March 31st, 2007 by Dr. Val Jones in Health Policy
1 Comment »
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 RevolutionHealth.com.
March 29th, 2007 by Dr. Val Jones in Health Policy
2 Comments »
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 RevolutionHealth.com.
March 20th, 2007 by Dr. Val Jones in Medblogger Shout Outs
2 Comments »
I am opposed to millionaires, but it would be dangerous to offer me the position.
–Mark Twain
As we consider the wastefulness of the healthcare system, I have heard many people complain that physician salaries are one of the main culprits in escalating costs.
Dr. Reece compares the average income of some of the highest paid physician specialists, with that of hospital executives, medical insurance executives, and fortune 500 CEOs. Check this out:
Highest Paid Physicians
1. Orthopedic, spinal surgery, $554,000
2. Neurosurgery, $476,000
3. Heart surgeons, $470,000
4. Diagnostic radiology, Interventional, $424,000
5. Sports Medicine, surgery, $417,000
6. Orthopedic Surgery, $400,000
7. Radiology, non-interventional, $400,000
8. Cardiology, $363,000
9. Vascular surgery, $354,000
10. Urology, $349,000
Executive Pay for Massachusetts Hospital CEOs
1. James Mongan, MD, Partners Healthcare, $2.1 million
2. Elaine Ullian, Boston Medical Center, $1.4 million
3. John O’Brien, UMass Memorial Medical Center, $1.3 million
4. David Barrett, MD, Lahey Clinic, $1.3 million
5. Mark Tolosky, Baystate Health, $1.2 million
6. James Mandell, MD, Children’s Hospital, Boston, $1.1 million
7. Gary Gottlieb, Brigham and Women’s Hospital, $1 million
8. Peter Slavind, MD, Massachusetts General Hospital, $1 million
2005 Total Annual Compensation for Publicly Traded Managed Care CEOs
1. United Health Care $8.3 million
2. Wellpoint, Inc, $5.2 million
3. CIGNA, $4.7 million
4. Sierra Health, $3.4 million
5. Aetna, Inc, $3.3 million
6. Assurant, Inc, $2.3 million
7. Humana, $1.9 million
8. Health Net, $1.7 million
Top Corporate CEO Compensation
1. Capital One Financial, $249 million
2. Yahoo, $231 million
3. Cedant, $140 million
4. KB Home, $135 million
5. Lehman Brothers Holdings, $123 million
6. Occidental Petroleum,, $81 million
7. Oracle, $75 million
8. Symantec, $72 million
9. Caremark Rx, $70 million
10. Countrywide Financial, $69 million
But the real story here is the salary of our primary care physicians – those unsung heroes of the front lines. KevinMD pointed out a recent news article citing $75,000.00/year as the average salary of the family physician in the state of Connecticut, and that their malpractice insurance consumed $15,000.00 of that. Although this is certainly below the national average for pediatricians (they start at about 110,000 to 120,000), I’ve seen many academic positions in the $90,000 to 100,000 range.
Now I ask you, does it seem fair that the vast majority of physicians (the primary care physicians) are making one tenth of the average hospital executive salary? Should doctors really be in the cross hairs of cost containment?
This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
March 18th, 2007 by Dr. Val Jones in True Stories
1 Comment »
Always do right. This will gratify some people and astonish the rest.
–Mark Twain
My favorite writer of all time is Mark Twain. His keen observations and uncanny ability to combine wisdom and wit makes his writing incredibly entertaining, don’t you think? I thought it would be fun to take a few of his quotes and illustrate them with true stories from my mental archives.
Today’s quote is about doing the right thing. I remember a case where a young internal medicine intern was taking care of a 42 year old mother of 3. The mother had HIV/AIDS and had come to the hospital to have her PEG tube repositioned. Somewhere along the way, she required a central line placement, and as a result ended up with a pretty severe line infection. The woman’s condition was rapidly deteriorating on the medicine inpatient service, and the intern taking care of her called the ICU fellow to evaluate her for admission to the intensive care unit.
The fellow examined the patient and explained to the intern that the woman had “end stage AIDS” and that excessive intensive care management would be a futile endeavor, and that the ICU beds must be reserved for other patients.
“But she was fine when she came to us, the line we put in caused her downward spiral – she’s not necessarily ‘end stage,’” protested the intern.
The fellow wouldn’t budge, and so the intern was left to manage the patient – now with a resting heart rate of 170 and dropping blood pressure. The intern stayed up all night, aggressively hydrating the woman and administering IV antibiotics with the nursing staff.
The next day the intern called the ICU fellow again, explaining that the patient was getting worse. The ICU fellow responded that he’d already seen the patient and that his decision still stands. The intern called her senior resident, who told her that there was nothing he could do if the ICU fellow didn’t want to admit the patient.
The intern went back to the patient’s room and held her cold, cachectic hand. “How are you feeling?” she asked nervously.
The frail woman turned her head to the intern and whispered simply, “I am so scared.”
The intern decided to call the hospital’s ethics committee to explain the case and ask if it really was appropriate to prevent a young mother from being admitted to the ICU if she had been in reasonable health until her recent admission. The president of the ethics committee reviewed the case immediately, and called the ICU fellow’s attending and required him to admit the patient. Soon thereafter, the patient was wheeled into the ICU, where she was treated aggressively for sepsis and heart failure.
The next day during ICU rounds the attending physician asked for the name of the intern who had insisted on the admission. After hearing the name, he simply replied with a wry smile, “remind me never to f [mess] with her.”
The patient survived the infection and spent mother’s day with her children several weeks later.
This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
March 17th, 2007 by Dr. Val Jones in Opinion
2 Comments »
One medical specialty has managed to avoid (nearly completely) the public eye: Physical Medicine & Rehabilitation (or PM&R). Physicians who choose this specialty are referred to as “physiatrists” or “rehabilitation medicine specialists” or “rehab docs.” But the truth is that very few people understand what they do, and unfortunately the rehab docs haven’t made much of an effort to explain themselves to their peers or the world at large.
A dear friend and mentor once asked me, “why did you choose such an odd ball specialty?” This rather direct question forced me to ponder my career decision, and to determine how it came to pass that PM&R was given the unhappy reputation of “odd ball specialty.” I’ll begin with a little background about the specialty and then explain why I chose to devote my life to it.
The history of PM&R
PM&R really traces its roots back to the American Civil War (1861-1865). This gruesome battle resulted in over 620,000 casualties and over 60,000 limb amputations. The modern specialty of general surgery developed through life saving trial and error on the battlefield. Massachusetts General Hospital, for example, was performing an average of 39 surgeries/year before the civil war, and this increased to 2,427 in the late 1800’s.
But physicians and surgeons were not prepared for the aftermath of war – tens of thousands of maimed and partially limbless now trying to live out their careers in a disabled condition. One confederate soldier, James E. Hanger, lost a leg in the war, and subsequently created America’s first prosthetics company, still in operation today. Unfortunately for the disabled, though, there was no guarantee that appropriate accommodations would be made for them to be fully reintegrated into society.
With the rise of surgery came a major realization: patients did not do well after surgery if they remained in bed. Conventional medical wisdom suggested that bed rest and inactivity were the most effective way to recuperate, but now with thousands of post-operative patients in full view, it became painfully clear that the patients who did the best were the ones that got up and returned to regular physical activity as quickly as possible.
Following this realization, the University of Pennsylvania created (in the late 1800’s) an orthopedic gymnasium for “the development of muscular power with apparatus for both mechanical and hot air massage, gymnastics and Swedish movement.”
A young Canadian gymnast trained in Orthopedic Surgery, Dr. Robert Tait McKenzie, was recruited to U. Penn to develop a new field in medicine: “Physical Training.” Dr. McKenzie created a medical specialty called “Physical Therapy” and he was the first self-proclaimed “Physical Therapist.” He wrote a seminal book on the subject called “Reclaiming the Maimed” (1918) and continued to practice orthopedic surgery until his death in 1938.
Other major medical institutions followed U. Penn’s lead, creating “Medicomechanical Departments” at Mass General and the Mayo Clinic. Technicians were trained to assist in helping post-operative patients to become active and reclaim their range of motion – these technicians were known as “physiotherapists” and formed the first physiotherapy training program at the Mayo Clinic in 1918.
World War I (1914-1918) resulted in millions of additional amputations, thus flooding the health system with disabled veterans. In response, the army created two medical divisions: The division of orthopedic surgery and the division of physical reconstruction. By 1919, 45 hospitals had physiotherapy facilities, treating hundreds of thousands of war veterans.
And then there was polio. Suddenly a viral illness created a whole new wave of disabled individuals, further stimulating the need for orthotics (leg braces and such) and rehabilitative programs.
World War II (1940-1945) resulted in yet another influx of disabled veterans. All the while the medical community was developing innovative programs to maximize veterans’ functionality and integration into society and the work place through the burgeoning field of Physical Medicine & Rehabiltiation.
Key players in the development of the specialty:
Dr. Frank Krusen developed the first physical medicine training program at the Mayo Clinic in 1935 and the “Society of Physical Therapy Physicians” (now the American Academy of Physical Medicine & Rehabilitation) in 1938. He coined the term “physiatrist” to describe the physicians who specialized in physical modalities for rehabilitating patients.
Dr. Howard Rusk founded the Institute for Physical Medicine & Rehabilitation in 1950 at NYU. Excellent research in the field ensued.
Dr. Henry Kessler founded the Kessler Institute for Rehabilitation, in New Jersey, 1949. More medical research was developed.
Mary E. Switzer successfully lobbied for the enactment of Public Law 565 which mandated that government funds be channeled towards rehabilitation facilities and programs for the disabled.
What’s in a name?
So as you can see, there is some good reason to be confused about the modern specialty of PM&R. It has undergone several name changes, molded by historical circumstance. Today, physiotherapists (they still go by that name in Canada) or physical therapy technicians have become a well known and respected profession: Physical Therapy.
Physicians who specialize in Physical Medicine & Rehabilitation are called rehabilitation medicine specialists or “rehab docs” or “physiatrists.”
-See Next Post for the rest of the story –
This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
