The Covert Rationing Blog

Grand Rounds at the Health Business Blog

May 13th, 2008 by DrRich

David E. Williams hosts Grand Rounds this week (and for an astounding fifth time!) at the Health Business Blog.  He’s managed to find many fascinating links, including one from this site. Please check it out.

Posted in Uncategorized | No Comments »

Covert Rationing Makes Malpractice Reform A Bad Idea

May 9th, 2008 by DrRich

Our friend Kevin Pho was undoubtedly correct when he pointed out in his recent op-ed in USA Today that arbitrary and unrestrained medical malpractice lawsuits are a blight on our healthcare system. The always-looming threat of malpractice suits elicits expensive and wasteful defensive behaviors from doctors and hospitals, and is a major source of physician frustration. Almost everyone except the trial lawyers (and their minions in the various federal and state legislatures) understand that medical malpractice is in dire need of reform.

So it deeply pains DrRich to say that significant malpractice reform at this juncture is a bad idea, certainly for patients, and in truth even for the medical profession.

Realizing that he has just alienated at least the estimated 60% of his readership who are of the medical persuasion, DrRich hastens to assure one and all that he is second to none when it comes to despising lawyers. Consider:

1) DrRich’s initial baptism by trial lawyer occurred right after he entered practice as a general internist 30 years ago. During his very first month of practice, he wrote a refill prescription for a patient whose own doctor was unavailable. Two years later he was named in a malpractice suit, alleging that he had written this prescription incorrectly. It turned out that the patient was not harmed by the medication (her suit was for another issue entirely, involving another doctor), and it also turned out that DrRich had written the prescription correctly in the first place. But it took a full 18 (nerve wracking) months of legal maneuvering to acquire a copy of the prescription from the plaintiff’s attorney, during which time DrRich was pressured to “settle” (he did not settle), and after which the suit against him was summarily dropped. Fortunately this has been DrRich’s only direct encounter with a malpractice suit, but unfortunately it was not his only encounter with lawyerly ethics.

2) Eighteen years later, by this time a professor of medicine and a cardiac electrophysiologist (hey - if you’re going to specialize, specialize!), DrRich was ensnared in one of the federal government’s very first major dragnets aimed at healthcare “fraud.” DrRich was, of course, completely and demonstrably innocent of all allegations. But proving his innocence required him to endure a severely prolonged, difficult and frightening ordeal, highlighted by an actual show trial before Congress (replete with masked, voice-altered witnesses). You can read the whole incredible tale here. (Memo to the Office of the Inspector General: Just kidding, you guys are great. Thanks for the memories.) It was this experience that prodded DrRich to finally ask himself what the heck was going on, and that ultimately led him to discover the Grand Unification Theory of Healthcare. (As a catalyst for discovering universal truths, DrRich has concluded, it would be far easier just to have an apple fall on your head.)

3) Then, another 10 years later, after DrRich had left the practice of medicine altogether to become a consultant and writer (which he had hoped would be a less hazardous venue), an attorney who was suing a big biotech company leaked to the New York Times a memo DrRich had written as a consultant to that company. The NY Times immediately made DrRich’s memo the subject of a major article that proved quite embarrassing (though inappropriately so) to the company. You can read the Times article here. Subpoenas immediately began raining down on DrRich from all directions, and his life once again needlessly became a circus of depositions and other legal maneuverings. DrRich will be happy to tell you all the details of this episode once he’s sure it’s all over, which at this moment he’s not.

All of this is simply to demonstrate that DrRich has earned his lawyer-despising chops the hard way. His numerous and oft-painful encounters with attorneys, during his long and varied career, have left DrRich more than a little sympathetic with the likes of Dick the Butcher, the cutthroat in Shakespeare’s Henry VI, who said, “The first thing we do, let’s kill all the lawyers.”*

So: If you’ve waded through this confession of faith, you can plainly see that DrRich is no friend to lawyers, and would like nothing better than to climb onto the malpractice-reform bandwagon, there to join his colleagues in demanding an end to the waste, intimidation, heartache and expense brought on by the systematic abuse of medical malpractice suits.

But alas, to his unending regret he cannot.

The reason he cannot, of course, is covert rationing.

A central goal of covert rationing is to make physicians answerable, above all, to one or more central authorities (whether the government or mega-insurance companies) rather than to their patients. The litany, to refresh everyone’s memory, goes like this:

• Healthcare rationing is unavoidable.
• But we’re Americans and Americans don’t ration.
• So we’ve deputized the government and the insurers to do the rationing covertly.
• Covert rationing requires controlling the behavior of physicians; specifically, it requires coercing them to place the needs of the payers ahead of the needs of their patients.
• Patients are thus fundamentally and purposefully marginalized within the healthcare system.

In a thousand ways, covert rationing leads directly to the destruction of the classic doctor-patient relationship, a relationship formerly revered and sanctified by law, tradition and ethics, in which the primary responsibility of the doctor was for the welfare of his/her individual patient.

Turning the physician’s efforts away from individual patients and towards the good of the whole (”good of the whole” as defined by guideline-creating groups and other policy-making bodies whose output can be easily influenced by central authorities) has become a major emphasis of today’s healthcare system. Accordingly, the death of the classic doctor-patient relationship has been decreed by Congress, supported by medical ethicists, upheld by the U.S. Supreme Court, and incorporated into guideline-directed routine medical practice. It is being taught to young doctors today from the outset, many of whom seem to regard the old notion that every patient should be evaluated and treated as a unique individual as anachronistic and inefficient.

When physicians abandon the classic doctor-patient relationship, even though it’s through coercion, they abandon what defines them as professionals. It diminishes doctors to a stature no higher than that of pieceworkers, who get paid by the procedure or by the completed checklist. It is the loss of this innate professional purpose, DrRich believes, which accounts for the greatest part of the frustration being expressed by physicians today.

For patients, the loss of the classic doctor-patient relationship - losing their one and only true advocate, whose job it is to take their part within an adversarial healthcare system - is a threat to more than mere professional pride or purpose. It is a threat to life and limb. Patients are left to their own devices, alone, abandoned, and marginalized in hostile territory, their ostensible Guides distracted by their own needs (and indeed, perhaps no more reliable than so many Gollums).

Consider the implications of the malpractice system to patients in such an environment. In a healthcare system where physicians are being urged, cajoled, threatened, incented and coerced to practice medicine to some statistical mean and not to the individual, and where the “mean” to which they are supposed to aspire is determined by central authorities mad with the need to covertly ration care, the only real leverage patients retain is the implied threat to sue doctors who fail to address their individual needs. The threat of malpractice litigation, as wasteful and counterproductive as it is, provides at least some degree of balance in the doctor-patient encounter, and gives doctors (even those whose professional pride has been successfully eroded by all the many efforts aimed at doing just that) a good reason to always ask themselves, “Is this action I’m about to take the action that THIS patient really needs me to take?”

And in a distressingly sad way, because the threat of litigation may cause some doctors to ask this question more often than the central authorities would like them to, the specter of malpractice suits may even, to some small degree, help to uphold medical professionalism. And at least to this tiny extent the threat of lawsuit, in the long run, may be beneficial to doctors.

There’s more. The malpractice travesty, as bad as it is, is at best a distraction. It distracts physicians from focusing on the main event, from that which is really destroying their profession. For once you destroy the doctor-patient relationship you leave the medical profession adrift and rudderless, buffeted by the four winds and capricious currents. You leave it subject to a gathering host of oppressors, with their decrees and directives that in earlier days would have been dismissed as beneath consideration. You leave it defenseless against encroachment from groups with far less training and expertise, but who can also do the piecework, fill out the checklists, follow the guidelines, and who have the government-sanctioned certificates to prove it.

In the face of all this, for doctors to focus exclusively or even primarily on malpractice reform - which, all niceties aside, will in some fundamental way further limit the prerogatives of their abandoned patients - is perhaps worse than merely a distraction. It is a complete capitulation. It is a plea not for the restoration of their profession, but instead for mere consistency, to force the plaintiffs’ attorneys to recognize, as the doctors themselves have done, that the standards of care have been formally diminished, that it is not fair to hold doctors to a standard in a court of law that they are enjoined from achieving in the clinic. It is an acknowledgment that the classic doctor-patient relationship, that which defines medicine as a true profession and not just a trade, is dead and gone and is not coming back.

If doctors will extricate themselves from a system in which they are working primarily for the government and insurers instead of for their patients; if they will reinvent styles of medical practice in which they can give primacy to their individual patients instead of to the payers; then at last we all will be morally obligated to insist on fundamental malpractice reform. But as long as doctors allow themselves to practice in an environment that systematically disenfranchises and marginalizes their patients, no reform should be supported or even permitted that will push patients farther into the margins.

DrRich has tried mightily during this past year to illustrate how covert rationing always leads to inefficiency, waste, inequity, destruction - and absurdity. That it can turn an utter travesty like our current state of malpractice litigation into something we ought to refrain from vigorously reforming is, perhaps, the most absurd result of covert rationing we have seen yet.

* Attorneys themselves famously insist that Shakespeare was actually paying them a compliment by putting these words in Dick’s mouth. What the Bard actually meant, they theorize, is that before any violent overthrow of a civil government can be effected, one first must eliminate the protectors of society, namely, the lawyers. But prithee! (Olde English for “Give me a break!”) Leave it to the self-serving lawyers to so completely twist a context as crystal clear as the one in which this line appears. Dick the Butcher, quite undeniably, was simply enumerating just one more delight - the premier one at that - to add to the veritable garden of delights that would become theirs once he and his gang took over. And anyone who says otherwise is either a member of the legal profession, or someone disgustingly sympathetic to it. Which (he is taking very great pains to point out), DrRich is not.

Posted in General Rationing Issues | 10 Comments »

More on Predatory Guidelines

May 6th, 2008 by DrRich

The Wall Street Journal Health Blog informs us that on Saturday last, participants at an American Psychiatric Association symposium apparently castigated the new American Heart Association guidelines on the need to do cardiac pre-screening of children with ADHD. (See DrRich’s previous posting on predatory guidelines, and on the new AHA recommendations.)

A pediatric psychopharmacologist from Harvard (DrRich wonders if any such exist anywhere else) named Timothy Wilens insisted there is no evidence that medication for ADHD causes sudden death. He referenced a recent report in the New England Journal of Medicine showing that the risk of sudden death in children on ADHD drugs is only 0.2 to 0.5 per 100,000 patient years, compared to a risk of 1.3 to 8.5 per 100,000 patient years in athletes under 18. Wilens jokingly suggested that perhaps “Parents should get an EKG for their child before yelling at them.”

Wilens then reluctantly admitted that at Harvard, the cardiac pre-screening recommended by the AHA has already been instituted in order to avoid legal problems.

So, by this graphic example, even when imposed guidelines are clearly believed to be completely unnecessary, even when that belief is strongly supported by published statistical evidence, and even when the guidelines have been promulgated in a demonstrably predatory manner that is more likely an invasion of professional turf than a protection of patients, guidelines are guidelines and must be obeyed.

We can fully expect to see many more examples of predatory guidelines, dueling guidelines, and all manner of other guidelines reflecting utter anarchy. Why? Because the manufacture of guidelines works.

DrRich rests his case.

Posted in Guidelines, Abuse of | 1 Comment »

Is Guideline Tyranny Causing Guideline Anarchy? (Part II)

May 2nd, 2008 by DrRich

Part I, The Tyranny of Guidelines, can be seen here.

Part II - The Anarchy of Guidelines

Once doctors have been successfully taught that medical guidelines are not really “guidelines” at all, but rather are specific directives with which they must fully comply, it follows that if you are a healthcare group or organization with an agenda, the thing you need to do is to manufacture guidelines that will direct doctors to do whatever it is that most benefits you.

Getting the guidelines to say what you would like them to say is easier to accomplish than one might think. While the practice of guideline-development is ostensibly a highly scientific endeavor that ought not to admit much bias, in truth and to a remarkably large extent it is a political activity.

The more the outcome of a particular guideline-development process is non-deterministic - that is, the more it is capable of being influenced by the personal, political, professional or fiscal agendas of the guideline developers - the more likely it is that you may find competing interest groups devising different sets of guidelines for the same thing. This process, which DrRich believes is only beginning, will eventually create an anarchy of guidelines. Within this anarchy, one can already discern several categories.

Category 1: Dueling Guidelines:

Example: Pharyngitis. Dr. Centor (also affectionately known as DB) is a widely recognized expert on treating pharyngitis, and he has written both on his blog and in the peer-reviewed medical literature on this topic. DB has also written about the many sets of guidelines that have been produced around the world for treating pharyngitis. In regard to 10 sets of guidelines (10!) that were developed by different groups of experts in the United States and Europe, DB notes that the various sets of guidelines show “minimal agreement.” So, for instance, guidelines developed in the United States (where most medical experts receive financial support from industry in one way or another) recommend antibiotics frequently in patients with sore throats, whereas in most sets of guidelines developed in Europe (where keeping costs down is arguably a more important consideration among the medical experts), antibiotics are almost never recommended.

DB further observes that “the 10 guideline groups did not agree on which [medical] articles to include in developing their guideline. More important, these guidelines demonstrate that all guideline committees start with implicit biases. . .The truth about guidelines is that they are molded though the value structure of the panel members.”

Example: Prostate Cancer Screening. DB has also pointed us to this example. The American College of Preventive Medicine (ACPM) concludes that medical evidence to date does not support routine prostate-specific antigen (PSA) screening. This negative opinion on PSA screening is generally supported by the American Academy of Family Physicians and the American College of Physicians. Routine screening, these groups say, may actually produce more harm than good (since false positive PSA levels are common and often lead to unnecessary procedures, and early treatment of prostate cancer often does not translate to improved survival). On the other hand, guidelines from the American Urological Association and the American Cancer Society strongly recommend routine PSA screening, since early detection of prostate cancer clearly saves many lives.

The pattern seen here is readily explainable: General medical practitioners and preventive medicine specialists will tend to give more weight to the overall dollar costs of screening, and to the cost of unnecessary medical procedures that invariably follow from “false positive” screening results. These groups will tend to require strong evidence showing overall benefits to a population before endorsing widespread screening. On the other hand, the groups who get paid to do the screening, or to do the procedures generated by the results of screening, or whose funding is related to the overall incidence of the disease being screened for, will always tend to favor widespread screening.

It is important to note three things here. First, both interest groups are making legitimate points. On one hand, widespread screening will be costlier for society, and may not demonstrate an improvement in overall outcomes across the population. On the other hand, widespread screening will certainly save the lives of many individuals whose cancer will be caught at a treatable stage.

Second, neither group is being completely altruistic here, but instead have produced guidelines that serve their own interests. Specialists who do procedures have a lot to gain by screening policies that generate more procedures. On the other hand, the remuneration for generalists (and preventive medicine specialists) is increasingly tied to cost savings, and to NOT referring too many of their patients to expensive specialists.

Third, both interest groups are comprised of respected experts who use “evidence-based medicine” to reach their conclusions. Everybody in this picture can (and does) passionately support their guidelines as being firmly founded on scientific processes.

Category 2: Predatory Guidelines

Example: Screening of ADHD children. Just last week the American Heart Association (whose physician members tend to be very procedure-oriented - and some might say avaricious - cardiologists) released unsolicited guidelines, recommending the pre-screening of children who have ADHD by a careful cardiac evaluation, including an ECG, before placing them on stimulant medication.

The reason for these new guidelines is that stimulant medication in rare individuals with previously undiagnosed cardiac disease can be dangerous. (So can running on the playground, but nobody is yet recommending cardiac screening before letting kids play.) ADHD today is a very common diagnosis (indeed, it almost seems as if being a boy is now a disease, for which drug therapy is usually required), and routine screening prior to therapy would be extremely expensive both in direct costs, and in the indirect costs related to false positives. Predictably, pediatricians have reacted somewhat skeptically to the AHA’s new guidelines, and the American Academy of Pediatrics (AAP) is asking pediatricians to wait while they scramble to make a formal response.

Members of the AAP recognize, perhaps only subliminally, that the AHA has made a power play here. A powerful interest group with its own agenda has reached onto the AAP’s turf, and has directed AAP member physicians - through the authority of formal guidelines - to change their behavior in a way that may or may not benefit patients, but that will surely benefit members of the AHA. The pediatricians who DrRich knows tend to be kindly, mild-mannered diplomats, in distinct contrast to many of the aggressive cardiologists he knows (and thrives among). So it remains to be seen whether the AAP will respond to this arrogant invasion of their turf with their own set of guidelines. But the non-confrontational idiosyncrasies of pediatricians aside, it is easy to see how “dueling guidelines” could be a natural result of predatory guideline actions like the one taken here by the AHA.

Example: Metabolic Syndrome. In 2005, the American Diabetes Association (ADA) released a stunning statement announcing that metabolic syndrome - to that moment a beloved child of the ADA - does not exist!

Metabolic syndrome is a set of conditions related to insulin resistance that greatly increases the risk of cardiovascular disease. It was initially described by a noted diabetes specialist, and for years remained in the purview of diabetologists. But then, in the late 1990s our friends at the AHA (who seem to be early adopters of predatory guidelines) became very interested in metabolic syndrome, and launched their own guidelines addressing it. Unable to compete with this much larger and much more powerful organization for “ownership” of metabolic syndrome, the ADA finally adopted the unusual tactic of declaring the condition nonexistent. (Those who do not understand why it is important for such organizations to retain ownership of various medical conditions do not understand fund raising.)

Today if you go to the AHA website you will find detailed guidelines on the diagnosis and management of metabolic syndrome. On the ADA website, which used to be loaded with information on metabolic syndrome, all you’ll find is their sad statement saying it doesn’t really exist after all. Patients who formerly had metabolic syndrome are now considered by the ADA to have “pre-diabetes,” which (because this sounds a lot more like a condition they ought to be in charge of rather than a bunch of heart doctors) they hope will place these patients back squarely onto their turf. But thanks largely to the skilled use of predatory guidelines by the AHA (of which DrRich is a proud member), the “metabolic syndrome” terminology has taken deep root in the medical community at large, and is not likely to go away.

Category 3: Industry-driven Guidelines

Industry does not get to create medical guidelines, much to its chagrin, but it has certainly recognized the practical conversion of “guidelines” to “ironclad rules,” and accordingly, is rapidly learning to influence the guideline-development process.

The pathway for doing so looks something like this: a) design a randomized clinical trial that will show that the use of your product substantially improves the outcome of some subset of patients, b) engage key medical thought leaders in the design, management and publication of the trial, c) showcase the results of the trial at major medical meetings, d) petition the guidelines committees of the appropriate medical organizations (aggressively guidelines-oriented organizations, like perhaps the AHA, are especially valued) to incorporate your product into revised guidelines. (If you’ve recruited your medical thought leaders wisely, they will be in a position to influence those guideline committees.)

DrRich may point out examples of this technique in future posts. Suffice for now to say that designing a clinical trial that has a very high probability of showing what you want it to show (step “a” in the process above), is often not particularly difficult. By their nature, randomized clinical trials do not eliminate bias (as many believe), but instead, allow the designers of the trial to control the bias, and thus to tailor the study to yield the desired results. Companies that make medical products figured this out a long time ago.

(The ability to bias the “evidence” is just one of the things that makes “evidence-based medicine” so very intriguing to anyone interested in the nature of objectivity. Or, it goes without saying, to anyone interested in covert rationing.)

Where Will the Anarchy of Guidelines Lead?

DrRich could go on and propose more categories of anarchical guidelines, but this post is already too long, and it is time to get to the point.

Regular readers will already know were DrRich is going with all this. To a healthcare system whose every pore is infused with the need to ration covertly, anything that stirs up anarchy, chaos and confusion can become a great friend. Such things keep doctors (the engines of healthcare spending) completely off balance.

Doctors know they must follow the guidelines or be damned, but when slogging through an anarchy of guidelines, which guidelines should they follow? Somebody, they will eventually plead, needs to bring some kind of order from all this chaos. And of course, a central authority will immediately answer the call, only too ready and willing to put things right.

The overall program, then, looks like this:

1) Make doctors understand that guidelines must be obeyed in every particular. (Done.)

2) Realizing that doctors think this way, various interest groups will begin promulgating numerous guidelines of their own, ultimately leading to “guideline anarchy,” and placing actual practicing physicians into a completely untenable position. (This process is beginning.)

3) Finally, everyone will acknowledge the need for some central authority to step in, sort through the manifold sets of guidelines, and select those (or assemble brand new ones from the parts) that will now become the “official” Guidelines Which Must Be Obeyed. This step is the one that will allow the central authority to select or tailor the guidelines that meet its own special interest (i.e, covert rationing), and to do it in a way that is not overtly heavy-handed, but rather, that rescues order from chaos.

4) Doctors, by this point beaten into submission, will not rail against the externally imposed guidelines, but rather, will be thankful that the central authority has brought wonderful clarity at last.

So once again, covert rationing acts on the system to disrupt its equilibrium; but as always, entropy eventually will become maximized and a new state of equilibrium will be reached. DrRich is no oracle, just a student of thermodynamics.

Posted in Guidelines, Abuse of | 2 Comments »

Is Guideline Tyranny Causing Guideline Anarchy? (Part I)

April 30th, 2008 by DrRich

The Tyranny of Guidelines

Anybody practicing medicine today needs to be serious about medical guidelines.

The original idea behind medical guidelines was to provide (oddly enough) a guide to physicians in caring for patients with a particular medical problem. That is, they suggested a generally preferred approach to medical care in view of current medical evidence, but did not attempt to dictate care in all cases. Medical guidelines were to serve as a roadmap which, while usually suggesting a favored route from point A to point B, always allowed that that for individual patients, some alternative route might be preferred or necessary.

As originally conceived, medical guidelines (based as they were in classic evidence-based medicine, as Dr. Poses reminds us) were designed to encourage the “conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.” It was simply assumed that in applying such guidelines clinicians would continue “integrating individual clinical expertise with the best available external clinical evidence from systematic research.” That is, guidelines were supposed to serve as a touchstone for doctors attempting to tailor the best available current evidence to the care of their individual patients.

It goes without saying that medical guidelines are actually not being used in this way today.

Under a healthcare system where controlling the behavior of physicians (in a vain attempt to control costs) is Job One, “guidelines” are treated as a set of unalterable rules - as definitive steps that must be followed in all cases, without exception; and that, if taken, will yield that which is defined as high quality medical care, and if not taken, will yield that which is defined as low quality medical care. Once quality is defined as compliance with guidelines, then “physician report cards” based on such compliance can be made available to the public, and can be used to steer patients to the “high quality” doctors and away from the “low quality” ones. Lately, the highly popular gambit of Pay for Performance assures that doctors are explicitly rewarded (like trained seals) for following whichever of the sundry lists of guidelines is preferred by the payer of record, to assure excellent quality (and, incidentally of course, to reduce cost).

And now, the most recent revelation from our friends at Medicare is that the mere existence of a set of guidelines can render certain medical problems, whose incidence in fact can sometimes be reduced but never eliminated, as “never events,” the occasional occurrence of which thus becomes punishable. When Medicare expanded its list of these “never events” a few weeks ago, the agency’s chief justification for doing so appears to have been the availability of guidelines that can allegedly reduce the likelihood of their occurrence.

It is notable that there are no rules for writing guidelines, and no generally agreed upon requirement for transparency (such as, for instance, elaborating on the criteria used for accepting, rejecting or ranking various sources of available medical evidence used in formulating them). A group of “experts” that has been given (or that has taken) the authority to develop a new set of guidelines assumes the role of potentates, and they can devise guidelines every bit as detailed and as extravagant as they choose (so long as they give the nod to, and can plausibly claim their work to be derived from, “evidence-based” considerations).

Once the new guidelines are chiseled onto stone tablets and brought down the mountain to the abject throngs of awaiting doctors (for it is almost always true that the mere practitioners who are charged with living by the guidelines are rarely the same as the exulted experts who get to devise the guidelines), it matters not whether physicians working under strict time limits will find it impossible to comply with each exquisite detail, or indeed, whether strictly following these guidelines might even have harmful unintended consequences for patients. The guidelines, once designated by various insurers or the feds as being “the” guidelines, must be obeyed. (And if it turns out that the guidelines simply cannot be obeyed, say, due to their sheer ungainliness, then large masses of doctors can be threatened with lawsuits for non-compliance, if not for accessory to murder.)

Guidelines treated in this manner clearly violate the original intent of evidence-based medicine in general, and of medical guidelines in particular. But when you’ve got to do whatever it takes to direct the behavior of physicians (the ones who, with the touch of a pharmaceutical-logo’ed pen, can bend the entire medical-industrial complex to their every whim), medical guidelines simply must be perverted into a tool of control.

Medical blogs have done a pretty good job of chronicling the growing tyranny of medical guidelines. A less well-documented result of this tyranny, a phenomenon that is just now coming into focus, is the mad scramble by diverse interest groups to promulgate their own sets of guidelines, and subsequently fight to have them accepted as “the” guidelines, thereby to gain control the medical agenda. Guidelines written by competing interest groups will often direct doctors to do very different things, and will set up some very interesting turf battles.

In Part II we consider this “anarchy of guidelines,” now taking shape as a direct result of the guideline tyranny under which doctors labor, and patients risk their lives.

Posted in Guidelines, Abuse of | 3 Comments »

Visit the Grand Rounds Smack Down

April 29th, 2008 by DrRich

Doc Gurley, revealing herself to be something other than the sweet, demure, lady-like blogger we’ve always thought her to be, hosts Grand Rounds this week in what we can only surmise is her true guise, a hard-nosed, show-no-mercy maven of professional brawling.  DrRich is proud not only to have been included in this pugnacious posting, but also and especially to have been recognized by someone who knows her pugilists as well as Doc Gurley obviously does as being “uber-Macho.”  The designation truly brings a tear to DrRich’s eye.

Posted in Uncategorized | No Comments »

On Crying Doctors

April 23rd, 2008 by DrRich

The New York Times yesterday published an essay by Barron H. Lerner, MD, on the question of whether doctors ought to remain stoic at the bedside, or instead ought to openly display their emotions. Lerner himself seems neutral on this question, and offers arguments from both sides (i.e., the advantages on one hand of the physician graphically displaying the deep empathy he/she feels for the patient, vs, on the other hand, maintaining the professional distance necessary to convey a sense of control and hope).

As it happens, DrRich agrees with DB on this issue. DB stresses “the importance of maintaining composure when everything seems to be failing. Patients deserve composure, empathy and a well developed plan.” DrRich believes that this ought to be a doctor’s default position.

Certainly there are times when it may be entirely appropriate for a physician to cry at the patient’s bedside, for instance, when the emotional outburst is completely spontaneous and simply cannot be held back, or when a patient is relating a particularly affecting personal story, or in other circumstances no doubt too numerous to mention (or too painful to think about). But in general, DrRich is convinced that doctors should not make a habit of expressing their emotions too frequently or too luxuriously to their patients.

(That’s all well and good, some of you might be thinking, but we really don’t care what DrRich thinks about crying doctors. We do not come here for gratuitous opinions on touchy-feely stuff like this. We come here to read hard analysis tinged with sarcasm, and to get all riled up about covert rationing. What the heck do crying doctors have to do with covert rationing?

To which DrRich replies: Observe.)

It seems more and more likely that our medical schools, busily training America’s Doctors of Tomorrow, have reached or are about to reach the following epiphany: A particularly wonderful way to repair the failing doctor-patient relationship would be to indoctrinate young future physicians (most of whom these days are said to be women, not that there’s anything wrong with that) that crying at the bedside - indeed, openly displaying their every emotion at the bedside - is a marvelously therapeutic act. A display of the doctor’s true emotions conveys a powerful message to the patient.

But as it happens, crying doctors actually convey two powerful messages to their patients.

First Message: I recognize and empathize with your humanity. I feel your pain.

Second Message: Your position is so dire as to be beyond even my ken. You are well and truly screwed.

It is this latter message that, in the opinion of DrRich, DB and others, ought to make most doctors on most occasions relatively circumspect about crying in front of their patients.

It is also this latter message that offers to make crying doctors a tool for covert rationing.

For one thing, when the doctor is reduced to tears (thus graphically announcing to the patient that the game’s about up; that there’s pretty much nothing, really, that’s going to change this bleak outcome; and how very sad it all is) - well! Talk about reducing your patient’s expectations!

A chief tenet of covert rationing is that patients who can be made to expect little will be satisfied with little. In most cases this is accomplished by simply coercing doctors not to tell patients all of their options. (Since doctors have proven more resistant to such coercion than the feds and the insurers would like, docs are now being herded into P4P and 7.5-minute patient encounters to assure the same end.) But if they can be encouraged to cry when delivering bad news, doctors can destroy patients’ expectations in a much more dramatic (and thus more effective) fashion.

Furthermore, the traditional role of the doctor when a patient’s outlook is poor is to take charge of a very bad situation, and with great empathy, patience and fortitude attempt to guide the patient through that situation with as much skill and courage as possible, even if the final destination looks very bleak. If the doctor instead becomes just one of the people who are crying about it, then the patient immediately perceives themselves to be abandoned and alone, placed into a position irremediably desolate, with no sense of direction, and no sense of control over their own destiny. Patients fighting illness from such a position do more than merely lose their expectations; they will also die much sooner and in greater despair than necessary.

So obviously, a healthcare system founded on covert rationing will see immediate advantages to espousing crying doctors. In the name of advancing empathetic physicians and fixing a broken doctor-patient relationship, we could, more easily and more often, substitute emotional support for medical technology, and effect the patient’s end more quickly and more economically.

Certainly, now that medical schools are teaching forms of alternative medicine that in former years would have made real doctors blush, DrRich would not be at all surprised to learn that courses being taught on the doctor-patient relationship are already encouraging young doctors to “let their emotions free” as a way of bonding with their patients.

Young doctors should not be taken in by such ploys. They should empathize with their patients, but remain strong, and lead their patients gently and resolutely through their ordeal. They should try to avoid allowing a free display of their emotions to break their patient’s spirit. Their job, instead, is to use their expertise to fortify their patient’s spirit, even in the worst of times. And above all they should not allow themselves to become the trained tools of an ultimately cynical healthcare system, that uses every ploy at its disposal to covertly ration care.

Posted in General Rationing Issues | 6 Comments »

Never Events? Never Mind

April 18th, 2008 by DrRich

Medicare’s newfound passion for quality has found yet another avenue of expression.

A year ago the Centers for Medicare and Medicaid Services (CMS) announced it would no longer pay for the treatment of certain medical conditions that occur after patients have been admitted to the hospital. These conditions were:

* Bed-sores
* Two kinds of catheter-associated infections
* Air embolism
* Mediastinitis after coronary bypass surgery
* Giving patients the wrong blood type
* Leaving objects inside surgery patients
* In-hospital falls

Now, according to the Wall Street Journal, CMS has proposed adding several new conditions to this list, to wit:

* Surgical site infections following certain elective procedures
* Legionnaires’ disease
* Extreme blood sugar derangement
* A collapse of the lung resulting from medical treatment
* Delirium
* Ventilator-associated pneumonia
* Deep vein thrombosis/Pulmonary Embolism
* Staph infection in the bloodstream
* Disease associated with Clostridium difficile infection

Several commentators admired by DrRich have blogged on the advisability of declaring these particular conditions to be “never events.” All agree that while certain of them clearly should never be permitted to happen (e.g., leaving claw hammers inside a patient’s abdomen, or transfusing the wrong blood), certain other ones are going to continue happening to some patients no matter how high the quality of the institution and the medical professionals. (DrRich particularly recommends the Happy Hospitalist’s cogent and entertaining analysis of the matter.)

Because this topic has been so well-covered, DrRich does not need to comment any further on the unfairness of insisting that doctors prevent every single instance of conditions that are often not particularly preventable; or on the fact that insurance companies (as they always do) will soon follow Medicare’s lead and also refuse to pay for these “never events;” or that hungry attorneys will now begin suing doctors and hospitals for unavoidable complications because those complications have been federally designated as avoidable; or even the fact that, having so deftly expanded the horizons of what can be considered a “never event,” the feds have cleared the path for defining virtually any medical condition they choose as a “never event.” (As a case in point, the feds’ own guidelines on preventing delirium, referred to in their own “fact sheet” that purports to justify the expanded list of “never events,” admit that there are no effective guidelines for reliably preventing delirium.)

There’s also no point in complaining publicly about this expanded list of “never events,” since the public is foresquare behind the notion that no medical complications should ever occur and if they do it is somebody’s fault, and equally behind the notion that the feds can squeeze quality into the system just by demanding it to be so. Therefore, any doctors who complain about these new, tough quality measures will reveal themselves to be both anti-quality and low-quality doctors.

Rather, DrRich will refer back to the true mission of this blog, and simply explain to his readers how this new “never event” strategy furthers the true mission of Medicare and the insurers, which is to say, covert rationing.

For Medicare and the insurers are like closet narcotics addicts - while smiling their pasty smiles and assuring us that each and every one of their new initiatives are only concerned with quality and nothing else, the whole time, with every ounce of their being, they are inventing ways to manipulate, deceive and twist each and every opportunity into some means of scoring another covert-rationing “hit.” Consequently, we cannot go wrong if we ask, each time we see some new program ostensibly aimed at quality improvement: Where’s the rationing?

One might think the rationing in this case is easy to spot. After all, if the feds stop paying for “never events” that actually cannot be avoided, they will save dollars right up front simply by refusing to pay for services rendered. But Medicare itself has estimated that its up-front annual savings from its original list of “never events” would be only about $20 million. And that seems hardly worth the effort.

The real savings will come from a place far more sinister than that. The “never events” initiative - just as the feds tell us - is aimed at changing physicians’ behavior. But quite predictably, that behavioral change will not be in the arena of quality improvement (since no amount of quality improvement can stop “never events” that are inevitable). Rather, the behavioral change will be in the arena of risk avoidance.

While it is unlikely that doctors will ever refuse to care for high-risk patients who are experiencing genuine medical emergencies, it is quite likely they will stop recommending elective medical therapy for high-risk patients. Patients who seem particularly prone to infection, bed sores, falls, blood sugar abnormalities, blood clots, delirium, or who seem likely to need intravenous antibiotics (which predispose to C. difficile) will be particularly targeted. Roughly speaking, these patients will include diabetics, the elderly, anyone with a clotting abnormality or a history of blood clots, the obese, people with immune disorders, and the chronically ill.

Doctors, of course, have always computed a risk/benefit analysis before offering elective services (such as hip replacement, coronary artery bypass grafting, back surgery, gall bladder surgery, anti-obesity surgery, etc.) to such patients. The increased risk of complications these patients face always has factored into such calculations, and into the doctor’s ultimate recommendation.

But now, the “risk” part of the risk/benefit analysis will include two important new risks, and this time they are risks to the doctor herself (and her institution): 1) If any of these complications occur, no payment will be made for the (often very expensive) treatment the complication will require; and 2) If a complication occurs, another “never event” will be tabulated in the federal database next to the doctor’s (and the hospital’s) name, which will inevitably show up in a public report card.

Lest anyone think that doctors would not really stop recommending clinically indicated care to patients just because of the personal risk it would entail, remember that it’s already happened, and is well documented. The government and the insurance companies have already conducted that experiment; it’s been completed, the results have been tabulated, reported, and duly noted. It turns out that doctors, like most other people, respond quite logically to negative incentives.

CMS knows exactly what it’s doing here.

Posted in General Rationing Issues | 4 Comments »

Smile When You Call Me Optimist

April 14th, 2008 by DrRich

In a previous post, DrRich gave his thoughts on the distressing condition of the American primary care physician (PCP), and described how the feds, the insurance companies, and the currents of history are conspiring to fundamentally devalue and disrupt their once-honored profession. Further, he attempted to describe some options that disaffected PCPs might explore which might possibly open the door to new, more sustainable business models.

This posting has generated a robust commentary, for which DrRich is grateful, as he thoroughly enjoys engaging in give-and-take with his readers, whose thoughtfulness and intelligence invariably challenges him to bring his analyses into sharper focus.

And based on this most recent commentary, DrRich finds that there is indeed an issue that clearly needs more focus - that of his purported optimism. It seems that some readers, in perusing the previous post, came away with the idea that DrRich is saying something like this: While history is demanding that PCPs must suffer a great disruption, history also points the way to their salvation; that, indeed, PCPs merely need to jump in the boat, and the currents of history will sweep them into the promised land.

To the extent that he created any impression that the transformation he’s proposing for PCPs is likely to be automatic, or straightforward, or easy, or without significant hazard, or (least of all) universal, DrRich most humbly apologizes.

He would like to set the record straight.

Here’s what history dictates: As long as there are free markets, the “final solution” being embraced by the insurers and the feds - that of a dumbed-down, malleable population of front line medical practitioners (whether made up of indoctrinated younger physicians, “broken” older physicians, ascendant nurses, or some combination of these) who will provide all basic medical services and control access to more specialized services - will ultimately not prevail. The large number of patients who have needs that will not be met by this solution will create an irreducible demand that the market will somehow conspire to meet. That, if anything, is the “optimistic” part of DrRich’s synthesis.

PCPs are in an unique position to fulfill much of this demand, and DrRich tried to describe two general pathways that might be explored for doing so (there are almost certainly others). But he certainly did not mean to imply that this would be easy to do, or that more than a minority of PCPs would embark on such a path, or would be able do it successfully. Indeed it seems likely that most PCPs will take the course of least resistance, as they seem to be doing now, gradually allowing themselves to be absorbed by the diminished model now being offered by the insurers and the feds, complaining about but not really fighting their fates, and all the while hoping for early retirement.

History reveals this to be the general rule. Most persecuted Puritans did not migrate to the New World (where they faced hurdles arguably even more off-putting than the threat of malpractice suits and specialist-dominated credential committees). Most Goths, upon being overrun by the invading Huns and facing the choice of absorption or migrating to territory occupied by somebody else, did not move south to sack Rome. Most PCPs will likewise accept their fate, and simply try to make the best of it.

Any pioneering PCPs who attempt instead to blaze these new trails will face huge hurdles, and they’re hurdles anyone (including DrRich) can see very clearly. They include the strong opposition (to put it mildly) PCPs will get from specialists as they explore ways to encroach on their turf; the attacks they’ll suffer from malpractice lawyers as they undertake to perform services traditionally done by specialist physicians (lawyers being the specialists’ great allies in this instance); the steady resistance of the insurers; the notion dearly held by most of the public that people shouldn’t have to pay for ANY of their own healthcare; and the parallel notion dearly held by many government officials that people shouldn’t be ALLOWED to pay for any of their own healthcare, and that any attempts to arrange for people to do so should be met with the most extreme prosecutorial wrath.

So, while DrRich believes history helps to explain what’s going on in the world of the American PCP, and helps (at least vaguely) to point the way for some of them, history rarely unfolds easily, or quickly, or without pain, bloodshed, tragedy and travesty. Generations (or centuries) can pass before a resolution is reached.

But if some insist on characterizing this as optimism, who is DrRich to object?

Posted in New business models for healthcare, Primary Care in America | 4 Comments »

Primary Care: Time to Reboot

April 8th, 2008 by DrRich

American primary care medicine has entered into a period of change. “Change” is perhaps too mild a term; many - especially the primary care practitioners (PCPs) themselves - might call it a period of crisis. In any case it is change so profound that one might be forgiven for thinking Senator Obama is already president.

Consider. PCPs have been hogtied to a dysfunctional reimbursement system that (thanks to the government, the insurers, the AMA, and their own specialist colleagues) has drastically and systematically devalued their training, expertise, and time. The very concept of what a PCP is and does (and indeed, what they should be called - whether PCP, family doctor, general practitioner, gatekeeper, or medical homemaker) seems in constant flux.

Whatever it is PCPs do, the government, the insurance industry, and experts on medical policy have spent years making the primary care job seem, well, easy. Their practices have been reduced to a series of discrete, easily cookbookified tasks. Each of these tasks can be directed by “guidelines” (devised, of course, by non-PCP “experts”), compliance to which can be easily tabulated and monitored, thereby to determine the adequacy of the individual PCP’s performance. And, because their job is now so codified, they are expected to perform it accurately and reproducibly in a matter of minutes (some say 7.5 minutes per patient encounter, though others will allow up to 12.5), just like any other rote industrial process.

To make matters worse, PCPs are slowly awakening to the realization that they are being squeezed out from the bottom. Some of what they do (the really easy stuff) is being corporatized into mini-clinics by the large drug store chains, and the rest is being threatened by newly assertive nurse practitioners and doctor-nurses, who are at least tacitly supported by the insurance industry. (Thanks to Dr. Poses for pointing out the relationship between doctor-nurses and big insurance.)

No wonder PCPs have become so terminally frustrated.

It is natural for PCPs to want to fight the changes that are destroying their profession, and causing their numbers to dwindle. Many have offered ideas. Gain the public’s support by alerting them to the impending and dangerous shortage of PCPs. Improve PCP payment schedules. Forgive the student loans of young doctors who choose primary care. Lobby congress for pro-PCP legislation. Offer novenas.

Some of this (DrRich is thinking the novenas) might hold off the inevitable for a time. But PCPs are fighting more here than just the government, the insurers, their specialist colleagues, and nurses filled with thoughts of vengeance (for 150 years of having to give unquestioning obedience to arrogant, clueless and unfeeling doctors, if you care to ask them). The PCPs are fighting history.

What is happening to PCPs is what happens to many experts whose jobs are fundamentally based on knowledge and/or technology. That is, as knowledge and technology advance, some (and perhaps a lot) of what the experts do can be sufficiently simplified and “democratized” that less well-trained individuals become enabled (or believe they are enabled, which amounts to the same thing) to do it themselves.

This is what the market is telling PCPs has happened to them. A substantial part of what they do indeed has been reduced to guidelines and cookbooks (thanks to remarkable advances in clinical studies and medical technology). The typical patient (note: DrRich said “typical”) with hypertension, diabetes, cholesterol abnormalities, and common infections can be relied upon to respond reasonably well to reasonably standardized therapy. And the market is saying to the PCP: “We can find ways of doing this without you.”

The same thing has happened countless times in history. The 1500-year monopoly enjoyed by the clergy in interpreting the Word of God was completely disrupted by the printing press and by the upstarts who translated scripture into the vernacular. The music industry has been fundamentally disrupted by digital recording software, which enables anyone with a PC to do things that had always required multi-million dollar studios. Ditto for book publishing. Ditto for real estate agents, accountants, car dealers, teachers, newspapers. All are wrestling to one degree or another with the “creative destruction” that is produced by advancing knowledge and/or technology.

For the most part, of course, nobody (except, perhaps, the doctor-nurses) will come right out and tell the PCPs to go away altogether. Instead, they’re telling them to dumb down, to just follow the rules, to stick to the guidelines and be paid to perform (one thinks of trained seals), to become like the lesser-trained practitioners who inevitably will be replacing them over the next decade or so. That’s where the profession is going, they’re being told. Get with the program, adapt to reality - or don’t let the door hit you where you keep your wallet.

Looking at the situation from this more historical perspective, one can see why it seems futile for PCPs to respond by railing and complaining, by lobbying for the public and the legislatures to understand that they’re actually quite important, by appealing to their specialist colleagues for more than lip-service support, or by trying to convince more medical students to choose a disintegrating profession such as this.

PCPs are in the path of a tidal wave of disruption, triggered by economic realities and enabled by technology. They are unlikely to prevail by a’wishing, and a’hoping, and a’singing, and a’praying.

From the perspective of history, it becomes apparent that what PCPs need to do is reboot. They need to reinvent themselves in a way that is compatible with the new reality. So far, they seem to be seeing only the disruption part of the creative disruption now tearing their profession apart. They need to find the creative part.

From a simple examination of history, two possibilities will immediately come to mind.

1) Just as advancing medical knowledge and technology has made it possible for lesser-trained individuals to encroach on their turf, so have the same advances made it feasible for PCPs to encroach on the turf of their snugger (and smugger) colleagues - the specialists. Observing how some of the bread-and-butter skills of the PCP have been sufficiently reduced to the point that nurses can do it, one finds it inconceivable that similar basic skills now monopolized by specialists haven’t been similarly reduced. It is undeniably true that for a lot of what specialists do, one doesn’t actually need a specialist anymore to do it. (As a cardiologist, DrRich knows for a fact that this is the case, but unfortunately he is bound by blood-oaths extracted by the high priests of his guild - oaths which mortgaged the immortal souls of his progeny down through 10 generations - not to mention the specifics. Sorry.) But look around. You’ll find examples easily enough.

Fundamentally, advancing technology allows individuals to migrate upwards into areas formerly occupied only by more specialized individuals. This is a law of technologically progressive societies. That nurses are aggressively migrating upwards onto the turf of PCPs is merely a case in point. So, rather than fighting a doomed-by-history rear guard action against the advancing army of nurses, why should PCPs not instead launch a blessed-by-history invasion of their own, against the smugocracy (the people whose jobs end in -ologist)? Heck, they’ll even have the insurers and the feds on their side for once (for the same reason the doctor-nurses now do). Wouldn’t that be novel?

2)Another law of technologically progressive societies is that, whenever specialists are displaced by upwardly mobile, technology-enabled non-specialists, there will always be a portion of the customer base that is likewise displaced. That is, the new, less-sophisticated service providers will be able to provide useful services to a majority of customers - but not to all customers. The customers with high-end needs, who are left out under the new regime, present a new business opportunity.

PCPs operate in a world where the majority of their patients probably have relatively common, relatively easily cookbooked medical problems, and most of these patients will do just fine with their new doctor-nurses. But a substantial minority will have high-end needs, either in terms of complex medical problems that cannot be reduced to simple treatment pathways, or in terms of atypical medical problems that are not easily diagnosed.

DB has discussed at some length this “long tail” in the patient population, as defined by some aspect of material complexity in their medical conditions. The long tail simply cannot be served by guideline-directed care, whether administered by doctor-nurses, or by those more malleable (or complexity-averse) PCPs who will simply allow themselves to be absorbed by the new, dumbed-down primary care regime. Long-tail patients, the outliers, will not be small in number. They will comprise an important new business opportunity, “new” because it is a niche that is not recognized today, as it will be when these patients are being systematically (instead of randomly) culled out.

That business opportunity can be filled by many of today’s PCPs. These will be doctors who enjoy puzzling through complex diagnostic problems, and dealing with complex management issues, and have been trained to do so. To DrRich, this spells “internist.” Doctor-nurses can’t do this job. Specialists can’t do it either. This will be a specific niche for internists.

The best part is that the feds and the insurers, in selling us on the dumbed-down PCP model, are busily assuring us that there is no substantial need for sophisticated PCPs (hence, the appropriateness of doctor-nurses). And in proving the point they’ll be able to rely on carefully constructed, population-based outcome measures (which, since they speak to the average patient, will look very favorable) to marginalize the complaints of the outlying patients. Having refused to acknowledge the existence of complex patients, they’ll hardly be able to make special provisions for their care.

This leaves the door wide open for internists to establish practices to provide healthcare services to patients with difficult diagnostic or management problems, who are being neglected and mishandled by the “official” healthcare system. (These patients know who they are, and are desperately looking even today for somebody to help them.) And since to insurance companies and the feds these patients don’t exist, these practices will have the opportunity to operate outside the system, as private-pay practices, which will eliminate the demeaning checklists, the one-size-fits all guidelines, and the stifling time limits under which PCPs now must operate. And, like plumbers and electricians, they can get paid for what their time and expertise is worth.

(To those of you who immediately object to such a thing because asking patients to pay themselves for medical care is unethical, DrRich asserts it is indeed possible to do this entirely fairly and ethically, while allowing almost anyone who wants this kind of service to have it, and some day he will describe how. But for now, just celebrate the right of people to spend their own money on their own healthcare even when it’s provided by actual physicians, just as [DrRich suspects] you celebrate their right to spend money on chelationists, homeopaths, or reiki practitioners.)

The bottom line, as DrRich sees it, is that the identity crisis now being experienced by American PCPs, while certainly catalyzed by healthcare economics and politics, is a manifestation of the natural and inevitable disruption produced by advancing knowledge and technology. PCPs may be the first, but all physicians will soon face similar challenges as long as medicine continues to advance.

If the PCPs respond logically to this crisis - that is, instead of fighting it, recognizing the opportunities it presents - their specialist colleagues will soon experience their own “encroachment from below,” which is the hallmark of a mobile, technologically progressive society.

Posted in New business models for healthcare, Primary Care in America | 16 Comments »