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Notes from the box

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I work at a health plan, doing utilization review.  I’m a “medical director”, which basically is what they call anyone with an MD at a health plan (or at least, at my health plan).  What I do, in essence, is sit in front of a computer, looking at requests sent in by clinicians for medications, procedures and equipment about which we request more information before we pay for them. (This is called “being in the box”, hence the name of this post).  It’s educational-I am an emergency physician, and I’ve had my horizons markedly stretched recently regarding the broad pageant of medical care.  Sometimes it’s a little disturbing how little thought goes in to what many doctors do.  We have a set of guidelines regarding what we’ll pay for, and what criteria must be met prior to authorizing payment for things.  The guidelines are available online-a few short clicks, and you can read all of them.  Now I recognize that doctors are busy, but it’s also not that hard-most doctors don’t need to look at all of them, just the ones they use most often.

Let’s take the matter of cholesterol lowering agents.  We have a step therapy guideline for “statins”, medications to lower cholesterol.  And they basically say “Try these cheap drugs first, then try these slightly more expensive drugs (and honestly, we as a health plan may have gotten a rebate of some kind on them, full disclosure), and if that doesn’t work (or if the patient has problems with those drugs) you can try these expensive drugs.”  And we routinely get requests for the most marketed of the drugs (Lipitor), from physicians who have not bothered to read the guidelines (which are entirely in line with any one of several models of good medical practice, in my opinion).  The requests are as often as not not filled out by the provider (which is fine).  Less fine is that the provider likely hasn’t even reviewed them-they either give some staff member a signature stamp, or they ‘rubber stamp” them by hand, so to speak.  Then we send out inquiries (usually handled at a level prior to me) of the form: “Has your patient tried $NAMEOFCHEAPERDRUG?”  And we get back a curt “No” written next to the question.  And then they’re surprised to learn we decline to pay for their failure to think it through: if we ask that question, it’s because we require that answer to be something other than “no”.  If you say”yes”, your patient may get their Lipitor.  If the answer is no, why not look at the possibility that the drug we’re asking about might be a good substitute to the one you originally asked for, and change the request?  If you write “Please change request to $NAMEOFCHEAPERDRUG”, we will be happy to do that for you.  You can even leave off the “Please”; we’ll still do it; I’m not proud.

I recognize that no one likes being second-guessed.  But really, there’s no evidence that any of the statins are better than any other ones-some are more potent, and the two most potent are steps 2 and 3 respectively (Lipitor is roughly equivalent to Crestor; Lipitor is pricier, and hence step 3).  So really, when you learn that the insurance company is asking why you’re using one or the other, have an answer better than “Because I say so”, because it makes you look silly and childish.  Do the homework; there are lots of software packages which can help you here – find one and use it (I’m a fan of Epocrates, myself, but there are lots of people who blog about medical software, and I’m not one of them).

More bothersome to me are the folks who want to widen the accepted uses for medications which are already really, really expensive, and which have the requirements right on the label.  Example: physician wants a medication which is used to treat $DISEASE-it’s a last ditch effort to control it in people who have allergic triggers, and controls one of the mediators of that in the body.  Levels of the mediator can be measured, and it’s not approved for people whose level is over a threshold limit (let’s call it 100).  There are a couple of reasons for this-one is that it was only tested in people who met that criteria, but the reason for the criterion is that there’s a dosing limitation-you can only give enough of this stuff to neutralize up to 100 units of the mediator in question.  Give more and you run in to problems.  My employer requires you to measure the level and send the result to us, so we can be sure you’re not giving this stuff outside the parameters set for it.  The physician had dutifully done this-and the level was clearly 250, well outside the parameters.  The request came in, and I declined to authorize payment for the stuff-there’s no evidence that it will do what it’s supposed to, and it’s stupendously pricey (read: a course is about $20,000, and you need it injected once a month for the rest of your life-which is likely to be quite a while, since asthma is generally a disease of the young).  The doctor called me to dispute the denial.

He didn’t have much in the way of new facts, to be honest.  He basically had tried it in a few patients and seen either good results, or at least not bad ones, and a couple of tiny (read: 18 patients) studies in people with an unrelated but analogous disease.  He thus felt it was safe, and felt that this patient ought to get it.  Problem is, there simply isn’t any evidence that it will work in people whose level is over 100, and he’s asking me to gamble $20,000 a month for the life of the patient that the evidence will show up.  That’s $20,000 that my employer could use to pay for other healthcare1. While I understand the provider’s point of view-he’s there with a patient who is in the hospital a lot, and he suspects (but does not know based on evidence) this might keep him out-at the same time, I want to say “Why did you ask for this, when you knew or ought to have known it would be denied?”  If you want to widen the indications for the pricey stuff, do the damn study.  It will take some time, but I’ll bet serious money that the company which makes the stuff would either pay, or help to pay, for a reasonable trial in whatever your patient population was.  And then, with that in hand, come to me.  “Here’s the study, published in $WHATEVERJOURNAL, [as long as it’s one with some editorial standards]; gimme the stuff.”  I’d give him the stuff, because he proved it works.

For Lipitor, the standard of proof is pretty low; while I say Lipitor is “expensive”, it’s not all that expensive in the grand scheme of things, and the upside is pretty well known.  For this expensive stuff, the evidence isn’t as good that it works in any population other than the one it’s been studied in, and it’s incredibly pricey.  You can buy a lot of immunizations for $20,000.  Hell, you can buy a lot of Lipitor for $20,000.  You can about buy one bypass operation, assuming it goes smoothly.  You know what you’re getting in those cases.  In the case I denied, what I was being asked to buy was a very expensive pig-in-a-poke.  And I wouldn’t do it.  Many other doctors are doing the same thing in their various areas of specialization – they’re widening the indications for expensive things without doing the appropriate homework to ensure that it works.  This has happened over and over, occasionally making it into the headlines-the primary example is the use of bone marrow transplantation for solid organ tumors (notably breast cancer).  In the late 90’s (I think) a lot of oncologists wanted to do this-there had been some small but encouraging trials, and oncologists were enthused, because it seemed to work in people who had no other hope.  It was a last ditch, Hail Mary, burn all the bridges intervention. Insurers wouldn’t pay for it, because it was experimental – they didn’t pay for experiments, the government did.  Given that, people besieged their legislators, demanding that they *make* the insurers pay.  And the legislators, seeing a vocal group who they’d rather not see in opposition to them at election time, gave in and wrote them a law which made the insurers pay for it.  Eventually the big study did get done, and unsurprisingly, bone marrow transplantation doesn’t work more than random chance would suggest for solid organ tumors.  All you do is kill people, unpleasantly, somewhat more rapidly, and much more expensively.

Medicine, at that level, really is a science.  At other levels it’s not; the art of getting people to take their medications might require changing to Lipitor, because the patient will take it owing to the fact that they’ve seen it advertised on TV so it must work.  I get that.  But when we get to the realm of single interventions costing north of $100,000 or more, the science needs to win.  And the science needs to win because if you let one person have it, you must let everyone similarly situated have it as well.  You can’t make exceptions, it’s not fair to the people who get the short end of the exception.  So if the science is not there, no one gets the expensive stuff.  Other things cost around the same as this stuff-certain medications to control multiple sclerosis come directly to mind.  The science for those is hard; if you have MS, these drugs will, in most cases, prevent or reduce your relapse rate.  I will approve those gladly; they keep you healthier, even if the data might not indicate that it’s cheaper overall (although I suspect they would, if anyone did that study).  You don’t have to prove cost-effective; just prove “actually makes you better more often than would happen by chance-preferably a lot more, but I’ll even accept *some* more.  And you’re golden.

 

1) Note for the record: while I’m not happy about aspects of the executive compensation at my employer, at the end of the day our medical loss ratio is 90% (we spend 90 cents of every dollar we collect paying for health care.  That’s among the best in the industry, bluntly speaking.  We don’t actually spend a lot on administration, and we aren’t paying shareholders (although we do still pay our board members-the trend is to not do so, as a non-profit entity.  I get both sides and haven’t yet formed a solid opinion regarding whether board members at big non-profits ought to be paid.  They ought, however, to be much more accountable; it’s likely that they get a lot of non-dollar compensation out of being a board member; it seems overkill to pay them.  But if you don’t pay them, they likely wouldn’t do it-we’re talking mostly about people who use money to keep score in their contests with the Joneses, so to speak.

Epidemiology for the win

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Authorities in Germany have, at last, concluded that bean sprouts were the causative agent in the recent outbreak of enterotoxigenic E. Coli they’ve been having. And the question does seem to arise: why did this take so long?

According to reports on NPR and elsewhere, the biggest problem may have been an over reliance on hard(ish) direct science, and a disinclination to rely on indirect methods. The German equivalent to the CDC is the Robert Koch Institute, named after a famed German physician and microbiologist, the man who isolated the causative agents of anthrax and tuberculosis (bacillus anthracis and mycobacterium tuberculosis, respectively). The man who put forth what are still called Koch’s postulates, which are guidelines to help decide what bacteria cause which diseases. And alas, the Koch Institute took them perhaps a bit too seriously. They were looking for produce from which they could isolate the causative bacteria, and that proved somewhat problematic, since there were either too many types of produce, or not enough bacteria on them. So they dithered, and named a few vegetable which, in retrospect, had nothing to do with the outbreak, and ignored the epidemiological evidence, which apparently pointed pretty unambiguously to bean sprouts as the culprit (the risk ratio, a measure of the likelihood that a particular exposure caused a disease, was something like 9:1; while that’s not “proof”, in the courtroom sense of the word, it’s enough, in epidemiology, to start getting the bean sprouts out of the stores).

In an outbreak, there are three competing priorities, in general: be fast, be thorough, and be right. As with other fields where these are desirable, you can generally have two, depending on the level of evidence you desire. Thing is, epidemiology is the science which points you in the right direction. It can be wrong, but the sources of wrong are pretty well understood, and easy enough to avoid if you don’t get sloppy. The folks at the Koch Institute weren’t sloppy, but they were neither fast, nor right (in the event, they eventually became right, but it took awhile, and they had a couple of false cucumbers, I mean starts). I don’t know what the issue was at the institute-it smacks of internal politics, in which perhaps the microbiologists were accorded more respect than the epidemiologists, but I hope that someone finds out, and corrects, the said politics. Europe can’t afford another flub set like this in the face of the next outbreak. And there’s always, *always* a next outbreak. The CDC and the USDA actually have a good process for investigating these kinds of outbreaks, since we’ve had so many of them (we practically invented enterotoxigenic E. coli, with the O157:H7 strain). I wonder if someone from there is even now on their way to a nice German “vacation”. My college roommate Greg Armstrong now works for CDC, and was involved in the early outbreak investigations of enterotoxigenic E. coli (aka Shiga-toxigenic E. coli) as part of the USDA E. coli O157:H7 STRIKE FORCE. I made fun of him about it at the time (“someone has diarrhea! Launch the black helicopters!”), but it’s important work. Bugs are smart, and as I heard it put recently, one smart person is not necessarily smarter than billions of dumb bacteria. We’re going to see more outbreaks, of this and other types, as bacteria mutate, learn ways around our antibiotics, and generally keep trying to kill us, not because they want us dead in the long run, but because they want us as food in the short run, and that tends to make some of us dead regardless. We need smart people to keep working on outsmarting the bacteria; if we ever get the idea that infectious diseases are done for, I promise a revelatory plague we won’t soon forget.

Why you want health care rationing

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During the current health care debate, many policymakers on both sides of the political spectrum have used the word “rationing” as a bogeyman to frighten people. “You don’t want health care rationing”, they say. “Health care rationing is bad”. When most people hear the word “rationing”, what they hear is “I get less”. Since most people have some concern that their health will decline, and want health care to be available to help them if it does, the idea of getting less health care is both unattractive and scary. Since policymakers know this, they use the term “health care rationing” as a way to get people to say “No, thanks!”
There has also been much discussion of “the public option”. The public option, put simply, is a government provided (and to some extent, funded) health insurance plan which would compete with private plans. Now, I am foursquare for a public health plan. Because it is my fondest hope that it will eventually lead to the end of the discussion of “rationing”. Because rationing is not truly what we’re talking about, usually. We’re talking about allocation. Currently, the health care allocation model in the US is widely acknowledged to be broken. Some people get too much, many people do not get enough, and overall we pay more for our health care than people in other nations, without being healthier as a result. A lot of very expensive activity is taking place, without getting the desired result. I cannot imagine anything more un-American.
The most obvious method of allocation is through your doctor. Right now, though, doctors are poor decision makers with respect to what might be called “rational allocation”. Their income depends on you-all of us-using health care. If your doctor keeps you healthy, he makes less money. There are other things at play-your doctor also wants to do a good job, and stay in the good graces of her colleagues-but it’s easy enough to convince yourself that doing more for a patient is in their best interest. That doing more testing, more invasive procedures produces more health. And while this notion is attractive-more is always better in America-it has the disadvantage of being contradicted by some pretty good science. Take heart catheterizations and stenting procedures, for instance. There is good science which shows that many patients would be as well or better served by proper use of medications to control their heart disease, instead of putting stents into them. But stents pay better-so stents are used aggressively, while medication is not. Insurance companies and Medicare don’t pay well for the thinking and discussion with patients needed to properly manage medications.
This is just one example of why your doctor is not necessarily using his best judgment in your best interest. He has to balance his interest in staying in business, and keeping her staff paid and her income at the level he’d like. I work with some excellent physicians, and I’m proud to be one myself, but we’re not superhuman. Those of us who work in private practice have to think about keeping the bills paid. Those of us who are employed have bosses who demand higher “productivity” (a code word for “see more patients and do more procedures”) in order to increase the number on the bottom line at the end of the year. Often our pay is tied to a specific “productivity” target. The pressure to do more will affect how we act as we go about doing our work, without regard to benefit for the patient. Your doctor can’t help it any more than you can help doing the things your boss demands to remain employed, or doing what your business demands to stay afloat.
The problem is that we are paying doctors for the wrong thing. We’re paying them piecework and counting on ourselves as individuals to be the best arbiters of our health. On the surface this sounds great-if everyone takes care of their health, everyone is healthy. In practice, that isn’t how it works. People tend to make tradeoffs in their health care, and most often what they trade is their ability to do something they want now, such as smoke, but postpone payment until later, when they develop the inevitable heart disease, or stroke, or emphysema, and beg their doctors to do something. The time to do something was when you started smoking-the thing to do was to get you to stop. But smoking cessation pays poorly, while heroic measures to save us from the consequences of our collective poor decisions pays well, so again we allocate our resources poorly. The analogy of changing your oil is apt here; if you tell your friends you bought a car and never changed the oil or put air in the tires, few of them will be surprised when your car one day breaks. Yet we are all surprised that our rate of preventable, or at least postponable, disease is so high. Don’t we have the best health care in the world?
Well, we have many smart doctors, and some of the best technology in the world. Neither of which makes the best health care system in the world. What it’s made so far is the most expensive health care system in the world. We spend more per person on health care in the US than any other nation, yet our performance on most major indicators of health is mediocre at best, and downright poor at worst. Why, if we’re spending all this money, aren’t we healthier? In part, we’re spending it on the wrong things-procedures pay well, but thinking pays poorly, so doctors will naturally do as many procedures as possible, while not thinking about the cost; in other fields, certain types of visits (psychopharmacology, for instance), pays well, but talk therapy (arguably as good, and less expensive than a lot of pharmacology) does not. No one is coordinating this marvelous edifice of health care we’ve built. Like any other large system which isn’t managed properly, it has gotten out of our control. We must, collectively, regain that control, or we risk having it collapse upon us.

A possibly unwelcome thank you

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I would like to take a moment, on the 5th anniversary of chapter 58 of the Acts of 2006 (better known as the Massachusetts health reform law) to thank some of the people responsible for making it happen. (Some of these are people I know personally, having interviewed them for a paper in graduate school. Some, like Mitt, I know only by reputation).

From the Great and General Court:

In the Massachusetts State Senate:

Former Senate President Robert Travaglini (D Revere)

MA state senator Richard Moore (D Uxbridge)

In the Massachusetts House of Representatives:

Former MA House Speaker Salvatore DiMasi (D 3 Suffolk (Boston)) (He may be a felon, he may not, but he helped make it happen. And as yet, he is presumed innocent, remember).

Representative Carl Sciortino (D 34 Middlesex (Medford/Somerville))

And let’s not forget:

From the Governor’s Office:

former Massachusetts Governor Willard Mitt Romney (R still not POTUS)

Yes, folks, Mitt Romney, former governor of Massachusetts and becoming perennial presidential candidate, was one of the primary architects of chapter 58. And honestly, I think that’s an achievement he ought to be proud of; he reached across the aisle, worked with people who thought differently than he did, and made something happen. He thought outside the box, and helped push it through. For those who feel it’s an unwarranted intrusion into your lives, think for a moment what kind of health reform a Democratic governor, working with a Democratic legislature, might have passed.

I’ll wait while you stop shaking.

There, feel better?

Seriously, I’m really bothered by the fact that Romney feels like he needs to hide one of his biggest accomplishments. If I were advising him, I’d say something like this: “Mitt, listen. Give up attracting the base of big donors who hate the law; they’ll never forgive or forget, and you’ll never be president that way. Go out there, and tell people how proud you are of having made that happen. How it shows you can work with Democrats, and that you’ll work with anyone with a good idea, in order to get the people’s business *done*. Because that, sir, is what people want. In the end, only the fringe is interested in all the he-said-she-said crap that’s been passing for governing recently. Most people want you to work together, find ways to reconcile your differences, and MOVE THE HELL ON. (Anyone remember what MoveOn started as? It was a group which wanted to Move On from the whole Lewinsky scandal, viewing it (correctly in my opinion) as a distraction from the serious business facing America at that time. Perhaps if we had, we might have addressed some of our current problems before they asplode all over the landscape. I’m not fond of what they’ve become in a lot of ways, but when they started I was all for them).

Really, we need to stop fixing the blame. It’s what we think we’re good at, when in fact we are not; the finger of blame points all ways, really. It’s time, folks, to fix the problems. In my sole opinion,  in 2006, Romney, a few policy wonks, and a couple of reps and senators got together, and worked out a compromise health restructuring which was a model for the nation. Was it perfect? Oh, HALE no; it sucked in a lot of places. But that’s the nature of making law; like so many things, lawmaking is an iterative process. Make a law, then tinker with it to make it work, or keep it working in the face of changing circumstances. And occasionally, you truly do need to scrap something and make new, because the topsy you create through endless iteration can, unless done very right, end up eating you. But in my sole opinion, chapter 58 was pretty good for a first attempt. And Mitt was one of the architects.

Well done Mitt.

Litigation does not correlate to quality of care

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So, the lawyers lost a round this week. Makes a body feel pretty good, honestly.

The New England Journal of Medicine, always my go-to journal of record, published a research piece this week (click the prior link, or find it at N Engl J Med 2011; 364:1243-1250) in which the investigators compared nursing homes which were sued often versus those which were sued infrequently. The question was whether the nursing homes which were sued more often had objective indications of poor quality based on national data sets. The short answer: no. Being sued had no correlation to your quality data; homes which had good quality were sued just as often (pretty much; there was *some* correlation, but not much). One of the most telling lines in the study was this: “Nursing homes with the best…records [top 10%] had a 40% annual risk of being sued, compared with a 47% risk [of being sued] among nursing homes with the worst…records [bottom 10%].”

Now this may sound like a success story in some ways; I wouldn’t blame you for thinking so. The lesson I take from it, though, is that litigation (which is expensive and heartbreaking for everyone except the lawyers) is a poor discriminator of who is good and who is not. And I personally believe that this poor discrimination stands in the way of true quality improvement, because if you are a nursing home (or a doctor, or a hospital), you look at this result and say “Why spend all this money on improving quality when we’re going to be sued anyway?”

If you answer “Because it’s the right thing to do”, you’re certainly not a hospital administrator, because the doing right thing balances no budgets, and increases no revenue, and improves no quarterlies, and those are the job performance indicators of the hospital administrator, just like anyone else in a business. And they have a point; most health care organizations are businesses (even the doctors, many of whom are small businessmen and women in the same way your plumber and your hairdresser are), and they need to keep the lights on and the payroll current; if a quality initiative costs money they need to pay those bills *and* the lawyers or the settlement, they’ll decide not to pay for the quality initiative, no matter how much they’d rather try to improve their quality. Not because they don’t *want* to do the right thing, but because they simply cannot *afford* it. Change costs money (ask Barack Obama), and if you don’t have money because you’re paying lawyers (or malpractice premiums, which are essentially paid to lawyers with a percentage for insurers and, oh yeah, a few patients), you can’t do change initiatives, even if you believe (as many doctors do) that some form of change is needed.

Most doctors, having heard the lawyers tell them that they (lawyers) are a force for quality improvement, have had little in the way of counterargument. This is the beginning of a counterargument with, in my opinion, legs, and quite possibly wings. The counterargument goes like this: “Maybe so, but your force is too expensive, and not effective enough. And so, like medicine, you’re either going to need to get cheaper, or be more effective”. I’m just surprised that this study wasn’t done sooner.

More on medicine being more effective another time.

Twenty

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Which is the number of ambulance patients we received between 0715 and 1030 or so.

So this morning, I noticed on my drive to work that we were having a bit of the dreaded “wintry mix”, and that driving was, um, dicey. The roads I was on had all been treated, but still, it was clearly icy out. Which always means an extra helping of the clueless people who have forgotten what winter driving is about since last winter, or who have moved here from Florida or Hawaii, and thus slide their cars out into some other car or stationary object. Or roll them over.

First up, Ramon, who was unrestrained in the back of a van, and bounced around, sustaining a lovely set of lacerations to his eyebrow and nose area, including a small but persistent arterial bleeder. Well, he needed a CT scan, but CT gets all shirty when the patient bleeds all over the scanner, not to mention that it just looks bad to not fix that. Given where it was, it needed a pretty closure, so he got a set of subcuticular sutures (under the skin, using absorbable suture; it’s a way of closing lacerations, and to make them look nice (it’s one of the several plastic (cosmetically pretty) closures. it takes a little more time, but it looks good, and it’s sort of satisfying. I hadn’t done one in a while, so Ramon gets subcuticulars. He also gets my lecture on seatbelts-turns out this s Ramon’s *second* serious car crash-you’d think he’d learned, but apparently he didn’t get the talk last time. Well, he got it in spades this time.

Meanwhile, the place is filling up with blockheads. Now, that’s not a comment on their mental acuity-much-but when you’re in a car crash, you usually get immobilized on a long board with a collar and blocks on either side of your head to keep it still. So, blockheads. Most are essentially uninjured-they’ll be sore in the morning, but not really hurt. One lady had a nasty ankle fracture (not from a car crash-she just slipped and fell). A lot of hip fractures. A *lot* of hip fractures; the orthopedic surgeon made his nut today, and can probably buy a new Ferrari 🙂

Only one really injured lady, who goes to Boston Medical Center, after Tufts farts around a bit too much. When I call for a transfer, I need to hear “Send her on down”; I know enough people at BMC that that’s the answer I get, while I don’t know anyone at Tufts, yet. (Tufts is the preferred provider for transfers, mostly because they’re cheap compared to other providers). As you can see, a lot of things factor into the decision of where to transfer people, one of the most important of which is “How convenient is it?” Note to tertiary facilities: if you want the transfers, make sure you have one call shopping. At Tufts, I need to call lots of people: for most of the other centers, one call does it all. In the case of the BMC, I can often call one of my former residents, who I can, for that reason, browbeat 🙂 Thus it was today; Dr. Tahouni did a resident rotation at QMC when I was there, and gladly accepted my transfer.

Towards the 2pm hour, it started to slow up to the regular pace. And I started to recognize that, for all the suck we’d had, it hadn’t really sucked that much. It had been **busy**; we’d been hopping, but the nursing staff had risen to the challenge, and called in people from upstairs and from home to spread the load. And stuff had gotten *done*, with good (if trenchant) humor, proper dispatch, and it had been overall a good day, for all the suck.

At the end of the day, several things happened. The housekeeper (the *housekeeper*) stopped by the desk to thank me. Now, be clear; she’d been working just as hard as the rest of us. I was touched. The charge nurse stopped by my desk (well, the one I was using), to thank me as well. And when my shift ended, I went round to all the nurses to shake their hands and thank them. They made the shift bearable; they took initiative, did the right thing, plowed the road for me (by, for instance, ordering films and tests which they knew I’d want but hadn’t gotten to yet), and generally did the things I want professionals to do. We were *BUSY*, but never out of control, and never in any trouble in terms of patient safety. Things got done, people were cared for, and it all just *worked*.

It was a good day.

I sent an email to my boss, to hopefully pass along to the nursing management, letting him know how it had been, and hopefully to give a shiny buff to the staff. I don’t mind working hard taking care of people; I dislike working hard just to make the minimal care happen. In this case, we all worked hard, and people received excellent care, and it all just worked.

Booyah.

Mammograms are less useful than you think

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An essay in this month’s Health Affairs is compelling reading, at least for folks like me. In brief, the author describes the reasons why she, despite a positive family history, does not get an annual mammogram.

The following paragraphs encapsulate the argument nicely, I think:

“If 2,000 women are screened regularly for ten years, one will benefit from the screening, as she will avoid dying from breast cancer. At the same time, ten healthy women will…become cancer patients and will be treated unnecessarily. These women will have either a part of their breast or the whole breast removed, and they will often receive radiotherapy, and sometimes chemotherapy. Furthermore, about 200 healthy women will experience a false alarm. The psychological strain until one knows whether or not it was cancer, and even afterward, can be severe.”

And:

“Another important fact from my friends at the Nordic Cochrane Centre: It has not been shown that women who undergo regular screening live longer than those who don’t. This information is available elsewhere in different forms, but I like the clarity and concision of the Nordic Cochrane Centre pamphlet—as well as its list of solid scientific references.”

Both of these are from the Nordic Cochrane Center, an offshoot of the Cochrane Collaborative, probably the most respected outcomes and effectiveness research group there is. Cochrane Reviews are widely thought to be authoritative answers to the question “What is the best way to diagnose and treat/manage $DISEASE?” Note that because they’re the best evidence there is doesn’t mean it’s what’s *done*, but the evidence is available if you want to look for it. They have a recently done an analysis of breast cancer screening with mammography which I have yet to read, but which is essentially a redo of the work the USPSTF did a while back on mammography, when they scaled back their recommendations to great political uproar. They came to the same conclusion: mammography doesn’t work as well as we think it does. We aren’t good enough yet to know who should be screened and who should not, and screening may not do all the good we’ve ascribed to it.

And now the political problem. A *lot* of people have invested a *lot* of themselves, their scientific and professional careers, their volunteering lives, and their incomes, in the goal of increased and aggressive screening, early detection and treatment. Which, it turns out, may not work. But these folks have sunk a *lot* of themselves into those goals, including making those goals the focus of their work- from oncologists and surgeons who treat breast cancer patients (who basically treat people with breasts as if they all have cancer, either now or Real Soon Now), to cancer survivors who are going to be hard to convince that either they would have survived anyway, or they basically got lucky by having screening at *just* the right time, to the thousands of people who have devoted their volunteer efforts to increasing awareness and funding for breast cancer research and treatment. None of those people wants to hear they may have been wrong. That they may have spent their time fruitlessly, needlessly. Or that the work they have devoted themselves to (and make their living from) may be, not just a waste of time, but an active harm to many women who worry needlessly about having cancer, or worse, who are treated as if they have cancer when they do not.

So no one is hearing the Cochrane review, just as no one hears the one which says that surgery for back pain is wrong, or that reducing dust mites doesn’t control asthma, or that any of a number of other things we do to control or treat disease don’t work. And some politicians, quick to sense an opportunity to get in good with a large voting block (people with breasts, or who know someone with breasts), are happy to decry the review, or the USPSTF guidelines, as a ploy to reduce health benefits for vulnerable people (with breasts).

There is, really, a science of figuring out what works and what doesn’t. It’s called epidemiology, and its sister science, biostatistics. They both require really large data sets to chew on to give results anywhere near accurate, but when large data sets are available, they’re really good at pulling some wheat out of that there chaff. And it turns out that mammography may be chaff, and maybe we shouldn’t be shilling for it the way we have been.

Read the essay. It’s thoughtful, well written, and enlightening.

Uninsurance rate up as poor economy rolls back insurance levels

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Writing for the Commonwealth Fund, a well respected health policy foundation, Karen Davis (one of the two important Karen’s in health policy, the other being Karen Ignani, the leader of America’s Health Insurance Plans or AHIP) noted that the number of uninsured people in the US continues to rise. This is a fairly clear result of the ongoing recession, as more people lose employer sponsored insurance, and more employers don’t offer employer sponsored insurance. Last year 7 million people lost the insurance they had through their employer. Seven million people added to the rolls of taxpayer funded health care, or left without any health care at all. Oh, sure, they can go to the Emergency Department, as former President George W. Bush famously remarked. But if they do, they’ll get a bill, and probably a bigger bill than their insurance company would have received for the same service. and definitely a bigger bill than they would have gotten for going to their own doctor-emergency departments charge a premium for being open 24/7/365, because it makes their overhead much higher.

“But wait”, you ask. “Wasn’t this part of the problem health care reform was supposed to solve?” Well, yes, it was. But the important provisions of that law, with a few exceptions, don’t take effect until 2014. Some of the provisions do take effect sooner-importantly, the provision which requires insurers to cover “minor children” up to age 26 takes effect today (September 23, 2010), as well as the elimination of lifetime coverage limits. But the major parts-the health insurance exchanges, the premium subsidies for middle-income families with children, the expanded Medicaid eligibility, and COBRA assistance for the unemployed-are still three years away. That may be too long for some folks who don’t have insurance now, but still need health care.

Here in Massachusetts we have an advantage-we’ve set those things up already, and when time comes to implement them, all we’ll really need to do is make sure they meet the Federal standards. Since Congress used the Massachusetts law as something of a template for the Affordable Care Act, most likely our exchanges will exceed the requirements quite a bit. We ought to be proud of that.

Doctors who care for poorer patients get poorer performance ratings

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Doctors and health policy analysts at the Massachusetts General Hospital in Boston recently examined performance measures for physicians – this is the data from the surveys you fill out occasionally when your insurance company asks you to rate your doctor. They found that doctors who take care of poorer patients (as measured by annual income) generally receive poorer performance ratings. This is a somewhat counterintuitive finding; most physicians perceive that patients with higher incomes (and generally higher corresponding educations) are more difficult to please.

This has serious implications for the future of performance measurement. Because insurers and Medicare want to link these performance measures to physician payment, anything that affect them is going to be closely analyzed by doctors, who naturally want to maximize their pay. If taking care of poorer (but insured) patients decreases doctors pay, doctors will be less likely to take care of this class of patient. On the other hand, adjusting the formula by which performance is measured to correct this specific imbalance will be politically difficult; physicians who have few of these types of patients will feel they are being penalized for their patient mix or choice of practice location.

Unanswered in all of this is the question of why these physicians get poorer ratings. All of the physicians in the study are in the same practice group; there is no mechanism by which patients can tell which doctors take care of poorer patients (so wealthier patients are not able to tell by looking at the patients around them whether their doctor is taking care of “rich” or “poor” patients, for instance). Do patients of higher socioeconomic status simply have an easier time communicating with doctors, and hence are more satisfied with their care than less-well-off people? Inquiring minds want to know (and are probably working on it even now).

This kind of data helps to craft better performance ratings, and may also help explain some aspects of health disparities. While some aspects of your health are solely under your control, knowing why people act a certain way towards health care providers can help you control those aspects better.

The “humble” neighborhood health center.

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The Great Brook Valley Neighborhood Health Center in Worcester changed names this Thursday, becoming the Edward M. Kennedy Community Health Center, a tribute to Ted Kennedy’s role in bringing Community Health Centers into being. Seems like a good time to review the history and role of a neighborhood health center.

Technically, a Federally Qualified Health Center is a community based organization which provides comprehensive primary and preventive care to a community, regardless of their ability to pay. They are generally governed by a locally based board of directors, and one of the unique features of the governance structure is that 51% (or more) of the board members must represent the population of the community (and generally receive their care there). Health care reform funding is expected to modernize existing centers, and significantly expand the network of centers nationwide.

Since health centers are a much cheaper way of providing health care, this can help save money for the health system overall, especially the parts of the system paid for by tax money. At the same time, people served at these health centers will generally be healthier, because the same research shows that the reason people who receive care at health centers have lower costs is because “providing quality primary care services can reduce the need for other ambulatory and hospital-based medical care, thereby lowering overall medical costs”.

Unfortunately, neighborhood or community health centers still carry the stigma of being places where poor people get their care-not a place you’d like to go if you had the chance to get out. People have a love/hate relationship with them-sort of like coming from a bad neighborhood that you still love, because it’s home. The stigma is in some sense justified-most of the people (70%) who get their care at neighborhood health centers are living in poverty by the federal definition. This is another way of saying, though, that they do one of the toughest jobs in health better than any other model of care delivery, for less money.

The facts suggest that we’d be served a lot better, most of us, if we got our primary care through a place which used the community health center model. Health care is almost never just about medicine, because so many other things impact your health. If your house is being foreclosed, it affects your health. If you’re having trouble handling your teenager, that affects your health. If your neighborhood is in the middle of an epidemic of flu, or norovirus, that affects your health. If your drinking is out of control, that affects your health. None of these problems are directly the responsibility of your doctor, but wouldn’t it be nice if, when you went to see her about them, she had the resources to work on the whole problem or set of problems, rather than just bandaiding over your symptoms?

That is what neighborhood health centers are designed to do; treat the whole person, in their family unit, in their community. And whatever you think of Ted Kennedy, I think that’s evidence of solid service to the nation.