The Opposite of Rationing

Posted on February 16, 2009
Filed Under Cardiology Topics, Fixing American Healthcare, Primary Care in America |

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Since beginning this blog, DrRich has spent far more time discussing the plight of primary care physicians than he has in discussing anything about specialists. This, despite the fact that the great bulk of DrRich’s 20+ years in medical practice was spent as a cardiac electrophysiologist, which is about as specialized as a doctor can get.

The simple explanation for DrRich’s PCP favoritism is that this is a blog about healthcare rationing, and however you want to cut it, among all the doctors now slogging through the once proud, once ethical profession of medicine, it is the PCPs who bear the brunt of covert healthcare rationing. Hence, PCPs (those, at least, who are still around despite the concentrated efforts of the healthcare system to get them all to quit) deserve the majority of DrRich’s empathy, his attention, and (lame though it may be), his advice.

Specialists, on the other hand, have been relatively immune to the perfidies of covert rationing. To be sure, they, too, are subject to “guidelines” that attempt to herd their behavior toward some end other than what may be best for the individual patient. But in many cases those guidelines are promulgated by the specialists’ own professional societies (at least if they are members of a politically savvy specialty, such as, say, the cardiologists), and so guidelines may often actually improve a specialist’s income.  And specialists can certainly be affected by efforts (largely, again, aimed at PCPs) to reduce the number of patients being referred to them. But proactive specialist organizations have proven adept at rising above this obstruction by tailoring messages directly to patients, resulting in patients self-referring for specialist care, or coercing their PCPs to refer them. So to a surprising extent specialists are neither participating in, nor are they unduly suffering from, covert rationing.

(Those readers familiar with DrRich’s Grand Unification Theory of Healthcare will recognize that, unlike the PCPs who have been rolled over into Quadrant III of the 4-quadrant healthcare map, the specialists are still luxuriating mainly in Quadrant IV, just as they have been for the last 40 years.)

So as often as he addresses the pitiful situation of PCPs, DrRich only uncommonly turns his attention to the specialists. Which makes it even more unusual that he is about to do so for the second posting in a row. (His prior post, faithful readers will recall, addressed the apparent willingness of gastroenterologists to subject their patients to uncommon pain and suffering in the interest of saving a buck.)

But the simple truth is that DrRich simply cannot ignore his cardiologist colleagues on this one.

At the latest Scientific Sessions of the American Heart Association, Dr. John Lee presented the results of a survey taken among 350 patients in Kansas City, MO, who had recently had angioplasty and/or stenting, on a purely elective basis, for the relief of angina (chest pain). The survey asked these patients questions about what they believed to be the reason they had needed the stenting procedure, and what they believed the effects of that procedure to have been.

It is important to note that it has never been shown, in stable patients, that elective stenting of partially blocked coronary arteries prevents heart attacks, prolongs life, or has any other beneficial effect except reducing the frequency of angina. Therefore, the only reason to do the stenting procedure in patients who have angina but are otherwise stable is to reduce the frequency of their chest pain (an outcome that is very important, but that most often could also be achieved with the use of medications).

The very limited nature of the potential benefit of angioplasty/stenting in patients with stable angina was demonstrated in a study, reported in early 2007, called the COURAGE trial. In the COURAGE trial, patients with stable angina were randomized to either drug therapy or stenting - and the results revealed that in the stented group there was no reduction in either heart attacks or death. When the COURAGE trial was published, commentators immediately speculated whether its striking results would cause cardiologists to finally cut back on the number of stent procedures they perform on patients with stable angina (estimated to comprise something like 70% of all stent procedures).  To such speculations, the cardiology community replied in virtual unison, “Don’t be silly. There is no new data in the COURAGE trial. We have known this all along. We have always done the right thing for our patients and will continue to do so.” All of which DrRich interpreted as, “We have no intention of changing our current practice, so we must have known this all along, and must have behaved accordingly. (And if you don’t believe us we’ll work up the guidelines to prove it.)”

Which just goes to show that doctors are human, just like the regulators and the insurance executives. Randomized trials whose results break your way are to be strongly embraced, waved about, defended to the death, and advanced upon the enemy with the searing regard shown to a regimental standard in the Civil War; whereas randomized trials that are not particularly favorable to your interests are to be torn apart for their statistical impurity, and when that proves impossible, brushed off as really pretty irrelevant in any case, and not deserving of any special consideration.

So: Cardiologists insist they never did think that elective stenting would prevent heart attacks or prolong survival, and it is in this light that they have been performing hundreds of thousands of elective stenting procedures over the decades. (That is, they have always done these procedures merely to help reduce the frequency of their patients’ chest discomfort, and everyone knows it.)

So one would think the cardiology community would be extremely disturbed, embarrassed, and indeed, mortified, by the results of Dr. Lee’s survey.

Dr. Lee reports that among 350 patients whose cardiologists had performed elective angioplasty/stenting to reduce their episodes of angina:

- 33% believed their procedure was an emergency
- 71% believed their procedure would help prevent a heart attack
- 66% believed their procedure would prolong their life
- 42% believed their procedure had actually saved their life
- 31% (only 31%) believed their procedure reduced their angina symptoms

The amazing, and pervasive, discrepancy between what elective stenting actually accomplishes, and what patients who have had them think they accomplish, is more than remarkable. It is astounding.

One can think of at least three explanations for the discrepancy.

First, a majority of patients are impervious to calm, rational explanations of expected risks and benefits, and when they find out they have a partial blockage in a coronary artery, then - despite those calm, rational explanations their cardiologists give them regarding their prognosis, the various treatment options available to them, and the expected outcomes with each - patients jump to the conclusion that death is imminent and only an immediate, emergency angioplasty can save them.

Second, a majority of cardiologists are telling their patients that because they have a blockage in a coronary artery, death is imminent and only an immediate, emergency angioplasty can save them.

Third, a majority of cardiologists are not actually lying to their patients (save by omission), but rather, advertently or inadvertently, are creating a certain impression. That is, they tell their patient, “Mr. Jones, you’re sitting on about an 80% blockage in one of your major coronary arteries. So there’s only 15% left; that doesn’t leave much room.  If it closes off - which can happen any time - well, I hate to think of what might happen. So: We can either open that artery up for you right now, good as new, or we can just give you some medicine and hope for the best.”  (Omitted in such an “explanation”  is the fact that most heart attacks are not caused by these “significant” blockages closing off, but instead are caused by the sudden rupture of plaques that, immediately prior to their rupture, would be considered “insignificant” blockages, often obstructing less than 10-20% of the artery. In fact, the art of preventing heart attacks in general is not the art of relieving partial blockages; it is the art of preventing plaque rupture - which is accomplished mainly through aggressive lifestyle changes, and medications to stabilize plaques and to prevent platelets from producing blood clots.)

DrRich finds explanations One and Two absurd as general propositions (though a few patients will always behave as in Explanation One, and a few doctors as in Explanation Two). The real answer (DrRich submits) is Explanation Three.  DrRich holds to this conclusion because a) he is a student of human nature, b) he has heard cardiologists saying this stuff to patients many times, and c) he thinks that a lot of cardiologists secretly still believe (despite their protestations that they never believed it) that stenting must prevent heart attacks and save lives.

The beauty of Explanation Three is that it allows cardiologists, through the magic of rationalization, to achieve the end they desire (more stent procedures), while telling themselves that they are being truthful to their patients (since, after all, they are not actually saying that their lives depend on receiving a stent this minute). Best of all, since Explanation Three is not actually a lie, its use preserves for cardiologists the right to become indignant should anyone (such as DrRich) accuse them of misleading their patients.

But what of DrRich? Why is he venting thusly when what the cardiologists appear to be doing is the opposite of rationing? Aside from the fact that the results of Dr. Lee’s survey are so striking that somebody needs to point it out to the public (notably, this survey was reported 3 months ago, and as yet has produced no discernible ripples either among cardiologists, or within the general media), DrRich finds it a useful illustration of the behavior of doctors. To wit: doctors respond quite nicely to incentives. The more you reward a behavior (such as paying them handsomely to perform invasive procedures) the more you get of it. On the other hand, the more you punish a behavior (such as penalizing them for the time they take and the medical resources they use in the attempt to deliver the kind of careful, considered individualized patient care which PCPs long to give), the less you get of it.

DrRich has discussed many times on this blog the results of disincentivizing PCPs from offering excellent, individualized patient care. Its why PCPs are an endangered species. Here, he merely points out that the “normal” way of doing things - incentivizing doctors to do lots of procedures for big bucks - while it is deeply appreciated by the medical profession, is not a good option either, and for the very same reason. Incentives - and disincentives - work, and will be honored by whatever methodologies can be conjured up to realize them.

Comments

20 Responses to “The Opposite of Rationing”

  1. Sandra Brown MD on February 16th, 2009 1:36 pm

    Dear DrRich,

    I just finished “Without Your Consent”, in which the author rails agains care maps (preferred practice patterns) and pay-for-performance medicine. Yet, in the case of cardiac stenting it would seem that an obligatory pre-stent trial of medical management would be a good idea. I like to think that most cardiologists - faced with a patient who comes in happy that a pill has decreased his angina - will be more squeamish about utilizing Explanation 3 to terrorize the patient into a stent. In other words, can we force cardiologists to act, in the first pass, as PCPs? Or is there no enforceable system? [PS I'm a subspecialist too.]

  2. DrRich on February 16th, 2009 1:51 pm

    Dr. Brown,

    In some systems (I’m thinking Kaiser and Mayo Clinic) it might be possible to do that, since physicians are all part of the same corporation.

    But in general what happens is, a patient with suspected angina is referred straight to the cardiologist (since PCPs no longer have time to make diagnoses or go into long explanations of new medical conditions with their patients). The cardiologist goes straight to a cath (with perhaps a stop in the stress/thallium lab), and inserts the stent during the same procedure, often (I postulate) with the type of “informed consent” I describe in Option 3. (Sadly, this may be the first time the cardiologist has actually met or spoken with the patient.) The patient is left thinking he/she just had his/her life saved, the cardiologist is a hero, and the PCP is appreciated for making a rapid referral.

    So the patient has had medical care delivered by a harried triage person, followed by a scripted specialist armed with a hammer and desperately seeking nails, when all the time what that patient needed was - a doctor.

    Where is the opportunity for a trial of antianginal drugs in this scenario (which, I agree, is the only reasonable thing to do)? I don’t see it.

    Rich

  3. Sandra Brown MD on February 16th, 2009 4:17 pm

    Puts me in mind of my professional sojourn to XX city, YY state which contained a cardiology group so hyperaggressive that it ultimately came to the attention of the CMS computers. True story: patients going to the medical building for GI appointments would occasionally get lost and enter the cardiology office, where their upper GI distress would be retranslated into expansive cardiology services. Not a weekly occurrence but not an urban legend either.

    Is it too late to say, “Do The Right Thing”? Because incentives may affect behavior but they don’t define the Right Thing.

    Answering my own question: way too late.

  4. BladeDoc on February 16th, 2009 4:43 pm

    While I agree with essentially everything in your post, I wouldn’t be too, too fast to eliminate explanation #1. A (vast) majority of patients referred to me for “their gallbladder” (their chief complaint is “it’s my gallbladder) based on 1. some sort of pain somewhere near their abdomen (sometimes chest, often on the wrong side) and 2. an ultrasound showing stones absolutely want their gallbladder out period, end of story. I have pissed more than a few people off by diagnosing something other than gallbladder disease (GERD, pneumonia, and ulcers to name a few) and sending them back to take medication.

    Many people just want to be “fixed” rather than take meds. P.S. I’d want the stent too. I hate taking medication.

  5. Sandra Brown MD on February 16th, 2009 6:39 pm

    BladeDoc’s last comment opens the discussion of risk and how to get patients to “really” understand it. Medication for angina could be legitimately branded as “a therapy that eliminates your risk of aortic laceration from a guide wire”.

    I think the new buzz words for informed consent are “decisional resiliency” or something like that. So I would pitch a stent to Mrs. Jones as: “Would you regret not trying medication first if you had an aortic laceration, which is an rare complication of this procedure that will probably kill you, and can occur even when your cardiologist has done thousands of stents without difficulty?” If rare is 1 in 1000 should the rational patient make a different decision than if it was 1 in 10,000?

    The flip side of the question is: does a cardiologist who doesn’t bother to offer medical therapy, and then has an operative problem leading to a severe complication, regret his decision?

    It seems from DrRich’s reply that if we could somehow slow this process down (time management: from check in to cath lab in 45 minutes), there might be some way to reroute the therapeutic approach.

  6. DrRich on February 17th, 2009 10:07 am

    BladeDoc,

    Were it as simple as it seems!

    Turns out that placing a drug-eluting stent these days (the only kind American cardiologists like to use) commits a patient to long-term (perhaps lifelong) therapy with Plavix. As the purveyor of a patient-oriented website on heart disease, I cannot tell you how many distressed patients have written to me with the following lament:

    “My doctor put in one of those drug coated stents and has me on Plavix. He says if I stop the Plavix I could die, and won’t let me stop it for any reason. But I need my gallbladder out because I keep having attacks, and the last one gave me blood poisoning. My surgeon says I need the surgery but he won’t do it unless I stop Plavix, and my cardiologist says no stopping the Plavix for any reason. What can I do? Can they just take these stents out so I can stop the Plavix?”

    There is no easy answer to this, at least not that I can find. The patient is left in the middle of a pissing match between surgeon and cardiologist.

    The fear of the cardiologist is that when one stops Plavix, there is a risk of sudden thrombosis of the coronary artery, which is often a catastrophic problem (i.e., sudden death). Few cardiologists seem to explain this to their patients before placing drug-eluting stents, the placement of which I consider an irreversible, life-altering decision. Even without the superimposition of a need for surgery, Plavix is a drug I would NEVER want to take for a long, long time.

    So, if cardiologists would do a sit-down with their patients before placing a stent (which, like much of medicine - as opposed to surgery, I’ll concede - merely substitutes one clinical problem for another), and explain to them ALL the ramifications of stenting, my guess is that a reasonable proportion of them would indeed opt for a trial of antianginal drugs before jumping in to such a thing. So: in my view it remains too bad that, apparently, many of cardiologists don’t do that.

    Rich

  7. DrRich on February 17th, 2009 10:24 am

    Dr. Brown,

    I am indeed suggesting slowing the process down for elective stent placement. See my comment above to BladeDoc.

    Unfortunately, when a patient presents with Acute Coronary Syndrome (which means the plaque has already ruptured, producing a myocardial infarction or unstable angina), the placement of a stent can indeed be life-prolonging, and time is indeed of the essence. Frankly, despite all the very good reasons for doing so, there really is simply no time to go over all the nuances and encourage careful deliberation (life and death being the main question). In these situations shaving minutes off the time in the door to achieving opening of an occluded artery is critical. So the patient arrives in the ER with an unstable, life-threatening condition, stuff happens, and they are left with what they are left with. Some day, one hopes, there will be a better way of doing this.

    I suspect that cardiologists tend to superimpose the “this is an emergency, time is of the essence” behavior, which is appropriate for ACS, on the entirely elective question of treating stable angina. Again, I don’t think they’re inherently evil for doing so, I think this is human nature. It is hard, I guess, for some doctors to associate two entirely different modes of thought and behavior with the very same medical procedure.

    I would suggest psychological screening prior to admitting doctors to cardiology fellowships (to assess the ability of the candidate to deal with nuanced decision-making), but if this practice were generalized my experience tells me that 83.5% of Americans would have to change careers. And that seems damned inefficient.

    Rich

  8. Guiac on February 17th, 2009 5:24 pm

    Then again unstable angina is only a narrow step from stable angina. I am no doubt biased since I work in the ED but a a few poorly phrased questions(originating from the unconscious mind to be sure) can easily be used to push the patients into the unstable angina pathway. And who is going to argue with definitive diagnosis provided by the cardiologist. Certainly not me!

    That said explaining in detail risks and benefits to patients is a hairy proposition. It works well in those who are medically savvy, but lets face it that is not the majority. I face this everyday when I see some sprained ankle that doesn’t need an xray. Do I casually apply the Ottawa ankle rules, spend 20 minutes explaining why they don’t need an ankle xray, and then send them on their way so that I can enjoy reading a patient complaint a few days later? Nope easier on me and the old pocketbook to spend 2 minutes with teh patient, 1 minute looking at the xray, and now sending the relieved patient on his way with a sprained ankle.

  9. Red Baron on February 17th, 2009 5:40 pm

    Nice post Rich.

    (I think) you know my view on complexity science. Our health care system will change whether we want it to change or not. This will either occur thru deliberate action/design or it will change(”collapse”) of its own weight, but it will change, ALL bubbles ALWAYS do.

    And when this health care bubble does collapse, it will be the more complex structures (in this case ’specialists’ like cardiologists) who will take the biggest hit in the change, and it will be the regions that have most aligned their economies toward the higher complexity built in this bubble (as is happening in Detroit and autos today).

    The only thing holding this all together right now is Medicare and we know where that is one day headed.

    Beyond that, people are people

  10. jeffrey dach md on February 18th, 2009 8:56 am

    Many people are surprised to learn that invasive treatment with angioplasty, stents and bypass fail to reduce mortality or heart attacks, when compared to conservative medical treatment with drugs.

    Dr Richard Shemin writes in Circulation in 2008,”Survival advantages of stent therapy for coronary artery disease over medical therapy have not been a consistent result in clinical trials.”

    A five year trial published in 2005 comparing stenting to CABG for multivessel disease shows no difference in mortality.

    Conventional drugs used for medical treatment of heart disease include: Beta Blockers such as Inderal, calcium channel blockers include Cardizem, Procardia, and Norvasc. Nitrates such as Isordil, Sorbitrate, Cardilate, Dilatrate, and Peritrate. Nitroglycerine skin patches include Minitran, Nitro-Dur and Transderm-Nitro. Diuretics and ACE inhibitors are used.

    Why does medical therapy work?

    Medical therapy reduces the oxygen demand of the heart muscle and allows time for the heart to develop microscopic collateral vessels which provides blood flow around the blocked arteries.

    To read more:
    http://jeffreydach.com/2009/01/13/cardiac-bypass-angiplasty-and-stenting-by-jeffrey-dach-md.aspx

    Cardiac Bypass, Angioplasty and Stenting by Jeffrey Dach MD

    Jeffrey Dach MD
    4700 Sheridan Suite T
    Hollywood Florida 33021
    954-983-1443

  11. Sandra Brown MD on February 18th, 2009 10:13 am

    So in Guiac’s example, would a high-deductible health plan cause the patient to forgo the X-ray after a reasonable amount of explanation and reassurance? I predict the conversation could be:

    “According to medical studies, because you have XYZ features and do not have ABC features it is very unlikely that you have any bone injury and an Xray is not needed at this time. However if you want one, it will be $120.”

    This is a great example because it embodies nearly every bad medical reason but good personal reason to order an unnecessary test.

  12. DrRich on February 18th, 2009 10:31 am

    Dr. Brown’s solution is, in my opinion, the right one.

    It allows the “system” to use reasonable logic to say when to stop testing, and gives the patient the opportunity to choose for themselves whether it’s worth $120 to improve the level of diagnostic certainty from 99% to 100%, and relieves the doctor of unreasonable risks of malpractice.

    Unfortunately, since it violates the overriding principle that individuals are not to pay out of their own pocket for any portion of their own healthcare, it is not to be permitted.

    Sorry.

    Rich

  13. pcb on February 18th, 2009 1:09 pm

    Dr. Rich,

    If any new chest pain that we think has a decent chance of being cardiac is evaluated with a stress test, a defect is found, and a flow limiting lesion is seen on angiogram, that is unstable angina (by patient history, not necessarily what’s going on in the vessel) and should be stented based on clinical evidence, right?

    If any person has a history of stable angina and symptoms are changing (in any teeny weeny way), then they have unstable angina and could be stented if a lesion is found?

    so….

    the only way you, as a patient, can get to the point of “stable angina” where you don’t necessarily need/want a stent is if you don’t see a doctor during the “unstable” period of your symptoms?

    Any thoughts?

  14. DrRich on February 18th, 2009 1:45 pm

    pcb,

    My only thought is: You get what you pay for.

    If they get paid to put in stents, and if stents are going to be questioned UNLESS the patient has unstable angina, and if the diagnosis of unstable angina is based on clinical assessment and professional expertise, then the definition of unstable angina will be strained to the breaking point, and beyond.

    I can name some other diseases where this is happening, but don’t wish to generate the wrath of certain interest groups at the moment. Maybe later when I’ve got more time.

    Rich

  15. David MD on February 19th, 2009 7:39 am

    Thank you for this marvelous posting. Jeffrey Dach MD’s posting is also well worth reading but the link was slightly incorrect in his posting….

    His posting speaks also of the economic costs of $100 billion per year…

    http://jeffreydach.com/2009/01/13/cardiac-bypass-angioplasty-and-stenting-by-jeffrey-dach-md.aspx

  16. Guiac on February 20th, 2009 1:13 am

    Dr. Brown, you bring up an interesting idea. Unfortunately I am heavily incentivized not to explain such rules to patients but rather to order the tests. Afterall I am to maximize the number of patients seen(we have long waits at my ED), as well as those pesky Press-Ganey scores that have to be maintained. Of course Dr. Rick has already provided the reasons why that can’t happen.

  17. Marilyn Mann on February 20th, 2009 9:10 am

    Great post, but I am confused about a family member’s situation. My mother-in-law (age 82) had a second MI 5 days ago. Cath showed several 80 or 90% blockages and 1 100% blockage. Originally she was told her options were re-do bypass, PCI or medical management. She complains of shortness of breath but no angina. Turns out the bypass is not an option because of lack of suitable veins.
    COURAGE excluded people with recent MI, so I am unclear how much it applies to her situation.
    She is already on a number of drugs for heart failure and atrial fibrillation. I’m not saying changes couldn’t be made, but I don’t know how likely it is that they would relieve her shortness of breath.
    Not sure if this changes anything, but she has heterozygous FH.

  18. DrRich on February 20th, 2009 8:44 pm

    Marilyn,

    I cannot offer specific medical advice on-line. Consider the following comments to be of a general nature which may or may not apply to your MIL.

    You are right, the COURAGE data does not really apply in patients with fresh MIs.

    The questions someone in your position should consider asking the doctor are: 1) what is causing the shortness of breath (heart failure, lung disease, angina equivalent, or other) and what can be done about it? 2) Would stenting reduce her symptoms, or are you doing it to prevent another MI? (Little or no evidence it would prevent an MI, unless there are known or suspected unstable plaques - which is a possibility.)

    Unless the shortness of breath is suspected to be caused by ongoing ischemia (angina equivalent), then the doctor should have to explain to a clear rationale for stenting, and explain why he/she is not primarily focusing on making her feel better (less short of breath).

    Rich

  19. Marilyn Mann on February 22nd, 2009 8:04 am

    Rich,

    Thanks for your comments.

    Marilyn

  20. Sandra Brown MD on February 24th, 2009 4:27 pm

    Guaiac I bet you could see those patients a lot faster if you didn’t have all this junk testing to do.

    DrRich, a few years ago the ophthalmologists built the palatial homes (when cataracts paid $2K a pop and took 15 minutes). Now it’s the cardiologists, around here anyway. Follow the expensive, high-volume procedure…

    Well everyone run read the President’s comments after the economic forum. Health care, health care over and over. Should we be scared but in a vaguely thrilled, happy fashion or should we start looking for viable non-medical retraining?

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