Friday, October 24, 2014

Fwd: qotd: Improving trust in the profession

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From: Don McCanne <don@mccanne.org>
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The New England Journal of Medicine
October 23, 2014
Public Trust in Physicians — U.S. Medicine in International Perspective
By Robert J. Blendon, Sc.D., John M. Benson, M.A., and Joachim O. Hero,
M.P.H.

One emerging question is what role the medical profession and its
leaders will play in shaping future national health care policies that
affect decision making about patient care.

Research suggests that for physicians to play a substantial role in such
decision making, there has to be a relatively high level of public trust
in the profession's views and leadership. But an examination of U.S.
public-opinion data over time and of recent comparative data on public
trust in physicians as a group in 29 industrialized countries raises a
note of caution about physicians' potential role and influence with the
U.S. public.

In a project supported by the Robert Wood Johnson Foundation and the
National Institute of Mental Health, we reviewed historical polling data
on public trust in U.S. physicians and medical leaders from 1966 through
2014, as well as a 29-country survey conducted from March 2011 through
April 2013 as part of the International Social Survey Programme (ISSP),
a cross-national collaboration among universities and independent
research institutions.

In 1966, nearly three fourths (73%) of Americans said they had great
confidence in the leaders of the medical profession. In 2012, only 34%
expressed this view. But simultaneously, trust in physicians' integrity
has remained high. More than two thirds of the public (69%) rate the
honesty and ethical standards of physicians as a group as "very high" or
"high" (Gallup 2013).

Today, public confidence in the U.S. health care system is low, with
only 23% expressing a great deal or quite a lot of confidence in the
system. We believe that the medical profession and its leaders are seen
as a contributing factor.

This phenomenon does not affect physicians in many other countries.
Indeed, the level of public trust in physicians as a group in the United
States ranks near the bottom of trust levels in the 29 industrialized
countries surveyed by the ISSP. Yet closer examination of these
comparisons reveals findings similar to those of previous U.S. surveys:
individual patients' satisfaction with the medical care they received
during their most recent physician visit does not reflect the decline in
overall trust. Rather, the United States ranks high on this measure of
satisfaction. Indeed, the United States is unique among the surveyed
countries in that it ranks near the bottom in the public's trust in the
country's physicians but near the top in patients' satisfaction with
their own medical treatment.

Part of the difference may be related to the lack of a universal health
care system in the United States. However, the countries near the top of
the international trust rankings and those near the bottom have varied
coverage systems, so the absence of a universal system seems unlikely to
be the dominant factor.

The United States also differs from most other countries in that U.S.
adults from low-income families (defined as families with incomes in the
lowest third in each country, which meant having an annual income of
less than $30,000 in the United States) are significantly less trusting
of physicians and less satisfied with their own medical care than adults
not from low-income families.

In drawing lessons from these international comparisons, it's important
to recognize that the structures in which physicians can influence
health policy vary among countries. We believe that the U.S. political
process, with its extensive media coverage, tends to make physician
advocacy seem more contentious than it seems in many other countries.
Moreover, the U.S. medical profession, unlike many of its counterparts,
does not share in the management of the health system with government
officials but instead must exert its influence from outside government
through various private medical organizations. Moreover, in terms of
health policy recommendations, the U.S. medical profession is split
among multiple specialty organizations, which may endorse competing
policies.

Nevertheless, because the United States is such an outlier, with high
patient satisfaction and low overall trust, we believe that the American
public's trust in physicians as a group can be increased if the medical
profession and its leaders deliberately take visible stands favoring
policies that would improve the nation's health and health care, even if
doing so might be disadvantageous to some physicians. In particular,
polls show that Americans see high costs as the most important problem
with the U.S. health care system, and nearly two thirds of the public
(65%) believes these costs are a very serious problem for the country.
To regain public trust, we believe that physician groups will have to
take firm positions on the best way to solve this problem. In addition,
to improve trust among low-income Americans, physician leaders could
become more visibly associated with efforts to improve the health and
financial and care arrangements for low-income people. If the medical
profession and its leaders cannot raise the level of public trust,
they're likely to find that many policy decisions affecting patient care
will be made by others, without consideration of their perspective.

http://www.nejm.org/doi/full/10.1056/NEJMp1407373

****


Comment by Don McCanne

Another unique feature of the U.S. health care system that sets us apart
from other nations: "You just can't trust doctors nowadays, but my
doctor is really good." What can we make of this?

In general, individuals are relatively satisfied with their personal
care. Low-income individuals are less satisfied, but that is likely
related to the deficient financing of their care and the consequences of
that - a characteristic of our fragmented, dysfunctional system of
financing health care. But, overall, our system is capable of ensuring
patient contentment.

It is the confidence in physician leadership that has deteriorated. The
authors of this article suggest some possible explanations, but it is
more likely that the image of the profession at large has changed from
that of the dedicated personal physician steeped in the Hippocratic
tradition, to that of the high-tech, entrepreneurial agent of the
medical-industrial complex. Combine that perspective with the very high
costs of health care today - costly care which physicians orchestrate -
and it is no wonder that the public is no longer as trusting of the
profession. Only "my doctor" is immune to this.

When you look at the role that the AMA had in the enactment of the
Affordable Care Act, it is evident that they were not there to represent
patients; they were there alongside the other elements of the
medical-industrial complex - especially the insurance, pharmaceutical
and hospital industries - to be sure that they got their own share of
the action. The only patient advocates present were the consumer
organizations that chose the default option of "political feasibility,"
becoming "strange bedfellows" of the private insurance industry.

There are many dedicated individual physicians and other health care
professionals who clearly place patients first. They are well
represented in organizations such as Physicians for a National Health
Program. They are also well represented in the AMA and the various
specialty organizations, but, as a collective voice, they are
ineffective in communicating the tradition of caring; rather they
passively communicate the acceptance of the medical-industrial complex -
a very sterile advocacy position.

Let's indulge in a fantasy. Let's imagine that our professional
organizations all joined together in a clarion call for comprehensive,
affordable, high-quality care for absolutely everyone - including those
low-income individuals who distrust the profession today. Single payer
would bring us such quality that is truly affordable.

With a voice unified in support of the patient, what do you think would
then happen to the level of confidence that the public has in the
medical profession? Physicians would once again relish respect as a
noble profession advocating for their patients. As an aside, it would
also mean that they would have a very pleasant work environment and be
adequately compensated for their efforts. If the system works for
patients, it will work for physicians.

Thursday, October 23, 2014

Fwd: qotd: Administrative burden on U.S. physicians

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International Journal of Health Services
Volume 44, Number 4 / 2014
Administrative Work Consumes One-Sixth of U.S. Physicians' Working Hours
and Lowers Their Career Satisfaction
By Steffie Woolhandler and David U. Himmelstein

Abstract:

Doctors often complain about the burden of administrative work, but few
studies have quantified how much time clinicians devote to
administrative tasks. We quantified the time U.S. physicians spent on
administrative tasks, and its relationship to their career satisfaction,
based on a nationally representative survey of 4,720 U.S. physicians
working 20 or more hours per week in direct patient care. The average
doctor spent 8.7 hours per week (16.6% of working hours) on
administration. Psychiatrists spent the highest proportion of their time
on administration (20.3%), followed by internists (17.3%) and
family/general practitioners (17.3%). Pediatricians spent the least
amount of time, 6.7 hours per week or 14.1 percent of professional time.
Doctors in large practices, those in practices owned by a hospital, and
those with financial incentives to reduce services spent more time on
administration. More extensive use of electronic medical records was
associated with a greater administrative burden. Doctors spending more
time on administration had lower career satisfaction, even after
controlling for income and other factors. Current trends in U.S. health
policy—a shift to employment in large practices, the implementation of
electronic medical records, and the increasing prevalence of financial
risk sharing—are likely to increase doctors' paperwork burdens and may
decrease their career satisfaction.

From the Discussion

A few studies have examined the amount of time physicians spend on
billing and insurance-related paperwork—a narrower definition of
administrative work than we used. A 2000 California study estimated
billing and insurance-related work consumed 4.9 percent of physician
time. In a 2006 survey, physicians reported spending 3 hours per week
interacting with private insurance plans, with primary care doctors and
solo practitioners reporting slightly higher figures; 81.5 percent
perceived that this work was increasing. A companion 2006 survey of
office-based private practitioners in Ontario found they spent 2.2 hours
per week interacting with insurers (vs. 3.4 hours in the United States
when Medicare and Medicaid were included along with private insurers).
Differences in the time spent on these tasks by non-physician office
staff were even larger; 20.6 hours of nurse time per physician in the
United States versus 2.5 hours in Canada; 53.1 hours per week of
clerical time in the United States versus 15.9 hours in Canada; and 3.1
hours per week of senior administrators' time in the United States
versus 0.5 hours in Canada.

Much time and money are currently spent on medical billing and
paperwork. A simpler system could realize substantial savings, freeing
up more resources to expand and improve coverage.

International Journal of Health Services (click on the article for the
abstract):
http://baywood.metapress.com/app/home/issue.asp?referrer=parent&backto=journal,1,176;linkingpublicationresults,1:300313,1

Full article:
http://org.salsalabs.com/o/307/images/Physician%20admin%20time_IJHS.pdf

PNHP Press Release:
http://www.pnhp.org/news/2014/october/administrative-work-consumes-one-sixth-of-us-physicians'-time-and-erodes-their-mor

****


Comment by Don McCanne

The health care system in the United States is unique for its profound
administrative waste. This article by Steffie Woolhandler and David
Himmelstein demonstrates the intensity of the administrative burden on
physicians - a burden that is correlated with lower career satisfaction.

The good news is that we could reduce that burden and improve
satisfaction by adopting a single payer system such as they have in
Canada. But then the bad news is that we have left the political agenda
in the hands of those who are adept at buying the votes in Congress -
especially the insurance and pharmaceutical industries.

It doesn't have to be this way. After all, we are a democracy, but we
have to make the effort to have our voices heard.

****

U.S. Department of State
Bureau of International Information Programs

What Is Democracy?

The essence of democratic action is the active, freely chosen
participation of its citizens in the public life of their community and
nation. Without this broad, sustaining participation, democracy will
begin to wither and become the preserve of a small, select number of
groups and organizations.

At a minimum, citizens should educate themselves about the critical
issues confronting their society--if only to vote intelligently for
candidates running for high office.

http://www.ait.org.tw/infousa/zhtw/docs/whatsdem/whatdm3.htm

Wednesday, October 22, 2014

Fwd: qotd: Important: Uwe Reinhardt on health care price transparency and economic theory

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JAMA
October 22/29, 2014
Health Care Price Transparency and Economic Theory
By Uwe E. Reinhardt, PhD

Citizens in most economically developed nations have health insurance
coverage that results in only modest cost sharing at the time health
care is used. Furthermore, physicians, hospitals, and other clinicians
and entities that provide health care within most systems outside the
United States are paid on common fee schedules uniformly applied to all
clinicians, health care organizations, and insurers. That approach
spares the insured the need to seek out lower-priced health care and
obviates the need for transparency on the prices charged by individual
clinicians and organizations that provide health care.

Not so in the United States, where every private health insurer
negotiates prices with every health care practitioner and organization,
where large public health insurance systems such as Medicaid and
Medicare pay fees that do not cover the full cost of treating patients
covered by these programs, and where uninsured, self-paying patients can
often be asked to pay whatever can be extracted from their household
budgets, sometimes with the help of debt collectors and the judiciary.
Economists call the approach price discrimination, which means the
identical service is sold to different buyers are different prices.

This approach to pricing health care has led in the United States to a
system in which, at one end of the spectrum, hospitals and physicians
are expected by society to treat low-income patients free of charge, on
a charitable basis, or for modest fees that do not cover the cost of
those treatments and then to finance that informal catastrophic health
insurance system for the poor out of the other part of their enterprises
that they can operate as profit-maximizing business firms. This is true
even in some of the large segment of institutions referred to as
not-for-profit. The harsh excesses that this quest for profits in health
care can unleash—even among not-for-profit hospitals—have been well
reported in various articles in the popular press.

Private employers in the United States have played a pivotal role in the
evolution of this system. They hired as their agents in health care the
private insurers who helped put that system into place, and they
supported it. To gain better control over the growth of their health
spending, employers have of recent resorted to a technique long
recommended to them by the market devotees among health economists,
namely, putting the patient's "skin in the game," as the jargon goes. It
is done with health insurance policies imposing on the insured very high
annual deductibles before insurance coverage even begins, followed by
significant coinsurance, perhaps requiring patients to pay 10% to 20% of
every medical bill, up to a maximum total annual out-of-pocket
expenditure that can potentially exceed $10 000 for a family.

This approach of shifting more of the cost of employment-based health
insurance visibly and directly into the household budgets of employees
amounts to rationing parts of US health care by price and ability to pay
and delegates the bulk of the hoped-for belt-tightening to low-income
families. Because the word rationing is anathema in the US debate on
health policy, the strategy has been marketed instead under the
felicitous label of consumer-directed health care, presumably designed
to empower consumers in the health care market to take control of their
own health care. However, this strategy, based mainly on economic
theory, so far has put the cart before the horse.

In virtually all other areas of commerce, consumers know the price and
much about the quality of what they intend to buy ahead of the purchase.
This information makes comparison shopping relatively easy and is the
sine qua non of properly functioning markets. By contrast,
consumer-directed health care so far has led the newly minted consumers
of US health care (formerly patients) blindfolded into the bewildering
US health care marketplace, without accurate information on the prices
likely to be charged by competing organizations or individuals that
provide health care or on the quality of these services. Consequently,
the much ballyhooed consumer-directed health care strategy so far has
been more a cruel hoax than a smart and ethically defensible health policy.

http://jama.jamanetwork.com/article.aspx?articleid=1917413

****

JAMA
October 22/29, 2014
Association Between Availability of Health Service Prices and Payments
for These Services
By Christopher Whaley, BA; Jennifer Schneider Chafen, MD, MS; Sophie
Pinkard, MBA; Gabriella Kellerman, MD; Dena Bravata, MD, MS; Robert
Kocher, MD; Neeraj Sood, PhD

Conclusions

Use of price transparency information was associated with lower total
claims payments for common medical services. The magnitude of the
difference was largest for advanced imaging services and smallest for
clinician office visits.

http://jama.jamanetwork.com/article.aspx?articleid=1917438

****


Comment by Don McCanne

In a JAMA editorial commenting on an article about price transparency
and health care spending, Uwe Reinhardt first describes the ridiculous
system we currently have, concluding, "the much ballyhooed
consumer-directed health care strategy so far has been more a cruel hoax
than a smart and ethically defensible health policy."

He then discusses the article by Christopher Whaley and his colleagues
in which they describe price savings resulting from health care price
shopping: an average of a mere $1.18 for clinician office visits, $3.45
for laboratory tests, and a more impressive average savings of $124.74
for advanced imaging services.

Imaging aside, think about that one dollar saved by shopping office
visit prices. Does that one dollar really pay for the labor involved in
price shopping, much less the additional transportation costs and other
inconveniences of going to a different doctor, not to mention the
disruption in care provided by a primary care medical home? Not exactly
a shopper's paradise.

Even the more significant savings in advanced imaging can have drawbacks
if it results in non-coordinated care outside of a system functioning as
an integrated unit, whether or not it is technically a single integrated
health care entity.

But what is really important here lies in Uwe Reinhardt's comments. As
he states, "other clinicians and entities that provide health care
within most systems outside the United States are paid on common fee
schedules uniformly applied to all clinicians, health care
organizations, and insurers. That approach spares the insured the need
to seek out lower-priced health care and obviates the need for
transparency on the prices charged by individual clinicians and
organizations that provide health care."

Other nations pay the right amount to sustain he system, without the
waste of overpaying some nor the threat of inequitable access caused by
underpaying others. No matter how much price transparency we have in the
United States, our highly dysfunctional, fragmented system of financing
health care will never get pricing right.

Yes, we need a single payer national health program. Under such a system
the pricing would be transparent to our public administrators, and who
better could determine whether or not the price is right? We surely can't.