Do We “Waste” Money on Terminal Patients? (Part II)

GUEST: Dr. Peter B. Bach
AIR DATE: 04/21/2012
VTR: 01/26/2012

I’m Richard Heffner, your host on The Open Mind.

And this is the second of two programs dealing with what perhaps we should call the “marketplace” of American medical practice.

Once again my guest is Dr. Peter Bach, Director of the Center for Health Policy and Outcomes at Memorial Sloan-Kettering Cancer Center here in New York. Dr. Bach has written frequent opinion pieces for The New York Times and the Wall Street Journal, valuing as he does ever more extensive communication between the medical profession and the lay public.

Last time my guest used a phrase many of us have only recently begun to hear: “Hospitalist”. He is one, and I’d like him not only to define again this new medical specialty…but also to define the implications of its existence for our traditional doctor-patient relationship. Fair question?

BACH: Absolutely. And thank you again for having me. One minor clarification. I’ll define “hospitalist” and explain why I’m not one, if you will …

HEFFNER: Okay.

BACH: But … the, the … there has been a shift, if you will in the work force structure in healthcare. And this … with relation to “hospitalists” this shift is that, if you will … in ancient times, let’s say … five years ago or more … traditionally doctors followed their patients into the hospital. So the same doctor you saw regularly when you were relatively healthy, when you became sick would … that same doctor would take care of you in the hospital. They would make rounds in the morning, they would check on you, they would talk to the … usually physicians in training in the hospital or other their staff and they would go back to their offices and take care of their other patients, who were out-patients.

HEFFNER: Who was in charge of the patient care at that time?

BACH: Well, at that time … usually it was your regular doctor, if you will … the one who you saw on the outside. Those doctors had privileges in the hospital where they admitted you. And even though there may be other doctors in the hospital that you would see, usually your attending physician or your physician of record was your, if you will, your regular doctor.

There’s been a shift … rather rapid … that patients who are being admitted now to the hospital and there’s a specialized doctor who works within the hospital, who then takes over the responsibility of your care. A doctor many of us refer to as “hospitalists”.

And those doctors are typically employed by the hospital and they work on a salary and their expertise is essentially taking care of people who are quite a bit sicker than patients who are out-patients. They understand the system within the hospital better, they’re usually better networked within the hospital, they’re familiar with … the sort of intricacies and also, idiosyncrasies of the particular hospital where they’re employed. And they take care of the patient until the time comes to discharge them back to the … their out-patient setting and then care is transferred back to the patient’s doctor.

I’m not a hospitalist, although I exclusively see patients in a hospital. That’s an artifact of my specialty, I’m a pulmonologist … and I happen to only serve one pulmonary function, which is … I see patients who are sick enough to be in the hospital, who also have a pulmonary problem. But I could be taking care of patients on the outside if, if my … if, well, my life were structured differently.

HEFFNER: Okay, let’s go back to the hospitalist, himself or herself. And indeed, is it mostly “herselves” these days?

BACH: It’s a good question. I don’t know the ratio, but it’s probably fairly close to fifty/fifty. The, the hospitalist … the emergence of hospitalist is interesting for a number of reasons.

One, and we talked this, I think, last week, was that it’s evidenced that there are doctors coming into the work force who are ready, more so, to do shift work … to be employed, to get regular old salaries and W-2 statements.

And are less, if you will, entrepreneurial. And in exchange for that they get … you know, a stable work environment … they get regular benefits and they get an ability to have a flexible schedule.

And those are all things that are desirable, I think, to people who are coming into the work force now, more today than, you know, even a few years ago.

HEFFNER: Why?

BACH: There, there can be any number of explanations. One is that going into the sort of entrepreneurial practice of medicine has become a lot less attractive, or in basic terms become a lot less lucrative.

So, you know, the willingness that people have to, kind of hang out a shingle and take all that risk and do all that extra work and all of a sudden become experts in running offices and the rest of it, is diminished because the returns are, are lower.

It could be that administrative complexity has also risen, making those sorts of activities even more challenging. But it also could be that, you know, we have a new breed of people entering the medical profession, who want to work in sort of team structures and have a different work/life balance and, you know, are more accepting of an idea that, like most people in America they can be employed by a larger entity and work in a collective way.

HEFFNER: Now, just between the two of us …

BACH: Yes …

HEFFNER: Am I better off …

BACH: … you’re not saying much about the size of your viewership …

HEFFNER: (Laugh)

BACH: … but okay …

HEFFNER: … am I better off, as a patient … if it is true that the entrepreneurial aspect of the practice of medicine is perhaps diminished or being diminished these days …

BACH: I … nobody knows. It is … it has become in recent years a sort of … a calling card of healthcare reform that we should get doctors on to a different financial incentive structure. For example, salaries or things that start to look more like salaries. All based on the premise that if, if I’m receiving a salary, I’m less likely to do additional services that are not beneficial or are potentially harmful … ah, purely for the profit of doing so.

That makes basic economic sense. There’s some evidence that such things occur more often when doctors have a financial benefit of doing more things. But we’re not … it’s not clear, really, if you took the current workforce and shifted them from these sort of financial incentives to a salary structure if they would actually, if you will, behave better, differently, or in a way that serves your health better. We don’t really know.

HEFFNER: Let me ask whether I’m … you think that I’m correct in my assumption that most people, patients, are as innocent or as unknowing or as plain dumb as I am when one begins to talk about hospitalists and the shift in the nature of medical practice.

BACH: I, I don’t think most people, even educated people, even some policy analysts understand … or have a good insight into the complexity of how medical care is either delivered or financed. Or in this case … staffed.

It, it’s … you know, we’re talking about three-quarters of a million practicing physicians in this … in the United States … ah, I think somewhat more nurses than that. Talking about 17%, 15% of the US economy … something … it’s a very large, complex thing and it wouldn’t surprise me at all that most people don’t know about hospitalists and sort of one slice of how we manage or how we’re starting to manage patients who become sick and have to go in the hospital.

HEFFNER: But what an incredibly important slice … that is.

BACH: Perhaps. You know, the, the data that we have … it’s not fully consistent … the data we have suggests that the hospitalists have not harmed care quality and if anything, maybe outcomes are slightly better.

And they have led to, because, if you will, they understand the nuances or idiosyncrasies of where they practice … they are able to achieve shorter lengths of stay with the same kind of outcome, just, you know, save a half day here or there because they’re preparing or they’re a little bit more up to speed on something to do.

You have to realize that it’s … the fact that we have more hospitalists may not be … not have been driven by more people being willing to go into it, if you will. But rather a shift in how much care is provided in the out-patient side compared to the in-patient side.

It used to be, if you will, that a lot of care was provided inside the hospital to patients who are, if you will, moderately … as well as very ill …

We have increasingly moved the patients who are moderately ill, if you will, back to the out-patient setting … keeping people from having to go in the hospital. That’s a good thing.

The consequence for your doctor, however, is that … in the old day they might say … for arguments sake … have on any particular day three or four patients in the hospital. Making the trip to the hospital, if you will, worth it … worth their time … and just, you know, making their relationship with the hospital more consistent.

And maybe nowadays they have one potential patient in the hospital. And then you sort of start to wonder, like … “Do it make sense for them to go all the way to the hospital”? You know we live in New York City, but, you know, for many, many cases … it’s … we’re talking about across the street.

But in most of the US, it’s not across the street, it involves a car ride, it involves parking your car … ride 20 minutes, 30 minutes each way. And if you only have one patient in the hospital, it starts to make less sense.

HEFFNER: But doesn’t it, and I’m asking you, again, as an innocent … although I think I told you before that my grand old physician years ago, Mack Lipkin, had said when he was about to retire … said, “Dick stay out of the hospital because they’re getting to (and I guess he was describing what you’ve just described) …

BACH: MmmHmm.

HEFFNER: … the hospitalist … getting to the point where I or my counterpart cannot be in charge of your care, but somebody you don’t know and I don’t know, will be so.”

What about the impact upon the patient’s sense of dependence upon the doctor he sees a few times a year … he depends upon … his family sees the same person. What about that personal connection?

BACH: Well, let me answer that a couple of ways. The first is there’s no empiric data. I don’t mean to act all scientist or anything. But, we don’t know. I don’t think it’s been carefully measured about those effects.

Another answer is … you know, of the important parameters, of course, everyone should care deeply about patient satisfaction and experience of care.

But you know we have a health care system that is bloated and costly and actually doesn’t provide as high quality care as it could or as other countries do, which are similar.

So, you know, my top priority, if you will is not the patient’s experience with care … care about it … it’s those other things. You know, actually making sure that they get the best care that we can get to them.

The next is that … it sounds like you, you had a … you have, you know, a tight relationship with your doctor. But, the data don’t suggest that that’s the experience of most patients at all.

That, you know, this notion of that, you know, each individual has for a doctor a sort of Marcus Welby idea … “Moonlight” Graham if you want to think of Field of Dreams since you’re a movie fan.

Ah, that most people don’t. You know, doctors and we talked about this last week … patients and doctors sort of bounce around in this way that was unexpected before a number of analyses, including one I was involved in, showed that there is no such bond for most patients.

And that, that reality is important to sort of work around. And if it’s chaos on the outside, if you will … then actually having consistency (laugh) within the hospital is something we should find desirable.

HEFFNER: Tell me more about that because you’re right. I, I think of Richard Cohen, my internist now and I can’t imagine doing without him or not being able to have him guide my medical destinies. As I had with Mack Lipkin years before. Is this not typical? Are you suggesting that …

BACH: No, by definition it’s, it’s … it’s highly atypical. Right. The average patient in Medicare … you know our work and other people … some of the government groups that analyze Medicare data have shown the average patient in Medicare sees about seven different doctors a year and 20% or 30% of those patients turn over to different groups of doctors each year … those doctors don’t necessarily work together and as patients develop more and more conditions … they actually see more doctors and the variation between the doctors they see rises.

And so it is, it is the antithesis of what you would want if, if you believe that, you know, an individual doctor who gets to know you well is sort of the path to both the satisfaction and high quality care. We don’t have that. We have the opposite.

HEFFNER: Let, let me ask you a question. I don’t think it’s an unfair one … you can yell “Foul” … do you think that’s a more desirable relationship to have … a patient with his physician with his physician … because at times you’re a patient.

BACH: I’d … I think … oh, sure … you mean as opposed to bouncing around randomly to doctors who don’t know you?

HEFFNER: No. No, no. As opposed to being at the tender mercy of a hospitalist?

BACH: Oh … if I had my druthers, I actually think I, I … a seamless interface, if you will, or path of communication between out-patient doctor and one who’s expert in in-patient care is probably preferable to having doctors on the outside following patients into the hospital.

The, the … so I think we probably disagree because I get the sense that you think the opposite.

HEFFNER: I feel the opposite when I think …

BACH: Yeah.

HEFFNER: … I have to pay respect to your … you’re a researcher, you’re a digger … you’re looking for numbers, you’re looking for facts. And I have only my feelings to depend upon.

BACH: But I’m facing, you know, fewer facts than I would like to have to assert, you know, a certainty … one …

HEFFNER: But we’re going ahead. You say you’re facing … you must mean the profession …

BACH: Right.

HEFFNER: … is facing …

BACH: The profession, the field … exactly.

HEFFNER: … okay, but we’re going ahead, nevertheless.

BACH: So …

HEFFNER: For economic reasons?

BACH: Not the first time. Ah, the … I mean for some of the reasons I described … right … that …

HEFFNER: Okay.

BACH: … fewer patients in the hospital per doctor … rising population of doctors who want to do this kind of work … the desire for the hospital to control the physicians … and have them, if you will, report up to the hospital because they’re using the hospital’s resources … right …

HEFFNER: Now wait a minute, wait a minute … let, let’s, let’s develop that a bit. Please expand upon the desire of the hospitals to control the physicians.

BACH: Ah … well …

HEFFNER: You said it, I didn’t.

BACH: Yeah, yeah … of course. No, it’s … it, it’s if you want another aspect of medical care that most people fail to grasp or perceive because it’s sort of hidden … but the, the current construct is the hospital, if you will, is, is a physical building, right that’s staffed and its got things like beds.

But the people who use the resources of the hospital … I mean the patients, of course … but people who direct the use of resources in the hospital … like which patient has to be in which bed … what happens within that bed … what the nurse provides them when they go have an x-ray or an operation, something like that … are doctors who … in most places in the US don’t have a … don’t, if you will, report up to the hospital. They have complex relationships with the hospital.

The hospital makes money as a result of the doctor’s providing their services within them. But, you know, the use of beds, the use of these other things is a bit of a push/pull there.

So, an alternative model and I happen to be a salaried physician employed by a hospital working at Sloan Kettering, but an alternative model is exactly that.

I essentially report up to the hospital. My use of the hospital resources on behalf of my patients … something I’m accountable to at the level of the hospital.

And so it allows … if you will, for everyone’s interests and goals to be better aligned. It’s really important in areas like quality improvement and patient safety, infection control. Those are one family of things that hospitals and doctors who work for those hospitals can kind of worry about and work on together in a team way.

But other areas it’s also important to in terms of homogenizing patient care following evidence based medicine. Migrating patients and doctors, if you will, to ever newer versions of electronic health records and things like that.

Having everyone employed makes it start to look like any other industry, where, you know, the place where the things are built, hires the people who are doing the building inside.

HEFFNER: You’re not saying this, I gather, with a sigh. You’re not saying “This is the way it is … ay de mi’.

BACH: I, you know, I … I’m a policy analyst. I … some of what I’m …

HEFFNER: All the more reason for me to ask you.

BACH: No. But, I mean, some of it … is just sort of statement of fact … this is what’s happening.

I think there’s a strong belief that this is a structure that’s going to be better for patients and better for an evolving healthcare landscape. For example, I mentioned electronic health records.

HEFFNER: Right.

BACH: The … for sure the healthcare reform law contemplates versions of this better integration … the accountable care organization concept is based on … not necessarily restructuring the financial relationships between physicians and hospitals … it doesn’t require hospitals to hire their own doctors, if you will.

But it does contemplate a, a financial tie between those two that’s much more linked to … if you will, there ability to collectively provide care at a lower cost and of higher quality. So that, you know, obviously suggests some sort of coordination and rowing in the same direction.

HEFFNER: You mentioned several times, this week and last week, electronic record-keeping, etc. You feel this is very important part of the whole development.

BACH: I do. I don’t think anyone in their right mind would imagine that a highly functioning healthcare system wouldn’t have an electronic background. We don’t have it now. Getting there will be hard. The software that’s available, the records that are available are not up to the task. The competition between vendors has caused all sorts of … I think … unanticipated problems … such as vendors locking records in a structure that can’t then be read by some other vendor’s software. Which we’ve obviously seen in other areas in the software industry.

But I can’t image that we can get to where we want to without having, you know … it all being based on electronic … for exchange of ideas and, and data. We’re nowhere close to that right now.

HEFFNER: What about time lag in terms of age of physician in this … if we’re going to have a no-man’s land in which physicians between the ages of 50 and 70 right now are not really going to be able to function terribly well …

BACH: You mean in an electronic age?

HEFFNER: Yeah. If we had what you think we need to have …

BACH: Yeah. I don’t know. I mean we certainly see at our hospital that the doctors, you know, are able to adopt … you know we’re fully electronic and our doctors who span decades in age … have been able to adopt the systems, that, you know, we’ve, we’ve integrated into all aspects of care.

So, you know, obviously, it’s traditional to assume that old fogies can’t run computers. But, ah … you know, I don’t think we’ve necessarily seen that. It certainly could be the case that younger people … I know in my office … I’m always … I always call young people when I can’t figure out something in Microsoft Excel or something … so … it’s ah … there’s some generational affect, but hopefully the tools are developed by people in ways that can be adopted by anyone.

HEFFNER: I suppose it’s a sidebar issue, but does the matter of privacy enter into this consideration, this important consideration of electronic records?

BACH: I think it’s everyone’s top priority.

HEFFNER: Really?

BACH: Yes. Because … ah … you know the old expression that, you know, humans can mess things up, but it takes a computer to create a real disaster … is … it bears heavily on … weighs heavily on people.

So the issues of privacy are important. Right now there are really quite a few, not only safeguards or regulations in place, that I think would mostly … at least strongly discourage people from being sloppy.

That’s doesn’t mean that … ah … things couldn’t happen. But I’m not aware of any important privacy breaches every happened in healthcare as a result of the advent of the electronic health records. And hopefully our systems are up to snuff.

That said you, you never want to create any system where you absolutely require yourself to drive … drive some parameter to zero. Because it creates such constraints on everything else. So, I think the truth is … and I could never be a politician because you can’t say things like this, but the truth is that if we obsess to the point of not tolerating any errors or leaks in privacy … we’ll never get anywhere.

That doesn’t mean we should just be free form about it, or willy-nilly, but I think the reality is, you know, we need to figure out ways to enforce the systems, there will be mistakes.

HEFFNER: Where? How?

BACH: Don’t know.

HEFFNER: You must anticipate something.

BACH: Oh, I don’t … no hardly. No, I just … I know the reality is that, you know, as we …

HEFFNER: Murphy’s law … if something can go wrong, it will. Simple as that.

BACH: I think it’s probably more the law of increasingly complex systems operating in systems that aren’t designed to accommodate them, is the problem. And I think this is why we see the kinds of mistakes that periodically get made.

But I’m making a much more basic, if you will, philosophical point that, you know, it’s … we can’t move forward if we cannot tolerate mistakes, because right now there’s estimates to suggest there’s 100,000 deaths a year do to patient safety errors. And every reason to believe that an electronic health record and system would drive that number down sizably. How many of those deaths would we have to avoid to tolerate a leak … a privacy violation. I think, you know, probably not that many. You know because those lives matter a great deal.

HEFFNER: Let me ask you a very different area of question and we only have four or five minutes left. About the young people who are thinking or who might have been thinking about medicine. What are the words of advice and I raise the question because so many of my friends who are doctors tell me … they tell their children, “don’t go into medicine”.

BACH: Yeah, it’s interesting. I, I have a young child … and we’re still working on whether he’s going to be a professional soccer player or a fireman. But I … it’s a tremendous profession … it’s tremendously rewarding, I wouldn’t trade it for anything. You know, like I said, the old days of medicine with the doctors having the houses on the water are gone. The, those houses now belong to people who create financial instruments, or figure out how to get people to click on internet ads. And that’s a reality. That’s a sad reality.

A friend of … a colleague of mine and I propose that we create a different structure for paying for medical school where we essentially could make it free for people. And I think that would be an important part of making medical school work and being a doctor work.

Because right now we have this mis-match between a very heavy debt burden that people take on to go to medical school and really a, a very bad way of trying to pay that back. Because many of the professions that are desirable for other reasons … like primary care … pay at such low rates that really taxes people and serves as a disincentive and drives people to specialize probably more than we need.

HEFFNER: I, I was aware of your colleague and your thought about this. Any reaction to it?

BACH: It, it’s actually been tremendous and we have spoken to people, you know, in Washington about it, as well as many of the organizations who worry about many aspects of medical school as well as fellowship training because if you remember, part of the proposal was actually to shift who got paid when they were doing their specialty and some specialty training.

And I actually … you never know, but I feel like it’s something that could be done, is desirable, we think is do-able within the Medicare regulations. That matters because Medicare pays for some specialty and specialty training through things called Indirect Medical Expenditure Reimbursements.

But, you know, it’s … I believe it’s a fully logical idea that pays for itself and would have numerous positive benefits. Anyone who’s been around healthcare policy will say “Oh, those are the parameters that guarantee its failure”, but … ah … I’m not yet that cynical.

HEFFNER: If I remember correctly, you weren’t talking about an outrageously expensive proposition here.

BACH: No, it’s a “wash”, actually … as currently constructed.

HEFFNER: Nothing is a “wash” … but …

BACH: No, it is, in this case. The cost … the full cost of educating people in medical school right now, on an annual basis is the same as the cash compensation of people doing some specialty training. Like within a few dollars. And, so all we proposed was medical school is free if you do some specialty training … like primary care … you get paid during that specialty training. But if you go on to sub-specializing …something like pulmonary medicine … my specialty … during that training period, instead of getting a salary … you would get nothing. You’d get benefits, but that would be the time you would take out loans to pay for your life.

And … because when you come out as a pulmonologist you’re well … much better compensated then when you come out as a primary care physician. The debt burden for financing medical school would sit on the people who went into higher paying professions like pulmonary medicine.

HEFFNER: Dr. Bach I hope that you get more and more people to pay attention to what you’re suggesting. Meanwhile I want to thank you for joining me again on The Open Mind.

BACH: It’s my pleasure. Thank you for having me.

HEFFNER: And thanks, too, to you in the audience. I hope you join us again next time. Meanwhile, as an old friend used to say, “Good night and good luck.”