NEW @ THCB PRESS: Surviving Workplace Wellness. Spring 2014. Al Lewis and Vik Khanna. e-book edition. # INNOVATION: PCORI APP Challenge

OP-ED

flying cadeuciiCMS released new data, shrouded thus far in needless secrecy: how much it pays individual physicians.

Unlike the Shroud of Turin, no one will question its authenticity. But authenticity doesn’t guarantee the data won’t intrigue, confuse, anger, perplex, confound and burn a few innocents at the stakes. That is before we conclude that more research is needed, or more colloquially stated, we still don’t have a clue.

Medicare bounty hunters, the modern day witch finders, are licking their lips for their share of the looted spoils. Academic researchers will be dissecting both wings of the bell-shaped curve of variation in payment to set the next battle between good and evil. But all eyes (pun intended) are upon Florida; specifically one particular provider.

The provider, an ophthalmologist, (you can look up the name) billed CMS for $21 million.

CMS paid ophthalmologists $ 5.6 billion. That’s more than the GDP of Burundi. CMS paid over a billion dollars for treatment of macular degeneration with Lucentis (Genentech).

Take a deep breath now. The treatment of one organ in over 65 year old American citizens is equal to the GDP of one African nation. Gini would have turned beetroot with embarrassment.

Diabolical? Scandalous? Shocking? Surprising?

None of the above, actually. If you think about it.

As we age, and age we do thanks to our lives being constantly “saved” by prevention, regulation and cures, arteries harden, brain atrophies and bones thin. And eyesight falters. Lens fog. Macula degenerates, reducing central vision making it difficult to read.

As we age, we consume more medical services. Yes, take that as an economic truism. And no, I’m not applying for membership of the Death Panel.

Here’s the thing. It’s nice to be able to see when you’re 75. It’s also nice to see when 85, and damn essential when 90.

Otherwise you might trip over the walking stick, fracture the neck of the femur, develop a clot in the deep veins, then a clot in the pulmonary arteries, then a raging pneumonia in ICU, followed by septic shock and a cardiac arrest. Then perhaps you may rest in peace. But not before a few interns have fractured half a dozen ribs during a well-intentioned but hopelessly misguided cardiopulmonary resuscitation that family members lobbied for to assuage their guilt for never visiting you in your nursing home.

Continue reading “It’s Raining Cataracts, Hallelujah”

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A recent ProPublica expose co-published with the Boston Globe typifies a growing gotcha genre of health journalism that portrays doctors as the enemy in a struggle for honesty and openness in medicine.

These reports make unfounded leaps in their efforts to subject doctors to levels of skepticism once reserved for politicians and lawyers. They’re going to end up doing patients a disservice.

For this particular hunting expedition ProPublica set its sights on Dr. Yoav Golan, an infectious diseases specialist caring for patients at Tufts Medical Center in Boston who also works with pharmaceutical companies developing antibiotics.

But in its zeal to argue how physicians like Golan are corrupting medicine through their industry partnerships, ProPublica went to press without an iota of evidence Golan is corrupt.

A close look at Golan’s impressive career suggests quite the contrary and raises questions about ProPublica’s claim to objectivity.

Yoav Golan is a remarkably bad choice for anyone who hopes to use him as a poster boy of pharma-physician malfeasance.

As Tufts said in a statement in response to the ProPublica story, Golan enjoys international respect in the infectious diseases community and has assisted the development of “two important antibiotics, including the first antibiotic developed in the past 25 years to treat the growing threat of deadly C. difficile.”

(Disclosure: I held an academic appointment at Tufts for one year when I was practicing in Boston, but in another department and I never met Golan before this story.)

That antibiotic, fidaxomicin, is pricey, and you’d think an industry shill would liberally advise its use. Yet Golan and his team advised a Tufts committee setting internal standards for its use that the hospital should heavily restrict the drug. “We were very active in making sure it’s not used in pathways where it’s not cost effective,” Golan told me.

Continue reading “Going after the Wrong Doctors”

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The problem of pain, from the viewpoint of British novelist and theologian C. S. Lewis, is how to reconcile the reality of suffering with belief in a just and benevolent God.

The American physician’s problem with pain is less cosmic and more concrete. For physicians today in nearly every specialty, the problem of pain is how to treat it responsibly, stay on the good side of the Drug Enforcement Administration (DEA), and still score high marks in patient satisfaction surveys.

If a physician recommends conservative treatment measures for pain–such as ibuprofen and physical therapy–the patient may be unhappy with the treatment plan. If the physician prescribes controlled drugs too readily, he or she may come under fire for irresponsible prescription practices that addict patients to powerful pain medications such as Vicodin and OxyContin.

Consider this recent article in The New Republic:Drug Dealers Aren’t to Blame for the Heroin Boom. Doctors Are.” The writer, Graeme Wood, faults his dentist for prescribing hydrocodone to relieve pain after his wisdom tooth extraction.

As further evidence of her misdeeds, he says, first she “knocked me out with propofol–the same drug that killed Michael Jackson.” Wood uses his experience–which sounds as though it went smoothly, controlled his pain, and fixed his problem–to bolster his argument that doctors indiscriminately hand out pain medications and are entirely to blame for patient addiction.

But what happens to doctors who try not to prescribe narcotics for every complaint of pain, or antibiotics for every viral upper respiratory infection? They’re likely to run afoul of patient satisfaction surveys. Many hospitals and clinics now send a satisfaction questionnaire to every patient who sees a doctor, visits an emergency room, or is admitted to a hospital.

The results are often referred to as Press Ganey scores, named for the company that is the leading purveyor of patient satisfaction surveys. Today these scores wield alarming power over physician incentive pay, promotion, and contract renewal.

Now hospital payments are at risk too.

Continue reading “The Problem of Pain: When Best Medical Advice Doesn’t Equal Patient Satisfaction”

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Politics is about expectations.

The Obama administration blew the doors off Obamacare’s enrollment expectations this week and scored big political points.

But in doing so, they may have set Obamacare’s expectations going forward at a level that can only undermine their credibility and that of the new health law.

What happens when the real number––the number of people who actually completed their enrollment––comes in far below the seven million?

What happens when the hard data shows that most of these seven million were people who had coverage before?

What happens when it becomes clear that the Obamacare insurance exchanges are making hardly a dent in the number of those uninsured?

Yesterday, the Los Angeles Times reported that the non-profit Rand Corporation estimated that two-thirds of the first six million people to enroll in Obamacare were previously insured––only two million were previously uninsured.

If all of the one million people who signed up in the last week were previously uninsured, that would mean that only three million previously uninsured people have purchased coverage in the government-run exchanges.

Rand also estimated that about nine million people have enrolled directly with the insurance companies, bypassing the government-run exchanges. But Rand also reported that the vast majority of those were previously insured.

If 20% do not pay, as has been the case since Obamacare launched, then the real Obamacare exchange enrollment number is about 5.7 million.

Continue reading “7.1 Million. Will the Obama Administration Regret Today’s Announcement?”

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In December, I defended the term death panel.  Specifically, I demonstrated that we already have, and for over 50 years have had, quite a number of tribunals that act as death panels.

For example, at least daily, UNOS denies potentially life-saving organ transplant requests. While the term “death panel” has a pejorative connotation, the essential concept and function is necessary. Particularly in situations of strict scarcity, life and death decisions must be made. They are made. And they will continue to be made.

So, the relevant question is not whether to “have” death panels. Instead, the relevant question is whether we want to openly “acknowledge” our death panels. I am reminded of a famous scene from the 1992 film, A Few Good Men. You will recall that the story revolves around the court martial of two Marines charged with the murder of a fellow Marine. The defendants had administered a “Code Red,” an unofficial punishment, against a fellow member of their unit who was not sufficiently squared away to meet the Corps’ standards.

In the film’s most famous scene, Lt. Kaffee (Tom Cruise) cross examines Col. Jessup (Jack Nicholson) about the Code Red. Lt. Kaffee says, “I want the truth!” Jessup responds:

You can’t handle the truth! Son, we live in a world that has walls, and those walls have to be guarded by men with guns. . . . I have a greater responsibility than you can possibly fathom.

You weep for Santiago and you curse the Marines. You have that luxury. You have the luxury of not knowing what I know, that Santiago’s death, while tragic, probably saved lives. And my existence, while grotesque and incomprehensible to you, saves lives!

You don’t want the truth, because deep down in places you don’t talk about at parties, you want me on that wall.

Col. Jessup’s point is that Code Reds are an invaluable part of close infantry training. But since they are “grotesque,” they are officially discouraged (even prohibited).

Is this the path that we should take with death panels? Since we find them grotesque, should we deny both their necessity and their existence? The argument has been compellingly made. In their 1978 book, Tragic Choices, Guido Calabresi and Phillip Bobbitt argued that the difficult but necessary life-and-death choices entailed in rationing can only be made by hiding them from public scrutiny.

In contrast, others call for open acknowledgement of death panels. For example, in a recent interview with Rolling Stones, Bill Gates rightly observed that we must deny even effective and life-saving medical technology to some people. “The idea that there aren’t trade-offs is an outrageous thing. Most countries know that there are trade-offs, but here, we manage to have the notion that there aren’t any. So that’s unfortunate, to not have people think, ‘Hey, there are finite resources here.’”

Gates is right. Calabresi and Bobbitt are wrong. The disadvantages of a “hide and deny” approach are substantial. First, it makes it more difficult to have our death panels operate in an open and transparent manner. This increases the risk of bias and corruption. Second, it means that they may not operate according to sufficiently deliberated principles. Third, a hide and deny approach means that death panels may not operate in a consistent and uniform manner from region to region. In short, hiding and denying death panels forecloses and delays much needed public discourse over how we want out death panels to operate.

Death panels, while tragic, save lives. And their existence, while grotesque and incomprehensible to many, saves lives. We don’t want the truth, because deep down in places we don’t talk about at parties, we want death panels.

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As a physician, I know the challenge of helping patients determine which health care options might work best for them given their personal situation and preferences.

Too often they — and their clinicians — must make choices about preventing, diagnosing and treating diseases and health conditions without adequate information. The Patient-Centered Outcomes Research Institute (PCORI) was created to help solve this problem — to help patients and those who care for them make better-informed health decisions.

Established by Congress through the Patient Protection and Affordable Care Act as an independent research institute, PCORI is designed to answer real-world questions about what works best for patients based on their particular circumstances and concerns. We do this primarily by funding comparative clinical effectiveness research (CER), studies that compare multiple care options.

But more research by itself won’t improve clinical decision-making. Patients and those who care for them must be able to easily find relevant evidence they can trust. That’s why our mandate is not just to fund high-quality CER and evidence synthesis but to share the results in ways that are meaningful to patients, clinicians and others.

We’re also charged with improving the methods used in conducting those studies and enhancing our nation’s capacity to do such research.

We will be evaluated ultimately on whether the research we fund can change clinical practice and help reduce the variations and disparities that stand between patients and better outcomes. We’re confident that the work we’re funding brings us and the audiences we serve closer to that goal.

Recently, some questions have been raised in health policy circles about our holistic approach to PCORI’s work. That view holds that direct comparisons of health care options — especially those involving high-priced interventions — should be the dominant if not sole focus of PCORI’s research funding approach as a path to limiting the use of expensive, less-effective options.

We agree that discovering new knowledge on how therapies compare with one another is a critical mandate of PCORI and is essential to improving the quality and effectiveness of care.  However, ensuring that patients and those who care for them have timely access to and can use this knowledge, so that they can effectively apply it to improve their decisions, is also very important.

Continue reading “How PCORI’s Research Will Answer the Real World Questions Patients Are Asking”

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Robert McNutt and Nortin  Hadler respond to med student Karan Chhabra’s  original post,  ”Actually, High Tech Imaging Can Be High Value Medicine” and the resulting discussion thread.

Thank you for your comments. First, we are happy you are so interested in medical practice and how to do it better. Please do not think for one second that our comments are critical of you.

However, since you persist in thinking that money matters, that you have the right to think that way during your care of a patient, and that economic principles help patients, let’s look again at this issue you have raised.

Nearly 20 years ago, Hadler published his first “Four Laws of Therapeutic Dynamics” (JOEM 1997; 39:295-8):

1) .    The Death Rate is One per Person

2) .    Never Poke a Skunk

3) .   There has Never been a Quack without a Theory

4) .   Institutions Die; People Live

Now we present, for the first time ever, the econometric corollaries, the McNutt-Hadler Credo for Value-laden Medical Decision Making:

1) Don’t think of money; think of what the money buys. No patient should be offered a pig-in-a-poke.

2) Don’t think for one moment that medical pricing is rational, let alone market driven. Medical pricing is designed to serve the greed of stakeholders, greed that seems to know no ethical boundaries. Caveat emptor is no match for “common practice” The only way the “consumer” stands a chance is if there are physicians committed to explaining the basis for clinical decisions in an unbiased, transparent, and ethical fashion.

3) If it doesn’t benefit the patient, we don’t care if they give it away – don’t prescribe or order it. (For example, no stable in-patient should have any of the following tests: amylase or lipase; any test for iron deficiency other than the ferritin; CRP, BNP, MRI after a CT of the head, or any chronic care medicine like a statin, iron tablet, heart healthy diet in a cancer patient, vitamin, a blood pressure medicine that costs more than the cheapest alternative, a non-generic medicine that is available in generic form, enteric coated aspirin, or bone scans in women looking for osteoporosis)

Continue reading “McNutt-Hadler Credo for Value-Laden Medical Decision Making”

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The 18-34 year old segment of our population is large, growing and important in our society. They are 80 million strong. Their attitudes, beliefs, values and actions are re-shaping the way every organization, business and institution thinks about its future.

According to a Pew Research report released last week, Millennials are independents and skeptics: 50% have no political affiliation, 29% no religious affiliation, and 19% say they do not trust established institutions to do the right things (versus 40% for Baby Boomers).

Millennials worry about money. A study by the Investor Education Foundation of the Financial Industry Regulatory Authority concluded that their concerns about their auto, credit card and school debt trump other issues.

Most think economic stability should come before marriage and family life. Half who went to college have a student loan to repay, and one third moved into the homes of their parents at some point to make ends meet.

And they worry about the future. Paul Taylor’s The Next America: Boomers, Millennials, and the Looming Generational Showdown predicts economic battle between Millennials and Baby Boomers:

“Every family, on some level, is a barter between the generations…If I care for you when you’re young so you’ll care for me when I’m old…But many Millennials won’t be able to afford that…The young today are paying taxes to support a level of benefits for the old that they themselves have no prospect of receiving when they become old.”

Pew survey data supports his contention:

  • 51% of Millennials do not think there will be any money for them in the Social Security system by the time they retire.
  • 39% believe they’ll get reduced benefits

So what do Millennials want from the health system? Their view is likely to disrupt how industry leaders operate their businesses and how policymakers make laws that govern its commerce.

Continue reading “What Do Millennials Want from the Healthcare System?”

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Last week, a study in the New England Journal of Medicine called into question the effectiveness of surgical checklists for preventing harm.

Atul Gawande—one of the original researchers demonstrating the effectiveness of such checklists and author of a book on the subject—quickly wrote a rebuttal on the The Incidental Economist.

He writes, “I wish the Ontario study were better,” and I join him in that assessment, but want to take it a step further.

Gawande first criticizes the study for being underpowered. I had a hard time swallowing this argument given they looked at over 200,000 cases from 100 hospitals. I had to do the math. A quick calculation shows that given the rates of death in their sample, they only had about 40% power [1].

Then I became curious about Gawande’s original study. They achieved better than 80% power with just over 7,500 cases. How is this possible?!?

The most important thing I keep in mind when I think about statistical significance—other than the importance of clinical significance [2]—is that not only does it depend on the sample size, but also the baseline prevalence and the magnitude of the difference you are looking for. In Gawande’s original study, the baseline prevalence of death was 1.5%.

This is substantially higher than the 0.7% in the Ontario study. When your baseline prevalence approaches the extremes (i.e.—0% or 50%) you have to pump up the sample size to achieve statistical significance.

So, Gawande’s study achieved adequate power because their baseline rate was higher and the difference they found was bigger. The Ontario study would have needed a little over twice as many cases to achieve 80% power.

This raises an important question: why didn’t the Ontario study look at more cases?

Continue reading “Why Bad Research Makes It into Good Medical Journals”

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I was reading a medical home advocacy group’s upbeat approach to a recent JAMA study that had found scant benefit in the concept when, suddenly, we tumbled into Alice in Wonderland territory.

The press release from the leadership of the Patient-Centered Primary Care Collaborative (PCPCC) started out reasonably enough. The three-year study of medical practices had concluded that the patient-centered medical home (PCMH) contributed little to better quality of care, lower cost and reduced utilization. This was an “important contribution,” said the PCPCC, because it showed “refinement” of the concept that was still necessary.

That was just the set up, though, to this challenge from Marci Nielsen, chief executive officer of the group. “It is fair,” said Nielsen, “to question whether these pilot practices (studied) had yet transformed to be true medical homes.”

Where might one find these true medical homes? The answer turns out to be as elusive as a white rabbit. Formal recognition as a medical home via accreditation “can help serve as an important roadmap for practices to transform.” However, accreditation as a PCMH “is not necessarily synonymous with being one.” Conversely, you can be a “true PCMH” without having received any recognition at all!

But maybe the true medical home does not yet exist, since, “the evidence base” for the model “is still being developed.”

In Through the Looking Glass, Humpty Dumpty scornfully informs Alice: “When I use a word, it means just what I choose it to mean – neither more nor less.” And so we learn that a true medical home means just what the PCPCC says it does.

It’s confusing. If the truly transformational medical home lies in the future, why does the PCPCC chide the JAMA researchers in this “otherwise well-conducted study” for failing to “reference the recent PCPCC annual report which analyzed 13 peer-reviewed and 7 industry studies and found cost savings and utilization reductions in over 60 percent of the evaluations”?

Continue reading “The Medical Home’s Humpty Dumpty Defense”

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MASTHEAD


Matthew Holt
Founder & Publisher

John Irvine
Executive Editor

Jonathan Halvorson
Editor

Alex Epstein
Director of Digital Media

Munia Mitra, MD
Chief Medical Officer

Vikram Khanna
Editor-At-Large, Wellness

Maithri Vangala
Associate Editor

Michael Millenson
Contributing Editor










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