Friday, November 30, 2007
In a few hundred words you will learn what the Relative value scale of physician payments is all about, a thumbnail description of how it works and more importantly of how conscientious physicians trying to do the right thing by their patients and not be charged with fraud are complicit with their own ultimate professional demise.
Everyone also needs to read this entry by HH and this commentary by DRRich to tie all the pieces together. As long as physicians simply play the government's game they cannot win.
Wednesday, November 28, 2007
In this entry Dr. Brody suggests that the fancy dinners at trendy eateries given by Big Pharma companies are more to reward the speaker than to influence the audience. He talks about what happened in Minnesota where legal constraints exist regarding how much can be spent per doctor per year by drug companies. Of course, if the docs in the audience pay any attention at all to the slides prepared by the "medical education" company or the words of the speaker, all the better. He suggests the talks are basically to reward ( bride) the speaker who is a high prescriber of the medication being lectured about at the talk.
I find it a bit hard to believe that this makes economic sense.Some speakers makes 75K or more per year. How much Lipitor ( or whatever) could one doc prescribe to make that worth while. I have noticed ( yes, I have accepted invitation to a few of these dinner) that many of the attendees are retired docs, nurses and pharmacists so Dr. Brody's comment that the room could be filled with cardboard cutouts and the sponsoring company would be as happy may not be too far off the mark.
Monday, November 26, 2007
Carlat is a practicing psychiatrist who writes an excellent blog dealing largely with psychiatric medications and critically analyzes clinical trials with psychotropic drugs. (There are a number of blogs dealing with that general topic and if a small fraction of what they say is true, you would probably never prescribe or take psychotropic medications.) His NYT article deals with several issues that I tend to harp on time and again in my blog including:
1 The idea that meta-analysis MA) should not be placed on the same pedestal in the hall of evidence based medicine (EBM)that houses the randomized clinical trial. They should be considered "observational " studies in which the subjects are trials and can rise or fall based on what studies the author includes and what summary statistic(s) the author chooses to use. And, of course, if the RCTs that comprise the MA are flawed the MA will be mega-flawed. I have written about that issue before here. As illustrated in Carlat's article, a MA presented by someone with appropriate academic credentials can be quite persuasive and such a presentation at a company sponsored training program was one of the major elements in the argument that convinced ( at least for a while) Dr. Carlat that Effexor was superior to the SSRIs .
2.Drug companies (or anyone for that matter) can stack the deck and cook the books of RCTs so that the efficacy of a given drug is put in the best light and the adverse effects minimized.As time went on Dr. Carlat became more aware of the deficiencies in some of the RCT which were used to support the position that Effexor was superior to the SSRI family and became more concerned with the hypertension and withdrawal symptoms that are associated with Effexor use.
3.His article refers to events that provide examples of how the tenets of EBM and the desire of physicians to have better treatments can be and are perverted .
Dr. Carlat was recruited by Wyeth and invited to their training seminar replete with various perks and cash payments to learn how to promote Effexor by visiting practicing physicians offices and educating them about the medication's purported superiority in the treatment of depression.
His article describes his gradual disillusionment with the arguments supporting Effexor and his activities and his decision to quit. He deserves much credit for admitting what happened and I admire his courage.
There is so much in the article that makes one feel bad about the medical business and the role that physicians play (as drug salesmen and sometimes as those who should know better when a salesman comes to call, and the AMA whose role in making money by allowing drug companies to have access to physicians' prescribing patterns-that still boggles my mind). This is not what I thought being a physician was all about. I cannot believe-as the article claims-that 25% of physicians act as drug shills one way or another , but if the number is even one tenth of that, I feel ashamed. On the other hand if you read this post, maybe 25 % is not too far off.
In the interests of holiday cheer, let me interject a positive story ( at least positive in regard to the actions of some retinal specialists).Go here for the tale of two drugs and the treatment of wet retinal degeneration and how the eye docs seem to be doing the right thing while the drug company...
The whole initiative is based on reductive linear reasoning that views the body as a machine and assumes that a standardised treatment will produce an equally standard unit of beneficial outcome. However, any practising clinician knows that the same treatment applied to two people with the same diagnosis can produce very different outcomes. Complexity theory suggests that the body is more usefully regarded as a complex adaptive system, characterised by rich interactions between multiple components that produce unpredictable outcomes. This analogy makes much more sense of clinical experience. Psychological states and social contexts exert measurable effects on the functioning of the body. Standardised treatments ignore all of this.
The purveyors and apologists of P4P will not, for the most part, be convinced either by cogent arguments or empirical data showing the harm in such programs.They are not about doing good or really promoting "quality" -in the good care sense of the word- They are about control and the purpose of controls is to spend less money and/or make more money or as Dr. Fogoros puts it, it is about covert rationing.
Thursday, November 22, 2007
Now we see this news item in which we learn that physicians were paid to switch from a brand name drug to the cheaper generic. According to the news report some doctors in Michigan were paid $100 by Blue Cross for each patient they switched from Lipitor to a generic drug. A news release from the AMA warns physicians that this or similar activities is illegal.
More and more we witness the downward spiral of physician's ethics and pride.
Wednesday, November 21, 2007
The major cause is decreasing take home pay. This plus increasing third party requirements and mandates and the threat of malpractice and the perceived greener pastures of the non primary care branches of medicine add up to the perfect storm.
And the cause of the decreasing take home pay is the system of CMS payment fee schedule. What follows is a description of how the price controls on physician's fees are implemented. In 1992 the RBRVS was put into place allegedly to mitigate the payment gap between procedure type docs and those who just see patients. Over the past 15 years it seems to have had just the opposite effect.
These price controls seems to have disproportionately impacted the income of the primary care sector. Until recently I was not ware of the role the AMA and a group known as the RUC played in this story. The AMA web site give a rather sterile and uninteresting rendition of who and what the RUC is. It is a group that gives advice to CMS about the details of the price controls.According to the JAMA commentary, their "advice" is put into motion about 80 % of the time by CMS. The committee is disproportionately represented by surgical and other non-primary care physicians. Of the 30 members, 27 have no term limits and the meeting are not made public.The proceedings are said to be proprietary (the AMA owns the CPT (current Procedures and Terminology to which the RVU ( Relative Value Unit) systems is linked.)
"All animals are equal but some animals are more equal that others."
So the story seems to be that the "remedy" set up in 1992 to make more equitable the payments from CMS to procedure and non procedure physicians has been largely controlled by a group of physicians who do procedures and the gap between the two broad groups has now so widened that there is now much scurrying to leave a sinking ship.
To summarize and embellish. There are wage controls on physicians fees. These are implemented by CMS with advice and consent from a procedurist dominated, AMA sanctioned group, the RUC. The third party payers follow suit. Wage controls lead to shortages (of primary care docs who are disproportionately impacted ),poorer quality and increased waiting times. Every year the AMA goes to Congress to plead, beg and weakly threaten them to not cut the overall CMS funding by as much as proposed. This dysfunction "system" is not going to correct itself.
I make no claim to the "answer". One approach that resonates in my libertarian consciousness is that made by the American Association of Physicians and Surgeons. The following is copied from their website. It is basically an escape route away from the wage controls and favors individual choice over the current command and control arrangement.
“FREEDOM FOR PATIENT AND DOCTORS WILL MAKE A DIFFERENCE.
H.R. 580 Seniors”Health Care Freedom Act of 2005, and
Say “NO” to Government Cookbook Medicine
“We oppose the various bills playing with the Sustainable Growth Rates (SGR), such as HR 3617, HR 2356, HR 1162 and S. 1574. Instead of changing the SGR, we support H.R. 580, the Seniors’ Health Care Freedom Act of 2005” that would allow the use of private contracts under the Medicare program. This is a win for patients, doctors and taxpayers as well.
“Our survey shows that 63% of doctors would be more willing to treat Medicare patients if unrestricted private contracts were allowed. Patients could pay doctors more than Medicare allows if they think the service is worth it. It would be up to the patient.”
I know ,the chances of something like that passing have to be slim to none and as Dan Rather was fond of saying, "slim just left town."Still it is good to dream of the day when physicians could join the other professions (lawyers,accountants, dentists, veterinarians,etc) who do not go to Congress every year to beg for crumbs.
Monday, November 19, 2007
What interested me and the author of the blog Health Care BS was that this is labeled a success. Labels are important and they have been used expertly in the medical care universe of discourse. The label "managed care" was a PR and propaganda home run. Who could be against care that is managed? The accurate label "rationed care" would not have flown.
The term "Medical home" cannot but evoke mom and apple pie. However, the version of managed care/P4P/control-what-the-doc-does that United Health Care has kicked off is anything but that. I have fumed about that before.
It seems that in Massachusetts, not everyone who is mandated to buy insurance has and many people who cannot afford insurance have signed up for a free health care program. I am not sure what part of this is a success.
Health Care BS quotes George Orwell. Here is another quote from Orwell.
Political language... is designed to make lies sound truthful and murder respectable, and to give an appearance of solidity to pure wind.
Sunday, November 18, 2007
But from time to time my cynicism of the medicine business ( I remember when it was a profession) fades away at the sight of a thing of beauty - a mind boggling piece of clinical research that I can appreciate all the more after years of grueling study and practice . Here is reference to a project that demonstrated that nursing home patients who have trouble seeing do better when they get glasses that help them see. Who would have thought?
And- in the same week, we are treated to a research paper that demonstrated that when clinical trials are done and/or sponsored by a drug company, sometimes the materials is presented in such a way as to put the drug in question in a favorable light. Here is a review of that publication.
The shocking revelations continue.We are also informed that (see here for a review of the research involved) that college students engage in binge drinking, participate in sex that is often unprotected, spend much time on the computer not doing homework and often stay up late. A likely future project is rumored to be investigating if college students call home for money.
Friday, November 16, 2007
I was not the only one taken back by comments on the beta-blocker peri-operative mortality morbidity issue
Wachter enlisted the comments of his colleague, Dr. Andrew Auerbach who, in regard to the study that demonstrated increased risk of stroke from peri-operative use of beta-blockers said in part"
"So I agree with Bob – it wasn’t unreasonable to include them as a quality measure at the time. We were wrong, but at least we are in good company (can anybody say estrogen replacement therapy?). "
That comment may appear to be more flip and radiates more hubris than was intended . There is nothing flip about a stroke. Being in good company will do little to improve a hemiplegia or aphasia and I am sure Drs. Wachter and Auerback would not belittle the seriousness of the unfortunate events that seemed to be more common in the beta-blocker treated group.
Quality measures to a greater or lesser extent often drive care and influence the way physicians care for their patients. If a physician should exert great care in deciding what to do for an individual patient it would seem a greater level of concern and contemplation should be expended in writing "rules" that will influence the care of many patients.
I do not mean to imply that physicians who author quality rules take their responsibility lightly but events such as the beta-blocker saga should perhaps make us insist on a very high standard of proof of efficacy and safety be shown before we presume to tell others physician what they should do particularly when those rules are "enforced" by economic carrots or sticks. Further when an intervention is to prevent something, i.e to decrease the risk of a bad outcome, the level of certainty should be higher than in the circumstance when the physician is treating a certain medical condition. In a seriously ill, patient you often have to act, even to use treatments that lack super solid proof or efficacy; when you are in the prevention mode, you had better be more sure.
The individual docs not only have a fiduciary duty to do what it right for the patient but they are held to a legal duty.
The individual physician deals with the stroke patient and has to answer to him and the family, and perhaps to the family's attorney while the quality rule writers have to answer to whom. The individual physician strives to do what it the right thing for his patient and hopes that what he does is right, the quality rule makers seem presume to know what is good for everyone. Obviously, they frequently do not.
Thursday, November 15, 2007
The push-come-to-shove-day is almost on us and this report indicates there are about 100,000 souls still uninsured. About one half may have incomes too high to qualify for state subsidies, but at this point no one is really sure of the numbers. More details can be found here. It seems that there is a contingent of healthy young men who don't want to spend there money on health insurance. It is time for the health insurance police to mobilize and make these people get insurance. We know how effective the state is in making people have insurance.
I have lived in two states with mandatory auto insurance. I was involved in two minor accidents , one in each state. As luck would have it, in both instances the other party did not have the mandatory insurance. Fortunately, I had on my policy a provision known as "coverage for uninsured motorists". Now why would such coverage be offered?
The insurance mandate idea reminded this Business Week contributor of the story of King Canute who tried to stop the rising waters by commanding the water to roll back.
Wednesday, November 14, 2007
I have seen so many Journal supplements that are poorly disguised promotions for certain medications or classes of medications that when I see a supplement I cringe, but the April 2007, volume 120 Supplement of the American Journal of Medicine seems to be different( although I don't rule out the possibility that the issue is promoting something or other since a major drug company sponsored it.) I have become very cynical over the last two years.
This is on a topic near to my heart, the heterogeneity of treatment effects (HTE) which I have written about before,highly recommending a landmark article in the Millbank Quarterly,which I think is no longer available on line.
The editor of the issue is Dr. Sheldon Greenfield from UC-Irvine School of Medicine. He presents an important editorial and co-authors an article with Dr. Richard Kravitz, also from UC-Irvine, who was the lead author on the above referenced Milbank article. I believe if you go to www.amjmed.com and register you can obtain the AJM supplements for free.
The major points made by Greenfield in his editorial are:
He asserts that there are 2 evolving phenomena that "impair the ability to develop guidelines, payment rules and quality of care measures based on randomized clinical trials (RCTs)." They are:
First,there is now a broader spectrum of illness severity included in trials . That is, more patients with less severe illness who will be less likely to favorably respond to an agent than the more seriously ill patients.This results in less ability of the trial to detect a true difference.
Secondly, RCTS typically exclude patients with multiple chronic diseases,
" Only to have findings subsequently generalized from young trial-eligible patients to these older,complex patients whose mortality from comorbid conditions reduces treatment effectiveness."
So, on the one hand more false negative trials and on the other hand, trials with less external validity which may be used anyway to make quality rules for groups of patients who may differ markedly and in important ways from those patients who took part in the trial.
More and more decisions are taken out of the hands and minds of the individual physician and the individual patient and determined by third party rules which in turn are increasingly "enforced" by the devilish P4P system. The work of Kravitz, Greenfield and others make it clear how flawed RCTs can be and it follows that rules and rule-derived payments to physicians based on these RCTs can result in clinical mismanagement and harm to patients.
So we can look forward to more quality rules that , in one sense, backfire and which will be enforced by the powers inherent in the economic hegemony that third party payers enjoy over physicians.
I have written about physician's spiraling downward pride and ethics (now known as professionalism) before as have others. Many hospitalists and emergency physicians are either employees of a hospital or are contracted with a hospital. When such things as the four hour rule and give almost everyone peri-operative beta-blockers become institutionalized as quality indicators it is not difficult to imagine the position a physician find herself if she dare object or worse refuse to play by those rules.Accusations of being a disruptive physician may be hurled and what happens to employees who do not play by the boss's rule.Of course, it is not just ED docs and hospitalist impacted by these rules and their enforcement mechanisms and not just those whose pay checks comes directly from a hospital. I still believe that physicians still want to act primarily in the best interest of their patients and many times still do but it gets hard and harder to continue to do so.
I am reminded of the old saw version of the Golden Rule (He who holds the gold makes the rules) . The economic reality of today's medical practice makes it harder and harder for the physician to act in the fiduciary interest of the patient and this is all the more bitter as we become more aware and educated in the foibles and weaknesses of the "knowledge" base on many of the quality rules allegedly derive from.
The blogger, The Happy Hospitalist, in his recent entry "Dr. Government Vs Littol Sally" and those who posted comments all sound the note that the good physician is the one who can determine when it is appropriate and in the patient's interest and when it is not to go with the guidelines. The constraints, incentives and feedback that physicians face constitute a practice environment that could not be less conducive to "dong the right thing".
Thursday, November 08, 2007
The preliminary autopsy findings did not reveal a cause.
According to a very good web site on sudden death in athletes which is actually entitled "Sudden Death In Athletes",The top three causes are Hypertrophic Cardiomyopathy (HCM)-26%, Commotio Cordis 20% and Congenital coronary artery abnormalities 14%. He was not struck in the chest and Anomalous coronary artery would have been noted on a gross autopsy but according to Dr. Douglas Zipes, a spokesman for the American College of Cardiology, differentiation between HCM and a very hypertrophied "runner's heart" can be difficult. At 5 miles into the race on a cool day there would be no reason to consider hyponatremia in an elite seasoned distance runner. I assume a cranial exam was done and no cerebral aneurysm was detected. So what is the answer? In some well publicized cases of athlete's death the answer was never made clear.
Two well known cases of sudden death during an athletic event,both leading to legal complications and controversy, were the deaths of Celtic basketball player,Reggie Lewis, and college basketball player Hank Gathers in Los Angeles. Apparently neither HCM nor anomalous coronary artery were the cause in either death which were surrounded with charges and counter-charges regarding how early symptoms were handled in these very "valuable"athletes.
In Italy, where the cardiology community is quite involved in screening athletes for potentially lethal cardiac conditions,an entity uncommon in the U.S. is said to be much more common namely, arrhythmogenic right ventricular cardiomyopathy (ARVC), a good discussion of which can be found here. The most common EKG finding is inverted right sided t waves, but this is also commonly seen with the benign incomplete RBBB pattern.A notch on the downstroke of the right precordial QRS complex is sometimes the tip off. In Italy, routine EKGs are recommended but that is not the consensus in the U.S. The Italian cardiologists have offered evidence that their evaluation which include EKGs have saved lives.
Shay's father has talked to the press and indicated his son had a history of "enlarged heart" as early as age 14 but he had been evaluated in the past and more recently and was given the OK to compete .
There have been rumblings for some time that the rush to use beta-blockers to reduce cardio-vascular mortality and morbidity during and after surgery was ill advised.The rumblers now have a more convincing argument.
Dr. P.J.Devereaux reported the results of the POISE trial, which was an drug company randomized trial of over 8,000 patients, aged 45 or over undergoing noncardiac surgery and who had or were at risk for arteriosclerotic disease. The treatment arm received metoprolol 2 to 4 hours pre-op and had the medication continued for one month after surgery.
There was a decrease in nonfatal MI ( 3.6% versus 5.1%) but there were more strokes in the beta-blocker group ( 1.0% versus 0.5%) and a greater total mortality in the treatment arm (3.1 % versus 2.3 %),
I have suggested before that quality measures may be hazardous to your health in regard to the four hour pneumonia rule. This may be an even more glaring example. I submit that in the rush to infuse "quality" into medical practice we may have codified a practice, that may generate more harm than good, (I am sure folks will argue over that) based on far less than convincing evidence.
Wednesday, November 07, 2007
Current issue of Mayo Clnic Proceedings critical of ED docs handling of vertigo and current diagnostic paradigm
Part of his approach is incorporation of the widely used classification proposed in 1972 by Drachman and Hart in which four categories are outlined.
non-specific, or lightheadedness ( what Samuels calls "true vertigo")
In the Nov. 2007 issue of the Mayo Clinic Proceedings, several authors are rather critical of the manner in which ED docs approach and manage vertigo patients. (Full text is available after registration on their site).
The editorialist comments that ED doc training seems lacking in neurological matters and in his analysis of a number of missed diagnosis of cerebellar infarction that histories were incomplete, neurological exams were inadequate and there was undue reliance on CT scans. I would like to hear what ED docs think of that ( if any read this).
One article suggested that the emphasize on "quality of symptoms" ( which is basically over emphasizing the above mentioned classification) may lead to missing diagnoses, the most important of which is cerebellar hemorrhage which in some instance is treatable by surgery. So not only are ED docs (just ED docs?) accused of screwing up, the paradigm taught for years and used by many is also under attack by this multi-institutional cadre of authors.
In a rather complicated article based on a survey of 505 ED attendings and residents the authors ( it seeemed to require 12 authors to interprete the results) concluded that "the dominant paradigm...is the quality of symptoms approach ....the standard approach ..suggests a potential link to misdiagnosis".
I think they are saying that over reliance on a simplified approach to vertigo/dizziness may lead to missed diagnosis of brain stem strokes and cerebellar infarcts or hemorrhages. The simplified approach they think is being used involves the following thought chain: vertigo--->vestibular--->otolaryngology type cause. The reasoning I thought was applicable was vertigo--->vestibular or central (brain stem or cerebellar cause.) In other words, one has to differentiate between peripheral and central causes of vertigo.
What always bothered me was "Don't miss cerebellar hemorrhage" and to that end I think the following points are valid and helpful,some of which the Proceeding's authors make.
Vertical nystagmus within a single bout of prolonged vertigo almost always means a central cause.
Head motion or positional trigger of vertigo usually means peripheral BUT cerebellar stroke related vertigo can also be made worse by head movement.
The typical head CT done in ED does not rule out a cerebellar hemorrhage and MR may be needed.
If the patient is so vertiginous or disqulibrated ( probably not really a word) that he cannot walk you had better really worry about a cerebellar stroke.
Absence of headache does not exclude a cerebellar hemorrhage.
You really need to do a history and a neurological exam. Brain stem strokes almost always have other neurological findings-diplopia,cranial nerve palsies ,dysarthria, etc-but midline cerebellar disease may only have vertigo, nausea and inability to walk so intense is the disequilibrium.So absence of cerebellar signs-upper extremity- dysmetria,past-pointing etc-does not exclude a cerebellar stroke.
I blogged about cerebellar hemorrhage before here.
In that posting I referenced an article written by an ED physician who missed a cerebellar hemorrhage and with more than a little courage discussed in detail how it happened.
The Proceeding authors' thesis is, in part, that more emphasis should be place on the timing or duration of the symptom(s) and on the triggers. Perhaps so but whether or not their survey indicates a major and widespread defect in diagnostic reasoning is unclear. David Drachman in a 2000 Annals of Internal Medicine editorial said that the physician needs to evaluate vision,vestibular function,motor function and search specifically for certain conditions. In other words, evaluate the patient,try and make sense of clinical findings and search particularly for potentially serious and treatable conditions. Rigid adherence to his categories was never intended.
Drachman's decades old outline is just that, an outline, a reasonable broad category checklist to consider in the evaluation of the dizzy patient not a rigid algorithm that would use a patient's description of symptoms as a mechanism for premature closure.
Thursday, November 01, 2007
Sites that list in detail the physician recipients can be found on the Health Care Renewal blog. Perhaps the most striking payment was for over six million dollars to the head of orthopedics at Brighams and Women's Hospital. There were 21 instances of physicians receiving one million dollars or more from one manufacturer.
Certainly, physicians can perform various legitimate consultative activities for drug and device manufacturing companies and we do not know what the fees were for but the accusations of receiving kick-backs delivers still another blow to the prestige and reputation of physicians in general.
Earlier I wrote about the accusation of renal doctors receiving rebates for the use (and some would say the overuse) of erythropoesis stimulating agents in patients with renal failure. I have also commented on the accusation that oncologists were profiting from the in-office administration of chemo drugs and that such profit may have lead to the inappropriate use of such drugs. From my positive personal associations with renal docs and oncologists I had no reason to believe those accusations and did not want to believe them but some who commented to my blog believed otherwise. No doubt many in the lay community will apply the adage "where there's smoke, there's fire" to this most current revelation about money exchanging hands.
Several years ago my brother-in-law after paying $90 for his first month supply of Zocor commented that his physician was probably getting a kick-back from the drug company. I self-righteously told him that sort of thing doesn't happen. I am not sure what I would say now.