Wednesday, August 20, 2008
So much for new ideas.
But on closer reading, the point must be accepted; that value is created as much by the arrangement of resources as anything else. The road to success is a via well though-out plan for execution in the context of a good understanding of the strategic landscape followed by a whole lot of luck…
The trouble with many people’s notions of how to bring business innovation to health care is that they are saddled with assumptions that apply to other aspects of the business world, but do not necessarily apply to health care.
For example, competition in health care frequently leads to increased consumption. Price transparency has the potential to paradoxically lead to rising prices, rather than price competition. (“Have we got a sale on brain surgery this week!”) The fact that a third party pays for the services completely distorts consumer behavior. And yet, health care is an under-estimated contributor to overall economic output.
Before trying to introduce innovation in health care, one must first acknowledge the structural reasons that argue against changing anything. Why adopt EMR? It doesn’t add value to the health of the patient in front of you. Frankly, it only adds work with the hope that someday in the future the collective information derived from such systems may improve something or other.
The real innovations in health care are related to the development of new technologies. Tagamet was a pill that nearly cleared surgical waiting lists (anyone remember how many vagotomies and pyloroplasties filled OR lists in the early 80’s?) Then laparoscopic surgery nearly destroyed the financial viability of half the hospitals in this country by reducing length of stay for surgery that would previously need four or five days in-house. Radiography got killed by CT which is displaced by MRI which will succumb to something else. Chemo has come so far that cancer survival rates have been upticking for the past three or four years. Certainly I have missed an awful lot of revolutionary medical innovations of the past two or three decades, but these are some which come to mind.
EMR will never be on this list.
Shared decision-making is not here.
Evidence-based medicine is of tremendous value but is certainly not a revolution.
Group medical visits for chronic disease will not bring down the walls, nor will disease management, case coordination, Health 2.0, concierge medicine, new insurance paradigms or new models for primary care training.
These items, which have engrossed my attention and dominated my interest for most of my career are not revolutionary technologies that will disrupt everything we now know about health care.
A bitter pill, perhaps, but innovations still make their way into health care delivery… the question is how?
Monday, August 11, 2008
It was famously published at the peak of the Internet boom. I'm not kidding, it was published in May 2000, two months after the March 10 intra-day high on the NASDAQ. It is filled with examples of companies that had come to understand how to create value from the arrangement of their intangible and difficult to measure assets.
Most of the companies no longer exist and the ones that survive today have learned how to value their assets in more old-fashioned ways than relying on intangibles. The authors never mustered the credibility to write anything else, except for Barry Libert who runs a blog for Amazon in between other ventures.
Enough time has passed to forget about how Arthur Andersen stretched the truth on their audits under a lame premise of reflecting the true underlying value of all those intangibles. But the temptation is always there to throw the baby out with the bathwater. The authors had a point. The true value of many things is not reflected in their price; the market for products is never efficient the way equity markets are. There is a strange rationality to economic decisions on the micro level but it is not always the correct decision based on an external objective framework.
Spock once challenged his father about marrying his human mother rather than a rational, logical Vulcan woman more like him. "It seemed logical at the time," was Sarek's response. So many things that patients do seem to have been sensible at the time.
A book on value written at the peak of a financial bubble teaches me that things may seem valuable or not based on a sentiment framed by the times. I'm not going to throw the book and its ideas out because of bad timing.
What is particularly relevant is that we are all looking for more value out of health care; patients, doctors, payors... everybody. But what value is that exactly? Value is perspective-dependent and has to be defined. It is hard to believe that an employer with a pension and health care benefit liability and a managed care insurance company define value the same way. Certainly a physician and a patient don't quite see ye to eye, but it's a better bed-mate than a Wall-Street reporting insurance com pany.
I've been looking at what primary care physicians do in terms of risk assumption and asserting that reimbursement is inadequate for the level fo risk. But risk (specifically the risk-management skill of the physician) is insufficient only a part of the determination of value to the patient. A lot of decisions depend on how that value is perceived at the moment. Illness has a strange way of changing the perception of value from a treatment!
More to come...
Thursday, August 7, 2008
This was in 1989. And nothing has changed.
The Post reports on the USPSTF revision to PSA screening recommendation, downgrading prior enthusiasm. Note the recommendation is not to deny screening. It merely states insufficient evidedence at this time to support screening. The major difference from prior recommendations (as far as can tell at this point) is the withdrawal of a half-hearted OK that had been given to people at high risk, like African-Americans, people with a family history and especially, men over 75.
The level of protest is remarkable in its lack of scientific integrity. "Too bad, we're saving lives." Well, that's not what the data shows. Men are living longer since PSA screning has become widespread is the same as the autism argument. Maybe men are living longer because of MMR. Have you ever noticed how males get autism more often?
At the risk of offending my favorite urologist, PSA'a are remarkable at their ability to efficiently generate billable procedures (i.e. trans-rectal ultrasound guided biopsy). Those with the greatest interest in a recommendation for universal PSA screening own surgical facilities or benefit from the procedures generated.
The USPSTF is a government agency and since the government, as the country's largest payor, may be construed as having an interest in decreasing its expenses, this agency is not beyond a natural incentive to skew its conclusions. But if you think it through, it means that the standard of proof is necessarily higher. This kind of bias is one I can buy into as more trustworthy. Personal opinion.
The bottom line is that the more people I do PSA's on, I will probably save a life or two, but at the cost of several people going through unnecessary stress, procedures and complications. The sad part about prostate cancer is that the PSA will also detect a number of cancers for which treatment will fail, or be irrelevant due to intercurrent illnesses. By not doing PSA's, I can keep several people peacefully in the dark, but miss one or two cancers that could be impacted. Those people whose cancers are missed but for whom treatment will have no impact also represent a huge malpractice risk. These people are the ones most likely to sue for missed diagnosis, even though the truth may well suggest a different conclusion.
The USPSTF did the right thing, but it would be interesting to revisit their original endorsement of high-risk screening and what changed in the data to support a change in recommendation.
Saturday, August 2, 2008
It is a brief and digestible history of the idea of compassion. It made me consider how the religious right views the morality of health care as a kind of theological experience of salvation through pity. It is truly opposed to (may I say positivist?) humanist notions that arose during the enlightenment. It is interesting to me, although perhaps unsurprising, that the origins of both liberal and conservative American political discourse lie in the Enlightenment. Smith and Rousseau are cut of the same material, albeit opposite surfaces of it.
The idea of health care as a right seems to be based on pure sentiment as a moral center, pushing a political process to assuage the suffering of those people for whom we feel sorry. The natural objection would be "Hey, what about me. I've worked hard. I've made all the right moves. These people are suffering because they screwed up. They have no right to anything I didn't have when I made my choices."
Naturally the truth is likely to fall somewhere in between these two positions. Helping people for whom we feel sorry tends not to help them. Conservative thought reveals that some programs create a tendency to dependency which should offend any liberal. But the doctrine of personal responsibility is a sham because it assumes that every choice is made from the same perspective, with the same natural abilities and skills and assume the same opportunities. Once the playing field is leveled in terms of genetics and the psychological, social and economic background of upbringing and then we can talk about personal repsonsibility as a political ethic.
What else have I learned? I have been using the term "enlightened self-interest" without understanding its pedigree traced back to Rousseau. Montesquieu's adherence to the idea that commerce increases "humanity" is close to my heart and sounds a little like compassionate conservatism without the religious wingnut contribution prevalent in American political thought.
Rousseau's attachment to equality is cloying. Nobody really believe is equality any more, do they? Given equal opportunities, no two people will ever produce the same value or achieve the same success, irrespective of the perspectives by which we judge success. It is often difficult to feel compassion for people whose own worst enemies are themselves. Ask any doctor who has ever seen a dysfunctional human being as a patient.
On the other hand, Rousseau's criticism of amour-propre is, in my eyes, an unerringly accruate criticism of America's vomitous middle class self-adulation: the best reason to deny health care to the poor is that I didn't have that advantage growing up and now I am rich and they are not. It discounts the central role of luck and chance and the Grace of God in determining success.
I do not understand the relationship of "modern moral realism" to the neo-con realpolitik of the 20th century. It is difficult to think of paralels between Rousseau and Donald Rumsfeld in the same chapter of political ethics. Rousseau's addition of sentiment to "enlightened self-interest" diminishes its value while the neoconservative denial of it simply darkens it.
Tocqueville's obesrvations should resonate to those readers that have recognized the degree of alienation and isolation in which we live. To find democracy partly responsible for any part of our modern angst is a mind-bending and sadening thought. But perhaps there is something to the fact that people who are more or less equal have little need for compassion as they go about their business.
Nietzche, like Ayn Rand, I still find sickening in that they both propagate this modern sense that the world is there to be controlled. It is the prime message of the serenity prayer to indicate that control is an illusion, yet the 21st century is filled with the drive to control and the anxiety which follows the failure toi control the uncontrollable. Resources, such as money, friends and power, come naturally to those who are best capable of managing and stewarding resources. That does not mean they come to those most willing to nakedly seek them.
So health care is a resource and an intermediate end to the well-being of others. It is an intermediate end because the final end is well-being itself. One cannot be well if one is not healthy but one can be healthy and decidedly unwell; from a philosophical, social and spiritual perspective. health is not just about CT scans and MRI's. Many have argued that health care is a waste of societal resources given the impact it has on the well-being of populations. I respectfully disagree, in that we still cannot measure neither health nor the contribution of physicians and other health care workers.
At the end of the day compassion as a sentiment will probably fail as a justification for health care and reform. On the other hand, a purely utilitarian approach suffers form the lack of empirical method and data. This article, strange as it seems, serves as a stepping stone in the evolution of my thinking about the purpose of health care and health care systems.
Friday, August 1, 2008
The thing that brought this to mind this cool coastal morning (yes, we're traveling) is the Lancet's publication of a study out of Seattle's Group Health Cooperative that challenges the degree of protection from influenza vaccine against pneumonia.
Influenza immunization of the elderly was close to my heart during my training. I often thought our approach was too soft, resulting in a 15% immunization rate at the time. Changing the message to a hard-sell, marketing-driven and (some said) fear-mongering approach improved our center's immunization rate to 50% in one season. However the numbers were small, so I barely achieved statistical significance (after considerable torturing of the numbers, I might add) and the study was presented but not published.
Most of all, the public health folks I worked with were leery of such an aggressive message. I protested that the 30 - 50% reductions in hospitalizations and mortality spoke for themselves. How could anyone exercise a different choice when the rational conclusion was so obvious? I never understood why my approach had been so unpopular.
By the time I moved to the states, I gradually became more aware of a public health approach to health messages that resembled marketing. Most notably, CDC's Julie Gerberding seems to have established an unprecedented emphasis on "communications" within her agency. For a time, I remained convinced of the soundness of this aggressive approach.
But as my career developed I started to perceive the flip-flops in medical recommendations. We thought nopbody should eat eggs due their risk of developing cholesterol problems. Then we thought it was OK to eat eggs and meat, even in a cholesterol-reduced diet. Now we worry only a bit about dietary fat as we start to concentrate much more on carbs. Anyone care to tackle estrogen and the risk of breast of cancer or heart disease?
Of course, this dialectic is part of the scientific process. Only people who know their methods are merely an approximatiopn of the truth are willing to make absolute-sounding statements and remain prepared to revise them on a moment's notice. In fact, scientists are only being absolute about what is known. Based on the best available information, we can say things with certainty that will be revised with new information.
This ain't the Bible folks, and even then... well maybe some other time we can discuss exactly how this library of books was assembled by bishops of the early church.
The new data is that the benefit of influenza vaccine is not as outrageously high as once believed. Perhaps my residency overseers knew something about original estimates. A better method for controlling the severity of illness reduced the magnitude of the apparent effect by simply reducing confounding. We give flu shots to the frailest of the elderly, so we over-estimate the impact on a large population who may not be quite as frail overall. Good job! The vaccine is still protective, and I still think anyone who avoids does not have the right information. But clearly, it's not criminally insane to say "I'd rather not."
Sometimes, skeptics rule!
Wednesday, July 30, 2008
I doubt there is a physician alive today who would not wish to improve the level of care she wants to provide. There may be disagreements in how to achieve such improvements, but browbeating is frequently counter-productive. Personal experience suggests that there are at least as many people out there who like to blame physicians for all the ills of the health care system as there are enlightened, inclusive systems-oriented people who work at developing consensus.
Physicians dread the moment when some quaint individual in a business suit calls a meeting so that we can talk about improving quality of care. The first shudder is caused by the simple notion that someone is to judge you work. Sometimes it takes a physician to understand the angst of a physician contemplating a bad outcome. There are memories of surgical grand rounds as students when the only things not flying were the scalpels.
The second shudder is the one that reminds physicians that they are the ones that will be sued, brought up on charges, reamed by administration or blamed by the community for outcomes they know full well depend on an entire system of care; a system which frequently appears too busy criticizing to see that it itself is broken.
What is quality of medical care anyway? The deeper I look into it, the more convinced I am that nobody knows. From a physician's perspective I can tell you with considerable certainty that it remains undefined and unmeasured.
That does not mean we cannot make some feeble attempts at understanding the beast! Patient satisfaction is a muddy concept borrowed from marketing. It is hardly "quality" as a physician thinks of it. It seems to be influenced by things like cleanliness, the age of magazines in the waiting room, the receptionist's attitude and other things unrelate to the physician's performance. In fact, many of these "Disney" factors are unimportant to many physicians. It's part of the administrative headache that needs to be taken care of by somebody else so that they can do their job.
Despite the lack of credibility and scientific weaknesses of the patient satisfaction paradigm, it is not a bad place to start. It helps us understand the patient's experience and work within it more effectively.
Wrong site surgery is not the be-all of quality. It does not effectively tell us how good the surgeon is, how she handles tissues, secures hemostasis, obtains a good cosmetic result when necessary or their ability to "get all the tumor". But it's a good place to start.
Overall health outcomes are a complex thing to study. Population health may be unaffected by provider practice patterns (I'm referring to the Dartmouth studies), but this is not necessarily a bad thing or something for which physicians are to be blamed. It is a fact to be taken into consideration when making overall policy decisions. But every physician knows, from bitter experience, that heroic measures have been wasted on patients whose own behavior keeps putting them in the way of harm. The cirrhotic who still drinks, the smoker with cancer or the welfare mom who gets pregnant in a drug-induced haze. Most docs know the best way to avoid poor outcomes is pick your patients, which is often as easy as picking your neighborhood. There is nothing wrong with helping the chronically over-served, but such people have better outcomes than their socio-economically deprived brethren, no matter what.
We may not yet be able to adjust for all the determinants of health outcomes, but I get a feeling from the literature that we can predict better than 50% of those factors. It's not up to the usual scientific standard of certainty, but given the extremely wide range of outcomes, it's not a bad job.
The problem with medical quality is when we approach it as an incontrovertible truth and use it as a weapon to flog the heck out of the most visible and central instrument in the provision of care: the physician. Nobody is going to improve the delivery of health care in America without the active participation and involvement of those people who deliver medical care and whether you call these people doctors, physician assistants or PhD nurse practitioners, those people will resent being beaten with the product of their own work.
Maybe acknowledging the limitations of our ability to understand, measure and improve medical outcomes and quality would yield a better result.
Thursday, July 24, 2008
Shopping at Costco, you always notice the overstock items run in a small number of sizes. Somebody overestimated the number of items manufactured in a given size. Sometimes it's easy to find your size, which probably means it was either butt-ugly or mis-priced.
My size is not easy to find. People with 18 inch necks are not usually 34 sleeve. You can find 18/36 and 17/34, but 18/34 just ain't easy.
I have message for the "shmatta" industry: America is getting fat! I'm not proud of it, but facts is facts and I'm not getting any younger, thinner or hairier on the top of my head. America is getting fat and the population's obesity no longer looks like a bell curve. Stop making clothes for the ideal of the human form and you will lose less money in unsellable overstock.
One good thing: tomorrow is the day I will start to exercise, knowing I finally found an 18/34 and will have a shirt I can wear to my next interview!
Saturday, July 19, 2008
For example, I was recently asked in an interview for a medical management position why "doctor's didn't do as they were told?"
Nearly a decade ago an administrator asked me "why all us doctors wanted to do was anything but see patients."
I was confronted by a patient and told I was greedy, that's why I spent so much time on the golf course. (There is a non-sequitur in this statement that I am at a loss to counter. Not only do greedy people spend little time recreating on the golf course, I gave up golf years ago because I couldn't get the ball past those little windmill blades on the mini-putt!)
It probably does relate to the landscape of economic activity and how it has come to treat the healing profession. After all, Arnold Kim's story shows that it is possible to make more money writing a blog than practicing nephrology. I guess you just have to put your mind to it and be ruthlessly realistic.
Don't get me wrong, I enjoy seeing patients. It's the noise that bothers me; the administrative, governmental, para-health professional pandering BS that gets in the way of simply being a diagnoser, counsellor, treater and hopefully confidante to another human being.
At some point it becomes possible to gain more professional satisfaction working as a blogger than a physician.
Yes it IS the economy!
Thursday, July 17, 2008
Interviewing is always a fun activity, and one which I am getting good at, with some mixed feelings. Physician groups with a strong professional streak talk about independence and the lack of managed care in their practice, important people in town who come through their doors and unlimited compensation based on how hard one is willing to work. We never hear about the price on one's family and loved ones of giving up nearly all leisure time to "properly" take care of people. Sometimes medicine can have a strange culture.
Service organizations, especially with public governance tell you their civil service salaries up-front and proceed to tell you about their wonderful government benefits. Intangibles count, I guess.
Teaching groups always talk with pride about full-spectrum family medicine, including ward service for children and adults, maternity care, nursing home, etc etc etc. It's a bit like an extension of professional pride with a service twist, but this is a rural area and family docs can get away with being "stem-cell" physicians. Any city worth its salt has enough specialists to prohibit the practice of being a true generalist. It seems vaguely unfair, but the other concern is that physicians are now guarding their lifestyles a little better than they did a couple of generations ago. Why would anyone want to be an internist, a pediatrician, a hospitalist, an obstetrician, a teacher, a manager and a business-man at the same time, even if they may be capable of doing some of those things on some occasions?
All I want is to sip wine from my deck at home on top of a desert river gorge with snow capped mountains off in the distance at the end of a reasonable day's work with some challenge but a minimum of heart-ache!
I know, I'm nuts!
Saturday, July 12, 2008
My surprise is that, in this day and age, any animosity between nurses and physicians still exists. Notably, a physician points out that the medical knowledge base is different from that of nursing's and that our training is complimentary. This appeared to unleash accusations of arrogance, apparently interpreting Happy's comments as an assertion that physicians are better than nurses.
I find it interesting that the accusation came from nurses. In the post-modern world, meaning can come at us from so many different directions. It is funny how an assertion can contain a strange, almost metaphysical evidence of the contrary.
To Guitar Girl RN, I say, Rock On. I'd work with you any day of the week.
Thursday, July 10, 2008
I'll keep the juicy details to myself, but the procedure I underwent today was interesting to say the least. I suppose every interaction with the health care system, upon which I pontificate with such earnestness, becomes an opportunity for reflection.
I was at an out-patient surgi-center accredited by The Accreditation Association for Ambulatory Care, not the Joint Commission. Yet another reminder that there are alternatives to the current accreditation structure enshrined in Congress' instruction to CMS. The principles of patient safety are straightforward and best practices are not intended to be expensive secrets.
The first thing I noticed was the regularity of all the questions required to assure safe surgery; name, DOB, surgeon and procedure were verified ad nauseum. Well, three times to be exact. It was busy and you could tell. The nurse that called me in from the waiting room butchered my name while carrying on a conversation with someone down the hall on the way to my changing room. She was one of those old-school nurses who has the answers for anyone on the floor who needs a hand. I trained with nurses like that and they're great. They are all business and have little time for molly-coddling. Everyone else acted with requisite sensitivity and professionalism, but you couldn't help but notice the fact that they were hurried.
The surgeon came highly recommended. He was one of the first in the valley and is known as a consummate, fast, precise proceduralist. Again, he is a no crap kind of guy; my wife's response was "No bedside matter. None. Whatsoever." It made me think of the Joint Commission again and their "bad boy" witch-hunt. Just to be clear, my surgeon is not the type to throw temper tantrums and such behavior is not acceptable under any circumstances, but there are better responses than a bureacratic regulation by an accreditation agency. As an aside; there's no crying in baseball and no whining in medicine!
Across the street is a Planetree affiliate hospital where my wife had her surgery a couple of months ago. They were every bit as professional as the surgery center , but the level of hand-holding compassion, empathy and care was just what my wife needed. This "patient-centered" approach is what gets you designated a Planetree hospital and I appreciated it more that I can ever articulate. This is the quality that most consumers see and what they frequently understand as quality of care.
I was more concerned with the manual skill and judgment of my surgeon and even that is purely subjective information gleaned by word of mouth. I was looking for qualitative information which cannot be expressed in numbers or percentages. Either way, I have regualry been impressed by the level of skill and compassion to be found in this little Western desert town. It's a darn sight better than anything we had in Maryland. And Atlanta... puh-lease!
I think the wave of consumerism overtaking health care is a good thing; after all we are all in it for the patients. But we would all be well-served to remember that quality has many nuances. Patient satisfaction is determined by "soft" features of health care delivery; things like compassion, caring and cleanliness. They offer dignity, more than anything else. Important as dignity is and as much as I appreciated the Planetree experience, it is not "right patient, right intervention, right time" which is all we know how to measure accurately.
Given my interest in quality of care, the uninsured and the public health impact of health care, it raises some other interesting questions. I believe that everyone is entitled to basic quality health care, but quality costs money. Oak-panelled walls and Louis XV chairs in wating room with a library of 19th century first editions make me happy, but if we define quality in terms of hotel services, speed of service and Planetree-style amenities, we may not be able to afford Healthcare for All. There is a fundamental conflict between two currents which I see as part of the same consumer-based movement.
Quality costs money and at the end of the day, we have to decide how much of it we can pay for and perhaps try to define what aspects.
Thursday, July 3, 2008
On vacation, with internet access problems, a market melt-down and the intense heat... oh the heat. Well, I'm the guy who wanted to live in the desert!
This is the summer of our discontent.
I was having a discussion with a colleague about the option of going into practice for myself versus being an administrator at a larger organization. This is probably a good time to evaluate what I've been doing.
I spent over a decade in medical education, got the admin bug and realized that primary care and universities had such disparately aligned incentives that university-based residencies did not represent a fruitful future. In fact, university-supported, community-based affiliations appeared to be the best compromise for a primary care training program.
Armed with an MPH and a desire to develop my management skills, I found an FQHC and had a great 3-year ride where I helped stabilize and grow an organization that served 10,000 of a potential population of over 100,000. I started yearning for greater growth, a larger organization and most definitely a smaller town without any beltway-style traffic.
Unfortunately I did not heed the words of an adviser who made the point that the majority of organizations in this country make medical practice and medical management particularly unpleasant. The last six months must be characterized as a failure, although the challenge was huge and clearly evident at the start.
So, in this context, my colleague was asking why I wanted to continue working in management. It is a good question, given that I believe that good management is invaluable to physicians. Perhaps I can be forgiven for having a bad taste in my mouth for the people I have worked with and for generalizing to the world of medical management. The sad part part is that "good medical management" is awfully hard to find and I am nobody's cavalry. The good organizations don't need me and the bad ones will chew me up.
But it's due to be a beautiful and hot weekend here in the desert and remember, it's not the heat... it's the humidity! Have a great 4th of July.
Saturday, June 21, 2008
Some things catch my eye, in both the medical and management literature that are worth passing commentary. I sometimes feel as though I have one foot in each of two different worlds, as though Alice were in both Wonderland and Kansas at the same time. These moments are probably not worthwhile subjects for a doctoral dissertation, but together I hope to generate some insights into both management and the practice of medicine.
That has always been the purpose of this blog.
A couple of medical management PhDs were writing in a journal for physician executives about core values required to be a customer-centric physician. Some of the core values are very familiar to physicians and easy to advocate. Those values include a belief in the importance of patient-focused service, patient-friendly service, listening to patients, working in a team, and the importance of people as individuals.
Mom and apple pie, right? Until you get to the last sentences: "You must remember that patients are honoring you with their care. You must convince them that you are honored to care for them."
This statement is true in almost every industry but medicine. Fact is that medicine has been sheltered behind a kind of social contract that, in the US, is in tatters. Physicians received several social and economic advantages in exchange for taking on some very difficult responsibilities.
Not only does policy have to take into account the fact that this contract no longer exists, but that its demise has left a wealth of bad feelings. Given the level of demoralization amongst physicians, it is difficult to feel honored about caring for a patient who does not really want your medical opinion or comes in demanding a service you don't believe is their best interest and moreover to do so in an environment of legal threat and diminishing reimbursement.
Given the deteriorating supply and demand equation in primary care, I am not so sure who should feel more honored to be in a physician-patient relationship. Frankly, I frequently work on empowering my physicians to say no. They will not face recrimination from administration if they refuse narcotic refills, unnecessary referrals or anything which goes against their better judgment. I have advised young providers reduced nearly to tears by dysfunctional patients not to waste their passion, energy and vibrancy on such patients.
For primary care to have an impact, it must be focused on people most likely to benefit. Motivating people (as in motivational interviewing) is necessary, but only in places where there are enough resources to meet the demand of already motivated patients.
Perhaps if the threats were minimized and morale improved, then it would be easy to engage physicians in being patient-centered and delve into the patients' unique perspectives. I firmly believe that physicians actually enjoy taking care of patients and would willingly explore ways of improving the care they deliver. What they don't enjoy is having to comply with external prescriptive recipes because being told they are doing a crappy job, all the while intuiting that they don't really control the outcomes they are being criticized for.
Perhaps policy and management stakeholders would do well to remember that it is ridiculous to talk of customer service when the second most important customer (the physician) is so poorly served by the system.
Thursday, June 19, 2008
She was a friend of mine.
We met at the University where she worked as a transcriptionist. She was quite a bit older than me, but we kept bumping into each other at coffee. I tend not to stand on protocol or social class, and shee seemed impressed that one of the the doctors would spend as much time talking to her. She mothered many of the staff and I was no different.
We bumped into each other outside work, in coffee shops, the more Bohemian restaurants in town and the occasional Tom Waits hangouts that have nearly disappeared from Atlanta's landscape in the years since I left. She would dress up as a tiger at Hallowe'en with what she called her tribe and they would march into Yuppie nightclubs, a motley crew of costumed animals, subversives and misfits.
I ran into her with various girlfriends during my exploring days and we had dinner to discuss them. I absorbed her advice and through the years, on reflection, her reflections were unerringly true. We discussed my dreams and plans and aspirations. Hers were limited somewhat, by her enviable ability to live vibrantly in the moment. I have never met a woman who lived more in the present.
She was a Buddhist who lived with a phone company technician in a gentrifying part of town. She loved to garden and occasionally offered me herbs she had grown, which I used (to cook with.) She had a big shaggy dog and two cats, her house smelled of incense and patchouli. She painted and I tried to encourage her. I asked to buy one of her paintings, but it was one of her favorites. She sold it to me a few years later when she needed money and she knew I wouldn't haggle with her.
Perhaps it was because of this relationship and my earnest innocence that I completely missed the flirtatious undertones of our conversations. In the end she remained a friend.
But I sometimes fear I am not a good friend.
Her friend called me once, not long after I met the woman who would become my wife. Toni had breast cancer. She was refusing treatment. I called, we caught up and the next thing I knew I was driving up to the mountain town she had moved to without her friend. I took my future wife in hand to meet my muse.
Toni was afraid, perhaps more afraid of the drugs than of the disease. It turned out she was in active treatment, if you want to call it that, with herbal treatments from an alternative medicine herbalist in the mountains. I knew where she was coming from given her personality and her beliefs. I felt it was her right... informed consent and all that, you know. I told her she really needed to think about medical treatment, but she looked so good and I was caught up in a relationship that was finally working, that I talked to her only once after that.
I got concerned when I started getting her answering machine and she didn't call back.
I was more concerned when I found that the number was disconnected.
I lost her friend's phone number.
I didn't keep in touch.
I got married.
I started a new job.
I found her obituary online. She had died the week I proposed to my wife, just a little over four years ago.
I think about Toni often, especially when I worry about why I don't keep in touch with my family or friends as well as I should. I think about her fears as I watch my wife make scary decisions of her own. Today, my wife is having her fourth breast biopsy in less than two years. She went through the chemo, radiation and drugs that Toni dodged. It's always a struggle and we have been blessed with good doctors, good coverage and no money concerns to affect our emotionally-laden and very scary decisions. They are difficult enough to make as it is, even if I am a medical person.
I pray that Toni is in the arms of the mother goddess, probably with a sad smile on her face, knowing that this is just one more thing that I need to go through for my own sake, even as it pales to what my wife is going through.
Wednesday, June 18, 2008
According to a June 11 CMS announcement, doctors will have to reconcile their NPI data with their IRS legal name data in order to get paid.
It is a befuddling regulation since, as an employed physician, 100% of my billings have gone to organizations that paid me a salary. Why check my provider identifier with my tax information. They don't correlate. I can pretty much promise you that they never have and sometimes the discrepancies have been fairly substantial. When I worked at a residency, I could bill enormous amounts of money for services I supervised, but was paid a pretty paltry academic salary for the privilege.
I am sure this will be a huge problem for docs in practice who bill under their name and get paid directly. Any discrepancy in any character in the field will ensure non-payment. This is not the kind of thing your laptop spell check will prevent. If this regulation is enforced to the letter, it will assure that services are provided free of charge.
I bet that this billing "error" can also be enforced as fraud and abuse, leading to criminal charges, treble penalties, and time in jail. I hear PhD nurses want to get into the practice of medicine... could you please remind me why anyone would want to do this?
And I thought insurance companies were the best at playing the game of using regulation as an excuse to get out of fulfilling their obligations. CMS must be attracting former insurance executives.
Monday, June 16, 2008
Some treat health care as an entitlement. It is the right thing to do because nobody should ever go without access to care in the face of illness. Illness is frightening, as are many other things in the world. But fear of getting sick is about as good a justification for universal health care as universal access to... say, attorneys. It may be a good thing to do, but I would rather push for universal access to information.
Many physicians see the health care system as a vehicle for the intellectual challenges and exercises in skill required of the practice of medicine. As an exercise in meritocracy, health care should be more available to those best able to pay for it. There has always been and will always be value in having uncommon skill or knowledge. I firmly believe that this drive, rather than the profit motive, is what pushes most physicians to specialize, sub-specialize and constantly and marvelously push back the limits of what can be done with the human body.
Health systems are also an opportunity to find a margin. Yes, health care is a business and in America, profit is not a dirty word.
Health care is also as "issue" for politicians, and to the extent that it affects voters, it influences the government agenda. It represents a way to get a vote.
Health care can be seen as a public health measure, which I tend to do. This suggests that those interventions that are most likely to help the health of populations (as distinct from the health of individuals) should get the most resources. With all due apologies to my sub-specialty colleagues,who are critical to our health care infrastructure from many perspective, it is here that primary care wins out hands down.
In fact, the broader the definition of health, the less medical it becomes. Securing water, adequate shelter, safe employment, reliable food sources, traffic safety and basic literacy are health issues that hardly fit into our usual conception of health care or the current reform debate. Immunizations, prenatal care and primary care are the most cost-effective things the medical world has to offer. PAHO and WHO publish guides for policy makers.
A health system like ours is at cross-purposes. Many advocate a total overhaul but that's not how change happens. Incremental change is more likely. Even if we were to reach some sort of tipping point in technology, or delivery, or insurance we will not likely see a complete change in a high resource service sector. Despite the complexity of the health system, care is still delivered one-on-one. All other discussions remain MBA-speak appropriate for the Harvard Business Review and little else.
Don't get me wrong, I like what I see in the health reform world. I like Dr. Val. I like Steve Case for that matter. I think what they are doing in consumer-driven health care is valuable. Jay Parkinson sounds like a smart guy and I might even ask him what he thinks about spreading his model to rural areas. I believe that the Future of Family Medicine project has enormous potential for change as evidenced by the TransforMED project and the rising popularity of the medical homes concept. PHR's have potential. RHIO's even more.
But none of these ideas are sufficiently transformative to represent the answer to a broken health system. Together, they represent a significant change in direction that incrementally may have an outsize impact.
The single notion that could have the greatest effect is the one that says we cannot and should not provide for every possible health benefit under the sun.
Rationing by cost (a barrier to access) is more acceptable than rationing by mandate, regulation, insurance company ruling or queuing. No rationing does not exist in any industry.
This means we must prioritize the things we cover. We make decisions all the time about what is covered and what is not covered, but we currently decide based on politics; that is to say the sum total of influence exerted by stakeholders and lobbies.
Frankly, it's not a bad way to do it; I don't believe in central planning. Look at Canada. But a better way to do it is follow the data. Otherwise every right wing crackpot and left wing entitlement-creator will have outsize say according to the way the political winds blow. Right now, we have two nutty ideas floating around: one way is expanding health care coverage under government tutelage and the other is giving tax credits to poor people to buy health insurance. As far as I'm concerned, government should only guide and create an environment for market forces to accomplish common goals (in this case, health.) Expanding government programs is not the way to do it. Tax credits for poor people are ridiculous; I can't get my poor patients to spend on bus fare if there is no IMMEDIATE benefit.
McCain is also promoting an idea to allow insurance companies to compete across state lines. Bob Vineyard at Insureblog seems to feel it won't work because of differing state mandates (the analogy is with credit card companies). In other words, states are already making choices about which benefits are to be covered. This may be viewed as rationing, or alternatively, choosing which parts of health care to subsidize. In fact, I prefer the subsidy position, because it puts us on more firm moral ground. If we chose to subsidize any industry, we should do it on the basis of data and a specific goal in mind. A utilitarian like me will view government's responsibility as creating the greatest common good i.e. the most wellbeing. This merges nicely with the broader definitions of health.
What I like about the McCain idea is that it represents incremental change. To address Vineyard's correctly pointing out that state mandates represent a serious obstacle, they are not insurmountable. A federal rule for companies selling insurance across state lines could be that they meet or exceed the benefits coverage of most states. These policies will be more expensive than policies sold in low-mandate states, but provide useful alternatives for those willing to pay. They will represent real competition in high mandate states, which are sufficiently populous to get people asking questions. There are other legislative and regulatory hurdles to get over, but ideas should not be discarded before a full and public airing.
Transparency in the insurance industry and in hospital pricing, expanding coverage for the uninsured and under-insured, a more flexible tax code to allow for the purchase of alternative insurance products, increasing adoption of IT and maximization of its potential in measuring and affecting quality, aggressive changes in models of care delivery and defining different levels of coverage according to health impact analysis are all a small part of the solution. Overall, there is a tremendous amount of value yet to be unlocked in the US medical system, but tearing a system apart to rebuild it from the ground is not a good option. Revolutions tend to be more destructive than creative.
Sunday, June 15, 2008
My experience has been one of utter frustration with maternity nurses, who should know better, but frequently feed their wards sugar water for no reason. Some kids can get hypoglycemic, but certainly not three quarters of the nursery. Some kids may lose weight, but that is a normal phenomenon, with the natural history of birth being a decline in weight and return to birth weight by day 10. It is not abnormal to lose weight, but it is abnormal to get formula or D5 on day 1.
These practices appear to me (on an anecdotal basis) to be widespread in places I have worked in the US, but they would be unacceptable in other places of which I have some knowledge: Montreal, England, or France. I understand from a cousin in Dubai that at least one hospital reflects the US's breastfeeding dysfunctions, so I am sure there is tremendous variation from country to country, especially by socio-economic class.
The harm done is that by allowing alternatives to breast feeding, we don't give a woman a reasonable chance of establishing her breast milk in the first place. To establish breast feeding, you need an infant sucking on a nipple, which provides the hormonal stimulus to produce milk in the first place. The more concerned you are that the breast milk may "not be enough", the more you assure the fact.
The problem with personal observations is the tendency to generalize. Finally, the CDC surveyed hospital infant feeding practices, as reported in MMWR. American hospitals persist in providing alternatives to breast feeding to infants, such as sugar water and formula. I am sure that most well-meaning maternity ward nurses will explain that they are trying to make sure babies gain weight or not become hypoglycemic. Unfortunately, entire wards of infants are not likely to suffer from the risk factors for hypoglycemia and weight loss in the first three days is a natural phenomenon that does not get babies in trouble if skilled observation and timely intervention is available.
So breast feeding suffers for entire populations as we chase the shadows of unusual and uncommon poor outcomes that rattle us to the point that it is easier to just chuck formula into every crying newborn's mouth.
Hopefully there will be more Edwinas around to take up the cause.
Tuesday, June 10, 2008
Dr. Val (via Joe Paduda) reports from "Fighting Chronic Disease: The Missing Link In Health Care Reform" conference that 50% of the (? adult) population has a chronic disease. In addition, chronic disease accounts for 75% of health care costs.
No wonder we can't afford health care in this country.
USA Today (via Kaiser Daily) reports that the lifetime cost of obesity is about 5 to 30 THOUSAND dollars.
The number of under-insured are rising. The Seattle Times coverage lingers on the plight of those with chronic disease who chose not to fill prescriptions due to the cost. If we focused on chronic disease care (i.e. secondary and tertiary prevention) to determine the impact of nearly 75 million uninsured and under-insured on the US health care tab, we could calculate an ROI. It would be a theoretical exercise to estimate the economic impact of universal health care.
It may not be a reason to do it; I was once told by an health care economist that some things that should not be subject to economic impact analysis. I think he found it morally repugnant. I agree, but finding dollars and cents calculations objectionable is not a reason not to do the calculation.
Maggie Mahar is right. Statistics and stories both inform policy in a way that neither alone can do adequately. There are thousands of moving stories of people in need (and a few stories of others taking advantage). Finding an acceptable way of providing universal coverage is the right thing to do. But we also deserve to know what the net effect is on our economic engine, even if it is an estimate or a guess.
Saturday, June 7, 2008
I guess it may have been apparent to a few that the new job in the Great American desert is not going well. When I took the job, it looked like a turn-around was well under way and the group was ready to establish a quality and improvement agenda.
I was wrong.
The CEO was fired six weeks into the job, the board is locked in a self-destructive lawsuit driven by ego and an attorney running for public office with a platform of attacking corruption in institutions.
The details of why I'm leaving this new job only sounds like sour grapes and so should be subject to a little self-editing. I have bad feelings about more than a couple of people, but they will fade in time. Hopefully not much dirt will stick as I dust myself off and move on.
CEO turnover at hospitals is 14% - 18% according to the ACHE. Secondary turnover (other executives leaving) is also high; 77% for CMO's. Competitors frequently take advantage of instability to poach senior executives, physicians and other key staff. Most CEO positions get filled within a year. The average tenure of a CEO is 5.5 years.
I can't find any references this morning, but out of a vague cloud of memory, I recall that CMO's last an average of 3 years. One of my colleagues tells me she had read it was 18 months!
This may seem strange to many folks in health care, but not so in the business world. The other kind of CMO (chief marketing officer) had an average tenure of 23 months in 2006.
So why do I do this? I am certainly asking myself the question as I read about Jay Parkinson's entrepreneurial approach to the health system.
I know that there is value in approaching health person by person, as in any form of medical practice. But enabling others to do the same is a matter of scale. I'm just thinking out loud here, but this health care system is not likely to be overhauled in its entirety, but rather incrementally. Even universal health care will only address the 14 - 18% of the population that really needs a little more help. We may or may not be reaching a tipping point that may or may not fundamentally change the way health care is delivered. There may or may not be disruptive technologies that will destroy the current health infrastructure.
Would you rather work within the system, outside the system or just chuck it all and keep seeing patients, giving up all semblance of an ability to influence the system or the health of populations? Or some combination of the above?
Fortunately my situation allows me the luxury of time to figure it out. The last thing you want is to jump from one bad job to another. So excuse me while I pursue the really important things in life and cruise out to the mountains in my Jeep for a little off-roading!
Tuesday, June 3, 2008
However, it is a fantastic example of how not to produce a sensible solution.
The FTC has been invited to comment and its first salvo is pretty negative, as reported here (sub req) and here.
We already know that the FTC believes that retail clinics have the potential of "making basic health care more accessible and affordable." This is the worst piece of hocum perpetrated on the American people since the war on terror.
The Illinois Medical Society, whose advocacy informed the bill, clearly took every possible step to restrict retail clinics (taken from their press release):
Everything is perfect until the last two clauses. The latter is clearly designed to expose the profit motives of pharmacy chains who speak with forked tongue: on one hand promote improved access to health care but on the other sell products deleterious to the health of the people whom they purport to serve. The former is pure protectionism.
The facility must have a referral system to physician practices or other health care entities appropriate to the patient's symptoms outside the limited scope of services provided by the facility.
The facility shall provide notification of any patient visits and outcomes to the patient's designated physician.
The facility shall establish appropriate sanitation and hygienic protocols. The facility shall have a designated receptionist and waiting area.
At the conclusion of each visit, patients shall be given a written notice stressing the importance of having a personal physician who can provide the full range of health care services. Patients shall be notified in writing of their opportunity to purchase medications from any provider whenever they receive a prescription at a clinic.
Illinois health care services provided must be in accordance with a limited scope of services as determined by the facilities' medical director and approved by the Department of Public Health.
No health care services may be provided unless a physician licensed to practice medicine in all its branches, an advanced practice nurse (APN), or a physician assistant (PA) is on the premises at the time the services are provided.
The facility must have a medical director who is a physician licensed to practice medicine in all its branches with active medical staff privileges to admit patients to a local licensed hospital. Collaboration of APNs or supervision of PAs shall not be construed to necessarily require the presence of a collaborating or supervising physician as long as methods of communication are available for consultation with the physician in person or by telecommunications in accordance with written protocols.
The facility shall maintain medical records for all patients for the period required of a licensed hospital under the Hospital Licensing Act.
All personnel shall wear on his or her person a clearly visible identification indicating his or her professional licensure status while acting in the course of his or her duties.
The facility shall operate under written protocols approved by the medical director and the APNs or the PAs providing services at the facility.
Payers shall not be allowed to waive or lower co-payments or offer financial incentives for visits to retail-based clinics in lieu of visits to primary care physicians’ offices.
Individual stores wherein these clinics exist will be prohibited from selling tobacco and alcohol products.
There are also clauses that restrict advertising fee comparisons by retail clinics, that a medical director can oversee no more than two retail clinics, a required receptionist and separate waiting area as well as an exemption for hospital or physician-owned retail clinics. In fact, higher copays for retail clinics would really make a lot of sense: if you want convenience you should have to pay for it.
So it's OK for us, but not for other people?
Every action provokes a counter-action. Did Illinois physicians think that there would not be objections to some of these clauses? To restrict advertising is simply wrong. There is no rationale for a medical director supervising the implementation of policies at more than one clinic. The need for a receptionist and waiting area does not level the playing field as much as prohibit a field of economic activity that relies on low overhead. The exemption... well, the US is the place I would expect such a two-faced clause to be challenged and ripped apart by adherence to simple constitutional principles. The exemption alone does more damage to the credibility of the bill, its sponsors and its advocates than any hard-nosed competitor could wreak.
This bill seems to be intentioned to provoke the reactions of external stakeholders. It appears to be the product of a purely confrontational approach to protecting one's turf, rather than a collaborative approach to promoting the health of the population.
Like it or not, external stakeholders have a lot to say about how we run our business. Removing the most restrictive clauses would let the rest of the bill stand on its own and make sure the correct message gets out: retail clinics add absolutely no value to the health system if the care delivered there is provided without the context of continuing primary care.
Market forces must decide the ultimate fate of retail clinics, maybe then, the FTC would revisit their assumptions about how the health care market actually works.
Monday, June 2, 2008
In case you've not been paying attention, there have been two waves of adverse event reports starting with reports of neuropsychiatric effects, such as suicide and depression. Now there are reports of convulsions in drivers and even simple personal accidents. The FAA banned pilots from taking the drug and sales of Chantix (varenicline) are collapsing.
I am not a fan of big pharma and only rarely do I become a grudging apologist, but I will take a healthy skeptical approach to the situation and shoot from the comfort of my lounge chair.
Part of this tempest is a study by the Institute For Safe Medicine Practices, which is involved in a new pilot method of reporting adverse events. As far as I understand, the pilot involves quarterly analysis of the Adverse Event Reporting (AER) Database, which accepts electronic side effect reports.
All adverse events are recorded and linked to a drug. At the point that a report, or any number of reports are made, there can be no assumption of causation. There are a set of epidemiological principles for establishing causation out of associations.
There is an additional problem that is well-known with voluntary reporting mechanisms... the same thing that customer service people know. A few people who squawk the most have the potential of skewing your results. Electronic reporting should make reporting more complete and thus less susceptible to the bias introduced by voluntary reporting. On the other hand, one could hypothesize that electronic reporting amplifies distortions in public perception.
Once a few reports are made, such that an association is reported in the media, things may snowball. People may begin report minimal events that they would not have otherwise reported or events that they did not consider to report. The media is incapable of shading nuances of association and causation or the real meaning of a further investigation by the FDA. Once reports exist, the FDA and the ISMP have no choice but to issue warning statements.
That does not mean varenicline is a bad drug, nor that it is more unsafe than continuing to smoke. It does mean that a new monitoring system is functioning as designed (assuming it is not being manipulated or introducing worse biases than it was intended to prevent.) We will have more information about adverse events for new drugs sooner and more accurately, for the benefit of empowered consumers.
Why should sales go down?
Saturday, May 31, 2008
I reflected to my acquaintance how different it was out here in the Western desert regions, where it seemed the employed docs sometimes felt they could act like it was their own shop and close up with less than a day's notice to stay home with the kids or go duck hunting or take whatever break is justified by a hard-working, highly-valued provider of a needed service by a grateful community.
You can't do that when there are 50 physicians and 300 employees whose work schedules are dependent on physicians providing billable services on razor-thin margins.
Well, maybe you can. It's all about the supply and demand equation, isn't it? If there aren't enough primary care physicians to go 'round, the tolerance for behavior inconsistent with a larger organization's overall well-being is better tolerated. And certainly the local physicians' culture has an important role to play. Texas docs, I was told were nearly never in large groups and they never tolerated overbearing administrative intrusions to their clinical or vocational independence.
I walked away from my conversation with a tall and lanky Texan (sorry for the cliche, but he was tall and nearly lanky), with an understanding of how different the situation is for physicians across the country and how my approach to change management and performance management is colored by my East Coast experience.
In areas where managed care penetration is high, employed physicians predominate by choice, and a high regard for academic analysis output exists, there is an atmosphere of understanding and willingness to work within a corporate environment. Evidence-based medicine, quality and performance improvement are all perceived as methods to improve health care delivery systems for the betterment of the community. Physicians understand the choice to enter employed positions and accept the trade-offs, giving up some independence for the sake of fewer administrative headaches, better benefits and perhaps, a reasonable lifestyle.
In areas where one or more of these conditions do not hold, physicians resent encroachment on their judgment, style or authority and mistrust the motives of administrators of all stripes. EBM, QI, and PI are bridles of control to be avoided at all costs and administrative entities are regarded to exist for their personal betterment and not the benefit of communities nor the doctors, Such physicians enter into an employed arrangement begrudgingly and only if they feel that their work is not subject to the kind of oversight that will reduce their independence.
OK, I'm dumb. I didn't realize the obvious until now. I have grown up in academic environments which are so dominated by various stakeholders that the independence of the community physician a distant recollection from the stories of William Carlos Williams; the vague memory of a historical work of fiction read in childhood. The East coast and its large cities are places where independent practitioners are abberations or mavericks worthy of awe, disbelief and admiration.
Elsewhere in the country, in smaller cities and younger landscapes, the independent practitioner has thrived and the battle for physicians' independence is much more vigorous.
It is possible to engage physicians any number of ways in future improvements to health care. The lessons of the East tell me that the best way is not confrontational. Without physicians, no meaningful reform is possible, despite the best efforts of other stakeholders. On the East Coast, docs have been beaten into submission. It took a long time, created a lot of ill feelings and did not accomplish much. The rest can do it faster, more collaboratively and with greater focus. The first step is to get a clear understanding of the situation and adapt to local environments.
Thursday, May 29, 2008
Number 1 is Iowa, a state with a great family practice residency and a primary care oriented medical school, along with a quality research university. Good access to top-notch reasonably-priced health care probably trumped the reputation of places like Massachusetts, that suffer from high costs.
So much for branding. After all, the two most important people who went to Harvard dropped out before graduating.
Even Vermont could not come in first, given their unparalleled social programs, but cost was factor there as well. Washington and Wyoming were the only western states that came in the top half (remember I live in The Great American desert... think West). My biggest surprise is seeing Minnesota in the 2nd quartile. I would have expected the State to rank in the top 10. Managed care has negative its effects on physicians, provider organizations and the pharmaceutical companies but it represents a way of providing more rational care to patients. Minnesota has the greatest managed care penetration in the country, but the majority are for-profit entities.
Just musings... but one might wonder if managed care, a dirty word to physicians and patients alike, may lose any purported benefits in the hands of a for-profit entity. Perhaps it is another example of an academically brilliant concept that gets distorted when handed over to real people. Kind of like God!
Of course the problem with rankings is in the detail. The indicators include equity, which is notoriously difficult to define (which income cutoffs do you use) and something called "potential to leave healthy lives". Let's not lose sight of what these rankings tell us:
- There is way too much variation across states (but perhaps this is what the founding fathers would have wanted.) Let the states decide if they care about kids or health care.
- It is possible to score very high as well as possible to hit rock bottom. In other words, the rankings can distinguish between states. In addition, there is internal consistency and, I suspect, some degree of external validity also.
- A very interesting observation emerges from the executive summary; quality and access correlate strongly. I recently heard from a CEO who was referring to managing physician performance that productivity was inseparable from quality (productivity=access). Even a clueless doc can do a great job, given three or four hours for a single patient. A physician's value to a community is measured differently than when measured one patient at a time. On a state level, quality is meaningless if there is no access.
Wednesday, May 28, 2008
The final paragraph of the article is particularly enlightening:
Judgmental programs tend to interfere with quality improvement. They score but do not support physician work and therefore are perceived by physicians as disempowering. Accountability combined with perceived inability to improve is a formula for creating frustration and antagonism. We propose instead an approach that identifies specific wasteful practices and then engages physicians in changing them.So it appears to be possible to engage physicians in quality improvement (QI) and achieve goals of cost reduction and reducing overuse, as long as it is in the context of improving care, something most physicians care passionately about. As long as they are cast as part of the problem, why would they do anything other than sabotage the solution?
I do not know many physicians who are heavily involved in quality improvement, but I have learned from recent experience, that physicians who have been beaten up by QI programs are very likely to resist and attack anyone who comes to them with a quality agenda, irrespective of their credentials. That is to say, the stupidity of others impairs quality-committed physicians ability to effect change and that needs to be part of an environmental assessment for any new quality management project.
OK, it seems obvious, but I'm human too!
Tuesday, May 27, 2008
Bzzz. Wrong answer.
The large chains are having less trouble dealing with their debt than smaller rivals, so it is easier for them to snap up relatively smaller entities opportunistically. The Tennessean (courtesy FierceHealthcare) suggests it may be partly due to the increase in un-reimbursed services to the uninsured. But a Chicago Tribune article points out that the kinds of savings you would expect from economies of scale do not appear in hospital charges. While prices have not gone up (that would get regulators paying attention), it is possible expenses have gone down. Increased margins means dividends for stockholders and cheap capital for not-for-profits.
The FTC is looking at unfair market practices in Evanston, Illinois and Virginia and even in rust-belt Pennsylvania, questions are being raised. The FTC's effectiveness is in question and vulnerable to counterattacks that the mergers are necessary for the health of the population and the area's ability to attract doctors.
Since primary care doctors do not usually practice in hospitals and primary care is the only segment of medical care (as distinct from public health) that improves the health of populations (as opposed to individuals), I would submit there is no impact of hospitals on the health of the communities where mergers leave a single dominant hospital provider, nor are the kinds of doctors they attract relevant.
The FTC should shut down bad mergers. On the other hand, the government could support market forces by encouraging better management and easier access to capital for community hospitals.
Friday, May 23, 2008
CMS was going to reduce payments to safety net institutions and close so-called loopholes that allowed states to invest heavily in expanding coverage in their jurisdictions with assurances of federal matching payments. Needless to say, the nouveau riche that run the right wing don't feel it's right to invest in low-income Americans. CMS started to create regulation that would cripple critical access hospitals and community health centers.
So perhaps we should celebrate that this round of attack is over, but vigilance is wise.
Have a great Memorial Day weekend!
We cherish too, the Poppy red
That grows on fields where valor led,
It seems to signal to the skies
That blood of heroes never dies.
The agency freely admits their ratings are faulty, but docs should just suck it up because it's a step in the right direction. However, despite the flaws, patients are charged different copays according to the rankings. In other words, although they know they don't really know what they're measuring, if they are measuring the right thing and if they can effectively differentiate between providers of different quality, they'll just use their system anyway and work on it later.
How about a little transparency here? Not to mention a little common sense? Perhaps it would have been a little more acceptable to run the system for a couple of years and refine it until it could be reasonably used to make decisions that involve money. No wonder doctors fear the concept of quality in health care. It appears to be a blunt instrument designed to further bludgeon a profession that has suffered much over the last two or three decades.
I went back to school because I recognized that I did not have the management skills I needed to succeed without upgrading. Too bad the managers already in place have not realized the same.
Wednesday, May 21, 2008
This recent JAMA article (subscription required) carefully studies the role of adding ultrasound to mammography in breast cancer screening. They found that the combination picked up more cancers but also increased the false positives. In the parlance of clinical epidemiology, it increased sensitivity but decreased specificity.
Or as Homer Simpson would say: DUH!
It is not uncommon that the two co-vary in opposite directions. You can virtually manipulate the sensitivity and specificity of a test by carefully choosing your cutoffs for indicating the presence of absence of disease. The test ends up performing according to your needs. Our purpose in combining tests is to maximize both sensitivity and specificity. HIV is a case in point, since it is an over-sensitive antibody test (won't miss anyone) followed by an extremely specific confirmatory Western blot (won't wrongly diagnose anyone). Most labs won't report a positive antibody unless the Western blot is also positive.
I wish the results of the breast cancer study would have shown a reduction in false positives by the addition of ultrasound. This has always been my fervent hope whenever I have added an ultrasound to a mammography. The lesson of the report is that ultrasound doesn't help that much and must be used with caution and judgment.
Journal Watch reports a JAMA editorialist pointing out that
despite the high number of false-positives, what high-risk women "probably fear most is a late diagnosis." That, she continues, is "the real threat they want to be protected against, not false-positive diagnoses."Again I must say, DUH!
This study is meant to help guide us through the emotionally charged fear of breast cancer. It packs a huge punch for any woman even suspected of having the disease. On the other hand, we need to know the real (scientific= truth) value of doing a test. Perhaps the editorialist is saying that since it is an emotional matter, neither the data nor the truth matter, as long as we only detect more stuff, cancerous or not.
The original article is very detailed and a great read for those with an interest in how to crunch numbers to guide investigative decisions. The editorial set me off!
Tuesday, May 20, 2008
I have been an employed physician for going on 15 years and an independent contractor for a handful. I enjoyed the contract years the most, but it was not a settled lifestyle and something told me to do what everyone else was doing. You know, settle down, get a job, travel on two weeks off a year like the rest of humanity.
Teaching was fun and it could only be done in a large institution. Eventually, I settled for a large University setting in the south. Yes, my ego was part of it. Everyone in the region was always impressed by credentials as a professor from the Harvard of the South. After all, I had come from the Harvard of Canada. (I won't dwell on the sarcastic undertone, but if it is subtle, please note it!)
The main arguments for a physician to enter into an employment agreement are for lifestyle (you don't have to cover everything in your practice), convenience (no hassle of being responsible for your own books, payroll and so on) and for leverage (negotiating better terms with insurances.) Maybe there are others and you're free to add them.
But that means you have to give up some autonomy. Unlike the rest of the work-a-day world, I wonder if physicians expect to continue having all the freedoms they associate with their own practices: make your own schedule, close up shop as needed according to immediate priorities, refuse to take direction to meet the needs of the organization...
Most administrations are respectful of the fact that their physicians and other providers are the backbone of any clinical services organization. Of course I have met some pretty untrustworthy people and entities along the way, full of backhanded politics, unreasonable requests and frank incompetence.
But my question is what did the physicians expect when they entered into employment agreements???