Physician Report Cards and the Designated Driver

January 28th, 2008 by DrRich

A new study in the February 2008 issue of the American Heart Journal shows that cardiologists in New York State are less willing to aggressively treat patients with severe heart attacks than cardiologists in other states, and that the mortality of these patients is significantly higher in New York. The authors of the report attribute this reticence to treat to the existence of public report cards in New York, which publish doctors’ names alongside their procedure-related mortality figures.

The study compared the treatments and the outcomes in 220 New York patients with 325 patients from states without public reporting systems, who had shock (severe circulatory instability) caused by myocardial infarctions (heart attacks). They found that patients in New York were significantly less likely to receive either diagnostic cardiac catheterizations or stents. Both groups of patients were equally likely to receive coronary artery bypass surgery, but the surgery was significantly delayed in patients from New York. Among all patients, the risk of death in the hospital was 50% higher in New York than in other states. But among patients who actually received either stents or bypass surgery, there was no significant difference in mortality.

DrRich has pointed out earlier the advantages of physician report cards to a system based on covert rationing. Let us review the many benefits that accrue to the payers:

1) Fewer expensive procedures are being done
2) Fewer emergency procedures are being done (procedures like the ones being avoided in this study are often performed in the middle of the night and on weekends, entailing overtime payments and other excess overhead.)
3) More high-risk patients (destined to be chronically expensive) die expeditiously.
4) The docs who do persist in doing these high-risk procedures stand out even more in the public report cards.
5) Eventually, NOT doing these high risk procedures will become the new de facto standard of care, and outliers then can be dealt with directly (instead of relying on bad report cards to weed them out).
6) All the while, payers can stand upon the altar of altruism, proclaiming transparency and the patient’s right to know.

The inappropriately negative fallout experienced by physicians conducting potentially life-saving procedures on high risk patients, of course, could be easily overcome by appropriate risk-adjustment methodologies (to account, for instance, for the very high mortality predicted for any patient presenting with shock due to myocardial infarction). But doing so would wreck the whole notion of using public report cards to further the cause of covert rationing. (See items 1 - 6, above.)

But, as usual, DrRich has a solution.

It’s called the Designated Driver.

Imagine the distinguished Chief of Cardiology approaching a promising 31-year-old cardiology fellow, who is finally at the end of his long course of training and at last is ready to enter practice, and saying, “Son, you are going to have a brief but spectacular career. You are going to be our Designated Driver.”

For an extraordinary annual salary and immediate vesting in a generous pension plan, this young man is going to have the honor of being the one who gets all the high-risk cases for the group. He will agree to do this as long as it is feasible, that is, as long as he’s not run out of town because his report card is so abysmally bad. Given the inefficiencies of collecting and processing data for report cards (a process controlled by tangled bureaucracies of one flavor or another, and often, by several tangled bureaucracies that have to devise even more tangled processes for some semblance of cooperation), this is likely to take at least 5 years, and in many cases may take 10. With a sufficient number of more “routine” cardiac cases tossed his way by his sympathetic colleagues (to help him buffer his report card statistics), he may be able to survive 12 or even 15 years. But in any case, by the time he is in, say, his late 30s, he’ll be able to retire quite comfortably.

The Designated Driver scheme is a win-win for everybody (almost). Very sick patients can get the procedures they need (i.e., the ethics of medicine can be shored up for a bit). Your typical cardiologist can enjoy his/her long, relatively risk-free career. And your young, aggressive cardiologist will be presented with a glorious challenge not unlike those of the gladiators of antiquity (save that when it’s finally time to face the old “thumbs down,” they will be spirited to a much more agreeable retirement.)

This solution, as brilliant as it is, will attract critics. And those critics will eventually demand (Gekkonians) or pass (Wonkonians) laws, regulations, and guidelines to turn the Designated Driver into merely one more manifestation of the federal crime of healthcare fraud, punishable by the usual massive fines and jail time.

So when that time comes we’ll have to think of something else. But for now, given the alternatives, DrRich recommends the Designated Driver to cardiologists in the great State of New York.

Posted in General Rationing Issues | 8 Comments »

How Important Is Cholesterol, Really?

January 24th, 2008 by DrRich

In addition to being the Rabble-Rouser-In-Chief for this fine blog and its groundbreaking parent website, DrRich for several years has also been the cardiology expert at About.com. (About.com is a New York Times company, but since his association with About.com predates that of the NYT, DrRich sincerely hopes that his more conservative readers will not hold this against him.) In this capacity, DrRich routinely tries to clarify for his readers (who are mainly patients with heart disease and their loved ones), controversial topics in heart disease. Because cardiologists (like all theologians) never tire of arguing over how many angels can dance on the distal pole of a defibrillation lead, and because the popular media delights in reducing these arcane arguments to breathless (and commonly misleading) headlines, there is a never-ending cascade of material upon which DrRich can draw.

Most recently, the results of a clinical study called ENHANCE has had many in the popular media (in response to new concerns voiced by medical experts), questioning the deeply-entrenched cholesterol paradigm - that is, the idea that LDL cholesterol (the bad kind of cholesterol) is indeed bad, and that anything we can do to lower it is good. Questioning the cholesterol paradigm - a belief system we’ve all been taught since we were babes in arms - is deeply disturbing, confusing and troublesome to many American patients (judging, at least, from the response DrRich has received from readers of his heart disease site).

These patients have been told for years to arrange their lives around the reduction of their cholesterol levels. And while the proportion of people who actually do so does not exceed the proportion who, in earlier times and under a different paradigm, actually arranged their lives so as to further their odds of spending eternity in paradise (modern sinners often preferring instead to rely on today’s equivalent of the deathbed conversion - the stent), the sudden notion that the cholesterol god is dead leaves these patients unbalanced, uncentered and oddly empty. They are also beginning to believe that their doctors, who (some appear to be saying) have been preaching a false doctrine at them for many decades, are even more full of cr*p than previously thought.

In response to this existential crisis, and so as to fulfill his duties to About.com and its parent company, DrRich has posted an article that purports to place all this in perspective, and more importantly, to give patients some guidance as to how to proceed in regard to their cholesterol therapy NOW (i.e., during the next 10 years or so, while the experts debate the issue, and argue over whether the current guidelines - the following of which doctors will continue to be paid-to-perform - actually make sense.)

Normally, DrRich would not trouble readers of the Covert Rationing Blog with topics pertaining to his other duties. But this recent cholesterol controversy has already attracted the attention of other medical bloggers he admires, some of whom have offered (for instance, here and here) very level-headed opinions on the matter. Frankly, while DrRich is clearly very comfortable pontificating on matters related to healthcare reform (and most other topics), he gets nervous touching on theology or its close relative, cholesterology. So DrRich will be very interested to know from readers of this blog if his advice - which, again, is aimed at American patients - seems sufficiently clear, and most of all, reasonable. The posting can be found here.

Thank you for your indulgence.

Posted in Cardiology Topics | 3 Comments »

How Physician Report Cards Can Enhance Covert Rationing

July 23rd, 2007 by DrRich

The state of California recently published a report showing risk-adjusted mortality rates for coronary artery bypass surgery, tabulated according to specific hospitals and specific surgeons. For instance, Dr. Charles Hoopes, a prominent and highly regarded cardiac surgeon, and director of the heart and lung transplantation program at the University of California, San Francisco Medical Center, received a “worse-than-average” rating. (The full report itself can be found here.) Reporters from the San Franciso Chronicle note that Dr. Hoopes’ statistically “worse-than-average” surgical mortality can be specifically attributed to his operating on two very high risk patients who subsequently died. If he had declined to try to help these patients, he would not have been rated worse than average. One wonders what Dr. Hoopes will do the next time a high-risk patient comes to him for a shot at long-term survival.

A study published in 2005 in the Journal of the American College of Cardiology reported that doctors practicing in states that require the public reporting of outcomes data are already holding back potentially life-saving medical care from patients who are at high risk. The authors compared the use of stents for coronary artery disease in New York, where reporting occurs, to Michigan, where reporting does not occur. They found that significantly more high risk patients in Michigan received stents than in New York. The mortality rate of stent patients was likewise higher in Michigan - until the data was recalculated to account for the underlying risk of the patients. Once this risk-adjustment was made, the outcomes were equivalent. So, the actual performance of physicians in these two states is equivalent - but doctors in New York are apparently optimizing their outcomes (and buffing up their reports) by avoiding the highest-risk patients.

Public reporting of outcomes data has several positive attributes. Knowing that the public is watching has caused many institutions to employ new and intensive quality control measures. Some doctors and surgeons who probably should have chosen another career have subsequently had to choose new careers. And patients have a right to know this data, so they can make more informed decisions.

But how do you suppose colleagues of Dr. Hoopes are feeling about now? Here is a prominent and respected surgeon whose colleagues (one suspects) believe him to be the victim of his choosing to do challenging surgeries that others would walk away from. They see his name on a public “worse-than-average” list, and prominently mentioned in newspaper articles (and on blogs); his reputation, his professional standing, and possibly his career in jeopardy.

An object lesson in spades.

The kind of high-risk cardiac patient we’re talking about has a high risk of mortality with or without the procedure - but it’s marginally better with the procedure. Importantly, if the doctor declines to do the procedure - declines to at least try for an improved outcome - the patient’s subsequent death is not publicly attributed to him/her.

If there’s a choice between pulling out the stops to try helping a patient in real trouble or safeguarding their careers - well, they’ve got to protect their careers.

So let’s imagine how the payers feel about this result. The patients who are reasonably likely to die anyway are now kindly doing so without the added expense of an invasive cardiac procedure. The payers get to champion transparency and the public’s right to know, to advertise their aggressive quality-improvement measures - and they save a lot of money besides.

The trick is for the payers - like the state of California, for instance - to maintain control of the “risk-adjustment” methodology that is used in these report cards. In theory and if applied with great care, such risk adjustments are supposed to prevent what seems to have happened to Dr. Hoopes. If not applied rigorously, then not so much. But the payer still gets to say,”Sure he treats high-risk patients, but our statistical measures take that into account. Worse-than-average is worse-than-average.”

Doctors who don’t trust the payers to do accurate risk-adjustment, in an era when payers are desperate to find new ways to covertly ration, will do their own “risk-adjusting.” The doctors in New York have demonstrated how that works.

The bottom line: if you are in a normal risk category, you may be marginally better off in a state providing such physician report cards. Some below-average cardiologists and cardiac surgeons in those states are now either treating warts or the illiterate. But if you are high-risk, consider moving to Michigan.

And once again we have demonstrated the Fourth Corollary of the Grand Unification Theory of Healthcare - Covert rationing corrupts everything it touches. Even physician report cards.

Posted in General Rationing Issues | 2 Comments »