Monday, August 31, 2009

The perfect storm

I wrote in my earlier post about the excellent work Deafening Silence is doing analyzing Dr. Ezekiel Emanuel’s writing. I had actually planned to do this myself at some point and I cannot tell you how glad I am to find someone else tackling it. When I was contemplating this project I did complete most of an analysis of Dr. Emanuel’s June 18, 2008, article in the Journal of the American Medical Association. The article is entitled “The Perfect Storm of Overutilization” and Deafening Silence has up three posts about this article: an overview; an examination of his International Comparisons chart; and a closer look at OECD health data in general.

After reading Deafening Silence, I decided to go ahead and put up what I had by way of analysis even though much of it duplicates Deafening Silence’s overview. I come to a particular conclusion about Dr. Emanuel and I think my analysis of this article leads to that overview. Please do go read Deafening Silence’s posts. She goes into far more detail, particularly about his statistics, and her overview of his article is in many ways more detailed than mine - and from a somewhat different angle.

The Perfect Storm of Overutilization (JAMA 2008). This article is actually co-authored but since no one is talking about the other author I will write as if Dr. Emanuel was solely responsible. This article is behind the firewall at the Journal of the American Medical Association but you can access a PDF here. I half agree, half disagree with his contentions here. Emanuel claims that overutilization in the United States is not to be found in quantity; according to him we do not consume “more office visits, hospitalizations, tests, procedures, and prescriptions than are appropriate”. Rather US overutilization consists of:

more costly specialists, tests, procedures, and prescriptions than are appropriate.

It is more costly care, rather than high volume, that accounts for higher expenditures in the United States

Emanuel attributes this type of overutilization to seven factors. The first four impact doctors, the last three impact patients:

1) Physician culture which rewards “meticulousness, not effectiveness” and “the most thorough and aggressive physicians” rather than the “prudent physician”. Emanuel objects to:

... a unique understanding of professional obligations, specifically, the Hippocratic Oath’s admonition to “use my power to help the sick to the best of my ability and judgment” as an imperative to do everything for the patient regardless of cost or effect on others.

2) “[F]ee-for-service payment misaligns incentives; it creates a big incentive for overutilization. ... the current system’s bias toward paying significantly more for procedures rather than for evaluation and management reduces physicians’ inclination to watch, wait, and communicate and increases their propensity to order a test.”

3) The flood of marketing directed at physicians with little or no (you guessed it) comparative effectiveness research.

4) Medical malpractice and the resulting defensive medicine.

5) A culture which values”high technology over high touch” resulting in “a patient perception that doing more tests and receiving more treatments and interventions is receiving better care.” (As an editorial aside, I think this is nonsense. The people I know are far more unhappy with five-minute doctor appointments than they are with a lack of MRIs.)

6) Direct to patient marketing of prescription medicines.

7) Third-party payment. Emanuel is worth quoting more fully on this:

In normal markets, demand is modulated by cost. But third-party payment for patients attenuates this control. Although patients experience deductibles, co-payments, and other out-of-pocket expenses, health insurance and government programs significantly shield patients’ decisions from the true costs of health care.

As you can see, little of this is objectionable other than Emanuel’s continuing distress over the Hippocratic Oath. What is most interesting about his seven elements is that the problems with fee for service and the problems with third-party payment militate against the very sort of government-run health system favored by most Democrats. Even the problems of medical marketing to physicians and patients would be best solved by a system in which patients had a reason to care about the price of their medicine not one in which the government paid for everything. And, of course, tort reform to address the costs of medical malpractice and defensive medicine does not even appear to be on the Democrats’ radar screen.

Thus, overall, I’d put Emanuel’s “Overutilization” article in the conservative column. So why does Thomas Sowell, for example, object to it so strongly that he chose to make it the focus of an article entitled “'Death Panels' Just A Rumor? Go Ask Ezekiel”? Well, in Sowell’s case it is partly because he either misunderstands or misstates Emanuel’s argument. Sowell claims that Emanuel’s overutilization includes the existence of “amenties” such as hospital rooms that “offer more privacy, comfort and auxiliary services than do hospital rooms in most other countries.” Sowell goes on to say:

At one time, it would have been none of Dr. Emanuel's business if your physician prescribed the latest medications for you, rather than the cheaper and obsolete medications they replaced. It would have been none of his business if you preferred to have a nice hospital room with "amenities" rather than being in an unsanitary ward with inadequate nursing care, as under the National Health Service in Britain.

The involvement of government gives Dr. Emanuel the leverage to condemn other Americans' choices — and a larger involvement of government will give him the power to force both doctors and patients to change their choices.

Um, no, at least partly. Emanuel does not consider amenities part of the overutilization problem. He lists insurance administrative costs; higher salaries for doctors and higher costs for prescription drugs; and greater amenities in hospital rooms and doctors’ offices (convenient location, more parking, nicer waiting rooms) as three contributors to higher health care costs in the United States. He then goes on to say:

The most important contributor to the high cost of US health care, however, is overutilization. Overutilization can take 2 forms: higher volumes, such as more office visits, hospitalizations, tests, procedures, and prescriptions than are appropriate or more costly specialists, tests, procedures, and prescriptions than are appropriate.

The amenities Sowell is so worked up about are not part of overutilization. Like insurance administrative costs and higher doctor salaries and drug prices, medical amenities are a driver of higher costs apart from overutilization. It is clear Emanuel considers them relatively unimportant and nowhere in his article does he suggest we do away with them. In other words, Emanuel is not suggesting the United States save money by dumping patients into filthy open wards. Deafening Silence’s analysis of this part of Emanuel’s article is more sophisticated - and more accurate - than Sowell’s.

A second problem with Sowell’s analysis of Emanuel is that it is not clear to me that Emanuel favors the amount of government involvement we have now via Medicare and Medicaid much less further government involvement. His policy section concludes in part:

Realistically, the most effective policy change would be to alter how insurance pays for medical services. ... It would help if patients were financially sensitive to the cost of care, but not if out-of-pocket costs inhibit use of needed services, resulting in higher costs later. This is not an all-or-nothing rationing scheme, but rather an ethical way to have patients experience costs but not at the expense of important outcomes.

In other words, if people knew the cost of the medical goods they were purchasing, understood their options, and had to pay for the care themselves they would make the decisions best for themselves. They might want the newest brand name medicine or they might feel the generic was worth a try; it would be their decision. They might - as they are able to do now - elect a private room or prefer to save their money for something else and choose a semi-private, four-person, or even open ward. That sounds awfully, I don’t know, conservative to me.

And the third problem with Sowell’s article is that none of what he quotes about Emanuel has anything to do with death panels. In fact, Sowell totally ignores the hook he could hang this argument on: Emanuel’s discomfort with the Hippocratic Oath. Sowell does attempt to claim that Emanuel is objecting to “quality” care but his mixing nice hospital rooms with the newest prescription drugs undercuts his argument. Again Deafening Silence does a much better take-down of Emanuel in this regard when she explains the dangers of practicing “good enough” medicine rather than “best outcomes” medicine.

In the end what distresses me about Emanuel is not his philosophical musings about how to ration health care but his attempt to redefine the meaning of the Hippocratic Oath. A generation of doctors who learn to look at old patients, disabled patients, and chronically ill patients and decide which ones should not get further resources is far, far more dangerous to our medical care than a panel convened to formally debate which procedures should be afforded to which patients. The latter is explicit and opposable; the former is implicit and almost impossible to fight back against. Furthermore, it is subtle.

Doctors can be fully committed to doing everything humanly possible for their patients and at some point honestly conclude that any further medical intervention is both pointless and cruel. But without that initial full commitment a doctor’s judgement about when to stop fighting becomes suspect. Is there really nothing else than can be done for me, my child, my spouse, my parent? Or is this one of the new breed of doctors who thinks that because I am in a wheelchair, my child suffers from Down syndrome, my spouse is a diabetic, my parent is old that we’re not worth any more of medicine’s resources?

Interestingly - and based on nothing more than a hunch - I do not think this is where Emanuel believes his views lead.* His 1997 article on physician-assisted suicide and euthanasia reveals a doctor who is deeply committed to the traditional view of the Hippocratic Oath. If I’m right about Emanuel’s basic decency and commitment to life it may simply be that since he would never become the sort of doctor who makes quality of life calculations on the fly he is unable to understand that others who accept his logic will do exactly that.

Along the same lines, Emanuel seems unaware of the contradictions in his own work. That same 1997 paper on physician-assisted suicide and euthanasia warns of the dangers of making those practices legal for fear they will lead to an overly-casual acceptance of them in situations where they may not be appropriate. Yet he seems to have no fear that the inclusion of societal factors in living up to the HIppocratic Oath might introduce equally over-casual acceptance of this type of balancing act. This would result in situations where doctors who would never consider easing an elderly or disabled person on his way see nothing wrong with deciding a little too early that this person is a hopeless case because there’s a teenager in the next room who would benefit from more attention.

As far as claims that Emanuel is a true believer when it comes to something like single-payer or Obamacare, his 2009 “Overutilization” article presents arguments that logically lead to a policy of patients purchasing their own health care to the greatest extent possible; he even recognizes the value of such a policy when discussing how to encourage patients to choose older, less expensive, proven procedures rather than newer, more expensive technologies not yet shown to be more effective. Yet he then goes on to say:

... private and public payers for health care must work on developing better financial incentives for physicians and hospitals to provide more cost-effective care. Many more experiments are needed with pay for performance, bundled payments, partial capitation, value-based payment, or other payment methods that promote prudent use of resources. Such experiments with different ways of paying for health care services must be combined with careful monitoring of utilization, cost, and quality.

He doesn’t seem to quite be able to make that final leap and realize that if patients were purchasing their own health care the market could drive much of what he hopes to achieve by imposition. When I first read this, I decided that either I must be missing some subtlety of Emanuel’s thinking or his range of options must be constrained by his world view to an extent unusual in a man who appears to be an interesting and original thinker.

However, reading this (highly recommended) New York Times article led me to a different conclusion (emphasis mine):

Given Dr. Emanuel’s well-publicized repudiations of doctor-assisted suicide and voluntary euthanasia, and his calls for a national health insurance voucher system that would eventually eliminate Medicare, Medicaid and employer-provided insurance - nonstarters at the White House - Dr. Emanuel says he is perplexed by depictions of him as a socialist euthanasia proponent.

I now think that Dr. Emanuel has made that final leap to realize the free market could achieve many of his goals but he also believes such an approach is not politically feasible. That’s reassuring in terms of his ability to reason logically but I’d prefer he stick to his guns in the political arena.


* This is a terrible thing to say about a 50+ year old man who is a leading scholar in his field but there’s a part of me that can’t help thinking his insistence on the need to redefine the Hippocratic Oath is driven to a large extent by what I call college bull-session logic. You know the kind of thing I mean:

It seems so clear that we don’t have enough money to do everything in medicine; it seems so clear that someone who is 95 and dying of cancer should not get a heart transplant; it seems so clear that we could do so much for children with the money we spend prolonging the life of the terminally ill for another week or month or year. Of course there are logical decisions that can be made here. Why shouldn’t we make them?

As I implied in my earlier post, much of what Dr. Emanuel talks about needs to be talked about. His talking about the problems with the Hippocratic Oath just seems juvenile to me.

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