Sunday, August 29, 2010
Time pressures and medical decisions
I was doing my usual scan of the blogosphere and national papers this morning and I came upon an interesting quote from John Oxendine, who is the Insurance Commissioner for the state of Georgia. He was commenting on the problems associated with various forms of add on insurance (such as insurance on modest retail purchases) and stated:
“This is the bottom line key with any kind of insurance,” Oxendine said. “You should never make a decision when you’ve got pressure and time constraints. That’s when people get ripped off and make a mistake.”
http://www.ajc.com/news/beware-of-add-on-601562.html
This is basically good advice for anyone under virtually any circumstances. Making rash decisions without taking time to weight the options is never a good idea. The irony here is within the realm of health care we make virtually all our decisions under the influence of pressure and time constraints. I understand that there are some circumstances where there are real time constraints where decisions need to be made quickly because lives are a stake. However, most encounters that patients have with physicians and their surrogates occur under circumstances where time pressures are artificially inserted, mostly to promote patient throughput.
Earlier this year I had by annual visit to my internist, dealing with the usual over 50 year old male issues. As some of you who have followed my blog for a while realize, I am skeptical of the mindless application of screening tools for prostate cancer. After much thought, I elected not to have a PSA drawn. However, the default mode is to opt in for PSA screening and I was the one who had to take the initiative to opt out. I cannot help but think of all the men who had their PSAs drawn with little or no discussion regarding the implications of what this test meant and the potential cascade of events which it might trigger.
I am the first to recognize that a full discussion regarding the upsides and downsides of PSA screening would be difficult to impossible undertake within the confines of the usual outpatient appointment. There is simply not enough time. However, what happens to patients as a consequence of this is even worse than the circumstances described at the checkout counter and add on insurance. At least there the default mode is to not purchase the item and you are asked to opt in with little time to think and little information to work with. In the doctor's office various add ons are added on as a default with virtually no discussion as to their risks and benefits.
Part of the issue is most of the broader medical community has actually given little thought to the actual value which these add ons provide to patients and they hold firm beliefs that indiscriminate application of these add ons is an unquestionable plus. The actual numbers may be much less impressive. Just how many people do you need to treat with a statin for one to benefit? If one screens 100,000 women with mammography over 20 years, how many lives will be saved and how much will this impact those without disease? How many people need to be treated with bone sparing agents to prevent one hip or compression fracture? How many patients with mild hypertension need to be treated to avert one vascular event and how many will be harmed by their medications?
One thing these interventions have in common is the decision to intervene and the selection of the specific intervention generally occur within the time frame of a basic office visit. The virtually guarantees that there is not sufficient time to actually discuss options. The implications are that absent this discussion, stuff happens. The default mode is to intervene. Tests are ordered and medications are started and given the time constraints and pressures are not likely to improve on subsequent visits, it is not likely that any meaningful discussion will happen in the future. Inertia will take over and cascade of intervention and treatment will continue indefinitely.
I see countless patients on long lists of expensive medications prescribed to prevent conditions which may never happen and they really have no clue as to why they are taking them. I do not mean to point the finger of blame at their primary care physicians. They are victims of the same faulty decision making architecture. No one has had the time to explain the odds and taking the time to do so is simply not valued by anyone.
“This is the bottom line key with any kind of insurance,” Oxendine said. “You should never make a decision when you’ve got pressure and time constraints. That’s when people get ripped off and make a mistake.”
http://www.ajc.com/news/beware-of-add-on-601562.html
This is basically good advice for anyone under virtually any circumstances. Making rash decisions without taking time to weight the options is never a good idea. The irony here is within the realm of health care we make virtually all our decisions under the influence of pressure and time constraints. I understand that there are some circumstances where there are real time constraints where decisions need to be made quickly because lives are a stake. However, most encounters that patients have with physicians and their surrogates occur under circumstances where time pressures are artificially inserted, mostly to promote patient throughput.
Earlier this year I had by annual visit to my internist, dealing with the usual over 50 year old male issues. As some of you who have followed my blog for a while realize, I am skeptical of the mindless application of screening tools for prostate cancer. After much thought, I elected not to have a PSA drawn. However, the default mode is to opt in for PSA screening and I was the one who had to take the initiative to opt out. I cannot help but think of all the men who had their PSAs drawn with little or no discussion regarding the implications of what this test meant and the potential cascade of events which it might trigger.
I am the first to recognize that a full discussion regarding the upsides and downsides of PSA screening would be difficult to impossible undertake within the confines of the usual outpatient appointment. There is simply not enough time. However, what happens to patients as a consequence of this is even worse than the circumstances described at the checkout counter and add on insurance. At least there the default mode is to not purchase the item and you are asked to opt in with little time to think and little information to work with. In the doctor's office various add ons are added on as a default with virtually no discussion as to their risks and benefits.
Part of the issue is most of the broader medical community has actually given little thought to the actual value which these add ons provide to patients and they hold firm beliefs that indiscriminate application of these add ons is an unquestionable plus. The actual numbers may be much less impressive. Just how many people do you need to treat with a statin for one to benefit? If one screens 100,000 women with mammography over 20 years, how many lives will be saved and how much will this impact those without disease? How many people need to be treated with bone sparing agents to prevent one hip or compression fracture? How many patients with mild hypertension need to be treated to avert one vascular event and how many will be harmed by their medications?
One thing these interventions have in common is the decision to intervene and the selection of the specific intervention generally occur within the time frame of a basic office visit. The virtually guarantees that there is not sufficient time to actually discuss options. The implications are that absent this discussion, stuff happens. The default mode is to intervene. Tests are ordered and medications are started and given the time constraints and pressures are not likely to improve on subsequent visits, it is not likely that any meaningful discussion will happen in the future. Inertia will take over and cascade of intervention and treatment will continue indefinitely.
I see countless patients on long lists of expensive medications prescribed to prevent conditions which may never happen and they really have no clue as to why they are taking them. I do not mean to point the finger of blame at their primary care physicians. They are victims of the same faulty decision making architecture. No one has had the time to explain the odds and taking the time to do so is simply not valued by anyone.
Sunday, August 22, 2010
Data/rules driven decisions vs. judgment/intuition based decisions
There is an outstanding essay published in the Harvard Business Review by Amar Bhide entitled "The Big Idea: The Judgment Deficit". http://hbr.org/2010/09/the-big-idea-the-judgment-deficit/ar/1
The essay is apparently a distillation of a book which is in the pre-release state at Amazon. I think I will need to read this. What the authors has done is to articulate something that has been rattling around in my own head. I am a numbers guy. I love data and find that I need data to manage my own small operation. However, I have always been skeptical of following the numbers blindly. (See archives http://georgiacontrarian.blogspot.com/2009/07/legacy-of-robert-mcnamara.html)
The essay and accompanying interview clearly communicate that data and judgment need to be partners. I know it sounds like common sense but we all find ourselves in situation where common sense is not so common. Quantitative tools are essential to assess whether legacy approaches to problems are actually effective and to develop rules based approaches to management. However, over reliance on quantitative tools and rules based algorithms which leave little or no place for human judgment can lead to disaster.
One particular insight put forth by Bhide related to the use of rules for systems for which there is an opportunity for gaming. Rules based systems work great for the coordination of inanimate things such as trucks or railroads. However, people learn the rules and have the proclivity to game any set of rules. The mortgage mess was created to a great degree by the reliance of rules based approaches to loan underwriting which no longer required those who were making the loans to make any real judgment about the suitability of the candidates and whether they were likely to repay the loans. Instead, a formulaic approach which for remarkable volumes and scalability was substituted.
I suspect I will get the full flavor of the analysis when I read the book but I can tell from the essay that the move toward optimal performance always will require data collection and analysis to develop rules of thumb, providing incentives and authority to managers to be skeptical of the rules that develop as a consequence of the data collected, further data analysis to respond to those gaming the rules, followed by additional judgment.. and so on, indefinitely.
We are in an early phase of this process in health care. We have rules of thumb based mostly on ancdote because our data collection tools are so dismal. There is a concern that we are moving medicine to far to cookie cutter, algorithmic based practice and this is a legitimate fear since the major driver for this appears to be financial. However, financial considerations are important. There is not unlimited resources to pay for health care and if we are to make medicine affordable to the world, we need to move to less expensive rules based models that do not rely on practitioners who make six figure incomes.
However, the rules need to be based on something other than cost saving and expert opinion. For the most part, data supporting adding real value to patients is slim to none for most of what we do, although I suspect we do a pretty good job at alleviating suffering. We just do not have great tools deployed to show this. It will be difficult to rely on the iterative process outlined about when there is a paucity of both the quantitative tools and the incentives for exercising judgment. Without that type of reflective and self correcting mechanisms, we cannot expect to innovate in the right direction.
The essay is apparently a distillation of a book which is in the pre-release state at Amazon. I think I will need to read this. What the authors has done is to articulate something that has been rattling around in my own head. I am a numbers guy. I love data and find that I need data to manage my own small operation. However, I have always been skeptical of following the numbers blindly. (See archives http://georgiacontrarian.blogspot.com/2009/07/legacy-of-robert-mcnamara.html)
The essay and accompanying interview clearly communicate that data and judgment need to be partners. I know it sounds like common sense but we all find ourselves in situation where common sense is not so common. Quantitative tools are essential to assess whether legacy approaches to problems are actually effective and to develop rules based approaches to management. However, over reliance on quantitative tools and rules based algorithms which leave little or no place for human judgment can lead to disaster.
One particular insight put forth by Bhide related to the use of rules for systems for which there is an opportunity for gaming. Rules based systems work great for the coordination of inanimate things such as trucks or railroads. However, people learn the rules and have the proclivity to game any set of rules. The mortgage mess was created to a great degree by the reliance of rules based approaches to loan underwriting which no longer required those who were making the loans to make any real judgment about the suitability of the candidates and whether they were likely to repay the loans. Instead, a formulaic approach which for remarkable volumes and scalability was substituted.
I suspect I will get the full flavor of the analysis when I read the book but I can tell from the essay that the move toward optimal performance always will require data collection and analysis to develop rules of thumb, providing incentives and authority to managers to be skeptical of the rules that develop as a consequence of the data collected, further data analysis to respond to those gaming the rules, followed by additional judgment.. and so on, indefinitely.
We are in an early phase of this process in health care. We have rules of thumb based mostly on ancdote because our data collection tools are so dismal. There is a concern that we are moving medicine to far to cookie cutter, algorithmic based practice and this is a legitimate fear since the major driver for this appears to be financial. However, financial considerations are important. There is not unlimited resources to pay for health care and if we are to make medicine affordable to the world, we need to move to less expensive rules based models that do not rely on practitioners who make six figure incomes.
However, the rules need to be based on something other than cost saving and expert opinion. For the most part, data supporting adding real value to patients is slim to none for most of what we do, although I suspect we do a pretty good job at alleviating suffering. We just do not have great tools deployed to show this. It will be difficult to rely on the iterative process outlined about when there is a paucity of both the quantitative tools and the incentives for exercising judgment. Without that type of reflective and self correcting mechanisms, we cannot expect to innovate in the right direction.
Sunday, August 15, 2010
Our dysfunctional medical school families
I am an avid reader of my colleague's blog "DB medical rants". I have never met Dr. Centor but I can discern from his blog that we share many of the same sentiments. In late July he wrote a blog entitled "Caring about students- Why is this not the norm?" http://www.medrants.com/archives/5684
I am an academician and have observed this phenomenon for more than 20 years. I never gave this much thought until recently. I was a product of training at a state sponsored medical school and I made only a very financial investment in my own education. I viewed my training as primarily self directed within an environment that gave me appropriate back up and guidance. I learned my craft in a see one, do one, teach one environment.
The world is different now with some changes sorely needed while others best characterized as being providing no or negative enhancements. Initiatives driven by the professional educator class at the LCME have pushed to create learning environments where students are less viewed as sources of cheap labor and increasingly afforded a status consistent with the large sums of money they pay for their education. One would hope that this change would result in better training. I am not so sure this is actually the case. Medical students are not as empowered to assume real responsibilities any more. They are often reduced to the status of what my children used to refer to as "watching guys".
When I was in training most of the training I actually received was from the house staff immediately senior to me. There are now initiatives to change this and increase interactions of medical students with attending physicians. This sounds reasonable given the tuition many schools charge. Shouldn't students have more interactions with the highly paid professors as opposed to the medical equivalents of the post-docs?
My question is who actually best models the behaviors which we want medical students to adopt? In some sense the medical school faculty are like surrogate parents. In the old model, medical students were raised by their older siblings because to a great degree the faculty functioned in absentia. The see one, do one , teach one model had its faults but at least the doctors who we modeled our behavior knew their primary role was the care of patients.
Because of the priorities of universities, medical school faculty who care to advance in the academic hierarchy need to place patient care and teaching related to patient care below other activities. They focus on specialty medicine because it allows them to generate sufficient salary to free up time to do research. This is not easily hidden from their medical student charges. The students are generally frighteningly smart and insightful. They quickly see this and see that there are few ramifications from not placing patients and patient care first. Like the alcoholic parent who tells their children not to drink, or the reckless driver who tells their child to be careful behind the wheel, they may hear us tell them that patients are important but our actions speak much louder than words. They will not likely follow our advice when we ask them to do as I say, not as I do.
I am an academician and have observed this phenomenon for more than 20 years. I never gave this much thought until recently. I was a product of training at a state sponsored medical school and I made only a very financial investment in my own education. I viewed my training as primarily self directed within an environment that gave me appropriate back up and guidance. I learned my craft in a see one, do one, teach one environment.
The world is different now with some changes sorely needed while others best characterized as being providing no or negative enhancements. Initiatives driven by the professional educator class at the LCME have pushed to create learning environments where students are less viewed as sources of cheap labor and increasingly afforded a status consistent with the large sums of money they pay for their education. One would hope that this change would result in better training. I am not so sure this is actually the case. Medical students are not as empowered to assume real responsibilities any more. They are often reduced to the status of what my children used to refer to as "watching guys".
When I was in training most of the training I actually received was from the house staff immediately senior to me. There are now initiatives to change this and increase interactions of medical students with attending physicians. This sounds reasonable given the tuition many schools charge. Shouldn't students have more interactions with the highly paid professors as opposed to the medical equivalents of the post-docs?
My question is who actually best models the behaviors which we want medical students to adopt? In some sense the medical school faculty are like surrogate parents. In the old model, medical students were raised by their older siblings because to a great degree the faculty functioned in absentia. The see one, do one , teach one model had its faults but at least the doctors who we modeled our behavior knew their primary role was the care of patients.
Because of the priorities of universities, medical school faculty who care to advance in the academic hierarchy need to place patient care and teaching related to patient care below other activities. They focus on specialty medicine because it allows them to generate sufficient salary to free up time to do research. This is not easily hidden from their medical student charges. The students are generally frighteningly smart and insightful. They quickly see this and see that there are few ramifications from not placing patients and patient care first. Like the alcoholic parent who tells their children not to drink, or the reckless driver who tells their child to be careful behind the wheel, they may hear us tell them that patients are important but our actions speak much louder than words. They will not likely follow our advice when we ask them to do as I say, not as I do.
Saturday, August 14, 2010
Disruptive innovation requires lower cost and generally lower quality options
There is a good piece published this month in the American Scientist by David Kent entitled "Just as good medicine". http://www.americanscientist.org/issues/pub/2010/3/just-as-good-medicine/1
This mechanism is not operative in health care. This is probably due to at least two factors. First, there is a regulatory environment which keeps out those who are most motivated to introduce disruptive innovations. In what appears to be a perfect example of regulatory capture, laws to control entry into the field of health care, designed to protect the public, appear to serve most those who are regulated. Second, because disruptive innovation generally does not come from organizations who are dependent upon the prevailing business models, there is basically no one who is motivated to disrupt the model which feeds their present economic machine. This is particularly the case of major health care systems which need to invest huge sums of capital to compete for lucrative high margin business. They, like the integrated steel producers described in Christensen's work, want to escape the low margin and high volume elements of the healthcare business. Why wrestle with capturing pennies on the dollar of ambulatory business when you can make money by the shovelful by doing high end scans and organ transplants.
None of this would be possible if the payment system in health care is not what it is today. The payment system prompted physicians to treat money in health care as Monopoly money, not quite real dollars. I have practiced medicine long enough to remember that the old world of reasonable and customary fees. Those who set their fees as reasonable proved to be the chumps and it became customary to set your fees at outrageously inflated levels. The entire structure of present reimbursement schedules is historically based upon who was most effect at establishing outrageous fees early on. Those who tried to be cost effective early on have lived to regret their decision given the subsequent cost control measures have mostly worked through broad and non-targeted across the board reductions. No room for low cost disruptive innovations here.
From the patient perspective, no one in their right mind will settle for less if it means no direct cost savings for themselves. Except for a few civic-minded altruists, most people will have the view that they have already spent their health care dollars on the insurance they have paid for. They are no going to settle for any lower tiered service. This is also recognized by David Kent:
It is reassuring that there is an understanding that what we are seeing is what happens when the market pricing mechanism is displaced. Politicians, authors, and policy wonks are desperately in search of an alternative to the price allocation mechanism which will allow for efficient allocation of resources. Good luck. This is not something to be conceived by some congressional committee, presidential commission, or as a product of some single foundation grant. Resources are scarce and the price mechanism has proven to be the single most robust mechanism for putting resources in the hands of people who can deploy them in such a way to benefit the most people, most of the time. Kent uses a ploy widely deployed to tar the market system, suggesting that most health care decisions are made under duress without the opportunity to reflect and weigh options. At least he states the the price mechanism alone cannot be the solution, implying it must have some role.
Without the role of price in health care, and I mean real prices which have real impact on those receiving services, there will be no real disruptive innovation. I would venture to guess that if the public can actual reap financial gain from low cost and lower quality options in health care, they will likely choose lower quality options. Yes, the screams will come up declaring that such options are not in their best interests and that the high cost and higher quality options are better for the public. Such logic can also be applied to higher cost options in cars, homes, and food. They can also be applied to the logic of where people choose to live. Should be afford people the option to buy a bigger house in a neighborhood with better schools if it forces them to drive a greater distance to work and thus places their lives in jeopardy? We all make trade offs and the best party to make the decisions regarding which trade offs are individuals and families. Changing the rules and incentives to make lower cost and quality options broadly available in health care is essential.
The fundamental tenet of this piece is that health care is so costly because virtually all innovations in this arena add costs and this aspect of the health care industry is unique. Clayton Christensen discusses this in his book, The Innovator's Prescription and this article highlights data which buttress this claim. In a study done by Kent and co-authors they found:
To explore this, working with colleagues at the Tufts Center for the Evaluation of Value and Risk (who maintain a comprehensive database of cost-utility studies), we enlisted Aaron Nelson, then a medical student, to help us sort through more than 2,000 cost-utility comparisons for any potential examples that might be decrementally cost-effective. We found that about three-quarters of published comparisons described new technologies or treatment strategies that increase both costs and benefits, and that most of these (about 65 to 80 percent) were cost-effective by conventional criteria (depending on which conventional threshold was used, $50,000 or $100,000 per QALY gained). Less often, published analyses described innovations that are either dominant or dominated (about 10 percent and 15 percent of the time, respectively), but only very rarely were innovations both cost- and quality-decreasing. Indeed, fewer than 2 percent of all comparisons were classified in the cost- and quality-decreasing “southwest quadrant”, and only 9 (involving 8 innovations) were found to be decrementally cost-effective (0.4 percent of the total)—that is, they saved at least $100,000 for each QALY relinquished.In basically all walks of life we make compromises, spending resources in some realm thus making the decision to not use them in another realm. Each of these decisions results in forgoing some things or settling for lesser quality products or services. We might purchase furniture at IKEA substituting our time for our money, deciding that we can use furniture made of composite materials as opposed to hardwoods. The truly market rocking innovations in virtually all areas onside of health care have involved the widespread acceptance of much cheaper but lower quality alternatives which capture market share. Long term consumers may obtain better products at lower prices but this is virtually always the result of disruptions made possible by lower cost and lower quality products and services.
This mechanism is not operative in health care. This is probably due to at least two factors. First, there is a regulatory environment which keeps out those who are most motivated to introduce disruptive innovations. In what appears to be a perfect example of regulatory capture, laws to control entry into the field of health care, designed to protect the public, appear to serve most those who are regulated. Second, because disruptive innovation generally does not come from organizations who are dependent upon the prevailing business models, there is basically no one who is motivated to disrupt the model which feeds their present economic machine. This is particularly the case of major health care systems which need to invest huge sums of capital to compete for lucrative high margin business. They, like the integrated steel producers described in Christensen's work, want to escape the low margin and high volume elements of the healthcare business. Why wrestle with capturing pennies on the dollar of ambulatory business when you can make money by the shovelful by doing high end scans and organ transplants.
None of this would be possible if the payment system in health care is not what it is today. The payment system prompted physicians to treat money in health care as Monopoly money, not quite real dollars. I have practiced medicine long enough to remember that the old world of reasonable and customary fees. Those who set their fees as reasonable proved to be the chumps and it became customary to set your fees at outrageously inflated levels. The entire structure of present reimbursement schedules is historically based upon who was most effect at establishing outrageous fees early on. Those who tried to be cost effective early on have lived to regret their decision given the subsequent cost control measures have mostly worked through broad and non-targeted across the board reductions. No room for low cost disruptive innovations here.
From the patient perspective, no one in their right mind will settle for less if it means no direct cost savings for themselves. Except for a few civic-minded altruists, most people will have the view that they have already spent their health care dollars on the insurance they have paid for. They are no going to settle for any lower tiered service. This is also recognized by David Kent:
It is beyond dispute that some mechanisms for the controlled distribution of these expensive goods and services are required. In most markets, prices play this role, and many feel that the fundamental problem in health care is that many consumers are shielded from the costs of their care. A system based largely on prices (that is, price rationing) may control costs better than our current system, but it would of course mean that those with the most money have first dibs on scarce health-care resources, and there might be little left over for those without means. (There are other reasons too why most consumers can’t be expected to comparison shop for emergency coronary angioplasty or for charged-particle radiosurgery for their glioblastoma the same way they might for gasoline, underwear and cling peaches). It is a fantasy to believe that price rationing alone can provide an acceptable mechanism for the controlled distribution of medical services, and some other means are thus also needed. Perhaps we should take it as a sign of the robustness of our democracy that this rather technical issue of the proper mix and variety of price and non-price rationing has somehow managed to plunge our national conversation about health-care reform into a Jerry Springer–style shouting match, except without the civility.
It is reassuring that there is an understanding that what we are seeing is what happens when the market pricing mechanism is displaced. Politicians, authors, and policy wonks are desperately in search of an alternative to the price allocation mechanism which will allow for efficient allocation of resources. Good luck. This is not something to be conceived by some congressional committee, presidential commission, or as a product of some single foundation grant. Resources are scarce and the price mechanism has proven to be the single most robust mechanism for putting resources in the hands of people who can deploy them in such a way to benefit the most people, most of the time. Kent uses a ploy widely deployed to tar the market system, suggesting that most health care decisions are made under duress without the opportunity to reflect and weigh options. At least he states the the price mechanism alone cannot be the solution, implying it must have some role.
Without the role of price in health care, and I mean real prices which have real impact on those receiving services, there will be no real disruptive innovation. I would venture to guess that if the public can actual reap financial gain from low cost and lower quality options in health care, they will likely choose lower quality options. Yes, the screams will come up declaring that such options are not in their best interests and that the high cost and higher quality options are better for the public. Such logic can also be applied to higher cost options in cars, homes, and food. They can also be applied to the logic of where people choose to live. Should be afford people the option to buy a bigger house in a neighborhood with better schools if it forces them to drive a greater distance to work and thus places their lives in jeopardy? We all make trade offs and the best party to make the decisions regarding which trade offs are individuals and families. Changing the rules and incentives to make lower cost and quality options broadly available in health care is essential.
Sunday, August 8, 2010
Escape from the health care gulag
I was at a party last night of colleagues from work. We were all of similar age, being in our late 50's or early sixties and all of us have lived in in our fair city for at least 10 years. All of us had children who had taken various pathways for education and many have children who were the product of the public school system (including my own children). I too was a product of the public school system and until recently have been an advocate of public education.
The landscape is changing and the public education systems in my area appear to be unraveling. My children are done with that phase of their education and I am somewhat removed from these as immediate issues although I do read about them almost daily in the local papers. Some of the attendees of the party have children younger than mine and and still have to grapple of how they will educate them. Of course there is the private school option but even among the university associated parent crowd, home schooling is an option. Hoe schooling is not just for religious fundamentalist crack pots any more.
I was fascinated by some of the stories about the development of the home schooling networks and the remarkable tools at their disposal. It now appears that home schooling is not an all or none phenomena. One of the mothers at this party described the various options available to the families in her neighborhood. Obviously, one can take on all aspects of schooling your children at home and there are all types of resources to do so. More often, groups of families form cooperative arrangements which divide responsibilities and more effectively identify specific areas of expertise. Furthermore they provide the social elements which may be lacking from an environment where children are schooled only by their parents.
The options go beyond even these. There are now opportunities for online courses and also for students to attend private schools for just specific courses. Obviously it takes motivated and bright students and parents to make this work but the outcomes are impressive with home schooled children outperforming their colleagues from public and private schools in almost all arenas. On top of this home schooling is growing in leaps and bounds basically doubling to 1.5 million children between 1997 and 2007. This may bode well for education in general but it does not bode well for the entrenched primary and secondary educational system which has become to a great degree ineffective and bloated.
What I find remarkable about this story is it is a grass roots story. The remarkable and apparently multiple effective options have developed without a central directing force and without massive state spending. As the old model of education has become less and less effective while at the same time more and more expensive, this alternative pathway has emerged in what appears to be a self organizing way. Frederich von Hayek should only be alive to see this!
I think there are lessons from this that we can take to the health care world. The teaching profession was professionalized about the same time that the health care world was as well. The teaching profession created an increasingly ineffective and expensive bureaucracy associated with failing public schools. Those with money escaped to private schools and until recently, those without money were stuck in the public school gulag. The home schooling movement allowed them to escape and for their children to thrive. It did not require a grand plan or obscene amounts of money. It was driven by an army of parents, amateur educators, relatively devoid of specific teaching credentials. The home school phenomena is yet another example of the rise of the amateurs as described by Clay Shirkey and the homeschooling movement can be viewed as a twist on the phenomena of crowdsourcing.
I pose the question to my readers - what elements of healthcare can and will be crowdsourced? I view the major push in the latest round of "reforms" as pushing for the creation of a large public system of health care. As health care reform is implemented and further entrenches an increasingly ineffective health care bureaucracy, we will see the rise of outlets that develop which allow for the public to escape the health care gulag. We all know about concierge medicine, but what other forms will develop and who will offer to provide what the public wants? Will the equivalent of the home health care network, analogous to the homeschooling movement arise? What tasks presently delegated to health care professionals can and will be done by amateurs? How will the state respond to this, as a facilitator or barrier to innovation?
The landscape is changing and the public education systems in my area appear to be unraveling. My children are done with that phase of their education and I am somewhat removed from these as immediate issues although I do read about them almost daily in the local papers. Some of the attendees of the party have children younger than mine and and still have to grapple of how they will educate them. Of course there is the private school option but even among the university associated parent crowd, home schooling is an option. Hoe schooling is not just for religious fundamentalist crack pots any more.
I was fascinated by some of the stories about the development of the home schooling networks and the remarkable tools at their disposal. It now appears that home schooling is not an all or none phenomena. One of the mothers at this party described the various options available to the families in her neighborhood. Obviously, one can take on all aspects of schooling your children at home and there are all types of resources to do so. More often, groups of families form cooperative arrangements which divide responsibilities and more effectively identify specific areas of expertise. Furthermore they provide the social elements which may be lacking from an environment where children are schooled only by their parents.
The options go beyond even these. There are now opportunities for online courses and also for students to attend private schools for just specific courses. Obviously it takes motivated and bright students and parents to make this work but the outcomes are impressive with home schooled children outperforming their colleagues from public and private schools in almost all arenas. On top of this home schooling is growing in leaps and bounds basically doubling to 1.5 million children between 1997 and 2007. This may bode well for education in general but it does not bode well for the entrenched primary and secondary educational system which has become to a great degree ineffective and bloated.
What I find remarkable about this story is it is a grass roots story. The remarkable and apparently multiple effective options have developed without a central directing force and without massive state spending. As the old model of education has become less and less effective while at the same time more and more expensive, this alternative pathway has emerged in what appears to be a self organizing way. Frederich von Hayek should only be alive to see this!
I think there are lessons from this that we can take to the health care world. The teaching profession was professionalized about the same time that the health care world was as well. The teaching profession created an increasingly ineffective and expensive bureaucracy associated with failing public schools. Those with money escaped to private schools and until recently, those without money were stuck in the public school gulag. The home schooling movement allowed them to escape and for their children to thrive. It did not require a grand plan or obscene amounts of money. It was driven by an army of parents, amateur educators, relatively devoid of specific teaching credentials. The home school phenomena is yet another example of the rise of the amateurs as described by Clay Shirkey and the homeschooling movement can be viewed as a twist on the phenomena of crowdsourcing.
I pose the question to my readers - what elements of healthcare can and will be crowdsourced? I view the major push in the latest round of "reforms" as pushing for the creation of a large public system of health care. As health care reform is implemented and further entrenches an increasingly ineffective health care bureaucracy, we will see the rise of outlets that develop which allow for the public to escape the health care gulag. We all know about concierge medicine, but what other forms will develop and who will offer to provide what the public wants? Will the equivalent of the home health care network, analogous to the homeschooling movement arise? What tasks presently delegated to health care professionals can and will be done by amateurs? How will the state respond to this, as a facilitator or barrier to innovation?
Saturday, August 7, 2010
Health care in a generally deflationary environment
The health care debate has been accompanied by numbers which can best be characterized as unreal...gazillions of dollars and the prospect of consuming the entire economy. The major focus on health care spending has been on health care inflation. Only yesterday I was watching a presentation of the Chief actuary of the Medicare Advisory Panel. Despite all attempts to paint a rosy picture about costs, virtually all plausible scenarios point to costs that will consume the economy as a whole.
In contrast to the health care economy, the fear rippling through much of the remainder of the economy is that of deflation. We are faced with limited demand and excess supply and an environment where we have moved to out of control spending to fearful savers who will not aid the recovery by either consumption or investment. This strikes me as an amazing disconnect. Why are production, consumption, and prices all but collapsing in many sectors of the economy while health care inflation continues on, minimally abated. Maybe I am missing something but the message I get from these simultaneous but discordant phenomena is these world are operating with very different incentive structures and there is something to be learned if we are clever enough with our powers of observation.
My take on this is that the divergence is due to two major factors:
1. We see continued robust spending in health care because those receiving services are insulated from their actual costs and they do their purchases with what can be viewed as someone else's assets. This may not be universal but it is common enough to continue to drive up costs.
2. There is a drive to keep costs down in the broader economy while it is quite the opposite in the health care economy. Substitution seeks lower cost alternatives in the broader economy while it is quite the opposite in health care economies. Substitution in health care generally is driven by the search for higher margins which is almost always associated with higher costs. In other words, in health care you make more money not by driving down costs, but by driving up costs.
If these are the major drivers of the divergence, the question arises as to what tools the states and Federal government have to reverse the effects of these incentives? The recently passed reforms do nothing to change these two elements. If anything the push is to have less skin in the game from those with health care coverage. Higher copays are viewed with prejudice as barriers to care and it seems reasonable that removal of these barriers will result in greater overall demand and consumption.
You might think that better information directing consumers as to what interventions are most effective might influence consumers be wiser in terms of spending their health care dollars. Consumers are likely to value different metrics than those which are studied, particularly when they are not spending their own money. Efforts to study actual effectiveness and bang for the health care buck with comparative effectiveness research are laudable. Unfortuantely the track record for being able to actually do the volume of studies needed to develop a robust database and to also develop a political consensus to actually abide by the conclusions of any unambiguous studies which call into question lucrative books of health care business is essentially non-existent. It amounts to wishful thinking coming to the defense of fantasy to believe this can serve any any basis to reign in costs spiraling out of control. It is not going to happen.
Assuming that we will face a general deflationary environment outside of health care, what will happen if health care cost continue to increase at a pace of 5-10% per year in such an environment? In an relatively unfettered market, this simply would not happen. People with a shrinking resource pool would cut back on their consumption and reallocate their spending to other areas. However, health care dollars are simply different since for a large segment of the population, it is use it lose it and because of this the pool of dollars chasing after health care services keeps growing. It cannot continue growing at the present or even close to present rates of growth. A general deflationary environment where health care activity is immune to deflationary pressures will only aggravate the distortions and result in even larger fractions of expenditures being directed to the health care economy. The debt generated by borrowing to pay for present expenditures will loom even larger in the future in a deflationary environment. One can only hope that we can borrow boatloads of money right now at virtually zero interest and hope that the deflationary scenario rapidly transitions to inflation to devalue the debts we have incurred them.
It is no wonder why no one seems keen on any long term investment in anything.
In contrast to the health care economy, the fear rippling through much of the remainder of the economy is that of deflation. We are faced with limited demand and excess supply and an environment where we have moved to out of control spending to fearful savers who will not aid the recovery by either consumption or investment. This strikes me as an amazing disconnect. Why are production, consumption, and prices all but collapsing in many sectors of the economy while health care inflation continues on, minimally abated. Maybe I am missing something but the message I get from these simultaneous but discordant phenomena is these world are operating with very different incentive structures and there is something to be learned if we are clever enough with our powers of observation.
My take on this is that the divergence is due to two major factors:
1. We see continued robust spending in health care because those receiving services are insulated from their actual costs and they do their purchases with what can be viewed as someone else's assets. This may not be universal but it is common enough to continue to drive up costs.
2. There is a drive to keep costs down in the broader economy while it is quite the opposite in the health care economy. Substitution seeks lower cost alternatives in the broader economy while it is quite the opposite in health care economies. Substitution in health care generally is driven by the search for higher margins which is almost always associated with higher costs. In other words, in health care you make more money not by driving down costs, but by driving up costs.
If these are the major drivers of the divergence, the question arises as to what tools the states and Federal government have to reverse the effects of these incentives? The recently passed reforms do nothing to change these two elements. If anything the push is to have less skin in the game from those with health care coverage. Higher copays are viewed with prejudice as barriers to care and it seems reasonable that removal of these barriers will result in greater overall demand and consumption.
You might think that better information directing consumers as to what interventions are most effective might influence consumers be wiser in terms of spending their health care dollars. Consumers are likely to value different metrics than those which are studied, particularly when they are not spending their own money. Efforts to study actual effectiveness and bang for the health care buck with comparative effectiveness research are laudable. Unfortuantely the track record for being able to actually do the volume of studies needed to develop a robust database and to also develop a political consensus to actually abide by the conclusions of any unambiguous studies which call into question lucrative books of health care business is essentially non-existent. It amounts to wishful thinking coming to the defense of fantasy to believe this can serve any any basis to reign in costs spiraling out of control. It is not going to happen.
Assuming that we will face a general deflationary environment outside of health care, what will happen if health care cost continue to increase at a pace of 5-10% per year in such an environment? In an relatively unfettered market, this simply would not happen. People with a shrinking resource pool would cut back on their consumption and reallocate their spending to other areas. However, health care dollars are simply different since for a large segment of the population, it is use it lose it and because of this the pool of dollars chasing after health care services keeps growing. It cannot continue growing at the present or even close to present rates of growth. A general deflationary environment where health care activity is immune to deflationary pressures will only aggravate the distortions and result in even larger fractions of expenditures being directed to the health care economy. The debt generated by borrowing to pay for present expenditures will loom even larger in the future in a deflationary environment. One can only hope that we can borrow boatloads of money right now at virtually zero interest and hope that the deflationary scenario rapidly transitions to inflation to devalue the debts we have incurred them.
It is no wonder why no one seems keen on any long term investment in anything.
Sunday, August 1, 2010
Overstating certainty
How do we know what we know? It is a simple question but not so simple to answer. Sometimes there are things that we know which require no proof. I love my wife and I know this. I am not required to prove this (except perhaps to my wife at times such as our anniversary). Whether I can prove this or not does not really affect other people.
Other beliefs have consequences which impact on one or many other people. In the world of health care, what we know dictates what we do and how we advise our patients. When someone presents with chest pain, shortness of breath, diaphoresis, tachycarida, and classic ST changes on EKG, we know they are at risk of cardiac arrest based upon hundred's of thousands of observations. Specific interventions have been tested in controlled fashions and although there are still gray areas in terms of optimum interventions, there are reasonably solid numbers in terms of risk associated with specific scenarios.
It is unfortunate that in many if not most of healthcare we see certainty where it does not exist and nowhere is this more disturbing than where health care and law intersect. There is a recent story about Dr. Marta Cohen, a pathologist in England who has taken on the study of the neuropathological findings in shaken baby syndrome. From the New Scientist:
It seems that by calling into question the dogma accepted as fact by an army of expert witnesses who have testified in trials over many years, Dr. Cohen has raised the ire of those who have a vested interest in maintaining the aura of certainty. The General Medical Council has placed restrictions on her medical license which bar her from further testimony as an expert witness. It appears that she was consistently spoiling the party by showing up to testify in trials and unlike her adversaries claiming the that the triad of findings were specific, she had actual data to support the opposite contention.
I have seen this before. Twenty five years ago the presence of genital or peri-anal warts in an infant was declared proof positive of child abuse. However, after putting countless parents through the ringer, we discovered that..oh never mind, such warts can be transmitted through many other means. Furthermore, the actual numbers which are relevant are poorly defined. Are half of the cases of genital or peri-anal warts in children due to sexual abuse? 25%? 10%? 1%? Who knows and who knows how to know? How many people were jailed or placed upon the sex offender list based upon the testimony of experts whose hypotheses were essentially untestable.
I have done a modest amount of expert witness work and reviewed a number of depositions. I am surprised by the culture of certainty which prevails. It is scary how many people who are certain they know, don't know that they don't know. Furthermore, they have no concept of what they need to do in order to know how they know. The casualties are people like Dr. Cohen who has the audacity to take on a contrary opinion based upon actually testing the evidence and the tools used to make these assessments of certainty. She had her license restricted based upon the fact she failed to agree with a consensus. Sounds like Galileo. Oh yes the sun does revolve around the earth.
Other beliefs have consequences which impact on one or many other people. In the world of health care, what we know dictates what we do and how we advise our patients. When someone presents with chest pain, shortness of breath, diaphoresis, tachycarida, and classic ST changes on EKG, we know they are at risk of cardiac arrest based upon hundred's of thousands of observations. Specific interventions have been tested in controlled fashions and although there are still gray areas in terms of optimum interventions, there are reasonably solid numbers in terms of risk associated with specific scenarios.
It is unfortunate that in many if not most of healthcare we see certainty where it does not exist and nowhere is this more disturbing than where health care and law intersect. There is a recent story about Dr. Marta Cohen, a pathologist in England who has taken on the study of the neuropathological findings in shaken baby syndrome. From the New Scientist:
http://www.newscientist.com/article/mg20727713.600-doctor-gagged-for-doubting-shaken-baby-syndrome.html?full=trueA triad of markers
The three markers for a shaken baby diagnosis are retinal haemorrhages in both eyes; subdural haemorrhages between the fibrous dura layer that protects the brain and the brain surface beneath; and swelling of the brain. Subdural haemorrhages are said to arise from ripping and shearing of so-called bridging veins. New lines of evidence challenge this hypothesis with the discovery that subdural bleeds are much more common in babies than generally appreciated, and for a host of innocent reasons(see "Anatomy of a murder?") .Last year, Cohen and co-researcher Irene Scheimberg of Barts and the London NHS Trust examined post-mortem tissue from fetuses and newborns and found subdural haemorrhages in 16 of the 25 fetuses and 20 of the 30 newborns. They also found haemorrhages within the dural layer itself, suggesting that the bleeding started here (Pediatric and Developmental Pathology, DOI: 10.2350/08/08/0509.1). The research is just the latest of many reports to show that subdural bleeds can occur without shaking(see "Anatomy of a murder?") .
It seems that by calling into question the dogma accepted as fact by an army of expert witnesses who have testified in trials over many years, Dr. Cohen has raised the ire of those who have a vested interest in maintaining the aura of certainty. The General Medical Council has placed restrictions on her medical license which bar her from further testimony as an expert witness. It appears that she was consistently spoiling the party by showing up to testify in trials and unlike her adversaries claiming the that the triad of findings were specific, she had actual data to support the opposite contention.
I have seen this before. Twenty five years ago the presence of genital or peri-anal warts in an infant was declared proof positive of child abuse. However, after putting countless parents through the ringer, we discovered that..oh never mind, such warts can be transmitted through many other means. Furthermore, the actual numbers which are relevant are poorly defined. Are half of the cases of genital or peri-anal warts in children due to sexual abuse? 25%? 10%? 1%? Who knows and who knows how to know? How many people were jailed or placed upon the sex offender list based upon the testimony of experts whose hypotheses were essentially untestable.
I have done a modest amount of expert witness work and reviewed a number of depositions. I am surprised by the culture of certainty which prevails. It is scary how many people who are certain they know, don't know that they don't know. Furthermore, they have no concept of what they need to do in order to know how they know. The casualties are people like Dr. Cohen who has the audacity to take on a contrary opinion based upon actually testing the evidence and the tools used to make these assessments of certainty. She had her license restricted based upon the fact she failed to agree with a consensus. Sounds like Galileo. Oh yes the sun does revolve around the earth.
Our koala health care economy
Koalas are interesting animals. They have adapted to survive in a very narrow ecological niche, consuming only eucalyptus leaves. This food source is a poor nutritional source, low in protein and energy and rich in toxins. Over time reliance on this solitary, non-optimal low energy food has resulted in a shrinking brain which has lost almost half of its former size. The koala is the product of compromise.
I see elements of the koala in health care financing at multiple levels. Within an academic medical center we have multiple missions including research, teaching and training, and patient care. Like all activities, these require an energy source, that being primarily human creativity and money. Track the funds that flow into an institution like my own and you find that the vast majority comes from a single source, the federal government. This cash flow comes in many forms including federal grants from the NIH, NSF, or the Veteran's Administration, direct payments from Medicare or Medicaid (indirectly through states), GME payments to support resident education, and federal grants and loan guarantees to support the education of a host of health care professionals. Federal monies are the eucalyptus leaves of the health care economy.
There is no question that the infusion of federal monies changed the health care environment and in the short term were a driver for dynamic change, much of it positive. However, because the growth and expansion based upon federal monies is not sustainable, it has created an economy which is unhealthy in terms of its increasing dependence upon a "food" supply which is both constricting in terms of what it can support and gradually more toxic in terms of poisoning other aspects of general operations.
The koala responded to sole dependence on a poor energy source with scaling back on what required energy, it its case its brain. Successful adaption meant re-allocation of energy to digestion and detoxification. I would suspect that at some point in the past the koala ancestors had a more varied diet but they evolved toward greater and greater reliance on what appeared to be an abundant but poor quality eucalyptus diet.
It now appears that the health care dependence on federal diets is looking more like eucalyptus leaves. While at one point in time this energy source was robust and supported missions with sufficient margins, it is not looking increasingly like a low energy source. Patient care supported by federal monies must be underwritten by subsidies from private insurers. The scramble for federal research dollars is looking more and more like a giant zero sum game with institutions making large bets vying for indirect dollars to offset operating costs. The entirety of graduate medical education is supported by GME dollars or VA monies to support resident salaries in a hospital based format. All of these pools are either shrinking or growing at a pace not capable of supporting these missions as presently configured.
Like eucalyptus leaves, these monies are also increasingly toxic. The regulations which accompany these monies require more and more oversight and reporting. This takes time, money, and people. Perhaps the most pernicious element of this scenario is the fact that the regulations are constructed in such a way that the more federal money you take, the more difficult it becomes to use other financial sources. Furthermore, the regulatory environment is capable of transforming other revenue sources, which may be of higher quality and less toxic, into eucalyptus like sources.
Ultimately, we need to be able to hedge our bets. Where are the financial resources going to come from to support all of these various important care, teaching, and research missions? I don't know. However, I do know that the more dependent we become on any given source, particular on a single source, the more at risk we become for a really bad outcome. We need to learn to liberalize the diets which feed this machine.
The koala spends its days eating constantly to derive sufficient energy to survive.
I see elements of the koala in health care financing at multiple levels. Within an academic medical center we have multiple missions including research, teaching and training, and patient care. Like all activities, these require an energy source, that being primarily human creativity and money. Track the funds that flow into an institution like my own and you find that the vast majority comes from a single source, the federal government. This cash flow comes in many forms including federal grants from the NIH, NSF, or the Veteran's Administration, direct payments from Medicare or Medicaid (indirectly through states), GME payments to support resident education, and federal grants and loan guarantees to support the education of a host of health care professionals. Federal monies are the eucalyptus leaves of the health care economy.
There is no question that the infusion of federal monies changed the health care environment and in the short term were a driver for dynamic change, much of it positive. However, because the growth and expansion based upon federal monies is not sustainable, it has created an economy which is unhealthy in terms of its increasing dependence upon a "food" supply which is both constricting in terms of what it can support and gradually more toxic in terms of poisoning other aspects of general operations.
The koala responded to sole dependence on a poor energy source with scaling back on what required energy, it its case its brain. Successful adaption meant re-allocation of energy to digestion and detoxification. I would suspect that at some point in the past the koala ancestors had a more varied diet but they evolved toward greater and greater reliance on what appeared to be an abundant but poor quality eucalyptus diet.
It now appears that the health care dependence on federal diets is looking more like eucalyptus leaves. While at one point in time this energy source was robust and supported missions with sufficient margins, it is not looking increasingly like a low energy source. Patient care supported by federal monies must be underwritten by subsidies from private insurers. The scramble for federal research dollars is looking more and more like a giant zero sum game with institutions making large bets vying for indirect dollars to offset operating costs. The entirety of graduate medical education is supported by GME dollars or VA monies to support resident salaries in a hospital based format. All of these pools are either shrinking or growing at a pace not capable of supporting these missions as presently configured.
Like eucalyptus leaves, these monies are also increasingly toxic. The regulations which accompany these monies require more and more oversight and reporting. This takes time, money, and people. Perhaps the most pernicious element of this scenario is the fact that the regulations are constructed in such a way that the more federal money you take, the more difficult it becomes to use other financial sources. Furthermore, the regulatory environment is capable of transforming other revenue sources, which may be of higher quality and less toxic, into eucalyptus like sources.
Ultimately, we need to be able to hedge our bets. Where are the financial resources going to come from to support all of these various important care, teaching, and research missions? I don't know. However, I do know that the more dependent we become on any given source, particular on a single source, the more at risk we become for a really bad outcome. We need to learn to liberalize the diets which feed this machine.
The koala spends its days eating constantly to derive sufficient energy to survive.
Subscribe to:
Posts (Atom)