The Covert Rationing Blog

Fun With Randomized Trials, and Breasts

July 18th, 2008 by DrRich

The Cochrane Collaboration has created something of a stir with its latest review on the advisability of doing breast self-examinations, which concluded, in essence, that they’re not advisable. Specifically, they found that women who perform breast self-examinations end up producing more harm than good, so women should be discouraged from the practice.

The Cochrane Collaboration is a highly regarded resource for those who value evidence-based medicine, medical guidelines, and the randomized clinical trials that support such tools. The experts at Cochrane conduct reviews of all randomized clinical trials (RCTs) that meet their strict criteria for scientific and statistical robustness, and periodically publish summaries of the scientific evidence thereby derived, on particular clinical topics. Cochrane reviews are thorough and straightforward, and virtually always present an accurate reflection of the up-to-date evidence as supported by RCTs.

Despite the respect in which the Cochrane Collaboration is held, DrRich finds it at least mildly interesting that their conclusions regarding breast self-examination have not been generally construed as being politically incorrect. After all, several aspects of political incorrectness, ones at least as incorrect as your more standard species of political incorrectness, can be readily identified within the Cochrane review. For example, one could easily allege that anti-women, anti-self-empowerment, or anti-early-detection thinking riddles this report. And if the review had emanated from say, the White House, one almost certainly would. But in fact most media reports, while expressing a certain amount of surprise, have seemed very reluctant to criticize the Cochrane Collaboration’s conclusions. And physician experts who have been excavated by the media for their comments have also given at least tepid support.

(Not all commentators have blindly accepted Cochrane’s recommendations. DrRich refers you to his colleague Trisha Torrey, for example, who expresses an appropriate amount of skepticism. But the traditional media, and their Rolodex physicians, have on the whole swallowed it. See here and here.)

The general support for Cochrane’s report on breast self-examination, DrRich submits, is a direct reflection of the exulted position that RCTs have achieved today all across the modern medical (and media) landscape. If a statistically legitimate RCT reaches some conclusion, no matter how strange, counterintuitive, or wrong that conclusion might seem, it is a conclusion that must be accepted. That this belief in RCTs trumps even the powerful social force of political correctness speaks to its ultimate strength.

DrRich has previously observed that our widespread belief in RCTs can be reduced to three main tenets:

1) Data derived from randomized clinical trials represents Truth.
2) Data derived from non-randomized trials represents Falsity.
3) If you don’t believe this, you are a heathen.

Objective observers will find it at least a little ironic that an attempt to claim the scientific high ground has so obviously resulted in a new religion, replete with its own dogma. True Believers will not see the irony, thus providing even more evidence that what we’re dealing with here is indeed a religion and not objective scientific thought. (Religions deal in mystery, and not irony.)

The sad truth is that the results of RCTs are invariably dependent on the bias built into their design, and even if internally they are statistically legitimate, they can often send us down the wrong path.

Those who design RCTs (the smart ones, at least) know this. They are like smart trial attorneys, in that they know the answer before they ever dare to ask the question. So they tailor their “question” in such a way as to yield the answer they want to get. Indeed, if a lawyer should end up asking a question that produces an unexpected answer, he or she is completely incompetent and ought to be sued for legal malpractice. In more cases than one might think, the same is true for those who design RCTs.

So, for instance, if you are a payer and want to limit the use of an expensive therapy, you design your RCT so that enrolled patients likely to respond to the therapy are diluted with lots of enrolled patients much less likely to respond, to assure that the average response of the whole population will be quite small. (In many instances the clinical characteristics of the likely responders and the likely non-responders will be reasonably apparent.)

On the other hand, if you are a company that wants to encourage the use of your product, you design an RCT that preferentially enrolls patients who are very likely to respond favorably, and then trust the marketplace (with a tweak from your DTC advertisements) to “extrapolate” the results to broader categories of individuals.

So RCTs do not in any way eliminate statistical bias, as most seem to think. Rather, they simply offer an opportunity to control the statistical bias in your favor. Since most doctors (and most regulators, guideline writers, and reporters) don’t seem to get this, it becomes relatively easy to fool them.

DrRich does not know if the people who designed the RCTs looking at breast self-examination tried intentionally to bias the results against self-examination, or if it was an accident. But that is what they did.

The RCTs which the Cochrane Collaboration reviewed looking at breast self-examination indicate that, in large populations of women in Russia and China, who go on to receive Russian and Chinese healthcare, breast self examination did not improve overall survival. And since those who did self-examination underwent twice as many breast biopsies, many of which revealed benign lumps, they experienced net harm. DrRich does not quibble with any of this. It is almost certainly true.

On the other hand, while most RCTs do not reveal it (since they look at aggregate results and not individuals), it is most often the case that some individual participants in even a negative study will experience benefit from the intervention being tested. In the breast-self examination studies, for instance, it is a certainty that individual women benefited at least to the extent that their breast cancers were detected earlier than they otherwise would have been. (In the Russian study this was proven to be the case.) These women had at least a shot at better survival by virtue of their earlier detection.

But whatever the overall results of these RCTs conducted in such exotic locales, they can have nothing whatsoever to do with women in America in 2008, who receive far more aggressive, tailored, and sophisticated therapy for breast cancer than women in virtually any other country in the world. (The optimal treatment of breast cancer depends on correct staging, on correct genetic testing of the tumor, and on optimizing the individual’s surgical and medical therapies, often employing very new drugs.) In any case, earlier detection of breast cancer is far more likely to be a significant factor in determining outcome in the U.S than it is in recently (or presently) Communist countries with 3rd world healthcare systems.

To be sure, DrRich does not pretend to know anything about the various specific institutions in Russia and China where these studies were conducted. Perhaps they were conducted in those rare showcase institutions that appear here and there under authoritarian regimes, of the sort Michael Moore frequents when he goes to Cuba, and where the level of medical care is said to more nearly approximate medical care in the United States. (Occasional institutions like this will survive even in the U. S. after Healthcare Reform, so that our Congresspersons will have someplace to go.) While this seems very unlikely - could a few showcase hospitals really accommodate the nearly 400,000 women enrolled in these studies? - one must suppose it is possible.

But even if all 400,000 study participants received showcase healthcare, advances in the therapy of breast cancer since the 1990s, when these women were studied, would likely yield different (and better) results today. Does any American oncologist believe that the early detection of breast cancer in 2008 does not improve a woman’s prognosis?

In light of such considerations, why are American doctors apparently so ready to accept the results of the Cochrane review, and to stop recommending breast self-examination? The answer is clear: It is because the data came from RCTs, and since RCTs always yield the truth (you heathen), all other considerations must fall away. Such is the depth of our faith.

DrRich will leave it for another day to discuss the favorable implications to the healthcare system of discouraging breast self-examination (such as having to pay for fewer biopsies), or the lessons that ought to be learned from this example about the advisability of blindly accepting formal guidelines just because they are derived from RCTs, and instead will simply give some friendly advice to the women who might be reading this blog:

First, it is probably a good idea to continue with your breast self-examinations. The downside of doing so is that you may be subjected to a breast biopsy for a benign lump. So take that into consideration. But the upside is that self-examination offers the (proven, according to the RCT data) potential for earlier detection, and therefore offers better odds of long-term survival if cancer is present.

And second, if breast cancer is diagnosed, try to get your therapy in the U.S. rather than in Russia or China. For the average patient in those countries, it would appear that cancer therapy sucks.

Finally, DrRich will close with this plea: Can our guideline writers, at least in the U.S., please refrain from creating new guidelines that are suitable for 3rd world healthcare systems, at least for the year or so it might take for the American healthcare system to actually be reduced to those levels?

Posted in General Rationing Issues | 9 Comments »

Getting Square With the Nurses

July 9th, 2008 by DrRich

Last month, DrRich wrote about how “doctor-nurses” are fixing to displace primary care doctors, and how the noble American Medical Association – champion, as always, of the American PCP – is mobilizing with decisive action to prevent this tragedy from taking place.*

One of the more remarkable responses to this article came in the form of a blog entry by DrRich’s colleague Annie, an entry which was, let’s say, critical.

DrRich is very sorry to have raised Annie’s ire, especially since Annie represents a combination of two of DrRich’s favorite kinds of people – nurses, and students of the Constitution. It is in this latter capacity that she writes for the blog Home of the Brave, a site that, if a bit leftward-leaning for DrRich’s tastes, is nonetheless dedicated to the very worthwhile goal of discussing “U.S. history, the state of the union, the state of the U.S. Constitution.” DrRich even gave top billing to one of Annie’s posts last week in Medical Grand Rounds – her nicely tuned article showing what the Founders might have said about the current sad state of the American healthcare system, an article which he now recommends again to everyone.

This public recognition of Annie’s obvious merits, despite the article she had written in response to DrRich’s posting on doctor-nurses, ought to attest to DrRich’s essential fair-mindedness and objectivity. For in that article Annie was less than kind to DrRich’s sensibilities. For instance, referencing DrRich, Annie said,

A few physicians are skeered of a new demon. They’ve got their Salem witch hunter judicial robes on, and they’re ready to order the press, the pyre or just a good old pompous piosity to their screed. What has their panties all in a bunch?

Doctorally educated nurses. I. am. not. making. this. up. They’re afraid of nurses.

What nurse bashing this is and based on what? Fear of competition?

Annie goes on some more about DrRich’s manhood and such (for the record, DrRich does NOT wear panties), but you get the idea.

More relevantly (more relevantly, at least, to everyone else if not to DrRich), Annie’s post points out that: a) nurses with doctorate degrees are not a new phenomenon; b) the vast majority of nurses are not out to displace physicians, or to usurp the title “doctor;” c) since there is an acknowledged shortage of PCPs, surely something has to be done to fill the void, and nurses – working in full partnership with doctors, as always – can help; d) the formidable Mary Mundiger (formidable, at least, to the lily-livered DrRich) does NOT speak for the large majority of nurses; and e) the organization that actually does speak for most nurses is the very reasonable American Association of Colleges of Nursing (AACN).

And the AACN is greatly disturbed by ideas, put forth by misguided paranoids like DrRich, that doctor-nurses may be getting ready to take over for actual physicians, and is distressed by the blowback that has already been experienced by the nursing profession as a result of such ideas. Indeed, Annie points out, the AACN is so alarmed by the resolutions being considered by the AMA (described here) - resolutions that, if passed, would potentially result in sending nurses a strongly worded letter - that it has issued a white paper itself urging the AMA not to take such drastic action.* This white paper passionately expresses

concerns regarding Resolutions 303 and 214, which are coming forward to the American Medical Association (AMA) House of Delegates. . .AACN is distressed by the tone of these resolutions, which may weaken the good working relationships established between many physicians and nurses….AACN requests that the AMA withdraw Resolutions 303 and 214, and if that is not possible, we urge members of the AMA’s House of Delegates to vote against these measures.

That is (Annie assures us, and the AACN certainly confirms), nurses, even most of the doctorally trained ones, want to play nice with physicians. And DrRich’s screed on the impending take-over of American medicine by hordes of aggressive nurses is both overdone, and very counterproductive.

In response, DrRich can only offer that he fervently desires that Annie, and any others who may have been offended by his earlier post, go back and read it again, but this time read it keeping in mind the following prompt: Irony. For DrRich’s comments were mainly aimed at satirizing the response of the emasculated and morally bankrupt medical establishment to the inevitable encroachment by nurses on what has traditionally been medical turf. DrRich was attempting to be ironic. (A colleague of DrRich’s, reading Annie’s posting, commented that those who miss the poorly-hidden subtleties of irony also may be likely to miss the well-hidden subtleties of difficult medical diagnoses. But this is unkind and likely incorrect, and DrRich chooses not to subscribe to it. Besides, this snide comment presupposes that DrRich does irony well, which may not be a good bet.)

Furthermore, DrRich would like to go on record to say that virtually everything Annie says (except for the personal stuff about his cowardice, Puritanical judgmentalism, exaggerated piety, panties, etc., much of which is simply not true) is pretty much correct. DrRich agrees that the large majority of nurses have no intention or desire to fundamentally displace American PCPs. And DrRich further agrees that doctors who resent nurses because they think they’re after their jobs are badly misguided.

But it’s not because ascendant nurses aren’t about to displace them that they’re misguided. They are indeed about to be so displaced. Rather, they’re misguided because most nurses don’t want any part of it either, just like Annie says.

Anyone who had read DrRich’s earlier articles on the plight of the PCP would understand that he does not consider the prospect of nurses encroaching on the turf of PCPs to be evil or bad, but simply the normal pattern in a modern society wherever advancing technology enables lesser-trained individuals to do things that in the past required highly-trained specialists. DrRich would never bash nurses for simply playing their natural part in the evolution of a technological society. He would sooner criticize a grizzly bear for dining on the entrails of an elk which had died of the mange.

The quotation Annie provides from the AACN white paper, protesting because the AMA is accusing nurses of doing what nurses are, in fact, doing (however involuntarily it may be) is quite telling. The train is leaving the station. The writing is on the wall. While it is clearly not Annie’s intent, or the AACN’s intent, or the AMA’s intent for nurses to replace PCPs, it’s happening just the same, as the night follows the day. Neither the PCPs, nor the nurses who may be startled and intimidated by the prospect, can ultimately stop it.

Those doctors who do view the encroachment by nurses as an unadulterated evil deed will see the protestations of innocence by the AACN - while events on the ground so clearly contradict them - as something similar to the soothing murmurings of the Japanese Ambassador while preparations for Pearl Harbor were in their final stages. They will see it as disingenuous at best, treachery at worst. But viewing it this way is simply wrong.

The posting by Annie and the white paper of the AACN are actually indications that most nurses are as apprehensive as are the PCPs they are displacing. And why shouldn’t they be? Look at the new responsibilities and risks the nurses will be acquiring - medical, moral, legal, financial and otherwise. Historical upheavals like this are often unkind to all parties involved, even the supposed “winners.”

If further evidence is needed that DrRich is correct (beyond simply studying the history of technological societies), simply read the July 2008 Update of the Hospital Outpatient Prospective Payment System issued by CMS. This document (if you can get through it) among other things removes language from the Medicare Benefit Policy Manual that had required that “services furnished in provider-based departments of hospitals must be rendered under the direct supervision of a physician who is treating the patient.” That is, non-physician care providers are now allowed to provide care for Medicare patients in a hospital outpatient department without any supervision by any physician who is caring for the patient.

CMS is already there, and is very obviously clearing the path for the inevitable. Everybody needs to get ready for this - the PCPs, and the patients, and even the reluctant nurses.

* This is an example of irony.

Posted in Primary Care in America | 5 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 »

Proof That Warren Buffet Reads This Blog

May 17th, 2008 by DrRich

Yesterday, Jacob Goldstein of the Wall Street Journal Health Blog reported that Warren Buffet greatly increased his stake in big health insurers during the first quarter of 2008. Specifically, he added 300,000 shares of WellPoint and 400,000 shares of UnitedHealth to the holdings of Berkshire Hathaway. Notably, the stock prices of both of these insurers have been tanking for months. So why would Mr. Buffet be buying them?

Mr. Buffet has a simple answer: “If we’re going to be buying things, we want to buy them on sale.”

To which the WSJ replies: “Of course, if it was simply a matter of increasing holdings that are falling, we’d all be billionaires. There must be more to it than that.”

Indeed, there is more to it than that, and careful readers of this blog (as Mr. Buffet must surely be) realize what that is.

The case against buying health insurance stock, it goes without saying, is plain for anyone to see. As DrRich has pointed out more than once, the mega-insurance companies have traditionally had three major pathways for increasing shareholder value:

1) Acquiring and privatizing community assets - generally non-profit hospitals and non-profit insurers - for a tiny fraction of their true value (through the collusion and/or ignorance of boards of trustees, state attorneys general, and state insurance commissioners), then letting the market assign the actual value of those formerly public assets to the company’s stock price.

2) Mergers and acquisitions of smaller insurers, i.e., through the consolidation of the industry.

3) Taking advantage of certain opportunities for “efficiency” that big insurance companies’ quasi-monopolies have bought them, such as cherrypicking patients, handcuffing doctors, retrospectively denying coverage to insured individuals, and the manifold other activities we can safely bundle under the rubric, “covert rationing.”

Obviously, all three of these pathways are closing off. There are few community-owned assets left to acquire, and consolidation has already left the U.S. with just a handful of important health insurance carriers. As for the “efficiencies,” opportunities here are drying up as well. For instance, this past December, shareholders of UnitedHealth Group (concerned because subscribers to the company’s insurance products had decreased by 315,000 in 2007) demanded a promise from company executives that the insurer would become “nicer” to its subscribers. Their own shareholders are wrecking their business model!

Insurance companies are left with the impossible task of trying to make a profit (and worse, to demonstrate continued growth) by actually managing the healthcare of sick people. This has never been accomplished in the modern era, and in all likelihood is not within the realm of possibility.

This explains why the stock prices of the big health insurers have been heading south for some time now. But what explains Warren Buffet’s enthusiasm for these failing businesses?

Two things. First, he recognizes the growing prospect of a Democratic victory this fall, in both houses of Congress and the Presidency. Second, he has clearly read and digested DrRich’s posting of six months ago that describes what will happen to the insurance industry with a Democratic victory.

Republican-style healthcare reform, even with a Republican such as John McCain, would bring the rapid and painful death of the health insurance industry. This, simply, is because the Republican strategy for healthcare reform relies on “competition and efficiency” in the private insurance market to save the healthcare system. Republicans, apparently, have not noticed that the insurance companies have been desperately trying their brand of “efficiency” for more than a decade now, and it’s been a disaster. The insurers have shot their efficiency wad; they’re entirely bereft of ideas; they haven’t a clue. Indeed, one can only imagine how the notion of a Republican victory, and the unbearable expectations such a victory will place upon them, must shake insurance executives to their core.

On the surface, Democrats will also put the insurance industry in an untenable position, as it is clearly their aim to drive insurers out of business (though they won’t actually tell us so). But Democrats actually have no performance expectations whatsoever for the insurance industry. Their only expectation is that the insurance companies should fail in due time. This prospect - as long as it’s preceded by one last, massive windfall - is quite acceptable to an insurance industry itself, which, realistically, can only be looking for a graceful exit strategy at this point.

As it happens, that one last windfall for the insurance industry is an integral part of the Democrat’s promise. For, before they drive private insurers into oblivion, the Democrats will present them with the gift of government-paid insurance premiums for many (Obama) or all (Clinton) of the 47 million uninsured Americans. These new premiums will amount to as much as $150 billion per annum. So, for at least a while, the Democrats will guarantee that health insurance profits will rise, executives bonuses will increase, and - more to the point - their stock prices will soar.

Which brings us back to what Warren Buffet is up to. DrRich is a great admirer of Mr. Buffet, and is sincerely happy to have been of assistance in furthering his understanding of the complex interplay between politics and the fiscal status of the big health insurers. So far, Mr. Buffet is playing the game perfectly.

DrRich does respectfully remind him, however, to carefully monitor this blog for the “sell” signal.

__________

Addendum. DrRich has just noticed that his deeply admired fellow blogger, DB, has challenged him this morning to a discussion of honor over the topic of malpractice reform, where DrRich has taken a very contrarian and highly unpopular position. Indeed, even DrRich hates himself for making such an argument. Nonetheless, DrRich is compelled, reluctantly, to answer in the affirmative (this being a matter of honor), and will post a reply within a day or two.

Posted in General Rationing Issues | 6 Comments »

Covert Rationing Makes Malpractice Reform A Bad Idea

May 9th, 2008 by DrRich

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

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

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

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

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

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

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

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

But alas, to his unending regret he cannot.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Posted in General Rationing Issues, Medical malpractice | 10 Comments »

Never Events? Never Mind

April 18th, 2008 by DrRich

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

CMS knows exactly what it’s doing here.

Posted in General Rationing Issues | 5 Comments »

How to Invest in the New Medicare Audits

March 11th, 2008 by DrRich

Several bloggers (including DB and Catron) have commented on the recent unleashing of Medicare’s “Recovery Audit Contractors.”

The RACs are a fun tidbit brought to us by the Medicare Prescription Drug Act of 2003. Under the RAC initiative, private contractors will soon be dispatched across the land to perform audits of billing already done by insurers, health plans and physicians. The objective is to find “overbillings,” which the providers will have to repay along with penalties. Further,the act explicitly allows for prosecutions to be brought for “fraud and abuse,” even if the providers have repaid any overbillings.

The purpose of the Recovery Audit Contractors will be, well, recovery. During the 3-year pilot of the RAC initiative, which took place in only 3 states, over $300 million were recovered. This wonderful success is the reason RACs are being turned loose everywhere.

The RACs are paid by commission. Essentially they are bounty hunters, and they get to keep 20% of whatever they collect. According to the Associated Press, hospitals and providers are just a tad worried that these contractors, being so generously incented, will prove a little overzealous in their enthusiasm to find fraud. But worried auditees should not look for sympathy from the public. “A little zealotry is what we’re looking for on the part of the taxpayers,” said Leslie Paige, spokeswoman for Citizens Against Government Waste. “We think it’s about time.” Indeed - everybody can get behind fighting fraud, which is what makes the fraud gambit such a powerful tool for covert rationing.

It is good to be an RAC, and, DrRich suggests, it would also be good to own stock in whichever companies are contracted to perform the audits. These outfits are about to harvest the vast bounty of obfuscation that Medicare has been carefully cultivating for 40 years, and has been carefully fashioning as fraud-traps for a somewhat shorter period of time.

DrRich has discussed on this site several of these fraud-traps. Boiling it down, NOBODY can interpret as a coherent document the 110,000 pages of turgid, incomprehensible, self-contradictory language that constitutes the Medicare regulations. And now, “nobody” officially includes Medicare itself.

This becomes apparent from a recent GAO report entitled “Improvements Needed in Provider Communications and Contracting Procedures.” The GAO report notes that the bulletins which Medicare carriers are required to send doctors periodically (to make sure they understand the regulations) are filled with dense, lengthy and poorly organized prose sufficient to make them unreadable. Even if they were readable, the GAO continues, these bulletins would do doctors little good since they routinely announce new regulatory policies well after the implementation date, when doctors will already have been guilty of violating such policies (and thus committing fraud). Finally, the GAO finds that when confused doctors contact the Medicare call centers for clarification on the regulations, they get the correct answer only 15% of the time. (Heck, even the IRS does substantially better than that.) And the Medicare websites, required under the regulations to clarify everything for the providers, universally lack “logical organization and navigational tools,” and as a consequence are nearly unusable.

So even when a doctor prospectively asks for instruction on how to comply with Medicare regulations (so as to avoid committing healthcare fraud and incurring huge fines and jail time) nobody is able to give him/her a straight answer. For, while it’s easy to look at a provider’s actions retrospectively (as the RACs are doing), and find something in the dense regulations that makes those actions imperfect, it’s not so easy to tell providers ahead of time how to navigate those regulations in pristine fashion. As the GAO report reveals, nobody knows how to do that.

This state of affairs is simply part of the covert rationing paradigm, of course. When your goal is to scare doctors into avoiding sticking their necks out for their patients, why would you want to give them a safe harbor for their actions?

So whoever you are, here’s a hot tip. Stop what you’re doing, find out which companies are doing these RAC audits, and buy their stock. These companies have a license to print money.

But DrRich is not here just to tell you what you already know. There’s a twist to this story you ought to take into account as you make your investments. Every time there’s an ostensibly cooperative effort between Gekkonians (in this case, the contractors doing the RAC audits) and Wonkonians (Medicare), there’s a back story that reflects the actual battle to the death in which these groups are engaged.

The RACs see the vast herds of providers (violators one and all) placidly grazing all across the fruited plains, just waiting to be harvested. Indeed, their chief problem will not be finding as much fraud and abuse as they want, but instead will be pacing themselves. If they harvest the herd with the enthusiasm of the Gekkonian buffalo hunters of the 1870s, then like those buffalo hunters, within a few years they’ll be out of business. On the other hand, killing off all the buffalo is just what the Wonkonians want them to do. Like their Wonkonian forebears of the 1870s, their real motive is to place the groups who depend on the buffalo for their survival in a state of penury, to break their independent spirit, to make them entirely dependent on the government, and at last bring them slouching onto the reservation. Once Wonkonians drive enough providers from the field, the beleaguered American patient and their remaining doctors will have no choice but to turn to the government for their healthcare. (A winning strategy here will obviously require the Wonkonians to vanquish all the private insurers before they cause all the doctors to leave medical practice, a strategy not without substantial risk. They will need to find ways of making it “inadvisable” for doctors to leave medical practice altogether; DrRich is confident they’ll be able to manage this aspect of the problem.)

In any case, if you do buy stock in the RAC companies, be sure to sell before the inevitable collapse.

Posted in Wonkonian Rationing, General Rationing Issues | 1 Comment »

Why Health Insurers Will Support Hillary Clinton

February 4th, 2008 by DrRich

As Hillary Clinton’s plans for American healthcare resolve into sharper relief, it is becoming clear that her plans dovetail quite nicely with the increasingly desperate needs of the health insurance industry. And, in contrast to 1993 (when the insurance industry initially supported her reforms, until getting a look at the monstrous volume of regulations she and her secretive committee finally produced, at which time they turned against her with extreme prejudice and a massive advertising campaign), this time Ms. Clinton can rely on the insurers’ steadfast - well, at least silence, if not outright support.

The difference? In 1993-94 the insurance industry had options. As insurers looked out across the healthcare landscape in that golden era, they perceived only opportunity as far as the eye could see. But then they spent the next 15 years clear-cutting that rich landscape. Today when it lifts its eyes from devouring its latest kill (prizes that now require the greatest of exertions), the insurance industry can see only growing desolation. Ahead lie lean times, if not oblivion.

It takes merely a quick look at how the health insurance industry has made all its money since 1994 to reveal just how barren its current prospects have become. This topic is treated in detail here, but to summarize, the insurance industry has made its billions in three ways:

1) Acquiring and privatizing community assets - generally non-profit hospitals and non-profit insurers - for a tiny fraction of their true value (through the collusion and/or ignorance of boards of trustees, state attorneys general, and state insurance commissioners), then letting the market assign the actual value of those assets to the company’s stock price.
2) Mergers and acquisitions of smaller insurers, i.e., through the consolidation of the industry.
3) Taking advantage of certain opportunities for “efficiency” that its quasi-monopoly has brought it, such as cherrypicking patients, handcuffing doctors, retrospectively denying coverage to insured individuals, and the manifold other activities we can safely bundle under the rubric, “covert rationing.”

All three pathways to profit are nearly gone. There are few community-owned assets left to acquire, and consolidation has already left the U.S. with just a handful of important health insurance carriers. As for the “efficiencies,” opportunities here are drying up as well. For instance, in December, shareholders of UnitedHealth Group (concerned because subscribers to the company’s insurance products had decreased by 315,000 in 2007) demanded and received a promise from company executives that the insurer would become “nicer” to its subscribers. (This, obviously, is a sign that insurers’ efforts at covert rationing - which simply means rationing by whatever means you can get away with - is reaching its effective limits. When your own shareholders force you to back off, you’ve gone too far.)

Now that its three pathways to profit are rapidly closing, the insurance industry is at last faced with a truly frightening prospect - having to figure out how to make a profit (much less continue to grow, as shareholders commonly expect and demand) by actually managing the healthcare of sick people. Since they have absolutely no clue as to how to accomplish this feat, the insurers find themselves staring into the void.

And this is where Hillary Clinton comes in.

Each year more individuals and employers are being priced out of the health insurance market, so health insurers are already severely growth-challenged when it comes to their classic source of premiums-based income. Already, tapping into federal health insurance funds has become the chief and most reliable source of growth for health insurance companies. To say it another way, private health insurance companies are now relying on federal programs as their only viable source of future growth.

So right off the bat, Republicans are a non-starter for insurance company executives who are looking for a presidential candidate to support. Republican candidates would have us rely on the efficiencies of the marketplace and the ingenuity of American companies to solve the healthcare mess. Perhaps this is true for some species of entrepreneurs, but not so with health insurance executives. While the insurance industry was able to support such free-market solutions as recently as 1994, today they have completely shot their wad, and are now entirely bereft of serviceable ideas. Indeed, their only serviceable idea is to do what they’re already doing to the fullest extent they can - to go on the public dole.

Either of the remaining Democratic presidential candidates would suffice, but of the two, Ms. Clinton clearly offers the better deal. She, like Mr. Obama, wishes to insure the 47 million currently uninsured Americans, and is willing to subsidize premiums for private insurance for at least a proportion of those individuals. That, obviously, is good for insurance companies. But unlike Mr. Obama, Ms. Clinton would go further in making the purchase of such insurance mandatory. And better yet, it appears she’s willing to at least consider forcibly deducting your health insurance premiums from your wages (which, really, is no different from forcibly deducting income tax, Social Security or Medicare payments from your wages - so no big deal).

So with a Clinton victory, the health insurance industry stands to reap one last windfall for their efforts, after which they will go quietly into the long night. It will be a graceful exit, and a delayed one - far, far better than what the Republicans offer (a frenetic spinning of wheels followed by catastrophic collapse.)

To an American health insurance executive, Ms. Clinton’s offer is as good as it can possibly get, given that it’s 2008 and things are as they are. If she is the least bit worried about encountering Harry and Louise again as she advances her plan for healthcare reform (or rather, Jason and Tiffany, as they’d have to be named today), Ms. Clinton can relax.

Posted in General Rationing Issues | 2 Comments »

Sudden Death Is Still the Healthcare System’s Friend

January 3rd, 2008 by DrRich

In an article published in the January 3 issue of the New England Journal of Medicine, researchers report that hospitalized patients who have cardiac arrest (sudden loss of cardiac function due to the onset of a heart arrhythmia known as ventricular fibrillation) are often not receiving defibrillation (an electrical shock delivered to the chest) within the recommended 2-minute window of opportunity. Further, patients whose defibrillation is delayed beyond the 2-minute window have a substantially reduced chance of surviving the cardiac arrest. The researchers recommend that hospitals take steps to administer defibrillation more quickly to patients with cardiac arrest, in order to improve patient outcomes.

An accompanying editorial (written by Dr. Leslie Saxon, an old friend of DrRich) points out that in public areas where Automatic External Defibrillators (AEDs) are available, such as casinos, the odds of surviving a cardiac arrest is over 50%. In contrast, the odds of surviving cardiac arrest in a hospital, according to this new study, is only 34%.

Dr. Saxon goes on to suggest that hospitals ought to employ readily available technology (technology ubiquitously found in AEDs and implantable defibrillators) to improve their survival statistics - presumably, to nearly the levels achieved in casinos and shopping malls.

DrRich finds this study enlightening, and the recommendations made by Dr. Saxon admirable.

But, unfortunately, there is a big and fundamental difference between the business interests of hospitals, and those of other institutions in which cardiac arrest is relatively likely to occur (i.e., institutions that tend to attract persons of a certain age and body habitus, who are likely to enjoy sedentary forms of excitement, and who do not particularly mind tobacco smoke).

Which is to say that in a casino, saving the life of a customer is good for business. Aside from the favorable publicity you might get on a slow news day, the saved person and his/her family and friends are likely to think favorably of your establishment for years (and scores of Social Security checks) to come.

The healthcare system, on the other hand, thinks differently about people who are prone to cardiac arrest. These are typically individuals with chronic and expensive medical problems - most often they have coronary artery disease, diabetes, or heart failure - and (as DrRich has pointed out before) their sudden death today will save the system countless dollars tomorrow. While nobody ever talks about this, one simply needs to look at behaviors to see the truth of it.

Hospitals ought to be embarrassed by these latest statistics. But, DrRich suspects, their principle reaction more likely will be one of concern, a concern that will take this form: Will this new study generate the kind of publicity that might force us to actually do some of what Dr. Saxon suggests?

We can expect hospital administrators to lie low and watch the media. If this study creates a ripple, expect a few press releases here and there about how they’re studying various process improvements, coupled with mild disclaimers about how sick these patients really are, being hospitalized and all, so one musn’t expect miracles.

In the meantime, if you’re one of the millions of Americans who are at increased risk for cardiac arrest, then unless you’re also one of the fortunate few whose doctors see fit to offer you an implantable defibrillator, you’re probably better off spending as much time as you can in front of the slot machines than in your local healthcare institution.

References:
Chan PS, Krumholz HM, Nichol G, et al. Delayed time to defibrillation after in-hospital cardiac arrest. N Engl J Med 2008; 358:9-17.
Saxon, LA. Survival after Tachyarrhythmic Arrest — What Are We Waiting For? N Engl J Med 2008; 358:77-79.

Posted in General Rationing Issues | 7 Comments »

The Practical Aspects of Fighting Confidentiality Clauses

November 19th, 2007 by DrRich

Last week, Roy M. Poses of Health Care Renewal asked the question: Why do physicians habitually sign contracts with health insurance companies, often without even reading them, when they know or suspect those contracts to contain language placing them or their patients at a disadvantage?

His question was prompted by a recent article in the LA Times documenting how Blue Cross of California had placed “confidentiality language” into contracts with physicians (and hospitals) that prevented them from publicly discussing fee negotiations, or even consulting with their attorneys for purposes of contract negotiation. According to the LA Times,

If they refuse to go along with the rules Blue Cross lays down for the negotiations, the providers say, the health plan threatens to stop sending them patients.

To his credit Dr. Poses is scandalized by such coercion. But to his greater credit he is even more nonplussed by the fact that physicians would cave in so readily to it:

I have personally witnessed several other anecdotes in which seemingly smart, dedicated physicians were willing to sign complex contracts which they clearly did not understand, usually with the excuse that “we would not be given this contract to sign if it were not in our best interest.” The contracts were long, written in complex legalese, and contained numerous questionable provisions, including provisions about confidentiality…

What is going on here? Were the physicians so conditioned by their prior hierarchical, ascetic training…that they really believed no one would ever give them a contract to sign that was not in their and their patients’ best interests? Were they too busy and tired to put in the effort to read the contract? Were they embarrassed to admit they did not understand it? Were they too conflict averse to contemplate refusing to sign the contract until they understood it and found it satisfactory?

He offers advice to these misguided physicians: don’t sign a contract until you really understand what’s in it, and you are confident that the contract is good for you and your patients. These doctors, he assumes, have just forgotten a fundamental business rule, and a pointed reminder will take care of it.

DrRich, being apparently (and sadly) more cynical than Dr. Poses, has another explanation.

When a health insurance company has gained complete control over a doctor’s access to patients, that company has also gained complete control over the doctor’s viability as a practitioner. From that moment, the doctor must do whatever he/she must to keep the insurance company satisfied. Under this sort of “business” arrangement, the concept of a “contract” takes on a whole new color.

When an insurance company (the party with absolute control) hands the doctor (the party subject to absolute control) a contract, they’re not offering a document that is subject to bilateral negotiation, with the idea of reaching an agreement that optimizes the the needs of both parties. No. They’re setting forth a list of infallible rules that are to be obeyed, rules no more subject to negotiation by individual doctors than the IRS regulations by individual taxpayers, or a Papal Bull by a humble nun. The doctor’s signature to that document is a mere kiss of the ring, a recognition of authority. To do otherwise than sign is to be excommunicated.

Faced with this reality, it is not surprising that doctors would sign insurance contracts without reading them, offering excuses like: “I’m too busy and important to waste my time with this tangled legalese,” or, “Since I’m a doctor and therefore pure in spirit, there’s nothing in here that can possibly be against my or my patients’ interests,” or even, “There are probably clauses in here that would give me an ulcer, but since I have to sign anyway I’d rather not find out about them.”

So while Dr. Poses’ advice to physicians is both wise and correct, DrRich suspects it will be received with the same sense of incredulousness that might have been expressed by Galileo if, at the time he was about to sign the forced recantation of his heliocentric ideas, a helpful bystander had tried to stop him with the admonition, “Wait, Galileo! Check your math; I think you may have had it right all along!”

Sometimes - and wishing to maintain one’s medical practice is one of those times - normal prudence and wisdom are not an option.

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