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Tuesday, October 27, 2009

Insurance fix - Yet again

Disruption - Who moved my cheese moments in history

I can't say I know exactly what is coming that will disrupt the world of medicine. After listening to the Christensen video and reading his book "The Innovator's Prescription", it is clear to me that economics, social and technical change will result in major changes in the not to distant future. As in the words of one of my colleagues you cannot have change if everything remains the same. The question is, what will actually change? What should change?

I won't begin to answer those questions since I am virtually guaranteed to be wrong. What I can predict without question is there will be winners and losers. I suspect that physicians will be perceived as being relative losers but the reality is more nuanced that this. Some physicians have already been relative losers in how the health care drama has unfolded. The fate of the reminder may turn out to similar. However, it is unlikely that docs will be driving cabs as suggested a number of years ago when sages predicted a glut of physicians.

Whatever the outcome, disappointment will likely be out of proportion to actual fate. There is nothing like rising expectations and feelings of entitlement which are subsequently dashed to serve as the genesis of major disappointment. This may serve as the source of personal disappointment or even population wide resentments. I recall reading a book "Balkan Ghosts" by Robert Kaplan a number of years ago. In this book he detailed the history of the Balkans. The book came out in the early 1990's immediately after the death of Marshall Tito and the fragmentation of Yugoslavia.

I was struck by the resentments described and their historical origins. It turns out that essentially every ethnic group within the confines of the former Yugoslavia had overseen a large empire at some point in the past and the geographic extent of each of those empires overlap extensively. All the groups believe that the largest area occupied by their respective historical empires represent their entitlement and they will have no peace until they can restore their specific empires to rightful places. Such expectations are the perfect set up for disappointment and conflict.

We have lived through what can be viewed as a golden age of physicians. The diagnostic and therapeutic powers we have acquired along with the remarkable earnings have been without parallel in modern history. Our empire is perhaps at its zenith. It is only a matter of time before our power and influence will wane and our earnings power will moderate. The reality that ours is a service activity and that we will become more and more beholden to our patients is not an altogether objectionable end point. However, it will mark a change from the PAX Doctorus empire. We and our patients will be best served by resisting the temptation to strive to restore the old order.

Thursday, October 22, 2009

Powerful tools out of control

I read an interesting book, "Demons under the microscope". It was a fascinating story about the origins of modern medicine, focusing on the the development of the modern pharmaceutical industry. Based upon the narrative of this book, the transforming event of modern medicine was the development of sulfonamide antibiotics in the early 1930's. Prior to the avialbility of this medication, physicians were uniformly therapeutic nihilists, and for good reason. Surgery, despite antiseptic methods was frequently complicated by life threatening and life ending infections. Childbirth was extremely dicey and frightfully large numbers of otherwise healthy women died from post-partum infections.

The introduction of sulfonamides changed more than therapeutics. Its introduction changed how people viewed medicine and how medicine viewed itself. The public's view of medicine changed to virtual awe. From expectations that included frequent and unexpected death from infection, the public moved to viewing physicians and modern medicine as regular miracle workers. However, that awe is now waning with an new generation whose perspective is that old miracles are now mudane expectations.

The boundless confidence of medicine post sulfa stands in marked contrast to the pessimism that marked medical therapeutics even months prior to the discovery of sulfa drugs. We tend to forget the extraordinary explosion of novel small molecule therapetics that followed sulfa development was preceeded by many decades of failed discovery, looking for magic bullets. The small molecule therapeutic explosion initiated by sulfa drugs unleashed not only a revolution in the control of infections, but also served as the impetus for development of coutless diagnostic and therapeutic interventions.

The tools that developed subsequently were simply unbeleivable. The chemical libraries with sulfa backbones were deployed to address other therapeutic targets such as hypertension and diabetes. Te ability to treat a host of primary and secondary conditions facilitated the drive to develop new diagnostic and surgical tools. The medical industry developed more and more powerful tools, much like the aircarft industry developed more and more powerful engines. Both of these industries strived to break through various barriers.

Successfully strapping a bizzilion horsepower engine onto an aircriaft ultimately required the simulataneous development of sophisticated control mechanisms. That much cannot be said for the health care industry. We have amazingly powerful tools which can be deployed in a host of ways but they are frequently deployed with either no control mechanisms associated or no one at the controls. That might not be a huge problem when those tools propel you at the speed of a gentle stroll. However, we increasingly find ourselves strapping therapeutic rockets to our patient's backs, excited that we can use them to gain altitude, without much forethought about where they will go and how they will land.

We can no longer live off the legacy of those pioneers who developed the first miracle drugs. Those miracles are simply what is expected as the norm. More powerful tools are great but the proliferation of options and the explosion of the diagnostic and therapeutic matrices make the development of control mechanisms essential for the next health care revolution.

Saturday, October 17, 2009

Christensen Video -

MIT Video - The Innovator's Prescription: A Disruptive Solution to the Healthcare Crisis

This is both an enlightening and very disturbing presentation. It should remind us that the only thing that never changes is that everything changes.

CPT: The mother of all financial evil in medicine

We have experienced a dramatic change in the culture within academic medicine with the marked changes in the relationship between industry and Universities. It has had some painful elements and perhaps has gone a bit overboard. However, the experience has awakened a consciousness regarding the underlying motivators of our actions, particularly relating to what we do to patients and why.

We are flawed human beings whose default mode is to look out for ourselves. The presence of industry influences for the most part gently molded and manipulated our behaviors, gently nudging us toward prescribing this drug or another, utilizing this test vs watchful waiting. I can say with a great degree of confidence that while industry influence may have pervasive effects throughout medicine, there are much more profound and undesirable influences which basically touch and strikingly influence virtually EVERY encounter.

I am talking about the CPT and how it controls what health care providers do. For those of you who do not know about the CPT, it stands for Current Procedural Terminology. It is a series of billing codes owned by the AMA which are required for billing essentially all encounters in medicine. Unless you are flying without any ties to third party payers, you are inextricably tied to use of the CPT.

The use of the CPT can be linked to two of the worst aspects of present day medicine. First, the practice of medicine has become heavily focused on money and revenues. In a recent article in the NEJM "Money and the Changing Culture of Medicine" by Hartzband and Groopman, they point to altered behavior in physicians who are involved in substantial sharing of financial data relating to their practices. The altered behavior included loss of empathy for their patients. The shared financial information they referred to was primarily the use of items such as P&L data for specific physicians.

They seem to have missed the most pervasive financial element which touches every encounter; the bill with its associated CPT code. Every physician (and extender) has basically every patient visit punctuated by an encounter with CPT. This serves as an immediate and consistent reminder that every service action has an external and arbitrarily assigned economic value, independent of any value received by the patient. The typical physician quickly learns what CPT codes are valuable, and what codes are to be avoided. Talk about immediate feedback loop! This is a B. F. Skinner dream. If this does not alter behavior I do not what what does.

The pernicious element of the CPT is not just the value assigned to any given code, but is the conceptual nature of what it values and what it does not value. The explicit message from CPT is you get paid for doing things recognized within CPT, for doing things to patients in your own little silo, and what is valued is only what you do and document when patients are in your presence. Doing things for patients when they are not in your presence is basically never linked to dropping a bill or a CPT code. In this case the lack of a CPT code is almost as reinforcing as its presence. The message is there is no code, no bill, and no pay.

One could potentially view this as a indictment of fee for service in general. However, the fee for service in and of itself is not the problem. Exchange of money for services or goods within an environment which allows for explicit and transparent pricing and a binary exchange system is the fundamental unit of exchange in free societies. This type of free exchange allows for wealth generating "win-win" transactions, the foundation for the remarkable economic transformation which has occurred over the past millennium.

The problem with CPT is it applies dysfunctional constraints in the form of an artificial set of allowable transactions associated with arbitrary and fixed values, unrelated to actual value received by patients. We then place CPT in a position to influence human behavior in a most fundamental way. Presto! It should be no surprise that it ends up altering our behavior in a way much more fundamental than drug rep donuts or big pharma pens. It is the most extreme case of the tail wagging the dog.

It should be no surprise that we have ended up with perverted incentives and fragmented health care. That is exactly what CPT rewards those involved to do.

Sunday, October 11, 2009

When franchise players leave the team

Today I read in the LA Times and the Washington Post that the poster child for integrative health care, the Mayo Clinic, is making moves to limit access to patients who have certain forms of Medicare and Medicaid. It is pretty obvious that they are making those decisions since their margins on those patients are less advantageous than patients covered under other insurers or those who pay cash. If the truth be told, they are likely pursuing a strategy publicly that virtually all other health systems are doing privately if they can.

What does it mean when major health systems limit access to insured patients. Obviously it means they will have a hard time getting what they want when they want it. The implications in a world post health care reform will very much depend upon how health care reform is structured. There will likely be outlets for que jumping for those who have means, although there is no guarantee this will be the case given our experience with Medicare. What sort of enhancements will be available to those who have means?

It may be that the Mayo model is dependent upon extracting higher rents from private insurance models and being geographically placed to avoid specific high cost, lower margin patient populations. If health care reform closes the avenues for patients to pay premium prices, either indirectly through their insurance or directly through their own pocketbooks, what happens to the Mayo model? Does their model have sufficient margins to continue with only the geography piece to exploit?

In contrast to the Mayo refusal to accept selected patients covered by Medicaid and Medicare, most public hospitals are happy when they can receive any payment for much they end up providing for free, but they do not represent the model for sustainable health care of the future. I suspect they may fare even worse under health care reform. The first thing to go will be their local subsidies. Taxpayers will not believe there is any reason for their tax dollars should go to pay for both underwriting a national health plan and their local public hospitals.

One thing that we should all expect is that things that our actions will always generate a combination of intentional AND unintentional consequences. The unintentional consequences which will unquestionably occur is that the only viable health care entities which will survive in the future are ones that can avoid spending more money than they take in. Virtuous, non-profit seeking organizations will do fine as long as their non-profit seeking behaviors result in consistently positive cash flows. That is not likely in the long run (or even in the short run).

In a world where prices for services float and multiple levels of service are priced through market measures, there are all types of opportunities for for health care organizations and providers to fill the almost infinite numbers of niches which ultimately serve human needs. However, the direction we are moving will result continuation of the status quo; financial survival of organizations that can figure out how to avoid the terrible trifecta: poor payers, bad geography, and poorly paying health care activities.

Thursday, October 8, 2009

Close but no cigar

I saw the article link on Greg Mankiw's Blog to Martin Feldstein's piece in the Washington Post ( It is an interesting idea which proposes to use a a government issued health insurance voucher to underwrite the private purchase of high deductible policies which feature a sliding scale deductible based upon a fixed percentage of gross income. He also advocates the voluntary use of a government issued credit card to cover the deductible if individuals or families do not have cash flow to cover expenses.

The upside is that this approach would create some pricing discipline in medicine, since people would be less insulated from the actual cost of much of medicine. It would be worth testing in a demonstration project. However, I see at least two major problems. First, I cannot see the Federal Government as an effective agent in terms of running a credit card company. How exactly would this work? Would this simply be farmed out to MasterCard of Discover? Would individual states handle this?

I have a hard time imagining Uncle Sam playing the role of loan collector. Granted, the Feds know a lot about our individual financial circumstances but I fear that political fallout would preclude aggressive collection of health care debts. A program like this would also be very prone to massive fraud.

It is great that the proposed program builds such an effective safety net. That is the very reason that I fear it has such a potential for similar or worse moral hazards than our present system. Ultimately, the only effective curb on ridiculous pricing of health care services is when the public in general feels their sting. Insurance insulates the public to a sufficient degree to insulate medical pricing from consistent downward pressures. This is not to say that lots of people don't get hurt by health care expenses. However, enough are protected to allow for the system to continue, for now.

This approach still does not explicitly address the problem with pricing in health care. Presumably since most of ambulatory care would occur below the deductible, how will prices for non-insured services be determined? While virtually all providers now participants in insurance plan, a move to high deductibles would prompt many to move to a non-insurance model. While I believe this would ultimately create a more rational pricing structure, the transition could be very disruptive. Would Medicare be part of this voucher program?

Sunday, October 4, 2009

Location, location, location

I am amazed that the longer I practice medicine, the more it looks like real estate. I know that sounds bizarre, but allow me to elaborate. There is a dictum in real estate which says something to the effect that the most important determinant of value is location, location, and location. Ostensibly what this means is the actual structure is really of secondary importance, no matter what anyone has put into it. What is most important is where the structure happens to be placed.

The practice of medicine follows the same rules. Instead of location we deal with context. Information in medicine is critical but information without context is difficult to interpret and potentially dangerous. When I was in training, we still checked serologic tests for syphilis on every patient who was admitted to the hospital. While this practice was perhaps useful at a time where the prevalence of syphilis exposure and occult carriage was significant in the patients who were being admitted, by the time I came along most of the positive blood test that came along were false positives. The screening test was a good test within a certain context but its application needed to remain within that context for it to be useful.

The utility of both diagnostic and therapeutic interventions need to be understood within the context they are validated. In fact, the entire practice of medicine needs to be examined within the context of who we see and why we see them. During the past century, there has been a fundamental change in the types of patients we see and why we see them. We have moved from a model of seeing patients when they clearly identifiable present problems to a model where we see them when they are feeling fine in the hopes that we can keep it that way. Unfortunately, I do not believe we have adequately modified our thinking to account for this dramatic change in context.

There was a time where most patients seen were actually sick. Our physical exam tools were validated (at least to some degree) within those contexts. Similarly, most of our diagnostic tests were validated within specific well defined disease contexts. Rales detected on chest exam within the context of fever and a cough points to pneumonia. A positive RPR within the context of a young sexually active man with a palmar plantar rash is meaningful.

Despite moving to a well patient model, we still do many of the same things to our patients, using tools that have been validated in patients with illness. What is the utility of listening to the chest of an asymptomatic 20 year old? What is the utility of examining every square centimeter of skin in a young, dark-skinned patient with no personal or family history of skin disease? What is the hit rate for relevant findings for any of these routine exams or labs in asymptomatic individuals?

Like real estate and location, the first thing to always consider in medicine is our location equivalent, context. We should not even begin to consider how many baths or how big the yard is until we have clearly defined location, location, location.

Informing and consenting

I read a piece on Medscape summarizing the findings from a recent Archives of Internal Medicine article (Hoffman - Arch Intern Med. 2009;169:1557-1559, 1611-1618.). In this study they found that fully one third of men who underwent PSA testing where not counseled ahead of time regarding the purpose, implications, and limitations of the screening test.

I can't say this was surprising. From first hand experience I can attest to the fact that we medical training focuses on wrote memorization of vast amounts of trivia, development of specific technical skills, and a culture of testing which relies on multiple choice tests which substitutes forced selection of the "right" answer for any actual appreciation of nuance and uncertainty. How can a physician present choices when this discussion has rarely been entertained in their training environment.

There are so many structural and cultural problems which influence this outcome that it is hard to begin to look where to make changes. I believe there are two principles which should guide us with our encounters with patients. First,after we have intervened we should be relatively confident that the patient is better off than before we intervened. Second, the principle of patient autonomy is (or at least should be) central to everything we do. Basically, adherence to these two principles will result in no intervention unless we believe the patient is better off AND we can convince the patient of this.

With this as a starting point, perhaps we should consider changing some terminology. We now engage in a process which is termed informed consent. Just the way the wording is set up places the emphasis on the consent, informing being just a modifier of the consent process. I propose we change this to informing and consenting. This places equal weight on both processes since the consent is actually meaningless without the informed piece.

There is an organization called the Foundation for Informed Medical Decision Making which is developing educational tools for patients to make such decisions ( This has tremendous potential but has a number of potential unintended consequences. It will be a source of pressure on physicians to remain informed. I have no doubt of the ability of information systems to outstrip the knowledge base of even well read providers. It will also provide a challenge in terms of who can and will vet the information. Perhaps a "Wikopedia" like model will develop with multiple editors. I am sure that will serve as a challenge to the keepers of the temple of knowledge. What is sure is physicians will be challenged in terms of being the sole source of proprietary knowledge. The asymmetry of information noted by Kenneth Arrow 50 years ago may have been a temporary state.

The great screening disappointment

There were two stories which hit the lay press this week which dealt with related issues, prostate cancer and melanoma. The NY Times article - Melanoma on the Rise, or Is It Just Diagnoses? By NICHOLAS BAKALAR September 28, 2009 ) is in fact one of series articles in the NYT dating back over 10 years which have raised similar questions after prompting from articles published in the peer-reviewed medical literature.

This article, reporting on a study published in the September issue of The British Journal of Dermatology, raised the question whether early screening using skin exams actually results in any patient benefit. The usual actors weigh in, stating the usual justifications for their positions, an exercise which I think is the equivalent of what we used to observe in our very small children when they engaged in "parallel play". They were in the same room and using the same toys, but they displayed little actual substantial interactions or exchange.

The realization that what appeared to be such a simple concept, that is screening for cancer, turns out to be so devilishly difficult is slowly playing out in the peer reviewed realm and inexorably spilling into the lay press. The history of the screening paradigm is wonderfully reviewed by Dr. Barnett Kramer (Editor of the JCNI) in a great video on the Research Channel.

It can be accessed via Google video. The take home message is it is easy to discover what can be diagnosed as early cancer. Whether what is discovered is actually biologically malignant and whether intervention prolongs lives is uncertain.

There are some very interesting parallels to earlier events in human history outside of medicine. Many has always had a desire to predict and control future events. Throughout much of history, these efforts have focused on supernatural deities and magical thinking. For over 1000 years the Oracle at Delphi held sway over critical decision making in the western world. The same origins of hard science in astronomy are intermixed with the magical thinking in astrology. The revolution of science and Newtonian mechanics led earlier generations of scientists to believe in determinism; that with enough information regarding our current state we could predict the future.

The quantum revolution of the early 20th century put an end to such thinking in the world of physics and the impact of this is still diffusing out, slowly influencing thinking in other predictive realms. It is unquestionably painful to the luminaries of both physical biological sciences, creating and understanding of the uncertainty which is inherent in any predictive activity. The hard lesson was that one can never be sufficiently informed about the present state to reliably predict the future state. Determinism is dead and this should be recognized as being true within medical sciences as any other branch of science.

Predictive health initiatives and screening activities to prevent future events are wonderful marketing tools. We all want them to be true, they attract idea patients (who are not sick), and they validate our own desires to have predictive powers. Like other fields (e.g - finance, meteorology, business) the value of health professionals is still linked to our ability to look into the future and we are understandably reticent to admit the limits of our prognisticatory capabilities. If we can't provide such information, where is our worth?

The problem with the predicting the future is that it has not happened yet. Where the stakes are high enough, prediction will always result in action which always has the potential to alter the outcomes. Whether the intervention made a difference is not discernible. It is Schrodinger's cat all over again.