Friday, July 24, 2015

Unintended Consequences Of Grading Doctors

Dr. Sandeep Jauhar has a nice piece in the 7/22/2015 New York Times, "Giving Doctors Grades".

He discusses some of the negative unintended consequences of "report cards" that supposedly rate a surgeon's quality based on patient mortality and complication outcome data.  In essence, they discouraged surgeons from taking on the tougher cases and instead created a perverse incentive for them to "cherry pick" only the healthiest patients.

He cited experience from New York state, which has used such report cards since the 1990s:
They often penalized surgeons, like the senior surgeon at my hospital, who were aggressive about treating very sick patients and thus incurred higher mortality rates. When the statistics were publicized, some talented surgeons with higher-than-expected mortality statistics lost their operating privileges, while others, whose risk aversion had earned them lower-than-predicted rates, used the report cards to promote their services in advertisements.

This was an insult that the senior surgeon at my hospital could no longer countenance. “The so-called best surgeons are only doing the most straightforward cases,” he said disdainfully. Research since then has largely supported his claim...
And:
Surgical report cards are a classic example of how a well-meaning program in medicine can have unintended consequences. Of course, formulas have been developed to try to adjust for the difficulty of surgical cases and level the playing field. For example, a patient undergoing coronary bypass surgery who has no other significant diseases has an average mortality risk of about 1 percent. If the patient also has severe kidney dysfunction and emphysema, the risk of death increases to 10 percent or more. However, many surgeons believe that such formulas still underestimate surgical risk and do not properly account for intangible factors, such as patient frailty.

The best surgeons tend to operate at teaching hospitals, where the patients are the most challenging, but you wouldn’t know it from mortality statistics. It’s like high school students’ being penalized for taking Advanced Placement courses. College admissions officers are supposed to adjust grade point averages for difficulty of coursework, but as with surgical report cards, the formulas are far from perfect.

The problem is compounded by the small number of operations — no more than 100 per year — that a typical cardiac surgeon performs. Basic statistics tell us that the “true” mortality rate of a surgeon is not what you measure after a small number of operations. The smaller the sample, the greater the deviation from the true average.
It's not that quality metrics are completely useless. But they can be dangerously misleading. And they can create perverse incentives that harm both patients and physicians. (Via H.R.)

Wednesday, July 22, 2015

Dropout Doctors

An interesting new article discusses, "Dropout Docs: Bay Area Doctors Quit Medicine to Work for Digital Health Startups"

One quote from the article:
Tech culture is very appealing when juxtaposed against the hierarchy and myriad hoops to be jumped through in clinical medicine.
Another quote:
Many of the dropout docs expressed a desire to improve the doctor-patient experience. In interviews with KQED, several said they spent very little time administering care during medical school, and they felt that patients were too often kept out of the loop.

A recent study found that doctors-in-training spend an average of just eight minutes with each patient. This is a drastic decrease from previous generations and is linked to more record-keeping requirements and restricted on-duty hours.
If young physicians find entrepreneurship more rewarding than clinical medicine, perhaps those who are setting the rules governing clinical medicine need to re-examine their policies. Until then, med school graduates should pursue whatever careers that they find the most professionally and personally satisfying.


Tuesday, July 14, 2015

The Power Of "I Don't Know"

From John Tamny at Forbes: "'I Don't Know': The Ideal Libertarian And Conservative Response To Obamacare's Failings".

It's important to combat the notion of central planning with freedom, not merely an alternative version of central planning.  By definition, freedom can yield new solutions not anticipated by anyone ahead of time.

Tuesday, July 7, 2015

Hsieh Quoted on Guns And Public Health In US News & World Report

Today's US News & World Report had a nice piece on the debate over whether gun violence should be considered a "public health" issue, and they quoted me as explaining why it should not be:
But some medical providers say doctors should stay out of the debate. Dr. Paul Hsieh, co-founder of Freedom and Individual Rights in Medicine, says he views gun crime and violence as predominantly about criminal justice and individual rights.

"I remain deeply skeptical of any attempts to frame important public policy debates as also 'public health' issues, especially when it concerns a long-running political controversy," says Hsieh, who writes on health care policy from a free-market perspective for Forbes.com. "Pretty much any public policy issue will ultimately have some sort of effects on the lives and well-being of Americans – but that doesn't mean they should all be considered topics of 'public health.'"

People are concerned that sharing information about gun ownership with doctors may not remain private, he wrote in a Forbes piece. "In short, I believe this undermines the critical doctor-patient trust necessary for the good practice of medicine," he says.
I thought they characterized my views fairly, and I was pleasantly surprised to see that they even turned the quote into one of the lead article graphics!


Monday, June 29, 2015

Hsieh Forbes Column: 3 Good Things In Health Care Innovation

My latest Forbes column is now up, "Three Good Things In Health Care Innovation".

I highlight some under-appreciated good developments in health care, centered around the theme that innovations in processes may be less flashy than innovations in technology — but can still save lives.

In particular, I discuss the following:
1) Improvements in cardiac care
2) Improvements in matching kidney transplant donors with recipients
3) Protecting the freedom of direct pay doctors
Our current system is very mixed, with both good and bad elements. Today, I wanted to focus on some of the good elements.

For more details on each, read the full text of "Three Good Things In Health Care Innovation".

Friday, June 26, 2015

Cowen On King

Naturally, there has been an enormous amount of commentary on the SCOTUS ruling yesterday salvaging the ObamaCare subsidies.

The quote I liked the best comes from economist Tyler Cowen:
I have not been a fan of Obamacare, which I consider to be a highly inefficient form of wealth insurance. Nonetheless, had this decision gone the other way at this point we would have ended up with something worse, or ended back at “Obamacare as know it,” but only after a lot of political stupidity and also painful media coverage. So on net I take this to be good news, although arguably it is bad news that it is good news.