Road To Hellth

Mar
8

Medical Specialty Certification Exams: The Real Scandal

Note to our readers:

This article was recently published on The American Thinker website, where it can be found here. We’ve added some additional comments at the end of the article based upon reaction to the original, and some additional thoughts and news we’ve had since publication.

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Earlier this year, CNN broke the story that generations of dermatologists have been “cheating” on their specialty board certification exams. Like their colleagues in radiology and most other medical specialties, large numbers of dermatology trainees have been studying for the boards by using massive collections of historical exam questions that were memorized and shared immediately after each year’s test. Having access to these questions is useful because many specialty boards re-use questions from previous tests. Until this year about 20% of the questions used by the American Board of Dermatology (ABD) were recycled from previous years, compared with about 50% for the written exam in radiology.

The widespread use of these so-called “airplane notes” or “recalls” has been common knowledge in the medical world for decades, but the flurry of recent press reports has caused consternation in the powerful board certification industry. Stung by the publicity, the American Board of Medical Specialties issued a press release condemning the practice and calling it an unethical violation of copyright laws. Apparently caught by surprise, the executive director of the ABD admitted that she’d “never seen airplane notes, but I’ve heard about it”, and subsequently cancelled a scheduled on-camera interview on the topic. Meanwhile, the American Board of Radiology hurriedly announced that its 2012 certification examination will be composed of entirely new questions for the first time in ten years. But while the lay press often frames the issue as one of “public safety”, the real scandal surrounding specialty board certification is quite different.

Modern specialty boards are holdovers from a time when there was little standardization or regulation of medical training. The American Board of Dermatology was founded in 1932, a time when various programs to train dermatologists ran for either one, two or three years. This era ended for good in 1981 when the Accreditation Council for Graduate Medical Education was established to regulate and accredit residency training programs for all medical specialties. Every physician in America is now superbly trained over a period ranging from three to seven years depending upon their specialty. As quality and standardization improved, medical boards began making test questions increasingly esoteric in order to preserve a normal statistical distribution of scores. Most boards also began grading “on the curve”; failing a percentage of examinees with the lowest test scores regardless of whether the content they missed was critical to the practice of safe, high-quality medicine. “Recall” and “airplane notes” developed in direct response to these “fail somebody” policies. As one radiologist said to CNN: “”If they had a test where you could study relevant radiology knowledge and they tested on it, that would be fine. Part of the problem is the test and the questions that they ask. Because some of the questions are so obscure, that unless you know that they like to ask questions about that topic, you’re not going to study it because some of them are completely irrelevant to the modern practice of radiology.”

None of this would matter except that medical boards have managed to turn their monopoly on physician certification into a multi-million dollar gauntlet of tests and more tests that must be passed in order for physicians to stay on insurance plans and hospitals’ staffs. Taking the initial dermatology board certification exam comes with a $2,500 fee, while regularly required “maintenance of certification” tests cost nearly $1,000 each. And therein lies the true scandal in the saga of board certification and “recall” questions: it’s not that the tests are allowing incompetent physicians to care for patients, but that they are keeping many highly qualified doctors from entering practice and earning a living.

The math behind this injustice is relatively simple. The nearby figure shows the score distributions of two hypothetical board certification exams like the one given by the ABD, each composed of 300 questions. The left-hand curve shows a normal distribution of scores if none of the examinees have access to questions from previous tests that are re-used on this one. The right-hand curve shows the change in scores that will result if 90% of the test takers already know the answers to 60 out of the 300 questions as a result of studying “airplane notes. Let us further assume that the specialty board in question decides that it will flunk out the bottom 10^th percentile of test takers as a matter of “ensuring the quality” of its certification procedures.

Although the curves look similar, the use of recall notes produces a big difference in the specific score that will be used to fail test takers. In turn, this translates into a major change in who will be allowed to pass the test. Over half of doctors who did not use “airplane notes” and who would normally have been safely above the 10^th percentile threshold will now flunk as a direct result of their inability to answer all of the re-used questions correctly. These well-trained and competent physicians will be wrongfully kept from medical practice while they prepare for next year’s $2,500 test. If they’re smart they’ll find a set of “airplane notes” to study from rather than risk failure yet again. It’s no wonder that training program directors have been known to encourage their young doctors to seek out every review course, old test question and study tool they can find.

In the modern world of American healthcare, none of this multi-million dollar hoop-jumping is necessary or even appropriate. Every accredited specialty training program director already knows exactly what their residents know because they work with them each and every day. By the time physicians completes their specialty training they’ll have been asked tens of thousands of questions by a host of attending physicians in almost every conceivable setting, from the surgery suite to the lecture hall. Training programs have the ability to hold back or terminate questionable residents at any time.

Gilding the medical lily with endless layers of deliberately esoteric tests and certifications does nothing to improve patient safety or well-being; it simply prevents significant numbers of competent physicians from providing much-needed healthcare services. It’s time for the medical establishment and the general public to decide that high levels of excellent training are far more important than all the testing in the world.

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In an effort to be perfectly constructive, we would like to suggest two alternatives to the current mess. The first is that one might have a board certification test that encompasses the truly important and mainstream information and examples of work-ups and treatment decisions that everyone in a given specialty ought to know. A pass rate of 100% should be the goal. What’s the point of flunking out ANY clinicians who know this basic and critical information? Make the old exams public for everyone to study. The entire point of the exercise needs to be ensuring basic awareness and good decision-making, not putting million of dollars into the coffers of self-selected specialty boards. A second alternative is asking residency training programs to do their own self-assessments of knowledge, decision-making and basic skills, and hold back or fail anyone who fails to meet their standards. This can again be based upon a national consensus of training program directors that documents those elements of training that are needed to produce good clinicians. Again, the goal should be a pass rate of 100%.

One has to wonder if there is not a class-action that should be taken against the medical specialty boards who recycle questions, that should be filed on behalf of all those who may have taken these exams and failed – quite possibly through no fault of their own – over the past 15 years.

One comment about the American Thinker article that struck us as being particularly interesting in light of the impending shortage of physicians is this one by someone using the pen name “Sud”:

I am boarded in 3 subspecialties and on my initial exams scored in the 90th percentile in my primary specialty with no special access to old questions. As of last year I am employed by a hospital that requires only 1. I will not recertify in the others. There is no economic advantage, and patients apparently perceive no quality advantage when they are perfectly willing to see a nurse practioner and refer to them as their doctor.

I believe “keeping many highly qualified doctors from entering practice and earning a living” is the whole point Dr. Perednia. Qualified physicians still cost more than government payers wish to spend. They have initiated price controls on physician services, inducing workforce shortages in primary care specialties so that when the baby boomers all start dying, and physician access is nil the sheeple will embrace single payer, and Big Brother can install less thoroughly trained alternatives as the answer to a failed system, whose failure big government has ensured. They may be PAs, NPs or eventually a newly minted CNA with a clipboard and clinical decision flowsheet at the end of a 1-800 number. If they don’t want physicians in general seeing patients, why on earth would they want board certified subspecialists.

Sud’s observations may sound a bit like a conspiracy theory, but the fact is that it makes absolutely no sense whatsoever to be making it harder and harder to be “qualified” to practice medicine as a physician, while at the same time expanding the ranks of lesser trained and lesser qualified physician assistants and nurse practitioners who are expected to make up for a shortage of doctors.

After this article was posted on The American Thinker, we were contacted by the folks at the organization Change Board Recertification. This organization has done some extraordinary work documenting the tens or hundreds of millions of dollars of “non-profit” profits that are flowing into specialty board coffers each year. RTH readers may well find this organization, and the specialty board tax returns that it has made available on-line, worth a second and third look.

Categories : Abuse of Power, Business and Law, Clinical Care, Economics, Ethics, Healthcare Policy, Politics, The Practice of Medicine

Feb
14

Emergency Medicine Goes Down the Rabbit Hole in the Evergreen State

by Dr. Doug Perednia

Just when American healthcare system seems so dysfunctional that it seems impossible to imagine how it could be screwed up further, a decision is made that restores one’s faith in the creativity of Man. But before you run out of guesses as to which particular decision we’re talking about today, we’ll just blurt it out. We are referring to last week’s decision by Washington State Medicaid to deny payment for emergency room evaluations incurred by its beneficiaries that this public insurance entity decides were, in retrospect, “unnecessary”. No “three strikes you’re out”, no quibbling over the diagnosis list, no excuses – Medicaid has washed its hands of these people.

We’d previous written about this story here and here, when the folks at Washington Medicaid were just getting warmed up at the end of 2011. Little did we know we’d be revisiting the issue so soon. Have the people running the Medicaid program in Washington State gone nuts, or are they just misomedicusists and misohospitaleists?*

Like nearly all public healthcare insurers, Medicaid in the great state of Washington is rapidly going broke. The state is faced with a $1.4 billion budget gap in the FY 2011-2013 biennial state budget, and has begun cutting all sorts of benefits to its Medicaid population. Thus far, these have included elimination of the Basic Health Plan that delivers health care to 35,000 low-income individuals, elimination of routine dental care for persons with developmental disabilities, long-term care clients and pregnant women; increasing the level-of-care requirements for personal care services; elimination of the Adult Day Health program; utilization management for mental health services; and elimination of medical interpreter services and, of course, reductions in payments to clinicians. But these pale in comparison with the innovation the state has devised in terms of saving on its annual Medicaid emergency room bill. It’s a program which, as nearly as we can tell, hasn’t yet been tried elsewhere. Call it “Heads We Win, Tails You Lose”. Here’s the story from The Seattle Times:

“Intent on cutting state budget health-care costs, Medicaid officials say the program will no longer pay for any medically unnecessary emergency-room visits, even when patients or parents have reason to believe they’re having an emergency.

The rules — arguably more drastic than an earlier proposal to limit Medicaid patients to three visits per year for nonemergency conditions — would block payment for ER visits for about 500 different conditions.

They would apply to all adults and children on Medicaid, with no exceptions, such as someone being brought in by ambulance or from a nursing home, or when patients have neurological symptoms or unstable vital signs.”

Of course the need for some sort of action to be taken is pretty straightforward: a certain number of Washington Medicaid patients are clearly abusing the system and costing taxpayers millions in the process.

“Dr. Jeff Thompson, chief medical officer for Washington’s Medicaid program, said the state is committed to paying for medically necessary care. But many times, he said, patients go to ERs when they would get better, and less expensive, care in a primary-care ‘medical home.’

‘The ER cannot be the medical home of the 21st century,’ he said. ‘We will not pay for diaper rash treated in the emergency room.’

Currently, there is ‘tremendous overuse and abuse’ of emergency rooms, Thompson said — amounting to at least $21 million a year.

Some patients show up as many as 120 times a year for costs of $20,000 to $25,000, he said, but until now, most ER doctors and hospitals have done little to deter them because the state paid the bills.

‘The ER physicians and hospitals have been abusing their privileges as providers of ER services for years, having the state pay for non-medically necessary services in the ER,’ Thompson said.

‘They have not stepped up as leaders to actually be better stewards of care and safety and the public resources,’ he said.

Under the new rules, ER services not paid by Medicaid wouldn’t be billed to the patient, leaving the doctor or hospital on the hook.”

While every reasonable person can agree that it defies logic, reason and good medical sense for any individual to rush to the emergency room for non-urgent or even trivial problems, one simply must treasure the rather unique assertion that emergency room physicians and hospitals are at fault for “abusing their privileges” as providers of services to the poor. As a rule, public insurance program payment is so poor hospitals and doctors lose money on virtually every Medicaid patient they’re forced to see. Believe us when we say that any patient showing up in your ER or office every third day is about as welcome as a porcupine in a waterbed warehouse, especially if you’re paying for the privilege of seeing them. One has to wonder if Dr. Thompson had to rehearse his lines in a mirror to master the art of reciting them without laughing.

For those of you who may not be familiar with the ins and outs of emergency rooms, federal law mandates that each and every person walking into one be seen and evaluated regardless of their ability to pay. This is a result of the Emergency Medical Treatment and Active Labor Act (EMTALA), which was passed by Congress in 1986.

Simply put, EMTALA says that every hospital that operates an emergency room and accepts federally funded insurance must by law, see, evaluate and, if necessary, treat each and every homo sapiens that walks, crawls or swims into their ER regardless of race, sex, nationality or ability to pay. If the doctors and hospitals involved lose money in the process that’s just too bad. If you don’t like it, close your emergency room. (Coincidentally, this last idea is one that seems to be catching on around the country as a direct result of the less-than-generous payments that publicly funded insurance is paying these days. A 2009 study showed that nearly one in every three emergency rooms in the United States has closed their doors over the past 20 years.)

So here’s the actual logic underlying this new Washington Medicaid initiative:

ER docs and hospitals are required by federal law to see and evaluate anyone who walks in – at their own expense if necessary.
If a Washington State Medicaid patient walks into the ER with a non-emergency and the doctors and hospitals see them as required by law, Medicaid will refuse to pay on premise that the provider are “abusing the system” and being lousy “stewards of care and safety and the public resources”
Since the doctors and hospitals are abusing the system by simply being there and doing what the federal government has said they must, they should not even be allowed to try to bill the patient directly for the visit.

It may not have occurred to Dr. Thompson and the other folks in charge of this “innovation”, but it seems self-evident that when a person repeatedly goes to an emergency room for problems that are not medically urgent, we are really talking about a social problem rather than a medical one. Heck, other states have recognized this reality. Oregon has launched a very useful and cost-effective program that essentially assigns a social worker to each high-cost Medicaid recipient. A major part of their job is to divert ER-abusing patients away from the emergency room and into keeping their regularly scheduled clinic appointments. As it turns out, sucking up an hour of social worker time is far less costly – and far more effective in changing behavior – than sucking up an hour of hospital and ER time. It makes sense once you bother to think about it. What the new Washington Medicaid program does is simply convert a social problem to an economic one, and then dump it on doctors and hospitals in the private sector. If this is the best government thinkers can do, we are all in some serious trouble. Heads should roll as a result of pulling this sort of stunt. Where’s the Queen of Hearts when you really need her?

However beyond the issue of the people running our healthcare programs are rational, competent, or even looking out for the best interests of taxpayers, there are two other more profound and troubling issues raised by this policy decision. Issues that affect all of us.

First, is there any limit to what the government may require law-abiding citizens to do without compensation? EMTALA requires doctors and hospitals to see patients regardless of their ability to pay, but does it free insurers of their obligation to pay for the care of their beneficiaries? Do all insurers have the right to do this, or just public insurers? How does requiring free people to work without compensation differ from slavery? Where are the limits? Can firemen be required to put out fires regardless of a community’s ability to pay them? Can police or firemen be required to work without pay on the principle that people’s lives may be in danger? Or should they only be paid if there really was some real risk to life and limb?

Second, if people – patients in this case – are behaving irresponsibly by, for example, going to an emergency room for diaper rash, why do they have no obligation to bear any financial responsibility for their actions? If the issue is simply that these patients are poor, why are any financial penalties levied on the poor? Why are the poor required to pay for parking tickets – an abuse of public space – but not clearly unneeded emergency room visits – an abuse of a private space? Is the government in the business of protecting its citizens, or merely itself? Where does the public interest end, and something more akin to abuse of power begin?

We may have already crossed that line.

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*Misomedicusist = Miso (greek) Medicus (latin) = hater of physicians

Misohospitaleist = Miso (greek) Hospitale (latin) = hater of hospitals

Categories : Abuse of Power, Business and Law, Clinical Care, Economics, Ethics, Healthcare Policy, Hospitals and Health Systems, Political Hellth, Politics, The Practice of Medicine

Oct
20

Mediocrity in Pursuit of Quality Is No Virtue

by Dr. Doug Perednia

Not long ago, we took a critical look at the, er, “evidence” behind the Department of Health and Human Services’ (HHS) (and CMS/Medicare’s) new policy regarding hospital readmissions within 30 days of discharge. For those who may have missed the excitement, these HHS/Medicare policies mandate dole out financial punishments to hospitals that are found to have a higher-than-average percentage of patients with certain diagnoses (heart attack, heart failure and pneumonia ) who are re-admitted within a 30 day period. Rather than simply docking the hospitals for the cost of the re-admission, or even charging a penalty on the admissions for each of these diagnoses, the federal government will seek to claw back a portion of payments for all Medicare patients admitted with any diagnosis over the course of the entire year. The largest potential reduction for a hospital would be one percent in FY 2013; two percent in FY 2014; and three percent in FY 2015 and beyond. This may not sound like much, but the Health Care Advisory Board estimates that about 60% of hospitals will affected to the tune of around $200,000,000 per year in lost revenue.

The only problem with this program to ensure “quality” is that it does not appear to be based on any rational analysis of the available data concerning readmissions. In fact, rather than basing the program on actual data, the Medical Payment Advisory Commission (who recommended the strategy to HHS) based its analysis on a computer simulation that did not in any way reflect reality. The result is that, statistically speaking, excellent hospitals are at least as likely to be punished by the government as not-so-good ones. It’s not the sort of strategy one could use to successfully train a pet, let alone operate a healthcare system, but what the heck. It’s the law of the land.

We’d sincerely hoped that this saga couldn’t get any more pathetic, but that turns out to have been wishful thinking. For this you can blame a recent study entitled “Risk Prediction Models for Hospital Readmission”, that was just published in the Journal of the American Medical Association by Dr. Devan Kansagara, et al.

Here’s the problem. Even if we were to (incorrectly) assume that the HHS/Medicare readmission policy was both appropriate and evidence-based, implementing it isn’t as simple as simply counting each hospital’s readmission rate per diagnosis, and singling out those with the highest rates. In the case of very sick patients, elderly patients or those with multiple chronic diseases, one might well expect that they might need to be readmitted at a higher rate than otherwise healthy people who happen to get pneumonia or have a heart attack. To compensate for this sort of patient selection bias, Medicare says it will “risk-adjust” the patients readmitted to each hospital. This would allow the regulatory bean counters to compare “patient apples” to “patient apples” much as they might any other commodity, and punish each deficient hospital with the correct financial penalty. This is an important part of making the regulatory process fair and balanced – so important that implementing the program without an effective method of adjusting for risk is frankly capricious, arbitrary and unethical.

How does one adjust for risk? It can be complicated. Ideally one would know in advance exactly which factors are most responsible for unpreventable readmissions, and be able to objectively measure and weight them appropriately.

Because the risk-adjustment process is so important, Kansagara and colleagues took it upon themselves to survey the world’s literature on the predictive value of models used to assess readmission risk for the purpose of comparing hospital performance. They were able to find reports on 26 different models used in a variety of different countries, including the U.S., Australia, Canada, Ireland, Switzerland, and the United Kingdom. Their findings? If you’re a regular reader of this column you’ve probably already guessed the answer:

“Data Synthesis: Of 7843 citations reviewed, 30 studies of 26 unique models met the inclusion criteria. The most common outcome used was 30-day readmission; only 1 model specifically addressed preventable readmissions. Fourteen models that relied on retrospective administrative data could be potentially used to risk-adjust readmission rates for hospital comparison; of these, 9 were tested in large US populations and had poor discriminative ability (c statistic range: 0.55-0.65). Seven models could potentially be used to identify high-risk patients for intervention early during a hospitalization (c statistic range: 0.56-0.72), and 5 could be used at hospital discharge (c statistic range: 0.68-0.83). Six studies compared different models in the same population and 2 of these found that functional and social variables improved model discrimination. Although most models incorporated variables for medical comorbidity and use of prior medical services, few examined variables associated with overall health and function, illness severity, or social determinants of health.

Conclusions: Most current readmission risk prediction models that were designed for either comparative or clinical purposes perform poorly. Although in certain settings such models may prove useful, efforts to improve their performance are needed as use becomes more widespread.”

Which of these models is Medicare going to use? We have no idea, and there’s a better than 50:50 chance that the folks at HHS don’t know either. But the poor predictive performance of virtually all of them is just one more reason that a program this poorly constructed should be shelved before it’s even started. How can hospitals be expected to improve their performance if the means used to evaluate them are shaky at best? Would anyone take the Olympics seriously if the judges in the long-jump measured the distance of each jump by pacing it off?

Like Caesar’s wife, the science behind the rules and regulations promulgated by HHS and the Center for Medicare and Medicaid Services should be beyond reproach. This one doesn’t even come close.

Categories : Abuse of Power, Bureaucracy Run Amok, Business and Law, Economics, Ethics, Healthcare Policy, Hospitals and Health Systems, Politics, Quality Questions

Aug
25

Medicare Is Going to Penalize Readmissions. Is This Evidence-Based Regulation?

by Dr. Doug Perednia

You’ve heard of evidence-based medicine, right? Evidence-based medicine (EBM) is the “good” medicine. Ideally these are things that clinicians do that have randomized, double-blind controlled trials behind them. Everything else, which is in reality almost everything, is the “bad” medicine. But don’t take our word for it. Here’s what President Obama said in a press briefing on July 22^nd, 2010:

“Part of what we want to do is to make sure that those decisions are being made by doctors and medical experts based on evidence, based on what works…. Right now, doctors a lot of times are forced to make decisions based on the fee payment schedule that’s out there. … the doctor may look at the reimbursement system and say to himself, ‘You know what? I make a lot more money if I take this kid’s tonsils out … I’d rather have that doctor making those decisions based on whether you really need your kid’s tonsils out, or whether … something else would make a difference…. So part of what we want to do is to free doctors, patients, hospitals to make decisions based on what’s best for patient care.”

To be perfectly fair, however, the President’s appointees have done plenty to undermine the administration’s supposed commitment to EBM. This happened first when Secretary of Health and Human Services Kathleen Sebelius initially embraced “evidence-based” recommendations that women in their 40s not undergo screening mammograms, only to scoff at the notion when the resulting political poo hit the fan.

It happened again with Dr. Donald Berwick, the Head of the Center for Medicare and Medicaid Services (CMS). Generally thought to be a staunch advocate for the use of EBM, he subsequently expressed allegiance to an alternative healthcare religion (we use this term somewhat tongue-in-cheek, since many of the positions taken by people on these sorts of issues often take on the characteristics of faith-based assertions rather than rational arguments when you look at the entirely of what’s being advocated), known as “patient centered medicine”. We’ll let Dr. Berwick explain in his own words, and refer the reader to an excellent post in the blog Science-Based Medicine for a good read of how schizophrenic our healthcare leaders can be with respect to the policies they’re recommending:

“First, leaving choice ultimately up to the patient and family means that evidence-based medicine may sometimes take a back seat. One e-mail correspondent asked me, “Should patient ‘wants’ override professional judgment about whether an MRI is needed?” My answer is, basically, “Yes.” On the whole, I prefer that we take the risk of overuse along with the burden of giving real meaning to the phrase “a fully informed patient.” I contemplate in this a mature dialogue, in which an informed professional engages in a full conversation about why he or she–the professional–disagrees with a patient’s choice. If, over time, a pattern emerges of scientifically unwise or unsubstantiated choices–like lots and lots of patients’ choosing scientifically needless MRIs–then we should seek to improve our messages, instructions, educational processes, and dialogue to understand and seek to remedy the mismatch.”

So we already seem to have a disconnect between the rhetoric of the President of the United States and the thoughts and actions of his appointees. Since this blog seeks to illuminate the Road to Hellth, the next question is whether take things one step further into regulatory hypocrisy?

That’s where the news comes in handy.

As part of the “ObamaCare” Accountable Care Act, the nation’s largest insurer (Medicare) is implementing a program that doles out drastic financial punishments to hospitals that are found to have a higher-than-average percentage of patients with certain diagnoses (heart attack, heart failure and pneumonia ) who are re-admitted within a 30 day period. Rather than simply docking the hospitals for the cost of the re-admission, or even charging a penalty on the admissions for each of these diagnoses, the federal government will seek to claw back a portion of payments for all Medicare patients admitted with any diagnosis over the course of the entire year. The largest potential reduction for a hospital would be one percent in FY 2013; two percent in FY 2014; and three percent in FY 2015 and beyond, but even these small percentages can add up. The Health Care Advisory board looked into this:

“Our analysis indicates that around 3,100 acute care hospitals will be included in the readmissions program, with more than 2,300 expected to face some degree of reduced payment as a result of having “worse-than-average” readmission performance. Further, we found that 26% of hospitals are likely to not see any readmissions penalty in FY 2013, while nearly 60% will face payment reductions of between $10,000 and $500,000. Based on this data, we expect to experience an average penalty of around 0.30% of inpatient payments–approximately $88,000 per hospital.”

In other words, Medicare will be clawing back about over $200,000,000 from “deficient” hospitals in 2013. And while the penalty is based on having “above average” re-admission rates, 60% of hospitals will be tripped up by the rules. This is reminiscent of Lake Woebegone, except that the majority of Medicare’s children are slated to be below average.

Readers willing to explore the unknown can find the details of this exciting re-admissions penalty program buried deep in this Federal Register notice.

Based upon this “quality enhancement” program and the stiff penalties to be levied, it must be the case that most hospitals have lots of unjustifiable re-admissions, right? And if we’re after outliers, presumably there is great variability in the rate of preventable readmissions. Moreover, the government presumably constructed this program by using evidence-based criteria for these numbers of irresponsible re-admissions. But most importantly, it’s gotta be the case that being above- or below-average is mostly just a case of competent versus incompetent hospital care, or these penalties are just as likely to punish good hospitals as bad ones. If that’s the case, their only real impact will be to suck more money out of the private payment sector (which already heavily subsidizes Medicare and Medicaid) and put it into government coffers.

So what does federal government and its regulatory experts know about readmission rates that have allowed them to create a program this wise and this powerful? Well for one thing, readmissions are clearly the fault of the hospitals involved. The Medicare Payment Advisory Commission says so. In a June 2007 report, it said three-quarters of readmissions are “potentially preventable.” How do they know this? It’s easy. They simply modeled it using software created by 3M Corporation. What could go wrong with that?

“For the purposes of this analysis, we explored identifying potentially preventable readmissions with software developed by 3M (see text box, pp. 108–109). Potentially preventable readmissions are those that in many cases may be prevented with proven standards of care; however, not

all potentially preventable readmissions can be avoided, even if hospitals follow best practices.

We used the software to identify which of the readmissions were potentially preventable. The 7-day rate for potentially preventable readmissions is 5.2 percent, the 15-day rate is 8.8 percent, and the 30-day rate is 13.3 percent (Table 5-2). Accordingly, 84 percent of 7-day readmissions, 78 percent of 15-day readmissions, and 76 percent of 30-day readmissions were flagged as potentially preventable.

Medicare spending on these potentially preventable readmissions is substantial: $5 billion for cases readmitted within 7 days, $8 billion for cases readmitted within 15 days, and $12 billion for cases readmitted within 30 days.”

Were there studies of actual patients and hospitals behind these numbers? Nope. Instead, MedPAC used the 3M model to calculate the “expected” distribution of readmissions and compare it to the actual rate for the various hospitals throughout the land. Amazingly enough it found something like a pretty darned conventional bell curve when they looked at the distribution of hospitals and readmission risk. Here it is:

Note that there is a greater than 5% difference in the predicted readmission rate between the worst hospitals and those around the mean, and a greater than 10% difference between the best and worst hospitals. Based upon this information, MedPAC and Medicare concluded that there was a terrible problem with negligent hospitals providing inadequate care and operating a “revolving door” policy for readmissions. But what happens if we look at real data instead of the predictions of 3M’s computer model?

For one thing, we find that there is an astonishingly low amount of variation in readmission rates among the thousands of hospitals in the U.S. Let’s take one of Medicare’s penalty diagnoses, congestive heart failure (CHF) as an example.

In contrast to Medicare,Keenan, et al. actually bothered to look at the historical 30-day readmission rate for CHF patients in a retrospective study using Medicare claims data. This is the real-life distribution that they found:

In the real world, the mean adjusted readmission rate is 23.6%. For hospitals in the 5^th percentile (i.e., the very best), the rate was 22.2%, while the readmission rate for 95th percentile (among the worst of the worst) was 25.1%. These are variations from the mean of only 1.4% and 1.5% respectively, about five times less than Medicare’s fabulous 3M computer model had predicted.

Just think about what this means for a moment. Consider a tale of two hospitals. One hospital is average, the second is, (according to Medicare), “terrible” with respect to its management of CHF – an outlier at the 95^th percentile. Each will admits 100 patients with CHF this year. Statistically speaking, by the end of the year the “average” hospital will have readmitted 24 patients, while the “terrible” hospital will have readmitted 25. How on Earth could anyone distinguish the readmission results of these two hospitals from chance alone?

But there is, of course, more to this story. What about MedPAC’s computer model assessment that a whopping three-quarters of 30-day readmissions are “preventable”? How does that square with the available evidence?

Here too, others have done a far better job than Medicare in developing real-world benchmarks. (Even scarier, in this case the others are Canadian.) Carl van Walraven et al. at Ottawa Hospital Research Institute and elsewhere took a look at all urgent, unplanned readmissions that occurred within six months among patients discharged to the community from 11 teaching and community hospitals over a four year period. “Summaries of the readmissions were reviewed by at least four practicing physicians using standardized methods to judge whether the readmission was an adverse event (poor clinical outcome due to medical care) and whether the adverse event could have been avoided.” Their findings? Only 18% were deemed to have been avoidable.

Let’s look back at our two hypothetical hospitals each having 100 admissions for CHF. At the “average” hospital, 4.2 of their 24 readmissions could be considered to be “avoidable”. At the “terrible” hospital, 4.5 of 25 readmissions will have been avoidable. This amounts to a difference of one excess “preventable” readmission for every 330 CHF patients admitted – hardly a number that can be reliably distinguished from chance alone when looking at gross readmission rates. Given that there are far more “average” hospitals than bad ones, Medicare’s methodology will statistically, and inevitably, punish more good hospitals than bad ones.

In medical terms, it’s as if the majority of patients found to have a lump will be slated for chemotherapy, simply because it’s possible that they might have cancer. Would you rely on doctors who takes this approach? Would you trust them with your family? Would you trust them with running your healthcare system?

It appears that the Administration and the ACA are hardly practicing evidence-based medicine when they dictate hundreds of millions of dollars in penalties for an actual majority of hospitals treating Medicare patients. Based on our analysis of the data, we’ve taken the liberty of paraphrasing the quote that President Obama made at the beginning of this post. Wouldn’t it be refreshing to hear a politician make this speech?

“Part of what we want to do is to make sure that those decisions are being made by [bureaucrats and politicians] based on evidence, based on what works…. Right now, [bureaucrats and politicians] a lot of times are forced to make decisions based on the fee payment schedule that’s out there. … the [bureaucrats and politicians] may look at the reimbursement system and say to [themselves], ‘You know what? I [save] a lot more money if I [create a computer model that claims that hospitals are incompetent, and then make rules that generate stiff penalties for hospitals whether or not they're doing anything wrong] … I’d rather have that [bureaucrat] making those decisions based on whether you really [did waste money], or whether … something else would make a difference…. So part of what we want to do is to free doctors, patients, hospitals to make decisions based on what’s best for [everyone].”

Don’t hold your breath.

But who are these miscreants with such high readmission rates, and is it even cost-effective to reduce them? And what should hospitals do under these circumstances?

We’ll take a look at those questions in our next post.

Categories : Abuse of Power, Bureaucracy Run Amok, Economics, Ethics, Healthcare Policy, Political Hellth, Politics, PPACA, Quality Questions, Uncategorized

Jun
29

Fake Patient Program Put on “Indefinite Hold”

by Dr. Doug Perednia

Yesterday we posted a description and analysis of the Obama Administration’s program to have contractors posing as patients call medical offices in order to determine whether doctors were discriminating against the poor and elderly in their scheduling practices. Well today the New York Times is reporting that the initiative has been placed in “indefinite hold”. This means that HHS will not say whether or when they really will carry out the program. After all, if they meant that the program was actually cancelled, they would have said “cancelled” . Instead the HHS spokesman merely said “We have determined that now is not the time to move forward with this research project.”

Well why not? If it was a good idea yesterday, why isn’t it a good idea today? Was the original announcement just a trial balloon to see whether or not anyone would complain about the sneaky and invasive nature of the inquiry? The only reason given in the article was a non-reason:

“Plans for the federal survey were devised by the office of the assistant health secretary for planning and evaluation, Sherry A. Glied, and the government retained a big survey research company to help conduct it. Ms. Glied declined Tuesday to respond to questions about cancellation of the survey…

Administration officials evidently concluded that the survey could be a political liability. But Christian J. Stenrud, a Health and Human Services spokesman, said, ‘Politics did not play a role in the decision’ Tuesday.”

The basic goal of the program – to acquire a virtual club that would be used to cudgel your doctor for behaving rationally – hasn’t gone anywhere. The speech that we described in our last post in which physicians are vilified for discriminating against the poor and elderly is still ready to go. It’s just waiting in the wings for a suitable triggering event.

The trusty reporters from the New York Times and the Wall Street Journal could prove it if they wanted by asking one simple question:

“Mr. President/HHS representative, do you believe that doctors are discriminating against the poor and elderly in their scheduling practices?”

To which the reply would be made:

“We simply don’t have the data to know whether this is the case. We certainly hope not. Since you’re brought it up, it’s something we should investigate.”

And the next thing you know, the secret caller program will be back in the saddle.

Categories : Abuse of Power, Clinical Care, Healthcare Policy, Political Hellth, Politics, The Practice of Medicine

Archive for Abuse of Power

Medical Specialty Certification Exams: The Real Scandal

Emergency Medicine Goes Down the Rabbit Hole in the Evergreen State

Mediocrity in Pursuit of Quality Is No Virtue

Medicare Is Going to Penalize Readmissions. Is This Evidence-Based Regulation?

Fake Patient Program Put on “Indefinite Hold”

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