Tuesday, April 25, 2006

Grand Rounds

This week's edition of Grand Rounds, the best of the medical blogosphere, is up at Health Business Blog!

Saturday, April 22, 2006

P4P is Unethical

Point/Counterpoint on Pay-for-Performance is a fascinating look at the latest buzzword, P4P, pay for perfomance. Dr.Robert Centor of DB's Medical Rants faced off against Dr. Michael Barr.

On the face of it, who could object to P4P? A doctor will be paid based on his performance. The better the quality of medicine he practices, the more patients he saves and improves, the more he will be paid. Oh, wait, that's not what P4P really means. According to Dr. Barr, speaking in support of P4P, the physicians who will be most highly compensated are "physicians who are perceived to be delivering higher quality for lower cost."

I have been thinking about that phrase for several days, and getting increasingly angry. That's because P4P as described by Dr. Barr is fundamentally unethical.

First, an example:

If an oncologist treats 10 patients at a cost of $1,000 each, and 9 survive, he has saved 9 lives for $10,000.

Now imagine that a second oncologist treats 10 similar patients. The first 9 respond to the $1,000 treatment, but, again, the 10th patient does not. However, this oncologist refuses to give up and creates a new treatment regimen. This regimen fails, too, and the patient is hospitalized with multiple complications of his disease. On the next try, the oncologist comes up with a life saving regimen, and patient #10 lives. Of course, between the first failed attempt, the second failed attempt, the hospitalizations and the third successful attempt, an additional $10,000 has been spent. The second oncologist has saved 10 lives for $20,000.

Whose "performance" is better? Who should be paid more, the doctor who managed to save 9 people at a total cost of $10,000 or the doctor who saved everyone by refusing to give up and creatively designing new treatment regimens at a cost of $20,000?

Obviously, the second oncologist is the "better" doctor. However, I suspect that a P4P system would consider him less cost effective and would penalize him accordingly. In fact, they might penalize the doctor quite severely since he cost the insurance company double the "average" amount spent by the first oncologist.

The example above shows the perverse results of a P4P system which uses "higher quality for lower cost" as its benchmark. It is not surprising that such a system would deliver perverse results because such a system is unethical on its face.

The fundamental relationship in medicine is the doctor-patient relationship. Society and the law recognize this by privileging this relationship in comparison to other types of relationship. The doctor has a MORAL and and legal obligation to put the patient's interests and well-being above his own. Obviously, not every doctor will do that. There are some doctors who might recommend expensive treatments purely to enrich themselves. However, we understand those doctors to be unethical, and they may even be subject to legal action.

In dramatic contrast, however, P4P attempts to inject the insurer into the relationship. Even more objectionable, the insurer asks the doctor explicitly to balance the patient's interests against the doctor's financial interest. This is fundamentally unethical and should be banned as a result.

American democracy is a rights based system, not a utilitarian one. Ethically and legally, you are not allowed to violate a person's rights even if it will increase overall happiness or utility. Each person in a democracy is shielded from the power of others and the power of government by these rights.

Similarly, the sanctity of the doctor patient relationship is a moral right. Insurers are not free to violate it simply because it may free up money to care for others (or more likely to profit the insurance company). Furthermore, it is UNETHICAL for an insurance company to ask doctors to violate this patient right.

Doctors should stand firm on this important point. We should refuse to participate in any system that is unethical on its face and we should aggressively charge the industry with their ethical violations.

Tuesday, April 18, 2006

Commonwealth Fund Report corroborates patient dissatisfaction

A recent report from the Commonwealth Fund offers statistical evidence that patients feel they are not getting treated with respect.

Key findings from the Commonwealth Fund report "Mirror, Mirror on the Wall: An Update on the Quality of American Health Care Through the Patient's Lens" include:

"Patient safety: Among sicker adults, Americans had the highest rate of receiving wrong medications or doses in the prior two years... "

"Effectiveness: The indicators of effectiveness ... were grouped into four categories: prevention, chronic care, primary care, and hospital care and coordination. ... U.S. patients fared particularly well on receipt of preventive care and care for the chronically ill,... Across the indicators of effectiveness, the U.S. ranked first ..."

"Patient-centeredness: [S]urvey questions asked patients to rate the quality of their physician care in four areas: communication, choice and continuity, patient engagement, and responsiveness to patient preference... The U.S. ranked last on nearly all aspects of patient-centeredness."

"Timeliness: Germany and the U.S. stand out among the six countries in terms of patients with health problems reporting the least difficulty waiting to see a specialist or have elective or non-emergency surgery. Yet Americans, along with Canadians, were more likely to say they waited six days or more for an appointment with a doctor or had trouble getting care on nights and weekends... "

"Efficiency: Compared with their counterparts in other countries, sicker adults in the U.S. more often reported that they visited the emergency room for a condition that could have been treated by a regular doctor had one been available and that their medical records or test results failed to reach their doctor's office in time for appointments... On measures of efficiency, the U.S. ranked last among the six countries,.."

"Equity: The U.S. scored last on seven of the nine measures of low-income patients not receiving needed care and had the greatest disparities in terms of access to care between those with below-average and above-average incomes. With low rankings on all measures, the U.S. ranked last among the six countries in terms of equity in the health care system."

"Summary and Implications
These rankings summarize evidence on measures of quality as perceived or experienced by patients. They do not capture important dimensions of effectiveness or efficiency that might be obtained from medical records or administrative data..."

"On four of the six domains of quality of .., the U.S. performs relatively poorly from the patients' perspective. On timeliness, the U.S. performs about average. Effectiveness was the only measure on which the U.S. system performed slightly better than the five other countries, due largely to greater use of preventive care services and better care for the chronically ill..."

"The findings suggest that, if the health care system is to perform according to patients' expectations, the U.S. will need to remove financial barriers to care and improve the delivery of care. Disparities in terms of access to services signal the need to expand insurance to cover the uninsured and to ensure that the system works well for all Americans. Based on these patient reports, the U.S. should improve the delivery, coordination, and equity of the health care system."

Friday, April 14, 2006

Good reading

Head on over to The Health Care Blog to check out this comment thread. I have been spending a lot of time there lately, debating the issue of healthcare financing with administrators and others. Fascinating discussion!

Wednesday, April 12, 2006

Saving money: What is the effect on patients?

Everyone is talking about administrative decisions to save money on health care. What upsets and frightens me is that I see precious little discussion about patients and how the administrative decisions affect them.

The fact is that heathcare "administration" has made healthcare worse for patients. I'm not just talking about the administrative nightmare that is healthcare, although that is extremely burdensome. I'm talking about the fact that you can't get a nurse to help you in a hospital unless you are having a cardiac arrest. I'm talking about the fact that seeing patients more "efficiently" means spending less time with them, time that would be spent answering questions, consoling, etc. The patient experience is demonstrably worse, and we haven't controlled the cost of healthcare or increased access.

Shouldn't we insist that healthcare administrators view their decisions through the prism of ethics? Is it ethical for administrators to insist that patients be processed faster, leaving less time for physicians to answer questions or to simply console in the case of bad news? Is it ethical to decrease the number of nurses in a hospital and leave the patients to fend for themselves? Medical ethics is a broad field of study. Is there a similar field of healthcare ethics?

Sunday, April 09, 2006

Respecting research subjects

The recent debacle in drug testing, which nearly killed the 6 participants, has been attributed in large part to the greed of the drug company. They were so intent on developing a profitable new product that they ignored the possible devastating impact on the study participants. Such unconcern is not limited to researchers motivated by profit. There is always a tremendous danger that research subjects will not be treated properly and respectfully by any scientist undertaking human studies research.

I saw this up close and personally when a dear friend entered a phase two trial for an ovarian cancer vaccine. My friend had had surgical debulking for a presumed borderline tumor and completed 6 months of platinum based therapy. She wanted to do everything possible to prevent recurrence and when she learned of a study of a potential vaccine, she enrolled.

I read the consent for the study and did a little background research. The vaccine sounded promising and the study appeared to have the appropriate safeguards in place. One of the most interesting details was that the vaccine preparation elicited antibodies that interfered with tumor markers assays. Therefore, the test for CA 125, the primary test used to follow disease recurrence and progression, was rendered inaccurate in study subjects. They would be monitored with a special assay for CA 125 that was not subject to the same cross-reactivity. The cost for this assay would be born by the study.

My friend had an allergic reaction to the vaccine, and, of course, was not allowed to receive further doses. Shortly thereafter, a regular CA 125 assay was elevated, indicating possible recurrence. Her oncologist was aware that the vaccine might be responsible and asked the principal investigator of the vaccine study for access to the special CA 125 test. The investigator refused.

In my naivete, I could not believe that the investigator refused, so I called him myself. We had a very unpleasant argument. The principal investigator, an MD, claimed that he was not responsible for anything that happened to women who dropped out of the study. Yes, he understood that the elevated CA 125 assay might be erroneous, but that was not his problem. He would not spend study money for the special assay and he would not help me obtain the assay even if the patient paid. I cannot even begin to imagine how this doctor could manage to justify to himself that complications from HIS study were not his responsiblity.

The matter might have ended there, except that I know how human research studies work, and I reported him to his IRB (institutional review board). Within 2 hours of talking with the head of the IRB, I received a call from the vice president of the company that manufactured the vaccine. He was so sorry for any difficulty; they had already arranged for my friend to have the assay performed and would pay for all costs associated with it. Shortly thereafter, the head of the IRB called back to assure me that he had spoken with the principal investigator and had made it clear to him that this would never happen again to any patient in the study.

Unfortunately, there was no happy ending. The special assay for CA 125 was also elevated. My friend had a true recurrence and has stage IV disease; she has been undergoing a succession of treatments ever since.

I have tried to understand why the principal investigator refused to help. The most cynical explanation is that he was planning to delete my friend from the study altogether, so he would not have to report any adverse results. Yet I suspect that the reasoning was not so malign. It was simply that the investigator felt that so much good would come from testing and gaining approval for the vaccine, that nothing else mattered. That is why IRBs are so important. An IRB that is functioning properly protects that patients' safety, but also assures that the welfare of individual patients will not be sacrificed for the success of the enterprise.

Thursday, April 06, 2006

Going beyond "medical" care

Practicing medicine is extremely demanding and sometimes it seems that it is almost impossible to manage the medical needs of extremely ill patients, let alone the psychological needs. It feels like there is no time to delve into side effects that are not mentioned or to address questions that are not voiced. Rebecca Peterson's experience of her husband's illness and death remind us that addressing these needs could relieve some of the burden on dying patients and their families.

Rebecca Peterson's essay, accompanying a very moving article on NPR, offers insight into dying of a brain tumor. Stewart Sellman was diagnosed at age 48 and died within the year. The article describes his progressive deterioration and the impact on his wife and two school age children. It manages to capture the horror that contemporary cancer treatment can be.

Although Selman's doctors took excellent care of him medically, they left him to struggle on his own with the side effects of his treatment. His wife did not realize until later that her husband's bouts of mania and paranoia, which destroyed their home life, were known side effects of his treatment. Because she did not know, she did not think to ask the physicians for support and treatment to ease the symptoms, and because she did not ask, the physicians did not offer the information that these symptoms might occur and could be treated.

As Selman's wife, Rebecca Peterson relates:

... it would also be such a relief if health care professionals not only warn of possible side effects, but have a plan in place for remedying them. Further, it is incumbent on the health professionals to not ignore the behavioral aspects of treatment, especially in illnesses involving the brain. It is immensely difficult to tell a doctor in front of your loved that they are imagining things that didn't happen – especially if your loved one doesn't believe you, and in fact, Stewart rarely believed that his behavior was unusual.

Peterson's plea serves as a poignant reminder about why medical care is about so much more than "efficiently" applying medical knowledge.

Tuesday, April 04, 2006

Administrators are responsible for much of what is wrong with healthcare

The purpose of this blog is to draw attention to ways that physicians can improve the care of their patients. While roaming the blogosphere to find topics for discussions, I am repeatedly drawn into arguments with health care administrators. I suspect that this is because so much of what is wrong with medicine today is in part the fault of healthcare administrators.

For example, Matt Holt on The Healthcare Blog, claims that 30% of what physicians do is “waste motion.” The comments from both doctors and administrators are revealing. You can check out the full thread, but I have excerpted some of my comments.

On the charge by administrators that 30% physician action is “waste motion”:

.., if those experts you quote were willing to take moral and legal responsibility for their pronouncements, I'd be willing to consider them. If they are so certain, let their conscience bear the possibility of causing avoidable deaths.

… As long as I have to take moral and legal responsibility, though, I'd rather trust my own judgment than that of "experts" who are free to walk away from any carnage that they cause.


The medical system is so unbelievably broken that it is difficult for me to get my mind around it. If you don't think it's completely broken, then you haven't been a patient lately. I have witnessed 20 years of health care consultants and reform and "evidence" based medicine and I have seen medical care get worse and patient dissatisfaction grow, and the worst thing about it is that no one saved any money. They just took money away from the patients and gave it to managers and administrators and consultants who make no one better and save nothing.


… over the last 20 years of healthcare "management", the patient experience has deteriorated in every way:

1. The cost of healthcare has not gone down as promised; it has gone up, both in terms of insurance costs and co-pays.

2. The administrative hassle to patients has risen dramatically as insurance companies arbitrarily refuse to cover various items. Spent any time on the phone with an insurance company lately? It's a nightmare.

3. The doctor-patient relationship has been irreparably harmed by the inability to maintain a lifelong relationship with a provider, and the inability of the doctor to offer enough time to the patient.

4. "Evidence" based medicine has failed to affect the quality of care. Bad doctors don't need better algorithms; they need better judgment. All the algorithms in the world will not help if the physician can't make the right diagnosis.

5. The fate of the uninsured is worse in every way imaginable. There is less money for free care, there are more uninsured and the opportunity for many average Americans to obtain health insurance from an employer has declined.

6. Been in a hospital lately? The wheels are coming off of hospital based care. There are not enough nurses to properly care for patients and those who are working are compromised by excessive patient loads. On top of that, they send you home "sicker and quicker".

… administration of healthcare is a complete failure. NONE of the central goals of cost cutting, improved medical care and improved access to care have been achieved.

The fact is that doctors are still taking care of patients and providing value. Administrators are doing neither. If you are still focused on "waste motion", you might consider cutting out healthcare administrators, managers and consultants. I have yet to see any evidence that the patient experience is improved in any meaningful way by their existence.