Richard D. Lamm is currently a University Professor, Co-Director of the Institute for Public Policy Studies and Executive Director of the Center for Public Policy & Contemporary Issues. Gov. Lamm, who served three terms as Colorado Governor from 1975-1987, has always been in the forefront of political change.
Archive for December 2011
Dr. David Gelber who writes the Heard in the OR blog recently had a must-read post published on KevinMD entitled “Rigid regulation can become detrimental to patient care.” Anyone and everyone involved in or affected by America’s healthcare system should read this article. It clearly illustrates exactly the type of good intentions that are sending patient, doctors and nurses further and further down the Road to Hellth on a daily basis. We especially recommend reading the comment by “dropspinner” in the comment section. It’s impossible to count the number of times that we’ve relied on nurses to do the right thing and use the intelligence and common sense God gave them. To see their efforts, and those of their physician colleagues, reduced to being forced to brainlessly do what administrators have told them to do “because those are the rules” is a terrible indictment of our healthcare leadership.
If you haven’t yet read Dr. Gelber’s post, read it now to follow the rest of the discussion.
How can we reform this type of bureaucratic and legal nonsense? (It is, after all, putting people at risk to no good end and costing us a fortune to maintain.) One step that would help is to adopt something like the “basic speed law” in lieu of all hard-and-fast rules of the type Dr. Gelber describes. (For those of you who don’t remember it from the driver’s ed course you took years ago, the basic speed law is that, regardless of the posted speed limit, you must never drive faster than is safe.) The underlying logic of the basic speed law is that the people who built the roads tell users how fast they can expect to drive to be safe under normal circumstances. However if the circumstances are aren’t cookie cutter, than the people on the scene are expected to use their best judgement based upon the particular circumstances that they’re encountering at the time.
Let’s re-state that. The basic speed law doesn’t tell you how fast to drive. Instead it gives you some technical data and limits, and then asks you to use good judgement based upon your specific circumstances. The basic speed law was created many decades ago, and has never been questioned or changed in all of that time. Why? Because the smart people who created our highway system understood and accepted that only those who are on the scene and directly involved can ultimately make the correct decision about what is “safe”.
Now how would we apply this to medicine?
We suggest that American healthcare adopt something we’re going to call the “Basic Safety Law” when it comes to crafting all rules and regulations used throughout the healthcare system. It reads as follows:
“When crafting any rule or regulation that directly or indirectly affects patient care, never make the rule more rigid than is safe. Always permit exceptions as necessary based upon the best clinical judgement of the clinician in charge.”
Here’s an example. The first situation Dr. Gelber describes is as follows:
The antibiotic I had ordered was Cefazolin, perfectly appropriate for the scheduled operation. The nurse informed me that, because there was the possibility the operation could be converted to open, she also had to receive Metronidazole in addition to the Cefazolin. I told her that the particular antibiotics she was insisting be administered were indicated if the patient was undergoing colo-rectal surgery, but all that was needed in this particular case was the Cefazolin. She replied that she was following the SCIP protocol and she would get in trouble if I didn’t order the Metronidazole. Not wanting to argue with the SCIP police, I ordered the additional antibiotic.
Under The Road to Hellth healthcare regulation Basic Safety Law (BSL) approach, the new rule will read: “If there is a possibility that the operation could be coverted to open, the patient should receive Metronidazole in addition to the Cefazolin unless the surgeon in charge of the procedure deems it to be medically appropriate not to do so.”
The consequences of this change are relatively obvious. For the purpose of safety, if the surgeon is unsure about what the appropriate antibiotic would be under the circumstances, the guidelines are there. However if the surgeon knows of a different strategy that is equally sound medically, there is room to improvise. What’s to keep surgeons from disregarding the guideline’s advice willy-nilly? Two things. The first is that, contrary to the apparent beliefs of most government and hospital administrators, the vast majority of doctors really do care about their patients and want to do well by them. Second, the existence of such a rule increases both the real and perceived consequences of making the wrong choice.
As example #2, consider this portion of Dr. Gelber’s story:
Two nights later I was on call for the Emergency Room. I received a call at about 10:30 pm from the ER physician requesting that I immediately come to the ER to attend to a Level I trauma that had just arrived. He took the time to explain that the trauma was a BB gun shot to the shoulder area and that a Chest X-Ray had already been done which was normal except for the BB which could be seen overlying the right clavicle (collarbone). He added that there was a small amount of swelling over the area the BB had penetrated, but otherwise everything was normal. My logical response was “Why do I need to come in to see a patient who obviously can be discharged home with an ice pack, antibiotics and pain med?” I was told by the nurse in charge that once a patient has been declared a “Level I” trauma I was mandated to see the patient within 30 minutes and only I, as the trauma surgeon on call, could make the decision to downgrade the trauma level. The trauma protocol clearly states that all penetrating wounds to the thorax be classified as “Level I”. The fact that this particular patient did not have a penetrating injury to his thorax was deemed irrelevant by the nurse who made the decision. The fact that the ER physician had evaluated the patient and determined that there was no significant injury was also deemed immaterial.
Here the trauma level had clearly been mistakenly assigned. In this case, the BSL would be applied as follows: “The trauma surgeon on call shall see a Level 1 trauma patient within 30 minutes unless the trauma surgeon and attending ER physician agree that the trauma level had originally been assigned in error.”
Similar logic can easily be applied to the other situations the good doctor has described.
Why don’t we have a “basic safety law” approach already? There are two reasons. The first, as Dr. Gelber has already described, is that many of the people making this rules don’t know what the heck they’re talking about. They’re not medically trained, and it is frankly irresponsible to place them in the position of making rules for doctors and nurses to follow. Second, the administrators and (well, bureaucrats) making these rules are too lazy to think in terms of “what if”. It is far, far easier to make inappropriately rigid rules and let others deal with the consequences. They can get away with not-quite-murder-but-closer-than-one-would-like, because there are no standards of quality for administrative work in healthcare. Think about it. It should be inexcusable that any patient should be placed in danger or that excessive resources should be used because a “medical” administrator can’t be bothered to build flexibility into their written (or unwritten) policies.
No one is minding the minders.
This is no way to run a healthcare system. EVERY rule and regulation that affects medical care needs to be specifically designed so that it can be overridden by the appropriate medical personnel. Furthermore, every rule and regulation should be subjected to review and comment at regular intervals. This would give those affected a guaranteed means of asking that it be revised or discarded based upon both experience in the field and the latest medical and scientific evidence.
Our lives and those of our families and children are too precious to trust to shoddy, rigid rules and regulations.
Over and over on these pages, we make the point that, for the most part, medical care is and should be something that is custom-tailored to each individual. Different people have different genetics, anatomies, physiology, personalities, preferences and financial circumstances. As long as they are willing to bear the financial weight of their decisions, there is no reason why the healthcare services offered to them should be any less personalized than their selection of clothing, transportation, cell phone services or anything else. By the same token, doctors should have the freedom to provide all patients with information about the entire range of options available to them. If any given patient can afford more than the minimum covered by whatever insurance policy they happen to have, it is only fair that they should have the right to avail themselves of whichever will give him (or her) the greatest utility.
But there is one area of healthcare in which it may be time to modify this approach just a bit and think not in terms of what’s best for the health of the individual, but what’s best for the nation. And that’s the much ballyhooed field of preventive medicine.
Politicians and those favoring a single-payer (i.e., government-run) healthcare system like to make a big deal out of preventive medicine because they believe that doing so somehow gives them the moral high ground in any healthcare discussion. A typical conversation with such high-minded folk often runs something like this:
Them: “Under my single-payer system, every American will get whatever healthcare they need regardless of their ability to pay. We can do this because single-payer systems are so much more efficient.”
Us: “All healthcare is rationed somehow, regardless of the way the system is financed. If you’re going to have a single-payer system, you must have a plan in mind for how it will ration healthcare goods and services. You’ve just said that everyone can have everything they need without regard to their ability to pay. What if they want unlimited end-of-life care in the intensive care unit, regardless of whether they are in a coma with little or no prospect of recovery? Will your system pay for that, and if not, who will decide what to deny and how?”
Them: “Look. The whole point is to make sure that everyone has preventive care so that they don’t end up in the ICU in the first place!”
Obviously no one in their right mind could be “against” prevention and still hope to run for public office, no matter how tenuous the link between the preventive measure and any real-world benefit might be. (And if preventive medicine were able to rid the world of all illness, the argument might even be valid. However in practical terms, one might be better off showing disdain for babies, puppies and the American flag as question the magical powers of prevention in public. )
But we digress.
By definition, the majority of the goods and services delivered under the rubric of preventive medicine are delivered to people who are healthy with respect to the specific illness to be avoided. The interesting thing about this is that it means that prevention is not so much a medical enterprise, but a distributive one. It takes no special medical expertise to hand a patient a sugar cube, and only slightly more to give an injection or do a pap smear. The technicians responsible for drawing blood or performing mammograms need not know anything about the diseases their actions may diagnose. In stark contrast to the rest of medicine, little or no individualization is called for. Once appropriate guidelines are crafted, the vast majority of goods and services to be distributed might as well be car parts or flashlight batteries for all of the finesse required for their administration.
This difference between preventive health services and medical ones is important because it implies that their financing and delivery systems can and should be completely different. Indeed, one of the mysteries of American healthcare is why they aren’t. The majority of services that could be termed “preventive” are still delivered in medical offices, clinics and hospitals, and are essentially covered as acute care services. The only prominent exceptions are the flu shots and varicella zoster (shingles) vaccines advertised and distributed by drug stores – mostly on a seasonal basis.
If we’re really interested in efficiency and cost savings in healthcare, this single approach to wildly different services makes no sense. Why would you want to limit the distribution of headlights, tires and oil filters to car dealers, or flashlight batteries to hardware stores? If we want these goods and services to be universally used and delivered as cheaply as possible, they should be separated out and delivered in by a line of regional “Prevention Superstores”.
By the same token, financing preventive services should be completely separated from the realm of conventional insurance. Unlike conventional care the use of preventive services is perfectly predictable, has nothing to do with random risk, and often produces at least as much social good as individual benefit.
The Superstore approach to preventive medicine has a number of advantages:
- Lower costs. Centralizing all of the repetitive, mundane tasks associated with preventive care would allow their costs to be driven down to their absolute minimum. Imagine a bare-bones warehouse like Costco, unassociated with a fancy marble-clad hospital or overcrowded medical office building. Patients take a number, and are taken care of in the order in which they arrive. The building is divided into different areas based on the services to be provided, such as vaccinations, mammograms, pap smears and screening blood tests. Syringes, vaccines and other supplies are purchased in industrial quantities, and at the lowest available wholesale price. The cost goal: dirt cheap.
- Higher efficiency. As each patient presents, their preventative services record is brought up in a dedicated database that is completely separate and distinct from their medical record. Based upon age, sex and other relevant characteristics, the preventative services to be provided on this visit are chosen based the most current guidelines available. Ticket in hand, each patient is then processed as quickly as possible for each item on their particular list. The center advertises widely in the community, encouraging each patient to come in at least once each year for their preventive care. Since everyone in the community gets their preventive services in the same place on a regular basis, awareness can be made much higher than it is now.
- Rational financing. If preventative services really do constitute a social good in a way that is distinct from all other healthcare then it’s only logical to reflect this in the way that they are financed. Subject to limits that we’ll discuss in a bit, this really is one area in which it makes sense for the federal government to provide funding in the same way that it pays for roads, defense, the Center for Disease Control and other public goods.
Other benefits of “Prevention Superstores” are more subtle. As Dr. Rich at The Covert Rationing Blog and Dr. Wade Kartchner at the Public Health and Pediatrics blog have observed, many of these tasks are a poor use of time for relatively highly trained physicians. They also happen to account for a large number of the “performance measures” that politicians and bureaucrats are fond of using as a basis for rewarding and punishing doctors. Moving them out of the clinic and into the Superstores would reduce the amount of busywork, record-keeping and bureaucracy that physicians are forced to handle. Hopefully this will free their time to work on the more complex and serious problems that they have been uniquely trained to handle.
Okay, now what about those financing limits? Should the government pay for all preventive services? After all, they all save lots of money, right?
Well, not necessarily. Cohen, Neumann and Weinstein explained this in a New England Journal of Medicine article around the time of the last Presidential election:
“Sweeping statements about the cost-saving potential of prevention, however, are overreaching. Studies have concluded that preventing illness can in some cases save money but in other cases can add to health care costs. For example, screening costs will exceed the savings from avoided treatment in cases in which only a very small fraction of the population would have become ill in the absence of preventive measures. Preventive measures that do not save money may or may not represent cost-effective care (i.e., good value for the resources expended). Whether any preventive measure saves money or is a reasonable investment despite adding to costs depends entirely on the particular intervention and the specific population in question. For example, drugs used to treat high cholesterol yield much greater value for the money if the targeted population is at high risk for coronary heart disease, and the efficiency of cancer screening can depend heavily on both the frequency of the screening and the level of cancer risk in the screened population.”
Therefore the most conservative approach is to ask the general public to cover only those preventive good and services that are both cost effective and known to save money. As shown in this figure and accompanying table from the same NEJM article, this can be done using the impact of any proposed intervention on quality-adjusted life years, or QALYs:
Note that it’s not always the case that prevention is more cost-effective than simply treating an illness once it appears.
Like all healthcare endeavors, preventive medicine goods and services run the gamut from saving money while improving health, to actually wasting money by making patients worse. It would be unreasonable to expect our fellow taxpayers to pay for all of these, any more than we should expect them to pick up the tab for unlimited acute care services for every citizen. How would Prevention Superstores help in this situation?
One reasonable approach is to ask the federal government to cover prevention goods and services that both save money and improve health, while leaving decisions about paying for other preventive services to individuals and their health insurers. Just as for acute care services, each individual can then decide whether the cost of the intervention is worth whatever the additional cost might be. Superstores can add value to the process by minimizing that cost wherever and whenever their reduced overhead and economies of scale permit.
There are plenty of ways to improve the efficiency in American healthcare, but we’re not going to find them by offering to penalize clinicians every time they fail to meet some arbitrary pay-for-performance criteria. It’s going to be done by making tasks like preventive care simpler, cleaner and less of a burden on patients and providers alike.
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