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Thursday, February 27, 2014

Selling a product the public does not want

The American Academy of Pediatrics has come out with a position statement directing families away from the use of retail clinics ( "AAP statement). The policy statement was reported on widely in the lay press but the full report is published online in the Journal Pediatrics (which is behind a pay wall). In the official report, the authors highlight the points raised in the 2006 report where the AAP originally published a report in opposition to the use of retail clinics. They highlighted the following points to justify their opposition:
  • Fragmentation of care
  • Possible decreased quality of care
  • Provision of episodic care to children who have special needs and chronic diseases, who may not be readily identified
  • Lack of access to and maintenance of a complete, accessible, central health record that contains all pertinent patient information
  • Use of tests for the purpose of diagnosis without proper follow-up
  • Possible public health issues that could occur when patients who have infectious diseases are in a commercial, retail environment with little or no isolation (eg, fevers, rashes, mumps, measles,strep throat)
  • Seeing children who have “minor conditions,” as will often be the case in an RBC, is misleading and problematic. Many pediatricians use the opportunity of seeing the child for something minor to address other issues in the family, discuss any problems with obesity or mental health, catch up on immunizations, identify undetected illness, and continue strengthening the relationship with the child and family. Visits for acute illnesses are important and provide an opportunity to work with patients and families to deal with a variety of other issues.
Furthermore, additional criticism was leveled based upon the observation that retail clinics as presently deployed are not compatible with the medical home model of care delivery where the priorities are:

1. The patient should have an ongoing relationship with a personal physician trained to provide first contact,
continuous, and comprehensive care;
2. The personal physician should lead a team of professionals who collectively take responsibility for the ongoing care of the patient;
3. The personal physician should be responsible for all aspects of the patient’s care;
4. Care should be coordinated and integrated across all elements of the complex health care system; and
5. Care should be facilitated through registries, information technology, and health information exchange.

Contrast this with the list with the reasons for retail clinic use identified in a recent WSJ article shown below: 

"Retail clinics also are generally open seven days a week, don't require an appointment, accept more types of insurance than doctors do and charge 30% to 40% less for similar services, studies show. Costs vary widely by region and service offered, but getting a common ailment treated at a retail clinic, without insurance, typically runs between $50 and $75....
Studies show that people who use retail health clinics tend to be younger, healthier and more affluent than average. As many as 70% of parents who use them have a pediatrician but say they can't wait for an appointment or take time off work when the doctor's office is open, said Ateev Mehrotra, a policy analyst at RAND Corp., who has studied the clinics for years....
 "Some pediatric practices say they won't see you if you go to a retail clinic," he said. "And we've heard that some patents tell retail clinics, 'Please don't tell the pediatrician that I'm here.'  "

This is a typical example of the medical community having priorities which are different from the patient communities. The AAP espouses principles which their membership and leadership value. They just don't happen to be what their patients value quite as highly. The retail clinics offer what patients and their families value most; access, convenience, and value. Well over half of the reasons listed above relate to convenience. I also assume that the "Did not want to bother the pediatrician" means gong to the pediatric office is a hassle for all involved. We are well over 75% of the justifications are driven by convenience

The pediatric community has probably been better about dealing with access and convenience than most the medical community, but they still appear to place a higher value on a host of other priorities. Like the broader medical community, there is a drive to convince patients as to what they should want and some degree of indignance when patients come to different conclusions when they weigh their options. Where the pediatricians see they bring value to patients is quite different from where patients seem to see where they obtain value. 

The most recent report is not so unyielding in that it recognizes some potential role in partnering with retail clinics to provide urgent care when the pediatrician simply cannot accommodate. They still are highly protective of the role of pediatricians and how they add value to their patients: 

"In addition, there has been scope of care “creep” within the RBC setting, as these clinics now provide services such as childhood immunizations and “school and sports physicals.” These offerings impinge on core preventive care services of the pediatric medical home and are mis-perceived by patients and families as an appropriate substitute for regular preventive care within the medical home."

Patients and their families want what they want and when given the opportunity, they will almost always chose convenience and cost over almost everything else. I am not sure I can fault that decision. While this might not be the case for obvious serious illness requiring unique expertise and capabilities, for the most part patients will get the service they desire when they use a retail clinic. Scare tactics suggesting that there is a clinically significant risk of missing some hidden pathology are basically never accompanied by actual numbers demonstrating the significance of such a risk. The risk to the standard medical office business model is much more likely than the risk to patient health.

Better, faster, and cheaper will always prevail. Good enough, faster, cheaper will come out on top as well.

Sunday, February 23, 2014

Do you like surprises?

I sometimes wonder what the future will bring in terms of surprises. Specifically, I wonder about what we (I) am doing now which will be considered unacceptable and undesirable at some point in the future. At the same time, I also wonder about what is now considered unacceptable which will become mainstream in the not too distant future.

Two hundred years ago there were many practices and beliefs which were mainstream and strongly held which have now been jettisoned. The one that comes to mind is slavery of African Americans. Slavery was accepted for thousands of years and is likely still accepted in many parts of the world. However, over the span of approximately 200 years, the moral climate the western world rapidly evolved from one where slavery was an acceptable practice to one where it is universally deplored. Similarly, custom backed up by law was used for centuries to restrict the freedom and actions of people based upon their sex, religion, ethnic group, or status at birth. All of this was viewed as being perfectly acceptable within the cultures where it
occurred, until it was no longer viewed that way.

It can be viewed as something which is part of a broader set of events. The tendency for human cruelty, at least within public realms appears to have receded. Yes, I can still tune into broadcasts of ultimate fighting and fans still celebrate fights on the ice in hockey, but this sentiment gets less acceptance over time. Similarly, people and organizations which celebrate hate, violence, and intolerance now function primarily at the margins of our society.  This trend is not something which is universal in the world. It is more the exception rather than the rule. Slavery still exists. Surprisingly, the world is purportedly less violent than at any other point in human history (Violence Ted Talk). However,  it is till plenty violent. One can hope that the tendency toward less cruelty continues.

What are we doing now which we will look back on with with great remorse? In the medical world, our behavior in regards to informed consent as recently as 50 years ago was absolutely deplorable. I have written about the syphilis experiments at Tuskegee and Guatemala, studies which survived study section reviews. The medical community had great enthusiasm for eugenic thought (Cold Spring Harbor). We physicians perceived that since our intentions were good, we should be empowered to recommend and do almost anything without judgment. The explosion of information now available to the public regarding medical decisions and recommendations is disrupting this process and will shine lights on specific decisions and recommendations. Difficult questions will be raised and more than a little embarrassment will follow. Public trust will degrade even more and more time will be required to explain our recommendations.  We will likely stop doing certain interventions, I am not sure what they might be.I perhaps am as blind as anyone. I will be surprised.

The flip side to all of this is we can also anticipate that there are current unacceptable activities which will be viewed as perfectly reasonable in the future. Up until the very recent past, racial intermarriage and homosexuality were considered unacceptable and in many locales, illegal. What do now view as reprehensible and unacceptable behavior which will be viewed with a ho-hum in the next 50 years? I am not hedgehog. I readily admit that my predictions are likely to be off the mark.  I suspect that pot will be legal and widely available within the next 20 years. I also suspect that the acceptance of gay marriage will open a wider discussion regarding the institution of marriage. Polygamy will be the next issue raised and in the absence of any strong legal framework to continue this prohibition, it will fall. This will lead to havoc in the legal realm, trying to sort out benefits due to those who had some sort of marriage arrangement to some other party, separated by death or some other circumstance. The like the legal simplicity of heterosexual monogamous unions for the simple reason that this will be replaced with a host of potential relationships with daunting combinatorial math of possibilities. More surprises on the way.

Within the health care realm, new possibilities of acceptable options for how we behave and organize may take the form of new providers of health care services. Our present health care organizational structure is held in place by law preventing new entrants into the game. How long will this hold together? The fortress that is the state medical licensing barrier has shared only pieces of  the health care business to optometrists, chiropractors, nurse practitioners, physical therapists, podiatrists, psychologists, social workers, and other therapists who can operate autonomously or semi-autonomously. Physicians still use the power of law to prevent entry of others into the health care arena, ostensibly to protect the public. If history of change  is consistent over time, this structure will also be viewed as the norm until the day it is not. It is a matter of time. This should not surprise anyone.

Wednesday, February 12, 2014

Medical Partisanship

How much more study do we require to understand that there are things which cannot be known? In the British Journal of Medicine (BJM link), a twenty five year follow up of the Canadian Breast Screening Study again failed to show any benefit in the screened group. Gina Kolata followed up with a NYT piece today (Kolata). I doubt this work will sway anyone. We have left the realm of a world settled by data and entered into the realm of medical partisanship where belief trumps everything.

I became aware of the work of Dan M. Kahan who recently published a working paper as part of the Cultural Cognition Projection. In the paper, he published the results of a clever experiment (Motivated Numeracy and Enlightened Self-Government) where he looked at conclusions drawn from simple data in 2 x 2 tables. The same exact data when linked to non-controversial scenarios (response of a rash to treatment with a cream) yielded completely different conclusions from individuals as opposed to when these data were associated with partisan questions regarding gun control. When strong beliefs entered into the equation, objective assessment of the data disappears.

Within the medical world, we have developed a host of partisan issues and we would be well served to
recognize this. There is no reason to undertake expensive and difficult studies if there is no sense that anyone will be swayed by the results. The best study designs are created by specialists with training in statistics, clinical trials,  epidemiology. The individuals involved in these endeavors are not generally the constituencies who the data will be used to sway. Increasingly the data must convince the partisans. So here you have it. 25 years of study and basically no benefit in terms of mortality in women who have used mammography when compared to the non-mammography group.This is not sufficient to convince the true screening zealots.

Much like the last time such an article was published in NYT,  the letters displayed remarkable partisanship. For the true believers, particularly those in whom mammography found what was diagnosed as cancer, no contrary information will convince them that their lives were not saved. It may be that for a vanishing small group, their perception may represent the truth. The estimates are somewhere in the realm of 1-2 per thousand screened for 10 years may have their lives saved. It is worth it? It depends on how you look at the question, whether the resources spent were your own, and whether similar resources spent differently may have saved or enhanced more lives.

This does not need to be a controversy for a simple reason. Screening mammography is a relatively cheap tool. The roughly $100, which needs to be spent every two years,  represents about two tanks of gasoline or a fraction of a family grocery bill for one week. If patients were required to pay for this out of pocket, would a well informed consumer, given all of the data we know, view it as a good investment of their own money? One can ultimately feel as strongly about this issue as you desire, and this can be translated into action through the allocation of your own resources. Something cannot be that important if you cannot convince a patient to allocate $100 once every two years.

My guess is if patients had to buy this product using their personal resources, it would be a tough sell, given how convincing the data is. There are some patients who will purchase just because the activity resonates with them.  I am also sure that a shrewd marketing campaign might be successful in convincing at least some additional patients to partake, much in the same way that marketers cleverly use fear to sell or sorts of products, whether it be insurance, home security, or anything that can be dressed up as a solution to some sort of personal threat. Fear sells. However, there is a not so fine line where patient educational materials cross over into marketing materials, especially if the fear message is is heavy handed and not supported by data which shows your customers garner actual value from their investment.

There are literally millions of choices we can make relating to how we allocate our personal resources. How we make these decisions depends upon our own individual preferences and our individual resources. I think I am on safe ground to say that the case for screening mammography is not going to get any more conclusive and there is no good reason to try to force some sort of universal set of actions on the parties involved. My take on this and a host of other screening activities is many are a bad deal for me and for other patients. There are better ways for me to invest my time and money.

The mammography controversy screams out that current insurance system only makes this problem oodles worse. We need to figure out how to take whatever resources that now go to pay for these back in the hands of women who can decide if participation makes sense. If they elect to get screened, they are no worse off than they are now. If they elect not be screened, they can allocate those resources to something else they deem of greater value.  Good and smart people will make a variety of decisions, not all of which all members of the medical community will agree with. Many women will continue to chose to be be screened. Many will not. It is not entirely clear what the best decision should be and we will likely never know that answer.  One size does not fit all.

Sunday, February 9, 2014

Difficult choices

Physicians were heartened by the proposed budget deal to address the festering wound which is the SGR fix. Yes, good news. However, the path to gaining control of health care spending always must always involve one specific outcome... spend less. The disagreements are always regarding the how that comes about. The CBO report ( addresses these issues, some in detail, and some in broad terms. From the report:
Most of the 16 options in this report would either decrease federal spending on health programs or increase revenues (or equivalently, reduce tax expenditures) as a result of changes in tax provisions related to health care. Some options would result in a reallocation of health care spending—from the federal government to businesses, households, or state governments, for example—and most would give parties other than the federal government stronger incentives to control costs while exposing them to more financial risk.
Eleven of the options are similar in scope to those in CBO’s previous volumes of budget options. For each of those options, the text provides background information, describes the possible policy change or changes, presents the estimated effects on spending or revenues, and summarizes arguments for and against the changes. The other five options—Options 1, 6, 7, 10, and 15—address broad approaches to changing federal health care policy, all of which would offer lawmakers a variety of alternative ways to alter current law.

Note that items 1,6,7,10,and 15 make up the bulk of the savings and although they do not specifically state this in the executive summary (I have not had a chance to read the entire report in detail), I also suspect these items make up the bulk of the ongoing savings beyond 2023. Recommendation #1, imposing caps on Federal Medicaid spending, is a recommendation which could not be any less timely. States have been hesitant to expand Medicaid because of their concerns about sustainability. Their concerns were focused on what would happen three years from now when the Federal payments promises would need to be renegotiated. This has been countered by the argument that the Feds are picking up the tab.  The frequently wrong but never in doubt crowd suggested that no one in their right mind would turn down free money.

It seems that the concerns perhaps are warranted and perhaps they will come into play before that three year window. The CBO is suggesting this be rethought just as the Medicaid expansion is only staring! This will be a huge issue and one can figure the way Congress deals with this is to push the real savings out until a different election cycle. Any way ones looks at this and depending upon how the Medicaid caps are imposed, there is a big chunk of change involved ($600 billion). If no savings are garnered from capping Medicaid expansion,  it has to come from somewhere else if the bill is to work. Look for creative accounting solutions which might be considered fraud if done in the private sector.

The additional items (6, 7, 10, 15) all address cost control as noted above by
...reallocation of health care spending—from the federal government to businesses, households, or state governments, for example—and most would give parties other than the federal government stronger incentives to control costs while exposing them to more financial risk."
These will all be very politically unpopular because they do exactly what needs to be done. Health care spending is out of control because we have created financial tools which induce the public to consume more health care than they would if they had to assume even close to the cost of what they are consuming. If Medicare beneficiaries got actual cash money from the Federal government to purchase insurance, they would over time become more prudent as to what they purchased. Similarly, if the Medigap coverage was throttled back, Medicare beneficiaries would become more aware of the costs of what they are consuming.
The same goes for reducing the tax preferences for employer based health insurance (#15). It is almost universally recognized that most of subsidies go to waste. The tax preferences afforded to health care benefits have resulted primarily in increased cost over time with little or no increase in value.

No significant cost controls will come about until the consumer has skin in the game. All the big numbers in this table assembled by the CBO focus on this aspect of the problem. However, this is politically untenable. There is still the widely held belief that people can be insulated from the cost of health care and not be affected in terms of their consumption patterns. It is simply wrong. Structure insurance to provide discounted prices through subsidies and it should be no surprise that one drives consumption through the roof and simultaneously perverts the pricing mechanism. No headway can be made on this until the underlying financial drivers are addressed. Anything which purports otherwise is simply wishful thinking.