CMS Reporting of Physicians [UPDATED]

[Update at the bottom]

It hasn't happened yet but there is insight to be had from CMS' handling of nursing homes. They just published a list of their Special Focus Facilities. The public list is restricted to facilities that have persistent deficiencies for several consecutive months.

The background paper on the CMS web site describes the following:

Most nursing homes have some deficiencies, with the average being 6-7 deficiencies per survey. Most nursing homes correct their problems within a reasonable time period. However, we have found that a minority of nursing homes have more problems than other nursing homes (about twice the average number of deficiencies), have more serious problems than most other nursing homes, and continue to have serious problems over a long period of time. Although such nursing homes periodically instituted enough improvements in the presenting problems that they would be in substantial compliance on one survey, they would be determined as providing substandard quality of care on the next. Such facilities with a “yo-yo” compliance history rarely addressed underlying systemic problems that were giving rise to repeated cycles of serious deficiencies. To address this problem CMS created the “Special Focus Facility” (SFF) initiative.

Physicians are rightly concerned about the replication of such quality assurance activities in their offices and practices. But it strikes me that, with nursing homes at least, the process was slow, deliberate, reasonable and pretty much fair.

There is a considerable amount of information and data available on the nursing home certification and compliance website. There was considerable push-back about the details of the criteria but it is difficult to argue against basic process and structural requirements for delivering decent care. There are over 16,000 nursing homes in the US, of whom 120 are currently on the SFF list and 54 names were named because they repeatedly failed to make improvements. That's a very small proportion of nursing homes, at the far tail end of the bell curve. There are about 120,000 physicians in the country, so that represents about 400 recalcitrant physicians in the entire country.

Physicians tend to focus on the content of care, not the structure surrounding it, and so tend to dismiss P4P as "pay for process" or worse. Moreover, one must acknowledge that some physicians are in control of the processes in their offices. The growing majority do not; they can scarcely influence procedures in their large and faceless corporate employers. The quality of physicians probably falls on a bell curve, but then, so does the quality of management. Hopefully, the folks at CMS know that they should only publish the names of the organizations, and not the individual doctors, for poor performance on process measures they cannot always affect.

Also, there is loud opposition comes from conservatives of libertarian ilk (like the folks at the Cato Insitute and my frequent fencing partners at InsureBlog), who do not believe that government can do anything right.

It seems that government is capable of getting it right sometimes. This, despite the fact that government frequently is responsible for the most infuriating and ridiculous attempts at controlling forces and markets where they have no business. The devil, as always, is in the details of implementation. There are forces that would publish poor performance by physicians prematurely.

But then, this discussion is premature. P4P has scarcely gotten off the ground. It is growing and moving towards some sort of public reporting of physician quality based on these process measures. I suggest physicians prepare themselves, work on streamlining their practices and, above all, wake up their lobbies.

I stumbled upon this article on The Wired for Health Care Quality Act. I apologize for having completely missed the fact that this legislation had even been considered, it is an unforgivable oversight. Well, I had heard grumblings that Congress was considering mandating the use of Quality Data, but I had no idea it had gotten as far as this. I guess I can't read everything, you know...

In short, Sen. Kennedy and 12 cosponsors are putting forward a bill to improve the health information infrastructure of the country. Title 3 directs DHHS to develop and review quality measures.

So, this is happening, it is happening now (and if not now, someone else will propose a similar bill as the political winds change), the lobbies are already involved, the information will become public in due course and we will all be competing against each other on the basis of a type of quality we (physicians) don't even recognize as relevant.

At least it looks like they won't be using billing data as the basis of the quality measures. That would be catastrophic to all concerned.

Health Wonk Review

Health Care Renewal is abuzz of late over drug company ethics. Comments from Maggie Mahar and Howard Brody are commendable, along with the discussions over Dr. Carlat's NYTimes Sunday Magazine article. It should be clear by now that regulation and legislation needs to level the playing field between consumers and pharmaceutical manufacturers.

Also check out the GoozNews article on health care costs.

Another Public Hospital in Trouble: A Lesson in American Race Relations

Both the NYTimes and the AJC report on the attempt to save Atlanta's Grady Hospital by replacing the current Board and demanding an infusion of capital from the usual players: the State and the two counties that the hospital serves. This does not sit well with Georgia's Governor.

There is a great tragedy being played out in many an inner city these days. My experience with Grady was brief but vivid, for a naive Canadian being introduced to racial politics of the US, colored by the unique history of the city at the center of the Civil War (or the War of Northern Aggression, as I was quickly taught.)

Poor inner-city blacks, socialized and acculturated to being poor inner city blacks, are accustomed to seeking all their health care at Grady. For nearly a century, providing this health care has been regarded a charitable act, frequently delivered by benevolent whites. Who knows? Perhaps this was considered the price of maintaining the peace.

The wounds of racism have healed better in the South than some other parts of the country, but the injuries were far worse to being with. This is where the social unrest of the Civil Rights Movement had its roots, not 10 blocks from the hospital. This was Martin Luther King's first stomping grounds, the place he spent his formative years, a place central to much of his life.

And yet, poor blacks get their health care at the emergency room. This is where I met a homeless diabetic who had enough sense to develop DKA on the coldest nights of the year. This is where I met a woman whose first name is a sexually transmitted disease her mother must have liked the sound of. And the one legged hooker with a pressure sore the size of Rhode Island.

These are not dumb people. These are people who don't know better because they've never been shown better. Put aside morality for a moment, put aside questions about who gets your hard-earned tax-money for a minute and you'll realize these are resourceful, intelligent people who are so messed up by their circumstances, they can not do any better. They are shaped by a dysfunctional system. The last thing they need ER primary care.

Buried at the bottom of the NYTimes article is the following:

Some black activists and elected officials had warned that the governance change would shift control of the hospital from black political leaders to white business leaders. The hospital’s problems, they said, are financial and not political.

So is that what this is about? Gradually over the years, Grady came to be controlled by prominent African-American activists and business players. The state and counties continue to fund an incompetent, inefficient, insufferable and impossible health system because the alternative is likely to be construed through the lens of American race politics.

And still, poor black men, women and children get substandard care because there is no incentive to actually improve what's available. God help minority populations when the important thing is maintaining control of the system, rather than delivering the service.

I suppose it is natural and inevitable for a previously oppressed populations to want to control their own community's assets and resources. I have seen this before; in Native communities in Quebec's North, with the French and English struggle in Canada and to a lesser extent with Latinos in the US. The control of health care by the target minority group does not ensure the delivery of appropriate care. How often and to what extent is the same scenario played out by County and public hospitals across the country?

A hyper-realist is saddened.

The Carnival of Life, Happiness and Meaning

I am getting into this Carnival thing,much like Grand Rounds and Health Wonk Review, where the best blog posts around a common theme are featured.

I offer The Carnival of Life, Happiness and Meaning because it is good to remember that health has to do with much more than medicine, management and policy.

This is the Holiday Season and whichever holiday you celebrate, remember to take some time out and enjoy it. The only thing that is real is the current moment and it will not return. Take some time on the Carnival and get some ideas...

The Avandia Mess

Forgive me, for sometimes I see humor in very serious issues. I developed a hyper-realist viewpoint a few years ago after reading Robert Greene and Joost Elffers' "48 Rules of Power", Machiavelli's "The Prince" and Sun Tzu's "The Art of War," the latter in the context of a strategic management course.

The events related to Avandia seem to me a brilliant depiction of power relationships and natural incentives. The science is nearly irrelevant, except to the extent that it is used (or misused) as a function of an individual's or a group's natural incentives.

The whole thing started with Steve Nissen's somewhat flawed meta-analysis of cardiovascular mortality associated with rosiglitazone [I will use the generic name from here on.]

The important feature of this article is that it raises questions about rosiglitazone, but does not answer them. Perhaps a little more substantial is the fact that he did not have access to original source data, because it is proprietary information owned and controlled by the pharmaceutical companies. To me, this is an important point that does not yet seem to have reached to the popular consciousness.

Does Dr. Nissen have an ax to grind? I don't know, but he certainly does have an interest in publication and the more controversial the information, the greater the attention and the greater the security of future grant money.

Valid point: Pharmaceutical companies insist on controlling and potentially suppressing clinical information about the drugs they wish to sell. This is natural and indignation is laughable.

Valid point: It is difficult, if not impossible to separate epidemiologically the contributions of CV disease from the contribution of the medication. A meta-analysis is probably not the best way to do it; it is hypothesis-generating, not hypothesis-proving. Meta-analysis is the most practical method of monitoring for safety. However, finding an association where it could reasonably have been expected is not newsworthy. Now, find me a causal chain based on real-world observation and I'll stand up and pay attention. I acknowledge this to be virtually impossible given the lack of openness in pharmaceutical research.

Valid point: Dr. Nissen took pharma money and published an anti-pharma article. Brilliant... somewhat dishonest, but brilliant. He publishes the following conflict of interest statement:

Dr. Nissen reports receiving research support to perform clinical trials through the Cleveland Clinic Cardiovascular Coordinating Center from Pfizer, AstraZeneca, Daiichi Sankyo, Roche, Takeda, Sanofi-Aventis, and Eli Lilly. Dr. Nissen consults for many pharmaceutical companies but requires them to donate all honoraria or consulting fees directly to charity so that he receives neither income nor a tax deduction. No other potential conflict of interest relevant to this article was reported.

It is a natural incentive for a researcher to seek funds and then seek publication, so attempting to place restrictions on researchers is not going to work in the long run. This is natural and indignation is laughable.

The drug industry's response was to vilify him. This is a Medscape summary of the academic wrangling. This from Science Daily. This from the WSJ Health Blog.

But the fact is that the science of meta-analysis is difficult, arcane and beyond the understanding of most scientists and physicians. There are a half-dozen epidemiologists I would personally trust to help interpret this information for me, if I thought it was worth it. But there are better things to save my favors for.

In fact, this is a political issue and the considerations include the pharmaceutical industry's profitability versus the cost of and safety of new medications. Is it any wonder that the industry responds in the blogs, the media and scientific articles with their own counter-arguments? The most prominent of these spokesmen is Peter Pitts, so his position is predictable in advance. This too is natural and indignation is laughable.

Does it make sense to expect the FDA to be the absolute arbiter on the safety of medications? Probably not; there is a threshold that needs to be recognized, because no extraneous substance can be consumed with impunity by the entire population. If the disease for which one takes a medication causes the side effect in question, greater caution must be taken; the epidemiology is extremely complex. People with diabetes get heart failure and people with depression commit suicide. This is not a causal link and the association is unsurprising.

So why the confusion? Follow the money:

• New medications are expensive for payers.
• New medications are profitable for the pharmaceutical industry.
  
• Physicians are susceptible to being style-mongers and trend-followers like anybody else; why not try the new and sexy drug?
  
• Impugning the safety of a new drug is an easy way to reign in the potential of over-prescribing and the unrealistic expectations bred by pharmaceutical marketing.
• The pharmaceutical industry has an interest in protecting their margins and their franchises.
• The research industry [yes, I said industry] has an interest in attracting attention for its research and securing future funding.
• The news industry is always looking for a new and sensational headline; "New Drug Risking Millions of Lives" is a great headline. The hair-splitting required of scientific reasoning does not make good copy.
  
• And then, there's the ambulance chasers... see the links at this blog post. Isn't this what it's all about?

I love this country because it is the balance of these lobbies and special interests that will determine what the regulation. For those who believe that there is an objective principle, such as truth, beauty or justice that will define our legislative and regulatory response, I applaud your "goodness."

But the naivety gets nobody anywhere.

Questions: Where The Rubber Meets The Road

For all the policy talk and all the problems of managing physicians and designing efficient delivery systems, the rubber has to meet the road some time. This happens where a provider of health care is working with a patient with the door closed. Beyond the door is the maddening world of what we call the health care system. There was once a time that the things that passed behind the closed door were sacrosanct; they are no longer. But like it or not, behind the closed door is the crux of the health care system, it is the place where every health care consumption decision must take place. And it is a mystery to every policy wonk, manager and patient who is not a physician.

Some years ago I used to teach residents at a large city university hospital and I was called to see a patient in the ER.

I was asking his wife some questions, when I noticed a look of pained irritation on his face. They were tired, I could tell. It didn’t take much imagination; she had had these pains for two days. They were in a frantic emergency room, waiting for a bed and had just finished with the emergency physician who decided she needed to stay and called our service. My medical student and intern had visited and when they called me, it was my turn. I too was tired, having been rounding all afternoon on the sickest patients we had in the hospital.

I pressed on hesitatingly and then he scowled and asked, “Why all the questions?”

How to explain, I wondered. The magic of medicine reduced to the most basic process, one of conversation. It is here, in the flow of questions and answers that I would find out for myself if someone missed anything important. We didn’t have a diagnosis, just stomach pains. Physicians are all trained to doubt the answers another has related to us. We go back to the patient and ask all the same questions, scouring the story for an inaccuracy. "Do it yourself or it wasn't done at all," is how I was taught.

Maybe the history just wasn’t as clear in my mind from the documentation the emergency physician left for me? After all, he jots down a few cursory notes, just enough to support his decision to call the admitting team and dictated the details. My intern is good, but relies on the medical student’s mindless repetition of every possible question . This is how they learn to distinguish critical information form all the other stuff in the medical history. As teachers we test their skill at organizing the relevant and discarding the questionable. My job, as most doctors would see theirs to be, is to be the final adjudicator of the plan. Funny how everything -- policy, management, insurance, consumer groups -- everyone impinges on this moment; the one where a patient and a physician put together a plan that makes sense to both the doctor and the patient.

As a student, I was taught that 90 percent of the diagnoses you make are made on the history alone and merely confirmed by the examination and laboratory. Diagnosis takes place far from the moment of the laying on of hands, which can almost be redundant in certain circumstances. We have no Star Trek tricorder to see deep into the body’s workings. We decide by talking, sifting through the peculiar tales filtered through a unique experience and told according to history, education and levels of understanding.

The tests we use are not as reliable as we think when used indiscriminately, like a shotgun. Statistics describe the limitations in their usefulness; sensitivity and specificity, positive and negative predictive values, to rule-in or rule-out any specific condition we may have in mind. Without the thought that precedes the study, whether it is a simple blood test or a sophisticated scan, tests can lead you to the wrong place. It is worse than a red herring which is unexpected and not created by the inherent uncertainty of the situation.

“I need to ask,” I find myself saying. “I know a lot of people have seen you, but at least for tonight, I’m the guy who’s in charge. Tomorrow I may ask another doctor or two to see you. I’m afraid they will want to get the story from you themselves.”

I waited for the question about the tests. “When are you going to find out what’s going on?” he asked. “We’ve been here three hours and nobody’s told us what the tests showed.”

“Not much, I’m afraid. At least nothing you’d want to hang your hat on. The hemoglobin is normal, so there hasn’t been any bleeding. The white count is normal, so it doesn’t look like a bad infection, you know, like an abscess or an appendix or something serious like that. She could still have a stone, but those results aren’t back yet. We may need to do an ultrasound in the morning.”

“What about the X-ray? Couldn’t you see anything on the X-ray?”

“It was normal.”

“So what’s causing the pain.”

I shrug my shoulders. “We have to take it one step at a time. Sometimes we can’t give you an answer right away. Sometimes, we can’t give you an answer at all, except that it isn’t anything bad.”

Tests are funny that way sometimes. They only show you something if a disease is there, but they don’t always tell what’s wrong, especially if the condition is not what it was designed to detect. Most tests are only meant to confirm the presence of one or two conditions, or else they just tell you something is wrong, without telling you what. It’s frustrating, but then you go back to the questions and check out you own skills this time. This time, maybe the patient tells the same story just a little different, not realizing that it is all the difference. The headache came before the throwing up, not after. Maybe it was a migraine, after all. We ask our questions and impatiently order more tests, falling into the trap of being indiscriminate. We ignore the possibility of remaining in the dark, because it is impossible not to understand everything that can happen to a human being.

Illness is fear, for the patient that he or she may suffer; for the physician that he or she may miss something and be blamed. In the end, it is the basic human skill of conversation that will save you.

Top 3 Literate Blog Posts of Thanksgiving Week

Maria and I are trading coasts. Goodbyes are hard and again, she makes the list:

1. Discordant at Intueri (vignette with a friend, resentment or loss?)
2. Listen by Vitum Medicinus (essay by a student learning the most important part of medicine)
3. Things to Be Thankful For by Dr. Wes (OK, it's hard to justify as literature but it's seasonal... You could always check out Fire Drill for a vivid little story of an urgent evacuation)

Best Wishes For Thanksgiving

On this wonderful occasion of over-eating, imbibing and then looking for a few minutes away from the rest of the family, I thought I would share a few reasons to be thankful, from a health perspective of course.

Above all, since the most important determinant of health is socio-economic status, we must be thankful that we have not been born into abject poverty.

How do I know this about my readers? First, you have access to a computer and thus, to information. Despite consideration being given to the social determinants of health in the literature of late, the role of information is dismissed or not given significant weight, but it could certainly be that access to information is a proxy for education and income.

The top 20% of the world's income-earners earn more than 70% of the world's income. I am one of them. Since a significant proportion of the world's high income earners are in the US, you may be in this group if you are celebrating today. Living in the West and owning a computer probably puts you in this group, even if your income is fairly low.

The odds for your living a healthy life is reasonably high, but I know some of my readers are not so fortunate. In the end, it is a random, unpredictable finger that writes our histories. No statistical model has ever accounted for the ineffable. We are still at the mercy of Brownian motion, the possibility of accidents and the finger of God. For no reason we can fathom, we may still be challenged from on high to overcome, without ever understanding why.

To all who seeks explanations, I offer my sympathy and support, but I suspect there are no reasons to be found for any of this but what we can attribute through our personal understanding of meaning in the personal context of our lives.

In the end, the personal context of our lives is, in my belief, shaped almost entirely by the people that surround you. Most of the attributes of human beings (e.g. kindness, industriousness, loving, strict) can only be perceived by or through another human being.

So enjoy the day, count your lucky stars for whatever you may have and above all, feast in your friends and family.

The Causes of Obesity

Jason Shafrin asks Why Are We Obese?

He comments on an NBER article and points out that a food tax would unfairly affect the poor.

I have two counters:
1. Who cares? As a matter of fact, the fact that a food tax affects anyone is the only way that it can potentially affect behavior. If a parking ticket costs me less than parking in the lot up the street, guess what I am going to do. The question is best asked: do food taxes affect consumption?
2. Let's focus on how the environment influences behavior. The physical environment and the logic of our routines dictates what and how much we eat.

I have gained weight since moving to the suburbs; being too tired after my absurdly long commute to take advantage of recreational opportunities in my neighborhood. I eat on the road much more often than I ever did and since I work in an inner city environment, I can pretty much tell you that there isn't a whole lot of fresh food available in poor urban neighborhoods. The concentration of high fat eating opportunities (fast food and convenience stores with poor food choices) in these neighborhoods is absurd. Any structural change that alters the supply-demand relationship here is welcome.

The community I serve is fortunate in having a community center with a gym. This is the exception and not the rule across the country. It's hard to exercise without a gym, it's hard to walk when the dealers are out, it's hard to ride a bike where there are no parks and when the traffic is unsafe.

Our weight is a reflection of our lifestyle. Needless to say greater caloric intake is part of the problem, but I think it's an uphill climb given how are lives have been structured.

Cavalcade of Risk

I am becoming more and more convinced that the work of physicians and health care is an exercise in managing risk. For this reason, I have become a regular reader of Cavalcade of Risk, the latest edition of which is currently up at Colorado Health Insurance Insider.

First, there is a picture of a couple of turkeys at the White House, only one of which received a presidential pardon [I really wonder why there aren't more political jokes made of this annual event, especially with the current administrative incompetence in evidence.] Additional humor comes from Bob Vineyard (a must read) and substantive analysis on either side of the Rand Health Insurance Experiment and implications for Workman's Comp.

Overall, a more than excellent edition.

On the Oversupply of Physicians

I have previously touched on the issue of a physician shortage here, here (in the context of concierge physicians), here (referring to the distribution of risk), here (in the context of mid-levels) and here (in discussing an influx of foreign physicians) . I am aware of literature that suggests otherwise, that there are too many physicians, who can generate their own demand.

Maggie Mahar makes hay commenting on Buckeye Surgeon's post and The Atlantic's article suggesting there is an oversupply.

The basic premise emerging should be that we are oversupplied with specialists and face a shortage of primary care. If a physician emerges from medical school with a heavy debt and the general perception that primary care physicians are somehow "less than," there is little incentive to dedicate oneself to a career reducing society's overall health care costs. Where's the reward?

Let's take it a step further, what happens when the primary care physician is overworked due to a local shortage? Chances are she'll just refer faster to a specialist who can take the time to figure things out. A referral is fast, easy and an efficient use of her scarce resources in the face of poor remuneration. At least the specialist will be well-paid for an extensive investigation, even though it may not really be strictly required. To take care of it herself would mean an extensive investment of time building the confidence of the patient, and truly assessing the risk of not being sued for non-diagnosis.

If she weren't very busy and really needed some extra income, she would probably learn a procedure like hemorrhoidectomy or laser skin dermabrasion or whatever is the rage, in order to keep up with the Joneses.

Now if a specialist is busy, he'll just do a few extra investigations, get the residents involved and above all, take no chances. It is the purview of the specialty not to miss any pathology, no matter how rare. Testing and further referral as necessary is the only way to go, especially in a litigious atmosphere.

If a specialist is not sufficiently busy, he will ensure that the maximal use of an appropriate package of investigations for the justifiable conditions. One urologist told me the proper response to any patient with prostate symptoms was an IVP, flow studies and a cystoscopy. I know his practice was sluggish, and he desperately needed to be busier, especially given the rent in the hospital's new medical office building.

These vignettes are not universal examples of every physician's behavior, but they illustrate the incentives in different settings. The one situation that does not drive health care costs up is a moderate level of work distributed to a reasonable number of primary care providers.

The sad fact is also, that covering the majority of everyone's health care costs will drive up demand to the extent that patients perceive such care as affordable. There is no cost control possible with expanded coverage.

Grand Rounds

Musical Grand Rounds this week comes from Mexico, so I have a couple of new International blogs to add to my reader... The first is Rico's own Mexico Med Student and the second is other things amanzi, which earned Rico's "Editor's Choice" this week along with the ever-present Sid Schwab . A truly excellent effort, despite not including my personal favorite late 20th century composer.

Doctors and Educators and How to Manage Them

I have previously said (in a the context of disease management) that if you want quality improvement, you may want to take the doctors out of it.

While it may seem paradoxical to improve the quality of care delivered by physicians by removing a part of the physicians' responsibility, the fact remains that physicians are generally preoccupied by the most acute findings in front of them at any given point in time. Documentation of what they have done, usually long after the fact, is not an acute priority activity.

Educating patients requires a skill set that is relatively uncommon amongst physicians They are not good at it, nor are they are specifically trained to do it. Education is not something you ask of your most expensive employee. I personally want my physicians diagnosing and making management determinations for the company's patients (i.e. generating billable events). Taking time to educate is not a financially sensible assignment for a high skill individual in any organization.

Not to put too fine a point on it, but I always thought there was some logic to the expression "Those who can, do. Those who can't, teach." And I am very proud of my personal teaching accomplishments, by the way, but I will never be anyone's top producer. Somewhere in the middle actually... I think.

On the other hand, a community health worker is specifically trained to educate, do outreach , follow-up with patients and see what else they may need. They are less expensive, but much more valuable when used in the right context. It is how organizations maximize value, by putting the right person at the right job. Otherwise, everything becomes more inefficient and thus more expensive.

This web site describes a UCSF initiave that demonstrates the value of community health workers in improving perofrmance on asthma quality indicators. Physicians are great at responding to the clinical circumstances, but they are not good at following "cookbook" recipes.

Most performance measures are process measures. They do not describe the diagnostic acumen or judgment of the physician; properties which MD's respect. They measure how well an organization adhered to a checklist (properties a physician dismisses all too easily).

It bears repeating, health care organizations can create the most value by putting the right task in front of the right person and the right person in the right job.

Patient Satisfaction and Physician Turnover

Primary care was the main driver for managed care through the 80's and 90's. It was based on the observation that health care costs were lower for people with primary care than without. Somehow the idea that primary care was important became subverted by the concept of "gatekeeper."

But insurance companies created the paperwork burden of a referral requirement, patients pushed back and primary care incomes started declining in the face of the consumer push-back.

Well that's my take on it and is pretty close to a consensus.

One piece of the puzzle is confirmed by a study that documents consumer's increasing dissatisfaction when there is turnover amongst primary care physicians (TOH: AAFP Now; reg may be req.) So remind me why there are panels for primary care in the first place? Shouldn't patients have access to their preferred PCP at all times, no matter what the insurance? Remind me why I need to put my best for patients at my current level of income and the under the constant threat of litigation. Oh ya, maybe it had something to do with the values, ethics and oaths of mine which all other health care stakeholders will shamelessly take advantage of at my expense.

Personally, I'd go "non-par."

Primary Care or Concierge Medicine: View from the ER

Panda Bear is a great blog; intelligent and well-considered.

A little story from the emergency room does a great job describing the factors that ended in an unsatisfied customer in the waiting room. Everyone plays into the system:

Not only are there not enough doctors to go around, especially in primary care, but we have an aging and incredibly sick population already making huge demands on our very finite medical capacity. Compounding the problem are diminishing reimbursements to physicians, madcap and increasingly byzantine bureaucracy, a predatory legal environment, and the resulting complete lack of common sense that makes it increasingly impossible for physicians to adequately treat the patients they see now let alone the marauding horde of aging baby boomers about to despoil such capacity as we currently maintain.

Dr. Bear's solution is one of concierge medicine, but that could open up a whole other can of worms. Much of primary care is not done right, so scarce resources are spent for naught. If it is done right, someone will have to pay up, but are there enough concierge physicians to go around? But I cannot disagree with the basic premise:

If your doctor only gets a pittance to see you, he needs to see a lot of patients to make a living leaving less time for each one. He’s not a bad guy but he has the same financial pressures on him as you once had before you retired and if you knew how little Medicare reimbursed him for his time, you could easily do the math and see that he’s not exactly as filthy rich as you imagine him to be.

But I can make one suggestion for the folks running Panda's ER: Put the coffee machine away from where patients can see.

Weekly Literate Blogs

In the spirit of Kevin, MD's Medblog Power 8, (but 1/10th the readership) I offer my weekly roundup of the best health blogs of the week. My criteria are subjective but can be characterized as belonging to a medical humanities approach, i.e one where stories or essays approach the level of literature. Rants, linkfests and other forms of web-based journalism have their place and their value, but I am focusing on a different kind of writing.

If you have any comments, feedback or suggestions, let me know. Especially if you can think of a catchy name for this weekly digest...

1. The Story of Fnu Lu at intueri
2. Conflict at Dr. Wes
3. A Personal Post at Random Acts of Reality

Restless Legs

John Mack is questioning the cost benefit of treating Restless Legs Syndrome (RLS). His analysis is a simple, back-of-the-napkin type of calculation and mostly accurate as far as I can tell.

Certainly there are cheaper alternatives, here quoting a Medscape article that requires registration:

Avoidance of caffeine, alcohol, or nicotine may help improve symptoms in some patients. Offending medications (see numbered list above) should be discontinued. Physical measures that may partially or temporarily help include a hot or cold bath, rubbing the limbs before sleep, or vibratory or electrical stimulation of the distal lower limbs before bedtime.

To continue in the callous dollars and cents vein, we could also look at the economic benefits of treating RLS.

First off, the majority of people who suffer severely are older, either middle aged or later. While some estimates put the prevalence of RLS at over 10%, the fact is the minority of these are severe. Even a prevalence of 3%, which John Mack prefers, includes a number of people with mild symptoms that can be managed conservatively without medications.

In case anyone forgot, medications are bad, carry risk of unforeseen adverse events and generally should be used only when necessary and only on the advice of a physician.

In my experience (anecdotal information like this should be taken with a grain of salt; it has no scientific validity, but in the absence of anything better carries just a wee bit of weight) the people most likely to complain of RLS are the elderly. They are retired and have passed the age of economic productivity. (I told you I was going to be callous.)

The only real economic consequence is the fact that adult caretakers of the elderly carry a burden of caring for their parents and grandparents.

It is nice having a drug in the armamentarium to treat RLS. It really has the potential of being a painful and debilitating condition, especially given how it interferes with sleep. But there is no way Glaxo's marketing folks should be trying to expand the "total addressable market" to over 20 million Americans. It is unwise for the company, since unrealistic forecasts are an Achilles heel for any investor or analyst to find, assuming they dig deep enough.

But my sympathies go out to big pharma. The huge revenues that came in over the past two decades have evaporated and the pipelines are dry. Could it be that they didn't invest their profits sufficiently in real innovative R&D, or have we come so far, breakthroughs are just no longer around to get!

Time will tell and I suspect that the more creative the marketing, the less innovation exists in pharmaceutical development.

Health Wonk Review

The new Health Wonk Review is up at Century Foundation's Health Beat. Thanks to Maggie Mahar for her extensive coverage of my submission; I am truly humbled. But also thanks to Hank Stern at InsureBlog. Despite, or because of, our ideological differences, we have managed to focus attention on some fundamental (and valid) values that play into opinions regarding health care.

Despite appearances to the contrary, I am not always sure I'm right, but I can tell it as I see it.
Maggie has done a terrific job this week looking at key issues in the policy world... but I have plenty more to read.

You get the health system you design

Every once in awhile, an amazing, brilliant and well-reasoned insight to health-care policy comes to my attention. The Agonist's breakdown of social policy as it affects health care resonates with me.

If you don't spread the wealth, if you don't have a broad middle class society, this is what happens. And it's not a question of "forces beyond anyone's control", it's a matter of deliberate government policy. Want a middle class society? Great. In exchange you have to give up having tons of obscenely rich people. You can't have both.

On the one hand, natural law means we will work harder and produce more if we have a reasonable chance to improve our living circumstances in so doing. If you spread all the wealth all the time, the incentive goes away. If you conserve the wealth and fail to redistribute resources, even a little bit, you get problems.

Prescriptions drugs without a doctor

Have you ever read the little piece of paper you sign at the pharmacy when you're picking up a prescription? Most people think they are confirming receipt of the medication. If you have read it, you'll know you've just confirmed that you didn't want to speak to the pharmacist for counseling.

Frankly, they're too busy counting pills.

I wonder why my wife, who is obsessive enough to count the pills from every prescription she receives, only ever finds that she has been short-changed. She has never once been the beneficiary of an error in her favor.

The FDA is holding hearings about allowing pharmacists to dispense medications currently available only by a physician's prescription. Pharmacists already dispense good advice about medications, direct people about over-the-counter drugs, and control a new class of controlled drugs that do not require a prescription. Specifically Plan B, the morning-after contraceptive, and many cold medicines, are kept behind the counter, to be sold only on a pharmacist's recommendation. This is the way many medications are sold in Europe, and they're healthier than Americans, right? It improves access for patients, so it has to be a good thing.

Presumably the college drop-out who manages and evaluates the retail pharmacist's performance, also gets to supervise the professional acceptability of behind-the-counter sales. Of course, the corporate chain retail pharmacies will be responsible enough to temper the incentives to sell as much product as possible, with some sense of quality control. The right of a pharmacist to refuse to provide any medication will be protected by a recognition that these pharmacists are independent and responsible professionals who know exactly what they're doing. Since counseling takes time, I am certain that retail chains and supermarkets will hire additional pharmacists to ensure the best possible advice for their customers.

I personally have no objection to psychologists, physical therapists and other paraprofessionals prescribing and being responsible for medications. I am quite certain they are capable of ordering lab work to detect liver and kidney abnormalities and examine patients to make sure the medication is working effectively.

OK, I will stop the sarcasm for a second right here...

In fact, allied health professionals are NOT specifically trained to monitor patients for side-effects and effectiveness. All they can do is dispense. I will not treat the side effects produced by another professional's decisions, except in an emergency. It is bad medicine and both the patient and the physician deserve the continuity of information. This is how we learn, even in the absence of a mistake.

Let's not forget the patients. My clinics dispense free medication at our $30 sliding scale visits. I cannot tell how often patients show up only wanting the medication and refusing to pay $30 to see the doctor, despite the fact that they are not under control and it has been 3 or 6 months or more since they were last seen.

Finally, let's make sure the trial lawyers are safe. After all, they have easy pickings with primary care physicians and drug companies when things go wrong. By shifting the responsibility to patients and pharmacists (whose liability coverage is not as rich as physicians), trial lawyers could find themselves out of significant contingency fees.

Follow-up on LA Heart-Attack

This is my blog and I run it the way I want.

You can call me a jackass and an idiot and any other choice words you choose. Creativity is a bonus, but stooping to profanity will get you deleted. You cannot call any readers or commenter stupid or offend them in any way, especially if they are grieving. You do not blame the victim.

I deleted an anonymous poster's comment this morning, but (s)he made some good points. I offer the comments below with edits where I thought they were appropriate. This whole thing is emotionally draining and a strain on the family of the deceased and I am aware that family and friends are reading. I am still trying to view this as a policy discussion with a really dramatic human impact, the nature of which has to be respected by everyone.

Remember, the following is from an anonymous poster responding to Missing a Heart Attack in LA:

Living in the LA area I have followed this in the news AND being a senior I am quite interested in LA County health facilities as I use them myself. I did a little investigation into this particular matter. It would seem from your post that you yourself are a medical professional since you claim your friend died of a heart attack.... well, after calling the county coroner they stated they would not have the autopsy results for another two weeks.

At this point we do not even know why he died. The Times reported he died of heart failure, however anyone who dies has heart failure. All that means is that the heart stopped. That happens when a person dies.

[...] Why did you stop at a county hospital? Verdugo Hospital is private and Olive View is county, which means it is free, obviously then the man did not have health insurance therefore Verdugo would have refused him treatment altogether. Don't you know that a private hospital can refuse treatment to those without insurance, like myself, with no repercussions? [Ed: This is untrue because of a rule known as EMTALA, but if a person perceives an obstacle to accessing care, they may not seek the care they need; the consequences of which are plain to see. This is an argument for universal health coverage.]

Also, the Daily News and LA Times reported that you and your friend had just come back from a "wild" weekend in Las Vegas. [...] Could that have been a contributing factor[?]

The Times [also] reported that your friend told the nurses at Olive View that he had been drinking and that he was currently intoxicated. [Could that have contributed to the nurse's judgment?]

[...]

Having used County Health Facilities myself I know there are at least 4 to 6 persons involved with every patients. When I visit the ER at a county facility I have to sign up with one person, wait to be triaged by another, sit in the waiting room with at least 40 other people; after triage I go to the financial person, then I wait to be called back to the ER and another RN checks me out, takes my vitals etc., then I wait to see the doctor.

It will be very interesting to find out what the autopsy and toxicology report from the coroner's office has to say.

While Anonymous adopted an abrasive tone, the post highlights that health outcomes such as this unexplained death in LA can have multiple contributing causes. This whole thing started when I posted on GruntDoc that an EKG would not necessarily have saved his life. As more details come out, it seems that an entire health system is under indictment and yes, patients are an integral player in the system and yes, they sometimes make mistakes too (Anonymous included). we still don't know enough of the details and they are contentious, to say the least. I think the purpose here is to understand what happened and with as little rancor and blame, try to come up with a way to minimize the frequency of system failures such as this.

MRSA versus the plague

While we are in the midst of a political and public relations panic, there is a story flying just under the radar that would be worthy of a real run-in-the-streets-screaming panic.

A wildlife biologist from Massachusetts working in the Grand Canyon died of the plague. The story from a TV news outlet [for God's sake!] is more thoroughly reported and researched than much of what I see in the NYT.

Forty nine people were given prophylactic antibiotics because pneumonic plague is so highly infectious, even casual contact justifies treatment. In general, anyone who has come within 6 1/2 feet of an infected person should take preventive antibiotics. Yersinia Pestis is classified as a Category A Select Agent, which means it can be weaponized or used for bioterror, but it can be handled in a biosafety level 2 lab. Most of this information is from the CDC.

There are three forms of the disease, bubonic plague which affects predominantly the lymph nodes, septicemic plague where the bacteria break through initial structural barriers and find their way into the blood stream and pneumonic plague, affecting the lung, which has a 50% mortality, even with treatment. If treatment is delayed more than 18 hours, survival is unlikely. I find it troubling that there are no useful clinical clues to the presence of pneumonic plague. Bubonic plague present with a violent febrile illness with marked lymph node enlargement, but there is no guarantee that the pneumonic form of the disease produces those kind of lymph nodes.

Yersinia pestis is usually contracted from the bite of an infected flea. The major repository is wildlife, as our biologist discovered; he contracted the disease after doing an autopsy on a mountain lion.

A little history lesson is provided via JAMA:

In AD 541, the first recorded plague pandemic began in Egypt and swept across Europe with attributable population losses of between 50% and 60% in North Africa, Europe, and central and southern Asia. The second plague pandemic, also known as the black death or great pestilence, began in 1346 and eventually killed 20 to 30 million people in Europe, one third of the European population. Plague spread slowly and inexorably from village to village by infected rats and humans or more quickly from country to country by ships. The pandemic lasted more than 130 years and had major political, cultural, and religious ramifications. The third pandemic began in China in 1855, spread to all inhabited continents, and ultimately killed more than 12 million people in India and China alone.

Lest you think I am taking my turn at panic-mongering, there have been no cases of the plague in the Southwest for several years, but increased activity has been noted in Arizona and new Mexico. We are only talking about an average of 13 cases a year and about 15% case fatality, but it is worthy of watching. There is as yet no sign of an increase in incidence, despite the endemicity of Plague in the Western reaches of the continent.

It is unclear to me if this biologist was careless or slipped up. For example, we don't know if he was supposed to be using personal protection like a mask. Even if he took painstaking precautions, his occupational risk was working with animals that represent the reservoir of plague in an area where the disease is endemic. Fortunately no resistance has been described, unlike MRSA. Personally I think it's only a matter of time before someone on Fox blames the plague on illegals coming across the border from Mexico!

While we're on the topic of foreigners and disease panics [this is intended as biting sarcasm], has anyone noticed that bird flu has claimed it's 91st victim in Indonesia, bringing the international death toll to 205? We're going into the winter and the UN is concerned this may be the year we start to get human-to-human transmission.

What the Heck is Cultural Competence?

Washington State has chosen to address the cultural competency of their physicians and providers.

While this is laudable in purpose, an effort to assure cultural competence is difficult to implement well. On the face of it, additional training seems the logical response to a deficit in cultural competence. Unfortunately, continuing medical education and training has never been demonstrated to effectively change the practice patterns of physicians, so there is no reason to believe it will work here.

One could try to increase the diversity of the physician supply, but my experience is that whereas this may improve the satisfaction of people with similar ethnic and cultural backgrounds, it does not address the competence of physicians dealing with a diverse group of patients. Foreigners of any given ethnicity are no better able to deal with other ethnicities than a plain vanilla white American boy.

Moreover, the way cultural competence is presented can be dangerous, the way many well-intentioned efforts succumb to the law of unintended consequences. For example I recently received a brochure from The Joint Commission (aka JCAHO) which represents different ethnic groups and their usual beliefs and behaviors about illness.

Many of the 'facts' presented are truisms and platitudes that only hold for some people in any given population. Not every Hmong rubs coins on their childrens' backs and not every Latina mother thinks about cold and hot illnesses. These beliefs are typical of ordinary people and thus much more dramatically influenced by socio-economic status within the culture that by the culture itself. It is tantamount to calling an Asian smart or an African athletic. Whether or not the statement hold true in the aggregate, the seed of prejudice (i.e. pre-judging) lies in assuming that the person in front of you shares those attributes.

Perhaps there is a different way to assure cultural competence, but also to address the underlying issues for poor communication between physicians and patients. Physicians are taught interpersonal and communication skills in medical school and residency, but the training is uneven and inconsistent between programs. To deal with every person on a psychosocial continuum is to see them as a unique collection of ethnic, cultural, social, family personal, biological and genetically determined experiences that need to be peeled away layer by layer without assumption, judgment or bias. Culture rightly become a focus, but only of one of several factors which shape the interaction.

In the cognitive specialties, like the primary care specialties, the ability to provide satisfactory care without excessive investigation is the key to assuring low-cost, high-quality health outcomes.

I would propose we completely and utterly abandon cultural competence (by the way, I am convinced Washington State is using "competency" in a grammatically incorrect way) as the framework for how we approach patients and replace with a broader psychosocially defined "communication competence concept." These can be taught through the current channels with an IOM-driven effort to influence curricula via ACGME and the AAMC. In other words, use current channels to support a broad communication-skills agenda rather than a narrow-focus of cultural competence.


Some resources can be found at HRSA, Joint Commission (aka JCAHO) and the ANM.

Better Health Care for our Politicians?

A local news outlet is looking at congressional perks and one of them is health care. They get more choices in insurance and it is cheaper, apparently due to the level of competition. There is a private Capitol doctor and access to a special ward at Walter Reed.

There is some hypocrisy to be noted about legislators who shoot down health care for children while keeping themselves well insured and with special and preferred access, or the shameful treatment of our soldiers in dilapidated facilities within walking distance of their own luxurious digs.

But on the other hand, maybe we should review our assumptions. How much does it cost to maintain facilities in condition to provide immediate and convenient service? Probably quite a bit, since we don't want expensive facilities and professionals sitting around without work to do, without providing billable services and simply waiting for the next client.

An inexpensive efficient system would keep all the professionals busy and keep the patients waiting. Some services are urgent, so the least urgent would have to wait proportionately longer for non-urgent services. This is like a patient in a car-crash bumping a routine hernia repair from a previously scheduled OR slot.

Would you pay extra to have your procedure at a facility in which your OR time was guaranteed? Perhaps it is acceptable to allow those individuals who can to pay for luxurious surroundings and improved convenience. There are some public health implications of access, but perhaps equal access is not desirable, merely sufficient access to achieve public health goals. After all, the interests of capital would prefer the ability to pay for better health care, much as our senators and congressmen claim as a perk of power. It seems the majority or Americans find it repugnant to allow some people to die because they could not gain access to a needed procedure or treatment due to differences in social class or insurance status. However, it is the way of the world to provide better quality for those who can afford it.

There is data emerging from the Health Disparities Collaboratives that community health centers provide a better level of quality than private facilities. CHC's do better in delivering necessary monitoring and treatment for diabetics, asthmatics and people with depression than private facilities. The facility I help run does a better job than my own physician's group.

On the other hand, we have long waits for new patients, old (but clean) facilities and a temperamental phone system. My physician answers calls personally and squeezes me in according to my needs and I have watched him do so for other (wealthy) non-physicians.

Capital may define quality in a different manner than public health does. This is an important observation to build a health care system we can all live with. It should not cost much to provide a basic and defined set of health services for low-income people. But it should be a system with sufficient drawbacks that people perceive an advantage to paying more for something better. That "something better" could involve greater coverage for procedures and treatments that do not yet have an overwhelming scientific advantage and to provide those services at a much greater level of convenience and luxury.

Weekend medical literature on the blogs

I am still writing this single weekly post to draw attention to the medical humanities. Good medical writing can take many forms, essays and anecdotes being foremost among them. The strange thing this week is the top 3 were all posted November 6!

1. Val Jones @ Dr. Val and the Voice of Reason (Revolution Health): The Man Who Couldn't Speak
2. Dr. Wes @ Dr. Wes: Another Portal
3. vitum medicinus @vitummedicinus.com :: a life of medicine: Can't Be Too Careful With Physical Exams

November

This is a personal post.

It was a cold and rainy November day in the DC area. It was a lot like the day we buried my grandmother fifteen years ago.

Fifteen years ago today my grandmother went into the OR to replace a heart valve. She did not survive. That was the day I lost my way.

One year later, to the day, my father started having chest pain in the middle of the night. I refused to believe it, the symmetry was too much. I thought it was an anniversary reaction of sorts. He died in the emergency room a few hours later.

And now fourteen years later, fifteen years after I started to get off track, my path has brought me here; to my wife, to the Great American Desert, to this new job. And to think of the people and the community that helped and got me here. Family, friends and above all, the Maker of this magical, wonderful, frightening world in which we wake every day and struggle to find a kernel of joy.

I was thinking about it this morning, and apart from narrowly avoiding an accident due to the tears in my eyes, I had to reflect on how my footsteps have been guided to this moment. We always have another chance, although nothing is perfect, there can be no doubt we are always moving closer to those things we need the most; to be true to ourselves, to feel useful in the world and to help one another as a fundamental reason to exist.

I know I have more to learn, more to contribute and more to accomplish and many people are a fundamental part of the plan, no matter how challenging those people can be. May we have the peace and discernment to find the path, stick to it as best as possible and always have faith that the plan is there, but it is only a lesson plan. We are challenged until we learn what we need to move on. I think this is why The Physician Executive is headed to the Great American Desert early in the New Year.

Defining Universal Health Care

Peter Huber has written a brilliant op-ed in today's IBD (via InsureBlog) which effectively dissects the issues surrounding universal health care. I recommend it to anyone who seeks to truly understand the issues with a minimum of dogma, but there is some.

Mr. Huber points out that medicine has entered the expensive era of chronic disease which is quite a bit more expensive to manage than the infections that dominated the early era of scientific medicine. He goes on to point out that a huge disparity exists in survival between the best and worst race-gender-county combination in the country. The explanation appears to be related to being "health-careless."

This last argument is a repackaging of an a centuries-old elitist argument that people do well because they make good choices and people do poorly because of poor choices. The logic that better consequences follow from greater adeptness at making choices is not at issue. The issues relate to the choices that will present to people born in certain circumstances. The choices I was born into were between a Subaru and a Mazda for a first car; some of my friends, between a Lotus and an MG. Others between the bus and the subway. Such possibilities present in health as well.

The greatest single predictor of health outcome is socio-economic status. The best way to be healthy in life is to be born into a wealthy family. While there are things that we can do to influence our health over the years, much is related to the vagaries of genetics and chance. In fact, genetics seem to affect behavior more than any of us would care to admit. Maybe our behavior, which governs our choices, is in fact frequently determined by our personality. The impulsive personality makes different mistakes that the meek and over-prudent one, but there are mistakes to be made all-round.

In a brief aside, I have made the observation that cocaine addicts seem to frequently have anxiety disorders which become apparent when the drugs have worn off. I have also observed that alcoholics were frequently depressed prior to their addiction reaching crisis. This is not a scientific or controlled observation, but I like to think a somewhat educated one. The implication would be that not all our poor choices are merely the result of having been careless and thus living the natural consequences of our actions.

If nature wins out over nurture, it becomes a eugenic argument and invites a return to royal systems of centuries ago. Even if nature does not completely win out, it still influences the outcome... of health, options being presented and quality of decision being made. Even in a mechanistic world, where everything can be explained by either nature or nurture, there must allowances made for accidents or chance occurrences that affect health.

Mr. Huber, cholesterol and most of the behaviorally determined health risks we face today, are nowhere near as lethal as cholera, or in fact, even TB, a slow-moving infection if ever there was one. The fickleness of the infectious era has not completely disappeared despite the modern impulse to control everything and believe that one is actually in charge of one's destiny. Being the captain of the ship does not imply control of the winds.

I feel the need to respond to a couple of other points. First, I do not understand universal health care to imply either an entitlement or a single payer. This is very important because it is at the root of the current health care debate which I would liken to two people arguing about a color: one person is screaming it's not white, the other screaming it's not black while all the while it was gray. Canada has a single payer and universal health care. Much of the Europe has state mandated or subsidized health care through multiple payers. The UK has a national health care system in parallel with a private system, which negates the common American fear that they won't be able to get health care outside the public system.

Universal health care ensures that everyone contributes. Health insurance then is the choice method for redistributing the financial risk. While this would result in adjusting a young person's cost of insurance upwards and reduce an older person's cost, I am not so sure the young would reject the notion. The young person still finds herself taking care of elderly parents or grandparents and living with the financial impact. Everyone stands to benefit from a pooling of resources, but the old elitist and eugenic arguments come to bear: why pool my resources with genetically inferior individuals who are unable to make wise choices.

I must agree with Mr. Huber about the reasons we must pursue Universal health care, although we come to very different conclusions:

The cost of health care has a big, direct impact on both the cost of labor and the marginal tax rate. If California defies the new medicine's economics by requiring insurers to ignore everything but age and geography, firms can flee to Texas or Shanghai. Efficient labor markets require efficient health insurance, which will be found only where actuaries are allowed to find out as much as the rest of us can, and craft policies accordingly.

While many people complain about the NHS, it accomplishes universal health care at the lowest cost in the Western world. In addition, it allows the wealthy and much of the middle class access to a better level of care in more luxurious surroundings and more timely intervention for non-life-threatening events. In other words, it achieves the objectives of providing a competitive level of health care at a competitive national cost. It is imperfect and probably wouldn't work here, it is instructive that one's assumptions are so porous.

I feel obligated to point out that the extent of federal subsidy could reduce the potential profitability of the insurance industry and that would be bad for America. Let's not be shy about calling a spade a spade: health care is an economic engine and many players share an interest. Insurance is probably the most powerful. The rest of us are learning what the actuaries already know, "the one with the most information wins..." But utilizing such information to pad one's margins and select people for coverage negates the original purpose of insurance, which is to share risk.

Universal health care can work, but before we even try to figure it out, we need to define it properly. Then we need to figure out a compromise that all the players can live with.

Cavalcade of Risk # 38 at My Wealth Builder

This particular blog carnival is one of the most interesting around, as it examines risk from many perspectives, including finance, health, insurance and the calculations ordinary people have to use in order to make the best decisions.

Kudos to Super Saver for an excellent edition.

Kudos to Lisa Emrich for consistently producing high level analyses of living with disability.

My Wealth Builder: Cavalcade of Risk # 38

Rate Doctors Properly

Instead of wasting our time with processes as absurd, unscientific and potentially misleading as web survey ratings and Zagat ratings of doctors, why don't we look into how Martindale ranks lawyers.

The Martindale-Hubbell Peer Review Ratings help in-house counsel and other sophisticated buyers of legal services identify, evaluate and select the most appropriate lawyer for a specific task at hand. Lawyer Ratings serve as an objective indicator that a lawyer has the highest ethical standards and professional ability and are used by buyers of legal services to justify their hiring decisions.

These are mostly peer ratings, with consideration given to "sophisticated buyers" of legal services. Perhaps in health care, the buyer is really the insurance company. I mean as a physician, you have to view the insurance company as the most important buyer, because they make the final payment decision, but the consumer's opinion still has a role to play. Frankly, not much, but some.

Something to think about, if capital wants to chase valid rankings.

By the way, I just threw someone else out of the office for lying to me. Hope Zagat is paying attention.

Dental Scandal in Washington Metro

This is disturbing, because we refer to a Small Smiles facility. Their Washington metro location has been open less than a year. In fact, they finally threw an opening reception for local stakeholders only a month or two ago. Although the news story is sensational, as it must be to sell advertising, the way these children were treated is simply not right.

I-Team: Small SmilesABC 7 News

As far as I know, Small Smiles is a for-profit. Recently, I was appalled to hear about a dentist at a Syracuse community health center who broke a drill-bit in a patient's sinus getting down to "Car Wash."

Mistakes happen in all environments, private, public, for-profit and otherwise. (By mistakes, I mean poor management, uncaring service, outright fraud and an almost criminal neglect of one's professional responsibility.) I just hope community-controlled not-for-profits do a better job being accountable.

Physicians Risk Getting Dragged Into Rampant Health Care Corruption

What makes us think that health care is immune to corruption? At what point do the Machiavellian machinations of politics, money and power become corruption in the first place? What makes us, as physicians, think that we are immune to the same natural forces that govern human conflict and the competition for resources and wealth?

Corruption is rampant in US Healthcare and it's not limited to Richard Scrushy and HealthSouth.

SCHIP was defeated because it threatened insurance companies, so says AHIP. I guess we didn't see their hand in Medicare Advantage, but what do you expect a lobby group to say? I can promise they will point out that community rating and guaranteed issue will force them out of business cost because of the perverse incentives that result in young people not buying insurance because it costs more, unless they were sick. They will not point out that the problem goes away if everyone is required to buy health insurance, as we do with auto insurance.

We do not need to look further than the pharmaceutical industry to see corruption at work in about as bald-faced a way as you could imagine. The excuse of expensive research is laughable, as we scrape the bottom of the barrel looking for new antibiotics for all the new superbugs. But pharma seeks a sure market, not innovation, despite the profit motive that should assure innovation. You and I both know, it's all about marketing.

Functionaries at the Consumer Protection Agency are under attack for accepting gifts. What makes physicians think they can accept gifts and still represent the interests of the health consumer. (Yes, that's the patient, whose interests we are sworn to serve.)

What makes us think they are not really bribes? I may have my price, but it sure ain't a pen, a couple of pads of sticky notes and a dinner at a local steakhouse. It costs a lot more than that to buy me! What makes us think that we are immune to conflicts of interest in medicine? What makes us think that we can actually continue to get away with an overt bias (manipulated by pharma marketers) in our continuing education? Why are physicians getting dragged into the cess-pool of dirty corporate games?

Hey, did you go to medical school to let yourself be manipulated by a Bachelor's level schmoozer from the sales department?

Grand Rounds

Grand Rounds is up at Counting Sheep, an "Everyday Nurses" blog. Our theme this week is pain; another compassionate collection of tales to remind us why we are here in the first place.

Missing a Heart Attack in LA: How Much to Prevent One Death?

So there was this horrendous story out of Olive View-UCLA where a young gentleman died after spending three hours waiting in an ER. His presenting complaint was chest pain and he died of a heart attack. He was 33.

Grunt Doc’s excellent blog asked “How in the world could this happen?” I commented that “Missing an MI does not make it wise use of resources to investigate every low-probability case.”

It started a vigorous discussion that highlights important aspects of how doctors and nurses, managers and policy-makers view health care differently.

First let me make it clear that Christopher Jones’ death is a tragedy and in no way can his death be condoned, excused or reconciled. My point is that resources are limited no matter what your product and both policymakers and health care administrators need to make difficult resource allocation decisions. In other words, no matter how you want to sugar-coat it for public consumption, rationing must occur in any industry.

We can build the best possible vehicle and make one available to every adult man and woman in the US, but that does not make it any more feasible to afford allocating of those kinds of resources to a single product of such quality. True, there are differences between a critical health care service and a vehicle, and difference in the consequence of lacking access to one or the other. But the cost of preventing this death is not a single EKG. There is a larger context in which a basic economic principle holds true and governs our lives, our jobs and our livelihoods. That we were not taught such economic truths in medical school or nursing school makes them no less true.

First, there is no way to know if Mr. Jones’ wait in the ER was appropriate or not without knowing what else was going on in that specific ER that specific night. Somewhere, a California policy-maker should be asking if the ER was overloaded and why? If it was because of chronic underfunding of public hospitals, the blame lies with the politicos and the crappy level of public debate that I have been complaining about since I started this blog. Dogmatic responses and misinformation does not help resolve the very real problems providers face in that place where the rubber meets the road. Also, ER overbooking may be due to public ignorance leading to misuse of ER resources by an unrealistic populace.

There should also be an administrator looking at the triage situation in this ER. One commenter on GruntDoc described an ER that did not have a private triage area where EKG’s could be done. This is probably unacceptable in a busy inner-city ER. Perhaps triage decisions were made that an acutely ill 80-year needed to be stabilized before the 33-year old could be seen. The moral implications of this decision go far beyond the purpose of this post, but think about it. It is not an easy, cut-and-dried decision if the resources are not there to take care of everyone all the time.

Second, I must bring up some purely clinical issues. I stand by my comment that an EKG on everyone who walks in the door with chest pain is not necessarily a wise use of resources. I have seen 20-year-old have MI’s, but this is not the classic patient. An EKG may be sufficiently sensitive in a higher probability setting, it may not be sufficient to rule anything out in a 33-year old. Risk factors and not the presence of chest pain determines the probability of heart disease. If the EKG is abnormal, the probability of a false positive is also pretty high. This is not an administrative responsibility, but a medical one; this is basic clinical epidemiology. Anyone who neglects pre- and post-test probabilities is practicing cookbook medicine and not creating value for all those health care dollars being doled out. (Yes, I am being a little sarcastic here…)

So there it is. I suspect that there were resource allocation decisions by both policy-makers and administrators that probably contributed to this death. As tragic as it is, not everyone can be saved, nor should we as a society try to save everyone. Then there appears to be a basic misunderstanding of the role of the EKG in triage contributing to the sense of outrage.

My final thought is that if physicians and nurses were left to make the resource allocation decisions, we would necessarily have an expensive solution. Providing for what our patients need is what we were trained to do, it is what we are best positioned to do, it is what we would give away the farm to do. Balancing my training as a physician and my education in policy and management is the fundamental conflict in my life. Shouldn't we all be a little concerned about the bigger picture, despite our built-in internal bias?

How MRSA Becomes a Public Joke

The best recent joke comes at the expense of local politicians getting in front of the media to promise to keep our schools safe from MRSA. It is a photo-op from publicist heaven.

Is MRSA really more common in schools? Probably not, since schools are the only folks who report MRSA infections or who are really try to "do something about it," using the parlance of a widespread public panic. Senator Schumer wants to start reporting MRSA. I hope he appreciates the cost of culturing every skin lesion larger than a pimple on a teenager's backside. (I spend a fair amount of time complaining about the quality of Republican and conservative logic and rhetoric, but here we have a perfect example of hair-brained ideas from the other end of the political spectrum.)

Another example is of a politician in Philadelphia who is dedicated to raising awareness about MRSA. This makes me wonder about resistant strep which will kill many more people if it gets loose. How about VRE, anybody? Maybe we should raise money for research the way we do for highways: “This bacterium adopted by the Rotary Club of Poughkeepsie.” You’d think that someone running for Philadelphia city council would be a little more concerned that murder could be a leading cause of death in certain sub-populations in parts of the city.

Although the NYT published an article that compared the risk of MRSA to other rare events (TOH, Kevin, MD) and people with the authority of Dr. RW, medpundit, Dr. Anonymous and the CDC keep offering updates the panic apparently continues, fanned by political rhetoric. (Yes, I have also previously written something on MRSA, but far be it for me to draw undue attention to myself...)

I don't know, maybe it's about the lawsuits. Maybe it's about TV ratings? All I know is that it is not about how many people are dying from MRSA. Here is a report that most people who die from MRSA are sufficiently ill to be dying of other causes anyway.

What are we doing about MRSA? Exactly what we should be. Additional ideas are welcome as long as they are not coming from tabloids, bad TV news shows and irresponsible senators.

Open Hospice

I have always been unhappy with the US approach to hospice care. It seems to be the final resting place, where we can forget about the dying and medicate them to within an inch of oblivion. This is not the purpose of hospice care.

Palliative medicine is a better term, and it applies to providing total care to people with terminal diagnoses. It is care that is focussed on comfort and well-being, not cure. But it is not putting a human being out to pasture.

The NYTimes features a new approach to palliation, but it is really the way the rest of the world does it. Maybe we have gotten so caught up in how to pay for it and prevent cheating and abuse that we took our eye off the purpose of hospice programs. There is a lesson here for all policy wonks, managers and regulators... abuse potentially leads to regulation that can defeat the purpose. There will always be cheaters and abuse, but the question is what are we accomplishing and at what cost. In the presence of too many regulatory requirements the train will never leave the station.

Best Literary Blog Posts

Every week, I choose three blog posts that exceed expectations, either due to exceptional writing, "essay" quality or evocative tale-telling. It is inspired by Kevin MD's MedBlog Power 8, where he shares the best blog posts of the week based on his subjective criteria related to controversy.

I have made the MedBlog Power 8 list often enough... I guess I like to find hot buttons, but weekends are for a hot cup of tea and an hour with your favorite book. My criteria for the literary 3 are not well-defined and fairly capricious, but it does not need to be so. I have started discussions with a couple of people who may have an interest in medical literature. Ultimately blogdom will influence the criteria and the affect the evolution of the this idea. Feel free to jump in and comment, offer opinions and the usual feedback. I am not even convinced this is worthwhile endeavor. Many view weblogs as a lesser form of journalism. This effort would point out instances that are much more than even 'just' journalism.

But I do think there was some amazing writing on the web this week:
1. Sid Schwab is wonderful writer and I hope he is compiling another book. He is also a regular on Kevin's list. This week I prefer Cool, an essay that evokes medical school days trying to learn the proper way to hold a surgical instrument when every surgeon felt the other guy's method was wrong. How anxiety provoking for a too-young, obsessive overachiever! I learned more reading this article than my entire surgical rotation. (Well, except the resident who gave me a few pointers on how to survive the scalpel-throwers... I wonder if Magic Marvin is still stapling stomachs?)
2. Dr. Rob is a Distractible Mind to be sure. His essay this week, on Blog Friends, is an epsitle to on-line friends, but also a thoughtful consideration on how the real world and the interactive web relate. It is an elegant essay written at a difficult time. Our prayers are with you Rob.
3. I used to run. Intueri runs. I don't run any more. I'm depressed. And she'll be in New York next year. It's a good thing.

It was three essays this week. I did not find a vignette I liked enough. Either it's in the air or I don't have enough time to find everything that's out there. Grand Rounds this week did the job. I was also tempted to add Henry Stern's Health Wonk Review, whose unusual historical theme was enormously edifying. But it's not an essay or a short story. Maybe an idea for the future...

I am celebrating a 15 day run with at least 100 visits daily (except three weekend days), which may not sound like much but is pretty good for four months blogging. Also, I celebrate my first McGill hit!

My weekend starts early this week... Opa kai hronia polla. It's a Greek & Italian wedding in Pittsburgh. Evviva gli sposi!

Health Wonk Review

The good folks over at Insureblog present this week's edition. As carnivals and reviews go, this is a most original and stunningly literate edition. In combines historical review on the occasion of All-Saint's Day with the best policy opinion on the web! It's a "can't miss" edition, and look for your-truly under 1886.