Jumping Through Quality Hoops

The Washington Post reports, "The Obama administration wants to dramatically change how doctors are paid".

Essentially, they wish to move away from the standard fee-for-service model and towards payments based on "quality".

In theory, this sounds good -- after all, who could possibly be opposed to quality?  And it's true that there are perverse incentives in the current system, where doctors get paid regardless of whether they are doing a good job or not.

But the various "quality" measures and "pay for performance" incentives we've seen so far from Medicare and Medicaid have at best a tenuous relationship with what most patients would see as "quality" care.  And this is an inherent problem in any system where the person receiving the service isn't the person paying for it.

As Dr. Michael Kirsch explained last year, many of these measures have "nothing to do about real medical quality, but... everything do about cost control." 

Patient care can also suffer, as physicians have to choose between following the quality measures vs. doing what's actually right for the patient. These quality measures can introduce their own perverse incentives.

For example, there was a push a few years ago to reward ER physicians for getting patients with pneumonia on antibiotics within a certain time frame.  As an ER radiologist, our job was to call the ER physician ASAP everytime we saw a chest x-ray on a patient that showed possible pneumonia so the treating physician could start the therapy within the allotted time.

Of course, this also took time away from other equally urgent work (for which there was no bonus.)

And this might not have been good for the patients either. Officials at the Centers for Medicare and Medicaid Service admitted that some of these measures could result in "inappropriate delivery of a service to some patients (such as delivery of antibiotics to patients without a confirmed diagnosis of pneumonia), unduly conservative decisions on whether to exclude some patients from the measure denominator, and a focus on meeting the benchmark at the expense of actual improvements in quality or patient outcomes."

As we see more quality measures introduced, we'll also see Goodhart's Law in action: "When a measure becomes a target, it ceases to be a good measure."  People will work to meet the metric, but that will have increasingly less value as a measure of whether actual quality care is being delivered. 

(Think of school teachers who teach "for the test" in order to maximize their students' scores on the standardized tests, and how that corrodes real learning.)

There's much more to be said on this topic, which I'll have to leave for a later time.  

Hsieh Forbes Column on "Right To Die"

My latest Forbes piece is now out, "Does Your Right To Life Include The Right To Die?"

I discuss the revived debate over physician-assisted suicide, especially in the wake of Brittany Maynard's decision to end her life following a diagnosis of terminal brain cancer. This issue is being debated in several state legislatures, including New Jersey and California, so we will be hearing much more about this in coming months.

I recognize that this is a controversial topic and that good physicians can disagree on this issue. Nonetheless, I believe this should be a legal option for patients, provided that there are appropriate safeguard to protect both the patient and the physician.

In my piece I cover three main subpoints:

1) Your life is your own.
2) The state has a legitimate (even vital) role to play in assisted suicide.
3) Physicians must not be required to participate

For more details, please read the full text of "Does Your Right To Life Include The Right To Die?"

(Much of this material is drawn from the recent Philosophy In Action podcast by my wife Dr. Diana Hsieh and her co-host Greg Perkins in their 1/18/2015 segment, "The Right To Die".)

(Photo: Brittany Maynard by Allie Hoffman
Creative Commons Attribution – Share Alike)

Epstein: The Baby Who Lived

Alex Epstein has a nice piece in Forbes entitled, "The Baby Who Lived: How Energy Saved My Friend's Son".

He talks about energy production, medical progress, and how those products of human ingenuity helped Pari, Keith, and their newborn son Charlie (pictured below, with their other son.)

From Epstein's piece:

It’s easy to take for granted that we have the ability to detect early problems with babies—not thinking that absent the machine that can detect those problems and the energy to power that machine, human beings past and present have lost untold millions of babies. It’s easy to take for granted that we have the ability to keep a three-and-a-half-pound baby alive—not thinking that absent the machine that can incubate it and the energy to power that machine, most of people’s beloved children who were born underweight would have died.

If the machines that move modern medicine don’t have energy, they are useless...

(Epstein is the author of the recent book, The Moral Case For Fossil Fuels.)

Quick Links: Canada, Medicaid, Doctors Switching Careers

"The Doctor Will See You in 18.2 Weeks". Update on waiting times in Canada's single payer system.

CNBC: "The great Obamacare-Medicaid bait 'n' switch"

Forbes: "1 In 4 New Doctors Would Change Careers If They Could Start Over"

Food Labelling Update

Ilya Somin: "Over 80 percent of Americans support 'mandatory labels on foods containing DNA'".

And watch out for that dihydrogen monoxide! 

Personally, I'm ok with DNA in my food as long as it's organic.

NYT on "Right To Try"

The 1/10/2015 New York Times had a detailed article on a growing grass-roots push for medical freedom, "Patients Seek 'Right to Try' New Drugs".

Some excerpts:

Since May, a string of states have passed laws that give critically ill patients the right to try medications that have not been approved by the Food and Drug Administration.

Deemed “Right to Try” laws, they have passed quickly and often unanimously in Colorado, Michigan, Missouri, Louisiana and Arizona, bringing hope to patients like Larry Kutt, who lives in this small town at the edge of the Rocky Mountains. Mr. Kutt, 65, has an advanced blood cancer and says his state’s law could help him gain access to a therapy that several pharmaceutical companies are testing. “It’s my life,” he said, “and I want the chance to save it.”

...The Colorado law, which is similar to ones in other states, permits terminally ill patients who have exhausted their treatment options — including clinical trials — to obtain therapies that have passed at least the first of three F.D.A. investigation phases. The law does not require companies to provide the treatment, nor does it mandate that insurance companies cover it; the law also allows insurance companies to deny coverage to patients while they use drugs under investigation.

The article also notes that the FDA has its own program for allowing ill patients to try unapproved drugs. But patients and their families complain that the bureaucratic delays can be too long.  One patient advocate said: "We don’t have time to jack around with bureaucratic practices when someone’s life is on the line."

I'm glad more patients are fighting for this option.  They're not violating anyone else's rights. And this might be their only chance.

Related graphic from US News & World Report:

 

Klein: EMRs Can Hurt MDs During Lawsuits

Dr. Keith Klein: "EMRs can hurt physicians during lawsuits. Here's how."

In particular, he warns of 3 common errors: incorrect information, copy-and-paste, and poor note-taking.  From his article:

Copy-and-paste is a necessary evil to save time during documentation of daily notes, but whatever is pasted must also be edited to reflect the current situation. Too often, the note makes reference to something that happened “yesterday.” For example, the sentence “Patient presented to ED with chest pain yesterday…” is pasted over the next two weeks in the daily progress note. An even more telling example is a sentence like “Patient’s admitting lab is normal…” being perpetuated while the actual creatinine levels rise every day.

In one case, the judge commented about copy-and-paste issues: “I cannot trust any of the physician notes in which this occurred and the only conclusion I can reach is that there was no examination of the patient … it means to me that no true thought was given to the content that was going into ‘the note.’”

Checkboxes, particularly those that pre-populate, can be a physician’s nemesis. It’s easy to click on checkboxes, and often they are pre-checked in templates. EMRs have been presented in court that show, through checkboxes, daily breast exams on comatose patients in the ICU, detailed daily neurological exams done by cardiologists, and a complete review of systems done by multiple treating physicians on comatose patients. Questioning in court as to how long it takes to do a review of systems and a physical examination, the patient load of the physician for that day, and how many hours the physician was at work cast doubt on the truthfulness of the testifying physician. A time analysis showed that there was no way the physician could have accomplished all that was charted that day.

Every physician obliged to work with EMRs should read Dr. Klein's piece.

Catron Explains ObamaCare 2015

David Catron has a nice rundown of the 2015 current health law: "Obamacare: The Real Pain Starts This Year".

Key new consequences include the employer mandate, higher premiums, more crowded emergency rooms, and reduced willingness of physicians to see government-insured patients.

Catron's bottom line:

Welcome to the brave new world of U.S. health care as reformed by the President and congressional Democrats. It is precisely the opposite of what most Americans wanted from reform. Eight months before Obamacare passed, Gallup conducted a survey in which a majority of the public unequivocally stated that controlling costs was its highest priority. Obamacare is actually increasing costs for both patients and providers, while reducing access for the former. And this is just the beginning. The pain will continue to increase until this malignant tumor is cut out of our health care system.

As always, theoretical "coverage" does not equal actual medical care.  Governments can promise the former, but not the latter.  For many Americans, this won't be quite so happy of a New Year.

(For more details, read the full text of, "Obamacare: The Real Pain Starts This Year".)

Irony At Harvard

Yesterday, the New York Times reported that, "Health Care Fixes Backed by Harvard's Experts Now Roil Its Faculty".

Basically, Harvard faculty are themselves feeling the effects of ObamaCare:

In Harvard’s health care enrollment guide for 2015, the university said it “must respond to the national trend of rising health care costs, including some driven by health care reform,” otherwise known as the Affordable Care Act. The guide said that Harvard faced “added costs” because of provisions in the health care law that extend coverage for children up to age 26, offer free preventive services like mammograms and colonoscopies and, starting in 2018, add a tax on high-cost insurance, known as the Cadillac tax.

Some related commentary:

Michael Cannon, Forbes, "Is The Faculty Of Harvard University Irrational?"
Megan McArdle, Bloomberg View, "Whining Harvard Professors Discover Obamacare".

Right now, I'm playing a teensy-weensy violin for the Harvard faculty.  (Image below from Amazon.)

Two From Adalja

Two recent pieces from Dr. Amesh Adalja.

"Too Big to Profit?", Forbes, 1/2/2015.
("Profit in medicine—considered a dirty subject today—is what helped to feed me.")

"Why Did 5000 Chickens Almost Cross the Road?", Tracking Zebra, 1/4/2015.
("To know infectious disease is to know the world.")

Catron On Legal Perils For ObamaCare

David Catron discusses 3 upcoming legal perils for ObamaCare in 2015.

Here is the opening to his piece:

Recent news coverage concerning Obamacare’s legal difficulties has been dominated by King v. Burwell, which challenges the controversial IRS decision to issue subsidies and penalties through federally created insurance exchanges in 34 states that refused set up PPACA “marketplaces.” The Supreme Court announced last month that it would take up King, and it will hear oral arguments in March. The alacrity with which the Court took up the case, upon which it will hand down a ruling in June, has rendered the law’s supporters nearly hysterical. But King is by no means the only legal threat Obamacare will face next year.

Ironically, considering the number of apocalyptic headlines it has produced, King v. Burwell probably presents less danger to the “reform” law than either of two additional lawsuits the Court could take up in 2015. The justices have already received a cert petition to hear Coons v. Lew, whose plaintiffs hold that Obamacare's Independent Payment Advisory Board (IPAB) constitutes a violation of the separation of powers doctrine. And it is a virtual certainty that the Court will also be asked to take up Sissel v. HHS, which challenges the law on the grounds that its passage violated the Constitution’s origination clause...

As Catron notes, none of these are "frivolous" lawsuits.  For more details, read the full text of his piece, "Obamacare's Coming Year of Living Dangerously".