Sunday, July 8, 2012

Pay for Performance Attacks Medical Quality: Lincoln Lucks Out

Why does Pay for Performance (P4P) make most physicians reach for Maalox? I have devoted a good portion of this blog’s real estate to dismantling the fallacy that pay for performance improves medical quality. It’s easier to argue that this clumsy and robotic approach diminishes medical quality by incentivizing physicians and hospitals to game the system to maximize their quality scores.

When an irritating high school student raises his hand and annoys the teacher with the inquiry, ‘is this gonna be on the test?, it is a forerunner of the concept of pay for performance. The Ivy League seeking student won’t study material that he knows won’t appear on the exam. Similarly, physicians and medical institutions will focus their attentions on achieving those outcomes that will be measured and graded, which might be at the expense of patients who ‘are not on the exam’. For example, if irritable bowel syndrome isn’t being measured, but GERD is, then will these patients be treated the same? Beyond this, I reject the concept that medical quality can be reliably measured and quantified.

There’s a Renaissance painting hanging on a museum wall. Is it a masterpiece? Since it’s tough to measure and judge art, should we use a ruler to measure the perimeter of the frame and consider this to be a quality surrogate? Absurd, yes. But, if you buy into this fantasy, it makes it a lot easier to measure quality.

Why shouldn't we apply the P4P concept into other professions.  Not surprisingly, folks won't speak out against pay for performance until they are sagging under its yolk. Consider the following P4P extensions.

  • Teachers' quality is judged by students' attendence
  • Musicians' quality is graded by ticket sales
  • Congressmen's quality depends upon approval ratings
  • Meal quality depends upon weight
  • Book quality depends upon # pages
This is the same silliness that is being imposed on the medical profession. Sure, they can present P4P to the public as rational policy, but no slogan can sanitize the scheme. Of course, serious reforms in the health care system are needed, including a hard look at how physicians and hospitals are reimbursed. Too often, the interests of the medical community and those we serve are misaligned. However, to force P4P on us and then use the results to reward or punish us financially is capricious, unreasonable and fallacious.  Perhaps, even the goverment knows this is not a true quality initiative, but a poorly disguised cost control cudgel.

Is this blog post any good? How can we grade it? By the number of comments? Number of retweets? Why agonize. Let’s all agree that a blog post’s quality can be measured by the word count. Here’s my suggested metric.


          # Words               Quality

               1 - 100                                    Poor

               101- 199                               Mediocre

               200 – 300                            Lousy

               301-400                                Below average

               >400                                      Superb

If the Gettysburg Address is graded using the above schema, we would see how overrated this speech is. The reason we have elevated this speech into the pantheon of American rhetoric is because we didn't have an available grading tool that would have shown us that Lincoln's remarks were ordinary political drivel.  Some presidents have all the luck. 

Let us hope that Pay for Performance shall perish from the earth. It is altogether fitting and proper that we do this.

Sunday, July 1, 2012

Supreme Court Upholds Obamacare: There's Order in the Court

President Obama enjoyed a towering victory days ago that I feel leaves the GOP reeling, although they are spinning the Supreme Court’s validation of Obamacare as a great gust of wind at their backs. While I would not have expected a different response from them, I fear that there is a developing wind that may blow them away in November. I offer this analysis as a tepid Romney supporter who will be voting more against Obama than I will be voting to support Romney.

The phrase Obamacare is peppered throughout this blog. I was recently chastised by an unabashed whale-saving tree hugger that I should abandon this derisive term which detracts from my otherwise unvarnished objectivity. On the evening that the Supreme Court's decision was announced, I was watching CNN and its pontificating pundits. Various panelists were spewing forth verbal pabulum telling us benighted listeners what we were supposed to think. John King, the moderator, and many members of the spin squad all used the term Obamacare freely and repeatedly. If CNN, the apotheosis of journalistic excellence, permits this term to be aired, then surely the Whistleblower is entitled to a free pass on this. For those who seek validation of why CNN is the ‘most trusted name in news’, simply zap this link for amusement. Because I am unfailingly fair and balanced, I disclose that Fox News was also eating crow.

We now know that Obamacare is constitutional which offers no support for the merits of the Affordable Care Act. While there are elements of the plan that I do support, I am deeply skeptical that the plan will control costs and increase medical quality. My fear is that medical costs will continue to escalate and that medical quality will suffer as physicians and hospitals compete in the Pay for Performance Follies where medical documentation and check mark medicine, not medical quality, is rewarded. Is the price for increased access to medical care for the uninsured medical mediocrity for all?

Here are just a few aspects of medical practice that won’t be counted but really counts.

  • Can the physician take an accurate medical history?
  • Can the physician skillfully examine patients? I’m a gastroenterologist. I’m supposed to know how to palpate the liver and perform other diagnostic tasks with my hands, eyes and ears. These skills will never be assessed by the government or insurance companies. Does that  that they don’t matter?
  • Does the physician know when a diagnostic test is not needed? (Tell me how you would test for this?)
  • Does a physician know when an incidental ‘abnormality’ on a CAT scan can be ignored?
  • Does a physician know how to deliver bad news to patients?
  • Does a physician know when watchful waiting is the right prescription?
  • Does the physician know how to manage medical issues on the phone at night when he does not know the patient? Which of them should be sent to the emergency room?  Why not send them all just to be safe? 
  • Does the physician know when to consult a specialist? Is sending every patient with chest pain to a cardiologist good medicine even if patients and specialists encourage this practice.
  • Is this physician compassionate?
A majority of Americans oppose Obamacare in whole or in part. This opposition has developed even before the plan’s bitter medicine has been swallowed. Can the administration continue to spin this by suggesting that the public doesn't yet grasp the plan?  Are we really that dumb?
Chief Justice John Roberts has pulverized the liberal argument that the Court is an arm of the Republican Party, as was bitterly alleged in Bush v Gore in 2000. While public support of the Court has been gradually ebbing, I have not personally believed that the justices pass their decisions through a political prism. Of course, they have different judicial philosophies, which is quite different from acting as a political partisan. Not only did the Chief Justice validate Obamacare, but he did so by joining the Court’s 4 liberal members to do so. I would have never predicted this and I doubt that many readers what have either. Chief Justice Roberts has the long view, and sees the Affordable Care Act as a speed bump. His overriding priority is to protect and defend the integrity of his institution. I feel that he deserves praise and respect for his decision, even though I was hoping for a different outcome. Had he joined with the Court’s conservative members and overturned Obamacare, he would have been lambasted by the political left. Why aren’t they praising him now? Wouldn’t such a response from them be' fair and balanced'?

Fairness means applying the same standard in all circumstances.  Reminds me of the the iconic four word phrase carved into the facade of the Supreme Court.  Equal Justice Under Law.

Sunday, June 24, 2012

You Have Cancer! How to Deliver Bad News to Patients.

When I see patients in the office, I try to guess their occupations from their demeanor and mannerisms. Salesmen are the easiest to ID. In general, they are gregarious males with manly handshakes. They laugh loudly and like to tell jokes. Teachers are more reserved and often give their narrative in a logical and chronological order, as would be expected. Another clue that the patient is an educator is that their appointments are usually in late afternoons. I have a solid record picking out the engineers and scientists. (For physician readers, I estimate that with regard to engineers, my sensitivity and specificity are 60% and 90% respectively.)

Engineers can be tough patients for gastroenterologists to treat. They operate in a computational universe, where numbers add up and problems have concrete solutions. Doctors, particularly gastroenterologists, function in an entirely different milieu. Our world is nebulous. Engineers see mathematical truths, while GI physicians see fog. When they see us with chronic nausea and abdominal pain, they are frustrated when we cannot provide them with a satisfying diagnosis.

I recall an engineer I saw some time ago. He was neatly attired and related his ominous symptoms in an intellectual manner, as if he were giving traffic directions. He was having trouble swallowing his food and was steadily losing weight, a presentation that generates the highest level of physician concern.

I scheduled him for a scope examination of the esophagus, and found the expected cancer. Afterward, he was seated with his wife as they awaited the news of my findings.

These minutes when we physicians know the bad news, and the patient doesn’t, are ponderous. We wish we could hold on to the secret and spare patients from the knowledge that will change their lives so brutally and irrevocably. Subconsciously, we stall. During those minutes, hours or sometimes days, physicians are in a different dimension, a medical ‘twilight zone’. Once we relate the news, however, we are hurled back to earth. Once the patient knows, then we are enveloped by an aura of cold reality.

How should physicians give bad news to our patients? Should we be blunt? Do we front load the heavy news or lead to it after several introductory sentences? Should we use euphemisms like ‘growth’, when cancer is the right word? Should we spin the information with hope and optimism, even if the medical facts contradict this assessment? Do we tend to sugarcoat for our own benefit as well as to soothe the patient? Should serious medical news ever be delivered on the telephone? How do we respond if the patient asks, “am I going to die?”

There is no standard strategy of how to do this right. In addition, patients are distinct human beings and must be approached individually. See First, a blog that emphasizes the importance of communication between physicians and patients, writes that false hope for patients may be the wrong prescription. Medrants, an academic physician and thoughful blogger, speaks for all physicians when he writes, breaking bad news may be the most difficult and important part of our profession.

I have spent 4 years in medical school, 3 years in an internal medicine residency followed by 2 years of fellowship training in gastroenterology. During those 9 years, I don’t recall a single lecture on how to deliver bad news to patients. Yet, I remember memorizing biochemical equations, the names of minute nerves and muscles, the function of microscopic components of cells, hundreds of medications and the natural history of arcane diseases that I have never seen in my career. The astute medical interns and residents I admired were those who could spew off the dozen or so medical explanations for an elevated calcium blood level. I wonder if medical training, at least in my day, had proper priorities for training physicians. Doc Gurley, a physician and folksy and irreverent blogger, recalls a single lecture she heard as a medical student on how to deliver bad news to patients. It impacts her practice to this day, two decades later.

Delivering bad news is a very difficult and unavoidable responsibility of a physician. Do I do it well? I think so, but I’m not really sure. I gave the news to my patient and his wife after I had made arrangements for him to see the necessary consultants in the coming days. I think that patients’ stress in these situations is eased when there is a plan that we physicians put in place. He listened without demonstrating emotion, and thanked me for my time. He then left with his worried wife. The news was still in his analytical left brain, where he stores his facts, figures and formulae. What happens when it crosses the Rubicon over to the other side?

Sunday, June 17, 2012

Bloomberg Soda Ban Ignites Controversy. What's Next?

I’m a gastroenterologist and I should be against obesity. I should counsel patients who have reached a designated rung on the body mass index (BMI) ladder on the risks of carrying excessive poundage and the benefits of achieving a more streamlined silhouette. I should encourage them to pursue a regular pattern of exercise and to choose food and beverage items wisely. I should advocate that the optimal tactic to achieve and maintain weight loss is to adopt a sustainable lifestyle change, rather than engage in a short distance sprint.

Any controversy so far? I doubt it. While I want my patients, and indeed everyone, to make wise choices in life, I won’t make them do it. Doctors advise and patients decide. Intelligent folks who know the risks of their choices are entitled to make them freely.

Mayor Michael Bloomberg, a RINO (Republican in name only), has recently issued a citywide sugary drink ban that has made news across the country and beyond. While there are loopholes that will allow some of the sugary spirits to pass through, the ban is still far reaching and will leave many New Yorkers parched. Did the governor choose wisely here?

There’s a conflict between an individual’s right to make personal choices and the state’s obligation to create sound public policies to serve the greater good. The governor and his acolytes argue that the millions of excessive pounds that are weighing down the Big Apple are costing the city gazillions of dollars in lost productivity and medical expenses. Opponents reel from another governmental edict controlling their personal lives.

If you agree with Bloomberg, then how far can and should the government go to control our behaviors? Who makes the decisions on what activities we engage in, us or the government? Who decides if an activity is meritorious or injurious?

If you support the soda ban, explain why you wouldn’t support the following proposals.

  • Ice cream and candy will now be available only by a doctor’s prescription.
  • Any individual who is 10 pounds over ideal body weight, as defined by the government, will be terminated from their jobs.
  • Cigarette use will now be criminalized and convicts confined until they are rehabilitated to protect their health and the rest of us from the scourge of second hand smoke.
  • Car owners of gasoline engines will be taxed heavily to encourage electric car use. Society is entitled to clean air and polluters must pay a price.
  • Those who selfishly won’t exercise and are at risk for medical complications that the rest of us have to pay for, will have a percentage of their wages garnished.
  • Every Monday the government will choose a designated food item that it deems to be not healthful and it will be banned for the entire week. Restaurants, grocery stores and food trucks will delight in wondering when their ‘number will come up’. The government can set up a lottery where the public can wager on which ingestible item will be that week’s contraband. Revenue can be used to fund the special ‘cigarette police’ who will be working in 3 shifts rounding up inhalers.
Every day, diet soda and other caffeinated liquids slide down my gullet. Does this promote better health? Probably not, but I want the choice of what I can eat and drink. Let’s have some perspective here. I’m not asking for the right to drive 90 miles per hour on the highway which threatens the state’s interest much more than it would protect my right to speed on the open road. Banning soda and other sweet elixirs doesn’t meet this test. Indeed, if government encroachment continues, it may drive many of us to drink. See you at ‘happy hour’.

Sunday, June 10, 2012

Choose Wisely Takes Aim at Unneccessary Medical Tests. Shooting Blanks?

Low Hanging Fruit

As I write this, it is months away from the election. The election season has been fascinating. I watched many of the Republican ‘debates’ which ranged from informative to entertaining to absurd. Candidates came and candidates went. Many enjoyed short lived surges, only to flame out afterwards. I was drawn early on to Jon Huntsman, but it seems that decent folks who tell the truth without pandering can’t succeed.

So, now we are left with Romney vs Obama, a contest that at present seems too close to call.  The continued anemic job creation statistics, which may not be the president's fault, will hurt him.  If the economy appears to creep forward in the months ahead, and there are no unforeseen events to sandbag the president, then I think he will prevail. It is the unforeseen that worries the Democrats. If several economies in Europe implode and drag us to the edge of the cliff, it will have a political impact here in November.

Neither candidate is ideal. Romney can be rightfully criticized for is ‘evolving’ political views and for lacking a real connection with everyday Americans, many of whom are suffering. Obama has resorted to classic class warfare, aiming his populist message to exploit envy for votes. His legislative triumph, Obamacare, is deeply flawed and was rammed through the legislature. Soon, the Supreme Court of the United States will decide if the law, particularly the individual mandate, is unconstitutional.

My advice? Choose wisely.

A new program called Choose Wisely was launched earlier this year, which deserves our close attention and support. It aims to eliminate unnecessary medical testing which accomplishes two important goals. It saves money and improves medical quality. The effort is under the aegis of the American Board of Internal Medicine Foundation and will continue for several years. Numerous medical societies and Consumer Reports will each identify medical tests and treatments that are being over utilized and should be curtailed. I am pleased that the American Gastroenterological Association is participating.

I’ll paraphrase some of the recommendations from the various participating societies.

  • Don’t give cancer patients chemo if it won’t do them any good.
  • Don’t subject patients to unnecessary colonoscopies.
  • Do not perform routine preventive medical tests on dialysis patients who don’t have long to live.
  • Do not perform electrocardiograms (EKGs) each year on healthy patients who don’t need them.
  • Do not perform cardiac stress tests on patients who do not need them.
Yeah, these suggestions sound absurd, but I guess we have to start somewhere. The medical societies are not just picking low hanging fruit, they’re picking fallen fruit that's on the ground. These initial recommendations are not controversial. At present, there is no surgical society participating. If there were, we could expect a bold recommendation such as ‘do not remove a gallbladder just because it’s there’.

Choose Wisely will confront obstacles and push back once the low fruit has been cleared. It will be very difficult to reach the fruit hanging on the higher branches. Physicians, pharmaceutical folks, medical device companies and hospitals have never been inclined to sacrifice their incomes to serve the greater good. This is why comparative effectiveness research (CER), a feature of Obamacare that I do support, will have great difficulty gaining traction. Any reform that saves health care dollars reduces some group’s income. Guess what happens then.

I support Choose Wisely, but I don’t find the opening recommendations to be all that wise. Shouldn’t we physicians already know not to perform unnecessary medical tests and treatments that patients don’t need? At least now, the public will be armed with official information to enable them to advocate more effectively for themselves.

As the program matures, the choices will become more controversial. There will be spirited disagreement over whether a medical intervention is unnecessary. I predict that those who stand to lose economically will take positions that protect their revenue stream. Indeed, voters may do the same thing this November.



Sunday, June 3, 2012

Improving Patient Satisfaction: What’s Holding Doctors Back?

Some time ago, I endured a medical staff meeting, where attendance is taken and 50% attendance of all meetings is required. I learned that they are serious about this rule when, a few years ago, I was demoted from active staff when I failed to attend enough meetings. This demotion did not demoralize me, as I was only losing my right to vote, which I did not regard as a cherished right with respect to voting on hospital affairs. I learned later, however, that the hospital’s insurance panels all required active staff status of its physician members. I decided that the right to make a living superseded the right to vote. My attendance lapses were remedied and my honor was restored.

Today, a hired consultant was advising us on the importance of improving our patient satisfaction scores. Which of the following reasons to improve were offered to the staff, all of whom regard ourselves as paragons of the medical profession? As in all standardized test questions, choose the best answer

(1) Improving patient communication improves medical care

(2) Self-criticism is an important exercise for physicians to pursue regularly

(3) No reason needed. We should simply do as we’re told

(4) It will give the hospital PR folks something to crow over

(5) None of the above

While there are many reasons that we physicians should want to improve our relationships with patients, making more money shouldn’t be our primary motivator. Yet this speaker ended his remarks emphasizing that these scores would be directly tied to the hospital’s reimbursement. Of course, this model will be extended to physicians’ offices also. There is something very ignoble about contaminating a noble profession with mercenary incentives. To me, it is doing the right thing for the wrong reasons. I recognize that my idealistic view is vulnerable. It is difficult to reject financial reward to spur physicians to satisfy our patients if nothing else motivates us to do so.

In our hospital, OB/GYN scored extremely high over the past 18 months that measurements were taken. Internists and hospitalists scored low, even lower than surgeons, who are not known for their cuddly bedside manners. I would like to post the graph of all specialties and their scores on this blog, but I fear it is proprietary and would place me in violation of several bylaws. After my prior demotion over medical meeting attendance, I cannot risk another confrontation and the public sanction that would follow. They might withdraw my privileges to perform rectal examinations, which would decimate a gastroenterologist’s practice.

There is a website that should be bookmarked by everyone reading this blog. The Hospital Compare site allows users to compare side by side, hospitals in your neighborhood with respect to patient satisfaction and other measurements. I strongly urge that readers spend some time examining data that your local hospitals are likely omitting in their glossy brochures that they use to promote themselves. The three community hospitals I attend all scored below the national average on the criteria being measured. In fact, using the standard grading scale used in high school, these hospitals would have received a failing grade. For example, only about 65% of patients at all three of these hospitals would definitely recommend the hospital to others. The website also presents other important data on patient outcomes, medical utilization and Medicare payments. I suspect that this website may spawn many future Whistleblower posts.

These data can be extremely useful to our profession. They can shake us up and encourage us to reflect and improve. All of us want to be the best we can be. What will it take to get us there? Will we do so because we recall Francis Peabody’s famous aphorism delivered nearly a century ago?

The secret of the care of the patient is in caring for the patient.
Or, will we need to be paid off.