Health Policy Essays

The following essays were written as part of 6 week Introduction to Health Policy course taken during my second year of medical school:

WEEK 1: Bodenheimer and Grumbach describe the US health care system as a “paradox of excess and deprivation.” Give several examples of what you would regard as “excesses” in the US health care system and explain why you would regard these as instances of “excess.”

Bodenheimer and Grumbach describe the US health care system as a “paradox of excess and deprivation,” in which some receive too little care while others receive too much. Given the fact that 15% of Americans (47 million) have limited or no health coverage, it is shocking that virtually all studies examining the opposite scenario, overuse, have found that up to 25% of hospital days, 25% of medical procedures, and 40% of medications could be done without (B&G). According to a 2011 New England Journal of Medicine article, “Options for Slowing the Growth of Health Care Costs,” 10% of patients are responsible for 70% of costs (NEJM).

One demographic guilty of disproportionately hogging limited health care resources includes those facing end of life issues. The cost of aging places huge burdens on health care spending. Those aged 65 and older cost an annual average of $8,776 according to the Kaiser Family Foundation. This is nearly double the $4,863 spent on 45 to 65 year-olds and nearly four times the $2,305 spent on 25 to 44 year-olds. A 2001 study published in Health Affairs revealed that 5% of Medicare beneficiaries die each year, consuming 27.4% of Medicare’s $327 billion annual budget during their last year of life (WSJ).

Another example of excessive health care spending is in the area of cancer treatment. According to recent data published in the Journal of the National Cancer Institute, greater than 90% of FDA approved chemotherapy agents approved in the last four years cost greater than $20,000 for a 12 weeks of treatment. In 2008, oncology drugs became the best selling class of drugs, bringing in $19.2 billion in revenue in the US alone, a four-fold increase compared to the ten years prior. The worst culprits include cetuximab which provides an additional 1.2 months of life for patients diagnosis with non-small-cell lung cancer at the price of $80,000 and bevacizumab which provides no increase in overall survival for metastatic breast cancer at the cost of over $90,000 (Medscape).

As former president Abraham Lincoln said, “In the end, it’s not the years in your life that count. It’s the life in your years.” And in these cases, I couldn’t agree more. Our society has a problem with accepting that death is a normal part of life. Cultural change will be critical to controlling costs. One way in which physicians can contribute to controlling end of life costs is to discuss and encourage their patients to develop clear advanced directives.

Finally, I believe that any health care dollars spent treating society-wide health problems caused by other areas of flawed government policy are wasted and should also be considered excessive. These would include treatment of obesity and diabetes as a result of needless farm subsidies responsible for the over-production of high fructose corn syrup at artificially low prices which then becomes a “cheap” input for many low-priced manufactured food products consumed disproportionately by those with limited financial means and school lunch programs that provide government subsidized pizza as a vegetable.

WEEK 2: Many health policy analysts believe that physicians ought to be the primary mechanism by which health care costs should be controlled. This is because physicians decide whether patients need a specific prescription drug, or surgery, or how long patients need to be in a hospital or this or that diagnostic test etc. Explain whether and why you agree or disagree with the claim that physicians should be the primary mechanism by which health care costs are controlled.

As of 2008, health care expenditures in the United States reached $2.3 trillion, 16.2% of the nation’s GDP. This amounts to nearly $8000 spent per citizen and is among the highest of all industrialized nations (Kaiser). Yet despite the astronomical amount of money being spent on health care in this county, we are no better off for it in terms of life expectancy, infant mortality, and many other health care quality metrics.

In a 2009 article, “Cost Conundrum” appearing in The New Yorker Annals of Medicine, physician Atul Gawande examines McAllen, Texas, one of the most expensive health care markets in the nation. In 2006, Medicare spent $15,000 per enrollee in McAllen, twice the national average. Located in the county with the nation’s lowest household income, does McAllen’s poverty rate explain the 68% increased incidence of heavy drinking compared to the national average or 38% obesity rate present in this community? Are the costs in McAllen higher simply because the population is less healthy? Are the people of McAllen receiving better health care than the rest of the nation? Surely the malpractice costs must be higher? To all of these common repsonses provided by physicians in the community, Gawande says the answer is no. However, Gawande finally came upon a surgeon brave enough to call the other arguments “bullshit” and explain that “there is overutilization here, pure and simple.” Another colleague chimed in that young physicians don’t think anymore and rack up extra charges with unnecessary tests and procedures. Rather than taking the time to suggest lifestyle changes to modify risk factors for patients presenting for the first time, many physicians in McAllen have the mindset that their patients are unwilling to change their habits and that they will simply return later with a more advanced disease state. Given this mindset, it is easy to see how they might automatically jump to more drastic, costly interventions as first line therapy. Gawande points to the primary cause of McAllen’s exorbitant costs to be “across-the-board overuse of medicine,” including more surgery, more diagnostic testing, more hospital stays, and more home health care compared with patients nationwide. Nationwide, states associated with the highest amount of health care spending are often near the bottom of rankings for patient care. Despite getting the most expensive care possible, patients in these states often didn’t have a primary care physician, had to wait longer for emergency services, and didn’t receive many low-cost preventive services (Gawande).

I think Gawande summarizes it best when he says, “Health-care costs ultimately arise from the accumulation of individual decisions doctors make about which services and treatments to write an order for. The most expensive piece of medical equipment, as the saying goes, is a doctor’s pen.”

While it is easy to suggest that bedside rationing become the primary mechanism to control healthcare costs, it is an over simplification to suggest that physicians in some parts of the country or that have affiliations with certain health care systems either intend to use proportionately more or less than their counterparts elsewhere in the health care system. When physicians from both high-cost and low-cost cities across the nation responded to a recent survey about how to treat a variety of patient cases, it turns out that when the evidence-based medicine was clear and the proper procedures were well established there was little difference in decision making. However, when the science was unclear some physicians took the path of the diagnostic sledgehammer, while others pursued a more convservative approach (Gawande).

So while many physicians may resent the loss of autonomy that an organized, structured approach to providing care along certain guidelines, data-driven treatment recommendations do have the tremendous power to influence clinical decision making and thus reign in health care costs. If physicians are truly going to control healthcare costs through their clinical deicion making, it will be important that they stay current with the latest evidence-based medicine in their area of practice to ensure that their patients receive adequate treatment without underdiagnosing or overtreating.

One last point made in the Gawande article is that the culture of medicine is currently undergoing an internal battle in which during “the sharpest economic downtown that our health system has faced in a half a century, many people in medicine don’t see why they should do the hard work of organizing themselves in ways that reduce waste and improve quality if it means sacrificing revenue.” Physicians need to keep in mind why they entered the profession of medicine which should have been to improve the quality of lives of their patients, not extracting profit from their diseases. When physicians receive kickbacks for their referral patterns or have an ownership stake in the hospital or diagnostic services that they recommend one certainly has to question the physician’s motives for the clinical decisions that are made.

Kaiser = http://www.kaiseredu.org/Issue-Modules/US-Health-Care-Costs/Background-Brief.aspx
Gawande = http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande?currentPage=all

WEEK 3: Defend or criticize the following statement: “We need to adjust the ratio of primary care physicians to physicians working in various specialty areas so that we are more in line with the distribution of physicians in the rest of the world. In other words, only about 40% of our physicians should be medical specialists and the rest primary care physicians. This would help to reduce medical costs by forcing physicians to judge more carefully who will benefit most from specialty care.”

When examining the health care system in the United States one must confront the ugly fact that despite spending more health care dollars per capita than any other country in the world, our health outcomes as measured in terms of life expectancy and infant mortality, do not adequately reflect a reward for our investments. We must acknowledge that more spending is not the solution to solving America’s problem and that above certain levels of investment the reality of diminishing marginal returns can not be avoided. Considering that 10% of patients consume 70% of health care resources, I believe that it is essential for cost-effectiveness research to become an integral part of practicing medicine so that our dollars can be more efficiently allocated to maximize the return on our investment and ensure that health care spending improve health outcomes for the most people possible at the lowest cost possible (Bodenheimer 2005).

In my last essay, I briefly touched upon the fact that through physician adherence to evidence-based medicine and a change in the culture of medicine that seeks to focus upon patient outcomes rather than personal profits we might be able to achieve this goal. I’ve also pointed to expensive chemotherapy treatments that only minimally extend patient lifespans and the use of extraordinary measures for those near the end of life as excellent examples of spending that does not yield improved quality of life for the patients being treated. I was also surprised to learn that from the text that 10% to 40% of imaging studies, which are one of the most rapidly inflating components of health expenditures, are not clinically necessary.

In addition to being useful for optimizing screening, interventions, and treatments provided by physicians, evidence based medicine can also be applied in the context of deciding which blend of health care workers provides the best outcomes at the lowest cost. For example, our textbook states that “studies comparing patient outcomes across regions in the United States have found that while a very low supply of physicians is associated with higher mortality, once supply is even modestly greater, patients derive little further survival benefit.” So are more physicians always the answer to improving health metrics? Well, that depend on what type of physician you’re talking about. Our text goes on to say that, “one exception to these patterns is when studies focus on primary care physician supply, rather than on overall physician supply or the supply of specialists. These studies tend to find that patient outcomes and quality of care are better in regions with a more primary care-oriented physician workforce.”

While there may be more prestige associated with pursuing a medical specialty amongst aspiring physicians, the data clearly shows that access to primary care is what matters most to improving the overall health of our population. America can do better than having only one-third of its physicians providing primary care and this allocation process needs to be examined for potential ways to incentivize bright minds to enter the field of primary care rather than seeing it as the specialty of last resort.

WEEK 4: Explain what you see Accountable Care Organizations to be; then assess what you regard as their strengths and weaknesses so far as health reform is concerned.

While the topic of Accountable Care Organizations has been a recent issue of contention between various factions of the health care community, it is my belief that by these organizations could potentially be the solution to obtaining the best possible patient care at the best possible price. From our past readings and small group discussions, it is clear that fee-for-service models of physician reimbursement have intrinsically perverse incentives for physicians that can lead to across-the-board overuse of health care resources for personal financial gain. We have also discussed capitation-based systems of physician compensation that transfer the financial risk of patient care away from the insurer and onto the shoulders of the health care provider. In the fee-for-service model there have been several examples of excessive spending on patient care without improvement in patient outcomes, in fact in many localities such as the case of McAllen, TX, which provides the country’s most expensive health care, the outcomes are worse compared to other health care organizations with lower spending patterns such as the Mayo Clinic which spends in the bottom 15th percenticle of Medicare spending per patient treated. And while capitation may be an effective form of price control, there have been some allegations that with these types of systems physicians are incentivized to limit care so that they may retain a larger amount of the capitation payment, rather than utilize the funds for potentially necessary care.

The benefit of Accountable Care Organizations would be to pay physicians based on the health outcomes of the patients receiving their care which would seek to balance the aforementioned problems of over and under-treatment. These types of organizations would also incentivize more emphasis placed on physician responsibility to tackle issues of lifestyle modification and limiting patients’ risk factors for disease for which many are under or not compensated for currently.

Opponents of ACOs cite decreased physician autonomy and the destruction of private practice physicians as potential negative side effects of implementing these types of organizations. Another concern is whether or not physicians actually have control over what their patients actions outside of their offices and worry that non-compliance to suggested treatment plans will have a negative financial impact on the health care provider for personal decisions made by patients that are outside of the physician’s control.

On the surface, the worry about loss of physician autonomy may be frightening to some, however when confronted with the facts that “an estimated 32,000 people die in US hospitals each year as a result of preventable medical errors” and that “five to fifteen percent of physicians are not fully competent to practice medicine, either because of inadequate medical skills, impairment caused by use of drugs or alcohol, or deficiencies resulting from mental illness,” one could also easily reach the conclusion that physician autonomy is part of the problem (B&G). Perhaps if physicians were able to devote more of their time to clinical decision making and less time focused on maximizing their profits patients would receive better care at a lower cost.

Concerns about whether or not physicians would be punished if their patients chose not to adhere to treatment plans are easily dismantled through risk-adjustment of the population served. It would be absurd to think that patient adherence to medical advice and baseline risks for disease would be the same between different patient populations across the country. Risk-adjustment would be absolutely necessary to ensure fair implementation and also to prevent physicians from electing to serve only populations that are already in excellent health. Another option presented in our text states that “because of these challenges in using outcomes as measures to monitor quality of care, process measures tend to be more commonly used. For process measures to be valid indicators of quality, there must first be solid research demonstrating that the processes do in fact influence patient outcomes” (B&G).

Time will tell whether or not ACOs will be able to achieve their stated goal of improving the health of our patients by holding care providers accountable for their outcomes.

WEEK 5: In lecture Len Fleck argued that the need for health care rationing is inescapable and that the key to fair health care rationing was the use of processes of rational democratic deliberation that were transparent and that resulted in self-imposed rationing protocols. Critically assess that proposal in your essay.

During his last lecture Dr. Fleck suggested that “the need for health care rationing is inescapable and that the key to fair health care rationing was the use of processes of rational democratic deliberation that were transparent and that resulted in self-imposed rationing protocols” and I would have to agree with him. The United States currently spends more per capita on health care than any other nation in the world and with nothing to show for this investment, as demonstrated by our dismal life expectancy and infant mortality outcomes.

When discussing the allocation of health care, it is important to that one understands the difference between rationing and cost control, which B&G summarizes as follows, “Not all cost control is rationing. Painless cost control is not rationing, because no limitation is placed on medical care expected to be beneficial. Painful cost control may require rationing because limits are placed on medical care expected to be beneficial.” Advances in medical technology combined with fiscal scarcity will make rationing of medical services necessary in the future, however I am in agreement with B&G that “to maximize beneficence and autonomy without violating distributive justice, no rationing of beneficial services should take place until all wasteful practices are curtailed; painless cost control should precede painful cost control.”

While most physicians are understandably uncomfortable with the prospect of “bedside rationing” or the microallocation of health care resources as they believe it undermines their commitment to upholding patient autonomy and acting with beneficence, there is increasing pressure for physicians to also consider the cumulative societal impact of their decisions. As B&G state, “If physicians refuse to accept two masters, then medicine will be granting microallocation decisions to insurance company and governmental officials. The physician of the twenty-first century will continue to face individual patient responsibilities, but will find it difficult to escape the obligation to balance the wishes of individual patients against the larger needs of society.”

The Oregon Health Plan has provided an excellent example of what a rational democratic deliberation process might look like. In 1994, Oregon expanded its Medicaid program to include 100,000 new impoverished, uninsured patients. In order to achieve a cost effective way to cover all of these new enrollees a prioritized list of services ranked by how many quality adjusted life years each treatment would produce. The legislature then decided to pay for the first 574 items on the 745 item list. Although this plan has experienced challenges as a result of state budgetary problems, this innovative approach will hopefully inspire other similar strategies that seek to spend health care dollars in areas that will provide the best outcomes at the lowest possible cost.

We must stop devoting 70% of health care resources to 10% of patients, while many others go without coverage for basic services. To those wanting what would be considered futile care or care not delivering an effective return on investment, hopefully they’ve got cash.

WEEK 6: Some people believe that high educational debt, and the different levels of income that U.S. physicians in different specialties can expect to earn, keep many medical students from choosing fields with lower pay, such as primary care. Does your educational debt, and the different levels of income you might expect to earn in different specialties, influence the way you think about your specialty choice and career? Why or why not?

As has been emphasized in several of our small group discussions, the United States spends more dollars per capita on the health care of our population than any other nation on the planet yet we have nothing to show for it as evidenced by our dismal infant mortality ratings and life expectancy metrics. One of the reasons for the inflated cost of medical care in the United States compared with other countries is our reversal in the ideal proportion of primary care to specialist physician ratio which has been suggested to be 2/3 primary care physicians and 1/3 specialists; the US is currently 2/3 specialists and only 1/3 primary care. The data clearly shows that access to primary is what matters most to improving the overall health of the population.

According to the AMA, the average educational debt for graduates of the class of 2010 was $157,944. This amount may be significantly higher for those paying out of state tuition, those carrying significant undergraduate debt, as well as for non-traditional students who have children or spouses to support while completing their medical education. Being a graduate of Michigan State University’s College of Human Medicine also increases a student’s chance of being highly indebted according to its appearance on U.S. News listings of “10 Medical Schools that Lead to Most Debt” in 2009. Given the excessive amount of debt that today’s medical graduates are facing, it is no surprise more and more aspiring physicians find specialties with higher rates of reimbursement to be more appealing than lower paid areas of practice such as primary care. A recent article in The Washington Post states that,” At the end of residency, they can stay in primary care and earn $29.58 an hour. Or they can specialize and make $74.45. Over a lifetime, a medical student who specializes can expect to earn $3.5 million more.” According to B&G, “The quest for profitability is further aggravating the primary care-specialist imbalance in the physician workforce in the United States. The number of US medical school graduates choosing careers in family medicine dropped by 50% between 1995 and 2005. The proportion of internal medicine residents entering primary care medicine rather than subspecialty or hospital careers plummeted from 54% in 1998 to 20% in 2005.”

In addition to decreasing the supply of primary care physicians, increased graduate debt has also been shown to have additional burdens on the health care system including decreased diversity of the physician workforce by preventing those from low-income backgrounds from attending medical school and also by promoting unsafe physician behaviors through moonlighting, as well as increased cynicism and depression among residents (AMA).

Given the information discussed, I would find it difficult to believe that financial considerations don’t weigh heavily into each and every medical graduate’s decision on what field of medicine to pursue, myself included. Surprisingly, the Washington Post recently reported that “the number of American medical students matching into primary care residencies jumped 20 percent between 2009 and 2011,” most likely simply due to the increased attention paid to the importance of primary care including its cost-effectiveness and the coming shortage. A similar spike occurred in 1997 during the presidency of Bill Clinton, when 40% of medical students pursued primary care residencies, during a time when HMOs were booming and there was increased emphasis placed on primary care as a way to limit expensive specialty care. Unfortunately, the Clinton health plan failed and HMOs rapidly lost market share.

I believe in my heart that primary care would be the most fulfilling field to enter due to the longitudinal relationships developed the patients, the satisfaction of knowing that one is devoting their efforts in the area where it will have the most impact on the health of the population, and the knowledge that money alone does not buy happiness and that many of the highest-paid physicians simply have no time to spend the excessive amounts of money they earn or time to enjoy their friends and families. Additionally, I believe that it is important for more primary care physicians to become in shaping health care policy in this country to address many of the underlying problems related to the economic incentives that have led to the primary care-specialist disparity we are seeing today.

Outside References:
AMA = http://www.ama-assn.org/ama/pub/about-ama/our-people/member-groups-sections/medical-student-section/advocacy-policy/medical-student-debt/background.page?
Washington Post = http://www.washingtonpost.com/business/success-of-health-reform-hinges-on-hiring-30000-primary-care-doctors-by-2015/2012/02/06/gIQAnslQ4Q_story.html