Monday, April 21, 2014

Liberal Dem, Conservative Doc

As a front-page blogger at Daily Kos and creator of the site's popular Daily Pundit Roundup, Dr. Greg Dworkin (f.k.a.DemFromCT, now blogging under his real name) is a high-profile political liberal.  On Twitter, he is an enthusiastic if scrupulously evidence-based proponent of the Affordable Care Act, defending the efforts it embodies to extend access, control costs and improve quality in healthcare delivery.

As a pediatric pulmonary physician with nearly 25 years in private practice, however, Dr. Dworkin spontaneously describes his approach to systemic change in the medical delivery system as "conservative."  He is not hostile to concepts such as coordinated care, bundled payments or risk-based payment -- in fact he has adapted to many changes along these lines over the course of years. He just sees innovations on this front as incremental and experimental -- and to be judged on the basis of evidence that's not in yet.

Dr. Dworkin's thinking about healthcare reform is also, to a degree, conservative in a more political sense. While he sees no clear benefit as yet from reforms in the way doctors and hospitals are paid, he does witness patients growing ever more cost-conscious as health plan deductibles rise and prescription drug coverage grows more restrictive. In a recent discussion of what healthcare reform looks like from the physician's point of view, he placed more emphasis on the effect of newfound cost-consciousness in patients than on changing incentives for doctors.

As with bundled payments, he said, the advent of consumer cost-consciousness is "a process that's been happening for a long time -- it predates and goes in parallel with the Affordable Care Act."

He sketched out the way such cost control works in practice.  "If the insurance company says to the patient, 'your plan for this year will let you use this drug but not that drug,' it may happen like this. You go to your regular doctor, it's time for renewal of the medicine, and thanks to electronic medical records as we start to prescribe we can get a sense of whether or not the patient is going to be charged in Tier 1, small pay, or in Tier 3, large pay. And if we see that they patient is going to be charged a lot -- or if they get the prescription, go to the pharmacy and find it it's going to cost them a lot of money, and  then they call us and say, 'Hey, did you have any idea how much it's going to cost me this year to buy this medication?' -- once we hear that we'll look for an alternative, perhaps suggested by the insurance company, perhaps on our own -- a similar medication that will do similar things, that is within network and will be cheaper for the patient."

"This is an example of how being cost-conscious at the office level is a daily thing -- every patient you see, you have this in your mind, and you would like to -- if they need medication at all --give them something they can afford."

The system sometimes generates tough choices, however -- or unfair choices. As a pediatric pulmonary specialist, Dr. Dworkin prescribes a lot of asthma medications that work best when inhaled. This can happen in two ways.  Most patients, he explains,  "now use hand-held devices called metered dose inhalers. Every pop is exactly the same dose. Very convenient, and that's the way most people take their medicine. Then there's nebulizers, which are devices about the size of an old fashioned telephone that you plug in the wall and get your mist out of the machine for about twenty minutes. It's a very inconvenient way of getting the same thing as when you've got the pocket inhaler, and the pocket inhaler only takes ten seconds instead of twenty minutes, It's portable:  you can walk around,  you can go on vacation."

On the merits, there's no comparison. "But the machine is the one that has the generics; the hand-held device doesn't come with generics. When you're trying to prescribe practical medicine for a kid so that they can stick with their lifestyle, have their inhaler on the high school basketball court prior to the game, you want them taking the inhalers, not the nebulizers --yet the nebulizers are the only generic form. If you want to use generics, great -- but sometimes you're forced on an inferior system."

I asked whether insurers generally covered the non-generics. "Some do and some don't. Every patient has to be individualized."  Medicaid offers good coverage for the hand-held -- as does most employer-sponsored insurance. It's people with more limited plans, e.g., high-deductible plans, that get hit with the hard choice.

The absence of generic inhalers is actually a well-documented story of pharmaceutical price-gouging. Patents are concentrated more in the inhalers than in the drugs they dispense, which are mostly old. Generic inhalers used to be widely available, but a 2005 FDA ruling banned them for containing chlorofluorocarbons (CFCs) alleged to deplete the ozone layer, and they were phased out between 2009 and 2013. As reported by Mother Jones' Nick Baumann, while the CFC ban was was under consideration, researchers pointed out that new CFC-free inhaler designs were likely to cause more environmental damage by emitting greenhouse gasses than the old inhalers did by emitting an insignificant quantity of CFCs. A pharmaceutical consortium that had developed the new inhalers (allegedly a billion-dollar effort) mounted a major lobbying effort to get the old inhalers banned anyway. They succeeded.

Life in the time of high deductibles

Dr. Dworkin also sees patients responding to the incentives generated by high-deductible plans and the tax-favored health savings accounts (HSAs) with which they're often paired. "Imagine you're in the situation where you've got a health savings account,  a large pot of money, and you've got to make the choices. Or, imagine you have a large deductible/small premium kind of plan. If  you've got a $6,000 or $7,000 deductible, at the beginning of the year, every cent until you hit that deductible, you have to pay first. Whereas in December you may not care whether your medication costs $60 or $240, in January you do care."  Of course, that dynamic also highlights a weakness in the incentive structure -- though many high deductible plans also demand high copayments once the deductible is met, reducing the incentive to spend big at that point.

Conservatives have long sung the praises of high deductible insurance plans and HSAs, arguing that giving patients "skin in the game" will create pricing pressure and generate competition among providers. Many of those same conservatives have recently turned around and attacked the ACA for offering mainly high deductible plans on the exchanges. The average deductible for benchmark silver plans is almost $3,000 and for the cheapest bronze plans over $5,000, according to Healthpocket , a company that compares and ranks health insurance plans. The ACA reduces these high out-of-pocket costs via Cost Sharing Reductions (CSR)  for buyers with incomes below 250% of the Federal Poverty Level. And many silver plans have deductibles in the $1,250 to 2,500 range. But those who pay full freight on ACA exchanges do indeed have a good deal of skin in the game.

Conservatives like to call high-deductible plans "consumer-driven healthcare," and Dr. Dworkin echoes that language. Helping patients navigate the costs and coverage limitations imposed by their insurance, he says, "fits to a tee with everything we do. Everything we do is supposed to be patient-focused. If not, why do we do it?" When he's helping a patient cope with costs, "it's still about the patient."

One important side effect of the ACA, in Dr. Dworkin's eyes, is putting healthcare cost issues in the news and so raising people's consciousness, even when they're not directly affected.  Most people, he notes, still get their insurance from their employer or Medicare and remain relatively insulated from the actual costs of the procedures and medications they access. With regard to the recent publishing of doctors' Medicare billing, and the resulting media  coverage, he notes,  "When you see those bills, your eyes get wide. What do you mean,  this drug costs $2,500 every two weeks? What do you mean that hospitalization cost $100,000 even though I only paid a copay? So in theory that drives change too."

Acronyms won't save us
Asked about ACA reforms that attack costs from the opposite direction -- moving payment for doctors and hospitals away from fee-for-service, toward "bundled" and risk-based payments -- Dr. Dworkin is receptive if somewhat skeptical.

For starters, he notes that efforts to pay doctors and hospitals for results, or pay a fixed fee per patient or medical "episode" rather than for each service provided (from aspirin to EKG), are not new. "If I see a patient in a hospital, a lot of stuff is bundled these days. If I see a patient in the office, things that you could have charged for ten years are part of the bundle. Things like that happen all the time."

With regard to another current totem, coordinated care, in which the various healthcare professionals treating a given patient, particularly one with chronic disease, communicate with each other and coordinate their efforts, he notes that it is easier in theory than in practice. "The problem is many people have different illnesses. What if somebody has asthma and diabetes: who's supposed to be managing them?  What if the patient has asthma and diabetes and depression? Who manages? Is that person with depression as likely as someone without depression to take their medications and so forth?  A lot of ideas sound good on paper but you really have to see how they work out in real life."

What about the Accountable Care Organizations funded on a pilot basis by the ACA, which are supposed to share in the reward if they succeed in reducing costs while accepting some risk of reduced payments if they don't? Are they changing the way medicine is practiced?

"Not yet. They might in the future --  but you don't need to have an official new technique or something that is given official status by being given its own initials. In Washington, that's how things work --if you don't have new initials it's not real. But there's ways to coordinate care and not have an official thing.   If you are working with kids in the community with asthma, for example, you can make sure you have good communication and liaison with the schools -- and talk to school nurses. You don't need to have an official status to practice communal medicine."

If that sounds cynical, Dr. Dworkin remains open to the possibility that all the ferment and experimentation in payment regimes may generate real improvements.  With respect to private insurers, he said, "There's many different mini experiments happening all the time that you don't hear about. Some work and some don't. The ones that don't are abandoned, the ones that work are incorporated into practice."

With regard to the move away from fee-for-service for generally, "I assume all that stuff's going to change because it's constantly changing. So the fact that it changes is almost background for me at this point."

The subtext here is that for Dr. Dworkin, medicine is always about trying to help patients, and he assumes the same is true for the vast majority of doctors. Of ACOs, he says, "like most physician groups they're trying to do the right thing, and the best way to do the right thing is to try to take care of your patients as well as possible -- the rest follows." Incentives that may induce doctors to over-prescribe are not top-of-mind.

When I asked about profiting by prescribing expensive drugs, he pointed out that markups are not permitted in his specialty, though they are in some, such as oncology (where hospitals and the physician practices they own in particular have been exposed for charging huge markups). Asked about profits stemming from prescribing imaging or testing, he pointed to the Stark Laws and anti-kickback laws prohibiting doctors billing Medicare and Medicaid from referring to patients to facilities in which they have an ownership stake.  What if the machine is in-house?  "You can take pictures, but a lot of the money pays for the upkeep of the machine." And if a practice buys a really expensive machine, is there no incentive to use it a lot? "You ought not invest that money unless you think there's actual use for the machine."

Bottom line on this front: "I'm not going to get into whether medicine is a capitalistic system in a capitalistic country which runs a capitalistic economy -- guess what?"

It is. And as long as we maintain a private insurance system, with most people getting their insurance through their employer, it will remain so, Dr. Dworkin suggests  -- though he adds that if the ACA reduces "job lock" as planned,, more people will have more skin in the game, and "other innovations may follow."

Dr. Dworkin puts some stock in physicians' voluntary efforts to generate cost consciousness within their ranks -- for instance, the Choosing Wisely initiative of the ABIM Foundation, in which, according to the ABIM website, "medical specialty societies, along with Consumer Reports, have identified tests or procedures commonly used in their field, whose necessity should be questioned and discussed." (Kaiser Health News recently criticized this project, suggesting that many specialties left the most lucrative dubious practices untouched.)  Dr. Dworkin also spoke approvingly of new prescription guidelines put forward by physician practice groups that encourage doctors to consider cost as well as effectiveness when prescribing. That change in practice recently made the front page of the New York Times.

Again, two premises guide here: doctors will want to do the right thing, and public attention to cost issues will drive significant change.

With respect to payment structure changes mandated by the payers -- ACOs, medical homes and the like --  I asked Dr. Dworkin if it was fair to say in sum that the jury is still out. He agreed that it was.

"I'm pretty agnostic about it. If it works, great. If not, we'll change it. It's happened before."

Dr. Dworkin is an empiricist, and the current state of healthcare delivery supports his judgments thus far. The evidence regarding the effects of managed Medicare, medical homes, and ACOs is inconclusive.  The impact of high deductibles and copays, on the other hand, is hitting more and more people, and seems pretty clearly a major factor in the slowdown in medical spending growth registered in the past decade.

Our discussion of healthcare cost control had a hole in it, I realized after the fact. What we did not discuss was the prospect of more extensive government control over the prices of medical procedures.  Such control need not imply a single-payer system or a system in which the government delivers healthcare directly. In France, Germany and Japan most people's medical bills are paid through private insurers, but the government sets the rates. In Switzerland, insurers negotiate collectively over hospital payment rates, with government oversight (while doctors are paid on a national fee-for-service scale). In the United States, the government as payer of Medicare and Medicaid bills sets benchmarks to a certain extent, but the control it exercises is weaker than in any other wealthy country -- and U.S. per capital healthcare costs are 50-100% higher than those of comparable countries, mostly because we pay far more per procedure than the citizens of other countries.

In a followup exchange, I asked Dr. Dworkin what he thought about strong government control over pricing. He responded that while government programs like Medicare and Veterans Health Administration provide some precedent, and people who use those systems like them, broader government control is "not politically viable at the moment with the Congress we have... it would mean disruptive change and people are not into that."

That's true as of now. But it remains to be seen whether the U.S. can really bend the cost curve without eventually moving toward, not single payer, but "more-unified payer," with government authority behind it.

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1 comment:

  1. Thanks for this thoroughly detailed and deservedly sympathetic look at my (blogging) colleague, Doc Dworkin.