Sunday, August 28, 2011

Should Patients Join the Pay-for-Performance Circus?

There was an extremely popular game show where several times each episode the emcee would shout out, "Survey Said!". Of course, this was just a game, not real life.  Now, several times each week I am asked to respond to surveys.  They pop up uninvited on the internet and are often veiled advertisements for products and services. They are on the back of receipts from coffee houses and doughnut shops.  Is it worth 10 minutes of my time clicking through the doughnut survey for either a free chocolate frosted doughnut or the chance to be entered into the grand prize drawing months later?  Hotels I stay at routinely follow-up with e-mail surveys for my feedback.  I suspect most folks delete these instantly, which skews the customer base to those who do respond. (Remember, disatisfied folks are often more motivated to give feedback than the rest of us are.) How often do we call a restaurant, a retail store, a bank or even a doctor's office to offer hosannas about great service?

Medicare recently released fascinating patient-survey data that raises interesting issues. In over 120 hospitals, patients rated the hospitals very highly, despite high death rates for heart disease and pneumonia. So, who do we believe here, the patients or the death rates?  I wonder if the patients' survey results were more optimistic since only the live ones were available to complete them.

Surveys are now serious bu$ine$$.  Reimbursement for hospitals and physicians will be influenced in either direction by patient satisfaction results.  But, are patients equipped to measure medical quality?  The discrepancy between the Medicare patient survey results and actual medical outcomes suggest that they are not the right tools for this task.  How can we expect ordinary folks to understand and rate medical quality when experts are confounded by the same mission?

Surely, there are important aspects of the medical experience that patients can evaluate.

  • On-time performance
  • Cleanliness of the facilities
  • Courtesy of the staff
  • Compassion and bedside manners
  • Responsiveness to billing issues
  • Ease of making appointments
  • Timely communications
  • Ease of reaching a living, breathing human being for a question or concern
But, while the above items are significant, are they true measurements of medical quality in the conventional sense?  Is the definition of medical quality being broadened simply to encompass measurable events?

Patients are being recruited under the Big Top, aka as the Pay-for-Performance Circus.  But, should patient surveys really count?  Or, do they count simply because their results are so easy to count?  Despite the dissenting arguments against P4P advanced on the Whistleblower, a must-read blog for health care thought leaders across the country, patient surveys will be folded into the expanding hydra of P4P programs. These programs won't measure true medical quality, at least in their current forms.  But, what a performance they will be.  The curtain will rise as the Secretary of Health and Human Services approaches the podium and shouts out, Survey Said!  What a Family Feud this will be.

Sunday, August 21, 2011

Tort Reform for Medical Malpractice System Another Study Needed?

Medical malpractice reform is in the news again. Of course, for the medical profession, the medical malpractice system is the wound that simply will not heal. For the plaintiffs bar, in contrast, the medical liability system is the gift that keeps on giving. I have argued that the current system fails on four important fronts.
  • Efficiency
  • Cost
  • Fairness
  • Quality Improvement
I admit readily that my profession has not been as diligent as it should be in holding ourselves accountable. We have not been forthright in admitting our medical errors, although can you blame us under the current medical liability construct? There is merit to the argument that tort reform is championed by medical malpractice insurance companies who have an economic agenda in this issue.

I recognize that certain malpractice reform measures, such as caps on non-economic damages, means that some individuals who have suffered severe injuries as a result of medical negligence, would not be adequately compensated. Nevertheless, I support caps because I am convinced it would serve the greater good, even though I would feel differently if I were one of the plaintiffs whose deserved compensation would be curtailed.

Despite the above admissions, the current system is a dysfunctional mess that fails in its mission to provide justice and fairness to the participants. More than physicians' arguments for reform, plaintiffs lawyers' pleass for maintaining the current system is permeated with economic self-interest. In my view, theirs is a weak brief that is transparent with regard to its true motives.

Here are some inarguable weaknesses of the current system.

  • The vast majority of patients harmed by medical negligence are not captured in the current system.
  • Non-partisan analyses confirm what we physicians know instinctively: litigation fear costs billions of dollars in defensive medicine, medical tests ordered to protect us, not our patients.
  • The majority of physicians targeted are ultimately released at some point in the process.
  • By stimulating defensive medicine, the current medical liability system diminishes medical quality, and does not serve as a deterrent against negligent care. Paradoxically, arguing that defensive medicine is negligent could be a potent niche for plaintiff attorneys.
The New England Journal of Medicine (NEJM) recently released a study after analyzing data from a medical malpractice insurance company involving over 40.000 physicians. Here are some highlights.

  • Every surgeon will face a medical malpractice lawsuit at some point in their careers. Is this a good lure to recruit talent into the surgical specialty?
  • About 7.5% of physicians face a medical malpractice lawsuit every year. 'Hey, I haven’t been hit for a few years. Is my number coming up soon?'
  • About 80% of claims against physicians are dropped. Would physicians be satisfied if a medical treatment were effective in 20% of patients?
  • Nearly 20% of neurosurgeons and cardiac surgeons are sued every year. Would you perform well at your job under a 20% yearly threat of being sued?
So, the NEJM has sprinkled some more data on a mountain of evidence that the current medical liability system is broken.  Did we really need another study?   Let's study if patients who are suffering heart attacks or severe pneumonias fare better if they are hospitalized rather than left at home.  Who can divine the outcome of this hypothesis?  After all, since this issue has never been published, who could predict the outcome?  Yes, of course, I am being deliberately absurd.

Some issues are self-evident and don't require a study to determine the obvious conclusion.  Yet, when it comes to medical malpractice reform, the current administration and Democratic legislators reassure us that they are serious about tort reform and want to 'study the issue' further. We hear the euphemism 'pilot program', which means quicksand.  Tort reform is moribund and has been assigned a DNR (Do Not Rescuscitate) status. Defensive medicine, in contrast, is alive and well. 

Sunday, August 14, 2011

Greedy Insurance Company Backs Down: The Little Guy Wins!

A few months back, while we were on vacation in Washington, D.C., my 17-year-old son Noah sustained an injury at 1:00 a.m. I was asleep, but this is usually a few hours earlier than he typically retires. In our hotel room’s bathroom, he dropped a glass and then managed to step in the wrong place. A sharp shard sliced through the soft skin between his great and second toes. Blood was spurting wildly and he woke me up with a shout. He was spooked.

We gastroenterologists are experienced at stanching bleeding, although I was uncertain how to do so without some kind of scope in my hand. I reflected on my ACLS training, which is a comprehensive 2 hour course that my partners and I take every 2 years. In between those sessions, I neither think about nor practice any advanced life saving procedures. It doesn’t seem rational that a community gastroenterologist should be schooled in temporary pacemakers, when most of us haven’t interpreted an EKG in decades.

I still remember the fundamentals of life support, the famed A, B, Cs, standing for airway, breathing and circulation. I decided to apply this to the hemorrhage at hand.

Airway: the windpipe was open and functioning

Breathing: the kid was breathing

Circulation: BINGO!

After going through this brief but critical checklist, I now knew where to focus. No need to intubate him. No need to call the front desk to rush a defibrillator to the room. No need for chest compressions, at least not yet. I considered tightening a tourniquet around his waist to clamp the aorta, but opted instead to apply direct pressure to the wound. Luckily, this high class hotel was equipped with just the medical apparatus I needed - a wash cloth. Once the bleeding slowed and I was able to visualize the wound, I realized that this was no Scotch tape fix. It was time for a field trip to the ER.

The hotel front desk advised me where to take him and 20 minutes later we were in Sibley Memorial Hospital. The care was excellent and the sutures were applied expertly by Gregory Cope, M.D. Two hours after our arrival, we were back in the hotel room. I decided not to rouse the kids at 9 a.m. for our intended trip to Ford’s theater, a site that has been deferred for a future trip.

Nothing is certain but death, taxes and emergency medical care bills. I reviewed the explanation of benefits form I received, which are never easy for me to unravel, even though I am somewhat of an insider of the medical profession. One of the 2 charges that I am responsible amounts to $391.50. I phoned my insurance company, always an opportunity for stress management, and reached a living breathing human being. Of course, I was first greeted by a mechanical voice who assured me that my call was important to them. Melanie, the insurance company customer service representative (Any reader agree with me that the phrase customer service is a euphemism?) explained that I had selected an out-of-service facility and was charged accordingly. After some research, she determined that there were in-network hospitals in the Washington, D.C. region. See what I mean about stress management?

“Melanie, let’s forget for a moment that I am a doctor and that you are an insurance company tool. It’s two o’clock in the morning. I am 500 miles away from home. My son’s foot is spewing blood. While you might regard me as irresponsible, I never contemplated whether the hospital was on the formulary. Should I have researched this issue then? How would I have done this at that hour? It’s challenging enough to reach a living insurance company soul during ordinary business hours. I wonder what my son would have thought if I told him we had to wait for authorization before we could leave the hotel. I’m sure this would have elevated his opinion of me as a doctor and a father.”
Melanie checked with a superior who agreed that under these circumstances they would reprocess the bill as an in-network charge. Victory! How much will I save? Probably, only a few bucks, but some victories are not measured in dollars. I ‘stuck it to the man’.

I have learned an important lesson from this experience. The next time I’m traveling with kids, I’m bringing paper cups.

Sunday, August 7, 2011

Is Cost-Effective Medicine on Life Support?

The concept of cost-effectiveness in medicine is elastic. One’s view on this issue depends upon who is paying the cost. Of course, this is true in all spheres of life. When you’re in a fine restaurant, you order differently when the meal will be charged to someone else. Under these circumstances, the foie gras appetizer and the jumbo shrimp cocktail are no longer luxuries, but are considered as essential amino acids that are necessary to maintain life.

In the marketplace, except in the medical universe, goods and services are priced according to what the market will bear. If an item is priced too high, then the seller will have fewer sales and a bloated inventory. Consumers will not pay absurd prices for common items, regardless of supernatural claims of quality.

  • Would you pay $100 for an ice cream sundae that boasted it was the best in the world?
  • Would you pay $1000 for a tennis racket that promised performance beyond your ability?
  • Would you pay $500 for a box of paper clips that never lose their tension?
Of course, you wouldn’t because none of this stuff is worth it, even if the quality claims are true. If any readers disagree, then send me a private email so I can enter into a business arrangement with you.

We lose sight of this obvious truth in medicine. It is not enough for a treatment to be effective. The benefit must be worth the cost. I realize that a cost-benefit analysis is interpreted differently by sick people and their families. I am sure this would be true for me and my own family. If my child needed a bone marrow transplant, I would devote my entire being to making this happen, regardless of long odds against success and a six figure price tag. In this hypothetical, I am no longer a smug blogger, but I am a terrified parent.

There will always be arguments about where to draw the line. Some treatments, such as routine vaccinations and proven preventive medical screening tests should be under the line. Other therapies that have minimal clinical benefit and astronomical costs should remain in high orbit and out of reach. All the stuff in between will be the grist for comparative effectiveness research, if it ever gets airborne.

A few months back, The New York Times reported on 2 new drugs, approved by the FDA for cancer treatment. Provenge, a new drug for prostate cancer extends life by 4 months at a cost of $93,000. Impressed? Wait, there’s more. Yervoy, a treatment for melanoma also extends life by 4 months at a cost of $120,000.

Are these two treatments under the line or over the line? In my view, as a spectator and not a sufferer of either disease, I think they should both be directly in the line of fire.

What’s your view?