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Saturday, January 29, 2011

Placing bets on the outcomes of health care reform

It will be at least a few decades before we can rightfully engage in some Monday morning quarterbacking relating to the the most wave of health care reforms. By the time that anyone can look back with sufficient time to really assess success or failure, it is likely that memory of where we were and where we desired to be will be so remote that no real consensus will be reached regarding success or failure, cause of effect, or future directions.

There sill be some unquestionable measurable milestones which will be available. Whether anyone will actually pay attention to them is doubtful. One set of estimates will be projected costs. With the exception of the Medicare prescription drug benefit (Medicare part D), no other health care entitlement implemented over the past 50 years has come in even close to projected costs. We can argue as to why that is the case but from my perspective, cost overruns are predictable when programs offer services where those receiving the services are insulated from the true costs. Medicare part D did buck this trend but it also contained the very unpopular donut hole provision where recipients did feel some of the sting of their medication costs. However, in the infinite wisdom of the new health care reform, this is going away, a politically popular provision but a fiscally irresponsible one. My bet is that part D will start to look like the rest of Medicare in terms of growth of expenditures beyond the rate and inflation and growth of the underlying economy.

The basic architecture of health care reform is to take the worst aspects of specific segments of the heath care economy and move to generalize these to the entire health care economy. Unfortunately, the attempts to generalize particular elements has selected the features which are the worst in terms of health care inflation. The stated goals are to expand the numbers of individual who use the insurance vehicle as the primary payment for their health care expenses and to move to increasingly insulate them from the cost of their care. It is hard to imagine any other outcomes other than worsening over consumption, escalating costs, and mis-allocation of resources. I believe it was Einstein who said  "Insanity: doing the same thing over and over again and expecting different results". Seems like he was describing the latest round of legislation.

In their attempts to create accountable care organizations (ACOs), there is at least an attempt to push the decisions relating to allocation of resources  relating to care away from a centralized command and control model and downstream closer to the point of care. This approach is not entirely without merit but unfortunately the devil is always in the details. Such an approach will require tremendous flexibility of individual operating units to respond quickly to unique local conditions. I am not aware of any precedent for such flexibility within the framework of such an increasingly monolithic state controlled network. While the health care reform bill was voluminous , the documents detailing the final rules will make the initial bill look like a scant amount of evening reading. As these rules get more an more onerous, more an more effort will be devoted to either staying within the lines or gaming them. Actual quality of care of delivering value to patients will fade quickly into the background as those who devote energy and resources to such noble endeavors will find that this focus will financially bankrupt them.

Enduring complex systems simply cannot be conceived by our feeble human minds.  However, we can anticipate how people will behave when particular incentives are put in place and from these tendencies, we can predict the direction of where broad movements will lead. We cannot accurately predict the timelines nor the absolute magnitude of shifts. Similarly, human nature is pretty consistent over time. We cannot predict what any given human will do nor can we predict how populations will behave within a narrow time line, but the arrow of human history shows some rather consistent trends over time.

When given the choice, people will want more. Yes there are exceptions of those with particular discipline but more often than not we will be gluttons when given the chance. Utopians have been conceiving of the means to change human nature for thousands of years and been moved by their passion to implement their visions. They have little to show for their efforts other than millions of dead, the casualties of murderous impulses to perfect humanity. Such efforts in the future are not likely to achieve any more success than Lamarckian attempts to create tailless salamanders by breeding animals after removing their tails. People remain gluttonous and will opt for more, particularly when their own costs for acquisition are modest.

Still, proponents of national health care will continue to draw from anecdotes of undesirable circumstances and outcomes to call for further dramatic action. It feels good to be part of the revolutionary vanguard, urging action. Success will be measured not by actual problem solving but instead by the mere implementation of some plan and the mass of resources allocated. Better to do something, even if ultimately destructive than be accused of doing nothing. Furthermore, there will always be more anecdotes to justify further action, allowing those driving the change to feel good about themselves, no matter how destructive their activities might be in the longer term.

It takes courage to buck the trend and resist the desire to go beyond simply championing what you believe is right and bypass individual choice by co opting the coercive  power of the state. Positive change  implemented by free people reaping the benefits of their good decisions or suffering the consequences of their poor decisions takes time, perhaps more time than what allows for appreciation by individual humans. There lies the problem. We are not only gluttonous but also impatient. That will not change.

We live in an imperfect world where there will always be "bad" outcomes and scarce resources. The mindset which believes that this situation can be improved by increasingly complex and coercive rules which need to be made increasingly so each time there is an undesirable outcome is a terribly dangerous and destructive mindset, no matter what intentions might underlie them .

Saturday, January 15, 2011

Getting down to the messy details

I good friend of mine sent me this link from  the Washington Post today. The piece is titled:

Basic' gets tricky in the health-care law -

by N.C. Aizenman

It starts off with:

Should health insurers have to cover treatment of Lyme disease? What about speech therapy for autistic children? Or infertility treatments?
Can they limit the number of chemotherapy rounds allowed cancer patients? Or restrict the type of dialysis offered to people with kidney disease?  This week an independent advisory group convened by the Obama administration launched what is likely to be a long and emotional process to answer such questions.
And the piece ends with:
After hours of testimony, the panel's chairman, John Ball, seemed to find only one point on which everyone could agree: "We have an impossible job."

This should come as no surprise.  Richard Epstein clearly articulated this almost 15 years ago during the controversy surrounding ClintonCare. In his classic "Mortal Peril" (published in 1997), he describes the barriers to implementation of positive rights.
The creation of minimum standards is moreover, a far more daunting enterprise than its modest label might suggest. Someone must specific the minimum....Minimum standards quickly transform themselves into "decent minimums" precisely to avoid these Malthusian overtones. Once disconnected from elemental survival the standards creep towards even higher minimum standards... The vast expansion of the overall level welfare rights has been well documented...

He goes on to describe our present circumstances exactly.
The demand for a system of minimum rights also creates manifold difficulties for figuring out how to equate marginal benefits and marginal costs, and the problem is endemic to any system of positive rights to health care. Initially there are no accurate prices for measuring costs and no observable metric for measuring benefits, and none for rationing service.
The more things change the more they remain the same. Perhaps before we pass a law requiring minimum standards we should at least have a process which can define what we are mandating. Who will make these calls and upon what metrics? What is the wisdom of creating an entitlement which is based upon executing an impossible task as the first step in deployment.

Responses to spectacularly bad outliers

I like the Numbers Guy who writes a column in the WSJ (Carl Bialik). His piece today in on the perils of trying to count and define mental illness. This piece was spurred by the groundswell of support for the notion that gun purchases should be prohibited for those with "mental Illness". That is all well and good but you still need to define what mental illness is and also define thresholds for when to invoke specific prohibitions. This it turns out is not so easy and in fact, it is almost impossible.

This particular has moved front and center because recent shootings by the deranged young man in Arizona. It is yet one more tragic episode in a long line of periodic tragic episodes involving troubled young men. There is something about men of this age who reach crossroads in their lives. Many make really bad choices which can result in individual and personal tragedies. The rare ones make choices which result in high profile and public tragedies.

It is the latter circumstances that create a public cry for some sort of early intervention. In the grip of such public tragedies our gut tells us this call seems reasonable. We need to act before things like this happen. We need to identify who is at risk and act to prevent such acts before they occur. However, when someone like the Numbers Guy starts to raise basic questions about how, our more reflective brains point to the reality that the best responses may be to change little.

The good news is such events are really rare. This is not to suggest that a lower frequency is not desirable. However, we are all too aware of the numerators but not at all cognizant of the denominators. You have to be aware of the latter in order to know how and when to act in terms of prevention. There are about 50 million men between the ages of 15 and 30 in the US. That appears to be the at risk group. While my recollection of history is incomplete and not exhaustive, public high profile events appear to occur every few years (Columbine, VA Tech, University of Texas (both this year and 1966)).  How are we doing by the numbers. Let us assume one public event per year done by one young male. That is one in 50 million. How low a frequency would be viewed as acceptable?

The behaviors exhibited by the perpetrators prior to their actions are always portrayed after the fact as strange, suggesting that someone (or some entity) could have acted ahead of time to prevent such events. The problem is the math. Odd behavior in this age group is not rare. Given the size of the group, even a relatively low frequency of odd behavior translates to big numbers. No matter how you cut it, predicting dangerousness is not a science. There are rules of thumb as opposed to definitive predictors. How many interventions would be required and of what type? Who would or could authorize them? How many simply eccentric people would be raked over the coals? What would constitute success?

The ignorant of the denominator phenomena is not unique to the mental health field. It permeates the entirety of medical practice. Our actions are driven by the outliers. One bad outcome and we feel compelled to propose re-engineering how we approach particular clinical problems. In terms of risk factors, much of the low hanging fruit has been harvested has been dealt with in the US. Unlike much of the developing world, we have few issues with sanitation and water issues, widespread infant mortality, and workplace deaths. Among selected populations, we still have problems with high risk behaviors resulting in morbidity and death (tobacco use, high risk sex, illicit drugs, and alcohol). While medical breakthroughs may mitigate particular consequences of these high risk activities, these behaviors will always be risky. However, cultivating anxiety in these populations does not tend to change their behaviors. Populations likely to benefit from action are generally not inclined to adopt changes

We have moved to address a host of risk factors for people living in relative affluence and spend an increasing amount of our time catering to the anxieties of basically healthy people. Despite their relatively low risk statuses, this population is very responsive to anxiety provoking marketing approaches. It is a great business model since it involves receiving regular payments from patient who are basically well. Well people rarely need unscheduled care and are more often than not gainfully employed. Odds are the problems we work to prevent were not going to happen anyway and are not likely to happen on our watch. However if physicians and their patients were cognizant of the actual numbers involved in these preventative measures, there would be much less enthusiasm. Yes, low dose aspirin in the right populations decreases the numbers of MIs, but only modestly more that the additional bleeding episodes.  Intervene with huge populations and only a handful of people might benefit. However, these interventions are targeted to populations which are more inclined to adopt changes whether they help them or not. They are more interested in the illusion of control than any actual results.

Maybe that is the key. Actual results do not really matter in the short term. It is only the illusion of control or the act of doing something that is essential. That is a sufficient end in itself, or at least until the next tragedy occurs. There is no limit to the variety of useless gestures which are at our disposal. We can only hope that the responses can limited to being simply useless and do not become destructive in and of themselves.

Monday, January 10, 2011

Doing vs. Documenting - Making and Explaining a Diagnosis

Doctors and Patients, Lost in Paperwork

ERproductions/Getty Images

It is a common lament among physicians. We spend too much time doing "paperwork" (computer work) and not enough time with patients. This complaint resonates with patients, who believe that their visits with their physicians are just too short. It sounds so compelling until you begin to ask some basic questions. What exactly do physicians actually do for patients? If direct patient contact is so valuable, who is it valuable to and why? What specific physician activities actually deliver value for individual patients?

Value added activities basically fall into three categories: Diagnostic services (solution shop), targeted value added interventions, and chronic disease management services. Each of these activities relies on different types of work process and has different deliverables to patients. This blog with deal with diagnostic work.

The deliverable for diagnostic services is a diagnosis. This has value because it is an accurate prediction of the future in regards to natural history of  disease and appropriate therapy if indicated. The higher the quality of service, the more accurate the prediction. Diagnoses which have no predictive value are of little or no value. Diagnostic services require the garnering and synthesis a lots of information from a host of sources. A "diagnosis" requires obtaining an accurate history and then applying a variety of diagnostic tests. The history is essential since virtually all diagnostic tests are context dependent and history is nothing more than the historical context. Direct patient contact is essential for the diagnostic process but perhaps we need to ask some critical questions regarding why. What specific tasks related to diagnosis are best done while with a patient? Since diagnostic work is all about information collection and analysis, what specific information is collected better or exclusively with direct patient contact?

An argument has been made that direct contact is essential because of the physical exam. The entire E&M billing process hinges on hitting the various bullets in the PE in order to meet specific billing levels. This is one of the worst cases of the tail wagging the dog. In my experience, there is modest value from the physical exam, which has historically been overrated. When elements of the physical exam are tested and attempts to validate specific elements of the exam have been done, the exam turns out to be not so reproducible. I am reminded of the impact of CAT scans on the bedside neurologic exam during my internship. For years we were  under the delusion that we could accurately map the location of lesions in the brain using bedside tests. When the CAT scan came along as a new gold standard, we realized that such tests should be relegated to history. I may get some credit for pushing on someone's belly, listening to their breathing, or looking in their ears when it comes to billing. However, in the absence of of any symptoms referable to these organ systems or body sites, my exam is not likley to bring any value to the patient, only to me via increased reimbursement.

 In my estimation, there is much more value from accurate historical information. However, it is my experience that much of this information can and should be collected outside the direct patient encounter. It can be collected more accurately and in a more structured format under less time constrained circumstances when not crushed into an office visit. This can and ideally should be outsourced to patients. Using physicians to act as a filter as to what needs to be documented or not leads to missing important pieces of information. This has been highlighted in Evan Basch's observation about adverse drug reactions. Reports by patients were much more complete than physician reported tallies and this allowed for more rapid recognition of adverse events in drug trials.

If the physical exam is of limited value and much of the history can be collected outside the context of direct patient contact, what use is our face time with patients? I would argue that the most important time with patients is after we have collected and synthesized information. At least in my experience, to come up with an accurate diagnosis, account for other items in the differential, consider different treatment options, and put this into a format which is understandable to your patient requires a great deal of work not in the presence of a patient. Medicine is more complicated now than it was in the past and it is nothing short of crazy to believe that you can or should do all of this on the fly during the time allocated by an office visit.

Once you have done your preparative work, the quality time with patients can deal with important decision like what patient really want and what they really fear. That is where real value is part of the direct patient encounter, where information can be applied to address specific human concerns as part of shared decision making. This is also fantasy. The real life encounter is filled with useless muda (, guided by inaccurate and incomplete information, and structured by a flawed payment system. However, railing against paperwork will not get us any closer to fixing the problem.

Monday, January 3, 2011

More on Death Panels

Death panels are back in the news. From the WSJ  (Dec 29, 2010)

The office of Oregon Democrat Earl Blumenauer, the author of the original rider who then lobbied Medicare to cover the service, sent an email to supporters cheering this "victory" but asked that they not tell anyone for fear of perpetuating "the 'death panel' myth." The email added that "Thus far, it seems that no press or blogs have discovered it, but we will be keeping a close watch."
The regulatory process isn't supposed to be a black-ops exercise, but expect many more such nontransparent improvisations under the vast powers ObamaCare handed the executive branch. In July, the White House bypassed the Senate to recess appoint Dr. Berwick, who has since testified before Congress for all of two hours, and now he promulgates by fiat a reimbursement policy that Congress explicitly rejected, all while scheming with his political patrons to duck any public scrutiny.
But if Dr. Berwick's methods are troubling, the substance is more than defensible. Certain quarters on the political right are following the media's imagination and blasting Dr. Berwick's decision as the tangible institution of death panels. But the rule-making is not coercive and gives seniors more autonomy, not less.

While I am more of the conservative bent, I must admit that the diatribe from the right is more disconcerting on this topic than the usual moronic drivel which emanates from the left. It is unfortunate that the discussion fails to draw attention to the real issues which require to be addressed.

The fighting words which, when uttered, render all rational discussion ended are" health care rationing." When will people learn that in addition to the certainty of death and taxes, there is always also the certainty of scarcity. The cornerstone of the entire realm of economics is the assumption that there are legitimate wants which go unfulfilled because there is never enough stuff to fulfill all human wants. Economics is essentially the study of the allocation of scarce resources. With the exception of the air, basically all resources are scarce. All resources (including health care) need to be allocated (read rationed) via some sort of mechanism. The only real question is how to allocate wisely.

What constitutes wise allocation? Which mechanisms consistently allocate resources wisely? Any mechanism which takes scarce resources and blows through them as if they are limitless is likely unwise. Any mechanism which consumes resources in such a way to guarantee their absence in the future is also unwise. Resources such as those needed to deliver healthcare are dependent upon health of both the social/legal structures and the economic engines which drive the generation of wealth and productivity. Just look at the health infrastructure in places like the southern Sudan or the Congo.

Ultimately, the choice in terms of allocation (rationing) of health care resources falls into either the political realm or the market realm. The knee jerk reaction is to reflexly discount the market to allocate health care resources because health care is either "different" or "too important" to rely on market forces. This is a perfectly reasonable perspective is one is completely ignorant of human economic history. When health care constituted  a trivial fraction of economic activity and consumed limited resources, such an oversight was of limited impact. Using political mechanisms to allocate a small portion of scarce resources resulted in mis-allocation of of resources at the margins of the economy. That is no longer the case.  We are using political mechanisms to allocate resources in a growing segment of the economy that runs the risk of consuming the entire economy, this killing the goose that lays the golden eggs (not a wise allocation strategy).

Since we have no choice but make choices about allocation of scarce resources in health care, we might as well use the mechanism which has shown to be superior in terms of most optimal (not perfect) allocation, the market using market based pricing mechanism.  It is associated with the most flexibility and the best long term track record of any allocation scheme which has been devised by man in recorded history.

Medicine cannot live in a world where we consume scarce resources and yet believe we are immune to the forces which are required to optimally allocate and use them. Whether we like it or not, an argument can and will be made that there is a point where resources allocated to health care would benefit people more if allocated elsewhere. Commonizing increasing resources in state hands and placing these discussions primarily in the political realm will guarantee that the political fights will get increasingly brutal. As Hayek noted in The Road to Serfdom  even when the state tries to steer only part of the economy in the name of the "public good," the power of the state corrupts those who wield that power. Hayek pointed out that powerful bureaucracies don't attract angels—they attract people who enjoy running the lives of others. They tend to take care of their friends before taking care of others.

Avoiding some type of resource allocation is not an option. Not placing it in a political realm is.