Pretty much everyone agrees that we need to improve the quality of healthcare delivered to patients. We’ve all heard the frightening statistics from the Institute of Medicine about medical error rates – that as many as 98,000 patients die each year as a result of them – and we also know that the US spends about 33% more than most industrialized country on healthcare, without substantial improvements in outcomes.
However, a large number of quality improvement initiatives rely on additional rules, regulations, and penalties to inspire change (for example, decreasing Medicare payments to hospitals with higher readmission rates, and decreasing provider compensation based on quality indicators). Not only am I skeptical about this stick vs. carrot strategy, but I think it will further demoralize providers, pit key stakeholders against one another, and cause people to spend their energy figuring out how to game the system than do the right thing for patients.
There is a carrot approach that could theoretically result in a $757 billion savings/year that has not been fully explored – and I suggest that we take a look at it before we “release the hounds” on hospitals and providers in an attempt to improve healthcare quality.
I attended the Senate Finance Committee’s hearing on budget options for health care reform on February 25th. One of the potential areas of substantial cost savings identified by the Congressional Budget Office (CBO) is non evidence-based variations in practice patterns. In fact, at the recent Medicare Policy Summit, CBO staff identified this problem as one of the top three causes of rising healthcare costs. Just take a look at this map of variations of healthcare spending to get a feel for the local practice cultures that influence treatment choices and prices for those treatments. There seems to be no organizing principle at all.
Senator Baucus (Chairman of the Senate Finance Committee) appeared genuinely distressed about this situation and was unclear about the best way to incentivize (or penalize) doctors to make their care decisions more uniformly evidence-based. In my opinion, a “top down” approach will likely be received with mistrust and disgruntlement on the part of physicians. What the Senator needs to know is that there is a bottom up approach already in place that could provide a real win-win here.
Some 340 thousand physicians have access to a fully peer-reviewed, regularly updated decision-support tool (called “UpToDate“) online and on their PDAs. This virtual treatment guide has 3900 contributing authors and editors, and 120 million page views per year. The goal of the tool is to make specific recommendations for patient care based on the best available evidence. The content is monetized 100% through subscriptions – meaning there is no industry influence in the guidelines adopted. Science is carefully analyzed by the very top leaders in their respective fields, and care consensuses are reached – and updated as frequently as new evidence requires it.
Not only has this tool developed “cult status” among physicians – but some confess to being addicted to it, unwilling to practice medicine without it at their side for reference purposes. The brand is universally recognized for its quality and clinical excellence and is subscribed to by 88% of academic medical centers.
In addition, a recent study published in the International Journal of Medical Informatics found that there was a “dose response” relationship between use of the decision support tool and quality indicators, meaning that the more pages of the database that were accessed by physicians at participating hospitals, the better the patient outcomes (lower complication rates and better safety compliance), and shorter the lengths of stay.
So, we already have an online, evidence-based treatment support guide that many physicians know and respect. If improved quality measures are our goal, why not incentivize hospitals and providers to use UpToDate more regularly? A public-private partnership like this (where the government subsidizes subscriptions for hospitals, channels comparative clinical effectiveness research findings to UpToDate staff, and perhaps offers Medicare bonuses to hospitals and providers for UpToDate page views) could single handedly ensure that all clinicians are operating out of the same playbook (one that was created by a team of unbiased scientists in reviewing all available research). I believe that this might be the easiest, most palatable way to target the problem of inconsistent practice styles on a national level. And as Senator Baucus has noted – the potential savings associated with having all providers on the same practice “page” is on the order of $757 billion. And that’s real money.
I highly recommend a bottom up approach, not top down. That’s how you win docs and influence patients.
By Steve Simmons, M.D.
Last week my partner wrote about The Funnel, and illustrated how patients are squeezed through a healthcare system that focuses on specific problems without allowing enough time to treat patients as individuals. We have shown how frustrating this is for doctors and demonstrated that a shortage of primary care physicians is a reality. However, we don’t believe it’s too late to reverse this foreboding trend. Today, my partner and I at doctokr Family Medicine are building a practice to care for our patients as individuals first. We have also added our voice to a growing chorus of physicians sounding ever louder, explaining the necessity of a healthcare system that places the art of caring for patients first.
The next time you sit in a doctor’s waiting room, look around and consider what, and more importantly who, you see. You might see a sick child or his worried mother. Our healthcare system does not see two people, rather it sees a 5-digit CPT and ICD-9 code. ICD-9 (International Classification of Diseases) codes were originally created by the World Health Organization (WHO) to track diseases across the globe. Today, CPT codes (designating patient difficulty) are combined with the ICD-9 codes by third-party providers to standardize the reimbursement process. Although over 17,000 ICD-9 codes exist to classify various illnesses, there is no code for compassion. More concerning, the system does not allow any time to ease the worries or fears of a mother.
The focus of a primary care doctor’s medical practice should be on the art of patient care. An individual should be treated as a whole and not the combination of their individual problems. But, a time may come when we must focus on one specific medical problem and seek the help of a specialist; such as an endocrinologist for diabetes or an orthopedist after an accident. Yet, without a primary care physician to coordinate our care and speak on our behalf, a patient’s wants and needs as an individual might not be considered in reaching a particular treatment decision. I can speak as a doctor, son, or patient when I say that anyone’s health can suffer at the hands of brilliant physicians working without the guidance of a coordinating physician who knows us well.
My mentor in medical school was an experienced family physician near retirement who offered me the following insight. There are two types of doctors and I would consciously or sub-consciously choose which one to be. One type of physician makes medical problems central in their patients’ lives and thus forces the individual to revolve around their problems. The other type works to keep the patient’s life central and tries to make problems rotate around the individual.
Those policy makers determining the future of healthcare should follow my mentor’s advice. Today’s health-care system has devolved to focus solely on problems and disease, often to the detriment of individuals and families. As decision-makers explore revamping our current healthcare system they could continue, unaware, in this same direction. But, I have to believe they would choose the other direction if they could remember how it feels to sit in a doctors waiting room surrounded by other people – individuals all. Nothing will change the fact that healthcare is ultimately about people, and not codes or a specific problem. Healthcare should help patients and their primary care doctors make good health and wellness decisions while basing them on an individual as a person.
Until next week, I remain yours in primary care,
Steve Simmons, MD
By Stacy Beller Stryer, M.D.
I read an interesting article in the New York Times last week, “Inside the Mind of the Boy Dating Your Daughter.” When I saw the title, I was instantly drawn to it because my older daughter is going to enter high school in the fall (yikes!) and has recently begun talking about boys. She currently attends a magnet school where most of her classmates are female. She just mentioned, for the first time, that there are no boys to like in her program, which makes for boring sleepover talks (but makes her mother exceedingly happy). Given that I think she’s the cat’s meow, I thought I could get a little “inside information” from reading the article before throwing her into the world of male testosterone and upperclassmen.
However, the article totally surprised me. Coming from a family of 3 girls and having 2 daughters, myself, I am much more comfortable figuring out what a girl might be thinking or feeling than a boy. I must admit that I believed the folklore that teen boys basically have sex on their brains. But, according to a study recently published in the Journal of Adolescence, this is not the case. Researchers had 105 10th grade teens complete a survey about sex, love and relationships. Reportedly, most boys said the main reason they would date someone was because they “really liked her.” The second most common reason they wanted to date someone was to get to know her better, and because they were physically attracted to her. Of note, 40% of the boys stated that they had already been sexually active and 14% wanted to have sex to lose their virginity. We must remember, however, that this was a relatively small sample size done in one school.
As a follow-up, the New York Times asked people to send in their comments about the article, and they discussed the results in the Week in Review. Many of the comments sent in were from adult men, who didn’t believe the teens answered honestly because, as these adults remembered, (?is their memory correct) they thought about sex, and only sex as teens.
An important and notable comment made by Dr. Andrew Smiler, the author of the study, is that parents are less likely to talk to their sons about relationships than their daughters. He stressed the need to talk to boys frequently about relationships, respect, trust and sex.
This gives me some hope that my daughter won’t be bombarded with a storm of testosterone the moment she enters high school. Actually, I am not too worried because I have been preparing her for the world of “boys” since she was much younger. For years we have talked about puberty, and as she has become older we have added relationships, values, possible uncomfortable situations, and waiting to have sex. I believe that this will carry her a long way. And, according to research, I am right, because telling a teenager to wait to have sex actually makes it more likely that they will.
As parents, we must remember to talk to both our daughters and our sons. Our discussions should start early. In elementary school, they should know what puberty is and how boys and girls develop. They should also learn about love and respect. As preteens, they should have talks regarding dating, relationships, and sex. If you wait too long, they will not hear you, or they will already have had to deal with a sexual situation and may not have known how to handle it. Amy Mirion and Charles Miron, authors of How to Talk With Teens About Love, Relationships, and S-E-X, also discuss how important it is to have small, ongoing dialogue rather than the one “big sex talk.” They suggest that, when parents talks with boys, they be direct and simple, and that they include topics such as love, respect, and values. They also stress the need for boys to actually be told to wait before having sex.
Just in case, maybe I’ll send some pepper spray to school with my daughter next year …
For more information on how to talk to your children about relationships, sex, and other risky behavior, check out the following websites:
As far as I can tell, there are very few physicians currently involved in the innermost circles of healthcare reform. This is concerning to me, not because I’m one of those “paternalistic doctors” who “drive up in their Porsches threatening to pull out of Medicare” but because I think that many policy makers don’t really understand the incredible complexity associated with doing the right thing for patients. Here is an excerpt from the WhiteCoat’s Call Room blog that perfectly illustrates why practicing good medicine often requires a break from protocol:
It isn’t just the patients who think I’m a bad doctor.
Based on the information from all the pinheads at Medicare’s “HospitalCompare” web site, I’m downright dangerous.
For those who don’t know about Hospital Compare, it is a site where the general public can compare the “quality indicators” for hospitals on measures deemed important by the AHRQ.
I failed to meet a couple of indicators recently, so I received notices from our hospital administration that I am now considered out of compliance with the HospitalCompare guidelines and am bringing down our numbers on the HospitalCompare.gov web site.
In other words, Medicare thinks I’m a bad doctor.
Let me tell you about the patients I screwed up on.
The first patient was a gentleman in his 70’s who started having chest pain at home. He got sweaty, passed out, and hit his head on the concrete floor in his house, causing a nice goose egg on the back of his noggin. When he arrived in the emergency department, he was still having chest pain, so we hooked him up to an EKG and … lo and behold … he was having a myocardial infarction.
According to the quality indicators at “HospitalCompare”, if a patient with a heart attack is going to receive thrombolytics (”clot busters”), the thrombolytics must be given within 30 minutes of the patient’s arrival at the hospital. If a health care provider takes longer than 30 minutes to administer thrombolytics to someone with a heart attack, the government considers that provider to be practicing bad medicine.
Now I’m faced with a choice:
A. Do I give clot busters to someone who sustained a significant head injury (and may be bleeding internally) so that I can look like a “good doctor” to Medicare and HospitalCompare.hhs.gov? If there is bleeding inside his brain, clot buster medications will make the bleeding worse and could kill him.
B. Do I perform a CT scan on the patient to make sure that there is no bleeding inside his brain before I give the clot-buster medications? If I do the CT scan, there is no way that we’ll get the results and be able to give the patient thrombolytics within the 30 minute window.
If I choose “A,” the hospital stays in the upper echelon of facilities that meet HospitalCompare.hhs.gov’s guidelines. Doesn’t matter if the patient dies – according to Medicare, “We’re Number ONE!”
If I choose “B” I’m doing what is right for the patient, but our hospital will look bad and HospitalCompare.hhs.gov will plaster it all over the internet that our hospital doesn’t follow Medicare’s rigid and sometimes life-threatening guidelines.
I chose “B.”
According to HospitalCompare.hhs.gov, my decision made me a bad doctor…