’s not good. America will never ration care for profoundly ill patients. And, sadly, the creation of physician shortages assures that there will be many more patients who present with late disease, simply because access to earlier care was not available.

So the message to the ACP is that it will not be possible to build a bigger workforce of Internists unless the entire physician workforce is expanded, and the physician-directed Medical Home will remain a distant dream.

Can it be true that the way we’re going to reform health care is to:

(1) Cut hospital reimbursement for readmissions (principally of poor people).

(2) Penalize hospitals and physicians who provide more services (principally to poor patients).

(3) Cut Disproportionate Share (DSH) payments to hospitals (which are for disproportionate numbers of poor patients)

(4) Reduce the amount of subsidies for low-income individuals to buy insurance.

Say it isn’t so.

Did you know that the poorest 15% of our fellow citizens consume more than twice as much health care as the richest?  That means that if health care spending for everyone could be the same as it is for individuals at the median, our nation would consume 20% less health care. That’s a sobering reality.

These extra costs are partially due to more emergency room visits, but they are mainly due to more doctor visits and more hospital admissions and more readmissions and longer lengths of stay and more in-hospital deaths, because poverty and illness go hand in hand, and outcomes are poor among the poorest, and coping with illness is far more difficult when you’re poor, especially if you lack a support system and education and language proficiency.

Poverty actually accounts for most of the regional differences in health care spending that have captured the attention of policy-makers and that I have commented upon elsewhere in this Blog. But the connection between regional variation and poverty is rarely made.

Solving this problem will not be easy. Part of the solution is in wider use of tools that are known to decrease these costs among poor individuals, such as interpreters and home health aids and other strategies that strengthen the local infrastructure that enables health care. Of course, durable solutions require attention to the underlying disease – poverty – and that’s the biggest challenge. But the stakes are high and the value is broad, not only for health care but for the lives of those who will otherwise be poor. Dealing with the high health care costs of poverty should be the top priority of 21st Century health care reform.

What good fortune I had to encounter Chris Hogan, a creative and insightful health policy consultant.  He was asked to figure out why home oxygen therapy costs Medicare 6-fold more in some states than in others.  The highest costs were in Wyoming, Colorado, Utah, Nevada and New Mexico, while Hawaii, Minnesota, North Dakota, Maryland and Rhode Island had the lowest. 

Some of this had to do with differences in the prevalence of chronic obstructive pulmonary disease (COPD), but the correlation was weak.  Then Hogan looked at a topographical map of the US, and it all made sense.  Spending was high at high altitude and low at sea level.  When both the prevalence of COPD and altitude were considered, the correlation was 0.93 (almost a perfect 1.00). 

Explaining regional variation is important. It guides coherent health policy. But coherent policy doesn’t come from assuming that variation is “unexplained” and therefore due to specialists (or medical equipment companies), which is what the Dartmouth group preaches. And that’s led to strategies from the Office of Management and Budget (OMB) to decrease spending in high spending areas by reining in specialists.  Maybe there are clinical reasons for that spending.  Whenever anyone has looked closely, they’ve been found. 

The quiet of an Easter evening was shattered by a phone call from an irate surgeon saying, “did you see Peter Orszag’s Congressional testimony last year and the one by Elmendorf (his acting replacement at the Congressional Budget Office-CBO) last month?”  Yes, I had seen both – they’re fundamentally the same.  Both cite a 2002 paper from the Dartmouth group claiming that less than 30% of the variation in health care spending among regions is accounted for by differences in illness rates, and differences in income explain little more. 

Their “poster child” for this statement is a study comparing Grand Junction, Colorado, one of the healthiest regions, and Birmingham, Alabama, one of the least healthy. By the Dartmouth group’s measure, the prevalence of heart disease, stroke and a number of other major illnesses is 55% higher in Birmingham than Grand Junction (although heart disease and stroke rates are actually double). And hospital and ICU days were right in line with this increased burden of illness: 48% more days and 38% more ICU days, so it’s not clear what the problem is.  It looks as though disease burden more than explains the variation.

But there are a few other rather important differences between Birmingham and Grand Junction. Birmingham’s poverty rate is 25%, which is more than double that of Grand Junction, and 76% of Birmingham’s population is black, compared to 0.6% in Grand Junction.  And contrary to the CBO’s testimony that “income explain little,” income explains everything.  Individuals in the lowest 15% of income utilize twice as much health care as those with higher income. 

In fact, if Alabama had the resources to provide all of the needed care to its citizens, utilization should not simply have been 38-48% greater in Birmingham, in line with its higher illness levels. It should have been 100% more, based on the combination of illness levels and poverty. And that’s exactly what is seen in northern communities, where poor populations with high burdens of disease inhabit urban ghettoes. But, unlike the circumstance in Alabama, these patients have access to facilities and resources that are established by the greater affluence of northerncommunities, and it is reflected in spending. 

The lesson is that illness maters. And poverty matters. And whether or not zones of poverty are embedded in regions of affluence matters. And together these factors explain most of the regional variation that the Dartmouth group and the CBO seem to have so much difficulty explaining. Which would not be a problem except for the fact that they are converting confusion over regional variation into confused health policy.

Here’s what Tim Skinner, Executive Director of the National Rural Recruitment and Retention Network (3RNet), has to say about MedPAC, the agency that advises Congress on Medicare. MedPAC fully embraces the Dartmouth line that “more is less” (more physicians produce poorer quality), and it has failed to promote greater support for graduate medical education (residency programs), which is the only source of new physicians in America.

Tim Skinner: “The MedPAC crew really has put the screws to this country. Everyone loses, but rural areas remain solidly behind.”

Rural America is hurting.  It’s difficult to recruit primary care physicians and almost impossible to recruit general surgeons. And the problems stretch beyond medical care to the economic stability of rural towns.

Gerald Doeksen estimates that one rural physician generates 17 additional jobs and $350,000 in additional economic activity annually through ambulatory care services alone.  General surgeons have still more impact — between $1.0 and 2.4 million annually. And even more, the financial viability of rural hospitals, commonly the largest employer, often depends on their ability to provide surgical services.

So it’s not hard to see why Skinner is worried. You should be, too.

A very good reporter asked a very good question. I had told him that one of the major problems with the Dartmouth group’s studies of regional variation was that their metric of health care utilization was the average level of Medicare spending in each region. The problem is that quality within regions doesn’t depend on Medicare spending alone – it depends on total revenues from all sources, and total spending doesn’t correlate with Medicare spending. This hangs as a cloud over their studies of outcomes among regions (see “30% Solution – A Treacherous Prescription”).   

The reported said, “but what about practice patterns? Dartmouth researchers found correlations between the number of days in hospitals for both Medicare beneficiaries and privately insured adults. Doesn’t that show that privately insured adults are getting treated similar to Medicare beneficiaries?”

Yes, but only within a particular hospital. Not within a region. As Dartmouth researchers showed, care is essentially the same for all patients (Medicare and others) within a hospital. But it is not the same for all patients between hospitals. In some hospitals, Medicare patients are mixed with more private patients and in some with more uninsured patients. All hospitals depend on total revenues when hiring nurses, creating systems, recruiting physicians, etc., and that’s what determines quality. No one payment source (Medicare or other) is representative of total revenues across a region.

This may be easier to understand in terms of race. Blacks and whites receive comparable care within particular hospitals, but the care that blacks receive across a region tends to be inferior because many are cared for in “predominantly black” hospitals, where care tends to be poor.

The lesson is that hospitals and regions are very different units of analysis, and observations in one should not be used to explain findings in the other. Unfortunately, that’s exactly what the Dartmouth group does. 

 In the month of March, the number of health care jobs increased by 13,500, bringing the total to more than 13 million, 12% of all jobs. At the same time, overall employment fell by 663,000, erasing the meager gains over the past decade and raising the unemployment rate to 8.5%, the highest in 25 years.

Despite the lack of overall job growth during the last decade, health care employment grew by 2,800,000 jobs, as it did the previous decade. The shocking fact is that, if health care employment hadn’t increased to this degree, today’s unemployment rate would be 10.5% rather than 8.5%.

Economists expect job growth to resume as the economy recovers. But which jobs will grow?  Certainly not manufacturing. And not financial services. Many states are looking to health care for these jobs.  They see health care as their economic engines. 

If health care expands to the same degree over the next decade as it did during each of the past two, how many more physicians should be expected? Historic trends suggest that growth of this magnitude should be accompanied be an additional 250,000 physicians, but our educational and training system will provide fewer than 100,000 of these.

If, as many believe, health care spending is sinking the economy, wouldn’t slowing the production of physicians be good? Or is health care an economic engine, as the jobs data indicate. The best answer is that It holds the potential for both, so finding the point of balance is important. It’s simply hard to imagine any appreciable growth in health care without the physicians who are at its epicenter.  So the next time you hear that we should expand access, increase quality and cut spending, reflect on what cutting spending means, not only for quality and access but for jobs.

Some folks from Nevada asked me why the Dartmouth group says that their state has excess expenditures when it doesn’t feel that way.  In fact, it’s so bad that 60 Minutes did a special about it on April 5th.  So I took a look at it, and here is what I found. There are two Nevadas, the Dartmouth group’s and the real one. 

According to Dartmouth logic, Nevada ranks

#16 from the top for Medicare per enrollee (high spending)

 #2  from the top for specialists per capita (among the most)

#35 for Quality (near the bottom third)

#44 for Mammography among Medicare beneficiaries (near the bottom)

The Dartmouth group would conclude that Medicare spending is high because Nevada has too many specialists who use too many “supply sensitive services,” yet outcomes (quality, mammography rates) are poor. The solution would be to create practice incentives so that those surplus specialists in Nevada would stop churning the system and give good care for less, instead. 

But in reality, although Nevada rank #16 for Medicare spending, it ranks

#43 for specialists per capita (among the fewest in the nation, not the most)

#43 for total spending per capita (among the lowest spending in the nation)

#50 for health care workers per capita (the fewest in the nation) 

#44 for Mammography among Medicare beneficiaries (very low)

#38 for Mammography among women 40-65 (also very low)

Everything except Medicare spending ranks low—low physician supply, few health care workers, low total spending and poor outcomes.  Outcomes, such as quality rankings and mammography rates, depend on total revenues (Medicare plus everything else), not just Medicare. The strongest correlate of mammography screening among Medicare patients is the rate of mammography screening younger women in the same community.  Mark Pauly calls this “spillover”  If efforts are made to reduce the number of specialists and reduce the amount of Medicare (and other) spending through practice incentives, Nevada’s health care will crumble.