Prof Sir Bruce Keogh, medical director of NHS England. Photograph: Rex
The NHS’s future is in danger because its model of care cannot meet the relentlessly growing demand for treatment caused by the ageing population, the service’s top doctor has warned.
Prof Sir Bruce Keogh, medical director of the NHS in England, said that without massive changes to the way the NHS treats patients, including far less reliance on hospitals, the service risked becoming unaffordable and could see its entirely taxpayer-funded status challenged.
In an interview with the Guardian, Keogh said: “If the NHS continues to function as it does now, it’s going to really struggle to cope because the model of delivery and service that we have at the moment is not fit for the future.”
An unprecedented shift of resources and care into GP surgeries was necessary to help the NHS withstand the twin pressures of rising demand and tight budgets, Keogh added, given the increasing numbers of patients turning up at A&E who needed to be admitted to hospital.
“If not, we will get to a place where the NHS becomes unaffordable and we will have to make some very difficult decisions which will get to the very heart of the principle of the NHS and its values. This will open up a whole series of discussions about whether the NHS is fit for purpose, whether it’s affordable, and whether the compact with the citizen of free healthcare for all is sustainable in the longer term.”
But he denied claims by medical bodies such as the Royal College of Nursing and by the Labour party that key NHS services such as accident and emergency, GP surgeries and ambulance services are struggling so much to cope with demand that the service is in a crisis. Waiting times at A&E are at their worst level since the current system of record keeping began in 2004 and three of the 10 ambulance trusts in England have had to declare a critical alert over the winter.
Asked if current pressures constituted a crisis, Keogh replied: “No. Everybody that’s working out there in the NHS knows that they’re under a lot of pressure at the moment. They don’t like the term ‘crisis’ being applied willy-nilly.
“It’s an evocative term which is also provocative and is used too freely for the wrong reasons. It’s a period of unprecedented pressure, of undue pressure. But the NHS is facing very difficult times, yes. The word ‘crisis’ implies that you can’t deal with it,” said Keogh. NHS frontline services “are going through a critical phase” but would recover, he insisted.
Healthcare in America is the perfect storm. The two things individuals fear the most -- fiscal and physical safety -- intersect at healthcare. The $2.8 trillion dollar industry is built to profit, in large part, from consumers. Medical bills are the #1 reason for personal bankruptcy in the United States, and a majority of those who file had health insurance.
As the owner of a consumer healthcare advocacy, this article is sadly not surprising. We see cases like this on a daily basis.
As a physician myself, I am not surprised at this. Doctors are human just like everybody else, and when pressure comes from above to swing one way or another, especially the subtle kinds of pressure that rankings and rewards represent, it's very easy to convince yourself that you're still doing the right thing in changing your practice behavior. Nobody is immune to social pressures or subtle pavlovian conditioning.
Ultimately the problem here is not truly the frontline MDs, though I bet that they're the first who will get penalized. It's the corporatization of medicine, the demand for higher and higher profit. I'm not talking about just for-profit hospitals, non-for-profit hospital systems often take just as much out of the system, only in those cases money is being extracted out in salary for those in the C-suite. Executives are often so divorced from the practice of medical care, that they don't see or care about the "helping and healing" aspect of care. Sometimes the pressure they exert is generally for the better, for example in the push for shorter hospital stays, but often for the worse as they drive the practice of bad medicine under the guise of efficiency.
Oh, and to those who say that all doctors are the problem. Be aware that is similar to saying "all teachers are terrible" there is an incredibly wide variety of MDs. Procedure oriented specialists make tons of money, but primary care doc salaries can be very mediocre.
I am a physician in a large group and we are also under a scorecard system each month regarding charges, tests ordered.I hate it! I am pretty sure it goes on more than you think. It is because the current system pays us to do more not to do what is right and necessary.
As a primary care physician, I can tell you that this type of corruption is endemic in our medical care system. Emergency room physician groups coach their physicians on how to dictate (read "exaggerate") notes that will justify maximum reimbursement. I saw this in Merced, CA. I'm seeing the same type of thing in Santa Cruz, CA where the local hospital sponsors meaningless "screening tests" to pump up its bottom line.
I keep forgetting, so please remind me:
Why is it that stealing billions from the government seldom results in a criminal prosecution, but shoplifting $50 leads to arrest and a felony charge?
"Still, when H.M.A. announced the Justice Department’s involvement in the lawsuits, investors and analysts shrugged, and the stocks for both companies involved in the merger barely budged." And here is the problem: the Federal Government coddles corporate interests. Until the government is willing to break the back of corporations that flaunt the law and charge and imprison the executives who drive the illegal activity, nothing will change. Oh, and it might help if the revolving doors between corporations and the federal government were closed, too.
Sadly this is very common. In fact, numerous not for profit institutions also practice the same way, just a lot more subtly. My friend who works as an admissions persons at a mid level acute rehab facility (under a not for profit institution) is under daily pressure to bring in more admissions. To buttress their philanthropic claims, they occasionally will admit a 'charity' case, but the doctors who admit and work with these patients, get penalized (by getting lower bonuses or no bonuses), as they bring in less 'collections'. The people who run the show in most hospitals are increasingly non healthcare providers. In my ICU, our Operations director is a 32 year old ex technician (who also know the CEO), who is clueless to the workings of an busy ICU.
There is little to no incentive in the healthcare industry to hold down costs. Worse yet, the rewards for performing unnecessary surgeries is huge, while the risks of doing them are essentially nonexistent. Here are a couple of articles that show what I mean.
Prostate Cancer Radiation Therapy Rises as Doctors Profit
Urologists who buy their own equipment to provide expensive radiation treatment are more likely to use it to treat prostate cancer even when the benefit for patients is unclear, research shows.
Prostate cancer is the most common tumor diagnosed in the U.S., where an estimated 238,590 men were told they had the disease this year. While only about 12 percent, or 29,270 men, will die from it this year, all will have to decide how, and whether, they want to treat the cancer.
A study published in the New England Journal of Medicine suggests that profits urologists make from referring patients to their own radiation facilities play an outsized role in the treatment decisions. One third of men whose doctors own radiation equipment get the therapy at a cost of about $35,000 per treatment course. The same doctors prescribed the therapy for just 13 percent of their patients before they had their own equipment and could profit directly.
“The results are striking,” said Jean Mitchell, the author of the report and a professor of public policy at Georgetown University in Washington, D.C. “It does appear that what’s driving this is financial incentives linked to ownership. Their behavior changes dramatically.”
Claims Data
Using claims data from the U.S. government’s Medicare insurance program for the elderly, Mitchell found that urologists who didn’t own the equipment prescribed IMRT for 15.6 percent of their patients in 2010, compared with 14.3 percent five years earlier. Its use among the NCCN doctors stayed constant at about 8 percent, while it soared to 44 percent among a matched-group of doctors who started to refer patients to their own radiation treatment facilities.
Self-Referral
“It’s crazy the way the system is set up,” Mitchell said in a telephone interview. “The patients are going to do what their physician tells them to do. The patient becomes almost like an ATM machine, with the doctor extracting as much revenue as they can.”
Ethical Practices
Physicians in general aren’t allowed to refer their patients for treatment in facilities that they also own, because of the financial conflict of interest. However, radiation, as well as in-office ancillary services, such as doing blood work and x-rays, are exempted under U.S. law.
The analysis found that doctors who owned the IMRT therapy were treating men ages 80 and older just as aggressively as younger men with early stage prostate cancer. Since the cancer is generally slow-growing, and radiation can carry immediate side effects, including erection problems and urinary symptoms, the older patients may experience only the harms and no benefits.
The study bolsters similar findings with other forms of self-referral. In fact, some urologists have incorporated pathology labs into their practices, boosting the number of biopsies they perform, Mitchell said. Research has found similar results in other areas, including advanced imaging and surgery at physician-owned specialty hospitals.
By some measures, Federico C. Vinas was a star surgeon. He performed three or four surgeries on a typical weekday at the Daytona Beach, Fla., hospital that employed him, and a review showed him to be nearly five times as busy as other neurosurgeons. The hospital paid him hundreds of thousands in incentive pay. In all, he earned as much as $1.9 million a year.
Yet given his productivity, some hospital auditors wondered: Was all of the surgery really necessary?
To answer that question, the hospital in early 2010 paid for an independent review of cases in which Vinas and two other neurosurgeons had performed a common procedure known as a spinal fusion. The review was conducted by board-certified neurosurgeons working for AllMed, a company accredited to audit health-care businesses.
Of 10 spinal fusions by Vinas that were selected, nine were deemed not medically necessary, according to a summary of the report.
More than 465,000 spinal fusions were performed in the United States in 2011, according to government data, and some experts say that a portion of them — perhaps as many as half — were performed without good reason.
The rate of spinal fusion surgery has risen sixfold in the United States over the past 20 years, according to federal figures, and the expensive procedure, which involves the joining of two or more vertebrae, has become even more common than hip replacement.
Washington Post analysis of 125,000 patient records also shows that roughly half the tremendous rise in spinal fusions in Florida has been on patients with diagnoses that experts and professional societies say should not routinely be treated with spinal fusion.
In 2009, a former compliance official at the hospital filed a whistleblower lawsuit alleging illegal financial incentives for doctors. The court filings make available an array of documents — e-mails, testimony, audits. These and other sources allow a fuller depiction of the financial rewards and relationships that depended on treatment decisions. They also show how hospital administrators responded when suspicions arose that a doctor, who was generating millions in profits, may have been performing unnecessary surgery.
Vinas and his colleagues in neurosurgery earned as much as thousands of dollars extra — above their base salaries — for each procedure after a certain threshold. The vast majority of Vinas’s earnings came from such incentive pay, according to legal filings.
According to government estimates, each neurosurgeon at Halifax Health was generating more than $2 million a year in hospital profits. The hospital charged fusion patients an average of about $80,000, according to Florida records on Halifax Health analyzed by The Post, ranking the procedure as one of the more expensive.
Baklid-Kunz detected Vinas’s rapid pace of work in an audit and asked for further review of his surgeries, documents show.
But she was discouraged from investigating further, she said.
“Hospital administrators didn’t want to touch Dr. Vinas,” she said in an interview.
Instead, they referred to Vinas and the hospital’s two other neurosurgeons as “our high rollers,” she said, and told her that rather than cracking down on their billing that “we need to make them happy.”
Medicare In the Spotlight
Medicare, the nation’s health-care system for people older than 65, is at the center of the debate.
The agency estimated the amount of money spent improperly on spinal fusions was more than $200 million in 2011, for example, and most of that was because the treatment was deemed unnecessary, often because a more conservative course hadn’t been tried, officials said.
How could this happen?
The answer, in part, is that the Medicare system is not designed to discourage doctors from performing it, according to past and present Medicare officials.
At a very practical level, the bureaucracy offers little incentive to weed out unnecessary treatment: Medicare hires contractors to issue payments to doctors, and those contractors are paid based not on how many claims they reject but on how many they approve.
above emphasis mine
US Healthcare System Greased for Fraud
Medicare pays contractors based on how many claims they approve. Good grief!
Very expensive prostate radiation therapy is conveniently exempt from self-referral laws.
Although physicians in general aren’t allowed to refer their patients for treatment in facilities that they also own (with the exception of radiation therapies), the problem of incentives is universal, across the board.
Physicians paid on an incentive model, like spinal fusion star surgeon Federico C. Vinas, have every financial incentive to perform needless operations.
Every step of the way, the US medical system is greased to perpetuate fraud against taxpayers, against patients, against insurers.
US Healthcare System Explained in Six Succinct Points
A constant battle is underway between insurance companies that do not want to pay any claims, even legitimate ones, and doctors and hospitals incentivised to rip off patients, insurers, and taxpayers with unnecessary surgeries and Medicare fraud.
Insurance companies demand massive amounts of paperwork out of rational fear of fraud and unnecessary treatments. Doctors perform for-profit (as opposed to for-patient) procedures that guarantee more explanations and more paperwork.
Doctors and hospitals have direct personal contact with patients, but insurance companies don't. In cases where doctors put patients at huge risk with needless procedures and surgeries, it's easy for hospitals and doctors to point their finger at insurance companies. On the other hand, many sincere, honest doctors have difficulty getting patients the care they should have because insurers believe they are getting ripped off by unnecessary procedures, even when they aren't.
Doctors make needless tests out of fear of being sued for not doing them.
The vast majority of healthcare costs occur in final last year or so of someone's life. Politicians who want to do something sensible about this issue get accused of "rationing healthcare".
Doctors not only have a financial incentive to prolong life needlessly, they also worry about not prolonging life out of fear of being sued by family members unless there is a living will, and perhaps even if there is a living will.
Obamacare Failings
It would have been nice if Obamacare fixed some of the above problems. Unfortunately, Obamacare did not fix any of them.
Fraud, ridiculous amounts of paperwork, and incentives to do the wrong thing were everywhere you looked before Obamacare. The same problems exist now.
Worse yet, Obamacare added to the mess by over-charging millennials and their kids, and undercharging smokers and others with unhealthy lifestyles. Except for those below certain wage thresholds, insurance costs are likely to increase.
Mike "Mish" Shedlock http://globaleconomicanalysis.blogspot.com
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As the owner of a consumer healthcare advocacy, this article is sadly not surprising. We see cases like this on a daily basis.