Endodoc

I know I haven’t written anything for a while now but I promise to get back to work.  But I have exciting news for those of you who have not already given up on following the health care reform debates.  I just read an article in the New York Times (online 10/16/09) that should be must reading.  The article is entitled “In Hawaii’s health system, lessons for lawmakers” and was written by Gardiner Harris.   The article summarizes the approach to health care coverage in Hawaii and the incredible success story.  It is interesting that the Hawaii “story” is just now being discussed but better late than never.  Read the article.  Then, let me know what you think.

I have stayed away from my website for a number of weeks for fear that I would be driven to  write about the current craziness surrounding the various competing health care reform proposals; I couldn’t figure out what I could write that would accomplish anything other than make me feel better about the chaos.  I’ve changed my mind; I am ready to offer a few unsolicited comments.

Let’s not forget why health care reform is desperately needed

In recent debates I have heard little about why health care reform is needed anyway.  The fights (?debates) have become more and more emotional and less articulate; the debate now seems to be more about politics and name-calling than anything substantive.  Please, please let’s all remember that our health care system is a mess and a very expensive one.  If we don’t fix things, we as a society will be diminished in many ways.

Why is the path to health care reform proving to be so difficult?

I cannot really understand if the Obama administration was so naive or so misinformed or both about the challenges that would face any meaningful reform efforts.  I think they understand now.  As I tried to point out in an entry last month,  any efforts to introduce meaningful reforms would be met with fierce opposition from those who felt they had something to lose.  How could anyone believe that health insurers, big pharma, hospitals, doctors, etc., would sit by and cheerfully accept changes in the system that tore into their revenue streams?  Yet we seemed to act that way.  Now, even the “common folk” are up in arms about what they see as provisions in health care reforms that will adversely affect them.  To add insult to injury, those politically opposed to the Obama administration see the health care issue as one which may give them an opportunity to “break” Obama.  So, it’s pretty easy to understand how we got where we are now in the debate.

What do we need to do to get back on the pathway to reform?

I believe that we need to back up and all take several deep breaths and think about the priorities.  In my opinion, the single biggest and scariest problem is the looming bankruptcy of Medicare.  More than 40 million Americans count on Medicare and the numbers are growing daily as our baby-boomers find they’re not babies anymore.  Depending on whose estimates you use, the program will be out of money in 2-5 years.  This is a CRISIS.  We need to address it now.  I don’t want to bore you with the details on how to fix it but you might want to check out some of my earlier entries for suggestions.  The bottom line is that we need to cut costs drastically while improving the program for seniors.  Medicare reform will be ( maybe I should be cautious and say “can be”) the template for fixing the rest of what ails the health care system.

I don’t care what side of the political spectrum you might be on and what your philosophy might be about the role of government.  If we do not fix our healthcare system we will all suffer.  In my opinion almost nothing in the current health care reform proposals ( or in the opposition to those proposed reforms) will take us to where we need to go.

I just want to call your attention to a very important article in yesterday’s New York Times (18 August 2009, page B1).  The article was entitled “Diabetes case shows pitfalls of treatment rules,” and was written by Barry Meier.  The article discussed the controversy surrounding a national guideline for treating patients with diabetes that was written in 2006 and withdrawn last year.  Basically, the national guideline recommended aggressive treatment of high blood glucose levels in all patients with diabetes only to reverse its recommendations; new data showed that for some patients, following the guidelines would increase morbidity and mortality.  The specific details of the case are important but perhaps not so important as the information it provides regarding how medical treatment guidelines are established and their pitfalls.

So-called national guidelines, consensus statements, and expert opinions should all be viewed with considerable suspicion since they are often put together by many interested parties with very different points of view.  Typically, such treatment guidelines are compromises hammered out among physician experts, insurers, special interest groups and are anything but “consensus statements.”  The problem with consensus statements and treatment guidelines put together by expert groups is that however incorrect they might be, individual physicians who ignore these guidelines when treating their patients run the risk of not having the treatments covered by health insurance or by risks of malpractice lawsuits when results are not satisfactory.  Anyway, I highly recommend that you read the article and I can asure you that my recommendation was not put together by a committee.

Over the past few months I have grown increasingly dismayed by the so-called “debate” on reforming the U.S. health care system.  In my opinion, what started as a mostly civilized discussion, has devolved into chaos; it  would be nonsense to describe the current goings on as meaningful discussions and clearly not a debate in the usual sense of the word.

I have been astonished at many of the statements I had heard from what I had formerly thought were reasonably intelligent elected officials.  I have been no less amazed at the statements from the general citizenry; the amount of misinformation out there is now almost impossible to counter with truth.

Here I am not trying to “peddle” any particular health can plan but only that some degree of sanity enter into the discussions.  In my opinion,  the problem is two-fold.  First it’s that those satisfied with the status quo (insurers, pharmaceutical companies, consumers who are satisfied with their health insurance, etc.) don’t want to risk any meaningful changes in the health care system.  Maybe they aren’t entirely happy with the status quo, but they fear that any changes in the system will be much, much worse.  What is that expression, something like “the devil you know is better than the one you don’t?”  The second aspect of the problem is that politics have gotten in the middle of things (big surprise).  It is clear that President Obama really wants health care reform.  Those opposed to his presidency, believe that failure of the President to achieve his  health care reform goals will “bring him down.”

I have no idea how things will end up.  I am not optimistic that anything good will rise out of the mess.  If I were running the show, I would back up and start over.  The first thing we need is a small group of experts to lay out a blueprint for a health care system as it would exist in the future.  The blueprint needs to deal with all of the current components of the system including private insurance, Medicaid, Medicare, the VA system, the U.S. Military health care system (troops and their families), and those people currently without any health care coverage.  We need to consider how all of these components would fit together or at least coexist.  We also need to consider how we would cut costs and slow the rate of future cost increases since, we can’t possibly afford universal health care without controlling costs.  We also need to decide how we would pay for health care.  There aren’t many options- a payroll tax, higher income taxes, a national sales tax, that’s about it.  We haven’t had these critical discussions yet (call it a debate if you wish) and we can’t really move forward without a comprehensive look at what the experts think the system should look like when it’s all put together in about 20 years (if we’re lucky).

Remember how back in high school and/or college you got to the nitty gritty of a difficult to understand novel by reading the “Cliff Notes?”  Well, just a FYI about a rather straightforward article in yesterday’s New York Times that summarized weight loss regimens based on cost, starting with the least expensive approach (zero dollars).  I thought the information in the article was pretty accurate and a good place to start for those who want to lose weight (like about 98% of people I know) but aren’t sure how to go about it.  Don’t be expecting to find some new sure-fire diet plan; it’s still all about motivation, calories in, and calories burned.

There was a very interesting article in this week’s New England Journal of Medicine. The article was written by Michael Mauer and associates and entitled “Renal and Retinal Effects of Enalapril and Losartan in Type 1 Diabetes.  Before I get into the study findings, I need to provide a bit of background information for those readers not up on treatment of diabetic nephropathy ( kidney disease).  Diabetic nephropathy is the most common cause of kidney failure in the U.S. and the most common reason for chronic kidney dialysis.  It is clear from the Diabetes Control and Complications Trial (DCCT) and other studies that the two biggest risk factors for the development and progression of diabretic nephopathy (in both type 1 and 2 diabetes) are blood glucose control and blood pressure.  A number of studies have also shown that use of a certain class of antihypertensive agents called angiotensin-converting enzyme inhibitors, or “ACE” inhibitors for short, can slow progression of diabetic nephropathy.  It is more or less established dogma that ACE inhibitors prevent progression of established diabetic nephropathy.  Even the American Diabetes Association strongly recommends treatment with ACE inbibitors in patients with diabetes who show even early signs of diabetic nephropathy (typically, leakage of small amounts of protein in the urine which is called microalbuminuria.  Many physicians treat their diabetic patients who do not show excessive microalbuminuria with ACE inhibitors on a prophylactic basis although the scientific evidence for such a treatment strategy is not well established.

The Mauer study design

Mauer and colleagues studied 285 people with type 1 diabetes at least 18 years of age with diabetes duration 2-20 years.  Patients were excluded from the study if they had hypertension or any evidence of diabetic nephropathy.  Most patients had kidney biopsies at the beginning and end of the study which lasted 5 years.  The patients were randomly assigned to one of three treatment groups: placebo, Losartan (an ACE inhibitor) or Enalopril (an ACE inhibitor.

Study results

Basically, the study showed no benefit in terms of development of elevated microalbumin levels with the ACE inhibitors; in fact, the Losartan group actually showed a statistically significant higher incidence of elevated microalbumin levels than did the placebo group.  Among the three  treatment groups, there were no differences in the extent of morphologic kidney changes over the 5-year period.  Both ACE inhibitor groups showed significantly less progression of diabetic retinopathy (65-70% less risk for progression).

So now what?

These results were, to say the least, surprising to many experts.  The question remains how to reconcile the Mauer study results with results of earlier studies and what to do with patients who are now being treated with ACE inhibitors?  In my opinion, we should not panic, but sit back and try to sort this all out.  There are some important limitations of the Mauer study that cannot be ignored.  First, only 25-40% of patients with diabetes ever develop diabetic nephropathy.  It seems clear that some patients are not prone to develop diabetic nephropathy despite having risk factors such as hypertension and poor glycemic control.  Some studies suggest there are genetic factors that either decrease or increase patient risks for the development of nephropathy in addition to the known clinical risk factors.  So, it is hard to know what to make of the fact that the placebo group showed only a 6% increase in cumulative incidence of abnormal levels of microalbuminuria.  Ideally, the study should have excluded patients who were at little or no risk for the development of nephropathy regardless of blood glucose control and blood pressure.  Of course, there was no way to do that.

Also, I wonder whether the investigators should have looked at their data with regard to patients’ levels of glycemic control?   The only A1c data in the study were baseline A1cs in the three treatment groups to show that the groups were similar at baseline in terms of glycemic control.  We already know that the level of HbA1c is a strong risk predictor for the development/progression of diabetic nephropathy.  Maybe the A1c trumps the effects of the ACE inhibitor; perhaps the ACE inhibitor is not protective unless the A1c is low?

So, for now I would recommend using an ACE inhibitor as a first line choice for treating hypertension in a patient with diabetes.  I would not, however (and never did) consider using ACE inhibitors to prevent the development of diabetic nephropathy.  I am still undecided whether to recommend an ACE inhibitor to a patient with abnormal and steadily increasing levels of microalbuminuria.  Of course, what complicates all of this are the Mauer study data on diabetic retinopathy; maybe the new dogma will be that ACE inhibitors should be used in all patients with diabetes to prevent/slow progression of diabetic retinopathy?  Most important, we should not forget the old dogma which still stands- glycemic control and blood pressure are both proven powerful risk factors for the development/progression of all diabetic complications.  If one “covers” all the risk factors for diabetic complications, there is no need to debate whether ACE inhibitors help or not.

The national debate continues to be a contentious one regarding just how we will pay for universal health care.  What seems clear is that at current costs, it will be virtually impossible to come up with a workable plan.  So, let’s just assume that we have figured out how to trim costs appreciably (you might want to check out my plan as discussed in previous entries, including the last one, June 24, 2009) and we are ready to implement the plan whatever it might be.  Who will pay for their health care?  The answer is clear- all people with sufficient income to cover the costs.  These people will by necessity be required to cover their own costs and also those of people who are unfortunate enough not to be able to cover the costs.  Who can’t afford to cover their own (and, perhaps other family members as well) health care costs?  The answer is that more or less, it’s the same people who now can’t pay for their health care by virtue of low income or, perhaps, no income, with one big exception- people who now would purchase health insurance if they could but at current costs, they can’t afford it.  Thus, if we can lower costs appreciably, the individual who does not have health insurance coverage through his employer, may be able to afford it.  At any rate, the burden for providing health care coverage to all will fall on those who can pay.  That’s just how it is.

Payment options

So, now I hope it’s  clear that the collective “we” will be paying for our health care.  There are only so many ways to come up with the bucks to pay the bills.  Let me list the ways:

1. Payroll tax for employers and employees

2. National consumption tax (a sales tax)

3. Higher income taxes

I can’t think of any other ways to pay for universal health care.  None of the ways are likely to be very appealing to very many people, but what else can we do?  My libertarian friends tell me that we should just drop all government and employer involvement in health care and let the market “do it all.”   Their hypothesis is that if we just “let go,” the market will “re-equilibrate” with dramatically lower costs for all.  Sure thing.

Right now what I see is that all the major players (e.g., Congress, President Obama’s team, the health care industry) are working around the edges with this proposal and that proposal to trim health care costs.  None of them really address the rather fundamental need for a real plan as to how we will pay for what we supposedly want which is universal health care.  I’m not optimistic that we yet have the political will to what we need to do to get where we want to go.  Too bad since the destination is a very nice place indeed.

I finally got around to reading the “hot” article in the June 1,2009 New Yorker magazine written by Atul Gawande.  The article which is entitled “The Cost Conundrum” with subtitle, “What a Texas town can teach us about health care,” has been making the rounds in Washington,D.C. since it addresses the cost issues in U.S. health care.  It has been said that President Obama has made the article must reading for all of the White House staff that are working on health care issues.

A summary of the article

Dr. Gawande has written yet another excellent article in a long series of article he has written about U.S. health care.  Here he explores the reasons that per capita Medicare spending in McAllen, Texas is about twice the national average- about $15,000 per enrollee vs. about $8000 per enrollee nationally (2006 data).  I don’t want to ruin a good story for you but basically, the reason for the cost differential is pretty simple- the physicians in McAllen, Texas order many more tests and procedures on average than do physicians in other places.  Furthermore, Dr. Gawande’s conclusion based on pretty good research, was that the reasons for the high costs in McAllen, Texas were partly a “culture” within the medical community of ordering lots of tests but also simple greed.  Dr. Gawande described the situation well but as in many of his other articles, he was short on solutions (not a criticism, just disappointment on my part).  He mentioned what some other communities were doing to keep costs down but seemed to end with the notion that we will need to “experiment” with different approaches if we are to find an effective way of controlling costs.

Do we really need to carry out extensive studies to figure out how to save costs?

Dr. Gawande has done an admirable job in describing one major reason for the astonishingly high U.S. health-care costs.  I disagree with him with respect to how difficult it will be to improve things.  It is true, the solution might be difficult politically, but in my opinion, not otherwise.  In earlier entries I discussed the issue of high costs and offered some solutions.  Let me try again.  Let’s focus on Medicare.

First, we should require that all Medicare enrollees have a “medical home.”  This could  be a clinic or a hospital or a group of hospitals and clinics.  The medical home is responsible for maintaining the enrollees’ medical records, presumably in an electronic form that is at least available to all caregivers within the medical home system.  Every enrollee has to have a primary care giver or at least a group of primary care givers within the same medical home.  The primary caregiver decides when the enrollee should see a specialist, get an MRI, etc.  The referral for the test, specialist appointment or whatever must be well documented in the medical record, particularly the justification.  What I am describing may seem quite a bit like the “managed care” of 10-20 years ago that went over like a brick balloon.  The difference here is that in the medical home, healthcare professionals make the care decisions not a clerk who decides yes or no on treatment requests by looking up the request on a big list (with managed care the answer was usually “no” regardless of the situation).

To summarize: each Medicare enrollee will have a medical home that is responsible for orchestrating all of the enrollee’s medical care.  The medical home’s performance will be monitored regularly and unusual patterns of referrals, test ordering, etc. will be investigated.

So, what’s in it for the medical home?  Clearly, the medical home will need some incentives for signing up Medicare enrollees.  I would recommend first that the reimbursements to primary caregivers be comparable to that paid by private insurers.  Second, I would eliminate the “facilities fees” that Medicare currently pays to hospitals and some clinics for seeing Medicare patients (these “fees” can be more than the caregiver charges for the clinic visit) and set up some system for providing a modest  annual fee to the medical home for each Medicare enrollee in their system.

How will the medical home plan save money?

The problem in McAllen, Texas is inappropriate referrals to specialists and the ordering of inappropriate tests and procedures.  This over-utilization of the health-care systemclearly makes medical care for Medicare enrollees in McAllen, Texas very expensive.  Sadly,the over-utilization doesn’t even result in better medical care and/or better health-care outcomes for the patients; it just puts more money in the pockets of the health-care givers.  If each Medicare enrollee has a medical home that is responsible to the government for every referral and for every test that is ordered with financial penalties for inappropriate use of the health-care system, I guarantee that serious efforts will be made to change medical practice behaviors.  Of course, it’s not about getting health-care givers to order as few tests as possible; obviously, many patients do need referrals to specialists and for various laboratory tests and procedures.  Rather, it’s about appropriate ordering.  There shouldn’t be a prize to the doc whose Medicare enrollees account for the lowest cost per capita.  Maybe those patients are not getting referrals and tests that they truly need?

One last thing.  In Dr. Gawande’s article there is a section about the cooperative approach physicians in Grand Junction, Colorado are taking to minimize costs.  Likewise, there is a section about the way physicians practice medicine at the Mayo Clinic in Rochester, Minnesota.  Even I as a jaded old physician, was excited to learn how well we really can do if we set our sights first on providing excellent care to our patients and make financial gain a lower priority.  Three cheers for physicians and other health care workers in Grand Junction and at the Mayo Clinic.

Earlier today I wrote an entry emphasizing the simple fact that we cannot hope to come up with a satisfactory plan to make major improvements in the U.S. health care system without first addressing the costs.  This afternoon as I was surfing the net, I saw a” hot off the press” post in the online New York Times.  It was an article written by Derrick Henry entitled “Obama may lack votes on health, Democrat says.”  Henry quotes Senator Dianne Finestein from California who apparently has made clear that she does not intend to vote for the health care overhaul bill as it stands because of the cost provisions.  Henry also quotes a number of other important senators who will not support a bill that is now estimated to cost up to 3 trillion dollars.  So, maybe I’m not alone in my concern that we are not on a path to pass legislation that will actually improve our ailing health care system?  People, I will repeat: we can control costs and get universal coverage but we will need to feel some pain along the way.  It is the only way forward.

The recent media frenzy surrounding the current health care debates in Washington has driven me to take a slight detour back to health care issues (I had been focusing on a series of entries about diabetes care).  In the fall of 2008 and extending into early 2009 I wrote quite a number of entries about the problems with U.S. health care and a proposal for fixing our ills (literally and figuratively).  Through the spring of 2009 I sat on my hands and listened to the debates and I have become increasingly dismayed at what I have been hearing.  I am now not one bit optimistic that the U.S. Congress will be able to enact any meaningful health care fixes.

Where do things stand at the moment?

It’s hard to be sure exactly what is happening in Congress.  The current debate seems to have centered on whether to have a government run health insurance (I’m not sure “insurance” is the correct term) option that would compete for customers with traditional health insurance companies.  The idea would be to keep the insurers “honest.”  It is my assumption that “keeping the private health insurance companies honest” means forcing the private insurers to compete with a reasonably priced government insurance option.  There is a long editorial about this subject in today’s New York Times (Sunday, June 21, 2009) as well as an article summarizing a recent national survey on people’s views about universal health care.  These are both worth reading but neither get at what I view as the “missing link” in almost all of the discussions about health care reform, namely, just how are we going to pay for things?

In my earlier entries about the U.S. health care mess I tried to emphasize over and over that the 2 big problems were inadequate access to health care and high and ever increasing costs.  I must have sounded like a broken record when I said over and over that we cannot hope to fix either of the 2 problems unless we fix both of them at the same time.  It’s all good and well to have a government health care option that competes with private insurers but no one has spelled out how we will be able to afford it.  The fact that a government plan would have lower administrative costs than private insurance plans does not in any meaningful way explain how we will be able to pay for coverage for many millions of Americans who currently have no health coverage or inadequate coverage.  Look at Medicare, another government run health care option.  It is fast going broke.  If we cannot control health care costs, not just slow the inevitable increases over time, we are doomed to failure.  We MUST “bite the bullet” and deal with the costs.  That is not a very appealing notion since there will need to be quite a bit of pain spread around.  We will need to pay primary care givers a little more and specialists much less.  We will need to pay hospitals and medical supply vendors much less for their services.  There is no way to decrease costs without paying some people, companies, and institutions less, and I mean, far less, than what we are now all shelling out for health care (over $8000 per year per man, woman, and child in the U.S.).

Just what am I trying to say?

Unless we tackle health care costs NOW, none of the current proposals for health care reform will stand any chance of getting through Congress when the costs of providing universal coverage are presented.  Remember Massachusetts; they had a relatively easy time dramatically increasing the number of insured people when they passed a law requiring all people to have health insurance, but they didn’t work on the cost side and the plan as it stands is not economically viable.  The New York Times survery on health care I mentioned above found that a majority of people in the U.S. who currently have health coverage would be willing to pay $500 more a year if it meant all people would have health care coverage.  That’s a laugh- unless we get our arms around health care costs, $500 will be only a small fraction of what the extra costs would be to provide universal health care coverage.  Then how willing would our good citzens be to chip in?