Burdensome Guidelines

The New York Times reports, "According to Medical Guidelines, Your Doctor Needs a 27-Hour Workday"\

Some excerpts:

The intent is admirable: Give doctors guidelines so they can be sure to cover what needs to be discussed with patients and help select options. Let’s talk about your diet and any problems you might have sleeping. Are you getting enough exercise? If not, here is some advice. You are due for colon cancer screening. Do you prefer a colonoscopy or a fecal test? Here are the pros and cons of each.

But there is a problem. There are just not enough hours in a workday to discuss and act on all the guidelines...

[I]magine a doctor shrugged off the chronic and acute care, as well as administrative work, and merely followed the preventive care checklist recommended by the U.S. Preventive Services Task Force, an independent panel of health experts. That would be 8.6 of the doctor’s hours each day, according to a study in the American Journal of Public Health.

As anyone who has been sped through a 15-minute annual wellness visit knows, doctors cannot be so exacting. That the guidelines are so thorough yet so often glossed over prompts questions about their usefulness. At the same time, doctors’ pay often depends on checking off guideline boxes.

This is not just a problem in the US: 

[I]mplementing all the British guidelines for improving patients’ lifestyles could require more doctors and nurses than are practicing in the entirety of Britain. 

Good intentions from central planners does not always translate to actual good medical practice by physicians on the ground.

Human Stories Vs. Electronic Medical Records

Dr. Susan Koven describes how, "As hospitals go digital, human stories get left behind".

Dr. Koven described an encounter with a patient, with enormously rich detail. But when she had to record the information in the electronic medical records, the system hampered her ability to tie key connections together:

My warm feelings vanished as I sat down to document the visit. While I’ve used an electronic medical record for several years, Epic, the system my hospital recently adopted, makes recording stories such as the one my patient shared especially difficult. Her grief and her fatigue, which are inseparable in reality, Epic treats as different problems. That she lives alone and there’s conflict in her extended family, which are also inextricable from her symptoms, must be filed under a tab marked “Social Documentation.”

Epic features lists of diagnoses and template-generated descriptions of symptoms and physical examination findings. But it provides little sense of how one event led to the next, how one symptom relates to another, the emotional context in which the symptoms or events occurred, or the thought process of the physician trying to pull together individual strands of data into a coherent narrative. Epic is not well-suited to communicating a patient’s complex experience or a physician’s interpretation of that experience as it evolves over time, which is to say: Epic is not built to tell a story...

The risk of this format, as physician and medical informatics expert Dr. Robert Wachter points out in a blog post, is that we may forget that “patients are more than the sum of their problems.”

A medical record that abandons narrative in favor of a list does more than dehumanize our patients. It also hampers a clinician’s diagnostic abilities. Take a patient I saw recently, a middle-aged woman with palpitations. She was perimenopausal, stressed out at work, having trouble sleeping, drinking lots of coffee to stay awake during the day, and had a family history of heart disease. Any one of those issues might explain her palpitations, but more likely some combination of interrelated factors was causing them. Sorting out the story is crucial to deciding which tests to order and what treatment to recommend.

The electronic records may make life easier for the hospital billing department. And they may make life easier for researchers trying to do population-based studies. But if it hampers the primary care physician's ability to actually care for the patient, we have a problem.

Catron Critiques Trump

David Catron of The American Spectator has a pretty harsh critique of Donald Trump's health care plan from the conservative perspective in his 3/14/2016 piece, "Trumpcare: A Hazy Plan From a Lazy Man".

From the opening of Catron's piece:

[T]ake a minute to peruse the health care proposal he has finally cobbled together and posted on his campaign website. And, rest assured, it won’t take more than a minute to read. Trump’s “plan” consists of seven random nostrums that appear to have been hastily cribbed from conservative and libertarian websites by his various flunkies. And it confirms yet again that neither “the Donald” nor his yes men are willing to do their homework...

(Catron also offers some broader commentary on Trump's campaign and isn't impressed.)

Armstrong On Insurance Vs. Care

Dr. Richard Armstrong of the Docs4PatientCare Foundation has another nice column out, "Why Health Insurance doesn't equal Health Care".

Armstrong's basic thesis is simple:

Health insurance as commonly “understood” is not true insurance.  This is one of the significant causes of our current national misunderstanding of health care financing which underlines the importance of these educational efforts.

But the details are important. He traces the transformation of insurance from simple risk pooling for rare-but-expensive events to the current dysfunctional system. And in the process also discusses some solutions to our current problems, such as Direct Primary Care.

(Read the full text of, "Why Health Insurance doesn't equal Health Care".)

Armstrong on Quality

Dr. Richard Armstrong asks (and answers) a critical question: "Who Determines Quality in Health Care?"

A couple of excerpts:

[E]verywhere you turn someone is measuring something or surveying something or requiring the reporting of metrics. Patients are flooded with satisfaction surveys, doctors are inundated with pay for performance reporting requirements, physician quality reporting systems and, soon on the horizon from the federal government, the new Merit Based Incentive System. It’s enough to make your head spin. So, just exactly what is going on?...

An estimated $3.5 trillion moves through our health care economy yearly. It should be no surprise that those who are purchasing health care would be concerned about the quality and value of their purchase. What is problematic is this…how do you measure it? Also, how can anyone be certain that they are measuring the “correct” things? 

To concretize the issue, Dr. Armstrong poses an example of a patient "Jack" who needs a hernia repair. As a surgeon, Dr. Armstrong will work conscientiously to do his best by Jack. But Armstrong notes:

[T]he doctor should be working for the patient. But what happens when a third party, a private insurance company or the government is the purchaser of health care on behalf of the patient consumer? We are experiencing that today in America and the confusion is becoming mind numbing for both patients and doctors...

Our “system” needs to focus clearly on producing high quality physicians and surgeons who understand why Jack and his family need quality care and that ultimately we are responsible to them, the patients. 

It is no surprise that those who are paying for the services expect quality and value. Maybe it would be wise for all of us to re-evaluate how we are paying instead of expanding ever more complex, confusing and expensive “quality assurance” processes. 

As Dr. Armstrong notes, piling on more regulations onto a flawed system based on third-party payments won't fix the underlying problem. I recommend folks read the whole piece for themselves, as I'm only scratching the surface of his discussion.

Interestingly, the New York Times recently published a piece by Dr. Robert Wachter with a similar theme: "How Measurement Fails Doctors and Teachers".  Wachter notes:

Avedis Donabedian, a professor at the University of Michigan’s School of Public Health, was a towering figure in the field of quality measurement. He developed what is known as Donabedian’s triad, which states that quality can be measured by looking at outcomes (how the subjects fared), processes (what was done) and structures (how the work was organized). In 2000, shortly before he died, he was asked about his view of quality. What this hard-nosed scientist answered is shocking at first, then somehow seems obvious.

“The secret of quality is love,” he said.

Our businesslike efforts to measure and improve quality are now blocking the altruism, indeed the love, that motivates people to enter the helping professions. While we’re figuring out how to get better, we need to tread more lightly in assessing the work of the professionals who practice in our most human and sacred fields.

By the way, there is lots more good commentary on health policy at the Docs4PatientCare Foundation website by Armstrong (pictured below) and others.

Doctors Vs. Bureaucrats

Dr. Marion Mass asks, "When will more Doctors stand up for their Patients and Themselves?"

An excerpt:

Let’s get back to what really matters: the patient. At the moment I heard about not having crucial antibiotics for a sick infant, I snapped. I walked to the nearest phone and dialed the pharmacy, “Dr. Mass here. Why is patient x waiting for meds?”………(party line reply delivered)….”I see. You are going to mix up the antibiotics and get them to the ER in ten minutes. Otherwise, I will call the hospital CEO and tell him that I am going to tell the parents that their child is in danger because of hospital policy. I will not have some (un-publishable word) bureaucrat dictate my patient’s care. What? …Oh, thank you.” Coming clean to let you know how fun and liberating that moment was, as the ER staff stared at me in shock.

I don’t wonder why more physicians don’t complain; it takes time. We are knee deep in CME, MOC, state and hospital mandates, insurance company fights, on and on. No wonder patients say we don’t take enough time with them. Furthermore, 80% of physicians are hospital-employed. Buck the system, lose a job. If you aren’t hospital-employed, you are bogged down keeping your indie practice alive for the sake of the patients you love...

Read the whole thing. (Via Dr. Megan Edison.)

Washington Post Vs. Paternalistic Breast Cancer Guidelines

Washington Post editor Marisa Bellack speaks out against paternalistic mammography guidelines in her editorial, "Don't worry your pretty little head about breast cancer".

She notes that "anxiety" is being increasingly invoked as a (bad) reason to limit screening mammography, especially for women between ages 40-49:

And yet, there was a 19th-century echo in the American Cancer Society’s announcement this past week of revised guidelines for breast cancer screening. Whereas anxiety was once a reason for aggressive medical intervention, it is now invoked to avoid intervention — an argument that is both patronizing and unscientific. There may be good reasons for women in their early 40s to forgo regular mammograms, but this isn’t one of them.

A reference to anxiety appears in the very first paragraph of the harms-and-benefits analysis commissioned by the cancer society: While early screening “reduces breast cancer mortality, there are a number of potential harms, including false-positive results, which result in both unnecessary biopsies and increased distress and anxiety related to a possible diagnosis of cancer.”

But the idea that anxiety is a major harm doesn’t have much scientific support...

There will always be uncertainty in cancer screening. And that uncertainty understandably fuels anxiety. But most false-positive mammograms are quickly resolved by additional imaging. Among the cases that progress to biopsies, 9 out of 10 show no sign of cancer. And even when there is a breast cancer diagnosis, that’s not equivalent to a death sentence. Doctors should be able to respond to anxiety rationally, putting fears in context and expediting follow-up testing and results to limit what can be an agonizing wait.

For more details, read the full text of "Don't worry your pretty little head about breast cancer".

See also this related Washington Post piece, "Why this Harvard radiologist still recommends women get mammograms at age 40".

(Link via Dr. Evan Madianos.)

Preventing Medical Errors

Medical errors will happen. As Arlene Weintraub notes in Forbes, "Doctors Are Screwing Up Diagnoses -- And Patients Should Speak Out".

An excerpt:

The authors of the IOM report identify several possible methods for encouraging patients to get more involved in their diagnoses. First, they suggest that the act of diagnosis should no longer be treated as a solitary task that takes place mostly inside a single clinician’s brain—but rather as a team effort that includes patients and their families. To achieve that, the authors admit, the entire culture of the healthcare system needs to change to one that welcomes patient feedback...

I personally think that patient should obtain their own personal copies any important medical records (including radiology studies on CT, pathology reports, etc.) in case they wish to review them at home or in consultation with an independent physician.

And overall, patients should treat physicians as advisors -- but not infallible authorities.

Adalja on Pyrimethamine and The Market

Dr. Amesh Adalja discusses "Pyrimethamine and the Market".  An excerpt:

While I have no understanding of how the new price was determined, it will eventually have to withstand the scrutiny of the market. If the price is set higher than the market will bear, because it is no longer under patent, other manufacturers will enter the market lowering prices. Ideally this would happen near instantaneously but, because of legislative barriers to entry, which include a multi-step approval process, it will take some time. Better alternatives to the current regimen may also appear in time as well.

Overall, however, infectious disease products have become less attractive to pharmaceutical companies and this, at root, is why we are left with just one manufacturer for many important non-patented products. The disincentives to enter this market are myriad and the ultimate answer to this scenario is not more intervention but to remove artificial barriers to entry, inviting the appearance of competitors in the market...

"Never Events" and Unintended Consequences

Doctors (like all people) respond to incentives. Here's one "unintended consequence" of the policy of "never events", as explained by orthopedic surgeon Dr. Thomas Guastavina:

"The sad story of how “never events” prevent obese patients from getting new hips"

Catron Takes Down Trump On Health Care

In his latest American Spectator piece, David Catron does a thorough take-down of Donald Trump on health care policy: "Trump Is No Friend of Free Market Health Care".

Here is the opening:

Most of Donald Trump’s public statements include the rote declaration that Obamacare is a disaster. This is true, of course, but it doesn’t tell us anything new. It’s only when he starts elaborating on his objections that one gets a sense of what he believes, and he doesn’t talk like a friend of the free market. During last week’s Republican debate, for example, he was asked about his past praise of single-payer health care and replied, “As far as single-payer, it works in Canada, works incredibly well in Scotland.” This answer was both antithetical to free-market thinking and profoundly ignorant...

For more details, read the full text of  "Trump Is No Friend of Free Market Health Care".

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.

Why CON Laws Need To Be Eliminated

"How State Certificate-of-Need (CON) Laws Affect Access to Health Care"

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.

Perry: Lessons From Cosmetic Surgery Markets

Economist Mark Perry has a written a nice review, "What economic lessons about health care can we learn from the market for cosmetic procedures?"

In general, these services are not covered by insurance but rather paid for by the consumers themselves.  Hence, consumers have a keen interest in finding the best value for their medical dollar.

As a result, prices have essentially stayed stable (or decreased significantly) after adjusting for inflation.  In some case, the prices have gone down in nominal dollars as well!

As Perry notes:

Most importantly, none of the ten cosmetic procedures in the table above have increased in price by anywhere close to the 88.5% increase in medical care services since 1998.  [Emphasis his.]

Perry summarizes:

The competitive market for cosmetic procedures operates differently than the traditional market for health care in important and significant ways. Cosmetic procedures, unlike most medical services, are not usually covered by insurance. Patients paying out-of-pocket for cosmetic procedures are cost-conscious, and have strong incentives to shop around and compare prices at the dozens of competing providers in any large city.

Because of that market competition, the prices of almost all cosmetic procedures have fallen in real terms since 1998, and some non-surgical procedures have even fallen in nominal dollars before adjusting for price changes. In all cases, cosmetic procedures have increased in price by less than the 88.5% increase in the price of medical care services between 1998 and 2014.

In other words, the problem we've seen of skyrocketing prices in the traditional medical market can't be blamed on "fee for service". Rather, the issue is the 3rd-party payor system, a point also made by others such as Dr. Richard Amerling in his recent Wall Street Journal piece.

Proper treatment of a problem requires a proper diagnosis, in public policy as well as in medicine.  Perry's work is an important pointer in the right direction.

Amerling Vs. Ginsburg on Fee For Service

The Wall Street Journal recently published a nice pair of columns on both sides of the issue, "Should the U.S. Move Away From Fee-for-Service Medicine?"

The anti-fee-for-service side was taken by Paul Ginsburg.  The pro-FFS side was taken by Richarad Amerling.

I basically agree with Dr. Amerling and I want to quote a couple of excerpts from his piece:

The real cause is the institution and growth of direct third-party payments. Inflation in health care was trivial until the mid-1960s, when Medicare and Medicaid were thrust into existence. The other big driver is the morphing of health insurance into a prepayment model, where even routine, low-cost care is covered. When neither the consumer nor the provider “feels” the cost of the service offered, it promotes overuse of medical services and high levels of spending. Government data show that 48% of health dollars were “out of pocket” in 1960. By 2008, this was down to 12%...

In other professions that feature fee for service but where third-party payments play a much smaller role, such as in law, dentistry or veterinary medicine, there is little excessive price inflation. Similarly, in areas of medicine outside the third-party-payment system, such as cosmetic surgery, Lasik eye surgery, and direct pay practices, prices have actually declined over time.

It is impossible to eliminate self-interest, which is embedded in human nature. But if some doctors and hospitals over time get away with unnecessary tests or padding bills, it isn’t because of fee for service. It’s because the patients are shielded from the impact by third-party payments.

Fee for service directly aligns payments with care, which is what most patients want, especially when facing serious illness. It’s incentive-based and increases the likelihood of quality care in a timely manner...

But I highly recommend reading both sides of this debate, "Should the U.S. Move Away From Fee-for-Service Medicine?"

Here is the related video.

McArdle on Economic Progress and Health Care

Megan McArdle has written a nice piece on economic progress over the past century, "It's Complicated. But Hopeful."

The whole piece is worth reading, as it helps put discussions of economics and standard of living in a good historical context.  But for this post, I wanted to quote from her discussion of how health care has become more "expensive":

In the 1950s, when the president of the United States had a heart attack, he got the absolute state of the art treatment from some of the top doctors in the country: blood thinners, painkillers, and bed rest.

Today, he would have had an array of scans and blood tests to diagnose his problem, and then his physicians would have been able to choose from an array of treatments—stents, coronary bypass, balloon angioplasty—to prevent future heart attacks. And thanks to epidemiology, public health campaigns, and an array of smoking cessation aids, he probably wouldn’t have had a four-pack-a-day cigarette habit, either.

1950s health care isn’t expensive; this same regimen would be a bargain at today’s prices. What’s expensive is things that didn’t exist in 1950. You can say that “health care” has gotten more expensive—or you can say that the declining cost of other things has allowed us to pour a lot more resources into exciting new health products that give us both longer and healthier lives...

For more examples of progress that we don't always fully appreciate, read the full text of "It's Complicated. But Hopeful."

WSJ On Records and Regulators

Two quick links to recent Wall Street Journal pieces worth reading.

Singer: "ObamaCare's Electronic-Records Debacle".

He highlights both the obvious and hidden costs of mandated electronic medical records, and how they harm patients in the real world.

Huber and Howard: ''What Failed, the new Cancer Treatment or Regulators?"

They discuss how rigid FDA testing guidelines hinder the approval of drugs that might work well for one subpopulation of patients, even if they have minimal effect on the general population.  In essence, this means stifling the development of "personalized medicine" and "precision oncology" based on an individual's unique genetic traits.

(As always, if these direct links only show the preview page, you can often read the full text for free by typing the article title into a Google search box, and getting the "Free Day Pass" version of the article.)

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".