Medical cost-control: no "Massachusetts miracle" yet

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    Medical cost-control: no "Massachusetts miracle" yet

    Writing in the NY Times, Abby Goodnough and Kevin Sack tackled long-simmering plans for medical cost-control in Massachusetts, the first news since Liz Kowalczyk and Noah Bierman last took up the topic in the Globe.

    [ Abby Goodnough and Kevin Sack, Massachusetts tries to rein in its health costs, October 18, 2011, at ]
    [ Liz Kowalczyk and Noah Bierman, Patrick unveils health overhaul, February 18, 2011 ]

    Besides getting an audience for Massachusetts, the main news is more realistic attitudes, since breathless reports from Liz Kowalczyk in summer, 2009, of hasty work that crashed the following summer. Election season came. Once the big insurance plans exercised well-toned muscles of campaign contributions, the music stopped.

    [ Pay for care a new way, state is urged, July 17, 2009 ]
    [ Officials draft plans for new system to compensate doctors, hospitals, September 27, 2009 ]
    [ Health payment overhaul shelved, July 4, 2010 ]

    Although resisting calling the plan "capitation," because of a disastrous 1970s experience with rate-setting, that is exactly what the supposedly "new" approach means. All that is (just slightly) new is the easily-gamed twaddle about "risk adjustment." However, possibly some lights have gone on in usually dim quarters.

    Reflecting on the on-going "experiment" at Blue Cross, Gov. Patrick is quoted as saying, "We've got to have scale. It can't be one-offs." More succinctly, State Rep. Steven Walsh, House chairman of the Joint Committee on Health Care Financing, is quoted as saying, "it could take 15 years to squeeze all the inequities out of the system."

    There are many more "kinks" than are currently making it into the news. The surge and collapse of growth in Medicare Choice, HMO-style plans after 1997 showed that when there are alternatives, most patients will reject rigid plans. Medicare patients were wooed back with the more flexible Medicare Advantage, PPO-style plans, but those plans are now under financial attack because they turned out more expensive to operate than conventional Medicare. It is not at all clear how capitation can ever be compatible with flexibility.

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    Medicine by the numbers

    Medical cost-control, however organized, has to mean doing less medicine--against the heavily interventionist medical cultures. The contrary point of view has long been around, but it has gotten little attention since years before World War II.

    At the NY Times, Tara Parker-Pope's insightful column recently hosted an article from Dr. Danielle Ofri, who has written four books so far about her early experiences as a medical student and practicing physician.

    [ When doing nothing is the best medicine, October 20, 2011, at ]

    Dr. Ofri waxes eloquent on hazards of aggressive care, writing, "every 'thing' a doctor does also has side effects--bacterial resistance from antibiotic overuse...radiation exposure...toxic drug interactions...." She has yet, however, to write a cogent analysis of financial and institutional pressures in medicine.

    At the Washington Post, while it was still a readable newspaper, articles in 2008 and 2009 explored examples of cost-effective medical care.

    [ Ceci Connolly, U.S. not getting what we pay for, November 30, 2008, at ]
    [ Ezra Klein, You have no idea what health costs, September 20, 2009, at
    [ Alec MacGillis and Rob Stein, Is the Mayo Clinic a model or a mirage?, September 20, 2009, at

    Almost nothing like that showed up in the blinkered Boston Globe, possibly because we have no local examples of cost-effective medical care and probably because Globe editors won't pay for out-of-state phone calls. The one cogent story was never followed up, after the Globe disbanded its Washington, DC, office.

    [ Michael Kranish, Health co-ops' fans like cost and care, August 19, 2009, at ]

    What we saw in the Globe, instead, was press-release specials about bureaucratic plans to slice into medical spending, without looking at long-term effects on patient health.

    [ Liz Kowalczyk, Panel crafts plan to cut medical spending, Boston Globe, September 12, 2009, at ]

    A Massachusetts obsession with medical management by the numbers stands to make people sicker, as a review of one aggressive care effort illustrated last year.

    [ Gina Kolata, Diabetes heart treatments may cause harm, New York Times, March 14, 2010, at ]

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    Similar experiences

    The story from reader "GreginMeffa" brings back memories--but it's odd. While suspicious of the medical community's views when it came to us, somehow we trusted what they did for our kids. We did have friends and contacts in the communities; perhaps that made the difference.

    When our older boy was at Children's in the early 1980s, for emergency surgery, we didn't stand guard in the ICU but kept informed through the surgeon, a colleague of a friend. It was a tough case, but Children's pulled him through. He's now a physician himself, and he has worked through many other trying situations. In one, with his own child in the hospital, he and his wife, also a physician, did as you did.

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    Remembering a lost miracle

    Pompous "sphincters" who populate most government policy-making jobs are always looking for the easy, the quick and the slick, when medicine--like many other areas of concern--is a welter of small things. That is the reason why the so-called "big thinkers"--really small-minded at heart--will never accomplish anything useful.

    Recently Paul Vitello, in the NY Times, and Bryan Marquard, in the Globe, wrote about a Massachusetts miracle that has been lost to us, on the death of Dr. Joyce Clifford, who was chief nurse at Beth Israel Hospital from 1974 to 1999, three years after it was merged with Deaconess.

    Dr. Clifford developed the practice called "primary nursing." When visiting friends at Beth Israel during the 1980s and 1990s, we and our friends found the care extraordinary, but when one us was there as a patient a few years ago, it was different: professional, perhaps, but less effective.

    Mr. Marquard gives a fuller picture of Dr. Clifford's life and career, but Mr. Vitello recalls what happened after she retired. Dana Beth Weinberg wrote about that at book length in Code Green: Money-Driven Hospitals and the Dismantling of Nursing [Cornell University Press, 2004].

    Prof. Weinberg described how primary nursing was destroyed at Beth Israel after the Deaconess merger. It a lesson we should not forget but one that will be utterly lost on the asinine policy makers who imagine they can brilliantly craft more effective medical care by shuffling how bills are paid.

    [ Paul Vitello, Joyce Clifford, who pushed for 'primary nursing' approach, dies at 76, New York Times, October 31, 2011, at ]

    [ Bryan Marquard, Joyce Clifford, changed how nurses work with patients, Boston Globe, October 28, 2011, at ]

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    Pick-a-disease: Gaming the new system

    The reason that so-called "risk adjustment" sounds like twaddle is that in the past similar schemes have been readily subverted. In the classic approach, widely applied for over 40 years, apparently healthy patients are "worked up" with a battery of lab tests and other diagnostics. As a newsletter directed at primary-care physicians once put it, "if a patient walks out with a clean bill of health, you didn't order enough tests."

    That, of course, was also the classic recipe for excessve intervention and excessive spending--putting at risk the real health of patients and the basic sustainability of health care. With the "new" capitation, the game will be to pick tests that can result in much higher capitation payments without big increases in numbers of resulting patient visits.