How Covert Rationing Precludes Efficiency

July 3rd, 2008 by DrRich

(Don’t forget to check out the Independence Day version of Medical Grand Rounds.)

Depending on which news source you read, physicians either are or are not about to get hit with a 10.6% pay cut from Medicare. (The actual outcome of the pay cut kerfuffle, some say, will depend on how many Republican Senators are buttonholed by how many American doctors at July 4 picnics.)

Many people have formed rather firm opinions on this matter. Physicians, for instance, mostly disapprove of the pay cuts. Others (most often non-Medicare-aged non-physicians with what is termed today a “progressive” outlook) feel strongly that doctors are among the most coddled and advantaged groups in the land, and that a modest sacrifice like this pay cut is the least they ought to be willing to offer for the public good. And of course, DrRich himself has an opinion on the matter, which will be well-known to most readers of this blog.

But on the other hand, most Americans haven’t really given it much thought. After all, most Americans are not doctors, they’re not on Medicare, they’re not politicians, and they’re not sick. Besides, some have suggested, the Bible-thumping, gun-toting masses are too disaffected with such concerns as the cost of gasoline, food prices, job security, health insurance, and the 15 (or 16 - one loses count) consecutive losing records of the Pittsburgh Pirates, to be able to concentrate on the truly lofty questions. Furthermore, it is commonly believed by well-educated (and especially progressive) persons that the great unwashed are just a bit too dim to understand the really important issues, and so must be reassured (and led along) with easy-to-digest, 10-second “executive summaries,” which can be repeated over and over and over, as needed. So, for instance, we can’t let a few greedy doctors and fat cat Republican Senators destabilize Medicare.

DrRich, on the other hand, who was himself held in captivity by two of these Bible-thumping, gun-toting hoi polloi for the first 18 years of his life before escaping to more enlightened environs, grudgingly came to realize they weren’t so dumb after all. Indeed, in comparison to many of the Harvard-educated Top Scientists and Top Doctors with whom DrRich (who did not go to Harvard) has had the honor of working, Mom, Dad and the guys in the steel mill (with whom DrRich also had the honor of working, back when America still had steel mills) displayed a very comparable degree of innate intelligence, and a far superior degree of general wisdom and common sense.

But not even Dad (the smartest man DrRich ever knew, uncommonly smart even for a steel worker) could have figured out how doctors are getting paid today, or what’s up with the projected physician pay cuts. (He would have easily brushed aside the assertion that doctors themselves ought to embrace the cuts out of a sense of altruism, or alternatively, guilt.)

The sad fact is that anyone who actually tries to look behind the headlines to figure out why physicians are (or are not) about to get hit with a 10.6% pay cut by Medicare will quickly be swept away by a maelstrom of tangled laws, policies, regulations, interpretations, guidelines, secret committee proceedings, quid pro quos, tit for tats, and “unintended consequences” of both varieties (i.e., the actually unintended ones and the secretly intended ones), that surpasseth all understanding.

Go ahead, try it yourself.

First, DrRich recommends you study the Happy Hospitalist’s latest exposition on how doctors actually get paid. It is the clearest explanation DrRich has ever seen. But even though Happy has taken very great pains to simplify the processes involved, in order to make them remotely understandable (and to such effect that he deserves a Pulitzer, or whatever the blogging equivalent may be), their complexity is breathtaking. Trying to explain how physicians get paid is akin to explaining how one achieves the mystic vision of the Great All; one can come close to the truth with the use of language, symbols, graphics, analogy, starvation, exposure to the elements and controlled breathing, but one must actually experience it to appreciate the essential wonder and transcendent awe.

Then, for a clear explanation of how changes to physicians pay are accomplished, DrRich insists you deconstruct Robert Laszewski’s article in Health Affairs. This is merely a description of Congressional procedure, not really that much more complicated than most things Congress does, and is necessarily much simpler to follow than the Byzantine convolutions tackled by the Happy Hospitalist. But still, it is fairly frightening that any aspect of America’s healthcare is decided in such a manner.

However, to really begin to get a general idea of the complexity of the whole system, one must synthesize these two articles - the process for regulating the system of physician reimbursement (Laszewski) and the system of reimbursement itself (Happy.) By “one,” DrRich is referring to you, the reader, as it is far beyond the poor abilities of DrRich to do so himself.

Don’t feel badly if you can’t synthesize this mess, either. For in truth, the physician reimbursement system is not meant to be understood by mortal man.

And that’s the point.

It turns out that this incomprehensible physician reimbursement system was set on its current path by one simple desire: to force doctors to covertly ration healthcare. As Laszewski explains in another article,

The idea was to set an “affordable” physician cost trend and when real costs exceeded that level Medicare would compensate for it by cutting future fees. The. . .message to doctors was simple: If you spend too much the Medicare program will compensate by cutting your fees in the future to balance things out. The objective was to give physicians a reason to control their costs.

Yes, that’s right. The original purpose behind this whole mess was to induce physicians to stop spending so much of Medicare’s money on patients’ medical care.

But when you set out to do such a thing, you can’t just come right out and say so, because that would be admitting to rationing. Instead, you’ve got to hide your real purpose in soothing language (generally it’s best to employ irony, and talk about improving efficiency and quality), and in bureaucratic processes that are so convoluted that the casual observer (or even the serious investigator) will not be able to discern their real intention.

Things get bad enough, as DrRich has described numerous times, when the bureaucratic entity running the covert rationing effort is a private insurance company.

But to really appreciate the potential for the opacity, complexity, and inefficiency demanded by covert rationing, one must study the government’s efforts in this arena. To the mere goal of profit which is the lifeblood of any company (too often fueled by excessive greed, one must admit), add the much stronger and additional aims of power and influence that fundamentally motivate our politicians, regulators, administrators, and others too numerous to mention who work for the government. Then stir in the absolute need to make convoluted deals, compromises and concessions with sundry interest groups and diverse colleagues and acquaintances, influences that may or may not have anything whatsoever to do with healthcare. Pretty soon you have the kind of “system” that is partially explained by a synthesis of the exertions of the Happy Hospitalist and Robert Laszewski.

The current physician reimbursement system is emblematic of what we might expect if we turned the entire healthcare system over to the government, and those who rail against such a single-payer system ought to use this example as an object lesson. For those who favor a single-payer system, however, such examples are simple to counter with illustrations of the egregious and heart-rending abuses perpetrated by private health insurers.

This is all to say that the real issue is not so much with the government or with the private insurers. Whatever travesties these entities perpetrate simply follows from the job we’ve all given them, which is, to ration our healthcare covertly. Covert rationing is rationing by whatever means you can get away with, and so utterly requires head fakes, misdirection, systematized inefficiencies, complexity, delusion (of self and others) and flat out lies. These things simply cannot be accomplished in a system characterized by transparency and smooth efficiency.

So if we’re going to continue rationing healthcare covertly, it really doesn’t matter all that much whether the rationing bureaucracy is controlled by the feds or private insurers. As the (other) Poet says, Fire or ice; either will suffice.

Posted in General Rationing Issues | 4 Comments »

Medical Grand Rounds, Vol 4, No. 41

July 1st, 2008 by DrRich

Welcome to Medical Grand Rounds, Volume 4, Number 41, July 1, 2008. This week, bloggers from across the Internet have submitted articles that will help us celebrate the 232nd birthday of the United States of America. Their patriotic postings, organized according to their relationship to the Founding, follow:

Lists of Grievances

Annie at Home of the Brave sets the tone for this week’s Grand Rounds. She does a brilliant job showing what the Founders might have said about the current state of the American healthcare system, in What They Were Saying: A Riff on the Declaration and Resolves of the First Continental Congress. The First Continental Congress, of course, met in 1774 to petition King George for a redress of grievances stemming from the Intolerable Acts. The King rebuffed their petition and a shooting war broke out the following year, which led to, well, quite a bit. (Faced with their own intolerable Acts, many doctors, in stark contrast to the Founders, simply keep their heads down and continue making those little marks on their Pay For Performance checklists.)

Ian Furst of Wait Time & Delayed Care is Canadian and knows something about healthcare and the bureaucracy (not that doctors in the U.S. have any excuse not to know the same thing). Ian analyzes the results of England’s 4-hour ER wait-time guarantee, and shows once again how bureaucrats tweaking one variable in a complex system always manage to create interesting unintended consequences. But, since these unintended consequences will always require further bureaucratic activities in order to produce corrections, they guarantee perpetual growth of the bureaucracy, and thus are seen, by the people who really matter, as exceedingly good things.

Speaking of the proper limits of government, Doc Gurley considers, in her post, Hope and Death, the implications of the California Assembly’s latest bill, essentially requiring doctors to tell patients when they are terminally ill. This information, no doubt, would substantially lower patients’ expectations, and patients with low expectations can be managed very cheaply. (Which explains the legislative impetus to become involved in such matters.) But as Doc Gurley points out, the definition of “terminally ill” is often in the eye of the beholder, and the definition favored by those running the healthcare budget may be quite different from the definition patients (and doctors, if left to their proper medical functions) would favor. Doctors not wanting to break the law (or expose themselves to yet another, particularly promising, form of healthcare fraud) will predictably begin shading the definition of “terminally ill” toward the cost-saving side, i.e., making the determination somewhat earlier than traditional (or proper). DrRich predicts that our faithful public servants will soon take note of the prolonged anguish that will ensue as a result of the newly prolonged (by legislation) duration of terminal illnesses, and their bureaucratic compassion will move them to legislate a mitigation; namely, a law requiring the easy availability of physician-assisted suicide.

The Happy Hospitalist this week offers one of his patented, in-depth analyses of the utter mess that Medicare has become, in This is What You Voted For. For a system that produces the exact opposite of what it says it wants to produce, you can hardly beat Medicare. Happy says, “Look out America, get ready for even lower access to cheap effective [primary] care and a highly expensive and wasteful proceduralization [by specialists] of your friends and family. . .Well America, this is what you voted for. I hope you’re ready to live with the consequences.” Taking into account the bizarre incentives, Byzantine inefficiencies, and systematized grievances that are provided in such luxurious abundance by Medicare, Happy (and DrRich) can only marvel in dazed wonderment that anyone thinks that turning the whole healthcare system over to these people is a good idea. Imagine our honored forebears clamoring to turn over the entire colonial economic system to the perpetrators of the Stamp Act!

And anyone who still thinks any government knows how (or can know how) to run a healthcare system should become a regular reader of Dr. John Crippen’s NHS Blog Doctor, to get a taste of what healthcare across the pond is really like. His recent posting, The Rise of the Healthcare Professionals, describes just a few examples of the systematized dumbing-down of healthcare that has accompanied England’s NHS, and will accompany any system in which codified policies, procedures, and guidelines, handed down from on-high and strictly enforced, replace genuine medical thought.

Inalienable Rights

DrRich has always been amused by those boutique diseases that doctors occasionally invent in order to justify new avenues for payment. Psychiatrists (in DrRich’s humble opinion) have been particularly adept at this game. Dr. Shock MD PhD gives us his opinion on the latest such neo-diagnosis - Internet Addiction. Dr. Shock, we are happy to note, is not enamored with this new disease, and to his very great credit finds in America’s founding documents an inalienable right to the Internet. All self respecting bloggers must unite against declaring as a disease the robust appreciation of the Internet!

The anonymous blogger who writes How to Cope With Pain wonders in Can I Still Blog? whether blogging is an inalienable right - and concludes that while it may be a right, the fact that something is a right does not necessarily relieve you of the attendant risks or consequences. So that’s why all those other physician-bloggers choose to remain anonymous! Is it too late to inform you that DrRich is actually a 58-year-old housewife from the upper Midwest who learned everything she knows about medicine from Dr. Kildare reruns?

Alvaro at Sharp Brains talks about the inalienable right of men and women to own functioning brains - and what they can do to keep them - in Why We Need Walking Book Clubs.

Theresa Chan at Rural Doctoring tells a painful story, in Another Reason Why Healthcare is Going Down the Toilet, documenting how some patients (and patients’ families) feel they have an inalienable right to all the time and toil they desire of physicians, and for free.

The Spirit of the Individual, That Which Made America Great

Rob, at Musings of a Distractable Mind, shows us that the independent, creative spirit that made America what it is remains alive and well - even in PCPs! DrRich has long maintained that PCPs need to think outside the box in order to salvage their profession, and in What are You Going to Do? Rob demonstrates thinking that is, uh, way outside the box.

Over at Insure Blog they’re talking about another aspect of the right to fend for yourself - this time, using a patient’s own cloned immune cells to treat cancer. This research, which comes from the UK, is not funded by the National Health Service, nor has the NHS expressed the least interest in it. So, one might say, the British government is keen to remain “independent” of potentially expensive cancer cures. Read about it in Interesting Cancer News.

David E. Williams at the Health Business Blog tells us about an idea whose time has surely come - enticing patients to take their medication by rewarding them with chances in a lottery. Now, what can be more American than that? Go read You gotta play to win.

Kim of Emergiblog reminds us in Give Me Empathy, or Give Me . . . Another Nurse, how, when we are sick and frightened, nothing can soothe us like the presence of a confident, knowledgeable and empathetic nurse. The continued empathy of nurses is quite remarkable to DrRich, who notes that nurses are under as much stress from the bureaucracy as are doctors. Add to that the stress from being expected to follow orders from those harried, frustrated, angry, not-always-clear-thinking doctors, while still doing the right thing for the patient - dual responsibilities that are not always 100% in alignment. Continued empathy under such challenging conditions can only be attributed to individual character and dedication.

Kerri of Six Until Me reminds us in My Own Shoes that knowledgeable, intelligent and rational patients will always take doctors’ recommendations under advisement, but may ultimately decide that their own personal situation is best served by some deviation from those recommendations. Such patients are not being “non-compliant;” they are considering the doctor’s advice within the context of the totality of their lives (which will always include data their doctors can never fully understand), and exercising their own individual judgment.

Christian Sinclair at Pallimed reports on the practice of hospice medicine during the ongoing Midwestern floods. His report reminds us of America’s greatest asset - the dedication, ingenuity and spirit of individual Americans - which is always most impressive under the toughest of circumstances.

Christine of You Don’t Look Sick tells us how patients can take a major step toward declaring their own independence from a hostile healthcare system - by taking charge of their own medical records. Great advice for any patient.

Standing Up To Powerful Authorities

Dr. Mintz takes on the all-powerful popular media in telling us the truth about the 8 drugs that doctors wouldn’t take. It is very popular to bash the drug companies these days, and accordingly, any negative news about (expensive) new drugs is invariably hyped far beyond any objectivity. DrRich would likely say that this behavior is just another example of covert rationing. But Dr. Mintz more usefully provides the objective truth about these “never drugs.” Perhaps, as a follow-up, he should write about the 8 sources of medical news that doctors (at least the smart ones) wouldn’t read.

JunkMD over at Progress Notes sounds like he’s just about ready to tell the feds what they can do with their latest pay cut. In They Just Don’t Get It, he is fed up both with his Medicare-age Senators and with fellow citizens who expect him to just sit there and take it. Maybe, he allows, it’s time to consider retainer medicine. “Opponents of this model wonder who will see the patients who can’t afford a retainer physician. Well, if none of us are in business, it won’t matter.” That sounds about right to DrRich.

DrRich his own self offers an alternative (and most uplifting) explanation for the fact that doctors apparently owe the IRS multi-millions of dollars in unpaid taxes. Rather than merely being tax cheats, perhaps these physicians are emulating their forebears who nobly defied oppressive Acts of Parliament by throwing tea into Boston harbor. But then again, perhaps not.

The Freedom From Misinformation Act

Dean Moyer of The Back Pain Blog helps one reader declare her independence from misinformation by answering the question Can Herniated Discs Really Heal?

Dr. Paul Auerbach at Medicine for the Outdoors tells those who are exposed to the smoke from wildfires (now raging in California) how to stay healthy. Being aware of oncoming threats in this case is a bit more complicated than “one if by land, two if by sea,” but is no less important.

When DrRich was a medical student, the only decent doctor show on TV was Marcus Welby, MD - a series that was heavy on personal interaction but weak on medical information. So cracking the books was the only good option for learning a little medicine. Today, medical students have many more options. Monash medical student, for instance, is fighting misinformation (his and ours) by reviewing episodes of House.

David Harlow of HealthBlawg reports on the launch of the Massachusetts eHealth Collaborative’s latest Health Information Exchange (HIE). An HIE is more about interdependence than independence, but then, our Founders also banded together (vowing to hang together so as not to hang separately), in their struggle for autonomy.

And Dr Penna reports on new information on Genetic Risk Factors for Alzheimer’s Disease. If you decide to get the test, don’t tell the government or United HealthGroup.

The Obligations of the Individual in a Free Society

Marshall, the Episcopal Chaplain at the Bedside, reminds us in Returning to those Hard Conversations that doctors caring for the terminally ill should more often just say the plain truth, even when it’s painful (for the doctors) to do so.

Dr. Val and the Voice of Reason informs us that it’s plain to both the Surgeon General and to any beat cop that “most people just don’t know what it means to be a good citizen anymore.” Read her plain-spoken interview with Sgt. Zlotkus here, then go do the right thing.

Tories

Some, when a growing conflict reaches the point of no return, will always side with the more powerful disputant. In the Colorado Health Insurance Insider, Louise writes about why doctors are unhappy, and postulates that as a result many physicians now say they are in favor of universal, single-payer (i.e., government) healthcare. DrRich simply notes that after the American Revolution, thousands of Americans who had favored continued rule by the King moved to Canada and got what they desired; and finds it interesting that today’s Americans who want the sovereign power to take over healthcare could do exactly the same thing (if they were to lose the “healthcare wars,” as unlikely as it now may seem), and with precisely the same result.

Am Ang Zhang of The Cockroach Catcher blog tells us about the systematic abuse of the diagnosis of Post Traumatic Stress Disorder by “an alliance of antiwar psychiatrists, VA hospital administrators, and patients who never saw combat or even Vietnam service but found that reciting the PTSD symptoms would result in the awarding of disability payments.” Read about it in PTSD: Diagnosis du Jour. Even John Adams has an opinion about this one.

Picnic Advice, or Don’t Be Stupid

RLBates of Suture For a Living wants to make sure we have a happy 4th. She posts again this year on fireworks safety - a matter whose importance she, a plastic surgeon, unfortunately knows all about.

The Samurai Radiologist at Not Totally Rad offers advice on keeping kids from ingesting foreign objects in Coming Soon to a Child’s Stomach Near You. SR helpfully reports on a missive he received from a concerned parent who is dismayed by the existence of such a thing as Kellogg’s Lego Fruit-Flavoured Snacks: “I just spent the first three years of my son’s life trying to get him not to eat blocks, and now you’re telling him they taste like [fornicating] strawberries. Thanks a lot assholes.” Picnic advice like this you can’t get just anywhere.

What Doesn’t Kill You Will Make You Stronger

Americans have learned repeatedly that adversity produces strength. So, if the rising prices of food have you down, Walter, at Highlight Health, urges you to be of good cheer! In The Upside of High Food Prices he describes how more people are eating local produce - and eating healthier. He neglects to point out (though DrRich will kindly take up the slack) the other problem caused by cheap food that is now being mitigated. We refer, obviously, to the fact that cheap food is the chief source of what has become the latest scourge-of-society: obesity.

Service and Sacrifice

Fighting for what you believe in is always costly, and the cost is never more apparent than in Healthline’s posting on Suicides in US Troops. If you know a serviceman or servicewoman this holiday, let them know how much we all love them and value their service and sacrifice.

The Most Important Aspect of Any Holiday

Bongi at other things amanzi offers us the sad and most affecting story of little k. On this holiday - or any holiday - the best lessen we can take away from k’s story is to gather around us those we love, give them a hug, then count our blessings and thank God for every one of them.

Next Week’s Grand Rounds

Next week Grand Rounds will be hosted by The Blog that Ate Manhattan.

Posted in Uncategorized | 15 Comments »

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 »

Happy Anniversary, If I Do Say So Myself

May 15th, 2008 by DrRich

They said it couldn’t be done.

They said, “An entire blog devoted to covert healthcare rationing? Ha!” They said, “Perhaps you’ll come up with a posting or two, but an entire blog? Why, you’ll run out of things to say inside of a week.” They said, “Covert rationing indeed!”

So today, on the First Anniversary of the Covert Rationing Blog, DrRich asks Them, “Who’s laughing now?”

Of course, because covert rationing is the lifeblood of the American healthcare system, the glue that holds the whole thing together, it is actually child’s play to come up with topics to write about. So DrRich does not feel as if he has accomplished any great feat here (despite having shown Them to be wrong! wrong! wrong!), any more than anyone should feel superior who has merely taken up the task to write down the obvious. If any accolades are to come his way, it ought to be for no more than his plodding persistence.

The real accolades ought to go to his fellow medical bloggers (many of the best of whom are listed in the column to the right), who have inspired and supported DrRich over this past year (and indeed, who are often quoted here), and who are doing a real service to American society. Few journalists in the mainstream media “get” what’s really going on nearly as well as these people do.

During the past year DrRich has attempted to interpret many aspects of American healthcare through the prism of covert rationing. Accordingly, both for readers who have been with him through the whole journey, and for those who have only recently found this blog, DrRich would like to take this opportunity to point to the posts which have generated the most interest, surprise or commentary. All of them illustrate the pervasive, destructive, wasteful, and enervating influence of covert rationing on the healthcare system and on American society - which (aside from keeping DrRich off the streets) is the real purpose of this blog.

Why patients should review their health records

Gag Clauses are obsolete for a reason

Medical home invasion

Pay for Performance and covert rationing (Part 2 here)

Why healthcare inflation is not explained by waste and inefficiency

A modest proposal for controlling drug prices

Let’s you sue Medicare

E&M guidelines and patient care

Physician Report cards and the designated driver

The transcendant importance of retainer medicine

Capitation and ratting on patients

How to invest in the new Medicare audits

Primary care - time to reboot

Never events? Never mind

On crying doctors

Is guideline tyranny causing guideline anarchy? (Part 2 here)

Covert rationing makes malpractice reform a bad idea

Posted in General Rationing Issues | 7 Comments »

Black Market Medicine - Staying Off the Grid (2)

February 26th, 2008 by DrRich

In a previous post, DrRich made a (more or less) tongue-in-cheek suggestion that our healthcare system is now presenting American physicians with a brand a new business opportunity - Black Market Medicine. Doctors operating in this new, blacker healthcare sphere would offer their patients “off the grid” healthcare services, that is, clandestine medical care. Their customers would be comprised mainly of otherwise law-abiding individuals who want and need medical care and who are even willing to pay for it (which, admittedly, will limit the potential clientele to a very tiny proportion of the American public), but who are afraid to leave a paper (or database) trail of their medical problems. In other words, they want their medical conditions to be professionally addressed, but wish to avoid documenting that dreaded “pre-existing medical condition,” which will be used to deny them future healthcare.

The occasion for revisiting this seemingly absurd idea arises from an article appearing in the most recent Sunday New York Times, which describes the case of Victoria Grove, an individual who did not want her doctors to know that she had a genetic condition - alpha-1 antitrypsin deficiency - which predisposes her to emphysema. Ms. Grove made the discovery herself using a home test kit. Having several family members with this genetic disorder, Ms. Grove understood that her condition meant she would need immediate medical care for her occasional bouts of pneumonia - but at the same time, she did not want her genetic condition to appear on her medical records. Thus, whenever she got sick she sought medical care right away, but never divulged her alpha-1 antitrypsin deficiency to her doctor.

At last, there came the day when a nurse decided Ms. Grove merely had a cold and did not need a chext x-ray. Ms. Grove tried to tough it out, but her condition worsened. She called the clinic to beg for antibiotics, and was told she needed to be seen in person before a prescription could be written. But she was too sick to drive. Finally, under severe duress, she caved in. From the Times: “‘I have alpha-1,’ she remembers sobbing into the phone. ‘I need this antibiotic!’”

Ms. Grove got her antibiotic, but from that moment she was outed.

American physicians: The desire of American patients to receive medical care while remaining off the grid is now undeniable; even the New York Times acknowledges it. The demand is there. Which of you will rise up to will meet it?

When DrRich says Black Market Medicine, that’s exactly what he means. These doctors will be functioning illegally, in the proud tradition of their spiritual ancestors, namely, the old pre-Roe back-alley abortionists who also dispensed their special variety of medical services on the sly, clandestinely, taking pains to leave no traceable record of their activities or their patients’ medical histories.

These new Black Marketeers will not be offering medical services that are themselves inherently illegal (like abortion was in the 1950s), but instead will be offering the same legitimate, routine medical care that you can get from any “on the grid” doctor. The only difference is that no formal record will be created - none whatsoever - of the care thus dispensed. Once the patient leaves the office, the encounter never happened.

Black market economies of any variety, of course, are inherently bad. Any product or service provided illegally is not subject to normal rules, regulations, or safeguards. (If there are enforcers of the “norm,” they tend to be even less savory than those in the employ of the feds.) The purchaser of those products or services is pretty much at the mercy of the seller, and has little recourse if the product or service proves faulty.

This is why black markets only arise when the legitimate pathway to the desired product or service has become so exclusive, oppressive, expensive, or toxic that anything would be better.

Which, again, fully explains why the time for Black Market Medicine is nigh.

Posted in New business models for healthcare | 5 Comments »

One Hell of an Exit Strategy

November 13th, 2007 by DrRich

How else to explain the strange behavior of insurance companies?

Item 1: Bob Laszewski at Health Care Policy and Marketplace Renewal points us to a Los Angeles Times article describing how one health insurance company (Health Net Inc.) has systematized its practice of rescinding health insurance policies of patients who become sick. The article describes 51-year-old Patsy Bates, whose coverage was rescinded in the midst of her therapy for breast cancer, allegedly for failing to disclose her accurate weight and the possibility of a prior heart problem at the time she had applied for insurance. See the article for details, but the point is that the alleged (and disputed) failures to disclose have nothing whatever to do with her breast cancer. They amount to mere excuses to cancel her insurance (but not until she needed it - they were delighted to collect the premiums up to that point).

This story is entirely consistent with the tale told by Lee Einer, the notorious insurance company “hitman” featured in Michael Moore’s film, Sicko. Einer has subsequently expanded on his former activities in gaining rescission for insurance companies on the Honest Medicine blog:

(When you get sick). . .the insurer will go after you “like it’s a murder case.” They will contact every medical provider they believe treated you, and will request medical records. They will contact every pharmacy which you are believed to have used, and request their records. They will go into your health history as far back as five years before you applied for coverage. If they find anything — ANYTHING — which they determine that you did not fully disclose, and which could conceivably have been captured by the questions on your application, they have you.

Laszewski expresses the puzzlement that any thinking American would express in regard to this kind of activity:

It’s hard to imagine a worse headline for the health insurance industry just as we are heading into what will be a fundamental debate over who should run our health care system. It is even harder to imagine a dumber thing for the insurance industry to do than continue to argue and litigate the notion that an insurer can cancel–or rescind–an insurance policy for a misstatement of fact on an application for coverage no matter whether that statement was intentional or material.

Indeed, for the relatively small amounts of money it can save (relative to the massively expensive PR campaigns these companies run to convince us of how innately caring they are, and which they completely negate with such antics), it is hard to imagine why they take this kind of chance.

Item 2: Health insurance companies are big contributors to Hillary Clinton’s campaign. This might seem counterproductive considering the widespread notion that, if her reform plans are fully implemented, ultimately the role of private insurers in the healthcare industry will shrink or even disappear.

Why would insurance companies engage in high-profile, counterproductive activities, and contribute to political candidates who may want to put them out of business?

DrRich has a theory.

Insurance companies have recognized that the end-times are nigh.

In the early days, their chief mode of growth was in acquiring public assets (such as non-profit hospitals and HMOs) for a tiny fraction of their actual value, then after absorbing them, realizing the true value of these assets in their stock prices. The insurance industry has also nearly finished the exhilarating, immensely profitable consolidation phase of its business cycle, such that a very few large outfits now tower over the health insurance industry. So now, for the first time in their history, health insurance companies are going to have to try to make a profit - or even more difficult, to demonstrate continued growth - by actually managing the healthcare of their subscribers.

Faced with this impossible, panic-inducing task, the risk of running illegal, high-profile rescission operations begins to seem worth it. The risk of getting caught is now measured quarter to quarter - not long term. “Our risk of getting caught in the next 3 months seems relatively small,” they must be telling themselves. “As for the long-term risk of getting caught, who cares?”

Ditto with the contributions they are making to Democrats, especially the Democrats who seem most likely to win, and to push their healthcare reform plans. Republicans, who invariably promote the notion of private-insurance-based solutions, must seem really scary to the insurers. If Republicans win, there will follow completely untenable expectations on the part of insurance companies. They’re the ones who will have to figure out how to control costs!

Democrats will also put the industry in an untenable position, of course, and will at least arguably aim to drive them out of business (though without actually telling us so). But Democrats actually have no expectations for the insurance industry, other than that they fail in due time. This, DrRich submits, is the insurance industy’s plan, too.

But before they drive them into oblivion, the Democrats promise to create for them one last, massive windfall - namely, the government-paid insurance premiums for many of the 47 million uninsured Americans. (Joseph Paduda at Managed Care Matters thoughtfully estimates for us that windfall as $150 billion per annum - not exactly chicken feed.)

So, for at least a while, under Hillary’s plan the insurance industry profits will rise, stock prices will rise, and executive bonuses will rise. This is as good as it’s going to get.

In 1994 the insurance industry (then early supporters as well) took a look at Hillary’s massive plan for healthcare reform, and said, “My God! We’ll be out of business in 5 years!” And they became intractable enemies of her reform plan.

Today, they look at their situation and say, “My God! We’ll be out of business in 5 years!” And they see in Hillary a means to engineer those 5 years into one hell of an exit strategy.

Posted in General Rationing Issues | No Comments »

The Aetna CEO Must Have Missed This

October 6th, 2007 by DrRich

The Wall Street Journal Health Blog now posts that Aetna CEO Ron Williams is “perplexed” about all the press coverage Microsoft has gotten for the launch of its on-line personal health record, while in stark contrast Aetna received almost no recognition from the press when it launched its own personal health record several months ago. To Mr. Williams this just doesn’t seem fair.

DrRich agrees, and thinks that the “advantages” of giving the big insurance conglomerates free access all your personal health information should indeed be broadcast far and wide. This is why (though Mr. Williams must have missed it), DrRich took pains to do just that a few months ago when the story was first abroad.

Perhaps what Mr. Williams should really be worried about is that apparently, Americans are ready to trust Microsoft (the company whose infamous security flaws have launched a huge and robust software security industry) with their personal health information instead of their health insurance companies. DrRich supposes they would rather trust an indifferent party (where, if security breaches occur, at least they will be inadvertent), than a party whose business model seems to allow (if not rely on) the purposeful maltreatment of their clients’ medical histories.

Posted in Gekkonian Rationing | No Comments »

Another Reason Patients Should Review Their Health Records

August 30th, 2007 by DrRich

In the Wall Street Journal today, Victoria E. Knight writes that smart patients will always review their medical records for accuracy.

“Not only can incorrect medical information lead to ineffective or harmful treatment — the Institute of Medicine estimates that as many as 98,000 patients die each year in hospitals from medical errors — it can also affect your insurability.”

Your health records, she points out, are analogous to your credit scores.

“Savvy consumers know to check their credit score before applying for a loan. What is less well known is that consumers can improve their chances of getting insured — and of paying lower premiums — by checking that medical information held by doctors, hospitals and pharmacies is accurate.”

There are a lot of reasons errors can appear in your file.

“Mistakes can arise from a mistyped diagnosis code or transcription error to an inaccurate diagnosis or a diagnosis that is out-of-date, say because a patient has gotten his or her cholesterol under control. And, if you have a common name, other peoples’ records can end up in your file. . .”

This is all very true, and these are very good reasons you should check your medical records. But in the spirit of this blog, DrRich would like to point out another reason.

You should check to see if your doctor is using your medical records for CYA purposes. This is especially true if you are a patient with a potentially expensive medical problem which, if your doctor followed all the guidelines to the letter, could result in substantial “medical loss” for the third-party payer (i.e., the doctor’s boss).

An example (which, in DrRich’s own clinical experience, is distressingly common): Say you’re a recent heart attack survivor. You’re pretty conscientious about taking all the medicines your doctor has prescribed to reduce your risk of another heart attack, and you’ve even changed your diet and started a walking program. Truth be told, you’re actually feeling better than you have in years. But then one day while putting the dishes away you have some kind of “spell.” One moment you’re opening a cabinet, feeling absolutely fine; the next, you find yourself laying on the floor with a bruised chin. Your wife, having heard a crash, is just now rushing in from the next room - so you know you were “out” only for a couple of seconds.

So, you go to see your doctor. You tell him what happened. He asks a few questions, nods, looks serious for a moment, then smiles and says, reassuringly, “Well, <Your Name>, I don’t think this is really anything to worry about. Sounds like you were just a little dehydrated. Happens all the time after a heart attack, what with all the pills and all. Really, nothing to worry about.”

Happy that the doctor thinks it’s nothing, you leave the office relieved. But might be surprised to read the note your doctor has put in your medical record:

“<Your Name> in for checkup. Doing well. Complained of an episode of significant lightheadedness two nights ago. Lost balance and fell, with minor trauma. Says thinks he was dehydrated from exercise program. Has felt well since. Nothing to suggest arrhythmia.”

This is a classic CYA note. Sudden, unexpected loss of consciousness after a heart attack is OFTEN due to potentially life threatening cardiac arrhythmias, and should ALWAYS be treated as a potential harbinger of impending sudden death. Unfortunately, treating it as a serious problem is usually expensive, requiring at least a hospitalization, and (if the evaluation is positive) the insertion of an implantable defibrillator. Such an outcome will not improve the doctor’s cost profile with his master, the third-party payer.

Your doctor should know that you are potentially at very high risk for sudden death. If he doesn’t know that, he’s stupid, and stupid is bad when it is seen in doctors. But stupid isn’t as bad as dissembling. And dissembling is what his note indicates.

Your doctor’s note does not accurately reflect what happened to you, or what you actually told him about the episode. Instead, it alters the facts just enough to make it seem reasonable for him to skip any further medical evaluation. If you have no further problems, no unnecessary dollars will have been spent and everybody’s happy. If you die, that’s terrible and all, but nobody reading the records will be able to fault him for doing what he did (or rather, for not doing what he didn’t). So it’s a win-win.

This is another reason for routinely reviewing your health records. In an era of covert rationing, you can protect yourself by not exposing your doctors to the ever-present temptation to “spin” the records. (Some doctors are regular DJs.) If your doctor knows you are going to read whatever he puts down, he’s a lot less likely to color the story to your disadvantage.

Indeed, for this very reason, DrRich would be especially suspicious of doctors who refuse to give you copies of your own health records.

Posted in General Rationing Issues | 3 Comments »

Free Personal Records From Your Health Plan? Not So Free.

July 2nd, 2007 by DrRich

Personal health records are, generically speaking, a wonderful idea. It is vitally important for American patients, in the name of self-preservation, to collect all their personal health records in one place, where they can control them, access them at will, and share them with healthcare professionals of their choosing as they deem necessary. Maintaining one’s own health records, in one form or another, is an important prerequisite for surviving the American healthcare system.So is it a good thing that America’s Health Insurance Plans and the Blue Cross and Blue Shield Association are planning to provide free personal health records to their plan enrollees? DrRich agrees with the folks at Patient Privacy Rights, who think not.

These altruistic insurers intend to offer their enrollees an on-line, electronic health record. The health plans will “automatically” populate the records with claims data (i.e., the information the insurance plans already have), and then “encourage” patients to populate the records with additional health information that might be important to an individual’s health (and that the health plan might find it useful to know).

As Dr. Deborah C. Peel of Patient Privacy Rights points out, there are several things health plans stand to gain from this endeavor. Among these are:

· An immensely lucrative data base they control completely.

· A rich compilation of patient data with no state or federal laws to prevent them from using the information any way they please.

· The opportunity to data mine the new information consumers add to their PHRs for medical underwriting.

· A great new business opportunity they can sell the PHR data of millions of enrollees to employers, drug companies, and data brokers.

What do the patients get? Dr. Peel tells us this also:

· No control over who can use and access their PHRs in these databases.

· No way to know how many other corporations will have access to their PHRs.

· No legal way to stop their PHRs in this database from being accessed, used, and sold.

· The misleading impression that medical underwriting will stop. Consumers are led to believe that that their PHRs in this database will not be used for underwriting, but insurers ALWAYS share enrollees’ health data with the Medical Information Bureau, which in turn gives every other insurance company access to the diagnoses, claims, and costs the patient and his/her family have incurred over their lifetimes.

· The only “right” they get is to approve the transfer of their PHR to another insurer if they change jobs.

Dr. Peel goes on to say, “The last place on Earth where patients want to keep their complete medical records is in the hands of their insurers.”

DrRich agrees.

Insurers are in the business of collecting healthcare premiums, then not spending those premiums on enrollees’ healthcare. That’s their business model: whatever they don’t spend on healthcare, they get to keep. If health plans were ever to do otherwise - that is, if they were to spend one penny more on an enrollee’s healthcare than they absolutely must - they would be guilty of defrauding their shareholders. Defrauding shareholders (individuals who, after all, have placed their trust in these enterprises) is a very serious offense, and no health plan considering itself an ethical corporate entity would ever, ever do that.

Indeed it is this business model that has caused our American society to rely on health plans as a primary means of covertly rationing healthcare. We provide them a huge incentive (i.e., the business model just described) to conduct this covert rationing, a nasty job that somebody’s got to do.

Naturally, then, it must seem like a very good idea to the folks running such health plans to provide personal health records for their enrollees. By doing so they will have a means to “capture” private health information that they would otherwise not have access to, and will be able to use that information in any way they see fit, without apparent limitations. This information might often prove very useful to them as they strive to fulfill the rationing mission our society has deputized them to fulfill.

DrRich’s advice is: certainly, by all means, compile and maintain your personal health records. This is a vital step toward empowering yourself within our hostile healthcare system. Even do it electronically. But do it yourself, or through some other business entity in which you are the customer. Don’t give your insurer another potential weapon as they forage for new ways to covertly ration your healthcare.

Posted in Gekkonian Rationing | 3 Comments »