Something Not Unlike Research

Before the ACP Ethics Manual, there was the Physician Charter

post by Paul Kelleher

In a nice round-up of reactions to the new American College of Physicians' Ethics Manual (discussed on this blog here, here, and here), bioethicist Daniel Callahan echoes what many others have said:

Just by mentioning the importance of cost-effectiveness, the policy breaks important new ground. The cost problem is getting worse all the time. We’ve got to find a way to break that logjam.

It is, however, worth pointing out that this is actually not new ground for the American College of Physicians. In 2002, the the American College of Physicians–American Society of Internal Medicine (ACP–ASIM), the European Federation of Internal Medicine, and the American Board of Internal Medicine jointly released "A Physician Charter", which was intended a sort of new Hippocratic Oath. According to health economist Victor Fuchs, the Physician Charter "has been adopted by physicians’ organizations that include a majority of U.S. physicians." 

The Physician Charter includes three Fundamental Principles and 10 Commitments. The three principles are: a Principle of Primacy of Patient Welfare, a Principle of Patient Autonomy, and a Principle of Social Justice. Among the commitments (and presumably justified by the Principle of Social Justice) is this one:

Commitment to a just distribution of finite resources. While meeting the needs of individual patients, physicians are required to provide health care that is based on the wise and cost-effective management of limited clinical resources. They should be committed to working with other physicians, hospitals, and payers to develop guidelines for cost-effective care. The physician's professional responsibility for appropriate allocation of resources requires scrupulous avoidance of superfluous tests and procedures. The provision of unnecessary services not only exposes one's patients to avoidable harm and expense but also diminishes the resources available for others.

A couple comments. First, notice that physicians are called upon to work with other stakeholders on the development of "guidelines for cost-effective care." My experience in talking with physicians (and physicians in training) is that they would rather be constrained by thoughtful, collaboratively developed treatment and diagnostic protocols than to be expected to "practice cost-effective medicine" in a discretionary manner at the bedside. Physicians would then not feel like they were "playing God," and would view themselves instead as providing "appropriate medical care" when they refuse to treat/screen/refer someone who does not fit a cost-effective protocol's indications.

Second, notice that what the charter does expect physicians themselves to do is to avoid the "provision of unnecessary services" through "scrupulous avoidance of superfluous tests and procedures." I have already suggested that this exhausts what the ACP meant when they encouraged physicians to practice "parsimonious care" in the Ethics Manual. (On "parsimonious," see Dr. Don Goldmann's comments in the round-up.) Again, the reflective view of physicians seems to be that while the doctor's job is to avoid providing harmful or unnecessary care, an understanding of what amounts to justified cost-effective care is more difficult to grasp, and should await a collaboration between different stakeholders with the power to shape cost-effective policy in a politically legitimate way.

A final theme in the round-up on ACP's Ethics Manual is that the Manual does not explain what it means to practice cost-effective medicine or how physicians are supposed to learn how to do it (this problem arises for the Physician Charter as well). Dr. Goldmann articulates what would surely be the first step envisioned by the Manual:

The true cost and effectiveness of a given treatment should be made available and utilized by clinicians as part of their decision making process. What I would love to see is increased pressure on the health care industry to be transparent about the true cost of what they’re making available to their providers and not make it so obscure that you can’t figure it out.

 But history suggests that simply knowing the costs will not be enough. Here is Steven Schroeder:

During the administration of President Jimmy Carter, hospital cost containment became a prominent health policy initiative. In response, the hospital industry argued that it could achieve those goals on its own, without government interference. This “voluntary effort” featured physician education as a strategy to produce more rational spending patterns and thereby lower costs. We tested this hypothesis at UCSF, evaluating 3 different educational strategies on the medical and surgical services over a 2-year period. The educational efforts, which included teaching about costs and benefits of various services as well as a detailed cost audit of services ordered by individual residents, were well received. But there was no significant decline in hospital charges compared with control groups. We concluded that—absent major involvement by hospital authority figures or changes in incentives— voluntary cost containment would fail. Eisenberg and Williams, who conducted similar studies at the University of Pennsylvania, likened voluntary medical cost containment to the fox guarding the chicken coop. Predictably, after Carter lost his reelection to Ronald Reagan in 1980, the voluntary effort vanished.

All this suggests that there is great virtue in having cost-effectiveness be a property of policies and protocols, not discretionary physician behavior. 

May Employers Ethically Refuse to Hire Smokers?

post by Paul Kelleher

From USA Today:

More job-seekers are facing an added requirement: no smoking — at work or anytime.

As bans on smoking sweep the USA, an increasing number of employers — primarily hospitals — are also imposing bans on smokers. They won't hire applicants whose urine tests positive for nicotine use, whether cigarettes, smokeless tobacco or even patches.

Such tobacco-free hiring policies, designed to promote health and reduce insurance premiums, took effect this month at the Baylor Health Care System in Texas and will apply at the Hollywood Casino in Toledo, Ohio, when it opens this year.

"We have to walk the walk if we talk the talk," says Dave Fotsch of Idaho's Central District Health Department, which voted last month to stop hiring smokers.

When I read a story like this, I always think first of the following passage from Michael Marmot's The Status Syndrome (pp. 68-9):

Here is a more contemporary picture of poverty. In an American city a young woman, let's call her Patty, sits and contemplates her life. She recalls that a researcher, doing a health survey, came to the local grocery store, where Patty works as a cashier, and asked her how much exercise she did. She laughed. Most of the day is spent sitting or standing behind the till. What about exercise at home? She lives in a crowded inner-city tenement building. She won't let the children play on the strip of asphalt nearby. Apart from broken glass, she is worried about the violence in this part of town.

Patty's reverie continues. The children come home from school and ask if they can go swimming. It would certainly relieve the long oppressive hours from Friday night to Monday morning that is the lot of a Single mother with two children. But joining a fitness club had been out of the question. They might as easily have a vacation on the moon. There is the Y. But it is an hour on the bus. With the bus, entry, snacks, and sodas for the kids, the trip would cost $30. A king's ransom, but it would fill a couple of hours at least. Then what? She and the children sit cooped up in their two bedroom apartment going quietly stir-crazy. Not so quietly. The children yell at each other and start to fight again. Patty lights another cigarette.

As she contemplates the week ahead, she thinks that the boy needs new sneakers. Why they have to be the ones with special laces, when he never does them up, is beyond her. Something about all the other kids having them. The girl has been to three different friends for dinner and a sleepover in the last month. She wants friends home to her place. Four children, pizzas all round ... Where is that money going to come from? Patty lights another cigarette. She remembers when she splurged and bought herself a pair of designer jeans. It was Mother's Day before last. Gallows humor of the Single mother to buy herself clothes that she could not afford on Mother's Day.

As she thinks about it, she realizes that the only money she spends on herself is the cigarettes. When she took the children to the clinic the other day, the nurse told her, for the umpteenth time, that she shouldn't be smoking: bad for her health and a bad example for the children. The hell with that, thought Patty, take the cigarettes away and what am I left with? That clinic nurse should try leading my life, and see if she's still worried about lung cancer in thirty years' time. I have enough trouble getting through next week.

Lots of "lifestyle choices" have effects on health care costs. A provocative example I cite in the classroom is a employee's choice to have a child. I don't know how the added costs of this choice stack up to the added costs of smoking; I need to look into that further. But putting the examples side by side makes for a useful thought experiment: do we have the same intuitions in each case about whether it's OK to refuse to hire the potentially health-costly applicant? If not, why not? If it is because having children is a "respectable" choice while smoking is not, then I would urge that we spend more time thinking about passages like Marmot's, as well as all the information we have about how people become smokers and what makes it so hard for them to stop.

I don't insist that these Marmot-inspired thoughts are dispositive. There's of course a lot more to say on this issue. As always, I'd welcome your thoughts and a continued discussion in the comments section.

Locating Values in Health Care Policy Decision Making

post by Paul Kelleher

A few days before Christmas, the New York Times's Economix blog published a characteristically excellent post by Uwe Reinhardt on the recently released Wyden-Ryan proposal (pdf). As many of you know, Reinhardt is a master when it comes to explaining complex health policy concepts and principles in clear, accessible prose for non-experts. In this particular post, Reinhardt pellucidly lays out "the major economic functions any health system must perform" (see his first numbered list for these functions). He then remarks:

Most of the debate over health policy in this country has been over two questions.

First, to what extent should healthier or wealthier members of society be asked to subsidize the health care received by their poorer or sicker fellow Americans? Second, influenced by the answer to the first question, who should perform the functions listed above: government, private nonprofit entities or for-profit entities?

The first of these questions is quite obviously a central values question for health policy, and I've written a few posts addressing it here on the blog. As Reinhardt notes, the answer to the second question must be influenced by the answer to the first, but the second question is also clearly more empirical and technocratic in nature than the first.

Reinhardt says that the Wyden-Ryan plan, which is a form of "managed competition," answers the first values question thus:

Let there be a limit to the extent to which healthier or wealthier Americans are forced to subsidize the health care received by sicker or poorer Americans – that is, to the practice of social solidarity.

According to Reinhardt, Wyden-Ryan incorporates this "truncated" conception of social solidarity by limiting the size of the voucher that individuals would receive to purchase health insurance plans within a regulated health insurance marketplace:

The major point of contention in the political debate over managed competition...is over the nature of the “defined contribution,” which defines the extent to which the concept achieves social solidarity in health care. The crucial distinction here is between “vouchers” and “premium support” (as explained in Section B of this Brookings Institution document). [emphasis added]

I think Reinhardt makes a slight mistake here, for I do not think it's true that the answer to this question--i.e. how generous the vouchers should be--"defines the extent to which [a form of managed competition] achieves social solidarity in health care."

To illustrate, imagine that you and I have both been given a very very generous subsidy by the government to purchase insurance on the open market. Let's assume it's $30,000. In most cases, this will be enough to purchase gold-plated health care for a single person. And this may well be true in your case, since you're relatively healthy. But now suppose I have a super expensive pre-existing condition. Depending on how expensive my condition is to treat, there may be no insurance company that would offer me coverage, even if I had $30,000 per year to spend on premiums. If we nevertheless think there is something wrong with that situation, we may choose to place regulations on the marketplace that forbid insurance companies from denying me coverage and that ensure I have affordable access to needed medical care.

Now, these regulation cannot exist in a vaccuum: if insurance companies are required to cover me, then other regulations will have to be put into place to ensure that the market doesn't become disfunctional. Such additional regulations are precisely the regulations the Affordable Care Act imposes for precisely these reasons, as Reinhardt masterfully explains elsewhere.* Yet since these regulations have potentially burdensome implications for others--e.g. they may involve an individual mandate (or its equivalent) and/or make insurance premiums more expensive for others--there is every reason to think that they too help define the extent to which health policy embodies social solidarity. Put differently, if you think it violates some freedom or prerogative of yours to be mandated to have health coverage or to pay a premium higher than is justified by your own actuarial health risks, then you may object to the marketplace regulations embraced by the ACA and Wyden-Ryan. And this may influence--or be influenced by--your understanding of the demands of reasonable social solidarity. 

This isn't a big disagreement with Reinhardt, obviously. And I hope he'd agree with my minor correction to his useful post. Still, I do think it's super important to be able to locate the areas of health policy that must be responsive relevant social values. Reinhardt himself proves why: since health care policy has so many moving parts, it may be possible to adjust several dials to achieve the same degree of social solidarity while lessening the burden placed on others. But we won't get it right if we think that the size of the voucher is the only choice that must be responsive to our understanding of social solidarity. 

*Really, if you are going to give someone you love just one thing to read on the ACA, give them the Reinhardt piece linked to here.

Future Medicare Cost Growth, the Baby Boom, and the Baby Bust

There is an informative and thoughtful article in today's Washington Post by Lori Montgomery on the current and future cost growth of Medicare.

The key facts are in the graph to the right. On the left is an orange bar graph with the good news: per capita Medicare spending has been falling recently. The line graph in the center is the bad news: Medicare enrollment is increasing, and it is increasing rapidly as we baby boomers retire. The net effect, on the far right, is a projected continuing increase in Medicare costs.

But my friend David States pointed out to me that we might look more closely at the projected growth in Medicare enrollment. To the right are data on the proportion of the US population that is 65 or older, with projections into the future (taken from the CDC). My graph is covering most of the same period as Montgomery's. But perhaps because she uses a different projection, or simply because I am plotting more points, it has a different shape. Notice first the rapid increase in this proportion as the Baby Boom retires. This is what will drive the expansion of Medicare costs, even if cost / retiree is stable. After 2030, however, the rate of growth of the elderly as a percentage of total population slows and then stops. As the CDC authors note:

...when the last Baby Boomers enter the ranks of the older population and the first Baby Boomer cohort enters the oldest old age categories, the proportion aged 65 and older will be relatively stable at around 20 percent.

This will happen because the baby boom was followed by falling birthrates (the "baby bust").

Let's not count on this, because long-term demographic projections are often wrong. Moreover, the percentage of very old (and very expensive) persons within the elderly may continue to increase. But suppose, for the moment, that the CDC is right.

There may be a ray of hope here. We need to find ways to hold down the growth of per capita Medicare spending, We need to do this by transforming care to make it more cost-effective. But if* we can find a way to control the growth in spending per retiree, and demographic pressure ends, we will have solved the problem of growth in Medicare cost.

*This is, as they say, a big IF.

When the high price of health care is a good thing

post by Paul Kelleher

If an [Implantable Cardiac Defibrillator] were a buck and a quarter, would we have gone through this entire process of reviewing the evidence at all? Maybe not. But because it's a bit more than a buck and a quarter we wanted to make sure the evidence was clear and that it was a benefit. We don't use cost to decide the evidence issue, but we do use cost to decide if this is important enough to address.

That is Dr Steve Phurrough, then-acting director of the Centers for Medicare and Medicaid Services Coverage and Analysis Group, speaking in 2003. I find this quotation shocking, and I wonder if others do as well.

I have no idea if things at CMS have changed since 2003, but this strikes me as illustrating one reason why it can be good for health care to be pricey. I do not claim that this reason makes it true, all things considered, that health care is so expensive. But its just not clear that we would be better off if health care grew on trees. 

Corporate coercion and health behavior: Is it really coercion?

post by Bill Gardner

Yesterday, I summarized a meta-analysis that suggested that corporate wellness programs provide a positive return on investment by controlling employee's health care costs. Today I want to look at whether these programs are coercive.

Ezra Klein raised this concern in his post on the successful Cleveland Clinic employee wellness program:

[C]onsider what [changing health behaviors] actually entails: Changing habits. Breaking addictions. Getting people to the gym. Who wants to hear about any of that from their employer? The clinic, however, didn’t give employees a choice. “First thing we said was we had to make our institution toxin free,” [Cleveland Clinic Chief Wellness Officer] Roizen said. “The biggest toxin we have in the U.S. is tobacco. So we began offering free tobacco-cessation programs to our employees. Then we banned smoking on campus. You can’t even smoke in the parking lot in your car. The first offense you get a warning, and the second you get fired. We fired two high- profile physicians who refused to quit. Then they knew we were serious.”

Klein (see also here and here) noted that

Whether [the Cleveland Clinic's] success is a model for American health care or a preview of a dystopian surveillance state is an open question.

Let's step back, though, and ask what 'coercive' really means. Suppose someone confronts you in the dark with a pistol and says, "Your money or your life." This is coercion. Now suppose you are diabetic and need insulin, but your pharmacist won't give it to you unless you pay for it. In both cases, you are in life-threatening circumstances, unless you give someone money. But in most cases we feel that even though the pharmacist may be pressuring the diabetic, he isn't coercing her. The reason is that we view a threat with a gun as an illegitimate form of pressure, whereas barring dire emergency we believe that pharmacists have the same right to require payment as any other merchant. We distinguish coercive situations from legitimate pressures based on our moral judgments. 

So is what the Cleveland Clinic does coercive? Americans have complex views about what norms employers can legitimately require you to conform to, but in general your employer has wide scope to regulate your behavior. Your boss can require you to be punctual, if that is essential to the functioning of the business. But you can't be discriminated against on the basis of your religion. Your employer can, however, require you to meet a dress code -- unless it's a matter of dress or grooming required by your religion. And so forth. How do we feel about pressure to conform to norms of healthy behavior? My sense is that as people come to understand that unhealthy behavior is a significant business cost, they will increasingly accept employers' monitoring and enforcement of norms about healthy behavior.  

But although I believe Americans would accept Cleveland Clinic style carrots and sticks as part of voluntary employment contracts, they would not accept them if they were imposed by the government. Citizenship isn't voluntary in the way that employment is.

 

 

The Prevention and Public Health Fund: Where is the money going?

post by Bill Gardner

Evidence-based strategies for preventing chronic diseases are essential for improving the health of current and future generations. So it is distressing to read Sarah Kliff's reporting on the political jeopardy of the Prevention and Health Fund:

Republicans have regularly attacked the $16 billion investment [over 10 years] in programs meant to reduce chronic diseases and improve Americans’ health. Wyoming Sen. Mike Enzi has quipped that the program was a “slush fund” for jungle gyms... “There’s certainly concern among the public health advocates,” says Jeff Levi, who chairs the new National Advisory Group on Prevention, Health Promotion and Integrative and Public Health “The concern is will it fall into a catch all category of things that can be cut, and that’s a challenge.” ...The White House proposed slashing its budget for the first time in its last deficit reduction proposal. House Republicans, meanwhile, would like to zero out the program’s funding in their budget...“The question is: are we funding the status quo, are we funding the stagnant quo, or are we getting an effort...that’s transformative?,” Maryland Sen. Barbara Mikulski vented at a Senate hearing on the fund last week.

Sadly, I think there is something to Sen. Mikulski's concerns. I looked at what the Fund is doing in the state of Ohio. The graph shows how much money will be spent on three types of activities in Ohio over 10 years (the vertical axis is in $1000s). The categories are:

1. Community and Clinical Prevention: Prevention activities that have been shown to be effective in reducing health care costs and promoting health and wellness. Specific activities include: a) Assisting communities with the integration of primary care services into community-based mental & behavioral health settings, b) HIV Prevention, and c) Tobacco Cessation. 
2. Public Health Infrastructure: To strengthen state and local capacity to prepare health departments to meet 21st century public health challenges and support the training of existing and next generation public health professionals. The money supports information technology, laboratories, public health training, and something called 'capacity building'.
3. Primary Care Training: Spending to expand the primary care workforce. These are training programs for (in order of increasing spending): State health care workers, physician assistants, advanced nurse practitioners, and primary care physicians.

There is an argument to be made for each of these categories of spending. But I'm concerned about the priority of infrastructure and training programs relative to actual community interventions. The latter appear to be getting less than $100,000 / year. The details will matter here. Are the Infrastructure and Primary Care Training funds being spent in ways that will generate a sustained increase in evidence-based preventive care by primary care practitioners? If so, the money could be well spent. If not, we will just have more doctors doing more of the same. I hope that the Senators push the Prevention Fund managers hard on this point.

 

 

 

Where all the women are strong, all the men are good looking, and the doctors are below the average

post by Paul Kelleher

Aaron Carrol reports and comments on a recent survey of primary care physicians:

Could it be that doctors might practice more aggressively because when they do, they make more? Well, only 3% believed that financial considerations could influence their own practice. Most, however, thought that other physicians would be affected by such things.

In addition to reminding me of Garrison Keillor's tag line about Lake Woebegone, I am reminded of this passage from Robert Frank's "Why Is Cost-Benefit Analysis So Controversial?":

Yet a potentially more worrisome aspect of the consequentialist position remains, which is that people who view their ethical choices in cost-benefit terms must also construct their own estimates of the relevant costs and benefits. The obvious concern is that their estimates will be self-serving. More than 90 percent of all drivers, for example, feel sure they are better than average. More than 99 percent of high-school students think they are above average in terms of their ability to get along with others. Ninety-four percent of college professors believe they are more productive than their average colleague.

[I deleted my final joke here. Don't worry, you didn't miss anything.]

 

Do Physician Earnings in the U.S. Offset the Costs of Medical Education?

post by Paul Kelleher

In response to my post this morning on international comparisons in physician earnings, Brendan Saloner asked in comments: "What about the higher cost of graduate medical education and time spent in low paying residencies, in the United States? How is that factored in?"

This is an important question, but note that the answer is unlikely to dull the force of the finding I reported, namely that the ratio of physician earnings to high-earners' income is lower in the U.S. than in [the average of] non-U.S. OECD countries. Unlike most other OECD countries, medical training in the U.S. is not financed largely by the public sector. So one might expect U.S. physicians to demand relatively more compensation in order to offset the loans they take out. But, again, physicians in other countries tend to make more as a percentage of the average high earner than do physicians in the U.S.  

It is still true, of course, that physicians in the U.S. make more in absolute terms than those in other countries. But how much more, once medical education is factored in? A recent paper by Laugesen and Glied that I cited this morning addresses this issue (whether they address it adequately is for you social scientists to decide!):

If a physician [in the U.S.] practiced for thirty-five years (based on a present-value formula), the additional earnings, net of expenses, required to pay off this [average tuition] investment would amount to about $21,300 per year for a primary care physician and about $24,400 per year for an orthopedic surgeon.

Although the tuition cost of medical education in the United States borne by individuals is substantial, it cannot fully account for the observed differences between the earnings of US physicians and physicians in all other countries. The difference between annual net incomes, after practice expenses, of primary care physicians in the United States and in the second most costly country, the United Kingdom, is $27,000—somewhat more than the estimated $21,300 per year of practice required to recoup the average tuition investment in education. The difference between the annual net incomes of orthopedic surgeons in the United States and the United Kingdom is $118,000—nearly five times the estimated $24,400 difference in investment repayment costs.

According to the McKinsey report I also cited this morning, of the $643 billion dollars that the U.S. spent in 2006 beyond the spending that would be estimated by its wealth, $64 billion is accounted for by higher-than-expected physician compensation.  

Do U.S. Physicians Earn More? Yes and No.

post by Paul Kelleher

Here is a Exhibit 14 from the McKinsey Global Institutes's Nov. 2008 report "Accounting For the Costs of U.S. Health Care":

This seems to suggest that there is something unusual about the U.S.: somehow physicians in America have a higher earnings-to-per capita GDP ratio than the OECD average. 

But this is just one metric one might use to compare U.S. physicians' earnings to those in other countries. Here is a table from a recent paper by David Cutler and Dan Ly:

 

The updated 2010 data used by Cutler/Ly still reveal a higher-than-trend ratio of U.S. physicians' earnings to per capita GDP. However, if one instead compares the ratio of earnings to the income of other high earners (i.e. income earners in the 95th to 99th percentile of the income distribution), the U.S. is actually below the non-U.S. OECD average. This is true both for specialists and general practitioners.

I was directed to the Cutler/Ly paper by a recent paper in Health Affairs by Miriam J. Laugesen and Sherry A. Glied, in which the authors argue that:

[T]he medical care delivery sector cannot be fully separated from the rest of the economy: Physicians everywhere are drawn from the peak of the educational distribution, and their earnings reflect the cost of drawing highly skilled people to the profession in an economy where the rewards for skilled individuals are higher than elsewhere.

ADDED LATER: To state it explicitly, Laugesen and Glied seem to be suggesting that instead of seeing the U.S. as the outlier (in terms of earnings/per capita GDP), you could see it as right there in the pack of all OECD countries (in terms of of earnings/high earners' incomes). The U.S.'s outlier status on the first score might then be a side-effect of (1) docs' salaries keeping up with high earners' as they do in all OECD countries and (2) the U.S.'s outlier status in income inequality.