27 July 2018
Dear Interested Reader,
Another Obit and Another Perspective
I am a regular reader of the “Perspectives” section of the New England Journal of Medicine. I can count on the fact that week after week I will get an excellent return on the time I invest in reading and thinking about the many issues presented and explained in these pages. Regular readers of these notes may have noticed that on several occasions I have devoted most of a letter to the review of an excellent “Perspectives” article. I really get excited when I have had personal experience with one of the authors. Such is the case this week with, “The Inevitable Math behind Entitlement Reform,” written by Michael E. Chernew, Ph.D., and Austin B. Frakt, Ph.D.
My excitement about this issue of “Healthcare Musings” is even greater because I can weave the information from the NEJM article with a much appreciated comment and informative obituary sent to me by an Interested Reader, Marin English, a pediatric oncologist who practices in Birmingham, England.
Dear Gene,
I hope you are well. I enjoyed this week’s article. Remarkably this week’s British Medical Journal only had one obituary. I enclose it and a regular feature that mentions it as well (scanned pages as even as a BMA member I struggle to get in to the BMJ).
Take care,
Martin
The “regular feature” in the BMJ was a “comments” column entitled Technology and today’s inverse care law written by a woman who is a GP in Glasgow and a regular contributor. The subject of the obituary was Julian Tudor Hart. On the surface of things it was confusing at first for me to try to understand the importance of the contributions of this 91 year old “GP” who had practiced in a small Welsh village, with an unpronounceable name, “Glyncorrwg, a coal mining community in the Afan Valley.” As I read the obituary I discovered that he was highly respected for his leadership and foundational work in improving the health of his community through preventive care and his advocacy for the underserved.
Between 1964 and 1987 Dr. Hart led efforts that brought many of the benefits of the “Triple Aim” to Glyncorrwg. His preventive health strategies for his community paid off. As his obituary notes, “In 1991 The BMJ published a study that found death rates in Glyncorrwg to be 30% lower than in the neighboring village, Blaengwynfi.” There are obituaries for Dr. Hart that can be found online from the Lancet, The Guardian, and the BBC as well as the BMJ, they all note the importance of his contributions. The article in the Guardian may be the most informative and generated several letters to the editor. Dr. Hart believed in the NHS as a way to approach the care of the underserved, but he seemed to always recognize how vulnerable those benefits were.
His most noteworthy contribution was a concept he formulated called the “law of inverse care.” It states:
“The availability of good medical care tends to vary inversely with the need for it in the population served. This inverse care law operates more completely where medical care is most exposed to market forces, and less so where such exposure is reduced.”
Better Health For All is “the award winning blog of the Faculty for Public Health”. The Faculty for Public Health seems to be a UK equivalent of the IHI. It published a series of articles this month that outlines Dr. Hart’s contributions and expands the description of the “law of inverse care.” They describe Dr. Hart as a committed socialist who had run for Parliament in the 60s as a member of the Communist Party. Their high level summary of his life’s work is worth sharing because it paints the picture of a physician who was committed to improving the health of the underserved:
Julian Tudor Hart was a visionary leader who combined advocacy for equitable primary care and social justice, trenchant critiques of market influences in health care and innovative research showing how whole population approaches to improving health could transform primary care.
I like the paragraph from the BMJ obituary that describes his retirement at age 60. Dr. Hart sets a high bar for anyone who wants to continue to be active and effective in the effort to improve practice after retirement.
Retirement from clinical practice in 1987 gave him time to pursue his interests outside medicine. He moved to the Gower Peninsula, where he grew vegetables, illustrated Christmas cards and books for his grandchildren, and even created a scale model of HMS Beagle. Mainly, however, he was writing and speaking. Described as “absurdly creative and hardworking,” he was prodigious in his output, which included more than 350 peer reviewed papers in all, as well as many books—most famously, A New Kind of Doctor and The Political Economy of Health Care. He held many awards and was a founder member of the Socialist Medical Association and honorary president of the Socialist Health Association. In 2006 he was awarded the Royal College of General Practitioners’ discovery prize for research in primary care.
It seems to me that Dr. Hart’s experience and understanding of the challenges of funding and delivering care in the NHS could be of great benefit to the struggle for the Triple Aim in America today. The Better Care For All post connected Dr. Hart’s work to the current funding debates in the UK, but it seems to me that he also has much to say that Americans should consider.
It [the law of inverse care] documented how those who most need high quality health care are least likely to receive it and how privately funded and delivered health care undermined high quality universal coverage. He observed that the removal of market forces from the provision of primary care with the advent of the NHS had resulted in improved access for disadvantaged populations, concluding that ‘a national health service can run quite well without the profit motive, and that the motivation of the work itself can be more powerful in a de-commercialised setting’.
I really like the statement:
…the motivation of the work itself can be more powerful in a de-commercialised setting’.
I think there is much to ponder in those words when we consider the lack of motivation and the burnout that has become such a plague in our system of care as it has become increasingly commercialized.
When I first read “The Inevitable Math behind Entitlement Reform,” I did not know of Dr. Hart’s career, and I had not heard of his “law of inverse care.” I doubt the authors of the paper realized how what they wrote was so demonstrative of Dr. Hart’s law. The article suggests, that If we extrapolate the conclusions of its authors, Chernow and Frankt, that there is more “trouble” to be expected in River City, Iowa and across all of America. They begin their recent “Perspectives” article with a startling statement of fact.
The projected growth in Medicare and Medicaid spending, which exceeds projected aggregate economic growth, is pushing policymakers to seriously consider further entitlement reform. At some point, Americans will probably be unwilling to pay higher taxes or increase borrowing to fund public health care programs. Capturing this view, House Speaker Paul Ryan (R-WI) has emphasized the importance of reining in spending on such programs, stating (accurately) that “it’s the health care entitlements that are the big drivers of our debt.”
There is a neat graphic that shows the projected growth in Medicare and Medicaid beneficiaries and the growth of expense in the two programs as a function of the increased number of beneficiaries, the expected increased utilization, and the expected growth in prices paid for services and drugs for beneficiaries of Medicare and Medicaid. The cost of the programs is increasing at a rate that is almost twice the rate of growth of the GDP. The authors come to the conclusion that such growth is unsustainable. They predict that conservatives in Congress will use these financial realities as a basis for advocating the containment of costs through reducing the size of the populations served, and cuts to benefits for those who continue to qualify for coverage. They conclude:
Current approaches to reform may therefore have to be different from past strategies.
Two obvious changes in strategy would be to increase the age of Medicare eligibility, or change the threshold of income and other parameters for Medicaid eligibility, like requiring work. If we use those tricks to contain costs, you can easily imagine millions of people losing coverage and access to preventative care that Dr. Hart demonstrated were so effective. When we sought to move toward universal coverage with the ACA we expanded access to Medicaid in those states that would accept the expansion. As progressive politicians talk about “universal coverage” they frequently talk about lowering the age for Medicare eligibility. Many “progressives” advocate for Medicare for everybody. The authors point out that if people lose coverage by changing eligibility for Medicaid, or if we raise the age for Medicare, we might shift people into the exchanges, or into the VA system, where public costs may be higher, and in these and other ways stress the finance of healthcare. One thing is certain, these moves are unlikely to be politically acceptable.
Savings associated with eligibility restrictions would therefore be at least partially offset by increased spending in other programs, but total savings could still be substantial. Given widespread resistance to such changes, however, cost-containment efforts focused on spending per beneficiary are more likely to be politically successful.
This discussion seems to be headed toward consistency with Dr. Hart’s “law of inverse care.” To repeat the law for emphasis, it says,
The availability of good medical care tends to vary inversely with the need for it in the population served. This inverse care law operates more completely where medical care is most exposed to market forces, and less so where such exposure is reduced.
The authors are interested in the intersection of economics with public policy, the market, and politics. The thing that stands out most about our system, is its high prices. They note that much has already been done to lower the prices in the public sector. As they say, “…much of the low-hanging fruit has already been harvested.” By 2026 MACRA will result in more than a 10% effective reduction in Medicare physician fees after adjustments for inflation. They state that overall physician payments are likely to fall as much as 0.3% per year over the next eight years. There has been some measurable slowing of the rate at which drug prices are rising despite the errors in the construction of Medicare part D. Medicaid reimbursements have been low compared to commercial plans and there will be pressure for public sector prices to rise. After their analysis, their conclusion is:
We believe there is more that could and should be done to reduce public-sector prices, but substantial price reductions would be needed to alter the trajectory of spending on public health care programs. Making these cuts would be politically difficult.
It is difficult to imagine price reductions in American healthcare that would not outrage medical institutions and practices, both public and private. The problem is not only that the cost of doing what is done now will likely rise, it is that the populations served by Medicare and Medicaid will be growing substantially over the next few decades and utilizations of current drugs and procedures are likely to increase continuing a growth in spending that will need funding. The answer to our cost dilemma may be lower prices, but lowering cost without changing eligibility and coverage in public sector programs will be hard if not impossible. As they say in Maine, “You can’t get there from here!”
The authors continue to explore the difficulty of “fixing” the cost problem. They see four possible choices since most of the increase in expense will come from increases in utilization. Here is where the advice or warning of Dr. Hart’s thinking should be considered.
1…dissuade patients from seeking care by charging them more at the point of service. Here they point out the fact that 85% of Medicare patients have supplemental “Medigap” plans. They add, “Policies that limit the generosity of such plans could reduce Medicare spending considerably. However, such strategies would increase beneficiaries’ financial risks, reduce access to care, and probably exacerbate health disparities.”
2…help beneficiaries improve their health by enhancing long-term care management and preventive services with the goal of avoiding more expensive services. This has been a core strategy since the earliest days of managed care. The authors are surprisingly unenthusiastic about its overall success. Their comment: “Evidence suggests that although this type of approach is probably beneficial to patients and may be cost-effective, it is generally not cost saving.”
3…relying on private health plans to help reduce utilization. The core of this point is to build on Medicare Advantage. The savings that Medicare has experienced through Medicare Advantage programs have come through lower utilization, but the savings have largely accrued to the plans and not the government. Any attempt by the government to extract more from the providers of Medicare Advantage plans would probably raise the price that consumers pay, or reduce their benefits.
4…change incentives for providers who are part of alternative payment models, such as accountable care organizations (ACOs) and episode-based payment. This was the innovative mechanism of the last decade. The authors clearly favor it. They say:
Such models aim to improve efficiency by severing payments from the specific mix of services provided. Population-based payment gives organizations the most flexibility to achieve that goal. Under alternative payment models, metrics of success move from admissions, bed days, or visits to measures of efficiency, such as spending and quality of care. Providers participating in such programs can essentially transform projected increases in volume into profit if they eliminate wasteful services. Yet although recent evidence suggests that such models can reduce spending, their effects are generally small.
The authors suggest an overhaul of ACOs, the solution that matches option four. Their modifications would make formation and management of ACOs easier. They would eliminate the “penalties for success.” I can speak from experience and say that the original Pioneer ACO process was one where “no good deed went unpunished.” They would also change the risk rules to make it possible for smaller groups to participate.
All of their suggestions are plausible, the second and fourth seem more likely to be acceptable. Number two is the approach demonstrate to be effective by Dr. Hart and broadly advocated by progressive organizations like the IHI. Capitation as practiced by thoughtful organizations like Kaiser and the old Harvard Community Health Plan showed us long ago the benefits of operating systems that functioned on the principles of population health. Certainly Dr. Hart and the NHS have demonstrated the benefit of preventive care coupled with programs constructed using the insights of population health. Sadly, here in America none of these approaches have ever been really appreciated, accepted broadly, or applied widely enough to have a lasting ability to change the status quo in most practices. They have generated broad resistance. The status quo uses the political process to resist most plausibly effective policies. Have we painted ourselves into a political corner from which there is no practical escape?
The “bottom line issue” becomes the question of whether or not we can eliminate overuse, misuse, and the underuse of services through any change in policy. If clinicians can learn to practice within the considerations of continuous improvement, and develop improved workflows that eliminate waste, and if the finance mechanisms can be set so that the practices that learn these disciplines can succeed, we would have a chance. We would perhaps be able to achieve progress toward universal coverage and the Triple Aim. Indeed we would have found the formula that Dr. Ebert advised us to search for when he said:
The existing deficiencies in health care cannot be corrected simply by supplying more personnel, more facilities and more money. These problems can only be solved by organizing the personnel, facilities and financing into a conceptual framework and operating system that will provide optimally for the health needs of the population.
The caution that we should exercise no matter what route we take to solve the finance problems that Chernew and Frakt forecast can be predicted by Hart’s “law of inverse care.” He is basically pointing out how dangerous it is to the health of disadvantaged populations to try to manage the delivery of care through the manipulation of financial incentives. Dr. Hart’s law would suggest that we may be on a fool’s errand to try to use any economic prods to improve care. In our system it is possible that the cost and quality of care for the “haves” could deteriorate even as we seek to exclude the “have nots” as a way of controlling costs. Dr. Hart’s law suggests that it is ultimately most productive in efforts to advance universal access to focus on what is best for the health of the patient and is consistent with our best internal motivations to be responsible professionals. The intent of most progressive healthcare professionals has been to work for the Triple Aim through clinical transformation and continuous improvement. That is what I think Don Berwick was advising us when he described The Third Era of Medicine: The Moral Era.
I would say that it all depends on the balance between external financial motivators and the intrinsic motivations of providers to want to do a good job that promotes health, serves our patients best, and represents good stewardship of limited public and private resources. For us to realize continued success as a country with good health and economic opportunity for all citizens, healthcare leaders and all healthcare professionals, need to accept responsibility for containing the cost of care. Dr. Hart knew over forty years ago that the mission of better care for all, but especially for the disadvantaged people among us, can never be realized with just a focus on making money. The leadership of organized healthcare must realize that individuals have other needs like housing, the education of their children, and saving for retirement. Collectively as tax payers we have other needs beyond healthcare that compete with healthcare for public support. We already underfund infrastructure, public education, public safety, and national defense. Employers cannot continue to be asked to pay more and more for the healthcare of their employees, and simultaneously increase wages while competing in competitive international markets.
Chernew and Frakt seem not to have a lot of confidence in the possibility that we will rise to the challenge. They can count and they know that there will be more and more Americans requiring public funding for their healthcare. As a result if we can’t be more effective stewards, and more efficient performers, we can expect that those who think they are paying too much will seek to limit those served both in numbers and benefits. Their view of the future suggests the sorts of discussions that got Dr. Hart thinking four decades ago in the UK.
Given these trends, policymakers should have no illusions about how easy it will be to reduce growth in Medicare and Medicaid spending. Increased growth in gross domestic product could improve this outlook by reducing the number of Medicaid recipients and increasing tax revenue, but inaction could lead to major problems if hopeful scenarios don’t materialize. Thus, although there are opportunities to reap more savings by using targeted initiatives to reduce prices, slowing per-beneficiary utilization growth will probably also be necessary. Policy tools already exist to reduce utilization, and we should continue to refine and harmonize them. Doing so will require a long-term commitment and patience from policymakers.
To avoid substantial damage in the near future and for the long term to the services that we provide the underserved, we will need much more than long-term commitment and patience from policymakers. To solve the problems that challenge us all while achieving universal coverage that provides quality care for every American at a price and overall cost that is sustainable for individuals, employers, and taxpayers, we will need an army of American healthcare professionals who have the energy, insight, and intrinsic motivation of a Julian Tudor Hart. The “law of inverse care” should be a concept that guides our thinking.
Staying the Course
The picture that is the header for this posting was taken by my son while on a delayed (by 3 years) honeymoon with his wife to São Miguel Island in the Azores. As I viewed the lovely pictures that they had taken on their hikes in this very out of the way place, this picture with its narrow path on a ridge line impressed me as a metaphor for the way forward toward the Triple Aim. The path is headed toward a beautiful place although it is not a “stroll in the park.” To complete the journey requires stamina, focus, and some skill. Many may look at the path and decide that it is not for them. Some may begin the journey but become discouraged and turn back or attempt to find an easier way to get to the same destination. A few will stay on the path and follow it to its rewarding destination. Along the way they will learn much about themselves and the ground they are covering. At the journey’s end there will be a great sense of accomplishment and satisfaction.
Experienced hikers prepare themselves for the challenges that they undertake. They pace themselves. They stop along the way to rest and enjoy the view, but then get back on the trail. They often meet others along the way. They know that their joy will be enhanced by sharing their journey with someone who is important to them. They eagerly anticipate the adventure associated with those they will meet along the way. They relish the possibilities for learning and enjoyment that they will enjoy from unexpected events and sights.
Don Berwick used the metaphor of a trail on the mountain in his original presentation of “Era 3” in healthcare. He noted that experienced hikers know that there is the possibility that they might follow the wrong trail when they come to the intersection of trails, but are prepared to come back down the trail and and rejoin the better trail to the top of the mountain when they realize that they have lost their way.
It’s hard to believe, but this will be the tenth weekend of a fifteen weekend summer, if you count all the weekends between the Memorial Day weekend and the Labor Day weekend. I hope that this weekend you will find a trail to follow and enjoy the journey with a friend or family member. You don’t need to go to the Azores, or to some other off the beaten path place. Much of the fun is finding a trail that will take you to a destination that will have meaning for you. You will be surprised and rewarded by the return on the investment of your time!
Be well, take good care of yourself, let me hear from you often, and don’t let anything keep you from doing the good that you can do every day,
Gene
