Indignant about inevitable arbitrage

Gilbert Welch penned an indignant piece in the Op-Ed section of the New York Times yesterday (link) titled "Diagnosis: Insufficient Outrage". I am generally a fan of his work, much of it focused on the limits of screening approaches to disease. In this piece Dr. Welch expresses profound dismay regarding the lack of professionalism serving as a brake on undesirable but not necessarily illegal activities in health geared toward extracting value from patients as opposed to delivery value to patients.

He is correct in his assessment that perverse incentive structures inflates the cost of health care in the US, driving costs through the roof and making it more expensive than anywhere else in the world. He notes particular examples:

"Consider another recent shift in health care: hospitals have been aggressively buying up physician practices. This could be desirable, a way to get doctors to use the same medical record so that your primary care practitioner knows what your cardiologist did.
But that may not be the primary motivation for these consolidations. For years Medicare has paid hospitals more than independent physician practices for outpatient care, even when they are providing the same things. The extra payment is called the facility fee, and is meant to compensate hospitals for their public service — taking on the sickest patients and providing the most complex care.
But now hospitals are buying up independent practices, moving nothing, yet calling them part of the hospital, and receiving the higher rate."

Well duh? This is to be completely expected based upon how the rules are presently written. It is called arbitrage, buying a product in one market and moving to a different market where you can sell the same product for more money. What in the history of mankind would lead you to believe this would not happen  in health care markets?

Yes, at the outset many if not most hospitals might balk at doing this, but if the activity is not illegal, the most entrepreneurial parties will jump on this. In the absence of the ability to sanction them, they will quickly become wealthy and influential within their fields and spheres.  Generous profit margins bring resources, credibility and soon those early adopters become the darlings of the industry, and find lots of other parties trying to emulate what has become "best practice". Given this, who would ever want to "leave money on the table". The reality is no one, except parties who are so principled they go out of business. Like it or not, the health care business has selection pressures.

This is inevitable, no matter how steeped a profession may be in "professionalism". Human nature is to look out for one's own interests first and then others later. There may be unique exceptions but to build a large system of exchange based upon altruism over self interest is to base your system on delusion. This is why markets tend to work better than other systems of resource allocation. They explicitly recognize that we work based upon the principle of self interest but the brilliance of markets is they also reward one's self interest by bestowing the highest rewards over time on those who figure out how to deliver what the public wants. It is not perfect but it is less imperfect than the alternatives.

Want to "sell" EKG's? Figure out how you can convince individual members of the public that they receive sufficient value from this test to justify spending of their own resources up front. Similar to colonoscopy, I suspect there would be no problem with overuse if people paid their own money or at least had a larger financial stake in the test. Based upon other markets, the costs would drop and better tests at lower cost would become available, assuming the public became convinced that these test actually added value to their lives. I predict many services will need to become much less expensive for the public to value them sufficiently to justify widespread use. The NNT calculus will need to change.

Dr. Welch has a prescription for the problem, one that I don't necessarily buy into:

"We could make the system better. We could ensure that everyone has access to the same set of prices, like the Medicare fee schedule. We could end the “fee for service” positive feedback loop — in which doctors and hospitals earn more for every procedure they do, which leads to overtreating patients — and instead have a flat fee. But the incentives will never be perfect. Ultimately, society needs individuals to be guided by ethical standards. And in medical care, those standards are getting pretty darn low.
Too many of us have passively accepted the situation as being beyond our control. Medical care in America could use a dose of moral outrage. It would be best for all if it was self-administered."

It is not going to happen. Richard Epstein's work on simple rules highlights a key point. As we deal with larger groups, the rules need to become simpler and more explicit. All sorts of parties are now part of the health care delivery systems, with almost 1 in five dollars of the economy involved in health care delivery. Physicians do not control this, not by any stretch and even if there could be some consensus among doctors that a common vision as to what is ethical vs not ethical could be reached, there is no way this could be imposed on the broader health economy. There is no way the consensus could be reached anyway.

We could try to resort to rule of experts. This idea was floated by Plato in form of philosopher kings, based upon the assumption that the public was too stupid to know what they should want. I won't contest that people may make bad choices, in matters relating to their health as well as other important matters. However, any attempt to delegate those decisions as a default to other expert parties runs into the self interest principle. Just look at the RUC. 

Indignance makes one feel good and self righteous. It might muster political forces which might harness this to guess what...further their own self interest. Who can look out for the interest of patients best? Patients empowered with information, their own financial resources, and incentives to spend them wisely. I can be pretty certain they would NOT spend their own money the way it is being spent now. That should be reassuring.

The pitfalls of spoken communciations

In my most recent blog, I highlighted a recent piece in the BMJ addressing the use of CT angiograms in the diagnosis of pulmonay embolism. Beside the major point of the piece discussed in my previous blog piece,  I was really struck by one set of comments by Dr. Daniel Cornfeld, a radiology professor at Yale:

“We sometimes find small pulmonary embolisms in a very distant vessel,” he said. “Oftentimes, I’ll tell them on the phone that it’s probably not significant. This sort of discussion probably happens very frequently, but I don’t make it part of the report. But maybe that makes me part of the problem.”

This is not unique. Discussions regarding test interpretation happen all the time yet they their conclusions fail to make it into the medical record.  Better to not have documented such uncertainties. They just get in the way of making decisions quickly. There is also a legacy mindset regarding the most effective way to communicate with medical teammates.  I am often told, just pick up the phone and call. What could be wrong with this?

The health care delivery environment is increasingly complex with multiple team members. We recognize that communications is a key activity in delivery safe and effective health care, but our appreciation of what it takes to accomplish effective communication is superficial at best. So we are implored to just "call" our colleagues, much like Dr. Cornfeld at Yale. The question is, just what are we trying to communicate when we pick up the phone and call?  Furthermore, what part of that spoken communication should be converted to the written word?

Similar issues arise with other support services. Anatomic pathology comes to mind. Similar to radiology, pathology often works on informatics platforms in separate silos from the electronic health records in which the rest of the health system works. Diligent pathologist will often call with particular diagnostic information, and discuss cases with bedside clinicians. They then go on to record some but not all of the detail in their reports with the clinician who sent the specimen recording what they heard of the conversion in a separate electronic record. The two are almost never reconciled and may bear limited resemblance to whatever the original conversation contained.

At the heart of the problem of communication in health care lies ambiguity of roles. What is the role of the radiologist or the pathologist? Is it their job to simply look at the images or slides rendered? How much history should they have access to or be required to review? Is it their job to convey the test limitations to the bedside physician if they believe that individual does not sufficiently understand the limitations of the test as applied to a given patient or does this create to much of a conflict of interest. Clinicians do not want their pathologists or radiologists to waffle. Just give me the diagnosis....

Increasingly sensitive tests redefine what is pathologic

There is a story reported in the New York Times (NYT) today which picked up on a paper published out of Boston University in the British Medical Journal (BMJ) entitled: "When a test is too good: How CT pulmonary angiograms find pulmonary emboli that don't need to be found."

The story sounds familiar:
1. New technique or technology heralded for early discovery of disease
2. New technology deployed and used widely
3. Explosion of silent disease diagnosed
4. Claims of lives saved used to justify widespread use
5. Overall death rates remain unchanged

In this case, the technology is CT angiogram to diagnose pulmonary embolism and with the widespread use of this technology, many more emboli are found. However, the question arises whether treatment of what are generally small and localized pulmonary emboli (PE) makes any difference in outcomes. PE's are generally treated with a course of anticoagulants, agents which carry significant risks of bleeding. If treatment is instituted for a trivial embolism which had little risk of causing harm, the likelihood of harm from treatment may vastly outweigh the risk of the underlying disease.

I colleague of mine who I met at the Society for Improved Diagnosis in Medicine (SIDM) has recently published an iBook entitled "The science and art of medicine" (link). It is a masterful work which should be required reading for all those who order or do diagnostic tests. He presents a framework to understand why diagnostic tests MAY be useful, based upon Bayesian probabilities.  All tests are validated within particular contexts and are ultimately useful because they provide prognostic information regarding endpoints relevant to patients. Increasing sensitivity of diagnostic approaches does not always lead to better diagnostic acumen.

The general public tends to view diagnostic tests as very binary. In their minds the test either shows you have a disease state or not. Unfortunately, the same mindset is not so rare among practicing physicians. This is a problem and it is a problem which is aggravated by both financial incentives as well as heavy reliance of faulty heuristics and reliance of intuitive system one based decision making. Reflection and appreciation of nuance takes time and the desire to move rapidly through one's work results in quickly moving to framing decisions as all or nothing. Tests are viewed as either positive or negative with a positive test meaning the patients has the "disease".

As we begin to realize that we are making decisions based upon flawed tests and flawed assumptions, the timing could not be worse. Health care is being stretched by cost cutting, changing expectations of the public, and massive disruptions of workflow by deployments of electronic health records (EHR's). How do we provide feedback to our peers and choices to our patients in an environment which leaves little or no time for reflection and discussion?