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Monday, September 28, 2009

What's the point?

The piece by Jamie Heywood: Forget Medical Privacy in Wired Magazine last week ( regarding patient access to medical records makes perfect first. However it raises a number of questions. Why have we not shared such records in the first place? What is the historical background regarding information conveyed from physicians to patients? What exactly is the contractual relationship between doctor and patient? Who hires the doctor? What is the specific agreement between patient and physician in terms of deliverables? What is the purpose of the medical records? Are all the purposes of the medical record the same for all parties who may need access to the record?

When you start to think about the medical record in this light, it appears that many elements and aspects of the medical record have never really been defined. For the physician, the record developed as a tool which allowed him (or her) to recall key elements of the patient’s history at subsequent visits. It was primarily a tool which allowed future care to be done with sufficient information about the past. The patient had little interest in these notes since they did not contain information which could be interpreted by the patient. There was generally no agreement that the physician would create any sort product such as a written document relating to the patient’s care. The physician’s job was to diagnose and treat.

At some point, the medical record developed additional purposes. It took on legal importance, perhaps sometime in the 19th century during the nation’s first “malpractice crisis”. In the 20th century it became an essential piece in justification of billings. In order to get bills paid, both physician and patient acquiesced to having a third party be privy to the physician notes. One of the third parties was the State since state payers became dominant players in the game. Furthermore, the medical record took on legal importance in that it took on specific and perhaps onerous legal protections in the form of HIPPA.

While the ambiguity regarding ownership and purpose of the medical record was not critical in an earlier era, it creates problems in the present environment. It represents only a piece of the ambiguity inherent in the entire structure of the medical encounter as currently structured. There is a contractual relationship between physician and patient and perhaps it is desirable to better define the nature of the deliverables. When I go to an attorney to deal with a specific legal issue, I generally have a defined expectation as to what I will have when the encounter is completed. Similarly, I have comparable expectations when I see my accountant or other financial advisors. These are fellow professionals who have created a much less ambiguous relationship with their clients.

The ambiguity theme permeates medical encounters. Our present encounter structure harkens back to an earlier era where the doctor patient relationship bore scant resemblance to our current times. We (as clients) now schedule meetings with a host of professionals in the hope that we derive some benefit. For anyone who has any concept of time management, an agenda-less meeting is an anathema. Yet, we actively discourage patients from bringing an actual agenda. Bringing a list is generally evokes outright hostility but why is this? Shouldn’t patients and physicians welcome transparency in regards to actual goals and objectives?

As it stands, some vague rationale for a visit may be understood. It may be represented by some brief and often misspelled reason for a visit typed into the schedule by by some call center employee who might as well reside in Banglore. It may be as nebulous as here for a “check up”. Ultimately what is the product of a specific visit? Would it not be reasonable for both patient and doctor to have defined the anticipated deliverables before the visit?

At least one of the deliverables might be a summary report which is geared to the patient. It should be structured is such a way that the conclusions of the provided are obvious as is the rationale for any specific interventions and tests. The report need not be available immediately after the encounter since not all conclusions and plans can be formulated in real time. This report unquestionably would belong to the patient. Whether all notes and information collected as part of the visit would belong to the patient could be open to debate. However, the simplest approach to this problem is to define the deliverables as everything the patient paid for; all tests billed to the patient as well as a summary report which contained defined elements. These elements would include the diagnosis, a modifier which could convey the degree of certainty (unquestionable, likely, possible, atypical), prognosis, reasons for treatment, and recommended interventions.

Instead, we engage in factory medicine, encouraged by payment schemes which were openly designed to encourage volume. Patients of earlier generations raised in a culture of deference to physicians and general stoicism tolerated the movement toward cattle call medicine, occasionally erupting in sporadic annoyance but more commonly responded with bewilderment. The newer Gen X and Yer’s failed to understand why, in a world increasingly engineered to cater to their individual needs, medicine was so unresponsive. Not surprisingly no one has a good answer other than this is how we have always done things.

Tuesday, September 22, 2009

The inherent dependence of specialists on generalists

I had some recent surgery to repair an orthopedic issue. The surgeon is extremely good at what he does. He benefits from being very focused on a defined skill set and he does what he does repeatedly and often. Practice does make near perfect.

For the model of physician care which requires defined and discrete tasks whose execution requires little knowledge beyond the specific organ-limited pathology, this approach works fine. The orthopedist may repair my knee, the gastroenterologist may peer into their periscope, the dermatologist excise the skin cancer, or the cardiologist may place their stent. Assuming the patient survives the immediate post procedural period and the repair holds, any other problem the patient may have is someone else's concern.

This whole model is predicated on the assumption that problems can be treated discretely. Many problems can be approached this way and there are substantial incentives to stake out your claim as a physician in an arena where problems can be managed with such distinct beginnings and ends. However, one of the problems with this approach is a product of hyper-specialization; the loss of the ability to do much of anything else.

Who in this model sees the big picture? I believe in the ideal world, from the perspective of a patient, the most valued healer is someone who cares for them, not someone who can do something to them. Interventions may be a piece of the care package, but as those whose professional activities become more and more focused on a limited number of things they do and think about, they become less valuable in terms of integrating care. There may even be a point where their skill sets render them incapable of this. When a physician has done nothing but robotic prostatectomies, or ERCPs, or Mohs surgery, or cataract surgeries, or knee replacements for countless years, they likely are not able to keep sufficiently up to date to perform any function which requires them to have a broad medical knowledge base outside of their narrow focus of expertise.

There may be financial advantages to individual physicians who can claim to be incapable to having the understanding which would allow them to care for many facets of their patient's needs. From the standpoint of controlling one's time and being paid optimally for acquired skills, the ideal scenario is assume responsibility for only a very defined period of time and to be paid as handsomely as possible for a defined intervention. However, I think virtually anyone would be hard pressed to see this as a model which would be highly desired by patients under any circumstances.

In virtually all other realms of human interactions the person who is most highly valued is the one who is in charge. We value those who can coordinate human activity, identify where activity has created real value, and see where other activities represent only Brownian movement. In medicine, assuming long term broad responsibility is like holding the "old Maid" in cards. It means making difficult decisions, open ended commitments, dealing with lots of uncertainty, being responsive to all types of patient needs and getting paid badly. If the building trade were like medicine, the most poorly paid schmucks would be the general contractors.

We still have cadres of generalists and specialists who maintain a generalist knowledge base. These docs often find themselves fielding calls from patients on a broad variety of topics, even outside their realms of expertise. Patients are good at detecting physicians who have a modest knowledge base and exhibit the slightest proclivity toward problem solving. Why any physician would persist in this type of behavior in the current climate may be hard to fathom. To some it is a higher calling. To others perhaps it is reflective of some sort of personality disorder, trying to gain stature by demonstrating competence beyond their peers. Given the present incentive structure, it is not unreasonable to predict the behavior will become increasingly less common at a very time where it is needed more than ever.

The trend toward hyper-specialization is not going away. Perhaps it is accelerating. When do we reach a tipping point? If 10% of the physician workforce is completely incapable of understanding anything outside of their narrow focus of technical expertise, is that a problem? What about 50%? 80%? Should someone else fill that void?

Wednesday, September 16, 2009

Ignorance is bliss

The longer I practice medicine the more I am struck with how strange the delivery of patient care has become. I believe the driver of this strangeness is rooted in a fundamental ambiguity as to what missions physicians are trained to achieve.

What are we as physicians supposed to do? What are the nature of the problems that we are trained to address? What interventions we perform or direct are of greatest benefits to the patients we see?

In order to address these questions, it is best to examine what drives patients to seek the care of a physician. Despite the fact that Americans have over one billion physician visits each year, we have limited detail on the specifics of what patients aimed to accomplish. Despite lacking data on specifics, it is reasonable assume that visits can fall into certain broad categories. Problems may acute or chronic, involve single or multiple organ systems, be associated with high or low stakes, marked or minimal symptoms, and may be readily amenable or not be amenable to specific interventions. The matrix of possible combinations is huge.

The ability to effectively deal with a patient who presents with any one of the many possible combinations is a product of training and experience. It is not possible that any single physician can be competent in managing all the different possible combinations. That reality is a driver of the movement toward specialty care.

The movement toward specialty care has created opportunities and choices for physicians. Because physicians cannot acquire all the knowledge and skills required to manage all the possible combinations, they must decide what not to learn and in what realms where they will not maintain competence. This is where problems develop.

In the present practice and training universe, what types of competencies are most attractive for physicians to acquire? The incentive matrix which drives these decisions is almost as complex as the matrix which defines patient disease characteristics. Attractive problems/scenarios include defined, correctable problems whose solutions are highly remunerated. The flip side of this equation are the tasks which focus on the management of "wicked", chronic, complex medical problems. Even before factoring financial rewards (which are limited for addressing such issues), it is not unexpected that physicians would tend to avoid acquiring the specialized skill sets required to manage such problems.

What falls into this bucket of complex, chronic care? These problems are open-ended, manageable but not curable, uncertain in terms of course and response to treatment, and time consuming to manage. As the population ages, these are common scenarios. The question is where is the downside for physicians in cultivating incompetence in terms of managing these types of problems?

It reminds me of an article published in the WSJ a few years back. I have pasted the introduction below. The full article can be found at the link below.

The Art of Showing Pure Incompetence at an Unwanted Task
by Jared Sandberg
Friday, April 20, 2007provided byWSJ

To learn something at the office can be difficult. But to refrain from learning something requires years of practice and refinement.

It's an office skill that Steven Crawley finds indispensable. "The inability to grasp selective things can be very helpful in keeping your desk clear of unwanted clutter," says the executive in HR, or what he calls "the dumping ground" of all unwanted office tasks. "I have developed a very agile selective memory across a wide range of nonvalue-added activities."

Thus it appears that many of the most valued tasks in terms of delivering value to patients have been placed in the dumping ground of unwanted tasks.

More pricing madness

The luminaries at the NEJM strike again. Published in today's NEJM - see comments below.

Systemwide Cost Control — The Missing Link in Health Care Reform
Posted by NEJM • September 2nd, 2009 • Printer-friendly
Jonathan Oberlander, Ph.D., and Joseph White, Ph.D.

Successful health care reform requires effective control of health care spending — without it, rising costs will continue to strain federal and state budgets, businesses, and families, jeopardizing gains in insurance coverage. The reform legislation now before Congress, however, cannot be relied on to control spending.

The Obama administration and others have emphasized the cost-saving potential of prevention, comparative-effectiveness research, disease management, and health information technology. But there is little evidence that these worthwhile measures would produce meaningful cost control over the next decade.1 The Congressional Budget Office (CBO) has consequently forecast scant savings from these sources, fueling debate about the affordability of reform2 and raising concerns among fiscally conservative Blue Dog Democrats, without whom health care legislation cannot pass.

In response, the administration has touted a proposal establishing an Independent Medicare Advisory Council (IMAC). The council would, along with the President, have broad authority to change Medicare rules in order to reduce program spending. Yet the scope of the savings that may be achieved through IMAC is impossible to know. And any savings would be limited to Medicare — a modest part of national health care spending.

Other cost-control proposals are more tangible. The Obama administration and Congress have proposed significant cuts in projected federal spending on Medicare over the next decade that largely involve reduced payments to hospitals and private Medicare Advantage plans. These savings, though, would be partially offset — at least in the House legislation — by the cost of canceling scheduled cuts in physician payments.

Moreover, there is a sharp distinction between restraining government spending on medical care and restraining systemwide spending. Slowing the growth of federal Medicare expenditures would not guarantee spending restraint outside Medicare. Indeed, to some extent, medical providers could respond to reduced Medicare income by shifting costs to private payers.

Nor would creating a new public insurance program guarantee that national health care spending will be restrained. With lower administrative costs and greater purchasing power, such a plan could provide less expensive coverage than that offered by private insurers. This, in turn, could lead private plans to find ways to reduce premiums to stay competitive, potentially generating substantial savings.3 But the public-plan proposal has been steadily weakened during the reform debate. Senate Finance Committee leaders have indicated that they intend to pass a bill with no public plan. And the strongest proposed public-plan model, in the House bill, would, according to the CBO, enroll only 10 million persons — about 3% of the population — in 2019. With such limited enrollment, such a plan would not make much of a dent in national health care spending.

The missing link in reform legislation, then, is any mechanism with the potential for systemwide control of medical spending. One straightforward way to achieve that goal would be to adopt a single-payer plan — but that would displace the private insurance industry and remains politically infeasible.

There is, however, another option that could control spending across both the public and private insurance pools. Other countries that have multiple insurers, such as Germany, Japan, and the Netherlands, use all-payer regulation to control costs. In these countries, insurers come together to negotiate, or the government takes the lead in setting, common payment rules for medical care. With a few exceptions, payments to all doctors in a given geographic area follow a standard fee schedule. Hospitals are also paid on comparable terms.

All-payer regulation has four major advantages.4 First, prices are significantly lower in systems with such regulation — “all-payer systems” — than in the United States. Lower prices are, in fact, the main reason why other rich democracies spend much less on medical care than we do. U.S. health policy analysts often assume that we can control health care spending only if fee-for-service payment is jettisoned. Yet efforts to contain costs are much more effective in those fee-for-service systems that regulate fees. An all-payer system would allow us to establish systemwide, enforceable spending targets. If the volume of one service — for example, imaging — increased quickly, fees could be adjusted accordingly. And if policymakers decided to increase payments in pursuit of other goals — such as increasing the number of primary care doctors — then payments could be adjusted across the board to ensure maximum effect.

Second, all-payer regulation reduces concerns that costs will be shifted rather than reduced and would create a fairer payment system. Currently, employers may worry that better control of Medicare spending could lead providers to shift charges to private payers. But an all-payer system would put employers and government in the same boat, broadening the constituency for cost control. Moreover, a fully implemented all-payer system would reduce access problems associated with price discrimination. The goal would be to eliminate or substantially narrow the differences in what various insurers pay for medical services. The result would be a much fairer payment system for providers, who are now punished financially for seeing patients who have no insurance or who receive Medicaid. Given the current payment disparities among Medicare, Medicaid, and private insurance, there would have to be a transition period during which differences would be narrowed. Still, an all-payer system would immediately simplify health insurance by standardizing fee categories and reducing payment disparities among private insurers.

Third, setting standard rules would simplify billing and reduce the related confusion and expense. The staggering price variation in the U.S. health care system5 would end, significantly reducing administrative expenses for providers who must now maintain costly billing systems and administrative staffs to cope with different insurers’ disparate rules. Standardization would also create more transparency for consumers, who could more easily determine what prices insurers were paying for services and thus their appropriate copayments.

Finally, a public insurance plan and private insurers could coexist. Concerns that the public plan would use its purchasing power to offer less expensive coverage and crowd out private insurers would be eased, since all insurers would pay similar rates. Many legislators have sought to protect the insurance industry by weakening the public plan. Instead, Congress should strengthen private insurers’ capacity to control costs alongside the public plan through all-payer regulatory reform.

An all-payer-regulation strategy should appeal to businesses, since it would help to slow rising premiums for employer-sponsored health insurance. It should similarly appeal to workers who worry about the growing costs of coverage. And it would provide fiscal conservatives with an effective cost-containment tool.

The medical community should also find much to like in all-payer regulation. By limiting contracting and billing expenses, it can reduce physicians’ administrative overhead. By insuring everyone and narrowing or eliminating gaps in payment, it can allow providers to treat all patients on the basis of their medical condition, not their finances. And by creating systemwide cost control, it would ensure that responsibility for controlling costs is shared by all, rather than concentrating the burden on providers who treat Medicare patients. In addition, all-payer regulation addresses important political constraints: the opposition of the President and most legislators to eliminating the private insurance industry, the urgency of cost control for many Americans, voters’ preference for minimal disruption — if any — of their own coverage, and the fiscal crisis that renders cost control essential.

Health care reform cannot be financed by seeking savings only from Medicare. It cannot be made affordable through the overly optimistic agenda of delivery-system reform with which many advocates began this year’s debate. It is time to turn to approaches for which the evidence is much stronger. An all-payer system offers the best hope for health care reform.

No potential conflict of interest relevant to this article was reported.

Source Information

From the University of North Carolina, Chapel Hill (J.O.); and Case Western Reserve University, Cleveland (J.W.).

This article (10.1056/NEJMp0907487) was published on September 2, 2009, at


Marmor T, Oberlander J, White J. The Obama administration’s options for health care cost control: hope versus reality. Ann Intern Med 2009;150:485-489. [Free Full Text]
Congress of the United States. Budget options, volume 1: health care. Washington, DC: Congressional Budget Office, 2008. (Accessed August 25, 2009, at
Hacker JS. The case for public plan choice in national health reform: key to cost control and quality coverage. Berkeley: University of California, Berkeley, School of Law, 2008.
White J. Cost control and health care reform: the case for all-payer regulation. Washington, DC: Campaign for America’s Future, 2009. (Accessed August 25, 2009, at
Reinhardt UE. The pricing of U.S. hospital services: chaos behind a veil of secrecy. Health Aff (Millwood) 2006;25:57-69. [Free Full Text]

Let me get this straight. The way to save money is to simply set the prices lower. It makes sense if you have no concept of the role of prices in coordinating human activities. Why not simply set them at zero and save some real money. Obviously that approach has some problems. However, what about setting them too low. How would you know if they were set too low? Will correctly set prices today be correctly set prices tomorrow? Will correctly set prices in Cleveland be the correctly set prices in Boston?

How do they come up with these ideas?

Monday, September 14, 2009

Value, incentives, and prices

A series of common theme permeate the health care debate. Two of the themes, value and incentives are linked through a common thread; price. When we hear value we think of benefit gained per unit of cost. When we hear incentives, we think of financial carrots. What do cost and carrots have in common? They are both understood under the umbrella of price. Incentives are the prices paid to induce someone, often a total stranger to do someone else's bidding. Perhaps most of us cannot be bought but most everyone can be leased. Nothing is ever truly free and the value of what we "value" can only be assessed by what we are willing to give up (cost or price) in order to acquire it.

Various things can be used as currency to make these measurements of value. However, the common currency is just that - It is powerful and valuable since it is broadly accepted. While the corruption of medicine by financial concerns may be broadly lamented, money still serves as the most powerful and consistently effective tool to entice the health care workforce to get out of bed each morning and serve their fellow man.

There is a broad consensus that one of the most problematic areas in health care is alignment of incentives. Our present system provides incentives to over utilize certain very expensive tools and to under utilize perhaps equally effective and less expensive approaches, delivering less than optimal value to consumers. A very brief moment of reflection may provide insight into why this may the case. What links value and incentives? Nothing more than prices.

The problem with administratively set prices is the best they can aim for is to reflect some sort of average price at a particular moment in time. Average prices are like average time. What is average time? It is what can be measured by a broken clock, accurately reflecting the time at least twice daily. However, using a broken clock to tell you time will not be a useful endeavor.

In the same sense, set prices are not good informational tools. They convey essentially no useful information regarding value and send the wrong information regarding incentives. For prices to convey useful information in these realms prices must be dynamic and changing, reflective of changing preferences and values which change with specific contexts.

A plan for overhauling a health care delivery system which ultimately depends upon prices set administratively is like building a sophisticated rocket with a faulty guidance system. No matter how well constructed, it will be guided by flawed information and the likelihood of it ending up where you desire is not likely.

Tuesday, September 8, 2009

The reality of rationing

I came across this piece published a few months back in the NYT.

June 17, 2009
Economic Scene
Health Care Rationing Rhetoric Overlooks Reality


More to the point: Rationing!

As in: Wait, are you talking about rationing medical care? Access to medical care is a fundamental right. And rationing sounds like something out of the Soviet Union. Or at least Canada.

The r-word has become a rejoinder to anyone who says that this country must reduce its runaway health spending, especially anyone who favors cutting back on treatments that don’t have scientific evidence behind them. You can expect to hear a lot more about rationing as health care becomes the dominant issue in Washington this summer.

Today, I want to try to explain why the case against rationing isn’t really a substantive argument. It’s a clever set of buzzwords that tries to hide the fact that societies must make choices.

In truth, rationing is an inescapable part of economic life. It is the process of allocating scarce resources. Even in the United States, the richest society in human history, we are constantly rationing. We ration spots in good public high schools. We ration lakefront homes. We ration the best cuts of steak and wild-caught salmon.

Health care, I realize, seems as if it should be different. But it isn’t. Already, we cannot afford every form of medical care that we might like. So we ration.....

This is only the introduction to this piece but it highlights the key point. Economics is by definition the study of the creation and allocation of scarce resources. While wishful thinking might lead us to want to believe that allocation of scarce resources should not play a role in delivery of health care, this is and always be just wishful thinking. We will always be faced with the difficult job of both creating and allocating scarce resources required for addressing the many needs and wants of health care.

What are the implications of such an obvious observation; that the basic laws of economics cannot be suspended when pondering how to organize and coordinate human activities surrounding health care delivery. There is an all too accepted standard proclamation relating to the markets and medicine is ""We just can't trust health care to markets". Given that health care requires coordination of human activities and the production and allocation of scarce resources, how do we go about suspending the most successful allocation scheme ever devised by humankind?

It might be reasonable to look for historical examples of alternative schemes for resource allocation which successfully used non-market based approaches to deal with large segments of the economy except for the fact that there are none. Purportedly successful state run command and control approaches to health care economies in other countries are all headed in the same direction toward bankruptcy and non-sustainability. Beyond obvious issues with fossilized and unresponsive bureaucracies, inadequate capital investments, and run away costs, virtually all successful examples have been present for the equivalent of an economic blink of an eye. They are based upon the same type of financial savvy and eye toward the future that marked Bernard Madoff's and Louis XIV's perspective toward the future...“Après moi le déluge”.

The default answer is to throw out the market, unquestionably the most successful resource allocation tool every adopted by man, when we deal with the health care economy. Why? There is no question that we can identify specific circumstances where markets do not work well in the health care environment. Perhaps it is not unreasonable to try to sequester these types of encounters and deal with them outside typical market based approach. What portion of present or proposed health encounters fall into this realm? What are the ramifications of moving and increasing portion of our economic activity into a non-market based allocation model, other than the guarantee of worsening mis-allocation of scarce resources and further compromise of generation of resources required to improve the human condition? I guess it is reassuring that so little is at stake when we commit to such a serious blunder.

Monday, September 7, 2009

Tribute to John Maddox

There was a time when scientists were advocates only of seeking the truth.

Lawrence Solomon: John Maddox, skeptic, 1925-2009
Posted: April 16, 2009, 10:05 AM by Lawrence Solomon

By Lawrence Solomon

Sir John Maddox, the legendary editor of the science journal Nature, died this week at age 83. The obituaries were laudatory, as might be expected given his role, over a 22-year career, in elevating Nature to one of the world's great journals.

But few obituaries referred to Maddox's reputation as a skeptic of doomsaying environmentalism and a skewerer of politically correct science.

In his most famous skewering, Maddox in 1988 first published a paper by French scientist, Jacques Benveniste, that supported theories of homeopathy. The paper described experiments in which substances, diluted in water to such an extent that no molecules of the original material remained, retain their biological activity.

Maddox then went to Paris, two experts in tow, to observe Benveniste's experiments first-hand. One expert, Walter Stewart, was a scientific fraud investigator; the other, James Randi (stage name The Amazing Randi), was a renowned magician. The trio then convincingly debunked the homeopathy claim in an article entitled "High-dilution" experiments a delusion.

Maddox's fame as a skeptic began in 1972 with the publication of The Doomsday Syndrome, a book that attacked predictions of environmental calamity. "Population growth, pollution, overconsumption of resources, genetic engineering, economic growth all, say the doomsayers, spell danger to the human race.... Although these prophecies are founded in science, they are at best pseudoscience. Their most common error is to suppose that the worst will always happen. And to the extent that they are based on assumptions as to how people will behave, they ignore the ways in which social institutions and humane aspirations can conspire to solve the most daunting problems."

And Maddox's finale as a sceptic occurred in 2005, following a London meeting of climate change sceptics. As reported in an article in the Guardian:

"Bob May, the president of the Royal Society, said the sceptics were a ‘denial lobby' similar to those who refused to accept that smoking caused cancer.

"But John Maddox, a former editor of the journal Nature, who attended yesterday's meeting, said the sceptics might have a point.

"He did not dispute that carbon dioxide emissions could drive global warming, but said: ‘The IPCC [Intergovernmental Panel on Climate Change] is monolithic and complacent, and it is conceivable that they are exaggerating the speed of change.'"

By 2005, John Maddox had been retired from Nature for 10 years, and Nature was no longer the truth-seeking journal that was its hallmark under Maddox. On climate change, Nature has become, in fact, monolithic and complacent, just like the IPCC positions it supports. Not surprisingly, Nature's reporting of its illustrious editor's death made no mention of his history of scepticism.
Lawrence Solomon is executive director of Energy Probe and Urban Renaissance Institute and author of The Deniers.

Saturday, September 5, 2009

Testing vs. Talking

Why do doctors run so many tests? Is this purely a construct of defensive medicine, trying to protect ourselves from a litigious society? I would suggest that concern about being sued is only a small part of the equation. A much larger part is an unintended consequence of how physicians are paid and the time constraints of practice.

Physicians (and other "providers") are evaluated via many different metrics. My favorite one is RVUs per clinical FTE. For those of you who are not familiar with such jargon, this is a measure of how much "work" a given MD is doing per the equivalent of a full time clinical position. It is interesting that actually talking to patients is not really considered work. Thus, the feedback we receive from such metrics is that if we invest our time in talking to patients, we are not really working and thus not really paid to do so.

Why should we think that talking to patients is of any value? Medicine should be practiced one patient at a time. Recommendations for interventions (or the wisdom of no intervention) need to be assessed on a patient by patient basis, since the suitability of any particular decision depends heavily upon patient specific circumstances. Even the most pedestrian of encounters may involve multiple different options where ideally patients should be at least reasonably informed regarding their options.

Unfortunately this is very difficult to undertake in our present ambulatory practice environment. As medicine becomes more factory like, the resource which is most short supply is time. Patients are stacked up like jet planes waiting to land at O'Hare. The way to deal with time and throughput pressures is to create a one sized fits all certainty to our encounters. Ordering tests are great for this. Whether it be biopsies, tests for Lupus, allergies, there is a false finality and certainty of a test. It also serves as a great way to force an end to the face to face encounter, thus freeing up the runway for the next plane to land.

Thus, while a CAT scan for a headache may not put money directly in the pocket of the evaluating provider, it spares them the need to discuss the uncertainty of the clinical evaluation of headaches, an activity which can be viewed through the lens of the payment system as not actually being work and thus monetarily almost useless. When faced with uncertainty and a choice to discuss this uncertainty with the patient vs ordering additional tests (even ones we do not directly benefit from financially), testing will always win hands down.

Fundamentals of the health care wicked problem

The public conversation regarding the myriad of problems associated with delivery of health care boils down to three basic themes. First there is the theme of fairness and entitlement; we have unfairly excluded significant segments of the population of access to services they should be entitled to. Second, we are going to go broke unless we change how health care is paid for. Lastly, health care as it is presently delivered fails to respond to patient wants and needs, even fully insured and financially well off clients.

Viewing the debate within framework the analysis and potential solutions become both clearer and more murky. Fixing one of the two imperatives automatically makes the other more difficult to address. Scaling back on spending likely aggravates the third imperative.

This raises the obvious question, what is the priority? The answer to that question really depends upon who you might ask and is at the heart of the gridlock we have faced for over 20 years. Any broad reaching federal solution likely will impose the priorities of one group (and likely a minority group) on the remainder of the population. How can one reform health care while maintaining sufficient flexibility to ensure the needs and wants of diverse populations (with different needs and wants) will be met into the indefinite future without bankrupting our children?