Saturday, May 27, 2006

To see what P4P is really all about, look at the Seattle Blue Shield experience

The May 26, 2006 posting on Health Care Renewal references a news report on the "quality" and P4P acitvities in Seattle.

As critical as I have been on the P4P issue, the reality seems even worse. In this case, according to the news report,the carrier dropped about 500 physicians from their plans by a secret quality assesment process (using biling records apparently), and sent letters to 8,000 patients telling them their docs were delisted because of quality and efficiency issues.

As an aside I would like to know why this is not libel per se or at least ordinary libel.

But that is not my main point. The following is:

If the physicians who advocate accepting P4P such, as the leadership at ACP, believe that P4P is or will be about thoughtful, well intentioned physicians agreeing on scientifically established quality indicators and compliant physicians being rewarded for showing they comply with them, I cannot help but believe they are either naive or disingenuous.It will be and-as in the Seattle case- already is about saving money and controlling physicians.

It was about a year ago that I blogged about the egregious "performance" program initiated by United Health Group in St. Louis. That program also had no resemblance to the features of a "good " P4P program that the AMA envisioned and was harmful to physicans and patients alike.

Physician groups who advocate P4P argue that if we do not work with the third parties to make the rules, all the rules will be made by them. The Seattle and St. Louis experience-as well as the entire managed care saga-tell us clearly the third party payers will make all the rules anyway.

Thursday, May 25, 2006

Presumption seems to be Doctors will not do right by patients unless....

Dr. Philip R. Alper's "IM Insights" appearing in "Internal Medicine World Report" monthly continue to be packed with insights born of thoughtful consideration of years of experience. In the April 2006 issue, he discusses " Will the Real Patient Advocate Please Step Forward?"

He recalls from his days of Internal Medicine training in the 60's that the internist was the person who provided "effective and comprehensive patient advocacy that activity being a "cardinal characteristic that set internists apart". Now it seems that numerous voices are telling us that decisions about care that may have previously been a joint effort made the physician and the patient are too important and too likely to be handled badly by the physician to be left in their hands alone.

Now, that advocacy role is being eroded away by several forces, one of which is the multiplicity of entities that all proclaim the need for such advocacy and self proclaim that role for themselves. In the rhetoric of many such advocates the presumption has become "The doctor will not do right by the patient unless other agents intervene "

Who are these advocates and what energizes their activities?

Well, almost everyone, but the most visible and vocal are :the Institute of Medicine,AARP,and the HMOs and insurance carriers and even the American College of Physicians but motivations of various members of this diverse list are not all the same.

Alper asserts that a " kind of blame game " is being played by the carriers.When their,at times, blatant denials of care evoked the ire of the public they backed off a bit shifting to more patient cost-sharing and blaming the high cost of medical care on "poor quality". Patients were not getting good value for their money and of course it is the physician who largely provides that care.It would follow that someone must oversee and manage the physician's care because left to their own devices docs will crank out poor value care.Audits, guidelines,pay for performance (tipping the docs for doing a good job)are,in this view, necessary to protect the patients from the default position of poor quality which physicians typically deliver unless third parties intervene to protect the patient.

Managed Care is a major force in all of this on several levels.On a practical level the time crunch physicians face leaves little time to be an advocate in many situations.More broadly, Managed Care's "quality movement" may well function as a more sophisticated "denial of care"-saving money under the rubric of convincing everyone they are improving care.

The model of independent individual physicians providing care to individual patients is antithetical to those who are strong advocates of a single payer system.A quality gap is a concept they might embrace. A crisis is great opportunity to bring about change.

There are many thoughtful,dedicated physicians who sincerely want to improve care to patients and whose motivations are not those of the insurance carriers which is to save money. There are many aspects of medical care in this country ( and every country) that could and should be improved. Working to do that is not always motivated by the cost containment model but at least some of the rhetoric of "patient advocacy" and "quality" is motivated by exactly that desire. Also, some of that rhetoric is driven by a desire -for whatever reasons- to replace what remnants of fee-for- service medical care by independent physicians still exist with a system less sympathetic to the individual and more attuned to notions of social justice and public health.

How did a profession historically dedicated to the premise of doing the right thing for the patient find itself constantly apologizing for what it does and being blamed largely for being responsible for what is being characterized as crisis in care? Why are we accepting that blame? Why do we not hear of a crisis in legal representation, in the services rendered by architects,contractors, or even car salesman and roofing companies?

Monday, May 22, 2006

According to ACP, Quality initiatives takes time and money and (so far) no reimbursement

The ACP observer-an American College of Physician's monthly newspaper format publication- has a section called "Measuring Performance"

The May 2,2006 presents the reader with anecdotal material about several internists' efforts to "close [various] quality gaps".

One internist is said to have spent an estimated $15,000 to increase the number of her diabetic patients getting the recommended annual ophthalmologist eye exam. They finally "solved" the problem (at the beginning only 35% of her patients received the exam annually) by having her office call the eye doc's office and make appointments for all 2,000 of her diabetic patients. At 15 k per project you have to wonder how much quality this physician can afford while waiting for the P4W repayment for her efforts down the road.

Other physicians' efforts are described in the article including the experience of one physician whose practice not only had to foot the increased overhead bill(s) of quality project(s) but two physicians left the practice because they were unwilling to accept the higher costs of running the practice.

The quality issues described in this article and the ones often discussed seem to be those related to patient compliance,for example, patients taking their aspirin everyday, patients getting their colon cancer screening, etc. I have a problem accepting the concept that there is a quality problem with physician's care in the circumstance wherein the patient -for whatever reason-does not comply with the advice. How far does one have to go to maximize compliance? Is there at some point a tension with the concept of patient autonomy and respect for patient's decisions? Do patients have to be monitored like children to be sure they are taking their vitamins ? Are we moving towards a version of extreme "paternalism", with a new twist -the twist being -"not only do we know what is best for you we going to check up on you to make sure you do it?

The article says "Until reimbursement becomes a reality,quality improvement efforts can cost more that they can yield financially" As CMS and third party payers continue to decrease reimbursements,ACP's solution,in part, seems to be to encourage internists to spend money on quality projects that may be reimbursed someday and for which we still await evidence that it all will really improve patient care.

The "lets narrow the quality gaps" movements is part of the ACP's scheme to salvage internal medicine. Their own publication's article about the grass root efforts along those lines is more likely to discourage than energize private doctors to join the effort. Bottom line losses have to impact decisions. On a more fundamental level, I believe labeling these simplistic projects based on some organization's arbitrary "quality target" as improving quality is flawed. The author quotes a IM residency quality project involving encouraging diabetic patients to have an annual foot exam involving in part having "a colorful brochure in the waiting room with tips of what to ask the doctor".

I cannot help but remember when being an internist was more about having the skills and dedication to take care of patients with complex (and simple) medical problems than having colorful brochures in the office exhorting patients to do the preventive medicine measure of the day.

Thursday, May 18, 2006

'Other people's money" and the moral costs of managed care

Dr. Patricia Illingworth is an associate professor of philosophy at Northeastern University and holds a PhD and JD degree. Her writings express well the observations that are commonly made by physicians about the world in which they live and work which is dominated by managed care.

Medical care came to be "managed " by the managed care sector because of the concept of "other people's money". To a large degree individuals pay for only a portion of their health care the remainder paid by either employers or the government. There was little issue made by these other people until the costs of health care rose to some threshold above which employers and other third party payers including CMS thought costs were getting out of hand. Then entered cost containment via the various cost savings actions of managed care.

Dr. Illingworth believes that the modification of the traditional fiduciary duties of physicians to patients by the duties of the for-profit corporation vis-a -vis shareholders is the root cause of many ethical problems generated by managed care. Basically the HMO strives to make money or save it and they introduce mechanisms to control physician behavior to that end even if that control involves abrogation of the fundamental duty of the doctor to place the patient first. The efforts of the HMO in that regard weaken the physician-patient relationship and damage the trust element in the relationship.

In her recent book, Trusting Medicine: The Moral Costs of Managed Care she outlines her argument and it is reviewed in the May 10,2006 issue of JAMA. It is gratifying to read an academician express many of the same views you would hear in the doctor's lounge at your local hospital- that is if there still was such a place.

In a review of an article she wrote for Northeasten University Magazine she is quoted:

"Part of the problem is that some commonly accepted principles of business ethics are fundamentally incompatible with traditional medical ethics...

Dr. Illingworth says bluffing (holding back certain information), puffing (exaggerating) and spinning (putting the best face forward on undesirable outcomes) are part of normal day to day business practices but have no place in the physician-patient relationship where honest relationships are essential to good practice. However, physicians dependent upon managed care companies may be influenced and controlled to the extent that their behavior favors the company's bottom line more than the patient's interests in spite of the doctor's effort to swim against the tide.

As the reviewer in JAMA noted, President Bush listed as one of the goals for health care was to "strengthen the doctor-patient relationship". Has the doctor patient relationship eroded so badly that it deserves to be a topic in a State of the Union address ? Maybe so.The erosion of patient trust and the deterioration of the physician-patient relationship are, in my opinion, directly related to managed care. I do not see how the trend can be reversed as long as managed care companies continue to exert hegemony over physicians.

As is so many matters,I have no solution but I do not believe that as long as managed care entities exert their domination over practicing physicians that such things as electronic medical records, having docs audit themselves to see to what degree they adhere to selected guidelines and calling it all a "medical home" will restore the deteriorating doctor-patient relationship.

Wednesday, May 17, 2006

Economy Class syndrome and which of Virchow's mechanism (s) may be to blame

A recent JAMA article (the full text is available on line) from Great Britain sheds some light on possible mechanism (s) involved in the development of venous thrombosis in long haul air travelers. ( Long haul is usually taken to mean 8 hours or more.)It does this by failing to demonstrate evidence for an increased tendency of the blood to clot after doing extensive testing for relevant blood coagulation system changes including tests for platelet activation,fibrinolysis,and coagulation factor activation.

The issue-in part- has been if the reported association between long haul flights and venous thromboembolism (VTE) is due to prolonged sitting -at times in cramped conditions- or does the air travel induce some increased tendency to clot perhaps related to hypoxia and or decreased atmospheric pressure ( hypobaria) and , of course, both could be operative.

This study simulated air travel using a hypobaric chamber to expose some 73 healthy volunteers to hypobaric hypoxia for 8 hours Persons with either the prothrombin gene mutation (G200210A) or Factor V Leiden were excluded. The study design compared sitting for 8 hours with and without the impositions of hypoxic hypobaric conditions. No significant differences in the various tests of the clotting system were found.

It seems that every talk on VTE has an obligatory introductory section mentioning Virchow's triad of possible culprits predisposing to thrombosis; 1)damage to the vessel wall, 2)alterations in blood flow (stasis or turbulent flow) and 3) increased tendency of the blood to clot. This paper goes at least part of the way to shift the blame in economy class syndrome to the second category. This should encourage travelers to move around as much as possible on the long flights and might be a disincentive to take a sleeping pill and sleep for much of the flight. The rest of the current advice package-at least for persons at no known increased VTE risk is to keep well hydrated and avoid alcohol. Persons recognized to be at higher risk should use graduated pressure stockings and consider low molecular weight heparin pre flight depending on the level of perceived increased risk (such as those with a history of VTE).

It should be noted that persons with Factor V Leiden and or the prothrombin mutation represent a different situation.The editorial in the same issue of JAMA noted that some evidence of hypercoagulability has been noted in persons with those two inherited conditions with exposure to flight conditions. Whether they should be offered low molecular weight heparin is an issue about which experts differ.

Tuesday, May 09, 2006

How drug companies know what physicians prescribe

It seems to be common knowledge among practicing physicians that the drug reps know who prescribes what.That type information is thought to be important to big pharma marketing activities. However, I was ignorant about how all this works.

The Blog that Ate Mahattan (TBTAM) explains it and references an article in the NYT.

It seems that drug store chains sell that information to various data gathering companies that then merge the data with the AMA's physician masterfile. This the file that is generated by rank and file docs across the country filling out the AMA's form. The AMA sells this information to various entities including database companies that supply the info to drug companies so that the drug rep knows if you are really using whatever drug.

There are legitimate uses for the AMA data base base. For example, the black box "dear doctor" letters sent out by drug companies to warn of side effects or recalls uses this information. However, providing data about individual doctor prescribing habits to drug companies is not a legitimate use.

Go to TBTAM to learn how to achieve a limited opt- out of the drug reps prying into your business. The AMA is getting some deserved flak for this activity and they are trying to placate docs and still maintain their lucrative data selling business.

Sunday, May 07, 2006

Devotion,curiosity, hard work and the Midnight Meal

JAMA has reviewed a book that would probably interest senior docs who trained in the 60' and 70's particularly at a big city hospital. According to the review there is plenty of interest for younger one as well. The book is The Midnight Meal and other Essays about Doctors, Patients and Medicine by Jerome Lowenstein,an internist who trained at Bellevue and stayed on to teach there.I like to think that thoughtful physicians who have been doing it for 30 years or more have something to offer. His comments do.

I took my pulmonary boards at Bellevue (back when it was an oral exam) and much he has to say resonates with my memories of another big city hospital, Charity in New Orleans.

In his section on
"Can you teach compassion? ", he writes

"...teachers in medicine can only hope to facilitate the development of students or young physicians,challenging and stimulating them and acting as role models."

I know much of my development was influenced by role models.I can still remember much about those physicians in surprising detail many years later. The passage of time has made it very clear to me how important those role models were

The reviewer says " Devotion, curiosity and hard work were the messages of these teachers"

The messages I got from my role models also included respect for the patient,duty to do what was right for the patient,the obligation to know as much as you could because that may acutally save a life or mitigate an illness's effect.There was no message sent about going home at five o'clock and leaving the problems to some one else.

The "midnight meal" part of the book's title refers to a meal, leftovers mainly, served late at night to the docs on call.Charity Hosptial did that as well-we called it "Late Doctors" It was a good time to catch consultants (our paging system left a little to be desired). The late meal was often the highlight of a night on call. It seemed that way at the time but the real highlight was the incredible and intense opportunity to learn how to be a physician by taking care of real patients often late into the night under the tutorage of more senior (sometimes only by a year or so) physicians.

Friday, May 05, 2006

JAMA reviews book on clinical judgment-"phronesis"

There is a favorable book review in the May 3,2006 issue of JAMA regarding what seems to be a very interesting book titled How Doctors Think: Clinical Judgment and the Practice of Medicine by Kathryn Montgomery. Dr. Montgomery is a professor of bioethics and medical humanities at Northwestern University.

One of her main themes is that clinical medicine is not a science.Even though I wonder if that statement is a straw man (I have always considered science as only part of medical practice as is implied when we talk about about the art and the science of medicine),there are a number of insights quoted in the review-enough to motivate me to order the book.

I quote from the review:

"Rather than considering medicine a science,she proposes that it be conceptualized as a rational,science-using practice.She draws on phronesis-the flexible interpretive capacity that enables moral reasoners to determine the best action to take when knowledge depends on circumstances-to characterize physician thinking in the clinical encounter as interpretive practice. In clinical medicine, this interpretive practice is displayed as clinical judgment which enables physicians to combine scientific information,clinical skill, and collective experience with similar patients to make sense of the particulars of one patient's illness and to determine the best action to take to cure of alleviate it."

"Clinical judgment done well is the intuitive and iterative negotiation of the patient's narrative of illness...This focus come with experience"

Aristotle spoke of the virtues of the ordered mind as including sophia (wisdom of first principles),episteme (emperical knowledge, techne (technical knowledge) nous (intuition) and phronesis (practical wisdom or prudence).

The evidence based medicine era with its emphatic focus on episteme and techne may foster the illusion that good clinical practice can be encapsulated in guidelines and pathways and that quality lies in obedience to them but it is the blending of those elements of science and technique with practical wisdom that makes good practice.

While Aristotle may have been bit harsh on the young the following quote captures the thought well that the particulars must sharpen the broad outline and abstractions of the "universals" that might correspond to the general clinical rules or guidelines and give them operational meaning tailored to the facts at hand:

"Whereas young people become accomplished in geometry and mathematics, and wise within these limits, prudent young people do not seem to be found. The reason is that prudence is concerned with particulars as well as universals, and particulars become known from experience but young person lacks experience, since some length of time is needed to produce it."
(Nichomachean Ethics)

Wednesday, May 03, 2006

Another reason to distrust company sponsored drug trials-fraud

Health Care Renewal in its May 3,2006 posting quotes a Wall Street Journal article that reveals alarming information about one drug trial involving telithromycin(Ketex),a macrolide antibiotic recently incriminated in causing serious liver toxicity and one that has been heavily promoted in various free "educational" publications and talks by infectious disease "thought leaders".

Physicians have probably to some degree become accustomed to looking more carefully at drug trials-when they have time to do it-to watch out for the usual bag of tricks, such as comparing the highlighted drug with an inadequate dose of a comparator drug. However, presenting outright bogus data-such as fabricated "patients" is a different level of egregious behavior.

HCR calls attention to the role of a contractor company,Pharmaceutical Product Development,INC (PPD) that facilitates and organizes -among other things-drug treatment trials as the most blatant culprits in this saga were private practice docs.

The story in a nutshell is that at least two of the private physicians taking part in the trial apparently fabricated data. Questions arise regarding the adequacy of oversight by both PPD and the contracting Big Pharma company, Sanofi-Aventis and the FDA conduct in the approval process will likely generate criticism as well. One of the doctors who ran a weight control practice somehow managed to enroll 30 new patients a day (the patients were supposed to have a respiratory tract infection requiring antibiotic therapy).The physician was subsequently convicted of mail fraud in regard to her activities in this trial.

As the investigation unfolds we will likely hear from both PPD and Sanofi-Aventis that they did everything according to the usual rules of research conduct but the bottom line seems to be that a drug was approved by the FDA and data from a very flawed trial may have been used to attest to its safety.

Randomized clinical trials (RCT) may be able to serve us well in the setting of determining the efficacy of a drug but the label of RCT on a publication does not tell us anything about the integrity of the data which in this case seems corrupted by fabrication. Fraud, lying and cheating may be harder to detect than statistical slanting of the data.


To me,the worse part of this sad story is that the most flagrant behavior was exhibited by private practice doctors.

Annals Internal Medicine letter" Seasoned internist blames Academic Medicine for much of internist's crisis

In the May 2, 2006 issue of the Annals of Internal Medicine, Dr. Ashok V. Daftary in a letter to the editor blames academic medicine for much in the unfolding saga for the demise of internal medicine.

He writes:

"Academic medicine is the carpenter that fashioned the coffin of internal medicine.Instead of reengineering internal medicine to accommodate changes, it cannibalized the discipline by reducing its worth, creating the hospitalist and ambulatory care internist. These were both nails that helped seal the coffin; the former reduced the influence of the internist in the acute care environment and the latter blurred distinctions between internists and those without medical degrees who practice in the ambulatory settings."

"...absent an identity, the internist's only remaining role is thought to be that of provider of ambulatory care to chronically ill whose medical problems are beyond procedural intervention and lucrative compensation."

I do not know the relative contributions of academia and managed care to the birth and growth of the hospitalist phenomenon but my default position is to always blame managed care. The "follow-the money" rule does not always lead to the right answer but that it where the smart money bets. I think at most some academic and "thought leader" internists were complicit.

I believe, though, that the recommendations to change the IM residency program to allow (or encourage?) the third year residents to opt to do more in patient or more out patient training-based on their future plans will only make worse the schism betweeen the hospital internist and the "officist" and do little to lessen the increasing fragmentation of medical care. And the idea that an IM resident could do the training, opt to be a office doctor and never -after the residency-take care of patients with complicated serious ilnesses in the hospital is so contrary to what a internist is (used to be ?) all about.