QUALITY QUICKIE: Seniors on the wrong drugs–Medicare & doctors on the wrong incentive plan

Two amazing articles in the NY Times in recent days show that–as John Mattison from Kaiser told me in 1996–although we know what to do we don’t know how to do it. First off a study of a PBM’s database containing all prescriptions written in 1999 for 765,423 patients over 65 found that 21 percent of the patients had at least one drug on a list of drugs potentially dangerous for seniors, and that half those prescriptions were for drugs considered to have the potential for serious adverse effects. (Here’s the California Healthline link with more details).Then we come to Thursday’s NY Times article about the long-term failure of what appeared to be a successful disease management project in Washington state–again because the incentives were in the wrong place. I think that the way Medicare (and other insurers) set up their incentives is mostly to blame. But The Industry Veteran has a more familiar foe in his sights:

Now believe it or not, fixing this isn’t that hard. In the bad old days of HMOs–the early 1990s–Friendly Hills medical group and others in southern California would get all their senior patients into a brown bag lunch, tell them to bring all the pills they were on, and then pharmacists would basically go around the getting the patients off all the drugs they shouldn’t have been on at all or ones that counteracted each other. And this was prior to computerized pharmacy records! Why hasn’t this spread (other than Caremark/Medpartners buying and destroying Friendly Hills in the mid-1990s)? Well Medicare doesn’t reward that activity, but it does reward the multiple visits to doctors to get multiple scripts. And even though doctors know that this is both bad medicine and a safety risk, there’s been no national movement to do much about it.

The subdued, temperate mice in healthcare analysis (I think he means me!–Ed) consider me entirely too hostile because I refer to physicians as Mafiosi and whores, but here’s an article from Wednesday’s NY Times that should elicit temperate responses only from corpses and theocratic fascists. Written by Gina Kolata, a groupie for anything in a lab coat, the article discusses a pilot program, called a "shared care plan," that Medicare ran in Washington state among people with concomitant diabetes and CHF. The program has two components: greater access to medical records via IT and the use of non-physician, clinical care specialists.

To paraphrase the gist of the article, physicians, patients and their families have access to a patient’s computerized medical records. This allows patients to note changes in their reactions to medications. Every physician in the geographic area can access the updated medical records. Then the clinical care specialists serve as personal assistants to severely ill patients, going with them to doctors’ offices, being available by cellphone to answer questions, and teaching them to manage their diseases. The program has reduced doctor visits and medical complications. Patients with diabetes have lower glucose levels, those with congestive heart failure have remained stable instead of getting worse, and third-party payers such as Medicare save money. Therein lies the rub. Participating in the program costs each doctor in the group $500 a month over four years for the electronic medical record system while other innovations, such as group office visits and e-mailing with patients, receive poor reimbursement, if any. As a result, physicians say they will refuse to participate in the program after the pilot ends.

Hell, we don’t need John Kerry to replace George Bush, we need Harry Truman to draft these Mafiosi physicians into the Army. Then they’ll comply!

As you know as a subdued temperate mouse I’m a sucker for those nice doctors but on the other hand, doing demonstrably the wrong thing because it pays better doesn’t appear in in the version of the Hippocratic oath I remember. So this is a clear case where Congress needs to step up, and in a bi-partisan fashion institute both pay-for-performance for Medicare to get us away from the FFS treadmill and hold hearings to shame the AMA and the rest of the "Mafiosi" into doing the right thing, right away. It’s been long enough.

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