Best Care Anywhere

by Phillip Longman

  And so we see results like these: in Elyria, Ohio, a small town near Cleveland, citizens have been receiving angioplasties at a rate of four times the national average. It turns out that nearly all these angioplasties were performed by a group practice of thirty-one surgeons in town who have exceptional enthusiasm for the operation, perhaps because it is what they know how to do and it pays well. In the absence of any definitive protocols concerning the effectiveness or appropriateness of angioplasties, regulators or insurance companies can do little or nothing to crack down on even such obvious examples of overtreatment.16

  And if the medical establishment is this much in the dark about what might be an appropriate way to treat your disease, where does this put you? It puts you in a spot where you can be very easily manipulated into just going along with whatever has become the customary way of treating your disease in the local medical community. Conversely, if you have made up your mind that you or a loved one should receive this or that operation or should try out some drug you saw on television or the Internet, you can probably find a doctor who will go along with your plans. Lacking clear guidelines about what constitutes appropriate care, a doctor stands a very real chance of losing a lawsuit for refusing to offer some specific treatment or referral, especially if most other doctors in town routinely go along with it. At the same time, doctors, unless they’re on salary, know that deferring to patient demands will put money in their pocket.

  Other dynamics are involved as well. Dr. So-and-So performs a bypass operation on a patient. This invasive procedure may or may not have been the most effective way to treat the patient; it may not have been needed at all. But the patient believes that Dr. So-and-So saved his life and tells friends and neighbors. Word spreads, and gets reinforced by some other patients of Dr. So-and-So. Other doctors in the community, who have little ability to evaluate the quality of Dr. So-and-So’s work except by word of mouth, hear these reports from their own patients, friends, and neighbors, and soon Dr. So-and-So’s reputation builds as the hottest cardiologist in town.

  For local hospitals and health-care plans, this means they must compete to get Dr. So-and-So on board, come what may. No mere hospital administrator gets to point out that there is no evidence of Dr. So-and-So’s treatments being effective or even safe. Why would he or she want to anyway, since Dr. So-and-So’s building practice is bringing so much money to the hospital. The administrator’s job is to keep Dr. So-and-So happy.

  This is pretty much what happened in one notorious case, that of Shasta Regional Medical Center in the small town of Redding, California. There, two rogue cardiologists, Chae Hyun Moon and Fidel Realyvasquez Jr., headed a team that performed extraordinary volumes of unnecessary and recklessly dangerous heart operations. In the end, both would lose their licenses, and each would pay a $1.4 million fine in lieu of federal criminal prosecution. Yet for years before, their building reputations as top-notch cardiologists brought in patients from all over Northern California. In gratitude, the hospital pampered them with department chairmanships and perks. Dr. Moon even enjoyed occasional use of the hospital’s emergency helicopter to fly to golf tournaments.

  Our Lady of Lourdes Regional Medical Center in Lafayette, Louisiana, provides another example of how high-volume rogue surgeons can escape scrutiny for years, either because hospital administrators don’t know, or profit from pretending not to know, how dangerous they are. At Lourdes, there were rumors for years that one of its surgeons, a Dr. Mehmood Patel, was performing vast amounts of unnecessary heart operations. Yet it wasn’t until one of Patel’s fellow doctors at last secretly sued him in federal court under a special whistle-blower law that the hospital revoked his admitting privileges. The hospital subsequently agreed to pay a fine of $3.8 million but still denies it had any way of knowing about the safety or effectiveness of Dr. Patel’s care.17

  As the number of specialists in a community grows, many people cut out visits to their primary care physicians altogether. Instead, they skip from one specialist to another according to what body part gives them reason to complain that day, all the while gathering more and more bottles for the medicine cabinet.

  Many other patients are like “Peggy,” an elderly woman profiled in a case study of the fragmented care typically delivered under Medicaid and Medicare. At age 83, Peggy went into mysterious decline, losing her appetite and eventually becoming so dizzy that she fell and injured herself in the bathroom. For a long time, she convinced herself and others that she was simply experiencing the natural consequences of aging. But when a worried son at last arranged for a comprehensive medical examination by her primary physician, it turned out she was taking four different arthritis medications prescribed by four different doctors. Embarrassed, she explained to her primary physician that she had heard of a few other doctors who were good at treating arthritis and sought them out.

  It’s a common delusion that when one doctor or pill doesn’t do the trick, maybe adding a few more to the mix will help one to feel better. As the supply of doctors and specialists increases, the culture of medicine becomes transformed. No longer is any single physician treating the whole patient or taking responsibility for coordinating a patient’s care. In places such as South Florida and Manhattan, it is no longer uncommon for patients to be seen by dozens of different specialists over the course of an ailment, each of whom will happily make referrals to still more.

  Over time, this pattern of care starts to seem normal to all involved. Some lonely elders even come to enjoy retelling their stories to different doctors or to those they meet in waiting rooms. It beats staying home and watching television. This fragmented form of medicine, which exists nowhere else in the world, might go on forever except that its financial costs are unsustainable, and its toll in medical errors, overtreatment, and neglect of prevention is, or ought to be, unacceptable.

  What’s Wrong with HMOs?

  Roemer’s pioneering work in documenting how supply creates its own demand in health care had a deep intellectual influence on the once idealistic movement to create health maintenance organizations. Today, many Americans view HMOs simply as organizations designed to make money by denying them care. And it’s a sad fact that many HMOs have wound up doing just that, or else using clever marketing techniques to make sure they cherry-pick only young and healthy customers who are unlikely to get sick. But it is important to remember that HMOs and other forms of managed care came into existence in large measure because of a big problem that is still with us and getting worse—namely, vast amounts of poorly coordinated, dangerous, and often excessive treatment.

  The original vision of those who championed HMOs was that this form of care would vastly improve the quality of American medicine and only incidentally lower its cost. Paul Ellwood, a pediatrician who more than any other single advocate built the case for HMOs, put it this way: “My own most compelling interest as a physician was in the integration of health care, quality accountability, and consumer choices based on quality first and, secondarily, price.”18

  In the late 1960s and early 1970s, a group of doctors saw two trends that worried them—a movement toward ever greater specialization and the increasing prevalence of chronic disease in an aging, sedentary population. Recognizing that this combination required a far more systematic, integrated, and scientifically driven approach to health care, they organized the precursors of what came to be known as HMOs. Specifically, they wanted an “integrated delivery system,” in which “primary care” physicians would coordinate care in large, multispecialty medical group practices that would in turn be part of a system of hospitals, labs, and pharmacies. Moreover, to address the problems of overtreatment and lack of prevention, care providers would be prepaid. As Alain Enthoven, another champion of managed care, once wrote, this would give “doctors an incentive to keep people healthy.”19

  Already by this time, it was becoming apparent to those who studied the actual effects of modern medicine on the population as a whole that a new model of care wa
s desperately needed. The crude death rate, or total number of deaths per year per 1000 Americans, was no longer declining by the 1960s. Partly this was because the fall in birthrates since the end of the baby boom years meant that children and young adults constituted a smaller share of the population. But modern medicine itself was also a factor. Its very successes were causing a pandemic of chronic disease.

  How? you might wonder. Until right before World War II, it was a truism of medicine that, as the once famous medical textbook The Principles and Practice of Medicine, put it: “Persons rarely die of the disease with which they suffer.” Instead, secondary terminal infections, primarily pneumonia, carried off most patients with incurable diseases, which is why pneumonia was once characterized by medical authorities as the “old man’s friend.”

  Then in 1937, for the first time in history, effective treatments for infection became available. The introduction of sulfa drugs, followed by the discovery of even more effective penicillin and other powerful antibiotics, radically changed the way most people aged and died. Between 1936 and 1949, the death rate from pneumonia declined from slightly under 60 per 100,000 to just 15 per 100,000. But this triumph of modern medicine came at a price. The old man’s friend and other secondary infections no longer claimed as many sick patients, so more and more people were left alive and still suffering from their primary diseases while also bearing an increased risk for such chronic conditions as cancer, congestive heart failure, or the disease that came to be known as Alzheimer’s.

  The unexpected result was that the incidence of chronic illness exploded while mortality rates for the population as a whole stopped improving. By the 1970s, far-sighted researchers such as Johns Hopkins’s Ernest M. Gruenberg started characterizing the rapid spread of chronic diseases as examples of medicine’s “failures of success.” Modern medicine, in a quite literal sense, was enfeebling the population. Obviously, the answer wasn’t to stop using antibiotics and other modern medical techniques. But the spread of chronic disease throughout the population did call for a new model of care.20

  At the same time, the family doctor who made house calls and knew the circumstances of his patients was passing from the scene, and no one was taking his place. The family doctor may have carried in his bag little more than a stethoscope and various vials of opiates and alcohol, but the personal attention he paid to patients had huge, and by the 1960s, increasingly well-documented, curative powers.

  Professor Kerr White showed in study after study how important an intimate and long-term relationship between doctor and patient was to health. Partly this was due to reasons you would expect, but White also found that much of the benefit of such a relationship came simply from the placebo effect. The very presence of a familiar doctor laying on hands or writing a prescription gave patients hope and strengthened their will to live.

  Also involved, White found, was “the Hawthorne effect.” This was a phenomenon, already famous in managerial circles, that was first observed in the 1920s among women workers in a Westinghouse plant in Hawthorne, Illinois. During the course of a company study, the workers’ productivity continuously increased under both good and poor working conditions. It didn’t matter, for example, if they were forced to work in dim light or bright; the women kept on working harder so long as the study continued. Eventually, researchers could only conclude that the women were flattered that someone cared enough to pay close and careful attention to what their jobs were like. White demonstrated a similar effect in health care. He showed that patients in the care of a familiar and trusted physician are demonstrably more likely to modify their behavior—quit smoking, reduce drinking, take their medications—in ways that benefit their health.

  Taken together, the placebo effect and the Hawthorne effect accounted for about half the benefits of all medical interventions, White showed. Armed with this insight, he went on to invent the concept of primary care and to pioneer the idea of an integrated or “managed” health-care system centered on primary care physicians. The hope was that patients in the future would not simply get lost or be ignored as they passed from specialist to specialist.21

  Such were the highly idealistic and data-driven concerns and issues behind the emergence of HMOs. What went wrong? Eventually, HMOs morphed into many different forms and hybrids. Some were nonprofits, others were publicly traded companies answerable to Wall Street. Some were “staff models” that put physicians on salary and effectively eliminated the problem of intentional overtreatment; others became little more than loose networks of doctors on contract. Some were run by idealists; others by shysters, crooks, and knaves who convinced themselves that the road to riches could be found by lowballing on pre-paid contracts and then denying their patients necessary care.

  Even the many HMOs that tried to do the right thing often ran into a fundamental flaw in their business model. Most remained small enough that the majority of their customers changed plans every few years, either because they moved to a different market or because their employers switched to a cheaper plan. For all but the largest HMOs, this circumstance demolished the business case for prevention and effective management of long-term conditions like diabetes. Before any returns from investing in a patient’s long-term health could be realized, the patient was likely to be enrolled in some other plan.

  By the 1990s, most people enrolled in any particular HMO had little or no choice in the matter; they were there because their employers were trying to save money. It didn’t help that many fee-for-service doctors felt threatened by the growing dominance of HMOs and other managed-care providers and complained to their patients about it. Nor were the negative press and lawsuits that some HMOs attracted helpful to the industry’s image.

  The result was a public backlash. But with the benefit of hindsight, we can see that it didn’t have to turn out this way. Proof of that are the big exceptions to the often poor performance of HMOs over the last several decades. These are institutions with high levels of patient satisfaction that are also lauded by health-care quality researchers for their patient safety, adherence to evidence-based protocols of care, and general cost effectiveness. They include integrated providers like Intermountain Health Care, the Cleveland Clinic, the Mayo Clinic, Geisinger Health System, Kaiser Permanente, and preeminently the VA, which ranks highest of all on most metrics of cost and quality and is in effect the largest—and purest—nonprofit, staff-model HMO in the land.

  What do these exceptions to the rule have in common? First, they are all large enough to achieve significant economies of scale. The VA’s scale, for example, has been an important precondition for the deployment of its highly effective system of electronic medical records, the cost of which it has been able to spread across a large base of hospitals and clinics. The same is true of Kaiser Permanente and the other examples of “best-practice” health-care delivery system mentioned above. Similarly, the size of these institutions means that the data generated by their digitalized information technology about what works and what doesn’t has far greater scientific value because the records are drawn from a very broad population. Also, their scale allows them the opportunity to integrate and coordinate care among a broad range of specialists who all work for the same institution and use the same patient records so that the care patients receive is far less fragmented (and dangerous) than found generally in fee-for-service medicine.

  So it’s important to take the right lesson from the HMO revolution. Though it produced many failures, it also produced institutions of exceptional excellence. Moreover, as we move closer to examining the lessons the VA has to offer to the rest of the American health-care system, it is important to remember that the problems that led to America’s experiment with HMOs and managed care did not go away. Instead, they got worse, and will get worse still in the future.

  Today, more than 90 million Americans live with chronic illnesses such as diabetes, cancer, and heart disease; and seven out of ten American deaths are caused by chronic illnesses. An aging population,
combined with the sedentary habits of modern Americans and medicine’s own “failures of success,” will continue to increase the burden of chronic diseases. On our current road, the human toll from medical errors will also increase as drugs become more potent and care becomes more fragmented. As Americans grow older, more and more people will also be killed by a health-care system that fails to deliver routine preventive measures while neglecting or mismanaging chronic illnesses like diabetes. Finally, there are limits to how much Americans can pay for health care without ruining both their own finances and those of their country. For-profit HMOs are not the answer, most people would agree. Nor is the answer simply to create more subsidies so that more people can have greater access to a fragmented health-care system that is grossly inefficient, ineffective, and unsafe. So what is the answer? The last three chapters of this book point the way.

  NINE

  Open-Source Medicine

  Many lessons can be drawn from the VA’s quality transformation over the last fifteen years, but among the most important are those concerning the role of information technology in twenty-first-century medicine. In this realm, as in health care generally, many paradoxes and counterintuitive realities abound, and communicating them is challenging. Some of us are knowledgeable about computers; others of us are knowledgeable about health care; few of us are knowledgeable about both. Then still more of us know little about either. The best way to proceed, then, is with concrete examples, drawn from the VA and elsewhere, that illustrate both the promise and the peril of the ongoing merger of information technology and health care.