Yves here. This post illustrates how the slow-moving and ineffective effort to rein in health care costs is becoming politicized. It is ironic in the article where the head of a hospital system professes to offer ideas of how to contain cost, no where does he mention the large deadweight costs imposed by dealing with insurers, which some experts estimate contributes as much as 30% of total costs when you factor in how much MD time is diverted from patient care to fighting to get paid.

In addition, the CEO is less than straightforward about discussing the bad incentives in the system, that doctors are paid for what amounts to piece work and therefore have a monetary incentive to treat overly aggressively. His discussion of “chronic and complex” care suggests that a big culprit is end of life care, when this is one of the few areas where typical costs in America are in line with advanced economy norms. By contrast, American doctors love to prescribe surgeries. For instance, for many orthopedic problems, things like ruptured disks and labrum tears are often asymptomatic, so if a patient has pain and an MRI shows a tear, that does not necessarily mean that the apparent problem on the MRI is actually what is giving the patient trouble. As a result, for most back operations, the patient results six months out converge with having left the ailment alone.

By Roy Poses, MD, Clinical Associate Professor of Medicine at Brown University, and the President of FIRM – the Foundation for Integrity and Responsibility in Medicine. Originally published at Health Care Renewal

The attempt to “repeal and replace” the Affordable Care Act has suddenly made health care dysfunction a hot topic in the US.

For example, today, in my local paper, the Providence Journal, Dr Timothy J Bainbeau, the CEO of the Lifespan Health System, the biggest regional health system weighed in on the problem of high and increasing health care costs. A close reading of his commentary suggests how the leadership of big US health care organizations needs to think about whether their actions have become more of the problem than a source of solutions.

The CEO’s Diagnosis and Prescription

Dr Babineau began unremarkably with:

American health care is expensive. Too expensive. On this, there is little debate. In 2001 the median U.S. household spent 6.4 percent of its income on health care; by 2016, the same household spent 15.6 percent of its income on health care. That bigger share of the pie leaves less for other essential purchases, such as food, education and housing.

What was his diagnosis? He stated that most costs are incurred in the care of severe acute or chronic illnesses. So his prescription was:

A critical (but often overlooked) point is the fact that as much as 40 percent of spending during chronic and complex episodes is avoidable if providers and systems adhere to established standards of care. Reining in runaway health-care spending must involve better management of high cost episodes of chronic and complex care.

So,

Rather than debate the actual percentage that is ‘wasteful spending’ (now commonly referenced at around 30 percent) we would be better served by continuing the hard work of identifying and eliminating areas within our own systems where needless variations in care add cost without improving outcomes.

To translate, most of health care spending is for severe acute or chronic illnesses. For patients with these problems, we do too much, that is, by failing to “adhere to established standards of care.” Therefore, we must learn to do less, by “eliminating areas within our own systems where needless variations in care add cost without improving outcomes.” His entire focus is on ending needless utilization, presumably of specific diagnostic tests, therapies and programs.

As an aside, his assertions ignore some real controversies. Dr Babineau implied that “variation” means needless or bad care. This echoes the old “practice variation” research school, which showed that the rate of certain services, that is tests or treatments, varies in different geographic areas. The problem is that this school has never clearly shown how much variation is due to variation in patients’ characteristics, including illness severity and preferences, and is therefore “appropriate” in some sense. It also fails to take into account how much variation is due to the inevitable uncertainty in diagnosis, and in predicting response to treatment. Few diagnostic tests are perfect, so test results can rarely prove a disease is present or absent, but just can suggest how probable it might be. Similarly, no treatment always cures, and most treatments have adverse effects. So at best physicians can only predict the probability that a patient will improve, remain the same, or be harmed by a treatment.

Whose Costs? Who Benefits?

It is odd, though, that while Dr Babineau wrote an essay on reducing costs, he did not even mention how much anyone pays for any particular test, treatment, program, service, etc. Nor did he mention whose costs most need reduction: patients’, health care systems’, insurance companies’, governments’, or “society’s” costs? That was probably due to his point of view, from the bubble of the hospital system C-suite, from which the viewof the outside world may be distorted.

Dr Babineau introduced his prescription for cost reduction with a defense of American hospitals.

American hospitals and health care systems are among the best in the world. Rather than decrying ‘American health care is broken’ and in need of rebuilding from scratch, a better strategy may be to look at what works well within our system and ask how we can build on those strengths while facing the escalating costs head on. Hospital systems are in the health-care business, and we should not be reluctant to say so. No matter what wellness and prevention programs we collectively offer, inevitably a small subset of the population will still get very sick, and it is a core mission of health systems — working in close partnership with our primary and specialty providers — to take the very best and most efficient care of them when that happens.

But should hospitals be “in the health-care business?” Most physicians of a certain age swore oaths on medical school graduation that we would put care of individual patients ahead of all other concerns, including making money. We surely have not fulfilled those oathes perfectly. Yet at one time health care and medicine could be seen as callings, just ways to make money.

In 2007, Dr Arnold Relman wrote(1) (and see this post):

The law also has played a major role in the decline of medical professionalism. The 1975 Supreme Court ruling that the professions were not protected from anti-trust law7 undermined the traditional restraint that medical professional societies had always placed on the commercial behavior of physicians, such as advertising and investing in the products they prescribe or facilities they recommend. Having lost some initial legal battles and fearing the financial costs of losing more, organized medicine now hesitates to require physicians to behave differently from business people. It asks only that physicians’ business activities should be legal, disclosed to patients, and not inconsistent with patients’ interests. Until forced by anti-trust concerns to change its ethical code in 1980, the American Medical Association had held that ‘in the practice of medicine a physician should limit the source of his professional income to medical services actually rendered by him, or under his supervision, to his patients’ and that ‘the practice of medicine should not be commercialized, nor treated as a commodity in trade.’ These sentiments reflecting the spirit of professionalism are now gone.

The Supreme Court challenge to attorneys’ and physicians’ professionalism was orchestrated by extreme market fundamentalists. Since 1978 when I obtained my MD from Brown, market fundamentalism (sometimes confusingly called “neoliberalism“) has become dominant in the US.

On the (now sadly dormant) Hooked: Ethics, Medicine and Pharma blog, Dr Howard Brody discussed the application of this reigning orthodoxy in economic. Basically, supporters of market fundamentalism et al seem to assume that all markets are idealized free markets, and that free markets are like a super computer combining all human thought to provide wisdom in the form of price information. Furthermore, since the market is based on supposedly rational choices made by free individuals, one cannot go back to question such choices.

Hence Dr Babineau is hardly alone in regarding all of health care now as a business. But he and many others like to ignore the theoretic problems with market fundamentalism applied to health care, specifically the possibilities that 1) people’s choice may not be free, may not be rational, and may not be based on coldly rational cognition and the best possible knowledge; and 2) one person’s economic choice may limit another person’s choices, or directly harm another person. And never mind that Dr Babineau leads a non-profit organization, which states (per the most recent, 2015 Rhode Island Hospital IRS Form 990) that its mission is “delivering health with care.”

Market fundamentalism suggests that hospitals and other health care organizations should be run like businesses to improve efficiency. Thus Dr Babineau allowed “it is a core mission of health systems — working in close partnership with our primary and specialty providers — to take the very best and most efficient care of them when that happens.” Efficiency requires the reduction of costs, but whose?

The worry is that Dr Babineau is really out to improve his own institution’s efficiency, very possibly because he has incentives to do so. There is considerable anecdotal evidence that hospital CEOs are rewarded for efficiency, but the effiicency of their own hospitals, not the health care system. CEOs may get incentives when they increase hospital efficiency by cutting the institution’s costs and/or increasing its revenue (look here for some examples.) Sometimes these incentives are hugely disproportionate to any improvements in net financial position (look here for examples). Sometimes CEO compensation goes up even when CEOs have cut the pay of or laid off lesser employees to cut costs (look here for examples). Sometimes their pay goes up even when their actions correlate with worsening quality of care (look here for examples).

I cannot find any published rationale for Dr Babineau’s compensation, but it is certainly substantial. According to the most recently available IRS Form 990 (2015) for Rhode Island Hospital, Dr Babineau’s total compensation (in 2014) was $2,405,868.

So the concern is that the sort of efficiency Dr Babineau advocates may benefit his organization’s and his own bottom line, but maybe not patients, or society. And the promise he made that his own hospital system will improve efficiency may actually conflict with his promise to improve patient care.

Summary

I submit that if we are really worried about why our health care system is sick, why we as individuals pay more and more for health care that is not improving, we should look beyond limiting practice variation or eliminating obviously useless, and hence perhaps uncommon services to improve “efficiency.” Instead, we should question whether health care can ever really function as a free market, and certainly whether hospitals, other health care “providers,” and health insurers should be businesses that put their revenues ahead of patients’ and the public’s health.

I am not a Catholic, but found the clearest voices on this issue to be those of the current and former Popes. Pope Benedict XVI decried the transformation of medicine and health care into a business. As we noted here, he wrote

during the current economic crisis ‘that is cutting resources for safeguarding health,’… Hospitals and other facilities ‘must rethink their particular role in order to avoid having health become a simple ‘commodity,’ subordinate to the laws of the market, and, therefore, a good reserved to a few, rather than a universal good to be guaranteed and defended,’

Furthermore,

‘Only when the wellbeing of the person, in its most fragile and defenseless condition and in search of meaning in the unfathomable mystery of pain, is very clearly at the center of medical and assisted care’ can the hospital be seen as a place where healing isn’t a job, but a mission,…

More recently, Pope Francis said,

Doctors, nurses and those who work in the field of health care must be defined by their ability to help their patients and be on guard against falling down the slippery slope of corruption that begins with special favors, tips and bribes, the pope told staff and patients of Rome’s ‘Bambino Gesu’ children’s hospital Dec. 15. ‘The worst cancer in a hospital like this is corruption,’ he said. ‘In this world where there is so much business involved in health care, so many people are tricked by the sickness industry, ‘Bambino Gesu’ hospital must learn to say no. Yes, we all are sinners. Corrupt, never.’

Thus, I challenge health care executives to state their willingness to put the care of patients ahead of their organizations’ revenue and own pay. Will anyone step up?

Reference

1. Relman AS. Medical professionalism in a commercialized health care market. JAMA 2007; 298: 2668-2670. [link here]