What do you think about the Physician Group Practice Demo project?

Been a long time since we wrote on this, but was wondering what you all are thinking about ACOs and the results of the PGP Demo project released earlier this month.

A link from this week's NEJM describing the results here.

And the original description and results from the PGP Demo project here

NEJM -- Failing to Thrive

Wonderful article from a former co-resident from MGH.

NEJM -- Failing to Thrive

How much governance over GPH funds is enough?

Been awhile since any of us has posted. I thought I'd start us up again. I came across this piece in Reuters -

Global healthcare fraud costs put at $260 billion | Reuters

A study by the European Healthcare Fraud and Corruption Network (EHFCN) and the Center for Counter Fraud Services (CCFS) at Britain's Portsmouth University found that 5.59 percent of annual global health spending is lost to mistakes or corruption.

A ~5% loss is not that bad, actually. And in all the global public health work that I have done, a tremendous amount of energy, human and financial resources is spent on reducing funding fraud.

I wonder if the investment in keeping this down to 5% is worth it - or if we allowed the total amount of fraud to increase, but spend less on policing, that actually more money would get to end recipients.

This isn't an easy one - and I don't know the answer - but I think it's worth asking ourselves how much governance over funding is enough governance? Are we policing the funds too much, and wasting time and money? Or are we not policing enough, and do people think that this 5% is too much of a loss?

Bittersweet Victory

The senate finally has the 60 votes it needs to avoid a filibuster from the increasingly ridiculous Republicans, who, for purely political reasons, have pulled out every trick in the book to obstruct health care reform. While this is certainly a good thing, my sentiments are mixed. On the one hand, health care will be extended to 31 million new people. On the other hand, Senator Reid's bill has way too many silly sweetheart deals, crazy payment schemes, and takes away the strongest lever for bringing down health care costs, i.e. the public option.

Some highlights of the "compromises" Democrats have made to get the bill passed:

• Nebraska's Ben Nelson was able to get extra Medicaid funding for his state. Reminds me of a 1st round draft pick petulantly holding out for a better contract.
• The ability for states to choose if their insurance exchange will pay for abortions.
• A two-tiered insurance system for people who want to have an abortion. I.e. you have to buy extra insurance in case you think you might want to have an abortion at some point. Ironically, the Catholic Church AND Pro-Choice both oppose this part of the bill.
• At least two national insurance providers chosen by the Office of Personnel Management, the same folks who run Congress' health plan.
• Higher penalties on "Cadillac" health plans excluding plans for people in high-risk jobs like police, firefighters, miners, and longshoremen.
• Higher penalties on the rich - 0.9% of income if you make $200K as an individual or $250K as a family.
• A tax on indoor tanning salons in lieu of a tax on plastic surgeons. I wonder if Beverly Hills has its own lobbyist.

All in all, I think this bill is necessary and it would be a disaster if it didn't pass in some form or another. Sadly, I think the forest is being lost for the trees - in my mind we have to pass health care reform to get three achieve three big outputs. 1) Cover as many people as possible. 2) Don't allow Insurance Companies to "cherry pick" customers. 3) Keep costs low by increasing competition and rewarding efficiency.

Health Insurers Caught Paying Facebook Gamers Virtual Currency To Oppose Reform Bill

This is unbelievable. Thanks to Jeff for bringing it to my attention.

Health Insurers Caught Paying Facebook Gamers Virtual Currency To Oppose Reform Bill

Am pasting the article below, but credit goes to the authors from the link above:

Health insurance industry trade groups opposed to President Obama's health care reform bill are paying Facebook users fake money -- called "virtual currency" -- to send letters to Congress protesting the bill.

Here's how it's happening:

Facebook users play a social game, like "FarmVille" or "Friends For Sale." They get addicted to it. Eager to accelerate their progress inside the game, the gamers buy "virtual goods" such as a machine gun for "Mafia Wars." But these gamers don't buy these virtual goods with real money. They use virtual currency.

The gamers get virtual currency three ways:

• Winning it playing the games
• Paying for it with real money
• By accepting offers from third-parties -- usually companies like online movie rentals service Netflix -- who agree to give the gamer virtual currency so long as that gamer agrees to try a product or service. This is done through an "offers" provider -- a middleman that brings the companies like Netflix, the Facebook gamemakers, and the Facebook gamemaker's users together.

It's this third method that an anti-reform group called "Get Health Reform Right" is using to pay gamers virtual currency for their support.

Instead of asking the gamers to try a product the way Netflix would, "Get Health Reform Right" requires gamers to take a survey, which, upon completion, automatically sends the following email to their Congressional Rep:

"I am concerned a new government plan could cause me to lose the employer coverage I have today. More government bureaucracy will only create more problems, not solve the ones we have."

OMGPOP CEO Dan Porter spotted the survey and took a screenshot for us. (Click on the image at the right to expand it.)

What is this practice called?

Paying people to act like political supporters is called "astroturfing," because its fake grass-roots campaigning. So maybe this should be called Virtual astroturfing. Virtual-turfing? Astroturfing 2.0?

Who are the people behind this?

Get Health Reform Right describes itself as a "project of organizations whose shared mission is to ensure consumers continue to have access to employer-sponsored healthcare plans."

We are concerned about federal legislation that would create new government bureaucracies that would unravel the workplace healthcare system where more than 160 million people get their coverage.

Under the "Who We Are" tab on GetHealthReformRight.org, the following organizations are listed:

• Association of Health Insurance Advisors
• America’s Health Insurance Plans
• American Benefits Council
• BlueCross BlueShield Association
• Council of Insurance Agents & Brokers
• Healthcare Leadership Council
• Independent Insurance Agents & Brokers
• National Association of Health Underwriters
• National Association of Insurance and Financial Advisors
• National Retail Association

Who are the gamers filling out the survey and sending emails to Congress?

Facebook gamers tend to fall into two groups: women in their 30s and 40s and teenagers of both sexes.

Is this legal?

Astroturfing, which involves real money, is not illegal, We can't imagine virtual curreny astroturfing would be illegal either. Whether or not it's ethical is a different question.

Who is profiting from this?

According to OMGPOP CEO Dan Porter, the middleman facilitating this transaction in multiple Facebook games is called Gambit. Up until a few weeks ago, these games included big hits like Zynga's Mafia Wars and FarmVille. Zynga has since removed all offers from its games. On its Web site, Gambit says its clients include:

• #1 MySpace Developer
• 20%+ of top 10 Facebook applications
• SmallWorlds.com
• School Vandals
• Foopets.com
• 2 Top 100 websites
• ...and over 150+ more

One important thing to remember:

Gambit is just the platform here, bringing three parties together: gamers seeking currency, game-makers seeking monetization, and companies (and, apparently lobbying groups) looking for customers.

OMGPOP CEO Dan Porter tells us it's most likely the case that Get Health Care Reform agreed to pay an ad agency for every letter-writer it recruited. Dan supposes it was this third-party that bundled the above survey with several others and submitted it into Gambit's offer network.

Update: We reached out to Gambit CEO Noah Kagan for clarification. He told us:

"It's not that Dan is wrong. But we don't run hot political issues. You don't have any evidence that this is from Gambit. We don't condone this in our system. Sometimes stuff does happen, but we've been very proactive in making sure that there's not negative offers in our system."

To this, Dan replied:

"My point all along had little to do with the Gambit platform. We are testing it in house and will deploy it and it has controls for how conservative a partner wants to be. I wouldn't use them if I didn't think it would provide value for our users in a safe way. Gambit and every other offers company simply bundle in offers from outside vendors. The primary distributers of this fake activism are companies you will never know, like webclients.net doing business under eltpath.com. [They] distribute this stuff to sources all over the web from from freecomputer4u to sweepstakes promotions to offer providers."

The response from Get Health Care Reform:

We've also contacted Get Health Care Reform using an email address listed on their Web site. We received the following message back:

Google tried to deliver your message, but it was rejected by the recipient domain. We recommend contacting the other email provider for further information about the cause of this error. The error that the other server returned was: 553 553 sorry, that domain isn't in my list of allowed rcpthosts (#5.7.1) (state 14).

How the Senate bill would contain the cost of health care : The New Yorker

Gawande has a new article out on the health care bill

How the Senate bill would contain the cost of health care : The New Yorker

Dr. Gawande writes:

Turn to Page 621 of the Senate version, the section entitled “Transforming the Health Care Delivery System,” and start reading. Does the bill end medicine’s destructive piecemeal payment system? Does it replace paying for quantity with paying for quality? Does it institute nationwide structural changes that curb costs and raise quality? It does not. Instead, what it offers is … pilot programs. … Where we crave sweeping transformation, all the current bill offers is those pilot programs, a battery of small-scale experiments. The strategy seems hopelessly inadequate to solve a problem of this magnitude. And yet—here’s the interesting thing—history suggests otherwise.

Gawande draws parallels to the history of American agriculture when the country slowly updated farming practices through a series of government-guided pilot programs. He argues that the health care bill will achieve the same end result, even though there is no one big hammer to control costs, just a lot of little ones.

Pick up the Senate health-care bill — yes, all 2,074 pages — and leaf through it. Almost half of it is devoted to programs that would test various ways to curb costs and increase quality. The bill is a hodgepodge. And it should be.

There is a danger in drawing parallels to other industries - I know that as a consultant - it is one of our downfalls when we try to draw a line with only one data point - but seems like an interesting parallel. Agriculture was their health care - a major source of the economy that needed a major overhaul to keep America competitive.

Regardless, I'm continually impressed by Gawande's thinking and prose.

Getting the Facts Straight on Health Care Reform

Wow, just read an awesome article by an MIT economist Jonathan Gruber in the NEJM. Finally someone has provided a cogent, well researched, and passionate rebuttal to all of the scurrilous talk that's been flying around in Congress. I was feeling a little down about health care reform watching the news, but reading this article has made me believe again! We absolutely must pass something substantial this year, and Gruber has basically bashed every possible argument against reform.

Slightly random

This is not health care related. I saw this small article buried in the nytimes -

Darpa Puts On Contest to Find 10 Red Balloons Across U.S. - NYTimes.com

It reminded me of the Xprize that Kedar had posted a few months back about developing a health care system. DARPA - the military research unit - is putting up a $40k to see which group can identify the location of ten balloons on one day located throughout the country.

I don't get it. They say it's to learn about behavior of creative groups in collaborative situations. I think it takes its cue from the Netflix $1 million prize which was for a group that could improve the netflix movie suggestions software. When I read between the lines, however, it feels like you could replace the word "balloon" with "terrorist" and you get a sense of what the agency is trying to learn. But haven't we for ages posted reward signs for wanted criminals and relied on the public citizenry to assist the police and military in finding "red balloons" ? I don't get. What are they trying to get out of this experiment?

Sorry for the random non-health care post. Was just really curious to me.

Pricing in health care

this is a bit of a stream of consciousness post - so apologies in advance -

I came across this article on GE's change in their health care plan:

Health Care: GE Gets Radical - BusinessWeek

They are essentially changing from a traditional high up front premium, predictable co-pay model to one where there is greater price transparency given that there is a higher deductible, lower premium.

Interestingly, my own employer recently changed health benefits from what was a "cadillac" plan (insurance plans that shield consumers from the true price of health care - the types of plans that are given to high priced executives or union employees) to something more reasonable, with slightly more price transparency - tiered co-pays that gives the consumer at least a modicum of insight that some drugs and services are more expensive than others.

As pricing becomes more transparent in health care (btw we've been talking about price for years now - health savings accounts were supposed to transform health care as we all became more price sensitive - but instead most of us use it to buy eyeglasses and get dental work) it's important to understand how pricing works in health care.

A bit more on pricing:

As you prob know from an earlier post, I'm a big fan of the baseline scenario blog - an extremely well written blog about finance. The folks at the baseline scenario also produce the Planet Money podcast for NPR.

They have recently been looking into pricing in the US health system. they had two very well produced segments on pricing for MRIs.
The first is at this link - and worth a listen - gives a fantastic historic overview of how we developed a fee-for-service system in health care, and how price has become so perverse in health care. Jeff and I had an argument about why partners health care takes such big price hikes in boston - and this podcast explains a bit why institutions like partners can justify taking those price hikes in services.

Then there's a follow up on pricing for MRIs in other countries - the podcast is at this link . what they find is that pricing for MRIs in japan are substantially lower. However, what's fascinating about the japanese health care system is that their approach to controlling health care costs is to reduce price. Since 1990, the government has implemented a strict policy that has capped increases in both medical - treatment fees and the price of drugs to around 2 percent annually since 1995 (muc lower than any other OECD country). Theoretically this makes sense, if you pay less then health care costs should go down. Right? Wrong. What happened in japan is there has been an expansion of health care providers - supply has gone up, japan's population is ageing very fast, technology is growing faster than price decreases, japan's wealth has triggered more visits to the doctor, - and physicians, the finely tuned economic beings that they are, have compensated with declining price with increasing volume. Remember basic microeconomics? Price times quantity equals revenue. If price goes down, a rational economic being increases quantity. Therefore, japan is the most medicalized society in the world - On average, the Japanese see physicians almost 14 times a year, three times the number of visits in other developed countries!

Alright - I'll stop here - take a listen to the podcasts, and I'll try to write more about consumer directed health plans in my next post.

When Less Isn't More

The United States Preventative Services Task Force just recently changed the recommendations for breast and cervical cancer screening prompting an outcry from rationing sensationalists that government is again trying to kill its citizens. In summary, they basically said that for average risk women, you don't have to do mammograms until age 50, and even then, only every two years. They've also said to do away with self breast exams, which have been proven to not reduce mortality since the huge trial that came out of China in 2004. The same is likely to come out for cervical screening - biennial screening starting at 21. These recommendations are made by very smart people who have looked at the data and found that the previous screening remmendations were not only overkill, they were probably causing more harm than good. Yes, a rare occurence when evidence appears to outweigh emotion. Yet the crazies are still going to get upset that this is really a way to reduce costs - some have even called this a subversive attempt at "female population control."
I, for one, applaud the USPSTF's courage in trying to shift the way American's consume healthcare. Part of the reason why costs in this country countinue to skyrocket is our complete addiction and over consumption of medications, imaging, and procedures. The funny thing is, I think our national anxiety level is such that people don't think it's a relief to hear it's OK to test less. Let's say, for example you ask 100 women: would you rather be told you have a suspicious lesion and find out it's benign or not be told at all? I bet 75% would prefer to go through the testing, the trauma, and the worry even though in the end, the outcome is the same, and all you did was waste time, money, and peace of mind. It's the fear of the very rare occurrence and the media frenzy that surrounds the missed diagnosis of breast cancer in a 38 year old that breeds this level of anxiety - no one ever hears about the woman who gets staph mastitis from the unnecessary biopsy...

Hilarious

This picture says alot -

Letters Lost, Meaning Found - City Room Blog - NYTimes.com

Is Brent James the savior of American health care?

If you read this week's Sunday New York Times Magazine, you saw this article about Brent James, the chief quality officer at Intermountain Health in Utah. The premise of the article, and Dr. James' philosophy is that data, systems thinking, and process improvement are the absolute best ways to improve patient outcomes.

For a while now, I've rejected the prevailing wisdom that individualized patient care is the best care. The US prides itself on the doctor's ability to decide what the right treatment is for any given condition, allowing him/her to tailor the panoply of available therapeutic options to make it just right for the patient. Of course, these choices are influenced by reimbursements, what's easiest for the doctor, and what restaurant the pharmaceutical rep lured you to last week. Naturally, if you ask doctors why they do what they do, they claim their actions are evidenced-based, yet the data overwhelmingly suggests enormous variation in physician practice.

In contrast, Intermountain has developed hundreds of protocols for routine care, which essentially automate decision making down to the level of what dose of beta blocker to prescribe for heart failure. The outcomes under this system beat the rest of the nation, and interestingly, doctors are not upset about the computerization of medicine. In fact, many docs feel that these protocols help them a) understand the evidence base, and b) relieve them of the myriad complex decisions that have to be made for every patient and are often overlooked during the course of a busy day.

While I think that the "Intermountain Way" isn't perfect, I think it's a great example of an organization who is really thinking about how to streamline and "hardwire" best practice into usual clinical routines. Add in Geisinger, Mayo, Kaiser Permanente, and the Cleveland Clinic, and you have the avant-garde of health systems thinking in America.

Rudolf Virchow and social medicine

Some random history for today:

I always thought Rudolf Virchow was an interesting physician. Granted he didn't believe in Darwinism or antisceptics, but he did have a great faith in medicine as a tool to lift the condition of communities. Virchow is credited with the founding of "social medicine" positing that disease is never purely biological, but often, socially derived.

I came across this page of his quotes and especially liked this one:

"Medicine is a social science, and politics is nothing else but medicine on a large scale. Medicine, as a social science, as the science of human beings, has the obligation to point out problems and to attempt their theoretical solution: the politician, the practical anthropologist, must find the means for their actual solution."

I leave it to you to determine this quote's modern day significance.

U.S. Health Care Reform Interactive Timeline

Noticed this on NEJM today - neat little interactive graphic on the history of health care reform with links to the relevant NEJM articles from that time.

Health Care Reform 2009 | U.S. Health Care Reform Interactive Timeline

of note, there is an interesting cadence to these efforts - a push for reform, followed by years of stability / status quo - granted you don't want to reform constantly, or too disruptive to system. But regardless, pretty much every other year for the last 50 years a health care bill has been passed.

This American Life series on health care

If you haven't listened to it already - This American Life has a two part series on health care in the US. Co-produced with NPR/Planet Money group (involved w/ the Baseline Scenario bloggers that I quoted the other day)

This American Life - part one
This American Life - part two

Calvin Trillin’s Theory, the financial crisis and health care mamangement

Calvin Trillin’s Theory at The Baseline Scenario:

Not directly health care related, but the chart when you follow this link is fantastic. Follow through with me on this and you'll see where I'm going (health care, like finance, has become too complicated for the old guard).

Recent Trillin op-ed recounted a fictional encounter where the interrogator asks what happened on wall st and the interviewee states smart people took over wall street.

"Then, however, as college debts and Wall Street pay grew in tandem, the smart kids started going to Wall Street to make the money, leading to derivatives and securitization, until finally: “When the smart guys started this business of securitizing things that didn’t even exist in the first place, who was running the firms they worked for? Our guys! The lower third of the class! Guys who didn’t have the foggiest notion of what a credit default swap was.”

In the blog link, there's an interesting point about how what's valued in CEO succession, doesn't necessarily lead to a good CEO. "Even when you don’t have the generational issue that Trillin talks about, the problem is that the sociology of corporations leads to a certain kind of CEO, and as corporations become increasingly dependent on complex technology or complex business processes (for example, the kind of data-driven marketing that consumer packaged companies do), you end up with CEOs who don’t understand the key aspects of the companies they are managing."

I wonder if this is an issue in health care. Has health care delivery become so complex, doctors are so disengaged from the process of health care management and reform, that we've slowly gotten ourselves into the current mess that we are in?

I'm really stretching the parallelism here, but I wonder if there is something to it. That's why I guess I'm such a big fan of giving more power to MedPAC - a technocratic body that is independent from politics, and infused with seemingly intelligent and capable health care reform thinkers.

High-Deductible Health Plans

An article in yesterday’s New York Times discusses the composition and relative merits of high-deductible health plans, which are most often paired with George Bush's favorite cost-containment vehicle, the Health Savings Account. Despite the bitter taste in my mouth when I think about our former president (blech!), I think that high-deductible health insurance plans do have some merit.

First, let's ask ourselves what the point of insurance is. Sounds obvious, but health insurance has metamorphosed into a creature nothing like life insurance or car insurance. In the latter, you pay a premium and if something happens, you first pay a deductible and then, for catastrophic accidents, you get full coverage. Interestingly, having this deductible actually promotes health, sorry car, maintenance activities. After all, you'd rather shell out 20 bucks for an oil change than the 500 dollars for a new transmission down the road - not to mention your car runs smoother in the meantime. Health insurance should really function the same way: you pay premiums and if something really horrible happens, you get totally covered after you surpass the deductible. The way most traditional plans work now, you continue to pay a percentage of costs when your bone marrow transplant costs $1 million, which is why healthcare debt is the leading cause of bankruptcy in the country. Because they cover such unlikely events, high-deductible plans can afford to have cheaper premiums since they make more money on the front end than they lose on the back end.

High deductible plans are meant to reduce the effects of “moral hazard,” which is the notion that people will use more of a good if they are shielded from the costs of consumption. As has been described on these pages, Americans are voracious consumers of healthcare, so perhaps exposing consumers to some of the costs, while not thoroughly penalizing them if something untoward happens, might reduce spending. Alas, health is not like car maintenance, and people have little insight into how health promoting activities may lead to lower financial (not to mention emotional and physical) costs down the road. Because health is so opaque for consumers, they might be willing to defer that colonoscopy if it means they have to shell out $1000 dollars. Furthermore, many of the benefits of health promoting activities wouldn’t accrue to the health plans, but probably to Medicare. Insurance companies, therefore, have no incentive to subsidize “good” behavior now if the beneficiary is the government 20 years from now.

So, this is where the Health Savings account fits in. High-deductible plans paired with HSA's benefit consumers because a) it's a pre-tax contribution and b) employers will often chip in the first $500 to $1000 dollars, and c) HSAs are portable and you never lose what you put in. The HSA is intended to offset the moral hazard problem with high-deductible plans - again, that irrational consumers will avoid costly health promoting activities like skin checks if they have to pay any proportion of that out-of-pocket. Contributing to the HSA is purely voluntary, though, and I suspect those who are trying to save money aren't likely to build a battle-chest of money in case they get sick.

From a pure economics standpoint, these plans make sense. For them to work for everyone, though, I think policy makers have to force insurers to provide basic stuff like checkups, Pap smears, mammograms, etc. for very low or even free prices.

Challenging the Assumption that Costs Always Rise

In this week's New England Journal, David Cutler, an economist and adviser to the White House, lays out a pretty solid argument for why costs might not rise in the future, even without health payment reform. Our prevailing assumption has been that health care costs will continue to rise, at a pace faster than GDP, until health care bankrupts the nation.

Cutler contends this might not be true based on three core ideas:
1) Technology: the rapid rise in health care costs over the past 10 years has been largely fueled by innovations in pharmaceuticals and medical devices. Cutler points out that the pipeline for new technologies is starting to dry up, and increasing imaging costs might be mitigated by imaging benefit managers akin to pharmacy benefit managers. A formulary for how to diagnose knee pain might not be far off. Further, he notes, profitable new technologies tend to draw lots of competitors, so cost growth is likely to be offset by increased substitution effects.
2) Health IT: Obama's plan to increase spending on EMR's and decision support may cut out huge amounts of wasted time in paperwork and administration, not to mention cut costs from duplicated diagnostic testing.
3) Chronic Disease Management: this one's a little trickier for me (see Sree's last post), but Cutler suggests that by improving disease management, we prevent readmissions and therefore reduce acute care costs. Whether these savings are offset by increased life expectancy is yet to be determined.

Overall, I found this article pretty well researched and thought out and I'm reassured that our Doomsday scenarios might not come to pass. That said, I'm kind of glad it looks like health care spend is on the uptick, because it means policymakers are more likely to pass substantial health care reform in the near term.

Primary care and the health care cost curve

Guys, I need to submit a blog post to policy2.org to kick start a conversation amongst policy makers and academics on the role of primary care in health reform. Specific question I was asked to answer was "how does primary care bend the cost curve". This is my response - can you give me some feedback in the next 18hrs? Argument flow is weak at points. Doesn't need to win any awards - just start conversation. Need to submit by end of work day tomorrow:

------

Expanding primary care will not bend the cost curve.

All primary care doctors do is postpone the time of eventual death. The patient lives longer and ultimately develops new and more costly diseases that are the consequences of aging.

Ever heard these arguments? I have and it’s fascinating. Intuitively, this makes sense to me. In the cold calculus of economics, good primary care will prevent disease and extend life. As they say, taxes and death are both inevitable. And death costs money, and I have to believe death when you are older is more costly than death when you are slightly younger.

I’m making two huge sweeping assumptions here. First - Primary care saves lives. Second – Death when you are older costs more money to the system. I did a quick literature search to challenge these assumptions.

So let’s question the first assumption – does primary care save lives?

Mackinko et al.did an interesting little interesting literature review in the International Journal of Health Services in 2007. They pooled together a series of studies, re-cut the data in order to assess primary care effect size and the predicted effect on health outcomes of a one-unit increase in primary care physicians per 10,000 population. What they found was interesting - Primary care physician supply was associated with improved health outcomes, including all-cause, cancer, heart disease, stroke, and infant mortality; low birth weight; life expectancy; and self-rated health. Pooled results for all-cause mortality suggested that an increase of one primary care physician per 10,000 population was associated with an average mortality reduction of 5.3 percent, or 49 per 100,000 per year. Not bad.

I am assuming this is not surprising. Primary care physicians include family medicine doctors, internists, pediatricians, and in some instances, obstetrician–gynecologists. Currently, primary care accounts for about one third of the physician workforce in America. For many, primary care physicians are the first contact for a person with an undiagnosed health concern, they provide patients with the opportunities to prevent disease and they offer continuity and coordination of care for many complex conditions. Given their pivotal role in delivering care, it follows reasonably that they will save lives.

Now the second question – does primary care save money?

This is the tricky one. But one of my favorite studies on this question is from Lubitz et al. from his New England Journal article entitled “Health, Life Expectancy, and Health Care Spending among the Elderly” in 2003. They found that elderly persons in better health had a longer life expectancy than those in poorer health but had similar cumulative health care expenditures until death. A person with no functional limitation at 70 years of age had a life expectancy of 14.3 years and expected cumulative health care expenditures of about $136,000 (in 1998 dollars); a person with a limitation in at least one activity of daily living had a life expectancy of 11.6 years and expected cumulative expenditures of about $145,000.

Goetzel had an interesting framing of this question in his 2009 Health Affairs article: “Providing certain preventive services, mostly in clinical settings, does not save money. But, then again, neither do most medical treatments. The issue relevant to this debate is how much value is achieved for any given preventive or treatment service. Instead of debating whether prevention or treatment saves money, we should determine the most cost-effective ways to achieve improved population health, and where to focus scarce resources to get the "biggest bang for the buck."

Note that I did not ask “does prevention save money?” If asked, I’m not sure I could defend the assertion that “prevention saves money.” For example, screening costs can exceed the cost of treatment if only a small portion of a population would get sick without any preventative services. As a society, it might be cheaper to simply treat, and not always prevent.

The question I asked, however, was “does primary care save money?” The role of the primary care physician is not just prevention. Not to be heavy-handed, but I do believe they are the guardians of health – they help the patient navigate the complex decisions of life and health – of prevention and treatment. I believe this is how the primary care physician helps control costs – by helping patients make rational decisions about their care, and providing the longest and healthiest life as possible.

These are just some quick thought starters. I now hand the conversation over to you. I encourage you to use Policy2.org to more fully engage each other, challenge and explore the data, and construct the story that helps us tell the American people that primary care physicians play a vital role in creating a healthier country with greater economic opportunity for all.

Lobbyists Pull the Teeth out of Health Care Reform

An article in today's New York Times describes the frantic efforts of lobbyists to limit payment reform and hinder policymakers efforts to curb the spiraling cost of health care.

One of the most obvious reforms that's been proposed would be to tax high cost health plans which fuel rising costs because employers are more willing to accept higher premiums when they're tax free. Employees, generally unaware of the cost of health insurance, remain in the dark about what their employers are paying and therefore have no incentive to limit costs themselves. Congress has appropriately considered taxing so-called "Cadillac" plans in an effort to direct employers to purchase less costly health insurance plans and expose consumers to more of the costs. Naturally this check on rising costs is being challenged by the interests that have the most to lose - hospitals, doctors, and insurance companies. Ironically, big-labor has also opposed the reforms even though it would mean employers may pass on the savings in the form of increased wages. The CBO has given this initiative high marks in terms of cost-saving, yet lobbying efforts threaten to kill this part of the bill in committee.

The second major reform is to set up a non-partisan independent Medicare Commission, which seems a lot like the NICE in the UK. The commission would finally leverage Medicare's significant purchasing power to negotiate prices for drugs and negotiate lower costs with hospitals. Drug companies have negotiated only $80 billion in cost reductions over 10 years, which not only represents a drop in the bucket in terms of overall profits, but actually protects them in the long run. By agreeing to small losses, they would actually be protected from further cuts by the Medicare Commission even if five years from now there are major benefits to be extracted. Likewise, hospitals and the AMA are vigorously opposing the $155 billion in reductions to hospital and physician payments even though bloated, inefficient, and often profitable groups working essentially in a cost-plus environment currently have no incentive to limit their costs. What's left? Pilot programs in coordinated care, health IT, and comparative effectiveness (which get seriously dinged by the CBO).

This is just sad, and it's not just Republicans - Democrats in the House are being maneuvered, too. The Baucus bill that represents the only real change in the status quo is being so ticky-tacked that it's going to come out totally ineffective. I understand the need to pass something with some sort of bipartisan appeal, but what's the point if it can't effect any real change? The fact that our political process can't put together something that benefits citizens instead of the influential people that fund campaigns is absolutely pathetic.