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Pay for performance – more red tape without improved quality of care

We all agree that improving healthcare quality is a critical goal, but there is no real consensus on how to achieve that goal. In recent years, a “Pay for Performance” or P4P strategy has been put forth by the US government’s Center for Medicare and Medicaid Services (CMS). The gist of the strategy is to pay physicians more or less based on certain disease outcome measures of the patients they treat. So if a physician treats a large group of patients with diabetes, that physician would be paid more/office visits if, on average, those patients demonstrated lower blood sugar levels, lower cholesterol levels, and less evidence of end-organ damage on various tests.

P4P assumes that a patient’s chronic disease outcomes are completely dependent upon the physician. To me, this underlying assumption (that the patient is not involved in his/her own health) is offensive. It is offensive because it assumes that patients are not in control of their lifestyle choices, that their circumstances can be summed up by lab tests, and that their doctor takes all the credit for their hard work to control their disease. It also assumes that patients and families need not be partners in the quest for optimum health – no, that is solely the responsibility of the physician. Ultimately, P4P is disrespectful to patients – it takes them out of the health equation, it presumes that they’re passive participants, and it depersonalizes medicine.

And it gets worse. If physicians are paid more for patients who do well, they will be tempted to “cherry pick” the most motivated and privileged patients. How does this help the patients who need the most help? It will further earmark them for lower quality care.

One of my favorite bloggers, Dr. Richard Reece, echoes my sentiments, further explaining how ludicrous it is to assume that doctors are in full control of patient health outcomes:

People spend 99.9 percent of their time outside of doctors’ offices and hospitals. This time gap is particularly important in patients with chronic disease. Your outcomes depend on how and where you live and work…

Many patients don’t follow doctors’ orders. Many never fill prescriptions, fail to get refills and avoid exercise.

Half-way technologies–stents, coronary bypasses, joint replacements, statins, etc.–don’t eliminate underlying diseases or change their basic pathophysiology. The problem here, of course, is many patients have overblown expectations at what these technologies will accomplish and often return to the behavior that led to the problem in the first place.

Even CMS recognizes the limitations of P4P:

Pay-for-performance is in its early stages of development and a great deal of work still must be done to determine the best method of approaching a comprehensive program.

But that doesn’t stop them from promoting the program to states that are in desperate need of federal funds:

CMS will provide technical assistance to those states that voluntarily elect to implement pay-for-performance programs. We also plan to work with states to encourage that evolving pay-for-performance programs include an evaluation component to provide evidence of the effectiveness of this methodology.

For some further examples of how P4P doesn’t work, check out the following blogs: 1) disaster in the nursing home setting and 2) a summary of recent research studies on the ineffectiveness of P4P by Dr. Poses (via KevinMD).

Then what is the real issue that we’re trying to get at?

Quality care is dependent upon the regular application of evidence-based medicine (EBM) to clinical situations. What is EBM? Every medical decision that physicians make should have a good reason behind it – and that reason, whenever possible, should be based upon scientific evidence that the decision has worked in the past. What I mean is that we spend billions of dollars on medical research to learn the difference between truth and error, and doctors should do their level best to apply the research findings to the care decisions they make each day. Now, keep in mind that there are about 6000 research articles published each day in the medical journals world-wide… so it may come as no surprise that (as Dr. Reece explains):

It’s well-documented doctors only follow preventive and treatment guidelines 50 percent to 55 percent of the time. Moreover, doctors could do a much better job communicating with and educating patients, deploying the Internet (for example) to reach patients when they are outside of the immediate care setting.

So what we really need to do, is support physician education efforts to incorporate the very best research findings into their clinical practice of medicine. How can a physician keep up with all the latest research? I maintain that the government’s efforts would be better spent on hiring physician task forces (to summarize the very latest evidence for the treatment of every disease and condition – and then supply simplified guidelines to docs across the country) than on scheming up ways to penalize physicians for treating patients who are sicker and less willing or able to take control of their health. It would be great if physicians were incentivized to use the latest clinical guidelines in their care of patients – but basing the incentives on outcomes (rather than on applying the guidelines) cuts out the patient’s responsibility as a partner in the treatment. As Dr. Feld rightly points out, quality care based on EBM could be vastly improved through a central EMR.

And what can patients do?

In this new era of consumer directed healthcare, patients need to understand that they really are co-partners with their doctors. A doctor can give you all the best possible advice, but if you don’t take the advice, then that doctor’s work on your behalf may be in vain. I believe that patients should be aware of the care guidelines that doctors use to treat them – and have access to a simple check list to track their own progress. I am personally helping to translate clinical guidelines into consumer-friendly lists for patients so that they can actively participate in, and follow along with, their care plan (so stay tuned for that). Revolution Health is committed to empowering consumers – and helping them to be a full partner on the road to wellness. In fact, we are developing a full suite of su
pportive services (including health coaches, chronic disease management programs, insurance advocates, nurse call lines, physicians available via email, and more) that will make it much easier for them to stay on track. In addition, we are enabling physicians to customize educational information for their patients, and participate (via IT) in a broader relationship with them.

There are many exciting improvements in healthcare currently under development. The Internet will play a central role in connecting patients and physicians to the scientific information that will help them get the best care no matter where they are or which doctor they see. I don’t believe that P4P is anything more than another misguided attempt to “improve healthcare quality” by creating more of the red tape that keeps doctors and patients from meaningful personal interactions.

This post originally appeared on Dr. Val’s blog at

Young and uninsured in Manhattan

My friend forwarded an article to me from New York Magazine. It is about the fact that many of the “20-somethings” in Manhattan choose not to buy health insurance. They reason that nothing really bad is likely to happen to them, so why pay the $167-300/month in health insurance?

Here are some of the strategies that these young uninsured use to stay out of harm’s way:

  • “I carry an expired Blue Cross card in my wallet. You never know, maybe they’ll think I have insurance and I’ll get better care.”
  • Rebekah takes vitamin C and echinacea.
  • “I do yoga to stay loose. I drink a lot of water so I don’t get sick, and vitamins.”

Ironically, Echinacea is actually a cousin of rag weed, and can create a cross-reactivity that may cause cold-like symptoms (leading the user to believe that she averted a more severe cold by taking the supplement). Vitamins are unregulated, and previous studies have shown that up to 50% of bottles do not contain the actual levels of vitamins and minerals displayed on their labels. Dangerously high lead levels have been found in popular multi-vitamins as well. Of course, there was a recent bottled water scare – with a certain brand found to contain high levels of arsenic. Yoga can be harmful to those who push themselves too hard, and to my knowledge there is no convincing evidence that high levels of vitamin C can retard viral illnesses.

Why don’t the young adults buy health insurance? Here’s what one young man said:

“What’s ironic is that I would never live without my cell phone, but I won’t consider buying health insurance. It sounds ridiculous to say that out loud, but the fact is insurance is just too expensive. If it was the same price as my phone”—$150 a month sounded reasonable to him—“I’d buy it in a second.”

The article goes on to describe a nightmare case of an uninsured young man who developed appendicitis. He ended up requiring surgery, and a prolonged hospital stay due to infection. His total bill was $37,000.00. He explained to the hospital that he couldn’t afford to pay, he discovered that he made too much money to qualify for Medicaid, so he sent them a nasty letter, threatening to sue them for malpractice. The hospital reduced the charges to $1,700.00.

A year later when asked if he now carried insurance, here is what the man said:

“Oh, no, I still don’t have any insurance,” he said, rolling his eyes to indicate that, yes, he knows how it sounds. “I think about it, but it’s not like I have a consistent income right now. I think about paying $300 a month on top of my other expenses, and it’s like, God, when’s it going to end?” He paused. “But, really, it’s more than that. I was just so disillusioned with the process. I wanted nothing to do with it, you know? And maybe because, in the end, I kind of managed to get away with it, I end up thinking …” He trailed off, not finishing the thought, but the sentiment was clear: He is still young, he runs, he does yoga, he takes all the vitamins. And it’s not like you can get appendicitis twice.


New York hospitals alone provide $1.8 billion in uncompensated care annually.


Are you sympathetic to the uninsured’s plight, or do you feel annoyed by their attitude?This post originally appeared on Dr. Val’s blog at

Two Teen Girls Take on GlaxoSmithKline

This is one of the coolest David & Goliath stories I’ve heard of in a while. As part of a science experiment, two 14 year old girls from New Zealand set out to test the amount of vitamin C in a popular black currant drink. Ribena’s marketing campaign suggested that the black currants in Ribena syrup had four times the Vitamin C of oranges, but the teen girls discovered that the syrup actually had about ¼ the vitamin C of oranges, and that the ready to drink form of Ribena had no detectable Vitamin C content at all!

The Commerce Commission had pushed for a fine between $275,000 and $350,000 and corrective television advertising. Glaxosmithkline wanted a fine of about $60,000 and no corrective television advertising.

GSK has a worldwide turnover of more than $61 billion, second only to drug giant Pfizer.

Although it’s unclear what the ultimate fine will be, this high school science experiment led to ensuring honesty in advertising. A far cry from the usual volcano/dry ice project that most of us worked on!

And by the way, Ribena is quite delicious.This post originally appeared on Dr. Val’s blog at

Cancer: do we really understand it? Part 2

-Continued from previous post

In contradistinction to these patients exposed to tumor cells who did not develop malignancies, other studies have shown that normal cells can become malignant in an environment where a malignancy had developed. One study, for example, followed two leukemia patients whose bone marrows were eradicated with radiotherapy and who subsequently received bone marrow transplants from normal donors. Two to four months following the procedure, the transplanted bone marrow donor cells were found to have become leukemic.(11)

Clearly, cellular environment plays a critical role in cancer development. Malignant cells infused into a normal environment may not produce a tumor while normal cells placed into an environment that had previously harbored a tumor can become malignant. We are no longer even sure from what cell type a particular cancer develops. Stomach cancer in mice has been shown to originate not from the lining cells of the stomach, as we had thought, but from bone marrow cells responding to experimentally-induced stomach inflammation.(12) The problem may be the environment not the “malignant” cell.(13)

Are we at least able to recognize clinically significant cancer? Can we confidently say, as one judge did when defining pornography, “I know it when I see it.?” Apparently not.

Autopsies on people who died of non-malignant causes have caused us to re-examine our definition of cancer. Patients with previously treated Hodgkins disease—showing no clinical evidence of tumor and thought to have been cured, who died of unrelated causes—were found on autopsy to have residual foci of the disease.(14) Although thyroid cancer is diagnosed in only 1 in 1000 adults between the ages of 50 and 70, on autopsy it has been found in 1 of 3 adults.(15) The prevalence of clinically apparent prostate cancer in men 60 to 70 years of age is about 1%; nevertheless, over 40% of men in their 60s with normal rectal examinations have been found to have histologic evidence of the disease,(16) and autopsy studies have found evidence of prostate cancer in 1 out of 3 men by age 50(17), a finding which rises to 7 out of 10 men by age 80.(18) Similarly, clinical breast cancer is diagnosed in 1 out of 100 women between the ages of 40 and 50;(19) on autopsy it was found in a startling 1 out of 2.5 women in this age group. Moreover, over 45% of the autopsied women had more than one focus of breast cancer and 40% had bilateral breast cancer.(20)

What, then, is cancer? What is responsible for the clinical behavior of cancer, sometimes lying dormant and undiagnosed because it causes no symptoms, sometimes progressing inexorably to death?

For the present, we don’t know the answers to these questions. We have developed treatment programs that offer the best current options for cure, but we should, and do, remain unsatisfied with these approaches. First, because they don’t always work and, second, because with rare exception, they are based on trial and error, not on an understanding of the disease process we are treating.

Once we identify the processes responsible for the accumulation of cells into tumors, we can treat these conditions more effectively, reduce or eliminate the side effects associated with many of our current “best practice” treatments, and remove the terror currently shadowing cancer the way terror used to shadow diseases like syphilis, tuberculosis, and pernicious anemia before we learned how they were caused and developed treatments directed at those causes. We are making progress. Stay tuned.


1. Bennington JL. Cancer of the kidney – etiology, epidemiology and pathology. Cancer 1973;32:1017-29

2. Salvador AH, Harrison EG Jr, Kyle RA. Lymphadenopathy due to infectious mononucleosis: its confusion with malignant lymphoma. Cancer 1971;27:1029-40

3. Lukes RJ, Tindle BH, Parker JW. Reed-Sternberg-like cells in infectious mononucleosis. Lancet 1969;2:1003-4

4. Agliozzo CM, Reingold IM. Infectious mononucleosis simulating Hodgkin’s disease: a patient with Reed-Sternberg cells. Am J Clin Pathol 1971;56:730-5

5. Mirra JM, Kendrick RA, Kendrick RE. Pseudomalignant osteoblastoma versus arrested osteosarcoma. A case report. Cancer 1976;37:2005-14

6. Taubert HD, Wissner SE, Haskins AL. Leiomyomatosis peritonealis disseminata. Obstet Gynecol 1965;25:561-74

7. Croslend DB. Leiomyomatosis peritonealis disseminata: a case report. Am J Obstet Gynecol 1973;117:179-81

8. Mintz B, Illmensee K. Normal genetically mosaic mice produced from malignant teratocarcinoma cells. Proc Natl Acad Sci 1975;72(9):3585-9

9. Lanman JT, Bierman HR, Byron RL Jr. Transfusion of leukemic leukocytes in man. Hematologic and physiologic changes. Blood 1950;5:1099-1113

10. Greenwald P, Woodard E, Nasca PC, Hempelmann P, Dayton P, Maksymowicz G, Blando P, Hanrahan R jr, Burnett WS. Morbidity and mortality among recipients of blood from preleukemic and prelymphomatous donors. Cancer 1976;38:324-8

11. Thomas ED, Bryant JI, Bruckner CD, Clift RA, Fefer A, Neiman P, Ramberg RE, Storb R. Leukemic transformation of engrafted human marrow. Transpl Proc 1972;4:567-70

12. Houghton J, Stoicov C, Nomura S, Rogers AB, Carlson J, Li H, Cai X, Fox JG, Goldenring JR, Wang TC. Gastric cancer originating from bone marrow-derived cells. Science 2004;306:1568-71

13. Bluming AZ. Cancer: The eighth plague – A suggestion of pathogeneisis. Isr J Med Sci 1978;14:192-200

14. Dorfman RF. Biology of malignant neoplasia of the lymphoreticular tissues. J Reticuloendothelial Soc 1972;12:239-56

15. Harach HR, Franssila KO, Wasenius VM. Occult papillary carcinoma of the thyroid. A “normal” finding in Finland. A systematic autopsy study. Cancer 1985; 56 (3): 531-8

16. Montie JE, Wood DP Jr, Pontes E, Boyett JM, Levin HS. Adenocarcinoma of the prostate in cytoprostatectomy specimens removed for bladder cancer. Cancer 1989;63:381-5

17. Oottamasathien S, Crawford D. Should routine screening for prostate-specific antigen be recommended? Arch Intern Med 2003;163:661-2

18. Pienta KJ, Esper PS. Risk factors for prostate cancer. Ann Intern Med 1993;118:793-803

19. Feldman AR, Kessler L, Myers MH, Naughton MD. The prevalence of cancer, estimates based on the Connecticut Tumor Registry. N Engl J Med 1986; 315:1394-7

20. Nielsen M, Thomsen JL, Primdahl S, Dyreborg U, Andersen JA. Breast cancer and atypia among young and middle-aged women: a study of 110 medicolegal autopsies. (Br J Cancer 1987; 56:814-9

This post originally appeared on Dr. Val’s blog at

Spider saves man from cancer

In my last blog post I was describing how adversity can be used for good, and as I was reading the medical news this morning I found another great example. While gardening, a British man was bitten on the neck by a spider. Now, the report doesn’t say exactly what type of spider this was, but judging from the outcome it was probably not a black widow or brown recluse. I’m assuming that the insect was some sort of common garden spider, though it must have had “fangs.” (Imagine my sister recoiling in horror here.)

As it turned out, the spider bit the man right next to a growth on his neck that he hadn’t noticed before. When he went to the doctor’s office to have the bite inspected, they found the growth and decided to biopsy it. The growth was cancerous, and the medical team was able to remove it before it had spread anywhere.

The little spider inadvertently saved a man from cancer. As he weaves his web, nestled between the coarse, hairy leaves of turnip plants, this tiny creature may never understand his contribution to humanity. Small actions can have a positive ripple effect, and a seemingly bad experience can save a life.

This post originally appeared on Dr. Val’s blog at

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