More Fun With Guidelines

May 27th, 2008 by DrRich

Lately DrRich has advanced the proposition that the “Guideline Movement” (the push to reduce all of medical practice to a set of fixed rules by which physician behavior can be controlled) is leading to guideline anarchy (whereby numerous interest groups, from the government to industry to professional societies, have begun a mad dash to create their own sets of guidelines in an attempt to get doctors to behave in ways that will further their own special agendas).

In the effort to give substance - and by extension, some level of legitimacy - to his theory, DrRich gave several examples of anarchical guidelines, and even proposed three different categories of them (i.e., Dueling Guidelines, Predatory Guidelines, and Industry-driven Guidelines).

DrRich is already beginning to see that, once you start looking for them, examples of guideline anarchy begin showing up all over the place. Consider a few of the more interesting ones DrRich has come across just over the couple of weeks:

Dueling Guidelines: Mammograms for women under 50.
DrRich was reminded of this obvious example by a reader. Whether women between 40 - 50 years of age should get routine mammograms has been a point of controversy for some years. Screening these younger women undoubtedly reveals cases of curable breast cancer that otherwise might have been missed. However, such screening also leads to many false positive mammograms, causing unnecessary invasive procedures (and unnecessary anxiety). Because the incidence of breast cancer is lower in younger women, it has been difficult to show objectively that the overall benefits outweigh the negatives of routine mammograms in this age group.

Still, the American Cancer Society, American College of Radiology, and the National Cancer Institute (groups that might benefit by more screening and by finding more cases of potential cancer that need to be evaluated) have long been persuaded that women over 40 should have routine screening. On the other hand, the American College of Physicians and the Canadian Task Force on the Periodic Health Examination (groups that traditionally have relied on overall population-based outcomes, and which are interested in cost savings) say that based on objective evidence, most women should wait until they are 50.

This example is interesting because it shows what happens to dueling guidelines over time. Due largely to vocal and effective lobbying from many groups in favor of screening, professional groups have tended to migrate from the “no” to the “yes” camp. The most recent converts have been the United States Preventive Services Task Force and the American Academy of Family Physicians, groups that traditionally have been in the “cost savings” camp. While the actual data has not changed appreciably, some guidelines have (apparently for non-data-based reasons).

Dueling Guidelines: Fancy anticoagulation for acute coronary syndrome.
A recent editorial appearing in The Lancet points with dismay to two sets of dueling guidelines, one from the American College of Cardiology (ACC) and American Heart Association (AHA), and the other from the European Society of Cardiology (ESC), on the use of two space-age anticoagulation medications in patients with acute coronary syndromes. While the details are fairly mind-numbing and can safely be left alone, the important point is that, after reviewing the same scientific evidence and using the same criteria for rating the evidence, the ACC/AHA essentially said, “yes, use the drugs;” while the ESC said, “no, not so much.” (We may be seeing a trend here, where professional organizations based in the U.S. seem to favor paying for fancy new drugs whose benefit may be considered by more cost-conscious organizations, like those in Europe, as marginal and not worth paying for.)

In any case, it is instructive to hear the lament of the Lancet’s editorialists, who complain,

“The committees reviewed the same research and used nearly identical criteria to rate the strength of the recommendations and to grade the quality of the evidence, but they interpreted the evidence for acute anticoagulant use differently and so reached different conclusions. Therefore, physicians who read recommendations from both the US and European societies might be confused.” (Eikelboom J, Guyatt G and Hirsh J. Guidelines for anticoagulant use in acute coronary syndromes. Lancet 2008; 371: 1559-1561.)

Yes, that’s dueling guidelines for you. If the editorialists would just become regular readers of this blog, they would not find their case so inexplicable.

Premature Guidelines: Beta blockers in noncardiac surgery.
This example requires defining a fourth category of guideline anarchy: Premature Guidelines are guidelines that are promulgated not so much before all the data is in (because all the data will never be in), but rather, before a reasonable amount of data is in. The reason organizations will find it advisable to jump the gun on guidelines is obvious - if you want to get doctors to act in a certain way, and if making guidelines is the best way to do that, the first ones to establish guidelines have a head start on controlling physician behavior.

Our example: Previous (but small) studies have shown that for patients at increased risk for heart disease who are having noncardiac surgery, treatment with beta blockers at the time of surgery reduces the incidence of heart attacks. So, the AHA and ACC (our recurrent friends and aggressive wielders of guidelines) have written formal guidelines that recommend the use of beta blockers in these patients. These particular guidelines, being attractively easy for bureaucrats to track by a simple review of medical records, have been very popular and quite widely adopted as quality measures, performance measures, items on P4P checklists, etc. Accordingly, lots and lots (and lots) of patients have received beta blockers during their noncardiac surgery because of these guidelines over the past several years.

But a very large and well-conducted study (the POISE study) now appearing in The Lancet shows that, while the incidence of heart attack is indeed reduced with the use of beta blockers, the incidence of stroke and of death are significantly increased. The net effect of using beta blockers turns out to be strongly negative. How embarrassing this will be for the AHA, ACC, and thousands of doctors and hospitals who have been dutifully following the guidelines so as to be good medical citizens!

The authors of the study have not played down the inflammatory implications of their new findings. According to theHeart.org, the lead author of the POISE study opines:

“If even only 10% of physicians followed these guidelines — which incidentally in the US are used in quality assessments, where you have people going around ranking hospitals in terms of whether or not they are giving perioperative beta blockers — and if the POISE data are true, then in the past decade 800,000 people would have died prematurely and 500,000 would have had a major stroke perioperatively because we gave beta blockers.”

Oops.

To be fair, an accompanying editorial, written by two physicians partially responsible for the existing guidelines, urges doctors not to panic, and suggests that there’s still a prominent place for beta blockers in these patients, and even suggests (vaguely) what that place might be. They are very reassuring. Unfortunately the data, at the moment, is not. All this will be straightened out over time, of course. But in the meantime we’ve got premature guidelines that remain in force, directing doctors to do something that - by all appearances - is harmful to patients.

(On his About.com heart disease site, DrRich discusses the POISE study, without the sarcasm, for patients who might need to interpret this new information. DB also addresses the implications of the POISE study, here.)

Way-premature Industry-driven Guidelines: Use of IVUS in stent placement.
In a presentation made earlier this month in Barcelona at the EuroPCR meetings, investigators urged that cardiologists use intravascular ultrasound (IVUS) whenever they place stents in coronary arteries. They urge this based on observational data suggesting that using IVUS (an invasive ultrasound technique for visualizing the interior of the artery) can lead to (marginally) improved clinical outcomes. This “suggestion” clearly does not amount to actual “guidelines,” but DrRich includes it here as an interesting view of the type of stuff that can quickly lead to guidelines.

The evidence currently supporting IVUS is not definitive, to say the least. It is based on relatively small observational studies and not on randomized clinical trials. But still, because IVUS is a highly specialized and expensive technique, it is bound to bring a very favorable level of reimbursement to cardiologists, if indeed it were a reimbursable technique. And a very important step to making it reimbursable would be to generate guidelines supporting (or preferably, demanding) its use. And to generate such guidelines, first one must create a groundswell of support among the cardiology thought leaders.

And that’s what was going on at EuroPCR. Indeed, the cardiologist/investigator who is the chief proponent of using IVUS (himself a major shareholder, consultant and speaker for the company that makes IVUS technology), urges that IVUS not be held to “unreasonable” standards such as those requiring randomized clinical trials, but instead that its advantages to patients are so patently obvious that it ought to be made a routine part of stent placement NOW.

Whether this particular example of way-premature industry-based guidelines will ever get anywhere, DrRich obviously cannot say. He offers this example simply as an illustration of the kind of “thinking” that, in the old days, used to lead to fancy dinners, $100 ink pens, trips to Honolulu, and even to compliant female companionship for influential (if geeky) medical thought leaders, all in an effort to increase sales; but that in the modern era leads to guidelines.

Posted in Guidelines, Abuse of | 1 Comment »

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 | 7 Comments »

More Guidelines: What Are They Smoking?

April 4th, 2008 by DrRich

This is a heads-up for all you primary care doctors out there, who struggle during each and every patient visit to get through your Pay for Performance Checklist of Vital Healthcare Services (different checklists for different patients, of course, depending on their insurer), during the 7.5 minutes that the feds and the insurance companies have graciously allotted to you, in order to document for the appropriate accountants your fine performance as a modern American physician.

No doubt one item that appears on your checklist has to do with counseling your patient on smoking cessation. It’s likely you may have thought this to be one of the less objectionable mandates. You can get through your well-rehearsed pitch on smoking cessation in 20 seconds or less (unless this is one of those rare patients who is actually serious about trying to quit), and thereby make up some of the precious time, from your 7.5 minutes, that you have already spent earning some more challenging check mark (trying, perhaps, to talk the patient into taking the extraordinary steps necessary to get his hemoglobin A1c down that last 0.5% to target).

So: 20 seconds spent on smoking cessation. Check.

But whoa. Not so fast there, Dr. Welby.

Did you know there are guidelines for physicians on smoking cessation? Did you know that these guidelines were devised under the auspices of the federal government, by a committee of anti-smoking zealots (not that there’s anything wrong with that)?

From this latter fact, of course, there are certain things we already know about these guidelines before we ever have a look at them. We know that they will be very long and detailed and tedious, because a) they are federal guidelines, and b) they are devised by people whose one and only mission in life - a mission that they clearly believe is far more important than healthcare reform, terrorism, or global warming (or global cooling, as it turns out the case may be*) - is to relieve the world from the scourge of smoking, and who have been given the authority (i.e., the guideline-generating authority) to make it your primary mission in life, too.

Now have a peek at the actual guidelines; here they are. Notice, first, that the federal guidelines for physicians on smoking cessation are 196 pages long. Notice how they step you through the process of counseling, and then step you through each of the measures you must take in order to assure that your patient achieves success. And notice that an early branch point in the process of counseling is where the patient informs you of whether he/she is willing to go any further with efforts at smoking cessation; and notice further that when the patient informs you that he/she is indeed NOT willing to go any further, the guidelines do not relieve you of your obligations, no, but instead provide for interventions you must now conduct on this unwilling patient “designed to increase their motivation to quit.”

This, of course, is all to say: Your 20-second spiel on the evils of smoking just doesn’t cut the mustard, doctor. To really earn that smoking-cessation credit on your P4P checklist, you need to do a lot more than that. The 196 pages of deadly serious federal guidelines detail what that is.

Lest you are tempted to dismiss as an absurdity the expectation that you’re supposed to cram 2 hours of anti-smoking counseling into a 7.5 minute patient visit, there’s one more thing you ought to know.

One John Banzhaf, Executive Director and Chief Counsel for Action on Smoking and Health (ASH), who bills himself as the “law professor who masterminded litigation against the tobacco industry,” is not taking lightly, doctor, your obvious laxity on following federal guidelines on smoking cessation. Accordingly he has sent a letter to each of the 50 state health commissioners warning them that he will soon begin instigating medical malpractice suits, on behalf of smokers who continue to smoke as the result of their doctor’s refusal to follow federal guidelines.

Mr. Banzhaf informs the commissioners that “physicians are killing more than 40,000 American smokers each year by failing to follow federal guidelines.” That’s right, doctor, you’re killing them.(Cigarettes don’t kill people; people kill people.) Specifically he invokes the doctor’s obligation to “warn the smoking patient about the many dangers of smoking and provide effective medical treatment for the majority who wish to quit.” (Emphasis DrRich’s.) That is, it’s your job not just to counsel them and treat them, but also to see that they actually quit smoking. If you don’t follow this mandate, you’re killing them. And you must pay.

When the federal government takes the pains necessary to draft detailed management guidelines for physicians, guidelines that, if followed as written, will save tens of thousands of lives each year, society has every right to expect you to follow those guidelines to the letter - and save those lives. (This is such a brilliant scheme for ending smoking-related death and disability, one must wonder why it hasn’t yet been applied to other intractable medical problems. Just think of the good that could be accomplished, for instance, by federal guidelines that require physicians to cure cancer.)

In any case, consider these guidelines next time you’re putting that little check mark next to “Smoking cessation counseling” on your P4P checklist, and ask yourself: “Have I really done all that I am obligated to?”

Just one last thing, doctor. DrRich may be overstepping his bounds here, and if so just ignore him. But come on. If this is what “traditional” primary care medicine has come to at last, why would you continue to do it? Let WalMart and the doctor-nurses take it if they want it so badly. Extricate yourself from this muddle and practice real medicine, and let the devil take the hindmost.

*If it’s really global cooling after all, shouldn’t we be lobbying our congresspersons to change the CAFE standards to require American cars to get no more than 5 miles per gallon? Let’s get that temp back up!

Posted in General Rationing Issues, Primary Care in America | 8 Comments »

Another Sign of the End-Times for the Doctor-Patient Relationship

January 16th, 2008 by DrRich

A feel-good story in the Philadelphia Inquirer does not make DrRich feel good.

The story extols a local (to Philadelphia) start-up company called Verilogue. Verilogue places digital audio recorders in the offices of physicians, and “captures every word” of the doctor-patient encounter. Verilogue then processes these conversations, appropriately scrubbing them of identifiers, and places them into a searchable digitized database. Verilogue’s clients - consisting, so far, of nine large but publicly unidentified drug companies - then pay to get access to that data for the express purpose of doing market research. According to the Inquirer, “Verilogue’s technology allows pharmaceutical and biotech firms to hear first-hand from customers, get a glimpse of the patient’s state of mind, progression of disease, and what is said about the company’s medications - or a competitor’s drug.” So, thanks to Verilogue, drug companies for the first time will be able to design marketing materials according to what actually takes place between doctors and patients behind those closed doors.

Drug companies will certainly find this kind of information useful, and (what with docs today having to cram all that P4P and other mandatory whatnot into their 7.5 minutes per patient encounter) eye-opening. The pharmaceutical marketing experts undoubtedly will learn that what they’ve got to do in order to encourage doctors to sell their drugs in this environment is to distill their marketing messages down to less than 10 seconds of utterly compelling prose. All that excessive verbiage they’re able to include in their luxuriously sedate and drawn-out TV commercials (warning about priapism with Cialis, for instance), will need to be cut out. Perhaps details like this can be packaged into an attractive pamphlet, which docs can toss at their patients as they process them through the efficient office experience (shoving them back out into the hall, bundle of clothing in hand).

Specific doctors are targeted for the Verilogue opportunity according to the needs of the company’s pharmaceutical clients. That is, which drugs are their clients interested in moving, and which doctors are most likely to see patients eligible for those drugs? Doctors who agree to record their patient encounters are, according to the company, paid an amount “similar to stipends paid to medical investigators in other clinical research.”

To witness the process in action, the Inquirer reporter helpfully visited the office of one Nathan Zankman, pediatrician. When a 4-year-old boy with asthma (one of the targeted diseases) came in, Dr. Zankman asked the boy’s mother for permission “to have their conversation recorded for use in medical research.” She agreed, later telling the reporter, “I look at it as helping medical research. . . .I’m a firm believer in science and technology. If companies could learn something from conversations about my son’s condition, maybe it could help someone else.”

So what’s not to like here? Allow DrRich:

1) Coersion. When their doctors ask to record the office visit, patients - already reduced to mere supplicants, seeking to have their medical needs fulfilled by doctors whose life work depends on keeping third party payers satisfied - are immediately placed into an untenable position. It would be very difficult for patients to refuse this request. In the Inquirer article for instance, Dr. Zankman allows that he has never had a patient turn down a request to record an office visit.

2) Wasting precious time. To whatever extent the doctor takes the necessary care to fully inform the patient as to the real purpose for the recordings, the time taken to do so is likely subtracted from the strictly limited office visit. Of course, the wasting of time can be minimized by not informing patients of what’s actually going on (see item 3).

3) Misinformation. DrRich suspects the Inquirer reporter was witnessing a pretty typical example of the Verilogue process. (Generally what happens when a reporter wants to showcase a new medical technology is that he/she contacts the company, which suggests a “model” physician for the interview.) At least in this case, it appears the patient’s mother was sadly misinformed as to what was actually going on. She was apparently led to believe the recording would be used explicitly for medical research, that is, would presumably advance the state of the medical art, and would potentially help future patients. But that wasn’t the case at all. The recording was being made only for market research. This is a purely commercial endeavor; it has nothing whatever to do with scientific or medical advancement, and everything to do with marketing advancement (specifically, to tailor marketing messages in order to optimize drug sales). So at the end of the day the patient and her little son were unwittingly drafted into a particularly sophisticated focus group.

4) Mal-compensation. Traditionally, participants in market research focus groups are paid for their efforts. Since in this case the patient is at least as much a participant in the generation of marketable data as is the doctor, the patient undeniably deserves his/her fair share of the proceeds. The cut should be at least a 50%, or preferably more since it is the patient whose personal medical information is being risked in a private, for-sale-to-whomever, corporate-controlled database. There’s no indication that the patients are being informed that this is a money-generating endeavor, let alone being offered their fair share in compensation for their participation and their personal risk.

There’s nothing about the Verilogue business model that’s inherently bad or unethical. There’s nothing here that couldn’t be fixed with sufficient disclosure, full transparency and appropriate compensation. In DrRich’s view, the two founders of this company - who come from a pharmaceutical market research background, and whose sense of propriety thus may have been professionally altered - should have established fairer processes. The reporter for the Inquirer should have discerned the problems with what she witnessed and subsequently wrote about. But at the very least, the doctors working with Verilogue ought to be taking pains to protect the rights and welfare of their own patients.

That they apparently do not may simply reflect thoughtlessness and greed. On the other hand, it may reflect the extent to which the doctor-patient relationship has been systematically destroyed. Once you have succeeded in destroying that relationship, all sorts of new business opportunities will open themselves up. Apparently these will be blithely accepted (if not celebrated) by all parties involved, and will even be subjects of ain’t-it-wonderful feature stories.

Posted in General Rationing Issues, Primary Care in America | 5 Comments »

Covert Rationing Even Wrecks Socialism

December 11th, 2007 by DrRich

Last week, John Goodman wrote a provocative piece about what he’s termed the “nonprice rationing” of healthcare. By nonprice (or nonmarket) rationing, Goodman means the kind of rationing you get when the government, rather than market forces, control the healthcare system - specifically, he’s addressing a system of socialism. He offers five principles of such nonmarket rationing, which I paraphrase here:

1) Any excellence that may exist is not systematic, but instead occurs spontaneously and randomly.
2) Access to this random excellence is not random; the rich and connected are the ones who get it.
3) The skills that allow people to succeed in a market system are the same skills that allow them to succeed in a nonmarket system (i.e., one’s wits will determine one’s access to excellence).
4) Doctors rationing at the bedside will make value judgments about their patients; youthful and highly productive (and presumably influential - DrRich) patients will get an unequal share.
5) People at the bottom of the income ladder will almost always do better in a market system.

To sumarize: Despite the inevitable efforts of the government to homogenize healthcare under socialism, pockets of excellence will still randomly appear. The rich, the connected, and the quick-witted will find those pockets of excellence. So: the same people who are getting decent healthcare today will continue to get better than average healthcare under a government system, and the peons will suffer even more than they do today under a more market-based system (where they at least have a shot).

Goodman also says:

I am probably one of the few people you interact with who has a real interest in understanding nonprice rationing of health care. In fact, I may be the only such person. . . .In fact, I don’t believe anyone has developed a real theory about it.

Readers, please do not think too badly of Dr.Goodman just because he has not yet heard of DrRich or his Grand Unification Theory of Healthcare (GUTH), the theory that explains everything. Dr. Goodman’s a busy man, and DrRich is, well, obscure.

Does the GUTH account for Goodman’s “nonmarket rationing?” Indeed it does. Does it reach the same conclusions as Goodman? Well almost, but not quite.

The difference? Goodman’s formulation could be applied to almost any aspect of a classic socialist system, where virtually all goods and services are controlled (i.e., rationed) centrally. The same five principles (with the possible exception of principle 4, which seems to refer specifically to physicians) would hold under a socialist economy whether you’re talking about healthcare, cigarettes, plumbers, or wheat.

Under a socialist system, there will always be shortages of everything; but on the other hand there also will always be special caches of the rationed item, which somehow will be made more-or-less available to the rich, the connected, or the quick-witted. (The Cuba segment of Michael Moore’s Sicko, for instance, nicely displays the special cache of healthcare excellence that Cuba makes available to the fortunate few, such as American filmmakers bent on embarrassing the Bush administration). This inherent aspect of socialism is merely a concession to reality. Perfect socialism, requiring as it does a fundamental change in human nature, cannot exist. So special caches (whether of gasoline or of medical excellence) will always be permitted to spring up and to persist, at least tacitly. Trading in these special caches, after all, is how the central authorities a) maintain their power, and b) get to have some of the special stuff themselves.

Goodman’s formulation derives directly from the classic behavior of socialist systems, and thus must be correct. And being correct, it must also be compatible with the GUTH; and so it is.

But the GUTH adds a twist. The twist is: We’re Americans, and Americans don’t ration. So the central authorities who control the American healthcare system have got to do the rationing covertly. (In contrast, rationing under classic socialism is quite open.) Covert rationing corrupts everything it touches (Corollary 4 of the GUTH). Ironically, it even disrupts the inherently corrupt style of rationing classically seen under socialist systems.

Goodman points out that under classic socialism,

Since there is no financial reward for excellence and no financial penalty for mediocrity, excellence tends to be the result of the enthusiasm, energy, and leadership of a few people scattered here and there.

That is, socialism creates no incentive for excellence. Whatever pockets of excellence you get will have to be created by a few special individuals who are unusually self-motivated.

What this formulation does not account for is that under the American healthcare system, dedicated as it is to covert rationing, the Wonkonians are aggressively putting into place several powerful reverse incentives. These reverse incentives, we’ve seen (we being readers of this site), are aimed at actively stamping out, eradicating, and punishing any self-motivated physician who tries, despite all obstacles, to deliver excellent healthcare. Among these are the mandate that primary care doctors spend only 7.5 minutes per patient encounter; invoking the magic of P4P to determine exactly what must and must not take place during that 7.5 minutes; grabbing the right to interpret clinical science in order to formulate the “guidelines” that inform P4P; coercing doctors to agree to egregious adhesion contracts that any sane person would find unconscionable; forcing doctors to practice under a set of coding “guidelines” that prevent good patient care and serve as traps for “fraud;” and in general, making every patient encounter subject to a web of regulatory speed traps that force doctors to concentrate on keeping the OIG at bay rather than on what the patient needs. In short, in their efforts to gain control of physicians’ behavior in order to covertly ration healthcare, American Wonkonians are creating insurmountable and systematic disincentives for excellence, and severe penalties for non-mediocrity. They have placed doctors in the untenable position of being utterly unable to fulfill their professional, traditional, legal, and ethical obligations.

The only way doctors will retain a realistic opportunity to achieve excellence under such a system (so as to service at least the rich, the connected and the quick-witted), will be to abandon the system altogether.

Perhaps somebody can purchase an obsolete Soviet aircraft carrier, convert it into a state-of-the art hospital ship, staff it with renegade American physicians, park it in international waters off the east coast, and ferry Congresspersons back and forth by helicopter to receive their well-deserved excellent healthcare. Under a covert rationing paradigm, that might be the only way to fulfill Goodman’s five principles, even if we end up with a fully socialized healthcare system.

Posted in Wonkonian Rationing | 8 Comments »

Let’s You Sue Medicare

November 26th, 2007 by DrRich

A post on this site last week provoked an enlightening discussion, which DrRich will now summarize for you, following which he will solicit a volunteer for a noble but dangerous mission.

The issue at hand is the contracts that insurance companies and Medicare present to doctors, which, while their terms are remarkably unfavorable, doctors sign with nary a peep of protest, often without even reading them. DrRich’s original point was that doctors have no choice but to sign, as their only other alternative would be to become florists (or concierge physicians).

In the ensuing discussion, a physician reader indicated that indeed, doctors have no leverage in the relationship with insurance companies and thus no choice about signing the contracts. Dr. Poses (who started this whole thing with a post on Health Care Renewal) seemed a bit scandalized by this notion. He responded,

. . .if physicians are really being forced to sign contracts under these circumstances, wouldn’t that be a national scandal? And aren’t you actually charging that crimes were committed, on a national scale, perhaps involving national conspiracies?

DrRich, wanting no part of accusing UnitedHealth Group or Medicare of criminal conspiracy, soothed,

It is not a crime, nor is it really a conspiracy. The health insurance companies and the feds are really just doing what we (i.e., society) have deputized them to do - to covertly ration our healthcare. To do that, they absolutely must gain control over the behavior of physicians. Accordingly these “contracts” are merely tokens of the authority insurance plans have gained over physicians, authority that has been sanctioned by society, legislated by Congress, and upheld by the Supreme Court.

At this point a high-powered attorney specializing in negotiation and dispute resolution - Vickie Pynchon (check her credentials for yourself here) - offered a very provocative comment suggesting that, while such contracts (which she termed as adhesion contracts) are not criminal, they may indeed be unenforceable.

Although the law generally frowns on these non-negotiable agreements, it will enforce them. . .unless they are BOTH procedurally “unconscionable”(i.e., one-sided and “offered” on a take it or leave it basis to someone with very little or no bargaining power) AND substantively unconscionable (i.e., so unfair that it shocks the conscience).

She then went on to say that, in California at least, several adhesion contracts have been found to be unenforceable by the state Supreme Court.

This information set DrRich’s mind aflutter. If the only criteria needed to deem a non-negotiable contract unenforceable were that it had to be both procedurally and substantively unconscionable, well then, let’s have a look at Medicare.

Is the agreement between Medicare and physicians procedurally unconscionable, that is, offered on a take-it-or-leave-it basis? Why, most certainly.

There is virtually no choice for the average primary care doctor to opt out of Medicare, since the vast majority of his/her patients are enrolled in Medicare, and without those patients medical practice would be nearly impossible.

Is the Medicare agreement signed by physicians also substantively unconscionable? That is, is it so unfair as to shock the conscience? Here, too, the answer seems plain.

Physicians accepting Medicare have their pay rate determined not by market forces, but arbitrarily, by acts of Congress. Congress has famously been dialing back physician fees lately, so that, to make ends meet, doctors have to make it up with volume, moving from patient to patient every 7.5 minutes. Further, Medicare has fallen in love with something called Pay For Performance, whereby the feds get to script for the doctor exactly what he/she must spend those 7.5 minutes doing “for” the patient (no matter what the patient’s actual medical priorities). Medicare has in addition promulgated thousands of pages of arcane rules, regulations, guidelines and hints for proper medical behavior that are far less clear than, say, the IRS code. And it has launched a major Fraud Reduction program such that any minor violation of any of those impossible-to-interpret rules, regulations, etc., etc. are regarded as Healthcare Fraud, which (Congress has ruled) is now a federal crime, punishable by triple damages, $10,000 per “violation” and jail time. One form of such Healthcare Fraud would be to offer a patient a medical service that the doctor thinks the patient needs, but that Medicare has decided not to cover. Giving the Medicare patient the means to purchase desired medical services with his/her own money, in other words, is a barred and punishable activity (See Section 4507 of the Balanced Budget Act of 1997). Medicare has not come after huge numbers of doctors for fraud, but it seems to have done so arbitrarily, and when it points its fickle finger at you, well, given the tangled web of regs, you’re always guilty of something.

Any normal person - that is, a person who is not a politician or policymaker (who find this arrangement to represent the natural order) or physicians (many of whom seem to have become gradually inured, like frogs in a vat of gradually heated water, to such constraints on their professionalism and humanity) - would be shocked by a “business arrangement” like this, at least if you suggested it ought to apply to them.

Clearly, by its obvious procedural and substantial unconscionability, the Medicare agreement looks unenforceable. DrRich gently suggested as much to Ms. Pynchon: Looks like we have a case, huh?

It might not be that easy, she responded. It seems that determining whether a contract is substantially unconscionable (i.e., shocking to the conscience) depends on who is the shockee. It’s best, she indicated, if you are part of some group perceived as being relatively innocent or powerless.

Despite physicians’ reputation for general incompetence in their business and financial affairs (deserved or not) I do not believe the courts would treat them with special concern when it concerns their entry into contracts — adhesion or otherwise. They would, I presume, be treated as highly sophisticated “consumers” of insurance programs who could, if they wished, simply opt out of an insurance-based practice for a cash-on-the-barrel-head means of earning their compensation.

OK, so it’s not a slam dunk. There’s a slight possibility - despite all the evidence to the contrary - that the Medicare agreement with physicians is enforceable.

But look: Doctors can plausibly argue that they’re constitutionally lousy businesspersons (as Ms. Pynchon helpfully reminds us), that they were raised under a regime of “learned helplessness” (see Dr. Poses article), or that they’re just too damned busy doing P4P to read convoluted folios of legalese.

So what do you say. Any takers? Let’s you go ahead and sue Medicare on the unenforceability of the contract they make all doctors sign (in a procedurally unconscionable way) that places them in a substantively unconscionable position. DrRich would do it himself, but he’s still recovering from his last close encounter with the wrath of the Feds. Time for someone younger and less damaged to take up the cudgel.

DrRich will hold your coat.

Posted in Wonkonian Rationing | 5 Comments »

A Unique Way to Salvage the Doctor-Patient Relationship

October 31st, 2007 by DrRich

As we have seen, covert healthcare rationing requires destruction of the classic doctor-patient relationship (since a common final pathway for covert rationing is the bedside). The government and private insurers accomplish this task by several mechanisms, but the one that has recently gotten the most attention on this blog is the gambit of severely limiting the time doctors can spend with a patient during each visit (through overt “efficiency” mandates, or through slightly less subtle economic disincentives), then scripting what the doctor must talk about during that limited time (through P4P).

In her “The Informed Patient” column in today’s Wall Street Journal, Laura Landro talks about efforts being made by some patients and some doctors to try to remedy this dire situation.

Savvy patients, recognizing that their lives may depend on getting their doctors to address their important medical issues (instead of the ones on an imposed checklist), and recognizing they only have a few minutes of face time to accomplish this goal, are turning to experts for help. And certain physicians and organizations are stepping up to the plate to help.

Landro points us to Dr. Marisa Weiss, a radiation oncologist who delivers a very clever presentation (from the standpoint of the patient) on how to talk to your doctor, and who has written a book on the same topic called (tellingly) “Seven Minutes: How to Get the Most from Your Doctor Visit.” This is the most approprate title DrRich can imagine for a book on the modern doctor-patient relationship.

Landro also mentions efforts like the Shared Decision-Making program pioneered by the Dartmouth-Hitchcock Medical Center in Lebanon, N.H., which has created a library of materials that patients can use to bring themselves up to speed on their medical conditions, so they can approach their brief audiences with their doctors armed with a reasonable foundation of knowledge.

Finally, Landro points us to Dr. Delia Chiaramonte, who established Insight Medical Consultants, a company whose mission is to help patients navigate the hostile American healthcare system. Delia (who wrote the compelling Afterword for DrRich’s book), is a true American medical pioneer. A well-trained and dedicated practicing internist, Delia eventually became terminally frustrated by the rules, performance guidelines, time limitations, and all the other ploys externally imposed on American doctors today to prevent them from fulfilling their duties under the classic doctor-patient relationship. She could have done what many other doctors do in similar circumstances - become a pathologist (a specialty where the doctor-patient relationship remains blissfully unhurried), become a florist or deep-sea fisherperson, or simply resign herself to an unfulfilling and frustrating career.

She chose instead to invent a brand new kind of medical career. If you’re not allowed to have a doctor-patient relationship within the practice of medicine, she reasoned, then maybe you can have one outside the practice of medicine - as a professional patient consultant. Delia offers private medical consultation to patients who need help that their own doctors are unable to give them. Her services include offering patients in-depth education on their illnesses, helping them research their options for therapy, assisting them with insurance issues, coaching them on getting the most out of doctor visits, and even accompanying them to important doctor visits. She offers patients what they really need, and what she wanted to offer them as an internist but wasn’t able to. By making patients more knowledgeable and more confident, Delia aims to strengthen their relationships with their own doctors - at least those doctors who believe in shared decision making and not in paternalistic medicine - rather than undermine it.

The path Delia has chosen toward her own medical fulfillment uniquely fills a vacuum in American healthcare that is (systematically) becoming more pronounced by the day, but that is only now being recognized by substantial numbers of doctors and patients. Her model is one that utterly discouraged American physicians might want to consider as they weigh their options. And it is certainly one that purposely-abandoned American patients should seek out, for their self-preservation.

Posted in General Rationing Issues, Primary Care in America | 4 Comments »

The AMA Takes on In-Store Health Clinics

September 21st, 2007 by DrRich

Despite the fact that covert rationing has systematically separated the interests of doctors from the interests of their patients, thus programmatically destroying the doctor-patient relationship, leaving patients to fend for themselves within a cruel healthcare system, and leaving doctors to wallow in frustration at their loss of autonomy and at the demolition of their once-proud, once-ethical profession, every now and again some doctors’ group will find the energy to raise its voice in protest over some new travesty.

This seems to be the case with the AMA today, which has bestirred itself into a genuine huff over the growing popularity of in-store health clinics. The AMA is deeply worried that these clinics, often located in large retail chain stores, will fail to provide American patients with the optimal medical care they so richly deserve.

The AMA’s concern, according to an editorial in the July 23 edition of the American Medical News, is related to how these clinics will “comport with medicine’s central dictum - First, do no harm.” The harm postulated by the AMA has to do with the in-store clinics’ “impact on physician practices - specifically, their potential to interrupt the physician-patient relationship and to undermine coordination of care.” (DrRich wonders: Doesn’t anyone at the AMA edit these editorials? Do they really want to complain, out loud, that their primary concern with in-store clinics is their impact on physician practices?)

Why are these clinics so dangerous? Well, a lot of reasons. First, they are usually staffed primarily by nurses and not doctors. Second, they are often run by companies (such as drugstore chains) that also sell medical products, so there might be a conflict of interest. (In fact, the AMA has called for formal investigations to look for such conflicts. DrRich believes this is called phishing.) And third, well, they might harm the doctor-patient relationship.

Why would patients allow themselves to be subjected to such risks? The AMA knows the answer to this, too. It’s mere convenience. The in-store clinics often have the same liberal hours of operation as the stores in which they reside. The waiting times are often minimal. (And, if patients find there is a wait, the magazine sections in many of these stores often have issues more current than 1993.) The nurses (yes, again, take careful note - these are often nurses and not actual doctors) sometimes seem more pleasant, unhurried, and caring than the patient’s own stopwatch-clicking primary care doctor. But it’s just plain wrong to sacrifice quality for mere conveniences such as these, and action must be taken to protect patients (simple things) who just don’t get it.

To limit the damage being suffered by unsuspecting patients (and, parenthetically of course, by physician practices), the AMA has proposed nine (nine!) principles that they would like to see legislated far and wide, and that will assure that in-store clinics meet the high standards the AMA would wish for them. (You can see these nine “principles,” which look a lot more like “rules” to DrRich, here.) It is probably mere coincidence that if the nine principles were all adopted, the in-store clinics would begin to look a lot more like the bureaucratic nightmares that many doctors’ offices have lately become.

It is all too easy to criticize the AMA for their actions regarding in-store clinics. Even the AMA’s invoking of the sacred doctor-patient relationship seems a bit sad, given that doctors themselves already have been systematically forced into abandoning that relationship. (If patients can’t have a doctor-patient relationship anymore, one wants to ask, can’t the AMA just step aside and let them at least have a nurse-patient relationship?) Capitulation to the central authorities who determine their viability as practitioners (thus relegating their patients to a place of secondary importance), even though done only under great duress, makes doctors’ protests against in-store clinics seem petty if not ironic.

But really, looking at things with the cold eye of reality, what else can the AMA do?

If the practice of medicine were an economic endeavor like any other, we would just tell the doctors, “Clearly, your patients are put off by the long waits, the inconvenient office hours, being rushed in and out of the exam room in 7.5 minutes, not being able to ask all the questions they want to ask, and scores of similar indignities that have become associated with seeing the doctor. No wonder they’re going to Wal-Mart for their healthcare. If you want to stifle these in-store clinics, which really do sound like a sub-optimal idea, then just learn to compete with them. Give the patients the convenience and the time they’re looking for - make them feel like they’re your chief concern and not an imposition - and you’ll run these guys out of town inside of a month.”

But that advice doesn’t work. Doctors can’t compete. They’re not allowed. The irrationalities, petty inconveniences, and low-grade indignities of visiting today’s doctor’s office are built in to the system (since stifling the demand-side of the equation is inherent to covert rationing). Limiting doctors to 7.5 minutes per patient visit has become a virtual mandate from the entities that are paying the bills; doctors have relatively little to say about it. Further, as we have seen, with the introduction of P4P even the content of these brief visits is increasingly scripted by some central authority. The patient’s needs have been purposefully and effectively marginalized. It’s become impossible for doctors to serve their true masters (those same central authorities), and satisfy their patients at the same time.

So when doctors begin losing their patients to a health facility that does not have to operate under the same constraints, the AMA really has no choice. If you’re not able to compete with in-store clinics on their own terms, then do whatever you can to bind them to the same kinds of constraints that bind you. Drag them down into the morass; truss them up with red tape; kill them. Do it.

Any enterprise that dares to challenge the infrastructure of covert rationing, by offering patients some small chance at self-empowerment, by giving them even the puniest opportunity for self-determination, will be treated similarly, and not merely by Wonkonian regulators and Gekkonian insurance companies. Even the doctors will act this way.

A resolute public demanding opportunities for self-empowerment is the only viable path out of our system of covert rationing. For this reason, DrRich is cheering on the in-store health clinics, as paltry a tool for patient-empowerment as it is.

Posted in General Rationing Issues, Primary Care in America | 3 Comments »

Pay for Performance and Covert Rationing (2)

September 14th, 2007 by DrRich

In a previous post, DrRich described the most obvious problems with Pay for Performance (P4P) when applied under a system of covert rationing. In the present post he addresses some of the more subtle and insidious aspects of P4P.

Consider, firstly, that the large insurers - and to some extent Medicare - have by now successfully dictated to primary care physicians that they can spend only 7.5 minutes (or perhaps 10 minutes if they’re lucky) per patient visit. This mandated brevity, indeed, is one of the chief complaints voiced today by both primary care doctors and their patients.

On the heels of this considerable success these same third-party payers now have launched P4P, which gives them the ability to dictate exactly how those doctors must spend their 7.5 minutes. If the doctors hope to avoid (at best) missing out on their 5% bonus or (more ominously) getting blackballed for delivering poor quality care, they’ll spend that allotted time doing whatever their P4P checklist says they must do.

Doctors can’t possibly do everything; P4P relieves them of the burden of having to decide which of the important patient care tasks they’ll do, and which will have to wait for a more propitious time, such as when the cows come home.

Now, DrRich will be the first to admit that most of the things on the P4P checklist seem potentially useful or at least benign. You can look at common P4P-approved tasks in a report from PriceWaterhouseCoopers, and see for yourself. How can anyone argue with cancer screening, cholesterol management, diabetes management, or the appropriate use of asthma drugs? These things are all good for patient care, aren’t they?

Sure they are. In fact, the designers of P4P programs have taken pains to make sure that the items they have put on on their checklists to date will not only reduce costs, but, whenever possible, will also be reasonably likely to improve patients’ health (or at least will be perceived that way). It’s one of the things that makes criticizing P4P so unrewarding.

But one would have to be very credulous indeed to believe, despite vociferous protestations declaring it to be so, that insurance companies and the feds are making a Manhattan Project out of P4P purely out of their passion for good outcomes. It is clear that reducing the cost of care is the chief driver of the P4P movement, and if it isn’t likely to reduce the cost of care, it isn’t going to make the P4P checklists.

Unfortunately, many patients need medical care that isn’t going to reduce the overall cost of care. Quite the contrary.

Take, for example, the 20% of Medicare patients who have at least 5 chronic medical conditions, and take at least 5 prescription drugs. Tending maximally to each of those medical conditions will likely cost a lot of money. Holding the office visit to 7.5 minutes, of course, goes a long way toward limiting the care that can be provided. But it still leaves the doctor with a disturbing degree of latitude. When deciding which of these problems to address during the brief office visit, the unfettered doctor might well choose a problem whose optimal management will greatly increase the cost of care. But happily, under P4P the decision of which problem to address is already made. The checklist reveals the appropriate choice.

For another example of optimal medical care greatly increasing the cost of care, consider the hundreds of thousands of heart attack survivors each year who are at increased risk for subsequent sudden death. Good clinical studies, supported by formal guidelines, recommend implantable defibrillators for many of these individuals. But implantable defibrillators, being extremely expensive, are mysteriously absent from anyone’s list of P4P clinical practice guidelines. (The sad fact is that preventing sudden death by any method, no matter how cheap - since it would prolong the life of patients who would otherwise continue consuming lots of healthcare due to their underlying heart disease - is diametrically opposed to the real purpose of P4P. Under a system of covert rationing, preventing sudden death is simply bad public policy.)

But P4P not only limits the options of the doctor. It also limits the options of the patient. While patients have the right to turn down therapy that is recommended by P4P guidelines (and that is duly parroted to them by their higher-quality physicians), they are unlikely to be offered alternative choices not sanctioned by the guidelines, unless that alternative therapy is cheaper, or their doctors are willing to defy the insurance companies or (even less likely) the heavy hand of the feds.

Finally, since succeeding with many of the P4P measures requires not only that the doctor treat the patient appropriately, but also that the patient become fully compliant with the treatment recommendations (carefully following, for instance, their diabetic regimens), P4P may cause doctors to avoid accepting into their practices patients who seem unlikely to follow their instructions. Such patients will tend to include the poor, the disadvantaged, and the undereducated. But then, in all fairness to P4P there’s really nothing new here; these individuals are already the most likely victims of covert healthcare rationing.

So P4P offers many advantages to a healthcare system predicated on covert rationing.

  • It pushes doctors to do the things, useful or not, that reduce the cost of healthcare.
  • It prevents doctors from doing the things, even if useful, that increase the cost of healthcare.
  • It helps weed out or change the behavior of doctors who “think they know better” than the centralized agencies of medical excellence.
  • It limits the options presented to patients.
  • It induces doctors to “cherry-pick” compliant patients, leaving the less accommodating ones to go fend for themselves.

No wonder everyone is on the P4P bandwagon.

Posted in General Rationing Issues, Primary Care in America | 2 Comments »

Pay for Performance and Covert Rationing (1)

September 11th, 2007 by DrRich

Pay for Performance (P4P) is the latest trend among health insurers and our friends in the government in their never-ending efforts to assure that patients in their charge are receiving top-quality healthcare. At least, that’s what they say.

Under P4P, certain “clinical practice guidelines” are developed by Medicare or private insurers, based on the principles of evidence-based medicine, to establish uniform standards of care for certain medical conditions. Then, doctors who meet specific “performance indicators” based on those guidelines will receive some sort of financial award at the end of the year. (The most common reward is a 5% bonus.)

Given the stated aims of P4P (quality improvement), and the fact that it is asserted to be grounded in state-of-the art medical science and mathematics, it immediately becomes inadvisable to criticize the effort, lest one be instantly revealed as a medical heathen.

DrRich will take the risk.

For, while P4P might be a reasonable tool for improving outcomes under some circumstances, under a healthcare system that fundamentally traffics in covert rationing (that is, where withholding healthcare covertly has become the prime directive), P4P is destined to be twisted to that end. P4P is an especially insidious tool for covert rationing precisely because it seems so reasonable and scientific on its face.

While P4P has been touted as a revolutionary new approach to quality healthcare, it is actually a repackaging of techniques traditionally used in managed care for many years. It is perhaps most similar to the “clinical pathway” initiatives that were common in the 1990s. The major difference, in fact, between clinical pathways and P4P is that the former were devised, implemented, monitored, and continuously adjusted locally, under the direct control of the doctors and administrators on the scene; whereas the latter are handed down from On High (either from Castle UnitedHealth Group, or from the Great City of Oz itself), and are not amenable to the continuous, data-driven process improvements that are the real hallmark of classic managed care. Far more than clinical pathways ever did, P4P threatens to become a matter of making ticks on a centrally-dictated check list.

P4P also relies on the Axiom of Industry - that the standardization of any process both improves quality and reduces cost. As DrRich has described elsewhere, the Axiom of Industry does not hold when the process involves actual human patients. This is because patients are not widgets. (While everyone agrees that patients are not widgets, the implication of this fact seems to have escaped many: What happens to the individual widget on an assembly line is immaterial - discarding even a high percentage of proto-widgets may be fine - as long as the ones that come out the other end are of sufficiently high quality as to yield the optimal price point in the market. Patients not being widgets, in theory we are supposed to care about what happens to the individual patient during the process.) Nonetheless, invoking the Axiom of Industry - equating reduced cost to improved quality - allows the central authorities to choose “quality measures” in their P4P efforts that will primarily reduce cost, and then to claim that their primary concern is for quality.

Those who have implemented P4P programs have been careful not to measure the results of their efforts based on patients’ actual clinical outcomes, but instead they determine the success of their programs based on the compliance of physicians with the received “practice guidelines.” Pay for performance is really pay for compliance. Compliance with guidelines received from on high BECOMES the outcome, the outcome that determines whether patients are receiving quality care.

But as any objective observer can tell you, care guidelines themselves are inherently problematic. (DB’s Medical Rants has an enlightening series of posts describing how this is so.) The scientific evidence used to establish guidelines is most often incomplete, is based on “idealized” and carefully chosen patients who rarely represent the actual patients seen by doctors in the wild, and is often inconsistent or contradictory. Such evidence can be applied to real patients only after careful consideration and interpretation, and making decisions based on such evidence requires a combination of clinical judgment and educated guesswork, even given a set of official guidelines. Whose judgment and guesswork ought best to be brought to bear - the clinician on the scene, or some remote bureaucrat? DrRich understands that the answer to this question is not straightforward for everyone, but he suspects most people would choose for their doctors to do it. In any case, the conceit voiced by proponents of P4P - that the right medical decision in most clinical situations can be predetermined objectively, and at a distance no less - is simply wrong.

But compliance is compliance, and doctors who do not comply with centrally-dictated guidelines will have a greater price to pay than merely missing their 5% bonus. Aetna, UnitedHealth Group and Cigna are already being scrutinized by the New York Attorney General for possibly steering patients away from less compliant (read: more expensive) doctors, on the purported grounds of their less-than-optimal quality of care.

These problems with P4P are at least reasonably straightforward and easy to spot. In his next post, DrRich will address some more insidious - and potentially more dangerous - aspects of P4P.

Posted in Gekkonian Rationing, Wonkonian Rationing, General Rationing Issues, Primary Care in America | 8 Comments »