Medical care costs and the entrepreneurial physician

Joe Gibe’s post last Friday about the incentives within US healthcare that drive the overuse of expensive technology made me think of an article I had read several years ago. In June of 2009 The New Yorker published an article by Atul Gawande describing his investigation of why McAllen, Texas had among the highest per capita Medicare costs in the country. He compared McAllen to the demographically similar city of El Paso and interviewed people involved in health care in both communities. His conclusion was that McAllen had an unusually large number of entrepreneurial physicians. These were physicians who saw medicine primarily as a source of revenue and who many times made much of their income from other things besides direct patient care.

He reached this conclusion after finding that the difference between McAllen and El Paso was that there was higher utilization of services for patients with the same medical problems in McAllen than in El Paso even thought the populations were similar and there was no evidence of those in McAllen having better results than those in El Paso. The thing that was different was how the physicians looked at medicine. Many more in McAllen saw it primarily as a business.

The point is not that being an entrepreneur is bad. There are many ways that we as a society benefit from those willing to take on risks and try new ventures. It just is not a good mix with caring for patients. To function well the practice of medicine needs to be a profession that is focused on doing what is best for the patient. We see that in the long tradition of Hippocratic medicine. The current model of medicine as a contract between physicians, patients, and payers sees medicine as a business and encourages the physician to be an entrepreneur. It puts the focus on maximizing revenue and not on the best interest of the patient. Even those who enter into medicine with the intent to put the interest of patients first can get caught up in the pressures of this business model.

As we look at ways to improve our broken “system” of providing healthcare we need to remember the importance of promoting the traditional focus of medicine as being a profession founded on beneficence. Gawande observed that those places where the best quality medical care is provided for the lowest cost are those where there is an emphasis on putting what is best for the patient above everything else.

Technology and health care reform


A couple of letters in this week’s Archives of Internal Medicine provide a picture of some of the more perverse incentives to overuse technology that are built into our current health care delivery “system.” One letter describes a study of proton beam therapy for treatment of prostate cancer. Proton beam therapy has never been shown to be superior to standard photon-based therapy for the treatment of prostate cancer; it is, however, novel, high-tech, “cool,” and way more expensive. The study showed that the mere availability of the technology, rather than any clinical indication, drove its utilization: “If you build it,they will come” (and spend!).

Another letter addressed the systemic factors that influence physicians to use more technology, whether clinically warranted or not: “The sheer amount of technology available may lead some [doctors] to look askance at the value of their clinical skill and bypass them in favor of testing. This can lead to a technological addiction that is every bit as difficult to break as a substance addiction.”  In the reply to this letter, the authors wrote of “several systemic factors that promote a ‘more is better’ approach: a reimbursement system that rewards diagnostic testing while failing to provide physicians enough time with patients to avoid it; performance measures that reward doing more with no attempt to measure doing too much; and a malpractice system perceived to expose physicians to legal punishment for doing too little but not for doing too much.”

The incentive to use more technology is not only inherent in the nature of technology itself (see Jacques Ellul’s The Technological Society), but is built into the fabric of our health care “system.” The cost of that technology is a large part of what is making health care unaffordable for all except the healthy. Any health care reform scheme that does nothing to change these structural incentives is so much wind. The reform schemes put forth by the two major political parties are pathetic, cosmetic band-aids that do nothing to get even close to the root of the problem (“Uh, let’s find different ways for people to buy insurance!”). Such band-aids amount to a joke; only it’s hard to laugh when so much is at stake.


Sources:  Aaronson et al., “Proton Beam Therapy and Treatment for Localized Prostate Cancer: If You Build It, They Will Come,” pp. 280-282; letter from Volpintesta, “Training in Uncertainty Has Value for Primary Care Physicians: Overreliance on Technology Can be Remedied,” p. 297; and the reply by Sirovich et al., p.297, Archives of Internal Medicine, Vol 172 (No. 3), Feb 13, 2012.

The aftermath of a state eugenics program


Elaine Riddick was 14 when she became pregnant by rape in North Carolina in 1968. A committee of five men called the Eugenics Board decided that, “Because of Elaine’s inability to control herself, and her promiscuity — there are community reports of her ‘running around’ and out late at night unchaperoned — the physician has advised sterilization. … This will at least prevent additional children from being born to this child who cannot care for herself, and can never function in any way as a parent.” A few hours after her son was born, a physician sterilized Ms. Riddick without her knowledge. (I am astonished to discover that there was still a Eugenics Board in my lifetime; I had thought that was all pre-WWII)

Now, more than 40 years later, another five-person board, the Governor’s Eugenic Compensation Task Force, has proposed giving $50,000 to each living victim of its eugenics program. Of the 7,600 people sterilized under the program between 1929 and 1974, some 2,000 are still alive. Ms. Riddick is incensed at the notion: “Fifty thousand dollars? Is that what they think my life is worth? How much are the kids I never had worth? How much?”

North Carolina was only one of more than 30 states that carried out eugenics programs that forcibly sterilized up to 65,000 people, but it had one of the more robust programs.  “The board’s declared goal was to purify the state’s population by weeding out the mentally ill, diseased, feebleminded and others deemed undesirable. . . In a 1950 pamphlet, the Human Betterment League of North Carolina said the board was protecting ‘the children of future generations and the community at large,’ adding that ‘you wouldn’t expect a moron to run a train or a feebleminded woman to teach school.'” The state carried out its program using deception if necessary, telling subjects that they were going in for appendectomies or that the operations were reversible.

Who knows which accepted, scientific practices of today will be the stuff of attempts at corrective action of tomorrow? Embryonic stem cell research? Commercial surrogacy? Paying young women to “donate” eggs? Human organ trafficking? Whatever it will be, as the story of Elaine Riddick demonstrates, money can never compensate someone for having their basic human dignity ignored and trampled upon.

(All quotes from the LA Times article link)

Religious freedom and health insurance

On January 20, 2011 the department of Health and Human Services announced its ruling regarding a controversial part of the current administration’s healthcare plan. The health care plan includes a provision requiring all insurance providers to cover contraception at no cost to those who are insured. There is a religious exemption in the plan that allows churches who are morally opposed to contraception to offer insurance to their employees which does not provide this coverage. However, this exemption does not include church-affiliated organizations such as schools and hospitals. After the original requirement was made public last August, many church-affiliated organizations had requested that they be included in the exemption. The announcement a week and a half ago stated that such church-affiliated organizations would not be included in the exemption and would have to provide the coverage even if it violated the moral convictions of the organization. Those organizations were given an extra year before they have to comply with the regulation, but their compliance will be required.

This ruling is a significant attack on religious liberty in the United States. Religious liberty should include protection from being forced by the government to violate one’s moral values. It should include more than just the freedom to have beliefs. It must include the freedom to live in a way that does not violate those beliefs. Since the primary religious organization that has taken a moral stand against the use of contraception is the Roman Catholic Church, many see this is a purely Catholic issue, but it is much more than that. I do not happen to agree with the Roman Catholic position that says that all contraception is morally impermissible, but it is a well reasoned position based on fundamental parts of the Roman Catholic faith. As such their position should be respected, and they should not be forced by our government to violate their moral beliefs.

One part of the ruling impacts many non-Catholic church-affiliated organizations. The requirement for covering contraception includes drugs such as Plan B and Ella that are used after unprotected sexual intercourse to prevent a pregnancy from continuing if one has occurred. These medicines are not actually contraception because they do not work primarily to prevent conception, but to prevent the continuation of a pregnancy before the pregnancy is known to exist. Many of us to come from an evangelical Christian position find being forced to pay for these medicines just as morally objectionable as the Roman Catholic Church views other types of contraception.

It is interesting that when Robert George, Timothy George, and Chuck Colson drafted the Manhattan Declaration back in 2009 they chose to affirm three foundational moral principles which Christians from the Orthodox, Roman Catholic, and Evangelical traditions all supported. Those three principles were the inherent dignity of every human being, marriage as a conjugal union of man and woman, and religious liberty. I think there are many who may have wondered why they included the third principle as something on which Christians needed to take a stand. This ruling by HHS helps to make that more clear.

Science, politics, ethics, and emergency contraception

Last December 7th, Health and Human Services Secretary Kathleen Sebelius instructed the FDA not to give over-the-counter (OTC) status to the emergency contraceptive drug Plan B One-Step for girls under age 17 (It is currently OTC for all women 17 years of age and older). Sebelius gave as her reason her “conclusion that the data … are not sufficient to support making Plan B One-Step available to all girls 16 and younger, without talking to a health care professional.”

Commentators immediately went ballistic, bemoaning the “fact” that the science shows that this product should be approved OTC for all ages, but that politics overruled the science. Last week a Perspective piece in the New England Journal of Medicine (NEJM) made the same assertion, as did an earlier Viewpoint in JAMA.

However, there is more to these claims of scientific-objectivity-being-overruled-by-politics than meets the eye. Science can only tell us what is or what can be, never what should be. You cannot from the premise, “We can do such-and-such,” derive the conclusion, “Therefore, we should do such-and-such,” without the intervening value statement that “Such-and-such is good, or desirable, or right.”

In his inaugural address, President Obama promised to “restore science to its rightful place” in government, to “base our public policies on the soundest science.” But public policy decisions are inevitably decisions about what should be done; every regulation in the law is an acknowledgement that those governing believe that one particular way of doing or taxing or regulating something is better than the alternatives. In other words, every policy decision is based in some part on ethics and morals — things which objective science cannot reveal to us. To “restore science to its rightful place” means “let’s get our facts straight.” This is important: good ethics (and good policy) must start with good facts. But science’s rightful place is not, and cannot be, to make the ethical decision for us.

Science can tell us the chances of Plan B One-Step preventing pregnancy after unprotected intercourse. It can give us statistics about how women use it and what the potential side effects are. It can not tell us whether or not it is a good thing that a 12-year-old who just had unprotected intercourse should be able to get the medicine without talking to an adult such as a medical provider.

Sebelius appealed to a lack of scientific data in making her decision; I do not know if she also had an unspoken political agenda. It seems at least mildly improbable that someone so staunchly pro-choice, who is part of the administration of a President and a political party that do not oppose Plan B on political or ideological grounds, would herself do so to gain political points or power. But I do know that, contrary to all the pundits, this decision, like all policy decisions, cannot be made by empirical science alone. The accusation of “Politics trumps science” is just a front for those whose own politics, morals, and ethics lead them to a different conclusion.

Inappropriate clinicians

An article in the December 28th 2011 JAMA reports a study of doctors and nurses in 82 ICUs across Europe and Israel. These clinicians were asked whether they had provided inappropriate care, defined as “care that clashes with your personal beliefs and/or professional knowledge,” on a particular day. More than one-fourth believed the care they provided on that day was inappropriate.

An accompanying editorial asks the million-dollar question, “If so many clinicians are providing care that is not motivated by its appropriateness, what then are they trying to accomplish?”

What, indeed? Isn’t providing care that contradicts one’s beliefs and knowledge tantamount to providing unethical care?

From my own experience, I will hazard a guess that if the clinicians had been questioned about a longer time period than just one day, way more than one-fourth of them would have reported providing inappropriate care; and that the problem of providing inappropriate care extends well beyond the ICU to clinicians everywhere. I will also hazard a few guesses at just some of the motivations behind providing inappropriate care:

-The clinicians want to please patients or families, and/or are experiencing pressure from the families to provide inappropriate care;

-The clinicians are required to follow guidelines that are based on the statistical analysis of large populations, but happen not to apply to the individual patient being treated;

-The clinicians are attempting to prevent a malpractice lawsuit by doing more tests and procedures than are appropriate;

-The clinicians are following inappropriate laws, such as the one  drafted by the NRA and the Florida legislature restricting physicians’ ability to properly counsel patients.

Most reasons underlying inappropriate care stem not from the deliberately unethical practice of the clinician (although I do not deny that such things occur), but from characteristics of the system which induce them to act in ways that they feel are inappropriate.

The idealist in me believes that most people who go into medicine and nursing do so because they want to help people. Virtually all of the nurses and physicians I know (and I know quite a few) want to do the best thing for their patients. But all of these idealistic people are taken and thrown into a system that influences them to act in ways that they believe are inappropriate. The clinicians find themselves, for reasons beyond their control, giving inappropriate care.

Is inappropriate care always unethical care? How can one be an ethical clinician in a system that prevents one from acting appropriately?

A Lament For the Loss of Community

This guest post is authored by LL French, a current student at TIU.

Community is dead. Cause of death: uncertain. But definitely dead, gone, passed, slipped on a banana peel, deceased, dead!

For Millennials like me, we’ve never lived in a world where neighbors help each other. After all, isn’t that the job of the government? Welfare? Food stamps? Medicaid? (Please note the heavy tone of sarcasm in my voice right now.)

Let me explain the reason behind my cynical rant on community. Today my little bioethics-obsessed mind ran across a CNN news article. In the story, Baby Pierce, a four-month-old with rare Heterotaxy Syndrome, needed heart surgery. Demanding the best care for her infant son, Pierce’s mother insisted on sending her baby to a top Boston hospital for his care.

Problem: Medicaid wouldn’t pay to send him to Boston when another “capable” hospital existed in Indiana.

Solution: fundraising on Facebook and donations from mothers of children with heart problems!

Now for the quote that convinced me that community was dead – in the words of Pierce’s mother: “I think it is sad that a bunch of moms and strangers who don’t even know me or my child have stepped up to the plate more than… the government, and insurance, and Medicaid.” This statement troubles me. She thinks “it is sad” for strangers to help? Isn’t that the very essence of community? Isn’t community, by definition, any group of people that come together to encourage, support, and protect you?

Should Medicaid have helped the young mother? I’ll leave that question to more capable minds. What I am shocked by is the assumption that strangers shouldn’t help! I fear we now live in a world where we rely on the government too much. We rely on the government to be the Good Samaritan that we once were. I mourn the loss of a traditional community where generosity to those in need was normative. Indeed, I fear bioethics and health care in general has much to lose if community dies.

Yes, I exaggerate. There is hope. Community is not dead, but perhaps transformed? Yes, we don’t live in a world where neighbors help each other. Instead, we live in a world where random people on Facebook can form a community to save a baby! Our traditional sense of community has been replaced by Facebook, Twitter, and texting, etc. As a natural cynic, I doubt Facebook’s power to bring people together in community, but Baby Pierce gives me hope that people can come together to form a new kind of community – but only if we are intentional in our pursuit of community and we lose this silly notion that strangers shouldn’t help each other.

See more on Baby Pierce

Of IOM, IT, EMRs, patient safety, and quality


If your doctor’s not looking you in the eye quite as much as he or she used to, it may be partially the fault of the Institute of Medicine (IOM).

In 1999, the IOM published a report entitled “To Err is Human: Building a Safer Health System,” which famously concluded that preventable medical errors cause up to 98,000 patient deaths annually. This was followed by the 2001 report, “Crossing the Quality Chasm: A New Health System for the 21st Century.” These reports touted, among other things, the power of health information technology (IT), including Electronic Medical Records (EMRs), to reduce medical errors, increase patient safety, and increase the quality of medical care. Subsequently, the federal government has stepped in, providing financial incentives for physicians who can demonstrate “meaningful use” of an EMR, and will soon be imposing financial penalties on those physicians who don’t climb onto the EMR bandwagon. Thus, the IOM is directly or indirectly responsible if your doctor isn’t looking you in the eye because she’s gazing into a computer screen instead.

Upon what evidence did the IOM base its assertion that EMR’s would improve safety and quality? Well … you know … it’s just kinda obvious, isn’t it? I mean, after all, it’s technology, and it’s gotta be better than paper, and it just makes sense that using more technology is better, right?

In fact, there was no data to suggest that health IT would improve either the quality or the safety of medical care. In the intervening years, as health IT implementation has exploded, there continues to be a paucity of data to suggest that health IT improves either the quality or the safety of medical care. There is good data that it introduces new errors and quality problems into health care.

Last month the IOM released a new report, calling for the formation of an independent federal body to investigate patient deaths and other adverse events caused by … drumroll, please … health information technology.

Dr. Richard I. Cook, an associate professor of anesthesia and critical care at the University of Chicago, said, “It’s not surprising that such adverse events are being found related to health IT, and it’s not surprising that those promoting these systems have neither looked for them nor anticipated them. To make large-scale investments in these systems and only now be looking at the impact on patient safety borders on recklessness.” Dr. Scot M. Silverstein, a consultant in medical informatics at the Drexel University College of Information Science and Technology in Pennsylvania, said that it is “unethical” to expand health IT so dramatically without understanding the precise nature of the risks it poses to patients.

“Reckless” … “unethical” …

Meanwhile, my doctor’s still not looking me in the eye because he’s trying to find something in the computer. Sheesh! This is quality improvement?? Have we simply created a new “Quality chasm”?


(The quotes above are from this story which was published in the AMA news.)

Infinite demand and the drawing of lines


Many of the problems with health-care financing in our country come about as a result of difficulty with line-drawing. I’m not talking about geometry, but about making hard decisions.

This difficulty with line-drawing is not new. In 1971, while Congress was debating national health insurance (!), a man named Shep Glazer testified in dramatic fashion before the House Ways and Means Committee about funding for renal dialysis — while hooked up to a dialysis machine. “Gentlemen,” he said, “what should I do? End it all and die? . . . If your kidneys failed tomorrow, wouldn’t you want the opportunity to live? Wouldn’t you want to see your children grow up?” After thirty minutes of debate in the Senate and ten minutes in a House-Senate conference committee, Congress voted to extend Medicare coverage to any and all who need dialysis. The uncharacteristically short amount of time spent considering this action, one that should have raised some very hard questions about things like the just distribution of limited resources, suggests that the hard questions were ignored in favor of doing something that feels on the surface very good — paying for everybody’s dialysis — but that has far-reaching, unexamined consequences.

An excellent article in the Chicago Tribune last week described a recent iteration of the old problem. Through medical advances, increasing numbers of our oldest citizens are being made healthier by procedures that were once reserved only for younger people: it is not unusual for people in their 90s to have hip replacements or a 102-year-old to have a heart valve replacement. Now, these are good things! These people are living more fruitful lives through medical procedures. But they are living under a system, Medicare, that does not consider price, but only benefit to the patient, in making decisions about what medical procedures it will cover. And as the proportion of the population receiving Medicare expands, and as expensive medical techniques proliferate, the demand for such procedures will be virtually infinite. Unfortunately ,the resources to pay for them will be all-too finite.

At some point we have to go beyond emotional appeals, beyond doing the thing that feels the best but which bankrupts the country (covering everything for everybody at any cost). At some point we have to draw lines, to make hard decisions about who will get what — and who won’t.

What is the most ethical, most just way to make this decision? The Tribune article mentions one solution put forth by Daniel Callahan and Sherwin Nuland: set a cutoff age (they suggest 80) beyond which people will not be covered for anything beyond “good basic health care.”

Callahan said, “If you want to save all lives, you’re in trouble. And if you want to save all lives at any cost, you’re really in trouble. . . We need to stop thinking of medicine as an all-out war against death, because death always wins.”

Callahan’s perspective in that last statement is a good corrective to distorted expectations of medicine. I don’t agree with how and where he draws the line on providing medical care; but if it gets the discussion going, it’s at least a place from which to start.

Musings from a nursing home


It has been five months today since my sister had the first of many brain surgeries for a burst aneurysm. I was visiting her yesterday, and the visit prompted the following random bioethical thoughts.

Health-care payment reform – My sister is in a nursing home, and until recently had been receiving various therapies. Earlier this month her insurance ran out, and suddenly — without notice — now she receives none.

This situation is not surprising, given the claptrap patchwork of healthcare payment that passes for a system in our country. The health-care payment reform debate has been so politicized — that is, it has become a tool of political power that each party wields as a weapon against its opponent — that rational, ethical discourse on the subject seems to have been left in the dust. There is a more ethical way to deliver health care; however, as long as we leave it up to lobbyists, interest groups, and two political parties that seem more intent on power than government, we will see increasing numbers of people left in the medical and political dust.

Human dignity – By some standards, my sister might be thought of as having lost her human dignity. Before June 11th she was an energetic, triathlon-running, blog-posting woman; now we are excited if she can manage a hand-squeeze or a groan. By some estimations, she might be said to have a “life not worth living.” According to some bioethicists, she doesn’t have what it takes to be treated with the respect due to human persons. I’m sure glad they haven’t been taking care of her these last five months.

The search for a cure – Putting aside for the purpose of argument all of the insurmountable hurdles that have to be overcome, imagine for a moment that the fondest dreams of certain researchers reach fruition, and that embryonic stem-cell therapy for brain trauma becomes a reality. Imagine (you have to imagine, because it is all imaginary at this time, never mind the rhetoric to the contrary): What if my sister could walk and talk and laugh again, if only we were willing to sacrifice an embryo, “a glob of cells smaller than the period at the end of a sentence,” maybe an embryo leftover from IVF in fertility-clinic-freezer limbo somewhere?

Much of the Church has taken a stand against embryonic stem-cell research, as is right. But it’s easy to oppose something that has no forseeable hope of becoming reality. What would happen if the unthinkable became possible? Would the Church still stand against it? If cures for your daughter’s diabetes, your son’s leukemia, your wife’s brain tumor, your mother’s Alzheimer’s, were an embryo away? Would we be like the liberal bioethicists and find justifications for what we now rightly oppose? Or would we continue to respect all humans, no matter what size or developmental stage, even to our own hurt?