Medical payment magic bites dust

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    Medical payment magic bites dust

    The pet program that the Patrick administration and Massachusetts legislature expect to control costs of medical care has almost completely failed in federal tests. That is hardly surprising, since in any issue involving finance or technical content, our dear Governor Patrick has been a miracle of nature: the nearest approximation to a perfect vacuum--perhaps the ultimate "empty suit."

    According to a recent Congressional Budget Office publication, "the evaluations show that most programs have not reduced Medicare spending. In nearly every program involving disease management and care coordination, spending was either unchanged or increased relative to the spending that would have occurred in the absence of the program."

    [ Lyle Nelson, Lessons from Medicare's demonstration projects on disease management, care coordination and value-based payment, U.S. Congressional Budget Office WP2012-01, January, 2012, at http://www.cbo.gov/ftpdocs/126xx/doc12664/WP2012-01_Nelson_Medicare_DMCC_Demonstrations.pdf ]

    The state plan is a rehash of capitation, with which the state failed to manage hospital and HMO costs in the 1970s and 1980s, abandoning programs as failures. The latest reincarnation, dubbed "accountable care," adds a twist of "quality-based" and "risk-adjusted" measures--just as readily gamed by medical financial planners and billers as the previous, failed programs.

    After breathless reporting in 2009 about an unrealistic, publicity seeking plan for a capitation-based medical payment system, in a Globe article July 4, 2010, Liz Kowalczyk finally had to admit the bubble had exploded.

    [ Liz Kowalczyk, State seeks to revamp way doctors, hospitals are paid, Boston Globe, May 7, 2009, at http://www.boston.com/news/local/massachusetts/articles/2009/05/07/state_seeks_to_revamp_way_doctors_hospitals_are_paid/ ]
    [ Liz Kowalczyk, Panel crafts plan to cut medical spending, Boston Globe, September 12, 2009, at http://www.boston.com/news/local/massachusetts/articles/2009/09/12/panel_crafts_plan_to_cut_medical_spending/ ]
    [ Liz Kowalczyk, Health payment overhaul shelved, Boston Globe, July 4, 2010, at http://www.boston.com/news/local/massachusetts/articles/2010/07/04/health_payment_overhaul_shelved/ ]

     
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    Rosy predictions for health-care reform proved false

    Former state rep. John McDonough overstated the case for health-care improvement under the 2006 subsidies and mandates. Of course the number of uninsured declined; that is what the program was about. By other measures, however, medical care has not improved much, and costs were not at all contained until the recently announced, fairly moderate increases in premiums for employer-sponsored plans. [ January 26, 2012, at http://www.boston.com/lifestyle/health/health_stew/2012/01/ma_health_reform_got_to_admit.html ]

    In particular--glossed over by Prof.. McDonough--emergency-room visits, which ran 23 percent above national averages in 2006, have remained a stubborn problem. The 2006 law was supposed to cause a large and rapid decline in the use of expensive emergency-room services, but that has not happened. The state remains far above national averages. [ Chelsea Conaboy, Visits to ER rise despite health law, Boston Globe, June 7, 2011, at http://www.boston.com/lifestyle/health/articles/2011/06/07/visits_to_er_rise_despite_health_law ]

     
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    Increased violence in the hospital setting

    Off Topic.       http://well.blogs.nytimes.com/2012/01/30/feeling-strain-when-violent-patients-need-care/?ref=science
     
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    Imaginary medicine: one of those things?

    Despite advances in many areas, medicine remains more art than science. While a few specialties such as cardiology have built "evidence based" reasoning into their training and routines, even those rely on guidelines that are commonly corrupted by payments from drug and device manufacturers to reviewers.

    Although cases of blatant corruption in psychiatry, orthopedic surgery or oncology get occasional press, the news media routinely ignore the sickest part of medicine: primary care or "internal medicine." Practitioners face thousands of symptom patterns, often with vague protocols for diagnosis and treatment. While trying to cope with those complex challenges, they earn less than specialists who deal with a much more predictable range of issues.

    New internists often come out of medical training with no assets and half a million dollars of debt, and they usually get no practical exposure to coping with health problems outside a teaching hospital. It would be amazingly stupid to imagine such circumstances could produce effective health care. However, that is exactly what most academics and nearly all politicians seem to imagine.

    Limited success with those issues in the U.S. comes entirely from within medicine. For just a few months, while federal "health-care reform" was an active political topic, reporters at the Washington Post and New York Times gave some of the issues an airing. Since then, there's been hardly any genuine interest. "It was just one of those things."

    [ Ceci Connolly, Health-care experts say reform should stress structural changes over cost, Washington Post, July 26, 2009, at http://www.washingtonpost.com/wp-dyn/content/article/2009/07/25/AR2009072502380.html ]
    [ David Leonhardt, Forget who pays medical bills, it's who sets the cost, New York Times, July 26, 2009, at http://www.nytimes.com/2009/07/26/weekinreview/26leonhardt.html ]
    [ Alec MacGillis and Rob Stein, Is the Mayo Clinic a model Or a mirage? Jury is still out, Washington Post, September 20, 2009, at http://www.washingtonpost.com/wp-dyn/content/article/2009/09/19/AR2009091902575.html ]
    [ David M. Herszenhorn, Current health-care legislation will not control medical costs, experts warn, New York Times, October 12, 2009, at http://prescriptions.blogs.nytimes.com/2009/10/12/current-health-care-legislation-will-not-control-medical-costs-experts-warn/ ]
    [ Alec MacGillis, Health bills would shift Medicare money to Mayo and other 'high-value' hospitals, Washington Post, January 6, 2010, at http://www.washingtonpost.com/wp-dyn/content/article/2010/01/05/AR2010010503572.html ]

     
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    Re: Medical payment magic bites dust

    http://www.kevinmd.com/blog/2012/02/surviving-landscape-physician-reimbursement.html
     
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    Dr. Pho of Nashua

    Dr. Pho's column won't display in our usual browser, so it's ignored unless someone describes an article and says why it's useful. Dr. Pho, a 1998 grad of BU Medical School who interned at BMC, is one of currently 11 internists at Nashua Medical Center. Of them, two are also certified in pediatrics and one in immunology.

    Before she left the Globe for Broad Institute in January, 2011, Elizabeth Cooney wrote a profile about Dr. Pho's views on medical economics. [ Blames state for BMC woes, September 29, 2010, at http://www.boston.com/news/health/blog/bostonmedicalcenter/ ]

     
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    Press-release popoffs

    Liz Kowalczyk, who knows a good story when Jay Gonzalez e-mails her a press release, reports that our stumbling, bumbling governor--grasping at any straw to make the evening news--has yet another plan to rein in medical costs. He is going to find out--somehow--when Partners has committed "anti-competitive behavior," and he will tell the attorney general on them. Naughty boys! [ Gov. Patrick proposes new way to target health care providers who abuse market power, Boston Globe, July 25, 2012, at http://www.boston.com/whitecoatnotes/2012/07/25/gov-deval-patrick-proposes-new-way-target-health-care-providers-that-abuse-market-power/OY6QrIvhchi4KgdECYQy2I/story.html ]

    Now, as Ms. Kowalczyk happens to know better than almost anyone, it was the attorney general's office--not the governor's office--that blew the whistle on medical monopolies at Partners and Brigham. [ Liz Kowalczyk and Scott Allen, Attorney General finds clout of hospitals drives cost, Boston Globe, January 29, 2010, at http://www.boston.com/news/local/massachusetts/articles/2010/01/29/attorney_general_says_clout_drives_up_health_costs/ ]

    However, Atty. Gen. Coakley did not dig that up on her own. The Boston Globe told her who was doing what to whom. [ Scott Allen, Marcella Bombardieri, Michael Rezendes, Thomas Farragher, Liz Kowalczyk and Jeffrey Krasner, A healthcare system badly out of balance, Boston Globe, November 16, 2008, at http://www.boston.com/news/local/articles/2008/11/16/a_healthcare_system_badly_out_of_balance/ ]

    We're now treated to a rehash by flatulent politicians who wouldn't know a significant idea if one bit them.

     
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    The witnesses and the truth

    Perhaps Globe reporters who cover medical finance are less capable than they appear. More likely, as the long-term readers have often seen, politically biased management laid down rules about what they can report, not including the truth. Anxious state legislators, stumbling and bumbling around the issues just like a lame-duck governor who signed off on another term, bought into the governor's non-solution. If he finds out Partners and Brigham have been misbehaving, he will tell the Attorney General on them. Naughty boys!

    According to to the NY Times, the plain truth is that, like most of its predecessors, the state's latest medical cost-control efforts have no chance of actually working: "a new commission would monitor the growth in health costs...[but] the bill contains no real penalty for missing the targets." [ Abby Goodnough, Massachusetts aims to cut growth of its health costs, New York Times, August 1, 2012, at http://www.nytimes.com/2012/08/01/health/policy/vote-looms-in-massachusetts-on-bill-to-limit-health-care-costs.html ]

     
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    Health-care fraud: "pay-for-performance"

    Thanks to White Coat Notes editor Chelsea Conaboy for bringing to the attention of readers an editorial from BMJ (British Medical Journal) labeling "pay-for-performance" a fraud against medicine, just as it is a fraud against teaching. [ Journal editorial: pay-for-performance a faulty policy in medicine, August 15, 2012, at http://www.boston.com/whitecoatnotes/2012/08/15/journal-editorial-pay-for-performance-faulty-policy-medicine/kPo1dkw2StIcksYhDMHijL/story.html ] [ Steffie Woolhandler, Dan Ariely and David U. Himmelstein, Why pay for performance may be incompatible with quality improvement, British Medical Journal preprint 345:e5015, August 14, 2012, abstract available at http://www.bmj.com/content/345/bmj.e5015 ]

    This is a touchy message for Globe reporters to transmit, because it obviously goes against heavily managed news policies at the Globe, where it appears that "truth is our least important product." As Ms. Conaboy explains, the BMJ article was responding, in part, to a recent research report in the New England Journal of Medicine, also described in the Globe this year by Ms. Conaboy. [ Ashish K. Jha, Karen E. Joynt, E. John Orav and Arnold M. Epstein, The long-term effect of premier pay for performance on patient outcomes, New England Journal of Medicine 366:1606-1615, 2012, at http://www.nejm.org/doi/full/10.1056/NEJMsa1112351 ]

    One would like to think that only our stumbling, bumbling governor and the State House windbags who drafted the recent "Act improving the quality of health care" would fall for such obvious, Chamber-of-Commerce-style duplicity as "pay for performance." [ Chapter 224 of the Acts of 2012 (S. 2400), Massachusetts General Court, August 6, 2012, at http://www.malegislature.gov/Bills/187/Senate/S02400 ]

    However, the 38 senators and 133 representatives who voted for this law are backed by ample partnership in mendacity. The decades-long failure in trying to reduce inflation in U.S. medical spending is testimony to mindless reliance on a so-called "free market" model of behavior that is a misfit to all professions--at least to the extent they really behave like professions. Overall, the recent Massachusetts law is mainly another exercise in manipulating payment methods, likely to prove as futile as its several predecessors.

     
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