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Friday, January 30, 2015

Health and Human Services announces push to end fee-for-service payments for Medicare

On January 26, 2015, the department of Health and Human Services (HHS) reported plans for a sustained effort to end "fee for service" in medical care. Fee for service is a model of payment we are all familiar with and it works really well when we get our car fixed or our dog groomed or our baby babysat. In these situations we want to pay for what we get, and if we aren't satisfied, we don't come back. If the dog's hair looks terrible a week later, we won't just go back to the same groomer and if any of the other people who do us service perform it in a way that makes us need ever more service we will go to someone else who gets the job done better.

Doctors and other medical service providers are primarily paid "fee for service" but most patients don't pay them directly and they don't have a good grasp of whether the job of doctoring is being done right, and they don't usually blame it on the doctor if he or she tells them that they need to keep coming back and keep getting things done in order to be healthier. The result is that doctors make more money by providing a service that keeps patients coming back for yet more treatment. A dermatologist is not financially rewarded for diagnosing and removing a potential skin cancer in one visit and calling us on the phone with the results, despite the fact that most of us would prefer that. He will make much more money by diagnosing the spot one day, having us return for a biopsy, then return to have the stitches out and to discuss the results, then again for the excision and then to review the pathology report. If I, as a primary care provider, treat a condition and in so doing make you sicker or more insecure, resulting in more visits, I will be monetarily rewarded. The economics of fee for service make medical care more expensive and more time consuming and don't encourage good health.

Payers, especially Medicare, have worked hard to reduce this tendency to make more money by doing more things, rather than by giving better care. Years ago they began bundling payments for hospital stays, paying by the diagnosis rather than the intensity of the treatment provided. Doctors' fees, though, have been relatively spared, as have costs of individual surgical or diagnostic procedures. With the introduction of the Affordable Care Act, Medicare has been phasing in the practice of not paying for preventable readmissions, which provides a strong incentive for hospitals to keep patients for long enough to ensure they are well enough to go home and stay at home. Some patients are too unstable, either socially or medically, to stay out of hospital long, which makes this strategy far less than perfect.

What HHS would really like, though, is for the health care system to provide appropriate and efficient service without significant oversight. This would cost them less and allow them to focus their attentions on something more interesting, like human services, whatever that entails.

In their January 26th announcement HHS has characterized the evolution of Medicare payment as a series of 4 steps or categories. The first is fee for service, which we are transitioning away from, at least sort of. The second category is linking fee for service to quality--we will still be paid according to the volume of work we do, but we will be paid better if patients are made healthier with better efficiency in how we use resources. The practice of not paying for preventable readmissions and not paying for the treatment of preventable complications is an example of this. Category 3 is paying us a little differently than fee for service while maintaining some of our present structures. The most talked about model is the Accountable Care Organization (ACO) which brings doctors and other service providers together to care for patients in a coordinated manner which will presumably save money, some of which will be given back to the providers as a bonus for doing such a good job. The other model, which works for smaller organizations, like clinics, is the Patient Centered Medical Home (PCMH). This pays physicians at a higher scale when they keep track of patients better, including having care coordinators for complex or high risk patients and making sure preventive health care is actually done. Both the ACO and the PCMH are total bears to set up, expensive, and require computer systems that function at a really high level and practitioners who know how to use them. The up front costs are amazingly high and the administrative support required is huge. Because of the massive amount of detailed data gathering and manipulation required to make these things fly, they burn doctors out and make us spend even more time looking at computer screens and less time talking to patients.

Category 4 is good, though. Category 4 is population based payment, and is the system that would reduce the need for HHS oversight. Clinicians or organizations would be paid to provide care to people for, say, a year. The incentive, then, is to make patients as healthy as possible with as little intervention as possible so that we can reduce the intensity of the medical care they need. Providing good, high quality care would mean patients are less likely to need expensive hospital stays or procedures.  This system provides an incentive for the dermatologist to take care of the little skin cancer in one visit and encourages me, as a primary care provider, to give you just the care that makes you healthy and confident. Some people actually like going to lots of doctors appointments and getting lots of tests, and they may not be pleased with population based payment. Care that makes patients a little happier for a lot more money tends to thrive under our present fee for service system,  especially with insurance paying the bills. This kind of care would happen less frequently. When better treatments do arise, there will be strong incentives to find ways to make them less expensive. Population based payment's natural tendency to improve value would definitely bring down healthcare costs. There will also be a tendency to stifle astronomically expensive innovation, which has been far more common than low cost innovation in our profit driven system.

HHS says that they hope to have 30% of Medicare patients in category 3 or 4 by 2016 and 50% by 2018.

Changing the way things are paid can be really difficult, however. This category 3, with the ACO and PCMH requirements, is so complex as to be almost impossible and maybe not even a good idea. Paying for population health sounds to physicians a lot like managed care, which we tried years ago and sometimes made us feel like jailers, denying patients care that was expensive but right for them. If patients have adequate input into what is valuable to them (it looks like the medical establishment is moving in that direction) some of those problems may be allayed. But one of the biggest hurdles is that if private insurance continues to pay fee for service, we will continue to have systems set up that push for us to do more rather than better. If we get good at taking care of a patient's needs in one visit rather than several, we may feel penalized if insurance companies other than Medicare now pay us less. HHS has decided to set up Learning and Action Networks to interface with private insurance and other payers to encourage them to adopt population based payments, which would save them money as well.

Population based payment is where I would like to see health care move, but it will be a painful transition, if it works. A huge amount of the money that goes into health care (I've heard figures as high as 50%) is spent on billing and all of the record keeping relating to that. If doctors and hospitals are paid by the number of patients for whom they provide care, we will not be billing insurers for what we do.  As lovely as it is to think of a system without billing, those people, doing that work, will lose their jobs. At least most of them will. As we reduce overdiagnosis and overtreatment, which would be a natural consequence of population based payment, hospitals will lose revenue and some of them will close, unless they can re-tool to help healthy people stay healthy. Radiology technicians and lab technicians will also lose their jobs, because much of what we do in medicine is based on an exaggerated idea of what is needed, shaped partly by generations of being paid fee for service. It will be particularly awkward to move from the very high administrative burden of category 3 to the simpler and more focused category 4 of population health and population based payment. Bureaucracies like to be large and tend to grow. At some point in this evolution they will need to shrink. Something like 17% of our gross domestic product goes into healthcare, which is a sizable chunk of our economy. The money we expect to save on more efficient health care is huge and may have a very large positive effect on something, Transitioning health care jobs to ones that are life sustaining rather than ones that react to disease and dysfunction could be beautiful, but it is not at all clear what it will look like on the way to that goal.

Thanks HHS for keeping us focused on a payment system that provides an incentive to keep people healthy, but do take it slowly and please prepare for the consequences.

Thursday, January 29, 2015

Treating the flu: does Tamiflu (oseltamivir) work and does it have side effects?

The flu season has really gotten into gear now with 46 of our 50 states reporting widespread influenza activity as of January 3, 2015. Influenza is a virus that infects the respiratory tract, causing sore throat, runny nose, fever and cough. Rarely people with the flu will have nausea, vomiting and diarrhea, but this is not "stomach flu" which is a term some of us use to describe any one of a number of viruses that give us intestinal symptoms. Influenza is the one where you hurt all over, you have a high fever and cold symptoms, then you start coughing and you can barely get out of bed for days. Sometimes it's milder than that, but it can also be more severe, affecting brain function and sometimes requiring oxygen or life support with a ventilator. It also kills people, on the order of about a half a million worldwide every year, either directly by the destructive effects of the virus or by setting the stage for a devastating bacterial pneumonia.

Flu is very contagious. A person with the flu can spread it to others for 1-2 weeks, and it frequently runs through whole schools resulting in as many as 1 in 3 children being absent from classes. The very best way to reduce the spread of flu is to have people with the flu stay away from people without the flu. Hand washing is also good. Epidemic flu usually lasts for about 13 weeks each year, tapering off toward the end of the season, and usually it's pretty much gone by March. This year we are starting with influenza A which is usually the most severe type, and the genetic signature is not one that is well covered by the present flu vaccine. The Centers for Disease Control (CDC) posted an article detailing the present flu situation. They estimate that the vaccine is 23% effective, but that is based on an odds ratio calculated by comparing a group of sick people who did or did not have the flu when tested and looking at whether or not they were vaccinated. What they mean is that if you are sick enough to be tested for the flu, you are 23% less likely to actually have the influenza virus if you got the vaccination. But the vaccine is still recommended because there will be influenza B coming around later as well as the non-seasonal flu, H1N1, which should be covered by the vaccine. There is also a chance that the influenza A you are exposed to could be one that has not genetically drifted, which might mean the vaccine would make you more immune to it.

This year's flu is a pretty nasty one, with many people getting sick enough to need hospitalization. It is not the most terrible we have seen, and is similar in how sick it makes people to the 2012-2013 season, 2 years ago. Because the vaccine is less effective this year, though, the CDC is recommending that physicians be very generous about prescribing one of the two influenza antiviral medications. These are oseltamivir (Tamiflu) and zanamivir (Relenza). Oseltamivir (which is not available as a generic) is a capsule or liquid which is dosed twice daily and costs a bit over $100 for a 5 day course. Zanamivir (also still on patent) costs a little less and is inhaled, twice daily, and is contraindicated in asthmatics since it can make them wheeze. The Cochrane Collaboration, an organization which reviews scientific data in an unbiased fashion, says that neither drug does much for healthy people infected with the influenza virus, and there is no really good data to determine if it helps people who aren't otherwise healthy or who are desperately ill with it. They both tend to make the symptoms a little less severe and shorten the duration of illness by 1/2 to 1 day. I have been prescribing them generously for years to my patients with the flu, since I know how nasty it is and have always figured that they could use all the help they could get.

A few days ago a friend asked me if I had heard anything about mental effects of Tamiflu. She said that an acquaintance of hers had a son who had committed suicide after being started on it. His girlfriend had just left him, but he was a very psychologically stable person, and this wasn't like him. She said that she had heard that the drug could make people mentally unstable. I thought that it sounded like hogwash, so I checked my handy dandy iPhone Epocrates app and found that behavioral effects and self injury were quite high on the list of serious side effects. Today I looked further into it and found that in Japan, where Tamiflu is used more commonly than in the US, they reported quite a few cases of psychological side effects, including delirium, primarily in children and adolescents within the first 48 hours that they took the drug, with something like 70 deaths. The Food and Drug Administration reviewed side effects, especially during the 2009 pandemic when Tamiflu was widely used and found that there were some psychological side effects reported, but pretty rarely. There were also some severe skin reactions, even resulting in death. There were more case reports, including a girl who had manic depressive symptoms that resolved only after a few months, out of South Korea. Tamiflu also makes about 1 in 9 patients vomit.

In general oseltamivir (Tamiflu) is safe and the influenza vaccine is safe. They are also both somewhat, though not gloriously, effective. Both are lucrative for the companies that make them. The flu is a huge public health issue, causing death and disability and work and school loss, and it repeats itself yearly, with varying intensity. Because control of the flu, even shortening illness by a day or decreasing transmission just a bit, is so very important on a population level it is likely that the down side to an individual will tend to be minimized. As an individual and as a member of a human herd, I will continue to get yearly flu vaccines and nudge my dear ones to do the same. If I wake up feeling like I got hit by a truck and then nanobots have attacked my mucus membranes with sandpaper I will probably take one of the anti-flu drugs (but maybe zanamivir since it is cheaper and probably won't make me jump off a balcony.) These are decisions, though, that individual patients should make after being fully informed of both effectiveness and potential side effects.

Tuesday, January 13, 2015

Bedside ultrasound in the developing world: what is it good for?

In the last year and a half I've been able to go to Africa 4 times and Haiti once, for which I give thanks that the world still produces abundant fossil fuels. That much airplane travel does make me feel a bit guilty, even though I'm not actually vacationing.

Going to far away places to practice medicine has always been something I hankered after, and it turns out that knowing how to do and teach ultrasound is a good way to get invited to exotic places. I think if I could do cleft palate surgery or eye surgery or had a traveling dentistry practice I could also be useful in foreign lands, but as an internist it is more difficult to find something that I can do well in a hit and run fashion which actually benefits people. Bedside ultrasound, particularly teaching it, fits the bill.

Forgive me for repeating myself if you've already heard the story, but when I quit my regular primary care practice, I learned to do bedside ultrasound. I fell quickly in love with the ability to see inside people, sharing with patients their living anatomy, quickly making appropriate diagnoses and designing appropriate management, following patients' response to therapy. I learned how to ultrasound the heart, lungs, liver, gallbladder, kidneys, bladder, spleen, intestines, great vessels, and also how to teach other people. It's been exciting and time consuming and tons of fun, and has become an integral part of my practice as an internist and hospitalist. I've written many blogs about how ultrasound has changed my practice, but I still get the question, "what's it good for?"

What it's good for varies according to the setting. A bedside ultrasound is usually done with a machine that is small enough to carry in one hand. Mine, a General Electric Vscan, is about a pound and has a screen that is just a few inches across. It gives surprisingly good pictures, but they are nowhere as good as the big ultrasound machine in the radiology suite. If that big machine was pocket sized, I'd be like the doctor on Star Trek. Because the bedside machines are smaller and less expensive than the full size ones, their resolution is a little bit worse, so they are best for asking relatively simple questions. Also bedside ultrasound is performed by doctors who also do things other than imaging and haven't spent the extensive amount of time radiologists have in learning subtleties of reading radiological images. At my hospital in the US I can answer questions with my small ultrasound machine like, "is there fluid in the peritoneum?" or "are there gallstones?" or "is the heart squeezing OK?" or "are the kidneys/ureters blocked?" I can feel confident about whether the bladder is over-full or whether there is fluid or infection in the bases of the lungs. I can see pulmonary edema and amounts of pleural fluid that are too small to be seen on x-ray. I can follow the course of intestinal distress such as gastroenteritis or obstruction. Sometimes I can't see enough to say anything, most often if the patient is hugely fat or is plastered with bandages or stickers that I can't remove. If I need to really know what is going on inside a patient who I cannot image with a bedside ultrasound, I can order a radiological study and usually get my answer in a reasonable time period. When I can look myself, though, my treatment decisions are more fluid and timely.

In the developing world there are less x rays and CT scans available, less official ultrasounds, and having the ability to do bedside ultrasound is pretty magical. There are many ultrasound machines in these out of the way places, and what is mostly needed is training. There could be more machines, of course, and when it becomes more clear how useful the technology can be, more resources may be focused in that direction. I have ultrasounded in Tanzania and South Sudan and the island of La Gonave, off the coast of Haiti, and the procedure, quick, painless and free, was profoundly influential. Last month while I was in South Sudan there was a war on nearby, and there were freshly and not so freshly wounded soldiers, which was a new thing for me. Here are a few cases of exactly what ultrasound has been good for in the developing world:

1. Young man with a gunshot wound to the leg. Is it broken? Is there a pus collection? Ultrasound is really good for ruling out long bone fractures and finding subcutaneous fluid collections. The wound was only in the muscle and a little cleaning and bandaging did the trick. No need to transfer this one to a higher level of care.

2. Different young man was injured in the face with shrapnel. He is unable to see out of one eye. Is the retina damaged (a bad sign)? Ultrasound is quick and efficient as a tool for looking at the eye, especially if the patient is unable to open it for an exam. This guy did have a thickened and abnormal retina with evidence of blood in the posterior chamber and a metallic foreign body. He is not likely to get his sight back in that eye.

3. Little boy shot in the chest and short of breath. Is it a punctured lung? A burst blood vessel bleeding into the chest? Is the heart damaged? For this boy it was none of these things, but a contusion of the lung, which looks a bit like pneumonia on ultrasound. A chest tube would have further compromised that lung and the boy avoided this procedure. Where is the bullet? It would have been great to have an x-ray to find that out!

4. A young woman with vaginal bleeding after three months of thinking she was pregnant. Is she having a threatened miscarriage or is this just an irregular period? Ultrasound is wonderful for seeing a uterus and whether there is a baby hiding inside. We saw many of these cases. Sometimes there was a baby, sometimes not. The treatment, bedrest vs. normal activity, was very different and knowing which was indicated could profoundly impact the whole family.

5. A little baby with an enlarging lumpy area on the lip. I could just imagine all of the creepy things it could be. The ultrasound showed it to be made up of blood vessels, so it is a cavernous hemangioma, which is a common benign tumor in infancy and usually goes away or shrinks by itself, and sometimes requires medications to help it go away.

6. A young man has been getting weaker, with swollen legs and a barrel chest. Is it heart disease? Perhaps something he was born with? These might be treatable with medications. Unfortunately it was not. There was a huge tumor obstructing blood flow to the heart and lungs. Good to know, though heart wrenching.

7. An old man, failing to thrive. He has back pain. Ultrasound shows he has a large bladder tumor which is blocking his kidney. Caught this late, and in a war zone, this is not treatable. Knowing helps his family to make plans.

8. An uncharacteristically pudgy woman with recurrent abdominal pain. Is it an ulcer? Actually no, her gallbladder is full of stones and is tender to push on. Surgery will help, and this lady lived in a place where that was safe and available.

9. A young woman with pelvic pain. Is it a tubal infection? A bladder infection? It is not hard to visualize the abdomen and pelvis with ultrasound, and this person had a ruptured ectopic pregnancy with blood loss into the abdomen. She will die without surgery and she will likely do fine with it. She was rushed, appropriately, to surgery.

10. A woman with a full term pregnancy: she hasn't been feeling the baby move. Is it in trouble? Ultrasound is absolutely wonderful for looking at babies, since they float around in a big balloon of water. This woman's baby looked healthy. Good news.

11. A woman acutely short of breath, with some chest pain: is it asthma (common) or her heart? Strangely enough her heart wasn't squeezing very well and her lungs looked wet. She responded well to medications for pulmonary edema and was fine the next day. I have no idea what that was about, and can't find out further because I'm home and she is probably lost to followup.

12. Pyomyositis: people get collections of pus in their legs and sometimes arms for no obvious reason. Then they get very sick and if the pus is not drained, they die. When a leg is swollen up it's pretty hard to know where to cut to release the pus unless something like an ultrasound tells you where it is. We doctors love draining pus. The young man in question, a retired child soldier, had relief of his condition and will get well.

13. A soldier, clearly sick after being shot in the belly: Has the bullet injured a blood vessel or vascular organ? Is there a significant amount of free air to suggest a major intestinal perforation? The FAST scan (focused assessment with sonography in trauma) looks for fluid, usually blood, in the belly and can determine whether a patient needs emergency surgery, if available, to avoid bleeding to death. Lots of free air looks like air anywhere, with air artifact and multiple parallel horizontal lines. This young man had peritonitis, with thickened bowel walls, fluid filled bowel loops and small amounts of fluid between the intestinal loops. He was transferred to a higher level of care after receiving antibiotics and fluids.

Also...babies with loud heart murmurs, young men with testicular swelling, the worried well...
Ultrasound in the developing world is great!