I would argue the problem is worse than it looks initially, if you run the process over time for awhile.
If covering the gap for a disadvantaged patient takes more resources (costing money), such a provider takes a cost hit. If that gap results in a worse score on the payor's quality metrics, that provider gets a smaller (or no) bonus at the end of the year - a revenue hit. This results in fewer resources available for the following year, and so on. This is a form of "death spiral".
Meanwhile, the "winners" build up financial "war chests" for technology, acquisitions, etc., so they become stronger negotiators versus the payors.
As a retired public school teacher after 35 years, boy, did this sound familiar! If you have different input, you get different output. Medicine is now finding out that it works this way for them, too, as health care is becoming redefined in the U.S.
More pay would be nice, but I suspect that, like for many teachers, better support of other kinds would be even more welcome.
Best of luck to you and your colleagues as we all puzzle this out.
Oregon Health Plan's (Medicaid) Coordinated Care Organizations are tackling social determinants of health, especially housing and care coordination outside the clinic. Studies show that just being housed was a huge factor in health improvement. As a measure of how out of whack our govt social safety net is, Portland hospitals and health plans are helping to fund affordable housing.
https://www.apnews.com/f4c66b4b23f347e6b1e118b1b3fd8d1c
1
I really appreciate this piece. It highlights the achilles heal of value based care. I suspect this argument would be stronger if we took the emphasis off of supporting (and paying) doctors and placed it onto better supporting patients.
Most people (including me) care less about how doctors or hospitals are paid than that patients have access to high quality service. I know there is overlap but the messaging is important to generate support.
If there were disproportionally more funding attached to these patients with greatest need, more clinics could build systems to let physicians and staff spend adequate time with our most vulnerable patients. Also this would enable out-patient clinics to hire social workers and nurse care management services. Paying higher rates could be dependent on clinics providing these services in an accessible way.
The clinic I work in would love to hire a capable nurse care coordinator but we thus far have had a had time competing with the salaries these nurses earn from in-patient positions or positions in specialty clinics.
2
I feel the same way as a teacher of poor students. So many complex needs, family system issues, transience, hunger, mental health concerns and we are still expected to teach them math and reading. Also to write grants for everything our school needs because we can't do fundraising. And I work in the city with the highest hourly wage in Canada.
11
I am a nurse practitioner at one of the many inner city hospitals in NYC. I applaud Dr. Khullar's succint description of what is it like to treat the most vulnerable of our population. The system in which we work is predicated on providers presenting the latest evidence of health-sustaining treatments and approaches to our patients. There are some things we can "do to" our patients - like a procedure or an operation. But most things rely on the patients' ability or willingness or both to be able to carry out the behavior change we are prescribing. That might mean injecting insulin, eating better, taking a pill, exercising or smoking cessation for example. Part of my job in junction with a physician like Dr. Khullar, and a social worker is to follow up on these people when they leave the hospital or clinic. But there is only so much I can do short of going to there home and physically putting the pills in their mouth or forcing them to exercise - totally ridiculous. Visiting RN services can help at times. Vulnerable patient's are at great risk for re-hospitalization, cardiac disease, diabetes, sky-rocketing asthma rates and other health disparities including death. We do our best to help these patients but when they can't read the words on a pill box, or afford the pills, and even when we use colors or symbols to help them - it still may be hard for them to participate. I agree with many of the commenters reflect on the similarities with education (teachers.)
10
Why not put 4 or 5 of similar people together to support one another, like a community, like a cancer support group. Then if one doesn't know something, he or she can ask their support person about their medication. Same as with exercise, getting together with like minded persons. People helping people!
TOXIC STRESS!! It's real, and it underlies many chronic illness including addictive behaviors and mental illness. Toxic stress alters brain chemistry - it virtually nullifies free will. It changes the reproductive DNA for 2 generations. This isn't opinion. It's fact.
#1 way to reduce toxic stress in vulnerable populations?
Decent housing, decent housing, decent housing!!!!
What happened to "housing first?" Safe, stable housing, is key, for example, in helping people overcome addictions, yet nowhere in the New York metro area, nor I daresay, most of the country, is any available. As counselors, we are taught the importance of "wrap-around services", yet there are virtually none for anyone who is vulnerable - this includes parolees, probationers, those who are addicted, and those who have mental illness problems.
What will it take to get our governments to pay for decent living conditions as part of our safety net?
There's an Armenian joke where the son-in-law holds his mother-in-law over a balcony. He tells her that unlike his neighbors, he respects her. He then opens his arms and as she falls, he says, "Go and live freely." That sums up our current policies. Kind of a "let them eat cake" approach.
10
@Jen Melikian
"Toxic stress alters brain chemistry - it virtually nullifies free will. It changes the reproductive DNA for 2 generations."
LOL. Did you learn this from Gweneth Paltrow?
2
The title is cute: “Is It Getting Harder to Care for Poor Patients?” No. It’s always been hard, damn near impossible, to do right by these patients medically when they are systematically left behind by a health care behemoth that doesn’t care about them the way we do. Even suggesting that adding “homelessness” or “low income” or any social determinant as an ICD10 code for billing or insurance purposes in the already terribly perverted game of incentives in which we operate is totally failing to see the point.
18
I have a lot of sympathy for doctors on the front lines of care. They are mistreated and abused by their hospitals and they have extremely hard jobs. They should be paid appropriately. I have less sympathy for hospitals and hospital administrators who put doctors and patients at risk to protect their bottom line and their million dollar pay checks!
The cost of health care has rocketed....slowed a bit by ACA but now completely without limit as Trump shakes hands, smiles, attacks journalists and children and tellls corporations: what the hell do what you want.
Doctors need to stand up through the AMA, unlikely, or other organizations and vote for universal health care and negotiated prices for everything from drugs to the basics and hospitals must be told to start fair pricing and billing no more $100 aspirin or those ridiculous charges that are fraudulent and removed if you call.
Hospitals hould be in the business of helping the sick not making money. I doubt this will happen in the current climate. I feel for the doctors and nurses and the patients they serve including most of us poor or middle class. Health care is a luxury only congress members and their families and members of the Trump administration along with billionaires can afford. This must change.
15
Swap the word doctor for teacher and we have the same issues.
18
I would like this country to spend as much time and effort, along with money on the poor as we do on Defense and wasteful Pork projects.
12
I often think we should have Doctors Without Borders and the Peace Corp working right here in our country. Whenever there is a free dentistry day anywhere in America, many 1,000s show up. Some will even wait in lines for days to make sure they get in. There are so many people without basic medical care, it's barbaric.
16
I observed the obesity epidemic slowly come to be over the last 4 decades, as I saw working females, add many frozen pizzas, and lots of pop onto the conveyor belt in front of me at the local grocery store. Too tired to cook, these women fed their families bad food most of the week. This was not limited to any economic class, or race, as the white and Hispanic people did this, it mattered little how much their annual income was, or is now. As they got even more money, they ate out most of the time. Restaurant food is laced with more sodium, sugar, and fat, also. Of course, the health outcomes are in, and many males whose fathers lived to 90 or older in our small town, have died by the age of 60. It is the food, the smoking, the alcohol, and the sedentary life. It matters little whether they are driving a $70,000 truck, a van, or an older model car, they are all doing themselves in with the modern age, of me too, who want what isn't good for them, with no regard of what the future outcome is for these behaviors until it is too late. Talk to our local doctor who just retired after almost 30 years, and he would agree. He and his wife have an organic farmer's market and restaurant, with all of the food grown locally, and the only people who utilize it are older females, who already were taking care of their health. Males, not so much, females under 60, are mostly overweight, on drugs for cholesterol, and blood pressure, and they drink a lot. Too late, sad truths!
11
You failed to mention that the so-called "baby boomer generation" is the first to be exposed to large amounts of pesticide & various types of radiation from a variety of sources. Exposure to Agent Orange has been linked in veterans to increased risk of developed Type II diabetes. There's been little to no research that I'm aware of (perhaps another reader is?) on the synergistic effects of exposure to pesticides (via food, lawns, trees spraying, pet flea control products, standard extermination treatments, etc), pthalates, and PFOS.
And then there's the lack of "walkable" communities. It's harder to stay in shape when your daily life includes alot of driving but little to no walking. Or your neighborhoods as so unpleasant (noisy, dangerous, no sidewalks, no trees, etc) that walking is pleasant only if you buy a treadmill (which not everyone can afford/has space for), or go to a gym (which takes more time out of one's day, how many of them offer free day care?, and of course, cost money to use). How many people garden? In the LI neighborhood I used to live in, fewer people garden/raise any of their own veg & fruit (although that part of LI was once an agricultural area), or even mow their own grass. Probably their commutes are too long, as well as hiring "landscapers" is probably a sign that one doesn't "have to" anymore. Forget designing low maintenance gardens/partially edible gardens.
7
The start of socialized medicine in Canada was not without battles with physicians. I am unfortunately not up on the chapter and verse of it but it began in Saskatchewan under Tommy Douglas of the CCF party, the precursor of our current NDP party. The Canada Health Act was brought in by the Federal Liberal Party because of threats of extra billing i.e. charging patients over what the government insurance paid, by the Doctors of Ontario. A lot of the battles were by expat British Doctors who had fled the National Health of the UK. Interestingly the politics of Saskatchewan currently is quite right wing.
4
Most physicians are not trained to deal with social problems. Years ago, there were social workers in hospitals to help patients with non medical needs which had an impact on their health care. Alas, they were not reimbursed for their time and they disappeared, partly replaced by nurse discharge managers, whose major goal is to get the patient safely out of the hospital before the insurance reimbursement runs out. Moreover, the so called safety net has been disappearing too. Most physicians don’t go into medicine for money, they have compassion and wish they could help. Resources are scarce , and time is money. With the current administration, things will get worse. I see no light at the end of this tunnel.
18
I completed my medical residency at a large inner-city hospital in New York City. Almost all of my patients were poor minorities with so many socioeconomic hardships that any additional illness or accident was a proverbial push off a cliff. I used to say that we would do much more good if we closed half the hospital and converted it to a mental health center / YMCA / soup kitchen / job training center. Unfortunately that has become even more true today. But how would you bill for that?!
35
Thank you for this article. I completely agree this is a huge problem and will further isolate a large population of patients if not addressed in the near future. I hope policymakers read this article.
7
Doctors are not magicians. They cannot turn around a results by choice outcome. It is time for people to make the changes they need to, whether to stop drinking, smoking, obesity, etc. Go to a large box superstore, wait in the checkout line, see what is being bought. I rest my case.
17
Yes and yet, how free are these choices, when the sugar is not only cheaper but also addictive and the advertising impactful?
9
That is not the doctor’s fault
3
I work as an RN in an inner city wound treatment center. We have sooooo many uncontrolled diabetics. There are few supermarkets in the city, and they are substandard compared to the suburbs. Patients miss appointments because of transportation issues. Outside radiology exams and medications are limited by insurance.
Most upsetting, I have been told to curtail patient teaching because it slows down productivity. Yeah, heal those wounds now, but do nothing to prevent future wounds from occurring. Gotta keep that assembly churning out MD income-producing procedures!
4
Dr Khullar has sipped the Kool-Aid provided by MBAs, administrators & marketers-that medical care is like a '50s manufacturing model of incentives - bonus payments for max production.
Of course, high risk patients require more services & no MD should be punished if an impoverished patient population cannot 'adhere' to prescribed care.
But the 15 minute appointment - bedrock of clinic practice and (often closer to 8 minutes) is a root cause of woe. A thorough physical exam & history is optional - no time for attention to personal details, incapacities, misconceptions, as well as specific 'social determinants' of their health.
Creating a trustworthy relationship with continuity over time requires more than a payment bonus or reduced penalties for poor outcomes. Medical care for complex patients isn't Jiffy Lube.
Incentives must include elimination of the assembly line pressures most primary care MDs and specialists have come to accept. Provision of nurse practitioners & physician assistants can provide less costly attention but can fragment the experience of both patients & clinicians. The Electronic health record may get all its boxes checked, but true engagement is undermined.
This is not a plea for 'bedside manner'- it is a plea to revive the time and continuity that is essential for good care, fewer errors and a semblance of an alliance between sick people and their caregivers.
These days- as systems are swamped, an adversarial rush prevails.
16
Do a search-and-replace of "teachers" for "doctors", and "reading" for "diabetes" and a few other terms, and you can resubmit this piece for publication in the education section.
30
Amazing that a physician can see and feel such social inequity and respond with, “but how am I going to get paid? For dealing with such people?”
3
It’s not the lack of empathy you’re implying in this snarky comment.
As part of a hospital practice I have a salary. “How am I getting paid” refers to what the hospital gets. If I don’t meet certain goals, I may find my job at risk. The hospital also can and does tell me not to see patients with less insurance. So there is a dichotomy between be very much wanting to take care of poorer patients, and simply not being allowed to.
31
I assume Peter Kaplan in Montclair NJ runs a soup kitchen and shelter out of his home. Yes, in Montclair, where the median home is $670,000 - well out of the reach of most doctors who have completed residency in the past 10 years. Please tell us, Mr. Kaplan, how you pay your mortgage if you work for free?
27
You are wrong in so many ways. I work for a rural hospital/clinic system where 50% or more of our patients are insured by Medicaid. The doctors, PA 's and nurse practioners I work with are caring, dedicated people. Believe me, they aren't getting rich. Many of our patients have multiple, complex physical and social problems.
16
I graduated from medical school more years ago than I care to think about. Using a broad brush I have seen many amazing advances in knowledge and technology. At the same time the social situation seems to have gone in reverse, widening the gap between those who can afford to become ill and those that can’t. I now work in an “underserved” area, pushing the rock up the hill over and over. I don’t have any great wisdom to impart but I know our ‘penny wise, pound foolish’ approach to providing medical care is wasteful and ineffective. Lack of easily accessible at the local community level means many small problems are treated with a metaphorical band-aid, eventually resulting in a life-threatening illness that requires admission, and all the expensive and time consuming wonders of modern medicine. Eventually the lucky patient is deemed fit enough to be discharged with a long list of instructions,explanations, prescriptions to fill and hopefully a feasible follow-up plan. Most hospitals try to address this by engaging Social Workers, home health care etc. Sometimes it works, often it doesn’t. Prescriptions don’t get filled (no money), appointments get missed (no transport) or any number of reasons conspire to ensure the problem recurs. Wash, rinse and repeat. Why not retire? I guess I feel I can still help in some small way. I win enough small battles, but the war? The idea that this great nation, as rich as it is can’t afford to provide good medical care to all is perverse.
37
As a resident in l994 my 55 year-old male patient, a manual worker, had cancer invading his spine, was deaf, divorced, with no social supports and no money. Social worker at hospital got him disability, hearing aids, an apartment, and a home nurse to check on him and aides to help all that help is now unavailable. Programs have been cut or eliminated.
God help the poor. No one else will.
39
American doctors don’t care about costs. The got into the profession to get wildly rich, and are part of a system of determined racketeering and opaque and fraudulent billing designed to bankrupt patients, that no other first world nation would tolerate. Read An American Sickness by former NYT journalist Elizabeth Rosenthal MD for a depressing catalog of grift and deception practiced by doctors, hospitals, Pharma and insurers, all motivated by greed. Or read her series Paying Until It Hurts. I guarantee you, nothing with make you angrier.
1
I personally know hundreds of doctors, and I don't know a single one who went into medicine "to get wildly rich"; my friends and classmates who wanted to get rich went into corporate law or finance. Doctors mostly go into medicine because they find it interesting, challenging, and want to help people. What happens along the way with its 80-hour weeks of training, abuse, and below minimum-wage salaries ($/hr) is that by the time they come out the other end, they're jaded, exhausted, and broke. They also realize that, with few exceptions, "your job will never love you back", and so all the things that have been ignored along the way - family, friendships, relationships, their own health - become paramount. Physicians who cheat and game the system are very much in the minority (and should rightfully be shamed for it). Most of the rest of us though are exhausted, burned out, still paying back loans, and trying to carve out a bit of happiness and stability while doing what we can for our patients in an admittedly broken and over-taxed system. You think socialized medicine is the solution though? Go check out the NIH - most of my British physician friends have fled to Australia!
THAT is the unsexy but true reality. Go read about that.
40
Wait, I’m supposed to be rich!?!?!? I missed that memo! It must have gotten lost with my loan repayment reminders!
3
I’ll answer this when I have some waking hours not struggling with EMRs, costly pursuing of imposed incentive targets, spending time with patients and getting punished for wait times, making sure my employees get paid. Otherwise I don’t have time for your spewing out nonsense
5
In a nutshell, here's the problem with ANY "pay for outcome" approach to medicine.
HUMAN BEINGS ARE NOT LAB RATS.
Even with PERFECT compliance with medical advice, not every body will react as expected to treatment. Being designated as "non-compliant" by a healthcare provider -- who after all is human and wants to protect him or herself from things like penalties because outcomes are not as expected -- will leave the people who need care the most the least able to get it.
Do we really want to go down THAT slippery slope, Doctor?
12
The author's experience sounds curiously similar to that of teachers. The newest teachers get the most difficult cases, and outcomes are sometimes measured without regard to the student's situation after they leave the school.
26
This is just another example of politicians and know nothings trying to fix the system. Although well intentioned, they haven’t lived in the system and don’t have a clue about the real world. There are studies that reflect the points being made but the policy makers design “fixes” with little input from people in the field. The classic example was Hilary Clinton attempt to fix the delivery system while excluding physician input. I’m not saying that the system doesn’t need change, just that change should be well planned and input from many sources is needed to do it correctly.
19
If I recall correctly, I think value-based payments typically only adjust payments by +/-2% of the Medicare payment. Most clinics don't even see adjustments in their payments.
2% of reimbursements when overhead is about 50% means 4% take home pay cut.
10
This is a nice analysis but out of date. The large payers gave up on better outcomes quite a while ago. They simply want the same outcomes for less money. Perhaps not surprisingly it’s easier to accomplish this with the poor than the luxury box holders.
17
Then please explain HEDIS data.
HEDIS measures work processes, not patient outcomes.
The fact that there is no measurement having to do with contraception, the number one thing that motivates women of reproductive age to interface with the healthcare system, makes me think that some providers with enough clout, such as Catholic health systems, have been able to influence which processes get measured by HEDIS, so that it looks like their physicians are delivering high quality care, even though they are not allowed to give women contraception.
Goes to show you that it's a very subjective activity, susceptible to bias, figuring out what high quality care is, so it's going to be even harder to know how to pay for "value." We have to expect that some effort will be made by the dominant players to extract even more money from the taxpayer than they already are.
Same issues in public education with value added models. ( VAM ). Teachers will shy away from students with social issues because there is greater potential for a negative impact on their careers leaving less experienced colleagues to pick up that assignment. With the investment of time and money put into becoming a physician the rewards in the form of compensation should be there. This makes plastic surgery or concierge practices attractive money upfront and no insurance company to deal with. How I long for my younger days before this got so out of control. Going to see my doctor in private practice before everyone was forced into a large conglomerate. I avoid doctors like the plague. They don't know me nor do they have the time necessary to establish a relationship. It is not their fault. It is a business model forced on them.
30
I just hope that doctors will continue to treat poor patients, because if I live long enough I'll be one of them, as will many of my friends. I'm 65, and most people I know of my age do not have enough money to live on if they make it to 90, or even 85, or even 80, in some cases. Although we joke about it now, underneath the laughs is anxiety and fear. Unless the US institutes some kind of affordable single-payer system, or legalizes euthanasia then there's going to be a lot of sick, elderly poor putting a strain on our already overburdened medical system, or just going without any care at all.
53
I would like to add, medicine needs more doctors who are from disadvantaged backgrounds. That means medical schools need to actively recruit and support students who have experienced the social conditions of their future patients. How would patient outcomes be if they were treated by residents and attending physicians who had themselves experienced food scarcity, violence, homelessness, poverty, lack of preventative care? Not only would they understand the challenges of their patients, they would also be very creative in solving them.
35
@Sarah
Even better, how about we elect *politicians* and policy makers from disadvantaged backgrounds? Very few healthcare providers have any control over the patients they are given, or over the clinic scheduling that limits their ability to provide even basic care to complicated patients.
There's plenty of compassion and creativity on hand to solve problems--but there's no time. Want better care? Schedule 20-40 minutes per patient, then 10 more minutes per patient to do their documentation. And schedule a bathroom break and a lunch break while you're at it.
1
@Sarah
Many medical schools look at non-academic factors during admissions. In ours, candidates of lower socioeconomic status are preferred, provided rest of their qualifications are adequate.
It is not just the socially complex but also the technologically complex as well. There is a push by insurance companies and hospital administrators to discharge quickly to save costs without a true understanding of how complicated it is to educate and discharge patients who have a tracheostomy, a ventilator, and a gastrostomy tube or parental nutrition. Patients on home dialysis and ventricular assist devices are increasing There is the expensive technological imperative that hospitals foster but then want to wipe their hands of these patients once the procedures are done into a fragmented, unsafe black hole. The medical/social/political complex did not prepare for the acuity of patients being sent home to exhausted caregivers with many other responsibilities. Some Boston hospitals are experimenting with different home care programs but we are a long way from providing adequate "safe" home care. I fear a collision course between patients, their family members, and hospitals unless the hospitals and insurance companies take more responsibility for the medical, social and technological care of patients they have reaped the profits from.
18
Dr. Khullar is correct and many organizations have recognized for years the importance of the Social Determinants of Health. One SDOH model estimates that the health care we receive accounts for 10% of living a healthy life. Health behaviors (smoking, diet, exercise) account for 40% and socioeconomic factors (income, education, social disruptions) account for another 40%.
A physician doing wonderful work on bringing the patient into the health care discussion (aka shared decision-making) is Dr. Victor Montori of Mayo Clinic. He provides tools for physicians and patients so that things like income and language are lesser burdens than they need to be.
I do not agree that we have to pay doctors to do better. If that were the case we would then be in arguments about the social factors that prevented the physician from obtaining better outcomes.
I vote for better and earlier education, Medicare for all and a minimum guaranteed income.
18
Single payer insurance , Medicare , for all .
Same price nationwide for prescription drugs , like in many European countries .
Using these basic parameters most of the red tape is eliminated and doctors would have more time to dedicate to the sick , without wasting it cherry picking the diagnostic tools and drugs each insane insurance company imposes.
American health care system is broken , fragmented and unjust.
Good education and health are at the basis of any civilized society .
47
A single payer system will never work until medical school is FREE. High graduate school interest rates and private banks willing to loan huge amounts of money for living expenses through fellowships are leaving doctors entering private practice with debt north of $600 -$700k. Then they enter an income based federal debt repayment program with huge private sector work arounds allows them to live the life style that their education entitles them too until their debt growing astronomically $1-2 Million before forgiven 20-25 years down the road.
Our non problem solvers in Congress are killing access to medicine for all of us because for profit based capitalism is diminishing access to medicine and making all of us poorer. Until profit centers up and down the medical supply chain is curtailed the 99% of us will become poorer as medical portion of our gdp continues to grow and exceeds 20%. Input costs must be curtailed in manors that improve output results.
24
Absolutely, SailorGirl. And not just medical school, but ALL training of those who provider health care services, including nurses, lab techs, etc.
Most doctors I know didn't go into medicine to run businesses or put themselves $500K in debt in their early 30s. They wanted to help sick people. We need to redesign the system so they can.
Also: tort reform AND reform of physician oversight, so that the small percentage of docs who actually cause serious issues due to malpractice lose their licenses, rather than being "covered" by their colleagues. And overhaul of drug R&D related processes (including tort reform) and intellectual property rights, to ensure that prescription costs for Americans are in line with those of the rest of the world.
Lastly, do away with for-profit hospitals, labs, treatment centers, etc. Shareholders shouldn't get one penny of the money that should be used to treat patients. We've seen that a profit motive does not create an incentive for efficiencies that are passed along to those who pay for the services -- which is ultimately the patients, through our premiums!!
5
As long as money can be made from the illnesses of others, our medical system will remain broken.
35
As an RN with 40 years of practice, I wholeheartedly agree; as long as health care is a business rather than a needed service for ALL who need it, (everyone needs it, obviously), and as long as income disparity continues to widen, the health of our citizens will be at grave risk. PJN
30
Been an attending physician for 25 year and have never once been in a luxury box at any event.
35
I was a medical resident in an inner city hospital 40 years ago. After that I was a supervising physician in the same clinic for a number of years. I'm sad to note that not much has changed regarding the care of the poor and disadvantaged during that time. A freshly minted resident would get a new patient with multiple chronic conditions and an eight inch thick pile of medical records. Most of the patients were poor and had complicating social issues.
( It's hard for a diabetic to eat a proper diet when there are no grocery stores in the neighborhood and he or she doesn't have a car.) Our clinic was fortunate to have had full time social workers who were a tremendous resource. They even had a fund to pay unlicensed taxi drivers who would transport the patients to and from the hospital. Many patients had multiple hospital admissions due to poor compliance with medication. Then, as now, a modest investment in social support would have saved lots of money, to say nothing of human suffering.
47
When a doctor is ranked on outcomes, he can improve his ranking by cherry picking otherwise healthy patients. So can a medical practice and a hospital. One can catapult a practice by simply declining to take Medicaid plans and promote taking patients on group plans rather than individual.
Add to it that Medicaid (not always the managed plans, but straight Medicaid) has woeful reimbursement, and those who treat the poorest and the sickest will fall to the bottom of the rankings. They have bad outcomes AND bad reimbursement.
Metrics are made to be gamed by the people who have the time and resource to game them. The bigger the practice, the more they can game the system. The poorer the practice, and the poorer the population it serves, the less time and opportunity it had to game the system.
It is the American way: don't get sick if you can't afford it.
35
It occurs to me that, on some level, these parameters should be applied when evaluating teachers, too.
25
This is an excellent idea. Maybe you can develop it into an op-ed piece for the Times.
1
I want to apply these parameters to or elected officials
3
I took care of a man who kept leaving the hospital against medical advice after a heart attack. He would get overwhelmed and frustrated, and then sign himself out. Sure enough, he would come back by ambulance a few days later. This happened three times. The third time, I suppose he felt comfortable enough with me (I kept an open curiosity about his frustration rather than a patriarchal tone), he showed me a piece of paper upon which were taped some of his pills.
It turned out he couldn’t read, and he became frightened and overwhelmed by what he was experiencing that he had to find solace at home. His kind neighbor had taken pills and drew a sun or a moon next to when they needed to be taken. This gentle soul and his kind neighbor taught me more than a pharmacology professor ever could have in that moment.
No medicine will work if a patient can’t understand, and no treatment will heal if the patient is so frightened they cannot hear.
As I said elsewhere, as long as medicine is treated as a business where money can be made from the illness of others, our system will remain broken.
126
I had a patient like this during residency. She had high blood pressure, diabetes, high cholesterol and obesity and had foot ulcers secondary to her diabetes. She was admitted multiple times to the hospital. English was her 2nd language and I learned over time, she wasn't much more literate in her native language.
I worked with one of my nurses to draw pictures and symbols for her and her husband on how to care for her feet and diabetes. Then I arranged a session for a nurse conversant in her language to demonstrate how to do the dressings, have her and her husband practice in her presence. To my attending's surprise -- she was skeptical but supportive -- the patient and her husband watched/ listened carefully, did everything correctly and that stopped much of her hospitalizations. It was one of my more gratifying experiences in residency. It took more time and effort but we probably saved the hospital tens of thousands of dollars in the long run.
16
Disadvantaged patients have always been among the most challenging patients to care for. At the same time, they also present a huge opportunity for cost savings for their medical care. We need highly functioning multidisciplinary teams to provide excellent care, prevent illnesses and complications, and reduce the cost of care. While we need to create incentives for our best and brightest physicians to care for these patients, we also need more broad social change to help. We need to recognize that because many of these patients are poor, they are unable to pay for their medical costs. As a result, we pay for their care through public programs such as medicaid, as well as through cost shifting when uninsured patients show up in our emergency rooms.
If we provide excellent preventive care, and appropriate social supports, we can improve the lives of our disadvantaged patients, while simultaneously reducing overall medical costs. I strongly support the initiatives which provide appropriate incentives for physicians to care for these patients.
23
Absolutely, let's include social factors in how we pay doctors. But isn't this the wrong end of the problem? A more caring society would support impoverished patients so they can refrigerate their insulin.
60
And it's not just physicians. As a neuropsychologist, I found that insurers more and more often allotted me either 2 hours or zero hours to work with desperate people whose complex contributory histories dated back to early childhood.
To provide decent care, I eventually worked 11-hour days, too often getting paid for only 3 or 4 of those hours. I loved my work, but my working conditions were brutal. Finally, I wore out and retired early.
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Dr. Khullar,
You are not saying anything new to those of us who have been around a while; it's just new to you. And that says something about your medical training. Professionals in public health and in nursing have long argued (100+ years), and demonstrated through research (45+ years), that the social determinants of health have a bigger impact on individual health than a 15 minute appointment with a provider. Indeed, nursing is the care of the sick, preventing sickness, and tending the environment (in the broadest sense) in which care occurs (a summary of multiple nurse theorists). But the American Medical Association's vision has always been more narrow because the medical model is what gets reimbursed, even though 50% of patients don't take their medications as prescribed as a result of that visit. The medical model works well enough if you are acutely ill, but not so much with chronic disease and its prevention.
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Exactly Kathleen. It's silly to expect doctors to solve most of these problems - they are caused essentially by their social situation. Couldn't agree more.
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Kathleen: your comment should be a NY Times Pick.
So accurate.
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Nurse?
When treating low income patients, not only do you have to select the right medication, but you have to spend 10 minutes price checking costs on Goodrx and printing coupons to make sure they can afford it. If they have no social supports and dementia, you have to fill their pill boxes for them. It is very costly time wise and and harmful to your value based reimbursements to care for these patients.
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Many of the socioeconomic variables constituting poverty, low level of educational attainment, and poor social support put patients at higher risk for poor outcomes. Without a car or good public transportation, getting to a doctor's visit is a significant obstacle for care. The co-pays for medication are significant if a patient does not have Medicaid, and patients make decisions to eat rather than take their medications.
Hospitals and doctors are penalized for re-admissions to the hospitals and complications, but don't have any control over the social forces that conspire to make it almost impossible for patients to stay healthy. We need the partnership of government leaders to take care of patients. Instead, they put up more roadblocks and discourage us from treating those who really need help.
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My mother was forced back into the hospital within a few days of a discharge that her doctor had fought bitterly, to the point of engaging his personal attorney to unsuccessfully keep her in the hospital, all because a Medicare clerk determined that, since she’d had a bowel movement, she was ready to go home after complex spinal surgery that clearly hadn’t healed enough for release (common for a 75-year-old patient in compromised health). When the local rescue squad returned her to the hospital with complications her highly respected neurosurgeon had predicted, Medicare tried to deny admittance, then attempted to penalize the hospital. Not only did the doctor’s attorney swing back into action, but several lawyers in my mother’s church took up her case with Medicare, and they finally backed down. Eighteen years later, I still haven’t forgiven them.
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Tomorrow was the second time my granddaughter was scheduled for surgery for a head and neck tumor diagnosed last January but now again denied by insurance. It doesn't matter that it will require a six to eight hour procedure that few surgeons want to take on because in is wrapped around the carotid artery and esophagus. They won't accept that not every surgeon is qualified for the procedure or willing to take it on. In the meantime she suffers in hideous pain. Doesn't matter how much you pay for insurance, a patient can still be denied because, frankly, under our capitalist medical system that is the name of the game.
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Julie: I am very sorry for what your granddaughter is enduring. It is heart breaking. I wish you strength and hope in the face of this most recent setback.
Health care is one of a half-dozen or so issues where public opinion goes in one direction but Congress does just the opposite.
Polls show that Americans want a single payer system but our politicians refused to even discuss the idea. Instead, we got the market-based Obama Care along with the Bush era soaring drug prices.
So why didn't we just vote for someone else? Because there was no someone else. The drug companies, hospital lobbyists and insurance companies made sure they tossed money on both sides of the isles.
What we have instead is a system that serves corporate profits very well, but serves neither the patient or their doctor, nor the taxpayer whose money gets shoveled into this dysfunctional system by the billions.
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"So why didn't we just vote for someone else? Because there was no someone else."
Hillary Clinton was trying to get health care for all when Bill was in the White House, she was First Lady and almost no one outside of Vermont had ever heard of Bernie Sanders.
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Stephanie. Was she trying to get health care for the deplorable and people who cling to their guns and religion. Sometimes the message is good but the problem is the messenger
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Single payer won’t fix these social determinants. Other countries simply use access to care as the rationing tool. They utilize more nurses and medical technicians with social work to improve some outcomes. But, they don’t pay for the expensive end of life care that we pay for here. Cancer drugs are more difficult to get. Life expectancy is longer through increased preventive care (vaccinations, etc). I think a basic single payer system to cover preventive medicine and emergencies would be a great place to start. We can’t have comprehensive care without significant changes to prescription drugs, pricing, geographic centralization, medical school debt, etc. this will be a generational shift that can’t be done overnight. Most other nations started with comprehensive care when it was cheap (before complex imaging, etc) and only added in cost effective options as they became available. The growing pains of restricting access overnight would soon cripple any single payer option, and giving too much to everyone would cause costs to rise too quickly. Anyone who has ever had tricare or been to the VA can understand these pro and con.
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If Dr. Khullar thinks he discovered anything new, I wish to disabuse him of that notion. I've been a physician for over 30 years and ever issue he describes were present long before then. I guess I should be concerned that he seems to think that there is anything new about any of it as it lows an amazing ignorance of the history of healthcare in this country..
For all the talk about outcomes, we still primarily pay based on how many services doctors provide and how much they get for them. It's why few patients infrequently get any counseling on healthy living much less care for mental health problems but have no problem getting tests and surgeries done.
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If only we had some sort of national system for dealing with healthcare. Like, oh, every other developed country in the world.
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I was inpediatric practice for 35= yearsin a relatively prosperousWest Michigan city. Care for the socially disadvantaged means people who have Medicaid. The miserable reembusementmeant that I couldn't afford to continu to serve that population, my landlord refused to takemy good intentions inlieu or rent. Those who want a single payer must be unaware of how much medical care people will consume hen it'e free to them; for some idea ask any primary care Doc in the military who sees dependents.When I was seeing them(patients with Medicaid), the night time phone calls (also free) were hellish. The people themselves, of course were wonderful I quit private practice to work at a Federally qualified Health Clinic, which was great.
probably because of transportation issues, keeping appointments on time was another issue. A single payer system is not going to ameliorate some of the basic flaws in our society. The poor will still be disorganized and lead lives that are chaotic.If Uncle Sugar is to be the single payer, where is he going to get the money?As Margaret Thatcher was alleged to have said:"Socialism is fine until you run out of other peoples money"
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Our current wealth care system is so fragmented that it's impossible to receive good medical care unless one has the time and energy to stay on top of everything every minute of the day one needs care. In other words, in America, our wealth care system is hazardous to your pocketbook and your health. The only people who do not suffer as much are the very rich because they can delegate their concerns to someone else and concentrate on recovering.
The problem with programs designed for poor people only is that they are often poorly run, funded, and thought of. The facilities are uninviting, the care isn't up to snuff, and the patients often need more care than they can get or pay for. The problem with our wealth care system is that it's not meeting the needs of 99% of us.
When was the last time we were able to keep the same doctor for more than a few years? When was the last time we were able to go for medical care without worrying about out of network costs or surprises on our bills and deductibles? When was the last time our doctors spent enough time with us and really answered our questions? In my case I think it was over 10 years ago.
We need a better medical care system. What we have works for the wealth care industry but not for us or our doctors. Both they and we deserve a system that treats us like human beings rather than cash cows.
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"Follow the money." Others have noted that insurance companies' profits are a % of the total, so any policy that increases costs will eventually increase profits, thus economic Darwinism will select for insurers that increase costs better.
Factoid from Commonwealth Fund article- if you combine medical and social services costs as a % of GDP/capita, the US falls between the Netherlands and Norway. We aren't saving money by being mean. https://www.commonwealthfund.org/publications/issue-briefs/2015/oct/us-h...
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The poor, like Jesus said, will always be with us; thus, it's imperative that our society cares for least of us. Poverty has many causes, the bulk of them structural in terms of economic and social policies (direct and de facto). Our society is built to favor medical care to those who can pay for it, the most well-off; but, as a result, it punishes the most needy and vulnerable. It's like we built Calvinist unconditional election doctrine into our socioeconomic system: sustained privilege for the materially privileged, and sustained damnation to those who aren't.
And it's the surest way to burn out physician populations: making them care for the most vulnerable and not supplying the social support to make the care effective and long-lasting. It become a Sisyphean saga that only the most committed providers can sustain long-term.
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