Wednesday, January 30, 2008
Grady is mismanaged, even though the CEO is hardly the cause of a half-century's neglect of market realities. He has resigned.
Retail clinics are a diversion and a general drain on scarce medical resources, but some readers have reminded me they are not likely to last. "Right you are," I must say to the gadfly commenter. A Walmart partner shows that mismanagement is hardly the exclusive domain of large public hospitals. One chain has gone bankrupt.
There is a clear connection between the two; it is further evidence of a maldistribution of resources from where they can have impact (primary care of chronic disease indigent populations) to low-impact: retail.
Tuesday, January 29, 2008
I actually have had a patient come in and tell me "If I have to live with pain, I'll live with it, but what is causing it. I really need to understand it."
I gave that guy narcotics.
I had someone come in and tell me, I really don't like how they make me feel, so I don't take the pills.
I encouraged her to take them, at least when she was home or in the evening.
Instead many patients come in and seem to require no opinion from a highly trained diagnostician, seek no suggestion from someone with experience of the risks of drugs and really don't seem to want to know what the doctor thinks. What most people with genuine pain do not realize is how many chronic pain patients come in with the tell-tale clues of malingering. There is nothing more frustrating and infuriating than being manipulated by a junkie, who comes in wearing a suit more often that you would think.
Once my radar is up, I tend to shut down. No candy from me. I may even be blinded to patterns.
Here is the story of one patient, left as a comment to an old post:
I haven't told this story anywhere, but this seems like a good place for my first time...I'll give the abbreviated version.
About 5 years ago, I started having bouts of severe runs and ungodly abdominal pain. No one could find anything wrong after two colonoscopies and numerous CT's. My primary care doc decided I just had IBS and gave me Bentyl, which did nothing for the runs or the pain. He refused to prescribe pain meds except for NSAIDs even though I was allergic to them. (He said he had a strict "no-narcotics" policy...he "hasn't ever prescribed a narcotic in his life, and he wasn't about to start with me"), I was in and out of the ER 17 times in one year at one point. The ER doctors called me a malingerer, drug-seeker, etc. One particular ER doctor did a rectal exam in a very rough, painful way for three minutes solid, and then told me to "remember this experience the next time I thought about sniffing around his ER for narcotics!" My PCP sent me to a shrink because "this pain stuff is all in you head and it's controlling your life. There's no pain medicine that can treat what's wrong with you."
In 5 years I had seen literally 15 specialists. One attack landed me in the ER after I started screaming in pain at a bus stop and a bystander evidently witnessed me threatening to kill a "ghost trying to eat my soul." This scared the crap out of me because my father had the same crap happen to him...it drove him to commit suicide. Needless to say that I was admitted.
I was given a PCA for two days, and they were about to just send me home when a young hospitalist looked at my chart and said to me, "I have never seen this disease before except in medical journals, but I think I may know what's wrong with you." He did a 24-hour urine save, and kept me in the hospital for another day, giving me whatever pain medicine it took to control my pain; he got it down to a tolerable level after adjusting the PCA thingie.
The next day, he came into my room, asked me about my pain and then asked if he could bring in some med students. I agreed, and wham! There must have been 15 people in there. It was then that he told me what he did with the urine. It sounds like he basically held my pee under a blacklight in a dark room and it lit up like a firefly's butt. He gave me a preliminary diagnosis of Acute Intermittent Porphyria. He then had the nurse draw a TON of blood, and the tests confirmed it. I stayed in the hospital for a week hooked up to the PCA and got Panhematin via IV and was put on a high carb diet. When I got better, I was discharged with a referral to a pain clinic (I'd been BEGGING my PCP for a pain referral for years, but he wouldn't hear of it since it was "all in my head.")
I recently sent the abusive ER doctor (and the hospital's patient advocate) copies of my test results along with a demand for an apology. Wanna place bets on whether or not the guy will nut up and apologize? The patient advocate sent a letter of apology...I'm thinking the doctor won't be so gracious.
Anyway, jsut thought I'd pass this along in hopes that the chronic pain patients here realize that there are good doctors out there, and here's hoping that some of the doctors think twice before writing patients in pain off as "head cases" so easily.
Acute Intermittent Porphyria affects between 3,000 and 15,000 people in the entire country. It is decidedly rare. I commend the no-narcotics policy for long-term undiagnosed pain but would urge practitioners to be cautious with patients who return and offer investigation. One method of dealing with patients we find difficult is to do limited progressive investigations and keep listening.
One day that pattern may jump up and slap you across the face as it appears to have done for this patient: intermittent pain, neuro-psychiatric symptoms and a family history of the same!
As for punitive examinations... well, large gauge NG tubes don't work at preventing suicidal gestures either. Maybe we need to listen a little more and punish a little less. The real drug-seekers do not allow investigation; they run away.
The cycle of provocation and reaction must stop somewhere.
Sunday, January 27, 2008
First, Dr. Suburban [whose new blog Suburban Emergency is starting off with some interesting provocations] describes a procedure that would have been done in many (but most definitely not all) ER's in the country. A conflict erupted over different stakeholders' definition of what is best for the patient, while nurses are playing Sudoku. The arguments are valid on all sides, as presented by Dr. Suburban, but think about how resources are distributed between hospitals and within this hospital.
The WSJ Health Blog raises some interesting questions about OTC meds, when The Lancet appears to endorse OTC birth-control. This too is advocated on its net public health merits and the point that anyone who wants contraception should have it. Of course, the costs associated with an unwanted pregnancy are much higher than any costs of adverse health events; that should be a given statement as obvious as "penicillin saves lives of pneumonia patients" would have been in 1945. But it is political.
Patient-centered medicine is a term I first heard from Moira Stewart and her colleagues in London, Ontario. The term has been used for advocacy, but is often thrown around as an excuse for organizing around the needs of one group or another within a hospital or across a health system.
It is in a physician's best interest to use the ER to reduce a wrist fracture, but safety prerogatives require an experienced support staff. It is in the patient's interest to have a minor procedure in the same part of the hospital she entered. There are risks to handoffs and risks to doing conscious sedation in the ER. Everyone wants to do what's best for themselves in this case, but uses the patient as their rationale. Did anyone ask the patient?
As for oral contraceptives, there are risks of increases cervical cancer if you believed that giving all women the pill will lead to rampant unprotected intercourse. Well, your daughter maybe... [Can you imagine how that statement would play it in Southern Baptist country??? I am being naughty aren't I?] I would also have to raise the issue of breast cancer, a miniscule but emotionally potent risk. Probably, the greatest population level risk would be an increase in thrombotic events. The net effect on a social-economic-health basis may very well be positive because of the reduction in unwanted pregnancy, not even considering ovarian cancer risk.
I wonder if we should ask the patient, if we were truly being patient-centered.?
Sometimes, no matter what, there is sufficient evidence to acknowledge that the correct patient-centered response is to say no. But before we stand on our soap-boxes claiming we are centered on the patients' interests, we should make sure we are not just trying to make our own lives easier.
Friday, January 25, 2008
In Maryland, the Board of Physicians says it takes 120 days to obtain a license (it usually goes faster). The last time I looked into California, it was over six months. States that decide they are over-doctored typically take longer than other states. There may be something to that, since I have heard of some primary care physicians having a hard enough time finding work that they are considering leaving California. But to be fair, I don't know if a couple of anecdotes are worthy of calling it an established trend; I will be watching.
The reason it takes so long is something known as primary source verification. Licensing boards are diligent in verifying every employment situation, every hospital affiliation and every training site. Sometimes they go so far as to verify every locum situation as well. If a physician has worked for a single weekend covering a rural hospital, someone will want to verify it. Even thirty years later.
This needs to be done.
But it generates an awful lot of paperwork.
Since some of my former employers are closed, it creates challenges in identifying the correct individual to provide important verifications. Unsurprisingly, many Canadian residencies are less concerned with American credentialing than I am. My former internship site is apparently renovating and having trouble finding documents for some guy who left the country ten years ago.
Such is life.
The trail is long and I am a bit of a Donabedian groupie, so I don't have a problem with primary source verification. However, there is an awful lot of overlap. There is the National Practitioner Database and the AMA, which offer some degree of triangulation, even though they are primarily a method of identifying complaints, lawsuits and other problems. Employers also do their own primary source verification, that way employers do not need to stay familiar with their state board's processes. In one instance, the state board was able to obtain verification and the employer was not. The employer insisted on a signed affidavit.
Then there are the insurers. One company I am familiar with refuses to begin a credentialing process until everything is in the file. Then it takes them four months to review. Then they do not pay for any services provided during the credentialing process. I understand the importance of credentials verification, but this sounds a little like manipulating a process to their financial advantage. Yes, I am talking about you, Amerigroup. (Gratuitous stock advice: consider buying the stock, but never the insurance.)*
I would never advocate the elimination of licensing requirements (if I hear someone quote Milton Friedman on the subject one more time, I will subject them to the merciless ridicule reserved for followers of cults, star energy, homeopathy and other quackery), but there are certainly some implications for a free market in health care. There is none.
We could streamline licensing procedures and credentials verification across the country. The CAQH already has electronic tools to facilitate the credentialing process. It would open up interstate competition in health care. (In a subsidized environment, heath care is driven by practitioners, so the competition is between jurisdictions and employers to attract them, not between practitioners to attract customers.) The problem of mal-distribution of physician resources would likely continue, but there are a very few examples of regulatory incentives to encourage physicians not to settle in cities or suburbs. Physicians flock to nice places to live until they start going belly-up. Or working for MinuteClinics.
As it stands, as a CMO, I am competing with much wealthier jurisdictions and facilities and then faced with an outsized regulatory burden to verify my practitioner's credentials and facilitate our payer's verifications. Moreover, the barriers to interstate movement of the medical labor force is at a level that makes me think of protectionist trade barriers.
I hope to see my first patient next week.
*I suppose there should be a disclaimer about the fact that my comment is meant sarcastically and not intended to represent real stock advice etc etc, but I assume that my readers are intelligent enough to figure that out for themselves. Caveat emptor.
Thursday, January 24, 2008
Medgadget and Scrub Gallery must be congratulated for their work and diligence, given how appropriate and worthy their choices appear.
Thank you to those who voted for The Physician Executive.
Monday, January 21, 2008
I was once blasted by the venerable Dr. Larry Green in public (which was embarrassing, given I was wearing a name tag with my real name) because he thought I was suggesting that family medicine was not a specialty. I speak in a convoluted fashion sometimes and he had misunderstood me, but the point remains; is generalism held in such low esteem that we must all be specialists?
NHS Blog Doctor has made a career of attacking the NHS, but he apparently sometimes slams his own colleagues on occasion such as this article on "GP's with special interests". In the UK, generalist physicians are called GP's. There is no such thing as a general internist (or very few) since by definition, a GP must see all patients without regard for age or gender.
Personally, I have a couple of niches that I am very good at, mostly cardiovascular and what may be called maternal-child health. In the absence of an available consultant, it is often wise for one physician to ask me about an area with which he is less familiar. In fact, I freely discuss clinical situations with as many physicians of the same or similar degree of specialization, as often as I can
This requires a collegial, non-confrontational atmosphere where everyone is trying to the best thing for the patient. Reading between the lines, I suspect that my favorite British curmudgeon has bureaucratic bone to pick with NHS functionaries who are trying to find ways to reduce costs. In the US, one might see insurance companies as playing the same role, although we have a much more malignant group of individuals threatening health care in this country. [Can you spell L-A-W-Y-E-R?]
Perhaps one of the knocks on generalists is that in the rush to save money, system players have forgotten that their purpose was to foster the distribution of resources in a manner consistent with the best population health outcomes. In so doing, we have devalued our generalists to the point that GP's in the US must be specialists for no other reason that they would have no credibility otherwise.
What a sad state of affairs. In Adam Smith's model, increasing specialization leads to productivity improvements and efficiencies from the concentration of skill. This is a good thing, since the commoditization of highly specialized products and services drives costs down. But to realize the cost savings, aren't there a number of requirements?
For example, trade barriers: there should not be barriers between French tapestry workers and Arab gold craftsmen in order to have a free market. It has been six weeks and I still do not have my new state license. I am correctly reminded that this is not bad; now try to take your US state license to Europe.
Short of eliminating licensing requirements, they can be streamlined and smoothed out, at least within the US.
Markets are also made when participants participate freely. I mention this, although it is a half-hatched idea: regulations that impinge on practitioner's freedom to exercise their best judgment may have the potential to be counter-productive. Most regulation, in my experience, creates a counter-current which sometimes overwhelms the original intent of that regulation.
One of the areas where generalists can contribute to the efficiency of markets might be the role of connecting patients to the proper specialty resource. One consequence of limiting access to specialties through insurance panels is that we have lost the benefit of informal networks that natural arrange themselves around GP-based social connections.
One thing I have lost in the US is the need for personal relationships with specialists. My friends, classmates and colleagues at McGill served the purpose of steering my patients to the right resource at the right time. It would take a phone call, a letter or a referral. Now, there is no point, I leave the job to a referrals coordinator who is familiar with the networks mandated by local managed care companies.
There was some value in those networks, but regulators got in the way. In the UK it is government, in the US, it is the market itself as insurance companies end up interfering with system features that could end up saving them money along with the easy cost reductions they were after in the first place. It is hard to perceive the net gain or loss of utilization review, referral requirements and other blunt instruments with which government and industry seek to reduce their own costs. But somehow, I suspect that it all depends on the numbers you choose to include and the time frame you choose to look at.
I will let others comment on the evidence and the economic veracity of what I assert, but it seems straightforward to a group of bloggers and curmudgeons. Let doctors do what they do and incentivize them properly to achieve the proper measurable outcomes.
Friday, January 18, 2008
At my first US job, it took only a couple of years after leaving my secure Canadian base (yes, I am being sarcastic) to find myself analyzing an incentive plan that was developed in the wake of the consumer backlash against managed care and the collapse of the forces spurring the development of the vertically integrated hospital system I had joined.
It involved dropping my income by 1/3 in exchange of the promise of making back what I earned if I worked twice as hard with no control of the patients that would be booked or the efforts that would be made to collect what I billed. Of course I would only get my incentive bonus if the hospital actually collected those billings. I could be exposed to contractual adjustments I knew nothing about and I couldn't understand why in the world an understaffed billing office worry about my $50 service when they had a $10,000 orthopedic charge to go after.
Not surprisingly, there is another side; a group of FQHC physicians are asking for profit-sharing
when we run nearly an operating deficit. The only reason the FQHC is sustainable are the government grants. While there may be some exceptionally well-run FQHC's that throw off enough operating margin to share with staff, we must always remember that our communities' most valuable assets are our non-profits.
I caught up with a post from the Happy Hospitalist (such an excellent blog, I can't begrudge the fact that he is beating me senseless in the Medical Weblog Awards competition for Best New Blog) where he points out how the National Quality Forum's suggestion that hospitals should be incentivized to prevent medical errors is being implemented by insurance companies. The list of never events is growing and becoming contradictory; a delirious patient cannot be restrained chemically or physically and if they fall, well... any outcome associated with age and ill-health will probably be denied. At least the insurance companies know that if they can get away from paying for the conditions associated with the terminal stages of human existence, they are likely to save a bunch of money. (Geico, please don't sue me for borrowing a few words from your slogan. I own stock in your parent organization!!!)
One day someone is going to offer me more money for less work.
I just know it.
Thursday, January 17, 2008
BiDil, pushed by NitroMed was a very effective combination of two old medications whose use hinged on a study that suggested that it was more effective in African Americans. Similarly, we are taught that calcium channel blockers are more effective in reducing blood pressure in African Americans.
I have always thought that the data upon which these assertions are made were rather sketchy and unconvincing (to me at least), despite the tinny ring of truth with which they were announced. "Blacks should be on calcium-channel blockers," I heard my colleagues of all races, teach the residents, and the words of a nephrologist friend rang in my other ear, "But their renal failure rate is so high, they'll have great blood-pressure control while they're on dialysis."
But he was a speaker for a drug company pushing a competing drug.
What is a poor practitioner to believe?
To suggest that one drug is better than other takes a head-to-head study, since the differences are so subtle, as to be beyond statistical verifiability between different studies with different investigators, different methods and a different patient mix. Unless there was a massive difference in survival over a couple of weeks, (i.e hard outcome, short interval, really big difference in outcome) as not to require the finesse of statistical control, it is hard to believe tis kind of assertion. Although NitroMed did a head-to-head, many other claims of one drug being better than another are based on the observation that the improvement in one study was bigger than the improvement in another.
Moreover this subtle outcome difference is predominantly associative, whose causal link must be made credible by a reasonable underlying pathophysiological process. Is there anyone in their right mind who would seek genetic differences in a specific race today? Not only is that a eugenically noxious concept, the very generalization required to make it clinically useful, is racist on the face of it.
For example, if a population is said to be more likely to respond to a given drug, or more susceptible to hypertension or more obese (or smarter, for that matter) it would behoove the practitioner to test the hypothesis with the person in front of them before drawing any conclusions. It is not the generalization that harms as much as the application of the general to the individual.
Even if African-Americans respond better as a group to this drug, it may not provide informaiton useful to a therapeutic decision.
Consider that it has been said that ACE-inhibitors are less likely to work in obese patients. The underlying pharmacology of drug distribution being affected by fat percentage, especially for lipophilic drugs, makes us think that there may be a credible scientific reason to... We may be more willing to escalate the doses or even exceed FDA recommendations, while monitoring extremely carefully for side effects, of course. After a few years, we may note that the variation in response is simply not important enough, given the cost difference and the wide choice of alternatives we have. If it doesn't work at low doses, let's just drop it and move on to other drugs.
How would a physician act differently with a hypothesis based on race, rather than weight? How is the marketing of a drug going to affect the way you ultimately try a medication, monitor for adverse effects and titrate the dose? Marketing certainly does affect the practitioner's judgment, but one must ask how? I can only see heart failure medications being initiated in a controlled hospital setting, and monitored very tightly in the outpatient. It is a situation where clinical response in the short-term is what counts, irrespective of race.
Moreover, NitroMed priced themselves out of the market and insurers and hospital P&T committees scoffed at the notion, when cheap generics exist for both components of BiDil. If the combination were so potent, the price still did not justify not taking 2 pills separately.
All I can say is this is what happens when marketing drives the drug discovery process. These are the types of drugs which have infested our armamentarium as a consequence of caving in t the profit motive of an industry in the hope of spurring innovation. All I can say is: "wrong kind of innovation."
By all means use the market, but do not blindly believe that the invisible hand is so discerning.
Wednesday, January 16, 2008
Remember, the practice of medicine represents an assumption of risk for levels of compensation that are not always appropriate. It is a good area to expand into if one is medically curious.
Tuesday, January 15, 2008
First Cato reminds us that the food is not what's cloned, it's the animals (duh... I think I will stop reading these guys; I may be somewhat of a libertarian, but I'm not a quack) and that cloning is not the same thing as genetically modifying foodstuffs. The difference is lost on anyone who identifies genetic manipulation as the "thing" they object to. It's sort of like saying eugenics is not genetically modifying humanity, since we don't directly manipulate the genes. [I know it's an old article, but it came up on my research.]
Apparently House Representative Rosa DeLauro had cow over cloned meats and introduced HR992: The Cloned Foods Act to go along with s414: Cloned Food Labeling Act. This puts Steven Pitts in the awkward position of defending the FDA and me in the equally awkward position of not having a beef with him.
Here are intelligent comments and reportage from Slate: "The conventional food we eat is already unsafe, so clones are no worse;" the NYT: "In theory, the procedure can produce meatier cows or pigs that are better able to resist diseases. In practice, the process produces a relatively high proportion of deformed animals that cannot survive, although scientists with the European Food Safety Agency said such rates were likely to decline as the technology improved;" the Washington Post: "While more complete research is needed on this technology, there is still an underlying objection from consumers based on ethical and animal welfare concerns;" as well as opinions from the European Food Safety Agency and The Center for Food Safety.
Eye on FDA has been consistently negative, here and here and here. Mark Senak makes the thoughtful comment that:
This is one debate, like the irradiation of foods and use of growth hormones in cattle, that one can expect to see continue for many years to come and where the science discussed has moved faster than the social context for the debate.
But I will go one further. The hypothesis that cloned meat is any different than what we normally raise is patently absurd and only deserve a superficial verification of nutritional composition. I feel the same about genetically modified foods. I cannot believe that there is anything that different about modifying the genes of corn in a lab as compared to what Mendel did in his garden eons ago. I say this knowing full well that cloned animals are more likely to suffer malformations and certain illnesses.
In my mind the real risk is one which cannot possibly be tested. Look for the unexpected, unforeseen possibilities that no one is considering; at least not in the press. What could the consequence be for an ecosystem in which genetic modifications are made with the rapidity that gene technology makes possible? These genes are released outside of the laboratory, where they interact with the rest of nature in ways that cannot be conceived or understood. There are limits to our understanding of the complexity of natural environments. This is one of the things we don't know we don't know (as opposed to the things we know we don't know... no this is not about Rumsfeld, but an actual, real unknown.)
We are modifying that natural gene pool at an unprecedented pace, and it's definitely out of the lab. All agriculture is based on genetic modification through the use of breeding and husbandry. Ain't no difference between that and what goes on in the lab, except it's faster now. And the birds and the winds are spreading genetically modified seeds to all four corners of this dear planet of ours and we have not even the sense to ask if there is a danger there. Animal genes are less likely to interact with the wild, but I am no farmer and judging from the difficulty of keeping human beings from mixing their genetic material indiscriminately, I somehow suspect there's loopholes in farming too. The mule may be a good example.
Our food is shot up with antibiotics and steroids and I'm still not convinced that alien slab of pale flesh is really chicken... sure doesn't taste like a real one anyway. I sometimes like to buy organic, but when my wife found out it could mean manure instead of chemicals, she goes out of her way to avoid it. No cow poop in our veggies! I reviewed an article or two, but it doesn't tell me what happens when a human being consumes food raised one way or another for 25 years or more.
Somehow I don't think safety is the issue. We can no more assure the safety of our food supply than we can guarantee a bus won't fall off an overpass tomorrow and land on your car on your way to work. But we should still get the chance to choose. Ninety percent of us won't understand the label anyway, so the industry's fear is misplaced.
Information never killed anyone, nor did it hurt an industry. Hiding information hurts the industries involved, as it raises the issue of a cover-up and spurs the imagination to see conspiracies everywhere. Keep this up and Mrs. Ammon is threatening no more cow at all! Imagine a vegetarian America growing it's own veggies on rooftops and home greenhouses across the country.
Remarkably, USDA has weighed in against cloned foods, as reported in the Post this morning.
Bruce I. Knight, the USDA's undersecretary for marketing and regulatory programs, requested an ongoing "voluntary moratorium" to buy time for "an acceptance process" that Knight said consumers in the United States and abroad will need, "given the emotional nature of this issue."Yes? And the point is?
Executives from the nation's major cattle cloning companies conceded yesterday that they have not been able to keep track of how many offspring of clones have entered the food supply, despite a years-old request by the FDA to keep them off the market pending completion of the agency's safety report.
At least one Kansas cattle producer also disclosed yesterday that he has openly sold semen from prize-winning clones to many U.S. meat producers in the past few years, and that he is certain he is not alone.
"This is a fairy tale that this technology is not being used and is not already in the food chain," said Donald Coover, a Galesburg cattleman and veterinarian who has a specialty cattle semen business. "Anyone who tells you otherwise either doesn't know what they're talking about, or they're not being honest."
Sunday, January 13, 2008
My wife had an episode of pharyngitis several years ago. Two days after seeing the doctor, being cultured up (rapid screen negative), she dragged herself to the ER with what sounds to me like a Quinsy. Both my friend and my wife are furious with the doctors and I can't blame them. I've had one or two bad outcomes in my life and I never felt good about them, nor did I expect someone to absolve me with a wave of the hand.
But doctor number one did not examine and doctor number two did.
Nothing may have changed. The outcomes may have been entirely the same. The management even sounds correct. But how will we ever know, if Dr. #1 robbed my friend's wife of the benefit of a two-second judgment?
It doesn't seem like much, those two seconds of an experienced eye... but I can tell in seconds what a lay person would be uncertain of forever. I would like to think that, whether physicians spend minutes or hours with their patients, it's in those two seconds that we earn our fees.
Saturday, January 12, 2008
Given the apparent anti-competitive stance of my last post on retail clinics, I am feeling a little schizoid.
But the more I think about it, I am more convinced than ever that retail clinics are harmful because they alter the landscape in ways that could be ultimately negative for health outcomes. If there is a need for non-ER, after-hours facilities to provide care for minor medical urgencies, it is partly the result of labor shortages in the face of increasing demand. I'll be blunt; nobody in their right mind will take the lifestyle impairments of 24/7 availability out of their primary care office given the current regulatory burden, liability and low level of remuneration in primary care. There are not enough primary care docs to meet the demand and they are not sufficiently well remunerated to provide the level of care it takes to keep people out of ER. They need more resources, but instead, I see resources going to retail clinics and moreover, benefiting large, profitable pharmacy conglomerates at the expense of primary care.
I am furious at Massachusetts because not every state has a progressive (note I did not say liberal) tradition of protecting the common good and a regulatory structure to support it. It is hard for me to believe that intelligent, well-meaning people with a commitment to public health have such a distorted and short-sighted view of the world that they truly believe they are doing good by allowing retail clinics greater sway. To be honest, I had not previously followed the story and do not now have a full understanding of the arguments in support of retail clinics in Massachusetts, but the result produces a visceral response in me. I am guilty of knee-jerk reaction in this case. Most of my arguments are at Paul Levy's Running a hospital and they do not require repeating here.
One statement in Greenspan's book that I think is relevant for some reason is that "too low a risk-adjusted return implies a waste of resources and productivity." From a macro-economic perspective, I can understand that.
Workers (including physicians), capital and other resources will be distributed according to their risk-tolerance, the risk and return profile of their chosen activity and the depth of their personal resources. Some people take 12 years to finish their neurosurgery training because they perceive that the return on their time and effort (as well as the opportunity cost of deferred income) justifies those resources. The return is measured in dollars and some qualitative sense of their happiness and vocational satisfaction.
Others complete their three or four years of primary care residency and get to the workforce a little faster, expecting to live a somewhat less stressful life and earn a little less for the same effort. But that income cannot be so low that it no longer provides an incentive for working harder. There is a risk that, at some point, reimbursement can become so low as not justify working harder. There is a point, where you just show up for work, do your eight hours and pay the mortgage. Sometimes the headaches of additional patients, hours away from family and satisfying regulatory masters just do not make it worth any effort beyond just staying afloat until retirement.
In the end, you have got to love what you do, enjoy the training environment enough to survive and make an assessment of what you can reasonably accomplish as well as what it is worth in future income and satisfaction.
Those who put in their three to four years to become primary care physicians do not expect the same reimbursement levels as people who have invested a greater part of their lives in training, but as the differential in reimbursement between specialists and primary care grows, two things will happen:
a) more people will gravitate to specialties until primary reimbursement catches up due to the supply-demand equation. There will be shortages as a consequence, frequently manifest by a lack of primary care access.
b) as the demand for primary care grows, primary physicians will simply not be willing to put up with requirements from hospitals, ER's, specialists and even patients that impose greater uncompensated responsibilities and liabilities. In other words, there is no incentive to work harder and longer, to make sure after-hours coverage exists.
Retail clinics provide the opportunity for primary care providers to seek additional revenue, at low risk, low effort and high compensation. It is ultimately good for them. What the heck; if they can compete and do well in the system, all the more power to them.
But wait a minute! Whose system is it? What is the purpose and objective of our system? I did not see the words "to improve the financial health of physicians" in the mission statement of any non-profit in the country, much less that of a progressive state such as Massachusetts.
Surely retail clinics are going to help pharmacies generate prescriptions, revenues and excess profits. It is definitely good for them and probably for the markets and the economy as a whole. But as I perused the Massachusetts Public Health Council Web Site, I did not find that the health of the public's 401K investments was part of their mandate.
I did, however find that the Council is composed of the chair of a University pediatrics department, an infectious disease specialist, an emergency physician, University chancellors, policy wonks and the like. I did not find a single person with academic primary care credentials who could indicate the potential of adverse impact on the primary care workforce. Also the majority of PHC members, necessarily come from the large contiguous urban core of Massachusetts, which is traditionally over-doctored and thus not subject to the same degree of primary care pressure as other parts of the country. Come to think of it, I bypassed Boston in 1996 because their academic primary care presence was just so darned weak. Those who have struggled in the shadow of the center of the American academic medical machine were much braver than I. Boston is simply not representative of the rest of the country, or perhaps even of the the state as a whole.
The thoughtfulness of a group of academics is usually measured from the perspective of their primary research or advocacy priorities, not the search for unintended consequences.
Let's return for a minute to the economics of the situation as an educated non-economist can understand it: "too low a risk-adjusted return implies a waste of resources and productivity." In health policy terms, I would interpret the "return" to refer to the health status of the population as adjusted for their baseline risk determined by age, gender, social and socio-economic status. If we had a good way of measuring the risk-adjusted return of our health investments according to some macro-economic unit (such as a state, for example,) and we found that it was high, we could infer that resources are deployed efficiently and effectively. If the return was low, I think Greenspan would assert that resources are not efficiently distributed amongst various health care activities in a manner consistent with the greatest good.
The return in question is not necessarily a financial one, although dollars could serve as a proxy for health, if one were to consider future health expenses.
Primary care resources are tight, so any distribution into activities that do not provide dividends in measurable indicators of health status will presumably diminish the absolute level of returns in other areas of health care activity. If we were to take diabetes as an example, reduced access to appropriate facilities could potentially result from the diversion of limited resources to retail clinics. We can only imagine the future impact of such a reduction in access on health outcomes for diabetics as well as any number of other chronic diseases.
Retail clinics do not better the health of the population for the amount of resources they consume. They have the potential to reduce congestion in ER's but do not address the underlying lack of a sufficient primary care workforce. Thus, it is possible that ER's will simply become congested with sicker patients over time, because those patients had worse access to primary care and suffered as a consequence. The alternative would have been to provide an incentive to non-profit community health centers (yes, I have a vested interest) to provide longer hours and expand into more areas in the state. I suspect that if they have not been able to do so, it is because they are unable to recruit a sufficient number of primary care providers at their current level of resources. Massachusetts and Boston in particular benefits from some of the highest concentration of federally-qualified community health centers in the country.
Remember, I am a non-economist and just a poor CMO of an FQHC in rural America, hardly able to compete with the best minds Boston has to offer this country. I know it would take several months of work to elevate my argument to the level of academic credibility and formulate a methodology to verify the hypotheses contained therein. But I have read similar arguments before in the academic literature, so I don't think that the Council was entirely ignorant of what we know about primary care and its importance to a health system. For my part, I have to go out and recruit a half-dozen physicians, respond to our local hospitals' needs and do what I believe is best to positively impact the overall health of my community. I hope our authorities let Massachusetts do the tinkering and use our regulatory powers to adjust the competitive environment with an actual health outcome in mind, and not just the health of our hospital emergency rooms.
I'd like to think that's what Alan Greenspan would say.
Friday, January 11, 2008
The other story was one of several reports on CVS' MinuteClinics being cleared to operate in Massachusetts: WSJ, David Harlow's Health Blawg, White Coat Notes at the Boston Globe, and Paul Levy at Running a hospital.
So hospitals are dying while corporate money mills with very little value-added are thriving. This evening, I spotted another post, reporting that 6 - 8 storefront, limited-service, retail clinics are going to open per day in 2008, over and above the 1000 already in existence.
There is a greater need in one area, but a greater profit to be had in another. Public hospitals fail while retail clinics grow.
I am a great believer in free markets, but fair markets rarely occur naturally. The current conditions are, in fact the result of regulations that provide perverse market incentives. Half the practice of medicine involves NOT PRESCRIBING MEDICATION!!!!
(Sorry, I'm yelling!)
Now, retail giants like CVS, have succeeded in developing vertically integrated style operations in which they control everything from the distribution channel to the provider's incentive. By most informed people's standard, quality is not defined by the highest possible prescriptions per encounter, but that is the natural incentive when a pharmacy chain controls the providers. Bonuses will be paid and employment decisions will be made according to the provider's ability to generate prescriptions.
And a public health authority voted for this? In Boston, with an incredible network of publicly controlled, not-for-profit community health centers? That makes absolutely no sense and without an adequate explanation of their logic, somebody please look for corruption or corporate threats on the face of it. As David Harlow points out, the diversion of resources will ultimately be damaging to the population's health. People need medical homes, not McDocs and McPA's. Nobody is coming to work for me, given that all I have to offer is a more difficult job and lower remuneration.
We must compete on a level playing field. The question is who is getting the more difficult patients and not being adequately remunerated for it. Who is getting easy encounters and getting the dividend of the prescribing revenue?
I can see 50 healthy people with coughs and colds with a good nurse and someone to answer phones and I can do it in 4 hours. In the same amount of time, I can properly do two complete geriatric assessments. The reimbursement differential per encounter cannot possibly cover the differences in resources, so I can't afford to do them properly. I cannot allow my physicians to do complete assessments and so will encourage them to refer out. MinuteClinics didn't worry about pushing those patients to me because they do not provide the service. Will you, dear reader, require me to have a different moral standard than MinuteClinics?
If retail clinics can push certain patients to me, then I can push those patients to someone else.
Health care facility managers segment their markets and subtly poach the patients that represent the best profit margins. Why hire a nurse practitioner with pain management background? Those patients are time-consuming, frustrating and unprofitable. Rheumatologists sometimes deal with elderly patients and time-consuming multiple medical problems, frequently more than they can compensate for in procedural fees from joint injections. In fact, poor people are generally a good bet to represent losses, sometimes even with Medicaid.
In a city like Atlanta, hospitals and ER's adopt the view that the "county hospital's" job is to take "those" people off their more productive hands. Some public/county hospitals do not recognize that this is the kiss of death.
Public and county hospitals must be in a competitive mood in order to recognize that their existence is threatened. Despite not having lived in Atlanta for three years, I am convinced that a major portion of Grady's trouble stems from the mind-set that "they" will never let Grady go under (meaning the counties and the state would always bail Grady out, no matter how much trouble they got into.)
Being sheltered from competition is part of Grady's problem.
Here, in the Great American Desert, I am in a community with three hospitals; one is county-funded (and trying to expand based on a public appropriation), one is critical-access (therefore subsidized by enhanced Medicare and Medicaid payments) and a stand-alone for-profit. It is only the for-profit that is knocking everyone's socks off. The others are trying to protect or expand their federal or local subsidy, rather than competitively expanding product lines, improving service levels or quality-of-care.
So we have contradictory forces regarding competition. In the case of MinuteClinics, competition harms the public health. In the case of public and county hospitals, the lack of competition is at the root of the problem.
In a free market, public and county hospitals must realize that they have to compete for the same kinds of profitable patients that MinuteClinics is after. But MinuteClinics must not be permitted to get away with such an artificially limited scope of service, by which they effectively block access to complicated patients, leaving the costs for others to bear. And damn the consequences that the rest of us who will have an even greater trouble recruiting competent providers to do the slugging in the trenches where it counts.
Thursday, January 10, 2008
In obesity, we have been running through scientific assessments of fad diets for a significant portion of the post-WWII period. Of course, the years have exposed a series of contradictory bits of evidence about weight loss. Does anyone remember the rice diet in the 60's? I was too young, except for some distant family members told me how much they'd gained! Then it was fat reduction in the diet, which I never really saw succeed. Then we had the low-carb diets like Adkins (eat all the fat you want) and South Beach (it's not the quantity, it's the quality of fat and carbohydrate that counts).
In the absence of real-world data (as opposed to controlled, quasi-laboratory environments) that incontrovertibly proves that either carbohydrate and/or fat intake reduction actually do work, I recommend to people to exercise and not exaggerate their intake. This study, although far from perfect, is another small notch in the favor of combined low-carb, low fat, high protein diets. It is too small to constitute proof, but it was certainly long enough at over 1-year follow-up. The concern about high protein intake and an association with renal problems (manifest by proteinuria) remains unanswered.
Fox is reporting on internet hormone sales and the secrets of great sex.
Wednesday, January 9, 2008
I am a co-finalist with Dr. Val and the Happy Hospitalist who have been favorites of mine, in the New Blog category.
I also made the best Health Policies/Ethics Blog category.
I am disappointed that Hank Stern and his comrades from InsureBlog did not make the list. They present controversial and different viewpoints with verve and intelligence. You still have my tip of the hat and plenty enough kudos from other sources. I look forward to the next time we do "combat."
On the other hand I am delighted that both intueri and Surgeonsblog made it in the Literary Blog Category. Whatever you feel, think or do, please take the time to vote.
Jon Kingsley is quoted as saying:
"Community rating alone does not ensure value, but must be combined with guaranteed issue, guaranteed renewal and broad if not universal participation so that insurers don't just end up pricing premiums to cover the sick," Kingsdale says.But Kingsdale knows that health care reform cannot succeed if it fails to control the underlying costs of health care.
If you ask Kingsdale how to reduce the costs of medical care, he has a long list of initiatives in his back pocket. These range from reducing hospital-acquired infections to managing variation in the flow of patients through the emergency rooms or operating rooms, to not paying for botched care, to reforming medical tort liability, to standardizing certain administrative processes, to constraining use of "me-too" brand drugs, to rigorous assessment of the efficacy of new medical devices and technologies.A reduction in costs has to come from somewhere and it appears that Kingsdale is referring to inefficiencies and waste in the system. It is somehow gratifying, even if only on a self-serving basis, that Kingsdale does not refer to physician and other health staff salaries. Most physicians would be concerned that improvements in outcome come at a cost, often it comes from their hides,in the form of unremunerated committee work or more unjustified interference with their practice independence.
But there is an alternate way, which is to reduce inefficiencies and the costs associated with those inefficiencies. I suspect that physicians are cash-accounting types, as opposed to accrual-accounting; they cannot see assets that they can't use to pay off their debt. It is hard to justify the adoption of technology at an up-front cost, if there is only a promise of future efficiency. There are no billable medical procedures associated with the technologies required to enhance the processes of care.
The performance and process improvement movement has had success in multiple industries explaining, justifying and demonstrating its value. Somehow health care has been more resistant and it is the largest single segment of the US economy, possibly larger than the entire federal government, ex-defense. [At any rate, it's pretty close.] I am not sure if it is the nature of health care, the fragmentation of the industry or physicians themselves that are to blame. It might possibly be that health care has grown so large that competing interests pulling in disparate directions are making it impossible to define a common direction.
Ask ten people about health care and they will give you ten opinions about what it should look like, possibly more than ten opinions if people like me are in the mix! It comes down to large pots of common resources being allocated with a purpose in mind. Allocating to health care is just to vague and allows a mercantilistic profit-motive to take over. [A mercantile profit-motive as described by Milton Friedman is not evil, and allows the common good to be provided by the invisible hand of a complex adaptive system such as our economy. I distinguish a mercantilistic concentration of resources in the hands of a few interests, which no longer reflects a free economy. However, I recognize I have just said a mouthful and mixed ideas from multiple great streams of thought in ways that they were never intended. I do so in the hope that I can clarify the ideology that underlies this post.]
For any large segment of the economy—and healthcare at 16% of the Gross National Product is huge—I only know two ways to allocate and manage resources: effective markets or centralized budgeting. We are trying the former in an effort to enhance competition and choice. I sincerely hope this works. To the extent that we find this wanting, we may be pushed toward the other alternative.But the article is thin on explaining the reasons to pursue universal health coverage, beyond stating the obvious, that it is the "right thing to do." This is a problem.
We cannot allocate to health care. Health care is not a purpose or a goal. We do not invest in health care unless we expect health care to provide a return on investment, which will be measured in new technologies, market gains and perhaps some tax dividends.
I would rather invest in the health of our workforce, which, it comes to mind, was the original rationale of insuring workers during the wage and price control era of WWII. Well, maybe it was a rationalization rather than a rationale, but it served as a useful framework to analyze success or failure for a time.
Health care may very well be the "right thing to do" but it may be more useful to identify constraints to economic productivity related to health care and address them broadly. For example we know that productivity losses from colds and influenza can amount to several hundred dollars per year. One model I found describes $40 billion dollars in aggregate economic impact of only the non-influenza respiratory infections.
Much of this data comes from the health effectiveness literature and there is certainly a great degree of interest from pharmaceutical companies in this type of data. [Please take your time with this link, it contains a lot fo food for thought, if you have not been exposed to these kinds of economic analyses.] It may make sense for policy-makers to leverage this type of information as a justification for universal health care. Perhaps an economic justification for health care can be built from even partial mitigation of the economic productivity impact of certain diseases or conditions.
A frequent knock on health care is that it is difficult to demonstrate an attributable reduction in mortality or an increase in life expectancy due to the availability of health care. But crude population statistics are a machete, compared to the scalpel of individual condition-specific economic analysis. On the other hand, neither instrument may be appropriate if you are cutting a lawn.
One thing for certain, I don't know that I can argue for or against health care as "the right thing to do" since it is a moral argument. I know how I feel, but bringing you over to my side seems like a futile exercise. A dollar-and-cents argument has to be balanced with a bit of compassion, but can provide the basis of a more productive discussion.
Monday, January 7, 2008
I came across physicians frustrated with a series of ineffectual management teams that they are not giving the current group a chance. I would not have come if I didn't believe the current group was worthwhile, but the docs may have seen too much over the years to believe in their current managers.
When doctors and medical staff are not given the credence and attention they deserve, they become passive-aggressive and actively subversive. That partially explains why I met a physician with angle closure glaucoma taking a sick day two days before a routine screening dilated exam!??!
[Angle closure glaucoma is precipitated and/or exacerbated by the dilating drops. The chronic open-angle form requires annual pressure monitoring and only occasional dilation. In any case, there was plenty of time to set up a screening exam within the required 30 days for a planned preventive service.]
Doctors are sometimes too smart for managers to handle. Managers need to spot BS quickly. In the end, it is the community and the patients that are the priority for both managers and doctors. When the environment has become full of mistrust, reminding both parties of their common mission is the only way out. It's been too short a time, but I see no reason this group cannot pull it out.
Friday, January 4, 2008
In my drive across the country, I encountered many languages. Coming from a polyglot city like DC, it is easy to be jaded about the American heartland and consider fairly white-bread. This is why it struck me that I encountered so many cultures along the way. I could have said that there were more non-English culture Americans along the way, but then I would be grandstanding.
I did run into a family of Greeks from Turkey along the way, an almost vanished cultural subgroup. Mostly I found myself conversing in my broken Spanish. First was a family from Cuba and we met in the St. Louis arch. Of course the dominant group was Mexican-American, who manned convenience stores, restaurants and hotels the entire length of the country, even in the most white bread areas. I even saw a young black man cleaning a hotel room, a truly unaccustomed site in this country over the last decade, but it was at a National Park, where reasonably affluent young adults work hard in exchange for the adventure of their lives.
All these impressions came on the heels of a radio talking-head saying something to the effect that the trouble with this country was the extent of illegal immigration. He was saying that people seemed to think it was OK to break the law or to simply ignore it in such unprecedented numbers.
So, that would mean that all laws must be vigorously enforced at all times. I’m glad this guy isn’t in charge of the highway administration; I would have been in trouble with speeding especially in some abandoned stretches of road in the West. But the level of policing required to eliminate all speeding in the country would be onerous, certainly it would be cost-prohibitive. Before the ACLU lost its way when the real issues gradually disappeared, they would have gently reminded us that not all laws are meant to be enforced severely given the risk that we could begin to look like a police state; a deplorable condition to be avoided at all costs. Indeed the fathers of this country did proclaim their liberty, or their lives!
If a law requires such severe and absurd efforts like building a wall across a natural resource like the Rio Grande, then I would consider the law worthy of re-evaluation. A law of the land is not a natural law. It is not the Law of Evolution, it is not a Law of God handed down to Moses, or elucidated by Mohammed or revealed by Christ. This country’s laws reflect intelligent people’s best bet on how to secure the greater good.
Our immigration laws are not only ineffectual; they are economically and socially counter-productive.
I caught a CSPAN rerun of Chris Matthews plugging his new book and he suggested that he had a problem with providing government documents to people who were not supposed to be here, i.e. making someone look like they had a status or legitimacy they did not have. That, I can understand. His position reflects serious thinking about how to approach the problem of rapid, undocumented immigration. But stopping immigration altogether is a boneheaded concept. Stopping illegal immigration is unlikely, given the strength of the forces behind migration. In fact, it is the complexity of human migration decisions that makes draconian immigration enforcement so stupid.
It is also economically counter-productive since I am convinced that labor is an asset for any country and does not represent a net burden in services. Some services relate to infrastructure that already exists and incremental increases are not necessarily harmful. Other services such as health care have raised some people’s hackles.
Those people who are up in arms over health care costs to immigrants need to come off it! Immigrants, especially illegals are mostly young, fit and hard-working. They do not come with the express purpose of seeking free health care for themselves or their families, although that may play into their needs after several years if their parents fall ill. There are numerous indications that immigrants, and especially illegals, use less health care and are more likely to pay for it than America’s own native poor. (By native, I mean born in the USA.)
The major burden in most areas is a fertility rate that approaches third world levels, but we’re too busy preaching the ineffectual dogma of abstinence to do anything about it (but that’s another post.) If anyone bothered to do a detailed economic accounting of the costs and benefits, I suspect it would quickly become clear that even illegal immigration is of net economic benefit to this country. Issues related to national security are just more fear-mongering to which I have become inured.
In construction and agriculture alone, this work force represents the ultimate in flexible, mobile work force to do labor of a kind no American would accept to do for any wage. To get native born-American to take up the back-breaking toil which is manual farm labor, we would all be looking at $8 tomatoes and a $20 head of cabbage.
If the problem is that there are too many immigrants, then I say it is the same old xenophobia that has affected people since time immemorial; a mean-spirited, deeply-rooted human fear of all that is unfamiliar. If the problem is only that such immigration is illegal, then I say change the laws. They are too impractical and poorly thought out for my liking. There are better and more intelligent ways to deal with a big incentive for economic migration from our southern neighbors.The fear of health care costs related to immigration is just one more ideological bone from the political demagogues.
Tuesday, January 1, 2008
Weight, smoking, exercise... these are the things that people typically resolve to improve. But how often do we hear someone say, my resolution this year is to improve my relationship with my daughter? How often is the resolution to keep in touch with my friends, or reconnect with colleagues from my last job?
In fact, from a purely careerist standpoint, one of the most important things anyone can do, is call one new person a day. This, I heard from a previous chairman who was encouraging me to call researchers and academics for networking. But, boy do I hate cold-calling. As it turns out, my personality is just not conducive to picking up the phone and calling someone to whom I have not been introduced. But I wish it was.
So here we are, shacking up in a motel in the Rockies, hoping the snow will settle down enough to make it back on the road and the thought comes to my mind: given all the communications technology available, I can spend all of New Year's Day on the phone calling up old friends and still not talk to anyone I had talked to in 2007!
The way my mind works, I'll probably create a spreadsheet so I can track how many people I am calling from each of three different categories...
Maybe I'd better just stick to those people who love me.
Happy New Year everyone.