Tuesday, January 4, 2011

We understand the problem, sir...

I was sent a clip from The Boston Herald this morning, quoting Dr. Domenic Paolini on the topic of forthcoming Massachusetts health care reform.  I don't know Dr. Paolini, but upon reading that he is a physician (heart surgeon, no less) and attorney, my interest was piqued.  Here is someone uniquely qualified to comment on the matter, I thought... offering perhaps not only a great perspective, but also some possible solutions as well.

Unfortunately, the piece offers the often repeated arguments against reform, but no real suggestions otherwise.  I've commented below on the specific elements of his case.
“When doctors lose money, patients lose lives, and limbs,” warned Paolini, a critic of the new health care payment plan state leaders will soon roll out.
That seems a bit dramatic.  He certainly has my attention, though.
“When doctors aren’t adequately compensated, they need to see more patients, and because there’s only so many hours in a day, they spend less time with patients, and less time preparing for patients, and that’s when accidents happen.”
I agree with the underlying concepts here.  Inefficiencies in our system, of which there are many, and shortages of key clinical personnel, which are well documented, do cause doctors to spend less time with patients.  The ever expanding paperwork requirements, which the home health industry is certainly also experiencing, also force clinicians to divert their attention and time away from the valuable skills they've acquired and toward less productive administrative tasks.  But... those tasks have been mandated by the need to standardize treatment protocols and to drive toward higher quality outcomes as well as the fact that some opportunistic providers and their agents have fraudulently billed for reimbursement.  Both have resulted in more demanding documentation requirements.  And more paperwork.

And for the record, doctors do need to be "adequately compensated".  The rigors of training and the personal sacrifices necessary to motivate college students through pre-medical programs and onto medical schools, residencies and advanced speciality training programs are real.  We want our top students to heed the calling to become physicians and to withstand the many challenges facing them as they pursue that goal.  Skimping on physician compensation is most decidedly not a viable solution to the perennial health care cost crisis.
By month’s end, Gov. Deval Patrick and the state’s most powerful legislators are expected to make national news, with a bill that aims to curb health care costs by changing how we pay for care.

If the bill becomes law, insurers will stop paying doctors for each test and office visit, and implement “global payments” and “accountable care organizations.”

All this means that in the future, insurers and the government will put doctors’ groups and hospitals on an annual per-patient health care budget, by giving them a lump sum of money to spend on care. Eventually, supporters say, doctors will stop treating a specific illness, and start treating the whole patient. And, they say, as our collective health improves, we’ll wind up paying less for health insurance.

It sounds great, but Paolini isn’t buying it. He’s skeptical because the architects of this plan claimed in 2006 that once everyone had health insurance, our premiums would nosedive, and that patently hasn’t happened.
Reaping the benefits of providing reasonable health coverage, including primary care services, will take far longer than four or five years to realize.  The investments in a person's health status when he or she is twenty years old may not prove out until a heart attack and complex cardiac surgery is averted thirty years later.

Additionally, we were paying for the uninsured population to receive care through the "Free Care Pool" and other even more obtuse funding systems.  And these costs were spiraling upward, causing premiums to rise.
Of this latest initiative, Paolini said, “We’ve already tried this, but back then it was called managed care, and that began when businessman decided to move money out of the health care system, and into their own pockets,” he added.

To make that happen, he said, the government and the insurers began slashing doctors’ pay.

“All the other money was going into the bureaucracy, the $2 million-a-year hospital administrators and the insurance companies,” he said, adding that they are the ones who have the governor’s and legislators’ ears. Take the money away from doctors, and watch the case loads and errors rise, Paolini said.
Even casual observers would conclude that in the recent health reform debate, physicians had "the governor's and legislator's ears", so I don't believe that lack of advocacy effectiveness is the real issue here.  Additionally, the "into their own pockets" argument is shallow at best.  Yes, some insurers and executives have benefited, but administrative costs are still a small fraction of total health system dollar outlays.  Additionally, the increasing complexity in the system driven by anti-fraud programs and the quest to develop better information systems and quality programs are expensive.  Payers, as well as providers, have had to bear those costs too.

Dr. Paolini does not talk about some of the other, perhaps bigger, problems.  These include:
  • The home health industry is currently experiencing very dramatic Medicare reimbursement cuts.  Yet... as has been argued in this blog, the cost associated with the provision of high quality home care services pales in comparison to the cost of institutional inpatient and emergency care.  For example, VNA of Boston clinicians are able to keep a higher proportion of patients out of the hospital than Massachusetts and U.S. averages suggest (25% readmission rate for VNA of Boston vs. 28% and 29% respectively).  Yet we are being cut at a disproportionately higher rate than other sectors.
  • Our aging population poses an ever increasing strain on our limited health care resources.  We're living longer and needing more operations, more diagnostic procedures, more medications and then, institutional care for longer periods of time.  I'm not arguing that we deny these services to these populations... only that we stop denying how much this all is costing us.
  • Palliative care is still viewed as "giving in" as we cling to life and hope for miraculous and intensive life saving cures.  There is nothing inherently wrong with this, but by the same token, we ought to recognize and encourage approaches that offer compassion and comfort when all professionals concur that the miracle cure isn't coming.

The health care cost and access conundrum isn't going away soon, despite the passage of Massachusetts and now National reform laws.  The problem is well understood, but simplified explanations involving fat cat insurance executives and threats of medical mistakes and death do little to promote dialogue and problem solving.


  1. Thank you Rey.

    As I have recently experienced the death of aged and infirmed friends and loved ones I find the last two bullet points critically important. Quality paliative care is the key. The gift of a good death exceeds the false hope of a miracle cure for me.

    I brought three Megabucks tickets today. My odds of winning at that are quite small: 3 in 175,711,536 or something. I am not willing to wager a fortune to make it 100,000 to 175,711,536 (Would that make it 1 in 1,757.11536 ?). It would be wasteful.

    Should I risk megamillions in health-care resources on a 1 in 2,000 chance to extend my earthly life a year or three - even ten? It seems wasteful.

    Anyways :) I have hope in another life where megabucks aren't needed and death is unknown.

  2. As a physician myself, I must say I find the author of the Boston Herald article to be over simplifying the matter. I appreciate your thoughtful response. Good blog.

  3. what about the problem of illegal immigrants and the fact that this is also making health care more and more expensive?

  4. If the issue is illegal immigration, then let's deal with that via our immigration laws and enforcement of those laws. I'm talking about providing quality health care and when those who need our care come seeking it, organizations such as ours provide it.

    What else would you have us do? Seriously, what else?

  5. Pretty well stated. If the doctor lawyer wanted to point fingers at "fat cats" he could have said pharma executives and the multi-million dollar sales armies they send out.

  6. At the hospital where I work, we unleash our employees into the political process. The docs are a force too. Home care has historically been an afterthought and so it's no wonder it got cut. Home care companies should probably snuggle up to bigger players as a matter of survival.

  7. Sometimes the "professionals" say the miracle cures won't come. But then sometimes they do.