Note this is a republication of an earlier version with a new headline and some introductory remarks..As pointed out by Bob Doherty in a comment to my earlier posting ( I am not sure that comment will survive this editing but that reflects my lack of mastery with blogger rather than an intent to silence his criticism) that the earlier headline was "demonstrably wrong". It said " The American college of Physicians endorses independent NP practices." To avoid misleading anyone I should have said what the current headline says namely that ACP has endorsed a house bill that does allow NP lead medical home practices.The ACP does not endorse NP lead practices in general only in the context of what is outlined in the house bill, ie in the context of the medical home practices.. Although my earlier headline is arguably technically accurate, it could be misleading and I hope my correction will satisfy Mr. Doherty's concerns. Judging from comments on Bob Doherty's blog I am not the only internist who has serious concerns about the issue of ACP going along with this element of the House bill and the ACP's support for what they do support is bad enough without me implying they are endorsing something worse. So here is the rest of the posting without any changes.
The American College of Physicians is endorsing a bill before the house that would enable NPs to practice independently in the context of the ACP sponsored "Medical Home". Further they seemingly welcome the opportunity to take part in a contest using certain quality measures to see who is the better provider.The bill,HR2350,can be read in all of vagueness and details yet to worked out here.
Go here to read what the ACP's man in Washington, Bob Doherty, has to say about how real practicing internists should enthusiastically get on board and strive to follow the appropriate quality driven guidelines to prove to the world that an internist provides better medical care that a RN with an extra two years Master degree that qualifies him as a NP.
Doherty says that the leaders of the ACP are endorsing this proposal because they are so pleased with the other elements of the bill, which include more training slots for general internists and some very modest increases in reimbursements from CMS and it furthers promotion of their highly touted Medical Home proposal. With these and other elements in the bill they are willing to endorse it even though the NP provision "goes past" what they had previously supported.
Doherty argues that if internists really were confident in their superior training they would welcome the opportunity to show they are better than folks with significantly less medical training. They should relish the opportunity to play a game even those it will likely be with rules that not disclosed (those devils in the details will be worked out later) and are likely to be written by folks who may well have an agenda which would be well served by either a victory for NPs or even a tie, which would also be a victory for the NPs . Go to the proposed bill and see if you can find what will be the rules of the comparison game between doctors and nurses.They are to be worked out later. So we should agree to a contest with rules to be worked out later?
Go here to read from the virtual pen of DrRich of the situation facing the general internist and his views of this "capitulation" of the ACP in his commentary that laments the now official nature of the death of the general internists even if the bill is not passed. (With the current state of the Republican party left toothless since the last election just about any democratic sponsored bill will be passed.) By virtue of their current stand the ACP has already stipulated that NPs are for practical purposes equivalent to internists.HR 2350 may set up more general internal medicine training programs but as DrRich points out what medical students with any modicum of cognitive function left would choose to enter a field of medicine that its professional organization has publicly stated that its members are equivalent to other health care providers with much less training. What does that about what the ACP thinks of an internist training and worth? What good will the Medical Home be to internists or the ACP when its Medical Home becomes a NP run organization?
The assertion that internists will prevail in a head to head who-gives -the- best- care contest seems to me to be naive or hypocritical. Does anyone really believe that such a comparison would be based on anything other than the usual "quality" measurements of compliance with easy to account guidelines and/or coarse grained outcomes too crude to show a difference in the short run.
If you think that it is not possible for this development be spun as a good news-bad news story read the second related commentary by DrRich. Go here for that. He suggests that this ACP capitulation could be taken as a opportunity for internists to get out of this "primary care" farce and become retainer docs leaving what primary care has become to a few internists who may just want to run the clock out and the NPs and whatever level of provider that the NP lead practices may devolve into.
This type of internist he and I trained to be may find professional satisfaction in a retainer practice ( at least before medical "reform" deems that to be illegal) or by becoming a hospitalist . The primary care environment that the internist turned officist now faces is-for many of us-not worth doing.
Friday, June 12, 2009
Monday, June 08, 2009
For those who worry about government managed CER,MedPAC may be your real worry.
From the WSJ we read about the entity that may be the group that really will pull the budget strings for Medicare and have major influence on what the third party payers pay ( if there are any left after medical care reform kick in).MedPac is not a well known word. What is it anyway? Here is what it is in their own words from their website.
The Medicare Payment Advisory Commission (MedPAC) is an independent Congressional agency established by the Balanced Budget Act of 1997 (P.L. 105-33) to advise the U.S. Congress on issues affecting the Medicare program. The Commission's statutory mandate is quite broad: In addition to advising the Congress on payments to private health plans participating in Medicare and providers in Medicare's traditional fee-for-service program, MedPAC is also tasked with analyzing access to care, quality of care, and other issues affecting Medicare.
By the way, the strange sequence of capital and lower case letters in MedPAC is necessary because MEDPAC is something else entirely.It is the PAC of the Minnesota Medical Society.
Here are the current players in MedPAC. They are appointed by the director of the GAO who is the Comptroller General, who is appointed by the president subject to congressional approval.
So far, their pronouncements have been advisory but a recently proposed bill will elevate their expressed wisdom to fiat. The commission will become a government agency whose decisions regarding Medicare payments will largely be determinative.(Congress will have to work out exactly how determinative it will be, i.e. how difficult it will be for Congress to over ride their decisions).
This is being heralded by some as a way to take politics out of governmental medical payment decisions. Let's see how that won't be political. The members are appointed by a presidential appointee. Their decisions will determine how billions of dollars will be spent. Explain to me how all of the major players (drug companies,hospitals,medical equipment manufacturers, physician associations) will not do all they can to influence both the choice of those who will populate the agency and their decisions. Lobbying is not directed to just elected members of Congress. Explain to me again how investing that much power in an agency will not be the one of the best opportunities for regulatory capture ever.
The term "regulatory capture" is of fairly recent origin, but the concept is not new. Here is what President Woodrow Wilson said in 1913.
"If the government is to tell big business men how to run their business, then don't you see that big business men have to get closer to the government even than they are now? Don't you see that they must capture the government, in order not to be restrained too much by it? Must capture the government? They have already captured it."
The Medicare Payment Advisory Commission (MedPAC) is an independent Congressional agency established by the Balanced Budget Act of 1997 (P.L. 105-33) to advise the U.S. Congress on issues affecting the Medicare program. The Commission's statutory mandate is quite broad: In addition to advising the Congress on payments to private health plans participating in Medicare and providers in Medicare's traditional fee-for-service program, MedPAC is also tasked with analyzing access to care, quality of care, and other issues affecting Medicare.
By the way, the strange sequence of capital and lower case letters in MedPAC is necessary because MEDPAC is something else entirely.It is the PAC of the Minnesota Medical Society.
Here are the current players in MedPAC. They are appointed by the director of the GAO who is the Comptroller General, who is appointed by the president subject to congressional approval.
So far, their pronouncements have been advisory but a recently proposed bill will elevate their expressed wisdom to fiat. The commission will become a government agency whose decisions regarding Medicare payments will largely be determinative.(Congress will have to work out exactly how determinative it will be, i.e. how difficult it will be for Congress to over ride their decisions).
This is being heralded by some as a way to take politics out of governmental medical payment decisions. Let's see how that won't be political. The members are appointed by a presidential appointee. Their decisions will determine how billions of dollars will be spent. Explain to me how all of the major players (drug companies,hospitals,medical equipment manufacturers, physician associations) will not do all they can to influence both the choice of those who will populate the agency and their decisions. Lobbying is not directed to just elected members of Congress. Explain to me again how investing that much power in an agency will not be the one of the best opportunities for regulatory capture ever.
The term "regulatory capture" is of fairly recent origin, but the concept is not new. Here is what President Woodrow Wilson said in 1913.
"If the government is to tell big business men how to run their business, then don't you see that big business men have to get closer to the government even than they are now? Don't you see that they must capture the government, in order not to be restrained too much by it? Must capture the government? They have already captured it."
Sunday, June 07, 2009
Must reading for all internists-DrRichs' take on the bill purported to save internal medicine
DrRich's blog entries typically are insightful and entertaining. This one goes way beyond his usual very high standards.Go here to read his reply to Bob Doherty's recent blog entry," Do internists have confidence in their own training when compared to NPs?"
DrRich writes about the death of internal medicine now being official.I sadly have to agree with him about the ACP supported bill before Congress which he discusses in the context of the current state of primary care in general and internists in particular.
DrRich writes about the death of internal medicine now being official.I sadly have to agree with him about the ACP supported bill before Congress which he discusses in the context of the current state of primary care in general and internists in particular.
Friday, June 05, 2009
CMS's "never events"-so much for reason and let the unintended consequences begin
Aggravated DocSurg offers cogent comments about the seeming lack of logic or common sense in their program of denying payments for so called "never -events". In particular he discusses deep vein thrombosis (DVT). In the recent issue of the NEJM we find an excellent commentary about an even more absurd requirement of this new set of CMS rules,this one involving falls in the hospital.
For those who advocate a "Medicare for all" approach for the United States, I suggest they read what Medicare itself says about the inclusion of falls in their never-events policy.Here is a sample as quoted from the NEJM commentary which explains clearly that CMS is making a requirement for some things that cannot be done.
If one follows all the best evidence driven rules and suggestions for how to prevent DVTs, DVTs will still occur. Under the best circumstances of the very best randomized clinical trials which involve meticulous attention to detail , and applications of the very best preventive measures, DVTs still occur. The incidence is not zero. Furthermore, in regard to falls , CMS recognizes as indicated in the quote above that there are no evidence based guidelines but hospitals and physicians have to obtain a zero incidence rate anyway.We don't know how you will do it but you have to do it.
I have been impressed by Thomas Sowell's approach to try and understand some of the actions of governmental agencies that appear to lack in common sense, or appear to be irrational or just plain silly. He says look at the incentives and constraints they face and the feedback or lack thereof to which they are subject. Here, however, it is difficult to understand how anyone (even a committee) could devise and publish for all to see something that is absurd. OK I 'll try and think about their incentives etc. If their aim was to save money and to dress up their work orders in the current jargon of safety and quality, maybe their plan makes sense to them, but for the rest of the world -not so much . If you make rules that are apparently subject to no appeal,your rules don't have to make sense.
For those who advocate a "Medicare for all" approach for the United States, I suggest they read what Medicare itself says about the inclusion of falls in their never-events policy.Here is a sample as quoted from the NEJM commentary which explains clearly that CMS is making a requirement for some things that cannot be done.
"There is no evidence that hospital falls "can be consistently and effectively prevented through the application of evidence-based guidelines." The authors of the CMS rule acknowledge this fact. In the final rule, as recorded in the Federal Register on August 22, 2007, they note that "although we have not identified specific prevention guidelines for the conditions . . . we believe these types of injuries and trauma should not occur in the hospital and we look forward to working with CDC and the public in identifying research that has or will occur that will assist hospitals in following the appropriate steps to prevent these conditions from occurring after admission." Although clinical trial results suggest that certain strategies may reduce the risk of falling in community settings, fall prevention in the hospital has been much less studied. What little evidence is available is not encouraging. A recent systematic review suggested that, at best, about 20% of hospital falls can be prevented.1 Moreover, no intervention has yet been shown to reduce the risk of serious injury, the outcome of clinical relevance."
If one follows all the best evidence driven rules and suggestions for how to prevent DVTs, DVTs will still occur. Under the best circumstances of the very best randomized clinical trials which involve meticulous attention to detail , and applications of the very best preventive measures, DVTs still occur. The incidence is not zero. Furthermore, in regard to falls , CMS recognizes as indicated in the quote above that there are no evidence based guidelines but hospitals and physicians have to obtain a zero incidence rate anyway.We don't know how you will do it but you have to do it.
I have been impressed by Thomas Sowell's approach to try and understand some of the actions of governmental agencies that appear to lack in common sense, or appear to be irrational or just plain silly. He says look at the incentives and constraints they face and the feedback or lack thereof to which they are subject. Here, however, it is difficult to understand how anyone (even a committee) could devise and publish for all to see something that is absurd. OK I 'll try and think about their incentives etc. If their aim was to save money and to dress up their work orders in the current jargon of safety and quality, maybe their plan makes sense to them, but for the rest of the world -not so much . If you make rules that are apparently subject to no appeal,your rules don't have to make sense.
Friday, May 29, 2009
Does ultra sound help decisions regarding length of anticoagulation for DVT
The answer provided in a recent issue of the Annals of Internal Medicine suggests use of U/S to help determine how long to continue anticoagulation in cases of DVT is a qualified yes. See here for abstract,full article requires subscription.
Why qualified? As is often the case the exclusion criteria for entry into a clinical trial limits the applicability. In this instance, patients were excluded if they have prior DVTs,"continuing risk factors or thrombophilic factors ( except for factor V Leiden)."
Previously I wrote about some evidence that an elevated d-dimer may be worthwhile used as indicator of the need for continuing anticoagulation. There appears to be some plausible pathophysiological rationale for both tests.( I remember when internists like to talk about pathophysiology rather than guidelines,quality indicators and coding techniques.)
Why qualified? As is often the case the exclusion criteria for entry into a clinical trial limits the applicability. In this instance, patients were excluded if they have prior DVTs,"continuing risk factors or thrombophilic factors ( except for factor V Leiden)."
Previously I wrote about some evidence that an elevated d-dimer may be worthwhile used as indicator of the need for continuing anticoagulation. There appears to be some plausible pathophysiological rationale for both tests.( I remember when internists like to talk about pathophysiology rather than guidelines,quality indicators and coding techniques.)
Thursday, May 28, 2009
Annals Internal Medicine commentary laments imminent death of internal medicine
Dr. David D. Nerenbert writing in the May 19,2009 issue of the Annals of Internal Medicine offers his analysis of why internal medicine is dying;"the progressive devaluation of individualized clinical judgment". See here for abstract.Subscription is required for full text.
In the past,he continues, "careful thought was thought to be our forte".He correctly observes that a physician cannot do justice to the complex,complicated patients with multiple medical problem in fifteen minutes. There is no time for careful thought and still stay in practice, at least not if you play the Medicare and third party player game. Can you do it all in fifteen minutes?Of course, you can't.Why are we even trying? How did the hour we used to spend for new patients and perhaps 30 minutes for return visits morph into the now prototypical 10 to 15 minute farce?" Because we can't afford to spend the time any more because the per visit charges are too low and we are trying to mitigate the economic loss by increasing volume.
Is it really all about money? Is the root cause simply the imposition of price controls by Medicare and the third party payers generally following suit. The practice pattern of internists in the 70s and early 80s of spending time with patients in the office AND caring for patients in the hospitals was made possible by the income level internists enjoyed in that era. Not only did the practice patterns depend on a reasonable level of income but the practice environment-bereft as it was of mandates and insurance company driven requirements-was one in which there was a strong sense of professional identity and satisfaction and prestige among other physicians,patients and others in the health care endeavor. And then the price controls from Medicare came on the scene around 1991 and gradually everything changed.See here for my earlier attempt at summarizing the events that marked the beginning of the end of the internist as we once knew him.
Is the rise of NPs and PAs and the birth and development of hospitalists based on the same economic causes? The consequences of price controls are well known and include: shortages, poor quality and black markets or rationing by favoritism. We have all of that except black markets (unless retainer practices are ultimately outlawed and then we will see the full spectrum of the effects of wage controls)
A small single digit increase in Medicare payments, federal funds to increase the number of internists trained, or a plan to help with medical student loans will not fix the internist's plight. More residency slots are not the answer when the current slots do not fill now.Those who choice a retainer practice may be able to sidestep the problem on an individual basis.Hospitalists can salvage one aspect of the practice on the internists of the 80's but some worry they can do so only at the pleasure of the hospitals and there is no guarantee of that in the future.
The origin of the internists dilemma is government imposed price controls and tweaking the prices a bit and increasing the role of government in medical care will not fix the systemic problem. Mandating health insurance for everyone will not fix the problem of too few primary care doctors; it will make it worse. Again, I point to Massachusetts as the canary in the mine shaft. See here for recent update in waiting times. Dr.Nerenberts's suggestion of a pilot program with internists being on government salary to take care of Medicare patients is again to purpose a governmental solution to a government caused problem, and I think few internists, as upset as they are with the way things are now,would sign up for a salaried government job.
In the past,he continues, "careful thought was thought to be our forte".He correctly observes that a physician cannot do justice to the complex,complicated patients with multiple medical problem in fifteen minutes. There is no time for careful thought and still stay in practice, at least not if you play the Medicare and third party player game. Can you do it all in fifteen minutes?Of course, you can't.Why are we even trying? How did the hour we used to spend for new patients and perhaps 30 minutes for return visits morph into the now prototypical 10 to 15 minute farce?" Because we can't afford to spend the time any more because the per visit charges are too low and we are trying to mitigate the economic loss by increasing volume.
Is it really all about money? Is the root cause simply the imposition of price controls by Medicare and the third party payers generally following suit. The practice pattern of internists in the 70s and early 80s of spending time with patients in the office AND caring for patients in the hospitals was made possible by the income level internists enjoyed in that era. Not only did the practice patterns depend on a reasonable level of income but the practice environment-bereft as it was of mandates and insurance company driven requirements-was one in which there was a strong sense of professional identity and satisfaction and prestige among other physicians,patients and others in the health care endeavor. And then the price controls from Medicare came on the scene around 1991 and gradually everything changed.See here for my earlier attempt at summarizing the events that marked the beginning of the end of the internist as we once knew him.
Is the rise of NPs and PAs and the birth and development of hospitalists based on the same economic causes? The consequences of price controls are well known and include: shortages, poor quality and black markets or rationing by favoritism. We have all of that except black markets (unless retainer practices are ultimately outlawed and then we will see the full spectrum of the effects of wage controls)
A small single digit increase in Medicare payments, federal funds to increase the number of internists trained, or a plan to help with medical student loans will not fix the internist's plight. More residency slots are not the answer when the current slots do not fill now.Those who choice a retainer practice may be able to sidestep the problem on an individual basis.Hospitalists can salvage one aspect of the practice on the internists of the 80's but some worry they can do so only at the pleasure of the hospitals and there is no guarantee of that in the future.
The origin of the internists dilemma is government imposed price controls and tweaking the prices a bit and increasing the role of government in medical care will not fix the systemic problem. Mandating health insurance for everyone will not fix the problem of too few primary care doctors; it will make it worse. Again, I point to Massachusetts as the canary in the mine shaft. See here for recent update in waiting times. Dr.Nerenberts's suggestion of a pilot program with internists being on government salary to take care of Medicare patients is again to purpose a governmental solution to a government caused problem, and I think few internists, as upset as they are with the way things are now,would sign up for a salaried government job.
Tuesday, May 26, 2009
Cogent commentary about the Dartmouth Atlas conclusions by a senior medical educator and troublesome observations by Atul Gawande
The Obama administration is promoting the idea that we can finance a wide and expensive variety of government programs-including better quality health care for everyone- by getting the waste out of medical care. The factual (alleged) basis for this claim to some degree comes from a widely quoted ecological study, the Dartmouth Atlas. The publications from this project apparently has had significant influence on policy recommendations.
This study divided the nation into five Medicare quintiles and then compared money spent with several outcomes.When the region's selected outcomes did not improve as expenses increased they concluded that the difference in expenditures was "wasted" money. Other conclusions are possible and from what I read may make more sense although no one speculation based on aggregate data should stand unchallenged. One such conclusion is that differences in poverty level and in total medical expenditure offer a better explanation ( see below) that the notion that for some basically unexplained reason physicians in some regions just are prone to waste money by doing too much in terms of health care services.
I suppose the suggestion is that greedy and/or misinformed physicians tend to congregate in certain parts of the country.There is at least some anecdotal evidence that that certain cities may in fact have significantly higher medical expenditures due to variations in medical practices at least some of which may be profit driven.
A recent article in the New Yorker by the prolific Dr.Atul Gawande seems to argue the case that McAllen Texas is such a city. The article is worth reading and I found it very troublesome as Gawande relates stories (mostly heresay) of physicians requesting kickbacks for hospital admission and thinly disguised kickbacks from nursing homes. How widespread are the practices narrated by Gawande and to what extent overall health care expenditures are impacted are questions that remain unanswered as does the question why would that be regional.
Go here to read analysis from a former medical school dean, and longtime physician,Dr. Richard (Buz) Cooper, who obviously has spent much time and effort in studying this problem. He argues that Medicare spending is not an accurate proxy for total medical care expenditure and that in states with more total medical spending medical care is better, a conclusion 180 degrees from the Dartmouth conjectures.
I continue to be impressed by how often aggregate data can be used to reach conclusions and policy advice that is conjectural and at times agenda driven. The Dartmouth project may be one .Another is the recent NEJM article on hospital readmission rates of Medicare patients, a topic for a future blog.In both instances the numbers are real but the underlying factors are difficult to tease out and may be refractory to statistical techniques designed to eliminate confounding.Data gathering and statistical analysis have become cheap and widely available ,what to do with the data requires reasoning and that is as scarce as ever.
Dr. RW (see here) has recently commented on the illogical and overreaching conclusions of the Dartmouth folks.
The Dartmouth Atlas project is funded by three large insurance companies or their foundations ( Aetna,United Health care and Well Point) with the other two contributors being The Robert Wood Johnson Foundation and The California Health Group Foundation.
To claim that results may be influenced by their source of funding risks accusations of indulging in a version of an ad hominem argument. Still you have to wonder if large insurance companies would continue funding for a long standing project that published results that did not further their business interests or if they would spend much money in supporting research such as that discussed by Dr.Cooper.If you run a medical insurance company you have to like a study that claims to demonstrate widespread wasted medical spending. It is of interest that here waste is defined by a third party observer not by either the providers nor the recipients of the services. Having said that, the results are either valid or not (or we just can't tell) independent of who financed the project.
I remember learning that ecological studies might at best serve as hypothesis generating activities not as generating answers so definite and certain that they could form the basis for sweeping health care changes.
I continue to be very suspicious about conclusions from studies based on aggregate data.Serious and thoughtful and non-biased commentators are able to offer opposite stories to "explain" the data. However, Dr. Gawande's observations about practices and hospitals in several cities with significantly different practice patterns and levels of medical cost (and profits) and perhaps quality of care make me wonder if the Dartmouth conclusions might be not quite as unjustified that I want to believe as that conclusion painfully bumps up against my philosophical priors and epistemological biases. At least I am less inclined to dismiss them out of hand even though there must be more to the story than marked regional variations in greed.
addendum; Minor spelling,grammar and syntax changes were made on 8/28/14.
This study divided the nation into five Medicare quintiles and then compared money spent with several outcomes.When the region's selected outcomes did not improve as expenses increased they concluded that the difference in expenditures was "wasted" money. Other conclusions are possible and from what I read may make more sense although no one speculation based on aggregate data should stand unchallenged. One such conclusion is that differences in poverty level and in total medical expenditure offer a better explanation ( see below) that the notion that for some basically unexplained reason physicians in some regions just are prone to waste money by doing too much in terms of health care services.
I suppose the suggestion is that greedy and/or misinformed physicians tend to congregate in certain parts of the country.There is at least some anecdotal evidence that that certain cities may in fact have significantly higher medical expenditures due to variations in medical practices at least some of which may be profit driven.
A recent article in the New Yorker by the prolific Dr.Atul Gawande seems to argue the case that McAllen Texas is such a city. The article is worth reading and I found it very troublesome as Gawande relates stories (mostly heresay) of physicians requesting kickbacks for hospital admission and thinly disguised kickbacks from nursing homes. How widespread are the practices narrated by Gawande and to what extent overall health care expenditures are impacted are questions that remain unanswered as does the question why would that be regional.
Go here to read analysis from a former medical school dean, and longtime physician,Dr. Richard (Buz) Cooper, who obviously has spent much time and effort in studying this problem. He argues that Medicare spending is not an accurate proxy for total medical care expenditure and that in states with more total medical spending medical care is better, a conclusion 180 degrees from the Dartmouth conjectures.
I continue to be impressed by how often aggregate data can be used to reach conclusions and policy advice that is conjectural and at times agenda driven. The Dartmouth project may be one .Another is the recent NEJM article on hospital readmission rates of Medicare patients, a topic for a future blog.In both instances the numbers are real but the underlying factors are difficult to tease out and may be refractory to statistical techniques designed to eliminate confounding.Data gathering and statistical analysis have become cheap and widely available ,what to do with the data requires reasoning and that is as scarce as ever.
Dr. RW (see here) has recently commented on the illogical and overreaching conclusions of the Dartmouth folks.
The Dartmouth Atlas project is funded by three large insurance companies or their foundations ( Aetna,United Health care and Well Point) with the other two contributors being The Robert Wood Johnson Foundation and The California Health Group Foundation.
To claim that results may be influenced by their source of funding risks accusations of indulging in a version of an ad hominem argument. Still you have to wonder if large insurance companies would continue funding for a long standing project that published results that did not further their business interests or if they would spend much money in supporting research such as that discussed by Dr.Cooper.If you run a medical insurance company you have to like a study that claims to demonstrate widespread wasted medical spending. It is of interest that here waste is defined by a third party observer not by either the providers nor the recipients of the services. Having said that, the results are either valid or not (or we just can't tell) independent of who financed the project.
I remember learning that ecological studies might at best serve as hypothesis generating activities not as generating answers so definite and certain that they could form the basis for sweeping health care changes.
I continue to be very suspicious about conclusions from studies based on aggregate data.Serious and thoughtful and non-biased commentators are able to offer opposite stories to "explain" the data. However, Dr. Gawande's observations about practices and hospitals in several cities with significantly different practice patterns and levels of medical cost (and profits) and perhaps quality of care make me wonder if the Dartmouth conclusions might be not quite as unjustified that I want to believe as that conclusion painfully bumps up against my philosophical priors and epistemological biases. At least I am less inclined to dismiss them out of hand even though there must be more to the story than marked regional variations in greed.
addendum; Minor spelling,grammar and syntax changes were made on 8/28/14.
Thursday, May 21, 2009
The IOM speaks: mandatory nap time for house staff
The very name Institute of Medicine for reasons that have eluded me seems to mean to many a venerable assortment of very wise people who unlike the rest of the human race are able to act without personal bias or agenda and do what it right or as the myth goes act in the public interest. Their latest unfunded quasi-mandate is to mandate nap time for residents and for the ACGME to monitor the program,which I guess means make sure everyone gets their naps.
Thanks goodness, for a change, some one has the gumption, to at least, question the consequences of this IOM's pronouncement. This article in the NEJM dared to ask the questions:what would the cost be and what is the evidence that the suggestions would achieve their stated goals. The answers: It would cost a lot and the evidence of beneficial outcome is lacking.
The IOM which has been around since 1970 is a non-governmental organization that was chartered as part of the US National Academies of Science.
Thanks goodness, for a change, some one has the gumption, to at least, question the consequences of this IOM's pronouncement. This article in the NEJM dared to ask the questions:what would the cost be and what is the evidence that the suggestions would achieve their stated goals. The answers: It would cost a lot and the evidence of beneficial outcome is lacking.
The IOM which has been around since 1970 is a non-governmental organization that was chartered as part of the US National Academies of Science.
More and More data is ganging up on Proton pump inhibitors
The story of PPIs apparently interfering with the beneficial effect of Plavix is widely distributed and read. Now we see data (see here for abstract) that links spontaneous bacterial peritonitis (SBP) in advanced cirrhosis with PPI use. This was a case control study with an OR of 4.3,so I cannot make my typical whinny remark about the appropriate level of concern with relative risks of less than 2.
PPIs seem to be the mirror image of statins which have an increasing number of studies indicating a new benefit.With regard to PPIs, we may have to worry more and more about bad effects including: pneumonia ( see here for a rather unconvincing study), fractures ( see here), heart attacks ( see here for a good review of the Plavix-PPIs issue by Dr. Richard Fogoros) and now SBP. I would not be surprised if H2 blocker sales may have an uptick.
PPIs seem to be the mirror image of statins which have an increasing number of studies indicating a new benefit.With regard to PPIs, we may have to worry more and more about bad effects including: pneumonia ( see here for a rather unconvincing study), fractures ( see here), heart attacks ( see here for a good review of the Plavix-PPIs issue by Dr. Richard Fogoros) and now SBP. I would not be surprised if H2 blocker sales may have an uptick.
Monday, May 18, 2009
Electronic Medical Records, tool to save health care costs or windfall for the tool makers
One of the package of health care "reforms" that will increase quality, provide care for all and save money is the widespread implementation of electronic medical records (EMR). The other major elements are comparative effectiveness research and preventive medicine.
Here is one economist's take on one aspect of the EMR issue.As much as
"change" was heralded as a major characteristic of the new administration it appears that some things change very little.Lobbyists still stalk the halls of government and sometimes score big.
Whether the massive savings alleged by the proponents of the health care reform will accrue from EMRs or not will have to be seen in time. We do not have to wait to see how certain purveyors of these systems will make out. See here for a Washington Post article on the efforts,some of which have been years in the making, to cash in on the federal outlay of
See a detailed discussion of this special interest issue as well as concerns about the safety of this rush to implementation of EMR by one expert on this subject at Health Care Renewal.
Here is one economist's take on one aspect of the EMR issue.As much as
"change" was heralded as a major characteristic of the new administration it appears that some things change very little.Lobbyists still stalk the halls of government and sometimes score big.
Whether the massive savings alleged by the proponents of the health care reform will accrue from EMRs or not will have to be seen in time. We do not have to wait to see how certain purveyors of these systems will make out. See here for a Washington Post article on the efforts,some of which have been years in the making, to cash in on the federal outlay of
See a detailed discussion of this special interest issue as well as concerns about the safety of this rush to implementation of EMR by one expert on this subject at Health Care Renewal.
Friday, May 15, 2009
Is the latest medical world cahoots insurance companies and academia
The Last Psychiatrist (TLP). suggests that an unholy alliance between medical insurance companies and medical academia is well underway.See here.
He discusses an article from medical academia that apparently concludes that the much hated by physicians "prior authorization" for medication is really a good thing. Good for whom? TLP suggests that the drug promoted is as likely as not neither the cheapest nor the best but rather the one for which a deal has been struck between the drug manufacturer and the insurers and or the medication management company. They don't need any stinking comparative effectiveness research.
The poster child for the new insurance company-medical academia alliance is found at Harvard where is found the "only medical school department cosponsored by a health plan". The plan is the Harvard Pilgrim Health Care and the department's name is The department of Ambulatory and Preventive Care.
Here is one paragraph from TLP:
"If you want to see what the next ten years in medicine look like, stop looking at Astra Zeneca. The next unholy alliance is between academic medicine and insurers/providers. The placebo controlled trials on the treatment of bipolar will no longer be controlled by Abott (Depakote off patent 2008), but by United Healthcare."
Next we will have to not allow medical students to have pens and mugs with insurance company logos.
He discusses an article from medical academia that apparently concludes that the much hated by physicians "prior authorization" for medication is really a good thing. Good for whom? TLP suggests that the drug promoted is as likely as not neither the cheapest nor the best but rather the one for which a deal has been struck between the drug manufacturer and the insurers and or the medication management company. They don't need any stinking comparative effectiveness research.
The poster child for the new insurance company-medical academia alliance is found at Harvard where is found the "only medical school department cosponsored by a health plan". The plan is the Harvard Pilgrim Health Care and the department's name is The department of Ambulatory and Preventive Care.
Here is one paragraph from TLP:
"If you want to see what the next ten years in medicine look like, stop looking at Astra Zeneca. The next unholy alliance is between academic medicine and insurers/providers. The placebo controlled trials on the treatment of bipolar will no longer be controlled by Abott (Depakote off patent 2008), but by United Healthcare."
Next we will have to not allow medical students to have pens and mugs with insurance company logos.
Tuesday, May 12, 2009
More on the three magic elements of reforming health care.
To reform" health care" (and to fix the nation's economy) we are told we must have electronic medical records, government funded and managed comparative effectiveness research and more prevention.
In regard to the first I strongly recommend that you go here and read about just how much trouble there has been so far with the security of computerized medical information and why does anyone really believe that problem will just go away. Go here to see a good summary of other non-security related serious issues with the EMR proposed panacea.
In regard to the second I strongly recommend that you go here to learn the real reason that Dr.Rich favors government funded and managed comparative effectiveness research which he designates as "CER" as opposed to the generic term of cer. Dr Fogoros makes the argument that all cer may be biased so it is not the case that he favors CER because it will be not biased.Read his entry to see where his argument goes. I suspect more that a few advocates of CER will not be pleased.
Of course, even if we have much more cer with the addition of the CER to the data base, it will be all for nothing unless the medical profession gets on board and acts according to the published comparative effectiveness research. The grand guru daddy of the hospitalists. Dr. Bob Wachter suggests for those who won't go along they should be". dragged" along. Wonder who will be doing the dragging. In the new world of CER,will there be the draggers and the dragees? You betcha.Dr. Wachter in his dragging proposal is less concerned than is the new AMA president regarding the risk of malpractice suits if adherence to the CER directed guidance leads to the withholding of certain procedures that arguably lead to bad patient outcomes.
All in all it may be a good time to be a retired doc but as for being a patient, not so much.
In regard to the first I strongly recommend that you go here and read about just how much trouble there has been so far with the security of computerized medical information and why does anyone really believe that problem will just go away. Go here to see a good summary of other non-security related serious issues with the EMR proposed panacea.
In regard to the second I strongly recommend that you go here to learn the real reason that Dr.Rich favors government funded and managed comparative effectiveness research which he designates as "CER" as opposed to the generic term of cer. Dr Fogoros makes the argument that all cer may be biased so it is not the case that he favors CER because it will be not biased.Read his entry to see where his argument goes. I suspect more that a few advocates of CER will not be pleased.
Of course, even if we have much more cer with the addition of the CER to the data base, it will be all for nothing unless the medical profession gets on board and acts according to the published comparative effectiveness research. The grand guru daddy of the hospitalists. Dr. Bob Wachter suggests for those who won't go along they should be". dragged" along. Wonder who will be doing the dragging. In the new world of CER,will there be the draggers and the dragees? You betcha.Dr. Wachter in his dragging proposal is less concerned than is the new AMA president regarding the risk of malpractice suits if adherence to the CER directed guidance leads to the withholding of certain procedures that arguably lead to bad patient outcomes.
All in all it may be a good time to be a retired doc but as for being a patient, not so much.
Monday, May 11, 2009
Will Protecting people from second hand smoke decrease heart attacks?
Well, the early relatively small studies gave the public health rule makers some empirical justification for claiming success, further study suggest the opposite.Here is a blog posting suggesting a couple of reasons why that could be.The blog's author is Milton Friedman's son David who was trained as a physicist but writes about economics and has gained some fame for Friedman 's Law.
I'll bet we will soon be seeing papers that conclude that the attack rate of heart attacks is significantly down since the implementation of various local laws outlawing trans fat.
I'll bet we will soon be seeing papers that conclude that the attack rate of heart attacks is significantly down since the implementation of various local laws outlawing trans fat.
Thursday, April 30, 2009
Whistle blowing is always risky,In Great Britain's NHS even worse,nurse looses a lot
Monday, April 27, 2009
Two of my favorite medical bloggers seem to disagree regarding CER
When I read a recent blog posting by DB,who postings inspired me to start to blog and with whom I rarely disagree, I was sharpening up my blogging tools to respectfully offer a view counter to his, but as is often the case DrRW beat me to the draw (See here).
Those who oppose or at least have serious doubts about government- run CER are likely not against comparing the effectiveness of various medical treatments ( i.e.. not against CER) but are very skeptical of the ability of a government agency to regularly turn out results that will be free of bias and may also reject the thesis that all drug company sponsored research is biased.
Research can be spun one way or the other-there are so many ways to stack the deck and cook the books that lurk beneath behind the pages of a research project.To believe that a government agency is a) without an agenda and b) incapable of making such an agenda-generated bias operational requires much more faith in the integrity of the government that I summon and seems to ignore what we have learned about how governmental entity really operate versus the high school civics views that describes things in terms of purported aims rather than in real results. A leisurely half hour or so with a discussion of Public Choice theory might disabuse many of the vision of government as a hybrid between Santa Claus and superman.
Dr. RW's final paragraph deserves much consideration:
No one that I know of is objecting to more unbiased data. But CER is not inherently unbiased. Moreover, it is inherently susceptible to design flaws for reasons I pointed out here, with several examples. Bias has more to do with who’s sponsoring the research than the type of research. There’s no reason to think that the government would introduce less bias. In fact, the government policy makers who are pushing CER are explicitly very biased. If you don’t believe me just read the Congressional Budget Office paper which was pushing for CER, which I cited here.
Those who oppose or at least have serious doubts about government- run CER are likely not against comparing the effectiveness of various medical treatments ( i.e.. not against CER) but are very skeptical of the ability of a government agency to regularly turn out results that will be free of bias and may also reject the thesis that all drug company sponsored research is biased.
Research can be spun one way or the other-there are so many ways to stack the deck and cook the books that lurk beneath behind the pages of a research project.To believe that a government agency is a) without an agenda and b) incapable of making such an agenda-generated bias operational requires much more faith in the integrity of the government that I summon and seems to ignore what we have learned about how governmental entity really operate versus the high school civics views that describes things in terms of purported aims rather than in real results. A leisurely half hour or so with a discussion of Public Choice theory might disabuse many of the vision of government as a hybrid between Santa Claus and superman.
Dr. RW's final paragraph deserves much consideration:
No one that I know of is objecting to more unbiased data. But CER is not inherently unbiased. Moreover, it is inherently susceptible to design flaws for reasons I pointed out here, with several examples. Bias has more to do with who’s sponsoring the research than the type of research. There’s no reason to think that the government would introduce less bias. In fact, the government policy makers who are pushing CER are explicitly very biased. If you don’t believe me just read the Congressional Budget Office paper which was pushing for CER, which I cited here.
Thursday, April 23, 2009
Still more thoughts on problems with EMRs and who or what is responsible for the patient
Here is a link to a discussion of more problems with electronic medical records (EMRs) that ties in with the issue of individual versus group responsibility.
The particular case involved a patient at an academic medical center in which
It took three days for the patient's care team to realize that the results entered into his EMR were for a biopsy they did not order of a lesion he did not have. Before the error was recognized, it had caused the patient "tremendous pain and mental anguish."
The author, John Goodman, continues with a theme I have ranted about before, (see here) the increasing lack of individual responsibility for patient care and the replacement with "team care" and computers systems are, of course,increasingly part of the team.
I believe that it is not coincidental that the same ACGME in their 2003 general core competencies statement mentions "systems" or "system" seven times but saw no reason to include the statement quoted above. The authors of the competencies are more concerned with team play, group dynamics,system this and system that, and conserving society's resources and fostering social justice than in inculcating in medical trainees a sense of individual responsibility for their individual patients, which is what I thought it was all about.
The particular case involved a patient at an academic medical center in which
It took three days for the patient's care team to realize that the results entered into his EMR were for a biopsy they did not order of a lesion he did not have. Before the error was recognized, it had caused the patient "tremendous pain and mental anguish."
The author, John Goodman, continues with a theme I have ranted about before, (see here) the increasing lack of individual responsibility for patient care and the replacement with "team care" and computers systems are, of course,increasingly part of the team.
At bottom, the error got as far as it did because of the "medical team" approach - no single person was responsible for this patient's care. Each person relied on the (erroneous) electronic medical record for his view of the whole.
We seem to be replacing personal physician responsibility with "systems".
With so much rhetoric these days about instilling professionalism in medical students and house officers how can individual responsibility be given such short shrift? In 2003 the ACGME eliminated the following statement from their pronouncements:
Physicians must recognize their obligation is not discharged at any given time or any given day.
No, that is not a typo -they eliminated what used to be considered a fundamental principle of the doctor-patient relationship,that the physician is responsible for his patient
I believe that it is not coincidental that the same ACGME in their 2003 general core competencies statement mentions "systems" or "system" seven times but saw no reason to include the statement quoted above. The authors of the competencies are more concerned with team play, group dynamics,system this and system that, and conserving society's resources and fostering social justice than in inculcating in medical trainees a sense of individual responsibility for their individual patients, which is what I thought it was all about.
Earth Day -some cogent counterpoints to the standard green koolaid
The first thing I remember about Earth day were reports of some cases of histoplasmosis in a group of well meaning well-meaners who breathed in a bunch of fungal spores when they set out to clean up their little portions of the earth.
Dr. Don Boudreaux,chairman of the economics department at George Mason University, submits this essay on what he is grateful for on earth day. He sums up his thoughts in this closing paragraph:
I am, in short, thankful for private-property markets that are the main driving force behind these (and many other) anti-pollutants -- a force so powerful that we today enjoy the incredible luxury of being able to worry, should we so choose, about very distant and very speculative forms of environmental problems such as species loss and global warming.
Dr. Mark Perry,economics professor at University of Michigan,wrote this editorial explaining what has driven the cleaning and greening of things since the 1970s birth of Earth Day. (hint it was not Al Gore). He ends his essay with this answer to what has made the earth greener.
Dr. Don Boudreaux,chairman of the economics department at George Mason University, submits this essay on what he is grateful for on earth day. He sums up his thoughts in this closing paragraph:
I am, in short, thankful for private-property markets that are the main driving force behind these (and many other) anti-pollutants -- a force so powerful that we today enjoy the incredible luxury of being able to worry, should we so choose, about very distant and very speculative forms of environmental problems such as species loss and global warming.
Dr. Mark Perry,economics professor at University of Michigan,wrote this editorial explaining what has driven the cleaning and greening of things since the 1970s birth of Earth Day. (hint it was not Al Gore). He ends his essay with this answer to what has made the earth greener.
.. capitalism has. Through wealth generated by the free market, we have enough resources to move beyond the subsistence economies that damage the environment, enough disposable income to fund clean-up programs, enough wealth to scrub and polish industry.
Only in advanced economies can the technology needed to recycle hazardous waste or to replace dirty coal-fired power plants with cleaner gas or nuclear plants be developed. That technology cannot be produced in centrally planned economies where the profit motive is squelched and lives are marshalled by the state.
There's nothing wrong with setting aside a day to honor the Earth. In fairness, though, it should be complemented by Capitalism Day. It's important that the world be reminded of what has driven the environmental improvements since Earth Day began in 1970.
Wednesday, April 22, 2009
Health Insurance does not equal health care
Worth reading is this commentary by internist Dr. Marc Siegel who cautions that "health insurance does not equal health care".Neither is the promise of a government of universal coverage equal to the actual delivery or ready availability of health care.
Medicare (which some may remember as the government program that promised not to interfere with the physician-patient relationship) has so limited the payment to physicians (particularly primary care physicians) that the promise for medical care for the elderly increasingly is becoming unfulfilled as more and more primary care docs opt out or at least refuse to see new medicare payments. This is government care for just one segment of the population.In Canada the unfulfilled promises can affect everyone or at least those who cannot go south and pay for their care.
A recent Texas Medicare Association survey indicated that only 38% of primary care doctors are accepting new Medicare patients and the situation is worse with Medicaid patients.
Problems finding a physician in Massachusetts affects everyone since they instituted the brilliant plan of getting medical insurance for all by simply passing a law that mandated it.This is the same plan that is now asking for a federal bailout.See here for how that is working out.
There are many interpretations for the cryptic lyrics of the song "Hotel California" which says in part
"...relax, said the night man, We are programmed to receive. You can checkout any time you like, But you can never leave! "
My interpretation is that the hotel provides the trappings or appearance of a service but not the real service. What does your national health service card mean if you have to wait so long for the care that it might not matter or if the shortage of docs gets to the point where little care is available.
Medicare (which some may remember as the government program that promised not to interfere with the physician-patient relationship) has so limited the payment to physicians (particularly primary care physicians) that the promise for medical care for the elderly increasingly is becoming unfulfilled as more and more primary care docs opt out or at least refuse to see new medicare payments. This is government care for just one segment of the population.In Canada the unfulfilled promises can affect everyone or at least those who cannot go south and pay for their care.
A recent Texas Medicare Association survey indicated that only 38% of primary care doctors are accepting new Medicare patients and the situation is worse with Medicaid patients.
Problems finding a physician in Massachusetts affects everyone since they instituted the brilliant plan of getting medical insurance for all by simply passing a law that mandated it.This is the same plan that is now asking for a federal bailout.See here for how that is working out.
There are many interpretations for the cryptic lyrics of the song "Hotel California" which says in part
"...relax, said the night man, We are programmed to receive. You can checkout any time you like, But you can never leave! "
My interpretation is that the hotel provides the trappings or appearance of a service but not the real service. What does your national health service card mean if you have to wait so long for the care that it might not matter or if the shortage of docs gets to the point where little care is available.
Tuesday, April 21, 2009
In Canada health care is a right,wait ,no it isn't?
In Canada, there is universal health care with a single payer and for the most part no opting of the system.Their supreme court ruled that patient rights were been violated because their access to health care was in some instances so delayed that it was no care at all.
Now consider the case of an orthopedic surgeon, Dr. Brian Day who is involved in legal proceedings with the provincial health care entity in British Columbia for accepting payment from a private citizen for medical care. See here for some details and here for details of Dr. Day's lawsuit which seeks to overturn the law in BC that bans private medical care. In this matter the government is arguing that the supreme court ruling does not apply because health care is not a right after all.
Wait,I thought the government of Canada provided medical care for all because of the belief that medical care was a right but now it isn't.
Now consider the case of an orthopedic surgeon, Dr. Brian Day who is involved in legal proceedings with the provincial health care entity in British Columbia for accepting payment from a private citizen for medical care. See here for some details and here for details of Dr. Day's lawsuit which seeks to overturn the law in BC that bans private medical care. In this matter the government is arguing that the supreme court ruling does not apply because health care is not a right after all.
Wait,I thought the government of Canada provided medical care for all because of the belief that medical care was a right but now it isn't.
Sunday, April 19, 2009
More concerns about Government mandated and financed electronic medical records
To reform medical care we are told that we need three things; 1)electronic medical records (EMR), 2)comparative effectiveness research (done by the federal government)(CER) and 3)more efforts at prevention . From these elements we can derive care for all,better quality care and great cost savings.(Why does this remind me of "cheap,fast and good-pick any two"?)
Concerns about the government mandated EMR have been recently expressed regarding the following issues:
1.The Legacy issue
2.The error problem
3.The monopoly problem.
While Dr. Michael O'Connor of the blog The Ether Way eloquently writes (see here) about a more fundamental problem with the EMR, namely that it is,at least in part, a cut-and-paste tool of the administrators and the regulators and not so much of the physicians caring for the patients and as such serves the ends of the first two groups much better than those of the physicians and patients and that physician sometimes resort to "shadow charts" as a work-around to the constraints of the EMR.
Dr. Wes offers this posting about the" Legacy problem" with EMR. This is easily related to by anyone who remembers floppy discs ( remember the kind that were really floppy) and how your current computer does not even have slot for those now. Some may have experienced how various drivers did not work when their new PC was driven by Vista and they were not supported by this new improved Microsoft product.Read the trajectory of frustration ,wasted time and money that is explained in detail on Dr.Wes's entry. As computer systems evoke, incompatibilities arise with older system still in use which can lead to increased costs or partial or complete abandonment of the system.
Another serious matter is discussed in detail on Junkfood Science.See here. The main point is that electronic records can be erroneous (errors creep in from various often unrecognized sources) and those errors can be lethal and good luck getting those changed or even finding out what they say.For a detailed description of just some of what can and does go wrong with electronic medical records, go here for an alarming essay by Dr. S. Silverstein (AKA MednformaticsMD) who has tirelessly been educating the readers of Health Care Renewal about the many problems with medical IT.
Still another issue is raised by a commentary in NEJM about which there is a WSJ article ( see here).Since the stimulus bill gives the government power to define and approve which programs and systems will be used there is the power to create a medical high tech monopoly leaving innovation and corrective improvements out in the cold.
Dr. O'Conner's critique of the EMR should be read in its entirety but here is one good quote.
Many EMRs read like Madlibs(for those of you old enough to remember what they are), because they are in fact cut-and-pasted snippets of data from other parts of the EMR, put in place to fulfill some billing documentation requirement or some regulatory imperative. Free text annotation is often discouraged, and frequently impossible to juxtapose next to the appropriate snippet of information in the chart. Some systems make it very difficult to generate any kind of free form documentation, and consequently critical events in the course of a hospitalization are never documented. In most or all hospitals, practitioners have developed a shadow chart that incorporates all of the critical information that practitioners need to know to care for a patient. The existence of these shadow charts has been driven by the hijacking of the medical record for billing and regulatory purposes. The creation of these charts represents additional effort for everyone who directly participates in the care of patients. That such busy people are willing to do this is striking. Little you want to know is in the chart; everything you need to know is in the shadow chart.
I'll admit I had not heard about shadow charts since I have been away from clinical care for a while. Perhaps a reader can inform how widespread this is.
We are told that to reform medical care, billions will be spent to ensure EMRs will cover
everyone's medical records and we can watch as the quality of care is monitored from "this perch" which may well consist of coarse grain and often erroneous data extracted from various EMRs (including the notoriously inaccurate coding information) often excluding the important nuances of the real medical world.
Concerns about the government mandated EMR have been recently expressed regarding the following issues:
1.The Legacy issue
2.The error problem
3.The monopoly problem.
While Dr. Michael O'Connor of the blog The Ether Way eloquently writes (see here) about a more fundamental problem with the EMR, namely that it is,at least in part, a cut-and-paste tool of the administrators and the regulators and not so much of the physicians caring for the patients and as such serves the ends of the first two groups much better than those of the physicians and patients and that physician sometimes resort to "shadow charts" as a work-around to the constraints of the EMR.
Dr. Wes offers this posting about the" Legacy problem" with EMR. This is easily related to by anyone who remembers floppy discs ( remember the kind that were really floppy) and how your current computer does not even have slot for those now. Some may have experienced how various drivers did not work when their new PC was driven by Vista and they were not supported by this new improved Microsoft product.Read the trajectory of frustration ,wasted time and money that is explained in detail on Dr.Wes's entry. As computer systems evoke, incompatibilities arise with older system still in use which can lead to increased costs or partial or complete abandonment of the system.
Another serious matter is discussed in detail on Junkfood Science.See here. The main point is that electronic records can be erroneous (errors creep in from various often unrecognized sources) and those errors can be lethal and good luck getting those changed or even finding out what they say.For a detailed description of just some of what can and does go wrong with electronic medical records, go here for an alarming essay by Dr. S. Silverstein (AKA MednformaticsMD) who has tirelessly been educating the readers of Health Care Renewal about the many problems with medical IT.
Still another issue is raised by a commentary in NEJM about which there is a WSJ article ( see here).Since the stimulus bill gives the government power to define and approve which programs and systems will be used there is the power to create a medical high tech monopoly leaving innovation and corrective improvements out in the cold.
Dr. O'Conner's critique of the EMR should be read in its entirety but here is one good quote.
Many EMRs read like Madlibs(for those of you old enough to remember what they are), because they are in fact cut-and-pasted snippets of data from other parts of the EMR, put in place to fulfill some billing documentation requirement or some regulatory imperative. Free text annotation is often discouraged, and frequently impossible to juxtapose next to the appropriate snippet of information in the chart. Some systems make it very difficult to generate any kind of free form documentation, and consequently critical events in the course of a hospitalization are never documented. In most or all hospitals, practitioners have developed a shadow chart that incorporates all of the critical information that practitioners need to know to care for a patient. The existence of these shadow charts has been driven by the hijacking of the medical record for billing and regulatory purposes. The creation of these charts represents additional effort for everyone who directly participates in the care of patients. That such busy people are willing to do this is striking. Little you want to know is in the chart; everything you need to know is in the shadow chart.
I'll admit I had not heard about shadow charts since I have been away from clinical care for a while. Perhaps a reader can inform how widespread this is.
We are told that to reform medical care, billions will be spent to ensure EMRs will cover
everyone's medical records and we can watch as the quality of care is monitored from "this perch" which may well consist of coarse grain and often erroneous data extracted from various EMRs (including the notoriously inaccurate coding information) often excluding the important nuances of the real medical world.
Tuesday, April 14, 2009
Comparative effectiveness research-more warnings
Those, including several medical bloggers, who seem to have placed more than a little faith in the notion of a government funded and run comparative effectiveness research program (CER) should read the following sobering posting from Health Care Renewal.
The commentary in part expresses concerns about the following recent comments from Governor Sebelius from her congressional hearing for head of HHS.
The author of the Health Care renewal entry is properly alarmed that use of the often garbage type data from EMR have a high likelihood of generating detailed printouts of elaborately presented ( replete with very low p values) results that could be misleading at best and more likely harmful. To expect such " highly uncontrolled" data bases to meaningfully determine if treatment X is better than treatment Y raises unrealistic expectations to a new level.
It seems to me that some pro government CER advocates make two mistakes in their advocacy of the government funded CER.
First, they maintain that we have no or at best very little comparative effectiveness data at all now so the government must provide it. Dr RW in this posting proves that is not the case. A recent example of non-government funded CER is the SYNTAX trial.
Secondly, they conflate the desire to have really good data on what works with the assumption that such will be the product from a government funded CER. Yes,it would be very nice if there were someway to have realms of great CER without bias and without spin but should we really trust a government agency who would somehow be populated by selfless, brilliant, dedicated public servants who would bring no biases to the table and who somehow will be immune to the outside influences that seemed to have plagued every governmental agency ever created and that the output from analysis would not be put to the purpose of limiting government payment for such treatment that they found inferior.
Limiting payment for medical services deemed inferior by data dredging exercises is not what we need to improve medical quality but may well be what government sponsored CER will bring.
The commentary in part expresses concerns about the following recent comments from Governor Sebelius from her congressional hearing for head of HHS.
“The goal,” Sebelius said, “is to provide every American with a safe, secure electronic health record by 2014." The nominee also endorsed efforts to use data gleaned from electronic medical records to conduct “comparative effectiveness research" (the authors bolding)(CER) to provide information on the relative strengths and weaknesses of alternative medical interventions to health providers and consumers.”
The author of the Health Care renewal entry is properly alarmed that use of the often garbage type data from EMR have a high likelihood of generating detailed printouts of elaborately presented ( replete with very low p values) results that could be misleading at best and more likely harmful. To expect such " highly uncontrolled" data bases to meaningfully determine if treatment X is better than treatment Y raises unrealistic expectations to a new level.
It seems to me that some pro government CER advocates make two mistakes in their advocacy of the government funded CER.
First, they maintain that we have no or at best very little comparative effectiveness data at all now so the government must provide it. Dr RW in this posting proves that is not the case. A recent example of non-government funded CER is the SYNTAX trial.
Secondly, they conflate the desire to have really good data on what works with the assumption that such will be the product from a government funded CER. Yes,it would be very nice if there were someway to have realms of great CER without bias and without spin but should we really trust a government agency who would somehow be populated by selfless, brilliant, dedicated public servants who would bring no biases to the table and who somehow will be immune to the outside influences that seemed to have plagued every governmental agency ever created and that the output from analysis would not be put to the purpose of limiting government payment for such treatment that they found inferior.
Limiting payment for medical services deemed inferior by data dredging exercises is not what we need to improve medical quality but may well be what government sponsored CER will bring.
Monday, April 13, 2009
Medical Home will not be enough, we need the Medical Village
I written before about my skepticism regarding the Medical Home concept.It has been suggested that the home does not go far enough and that a "village "concept should be explored and possibly adopted. Here is one doc's version of how that village concept would be applied to one aspect of medical care. Thanks to Dr. Hal Dall's blog for insightful comments and satire.
Tuesday, April 07, 2009
Statins (or at least one of them) seems to just get better and better
Just as we thought there could not possibly be any more purported benefits of the statin drugs we are treated to still another reason to get on the bandwagon- prevention of venous clots.
At least that is what we are told by more breaking news from the latest paradigm shifting, landmark study, the JUPITER trial. We now learn that in this large , randomized trial of persons whose LDL were less than 130 and their CRP were greater than 2,that there was a 43 % decrease in the incidence of venous thrombotic disease in the rosuvastatin (20 mg) group. See here for the entire article from the NEJM.
Previously I had blogged about the reported benefits of pre-operative statins in terms of fewer deaths,fewer strokes and a lower incidence of atrial fibrillation.
At least that is what we are told by more breaking news from the latest paradigm shifting, landmark study, the JUPITER trial. We now learn that in this large , randomized trial of persons whose LDL were less than 130 and their CRP were greater than 2,that there was a 43 % decrease in the incidence of venous thrombotic disease in the rosuvastatin (20 mg) group. See here for the entire article from the NEJM.
Previously I had blogged about the reported benefits of pre-operative statins in terms of fewer deaths,fewer strokes and a lower incidence of atrial fibrillation.
Monday, April 06, 2009
What the heck could increased variation in red blood cell size have to do with heart disease or mortality?
This article from the Archives of Internal Medicine seems to link a measure of variability in red blood cell (rbc) size with all cause mortality. As the article explains, previously there had several studies that suggested a link between heart disease and RBC size variability as judged by measurement of the RDW by automated blood cell analyzers. (See here for one article linking elevated RDW and adverse clinical outcomes in patients with heart disease). The Archive article examined a large data base for evidence of a similar correlation with all cause mortality and seemed to find one that reached statistical significance.
The RDW is the red cell distribution width which is the standard deviation of red cell width divided by the mean cell width and normally is around 10-15 %. Remember we used to talk about anisocytosis. It may have some limited utility in differentiating iron deficiency anemia from thalassemia with the RDW increased in the former reflecting the fact that in iron deficiency there are two populations of red cells and in thalassemia there is a more homogeneous population of relatively small rbcs. In my experience, it is a by product of automatic blood cell analyzers that most docs ignore, including a couple of hematologist associates I asked about it.
The study authors also wondered how/why RDW seems to correlate with all cause mortality.They investigated the relationship between C reactive protein (CRP) and RDW postulating that somehow inflammation was involved but that did not seem to be the case.
How long will it take for the JUPITER data be dredged to see if statins ( at least rosuvastatin) can lower the RDW?
The RDW is the red cell distribution width which is the standard deviation of red cell width divided by the mean cell width and normally is around 10-15 %. Remember we used to talk about anisocytosis. It may have some limited utility in differentiating iron deficiency anemia from thalassemia with the RDW increased in the former reflecting the fact that in iron deficiency there are two populations of red cells and in thalassemia there is a more homogeneous population of relatively small rbcs. In my experience, it is a by product of automatic blood cell analyzers that most docs ignore, including a couple of hematologist associates I asked about it.
The study authors also wondered how/why RDW seems to correlate with all cause mortality.They investigated the relationship between C reactive protein (CRP) and RDW postulating that somehow inflammation was involved but that did not seem to be the case.
How long will it take for the JUPITER data be dredged to see if statins ( at least rosuvastatin) can lower the RDW?
Thursday, April 02, 2009
Is the Massachusett Universal coverage plan the canary in the mine?
See this article from WSJ online to gather facts about how poorly things are working out in the grand universal health care program for Massachusetts.
Three years into the program (which has been labeled the Bay State bait and switch) the costs have increased far beyond the projections that were part of the program's promises. The budget projection for 2010 is 880 million which is a 42% increase from the 2006 number. (other projections go even higher, see below). They have increased fines for those who can afford insurance but choose to not sign up, also increasing are premiums and penalties for business. A panel has been set up to look at options. It is never good news that a panel has been set to "find solutions". Limiting care is one,limiting profits for insurers is another after premiums and penalties have increased to a point were public outcry becomes too loud.
Proponents had promised universal coverage with lower costs.
Go here for many more details of how badly things have gone as outlined on the Blog Junkfood Science.Here is an except:
By February of this year (2008), the state was asking the Federal government to bail it out ( my bold) and cover half of the program’s costs from 2009 through 2011. According to the Boston Globe, the program will cost taxpayers $1.95 billion this year and is expected to cost $1.35 billion annually by June 2011 — figures that “far outstrip the original plans.” Massachusetts medical authorities, in efforts to keep the program solvent, had approved changes in December to cut payments to doctors and hospitals, reduce choices and benefits for patients, and possibly increase how much patients have to pay.
The WSJ article closes with:
The real lesson of Massachusetts is that reform proponents won't tell Americans the truth about what "universal" coverage really means: Runaway costs followed by price controls and bureaucratic rationing.
At least citizens of Massachusetts have a safety value, something that might not be readily available if the Mass. plan goes national.
We are promised universal health care that will magically be less expensive because of the promised savings of "investments" in medical IT, comparative effectiveness research and preventive medicine.The plan seems to be spend more on health care so we can save more.What could go wrong with that?
Three years into the program (which has been labeled the Bay State bait and switch) the costs have increased far beyond the projections that were part of the program's promises. The budget projection for 2010 is 880 million which is a 42% increase from the 2006 number. (other projections go even higher, see below). They have increased fines for those who can afford insurance but choose to not sign up, also increasing are premiums and penalties for business. A panel has been set up to look at options. It is never good news that a panel has been set to "find solutions". Limiting care is one,limiting profits for insurers is another after premiums and penalties have increased to a point were public outcry becomes too loud.
Proponents had promised universal coverage with lower costs.
Go here for many more details of how badly things have gone as outlined on the Blog Junkfood Science.Here is an except:
By February of this year (2008), the state was asking the Federal government to bail it out ( my bold) and cover half of the program’s costs from 2009 through 2011. According to the Boston Globe, the program will cost taxpayers $1.95 billion this year and is expected to cost $1.35 billion annually by June 2011 — figures that “far outstrip the original plans.” Massachusetts medical authorities, in efforts to keep the program solvent, had approved changes in December to cut payments to doctors and hospitals, reduce choices and benefits for patients, and possibly increase how much patients have to pay.
The WSJ article closes with:
The real lesson of Massachusetts is that reform proponents won't tell Americans the truth about what "universal" coverage really means: Runaway costs followed by price controls and bureaucratic rationing.
At least citizens of Massachusetts have a safety value, something that might not be readily available if the Mass. plan goes national.
We are promised universal health care that will magically be less expensive because of the promised savings of "investments" in medical IT, comparative effectiveness research and preventive medicine.The plan seems to be spend more on health care so we can save more.What could go wrong with that?
Wednesday, April 01, 2009
NHS's hospital from hell showcases performance measures
The British NHS is investigating how things could go so very wrong at one of their hospitals,the Stafford hospital. See here for the newspaper report that puts at least part of the blame on a situation where mindless adhering to quality targets may have caused deaths.
See also here for the story that has this quote:
...So what the government decided to do instead was make hospitals compete on things that mostly weren't related to clinical outcomes; things that could be easily measured, such as the four-hour wait in A&E. If you talk to clinicians, they'll say this has nothing to do with outcomes and doesn't improve the care that patients receive. You can find ways to fiddle the numbers to tick that box, and you can put resources in to try to meet the targets.
At a time when the incredibly bad care that is documented in the two above cited newspapers article was taking place the hospital was getting pretty good grades on its various performance measures.
One such target was "get the patients out of (A&E ) accident and emergency) to the wards in 4 hours.".If you thought there were problems with the U.S. "4-hour pneumonia rule"....
I have blogged before on Goodhart's law which says:
"Once a measure is made a target for the purpose of conducting policy it will loose the information content that would qualify it to play such a role".
While the mindlessness of treating to the quality measure is part of the problem at this NHS hospital there is much more wrong than that .See here for Health Care BS's take on the matter.
See also here for the story that has this quote:
...So what the government decided to do instead was make hospitals compete on things that mostly weren't related to clinical outcomes; things that could be easily measured, such as the four-hour wait in A&E. If you talk to clinicians, they'll say this has nothing to do with outcomes and doesn't improve the care that patients receive. You can find ways to fiddle the numbers to tick that box, and you can put resources in to try to meet the targets.
At a time when the incredibly bad care that is documented in the two above cited newspapers article was taking place the hospital was getting pretty good grades on its various performance measures.
One such target was "get the patients out of (A&E ) accident and emergency) to the wards in 4 hours.".If you thought there were problems with the U.S. "4-hour pneumonia rule"....
I have blogged before on Goodhart's law which says:
"Once a measure is made a target for the purpose of conducting policy it will loose the information content that would qualify it to play such a role".
While the mindlessness of treating to the quality measure is part of the problem at this NHS hospital there is much more wrong than that .See here for Health Care BS's take on the matter.
Monday, March 30, 2009
Should "preventionists" treat the population and real docs treat individuals?
I had not heard the term "preventionist" before reading this excellent entry by Dr. Michal Accad. His thoughtful essay in part delves into a topic that has interested and bothered me for years, the individual versus the collective and in the medical context population health versus individual health.One of my rants on this topic can be found here. (One indicator that you probably have run out anything to say is frequently quoting yourself.)
I quote his final paragraph wherein the term "preventionist" appears, I think tongue in cheek.
... But since population medicine has little to do with individual medicine, and since the application of primary prevention requires no diagnostic skills to identify the subjects of predilection, the advocated intervention need not be practiced in the doctor’s office. I propose that JUPITER’s precepts be promoted in specialized “Centers of Excellence,” public health dispensaries where competent preventionists could directly indoctrinate the public to the many values of the modern wisdom, un-distracted by the chaotic environment of a clinical practice. And thus relieved from the burdens of a task at which they are so woefully “inefficient,” the primary care physician could then return to their humble original calling, the care of a patient with a chief complaint.
The primary care physician increasingly is called upon to to be a preventionist under the threat of being accused of not practicing quality care and not receiving his bribe (aka P4P ).
My favorite P4P quote continues to be:
"He hands you a nickle.He hands you a dime.He asks you with a grin are you having a good time"...Dylan from Maggie's Farm.
Prevention is one of the holy trinity (along with EMRs and quality systems) that will bring the new age of greater health for all, less money spent and really good care for everybody. In terms of the world of the internist, it is the office internist (one variety of the officist) upon whose shoulders falls the obligation to ensure his patients (clients, customers) have been quizzed and then instructed to do whatever they are supposed to do to strive for wellness from submitting to colonoscopies and flossing and using their seat belts.The other sub-species of internist (the hospitalist) can still for the most part manage sick patients leaving the administrative tasks of prevention to his 8-5 office cousins and increasingly to their extenders.
I quote his final paragraph wherein the term "preventionist" appears, I think tongue in cheek.
... But since population medicine has little to do with individual medicine, and since the application of primary prevention requires no diagnostic skills to identify the subjects of predilection, the advocated intervention need not be practiced in the doctor’s office. I propose that JUPITER’s precepts be promoted in specialized “Centers of Excellence,” public health dispensaries where competent preventionists could directly indoctrinate the public to the many values of the modern wisdom, un-distracted by the chaotic environment of a clinical practice. And thus relieved from the burdens of a task at which they are so woefully “inefficient,” the primary care physician could then return to their humble original calling, the care of a patient with a chief complaint.
The primary care physician increasingly is called upon to to be a preventionist under the threat of being accused of not practicing quality care and not receiving his bribe (aka P4P ).
My favorite P4P quote continues to be:
"He hands you a nickle.He hands you a dime.He asks you with a grin are you having a good time"...Dylan from Maggie's Farm.
Prevention is one of the holy trinity (along with EMRs and quality systems) that will bring the new age of greater health for all, less money spent and really good care for everybody. In terms of the world of the internist, it is the office internist (one variety of the officist) upon whose shoulders falls the obligation to ensure his patients (clients, customers) have been quizzed and then instructed to do whatever they are supposed to do to strive for wellness from submitting to colonoscopies and flossing and using their seat belts.The other sub-species of internist (the hospitalist) can still for the most part manage sick patients leaving the administrative tasks of prevention to his 8-5 office cousins and increasingly to their extenders.
Wednesday, March 25, 2009
If you get Universal health care with a single payer you better have a "safety value"
In Great Britain, at least for some, the safety value for the NHS is private health care. In Canada, if you can afford it, the safety value is to leave and get the care in the United States or overseas, perhaps in India.
Here is a reference to comments made by the Director of Trauma at McGill Hospital Centre in regard to the events surrounding the death of Natasha Richardson. He said in part:
"It's impossible for me to comment specifically about her case, but what I could say is ... driving to Mont Tremblant from the city (Montreal) is a 2 1/2-hour trip, and the closest trauma center is in the city. Our system isn't set up for traumas and doesn't match what's available in other Canadian cities, let alone in the States,...
The system is not "set up" for trauma in part because there were no air evac helicopters in that area. As pointed out by others capital investments in the health care system in Canada are costs to the system that cannot be recouped. In the US, the purchase of,for example, an MRI, is also a cost to the hospital or clinic but it can be recouped and typically is a profit center. So hospitals under which system are likely to have MRIs readily available?
It is important to recognize that "universal health care coverage" and "single payer" are not the same thing.
David Henderson of the econlog blog has this to say about the single payer system in Canada:
The essence of "single payer" medicine is that no one other than the government is allowed to pay for medical care. Thus the term "single payer." There are a few exceptions in Canada but, by and large, the more serious the ailment, the more stringent the ban. So, for example, if you want to be treated for cancer in Canada, you can not do so legally and any doctor or hospital that tries to charge you faces serious penalties, up to and including a prison sentence. In that sense, Canadian health care is one of the most totalitarian systems in the industrialized world and is far more extreme than the National Health Service of Britain.
When rationing by waiting turns into health care denied by health care delayed ( as numerous anecdotes or case reports indicate) as occurs in Canada the single payer may in effect work directly counter to the promise of universal care that the single payer system promises. There are many problems of single payer system as a cursory study of the health care in Canada and Great Britain will show, but a single payer system that outlaws private care is, as David Henderson says, about as totalitarian as you can get since your life is in the hands of the state.
Here is a reference to comments made by the Director of Trauma at McGill Hospital Centre in regard to the events surrounding the death of Natasha Richardson. He said in part:
"It's impossible for me to comment specifically about her case, but what I could say is ... driving to Mont Tremblant from the city (Montreal) is a 2 1/2-hour trip, and the closest trauma center is in the city. Our system isn't set up for traumas and doesn't match what's available in other Canadian cities, let alone in the States,...
The system is not "set up" for trauma in part because there were no air evac helicopters in that area. As pointed out by others capital investments in the health care system in Canada are costs to the system that cannot be recouped. In the US, the purchase of,for example, an MRI, is also a cost to the hospital or clinic but it can be recouped and typically is a profit center. So hospitals under which system are likely to have MRIs readily available?
It is important to recognize that "universal health care coverage" and "single payer" are not the same thing.
David Henderson of the econlog blog has this to say about the single payer system in Canada:
The essence of "single payer" medicine is that no one other than the government is allowed to pay for medical care. Thus the term "single payer." There are a few exceptions in Canada but, by and large, the more serious the ailment, the more stringent the ban. So, for example, if you want to be treated for cancer in Canada, you can not do so legally and any doctor or hospital that tries to charge you faces serious penalties, up to and including a prison sentence. In that sense, Canadian health care is one of the most totalitarian systems in the industrialized world and is far more extreme than the National Health Service of Britain.
When rationing by waiting turns into health care denied by health care delayed ( as numerous anecdotes or case reports indicate) as occurs in Canada the single payer may in effect work directly counter to the promise of universal care that the single payer system promises. There are many problems of single payer system as a cursory study of the health care in Canada and Great Britain will show, but a single payer system that outlaws private care is, as David Henderson says, about as totalitarian as you can get since your life is in the hands of the state.
Tuesday, March 24, 2009
Tight glucose control in ICU seems hazardous
In the March 24,2009 on line issue of NEJM the results of the Nice Sugar trial are published and shows that conventional treatment ( target glucose less than 180) as opposed to tight control (defined as 81-108 glucose target) is better. This was a very large trial with over 3000 patients in each arm.
In the tight control group 27.5 % died versus 24.9 % deaths in the conventional treatment group.Severe hypoglycemia (less than 40) occurred in 6. 5 % of the intensive treatment group versus 0.5 % in the conventional treatment group illustrating once more that more insulin may drive the blood sugar too low and be harmful.
Even though meta-analysis have generated conflicting results regarding the efficacy and safety of tight glucose control, both the American Diabetes Association and the American Society of Clinical Endocrinologists have recommended tight control.
The study authors of the NICE trial offered this understatement "Our findings suggest that a goal of normoglycemia for glucose control does not necessarily benefit critically ill patients and may be harmful",
This seems to be another example of the ready, shoot, aim approach to guidelines bringing to mind the ill advised rush to give everyone beta blockers peri-operatively which was probably laid to rest with the publication of the POISE Trial. Let me repeat what I said after that trial was published.
If there is a lesson here it is not just that a large randomized clinical trial gives results opposite to earlier smaller trials-that is a story we have heard more than once before. The lesson is not that expert committees sometimes have to revise their recommendations as new information becomes available.The lesson I think that should be emphasized is that overzealous quality rule writers and enforcers can be a hazard to your health ( and I have said that before). Read Dr. Devereaux's comments regarding how many patients may have been harmed by taking peri operative beta blockers and then wonder how many patients received them simply because premature quality guidelines were in place and physicians were caught up in the rush to treat even though it seems clear now that the evidence for such zealous efforts was inadequate. Dr. DB (AKA Dr. Robert Centor) nailed it when he recently spoke about in this regard " the performance and quality movement which has a 'ready,fire, aim' philosophy".
In the tight control group 27.5 % died versus 24.9 % deaths in the conventional treatment group.Severe hypoglycemia (less than 40) occurred in 6. 5 % of the intensive treatment group versus 0.5 % in the conventional treatment group illustrating once more that more insulin may drive the blood sugar too low and be harmful.
Even though meta-analysis have generated conflicting results regarding the efficacy and safety of tight glucose control, both the American Diabetes Association and the American Society of Clinical Endocrinologists have recommended tight control.
The study authors of the NICE trial offered this understatement "Our findings suggest that a goal of normoglycemia for glucose control does not necessarily benefit critically ill patients and may be harmful",
This seems to be another example of the ready, shoot, aim approach to guidelines bringing to mind the ill advised rush to give everyone beta blockers peri-operatively which was probably laid to rest with the publication of the POISE Trial. Let me repeat what I said after that trial was published.
If there is a lesson here it is not just that a large randomized clinical trial gives results opposite to earlier smaller trials-that is a story we have heard more than once before. The lesson is not that expert committees sometimes have to revise their recommendations as new information becomes available.The lesson I think that should be emphasized is that overzealous quality rule writers and enforcers can be a hazard to your health ( and I have said that before). Read Dr. Devereaux's comments regarding how many patients may have been harmed by taking peri operative beta blockers and then wonder how many patients received them simply because premature quality guidelines were in place and physicians were caught up in the rush to treat even though it seems clear now that the evidence for such zealous efforts was inadequate. Dr. DB (AKA Dr. Robert Centor) nailed it when he recently spoke about in this regard " the performance and quality movement which has a 'ready,fire, aim' philosophy".
The other side of the health Care "debate"
As for as the main stream medical journals (JAMA, NEJM, Annals Internal Medicine) the health care issue is largely already decided with certain conclusions reached and as such now exist beyond debate or refutation. The conclusions are :U.S. health care costs too much, many folks are "denied" access to care and the care is of inferior quality to that received in the other developed countries.
There are cogent arguments to the contrary and those can be found here.
The authors include John Goodman , a Phd in Economics and a prolific author on the subject of health care economics but unlike Uwe Reinhardt is rarely quoted in the big three journals mentioned above. (It seems to help to be on the board of a managed care company to get quoted in JAMA).
Another author is Dr. Robert M Sade. I first heard of Dr. Sade when he published a NEJM article in support of the proposition that health care is not a right. The type of fire storm that his article elicited was not unexpected and included a blistering admonition from the editor of the journal. Dr. Sade, a trained heart surgeon, later left practice and has devoted some of his energies to biomedical ethics and health policy and organ transplantation issues.
Dr. Wes gives his views on the "broken health care system" here.
There are cogent arguments to the contrary and those can be found here.
The authors include John Goodman , a Phd in Economics and a prolific author on the subject of health care economics but unlike Uwe Reinhardt is rarely quoted in the big three journals mentioned above. (It seems to help to be on the board of a managed care company to get quoted in JAMA).
Another author is Dr. Robert M Sade. I first heard of Dr. Sade when he published a NEJM article in support of the proposition that health care is not a right. The type of fire storm that his article elicited was not unexpected and included a blistering admonition from the editor of the journal. Dr. Sade, a trained heart surgeon, later left practice and has devoted some of his energies to biomedical ethics and health policy and organ transplantation issues.
Dr. Wes gives his views on the "broken health care system" here.
Monday, March 23, 2009
The new HFA inhalers may or may not help the environment and drug companies but are the users the forgotten men?
Here is on article discussing the possible cons of the introduction of the HFA inhalers and the outlawing of the older CFC type (except for Maxair).
Some patients complain they do not work as well and more complain about the increased costs and more than a few physicians have spent time educating patients regarding their use and offering reassurance.
If you wonder, as I do, about how much effect the CFC pulmonary inhalers have on ozone depletion and how much good this prohibition will generate, this reference might offer some information and opinion in that regard.
When I wrote about this before I said:
.. I think this is the first time that the FDA [has banned] a medication or group of medications not because they are thought or proven to be harmful to those who use them but because they are thought to possibly harm folks who do not use it. (OK, the purported skin carcinogenic effect of increased sun rays from the purported decrease in ozone layer thickness would affect everyone- even asthmatics.) Since the task of determining harm to medication users has proven much harder that the FDA or anyone ever thought, it is admirable that the FDA will take on an even more difficult task.
I don't have a tracking on the course this regulation took through the regulatory mechanisms and who supported it, but I cannot help but wonder if we are dealing with still another instance of the "Baptists and the Bootleggers". Since there are no generic versions of the HFA inhalers, guess who the bootleggers would be and would the Baptist role be played be the more radical environmentalists?
Some patients complain they do not work as well and more complain about the increased costs and more than a few physicians have spent time educating patients regarding their use and offering reassurance.
If you wonder, as I do, about how much effect the CFC pulmonary inhalers have on ozone depletion and how much good this prohibition will generate, this reference might offer some information and opinion in that regard.
When I wrote about this before I said:
.. I think this is the first time that the FDA [has banned] a medication or group of medications not because they are thought or proven to be harmful to those who use them but because they are thought to possibly harm folks who do not use it. (OK, the purported skin carcinogenic effect of increased sun rays from the purported decrease in ozone layer thickness would affect everyone- even asthmatics.) Since the task of determining harm to medication users has proven much harder that the FDA or anyone ever thought, it is admirable that the FDA will take on an even more difficult task.
I don't have a tracking on the course this regulation took through the regulatory mechanisms and who supported it, but I cannot help but wonder if we are dealing with still another instance of the "Baptists and the Bootleggers". Since there are no generic versions of the HFA inhalers, guess who the bootleggers would be and would the Baptist role be played be the more radical environmentalists?
Friday, March 13, 2009
Wait-Maybe electronic medical records might not save money.
We have been told by President Obama that we cannot fix the economic mess without fixing health care (and education and the environment, for that matter). OK, some of us think that may rank as the non sequitur of the year (decade?) but let us look deeper. Electronic medical records (EMR) has been heralded as one of the ways we can simultaneously improve quality,provide medical care for all and save money. One prominent medical blogger and a fairly well known medical author both suggest that might not be true at least in regard to money part.
KevinMD, see here, offers a interesting take. Hospitals may get more proficient at maximizing coding techniques with computers and therefore increase their share of the medicare and insurance pots and thereby increase costs.With the stimulus plan the government will give money to the hospitals to get the computer systems to code better and get more payments.
Dr. Jerome Groopman whose writings on medical cognitive tricks and traps has now taken on the topic of putative savings from EMR and challenges the often quoted Rand study that claims EMR would save huge amounts of money.See here.The study needs to be analyzed on its own merits as Dr. G. apparently has done but it did not go unnoticed that the study was founded by HP and Xerox, who could be described as interested parties. We all know how the money behind drug studies always raises a red flag and a reflex skepticism of the results but here only now ( at least I can't find other references) does someone make that point with the Rand study.
KevinMD, see here, offers a interesting take. Hospitals may get more proficient at maximizing coding techniques with computers and therefore increase their share of the medicare and insurance pots and thereby increase costs.With the stimulus plan the government will give money to the hospitals to get the computer systems to code better and get more payments.
Dr. Jerome Groopman whose writings on medical cognitive tricks and traps has now taken on the topic of putative savings from EMR and challenges the often quoted Rand study that claims EMR would save huge amounts of money.See here.The study needs to be analyzed on its own merits as Dr. G. apparently has done but it did not go unnoticed that the study was founded by HP and Xerox, who could be described as interested parties. We all know how the money behind drug studies always raises a red flag and a reflex skepticism of the results but here only now ( at least I can't find other references) does someone make that point with the Rand study.
Sunday, March 08, 2009
What does universal health care have to do with the economic mess?
Tell me again why we cannot get out of this economic mess without fixing health care? I have read over twenty putative explanations for why and how we got where we are in one scary recession and so far none of the financial pundits nor card carrying economists have suggested that lack of medical coverage and too high health care costs caused the problem or was even a major contributing cause.
I have read that we had first a housing boom and then a bubble and then a crash whose effects were hyper-amplified beyond most analysts' wildest fears by a situation in which: entities that made loans sold them to others who packaged them in ways few understood, many of the loans were made to people who could not afford them,mortgage based securities (MBS) based in part on bad loan were markedly overvalued by rating companies,financial entities who bought and sold MBSs were dangerously over leveraged and according to one school of economic thought (the Austrian School) a major driving force was the artificially low interest rate driven down by the Federal Reserve system in this country and by other central banks around the world.
If one plows through a lucid and laboriously documented academic discussion by Marcus Brunnermeier from Princeton's economic department you will be treated to a discussion of how he suggests the housing bubble was made possible by cheap credit supplied both by a surplus of foreign ( mainly Asian) money looking for a good return on investment and an expansionary Federal Reserve Policy,of lowered lending standards ,of major changes in the banking system (i.e. going from loan and keep , to loan and sell off the loans), of various actions by banks to establish a "shadow banking"system involving off balance sheet investment vehicles exposing them to liquidity risk, of investments entities relying more and more on a borrow short and loan long arrangement . In short he describes elements of the events that took place as a mortgage crisis was amplified into a severe finanacial crisis.
If medical costs and folks without medical insurance played a role in any of this he and every other economists and financial analysts and pundits who has written about it really missed the boat.
Yet, we told by the new administration that we cannot get out of this financial mess without fixing the health care system. We are told that for recovery we will have to simultaneously cut medical care costs and ensure that everyone has medical care and improve quality of care. Of course, there are good arguments to the point that we do spend a lot of medical care and thoughtful people have a legitimate concern that some folks do not have health insurance and that there is a great deal that needs fixing but what do those concerns have to do with a housing bubble,burst, and mortgage crisis amplified into a financial crisis and why is a health care fix a necessary part of recovery?
Dr. Krauthammer hammered away at what he describes as Obama's glaring non-sequiturs in his Washington Post commentary dated 3/6/2009 entitle "The great Non-sequitur"
President Obama has asserted that the mess we are in relates to the country failing to obtain universal health care, green energy and better education. Dr. Krauthammer gives us this quote from the President's speech in which we are seemingly finally told why the real reasons of why we are where we are now:
"Our economy did not fall into decline overnight," he averred. Indeed, it all began before the housing crisis. What did we do wrong? We are paying for past sins in three principal areas: energy, health care and education -- importing too much oil and not finding new sources of energy (as in the Arctic National Wildlife Refuge and the Outer Continental Shelf?), not reforming health care, and tolerating too many bad schools.
Krauthammer says in reply:
.. the list of causes of the collapse of the financial system does not include the absence of universal health care, let alone of computerized medical records. Nor the absence of an industry-killing cap-and-trade carbon levy. Nor the lack of college graduates. Indeed, one could perversely make the case that, if anything, the proliferation of overeducated, Gucci-wearing, smart-ass MBAs inventing ever more sophisticated and opaque mathematical models and debt instruments helped get us into this credit catastrophe. .......
Clever politics, but intellectually dishonest to the core. Health, education and energy -- worthy and weighty as they may be -- are not the cause of our financial collapse. And they are not the cure. The fraudulent claim that they are both cause and cure is the rhetorical device by which an ambitious president intends to enact the most radical agenda of social transformation seen in our lifetime.
Whether on not you agree with Dr.K's characterization of what Mr. Obama's agenda really is, it is very hard to accept the claim that fixing his big three initiative is necessary for the economic repair.To be fair I have to recuse myself regarding expressing an opinion on the carbon cap and trade issue,I have not researched that enough to justify comment but if the lack of a universal health care plan in this country is a cause of the economic downturn, it must be the best keep secret on the century. Should not Great Britain have been spared the economic turmoil since they have had a universal health coverage system in place for years?
I have read that we had first a housing boom and then a bubble and then a crash whose effects were hyper-amplified beyond most analysts' wildest fears by a situation in which: entities that made loans sold them to others who packaged them in ways few understood, many of the loans were made to people who could not afford them,mortgage based securities (MBS) based in part on bad loan were markedly overvalued by rating companies,financial entities who bought and sold MBSs were dangerously over leveraged and according to one school of economic thought (the Austrian School) a major driving force was the artificially low interest rate driven down by the Federal Reserve system in this country and by other central banks around the world.
If one plows through a lucid and laboriously documented academic discussion by Marcus Brunnermeier from Princeton's economic department you will be treated to a discussion of how he suggests the housing bubble was made possible by cheap credit supplied both by a surplus of foreign ( mainly Asian) money looking for a good return on investment and an expansionary Federal Reserve Policy,of lowered lending standards ,of major changes in the banking system (i.e. going from loan and keep , to loan and sell off the loans), of various actions by banks to establish a "shadow banking"system involving off balance sheet investment vehicles exposing them to liquidity risk, of investments entities relying more and more on a borrow short and loan long arrangement . In short he describes elements of the events that took place as a mortgage crisis was amplified into a severe finanacial crisis.
If medical costs and folks without medical insurance played a role in any of this he and every other economists and financial analysts and pundits who has written about it really missed the boat.
Yet, we told by the new administration that we cannot get out of this financial mess without fixing the health care system. We are told that for recovery we will have to simultaneously cut medical care costs and ensure that everyone has medical care and improve quality of care. Of course, there are good arguments to the point that we do spend a lot of medical care and thoughtful people have a legitimate concern that some folks do not have health insurance and that there is a great deal that needs fixing but what do those concerns have to do with a housing bubble,burst, and mortgage crisis amplified into a financial crisis and why is a health care fix a necessary part of recovery?
Dr. Krauthammer hammered away at what he describes as Obama's glaring non-sequiturs in his Washington Post commentary dated 3/6/2009 entitle "The great Non-sequitur"
President Obama has asserted that the mess we are in relates to the country failing to obtain universal health care, green energy and better education. Dr. Krauthammer gives us this quote from the President's speech in which we are seemingly finally told why the real reasons of why we are where we are now:
"Our economy did not fall into decline overnight," he averred. Indeed, it all began before the housing crisis. What did we do wrong? We are paying for past sins in three principal areas: energy, health care and education -- importing too much oil and not finding new sources of energy (as in the Arctic National Wildlife Refuge and the Outer Continental Shelf?), not reforming health care, and tolerating too many bad schools.
Krauthammer says in reply:
.. the list of causes of the collapse of the financial system does not include the absence of universal health care, let alone of computerized medical records. Nor the absence of an industry-killing cap-and-trade carbon levy. Nor the lack of college graduates. Indeed, one could perversely make the case that, if anything, the proliferation of overeducated, Gucci-wearing, smart-ass MBAs inventing ever more sophisticated and opaque mathematical models and debt instruments helped get us into this credit catastrophe. .......
Clever politics, but intellectually dishonest to the core. Health, education and energy -- worthy and weighty as they may be -- are not the cause of our financial collapse. And they are not the cure. The fraudulent claim that they are both cause and cure is the rhetorical device by which an ambitious president intends to enact the most radical agenda of social transformation seen in our lifetime.
Whether on not you agree with Dr.K's characterization of what Mr. Obama's agenda really is, it is very hard to accept the claim that fixing his big three initiative is necessary for the economic repair.To be fair I have to recuse myself regarding expressing an opinion on the carbon cap and trade issue,I have not researched that enough to justify comment but if the lack of a universal health care plan in this country is a cause of the economic downturn, it must be the best keep secret on the century. Should not Great Britain have been spared the economic turmoil since they have had a universal health coverage system in place for years?
Thursday, March 05, 2009
Two (three) must read articles on clinical guidelines
Clinical guidelines,virtually non-existent a few decades ago now have reached hyper-epidemic proportions. Two of the best medical bloggers have recently penned commentaries that are must reading. DM,know in the real world as Dr.Robert Centor published a great editorial in JAMA
DrRich, known in real life as Dr. Fogoros wrote the blog postings linked below and as usual gives a take on the guidelines issue that should make physicians and other interested readers sit up and notice and one that I'll bet you won't see elsewhere. Dr. Fogoros is a card-carrying cardiologist (well maybe, he does not carry his card any longer and after they read his Part 2, they may try to take the card away) and with the credibility that should go with that dives into the subject of cardiology guidelines.Part 1 is good but Part 2 should knock your socks off and offers a great insight into what we might expect from comparative effectiveness research even if the government sponsors it as long as they use humans to do the work.
DrRich, known in real life as Dr. Fogoros wrote the blog postings linked below and as usual gives a take on the guidelines issue that should make physicians and other interested readers sit up and notice and one that I'll bet you won't see elsewhere. Dr. Fogoros is a card-carrying cardiologist (well maybe, he does not carry his card any longer and after they read his Part 2, they may try to take the card away) and with the credibility that should go with that dives into the subject of cardiology guidelines.Part 1 is good but Part 2 should knock your socks off and offers a great insight into what we might expect from comparative effectiveness research even if the government sponsors it as long as they use humans to do the work.
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