Price transparency and the rebar steel of health care

A colleague of mine sent me a link to a NY Times piece;

Bringing Comparison Shopping to the Doctor’s Office
By CLAIRE CAIN MILLER
Published: June 10, 2010

http://www.nytimes.com/2010/06/11/technology/11cost.html?hpw

It highlights some important steps on the road to price transparency. However, the final line contains a telling statement which reveals just how naive the author is.

At this stage, Castlight works best for big companies that are self-insured and for outpatient doctor visits for which quality does not vary greatly.

It makes sense that shopping on the basis of price is most applicable to the realm of medicine in which patients have the most time to look for what they want and look for deals. However, to state that quality in the ambulatory medical world does not vary is hard to fathom. A more accurate assessment is that quality in the ambulatory world is not consistently measured. Castlight appears to recognize this fact since earlier in the article it is note:

Castlight plans to add quality measurements to its price information. There are already several providers of that information, though there is no standard set of quality measurements in medicine. 

This again reminds me Clayton Christensen's analysis of the entry of the mini-mills into the steel industry. They entered the markets by making rebar steel where they could compete purely on the basis of price. No one cared that the steel made was of poor quality since there were basically no specifications, no one was equipped to measure quality, and the product was buried in concrete to top all things off.

In the ambulatory medicine world, what measures that exist are at best  poor proxies for something else desirable. Few patients would recognize that these quality metrics bring any real value to them as well for the simple reason that the links to them personally are tenuous at best. Many patients may need to be treated for many years for a few to actually benefit.  Measures of immediate and consistent impact would require validated measures of diagnostic accuracy and the ability to measure whether medical encounters actually solved problems. At this point in time ambulatory measures focus on surrogate markers such as blood pressure, hemoglobin A1c, and vaccination rates. These are perhaps great interventions to decrease the rates of illnesses at some future point in time. How about measures which assess how well we are doing in alleviating problems in the here an now? They basically don't exist.

The product of this situation is starkly simple. What cannot be measured is basically ignored.  Ambulatory medicine is the rebar steel of health care. The quality of ambulatory medicine varies hugely. You can make a lot of money in the ambulatory realm. It requires volume and no particular keen eye toward quality. Make it by the ton, price it to sell,  and as long as no one can measure specifications, your business model will be robust.

The power of unfocused data collection

One of the most frustrating elements of practicing medicine is the how often I am required to admit that I don't know. In particular, I am most frustrated when a reasonable and intelligent patient poses a logical question regarding the natural history of some common disease and I must reply by saying we simply don't have good information to address such a question.

Much of the data on frequency of disease, particularly in ambulatory contexts, comes from administrative and billing databases. They were not set up to be used to study disease frequency but mostly to track the collection of money. We are fortunate that someone decided to add a few additional data fields for whatever reason. They are limited since the diagnostic data and classification schemes used are very flawed.

There are many additional examples of how broad collection of data or samples resulted in huge dividends years later in realms that could never have been anticipated when the collections were started. Serum and tissue banks historically were initiated for essentially open ended purposes. When new pandemics erupted such as HIV presented, serum banks were used to look for where the disease originated. When new models of disease pathophysiology are considered, tissues banked for other purposes allows for rapid testing of hypotheses.

The same applies to data collection. Perhaps no other entity embodies this better than Google. They are data hoarders like no other. They do not make decisions regarding what they save. When the time comes to look at an interesting question, they do not worry about whether they  saved the relevant data. They simply save everything. Last year an article was published in Nature describing how by simply looking at Google cold and flu queries they could demonstrate where influenza outbreaks were occurring, well before the CDC tracking system identified these peaks.

Within the world of clinical research, we have good news and bad news. The good news is we have data collection and analysis tools which make things possible which were simply not possible before. The bad news is what we are called upon to do before we can deploy them. Because of privacy concerns, we are now asked to define what information we want to collect and why. I would argue that if we have learned anything in the recent past it is that we cannot anticipate what element of what we collect (whether data or samples) will be of most value and the best collection strategy is to collect as much as possible. Key breakthroughs in understanding may simply happen as much through chance as anything else. Chance favors the prepared and in the world of data, being prepared means you have collected the data.

Conspiracy of silence

I always enjoy the Sunday posting from the MD Whisteblower.  Today, he wrote a piece on unnecessary medical testing, particularly issues revolving around referrals for imaging and diagnostic procedures. He describes a particular scenario where a patient presented with minor rectal bleeding :

I have never liked serving as a technician gastroenterologist, but I am often asked to do so. Like every other gastroenterologist, I have performed requested procedures that were reasonable, but that I would not have personally recommended if my advice had been sought. The patient referenced at the top of this post was in a different category. This was not a 'gray area' issue.

This particular patient was having some minor rectal bleeding. He had already had the pleasure of a full colonoscopy this past November, when hemorrhoids were discovered. No additional testing was necessary for the current minor bleeding, as hemorrhoids were the likely culprit. The request for an EGD was nonsensical. The ordering physician had no economic conflict of interest in ordering the test; only the gastroenterologist would benefit financially. An EGD here was like ordering a foot x-ray on a patient with a sore throat.

This scenario raises so many questions it is hard to know where to start. The major questions that come to mind are:


1. Who do you work for in this circumstance?  
2. What job were you hired to do?  


Until it is clear what the answers are to these questions, all other discussion are essentially moot. Let us address the first question. Most economic transactions are fairly straight forward since there are generally two parties, a buyer and a seller. There may be a broker who facilitates the transaction but it generally pretty clear who the principal parties are. In a health care transactions such as described by the MD Whistleblower are extremely common and in my estimation the problem is the confusion relating to these two questions.


For a specialist who is dependent upon referrals, it is pretty clear that they are more beholden to their referring docs than to the patients who are referred. How else could you justify actually doing the equivalent of  a foot x-ray on someone with a sore throat. Because of the financial structures which have evolved in medicine, physicians are only marginally beholden to patients with some specialties essentially not beholden at all. 


The second question is inextricably linked to the answer of the first. If any given physician who has been pulled into the care of a specific patient is primarily working for someone other than the patient, the job they are hired to do may or may not actually provide any value to the patient. In the scenario described in this particular blog, the job the MD Whistleblower was hired to do was to reduce the exposure of the primary care MD to the legal risk of failure to diagnose. In this case there essentially no potential value to the patient. This unfortunately placed the consulting MD in a precarious position of either being a true advocate for the patient by revealing the absurdity of the consultation  and alienating his employer (referring MD) or continuing to play the game. 

I do not mean to pick on the GI field. The MD Whistleblower simply described a great scenario to use as a springboard. The same game happens ever day in other specialties. Overwhelmed primary care MDs send consult missiles to get patients out of their offices and relieve themselves of the responsibility of explaining the nuances of risk and the ability of testing to predict risks. Technically focused specialists are most highly rewarded for maintaining a state of blissful unawareness of anything that might prompt them to stop and convince patients that they do not need that EGD, CAT scan, skin biopsy, or cardiac catheterization.  

I believe the only way out of the quandary is to educate patients to ask these two basic questions whenever they have encounters with physicians. The answer to the first question will invariably that the MD claim he (she) has been hired by the patient. It might not be entirely true, but it will at least serve as a reminder how it should work. The answer to the second question is where things will get interesting. I can imagine the the conversation regarding the scenario described above with a patient who has been educated to ask the right questions.

Patient: What job am I hiring you to do?

Doctor: Your primary care MD referred you to me to do an EGD.

Patient: Why will this be useful to me?

Doctor: It might find an  undefined source of blood loss?

Patient: How likely is that to be the case?

Doctor: Vanishing small to non-existent. I will be happy to comply with your doctor's request. Is this what  you want me to do?

I can also imagine the more likely conversation going like this:

Patient: I had some minor bleeding and my doctor sent me for this test?

Doctor: Yes I know. Here sign this consent for the EGD. 

Patient: Can I really die from this test? 

Doctor: Not really, legal makes us include this language

What it boils down to is uninformed patients will always be prey. We would like to believe that the medical profession will be driven by altruism primarily. As much as it hurts me to admit this, there are cultural elements which permeate the business of medicine that most closely resemble cultural elements more commonly associated with used car sales. We are not going to change human nature and the best defense for dealing with this is informed consumers.

Dealing with complex new technologies

Kenneth Rogoff's piece in Project syndicate is very provocative.
http://www.project-syndicate.org/commentary/rogoff69/English

In this piece, he identifies that the gulf oil spill underscores a much more universal issue:

The disaster, however, poses a much deeper challenge to how modern societies deal with regulating complex technologies. The accelerating speed of innovation seems to be outstripping government regulators’ capacity to deal with risks, much less anticipate them.

This issue is not limited to drilling for oil. It basically touches upon every aspect of a rapidly changing human existence where change is driven by leveraging technological progress. Every technology deployed to improve human existence has been accompanied by risk and trade offs. The harnessing of fire was one of the most monumental technological achievements  in all of human history. We are still dealing imperfectly with its risks.

It is easy to toggle between health care and non-health care worlds when reflecting upon upon positive and negative impacts of technology and innovation. Petrochemical based energy has been the engine which has released vast portions of humankind from the bondage of existences which are brutish and brief. In some respects, the present oil disaster can be likened to the rare horrible reactions to a miracle drugs such as drugs used to treat HIV. Should we ban abacavir since it can cause devastating and life threatening allergic reactions even when the number of people whose lives are saved vastly outweighs the rare and devastating impact of idiosyncratic reaction?

Within medicine, a dizzying array of technologies have been deployed within the past 100 years. When the risks of everyday life were so common that no one was particularly surprised when would randomly strike down healthy persons, risks of deploying innovative approaches to the treatment of life threatening illness was a no brainer. However, as we have decreased the risks of everyday life, we have also simultaneous altered expectations as to the promise of innovation and the benignity of its deployment.

Deployment of technologies sufficiently powerful to make a meaningful impact on human existence will always  be associated with risk. We will never be able to define rational policies and approaches to managing the risks until we recognize that there will always be trade offs and appreciate and understand both the quantitative  and emotional elements.

Even more gaming...

I love following Art Diamond's blogs. He always seems to find such interesting stories.

http://www.artdiamondblog.com/archives/2010/05/_a_space_heater.html

The lesson is again, more rules means more opportunities to game the rules. When the personal gaming opportunities outweigh the accrued costs to the many, time to rethink the rules.

Is the practice of medicine best done as an individual or group activity

I am reading David Sloan Wilson's "Evolution for Everyone". I first heard of him through a lecture I found on iTunes University which prompted me to buy his book. It is well worth reading. One of the basic tenants of the book is that one of the key developments in human evolution was the development of tools which furthered human cooperation. These included both physical traits such as highly visible eyes with stark contrast between iris and sclera, personality traits, and cultural norms which favor group v. personal accomplishments.

I happen to practice medicine in an academic health care setting. Academic success and promotion are predicated almost exclusively upon personal accomplishments. The hard currencies recognition are "my papers' or "my grants". Outside of scholarly activities, the clinical metrics are also very individually based. The sad truth in the clinical realm is that clinical excellence simply does not exist by any measurable metric. Yes, when the president of the University has a friend or family member who needs the best care, everyone knows who they should see, likely a solid if not stellar clinician not otherwise recognized. Those within the clinical realm are otherwise recognized by individual metrics of gross billings or RVUs. There are not other measurements which might assess how well they facilitate the functioning of those around them.

The model is pretty clear. Measure and reward on the basis of individual accomplishment and hope that this translates into success at the level of the group. This is simply wishful thinking. As David Sloan Wilson points out, virtually all moral codes throughout the world are successful because they value behaviors which further the ends of groups as opposed to individuals.  In particular, physicians view themselves as a world apart. We attempt to select for extraordinary intellect and assumes that this will translate into some sort of higher moral judgement. However, the feedback on the individual metrics is persistent and consistent while the feedback on the group success is virtually non-existent.

In my environment, at least I am surrounded by colleagues and trainees, although not always when I may benefit from their insights and input. When evaluating a patient in a time constrained context,  inputs from other physicians, trainees, and staff would likely improve the quality of diagnostic assessments. In very elegant studies of group v. individual decision making using a "twenty question" model of analysis, he found that stellar individual performers almost never translated into outstanding group performance. Furthermore, those participating as individuals found it less gratifying than those participating in groups. Yet, I see the practice of medicine as increasingly being practiced in isolated ambulatory settings as solitary endeavors, whose success is measured by tabulation of measurable but irrelevant metrics.

Einstein is to have said that:

If I had an hour to solve a problem and my life depended on it
I would use the first 55 minutes to formulate the right question
because as soon as I have identified the right question
I can solve the problem in less than five minute

 Humans as a whole have triumphed because we have acquired the tools and inclination for cooperative activities. Within medicine, we have adopted a culture and metrics which value and overwhelmingly reward individual accomplishments which further individual ends alone, many of which are irrelevant or destructive to success of the whole. We in academic medicine who have been placed in the position of training future clinicians and scientists and modeling behaviors they can and should emulate. I maintain that we are making a fundamental error by doing this within a culture which explicitly values individual achievement and self promotion above everything else.

The immediate effects of health care reform

This could be a very short blog. Health care reform passed and we are simply waiting for something to happen. Nothing substantial has happened yet. We are anxiously waiting to see if the SGR fix goes through and concerned about the effects if we see a 21% hit on MD payments from Medicare. Such a cut will be impactful to say the least. However, this has little to do with the Patient Protection and Affordable Care Act of 2010. According to Wikipedia, the following elements went into effect immediately after President Obama signed the bill:

The Food and Drug Administration is now authorized to approve generic versions of biologic drugs and grant biologics manufacturers 12 years of exclusive use before generics can be developed.^[30] 

The Medicaid drug rebate for brand name drugs is increased to 23.1% (except the rebate for clotting factors and drugs approved exclusively for pediatric use increases to 17.1%), and the rebate is extended to Medicaid managed care plans; the Medicaid rebate for non-innovator, multiple source drugs is increased to 13% of average manufacturer price.^[30] 

Support Comparative Effectiveness research by establishing a non-profit Patient-Centered Outcomes Research Institute.^[30] 

Creation of task forces on Preventive Services and Community Preventive Services to develop, update, and disseminate evidenced-based recommendations on the use of clinical and community prevention services.^[30]

The Indian Health Care Improvement Act is reauthorized and amended.^[30]

What has the average American noticed thus far? Absolutely nothing! When will the average Joe or Jane actually notice something which is a direct consequence of the legislation? That is not clear to me. There are a few stipulations which will be enacted over the next year which will require insurers to spend 85% of premium dollars on actual "health care", a completely unenforceable requirement since no one can really define what that is. Insurers are already hard at work redefining what this actually means and you can be assured that legions of nurses and doctors on the insurers payroll will have their tasks redefined from the administrative to care realms. When these are enacted, what will we notice? Not much I suspect.

Most of the meaty elements of the bill do not go into effect until 2014 and many do go into effect until 2017 or 2018, The pundits are debating in earnest what the effects of this bill will be. They can only guess and the sad truth is there is no way that we can ever determine whether events happening a decade from today (positive or negative) will be linked causally to the legislation drafted and passed this year. We cannot hold anyone or anything accountable when the actions and the consequences are separated by such a time span.

I understand why we have a fascination with sports, games, and music. I can go to a golf driving range and get a bucket of balls to hit. I may be dismal but I can get immediate feedback from making adjustments and trying again. I know when I am doing things right and when I have it all wrong and I know it almost immediately. The same is true of playing a musical instrument or playing video games. We are wired to respond to feedback and to understand these feedback time frames. If we do something which does not further our ends, we quickly realize this and generally cease activities which do not accomplish our goals. This is particularly true if the actions result in harm or physical discomfort.

If the feedback time frame is delayed, many humans get into trouble. The most obvious examples are those involving addictive substances or behaviors. The immediate effects may be pleasant and the dire consequences delayed days, weeks, or years. This is a recipe for disaster. When the timeline for assessing consequences of legislative and legal interventions extends to generations, we are essentially toast. I have my doubts that the current health care legislation will accomplish anything it has set out to do. By the time that the key provisions are actually enacted and sufficient time has passed to make an assessment of actual success or failure, we will have forgotten why various provisions were enacted and likely have modified many elements based upon political expediency. We will have no reference points, no control groups, and those in power will share scant resemblance to those who passed the legislation in the first place.

A major problem with entrusting political entities with solving problems is that the feedback loops involved are so dismal. It is not like shooting a basketball or playing the piano where you know you have missed the foul shot or hit the wrong keys. When political entities effect changes, we virtually never know if we got it right. There are no gold standards and the time frames required to assess the wisdom of interventions is beyond even the most focused and enlightened human attention span. Present decisions are virtually always driven by short term political expediency.If present decisions, driven by such short term motivations, happen to be wise long term interventions, it is simply dumb luck. The question arises.. Why entrust entities and institutions which are inherently unaccountable with such responsibility?