Reading List: Halloween Edition

Public Policy Contributor Brad Flansbaum writes…

I have come across some topical material that might have some interest for SHM blog readers and thought I would pass it along. It goes without saying, you can read it while “inspecting” your child’s trick or treat bag; just don’t get chocolate on the keyboard.

A flourish of press descended upon the Relative Value Scale Update Committee (“the RUC”) with two hard-hitting pieces from the WSJ and the Center for Public Integrity. It was odd they appeared on the same day, but both are good and expose what many folks have known for some time, mainly, biases abound in a dysfunctional rate setting process. For those unfamiliar with the RUC, it is the body that assigns and delivers CPT code value recommendations to CMS, a group largely comprised of subspecialty physicians under the imprimatur of the AMA:

“A recent analysis for the Medicare Payment Advisory Commission, or MedPAC, a Congressional watchdog, calculated how much American doctors would make if all their work was paid at Medicare rates. It found that the primary-care category did the worst, at around $101 an hour. Surgeons did better, at $161. Specialists who did nonsurgical procedures, such as dermatologists, did the best, averaging $214, and $193 for radiologists.

The imbalance has stoked fears of a shortage of primary-care doctors, as well as a relative shortfall in the amount of primary-care services patients receive, compared to specialist procedures. “The fee schedule we use to pay physicians in Medicare leads to the wrong mix of services and the wrong mix of doctors,” says Robert Berenson, vice chair of MedPAC and a researcher at the Urban Institute. “It produces increased spending for Medicare and for the rest of the system.”

Along those lines, Archives of Internal Medicine also published two studies this week, one an analysis of physician pay, the other a survey on physician opinions on reforming reimbursement. No surprise, primary care physicians know the disparities well:

“…wages for surgery, internal medicine and pediatric subspecialties, and other specialties were 48%, 36%, and 45% higher, respectively, than for primary care specialties.”

“…there was broad support for increasing pay for generalists (79.8%), but a proposal to offset the increase with a 3% reduction in specialist reimbursement was supported by only 39.1% of physicians, [22% of surgeons].”

With the demise of national newspapers and the investigative pieces associated with them, society is losing a resource to expose malfeasance, fraud, etc., in the public and private domain. While a few outlets like the New York Times and Washington Post continue this activity (think Pulitzer Prize and the Walter Reed hospital story a few years back), the public loses an “honest broker” that often kicks off congressional investigations and uproots corruption. If you are not familiar with ProPublica, you need to bookmark their site and check in occasionally. Their professionalism and commitment to ethics merits attention and makes for some terrific work. Most recently, they published a story, Docs for Dollars, an expose on pharma dollars going into the pockets of physicians for industry promotion. On the site, they compile total payments to docs; individual amounts and dates are included in a searchable database.

“All told, 384 of the approximately 17,700 individuals in ProPublica’s database earned more than $100,000 for their promotional and consulting work on behalf of one or more of the seven companies in 2009 and 2010. Nearly all were physicians, but a handful of pharmacists, nurse practitioners and dietitians also made the list. Forty-three physicians made more than $200,000 — including two who topped $300,000.”

With the midterms coming up, you are likely undergoing an advertising bombardment the likes of which we have never seen before in an election cycle. The health care debate is front and center, and no doubt, you have heard the partisan bickering regarding the constitutionality of the individual mandate. There are lengthy pieces in both print and online discussing the merits of the general welfare (which allows taxation) and commerce clauses. Depending on your constitutional beliefs, you can make a fair case in either direction for their application (or lack thereof). This post from the Atlantic was particularly good and accessible:

“The tax penalty imposed by the new legislation on individuals who refuse to insure their families really isn’t based on something most of them can choose to do or not to do. It’s based on something they almost certainly do not, and probably cannot, refuse to do: consume health care services. No matter how thrifty and antisocial any of us may be, no matter how devoted to homeopathy and Yoga, eventually virtually all of us will end up in an emergency room, hospital, or hospice. Even if by extraordinary effort we prevail on others to stand by and allow us to bleed out on the rumpus-room floor, we usually cannot convince them, no matter how earnestly we plead, to let our children die; state law will require they be treated. And someone will pay the cost. That you were “inactive” in getting them the care your children require should not exempt you from being the one who pays their bills.”

If you want an absolutely mind blowing graph to look at time trends and various global metrics, e.g., what the US spends on healthcare, check out this site. Wow. Play with the data a while and you will realize how potent a tool the Internet can be with just a few clicks.

Finally, another piece from the Atlantic, and a story I highly recommend. We all pick something up never expecting to succumb, but this chronicle was fantastic. Not a person I have sent it to has failed to email back and say thanks. Ever hear of Dr. John Ioannidis:

“He’s what’s known as a meta-researcher, and he’s become one of the world’s foremost experts on the credibility of medical research. He and his team have shown, again and again, and in many different ways, that much of what biomedical researchers conclude in published studies—conclusions that doctors keep in mind when they prescribe antibiotics or blood-pressure medication, or when they advise us to consume more fiber or less meat, or when they recommend surgery for heart disease or back pain—is misleading, exaggerated, and often flat-out wrong. He charges that as much as 90 percent of the published medical information that doctors rely on is flawed. His work has been widely accepted by the medical community; it has been published in the field’s top journals, where it is heavily cited; and he is a big draw at conferences.”

Finally, two great books I recommend highly if you like presidential and congressional history. Both fascinating, well written, and helpful if you need to get up to speed on what makes our legislative and executive process tick:

1. The Heart of Power: Health and Politics in the Oval Office
2. The Broken Branch: How Congress Is Failing America and How to Get It Back on Track (Institutions of American Democracy)

Also, if you are like me and listen to podcasts (they are like shirts, your favorites drop up and down in the pile depending on the month), I have really gotten into The Moth. They are hit and miss, but at a minimum always entertaining. Many are outstanding however, and the storytelling will really suck you in.

Finally, some CD picks for you if you are feeling adventurous: here and here. Two great ones I have played the heck out of the past year. For those who like it a bit louder, this one is tops.

Anyway, enjoy your M&M’s and statin sundae

Brad Flansbaum

Bradley Flansbaum, DO, MPH, MHM works for Geisinger Health System in Danville, PA in both the divisions of hospital medicine and population health. He began working as a hospitalist in 1996, at the inception of the hospital medicine movement. He is a founding member of the Society of Hospital Medicine and served as a board member and officer. He speaks nationally in promoting hospital medicine and has presented at many statewide meetings and conferences. He is also actively involved in house staff education.

Currently, he serves on the SHM Public Policy Committee and has an interest in payment policy, healthcare market competition, health disparities, cost-effectiveness analysis, and pain and palliative care. He is SHM’s delegate for the AMA House of Delegates.

Dr. Flansbaum received his undergraduate degree from Union College in Schenectady, NY and attended medical school at the New York College of Osteopathic Medicine. He completed his residency and chief residency in Internal Medicine at Long Island Jewish Medical Center in New York. He received his M.P.H. in Health Policy and Management at Columbia University.

He is a political junky, and loves to cook, stay fit, read non-fiction, listen to many genres of music, and is a resident of Danville, PA.

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