POLICY: Hmmm….Docs are always docs

So Krugman writes about Cleaning Up the Health Care Mess and the NY Times publishes a bunch of  letters. Krugman basically said that we’d eventually need some kind of government-regulated health care system, and that limits would have to be put on what’s done. Despite the fact that the crisis in our health care system is to the point that even General Motors has noticed and wants out, 5 out of 7 letters are from doctors, and almost all of them are going on and on about government interfering with patients choice, their autonomy, etc, etc, etc.

Perhaps we are just back in 1936 after all. But isn’t it about time the collective physicians of America moved on and realized that they’d better start positioning for a world in which they have to cut a better deal?

Otherwise they’ll be moaning about how it all went wrong when they took on the hospitals, as does this guy. Unlucky for him that he bought at the top, and not on the way up like his colleague in North Dakota.

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  1. Dr. Coulter’s statements are interesting. Yes, of course, long-term abstinence requires short-term abstinence, but Naltrexone has not been demonstrated to be “highly effective” at reducing relapse, nor has it been demonstrated to be useful in ongoing treatment of alcoholism. The major studies in the field have had inclusion errors in which they failed to study alcoholics (rather, they studied alcoholics who had been drinking heavily — not the usual group one would see in an outpatient setting). They had outcome measure design flaws by not looking for abstinence; some looked at days before return to HEAVY drinking, while others looked at a new parameter called “cumulative abstinence rate.” They used insufficient durations for lifelong disease issues. In my opinion, speaking as a board-certified addiction psychiatrist, naltrexone has not yet been demonstrated as being useful. I’ll wait for the new, improved, research.

  2. Stuart Gitlow writes about Naltrexone:
    “This drug [Naltrexone] was recently approved for use for alcohol dependence. But a close review of the literature indicates that while naltrexone leads to short-term abstinence, there is no evidence that either naltrexone or short-term abstinence lead to recovery from the illness or long term sobriety. In fact, the drug has essentially no place in the treatment of alcoholism…”
    This is bizarre. Long-term abstinence requires first achieving short-term abstinence. Naltrexone has consistently been demonstrated to be an extremely safe and highly effective treatment in reducing relapse to active alcoholism. Unique among available treatments, those who do relapse on Naltrexone consume half the quantity of alcohol of those not prescribed the medication.
    Naltrexone has been shown in a recent JAMA study to be suitable for use in primary care physician office settings. For the first time, a treatment for alcoholism is now available that can be used in the same manner as treatments for thousands of other diseases: in the local office of the patient’s primary care physician. This is a milestone development in the treatment of addictions.
    Naltrexone is an extremely effective, safe, convenient, and well-tolerated treatment for alcoholism. It is appropriate to be tried in the care of most active alcoholics. Much can be gained, and little risked, by the use of this medication.
    Best wishes,
    Steve Coulter, MD

  3. Tom, your comments make a number of assumptions, the most important of which is that guidelines are developed by what we’re both calling the Best in the Field. I think we’d both agree that the Best in the Field is the doctor who has the greatest success in reducing morbidity and mortality for a given disease. There are obviously other factors, but that’s the most important one. When I think of the doctors to whom I refer my patients with given illnesses, the docs that we docs think of as best in a given field, they’re not the docs developing guidelines. They’re not the academics, who are always aware of the latest literature. They’re not the managed care leaders, who are always aware of cost containment issues. They’re not the state medical consultant, who understands the political ramifications of various approaches. The docs that are inevitably the best are the full-time clinicians who are seeing every possible variant of the disease in question. They’re probably on voluntary faculty so that they also see the inpatient variety of the illness at a tertiary care facility, and they’re up on the literature but have no bias or investment in any particular outcome.
    The folks writing the guidelines aren’t those docs. The folks writing the guidelines have MANY significant interests beyond that of simply reducing morbidity/mortality, interests which are important to our society but which may not be as important to the individual patient. For instance, for society I think the cost of healthcare is very high; I might try to reduce it. On the other hand, if my mother is ill, I don’t care what the costs are; I’ll make sure she gets the best care possible.
    Your point about choosing a doctor at random is well-taken. If you are choosing randomly, then you probably will get better care if your chosen doc follows guidelines. On the other hand, I would hope you’re saying that for effect and not really buying medical care that way. There are many ways of locating the physician in a given field with the best reputation in an area, but the simplest is to ask your family physician (whom you’ve chosen randomly, perhaps) who the best is for the disease in question. If he or she really doesn’t know, then you immediately know you need to find another doc. I might tolerate having an “average” housepainter, but I wouldn’t tolerate having an “average” doctor any more than I would tolerate having an “average” auto mechanic.
    As you say, an average doc gets a little better in terms of outcomes by following the guidelines. If it were me or my family, though, I’d stay far away from any doc who really does get better outcomes by following the guidelines.

  4. > Who would you want as your MD? Someone who
    > follows the guidelines? Or someone who questions
    > everything and would follow a guideline only once
    > he or she is convinced of its value?
    Dr. Gitlow hinted at this, but I myself have some (possibly misplaced) trust that the process of vetting guidelines produces diagnosis and treatment plans on average better than a randomly-chosen physician will come up with on his own. So, if I must choose a doctor at random (and basically I must because useful information about doctors is well-nigh impossible to come by even for the relatively well-informed) then I think I prefer a doctor who follows guidelines. If a doctor wants to deviate from an established, well-accepted guideline, I want to have him articulate his reasoning very clearly to me; convince me (and perhaps another doctor) the guideline is inappropriate at least in my case, and that he has a better idea.
    I do recognize that there are huge swaths of medicine for which there are no firmly established guidelines, and that therefore the training and good judgement of physicians is absolutely indespensible. We all do (I think). I even like it when a doctor comiserates with me a little, although I do not insist on it (Dr. Clark). I myself have a condition for which there is no “standard treatment” and have relied on two doctors to help find a treatment. Even so, I do not think it denigrates in any way the good judgment of physicians, even (or especially) the Best in Their Fields, to insist they follow guidelines when appropriate, improve them when they’re deficient, and develop them where they’re absent for use by other physicians and allied providers. I think it appeals to the highest and the best physicians (and scientists) have to offer.
    > Standardization gets rid of [the best treatments]
    How?! The Best in the Field will be following guidelines quite closely for the 85% of cases (or whatever) for which the guidelines are appropriate, and will achieve excellent outcomes (risk adjusted, of course) for the remainder. After all, the guidelines were developed by the Best in the Field in the first place.
    The Best in the Field will be able to identify the case for which the guideline is not appropriate, and document the fact of the inappropriateness. And even the mediocre ought to be able to do so, and then send the unusual patient to one of the Best in the Field.
    Have I missed something?

  5. A number of comments have been made concerning standardization. The basis of medical training, and really what differentiates it from training for PA’s, nurses, and other allied healthcare professionals, is the education in basic sciences that we receive such that we’re able to theorize and speculate with intelligence rather than guesswork. That’s why physicians do not follow protocols, guidelines, or other similar processes very well. If a patient comes to my office suffering from an illness, I may use my knowledge of the patient, the literature, the pharmacology, and the epidemiology of the illness to select the treatment. Why, you ask, you I think I’m better than the standardized guidelines based upon studies of hundreds of people? Easy answer, but requires some explanation.
    First, the standard guidelines are based upon population statistics. Population statistics, while they are wonderful for determining broad-scale outcome data, or an overall recommendation of which treatment is likely to work a majority of the time, are awful for determining the best approach for each individual case encountered. Each case has many more variables than have ever been considered within such population studies. And my knowledge as a physician is good enough, thanks to long years of training, to make a decision based on ALL the information, not just upon a standardized guideline that a dog could follow.
    Second, and just as important, is that the quality of much research of late is questionable. For example, let’s look at the recommendation that Naltrexone be given to alcohol dependent individuals. This drug was recently approved for use for alcohol dependence. But a close review of the literature indicates that while naltrexone leads to short-term abstinence, there is no evidence that either naltrexone or short-term abstinence lead to recovery from the illness or long term sobriety. In fact, the drug has essentially no place in the treatment of alcoholism (my opinion, but this is also my area of expertise). Is naltrexone on standard treatment guidelines now? In fact, it is on some. Should it be? That’s where I come in as a physician, to make the determination as to whether I agree, whether I believe, and whether I will subject my patient to something that others have said is the right thing.
    Who would you want as your MD? Someone who follows the guidelines? Or someone who questions everything and would follow a guideline only once he or she is convinced of its value? I suppose that depends, because some doctors won’t follow a guideline because of foolishness or lack of knowledge, and some won’t follow it because they’re the best in the field. Standardization gets rid of both. And I’m not willing to accept that. I don’t believe we should get rid of the BEST health care in order to also get rid of the worst.

  6. > I often wonder what the boards of trustees
    > are doing to maintain the interests of the
    > community.
    Unfortunately, not enough, IMNSHO. This should be another thread, but I’ll tell two little stories here, and maybe Matthew or somebody else will look for POLICY/GOVERNANCE articles to blog. I would like to further explore this aspect of the industry.
    I was fortunate to speak with the COO of the SSM Health System, Bill Schoenhard, about a month ago after a talk he gave on SSM’s pursuit of the Baldridge Award. He said that just recently he was wandering around in one of his hospitals and he heard a couple of nurses(?) using some of the language of Quality Improvement in a discussion they were having about solving quite a local (to them) sort of problem. He was gratified that the line-level folks were beginning to use this kind of language and thought process.
    “Beginning to Use”. Sister Mary Jean Ryan brought CQI into SSM about 20 years ago. Mr. Schoenhard has been in his post as COO for that long too. After 20 years, the cultural transformation is “beginning” to make it to the line level. This is what we chatted about a little bit. How many health systems or hospitals have such a stable executive leadership? Or even boards? Isn’t the average tenure of a hospital president about three years? How likely is it for the SSM experience to make it in other hospitals or health systems? Two decades of sustained, single-minded effort is evidently what it takes BEGIN to effect real change.
    This sort of direction MUST come from the boards of the hospitals or health systems. It is the only way. This means the board members must be quite actively involved: it will not do to have the board member be the local bank or factory president: he doesn’t have time to do two jobs. Which brings me to my next point.
    The local business leadership in a community seem to have a conflict of interest with respect to the community hospitals. In their day-jobs, they have a duty to minimize healthcare expense. But they’re often (usually?) on the board of the local healthcare organization. This would seem to lead the boards to a state where they want the local hospital to succeed “enough” to keep the doors open, but that’s all.
    This is not good for what is often the largest employer in a county. “Be a nurse or health system manager and guarantee yourself a job that pays as poorly as the local factory owner can make it pay. Your performance will not matter.” It is not good for those of us in cities either. Ultimately it is not good for patients or doctors or managers. Regression to the mean, and all that…

  7. It is difficult to sympathize with the cardiologist about his speciality hospital. They do tend to aggravate the problems. But, it is not all about money. Everyone likes their own space when they can get it and security, or the perception of it, is such a comfort.
    Now that they have CEO’s, hospitals have become imperialistic and want to control everything in sight. I often wonder what the boards of trustees are doing to maintain the interests of the community. Just a thought.

  8. I don’t think I will leave medicine. You never know. I have been doing it for 8 years and, although I make a comfortable living, it is LESS then what I made 8 years ago. The cost of living is climbing and so my relative value is falling and that just does not feel good, when you continue to work just as hard if not harder.
    I think it is also important for everyone to realize that there is a huge disparity between what some doctors are making and what those of us in primary care are making. The average dermatologist might make $250K and work 9 to 5 without after hours call. Whereas the family docs I know work much longer hours, come in in the middle of the night and average $130K. That dermatologist removes a simple mole in the office and gets $300 for it. I do the exact same procedure and get $80 for it.
    EBM, metrics, IT…again, I am all for it. In fact, I was the first in my community to purchase an EMR. But we have to find a way to control costs and as long as big government and insurance company CEOs making 9-figure incomes are a part of the health-care equation, the little guys (me and my patient’t employers) are getting squeezed. Trim some of the beauracratic fat off of the healthcare ham and we can share in the savings and better afford to optimize the IT part of our business.

  9. Well, Dr. Hinson, I hope it does not come to leaving primary care or medicine altogether for you. And yes, the benefits of EBM, metrics, IT, and the rest flow 90% to patients, and maybe 10% doctors. This is a problem: we want big organization capabilities from a small organization industry, and the transition is going to be very painful.

  10. Elliot, Dr. Gitlow is not saying that he is smarter then you. You seem to have some insecurities about MD’s thinking they’re smarter then you. I am not smarter then a lot of my friends, but I am smarter then the average Joe. And I did dedicate myself to make it through medical training to do what I do because this is what I want to do. Would I want to do this if it lead to me making less then my plumber? Guess what, he already makes more then me and his income is actually climbing year to year! Would I want to do this if it lead to me making less then a 9-to-5 insurance salesman? No. Why would I continue busting myself, sacrificing my own health and time with my family, in this emotionally draining 80-hour a week job (primary care), for less then I am worth? I would go and sell insurance or find some other job.
    I do not mind evidence-based standardizations in medical care, and I do not mind the information technology that will have to go with such standardization. But we will be the group that benefits least from it. Patients will benefit (at least until they cannot get a test they think they ought to have). The organizations that pay for medical care will benefit. But I won’t. So, if you’re going to screw me with more and more regulations, at least buy me dinner first!

  11. > “Cancer care as individualized as you”
    If I thought that a randomly-chosen oncologist knew enough about molecular biology to tailor a treatment “just for me” in time to do me any good, I might be moved by something like this. As it is, this is only a marketing slogan, and means about as much as any other marketing slogan.

  12. No, the public appropriately does not accept “standardization of medicine” in the way it is too often conceptualized. For those driven by “consumer focused” care, a billboard in my community advertising a local hospital is worth contemplating – a row of bright flowers with the line “Cancer care as individualized as you”.

  13. With all due respect to Drs. Gitlow and Clark, the idea that medicine should not be standardized is one of things standing in the way of higher quality, lower cost medicine. I would have thought that if there was any evidence that foreign doctors or physician stand-ins had worse outcomes, then someone would be trumpetting it to the heavens. Perhaps I have missed the studies; any pointers? The practice of medicine in this country is so much more costly because of variability of care (see Dartmouth, see Stanford). That variability is tolerated because doctors (and the public) won’t accept any infringement on their perogatives.
    Finally, I have to point out that Dr. Gitlow is engaging in some unwarranted snobbery when he suggests that physicians have “the right stuff”. I grant you that physicians need to be smart, but they are not, in my experience exceedingly smart. I had three roommates in my freshman year, only one of us became a doctor and there was nothing to distinguish him over the rest of us regarding intellectual capability. The one thing that prospective doctors have over most other students seems to be a willingness to engage in mindless drudgery with the eyes on the prize. In fact, one of the things that really makes me question doctor’s intelligence is their harping on the debt they incur (mostly at generous terms). The payback on a medical school education is one of the best investments available far exceeding the payback for the average 4 year degree.

  14. I agree with Dr. Gitlow that US physicians are not going to work at our jobs with any further significant pay cuts. We are a talented and smart bunch and can indeed change careers. The issue then becomes who will be practicing medicine. The two most likely applicant pools are physicians from other countries, and non-physicians (prescribing nurses, physician assistants, and organ-specific providers such as dentists, podiatrists, psychologists, optometrists). International medical graduates are currently providing a significant percentage of family practice trainees in the US, and non-physicians are gaining prescribing powers and procedural powers in many states. Many people bemoan the loss of the family doctor, but the incentives are not aligning for their return.
    Again I will insist that a physician is in no way related to a “technician of the body”. An argument could be made for those who do technical procedures, (with respects to Dr. Novack), but physicians and surgeons only merged as professions relatively recently. Too many patients and wonks seem to think one should be able to drop off a body as though at an auto garage, have someone skilled fix it while they do something else, then come back and pick it up later totally repaired ( except that no one thinks their auto insurance should pay for their preventative oil change). You can run physical plant operations in this way, but not a profession charged with helping people manage their pain, suffering, and disease.

  15. Tom- touche — but you have not seen my kitchen.
    I happen to agree with you that the future will not likely hold across the board income increases for physicians. Your scenario of doctors as employees is what the major hospitals and bureaucrats would like. Both groups really do not like the idea of doctors working for cash outside of the system (I am not sure if Matthew does either).
    By helping to establish the current medicare system, doctors have added some of the worst features of unions — monolithic lobbying, meritless pay increases, and the ability to scream when the rules they helped establish are altered somwhat so that they are no longer in their favor.
    However, everyone must understand that the real money and power in healthcare today is not in the hands of physicians– if it were, the medicare payment cuts (in the face of hospital and insurer increases) would not have happened, medical liability reform would have already passed the Senate and the Stark laws would be diminished.
    I will continue to remind Matthew as he fires away on doctors that his wit and wisdom ought to be equally applied toward the real power brokers in healthcare.

  16. There won’t be lower pay with the current doctors, nor will there be lower pay with doctors the way we currently grow them. Currently, we take the kids that do the best in high school, then do the best in college, then do the best on their MCATS, then don’t mind being $200k in debt and having no income until they’re 30 or so, then require them to pay massive malpractice liability payments each year, jump through outrageous regulatory hurdles, and follow recurrent training guidelines and requirements. And then we say: “we’re going to lower your pay.” I don’t think so. I think you’ll get an entire generation to say, “Take a hike.” You’ll then end up with whomever you can get to be a doctor, and we’ll see a rapid deterioration in quality of care and a large number of would-have-been-doctors going off to do other things. I run a cash-only practice, so I don’t care from a business standpoint. Patients pay at the time they’re seen. The business aspect couldn’t be easier; I charge less than most docs and I net more, all without turning anyone away. But since so many docs are reluctant these days to try that type of practice, I fear for the changes in the wind. The changes won’t change my practice at all, but they’ll sure change what kind of healthcare I can obtain in 20 years for the worse.

  17. That’s the great thing about writing THCB. You can stick up a quick post knowing that Eric, Eliott, Tom and others will have a great conversation about it (if you pick the right subject), while U no Hu will chime in about another subject linking it all to a certain insurance product!
    I’m not sure Eric’s going to like my next post, but he did suggest it!

  18. I’d also like to hear what ‘cut a better deal’ means, but I see Matthew’s point about the “woe is me” aspect of the article: the asymmetry in the laws concerning self-referral and restraint of trade. I am wondering even so whether the hospital in the story broke restraint of trade or anti-trust laws. It seems to me they did.
    As for hospitals being ‘vessels’ that do not provide care unto themselves: neither evidently do orthopedic surgeons provide care unto themselves or they’d be operating in their kitchens.
    When doctors decide to own (and are allowed to own) their own hospitals, they find themselves in a triple role: doctor, manager, and owner. It has amazed me to see that when doctors have a clear financial interest in a hospital, all manner of cost-saving innovations resisted so fiercely in other peoples’ hospitals all of a sudden become eminently reasonable: supply standardization, scheduling standardization, rational capital spending, basing admission decisions on acuity, procedure standardization, process standardization, and so-forth. I bet we even see an improvement in collegiality among doctors and non-doctors when the doctors are personally hurt by staff turnover. This is the upside of recombining these roles, and it is too bad that professionalism doesn’t substitute for it. But it doesn’t.
    I can see only two things to be done about it: make the doctors employees, or make them owner/managers. The current approach that separates the “technical” and “professional” components doesn’t seem to work very well. Funny how it is the doctors who asked for this separation so many years ago.
    Since we have already one off-topic comment: as for the popularization of the HSA meaning that freedom has won, that is just nonsense unless one equates “tax advantaged” with “freedom”. Since it is politically difficult to fix a real problem, namely that different kinds of compensation are taxed differently, the Republicrats have added still more central planning to the mix. Sounds to me like a Commie Plot to lull us into accepting more Big Government, these HSA things. They should be eliminated from the policy mix forthwith! Defend Freedom! No HSAs!

  19. Neurosurgeon, historian and author Dr. Miguel A. Faria, Jr., MD said, “Managed care and managed competition are unstable entities that will eventually collapse under their own bureaucratic weight, ultimately giving way to either fully socialized medicine (a la Canadian or British, if not the former Soviet style) and total government control — or freedom.” The battle is over and freedom has won. Even if Senator John Kerry (D-MA) had won the Presidency he could not have stopped the HSA.
    Watch the State of the Union, you will see.

  20. I think “cut a better deal” to most doctors means making more money, but that simply is not on the menu this time around. Doctors will find themselves working for less money in the future. They need to figure out what besides money is important to them and try to “cut a better deal” in that realm. Do they want fewer hours? Do they want better IT support? Do they want better health outcomes? Do they want better healthcare access for all patients? Do they want more ongoing career development?
    All of these are on the table, but a futile rear guard action against lower reimbursement rates and supposedly outrageous malpractice insurance rates will lose. The secret that lurks underneath this policy discussion is that most doctors are not brain surgeons or rocket scientists (most rocket scientists are not rocket scientists); most doctors are highly educated technicians of the human body. Despite protestations to the contrary, doctors have no ability to buck the inevitable. Some can retain their former position through a cash only practice (better be a good businessperson); some can survive because of their demonstrated superiority (divas are divas because they are so good), but most will be absorbed into the new reality kicking and screaming – or smiling. The new reality for doctors will almost certainly mean lower pay, increased standardization, and more IT. Do US doctors (we’re talking mainly the good old USA only here) want to negotiate the other changes that happen at the same time or rail against these relentless trends working vigorously to delay (but not prevent) them some number of years.

  21. Matthew– please tell me what ‘cut a better deal’ means…
    Also- I do not think you actually read the WSJ article, as the point is not ‘woe is me’, but rather an explanation of what can happen when hospital systems devote their money and energy to defeating any real competition– and not enough on their own processes and systems to facilitate the delivery of health care. Hospitals are ‘vessels’ that do not provide any care unto themselves– they need the doctors, nurses, technicians to actually deliver the care.