Road To Hellth

May
15

Learning the Wrong Lesson

We should be careful to get out of an experience only the wisdom that is in it and stop there; lest we be like the cat that sits down on a hot-stove lid. She will never sit down on a hot–stove lid again – but also she will never sit down on a cold one anymore.

–Mark Twain

A big part of the problem with having non-medical people such as legislators and regulators govern the process of medical care and medical education is that they’re just not very good at it. Of course this should hardly be surprising. Why should they be? At its very core, medicine is a scientific endeavor that happens to be tinged with decisions about the best use of scarce resources. The vast majority of Americans, Britons, Canadians, or indeed the citizens of any country don’t know enough about medical science or medical education to fill a thimble. Their elected representatives and regulators are in exactly the same boat. Yet they don’t seem to have any qualms about making snap decisions that will adversely affect whole generations of their fellow citizens.

Consider the flurry of laws that have been passed to limit the number of hours that medical students and residents may work in the course of their training. What could be more logical? Tired people make mistakes and mistakes are bad, therefore make sure that resident physicians are never tired. And if everything else were equal, that might be true. But in the real world things are rarely that simple. The problem is that inexperienced and unknowledgeable people make mistakes too; other things equal, would you rather have your doctor be tired, or inexperienced and unknowledgeable?

It may be hard for the average person to believe, but the notion of staying up for long hours to take care of patients didn’t just pop up out of nowhere. Part of the whole idea of intensive medical training with all-night call is to cram as much experience, knowledge and continuity of care as one can possibly fit into a fixed number of years. Time is a scarce and desirable (and therefore expensive) commodity. If we were to allocate more years to residency training in order to make up for all of those new hours off, it will inevitably add to the cost of healthcare. (And heaven knows that nobody wants that!) Of course the mistakes made by inexperienced physicians will add to healthcare costs as well, but that particular thought may not occur to a legislator or regulator who has never been through the process.

The process of training doctors takes so long that unintended side effects of poor policy decisions take years to appear. But appear they do. It’s only now, after a few years of having these laws around that we’re seeing the result. It’s not a pretty picture.

Just last week, a leading British surgeon who is routinely expected to work for hours on end during complex surgeries, publicly expressed his exasperation at European rules that prevent physicians in training from working more than 48 hours per week:

Edward Kiely, a consultant at Great Ormond Street Hospital, said the rule was based on a European directive “designed for Spanish lorry drivers” but was damaging to doctors’ training and disrupted “continuity of care” for patients.

He said: “It’s not correct that you can’t function properly when you’re tired. Mothers look after children. They’re often tired, but that’s the job and you get on with it.”

Kiely, who oversaw the 14-hour procedure in 2010 to separate conjoined twins Hassan and Hussein Benhaffaf, has 45 years’ experience as a surgeon, with 15,000 operations under his belt…

He said that under the old system, one surgeon would see a patient through from diagnosis to post-operative care, but now “many different doctors” would be involved.

“The continuity of care is disrupted and that is bad medicine,” said Kiely

And, of course, the limitation in hours is even worse when trainees are required to spend that time concentrating on “communication” and “teamworking” (not to mention “listening”, “sensitivity”, “ethics” and the endless typing required by electronic medical record systems) rather than the real science and practice of medical care. A study published last year in Postgraduate Medical Journal found that:

Junior doctors reported that they did not feel equipped to care for seriously ill patients in hospital and this may have got worse, it was found.

Changes to the medical school curricula that put a greater emphasis on communication and teamwork may have been to the detriment of the basics such as treatment, prescribing and managing emergencies, the study suggested.

An analysis of research papers looking at the perceptions of newly qualified doctors published between 1993 and 2011 found in most areas junior doctors felt better prepared for the job.

However in prescribing and acute care, the picture appears to have deteriorated, the researchers said…

Co-author Dr Sam Smith, said: “Junior doctors feel prepared in communication but don’t feel prepared in acute care. There has been a lot of emphasis in training on communication lately.

“One of the reasons that junior doctors might feel more prepared in some of the other domains is the emphasis on communication and teamworking . It is very difficult to keep the same level of emphasis on other things when new things are added in.”

Oops. One would have thought that taking care of acute illnesses would have been at the top of the medical education “to-do” list.

So how did this particular regulatory decision come to pass? In the United States, these rules were implemented in the immediate aftermath of sad and unfortunate Libby Zion case. And in one of the best, most educational and most enlightening explanations of the way in which many of these decisions are made in healthcare in the 21^st century, we would like to bring your attention to the following except of a Medical Grand Round recently given in Portland, Oregon by Dr. Lisa Rosenbaum.

Dr. Rosenbaum is a gifted writer and speaker, who recently finished her own training in internal medicine and cardiology. She comes from a very medical family, and happens to be the granddaughter of Dr. Edward E. Rosenbaum. The elder Dr. Rosenbaum is the author of the book A Taste of My Own Medicine, which was later turned into the movie The Doctor. A description of her relationship her physician grandfather is woven throughout her hour-long presentation.

Regardless of whether you are a patient, an administrator or a medical professional, this video is well worth the nine minutes it takes to watch. It talks about how easy it is for us to learn the wrong lesson from associated events, and how important it can be have more than just a superficial knowledge of what it’s like – and how difficult it can be – to take care of patients in the real world.

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Categories : Business and Law, Clinical Care, Economics, Ethics, Healthcare Policy, Hellth Across The Pond, Politics, The Practice of Medicine

Jul
25

Gonna Wash Those Germs Right Out O’ Your Chair?

by Dr. Doug Perednia

We Americans can learn a great deal from our friends in the United Kingdom if we simply take the time to pay attention. For today’s lesson, we’re most grateful to Dr. Stephanie Dancer, Consultant Microbiologist at the NHS Lanarkshire, and fellow blogger The Ferret Fancier; the former for her work and permission to republish her presentation here, and the latter for bringing this whole thing to our attention. While the topic at hand is most directly about infection control and the best way to defend against the spread of methicillin-resistant Staphylococcus aureus (MRSA), the lessons and implications go well beyond infectious disease and take us on a short trip down the Road to Hellth.

Pants policies and paranoia

For those of you who may not be in tune with such things, MRSA is a potentially harmful strain of bacteria that often infects wounds or breaks in the skin. It is highly resistant to treatment by conventional antibiotic therapy. MRSA bacteria are responsible for a substantial percentage of hospital-acquired skin infections, and such infections can be extremely expensive and difficult to treat. The bacteria can also be encountered among relatively healthy people in the larger non-hospital community – and is often spread as a result of sharing razors, sports equipment and other items that come in contact with the skin. As is the case with many health problems, this is one that we’ve largely created for ourselves through the ubiquitous and often indiscriminate use of antibiotics for everything from scratches to animal feed. Nevertheless it’s important to try to limit its spread because our treatment options for MRSA-related illness are rapidly disappearing.

We strongly encourage all of our readers to go through Dr. Dancer’s excellent slide show on the topic of MRSA embedded above. But for the benefit of any of our readers who may be time-constrained and/or impatient we’ll provide a short synopsis and make a couple of observations.

Soon after it became apparent the MRSA was a problem that would not go away, medical researchers began to think about how it might be possible to limit the spread of this organism in the hospital. One strategy that was formally investigated in the late 1990s was the enhanced use of hand washing among healthcare personnel. In 2000, Dr. Didier Pittet and his colleagues in Geneva Switzerland launched a study in which they carefully observed the hand washing practices of in-hospital providers and actively promoted hand hygiene, especially with the use of bedside alcohol-based gels, and tracked the impact on MRSA infections over time. One result was that while the hand cleaning rates among nursing and support personnel improved significantly over the three year study period, hand cleaning among doctors did not. A second result was that both hospital-acquired infections and the MRSA transmission rate fell substantially. The impact of this study was immediately felt around the world, as hospitals everywhere proceeded to launch intensive hand-cleaning programs of their own.

As people are wont to do in such cases, healthcare and political leaders everywhere began to look for ways to improve upon the hand washing crusade. “After all”, they reasoned, “if a little hand washing is good, more is better, right?” Administrators in the United Kingdom took the leadership bit between their teeth and began to run hard and fast.

As illustrated by Dr. Dancer, they launched into a fairly astonishing variety of interventions including the production of posters, life-size cardboard cutouts of admonishing nurses, audits, conferences, flyers, “hand-hygiene coordinators”, badgers badges, UV detectors, TV monitors, additional sinks, disinfectant dispensers, warning letters, flashing signs, committees, sniffer dogs, more audits, and lots of additional managers and administers to name just a few. In 2007 and 2008 three separate government departments came out with MRSA-related guidelines dictating that healthcare providers had to eliminate their personal use of wristwatches, jewelry, neck ties, white coats and pens or pencils in outside pockets. They were further instructed to go “bare below the elbow, and forbidden to leave work in their uniforms. Finally, on January 29, 2009 the government in Scotland really took the gloves off. It established a “zero tolerance policy” for providers who failed to wash their hands, complete with the threat of firing.

“A ‘zero tolerance policy’ for NHS staff who fail to wash their hands was today declared by the Scottish Government.

And the public will be able to check superbug infection rates and levels of hand cleanliness for each hospital under the new measures.

The latest moves in the battle against hospital infection were announced today by health secretary Nicola Sturgeon.

A ‘one-stop shop’ is to be set up to give public access to all published information on hospital infection rates and hand hygiene compliance.

This will be available on a website which will be established by the end of the month.

The ‘zero tolerance’ approach has been set out by the Scottish Government’s chief nursing officer, Paul Martin, in a letter to all health board chief executives.

Figures earlier this month showed varying levels of compliance for hand hygiene.

The target level for compliance in Scotland is at least 90%. Overall, this target is being exceeded, at 93%.

But within this total, compliance levels vary from 95% for nurses to 84% for medical staff.

Ms Sturgeon said: ‘Hand hygiene is a simple, but essential, part of our drive to tackle infections in hospitals, for everyone from consultants to clerical staff.

‘That’s why we are now adopting a zero tolerance approach to non-compliance by NHS staff to ensure we build on the great progress that has already been made.’

The new drive includes an eight-week advertising campaign.”

Not to be left out, politicians “across the pond” in the U.S. have taken up the cause. In April of 2011, Sen. Jeffrey D. Klein and Democratic colleagues in the New York state legislature sponsored S4909, which mandates a “Health Care Practitioner Hygienic Dress Code” that is similar to the rules imposed in the U.K. At the time of this writing Senator Klein’s bill is still in committee, but infectious disease specialists have questioned its clinical value:

“The New York legislation “sort of verges on hysteria,” said James L. Cook, MD, chief of the Section of Infectious Diseases, Immunology and International Medicine at the University of Illinois College of Medicine in Chicago. “You’ve got to decide. Do you want to use the evidence? … There is nothing to suggest that anything you find on someone’s article of clothing is likely to be transmitted to a patient.”

Apparently undeterred by any potential criticism, however, the bill’s sponsors are continuing to forge ahead. Indeed, when asked to comment, Senator Klein even took an approach ironically reminiscent of Star Trek’s “Dr. Leonard McCoy:

“’I’m an attorney, I’m not an MD,’ said Klein, a Democrat who represents the Bronx. ‘This is a simple and noninvasive approach to alleviating the infections that are taking place in hospitals and which are a serious problem — not only in New York, but across the country.’”

This really brings us back to Dr. Dancer’s presentation. What does the medical evidence say about the top-down measures being imposed – as they invariably are – by the vast government bureaucracies governing healthcare these days? In a nutshell, it amounts to this:

Bare below the elbow? “Bare below the elbow improves wrist washing.” Unfortunately, there is no evidence that this provides any medical benefit.

Using alcohol gel? “No effect on MRSA.” It also does not appear to have any impact on the control of C. difficile infections or transmission of pathogens in the ICU.

Rabid hand cleaning vigilance? MRSA infection rates in hospitals have declined over the same period of time that these programs have been placed into effect, but so have efforts to enhance screening for MRSA, reduce infections caused by IV lines, and improve topical care. No one has yet sorted out how the benefits of hand cleaning compare with the impact of all these other interventions. Interestingly enough, despite all of these measures, infection rates of methicillin-susceptible Staphylococcus aureus have not changed at all. This suggests that the progress we’re making with respect to reducing MRSA-related infections mat well have nothing whatsoever to do with hygiene, but everything to do with more judicious use of antibiotics in the hospital.

Dr. Dancer then goes on to make a very good case that hospital overcrowding and a heavy load of bacterial contamination on the surfaces of everything one touches in NHS hospitals probably more than make up for any benefits garnered from all of this “zero tolerance” nonsense. After all, what good does it do to clean your hands in the very next thing you touch is already contaminated? In one study 5% of the fingertips of healthcare workers were contaminated with MRSA: 6% after clinical contact, 7% after environmental contact, and 4% after no specific contact. In fact, preliminary data shows that simply hiring additional cleaners can reduce the bacterial load in rooms by 33% and cut the rate of MRSA infections in half. Why haven’t the politicians and bureaucrats mandated that this be done routinely in NHS hospitals? Because it’s expensive relative to simply ordering doctors and nurses to do things that are highly visible, but have little or no real impact on infection rates.

Politics, anyone?

Let’s not kid ourselves. There’s still an enormous amount that we still don’t know about the best way to do many things in healthcare. Any physician who’s been in practice more than ten years can point to a host of “facts” (s)he learned about the cause and treatment of illness that are now known to be completely wrong. And when it comes to making improvements, the obvious is often faulty. It was “obvious” that electronic medical records would save the healthcare system billions each year in time and money; our experience thus far has been disappointing to say the least, (with the NHS again leading the way). It was “obvious” that having the government fix the price of healthcare goods and services for the past 40 years would lead to healthcare cost containment. We all know how that turned out. And now it’s “obvious” that an unaccountable board of unelected “experts” like ObamaCare’s Independent Payment Advisory Board can magically control the cost of Medicare without reducing benefits, quality or access to care.

So let’s learn one thing from our British cousins, shall we? When it comes to a clearly medical problem such as infection control, the best thing our political and bureaucratic leaders can possibly do is politely ask the medical community to: (1) seriously research the problem; and (2) implement medically valid solutions based upon their findings. Don’t pass laws. Don’t generate regulations. Don’t specify behavior or procedures. Just ask the medical community to do the best it can. Then go right back to placing your own economic, ethical and political house in order.

That one task alone should keep you fully and completely occupied.

Categories : Clinical Care, Healthcare Policy, Hellth Across The Pond, Political Hellth, Politics, Quality Questions, The Practice of Medicine

Jun
5

How Can We Apply “First Do No Harm” to Government? – Part I

by Dr. Doug Perednia

Excess administrative overhead expense is the single largest source of source of savings currently available to the U.S. healthcare system. As documented in Overhauling America’s Healthcare Machine, the sheer magnitude of administrative waste and inefficiency is staggering. We’re talking hundreds of billions of dollars each year. A substantial portion of this overhead can be attributed to the way in which private insurance companies are permitted to operate. Accountable to no one but themselves, the amount of foolish and unnecessary work they create for patients and providers is legendary. None of the forms are the same. None of the policies are the same. Everything requires pre-authorization. If you want to pre-authorize something, all of the records have to be submitted. Generally speaking, it’s impossible to find a person in authority that you can speak to on the phone. Records and requests are repeatedly “lost”. Policies and formularies are continually changing. Heck, most insurance card don’t even have information about deductibles and co-pays printed on them anymore; clinic staff are now supposed to take the time to call the insurer or log on to their website to figure it out. And don’t even get us started on “denial management”.

One way of reducing these costs is by adopting a “single-payer” system. (Typically this “single payer” is the government, but it doesn’t necessarily have to be. One could, for example, give a single private insurance company a monopoly on selling health insurance nationwide.) Enlisting a single payer can eliminate all sorts of administrative expenses: reducing the number and types of forms required, providing a uniform policy with respect to referrals, pre-authorizations, formularies and coverage, streamlining billing, and obviating the need for advertising. Indeed, the case for a single payer seems so compelling that single-issue organization have been created on its behalf. Some of these include Healthcare-NOW!, the 18,000 member-Physicians for a National Health Program, the 581 labor unions represented by Unions for Single Payer Health Care, and dozens of others. The state of Vermont has just passed legislation mandating the creation of a single-payer system of healthcare within that state, sadly without having a plan in place to finance it. It calls for all healthcare in the state to be “managed by a five-member board, [that] will set reimbursement rates for health care providers and streamline administration into a single, unified system.”

So many of the prospects for single-payer healthcare are so useful and charming, that at first blush it’s hard to see why anyone wouldn’t be in favor of it. But just as there’s no rose without a thorn, turning the healthcare system over to any single payer does have one terrible flaw: if there is only one all-powerful organization in charge, what happens to all of us patients and healthcare providers if, or perhaps when, the people running it decide to screw things up? This is of particular concern if the single payer happens to be the government. Because of its control over the law, regulations, taxes and the armies of people who enforce all of them, not only can the government make things go badly, it can make them go very badly, and with little recourse on the part of those most adversely affected.

One never hears single-payer advocates discuss this problem. This seems odd because, as an advocate, you would presumably wish to anticipate and address any potential objections to the policy that you would like others to embrace.

And it’s not as if the prospect of gross administrative incompetence is novel or difficult to imagine. There are plenty of examples of government mismanagement anywhere one might care to look, from the federal government’s role in creating the recent housing bubble to the management of defense procurement. Moreover, none of this absurd and fiscally irresponsible behavior is new, or should be unexpected. Nearly a hundred years ago during the first World War, the U.S. government decided to enter assist the shipbuilding industry by creating the Emergency Fleet Corporation (EFC). The result was a classic bureaucratic mess in which ships that would have cost $75 per ton to build in the United Kingdom cost the U.S government $145 per ton. President Wilson’s own Treasury Secretary reported that:

“Appalling prices were paid for everything that had to do with a ship. Engines and other equipment were purchased at such as staggering cost that I fancied more than once that the machinery we were buying must be made of silver instead of iron and steel.”

By the end of the program the EFC had received 2,311 ships, nearly a quarter of them made of wood and already obsolete.*

But even the Federal Emergency Management Agency’s performance during Hurricane Katrina can’t hold a candle to the poor planning, mismanagement and counterproductive behavior that we’ve already seen in state and federally-managed healthcare programs, both in the U.S. . Consider just a few of the following examples:

- Wildly inaccurate financial projections. From the very beginning of the Medicare program, federal legislators and administrators have shown a complete inability to accurately estimate the program’s true costs and control their urges to provide more benefits than can be realistically financed. Hayward and Peterson’s now-historical 1993 article, “The Medicare Monster” :

“At its start, in 1966, Medicare cost $3 billion. The House Ways and Means Committee estimated that Medicare would cost only about $ 12 billion by 1990 (a figure that included an allowance for inflation). This was a supposedly “conservative” estimate. But in 1990 Medicare actually cost $107 billion.

This is a mere bagatelle compared with “conservative” projections for the next generation. The Congressional Budget Office estimates that Medicare will cost $223 billion by 1997. Constance Homer, deputy secretary of Health and Human Services, warns that “by the year 2003, at the current rates, we will be spending more on Medicare than we do on Social Security.”

In fact, Medicare spending in 1997 was just $215 billion, and Social Security spending (at) was still higher that Medicare spending (at $483 billion vs. $275 billion) in 2003, but that’s small consolation given the fact that both funds are now operating at a deficit. Another chronic problem that governments seem to have with healthcare is honesty – especially with respect to accounting. Medicare actuaries have been objecting to the annual financial projections of the nation’s Medicare Trustees for decades, and even generations. Take a look at this passage from Hayward and Peterson:

“But even the supposedly pessimistic assumptions behind these projections aren’t realistic, and herein lies another small drama. Roland King, the chief actuary of the Health Care Financing Administration (HCFA), has been blowing big holes in the projections. King has to sign off on the “actuarial soundness” of the projections in the annual report each year. Acknowledging the “garbage-in, garbage-out” quality of the projections, King has noted in his statement that the projections assume unprecedented growth in average wages over the next generation.

The projections assume real income growth (pay increases adjusted for inflation) substantially above the trend line of the last 25 years. Calling this “unjustified optimism,” King notes that even the “pessimistic” projection assumes that real income will grow at an annual rate that is faster than the cumulative rate for the last 25 years.

King concludes in a memorandum he circulates with copies of the Medicare annual report: “Indeed, the assumptions are so optimistic that even the pessimistic assumptions project real earnings increases during the next quarter century, and each quarter century thereafter, will be many times the increases of the last quarter century….The Trustees’ assumption that real earnings growth rates will suddenly accelerate to levels that substantially exceed the real earnings growth rates of the last quarter century must be viewed as unreasonable.” King believes that the actual actuarial deficit will be 60-percent higher than even the pessimistic forecast.

The Hospital Insurance Fund trustees have had a prickly reaction to King’s observations. In last year’s annual report, the trustees offered this grumpy dismissal: “We believe that the comments on real-wage gains by the HCFA Chief Actuary also represent an expression of a preference outside the bounds of the legally required actuarial opinion.” In an appendix of the latest annual report, the trustees take aim at King again, but without offering any substantive refutation of his arguments: “It is perplexing and disconcerting that an actuarial opinion with unjustifiable qualifications has been allowed to be repeated for several years in the HI reports.” In other words, shut up.”

If this sounds hauntingly familiar, one need look no further than this recent Road to Hellth post describing the second year in a row in which Medicare’s own actuaries have filed a report that politely characterizes the numbers in the Trustee’s report as pure fantasy. It is no exaggeration to say that the consistent inability of government to either predict, or stay within, its governmental healthcare budget is a major contributor to America’s current multi-trillion dollar deficits.

- Inept procurement and use of healthcare information technologies. The federal government has spent billions on defective, hard-to-use and non-communicating electronic medical record systems (EMRs) for the military that have been, or soon will be, scrapped. The DoD’s current AHLTA system has charitably been described as “a debacle.” And soon President Obama will be tossing billions more good dollars after bad to fix or replace them. This system is just the latest in a line of defective EMR deployments stretching back decades to the military’s CHCS I and CHCS II programs. Even worse for the private healthcare sector, the government’s obsession with deploying fancy, expensive and hard-to-use EMRs is now being forced on them as a result of the American Recovery and Reinvestment Act of 2009. In all fairness, the U.S. government is far from alone in its wasting tax dollars on defective EMRs. “Across the pond” in the United Kingdom, the National Health Service has wasted many billions more (currently over 11 billion pounds and counting!), and still doesn’t have any idea when it will have a workable system.

- Expensive and disruptive incentive programs that produce little or no clinical benefit. As we’ve seen previously, both the NHS and Medicare have launched pay-for-performance (P4P) programs that reward and/or punish clinicians for engaging in specific rote behaviors. By 2015, all Medicare clinicians will be forced to report quality metrics to the government or face penalties. Although these programs clearly frustrate clinicians, add to administrative overhead and increase the complexity of the healthcare system, a number of studies have now found that P4P does not appear to improve care. Yet the programs continue.

- Payment systems – mandated by law – that dramatically increase administrative overhead. Regular readers will know that we’re referring to Medicare’s one-of-a-kind Resource-Based Relative Value Scale, or RBRVS. Surely one of the most complex, special interest-manipulated and administratively expensive medical payment schemes ever conceived, the RBRVS spawned the Relative Value Scale Update Committee, or RUC. This system has pitted specialty physicians against primary care doctors (which, coincidentally, may have been one of the ideas in the first place), directly reduced the number of primary care physicians available, spawned an expensive and sophisticated medical billing industry in which “code manipulation” is the order of the day, and has provided hundreds of millions of dollars (if not billions) in indirect subsidies to The American Medical Association. No other country in the world has seen fit to adopt a similar system. The RBRVS system has now been in place for over 20 years – more than enough time to appreciate its defects and replace it with something far simpler and less expensive, yet it remains the law of the land.

- Payment policies that routinely pay for less than the cost of the goods and services consumed. This has been a universal problem for government-run healthcare systems around the world. As T.R. Reid documented in his book The Healing of America, inappropriate payment practices have led to doctor strikes n Germany, shabby and rundown healthcare facilities in Japan, and long waits for care in Canada. In the U.S. state and federal underpayment policies have resulted in a wide variety of ill effects. These include forcing physicians out of Medicaid (and, in the near future, Medicare), increasing the cost of care to private individuals and businesses as they subsidize government healthcare programs through cost shifting, reducing the real income of clinicians and increasing the number of providers opting for early retirement.

If we’re really and truly objective about it, it’s hard to come up with any reason to think that a government-operated single-payer healthcare system is going to be efficient, cost effective or even fair. Our experience – and the experience of many other countries – has been exactly the opposite. This is not to say that simply turning the American healthcare system over to private insurers is necessarily going yield any better results. If anything we should be ashamed of the rapacious and inefficient behavior that our society (and its state and federal governments) have been willing to tolerate in the private health insurance market. Anyone with any doubts in this regard need merely pick up a copy of Wendell Potter’s book, Deadly Spin.

So here’s the real question. Whether or not we enlist a single-payer system, what measures can we take to save government from itself with respect to healthcare? This will be the topic of our next post. In the meanwhile, we welcome your comments and ideas.

*Cruikshank JL, Schultz AW. The Man Who Sold America. Harvard Business Review Press, 2010.

Credit for the image goes to The Smallest Minority website.

Categories : Abuse of Power, Bureaucracy Run Amok, Clinical Information Technology, Economics, Electronic Medical Records, Healthcare Policy, Hellth Across The Pond, Overhauling Healthcare, Politics, Solving Problems, Uncategorized

Feb
18

Pay-for-Performance And Other Healthcare Policy Delusions, Part 2

by Dr. Doug Perednia

In previous post, we looked at the evidence, or rather the lack of it, behind the use of “pay-for-performance” (P4P) programs involving healthcare information technologies. Now let’s turn to a topic that is more traditionally associated with the P4P concept: using money in a direct attempt to influence the way in which physicians practice medicine on a daily basis. The important news in this case comes from an enormous study that examined the records of nearly half a million patients with hypertension (i.e., high blood pressure) in Great Britain between 2000 and 2007, however the results were just released in January of 2011.

In this study, Britain’s National Health System offered to pay physicians up to 25% of their annual salary based on the proportion of their patients who achieved certain “quality of care” indicators. There were 136 indicators involved to choose from, five of which involved management of high blood pressure. These included the frequency of blood pressure measurement and the proportion of patients whose blood pressure was controlled, both of which were incentivized with the offer of payment. The authors also looked at the rates of new treatment for hypertension and the use of intensive therapy, neither of which was part of the P4P payment program. One thing that was particularly nice about the way this study was done is that the investigators actually bothered to look at the all of the measures in the period before the P4P program was implemented as well as several years afterwards. This gave a detailed “before and after” picture of what actually went on over a prolonged period of time. Once nice thing about a study this large that is carried out over such a long period of time is that don’t have to fret about sample size, whether the statisticians did their job correctly or many of the other hazards that plague less Herculean efforts. So let’s head straight to the results as shown in the next three figures from the paper.

Effect of pay-for-performance and blood pressure control and monitoring in United Kingdom.

In this first figure, we see the affect of P4P on the percentage of patients with controlled blood pressure and monitored blood pressure before and after the incentive was put into place as denoted by the vertical grey bar. As you can see, the percentage of patients with controlled blood pressure fell significantly during the whole five-year period, while the percentage of patients who had their blood pressure measured each month rose significantly. However these trends were established well before the incentives were put into place. The affect of P4P? Exactly nothing. Zilch. Zero. Nada.

Effect of P4P on intensity of treatment for hypertension.

This second figure shows the impact of P4P on whether physicians began drug therapy, and the degree to which drug combinations were used in an attempt to control blood pressure. Again, the long-term trends were not affected ion the least by P4P financial incentives.

Effect of P4P on hypertension-related adverse outcomes (heart attack, stroke, kidney failure, heart failure).

This third figure shows us the impact of this particular P4P program on hypertension-related adverse outcomes such as heart attacks and strokes. Once again there was absolutely no impact on the trends that existed before the program was put into place. Notice that, if you have simply done a simple “before” and “after” study that did not collect data at close intervals, one might have concluded that the effects of P4P were statistically significant.

After noting that there was no evidence that P4P had any impact whatsoever, the authors summarized the results this way:

“These findings may have several explanations. Firstly, given the observed improvements in quality of care indicators for hypertension in the years before pay for performance, such as more frequent monitoring of blood pressure and increasingly more aggressive treatment, doctors may have already been implementing the appropriate changes in practice to achieve the pay for performance standards. Although the financial incentives in the policy were considerable, it is possible that the pay for performance targets for hypertension were set too low and therefore doctors did not need to change behaviour significantly to attain them. A smaller study of the United Kingdom’s pay for performance initiative, which evaluated the impact of this intervention on calculated clinical quality scores for selected conditions (but not controlling for secular trends), found that the policy led to short term, modest improvements in the quality of care for two conditions: asthma and diabetes. Once the targets were reached, however, improvements in quality slowed.”

This is certainly a cautious approach. Rather than conclude that P4P doesn’t have any useful affect, maybe it’s just that we didn’t set the bar high enough? After all, a previous study showed that, as soon as you imposed a P4P program things suddenly got a lot better. Hmmm. Let’s take a closer look at that other study.

In this case, we have the before-and-after points comparison design that was fortunately avoided in the recent hypertension study as a result of collecting and measuring data continuously. The investigators looked at quality indicators for three different diseases that were included in the P4P program: coronary artery disease, diabetes and asthma. The P4P incentives were implemented in 2004.

Well gosh. From here it looks as if the incentives didn’t do a darned thing for the trend in the quality of management of coronary artery disease, but worked pretty well for diabetes and asthma. At the same time the incentives did not appear to do much for a patient’s ability to actually get in to see a physician. Access to a particular doctor actually declined after the incentives were introduced. Perhaps they were too busy filling out paperwork?

But the more interesting story is told by looking at what happened to particular quality indicators that either were or were not included in the incentive program as of 2004.

The interesting thing here is that the scores for pretty much all quality indicators took a big jump between 2003 and 2005, whether or not they were associated with any sort of incentives. It just so happened that all of the quality indicators that were incentivized started out higher than the non-incentivized indicators, but of course it’s the trend that really matters if we’re looking to rationalize the benefits of P4P. So when you come right down to it, one would have to conclude that, as in the case of the first study we examined, P4P had no beneficial impact whatever. Whatever happened was pretty much going to happen anyway.

We’re already covered a lot of important findings, but let’s look at one more recent study from 2009. This one looked at the unintended consequences of P4P on physicians in England and in California. P4P programs were implemented in both places, but with one key difference: the physicians in England were able to exclude patients (or report them as exceptions) if they refused treatment or were non-compliant. The investigators then interviewed 20 primary care physicians in both locations to see if any adverse consequences occurred as a result of their participation in their respective programs. They found that three major themes emerged from their analysis: “changes in the nature of the office visit, threats to the physician-patient relationship, and threats to professional autonomy.” We should let the researcher’s finding speak for themselves on each count. First, with regard to the changes in the nature of the office visit.

“Compared with California physicians, English physicians faced a much larger number of targets (80 vs 12 clinical targets in the statewide program at the time the interviews were conducted), and the program in England relied exclusively on data captured from electronic medical records. Pop-up boxes on the computer screen highlighted any areas of activity required to meet targets, prompting clinicians to take action or enter data during the office visit.

‘You look at the screen and the screen’s completely obscured by the list of yellow boxes, and it’s always trying to balance up the mood the patient’s in and getting the boxes ticked, especially with people that don’t come in that often. You know, they come in and tell you, you know, that “Oh, my son’s died last week,” and you go, “Yeah, yeah, whatever. Do you smoke?” or “Yeah, watch, watch your weight” and stuff…

One of the things that happens is the patient comes in, the boxes pop up, and you get straight into doing all that stuff… and they’re out of the room…. And I just think there is just more chance to, you know, miss [something significant], and that’s such an important bit, isn’t it…?’”

Gosh, that sounds like a great patient and provider experience, doesn’t it? Especially if you know that the P4P incentive isn’t going to result in any significant change in either the quality of healthcare delivered or the clinical outcome. California physicians largely did not share this same experience for two reasons. The first is that most of them didn’t even know what the P4P quality measures were, or the targets they were supposed to achieve. The second is that most of them did not have the “blessing” of electronic medical records to dictate their every action.

Next, the affect of P4P on the ongoing physician-patient relationship. The greatest affect in this case was predictably on the physicians in California because they could not report or exclude non-compliant patients from their P4P reporting statistics:

“Although the absence of electronic records and computerized prompts meant that targets were seen as less disruptive of the flow of office visits among US physicians, adverse effects on physician-patient relationships were nevertheless identified, especially among physicians affiliated with organization A, the organization with the largest financial rewards. Physicians affiliated with this group expressed resentment about patients who refused to comply with their advice. In extreme cases patient noncompliance led to physicians telling patients they would be dis-enrolled unless they changed their behavior.

‘I tell them to leave. I told someone, you’re killing my pay for performance. You are the one that keeps being my outlier. Go join another medical group…’

The inability to exclude patients who refuse treatment or testing (unlike the UK system) appeared to increase pressure to cajole and persuade patients to secure their compliance. Other strategies reported by physicians included accusing patients of damaging their physician’s rating or lying to patients about the financial consequences of their refusing to comply.

Some physicians also reported bypassing informed consent procedures to meet screening targets for Chlamydia trachomatis. In addition to considerations of ethics, choosing not to request informed consent raises questions about the potential damage to doctor-patient relationships when patients who are tested without their knowledge are subsequently found to have a positive test for C trachomatis.

‘Well, everybody who didn’t have one, we sent out a form with a letter for Chlamydia screening. And we got 5 people who actually came back and did it, out of I don’t know how many hundred. So now, anybody who comes in and is in that age, I just tell them to get a urine. And I just send it in. This is life: I just send it in. If we’re going to be rated on it by somebody, that’s fine. We do it.’”

The moral here seems to be that when you implement a coercive process, you end up with a coercive process. Once again, we as patients can take comfort in the idea that the people managing our healthcare system don’t seem to mind “destroying it in order to save it”. Heck, who needs a trusting and mutually supportive physician-patient relationship anyway?

Finally, the investigators reported a “perceived impact on autonomy”:

“Whereas in England all primary care physicians were allowed to vote before the introduction of the new incentives arrangements, in California proposed indicators were published on the Internet and public comment was invited. [In other words, there was little, if any, meaningful physician input with respect to this change in the way healthcare services were to be delivered. –Ed.] Despite efforts in both contexts to consult primary care physicians and to encourage commitment to the process, and despite the larger number of targets in England, English physicians were generally more supportive of and accepted the targets that formed part of the pay-for-performance program. Differences in attitudes appeared to be related to perceptions about the implications of the respective target regimes for clinical autonomy.

Most of the English physicians suggested that the targets were helpful and did not appear to view them as undermining their ability to act as autonomous professionals.

Although some Californian physicians were supportive of pay for performance, most expressed much less satisfaction with it than their English counterparts. The incentive program was perceived as something externally imposed and managed, which made physicians feel that their autonomy was being challenged or that they were not trusted to perform in the absence of incentive payments.

At the same time US physicians believed they were being held accountable for things beyond their control. Data on their performance were generally collected by third parties, and the situation was compounded by the physicians’ inability to exclude patients from performance data if patients refused treatment or the targets were inappropriate for other reasons…

‘Physicians are monitored more than anybody. Are attorneys monitored? No. Are dentists monitored? No, not as far as I know. Are chiropractors monitored? No. So, it seems to be that physicians have either rolled over and given over their rights, and maybe they’ll be pushed to a certain point where they will rise up and say, “No more.” I don’t know…’

The system was viewed by many as unfair and opaque because it failed to take account of variations in practice populations, comprised indicators that were not amenable to control by physicians, withheld money that was due to physicians, and added to workload.

‘You might get a little bonus of money that some doctors would’ve considered part of their rightful payment to begin with. So the whole notion of withholds leaves a very bad taste. If you say, “What do you think of withholds?” that’s like saying, “What do you think of hemlock?” Not something I’d want to take. The problem with paying for performance…is it smacks of a withhold…. There must be adequate accounting methodologies to account for the recalcitrant patient or the patient who refuses for whatever reason treatments and therapies, and that’s not in the current model. It’s a source of disgruntlement…’”

At this point one really should be asking oneself, is making our nation’s physicians angry, frustrated and depressed a good thing? Is it something that we really ought to be doing, especially if there is no evidence that we’re deriving any meaningful clinical benefit as a result of the exercise? Does it makes Americans healthier or safer, or does it make the world a better place? Most importantly, P4P programs have very tangible monetary costs because they add to the complexity of the healthcare system and incur substantial costs to implement and administer. Given the evidence we’ve seen, why would any rational human being – let alone the (presumably) gifted thought leaders and administrators that we’re paying to manage our healthcare system – think that this is a good idea?

Perhaps the most important lesson that we can learn from the P4P research to date is what it says about the quality of healthcare leadership. More on that in our next post – Part 3 in our “P4P adventure” series.

Categories : Bureaucracy Run Amok, Hellth Across The Pond, Quality Questions

Apr
13

Our Crystal Ball “Across the Pond”

by Dr. Doug Perednia

It’s always fascinating to read the healthcare weblogs originating outside the United States. Those from the United Kingdom are especially useful for an American reader because they reveal the likely fate of any American government-operated healthcare system. I especially recommend The Jobbing Doctor, but there are many good ones and a complete list can be found here. Sad to say, one of the best British blogs, “Dr. Crippen’s” NHS Blog Doc recently ended with his retirement, but I have recently discovered that the contents have now been preserved here. (Thanks for the tip, readers!)

As documented in the video below, healthcare technology and administrative services are the most important parts of the British healthcare system. This rapidly becoming the case in the U.S. as well.

Keeping up with these blogs is terribly important. Not only do they make fascinating reading in and of themselves, but they also provide insight into what a government-run national healthcare system looks like in a country that shares many of the same social and political attributes. These include a similar system of law and justice, of clinical practice, and most especially a similar two-party political system. The Labor and Conservative Parties of Britain bear a strong resemblance to the Democrats and Republicans in many respects. These include their “liberal” and “conservative” leanings, frequent ethical lapses and a substantial degree of dysfunction when it comes to governing. While American pundits may argue and speculate and hypothesize about what a single-payer system or government-run healthcare might be like, our British cousins have already done the experiment for us and we would be foolish indeed not to learn from their example.

One thing you’ll see right away when you read blog posts by the Jobbing Doctor and Dr. Crippen, is that the healthcare systems in the U.S, and the U.K. share many of the same problems. Perhaps the most important of these is sheer inefficiency. I write a great deal about inefficiency in my blog posts because it’s a cruel and unforgivable waste of scarce resources. Our citizens literally suffer, become impoverished and die each and every day because money and personnel are channeled into idiotic and unproductive activities. The manifestations of this inefficiency differ somewhat from Britain to the U.S., but in both countries the well-intentioned actions of the government is an all-too-frequent root cause. In the United States, the government’s contributions to inefficiency spread into the well beyond Medicare, Medicaid, and TRICARE; generally hobbling the private sector.

Beginning this week, many of our future posts will touch upon U.S.-U.K. parallels in their respective roads to hellthcare. Why do these parallels exist? Because politicians, regulators and bureaucrats are pretty much the same everywhere. These folks typically want money, power and – most of all – control. Even if they care about healthcare (and I’m not saying that they so), they typically don’t know a damn thing about it. This isn’t good for the rest of us, but there you have it.

Atypically, our first “over there” comparison will begin with a post that originated in Alabama with “Dr. Dalai” in the southern United States. You can read it here, right now.

Categories : Hellth Across The Pond

Archive for Hellth Across The Pond

Learning the Wrong Lesson

Gonna Wash Those Germs Right Out O’ Your Chair?

How Can We Apply “First Do No Harm” to Government? – Part I

Pay-for-Performance And Other Healthcare Policy Delusions, Part 2

Our Crystal Ball “Across the Pond”

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