Even more gaming...

I love following Art Diamond's blogs. He always seems to find such interesting stories.

http://www.artdiamondblog.com/archives/2010/05/_a_space_heater.html

The lesson is again, more rules means more opportunities to game the rules. When the personal gaming opportunities outweigh the accrued costs to the many, time to rethink the rules.

Is the practice of medicine best done as an individual or group activity

I am reading David Sloan Wilson's "Evolution for Everyone". I first heard of him through a lecture I found on iTunes University which prompted me to buy his book. It is well worth reading. One of the basic tenants of the book is that one of the key developments in human evolution was the development of tools which furthered human cooperation. These included both physical traits such as highly visible eyes with stark contrast between iris and sclera, personality traits, and cultural norms which favor group v. personal accomplishments.

I happen to practice medicine in an academic health care setting. Academic success and promotion are predicated almost exclusively upon personal accomplishments. The hard currencies recognition are "my papers' or "my grants". Outside of scholarly activities, the clinical metrics are also very individually based. The sad truth in the clinical realm is that clinical excellence simply does not exist by any measurable metric. Yes, when the president of the University has a friend or family member who needs the best care, everyone knows who they should see, likely a solid if not stellar clinician not otherwise recognized. Those within the clinical realm are otherwise recognized by individual metrics of gross billings or RVUs. There are not other measurements which might assess how well they facilitate the functioning of those around them.

The model is pretty clear. Measure and reward on the basis of individual accomplishment and hope that this translates into success at the level of the group. This is simply wishful thinking. As David Sloan Wilson points out, virtually all moral codes throughout the world are successful because they value behaviors which further the ends of groups as opposed to individuals.  In particular, physicians view themselves as a world apart. We attempt to select for extraordinary intellect and assumes that this will translate into some sort of higher moral judgement. However, the feedback on the individual metrics is persistent and consistent while the feedback on the group success is virtually non-existent.

In my environment, at least I am surrounded by colleagues and trainees, although not always when I may benefit from their insights and input. When evaluating a patient in a time constrained context,  inputs from other physicians, trainees, and staff would likely improve the quality of diagnostic assessments. In very elegant studies of group v. individual decision making using a "twenty question" model of analysis, he found that stellar individual performers almost never translated into outstanding group performance. Furthermore, those participating as individuals found it less gratifying than those participating in groups. Yet, I see the practice of medicine as increasingly being practiced in isolated ambulatory settings as solitary endeavors, whose success is measured by tabulation of measurable but irrelevant metrics.

Einstein is to have said that:

If I had an hour to solve a problem and my life depended on it
I would use the first 55 minutes to formulate the right question
because as soon as I have identified the right question
I can solve the problem in less than five minute

 Humans as a whole have triumphed because we have acquired the tools and inclination for cooperative activities. Within medicine, we have adopted a culture and metrics which value and overwhelmingly reward individual accomplishments which further individual ends alone, many of which are irrelevant or destructive to success of the whole. We in academic medicine who have been placed in the position of training future clinicians and scientists and modeling behaviors they can and should emulate. I maintain that we are making a fundamental error by doing this within a culture which explicitly values individual achievement and self promotion above everything else.

The immediate effects of health care reform

This could be a very short blog. Health care reform passed and we are simply waiting for something to happen. Nothing substantial has happened yet. We are anxiously waiting to see if the SGR fix goes through and concerned about the effects if we see a 21% hit on MD payments from Medicare. Such a cut will be impactful to say the least. However, this has little to do with the Patient Protection and Affordable Care Act of 2010. According to Wikipedia, the following elements went into effect immediately after President Obama signed the bill:

The Food and Drug Administration is now authorized to approve generic versions of biologic drugs and grant biologics manufacturers 12 years of exclusive use before generics can be developed.^[30] 

The Medicaid drug rebate for brand name drugs is increased to 23.1% (except the rebate for clotting factors and drugs approved exclusively for pediatric use increases to 17.1%), and the rebate is extended to Medicaid managed care plans; the Medicaid rebate for non-innovator, multiple source drugs is increased to 13% of average manufacturer price.^[30] 

Support Comparative Effectiveness research by establishing a non-profit Patient-Centered Outcomes Research Institute.^[30] 

Creation of task forces on Preventive Services and Community Preventive Services to develop, update, and disseminate evidenced-based recommendations on the use of clinical and community prevention services.^[30]

The Indian Health Care Improvement Act is reauthorized and amended.^[30]

What has the average American noticed thus far? Absolutely nothing! When will the average Joe or Jane actually notice something which is a direct consequence of the legislation? That is not clear to me. There are a few stipulations which will be enacted over the next year which will require insurers to spend 85% of premium dollars on actual "health care", a completely unenforceable requirement since no one can really define what that is. Insurers are already hard at work redefining what this actually means and you can be assured that legions of nurses and doctors on the insurers payroll will have their tasks redefined from the administrative to care realms. When these are enacted, what will we notice? Not much I suspect.

Most of the meaty elements of the bill do not go into effect until 2014 and many do go into effect until 2017 or 2018, The pundits are debating in earnest what the effects of this bill will be. They can only guess and the sad truth is there is no way that we can ever determine whether events happening a decade from today (positive or negative) will be linked causally to the legislation drafted and passed this year. We cannot hold anyone or anything accountable when the actions and the consequences are separated by such a time span.

I understand why we have a fascination with sports, games, and music. I can go to a golf driving range and get a bucket of balls to hit. I may be dismal but I can get immediate feedback from making adjustments and trying again. I know when I am doing things right and when I have it all wrong and I know it almost immediately. The same is true of playing a musical instrument or playing video games. We are wired to respond to feedback and to understand these feedback time frames. If we do something which does not further our ends, we quickly realize this and generally cease activities which do not accomplish our goals. This is particularly true if the actions result in harm or physical discomfort.

If the feedback time frame is delayed, many humans get into trouble. The most obvious examples are those involving addictive substances or behaviors. The immediate effects may be pleasant and the dire consequences delayed days, weeks, or years. This is a recipe for disaster. When the timeline for assessing consequences of legislative and legal interventions extends to generations, we are essentially toast. I have my doubts that the current health care legislation will accomplish anything it has set out to do. By the time that the key provisions are actually enacted and sufficient time has passed to make an assessment of actual success or failure, we will have forgotten why various provisions were enacted and likely have modified many elements based upon political expediency. We will have no reference points, no control groups, and those in power will share scant resemblance to those who passed the legislation in the first place.

A major problem with entrusting political entities with solving problems is that the feedback loops involved are so dismal. It is not like shooting a basketball or playing the piano where you know you have missed the foul shot or hit the wrong keys. When political entities effect changes, we virtually never know if we got it right. There are no gold standards and the time frames required to assess the wisdom of interventions is beyond even the most focused and enlightened human attention span. Present decisions are virtually always driven by short term political expediency.If present decisions, driven by such short term motivations, happen to be wise long term interventions, it is simply dumb luck. The question arises.. Why entrust entities and institutions which are inherently unaccountable with such responsibility?

More about prices

I get the TOC from the NEJM. I am very grateful for the editors of the NEJM for providing me with a constant source of nonsensical analysis which serves as inspiration for my blogs. This week at least two authors wrote pieces which clearly identified historical problems with pricing medical services as a source of problems which are at the heart of issues which we have yet to effectively address.

http://healthcarereform.nejm.org/?p=3480&query=TOC
http://healthcarereform.nejm.org/?p=3375&query=TOC
http://healthcarereform.nejm.org/?p=3478&query=TOC

The problem boils down to this. Prices for health care services are by and large administratively set. Administrative pricing never gets prices set correctly. When prices are not correct, it creates perverse incentives by sending the wrong information to all parties involved.  The health care economy will continued to be screwed up as long as the prices are set incorrectly.

It would seem that the heart of the problem is not that the prices are incorrect, it is that the methodology used to define prices within health care is wrong. It is not that we have selected the wrong experts to set the prices, it is we have elected to use experts at all.  If this were a fuzzy arena in economics, with experts weighing in that there were many examples in history where administratively set pricing was the foundation of a robust and durable system, I could see how this analysis might be widely embraced. Heck, we just need to find just the right administrative entity or administrators!

However, history is completely and utterly devoid of ANY SUCH EXAMPLE. The administrative pricing model has perhaps one of the most perfectly consistent records of anything in the history. It has NEVER worked. Yet this indisputable fact appears no where in any of these discussions. We need to give Robert Berenson  credit in that he recognizes that present solutions to the pricing problem are woefully inadequate and that their correction is key to any future solution.

Paradoxically, it will be necessary to correct mispricing and other flaws in existing fee-for-service payment systems in order to ultimately dismantle them.

The challenge will be to know when things are fixed. As long as we use the administrative model to price health care, we can be assured that we will not need to worry about this any time soon.

 

Further observations on the episode based model of patient care

I am playing catch up today, dealing with tasks which I simply could not shoe horn into my week's activity. One of those tasks is completing notes on patients who had visits to see me yesterday. They were all complicated, presenting to me because they had problems which were not amenable to common diagnostic or treatment pathways. Virtually all of them will require treatment outside the bounds of standard practice.

Theoretically I could deal with all of the work involved in their care while they were in my office. However, there are time and resource constraints. Let me list all of the tasks which need to happen to complete an episode of care and prioritize which ones must get done and when.

1. Check in including co-pay collection and verification of insurance
2. Rooming
3. Nursing assessment - vitals, meds
4. History - new or interval
5. Physical exam
6. Assessment and synthesis of information
7. Generation of plan which ideally includes some sort of procedural element
8. Patient education
9. Check out
10. Documentation of all of the above
11. Communication with patient in the interval before the next visit

I pose the question, which of these items can be done poorly or not at all and not put immediate payment in jeopardy.  The way I see this the only thing which absolutely must be done are items 1, 2, 7, 9, and 10. Granted there needs to be some sort of history and physical documented. It does not have to be particularly accurate or include any useful information. Everything else can be stinted.

In the episodic care model, the ideal business practice is to make any patient requiring any sort of care between visits unhappy in order to stimulate their desire to seek care elsewhere. If the problem at hand at the time of a visit cannot be complete dealt with in the time frame of the brief visit, the activity outside the time frame of the office visit is volunteer work. Not everyone is cut out for volunteer work.

So here I am on Saturday morning doing my volunteer work. Sometimes it requires that we actually do a literature search to identify the rationale for a particular therapy. You cannot always review the relevant portions of the medical record when your patients are landing in your waiting room like planes lined up for landing at O'Hare international airport. That is relegated to your volunteer time or it never gets done. The sanctions for doing a mediocre job in managing complexity is you are relived of the responsibility of managing complexity. Some sanction.

The episodic model rewards only one thing...volume. You get paid for volume and not penalized in any appreciable form for the absence of quality. Volume is easily measurable and quality is not, particularly in the outpatient realm. I think that Clayton Christensen hit the nail on the head when he saw the parallels between the steel industry and health care. We are basically engaged in the manufacture of re bar steel. There are no specs on quality, for the most part it gets buried so no one can check,  and we just need to generate it by the ton. Occasionally the quality is so bad that someone gets burned, like the occasional parking garage collapse brought on by substandard re bar support. However, this is so rare as to be a non-issue from a business model standpoint.

Let me review the enhanced assessment of the episodic care model. Essential elements in red:

1. Check in including co-pay collection and verification of insurance - this is obvious based upon Sutton's Law

2. Rooming - no face to face encounter, no payment 

3. Nursing assessment - vitals, meds -as little as possible. They might find something you have to deal with.

4. History - new or interval. See #3 above

5. Physical exam - WNL - we no look, we no listen

6. Assessment and synthesis of information - why bother except for identifying high margin CPT opportunities

7. Generation of plan which ideally includes some sort of procedural element - whether the patient derives value or not 

8. Patient education - why bother

9. Check out - another opportunity to collect cash

10. Documentation of all of the above - Non patient specific templates are the best. They are not required to contain any information useful to patient management, only billing. 

11. Communication with patient in the interval before the next visit - to be avoided like the plague. If they have issues which require this, invoke strategic incompetence and send elsewhere.

How to create a patient centered system

I would like to thank my fellow medical blogger notes from RW http://doctorrw.blogspot.com/2010/05/donald-berwick-im-extremist.html, citing a very interesting article written by Donald Berwick in Health Affairs last year. http://content.healthaffairs.org/cgi/content/full/28/4/w555 . The piece is entitled:

"What patient Centered Should mean: confessions of an extremist."

Abstract: Patient-centeredness" is a dimension of health care quality in its own right, not just because of its connection with other desired aims, like safety and effectiveness. Its proper incorporation into new health care designs will involve some radical, unfamiliar, and disruptive shifts in control and power, out of the hands of those who give care and into the hands of those who receive it. Such a consumerist view of the quality of care, itself, has important differences from the more classical, professionally dominated definitions of "quality." New designs, like the so-called medical home, should incorporate that change.

The piece is very provocative for a host of reasons and could serve as the source of blog commentary for weeks on end. It identifies that initiatives to achieve the generally agreed upon goals of quality, value, safety, efficiency, professionalism, and patient centered care create conflicts where you can achieve one or more only at the expense of one or more of the other goals. Overall the achievement of any of these goals will be restricted by the same thing that restricts the achievement of any other goal;


1. Scarcity of resources
2. Competing priorities and agendas - which desirable outcomes take priority?
3. Uncertainty regarding how interventions will be translated into outcomes 


Berwick, in claiming to be an extremist, admits this and comes down on the side of radical consumerism in health care.  I must say that I am sympathetic to his radical health consumer agenda. I still maintain a reasonably active practice and my conscience prevents me from being anything from completely honest and transparent with any patient I deal with. If they (patients) were not my priority, I would  feel obligated to tell them so. I can not in good conscience tell them that and since I desire to remain active in patient care, I choose to make them my priority. However, in taking on such a health care consumer advocacy position, you need to realize that there must still be a brake the consumption of resources needed to fulfill patient wants. Ultimately, someone needs to say no. 


Each individual physician can choose how to allocate their individual scarce resources. No individual physician has infinite hours or energy. We all limit the numbers of patients with whom we create therapeutic relationships and which specific patient wants we choose to fulfill.   However, how policy makers react to devise system-wide approaches is an entirely different story. Fundamentally, it is a paper, scissors, rock problem. To be patient centered as a system we must be responsive to what patients want. In the world outside of health care, patient wants are are essentially unlimited and the limits of fulfillment are based upon decisions made by individuals deciding how they want to allocate their limited personal resources.


In the Alice in Wonderland world of health care, patient wants are also unlimited. In contrast to the world outside of health care, resources are commonized and the agencies responsible for allocation of scarce resources are charged with making decisions to optimize efficiency, quality, value, safety, and patient centered care. To deliver efficiency and value to the system, they must say no to some patient wants and fail to be patient centered.  To not say no requires us to infinitely commonize and direct more and more resources toward health care, ultimately bankrupting our economy.


In the very consumerist world outside of health care people deal with their infinite wants within the context of their limited personal resources by creating personal priorities. Vendors strive mightily to deliver value, competing for the scare consumer dollars.  The net effect is the relentless drive to value, with goods and resources of increasing quality becoming available more broadly at less cost. Where specific consumer breakthroughs happen is unpredictable but what is certain is they happen.  As an alternative to this consumerist vision outside of health care, we are offered a professionalism model to deal with the competing priorities and conflicts of interest inherent in the doctor (health care worker) - patient relationship. 

"Professionalism" versus "consumerism." The sociologist Eliot Freidson, in his classic study of health care, Profession of Medicine, defines a profession as a work group that reserves to itself the authority to judge the quality of its own work. Freidson posits that society cedes this authority to a profession because of three beliefs: (1) altruism—that professionals will work in the best interests of those they serve, rather than their own interests; (2) expertise—that professionals are in command of a special body of technical knowledge not readily accessible to nonprofes-sionals, and (3) self-regulation—that professionals will police each other.

It appears that in order to embrace such a model, we will need to model our behavior on Plato's philosopher-Kings, who are to act as guardians of the general good and are immune to the pitfalls of their non-rational appetites. This is simply unrealistic and a denial of human history. Utopian schemes based upon altruism and self regulation have  a perfectly consistent track record. They always fail.  Optimal achievement of the system goals of quality, value, safety, efficiency, and patient centered care can neither be planned nor accomplished through a command and control environment with decision making and controls delegated to non-self interested elites. I would argue that to create a truly patient centered  health care system can only be created through a market based health care system where patients (medical consumers) define the priorities and push for quality and value by controlling allocation of their own scarce resources. A system which is truly patient-centered is one where the primary agent saying no is the patient themselves, based upon their decision that their own resources would be better spent on something else.  It may not be perfect but it has proven to be the best model of optimal allocation of scarce resources and fulfillment of consumer needs in all human realms. 

Over diagnosis of cancer- again

http://jnci.oxfordjournals.org/cgi/reprint/102/9/NP

H. Gilbert Welch, M.D. and William Black, M.D., of the Dept. of Veterans Affairs Medical Center, White River Junction, Vt. and the Dartmouth-Hitchcock Medical Center used data from large randomized screening trials to estimate the extent of overdiagnosis. They found that about 25% of breast cancers detected on mammograms and about 60% of prostate cancers detected with prostate-specific antigen (PSA) tests could represent overdiagnosis. In a lung cancer screening trial of chest x-rays and sputum tests, they estimate that 50% of the cancers detected represented overdiagnosis. They argue that this estimate will only increase with spiral CT scanning, which, in one observational study, found almost as many lung cancers in non-smokers as smokers.

The authors also point to cancer incidence and mortality statistics as evidence of overdiagnosis in some cancers. For five cancers—thyroid, prostate, kidney and breast cancer, and melanoma—data from the past 30 years show an increasing number of new cases but not an increase in deaths. In each of these cancers, an increase in screening or imaging tests has been associated with an increasing rate of new diagnoses.

The screening industry will not melt away since it drives traffic and dollars to high margin medical activities. It also has zealous supporters within the patient communities. Despite Dr. Welch's fervent and persistent cries, no amount of statistical data will sway the physician and patient zealots. Some day there will be a tally of the costs of over diagnosis and over treatment. Risk assessment will move beyond the paraffin, textiles dyes, and light microscopy and the label of cancer will be restricted to diseases that actually have malignant behavior.  I am not sure when that will happen.

The CPT and financially inspired savantism

From Wikipedia:

Savant syndrome, sometimes abbreviated as savantism, is not a recognized medical diagnosis, but researcher Darold Treffert describes it as a rare condition in which people with developmental disorders have one or more areas of expertise, ability, or brilliance that are in contrast with the individual's overall limitations. Treffert says the condition can be genetic, but can also be acquired.

What does this have to do with health care? Savantism is most commonly recognized as a developmental disorder but it has also been recognized that it can develop later in adult life. I would argue that the CPT based payment system has functioned as an evolutionary impetus to create a culture a medical savantism.

The CPT contains about 7000 billing codes and is basically divided into two basic types of codes. One type, which makes up the vast majority of  codes identifies a billable activity which tends to be technical and procedural, and is focused in time and space. These tend to be identified as higher margin activities and successful billing and collection for these activities is not dependent upon mastery of a broad knowledge base in medicine out side of the particular technical expertise.  These specific technical codes make up  about 99% of the CPT codes.

The second type of codes is an evaluation and management code. There are distinct codes for particular contexts whether that be inpatient or outpatient, new patient or follow up, consultations or non-consults. They all follow the same basic format and there essentially five levels of E&M services; easy, minimal difficulty, moderately difficult, very difficult, extremely difficult. The key point n all this is that management of the most difficult problems which is paid by an E&M code results in less financial renumeration than the payment received from many of the defined technical activities.

The most financially advantageous position to be in is to find a highly remunerative focused activity and become incapable of more modestly or poorly paying services. Everyone in medicine shares the E&M codes and this results in no one becoming their champions. The E&M services are at best a loss leader. From purely a financial perspective, why invest the time and effort to maintain competence in broad problem solving when strategic incompetence means being able to focus on what you do well  and what pays well.

What does medicine look like when there is a wholesale exodus from from trying to see the big picture and the biggest rewards are directed towards those who have pursued their focused technical expertise with savant like zeal? It looks like our present medical model.  Call it financially inspired savantism.

 

When does the pre-season end

I remember when my children were young and I had shared the job of driving hordes of them to various sporting activities (as well as my stints as coaching). I recall one day early in one particular soccer season when I was chauffeuring a carload full of ten year old boys, all playing on one particular team. Their season had not starting out very well and some of the boys were lamenting their situation. However, one of the boys astutely pointed out that the first few games really did not count. They were only part of the pre-season.

I was reminded of that episode frequently over the next decade as I watched my children and others navigate their adolescent and young adult years. I realized that the concept of the pre-season has relevance well beyond the realm of amateur and professional sport. However, unlike the realm of sport,  the transition from pre-season to regular season may not be so well defined.  Perhaps that is one of the reasons that we like the world of sport where the rules are so well defined.

In the realm of politics, the internet and archiving of virtually everything has rolled back where the pre-season begins. Elena Kagan's undergraduate thesis is making its rounds of the internet, being mentioned today on Greg Mankiw's blog. The original link to Princeton's distribution network has been inactivated, something I find rather curious (see below). From what I read, the content comes across as sympathetic to socialism but that was not the major theme. The major theme was consensus and unity is essential for success of the socialist movement, a lesson which Elena Kagan may have generalized beyond the left.

In reading excerpts from Elena Kagan's undergraduate thesis, I was brought back to listening to car full of 10 year old boys and the pre-season. When does the pre-season end in regards to public declarations of our beliefs regarding political, philosophical, and social positions?  Should we counsel young people to be careful regarding what they say and write because it might influence other's opinion of them 20, 30, or 40 years hence? I never gave a moments thought as an undergraduate student that anything I wrote for a course could be resurrected during my professional career and require any explanation. Should teachers who provide oversight to editors and writers of their high school papers caution their students that their positions might be second guessed 30 years hence?

The transition from childhood to post-pre-season adulthood now happens very abruptly. Just ask the parents or friends of an inexperienced high school student driver who wrecks their care and kills themselves and/or others. Just ask the sexually active teenager who contracts HIV and is committed to a lifetime of treatment.   This age is marked by impulsiveness and recklessness without the the understanding of the possible consequences. We can go from doing goofy and apparently harmless things in high school to the front page of the New York Times in the blink of an eye. Just ask the three members of the 2006 Duke Lacrosse team who were falsely accused of rape.

However, thinking and writing should be different. We do not want our young people to recklessly push the bounds of truly high risk activities. However, why should we make thinking, writing, and the exchange of ideas  into a high risk activity? Why should Princeton need to remove access to Elena Kagan's undergraduate thesis. Are the only pieces safe to post the ones which no one has any interest? What good are those ideas?

Therapeutic deception

No matter how much we would like to distill medicine down to something explainable and predictable, we are always going to be confronted with phenomena which defy explanation and run contrary to conventional dogma. Enter again the placebo. There is a nice piece in the online version of the Boston Globe which I came upon through Arts and Letters Daily:
http://www.boston.com/bostonglobe/ideas/articles/2010/05/09/the_magic_cure/?page=full

The piece summarizes nicely some of the more contemporary work on placebos for the treatment of human diseases. It raises a number of particularly interesting questions regarding placebos and their deployment in medical practice. One particularly devilish issue is whether a physician is obligated to reveal they are using a placebo for treatment. The author actually suggests there is data that placebos may work even if the patient knows they are placebos. I wonder if we would be obligated to inform the patient that there are side effects associated with placebos (nocebo effect)?

I suspect this issue will gain even more attraction in the future for the simple reason that our therapeutic endpoints become more and more focused on patient reported outcomes. It is difficult to imagine that placebos will have much effect on a fractured femur, sepsis, or a DVT. However, as we become more focused on end points relating to patient perceptions and symptoms, and the active drugs deployed have more subtle effect sizes, I can imagine that the placebo may become a better, safer, and cheaper alternative. How can we use this approach without violating patient trust?

It may be we need to delude ourselves first in order to allay our guilt that we might be deceiving our patients. An exclusion from practice may be too accurate reality testing.  Perhaps we will need to develop medications which impair our reality testing?