Saturday, March 14, 2015

How The Ruling Class Impacts Your Health Care and Why They Need To Be Stopped

The truth crops up in unexpected places.  A colleague directed me to an article is USA Today that I found to be very interesting.  It clearly describes the central problem with health care in America.  From that article (see reference for full text, clinic map and video):

"This is the crux of the whole thing," said Wanda Kuehr, a psychologist who agreed to speak out about the problems after retiring Feb. 2 as the program's director of clinical services. Non-medical managers want to "get the reports in on time and fill the slots. They think that makes a good program. Our goal is to give treatment to soldiers. And (the bosses) see that as inconsequential ... What's happening to soldiers matters and the Army can't just keep pushing things under the rug."

The report details what happened when the Army's outpatient substance use clinics were shifted from medical oversight by the Surgeon General's Office to the Installation Management Command.  This change occurred in 2010.  Some of the changes noted are striking including a basic error in hiring an unlicensed counselor.  Since 2010,  90 soldiers committed suicide and 31 of those suicides occurred after reviewers concluded that there was substandard care.   They could not conclude that the substandard care was causal.  Review of additional data showed that 7,000 soldiers were identified as having a problem but not offered treatment.   Half of the 54 substance use clinics were rated as substandard, specialists identified "poor continuity of care" as a problem, and staff attrition as a significant problem.  Only 309 of 352 counseling positions are currently filled.  The same article estimates that 104,000 soldiers have drinking problems.

What is the significance of this report?  I don't think there is anything unique about what happened to the Army's substance use clinics when the management changed.  It has been happening everywhere else for at least 25-30 years.  Before that time, medicine and specialty departments were managed by senior clinicians based on merit.  The department heads were active clinically and they were valued for their clinical and research expertise.  Some of the most valuable teaching experiences I had during my training occurred due to direct contact with these department heads.  Reviewing brain and spinal imaging with the head of the Neurosurgery Department.  Doing rounds at night with the head of the Renal Medicine Department.  The list goes on.  The point is that all of these experts were engaged in treating patients and teaching medical students and residents.  They had an intimate connection with the provision of care and the profession.  Many of them also had great personalities.  So what changed?

They changes were subtle at first.  When the managers took over they decided to replace some of the department heads at the periphery.  Suddenly there was no longer a certain department that people counted on and their duties were subsumed by another department.  The dislocated clinicians either quit in frustration or were relegated to a more peripheral role in the clinic or hospital.  They could no longer support a teaching mission and suddenly that block of knowledge was no longer available to students.  These experts were consulted in complicated cases to back up the generalists who were now seeing their patients.  The next step by the managers was to suggest that productivity in the larger departments was uneven.  They suggested that they had a metric so that would assure that everyone in the department was pulling their weight.  When I first heard that explanation, I looked around and concluded it was a myth.  Everyone in my department was a hard worker and that was borne out by the actual numbers.  The numbers were the real story.  The rhetoric had allowed the managers to introduce a system to manage productivity that was completely subjective.  But that was all the managers needed to develop a system to manage knowledge workers like production workers even to this day.

Why would anyone want to be a manager?  Well it seems like easy work if you can get it.  Instead of dealing with complex problems that require you stay current in a certain body of knowledge, interact with people in an ethical way, and have extremely high levels of accountability why not just manage numbers and tell people what  to do - especially people who are as politically inept as physicians and their professional organizations.  If I ask physicians that question, I usually hear that being a manager or studying business would just be "too boring."  That may be applying a medical metric to business that could be far from the mind of managers.  Some business educators and critics have pointed out that over the past 2 decades, there is evidence that managers have developed who are focused on short term results and in some cases "the pursuit of short-term shareholder interest, as well as naked self-interest on the part of managers, into managerial virtues." (reference 2).  Instead of a manager who knew and was promoted from within the business and who had a vested interest in the quality of the services and interests of the employees, we now have a class of managers who are mobile, highly paid, and have no particular expertise in the affected business.  Piketty notes that the United States has invented a "hypermeritocratic society" of "supermanagers".  These supermanagers are typically executives of large firms who have been able to obtain "historically high, unprecedented compensation packages for their labor."  He also concludes that "the vast majority (60-70%) of the top 0.1 percent of the income hierarchy in 2000-2010 consists of top managers."(p. 302).  I don't know Piketty well enough to say what his conclusions about why this meritocracy exists.  He does point out that it is twice as likely to occur in the financial services industry.

There are interesting parallels in the management of financial services and medicine.  In both cases, the managing class came about largely as an invention of federal and state governments.  The invention of the manager's tools in medicine (billing and coding, utilization management, prior authorization, managed care) parallels the development of credit reporting and the ability of financial manager to put your savings and retirement funds at risk all of the time without offering you any compensation for the use of your money.  Both of these systems are subsidized by huge hidden tax subsidies from American taxpayers.

When I try to talk with people about this problem their eyes glaze over.  Advantage to both the financial and business managers.

In the meantime, when you drive by your local hospital and it claims to be one of the "Top Hospitals in the US" - don't be surprised to learn that there are at least 600 hospitals on that list.              

George Dawson, MD, DFAPA

1:  Greg Zoroya.  Investigation: Army substance-abuse program in disarray.  USA Today.   March 12, 2014.

2:  Rakesh Kurana.  MBAs Gone Wild.  The American Interest.  July 1, 2009.

3:  Thomas Piketty.  Capital in the Twenty-First Century.  The Belknap Press of Harvard University Press.  Cambridge,  Massachusetts 2014.


  1. One question I have is how payers ought to be treating providers--given that so many institutions are not always necessarily acting in the best interest of the patient, e.g., rehab hospitals holding on to patients until Medicare pays out its maximum amount and then discharging them shortly therafter.

    Sometimes, this is probably unconscious, but it's doctors who are the ones recommending care/procedures (and it's mostly procedurally-based specialties that I'm talking about) that may not be in the patient's best interest. Surgery at the very end of life is one example, but back surgery is an issue too. A lot of it is not terribly useful, and it costs a lot of money. But there's a doctor whose clinical judgment said it was a good idea.

  2. I think there is not much of a question that payers treat most institutions poorly in the first place and that has led to the institutions developing a business like approach to procedures and admissions and discharges. It is a selective process with some specialties being more favored than others. You can see the results in terms of a large Cardiology and Oncology infrastructure over the past decade with deteriorating mental health and addiction.

    The argument about unnecessary procedures has been debated for a long time. A think tank came out with the argument back in the 1980s and yet when a review organization ( where the physician reviewers were all carefully screened for conflicts of interest ) looked at the problem, they did not find enough unnecessary procedures to pay for the program.

    I think the best protection against both unnecessary procedures and aggressive end of life care is a primary care physician who knows you well and not a reviewer sitting in a room many states away representing the best interests of the insurance company. People without primary care physicians tend to approach specialists directly and they may not have a realistic view of the potential outcomes.

    1. Complicated--If you look at MA, the hospitals affiliated with Partners--a network arising from the merger of MGH and Brigham and Women's--are paid much more from private insurers than other hospitals with no clear added value.

      I think the best protection against both unnecessary procedures and aggressive end of life care is a primary care physician who knows you well and not a reviewer sitting in a room many states away representing the best interests of the insurance company.

      That could be an argument for capitation but then you risk people being denied care. Trying to figure out alternative payment models is tricky. Some of the demonstration projects for dual-eligibles (many of whom have SMI and multiple chronic conditions) involve organizations taking on clinical care responsibilities and risk-adjusted payments from Medicare and Medicaid. The one I'm most familiar with is a mission-driven organization, but it means that the every provider is thinking about cost. Is metformin going to work just fine for this patient? Can we teach them how to use insulin themselves even if that means buy an expensive insulin pen, etc.? They are totally focused on intensive primary care with "behavioral health".

      And if the patient is homeless, it may mean providing them with housing. They are doing this, because it saves money, but they also believe that is better care. See Don Berwick's Triple Aim.

  3. Berwick and all of these other guys with big plans lose me in several ways. Cost effectiveness - which I believe is one of his Triple Aims is rhetoric for rationing. People can say that rationing is required and that's fine but it also requires some honesty. First of all not everybody starts off on the same foot with rationing. Psychiatric services were cut about 40% more than anything else in the 1980s and 1990s just because administrators realized they could do it with no resistance. Much of that was capitation. Second, mental health services were decimated at the time when there was a huge Cardiology infrastructure being built out. Most mental health services are nowhere as sophisticated and the rhetoric is "well psychiatry is just a step child to the rest of medicine".

    The real result is that if you have an acute psychotic episode, most payers will allocate about $5,000 and the hospital will try to get you out in 5 days. The facility may be a run down dump with no services that you would want to flee from anyway and your relatives may have a heck of a time getting you seen because you are not "dangerous" enough.

    On the other hand, if you are any middle aged guy with chest pain (forget your cardiac risk factors) - you will be whisked into a CCU, state of the art care and if your enzymes are negative you will have a stress echocardiogram done before you leave in the morning. Hospital gets reimbursed probably 4 - 5 times as much as the admission for psychosis - assuming that somebody can get you in!

    Bottom line is that psych services have been cut to the bone for decades and as a result the quality is pathetic. Med/surg services often have Cadillac care, better quality and more reasonable threshold. The only difference is that they have NEVER been rationed like psych services - not even close.

    All the big administrators also never look to the real savings - cutting all of the administrators. In 30 years I have never figured out what they add except the next great idea that physicians end up jumping though the hoops for.

  4. There has always been rationing by ability to pay. I think that there is a decent model where some of the money from cardiology gets diverted to primary care and psychiatry/behavioral health. But I think we probably disagree about the way to get there. Thank you for your thoughts, though.

    1. Quite obviously - hand me downs from other services who get reimbursed at much higher rates is why we have prisons full of psychiatric patients and a permanent steady state of patients piling up in the ED and getting admitted and thrown out to collect a meager DRG payment.

      By comparison, any new onset of a psychotic disorder should get at lest the equivalent amount of care as a middle aged person presenting to the ED for chest pain. That will never happen with "diverted money" and treating psychiatric patients like second class citizens.