Failures of Health Class

I have remarkably fortunate in terms of illness in my family. My children have experienced a variety of health problems, some of which required hospitalization. However, my wife and I are medical professionals and we have know how on how to deal with the medical delivery system. We knew when specific issues needed to be dealt with immediately and where to go to effectively solve specific problems.

Both of my parents have been remarkably healthy until very recently, which I have viewed as a remarkable blessing. Over the past month, my father has developed some new health issues and each time my parents have health problems or encounters with the health care system,  I learn I have some new blindspot when it comes to appreciating the health care system. I have come to realize is that minor health concerns which force one to interact with elements of the health care delivery system as like small dress rehearsals for when something major comes along. Without these dress rehearsals, even the most educated and together people are ill prepared to deal with new and major health issues.



My medical education and even more so my experience in practice has taught me about effective approaches to managing illness (even my own) and the capabilities and limits of current medical care. The question is, how much of this knowledge base is part of an ordinary education? The answer is almost none. It made me think back upon my own education prior to my dive into medicine. I recall my first exposure to human health issues, that being health class in middle school and high school. It was an absolute joke focusing (rather ineffectively) on sex ed, sexually transmitted diseases,drugs and alcohol. While these are rather high stakes issues and I do not want to discount any importance of any effective approaches to deal with this, two obvious observations remain.

First, the courses were a joke and completely ineffective. Those who taught them tended to be poorly prepared and the brunt of jokes. From what my own grown children tell me, there has been little change since I was growing up. Second, the range of experiences I have had dealing with health issues both personally and professionally had focused on a set of experiences which is completely distinct from what was highlighted in my health classes. What perhaps is most striking is the complete lack of any practical knowledge regarding how to navigate the health care delivery system when an individual or family member is ill.

What struck me about my father's recent health issues is how completely unaware my parents were about how to deal with basic health issues. They had no notion of what constitutes urgency, what issues they should be concerned about and which ones were less ominous, and where they should go to have specific issues addressed. They are both very intelligent and well read and have a lifetime of experience in other realms. It is nothing short of remarkable that such highly educated people can have such a huge blind spot.

Perhaps it is not that surprising since our present education system is rather biased away from practical knowledge. Health education professionals are rewarded to focus on high profile and titillating public health targets such as sexually transmitted diseases and obesity despite the apparent futility of such quests. It is my opinion that the time would be better spent educating people about perhaps more mundane but very practical aspects of health and health care.

This could include simple rules based approaches to ubiquitous illnesses. Virtually everyone can expect to develop URI's, a myriad of GI illnesses, urinary tract infections, yeast infections, dermatitis, wheezing, lacerations and abrasion, sprains and possible breaks, and soft tissue injuries. All of these common scenarios have rules based protocols which should not be viewed as trade secrets. It is nothing short of bizarre that students complete a college education and have no clue as what to do when they (or a family member such as a child or older parent) develop a respiratory infection. Health class would perhaps better serve their needs if were lighter on the diatribes focused on firearms, water pollution, overeating and refocused on common and predictable issues which drive health care service consumption. For example, perhaps we should impart the know how as to what to measure (temperature, respirations, pulse, BP) and when a visit to an urgent care setting is recommended. What medications should be routinely stocked and used.  What to do about dehydration, nausea, vomiting, or diarrhea? Again when and who to call and when an ED visit might be in order.

Redirecting efforts to educate and impart practical knowledge may also establish credibility for health curriculum. Spending time and money trying to focus on convincing people to not do what they want to do is is a recipe for failure. Mixing in some practical knowledge for dealing with issues that make them feel bad is more likely a winner.

Given my own recent experience with parent health issues, I am tempted to also push for inclusion of family health issues into a practical health curriculum. While our own aging will be part of our lives (hopefully), the aging or our parents will almost certainly precede this (barring their or our early demise). Our educational system fails to prepare us in any practical way for either our own or family aging issues.  I have my doubts this would be effective. Health curriculum generally includes normal growth and development but oddly enough development seems to stop once adulthood is reached. The absence of any recognition of aging may be justified on the basis that the target audience suffers from the illusion of immortality and this information would fall upon deaf ears. However, the lack of any information acknowledging aging as part of normal development may be part of the problem.

I could go on and on but I won't. There may be exceptions and I would love to be made aware of a curriculum which addresses these more practical considerations. I suspect they are few and far between. There is a common thread which I touched upon in an earlier piece I wrote about medical knowledge vs. know how. We are still experiencing the legacy of the Ancient Greeks and the clash between the philosophies of Sophists focused on practical knowledge and the school of Aristotle and Plato whose focus of education was on the search for timeless and universal truths. Timeless and universal truths are important. For an educational institution they will put you on the map but for the rest of the world, education also needs to transmit practical knowledge. It is the glue that holds complex societies together. 

The value of words - What is Value?

I was in a meeting where we discussed the principles of physician compensation. I am actually very proud of my institution in that it is making a concerted effort to get beyond the focus on financial metrics. However, I again was reminded of the difficulty of getting beyond flaws which reside outside of your individual institution, particularly when they are flaws in how people and organizations are financially rewarded for the work they do. No matter how much we want to rise above financial considerations, we are dependent upon money to fuel the engines that drive health care. While money may not be the sole consideration, when it is in short supply, it becomes the major consideration. And it appears to always be in short supply.

As a surrogate for actual billings and collections, we are moving to the use of RVUs, relative value units. They come across with at least the patina of legitimacy. My problem with RVUs is they have been described as the worst of Boston disguised as the best of Chicago. They use the word value but it begs the question as value to whom? RVUs are calculated based upon the objective theory of value, assuming that the value of any good or service can be determined by measuring the inputs required to produce it. This is a fundamentally flawed assumption. No matter how complex the service delivered to any given patient, if the service does not provide something of value to the patient, it is by definition of no value. It might be argued that RVUs are a useful however rough approximation which may be on average correct. I suspect that a closer approximation to reality is that the value assigned to a given activity is almost never aligned with the value actually garnered by actual recipients.

RVUs may be a useful accounting tools when trying to calculate the value of given activity to a practice or health care organization. However, this is where the term value becomes confusing. When various medical pundits throw out the term "value" in medicine, the implication is they are talking about value to patients. Michael Porter summarizes the challenges well in a recent NEJM piece:

The current organizational structure and information systems of health care delivery make it challenging to measure (and deliver) value. Thus, most providers fail to do so. Providers tend to measure only what they directly control in a particular intervention and what is easily measured, rather than what matters for outcomes. For example, current measures cover a single department (too narrow to be relevant to patients) or outcomes for a whole hospital, such as infection rates (too broad to be relevant to patients). Or they measure what is billed, even though current reimbursement practices are misaligned with value. Similarly, costs are measured for departments or billing units rather than for the full care cycle over which value is determined. Faulty organizational structure also helps explain why physicians fail to accept joint responsibility for outcomes, blaming lack of control over “outside” actors involved in care (even those in the same hospital) and patients' compliance.

http://www.nejm.org/doi/full/10.1056/NEJMp1011024

The other term which has ambiguous meaning is the word productivity. Within large integrated healthcare systems, productivity is measured by RVUs billed or collections per FTE. Obviously this is a reasonably good measure of value to the healthcare system in our current environment where providers are "paid per click". This idea of productivity may provide almost no information regarding actual value to patients. I suspect that Dr. Mark Midei was viewed as one of his hospital productivity "stars" right up until the day that he was indicted for Medicare fraud for placing stents in patients who did not need them. Productivity is defined as outpoint (outcomes) per worker per unit of time. From the hospitals perspective, the most readily measured output is the money coming in. More money coming in tracks with greater productivity from their perspective. It is hard to fathom that if money is coming in, there is little or no value being generated. That is why behaviors which appear to be outrageous in retrospect go on for so long. Who is going to pull the emergency stop cable on activities which which the only obvious elements is they are ridiculously lucrative? That they are wasteful and not productive is all a matter of perspective and the most readily measurable elements make them look very productive in real time.

So we are left with ambiguous language and a world where we are waiting for the financial phase shift in health care where we will rapidly go from productivity being viewed as doing as much activity as possible to doing as little as possible and remaining effective. How do you plan for such a transition? As one of my colleagues says, it is like planning to rewire the house with the electricity still live. Maybe it will be easier to simply build a new house or at least create a new wing with a separate fusebox?

Medicare Fraud -The inevitable product of the system designed to deliver fraud

The WSJ just published a piece highlighting unscrupulous billing practices which likely costs Medicare billions of dollars.
http://online.wsj.com/article/SB10001424052748704851204576034332420051722.html.
http://online.wsj.com/article/SB10001424052748704457604576011382824069032.html.

The comments which followed the article fall into the usual finger pointing mode... inept government, unethical providers, FMG's, inevitability due to human nature, etc. I am reminded of the mantra of the healthcare safety movement that unfortunate results are often the result of poor system design which predictably generate undesirable outcomes.

Let us look at the story described in the WSJ article. A particular high profile doc in south Florida aggressively bills Medicare for physical therapy services to the tune of millions of dollars. Our immediate response is this is unscrupulous and he has been gaming the system. This is likely a correct conclusion but perhaps a deeper analysis is warranted. What part of his activities were undesirable? Is it the fact that he was able to project his expertise and services to large numbers of patients? In other realms of business that is viewed rather positively. In fact, one of the major criticisms of the health care industry has been the lack of productivity gains over the past 40 years.

http://theincidentaleconomist.com/wordpress/the-health-care-productivity-problem/

Was he claiming to deliver services when the work was delegated to some other person? That is a possibility but again, where is the harm if the patient actually received and benefited from the service. Is that not gain sharing? Licensing requirements may have been violated but if the patients received the service and benefited from this (and were not harmed), it is more likely that the licensing requirements are serving the provider guilds more than the patients. Delegation to less expensive providers and movement to rules based delivery systems drive productivity gains. If we use volume as a criteria to identify fraud, we will be inadvertently targeting the very entrepreneurial innovators who can lead us to productivity gains. 

Was he actually delivering value to the patients that he served? We have absolutely no idea. Here lies the problem. We have deployed a payment system which divorces the payment from the actual delivery of value. This actually is built into the system at multiple levels. First, the actual level of payment for services is set administratively and it is set to a one size fits all. No matter how valuable the service is to any given patient the value to the provider to deliver the service is the same. The pricing system is devoid of differentials to prioritize who should actually receive the service. On one side, this prevents those from who value the service most highly from being priority customers and on the other side, it creates a perverse incentive to deploy the service to even those who will derive little or no value from it.

Even if there was some sort of price differential based upon actual value to the recipient, the insulation of those actually receiving the service from the entities paying for it means there is an almost total loss of discipline in the process. In the case of the physical therapy sessions billed by this Florida physician, which patients are not going to like getting back rubs that they do not pay for. I suspect that if Medicare were to survey the patients who received the services to determine whether they believed they were the victims of fraud, they would likely find very few who believed they had been victims. Even the ones who received no services at all, why should they care? They likely received no bills either. Design a system like this and what do you expect? While at the onset most participants will stay within the lines, it only takes a few "gamers" to discover and exploit the weaknesses. The rest of the world will follow them when they are cautioned not to leave money on the table redefining the bounds of decency as they do so.

The fundamental flaw is the financial triangle. Two way exchanges are not nearly as open to rampant fraud because those who pay are the ones who receive the service. No service, no payment. No payment, no service. The three way is never desirable and even more so in a realm where there are not ready checks and balances. Transaction one is to send the money to some agent whose primary desire is to hold on to the cash. Transaction two is some sort of medical service delivered by an agent who has a motivation to do as many things as possible and convince the recipient of those services that they are necessary and valuable. Transaction three is the claim of the health care provider on some share of the cash accumulated by the payer from transaction one. Distantly linked to the previous transactions are the purchase of health insurance which is temporally divorced from the actual delivery of services and only opaquely linked in terms of cost and use. There are essentially no immediate or delayed rewards for anything resembling good citizenship. Those who come out ahead financially are ones who game early and often. The difference between "legitimate" gaming and fraud is blurring to start with and morphs constantly over time.

The point is there will always be people who game whatever system that exists. Once the pioneers demonstrate that pushing the envelope creates financial windfalls, even those with less entrepreneurial spirit follow their leads. In the marketplace of a price coordinated economy where those who receive the service actually pay for it, fraud exists but it is hard for it to grow to such proportions. People who pay with their own resources are much more prudent in terms of spending. Furthermore, the more people who exploit particular avenues, the greater the availability of particular services and the more the price falls. Systems such as Medicare have few feedback loops to identify real value and have no real time price signals. Supply has little relation to demand. For Medicare, price is simply an accounting device devoid of the ability to coordinate human activity within any meaningful time frame. Providers respond to price by doing more of what drives their margins irrespective of what value is brought to patients.

The talent available looking for points of weakness will always outstrip the ability to detect and respond effectively to fraud. No matter how robust the engineering appears to be, it will always be flawed since it is based upon a foundation which cannot support it.

The pandora's box of sedentism

I recently again  listened to the Teaching Company course "Big History" by Professor David Christain. It is an absolutely fascinating series of lectures which take one from the Big Bang to the present day (in 48 lectures). There are so many interesting elements of this course but the one that struck me this time around was the discussion of the concept of sedentism.

Sedentism is defined in Wikipedia as:

In evolutionary anthropology and archaeology, sedentism (sometimes denominated sedentariness), is a term applied to the transition from nomadic to permanent, year-round settlement.

Professor Christain suggests that sedentism was not as simple as nomads settling down when they they figured out how to farm and domesticated animals. He suggests that sedentism was a type of a trap which created a series of moral dilemmas which we are still grappling with today. Nomadic hunter societies simply did not allow anyone the luxury of carrying those who could not carry themselves. It was a cruel world where those who could not travel did not survive.

The initial transition to sedentism potentially started with cultures who stopped wandering because of  they lived in locales where food was so abundant that people could settle down. However, once settled, the trap was sprung. It likely prompted an expansion of population which created imperatives for intensifying exploitation of local resources. Remaining in one place expanded the possibilities for supporting populations which could not survive in a wandering society.

Once a society was constituted to support those who who needed resources they could not generate themselves, it set the stage for a series of moral dilemmas which we are grappling with today. In Natufian culture over 10,000 years ago, the entitlements were likely very modest. Settled people came to accept that they could not leave their elders and family out in the elements and refuse to feed them. While their ancestors were incapable of carrying the old and invalid, the change to a settled people created a whole new world of the possible. Many of the possibilities set the stage for explosive human development. It was at the cost of creating a question which we will grapple with as long as people are around.

The moral imperative to care for those who cannot entirely care for themselves is part of what makes us human. It is not simply a drain on resources but I believe our empathy and willingness to to help sustain others is a key element in the development of complex social and productive networks. However, it consistently places human populations in moral dilemmas where limits must be placed on largess.

Over 10,000 years ago, the transition to sedentism set events in motion which now compel us to scramble for resources to provide complex mix of goods and services (including medical services).  Resources will always be scarce in that legitimate wants will always outstrip the resources available to meet them.  No longer does it suffice for us to simply provide basic shelter and subsistence diets for those who have limited capacity to generate their own resources. It begs the question (s) - How much or little are people entitled to and why? What is the minimal set of goods and services now? How will this morph over time and how fast? How are these decisions to be made? 

These are not easy questions because they have no durable answers. Beware of anyone who who is sure of their answers.

 

Donald Berwick and the office visit

I have included a series of links below, which I came upon after reading Dr. RW's blog - http://doctorrw.blogspot.com/2010/11/office-visit-is-dinosaur-berwick.html

Dr. RW's blog as well as the post in First Things expressed complete dismay regarding Berwick's comments relating to the need for office visits. The Berwick comments originated from a piece he wrote in 2002 entitled "Escape Fire", which described events in the 1949 tragedy in Mann Gulch which took the life of a number of smoke jumpers. He elegantly identified parallels between the dogma of the smoke jumper training at that time and the role in guaranteeing the tragedy and the present state of health care in the US.

http://www.ihi.org/NR/rdonlyres/683C2FA5-7AF9-42E0-BD70-24591D390AC8/0/Berwick_EscapeFire_CommonwealthFund2002.pdf

It is an interesting piece and quite independent of hearing Berwick's story and reasoning, I find I share his sentiments regarding office visits. I also suspect that I am true to my contrarian roots in that the idea that delivering value to patients may not require face to face visits to the degree which we have previously believed is an idea that does not appear to be widely embraced within MD professional circles... as least not yet. The arguments to the contrary are somewhat telling and appear to supported by belief and declaration as opposed to actual data. http://www.firstthings.com/blogs/secondhandsmoke/2010/11/16/berwick-wants-to-do-away-with-80-of-dinosaur-patientdoctor-office-calls/

I toggle between the world of MD's and the world of non-health care folks. I am consistently struck by the perceived value of face to face visits within the MD world and how that contrasts with the annoyance this seen as within the world of those who are the seekers as opposed to the deliverers of care. When I see patients which I do primarily in the ambulatory setting, I always look at the visits asking one question. What specific piece(s) of information did I garner from this encounter which informed me in such a way to alter the management of the patient's condition and could that information have been garnered in such a way which would be more efficient in terms of everyone's time and money?  I generally conclude that much of the activity associated with the visits could have been done better outside of the context of a visit that was very time consuming and wasteful to my patients.

Others argue to the contrary. For example, one of the comments on the First Things piece was:

In order to make an accurate diagnosis, doctors MUST have, in person, interaction. The diagnostic process, requires the doctor to assimilate all of the physical findings, such as skin color, and texture, heart, breath, and bowel sounds, and the nuances, of these that can only be detected with stethoscopes, pulse, alterations, detected by palpation, of the various organs. They take this information, combine it with their vast (hopefully!) knowledge of anatomy, physiology, biochemistry, pathology, and clinical experience, to formulate a diagnosis, and subsequent treatment plan. This can only be accomplished, the “old fashioned” way, by personally examining the patient. Indeed, all large part of the diagnostic process, is done, as a result of the physical examination, and the history, provided by the patient.

I agree that diagnostic work is incredibly important and requires the assimilation of lots of information. However, what worse context to do this than in a hurried face to face encounter where the collection and inputing of information is rushed and the formulation of a DDx and treatment plan occurs under time pressured conditions. It only makes sense that moving as much of this outside the time constraints of the face to face encounter will limit errors which occur more frequently when we are pushed for time.

What information can be collected at a face to face encounter? This author suggests that it is information derived the "old fashion way" from the physical exam. However, all tests need to be validated in some fashion to determine whether they provide information which is reproducible and predictive of some outcome. My own experience with elements of the PE show that whenever new technology comes along which allows elements of the physical exam to be tested with additional rigor, the value of the exam ends up being much less than initially suspected. The bedside neuro exam was almost immediately found to be suspect when the CAT scan became available. The ability of clinicians to listen to the heart and predict anatomy was found to be sorely lacking when cardiac echo was available. How many phantom spleen tips have been identified on the abdominal exam? Who ever sees anything actionable looking into the ears of someone with no ear complaints. For the vast numbers of asymptomatic people who come for regular checkups, the physical exam is likely worse than worthless.  What is the predictive value of the physical exam in someone who has no complaints? I can not know for sure but I suspect it never been tested. However, the more bullets checked, the more you get paid.

The only thing I can state with certainty is the face to face exam is most consistently of  value to the health care system and provider that drops the bill.  Many visits may bring value to the patient but the persistence of this encounter structure rests upon the value brought to the provider. Changing the payment system to encourage alternative compensation arrangements would redoubtably release a  wave a welcome change.

Where will change in health care come from?

It has been a long time coming and it will likely be still a while before change fully plays out in the health care arena. There is a consensus that our economy cannot accommodate sustained growth of the health care economy which is well above both the growth rate of the overall economy and greater than inflation. The possible scenarios for the end game are too numerous to count and can range from enlightened change and adaption to a Mad Max post apocalyptic hell. I suggest that something entirely different will happen.

Our medical model is based upon a training and credentialing model which may not be the best fit for a rapidly changing world. It is increasingly incapable of change. Rather than provide improved and more efficient approaches to training a health care workforce which can re-invent themselves on a recurring basis and better serve the public, it is better suited to protect itself. Undesirable outcomes trumpeted in the press serve as justifications to reinforce a regulatory framework which does more to serve the interests of those regulated than serve the public at large. No better examples of regulatory capture can be found in health care than anyone else. Whether one deals with state licensing, hospital credentialing, or residency oversight, each additional layer of regulatory hoops creates barriers to entry and brakes on innovation. While the initial motivation and justifications are to protect the public, the ultimate winners are the regulated.

No lesser developed country can afford to duplicate such a wasteful  and dysfunctional system. Much the same as when the US military found it could train highly skilled corpsman to deal with complicated health issues during the Vietnam war and this spawned the development of the PA profession, new models of health care delivery will come from developing countries. It is only a matter of time before rules based management and electronic decision support tools will allow for better and less costly management of the vast majority of common conditions. While resistance to these changes will be difficult barriers to deployment in the US and other western countries, I suspect that this will not be the case elsewhere.

Over time, data will become available which will demonstrate whether more expensive models retained in places like the US are actually superior in outcomes over less restrictive approaches that will be deployed elsewhere. I suspect it will be like any other model in history where high cost activities move offshore to find lower cost alternatives. There might be some modest quality decrement but the cost differences will dwarf any quality loss. The guilds will put a valiant fight but like the Luddites who fought mechanical looms, they will be relegated to the category of a curiosity of history.

 

 

Juan Williams and our reptilian brains

The furor over Juan Williams remarks and his subsequent dismissal from NPR is finally settling down. I have given the events some thought and being the contrarian that I am, I thought I should weigh in with a contrarian opinion. I think I understand the genesis of  of Mr. Williams thoughts and comments regarding his fears. Oddly enough, I suspect that the response of the President of NPR is likely to be explained by the same mechanism which generated Mr. Williams remarks.

Because of my interest in how doctors and patients perceive and respond to risk, I have delved into the works of a number of authors who publish primarily outside the realm of medicine and health care. Two particular works, "Risk" by Dan Gardner, and "How we Decide" by Jonas Lehrer deserve highlighting. Although each book has a different focus, both highlight elements of the human brain and human decision making which are extremely relevant to the Juan Williams brouhaha.

Human brains are millions of years in the making and our cognitive functions are built on a platform which is not particularly linear or rational. The rational and deliberate part of our brains is only part of the story. The more ancient and sometime referred to "reptilian" brain operates in each of us and its functioning and continues to serve vital functions in our day to day existence. We care constantly placed in positions where we must make judgments. Some of those judgments require thoughtful deliberation and weighing of all the data. Some require a quick assessment and reliance on gut feeling to decide.

In Jonas Lehrer 's book, he describes the decision of a radar operator in the Persian Gulf who sees echoes on a screen and is forced to make a rapid decision as to whether they represent a friendly A6 attack fighter or attacking missile. He has little time to weigh all the data, only time to look at the echoes and intuitively make a decision. He decides that the echoes represent a hostile missile and correctly so. He accomplishes the feat, using a phylogenetically ancient system, common to  gazelles at the watering hole, sensing of a cheetah is nearby. This system can process lots of information without us actually being consciously aware of all of it. This has been referred to as system 1 or "gut".

System two is the more deliberative system. Gardner refers to this as "head". Head is more plodding and methodical. Head is data driven and rational. Some problems appear best addressed with the rational plodding approach while others are more amenable to intuition (think of Malcolm Gladwell and "Blink"). Most decisions require input from both systems.

When Juan Williams remarked on the fear he sensed when he saw someone in Muslim garb on a plane he was boarding, he was simply recognizing that system 1 was activated. The reptilian portion of his brain was firing off in a similar pattern as our ancestors when they came down to the watering hole and their hair stood up on end if they sensed a predator near by. We all have those moments, perhaps walking down on dark street or entering into a neighborhood where you do not know anyone and perhaps people look different from you. We can't help but have these feelings. They are system 1 talking to us. We can not turn this off, nor apparently should we want to. System 1 is an integral part of our decision making apparatus.  Lehrer descries the fate on one patient who post brain surgery became essentially devoid of emotion and also lost his ability to make decisions.

We are not entirely rational creatures and it is crazy for someone to be disciplined for acknowledging that he has fears that he cannot fully explain. We all have fears which derive from system 1 and all we can expect is that we do not act rashly on all of them. I suspect it is in the long run desirable to reflect upon them and share them with others. Juan Williams was open and honest about his fears but did not act upon them. I suspect that if we scanned Vivian Shiller's brain and saw the predominant structures activated when she decided to Fire Juan Williams, we would find she was driven to react mal-adaptively more by gut than head. Her reptilian brain also got her in trouble.   

The Ruckus over the RUC

Perhaps the cat is out of the bag with the publication of a front page story in the WSJ on the Relative Value Scale Update Committee, other wise known as the RUC. This entity, conceived after the Resource based relative value scale (RBRVS - aka real bad reimbursement very soon), to set fees for Medicare. The payment framework was rapidly adopted by third party insurers and the RUC mistakes quickly became everyone's mistakes. It has functioned at least in part because it has functioned in the shadows. The public was clueless as were most physicians. I gave a talk at a state medical meeting three years ago on health care economics and asked for hands of who knew what the RUC was. Less than 10% of the audience raised their hands.

Thongs are changing as evidenced by the front page WSJ story (which spills over to an entire page on A16). The WSJ article shows the photo and picture of the head of the RUC. I strongly suspect that she will be getting additional calls. I also suspect that the names of the panel members will begin to leak out.THe names are not posted on the AMA website Lots of prying eyes will begin to scrutinize the methods and the math. It will not be pretty.

 (From physician Panel Tilts Medicare Fees - WSJ October 27, 2010 http://online.wsj.com/article/SB10001424052748704657304575540440173772102.html?mod=ITP_pageone_0

 So here you have it, pricing by committee which perverts the allocation of resources in one sixth of the entire economy. How anyone with any conception of the role of pricing in the allocation of resources could think this could work is beyond me. It is ironic that the William Hsaio, the Harvard Professor whose work served as the intellectual basis for seemed to be surprised by how this has all turned out. He argued that you cannot turn to the physicians who will be doing and billing for the services to derive the information needed to price them accurately.  They will just game the system. Well duh!

 However, who can you turn to to derive this information? It is a fundamental problem with administratively set pricing structures. It will also dog the newly constituted Medicare Payment Advisory Board which will be charged to:

Establish an Independent Payment Advisory Board comprised of 15 members to submit legislative proposals containing recommendations to reduce the per capita rate of growth in Medicare spending if spending exceeds a target growth rate. Beginning April 2013, require the Chief Actuary of CMS to project whether Medicare per capita spending exceeds the average of CPI-U and CPI-M, based on a five year period ending that year. If so, beginning January 15, 2014, the Board will submit recommendations to achieve reductions in Medicare spending. Beginning January 2018, the target is modified such that the board submits recommendations if Medicare per capita spending exceeds GDP per capita plus one percent. The Board will submit proposals to the President and Congress for immediate consideration. The Board is prohibited from submitting proposals that would ration care, increase revenues or change benefits, eligibility or Medicare beneficiary cost sharing (including Parts A and B premiums), or would result in a change in the beneficiary premium percentage or low-income subsidies under Part D. Hospitals and hospices (through 2019) and clinical labs (for one year) will not be subject to cost reductions proposed by the Board. The Board must also submit recommendations every other year to slow the growth in national health expenditures while preserving quality of care by January 1, 2015. (from Focus on Health Reform - http://www.kff.org/healthreform/upload/8061.pdf)

So, how are they going to this any better than the RUC? Who are they going to turn to to get timely and accurate information upon which to base their pricing information? How are they going to adapt to change and innovation? How will this group of politically appointed and motivated individuals assign value to the billions of encounters that patients have with those who provide an almost infinite variety of medical services? Very badly I suspect.

Magical vs. Methodical

I am an optimist, perhaps bordering on being delusional at time. I am methodical and systematic in how I approach problems and I assume that this is a characteristic shared by my colleagues and even my patients. I am constantly reminded that this assumption is simply wrong. Nevertheless, I hold on to this belief system. I am not sure why.

Today, I was pulled in to see a patient by one of the PA's I was supervising. This patient was undergoing chronic outpatient treatment for a distinct condition under the supervision of another physician. The patient was actually visiting from well out of town. He was a very sophisticated professional who had achieved much and was highly regarding within his own field (non-medical - he was a chef). He was availing himself of treatment not available in his home community thousands of miles away.

Here is the bizarre part of the story. He was referred to our office for a distinct difficult and chronic problem which ad already been exhaustively evaluated and treated at one of the most famous integrated health care entities in the world. He had undergone literally months of diagnostic evaluations and countless treatment approaches at the hands of some of the most intelligent and diligent physicians anywhere. So, when he comes to visit our fair city, someone has the brilliant idea of garnering a 15 minute slot with my PA for a second opinion. He comes with no records and basically no recollection of what had been done, diagnostically or therapeutically.  We briefly played a variant of medical 20 questions... Did the medicine sound like??? Did the test sound like??? until I realized that this was going to go no where.

I guess I assume that patients and referring physicians have some conception of what it takes to evaluate and treat people with complicated medical problems. I have to say I was tempted to ask this patient how he would react if I came to him saying that I had this great meal and I would like for him to recreate it immediately. However, I remembered only that it had a main course, it contained meat, and involved a sauce.

I perhaps should expect such lack of insight from the patient but what about the referring physician? Shouldn't someone with medical school and residency training in almost anything understand that referring a patient under these circumstances is crazy. Perhaps they thought we would be able to cast a spell upon this gentleman and purge the evil spirits. Perhaps it did not occur to whomever initiated the endeavor that medical problems are best solved by methodically analyzing the data, creating a differential diagnosis, and weighing options. Most likely no one gave it a moments thought beyond the impulse to call and secure an appointment even if it was not with anyone who was in a position solve their problem.

The magical thinking perspective is the default mode. When we ask patients to secure records from previous evaluations, they view it as an imposition. At least part of the reason for this attitude is some realize many of the records contain little or no actual information. When we ask them to provide information in the form of questionnaires, they follow the principle of opening the door wide enough only to get through. They appear to have a hard time conceiving that the information provided might actually be useful. To some degree the medical profession historically has fostered the belief that physicians power over disease bordered on the magical. Current TV drama tends to underscore very short time lines and ad hoc functioning of the medical profession. Heroes in this world require little time or data to solve issues, relying instead on intuition, gut, and impulsive decision making skills. It may make great TV but it is not the best way to deal with most medical problems.

Health care reform without HR3962

The WSJ published a piece by Avery Johnson entitled: "In Treating Cancer, Insurer Tries New Way to Pay Docs" in today's paper. http://online.wsj.com/article/SB10001424052702303550904575562440652409512.html?mod=ITP_marketplace_0#articleTabs%3Darticle

While many of the comments focus on the elements of the piece suggesting that doctors may push chemotherapy because of a financial incentive, I think the most interesting observations can be summarized in the following statements:

The program, which the insurer plans to announce Wednesday, attempts to address potential overuse of expensive cancer drugs by eliminating any incentive for doctors to choose a drug based on profit. As a result, oncologists will be reimbursed at cost for whatever drugs they prescribe and receive a separate payment covering their services..... Many cancer drugs are infused by doctors in their offices, and historically doctors have purchased the drugs and billed insurers for their cost, plus a profit margin of around 15%, says Lee Newcomer, UnitedHealth's vice president of oncology......UnitedHealth estimates that drugs account for 65% of an oncologist's income.

65% of all oncologists income estimated as coming from infusion of drugs. I am not sure where these numbers come from but if they are true, they raise all sorts of issues. First, any activity which eliminates 65% of income from a particular segment of a health care providers is likely to have some nasty consequences. I don't know what they might be but there will likely be some major casualties, both in terms of individual physicians and institutional. I would venture to guess that the major investments that health care concerns made to develop large and capital intensive cancer centers could look bad as their planned profit centers become cost centers.

If 65% of oncologist incomes comes from mark ups on drugs, it highlights the madness associated with the role of physicians in patient care and defining where physicians actually bring value to patients. Gaming the margins on drugs has allowed oncology to delivery cutting edge care and reward oncologists for the role they play. Everyone has recognized that the fee structure associated with the cognitive and management work in oncology (and medicine in general) is not adequate. Many sub specialty have avoided taking on the battle of pricing their truly valuable cognitive services appropriately as long as they have they have their own proprietary technical billing gimmick which they can milk.

Oncology and Rheumatology have their infusion centers. GI has colonscopy, ENT has sinus surgery, Dermatology has Mohs surgery, Cardiology had stent placement, and Allergy has skin tests and allergy shots. Ophthalmology had cataracts but their fate should serve as a lesson for others who bet the ranch on becoming dependent on a few narrow cash cows.  The question is are these lucrative elements of practice the things which really bring value to patients? Not likely. In my estimation docs are paid poorly for doing the really difficult things which make the big difference in patients with chronic disease burdens. For that reason there are few physicians who want to to take on the long term responsibility for care of people with chronic diseases. Everyone in medicine knows this.

However, as the cash cows get identified and picked off by either Medicare or private insurers, the landscape will change. Some specialists will simply take refuge in the world of aesthetics. It is not proprietary and is open to basically anyone who can take a weekend course, has reasonable people skills, and is OK with their hands. Not everyone can do facial reconstructions but most anyone can inject Botox and fillers. It may even be a big market which can accommodate many physicians. However, the availability of practitioners who can inject Botox into your wrinkles won't soften the blow much when you can't find anyone to treat your breast cancer, mutilating arthritis, or inflammatory bowel disease. My guess is that as the payers pick off the the selected cash cows, calling their margins too large, there will be little inclination to make anyone whole by trying to appropriately value the cognitive work which is essential in effectively deploying all of our technological medical marvels. The squeeze will be on.

 It may work out just fine. Those of us whose primary tool for practice is our brain may find that we can operate in a very low overhead environment. Others may elect to operate outside of the third party payment scheme, or at least one operated by the state. Many may do both. We will finally be able to see how cognitive medical services are valued by the public when the only way they will be available is if they are paid for by the end users and priced by market forces.  That is where real health care reform will happen.

 

Tuskegee Redux

An amazing story broke in the news yesterday regarding human experimentation studies with syphilis in Guatemala in the late 1940's. At the Center of this was John Cutler, who went on to play a central role in the infamous Tuskegee study, followed by a long career in Public Health at the University of Pittsburgh. While Cutler's role in the Tuskegee (and Sing Sing)  study has been explored extensively, his earlier role in syphilis studies in Guatemala had evaded detection until Dr. Susan Reverby stumbled upon his writings when reviewing Dr. Cutler's papers. While Cutler came into the Tuskegee study decades after it had begun, his role in the Guatemalan study was much more damning. The study subjects were prisoners and mentally ill and the rationale for their choice appeared to be specifically because Dr. Cutler knew such studies could not be done in the US.

The revelations are a public relations nightmare for the PHS. Furthermore, they also create all sorts of problems for the University of Pittsburgh where he served as chairman of Pitt's department of health administration and was acting dean of the Graduate School of Public Health in 1968 and 1969. He retired in 1985 from the University although he reportedly remained active until shortly before his death in 2003. Since 2005, the John Cutler Global Health Lecture and Award has been bestowed upon candidates annually. I am not sure I would want to include such an award on my CV going forward.

However, we all should all be wary of judging Dr. Cutler for what he did unless we really think hard about understanding what specifically about his undertakings was so reprehensible. Do not get me wrong. In my estimation, what he did early in his career, particularly the studies in Guatemala are so unacceptable that his subsequent accomplishments provide hardly any cover.

One principle which trumps virtually all other principles is that of autonomy. With very rare exceptions, patients and research subjects have unquestionable control over their own bodies. No matter what our intentions as individual clinicians and researchers, we must respect the autonomy of others who we interact with. All other goals and aspiration that we have as clinicians and researchers must be subservient to the principle of autonomy.

If the reports are correct regarding Guatemala, Dr. Cutler grossly ignored the principle of autonomy. However, he was not alone as evidenced by later work by Dr. Beecher published in the NEJM. http://whqlibdoc.who.int/bulletin/2001/issue4/79(4)365-372.pdf  Although he was criticized for his role in Tuskegee during his lifetime, his legacy was left pretty much intact, as evidenced by the lecture and award at University of Pittsburgh which bears his name. My guess is it will not survive these revelations.

While this particular revelation has substantial shock value and I do not think there are ongoing and gross violations in federally sponsored research programs now of this magnitude , I would venture to say that we still don't have this autonomy thing fully worked out. That is because our general perception of the "wrongness" of what Dr. Cutler did is based upon gut and shock value and not a true understanding of the specifics.

At the very heart of the problem is the process of informed consent. People should have control over their bodies and control means the ability to agree to partake in various activities. That is the consent part. We all know that means to get permission and agree to something, whether test, treatment, or participation in a study. However, in my estimation it is the informed part is where the problem lies. We all know that what Dr. Cutler did was wrong because we all know there is no way he could have convinced that number of people to participate in such studies if they were actually informed sufficiently to let them know what they were getting into.

In the present, patient and subject participation is generally within contexts where reasonable people well informed might decide either way, to participate or to not participate. Under these conditions, how can we tell if patients/subjects have been adequately informed? I would argue that the infrastructure we have put in place will protect against the most grievous transgression, but primarily serves the needs of the clinicians and research sponsors. It constructs a legal framework and paper trail  which serves as a charade for patient protection, a perfect example of regulatory capture.

As I march through my days on those that I function as a clinician, I am struck by the the hurried decisions I make, recommending diagnostic and therapeutic interventions which are based upon little or no hard data. Because of my particular awareness and sensitivity to this issue,  I at least make a serious attempt to focus on the informed part of the equation. However, it is very difficult to assess who is truly informed. No good tools have been developed to help us with this process. Does the patient understand what is at stake? How should we frame the question?

I suspect that my practice in my particular specialty is not very different from other practices. The clinical scenarios might be different but virtually all are marked by hurried decisions made with insufficient data, limited time for reflection, and patients who haven't a clue as to what they have agreed to. This is important for both procedural endeavors (where historically there has been the most emphasis) and for diagnostic tests, (For an interesting spin on this see http://getbetterhealth.com/the-american-cancer-societys-hype-prostate-cancer-screening-clearly-saves-lives/2010.10.02). It does not matter whether someone has signed a piece of paper. Consent is basically meaningless unless it is informed consent.

Let us roll the clock forward fifty years and I can see the outrage. Dr, Cutler never made an attempt at obtaining consent from his subjects and it could be said that he misled them, particularly those involved int he Tuskegee study. Few questioned these actions at the time but he is currently (and appropriately) judged harshly for these transgressions. It could be argued that we in the present world make only feeble efforts at true informed consent. This may not be viewed as a serious transgression through our present day lenses but will this be viewed with similar outrage to Tuskegee in the future?

Anecdote driven activity

The AP published a story by Jennifer Kerr earlier this week on the activities of the Consumer Product Safety Commission (CPSC) relating to science kits for children. http://news.yahoo.com/s/ap/20100929/ap_on_bi_ge/us_children_s_products_safety
It seems that the CPSC is worried that items such as aper clips and rulers within these kits have not been properly tested for safety. The manufacturers of the kits believe that these common household items should not require specific testing since they don;t require this when sold separately. The commission voted 3-2 to decline a waiver for this application.

I was intrigued by this story, prompting me to explore the CPSC site with various CPSC publications. http://www.cpsc.gov/cpscpub/pubs/pub_idx.html as well as the CDC site for data on death from various causes http://www.cdc.gov/nchs/data/nvsr/nvsr58/nvsr58_19.pdf. My question is what type of data would prompt the CPSC to be mindful of placing tighter regulatory scrutiny upon paper clips and rules. The best answer i could come up with was this was not a data driven endeavor.

At the CPSC I found tables summarizing the number of deaths and accidents that could be attributed to accidents with toys.

I am not particularly happy about any deaths of children from accidental causes but I think we need to look at these numbers within the context of the overall denominator. There are approximately 20 million US citizens under the age of 15, meaning the risk of toy related death in 2008 for this group was literally one in a million. Death in children is more likely related to some sort of congenital condition (primarily cardiovascular), accidental deaths (primarily drowning, motor vehicle), and infections.  To invest such time and effort in the regulatory endeavors which the CPSC builds cannot be justified on any rational basis. It appears to be that their efforts are best justified by the desire to justify their own existence. To that end they find the public relations ploy of scaring parents about the danger of toys and play pays handsome dividends in terms of their own budgets. A few scary anecdotes go a long way to accomplish this goal, whether intentional or not. However, we end up in an absurd place, looking to do safety tests on common household items. I wonder if they will next request to do safety testing on the packing materials, including the air in the box.

This type of behavior is not limited to the CPSC and they should not be singled out for special treatment. Indeed, medicine uses the same approach to highlight "problems" which require scrutiny.  My favorite area in medicine which parallels the CPSC behavior is medication monitoring which is hopelessly driven by anecdote. When the famous TV drama ER was on the air, the producers used the principle that if anything happened in the ER anywhere in the country once, it would occur hourly on the TV drama. Shooting, hostage scenarios, plague, bomb threats, you name it, the implication was these should be our primary concerns.

Likewise, if one patient anywhere has been reported to have a particular bad outcome on a given drug or after a given intervention, whether mechanistically linked or not, we will be called upon to restructure how we manage future scenarios based upon rare anecdote. We are concerned with the numerator and not the denominator. To avoid the one in a million unpredictable bad outcome we alter daily practice in such a way that we are guaranteed to hamstring our practices, mis-allocate scare resources and compromise patient care.  We end up doing the equivalent of the CPSC attempts to regulate paper clips and rulers.

Many within the medical profession have lamented the role of the legal profession as drivers of this. I must agree that the legal profession has not been shy about exploiting the environment of fear. However, they could not have made such headway if the health care world did not leave them with such opportunity in terms of operating in such a data poor realm. Beyond that, we have not cultivated a world within health care which is driven by data. We have resisted creating meaningful and measurable objective milestones to be held accountable to not realizing that these can be our best defense against capricious legal intrusions. It has also created openings for other regulatory entities to come in and fill the vacuum, making us measure the measurable and not necessarily what is important.

Those who take care of patients need to step up and realize that part of our job is to address how we can put systems in place which permits us to make important measurements which allow for important mid-course corrections. It is an important part of patient care. We can no longer use a reactionary system driven by rare anecdote.

Framing issues and informed consent

We are all choice architects, influencing our patients by describing options in different contexts. This is devilishly difficult given the time constraints created by our present payment structure, the imperfect nature of the data we have at our disposal, the varying preferences and educational backgrounds of our patients, and our own biases hidden from our ability to appreciate their influences. This past week there was yet another major study published in the NEJM regarding the effectiveness of screening mammography on prevention of breast cancer. It was another case of looking at the glass and saying whether it was partially full or partially empty. 
http://www.nejm.org/doi/pdf/10.1056/NEJMoa1000727


My sentiments on this align with Gilbert Welch who wrote an accompanying editorial. The basic take home message was that in order to save one life the authors found they needed to screen 2500 fifty year old women for 10 years in order to save one life. These efforts would generate 1000 false positive tests and likely expose 15-20 women falsely diagnosed with breast cancer to various forms of treatment including surgery and chemotherapy. Within a cohort of 1000 women, on average 4.5 would die of breast cancer in 10 years and this would drop to 4 with deployment of mammography. 


My question is, now that this and other studies supporting similar numbers have been completed and published, how many women will be given this data as part of their routine discussions to have mammography?  I suspect next to none. 


Medicine is filled with these types of issues. Basically healthy people with few if any symptoms come to us for some sort of service. They want reassurance. We have become increasingly equipped to offer an array of services to prevent some sort of undesirable future outcome. Unfortunately we as physicians don't understand the numbers particularly well and we are not encouraged to present them in an understandable and transparent format to our patients. 


In Dr. Welch's piece that accompanies the NEJM article, he raises the issue that physicians are being judged on quality metrics that include participation of their patients in various activities such as screening mammography. This gives clinicians a vested interest in getting patients to comply with various, purportedly beneficial activities. However, just how beneficial are these activities and what information should be shared with patients before they commit to any given course of action?


I came across an article by D Misselbrook and D Armstrong. 276. British Journal of General Practice, April 2001 where they looked at patient responses to the following scenarios:

The results are quite startling. 

Depending on the data presented and the framing, anywhere from two thirds to less than twenty percent definitely would agree to treatment. Those who likely would decline went from about twenty percent to well over half. 

What are we to do with such information? What is the correct approach to informing patients? I have little doubt that using the NNT or PPB approaches will result in fewer patients electing for certain interventions.  Is that reason enough not to share this information? I do not think so. In fact, it seems to me that the quality of the informed consent process could be directly assessed by the number of patients who actively decide against specific measures. Too high a level of compliance with certain measures might equate with evidence of an inadequate informed consent process and a lower level might be a good measure of the quality of the informed consent. 

Bending the cost curve

Other than those who are admirers of Louis XIV and his philosophy of  "Après moi le déluge", there is widespread agreement that continuing our present path of growth in health care spending is not sustainable. All political posturing and bluster and magical thinking aside, how can this actually happen? 


This does not involve higher math and uses the mathematical tools which I learned in elementary school.  We need to either spend less or increase the pool of resources which can be tapped to pay for health care or a combination of both. However, we need to define which actions would result in either of these two outcomes and then define which entities are empowered to make those decisions. None of this is easy.


First of all, how can we predict that any given action by any given entity will have the expected outcome? In addition, saving money is not the only charge of those whose mission is to remake the health care system. Competing imperatives include increased access, lower out of pocket costs, sufficient payments to guarantee provider participation and availability of services, long term support of health care education, support for research, support for quality initiatives, promotion of innovation, fairness and functionality of the tax code, and limiting the tax burden in order to promote overall growth of the economy. Any action taken by any numbers of parties to further any one of the above goals will have impact on how much is available to be spent on health care and how much will be spent.

Let me simply highlight one interaction between competing imperatives. Despite the huge increases in the total amount spent on health care, the portion of costs which fall upon the medical consumer (patient) has on average fallen since 1960. On one level this is highly desirable in that out of pocket  (OOP) expenses do not create a barrier to accessing what patient need (see chart).

On the other hand, insulating people from the costs of goods and services creates all sorts of moral hazards, the worst of which is the tendency to over consume or utilize more expensive approaches which may bring limited if any additional benefit for the additional dollars spent. In the broader economy, substitution options  create downward price pressures on goods and services. In the medical realm, this mechanism works poorly if at all since substantial portions of the public have historically have not been motivated to cost shop since their insurance insulates them from such cost differentials. This may or may not be changing.


As I see things, the only way this changes is by implementation of some sort of gain sharing mechanisms. The public will not broadly buy into cut backs in their benefits unless the gains are explicitly shared with  them. Short of actually paying patients to use cheaper interventions, which would create all types of perverse incentives, we are left with having patients pay more for more interventions that have lower cost (and perhaps lower quality) alternatives. Otherwise, why stint on your own care when you have nothing to gain from it.


How this can actually come about is another story. None of the parties presently involved is either empowered or incentivized to make the changes which can result in bending the cost curve in the desirable direction.  It is only the rare politician who will be re-elected by promising his constituents that she/he will deliver less. Few people other than those with martyr complexes are driven to pay more to get less from the health care system. Physicians will refuse to play both patient advocate and cost containment agents simultaneously. Insurers will not be capable of being effective agents for cost containment. They will not gradually move their business model to simply collecting a fee for claims adjudication and check cutting and leave the thorny job of saying no to their political masters who will provide more and more of the funds to keep the health care monster alive. 


It brings us back to how can this be managed and I again get back to the best model for scarce resource allocation; markets. There is no question that such a model will remake the health care industry into something very different from what it is today. There will be great resistance to this approach given the bias that markets can not work for health care. Ultimately we will have no choice. The only approach which can bend the curve is for each of us to husband our individual resources and for health care purchases to compete with other individual wants and needs on an even playing field. If those within the health care industry cannot convince the public that their investment in their own health is worth the expense is worth it, the cost of moving that decision making process for resource allocation to another entity will prove to be disastrously expensive in the  long term.    

A surprise every 15 minutes

Every time I see patients in the typical ambulatory setting, I still marvel at how ridiculous our processes and workflows are. I have a practice which includes new referrals for complex problems and follow up patients, also generally with complex medical issues. For the patients who I see initially, I insist on record review before I will schedule them. Patients and physicians complain about this requirement and this generally impacts my patient satisfaction scores since all parties view this as a barrier to getting in to see me. Few appear to connect the dots that perhaps collection of information before the patient arrives at my office is critical for me making sure they are actually coming to the right place to address whatever problem they have.

The usual triage mechanisms in place involve the patient and someone at the other end of a phone line, generally someone with virtually no medical training. In our institution, the historical measure for productivity of those who received the calls and scheduled appointments was simple. How many calls can you handle per unit of time. Place any caller in any available appointment slot to keep the patients and their manager happy. Whatever information which might have been collected at the time of the call relating to the reason for the appointment was either not recorded anywhere or amounted to an obscure or inaccurate complaint, generally conveyed with tortured and often comical spelling. What the heck of someone drove five hours for a brief encounter with the wrong physician. We use tools which basically guarantee that this will happen.

I have wracked my brain trying to think of other industries with similar business models. There are some parallels with auto repair shops. However, they generally collect much more information regarding the challenge ahead of them than we do and manage time expectations much better than physicians. Imagine that, falling short of the bar set by auto mechanics. Perhaps I am being too hard on the medical profession. People are much more complex than cars and trucks. They cannot leave their body at the office and go on with the rest of their business using a loaner, at least no yet.

However, we are going to go nowhere until there is a broad recognition that we go about our business using a model which is fundamentally flawed. I should not use a process in my office which is based upon being surprised every 15 minutes. When I walk into a room with a follow up patient, I might have a hint of what I will face, but generally not. For my follow up patients with chronic and symptomatic disorders, I usually have implemented some treatment protocol some weeks in the past. Short of me calling each individual patient on a regular basis and asking them how they are doing, we remain blissfully unaware of what has transpired in the intervening periods between appointments. I actually do call patients but it is generally hard to reach people and it is not an efficient use of my time.  In a world of widespread and robust communication tools which allow us to collect all types of information automatically and in structured formats and which have been widely deployed in many industries, health care remains a remarkable exception.

At least part of the lag could be traced back to HIPPA. Perhaps more early adopter types might have tinkered with small scale projects to form the basis for larger and enterprise based tools. This has not happened, at least on any widespread level. I don't see MD/patient communication apps on my Droid phone. I do not think they exist for the iPhone either. The only way we will see the development of such tools  is for each large vendor to develop expensive enterprise patient portal tools which will need to comply with HIPPA, CCHIT, and whatever. These will be applications developed by committee and will likely serve everyone's needs equally badly. I will be surprised if they are robust and adaptive. They need to be both if they are to allow for the type of information exchange which will allow for physicians to recognize and be responsive to patient needs and to collect information is formats which will allow people and systems to review what they are doing and find areas for improvement.

At some point in the not to distant future, substantial numbers of patients will come from generations that have integrated electronic social networking tools into their daily lives and they will look at the way we do business now as some form of madness. Some already do. They are appalled that they cannot communicate effectively with me because they have to run the phone tree gauntlet or hope that I received the fax they sent. We surreptitiously use emails but since they are technically forbidden, the information never makes it into the actual medical record. It amounts to work arounds heaped on work arounds.

So we wait and continue to run our practices using the information tools of the last century and structure our days seeing patients in the context of agenda- less meetings and surprises every 15 minutes. Health care reform was most focused on increasing the number of people who get access to this dysfunctional system and paid scant attention to the barriers already in place which thwart efforts to re-engineer our processes. I am tired of bing surprised every 15 minutes, particularly when the tools exist to fix this problem right now.

Rethinking Science

There is an excellent piece from The Economist: http://moreintelligentlife.com/content/ideas/anthony-gottlieb/limits-science

Good sense is the most fairly distributed commodity in the world, Descartes once quipped, because nobody thinks he needs any more of it than he already has. 

It is always great when the lead off for an essay has such a pithy quote. The author goes on to write:

No group of believers has more reason to be sure of its own good sense than today’s professional scientists. There is, or should be, no mystery about why it is always more rational to believe in science than in anything else, because this is true merely by definition. What makes a method of enquiry count as scientific is not that it employs microscopes, rats, computers or people in stained white coats, but that it seeks to test itself at every turn. If a method is as rigorous and cautious as it can be, it counts as good science; if it isn’t, it doesn’t. Yet this fact sets a puzzle. If science is careful scepticism writ large, shouldn’t a scientific cast of mind require one to be sceptical of science itself?

 There is no full-blown logical paradox here. If a claim is ambitious, people should indeed tread warily around it, even if it comes from scientists; it does not follow that they should be sceptical of the scientific method itself. But there is an awkward public-relations challenge for any champion of hard-nosed science. When scientists confront the deniers of evolution, or the devotees of homeopathic medicine, or people who believe that childhood vaccinations cause autism—all of whom are as demonstrably mistaken as anyone can be—they understandably fight shy of revealing just how riddled with error and misleading information the everyday business of science actually is. When you paint yourself as a defender of the truth, it helps to keep quiet about how often you are wrong.

Thus, despite having a set of tools unrivaled in regards to identifying truth, science and scientists are wrong more often than begin right. The science is undergoing continuous revision. This is obviously relevant to the practice of medicine. It is cumbersome in a world where patients want to know THE ANSWER or THE DIAGNOSIS to respond with hedging.  It unquestionably cuts into billing to have to deal with the messy world of gray as opposed to black and white.  Furthermore, this may call into question the actual role of science and evidenced based medicine. 

When I see a patient and discuss options to deal with a particular problem, the science and evidence are important but represent only a part of the picture. They may help guide any decision by providing a background as to the likely outcomes. How the patient deals with this information (if actually available) is not a scientific question but a personal question. Science cannot and should not dictate the answers to personal decisions. It is critical that we know when our data is good and revealing of underlying trends. How people use this data and what outcome they decide is desirable should be their call. Only they know what their particular goals are.

The assumption promulgated in policy circles is that what should be delivered (and paid for) in the health care realm can be decided on the basis of science. That is one of  the driving forces behind the EBM movement. However, you need to ask whether patient decisions regarding health interventions are fundamentally scientific questions. While these decisions may be influenced greatly by data and products of scientific inquiry,  I believe the answer they are personal decisions. These decisions are also highly influenced by individual and personal goals which are highly disparate within any given population.      

However, this paradigm is not so simple because there is often another party involved, the payer of the service. The payer generally has some sort of fiduciary responsibility to yet another party (taxpayer, stockholder, business owner). Science is injected into this mix based upon the assumption that we can use science to decide what health care interventions are needed. Perhaps it is reasonable to use scientific and statistical methods to define whether on average a particular intervention and allocation of resources generates a net positive effect in a given population. However, it is a pretty poor tool when it comes to accommodating individual needs. Using scientific algorithms to decide personal questions will almost certainly result in wasteful allocation of resources and  substantial personal disappointment. 

We are all gamblers

I am reading a book by Peter Bernstein entitled "Against the Gods: The remarkable Story of Risk". As those of you who have read my previous blog pieces already know, I am fascinated by concepts of risk and prediction. I believe that understanding these concepts are absolutely essential to the practice of medicine. Unfortunately, the general public as well as the medical profession has a poor grasp of these concepts and it serves as an impediment to best decision making.

What is most intriguing about the history described by Bernstein is that gambling was the driver of gains in the statistical realm which ultimately catalyzed the quantum leaps in expanding the understanding of the statistical tools and concepts required to both understand and predict risks. One the concepts were understood as they related to dice and cards, the mathematical application to other domains outside typical gambling became apparent. The rest is history in the world of finance and insurance.

At the most fundamental "gut" level, I think all of us understand that we are constantly making bets and weighing the odds. I suspect that one of the attractions to the world of overt gambling is the rules are more explicit, the stakes are reasonably well defined, and the outcomes are tightly temporally linked. We do not need to wait a long time to discern whether we are winners or losers. Furthermore, it is easy to tell. The outcomes are not ambiguous. If there is anything we humans like it is certainty and immediate gratification.

The practice of medicine is laced with bets. In contrast to the clarity of the gaming tables, medicine is filled with uncertainty overlaid with ambiguity. Take a population of patients with mild hypertension. Intervene with some sort of medication in thousands of patients, follow for decades, and statistically someone is a winner but no one knows who. Similarly, screen tens of thousands of patients for breast, lung, or prostate cancer using whatever tool which is in vogue. In contrast to patients with hypertension, patients who participate in cancer screening get an almost immediate feedback with what appears to be a result which is as unambiguous as rolling snake eyes. The problem is that virtually no medical tests are that black and white. We would like to be able to predict with certainty the winners and losers (although in the end we are all losers) and most of the public and much of the medical community have virtually no appreciation of the limits of these tests.  They fail to understand that the diagnosis of cancer in many cases is simply a prediction about what might happen in the future with no way of knowing whether the prediction is correct 95%, 50%, 5%, or 0.5% of scenarios.

In my own practice I have solved this problem by focusing on the present as opposed to the future. I deal primarily with patients who are symptomatic and uncomfortable and my measure of success is whether I am able to fix that. I like to say that I deal with present problems as opposed to dealing with things that might happen in the future. I still need to be aware of what might happen in the future, particularly as it relates to what my interventions may cause in the future. When trying to address someone is is in pain, is short of breath, is itching from dermatitis, or is functionally impaired in some way, all possible fixes entail some risk of creating some new or worse problem.

The obvious question which any well informed patient should ask is how likely is that to happen? Alas, there lies the problem with even the most modern medicine. For the most part, we do not know. In the 16th century, gamblers were in similar straits. Men had been playing dice games for literally thousands of years but it was not until the works of Girolamo Cardano, a Renaissance man and inveterate gambler that assessment of risk and odds changed. His work revolutionized how the financial world dealt with risk, moving it from gut and intuition to statistical analysis. With his mathematical tools, he could precisely predict the odds of rolling a two or a seven. The same principles were applied to annuities, insuring commerce,  and finance.

For the most part, risk assessment in the practice of medicine still operates primarily at the gut level. The statistical tools exist but they require actual data to be applied. Absent the availability of relevant data, we are left with a world similar to those throwing dice prior to Cardano. We may understand that we are placing all types of bets but we don't have the tools to understand the odds.

Rethinking multidisciplinary care

I attended a conference whose sole purpose was to bring together experts with experience in running multidisciplinary clinics. None of my previously conceived notions were altered much. There was a very sobering introduction which highlighted two themes. The first was the accountable care organization concept. What we are facing is the construction of totally new models of care which are to be created based upon top down mandates by organizations poorly equipped to assess how they are doing. The second theme was that the growth in health care spending was simply not sustainable meaning that the ACO construction will need to happen in a world of serious cost constraints.

There was lots of discussion, actually very interesting discussion, but there was a serious disconnect. The consensus was that multidisciplinary care was better for patients but the only way to get it was to spend more, not less money. There were many participants who described their own experience with such clinics, and although there were exceptions, most of these models involved having multiple physicians engaged simultaneously. After the conference, I started to run the math. What would it take in terms of  revenue to simply cover the cost of simply the doctors in the room? For circumstances described where there were three specialists in the room at once, let's make a few simple assumptions. The average specialist salary can be conservatively estimated at $200K/year. Assuming they spend 40 hours/week in direct patient care and 50 weeks of work (likely an overestimate), this amounts to 2000 hours. This means to simply cover their salary you need $100/hr per specialist. For the typical institution, the overhead rate is at least 60% and likely closer to 70%. This means the MD costs of $300/hr will require collections of almost $1000/hr. The overhead may be even higher since there may be particular support needs for these clinics.

Irrespective of whether insurers should or could cover these costs, you need to ask the question, can we accomplish the same outcomes using a much less expensive approach. What other activities require the simultaneous activities of multiple six figure professionals delivery service to people, one at a time? It would be nice if we could all hire the equivalent of Michelangelo to paint our living room but most of us settle for the local contractor who might hire a few undocumented workers to save a few bucks.

Virtually all industries have seen tremendous gains in productivity since WWII and in each of these cases the gains have been made by the use of automation and movement away from manual and people dependent processes. One major exception is health care. Within health care we only partly aware of the spiraling costs but because of how our individual incentives are structured, our individual financial gains are directly linked to how much of the insurer's and patient's money we can spend. Our productivity is measured by how much we generate in billings and collections. It is the only way we can keep such an inefficient system solvent.

Getting back to multidisciplinary care, my question is what can multidisciplinary clinics deliver which is not delivered in our present model? One obvious answer is better communication and coordination of care. However, at what cost is it to use the most expensive people in your system in this way?

 I am sure that MacDonald's could hire and pay for Le Cordon Bleu trained chefs to flip burgers and it might improve their food. Geek Squad could hire nothing but MIT PhD's s to repair computers and they would likely raise their quality parameters to some degree.  If we had fast food and appliance insurance, we might end up with these HR placements but that is not the case in the current world. The party line is health care is different and at an emotional level one can easily make this case. At an economic level this is not he case. If we keep up our present course of action we will go broke.

We can create a system with coordinated multidisciplinary care of complicated disease but we cannot design this around such an inefficient use of such valuable resources. We need to identify where physician expertise actually makes a difference and distinguish these tasks from tasks that be be delegated to people who require less training or to machines. In the former category, other industries which were previously reliant upon rare talent who used intuitive decisions making skills to create unique products or services, make huge productivity gains when they could develop rules based processes to replace intuition. DuPont at one point in time had a virtual monopoly on synthetic fiber development business since they basically employed all of the talent who had the skills to develop new fibers using an intuitive approach. The development of better understanding of 3D chemical structure, powerful desktop computers, and software which allowed for modeling at modest cost  put the tools to develop new fibers in the hands of a vastly broader group. It was not necessarily good news for the highly paid chemists but it was good news for those who benefits from the availability of an abundant variety of inexpensive synthetic fibers.

People are expensive and industries such as the auto industry have replaced expensive people with machines which are in fact better suited to do particular tasks. In health care machines such as computers might be ideal for data collection and tracking, flexible learning and testing, and decision support tools.  If we are to carry out the mandate to improve care while saving money, we will need to borrow heavily from other industries which have made large productivity gains. We have no choice but automate and delegate.

You might ask about the human element to health care. It may sound like the future I paint sounds bleakly sterile and devoid of human interaction. It may move in that direction but I suspect we will be pleasantly surprised. Automation of other industries freed up people to do tasks they were better suited for. In the case of health care, I suspect delegation and automation will free up time for valuable problem solvers to spend their time actually solving problems and communicating with patients and other members of the health care team. True multidisciplinary care will happen much more readily when the individual costs are not so prohibitively expensive that the primary focus of the care giving team is to figure out how they can support themselves and not their patients.