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Thursday, December 16, 2010

When do we get our free preventive health care?

One of the most exasperating things about the Affordable Care Act (otherwise known as health care reform) is the fact that its many provisions don’t just start immediately, but rather are phased in over a really long period and at seemingly random intervals.

As a physician, I often hear my insured patients say things like “I can’t afford a colonoscopy right now” or “how much will a mammogram cost me?” I tell them that with the health care reform legislation they won’t have to pay for either one of these things. Unfortunately, my response has been a misleading oversimplification.

It is true that one of the most welcome parts of the Affordable Care Act is that recommended preventive care services will be paid for in full, without co-pays or cost sharing. But when?

Medicare and Medicaid programs will begin covering preventive care services at 100% on January 1, 2011. The services included are at this link:

Private insurance companies have a year from the passage of the law to comply with this provision. So if you are privately insured, you may need to wait for several more months.

But what about the people who are told by their insurance companies, that, no, they don’t have coverage for colonoscopies or pap smears or flu shots or smoking cessation counseling or any of that stuff? Doesn’t the law apply to everybody?

Because the health care reform law had to allow people to keep the insurance coverage they had if they wanted to keep it, certain policies are “grandfathered” so that they remain the same as they were at or prior to March 14, 2010. Any insurance policy that a person maintains continuously, that doesn’t change its provisions in any significant way, can continue to not provide fully covered preventive care services. If the policy changes its coverage limits or the services it covers, that policy is no longer grandfathered and must fully comply with the law.

Most of the other provisions of the health care reform package do apply to these grandfathered policies, except for the fact that an individually insured person who was not covered for a pre-existing condition that was excluded will remain that way, and that there may not be full coverage for visits to pediatricians or gynecologists.

Why would a person want to stay insured under one of these grandfathered policies? Probably because the private health insurance companies are at this point doing their very best to increase the prices on new policies before many of the other provisions of the act go into effect in 2014 and thus the cost of the newly created policies that conform to the new law is pretty steep, in many instances. Private health insurance is presently going from wickedly expensive to unaffordable for many Americans. Keeping one’s old policy, even with nasty rate hikes may be the only option many people see open to them.

Why do health insurance companies not voluntarily cover preventive services? Surely it saves them money to prevent rather than treat disease. Unfortunately that is not always true. If all women received mammogram screening at recommended intervals, the cost per year of life saved would be 40-50,000 dollars. If a person doesn’t receive timely screening, the breast cancer that results might be expensive to treat, but that will be offset by the many women who never had mammograms. In addition, some people who are not screened for disease die quickly and relatively inexpensively. Those who survive will likely be costlier to treat in the future. It is not in the best interest of an insurance company whose motive is profit to aggressively screen for most diseases.

Monday, November 29, 2010

Marijuana, Darvocet, Colchicine and the ineffective politics of medicine

The Food and Drug Administration (FDA) has made two bold steps in the last month. They have asked the manufacturers of pain medications containing the mild opiate propoxyphene (Darvon) to voluntarily take these products off the market, and they have removed from the market all generic forms of the drug colchicine that is used to treat gout.

Initially, this all seems ridiculous. Both of these drugs are nearly ancient, with a track record of successes, failures and side effects that goes back decades.  On further examination, it still seems pretty stupid, though quite a bit more complex.

Thursday, November 18, 2010

The sky is falling! Medicare payments to physicians will be cut by 24.9% on December 1, 2010!

Since Medicare, the single payer health insurance program for citizens age 65 and over, was signed into law in 1965, medical care for seniors has become more universally available and increasingly expensive. Since Medicare insurance looked to doctors and senior citizens like a blank check, services offered to older Americans rapidly expanded as did their unit cost and consumption of those services. The American government has tried various schemes for reining in spending, none of which have been popular or effective. In 1998, we decided to try the "sustainable growth rate" formula to control costs. Under that law, Medicare expenses were allowed to rise a certain amount, that which was considered to be a sustainable amount, based on inflation and other costs, and if those costs rose by more than the target, reimbursement for services under medicare would be reduced for the next year to an extent that the target of reasonable cost increases could be reached.

In 2002, Medicare payments were reduced by 4.8%, meaning that doctors who treated medicare patients, patients who already paid less than most patients insured privately, received a pay cut relative to the previous year. Many doctors decided that they could no longer accept Medicare insurance, and stopped seeing patients whose only insurance was Medicare. This was an ugly scene, with unhappy doctors and unhappy seniors.  After that time, each year's Medicare expenses have exceeded targets and congress has stepped in at the last minute and staved off cuts to Medicare reimbursement. Each year that the cuts are delayed, they are added to the next years planned cuts. Now, by the sustainable growth rate formula, doctors' reimbursements for treating Medicare patients are slated to go down 24.9% by December 1st.

Doctors are wringing their hands, sending letters to their patients and predicting terrible outcomes for the care of seniors. They are also expecting, once again, that congress will step in and avert this crisis. And of course we will be saved again from this cut because the cut is now unimaginably huge. Congress has promised a fix to the sustainable growth rate formula, because this last minute reprieve thing has gotten ridiculous and is a colossal waste of time and effort. But the problem is not the SGR, but rather that providers of care for patients with Medicare do nothing substantial, year after year, to control costs.

Oooh. Saying that could really get me in trouble with my doctor friends.Why, they might ask, is it up to us, who work so hard for such small reimbursement, to reduce Medicare costs? The answer is that nobody else appears to know how to do it, that we have a major stake in making sure that this system works, and that we have large organizations such as the AMA which have the manpower, political clout and most importantly knowledge of the situation to do the job. Congress doesn't know how to do it. They aren't medical. Patients can't do it. It's really up to us.

Where, then, is the waste? Won't we have to deny care to people who need and deserve it in order to cut Medicare costs? Absolutely not. We do so much in medicine that is unnecessary, from CAT scans that are not indicated, to surgeries that don't help, to high tech care at the end of life that was never what the patient wanted, that cutting even a fraction of it would be adequate to balance the budget. Many of the small projects funded by the health care reform bill will help, but the process is by no means on autopilot.

Yesterday I received in the mail the summary of Medicare benefits for my father in law who died in a local nursing home of pneumonia this summer at the age of 90. Both he and my mother in law had become demented, him from multiple strokes and her from Alzheimer's disease. They were at a nursing home where the care is excellent and where they know both me and my husband well. So when I saw that he had been charged over 200 dollars a day for "oral function therapy" which I have determined consisted of having a therapist coach him on eating, I was surprised and disappointed. In the bill I saw, he had charges for this and for speech and hearing therapy which over the course of 2 weeks during which he was mainly doing the work of dying, added up to over $2600. It is, of course, hard to interpret these bills, but it looks like Medicare shelled out something over $1000 for these therapies. That's a lot of money. But multiplied by the over 1.4 million people in nursing homes in the US, it starts to be real money, to the tune of $1.4 billion dollars a year. This particular item is only a tiny issue compared to all of the other nursing home related waste, and nursing home related waste is a mere speck on the horizon of total Medicare waste. The total budget for Medicare in 2010 is about 380 billion dollars, and it really looks to me like cutting 25% of this would not be hard, if we paid attention.

The question that is left for me at this point is what to do about this specific bill. I am in the same situation as many people who get billing statements from insurance companies. The amount that the insurance company leaves for the consumer is pretty small, and I'm tempted to just leave the whole thing alone, after notifying everyone at the nursing home and everyone who is a doctor who will listen exactly what these therapies end up costing.  If I call a fraud and abuse hotline at Medicare, they might come down hard on a nursing home that I think is excellent, and the real problem, which is that this sort of thing is going on everywhere, will go unaddressed.  If it was my nickel, I would never let something like this go. With an insurance company acting as an intermediary, though, the motivation for an individual, who actually knows the value of the service being given, to make the kind of fuss it takes to reduce costs, is limited.

Monday, November 1, 2010

Health Insurance Premiums go up, again

A year ago I decided to shed my company health plan and buy an individual plan with a high deductible for my family. The cost of my employer plan had reached nearly $900 for my family of 4 who never use health insurance, and the deductible was $1000, which meant that any care we have received in the last 10 years would have been unreimbursed. I found a plan with a deductible of $7000, which I could combine with a Health Savings Account for $481 a month. How clever, I thought. I have really bucked this system!

I just got my bill for the health insurance plan that Premera Blue Cross decided to provide for me in place of the plan that I signed up for a year ago. A few weeks ago I had received a glossy color sheet describing how my plan was changing, due to health care reform. My new plan would cover all health maintenance with no charge to me out of pocket, but would no longer have any coverage for various alternative medical services or eye care services. The overall deductible would be the same.

How much, you may ask, is this new plan that sucks marginally more than my previous plan? It is now about $630 bucks a month, a 30% increase over last year (with no dental coverage). As far as I could tell, there is no cheaper, crappier plan available to me. I will just have to suck it up and pay the extra nearly $2000 a year for my really truly catastrophic coverage. This will, of course, cover my deductibles on preventive services, which might have added up to as much as $200 a year with the previous plan. These figures are lower than many Americans’ since our family has no medical problems and our state has some of the cheapest medical costs in the country.

The Seattle Post Intelligencer reports that Regence has raised rates in the double digits for 4 years in a row, on average 91% since 2007. They have a nearly 1 billion dollar surplus, which increased 12% in the last year. Provisions of the health care reform bill will make health insurance more competitive, but not until 2014. That is plenty of time for insurance rates to double and then some.

Most people are in exactly the same situation that I am in, or worse, no matter whether they are insured by their employer, by the military or by the government through medicare or medicaid. To some extent, everyone has a bite taken out of their overall income due to the cost of insuring for health care. The cost of health care itself continues to rise, but much more steeply because health insurance companies continue to pay for these expenses, make the billing for them more difficult and therefore more costly, and hand all of those costs over to the consumers of health insurance with a hefty and increasing markup.

What shall we do, then? I do hope we all become uncomfortable enough with the status quo that we begin to calculate the true cost of a good health care system and re-evaluate what place our present third party payment system should have in it. Negotiating payment for the services that we as individuals or communities need and buying those services would take a great deal of cooperation between providers and consumers, but could radically reduce our dependence on health insurance companies.

An example of paying for expensive services in a proactive way is our local air ambulance service. We are a rural area and many serious injuries or cardiac emergencies are treated in our nearest big city which is 90 miles away. Sick patients are transported by Northwest Medstar to Spokane by helicopter or fixed wing plane, at a cost of over $20,000 per ride. Blue Cross will pay 30% of this if they even agree that the transport was necessary. For $59 a year, a person can buy a “membership” to Medstar which covers any air transportation needs. This is not charity, but simply a calculation by medstar of what it costs to support their services.

There are no other alternatives to our present insurance coverage that are available to me and my family at this point that are not either irresponsible or more expensive. I will continue to push for a community sponsored alternative to health insurance. Our hospital could make this happen if there was adequate cooperation from the doctor groups in town. Even without that, we could do a smaller pilot project to provide primary care, lab, hospital and imaging services. The incentive to do something like this will continue to increase as premiums rise. Interest in this has been high with our hospital’s administration and regardless of tomorrow’s election outcomes, I expect to see creative grass roots alternatives to our present third party payment system.

Sunday, October 17, 2010

The Physical Exam

The New York Times has taken note of Abraham Verghese's efforts at Stanford University School of Medicine to revive the art of examining patients. One gets the idea in this article that most medical schools have let the entire subject slide, which is not true. Nevertheless, enthusiasm for the hands on aspect of data gathering has declined somewhat. When I was in training about 25 years ago, my clinical teachers took the subject of teaching us how to identify pathology in a patient seriously. Johns Hopkins medical school was at that time held up as a model of a clinical teaching institution, so training medical students and residents in the arts of examining hearts, blood vessels, livers, spleens, bones and joints was clearly going to be part of the curriculum. Many patients who moved through the clinics and hospitals associated with Johns Hopkins donated important pieces of their time and dignity in the service of teaching what would be generations of physicians how best to do this. When I finished my training, I felt confident enough to continue to teach myself these skills as I treated and examined 10s of thousands more patients.

The perceived value of the physical exam, however, has taken many hits in the years since I graduated.  Well known and oft quoted studies showed that even specialists in liver disease could not tell the difference between belly fat and fluid in the abdomen, that cardiologists couldn't agree on the identity of the many heart sounds associated with failing hearts and valves, and gynecologists were unable to identify ovarian cancers by physical exam at a stage when it had an impact on survival. Many doctors began to back off on the level of intensity of their examinations, partly because they were not entirely sure whether they believed what they saw, felt or heard in a patient's body. Technology such as CT scans, MRI scans, x-rays, ultrasounds and mammograms became much more universally available, and we began to rely on them more. Very little was said about the fact that these, too, are inaccurate in many cases, and only now are we beginning to recognize the fact that both the radiation and the costs associated with these tests carry a significant toxicity.

A good examination takes some time. It doesn't necessarily take much time, but in the hands of a doctor who is not comfortable performing it, the choreography is tricky. In large practices where doctors are expected to see patients at 10 or 15 minute intervals, there is not enough time to have a patient undress and be examine, document the findings, order the appropriate tests and prescribe the appropriate medications, especially if the physician is expected to actually speak to the patient about what is going on.

Teaching the physical exam is part of the art of medicine. Over the years that a doctor practices, he or she will see many presentations of many diseases and develop theories about what findings are indicative of things such as prognosis, response to treatment and subtleties of diagnosis that were never a part of their training. If that physician has an opportunity to teach, these pieces of knowledge will be passed on to students who will further cultivate it based on their experiences. Many of the "clinical pearls" that are developed in this way can never be scientifically tested, but will have immeasurable value.

Much of the information I get from examining a patient, looking in mouths, listening to hearts and lungs, feeling thyroids and lymph nodes, doesn't influence my diagnosis or treatment of a patient, except due to lack of unexpected findings. As a betting person, since the majority of physical exams are normal, I might choose to simply not do them, and assume that they are normal. It would save a lot of time. But without a physical exam, the two of us, me and the patient in the room, are just talking heads, telling interesting stories. Humans are made multisensory creatures, and our communications are best when they include all of our senses. Even the crudest of my senses, my nose, tells me information that is valuable. The touch of hands to skin is a communication that involves two, and the information flows both ways. A patient can sense my confidence, empathy, skill or lack of it. Facial or body movement in response to my hands tell me what kind of problem, how serious and how the person being examined handles illness.

I appreciate the fact that Dr. Verghese is tackling our lack of enthusiasm for the physical exam, bringing his obvious joy in the subject together with his charismatic teaching style to get a new generation of doctors excited about what they can do with their own hands, ears, eyes and noses. Those of them that teach will undoubtedly allow his gift to keep on giving.

This is a link to the article on Dr. Verghese in the New York Times:

Tuesday, October 12, 2010

What now? What must we Champions of Medicine do, other than not spend $5000 to attend Newt Gingrich's party?

Quite a number of perfectly adequate and hard working doctors have been invited to go to Washington to dine with Newt Gingrich. Most of us have decided not to go, though the tenderloin did sound tempting. But now that we aren't going, and health care reform is most likely a done deal, what is left for us to do? We are the Champions of Medicine, so are we just supposed to throw our capes over our shoulders and ride off on our white horses? "My job here is done..." I will say, as the music starts and the credits begin to roll.

Despite our hard work over the last harrowing year, there are still some problems with the American Health Care System, as it is sometimes called. It is too expensive, costs are rising and people are suffering because they can't get the care they need.

What have we gotten with the Affordable Care Act? We have funding for various projects aimed at making medicine more cost efficient and we have payment methods, public and private, that will make it possible for more people to get medical care at a cost they can afford to pay.

This is a major step in the right direction, but there are some major missing pieces. Mr. Gingrich would like to scrap it and start over, but then he clearly hasn't read it since he thinks we now have socialized medicine. Much of what wants to be improved in medicine can't be legislated, so I would like to keep what we now have and see what else needs to be done.

Costs are still rising and this is, at least at this point, threatening to stifle economic growth at a time when our country is struggling to be competitive in a world market where medical care is not a major part of the cost of doing business. This needs to be turned around quickly.

Despite new regulations requiring insurance companies to make policies cover basic medical needs at a cost that people can tolerate, insurance products are even now getting more expensive and less generous. Our continued reliance on insurance to pay the bills not only limits any incentives for costs of medical care to go down, but makes the insurance companies powerful enough that they will certainly have a significant influence on policy which will lessen the effectiveness of the regulations.

Doctors don't understand the new laws and are fearful and suspicious. This is causing doctors who have been in practice to consider narrowing the scope of their practices so they are less vulnerable to public insurance changes, and in many cases to consider retiring. The widespread experience of being sued for malpractice already shortens the careers of many physicians, and the lack of any serious attempt of the recent bill to solve this problem has disillusioned many of us.

So what must we do?

First costs need to go down.  In looking at everyday medical practice as it goes on in my community it is clear that much of the excess money spent in medical care is due to the whims of care providers, inadequately informed by science and without knowledge of the costs involved. Almost nobody knows what most of the tests or medications we prescribe cost. Merely being made aware of costs, coupled with more widespread education on appropriate use of medications and testing would make a huge and nearly instant impact on medical costs. This can happen, but could be facilitated by our national organizations. If they are unable or unwilling to mandate transparency of costs and provide leadership on appropriate care, we can do this at a local level through working with our hospitals, clinics and pharmacies to share information.

Costs could also be impacted by changing the way physicians are paid. If we were not only aware of costs but were paid to care for a group of patients rather than by the individual encounter, there would be strong incentives to keep patients as healthy as possible so that they didn't require doctor visits or hospital care. This would line our incentives up with what patients really want: for us to keep them healthy and care for them effectively when they are sick.

One way of providing health care of this type would be through community health care systems on a cooperative model. Communities of people already spend huge amounts of money on health care, and if they pooled those resources and that money did not need to move through an insurance company in order to pay for necessary care, it would buy a great deal more health care. The health care bill supports creation of structures like this, but does not in itself make them happen. That is up to us, in our communities.

I'm not sure it is possible to reassure doctors that all will be well as health care reform goes into action, but if our own national organizations, such as the American College of Physicians and the AMA, show leadership in making our own positive changes we will all feel more in control of the process. 

Suing for malpractice continues to be the dysfunctional approach often taken when a patient has a bad medical outcome or a mistake is made, especially if care was very expensive. We can, even now, tackle this in our communities by making ourselves aware of bad outcomes and medical mistakes and offering compensation as well as honestly evaluating what went wrong. This process can be done by hospitals and clinics, and has been shown to reduce costs overall.  Suing for malpractice destroys lives of both injured patients and physicians, as they spend years in rancorous argument, and the medical community then loses the opportunity to learn from mistakes.  Any federal law reforming medical malpractice is certainly years away, since the tort system has traditionally been a way to protect those who are vulnerable, and it is hard to make the case that medical injury should be handled differently from other sorts of injury.

I'm thinking that perhaps there is still quite a bit of work for all of us Champions of Medicine to do. I think I'll save my  5 grand and travel expenses and hotel fees and just hang out here at home and work on this stuff.

Monday, October 4, 2010

Newt Gingrich invited me to a party!

Today I received an invitation to an election day party from Newt Gingrich himself! Apparently I have “made the cut” as one of the 2010 Champions of Medicine and will receive a handsome certificate at an election day party at the historic Ronald Reagan Building in Washington D.C. Newt has confided to me that he has worked tirelessly of the course of his career for health care reform. He understands that I have faced challenges during the Obama administration's first two years and that this year has been especially difficult for me with the “Democrat held Congress essentially dismantling the world’s greatest healthcare system and replacing it with the failed model of socialized medicine.”

Newt wants me at the party mainly because he wants to be surrounded by the best and brightest this country has to offer on the “night we set the wheels in motion to repeal Obamacare and replace it with real, meaningful reform.”


I would love to go! I would have absolutely no hesitation in asking uncomfortable questions and spreading sedition among the gathered faithful. For all the good that would do. But life is so full of really great things to do that don’t involve being in Washington DC on election day. There are long walks to be taken in the woods. There are songs to be sung with friends. There is a conference to be organized about appropriate use of technology at our hospital. There is real information about what is going on in my field to be read and digested and maybe turned into essays on why the finest healthcare system in the world fails to take care of its own at an affordable price, and how it can be tweaked to face its challenges. There are stories that need to be heard, poems that need writing, children to be raised, jokes to be laughed at.

I’m still filled with questions about this invitation, though. How stupid does he think doctors are? Are we really stupid enough to think that the reform package dismantled the finest healthcare system in the world and replaced it with socialized medicine? Why invite me? I’m not even Republican. Could he have invited many thousands of doctors, and if so mustn’t he believe that his message would sway very few of them, since he can’t feed thousands of doctors dinner at the Ronald Reagan building? And if I did go, what are the choices of entree?

Monday, September 20, 2010

what do I mean by cost effective medicine?

It is not uncommon for comments about cost effective medicine to be met with mistrust by patients.  Saving money is fine, but not if it means that when I, personally, as a patient, am in pain or sick, will have to wait for relief, get suboptimal care or be denied a life saving treatment. I, as a doctor, am also a patient, and can fully sympathize with this opinion.

When I envision cost effective medicine, I mainly see an absence of cost ineffective medical interventions.  Without these big yellow lemons of common medical practice, there will be more time and money to provide care that is meaningful. So what are the top shelf worst and most cost ineffective practices? It would be beautiful to see a well funded study of this question, but I haven't seen such a thing, so I will dip down into my well of 25 years of medical experience and pick out several of the things that I, as a patient, don't want to happen to me. These are things that are costly, common and have very little value in terms of maximizing health or happiness.

1. I go into the emergency room with severe abdominal pain and before anyone asks me questions that might be relevant (have I ever had this before, what did I just eat, have I ever been evaluated for this and how...) an abdominal and pelvic CAT scan are ordered and I receive a radiation dose equivalent to over 300 chest x-rays and a bill for $2500.

2. I reach a ripe old age, am having significant problems with my memory, joints, digestion, plumbing and whatnot, and suddenly my heart stops while I'm sitting at a meal at the nursing home.  I am resuscitated, rushed to the hospital where I remain on life support for a couple of weeks with lines and tubes and beeping machines as my family tries to figure out whether I really would have wanted all of this. Costs for this kind of end of life care often run as much as $10,000 a day.

3. I go the the doctor for high blood pressure, and sure enough I do have high blood pressure.  He goes into the sample closet, gets me the newest anti hypertensive medication on the shelf, shown by drug company sponsored studies to have minimal side effects, and I take it, then fill the prescription which costs about $300 a month when a generic of proven track record would have worked just fine and cost $4.

4. I have chest pain and tell my doctor.  She wants to make sure she isn't sued if I have a heart attack, even though my chest pain is only with taking a deep breath and is never associated with exercise, so she orders a nuclear imaging stress test.  The radiation dose is huge and the bill is $6000. Later I get lung cancer, and cannot be at all sure that it wasn't caused by radiation.

5. I have knee pain and am overweight.  I can't get dietary counseling because my insurance doesn't cover it, but I can get an x-ray, then some arthroscopic surgery which doesn't help but costs about $30,000. I now am overweight, have knee pain and a nifty scar on my knee.

6. I am uninsured or underinsured so can't really afford to go to a primary care doctor for my cough.  It gets worse, so I go to an emergency room.  The evaluation includes a chest x-ray, breathing treatments and an expensive antibiotic and no followup or smoking cessation advice.  I didn't need the antibiotic and get antibiotic associated diarrhea and eventually require hospitalization. Total cost of this perfect storm is in the 10s of thousands of dollars.

7. I am an 80 years old man and go to my doctor  for a physical exam.  He says that I need a prostate exam and PSA testing for prostate cancer. He finds prostate cancer, I get evaluation then radiation therapy, causing me to decline to the point that I now need to be in a nursing home because of urinary and fecal incontinence. I would not have died of the prostate cancer had it gone undiagnosed.

8. I am a 40 year old woman, go in for a physical and am told to get a mammogram. The mammogram is abnormal so I get another 6 months later. It is still abnormal so I get a biopsy.  The biopsy is normal. When I get my next mammogram it is abnormal too because I have a scar.  I get an MRI of my breasts and that is equivocal.  I get another biopsy which is normal.  This process is repeated yearly until what is left of my breasts resembles the surface of the moon.

There are cost effective solutions to all of these problems which rely on adequate access to primary care physicians and good choices about when to use technology. Making medicine cost effective is about making it better. Dollars spent on health care should be in the service of health and happiness and nothing else.

Saturday, September 18, 2010

JAMA commentary article suggests teaching medical students to be cost conscious

This week's JAMA presents an article by Samuel Sessions MD of Harbor UCLA Medical Center and Allan Detsky of Mount Sinai Hospital in Toronto suggesting that teaching medical students to be aware of cost when learning to treat patients.  They recognize that physicians have an ethical responsibility to pay attention to the fact that medical expenditures are increasingly threatening America's economic viability and point out that training in cost-effectiveness needs to start in medical school.

A few years ago I let my membership in the American Medical Association lapse since I felt that the did not represent me as a primary care physician and a socially responsible human being. During the debate around health care reform, they have not demonstrated leadership in helping American medicine move in the direction that will result in reducing costs and improving access for people who need medical care. They have, however, published articles in the Journal of the AMA by many thoughtful and visionary authors which have informed readers. The JAMA is a free publication, at least the print edition, to physicians, and is at least partly subsidized by advertising, as are many medical publications, and its circulation is huge. I have continued to receive it since my membership has lapsed and I am grateful for that.

Today when I decided to share this article in my blog, I attempted to access it online and found that I will have to subscribe to the online version if I want to copy and paste its text into this commentary.  I'm not ridiculously cheap, but I haven't yet decided that I want to give money to the AMA. Luckily, this article has made quite an impression in various online sources, so I will quote ScienceDaily:

"The commentary is written by Samuel Y. Sessions, MD, JD, a Los Angeles Biomedical Research Institute (LA BioMed) investigator, and Allan S. Detsky, MD, PhD, Departments of Health Policy Management and Evaluation and Medicine, University of Toronto.
"New physicians will be at the hub of the health care system throughout their careers as both patient advocates and allocators of resources," the authors write in the JAMA commentary. "Instead of considering economic forces to be extraneous, medical education should develop approaches to better equip physicians for this dual role through improved teaching of evidence-based medicine that reflects both economic and statistical realities. Good patient care and good public policy demand no less."
The commentary notes that health care spending continues to grow, reaching 17.3% of gross domestic product in 2009. It points out that physicians "play a critical role not only in the well-being of their patients but also in the nation's economic welfare" as they make choices about how to care for their patients. As a result, the commentary calls for "incorporating information about economic realities into medical education to enable physicians to make better-informed decisions for patients and for the United States."
The authors point out that physicians' diagnosis, choice of medication and course of treatment can affect spending and patient well-being for years to come. To ensure economic realities are part of the physicians' decision, the authors call for a "core, required medical school course that would consolidate and integrate elements of existing health policy, ethics, and evidence-based medicine courses and modify them to better reflect overt and covert economic influences on clinical decisions."
The authors also call for revising "the remainder of medical school and residency curricula" to incorporate economic realities so that the medical students and residents would take these into consideration in their medical decision-making.
"The primary goal of incorporating economics more directly into medical education would be to improve physicians' critical capacity to assess all factors affecting their decisions, as well as their social and ethical implications," the authors write.
This is all extremely heartening.  I was especially pleased to find the article quoted so many places, because it is all well and good to have a great idea, it is something quite different to do something about it. When many people are excited, as they seem to be, momentum may build in the direction of change.  The next step in such a thing would be to have the idea attach itself to some money--perhaps a grant to medical schools that try it.  Medicare already funds a great deal of medical education and perhaps the proper direction for this to take would be for folks in the new center for Medicare innovation (part of the health care reform bill) to notice that it is a terrific idea and stipulate that medical schools receiving funding from Medicare begin to teach a comprehensive curriculum based on cost effective care.

Wednesday, September 15, 2010

Treatment of Sleep Apnea--the cost of a good night sleep

Obstructive sleep apnea (OSA), that is snoring with episodes of not breathing, probably affects more than 1 in 20 people.  It is most common in older men, though certainly not limited to this group. Risk factors include obesity, large neck size and limited room for air passage in the back of the throat.  When a person has OSA he or she may wake up hundreds of times a night as breathing is stopped by floppy tissue in the airway and the drive to breathe arouses them enough to take an effective breath.  This loud irregular snoring and snorting also interrupts the sleep of a partner in the same bed. People with sleep apnea have a lousy quality of sleep, rarely reaching the lower sleep levels and are less productive during the day than healthy sleepers and often fall asleep in meetings, movies and while driving. Years ago we discovered that application of a mask to the nose which applies a constant air pressure to the breathing passages can improve nighttime breathing and nighttime sleep. These are called CPAP (constant positive airway pressure) devices and are now commonly used in the treatment of OSA. People who use these devices have better oxygen levels during sleep, which benefits their hearts and brains, and usually feel more rested during the day.

This sounds really good so far. Treatment of sleep apnea is a success of modern medicine. Using CPAP is pretty easy, causes no major side effects and relieves suffering. A slam dunk. Unfortunately the process of getting tested for sleep apnea plus the CPAP machine and supplies is tremendously expensive. In order for an insurance company to cover their bit of the CPAP equipment, a sleep study must be completed and if OSA is diagnosed, another sleep study must be done to see what settings to use for optimal treatment.  This involves the patient spending the night in the hospital while hooked up to a machine that measures brain waves, limb movements and oxygen levels. At our hospital a sleep study costs over $2500, the physicians reading of the data costs nearly $600 and those costs are usually multiplied by 2.  The evaluation can be done with one night and that is a bit cheaper but still no great deal.  At our local durable medical supplier the CPAP machine and supplies cost close to $2000 and some of those supplies need to be replaced several times a year. With good evaluation and a good medical equipment supplier who follows up regularly, about half of the people who are diagnosed with sleep apnea can tolerate CPAP.

There is another option, though, that appears to work for some people.  A device that is quite a bit like a boxer's mouth guard can be made which places the lower jaw in a jutted position and improves breathing without the mask and tubes and such.  These oral appliances are carefully fitted and are amazingly expensive.  One of these things costs around $1200-$5000.  Why? All I can figure out is that the cost is competitive with CPAP and is the only viable option for people who can't stand a tight mask on their faces. Why doesn't someone make one that seriously undercuts the rest? I'm not sure. Perhaps because the market is small.  It sure seems like an insurer or an uninsured consumer could take a look at this not very complex piece of rubber and refuse to pay more than it is actually worth. Apparently that is not how things work.

It is definitely true that people feel better with better sleep. It is wonderful that the treatment of sleep apnea is such an active field, but none of this stuff needs to be this expensive.  This is yet another case of the free market system not acting to lower costs because the actual consumer rarely pays for the product. Insurers pay for most of these costs, and why they agree to do so is beyond me. A sleep study should not cost $3000. In fact, most people who have sleep apnea have really pretty classic symptoms and could get by with a test called an autotitration, in which the CPAP device is set up to adjust itself and a less expensive data set is gathered by a simple device that measures oxygen levels.  I asked the durable medical supplier how much they charge for an autotitration and they said that there is no charge.

What about the machines themselves? Many people with sleep apnea eventually quit using their CPAP machines because they are too uncomfortable or too inconvenient, or because they lose weight or die.  What happens to these expensive machines? Usually they go to a garage or basement somewhere and become a home for spiders. Because they are regulated as a medication would be, they cannot be sold without a doctor's prescription and durable medical suppliers do not refurbish them.  E-bay doesn't sell them, but there are companies that refurbish old ones and sell them online.  These machines can cost as little as $100-$200. I'm not sure how these companies get around these regulations.  Occasionally a person can pick up one of these things at a garage sale or Goodwill, but this is illegal and it is not straightforward to adjust them. Certainly a motivated medical profession could manage to make use of all of these wasted machines.

A reasonable conservative estimate of the number of treated patients with sleep apnea in the US would be about half a million, and the cost to treat per person at the very least $6000 each.  If the cost of evaluation were reduced to the cost of a heavily discounted CPAP machine which could do an autotitration for diagnosis (we will call this cost $1000 for simplicity sake) the cost savings without sacrificing quality would be over $2 billion.  

Tuesday, August 24, 2010

Electronic medical records, revisited

Last night I realized that I actually do like having a computerized medical record system.

I have had a love hate relationship with our computerized medical record system since we adopted it in January of 2007.  We decided to make all of our records and billing electronic in 2006 and tried out several systems before deciding on General Electric's Centricity product.  It was expensive, over $100,000 for our 9 physician group, not including the loss in production as we learned how to use it, and not including many of the laptops and desktops and printers and other hardware. When the system "went live" we all slowed our history taking and record keeping to a snail's pace and were hard pressed to see half as many patients as we had before the system was in place. We all stayed late and came in early. Eventually we adjusted to it, and after a year, we were not as fast, but almost as fast as we had been before. We lost 2 physicians who really couldn't deal with it and had trouble retaining a couple of newly hired physician because it was difficult to use. We kept better records, eventually. Some of the nurses and other office staff couldn't adjust and left.

Sounds bad, I guess.

But there's more. It would freeze up when we did certain things that were supposed to work, like faxing a prescription, and stay frozen for 5 minutes before resetting itself. There would be system updates which caused new bugs to appear. If one person was using a document, another person would not be able to use the document until various closing rituals were performed, and if they were performed wrong, a chart could be in a state of limbo that only the IT guy could fix. 

Now these problems are only a bad dream. There were other ones too which I thankfully can no longer remember. We are left with only the bugs that seem to be completely resistant to all attempts to treat them, and bugs that are intrinsic to the system.

There is no back button. There is no automatic spell check (though you can spell check manually). Once a document is electronically signed, it can't be changed, and it is easy to accidentally sign a document. There are no autocomplete functions. My cursor jumps, and so when I am typing, all of a sudden I am no longer creating text and I have to manually put the cursor back where it is supposed to be.  Sometimes  the jumping cursor will randomly highlight text and then when I start typing again it deletes the highlighted text. Occasionally vital signs are entered and just don't appear on the final document, but you can make them appear by re-entering any value into the form. Documents are much longer than they need to be and look awkward.  I can't look at a patient's medical record in the same window that I am using to take their history.

When I tell people this, they say, "oh, you just have a bad system." Well, yes, obviously that is true.  Nevertheless, this General Electric product is one of the most widely used medical record keeping systems, and being able to communicate with other medical offices and hospitals by way of shared software is one of the major reasons to computerize records. The obvious solution to bad electronic medical records system is to create a great electronic medical record system and make it inexpensive or free, perhaps supported by a government grant, so it out-competes all of these other really-not-very-good systems that we have adopted for lack of a better options.

But that was not the story that I wanted to tell.

I actually wanted to say that providing medicine the way I think it should be done, at a time that is appropriate and in a place that is expedient, has been made much easier by the fact that I can access a patient's medical record from my laptop, anywhere I have internet access, and can send prescriptions and keep records in a way that lets me review what has happened, and later to remember what I have done.

Yesterday when I got back from backpacking, where there was no cell phone service and even google earth couldn't find me, I found a message on my answering machine from a patient who needed help. I was able to sit down at my laptop, see what medications she was taking, see what, if anything, other doctors in my practice had done for her, and discuss medications, side effects and interactions with her. I was then able to order the appropriate change in medication and relay it to her pharmacy, which would get the information the following morning since it was 9:30 at night. It was good medicine, practiced at the most appropriate time for me and the patient, and there were minimal associated costs.

Electronic communications have expanded the way that medicine can be practiced, including the possibility of web based communications to patients with shared problems, e-mail communication, video chatting and efficient communication between doctors of different specialties.  I don't use even a fraction of what is available, but I can certainly see what powerful tools exist.

Many things get in the way of making these electronic tools acceptable in our practices. The difficulties in buying functional software like I described in the first several paragraphs is one barrier. Issues of protection of privacy are another. Not least, however, is the fact that the majority of physicians are still paid only for face to face contact with patients, and there is no easy way to change that without fundamentally changing the business of medicine.

We could, of course, simply start charging for all forms of communication, and remain in the "fee for service" model. This would involve more complex billing plus long and incredibly irritating negotiations with public and private insurance companies. We could also fundamentally change the way health care providers are paid, and pay people like me salaries to do the jobs we now do without the complexities of scoring each problem solved, procedure performed or patient seen.

I think that electronic communication and record keeping can, at best, provide an excellent backdrop for community funded health care. Most physicians loathe the complexities of billing for the minutiae of our work, and we would love to be able to put all of our hearts and energies into the actual care of patients. If communities were able to hire the services of hospitals, doctors, nurses and other staff, we would be able to care for people using all of the appropriate and available technology. Our present system of billing keeps most of us firmly entrenched in communication technology that is many decades old.

Thursday, August 12, 2010

Estrogen: the pendulum swings again

The following essay addresses the present tendency of scientific medicine to rely heavily on studies which address the effects of treatments on populations rather than individuals.  It has been clear, always, before and after various large scale studies of the effectiveness of estrogen, that hormone therapy is good for some people and not good for others. Nevertheless, at great cost to patients in money and time and quality of life, we have at various times pronounced estrogen to be good either for everyone or for no one.

When the Woman's Health Initiative study was stopped in 2002 due to increase heart attacks and breast cancer in the women treated with estrogen and progesterone the non-medical press circulated the story extremely effectively, and within a year very few women did not know that the estrogen they had been prescribed and told would save them from all sorts of misery was actually toxic and evil.  It was a bad year for estrogen.

In the 8 years since then doctors, researchers and menopausal women have gradually processed much of the information that came from that large, double blind multi-center trial, and recommendations have matured. It is clear that conjugated estrogen plus medroxyprogesterone is not good for preventing dementia and leads to an increased incidence of breast cancer, heart attacks and strokes.  Statistically the combination of hormones does not lengthen a woman's life, but then it doesn't shorten it either. It does reduce hip fractures, colon cancer and diabetes. Some women feel better on hormones and some feel worse, but statistically quality of life is a wash.

But WHI was a huge study, involving over 160,000 women over more than 12 years. The amount of data from this group of women is tremendous and it is potentially powerful enough to answer questions like "which women experience which side effects?" and "who should take estrogen and who should not?" As an individual person navigating the shoals of menopause, these are the questions that are most relevant.

This issue of Internal Medicine News reports on Dr. Richard Santen's conclusions as part of a task force from the Endocrine Society on hormone therapy.  Apparently when one analyzes the subgroup of women in their early 50s and those within 10 years of menopause, a significant 30-40% reduction in overall mortality was seen in estrogen users, with or without progesterone. This is, of course, just the group of women who would be likely to want to use estrogen for treatment of the hot flashes, mood changes and sleep disorder so common in early menopause.

As a physician who sees many women as they experience the end of regular menstrual cycles along with the joys of waking up multiple times each night in puddles of sweat and being unable to remember what it was that they were supposed to be doing right now, I will again have to adjust my recommendations regarding the use of hormones. I will continue to struggle with answering questions about which forms of hormones are safest, how long to take those hormones, when and how to stop them. The WHI will be unable to answer many of these questions due to its study design. I will, however, have a new piece of information to support the women I treat who feel they really want to take estrogen.

Here is a link to the Internal Medicine News article.

Thursday, July 29, 2010

Gaming the new system?

Last night I attended a program put on by the hospital about health care reform. The first speaker had clearly spent a great deal of personal time and energy working with folks who really didn't want the health care reform bill to pass. He had a good ole boy presentation style, peppered with sarcasm and full of predictions of imminent doom for the world as we now know it.  The only saving graces for his talk were that the food was excellent and that he used so much insurance and benefits jargon that the majority of the audience quit listening to him.

The second guy was more balanced.  He identified himself as a moderate republican, and though he didn't particularly like the health care bill as a whole, he presented a pretty balanced review, and looked at ways we could allow it to improve health care.

His major points included the fact that "accountable care organizations" (ACOs) are likely to become a dominant way to deliver health care, with their focus on coordinated care of patients from hospital to clinic to home. An ACO will consist of doctors, nurses, hospitals and supporting staff who will provide full spectrum health care for patients and be reimbursed based on the severity of the patients' illnesses and the quality of their care. Challenges for these organizations will be functioning in small communities and working out who gets what money for what job.

He addressed the idea that the bill would be repealed, and argued that it is extremely unlikely, even if the next administration is republican dominated, for that to happen. Many of the bill's early achievements will be so attractive to the majority of Americans, including expanded health care coverage for preventive services and to the uninsured or underinsured, as well as breaks for small business presently strapped by high health insurance costs, that dismantling the whole thing would be suicidally unpopular.

Apparently this second guy, a Washington lobbyist, will be working with our hospital to help us qualify for some of the grants available in the bill for organizations wanting to innovate in health care delivery. Many of these grants are particularly applicable to a small community such as ours, and could help us move in directions that we have discussed in the last year.

Tuesday, June 29, 2010

Community organizing for health care reform: what we have to do now

We had our 4th meeting of doctors and staff interested in improving access, cost and overall quality at our hospital. It was well attended, but mostly by staff and board members rather than physicians. I guess we doctors think we are too busy to talk about health care reform. We had me, an internist, a psychiatrist, a radiologist and and emergency doc. Thinking was clear and focused, and the meeting was productive, as much as talking can be. We came up with several items needing action, and discussed several items that are moving solidly in the right direction.

1. My Own Home: an organization is being born which provides all sorts of resources to older folks wanting to stay in their own houses rather than moving to retirement homes.  It will be supported by grants and will require membership payments. It will probably really start functioning in the next year. It is moving in the direction of getting up and running as fast as is practical.

2. Direct or prepaid medicine: there is quite a bit of interest by the hospital leadership in looking at some sort of community based prepaid health care.  This would involve using the money that is already being spent on health care, by individuals and insurance companies, to provide comprehensive health care for the whole community.  There are models for this elsewhere. Grand Junction, Colorado, has a system that provides affordable health care for the whole community, and we are a good size and makeup for that sort of thing.

3. Physical therapy--appropriate utilization and rapid transition to exercise programs: This is already happening.  There is room at the hospital wellness center and costs are low, so many people who go to physical therapy multiple times because that is the only exercise they every get can be transitioned into something much cheaper and more appropriate.

4. Information systems: The hospital just made the decision to buy an electronic medical record system, and will start using it, ever so gradually, in the next few months.  This will make monitoring of costs and outcomes much simpler.

5. Radiological testing--making it more appropriate to avoid excess radiation exposure and monetary costs: This will be aided a great deal by the computer ordering of tests. Criteria for appropriateness can be evaluated at the time the test is ordered, and duplication can be avoided.

6. ER use: There is still a great deal of money spent due to patients being seen in the emergency department when seeing a primary care doctor would be more appropriate. This involves excessive testing and insufficient followup, and is associated with higher costs than appropriate care would have generated. This will require a work group to figure out the best approaches. Some suggestions included diverting patients to primary care providers who indicate in some way that they are available and willing to work with these patients for a reasonable fee. Another helpful service would be 24 hour van transportation to get patients home after treatment and evaluation are completed. This kind of service would more than pay for itself, and the hospital CEO said he would move on that.

7. Cost-of-care clinical conferences: I would really like to present case conferences which look at the costs incurred at all stages of a patients hospital stay, along with the clinical outcomes. This can probably be done, with attention to confidentiality, and would really inform some of our choices. I will work on this.

8. Cost transparency for patients: the billing department is working on this, but the progress is slow.  They really need more staff to get an efficient interface working.

The hospital has been very receptive to ideas that involve streamlining care and costs, which initially surprised me. They are aware of a new climate of belt tightening, though, and would like to be involved in the process as much as possible.

Wednesday, June 23, 2010

CT scans--why not?

The New England Journal of Medicine this week published two articles on imaging technology.  The first was about the safety of CT scans and the second was about the indiscriminate use of radiological imaging of all kinds. Imaging of the human body is big business and important in the progress of diagnosis, but once a machine or technique is invented, its use is mostly unregulated and largely up to our discretion, without supporting scientific evidence of usefulness.

CT scans do cause cancer. This is because ionizing radiation causes cancer and CT scans carry lots of that. Every year 10% of Americans get a CT scan, and many people have multiples. Each CT scan carries 100 to 500 times the radiation dose of a standard chest x-ray if done properly.  If an error is made, much more radiation can be delivered. Sometimes a patient might find out about such an error, but most often there would be no symptoms and no recognition.

CT scans also do save lives.  They detect problems that would require emergency surgery before they are life threatening. They detect conditions which would remain painful or disabling mysteries for years without imaging. The trick is using them appropriately.

CT scans of the abdomen and pelvis usually carry the greatest radiation dosage because there is so much tissue that has to be penetrated in order to get a good picture. In this New England Journal article ( the patient in question got 2 CT scans of the head in short succession, arguably for no good reason, and one of them carried an erroneously high dose of radiation, resulting in significant brain toxicity. It could have happened to anyone.

Also an issue for this patient was the fact that a special CT scan called a perfusion scan was done to see if she was having a stroke. I have not ordered these yet myself, and just recently heard about a patient for whom such a scan was suggested as a way to evaluate an odd and transient symptom.  These brain perfusion CTs carry a much higher radiation dose than a standard head CT, with the risk of radiation damage to brain and scalp and obvious increased risk of malignancy. Since most of us have, at one time or another, had disturbing neurological symptoms, wooziness, confusion, dizziness and the like, such a scan may gain significant popularity in the future, with results that will be irreversible to the patients who receive them for inadequate indications.

Saturday, June 19, 2010

The pseudoscience of medicine

The training that leads to becoming a physician is long, taxing and requires academic stamina and intelligence to complete. Nevertheless, most of what we eventually learn is practical: how to take care of patients in sickness and health. This is as it should be, since that is what we mostly do. Nevertheless, because we take many many hours of science related classes, most physicians consider themselves to be scientists. And that we, mostly, are not.

In my years of training I have learned how to construct a hypothesis, test it and use my data to make a conclusion. I know how to document my data, and I know how to perform simple statistical analyses.  I know how to interpret statistics I read in other peoples' work, for the most part. But because I am always looking for ways to use the science I read to help me in patient care, I often make inferences that are speculative and probably just plain wrong.  It works for me, though. I need to plug the science I read into the craft of medicine I practice in order for it to be meaningful to me, and sometimes my inferences might just be correct.

Take for instance standard clinical trials which look at the effect that a certain intervention, say a drug treatment for cancer, has on a group of people.  That clinical trial will show that the in the group getting the drug the cancer will go away for a certain percentage of the people getting it. This result will be compared to results for a placebo group or a group getting a different drug. If the group getting the drug has a higher level of response than the placebo or different drug group, the interpretation will be that the new drug works. This is where the speculation starts to be misleading. I will then tell the patient I see that this new drug works best, and the patient may then choose to take it rather that watching and waiting or taking the other drug.  But it isn't necessarily true for this patient that the drug works best, because patients are different, and withing the group that got the new drug, there are very likely patients who would have done better getting no drug or another drug. So I really can't, and shouldn't tell the patient that the drug works better. But just to make it as simple as possible, I do. And most doctors, until they sit down and think about it believe that this is true, that the drug that comes out on top in the clinical trials is the best drug, and they will proceed to use it preferentially.

I have been attempting to explain this sort of thing to my patients more often since I have been thinking about it, but I think it just makes them uneasy.  They want an answer from me: what choice is best.  Now that is not true of all patients. Some of my more thoughtful patients are glad to have many options open to them. It is more honest to discuss these things, but they are complicated and definitely not reassuring.  The use of estrogen is a frequent subject for these discussions.  Estrogen causes various harms in some people, including increasing the risk of breast cancer and vascular events when combined with progesterone, but it also saves people from breaking their hips and reduces the risk of colon cancer. It definitely helps relieve the sleeplessness and hot flashes of menopause as well.  So is it good for a woman or bad for her? I guess it depends on what she values.

Another thing that physicians do that makes us feel like scientists is we measure things.  We measure how much pressure it takes to stop the blood flowing in someone's arm. We call that the blood pressure.  We measure the number of blood cells in a cubic centimeter of blood. We measure weight, temperature, height and head circumference.  We count the number of times we feel the blood pulsing in someone's wrist per minute. We are reassured of a person's health based on these numbers. The numbers themselves may be misleading, as in the case of the blood pressure. The pressure it takes to stop the blood flow in the arm can go up if the arteries are particularly tough and springy. We don't necessarily know that this is a bad thing. The blood pressure can vary depending on recent exercise, time of day and emotional state. But that really isn't the most basic problem.  What I think is more basic is the fact that we have decided that the things we can measure, and routinely do measure, are the important things, and we mainly base our studies on these pieces of data that we have decided are important because we can quantify them.

I recognize that medicine has, at times, significantly improved the quality and quantity of peoples' lives, so disrespecting it based on its fallacies is unkind and unfair. I would really just like to see my medical profession lighten up and recognize that much of what we see as fact is not. This could nicely dovetail with the recent emphasis on what is called "shared decision making." We have come a long way from the paternalistic past of medicine, and have another long way to go.

Wednesday, June 9, 2010

800 pound mooses and the American College of Physicians

The American College of Physicians has created an initiative to reduce costs and increase quality.  It is called the High-Value, Cost-Conscious Care Initiative, and was launched at the annual meeting in April.  They plan to focus on overuse and misuse of ineffective tests and treatments, of which there are many.  The congressional budget office estimates that 700 billion dollars yearly is spent on tests and treatments that do not improve health.  I suspect they underestimate that significantly. At the same meeting the college revealed plans to lobby for changes in health care policy not quite adequately addressed in the health care reform package, including prolonging salary bonus for primary care doctors treating patients on medicare and medicaid.

This is good! Even great. Why did this take so long?

I expect that part of the problem has been that it is difficult to find consensus in changing a system when there is considerable concern about loss of income and loss of respect. 

Issues not mentioned in the articles I have read about the meeting which are difficult to address include the fact that the present 10% bonus for primary care physicians doesn't come close to making the salaries of specialists and family practice or internal medicine doctors equal.  Providing adequate numbers of high quality primary care doctors is absolutely necessary to raise the quality of health care and health in general, and the oversupply of specialty physicians pretty much guarantees that too much expensive and unnecessary specialty care will be delivered.

Also, addressing the large and irritable moose sitting in the corner of the room during this discussion, some physicians really do make too much money.

I don't think that physicians should have to take extra jobs as cab drivers to support their families, as happens in Cuba, and there are many issues suggesting that physicians' salaries should be higher than average salaries, but a starting salary of $500,000 for a neuroradiologist is just plain out of balance. A full time primary care doctor can expect to pull in $150,000 at the height of his or her career, and in small towns or if the physician is female, that number is significantly smaller.

It is difficult to address this issue in a group like the American College of Physicians, because most people don't want to see their salaries shrink, and these large organizations are responsible for representing all of their members.

(Note: the 500 pound gorilla has been replaced with an 800 pound moose due to regional differences in fauna. i.e I'm from Idaho.)

Tuesday, May 18, 2010

How Does Cuba Do It?

Cuba has achieved a life expectancy approximately equivalent to the US, despite a long standing embargo on food and medical supplies and despite spending a small fraction of the amount of money per person on health care than we do.

A Stanford social sciences researcher, Paul Drain, has studied Cuba's medical system and has identified a few factors that may be responsible for their success.  Cuba completely subsidizes medical training.  After high school, students who are interested in medical school and qualify for it attend 6 years of combined college and medical training, complete with a stipend for living expenses and then 3 years of postrgraduate training in primary care medicine.  Many do rural health residencies either before or after the postgraduate training. After becoming family practitioners, 35% of them do further specialty training and the rest remain primary care doctors.  There are many multi-specialty clinics which provide care in cities, and small primary care clinics that serve small neighborhoods.  Their vaccination rate is excellent as is their rate of professionally attended births.  Everyone sees a doctor at least once a year and sometimes these are home visits.  Doctors are not paid highly, but then they emerge from training without the usual multi-hundred thousand dollars of educational debt that they end up with in the US.

If one were to look at the economic incentives that have lead to our excessive health care expenses and our shortage of primary care doctors and effective preventive medicine, it is not hard to see how we have landed in our present circumstances.  It is a bit harder to see how we should escape from them.  Certainly subsidizing the training of primary care physicians would be a good start.

Paul Drain was interviewed for Wired, and published an article in the April 30 issue of Science magazine.  This is a link to the Wired article.

Sunday, May 16, 2010

vitamin D--the controversy

In the last year vitamin D has been making headlines. It is not a new vitamin. It was first synthesized in the 1920s and deficiency of the vitamin was known to be a cause of rickets, a bone deforming disease, associated with reduction of sun exposure with the movement to crowded living conditions with inadequate sun exposure during the industrial revolution. It is important in regulating absorption of calcium in the gut and deposition of calcium in bone as well as having a role in  supporting the immune system.  Vitamin D2 can be made by plants and was added to milk and cereals in order to prevent rickets in children starting in the late 1920s.

Vitamin D is available in relatively small amounts in various foods, especially fatty fish and beef liver. Normally these food supplement the vitamin D made in the skin when we are exposed to certain wavelengths of sunlight.  Dark skinned people are less efficient at producing vitamin D from a given amount of sun exposure, which partly accounts for the fact that evolution has put light skinned peoples at the extremes of northern and southern latitudes.  Even so, in the winter at the arctic circle, there is no radiant light sufficient to allow the skin to synthesize vitamin D.

Recently data has been piling up about the benefits of vitamin D and the various forms of ill health associated with vitamin D deficiency.  A study in 2008 published in the Archives of Internal Medicine showed a higher death rate in adults with lower vitamin D levels, for instance.  Other studies have shown and increased risk of influenza and possibly cancer in patients who are vitamin D deficient. Some high profile studies have shown an improvement in fall risk and fractures in elderly patients who are given vitamin D supplements, with or without calcium, but other studies have shown no effect at all.

I practice medicine in a town which is significantly north of the equator, thus providing little sunlight of a wavelength effective for production of vitamin D in the skin during the winter.  This combined with cold temperatures means that when I check the vitamin D levels of patients at the end of the winter, about half of them are significantly deficient.  This is huge. It implies that half of the patients I test are ill in some way, are courting fractures and other vitamin D related maladies such as infections and bone pain and overall sickliness.
Just this week an article published in the Journal of the AMA by Kerrie Sanders et al studied a group of community living people, aged 70 and over, who were given a huge dose of oral vitamin D once a year with the expectation that the resultant increase in vitamin D stores would reduce falls and fractures.  The results, however, were surprising. Significantly more of the vitamin D treated patients developed falls and fractures, especially in the 3 months following receiving the large dose. Interpretation of this finding included thoughts about odd physiological responses to huge doses of vitamin D, which seems plausible, and less plausibly, that since these people felt so chipper after getting their supplement, that they were out and about more and so fell down and broke bones.

There are many issues brought up by this article, which are especially relevant in this year when vitamin D has ridden into the practice of medicine like a handsome sheriff with a white hat.

1. Do we trust laboratory tests of vitamin D levels to tell us if a person needs vitamin D supplementation?  Darker skinned people routinely have lower vitamin D levels, but aren't clearly sick because of it.  In my experience, deficient levels of vitamin D are randomly associated with skin color, diet or sun exposure, and not usually associated with overall health of the patient. I have been told that laboratory levels are not necessarily consistent from test to test.

2. How should we supplement vitamin D? The studies that have shown good effects of supplementation used daily doses of around 800 units, yet many of my patients who already take this dose daily are found to be deficient. Normally we replete vitamin D levels with 50,000 units of vitamin D twice weekly for 6 weeks, followed by recommendations to take at least 1000 units of vitamin D thereafter. Is this method wrong?

3. Is it cost effective to test for vitamin D deficiency, or should we just supplement everyone's diet with oral vitamin D? Not everyone's insurance pays for a vitamin D level and the test can run up to $150.  If we do test for deficiency, do we need to re-test to make sure the person is adequately repleted and if so, how often? If we want to achieve the goal of maximum health for minimum time , money and anxiety spent, how best should we do this with regard to vitamin D?

Vitamin D in a form that a person with a healthy liver and kidneys can use is inexpensive, but the widespread treatment of what may or may not be a disease is presently consuming huge amounts of resources of time and perceptions of health.

Wednesday, May 5, 2010

Why does Congress try to cut Medicare spending every year and then not do it at the last minute?

Pending huge cuts in Medicare make headlines yearly.  “Doctors sweating bullets: Medicare spending due to be cut by 21%!”  In the medical rags we hear that “this year the cuts will really occur and then no doctor will provide care to patients on Medicare.” But then, sure as spring follows winter, the cuts are forestalled. Does this seem silly to anybody else?

This week’s New England Journal has an article that addresses this problem clearly.  I read the article, written by Dr. Bruce Vladeck, as saying that we are stuck in a legislative bind with regard to medicare spending, both because we spend too much on medicare, mainly due to the fact that we overspend in general without adequately supporting primary care, and also due to rules we established years ago regulating overall expenditures for the Medicare program.  The rules were good, if a bit optimistic, and required that we curb overall outlay for Medicare year by year.  Each year that we fail to live by the formula that cuts Medicare spending increases the required cuts for the next year, so that required cuts have become virtually unimaginably large at this point.  Many of the things that we spend money for in the Medicare program are overpriced, but we are trapped at this point by a relative value scale that favors payments for procedures and specialty care over the thinking, listening and prescribing that is involved in primary care.  The formula that governs our medicare payments is called the Sustainable Growth Rate (SGR) and clearly needs some very fundamental revision.

This last weekend I was on call and had direct experience with what it means to be paid well for performing procedures.  I had a pretty busy weekend, but most of it was managing issues over the phone.  I make no money for that, but it is one of the most useful things I do. I don’t mind providing this service, but it does not feed my family.  I spoke to a woman whose mother was dying at home and having the agitated delirium that is so common in the last few days of life.  We arranged for her to get appropriate medications and I attempted to get her set up with hospice, which wasn’t possible on a Sunday. I helped arrange for the Red Cross to pay for and obtain medications for a man whose house had burned down, pawing through his computer records, speaking with his wife, and negotiating which of his many pills were vital. Then I was called in to the intensive care unit twice due to a potentially fatal heart arrhythmia in a patient on a ventilator recovering from a severe lung infection.  As part of his treatment his heart needed to be shocked into a more stable rhythm on 3 occasions. This involved the nurses placing sticky patches on his chest and back, hooking him up to a cardioversion machine, and pressing a button at my request.  I spoke 3 words “100 joules, unsynchronized” and received hundreds of dollars for that each time.  I guess it all evens out in the end, but it’s a pretty screwy payment system.

I am attaching a link to the article which addresses the SGR much better than I can.

Thursday, April 29, 2010

What the health care reform bill is actually doing

Lately I have been attending various administration level functions at our hospital, as the doctor who has ideas about reducing costs.  I suspected, when I began rabble rousing, that the hospital administration would passively or even actively oppose open discussion of where money was being wasted, since most of that wasted money seemed to go directly into the hospital's accounts.  Apparently the hospital associations have been reading the writing on the wall for some time, and have realized that there will be cuts in their revenue. The administration was already interested in cost transparency when I began to push for it, and the CEO as well as members of the board have been very receptive to various ideas that would improve quality and efficiency, even to the point of considering options for providing a health care package to our whole community.

In a meeting lately, a representative of the corporation that owns our hospital spoke, during a talk I gave, on the corporation's efforts to understand the provisions of the bill and prepare for the impact on hospital functions.  The lawyers don't really understand it all yet, but are working hard to see which pilot programs we would be eligible for, and where we need to tighten up with regard to quality and spending.

Recently I got two letters from different insurance companies, one a government payer, one a private payer, about their new plans for requiring certain information from doctors before approving non-emergency imaging procedures, such as cat scans and MRIs.  The radiology department itself hopes to make these unnecessary by policing the appropriate use of these tests to avoid duplications and excess radiation exposure.

Are all of these changes mandated by the health care reform bill? No, not at all. Were they ongoing before the discussion of reform began? No, certainly not in my awareness.

I am coming to the conclusion that the entire painful process of debate, public protests, political grandstanding and eventual passage of a flawed and ridiculously long and complex bill has had some profoundly positive consequences.  Doctors, who have frustrated me by their apparent lack of engagement with this whole process, have been bombarded with the issues in the media for months. They can't help but realize that cost and waste and lack of transparency are issues. Realizing this cannot help but influence their conversations with patients and their practice styles. Because the bill is long and hard to comprehend, doctors and hospitals are projecting all of the problems of our health care system on the bill, and are attempting to solve problems that have either not been solved by the bill, or in some cases, not even addressed.

Because so much that we do in medicine carries a high pricetag, even small changes in the efficiency of our practice will result in huge dollar savings. I would not be at all surprised to find that in a few years the estimates of savings from the congressional budget office significantly underestimate the savings we actually see.

Wednesday, April 28, 2010

What is the problem with "fee for service"?

When I first started to the hear the mantra "the problem is fee for service" in the discussion of health care reform, I couldn't quite wrap my head around it.  What exactly did this mean?  I had worked for an HMO, received a salary, and now that I no longer work for a salary, and make money based on the amount of work I do, I feel more free to practice the way that works best for my patients, me, my family and my friends. Sure, higher performing systems like the Mayo Clinic work with salaried physicians, but doesn't that take away those physicians' incentives to provide the best service?

The problem with fee for service is that the services for which I charge a fee are not the services which are of value to my patients.  What patients want, mostly, is good health with a minimum of time, effort and money spent to get it. What I charge them for is face to face time in the office.  What I spend most of my time doing is solving problems in a context that is different from face to face time with my patients, and I am not usually paid for that at all.  So the face to face charges subsidize the huge amount of problem solving.

The problem, then, is fee for "service". The problem is the definition of service.  In order to be focused on giving what patients actually want, it would be very helpful to be paid according to the effort and efficient provision of those services.

Perhaps he rest of you had already figured this out, but I am a little bit slow sometimes.  This does actually mean that the whole way of providing care and compensating for it needs to be re-vamped to adhere to service that is actually useful, not making work, looking busy, complicating issues in order to appear more competent.

Wednesday, April 14, 2010

Options for reform of the medical malpractice system

This article, in the New England Journal, offers some truly innovative ways to deal with the fact that suing for medical malpractice rarely serves the purpose of compensating the injured party or improving the dysfunctional system or practitioner. I intend to propose an institutional "disclose and offer" option at the hospital where I work, since it seems unlikely that a better option will replace medical malpractice as it now exists, at least during my lifetime.

Here is the article, in full, because it is all good:

by Michelle M. Mello, J.D., Ph.D., and Thomas H. Gallagher, M.D.

In February 2010, the Illinois Supreme Court ruled that the state’s cap on noneconomic damages in medical malpractice cases violated the Illinois constitution.1 This development has contributed to growing pessimism about traditional approaches to medical liability reform. In some quarters, interest is shifting to innovative reforms that can be implemented by health care institutions and liability insurers without requiring changes in the law. These approaches provide a better balance between the interests of providers and those of patients and illuminate a path around the political gridlock over tort reform. They also afford opportunities for health care institutions and liability insurers to take the lead in reforming the processes for providing compensation for medical injuries.
Here, we focus on emerging models of disclosure of medical injuries and early resolution of cases (”disclosure and offer” programs). Other models of private reform, including mandatory binding arbitration and voluntary mediation, have reportedly had some success but have failed to become widespread. The market may be more receptive to disclosure-and-offer approaches, which link the compensation system to improvements in patient safety.
In general, private, institution-led reforms have many advantages. First, most of the reforms can be pursued without legislation. In some states, it is nearly impossible to effect liability reform because of political divisions fostered by powerful interest groups. In others, the legislature is dysfunctional and unable to accomplish major reform or is hamstrung by budgetary problems. Initial optimism that federal health care reform legislation would include major liability reform eventually faded, though the Obama administration has made a substantial commitment to supporting demonstration projects in which health care systems or states implement innovative reforms.2
Second, institutional reforms can be led by physician champions and other insiders, promoting buy-in from clinical and risk-management staff. Third, because most private approaches do not abridge legal remedies, they may be more palatable to consumer groups, trial-lawyer organizations, and patients. Fourth, private approaches can be tailored to each institution’s unique culture, systems, and resources. Finally, institution-led approaches represent a market solution governed by market forces. Insurers and health care organizations (and perhaps even clinicians and patients) can “vote with their feet,” and successful programs can be expanded and replicated, while unsuccessful ones are discontinued.
The disclosure-and-offer approach has been implemented by a handful of hospital systems and liability insurers, building on an early experiment at the Veterans Affairs hospital in Lexington, Kentucky.3 Three distinct models have emerged. All begin with an organizational policy of full disclosure of adverse events and training and support for clinicians to aid them in making disclosures. All share a general philosophy of risk management that holds that being candid about medical injuries, apologizing when appropriate, and providing for the patient’s financial needs (in at least a limited way) through a quick, accessible process will eliminate the impetus for most patients or families to sue and will spur institutional learning and safety improvement. The models diverge in their specific approaches to compensation.
In what we call the “reimbursement model,” the institution offers to reimburse the patient for some out-of-pocket expenses related to the injury and for “loss of time.” The program has a predetermined limit on reimbursement (typically about $25,000 for expenses and $5,000 for loss of time), and reimbursement is offered without an investigation into possible provider negligence. Patients who accept the money do not waive their right to sue. However, injuries that are clearly due to substandard care, as well as fatal injuries and cases in which a claim has been filed or an attorney is involved, are excluded and handled through traditional claims processes. The best-known example of this model is the “3Rs” program operated by COPIC Insurance, a private, physician-directed medical liability company in Colorado.
The “early-settlement model,” pioneered by the self-insured University of Michigan Health System,4 is quite different. There are no preset limits on compensation. Compensation is not generally offered unless the institution, after an expedited investigation, determines that the care was inappropriate. The offer may include compensation for all elements of loss that are compensable in tort cases, including medical expenses, lost income, other economic losses, and “pain and suffering.” To accept the money, patients must agree that it constitutes a final settlement, thus foreclosing a lawsuit. The early-settlement approach is applied to all injuries; there are no exclusion criteria.
The third model, proposed in scholarly work on the basis of the successful experience of several foreign countries, is health courts.5 Patients are informed, at the time an injury is disclosed, that they can file a compensation claim with the provider or its insurer. A panel of experts, aided by decision guidelines, determines whether the injury was avoidable — a determination that turns on whether the injury would ordinarily have occurred if the care had been provided by the best specialist or an optimal health care system; the avoidability standard is more generous than the negligence standard. For avoidable injuries, the institution offers full recompense for economic losses plus an amount for pain and suffering according to a predetermined compensation schedule that is based on injury severity. Some health court proposals envision that patients who are dissatisfied with a decision could bring their case to a second administrative panel or judge provided by the state, with a limited right of judicial appeal.5 Alternatively, in voluntary health court models (in which a state process has not been created through legislation), patients could reject the compensation offer and file a lawsuit, unless they had previously waived this right as a contractual condition of receiving care. Although health courts have not yet been adopted in the United States, President Barack Obama recently called for “demonstrations of alternatives to resolving medical malpractice disputes, including health courts.”2
A key feature of all disclosure-and-offer models is that the information obtained from the investigation and resolution of injury cases is used to improve patient safety. All the countries with health courts maintain and analyze large national databases of medical injuries to identify dangerous conditions or processes and share that information with health care institutions.5 Within U.S. institutions operating disclosure-and-offer programs, the analysis and sharing of data strengthen relationships between risk managers and patient-safety officers, facilitating the implementation of safety interventions. Liability insurers can use other strategies to promote safety, such as offering financial incentives to clinicians for completing disclosure training, following safe practices, and reporting incidents promptly to risk-management officials. Although all these measures can be pursued within traditional claims-management processes, disclosure-and-offer programs create structures and institutional commitments that enhance their effectiveness.
Nevertheless, institution-led malpractice reform has limitations. The development of local programs exacerbates the patchwork nature of compensation for medical injury, which originates from variations among juries and state tort reforms, and can cause inequities in compensation for patients with similar injuries. In addition, institutional innovations are harder to evaluate rigorously than are statewide reforms. More innovative reforms are riskier than more traditional types of reforms. Health courts have not been tested in the United States, and it is unclear to what extent the successes reported by pioneers of the reimbursement and early-settlement models would be generalizable to other institutions. A program’s success would probably be affected by the particular organizational structure of the institution, the availability of resources, the institution’s tolerance for risk, and the personalities of those involved in implementing the program. Furthermore, the fact that private reforms generally preserve legal remedies constrains their ability to limit litigation.
Institution-led reform may also be hampered by regulatory requirements. For example, state insurance departments, which regulate the management of malpractice claims, may be more permissive or less permissive in their attitudes toward disclosure-and-offer programs. The federal requirement that all claims payments be reported to the National Practitioner Data Bank may discourage physicians from agreeing to early settlements, though the requirement does not apply to reimbursement programs. Finally, leaving reform to private institutions may result in reforms that are driven more by financial benefits for hospitals than by considerations such as improved performance of the injury-compensation system or “doing the right thing” for patients.
Certain policy measures could stimulate more widespread adoption of private malpractice reforms (see table). This experimentation is not free of risk, but institutions should seize the opportunity to lead rather than wait for tort reform at the federal or state level. Their ingenuity, vision, and commitment to helping injured patients can improve a system that bedevils providers, patients, and policymakers alike.