Notes from the box

Uncategorized

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.

Mortality amenable to health care

public health

“Mortality amenable to health care” is a statistical measure of the, well, mortality amenable to health care.  Briefly, it’s a measure of how many of a population’s deaths from certain causes could have been prevented by proper health care, or as the authors of a recent paper put it: “potentially preventable with timely and effective health care”.  It’s a statistic which in itself means nothing (it won’t tell you whether your grandmother’s death could have been prevented by timely and effective health care), but which can be used to compare different populations (like, people in different countries or (in the US) different states, and to track changes over time in the health care being provided to a population (if the MAHC is rising, then either the timeliness, quality, or amount of health care available to the populations is falling).

In a recent study reported by the Commonwealth fund (in the Journal of Public Health Policy, citation at the link), a group of three authors found significant differences between the various states in this measure, ranging from a low of 64 per 100,000 in Minnesota to a high of 142 in Mississippi (what a surprise) and a whopping 158 in the District of Columbia (bet it’s not among politicians, and also not a surprise).  Furthermore, they found that the US placed dead last in this measure among the 19 developed nations for which data was available from the OECD.  (The lowest?  France, at 65 per 100,000.  France, people.  Seriously, that sucks so much I can feel the interstellar vacuum getting harder).

Even better, the authors showed that there were some hard indicators of which regions or populations were going to have high MAHC, based on already measured public health indices.  Number of diabetics getting recommended preventive care, visits to emergency departments(1) by asthmatics, readmission to hospitals of recently discharged people, and admission to hospitals of long-term nursing home residents were all indicators of high MAHC.  These are the kinds of measures which doctors are railing against (well, to be fair, many doctors.  Other doctors, like me, are cheering the measures, and demanding they be used to provide the public some openly available information about the health care providers in their region).  Because many doctors feel both helpless to change those numbers, and trapped by a reimbursement system which, in effect, punishes them for making the numbers better.  This doesn’t work so much on an individual level: ask a specific physician whether they’d like to fix those numbers, and they’ll all tell you “Of course!”, but it works in subtle ways.  Fixing the numbers means working together with people who have traditionally been, not enemies, but rivals: hospital administrators, nursing home administrators, politicians in some cases.  And as you fix them, you watch your income figure drop, and suddenly there are just…other priorities.  Going to the meetings that keep the “fix the problem” process on track becomes less important.  Maybe you are frustrated with one of the other participants, and decide to say so to your colleagues, or the other members, or, heavens forfend, the media.  And suddenly the process is derailed; these things happen, couldn’t be helped, back to business as usual.  It’s never so open as “I decided to kill the process because it killed my income stream”, but that’s nevertheless what happened.

When it comes time to make the kinds of changes we need to make, I believe it’s crucial to 1) acknowledge the fact that income is a factor, and take steps to minimize and equalize the impact, and 2) see that the process keeps going, despite the lost income.  Maybe, after a while with the new system, new income streams will be found which encourage doing the right thing-that’s always been my thinking.  And one of my fondest hopes.

—

1) Never “Emergency Room”.  It’s the “Emergency Department”. That’s probably the only absolute in the Physician’s Pen style guide.

The problem is not the cost of health care

Politics, ,

In an interview with the Kaiser Family Foundation, former US Senator Jim Danforth spoke about the future of the upcoming “super committee” negotiations to reduce the deficit. Senator Danforth was a member of a similar committee constituted in the mid-90’s, also bipartisan, with the same partisan divide which now obtains. One of the things he is reported to have said is “the problem is the cost of health care”.

Well, I must respectfully disagree that *the* problem is the cost of healthcare. It’s *a* problem, to be sure; health care is expensive, and I recognize that a lot of both the national budget, and people’s personal budgets, are going toward health care expenses nowadays. But I think it’s overkill to call it THE problem, when there are, in fact, other problems which are making healthcare prices a larger issue than they deserve to be.

Let’s see. Jobs are the first problem to come directly to mind. In the US, a lot of health coverage flows from having a job, so if many people don’t, health care costs become magnified. Like many people, I was surprised when the administration decided to make health care the first big problem they tackled after the election. In my math, it came about third, after jobs and repairing/restructuring the banking sector. But those problems were, I suspect, both harder than health care. For government, the only way to make jobs quickly is to hire people, directly, or to fund a lot of work which causes businesses to hire people, indirectly. Another argument says that government can reduce regulation to stimulate job growth, such as by repealing environmental regulations or the minimum wage law. This has some merit, but it won’t make jobs *now*, and it has effects in the future which are unacceptable to many. (Repealing the minimum wage will make jobs which won’t pay family expenses nor, likely, provide health care. Repealing environmental laws will have health effects we will, eventually, have to pay for. Guess who will have to pay? If you guess “not the company which made the environmental mess”, take a gold star and feel good about yourself for the rest of the day).

Reforming the banking sector comes second in my personal list of things which needed doing. I’m not going to talk much about that, because others have done a better job, other than to note that until that Charlie Foxtrot is cleaned up to the satisfaction of more people, confidence in the stability of the market will continue to be poor, at best. The only people who are confident that there will not be further banking collapses are bankers, and they have not proven their trustworthiness in this matter.

So health care costs are not the most important thing. They’ve become the most important thing, because they’re getting all the attention, but health depends on more than just “medical care”. It depends on having a job, so you can stop worrying about making your mortgage payment and putting quality food on the table. It depends on having a society around you which is vibrant and self-assured, and which knows it can take care of itself regardless of the shifts of fortune. Because that society is much more likely to care for you when you need care than a society which is terrified of the next economic or natural disaster, knowing that we’ve only barely survived the last ones. And that society is much more likely to foster your continued good health, instead of making you sick enough to need health care.

Paying the price

Politics

This may be a bit more personal than a lot of the content I have here.

From 1990-1995, I was a resident at what was then Boston City Hospital, and is now Boston Medical Center.  BCH sits in Boston’s South End, and is roughly at the intersection of South Boston, Roxbury, and Dorchester.  Roughly.  Then, as now, it is the City of Boston’s “Knife and Gun Club”.  Every major city has at least one-the hospital where the serious penetrating trauma mostly goes, usually because it’s in the part of town where most of the penetrating trauma happens.  Usually, it’s a poor part of town-the part where most of the people are people of color.  It’s where you end up if you’re out of work, out of cash, and out of hope.  And if you were unfortunate enough to have been born into that, you generally stay because it’s home and all your friends and family are there, or because you can’t get out-you don’t have the education or training for a better job, and you can’t get the education or training while still working the job, which in general doesn’t offer generous time off or tuition reimbursement.  Some folks manage it, through very hard work.  But it asks much of folks to be like superman just to get a little security, when many of the people making decisions had security handed to them on a plate (and to be clear, I am one of them).

Your population (which is medicalese for “the people you see”) are most often at the end of their resources.  They didn’t have many in the first place, and any illness uses them up.

And these, folks, are the people who are going to be the worst hit by program cuts now in progress at the federal level.  Not “fraud, waste and abuse”.  Not wastrels and do-nothings; most of these people work hard for their money.  Not a few of them take care of your elderly relatives, or clean your office building, or work on your car at the local Jiffy Lube.  Some are disabled from birth; they didn’t get much of a shot from the word “go”.  If you have Down’s syndrome, and can be productive but need a little help, tough.  If you have to care for an elderly relative, sucks to be you; if you’re hanging on to your job only because you get subsidized child care, or elder day care for your aged parent, get ready to cowboy up, because that stuff is going away.

Know what isn’t going away?  Subsidies for industries which can afford lobbyists.  Tax breaks for corporations.  (Gotta have someone creating those jobs-except the only industry which is creating jobs right now is health care (which is being cut, because when you look at it, most of those jobs are being paid for by tax dollars)).  Anything, in other words, which helps people who pretty much don’t need any help; they have a lot already.  That stuff is sacred, because those people have influence.  (which they’ve bought with the money they haven’t paid in taxes).  And the argument is always the same: if you cut that stuff, if you increase taxes on those people , you’ll stifle economic growth.  It’s the same, tired supply side argument which has failed over and over again, but which too many people unaccountably still believe.

(Hang in there; I’m getting around to a point).

And when the neighborhood I used to work in explodes once again in drug and gun violence, the people who don’t need the help are going to be surprised.  They are going to call for harsh suppressive measures for the violent elements.  They aren’t going to care that the people who are rioting, who are mostly shooting each other (with an occasional bullet for some rich kid (or rarely adult) who either strayed into the line of fire, or was slumming looking for cheaper drugs than he could get in the suburbs), do not, as my ex-father-in-law used to put it, have a pot to piss in.  The people who are both shooting and getting shot are (bluntly) poor.  They see people who are rich all around them.  And they know, they know, that the rich people want them to stay poor.  Because they know what’s going on at the top.  They know that tax breaks are for people who are not them, and that tax money goes to people who are not them, and that pretty much everyone has written them off.  They know that when the going gets tough, it’s not “everyone all together, E pluribus unum“. It’s “I got mine, and the devil take the hindmost”.

And I think that sucks, frankly.

If we’re going to pretend to be a nation composed of disparate parts, we need to act like one.  We need to see our neighbors as people.  All of them.  Including the ones who aren’t much like us, whether it’s because they’re brown, or gay, or Jewish.  Or poor.  And in my sole opinion, we need to do what we can to help people be stable in their lives.  Not meaning “keep anything from changing”, but definitely meaning “Keeping them from losing hope, keeping them trying to be better, stronger, more than they are now”.  Not just poor people; all people.  Enough of us have lost our way.  Enough have forgotten what it means to be part of something bigger than ourselves.  These people are on our crew, as Captain Malcolm Reynolds puts it in “Firefly”.  That doesn’t mean we have to like them, or let them get away with everything they’d like.  But it does mean that when they fall, as some inevitably will, that we will come back for them.  That we will pick them up, make them as whole as we can, and teach them not to fall again, if we can.  We can make people more resilient, and when we do, I think we’ll find that our entire society becomes more resilient.  When I was a resident, I always felt that a part of my job, when someone came to the Emergency Department, was not just to help them deal with what was going on now, but also to help them understand what had led to the emergency, so that in the future they could avoid it.  I’ve done my best to keep that up as I’ve practiced, and more than a few people have told me that “No one has ever explained [their health problem] to them like that before”.  Well, we have, as a nation, a fiscal problem.  And I honestly think that if you look, you’ll find that we’ve done all we can with cutting.  I’ve lived with a lot of people, friends and strangers, in combined households-I suspect most people have, at some point in their lives.  You live with a roommate, a housemate, a lifemate.  And I’ve had a household budget, in the same way we have a national budget.  We need to face the fact that a national budget (like a household budget) consists of both income and expense. If we have too many expenses, we can look to see what can be cut.  And if we, as a nation, decide to cut some I like, well, I don’t always get what I want.  Maybe we don’t need the deluxe cable, but we need the electricity. But if we decide to do nothing but cut, and don’t decide that maybe someone needs to contribute a little more of their surplus income to the household, we’re not going to last long as a household, because we’ve cut all the things which hold us together.

Host, agent, environment

public health

In infectious disease, we tend to talk about the triad of factors which lead to disease.  These factors are host, agent, and environment.  In human disease, the host is a human, of course, but each human comes with a set of genes, co-existing diseases, nutritional status, and so on.  An agent is something which causes disease-a bacteria, a virus, or a toxin.  And environment is, well, environment.  The milieu in which one lives.  The world around you-clean or dirty, safe or dangerous, pleasant or ugly.

Medical students are taught this paradigm early on, usually during microbiology in their first year.  And after that, most of us go on to forget environment entirely, concentrating on host and agent.  In some ways, this is predictable-we see the hosts as patients, and the agents as the enemy.  And it has resulted in a lot of success for us as physicians; while I continue to decline the “best health care system in the world” appellation, we physicians are, individually, often excellent at what we do, and occasionally, we rise as a team to something near excellence, in individual cases or groups of cases.

We’re at the point, though, where working at the host/agent interface, while effective, is more and more costly.  If we want maximum bang for our buck, or even to make the bucks we’re spending elsewhere more effective, we must act on the environment.  In part, we should do this because, like any three legged construct, if we make two legs strong, the third leg will inevitably break and we fall.  In part, of course, we should do it because it’s right.  But mostly, in my opinion, we ought to do it because if we do we can get better health for free.

(Well, relatively free.  Cheap, anyway).

What’s the environment, in this situation?  It’s everything that isn’t host, essentially.  How easy is it for you to get food?  How stressful is it to walk around in your neighborhood?  What toxic substances are in your soil, your water, your air?  All of this matters, because it all informs what sort of host you present to the agents.  If you are constantly exposed to a low level of a toxin, your reaction will be different when exposed to a high level of that same toxin, or a related one.  (Might be better, might be worse; it depends.  Point is, it’ll be different, and the differences are part of why you either stay well or get sicker than someone from a different environment).  If you are chronically stressed, your reaction to a minor additional stress will be different than someone who generally has it pretty good (this is one of the theories of why African-Americans have higher rates of things like high blood pressure and cardiovascular (heart disease and stroke) issues.  Racism, goes the theory, makes your general stress level higher, and this translates into higher disease rates.  It has the advantage of being plausible; it has the disadvantage of being hard to craft a policy solution around.

And here we come to the point of this little diatribe.  Environment matters in health.  It makes you who and what you are, and in turn it dictates, in some ways, how you will respond as a biological organism to a health threat.  In the US, though, we seem entirely content to ignore the role environment plays in disease, especially if it means improving the environment of someone other than ourselves.  We (a significant fraction of “we”, in any event) dislike government regulation of the environment.  We don’t like the idea of transferring our wealth to improve the health of others.  But we balk much less (so far) at the idea of transferring our wealth to cure these folks once their environment has made them sick (which is essentially what laws like EMTALA, the Emergency Medical Treatment and Active Labor Act, require; if you get sick, you must be treated-as long as you can drag yourself to an emergency department, or in some jurisdictions, can get an ambulance to pick you up).

Are we, anytime soon, going to realize that we are being penny-wise and pound foolish?  Money spent to improve the health of a whole population really does “lift all boats”; healthier people are consumers for longer, can provide you services better, or be better employees, or better employers, or any number of things which will make your world better because there are healthier people in it.  And “environment” often has very porous walls; a problem in someone else’s environment, be it a toxin or a level of social unrest, has a way of leaking into your environment, whereon it is the very devil to get back out without getting it out of every other place where it can be found.  This was a lot of the point behind the advances in public health made in the 19th century – laws to improve everyone’s health by improving the environment (“No Spitting” laws made an enormous dent in decreasing TB transmission well before we could treat TB), really did improve everyone’s health, rich and poor alike (if your servants don’t have TB, you are less likely to get it, for instance).

In high school, I chanced to read a poem by John Donne, about how no man is an island.  The last line has always struck me, especially if read the right way, as by an advisor to a king: “Send not to know for whom the bell tolls.  It tolls for thee”  (John Donne, Devotions Upon Emergent Occasions (1624), Meditation XVII).

Epidemiology for the win

Uncategorized, , , ,

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.