September 28th, 2009 by Shadowfax in Better Health Network, Health Policy, Opinion
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A thoughtful and (dare I say it) balanced look at medical malpractice in today’s NYT:
Malpractice System Breeds More Waste in Medicine – NYTimes.com
The debate over medical malpractice can often seem theological. On one side are those conservatives and doctors who have no doubt that frivolous lawsuits and Democratic politicians beholden to trial lawyers are the reasons American health care is so expensive. On the other side are those liberals who see malpractice reform as another Republican conspiracy to shift attention from the real problem. […]
The direct costs of malpractice lawsuits — jury awards, settlements and the like — are such a minuscule part of health spending that they barely merit discussion, economists say. But that doesn’t mean the malpractice system is working.
The fear of lawsuits among doctors does seem to lead to a noticeable amount of wasteful treatment. Amitabh Chandra — a Harvard economist whose research is cited by both the American Medical Association and the trial lawyers’ association — says $60 billion a year, or about 3 percent of overall medical spending, is a reasonable upper-end estimate. If a new policy could eliminate close to that much waste without causing other problems, it would be a no-brainer.
Read more »
*This blog post was originally published at Movin' Meat*
September 24th, 2009 by KevinMD in Better Health Network, Opinion
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Over at Slate, Christopher Beam takes a balanced look at the issue. He acknowledges that, yes, American physicians get paid proportionally more than the average employee when compared to other countries.
But that should always come with the caveat that other countries, like Great Britain and France, heavily subsidize medical education, while the average American medical student graduates with debt in excess of $150,000. Furthermore, the cost of medical malpractice insurance is significantly more fiscally burdensome for doctors Stateside.
Listen to Princeton’s Uwe Reinhardt, a favorite economist of health reformers, who says, “doctors’ take-home pay (that is, income minus expenses) amounts to only about 1 percent of overall health care spending, or about $26 billion. That’s a drop in the ocean compared with overhead for insurance companies, billing expenses for doctors’ offices, and advertising for drug companies. The real savings in health care will come from these expenses.”
Indeed.
By the way, thanks to Mr. Beam for including a quote and link from yours truly.
*This blog post was originally published at KevinMD.com*
September 22nd, 2009 by Happy Hospitalist in Better Health Network, Opinion
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What’s wrong with using standard of care as the threshold of medical negligence? I walked you through a case, point by point, as to how the failure to diagnose cannot be considered negligence and why the process of the differential diagnosis must be protected from the fear based legal system we operate in.
When the differential diagnosis became a legal driven process, we physicians lost our ability to offer cost effective, clinical driven medicine. We became front seat drivers in the world’s largest Ponzi scheme known as the Medicare National Bank. A
99 trillion dollar black hole of defensive medicine.
What is it about the threshold of standard of care that makes it irrational? Why is that the standard for negligence? And what exactly is it? In six years of clinical hospitalist practice, three years of residency and four years of medical school, I have never taken a lecture, never seen a presentation, and never read a book about the mystical standard of care. In fact, I find myself grasping to comprehend exactly how to define its very existence.
The great legal resource,
Wikipedia, defines standard of care as
The requirements of the standard are closely dependent on circumstances. Whether the standard of care has been breached is determined by the trier of fact, and is usually phrased in terms of the reasonable person. It was famously described in Vaughn v. Menlove (1837) as whether the individual “proceed[ed] with such reasonable caution as a prudent man would have exercised under such circumstances.”
It goes on to define that reasonable caution as the
Bolam Test
Bolam v Friern Hospital Management Committee [1957] 1 WLR 583 is an English tort law case that lays down the typical rule for assessing the appropriate standard of reasonable care in negligence cases involving skilled professionals (eg doctors): the “Bolam test”. Where the defendant has represented him or herself as having more than average skills and abilities, this test expects standards which must be in accordance with a responsible body of opinion, even if others differ in opinion.
I see a problem with what the standard has become. If everyone in my community orders a head CT for drunks with altered mental status, that represents an action by a responsible body of opinion. Does it mean it’s the right opinion? It does not. When the body of opinion has been contaminated by a persistent and progress fear of litigation, the standard defies the evidence, and itself creates irrational bars of achievement that can never be sustained. The responsible body has itself become irresponsible.
If we are to be a science driven profession, we must be allowed to maintain our integrity, without the fear of legal retribution for failing to uphold the irresponsible responsible body of opinion. Our standards are no longer based on science. When everyone orders the CT scan in drunks with altered mental status, the standard itself has become unreasonable.
Yet the marked deviation of the standard of care from the science of care marches on.
I have argued that standard of care is a local phenomenon. It is what ever the local community of professionals says it is, as they are the responsible body of opinion. The standard for evaluating a pulmonary embolism in downtown Chicago is not the same as the standard in rural New Mexico as it is in the jungles of Africa.
A lawyer previously responded that the local community should not set the standard. They argued that the standard should be a national, or perhaps an international evidence based standard. If science is science, there is no reason to believe that evaluating a pulmonary embolism in the United States should be any different than it is in the jungles of Africa. The most important factor in medical decision making if often not the science but the way the science is practiced on a local level.
The
standard of care in
McAllen, Texas is not necessarily the same as the standard of care at the Mayo Clinic. Is the cost difference legally driven or is it money driven at the local level? I suspect the contribution from both is enormous. Some argue that we should practice as Mayo practices. Mayo may be cheaper, but it isn’t cheap. I would argue that even under their payment model as a large salaried multispecialty organization with economies of scale, the ability to practice defensive medicine still thrives. Who says what costs $8,000 in McAllen but costs $5,000 at Mayo couldn’t be done for $2,000 if the victory against defensive medicine was won? I suspect it could, if physicians weren’t held to irrational standards by the unreasonable
reasonable body of opinion.
If the standard in McAllen is to do a heart catheterization on everyone with chest pain, that is what the community has decided. If the standard of care at Mayo is to do a cardiac stress test, that is the standard at Mayo. If the standard in the African jungles is to do a history and physical, that is the standard in the African jungle? What is the right standard?
The right standard is the one that doesn’t get you sued.
Now, are all three standards of care based on science? No. They are based on what the community of physicians has decided should be done. There will always be a large disconnect between evidence based medicine and clinical medicine. It is not reasonable to do a CT scan to evaluate a pulmonary embolism in the jungles of Africa if that is not the standard, even if the evidence suggests otherwise. Clinical factors should always drive the medical decision making.
Some have argued the standard of care should be founded in evidence based guidelines and not local practice expectations from responsible bodies of opinion. Rarely are guidelines clinically relevant in the hundreds of decision trees physicians make every day in their diagnostic processes. Guidelines are based on studies with limited populations of patients whose neatly defined age groups have packaged disease processes. The realities of clinical medicine make many guidelines unworkable and unreasonable.
My post here is an example of the limited value of guidelines in the differential diagnostic process. Not only are the guidelines often not relevant, they are often contaminated by medical societies and other big businesses with a money driven agenda and stealth conflicts of interest.We must also remember that most guidelines are not based on science but rather based on
expert opinion. All physicians are experts in their scope of practice and their opinions should therefore carry the same weight as the opinions expressed on academic based guidelines. Those that believe national standards should exist to drive standard of care practices across the vast clinical spectrum lack an understanding of what it means to be a physician.
Some lawyers wish to believe that having X, Y, and Z data points means doing A, B and C. Some wish to believe that failure to do so represents negligence as a responsible body of opinion would have done so.
I have never been introduced to this responsible body of opinion. I have no way of speaking for their recommendations. We have local culture driving decision making. We have limited national guidelines often corrupted by external influences. We have a legal system, who’s negligence is based on responsible bodies of opinion, opinions which have been established by fear driven medicine.
So what exactly does it all mean? When I order a lab or a test or a procedure or an x-ray to make my clinical decision making, I don’t sit there and think to myself, “What is the standard of care?”
I think to myself, “What is my expected action or reaction from doing this? What am I trying to accomplish?” I have never been introduced to this elusive responsible body of opinion. I have never been invited to a luncheon. This responsible body has never asked me out for a drink. I have never gone on a date with this body. I have navigated through ten years of clinical medicine and I have never once been formally introduced to this all knowing body of opinion.
By establishing the threshold of negligence as a vague responsible body of opinion, a concept which few physicians have studied, few physicians can quantify and few physicians trust, we have built exactly what the medical-legal-industrial complex has prepared for us: A high volume, high supply, high demand, high cost fear driven reality that we all pay for with out of control health care inflation.
If you think Mayo care is cheap, the time has come to consider that even the highest quality, lowest cost centers in this country could reduce their utilization of health care resources by 1/3, 1/2 or more if the fear of civil retribution for failure to diagnose was taken off the shoulders of passionate and devoted physicians from all fields of training and they were allowed the freedom to employ their differential diagnosis skills in a manner consistent with scientific inquiry and not a legal driven fear.
The longer we deny the fear, the quicker the end will be here.
*This blog post was originally published at A Happy Hospitalist*
September 21st, 2009 by Emergiblog in Better Health Network, Health Policy, Opinion
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Well, I lead a double life but it isn’t out dancing in formal wear!
“There is time for only fleeting thoughts about that dance you’ll attend during off duty hours.”
There isn’t even time for that.
Besides, who attends a dance during on duty hours?
Well, I guess the most important thing is that our hands are “soft, smooth and free from redness” because “your patients like it and your date expects it”.
Oh yeah?
The day they use a hand sanitizer thirty times in a shift and wash their hands another twenty, they can talk to me about soft hands.
********************
My husband won’t watch football with me because I tend to get hyped up and throw things at the TV when I get upset.
That explains why there were Notre Dame pom poms and a Cleveland Browns jersey at the base of the set this weekend.
I also like to talk back at the President when he is speaking on TV. Usually it’s things like “Say WHAT?” or “Give me a break!” “Get. A. Clue!” is usually a good one. This last speech, the one to Congress about health care, was no exception. My first comment came a bit into the speech when I noted a few times that “I haven’t heard a single thing I disagree with yet” and “he’s right on that point”.
I was afraid hubby was going to need smelling salts.
But I’m like, “let’s hear how he is going to pay for this…let’s hear him out”.
And then I heard it.
And then he lost me.
*****
There were two comments that I could not let go. I looked them up in the text of the speech to make sure I had heard them correctly.
“…we’ve estimated that most of this plan can be paid for by finding savings within the existing health care system a system that is currently full of waste and abuse.”
“The only thing this plan would eliminate is the hundreds of billions of dollars in waste and fraud…”
Hundreds of billions of dollars? Billions? With a capital “B”?
Waste. Abuse. Fraud.
This means that in order to pay to the proposed health care reform, we have to find enough waste, abuse and fraud to cover expenses.
*****
But I have some questions.
What is the definition of “waste”? To the extent that “waste” means inefficient bureaucratic practices that use up monetary resources, I can get on board with that.
Abuse? What kind of abuse? Using the system inefficiently, like calling an ambulance for a stubbed toe? Remember, the President is using the term “abuse” to represent a potential income stream for the new system, so it would have to encompass behaviors that spend money that should not be spent. Money is spent on patient care, so is he talking about patients abusing the system?
And then there’s fraud…
That’s a crime, folks.
Hundreds of billions of dollars in waste and fraud?
The President must think that there are an awful lot of criminals in the health care system.
So what’s my point?
*****
My point is this: funding for the new proposed health care system (see “most of this plan…”, above) is based on finding waste, abuse and fraud.
What happens when all the waste is taken out, all the abusers are stopped, the fraudsters jailed and the system needs more funding? Does that not make it imperative that we keep finding waste and abuse and fraud? Does that not mean that what constitutes waste, abuse and fraud must be constantly expanded to make up for rising costs?
This can’t be good.
I am in total agreement that our system can be streamlined, big time.
And maybe we could find enough money in waste, abuse and fraud to make it pay for itself, but I doubt it.
If we could do that, wouldn’t we have done it already with Medicaid and Medicare? The budgets for both are getting slashed on a regular basis. Drop the waste, abuse and fraud in those programs and then come back and tell me how much better their budgets are.
If we can’t do it in an existing government-provided system, how on earth do you expect us to believe it can be done on a larger scale?
*This blog post was originally published at Emergiblog*
September 16th, 2009 by DrRob in Better Health Network, Health Policy
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I got something in my e-mail this morning. It’s a press release aimed at helping with prostate cancer awareness month, and is supported by Lance Armstrong’s foundation.
SURVEY SHOWS AT-RISK MEN LACKING IN PROSTATE CANCER KNOWLEDGE
SUNNYVALE, CALIF.,– September 9, 2009 – Prostate cancer remains one of the most commonly diagnosed cancers in the United States. In fact, one in six men will develop prostate cancer. It is also the second-leading cause of cancer death in the United States. But a recent survey suggests that many men at risk for the cancer still aren’t aware of all available treatment options. The survey, conducted late last year, reveals that nearly 50% of men aged 40 and older are not aware of the most common approach to surgery for prostate cancer — robotic-assisted surgery to remove the prostate. “I had to do my own research and then self-admit myself to the [hospital],” says surgery patient Tim Propheter. “…. Most people are just told … ‘Sorry, you have to have surgery, and we’ll set you up for such and such day,’ and they don’t know any better until they run into someone like me,” he says. This lack of information persists despite the fact that prostate cancer treatment has changed dramatically in the last decade. For example, surgery — which remains the gold standard treatment for localized prostate cancer — has become much less invasive. According to the American Urologic Association, the major benefit of prostatectomy, or prostate removal, is a potential “cancer cure” in patients with localized or early stage cancer.
Guess who the press release was from? Guess who sponsored the survey? The following was at the bottom of the email:
About the survey
Data was collected from 1000 self-selected adult healthcare information seekers through an online panel available through Ztelligence.com, using an survey questionnaire. Fifty-four percent of those were male and 46 percent were female. The results reflect only the opinions of the healthcare seekers who chose to participate.
About Intuitive Surgical, Inc.
The survey was conducted by Intuitive Surgical, Inc. (NASDAQ: ISRG), the manufacturer of the da Vinci Surgical System, the world’s only commercially available system designed to allow physicians to provide a minimally invasive option for complex surgeries. Intuitive Surgical, headquartered in Sunnyvale, California, is the global technology leader in robotic-assisted, minimally invasive surgery (MIS). Intuitive Surgical develops, manufactures and markets robotic technologies designed to improve clinical outcomes and help patients return more quickly to active and productive lives. The company’s mission is to extend the benefits of minimally invasive surgery to the broadest possible base of patients. Intuitive Surgical — Taking surgery beyond the limits of the human hand.™
Imagine that. A survey done by company that sells the da Vinci robotic surgical equipment shows that men have tragically no knowledge of the da Vinci robotic prostate surgery!
So let’s see what the evidence shows:
- Prostate cancer occurs in 186,000 men each year and kills nearly 29,000.
- In a well-known autopsy survey, over 1/3 of men over 80 were found to have cancer present in their prostate without evidence of significant disease. It is not clear how many of these men will progress to overt cancer, but it is very clear that this is the vast minority.
- PSA Testing (the blood test for prostate cancer screening) is by far the largest source of surgical candidates. It is a controversial test, having a high rate of false positives and an unproven record of significant benefit.
From the reference uptodate.com:
The European Randomized Study of Screening for Prostate Cancer (ERSPC) reported a small absolute survival benefit with PSA screening after nine years of follow-up; however, 48 additional patients would need aggressive treatment to prevent one prostate cancer death. Although the report did not address quality of life outcomes, considerable data show the potential harms from aggressive treatments. Further sustaining the uncertainty surrounding screening, a report from the large United States trial, the Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial, published concurrently with the European trial, found no benefit for annual PSA and digital rectal examination (DRE) screening after seven to ten years of follow-up. The crux of this screening dilemma was aptly stated by the urologist Willet Whitmore, who asked “is cure possible in those for whom it is necessary, and is cure necessary in those for whom it is possible?”
The most important line in this is at the end of the first sentence, stating that 48 patients would need aggressive treatment (including prostatectomy) to prevent one prostate cancer death. So how much does “aggressive treatment to prevent cancer death” cost?
From the Journal of Clinical Oncology:
For patients in the treatment-received analysis, the average costs were significantly different; $14,048 (95% confidence interval [CI], $13,765 to $14,330) for radiation therapy and $17,226 (95% CI, $16,891 to $17,560) for radical prostatectomy (P < .001). The average costs for patients in the intent-to-treat analysis were also significantly less for radiation therapy patients ($14,048; 95% CI, $13,765 to $14,330) than for those who underwent radical prostatectomy ($17,516; 95% CI, $17,195 to $17,837; P < .001).
note: it was very hard to find numbers here. This is actually from Medicare claims from 1992 and 1993, so it is a huge underestimate from today’s numbers.
Which means that based on the 1992 numbers, you would spend $672,000 to save one life using radiation therapy and $1,084,000 if you used surgery. This does not take into account the consequences of surgery for the men who underwent the surgery.
What about robotic surgery? In a comparison of the cost of open prostatectomy to robot-assisted surgery, the cost is even higher.
Cost was the one area in which the older open surgery was the clear winner: Open radical prostatectomy costs $487 less a case than non-robotic laparoscopy and $1,726 less than robot-assisted prostatectomy.
According to the review, “Shorter operative time and decreased hospital stays associated with the robotic procedure did not make up for the cost of the additional equipment expenditure.” Estimated costs of the robotic system to a provider run about $1.2 million a year, with maintenance costs of $120,000 a year and one-time costs of $1,500 a case.
To summarize:
- Prostate cancer screening is controversial, as it fails to differentiate between the minority of men who would die from the disease from the majority who would simply die with it.
- PSA Testing as greatly increased the number of men diagnosed with early stage cancers.
- Prostate cancer surgery or radiation therapy is recommended for men who have early stage cancers.
- Aggressive prostate cancer treatment has to be done 48 times to save one life.
- The most expensive treatment for prostate cancer is prostatectomy, or removal of the prostate.
- The robotic form of the surgery is a higher-cost procedure by a significant amount.
So, an expensive form of surgery that may not be appropriate is done on a group of men identified on a very unreliable test yielding a very small number of lives saved and a lot of men who then have to deal with the physical consequences of the surgery. Why in the world is this being promoted at all?
Money. Here’s the homepage of one of our local hospitals. They have aggressively marketed da Vinci surgery on television, billboards, and the radio.
Why do you think they would pay as much money as they do for this device? It’s good business? Not so fast. Dr. Paul Levy stated back in 2007 about this very procedure:
Here you have it folks — the problem facing every hospital, and especially every academic medical center. Do I spend over $1 million on a machine that has no proven incremental value for patients, so that our doctors can become adept at using it and stay up-to-date with the “state of the art”, so that I can then spend more money marketing it, and so that I can protect profitable market share against similar moves by my competitors?
No, hospitals are employing this just to keep pace. The real winner in this is Intuitive Surgical, Inc., who has been a darling of Wall Street, beating estimates in earnings with a Q2 net profit of $62.4 Million.
Why is the cost of healthcare going up while physician reimbursement goes down and hospitals go out of business?
It’s Intuitive.
God Bless America!
*This blog post was originally published at Musings of a Distractible Mind*
