Unbalanced Equations

I have come to believe that, at least in the U.S., we will find it very difficult to have meaningful and high-impact changes in healthcare while the main focus remains on saving money.

This DOES NOT mean that I don’t think there is a need to rein in costs.  Clearly there is.  I only mean to say that saving money is, by itself, inadequate. 

I first started thinking about this when I read Atul Gawande’s “The Hot Spotters.”  He details an effort to help “super utilizers” of care in Camden, New Jersey.  And while Dr. Gawande rightly emphasizes the impact this had on patient outcomes, he also focuses on the savings that were realized by the program.  

This is not an isolated case.  To name just one other example, Massachusetts General Hospital participated in a three-year demonstration project to improve care and coordination of Medicare services, resulting in a 20% reduction in hospital admissions and a 25% reduction in emergency department visits, with a 7% annual savings among enrolled patients after accounting for intervention costs.

So if we have lots of examples of our ability to take specific, measurable, and attainable actions that result in significant cost savings in our healthcare system, it begs the question: why are we not seeing across the board drops in expenditures?

There is no doubt that the answer to this question has multiple layers, but the Camden example is indicative of what I think one of those layers is. Dr. Gawande goes on to write that some healthcare systems and individual professionals actively resisted – one might even say sabotaged – these super ultilizer efforts because the savings were impacting the bottom line.  It’s a clear cut example of why cost cutting in and of itself will not be the solution. We might all agree that it is a wonderful thing for a patient to go from having six diagnostic tests per month to two.  But the providers administering those tests and the labs that process them might not feel the same way, since those tests are some of the “products” they sell to generate revenue.

This is why I was not appalled, as some might have been, during my Eisenhower Fellowship when one healthcare policy person in Germany told me that the primary question regarding whether the country’s statutory health insurance companies cover a drug or procedure is its efficacy.  If it works, the person said, “then we do it.  Cost is not put in the equation.” 

A few years ago I probably would have reacted a lot differently. How can you not factor in cost? But that is where my thoughts have evolved. If your main objective is savings, the result will be blunted because of the economics.  Germany's answer to this conundrum has been a socialized system with regulated pricing, a method that the state of Maryland has fashioned for its own purposes with its Health Services Cost Review Commission.  But barring that type of strategy, which despite Maryland's success is not likely a viable way forward in the United States as a whole, cost savings have to be linked to other revenue generating opportunities for maximum results, or at the very least a trade off between profit margin and market predictability.

This is not an easy thing to do.  But unless we put both revenue and savings into the equation, we will likely continue to lament how much unnecessary spending is occurring for substandard outcomes.

Medical Interpretation: Saves Money, Improves Outcomes

One of my final meetings in Germany was with Honey Deihimi who directs social integration at the Federal Commission for Integration in Berlin.  Our conversation, where Honey spoke as a private individual and not as a  representative of the German government,  mainly revolved around care for immigrants and refugees in Germany, but as we went on, we talked about medical interpretation.  

                                                                     Honey Deihimi

In the United States, courts interpreted Title VI of the 1964 Civil Rights Act - which states that recipients of federal funds may not run their programs in such a way as to create discrimination on the basis of race, color or country of national origin - to mean that medical interpretation was mandated for any entity receiving federal funds.  This eventually led to the CLAS (National Culturally & Linguistically Appropriate Services) standards in 2000 in order to “Provide effective, equitable, understandable and respectful quality care and services that are responsive to diverse cultural health beliefs and practices, preferred languages, health literacy and other communication needs.”  With specific regard to medical interpretation, it was believed that  providing this service had the potential to improve access to care, quality of care, and, ultimately, health outcomes.

Unfortunately, as of 2013, these standards only hold the status of recommendations, not enforceable policy.  Still, one hopes that healthcare providers, especially those who see an ethnically diverse group of patients, will move forward with these standards.  Their efficacy is certainly without question. 

More than 25 million people in the U.S. have limited English proficiency (LEP), according to the U.S. Census. And when such people need medical care and do not have access to professional interpretative services, it can lead to negative clinical consequences. One study showed that LEP patients stayed longer and had to return to the hospital more frequently when no medical interpreter services were provided, a situation that drives up costs for hospitals.  Also, data have shown that interpretation can improve patients’ utilization of preventive and primary care services, such as follow-up visits and medications, that potentially may reduce costly complications from chronic conditions.  (Other data about the clinical importance  and cost benefits of medical interpretation can be found here, here, here, here, and here.)

Honey told me that she and others are trying to make the case in Germany for mandated  medical interpretation.  Beyond that it is the right thing to do, in a growing, mobilized international world, Honey said, it makes sense to have these services available.  But, “language barriers is one of the biggest obstacles we face,” she said.  Currently, interpretive services must be provided for people who are blind or deaf, but there is no law or even policy that requires interpretation to be provided in the medical setting for those who have limited proficiency in German.  Honey hopes that this situation changes in the future.

Service to the Poor and Sick

I sat in the spartan waiting room with a handful of patients.  One was laying out over four chairs.  Another set of people were huddled in a corner, speaking softly.  In the hallway I could see two women and a man alternately enter and exit through several doors.  Their movements were hurried but purposeful.  Over the next 45 minutes, the people in the room with me were ushered in through these doors, and then later exited.

Twenty minutes after my interview was scheduled to start, the man I first saw in the hallway entered the waiting room.  He apologized for the delay but had only in that moment finished with the last patient for the day. He introduced himself as Hanno, an internal medicine physician who volunteers at the Malteser Migrant Medicine (MMM) clinic in Berlin.

MMM helps people who do not have valid residency status in Germany.  They work anonymously in cooperation with other medical providers, churches, and charitable organizations to provide assistance.  The clinic is part of a much larger operation that evolved from the Order of Malta, one of the oldest institutions of the Christian West, and acts according to the principle which is manifest in the motto Tuitio Fidei et Obsequium Pauperum: "Witness to the faith, and service to the poor and sick."

They could not have found a better exemplar of this motto than Hanno.

                                                    Dr. Hanno Klemm with a clinic nurse

Dr. Hanno Klemm volunteers at the clinic three days per week.  He sees "just enough" patients in a private practice to make enough to live on.  "Money is not very important to me," Hanno said.  He speaks four languages and has enrolled in a romance languages class so he can learn Spanish, French, and Portuguese.  Knowing many languages is very helpful since Hanno never knows who he is going to encounter in the clinic and there is no budget for interpreters.  Last year Hanno estimates the clinic saw over 10,000 patients, a number which he expects to increase substantially this year with the levels of migration that are occurring.  The clinic depends on Hanno and the other 11 doctors who staff the clinic because the entire budget for the organization is 35,000 euros (about $48,000) per year.  All services to patients are delivered free of charge, and lab work is done at a substantial discount arranged with a local company.

Like Casa de Salud, the clinic encounters many patients who need additional treatment.  The clinic has access to a social worker, but she is only available twice a week and her caseload is packed, so Hanno is often doctor, social worker, and referral coordinator all wrapped into one.  For every patient he sees who needs a hospital, for example, Hanno must arrange for a hospital to take the patient and then negotiate costs.  On the day I visited, Hanno spent most of the morning in between seeing patients calling a neurologist to try to secure an appointment for a patient seen the previous day.

Despite how hard the work is for the doctors, Hanno and his colleagues are able to keep the slots filled during the three days per week the clinic operates.  "We just keep on being creative," Hanno said.


I came away from my visit with Hanno deeply impressed, and very humbled.  MMM sees more patients than Casa does with one-fifth of the volunteer providers and 5% of the budget that my organization is privileged to have, not to mention having to rely mostly on the doctors themselves for referrals (at Casa I have a full time person working referrals and a team of five that manages the entire external operation).  It is a reminder to me that persistence and passion on behalf of a worthy cause can surmount all obstacles.