Physicians

Measurables and Immeasurables

It all sounds simple enough. You measure everything you do. You gather claims data. You measure what works. You show measures of what works to doctors and nurses. You write protocols for doctors and nurses to follow what works. You pay more for what works. You pay less for what doesn’t work. You remove pay incentives that cause doctors to do more. You gather together doctors who lead organizations with track records for providing better care at lower costs at the White House.

You trot out the theory of evidence-based care,

1. For any given diagnosis, the doctors has a number of options, and you assume most diagnoses fall neatly into diagnostic bins.

2. Committees of doctors and others, such as health plans and Medicare medical directors, track data outcomes related to these options and develop protocols for best results.

3. Doctors follow protocols, and outcomes improve.

Voila! You have the rudiments of a national policy for providing higher quality care at lower costs.

But, as always, simply measuring care to achieve better results has sticking points. The devil is in the details. The devils are the doctors.  The scientific method and the political realities conflict. Physician and patient human nature keeps muddying the big picture. They insist on doing what they think is best based on experience. Critics say you cannot extend one organization’s results to the nation as a whole when salaried physicians dominate that organization and independent fee-for-service doctors take care of 90% of patients.

In any event:

1.Doctors resist protocols, preferring instead their clinical intuition based on their experience.

2. Hospitals and doctors lose money when they improve quality and reduce complications for which they were previously paid.

David Leonhardt, a New York Times economics expert, brilliantly explains these sticking points and how to side-step around them in his portrait of the life and works of Brent James, MD, the 58 year old chief quality officer of Intermountain Healthcare, a hospital system in Utah and Idaho, with an overwhelmingly Mormon patient constituency. According to Leonardt, “James’s answer to such skepticism — and there is a lot of it, especially beyond Intermountain — is to show results. Intermountain has reduced the number of preterm deliveries, as well as the number of babies who must spend time in the neonatal-intensive-care unit. So-called adverse drug events, which include overdoses and allergic reactions, were cut in half in the mid-1990s. A protocol for dealing with one broad category of pneumonia cut its mortality rate by 40 percent over several years. The death rate for coronary-bypass surgery was cut to 1.5 percent, from the national average of about 3 percent. Medicare data on heart-failure and pneumonia patients show that Intermountain has significantly lower-than-average readmission rates. In all, James estimates that the changes have saved thousands of lives a year across Intermountain’s network. Outside experts consider that estimate to be fair. “James gets results by being deferential to doctors and by appealing to their sense of idealism, which he calls ‘the flame.’ That flame burns brightly within the heart of any physician. It’s what brought us into medicine. That’s what defines us as a profession. And that’s your real leverage point. There are a few outliers, but don’t let those outliers get you off track.” James notes that many medical questions still have no data-proven answer. Many never will. When patients have conflicting symptoms, statistics and protocols won’t always help. Sometimes, intuition is the only good tool a doctor has.Besides, intuition, other immeasurables exist. How do you define and measure“quality” with patients and doctors when quality is in the eyes of the beholder? How do you measure the quality of physician and hospital performance, when outcomes depend mostly on patient behavior outside doctors’ offices and hospitals? How do you define compassion, bedside manner, patient expectations, trust, efficiencies and understanding of communication, promptness and convenience of access, and amenities at the point of care?To sum up, government can mandate what the doctor measures, what it will pay doctors from its deep tax treasures, but it does not have the retrospective perspective, to define or measure the unclassifiable subjective, or patient-doctor intangible relationship pleasures. 

Richard L. Reece, MD is author of Obama, Doctors, and Health Reform and blogs at www.medinnovationblog.blogspot.com.

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  1. ANGIOPLASTY SIDE-EFFECTS
    Angioplasty has proved to be a boon for patients suffering from heart diseases in the last 2-3 decades. It is efficient, economical, time-saving and involves less fuss. But in spite of that, there are a few side-effects of angioplasty as well. Let’s have a look at what could be the possible risks involved in and how to overcome them.

  2. “That’s true but it doesn’t tell the whole story. There just aren’t very many programs comparable to Kaiser across the country. It would be interesting to know what the local market percentages are for integrated systems.”
    Karen – What do you think accounts for this? As I’ve asked in the past, if Kaiser is such a superior model, why hasn’t it taken hold in most, if not all other markets? I can think of several potential reasons but they are all mere speculation on my part. First, it is incredibly expensive to build a self-contained network that includes hospitals. To throw an insurer into the mix as the owner of the provider base further complicates the matter. Second, assuming a modest premium differential at most, a very large segment of the population, especially the relatively healthy, just plain prefers a broad network offering maximum provider choice to a narrow network. The third factor is a bit more practical. In crowded suburban areas of the Northeast, Mid-Atlantic and Midwest, people may be unwilling to travel a considerable distance, in time or miles, to reach an integrated multi-specialty clinic or one of the closed network’s hospitals when there are numerous comparable providers much closer to home. This is especially true during cold, snowy or icy winter weather which is generally not a factor in Northern and Southern CA. Finally, even for patients with a chronic disease that needs to be managed, many of us are perfectly capable of doing their part including maintaining copies of key test and procedure results, and keeping their PCP or main specialist informed regarding what other specialists do or recommend. This describes my own relationship with my cardiologist / PCP who works in a practice with six other doctors who do not (yet) use electronic records. The bottom line is that the Kaiser model may not offer as much money saving potential or nationwide applicability as its proponents think it does.

  3. “That confirms that most people prefer the flexibility of a broad network vs. the limitations of a narrow network HMO as long as the insurance premium differential is not too wide.” — Barry
    That’s true but it doesn’t tell the whole story. There just aren’t very many programs comparable to Kaiser across the country. It would be interesting to know what the local market percentages are for integrated systems.
    “If they want to grow and have the capacity to handle many additional members, I would expect them to price more aggressively to pull market share away from competitors.”
    According to Halvorson, Kaiser is currently building six hospitals so they seem to be growing quite healthily. From what I’ve seen, Kaiser tries to balance growth with expansion. A reputation for long appointment delays and overcrowded facilities are the last thing they want. They price as aggressively as needed to meet their internal growth targets.

  4. Margalti,
    You really seem to know very little about healthcare law regarding “allowable” charges, EMTALA, Medicaid, TriCare, etc.
    The short version: When you are mandated to provide a service on demand without anyone required to pay for the sevice, it is theft by legislation. (EMTALA). When you are told what you may charge for a service and told what you are going to get, then your right of contract has been stolen.
    When you are told you will get 9% or 21% less this year than last year for a service (and you will like it and have no appeal) that is theft by fiat.
    There are only two responses possible: 1. Roll over and take it. 2. Deny the service to those not paying enough. That is why Medicaid has been such an albatross. Today’s doctor will not be here tomorrow under this type of reform.

  5. Karen – Thanks very much for the link to the Congressional Research Service paper. It was interesting to note that the term actuarial value refers to the percentage of costs for benefits across a standard population and average medical prices. It does not speak to what any one individual would actually pay out of pocket. The paper also indicates that only 23% of the population is in HMO plans vs. a much higher percentage in PPO’s. That confirms that most people prefer the flexibility of a broad network vs. the limitations of a narrow network HMO as long as the insurance premium differential is not too wide. I have no idea how wide the differential would have to be to induce a much higher percentage of the population to accept the HMO structure.
    In thinking about Kaiser specifically, if they can demonstrate clear outcome superiority because of their use of electronic records and integrated group practices in, say, the management of chronic disease including diabetes, asthma and heart disease, it is quite likely that they will attract a disproportionate number of members with these conditions. For healthy people, by contrast, that disease management capability will have no perceived immediate value. Those folks would likely much prefer the flexibility of being able to access a broad network when and if they need care. As Nate suggested in an earlier comment, that could leave Kaiser with a disproportionate number of high utilizers among its members.
    Separately, it was also interesting to read that Medicare Parts A, B and D earned an actuarial value of only 76% which was worse than the PPO’s.
    ICE – If Kaiser or any other provider group or insurer had a clear cost advantage vs. its competitors, I would not expect them to pass on the entire differential to members or potential members in lower premiums or enhanced benefits. If, as Karen suggested, they are at or near their capacity, they may not be interested in attracting new members beyond what they need to replace normal churn from job loss, people who move, age into Medicare or leave the Kaiser system for other reasons. If they want to grow and have the capacity to handle many additional members, I would expect them to price more aggressively to pull market share away from competitors. At any rate, like most non-profit insurers, their net profit margin is very low which implies they are already pricing their products as aggressively as they reasonably can.

  6. I again wanted to point out an overlooked aspect of this issue, that payers have not been eager to embrace payment methods that recognize and reward the documented outcomes improvements and cost reductions at innovative places like Intermountain, Geisinger, and Virginia Mason. See my article on this in the November issue of Managed Healthcare Executive.
    http://managedhealthcareexecutive.modernmedicine.com/mhe/article/articleDetail.jsp?id=638750&pageID=1&sk=&date=
    –Harris Meyer

  7. 108Days,
    I am already paying taxes for stuff I don’t support. Lot’s of stuff. Always have. It’s not stealing. It’s democracy.

  8. Response to MD as Hell, who said:
    Following protocols or guidelines or rules will never save your a** in court, which is why we need tort reform for cost control more than anything else you are jabbering about.
    Part of Tort Reform — which is needed to “bend the cost curve” is to establish “official, sanctioned” guidelines and to make it harder to sue an MD who followed them.

  9. Margalit, one could ask you the same question..
    If the government taxed you to pay for progams and/or services you disagreed with, would you have any objection or would you lay down and be taxed? Did you agree with the GM bailouts? Wal Street bailouts? Cash for Clunkers? Maybe so, eventually they’ll come up with one you don’t agree with.

  10. Barry Carol wrote: “If you compare comprehensive PPO and non-Kaiser HMO plans to Kaiser, the benefits are essentially comparable and the premiums are comparable or within a few percentage points of each other as well. Historically, HMO’s offered a lower premium in exchange for less provider choice or a narrow network vs. a broad network. With salaried doctors and electronic records, which is the direction reformers want to move in, there should be cost advantages. If there are, they should be easy to demonstrate and should be reflected in lower premiums charged to members. “
    Barry, let me heist a page from MD as HELL (& no royalties for you, MDaH!) and inquire as to why, if I’m keeping a population healthier at competitive prices, I’m OBLIGED to give you a better rate to boot?
    You’re getting something valuable at a service/price point you can’t get elsewhere (else why are you buying it from me?), and I (as Kaiser) am keeping the delta.
    That’s market dynamics at their finest.

  11. Md as HELL, I don’t quite understand. Do you consider government taxing and paying for programs and services you personally disagree with, stealing?

  12. jd,
    Even shorter: don’t rip me off and call it reform. You are just stealing from me. I will give away the world at my discretion to anyone who needs help. But I will not let you steal it from me so you can give it away and thump your chest.
    If you don’t see the difference, then you really are a jd.

  13. Barry:“Kaiser, even in Northern CA where it is well regarded and has a significant market share, has not been able to offer health insurance for meaningfully less (including member co-pays and deductibles) than its traditional competitors, both for profit and not for profit.”
    The actuarial value of the HMO and PPO, which includes more than premiums and co-pays, is discussed in a Congressional Research Service report from April. Comprehensive HMO plans like Kaiser are about 93% efficient vs 80%-84% for PPOs with similar plan provisions.
    http://assets.opencrs.com/rpts/R40491_20090406.pdf
    I think that Kaiser and traditional insurers have different objectives in the marketplace. Insurers compete for more patients to increase their revenue and profit. Kaiser’s objective is to increase the number of patients that have comprehensive care. There is no advantage to Kaiser to competing on price and flooding its facilities beyond capacity. Right now, Kaiser can charge market rates and use the difference between what it costs to deliver services to invest in major projects such as EHR and to grow the system at its own pace.

  14. Margalit, thanks for the elaboration. I certainly agree that there are many many cases where no clear protocol exists to be applied. But no one who has looked into the subject argues with that. No one at Mayo or Intermountain is saying “we now have a protocol for everything” or even more than a fraction of cases.
    Here is what I think is the key point: when we are confronted with a situation with an imperfect protocol or no clear one, physicians need to get away from engaging in one-off treatments that are not systematically recorded and the outcomes measured. Physicians need to see themselves as building up and improving protocols. Which is just to echo the point of the Intermountain chief that science shouldn’t stop at the actual practice of medicine.
    At the end of the day, I think 99% of us in healthcare will get to the same place. There will always be cowboys like MD as Hell who feel no responsibility to improve their performance or answer to anyone other than themselves and Mammon. Shorter MD as Hell: Give me my money and leave me alone!

  15. Attention all,
    “Guidelines” are BS. They will be hailed when they appear to work. The doc that follows them when they don’t work will be sacrified under the guise of “they were not mandatory; it was the doctor’s job to do different.”
    Mayo and the other centers are treating a different patient population than the general hospitals. Their patients are selected for potential benefit of tertiary treatment. The really sick patients are treated locally.
    There is very little evidence for anything we do. That’s why it was known as “medical arts”.
    Following protocols or guidelines or rules will never save your a** in court, which is why we need tort reform for cost control more than anything else you are jabbering about.

  16. Margrait, John Ballard, jd
    Margrait–
    Your response makes sense. I apologize that my response to your first coment was so brusque.
    I’m afraid I was just irritated by the original post. I am sorry
    I completely agree that we need a combination of guidelines (not rules) and physician judgment.
    But if a doctor often practices in a way that often violates guidelines, someone needs to ask “why?” (This is why I like the idea of doctors practicing in large groups where they are all looking at the same chart for a particular patient, and rasing questions if a doctor is an outlier.)
    In some cases, a physician will be practicing differently becuase he has different patients–more very poor patients, more non-compliant patients, more patients who are much older and much sicker, etc.
    But in other cases, there is no good explanation as to why he is an outlier.
    Finally, Intermountain in Utah is not unique. Geisinger in Pennsylvania, Mayo in Minnesota, the Cleveland Clinic in Cleveland, the Community Co-operative int eh state of Washington, UCSF in San Francisco, are just a few examples of places that are practicing more efficient medicine–providing much better value for health care dollars ..
    John Ballard–
    You wrote that the story of Intermountain is “yet another blue ribbon example of good outcomes at lower costs than the usual handful mentioned. The marked improvement in the reduction of C-sections and neonatal complications was also impressive .”
    I agree. And this is exciting.
    jd–
    What you have to say about “protocols” (or guidelines) is spot on:
    “They do not say ‘If you do X, outcome Y will result.’ What they say is that in a preponderance of cases, doing X in a certain situation has had better outcomes than other treatments considered (A, B, C) and so it is recommended/required over A,B,C for the relevant situation as a first-line treatment.
    “That’s very different than something deterministic and monolithic. It in no way removes the ability to experiment/innovate.”
    jd–Yes, yes, yes. Thank you for putting it so well.
    twa– I agree.

  17. jd,
    I have obviously failed to convey what I meant to say. So let me try again.
    Roughly speaking, I can see four types of “protocols”.
    1) The operational protocols aimed at reducing errors and infections and so forth. Those are of course to be observed. There is no art involved in washing hands properly.
    2) Procedure protocols like the one mentioned in the article regarding inducing labor before 39 weeks for no particular reason other than convenience. Again, no controversy here. These are easily measured and easily applied elsewhere.
    3) Treatment protocols or guide lines or algorithms. In my opinion, it gets a bit dicey right here and not because of the “art” component of medicine. We just plain don’t know enough about the science in order to be exact in many complex cases. Maybe one day in the future we will.
    There is of course immense value in collecting and dispersing evidence. There is value in knowing that “doing X in a certain situation has had better outcomes than other treatments considered (A, B, C)”. The problem is in the definition of “certain situation”. Most studies involve a handful of considerations, like condition, gender, age and maybe certain comorbidities. Is that enough information to define the “certain situation”? Probably not. Is there another study somewhere showing slightly different results for slightly different “certain situations”? Probably yes.
    Should the treatment course be recommended then? Maybe. Should it be required? No. Sometimes there is no “do over” in this field.
    4) Diagnosis protocols or trees are probably the least useful for physicians, or at least ought to be so. If anything has any major art component in it, diagnosing complex and sometimes contradicting symptoms is the one. This is where the unquantifiable activities come in, like taking histories, listening, creating a trust relationship, etc. I have no idea how to measure that and of course this is where many errors occur. Maybe long term studies of many factors when we get everything computerized will help.
    As to education, there are different ways to teach students. The oldest model is probably apprenticeship – watch me and learn whatever you can. Not sure how much of that is still occurring, but obviously it has major drawbacks.
    The other way is to teach people how to think and how to analyze new situations so hopefully when they encounter the unknown they can apply the analytic tools they have developed.
    The third way is to teach people where to find the answers without bothering with the underlying principles for each and single case. This is similar to the unfortunate use of graphing calculators in high school. How many kids today really understand how to find an intersection of two quadratic equations and what it really means? If the calculator is out of batteries or if we need three equations and the contraption only handles two, it’s a lost cause. Fortunately, math is a very exact science.
    I think you may want to read Dr. Groopman’s book. It’s not about not wanting to measure, or use, evidence. It’s about the current limitations of such approach that need to be acknowledged before we load the guns with yet another silver bullet.

  18. I continue to find this “debate” baffling each time it reappears. Modern medicine, to the extent that it is different from mere tradition and quackery, is founded on science. That is to say, it is founded on controlled observation and systematic measurement to find reliable generalizations that can be used to predict and control aspects of our world.
    When we reach the limit of (the moment’s) scientific knowledge, the practicing physician often has no choice but to rely on personal experience and their “gut” feeling. That is unobjectionable and doesn’t make it quackery, but it does mean that you’ve leapt beyond anything specific to the methodological foundation of modern medicine. Quacks and shamans have their personal experience and “gut” feelings too.
    The key difference for physicians in the modern age is that their authority in having better knowledge than quacks and shamans is founded on science, so they betray the very foundation of their claim to knowledge if they want to stop the march of scientific progress and take a stand against further diminishing the number of things over which personal experience and gut feelings are used rather than accepted scientific studies.
    That’s why I literally cannot make sense of views like Margalit’s or Dr. Reece’s if they are meant to be some kind of rejection of the “try to use more scientific protocols” position. These views are very common among physicians, and I think rest on a deep confusion. Here is Margalit:
    “I am all for measuring everything that can be measured. There is plenty of evidence that deterministic protocols can save lives. There is also plenty of evidence that deterministic protocols will fail for a significant number of cases.
    From a population perspective this “percentage tennis” strategy will work just fine. On an individual level, it is much less acceptable.
    So obviously a combination of guide lines and physician judgment is most likely required. The concern that Dr. Groopman raises is that if we educate doctors to rely solely on protocols, they may never develop the ability to substitute judgment when a protocol is inappropriate or unavailable.”
    First, these are not “deterministic” protocols. They do not say “If you do X, outcome Y will result.” What they say is that in a preponderance of cases, doing X in a certain situation has had better outcomes than other treatments considered (A, B, C) and so it is recommended/required over A,B,C for the relevant situation as a first-line treatment.
    That’s very different than something deterministic and monolithic. It in no way removes the ability to experiment/innovate. The protocol is always founded on specific comparison treatments, and so if you want to try something new you can make the same arguments you always could to conduct a study. If X (the protocol treatment) only works some fraction of the time (as it will), and you can convince NIH, pharma, etc. to fund the research, then of course it can continue to be done. Any protocol that isn’t perfect will have a combination of human curiosity, human interest (healing the sick) and corporate greed to support new research to improve the protocol.
    Similarly, if you’ve tried the protocol treatment but it didn’t work in this case, then obviously you have license to try other things. Maybe go back to A, B, or C, maybe enter the patient in a new trial, or maybe think up your own new treatment. As the folks at Intermountain say, you can deviate you just have to have a reason for doing so.
    In fact, a well-written protocol will include fall-back treatments where the evidence exists to prioritize more than one option. Where that doesn’t exist, you’re just shooting in the dark. It happens, a lot, but why romanticize it?
    And so again, I simply cannot even make sense of this final statement of Margalit’s:
    “…if we educate doctors to rely solely on protocols, they may never develop the ability to substitute judgment when a protocol is inappropriate or unavailable”
    What sort of protocol education from the land of idiots could this be? Maybe this: “When presented with what appears to be condition P, use treatment T. T will work. Don’t ever deviate from it. But if despite our assurance T doesn’t work, keep doing T anyway.”
    If that’s what a protocol looks like and people are educated to adopt this sort of attitude towards protocols generally, then Margalit is right that physicians may “develop the inability to substitute judgment when a protocol is inappropriate or unavailable.” But using protocols doesn’t look like that!
    PS-There are also protocols for things like lowering hospital-acquired infections and other kinds of medical errors/imperfections. These are in some ways similar and in some ways different from treatment protocols, but they don’t seem to be what Margalit and Dr. Reece had in mind.

  19. Let’s see if this comment gets posted. We are so confident that the government will do a good job of saying yea or nay to medical treatments? The current system is not perfect but I prefer it to a bunch of bureaucrats getting between me and my doctor. Do not think for a minute this process will not be politicized.

  20. Reece captures the situation well. There are significant pockets within which evidence based practice is anathema. A recent study in the NEJM confirmed that some 50% of physicians oppose comparative effectiveness research. Now why would that be?
    Physicians may be barriers to improvement, but an even more significant barrier is health system administration. Too many system CEO’s view physician leadership as a VP level function at best. Real improvement will come when more systems are lead by physician executives. Who has dome more to advance the quality agenda than James? Why then is he still only a CMO?

  21. How can you measure medical quality? See http://bit.ly/3hPKay You cannot measure a physician’s history taking skills or his physical examination techniques. You cannot measure empathy or compassion. You cannot measure medical judgment. The above criteria are what really matters, and they are unmeasurable. Instead, ‘quality measurers’ will count data that is easy to count, but is a flawed surrogate of true medical quality. http://www.MDWhistleblower.blogspot.com

  22. I agree with what is posted except it sounds like the same old, same old. You can’t measure a dr-patient relationship. True. You also can’t measure what makes a good teacher. True. But that certainly does not mean that you shouldn’t try to measure ANYTHING in the entire system, and use those measurements to improve performance.
    This continual resistance to objective performance/outcome measurements has dogged both medicine and education for many, many years – and look where we are in both arenas – not in very good shape.

  23. Maggie,
    I actually have a lot of respect for research and I did read the NYT article as well as Dr. Groopman’s book and I am not criticizing the good work done at Intermountain.
    However, in order for research conclusions to be applicable elsewhere, both the researched environment and the one where you intend to apply the conclusions have to have the same basic structure and all variables need to be considered. My contention was that places like Intermountain are rather unique and their methods of changing outcomes may or may not apply elsewhere.
    What I was trying to point out is that a physician at Intermountain is not operating on the same terrain as his counterpart in private practice and therefore the methods that lead to quality improvements at Intermountain will not necessarily apply well to the rest of the country. The “flame” is not quite enough.
    I am all for measuring everything that can be measured. There is plenty of evidence that deterministic protocols can save lives. There is also plenty of evidence that deterministic protocols will fail for a significant number of cases.
    From a population perspective this “percentage tennis” strategy will work just fine. On an individual level, it is much less acceptable.
    So obviously a combination of guide lines and physician judgment is most likely required. The concern that Dr. Groopman raises is that if we educate doctors to rely solely on protocols, they may never develop the ability to substitute judgment when a protocol is inappropriate or unavailable.

  24. Here’s the link.
    Someone left in another comments thread.
    http://www.nytimes.com/2009/11/08/magazine/08Healthcare-t.html?_r=1
    …once a treatment enters the mainstream — once we know whether it works in certain situations — science is largely left behind. The next questions — when to use it and on which patients — become matters of judgment, not measurement. The decision is, once again, left to a doctor’s informed intuition.
    “There are some real advantages to that,” James says, “and in some ways there are some real disadvantages too.” The human mind can sometimes do a better job of piecing together amorphous bits of information — diagnosing a disease, for example — than even the most powerful computer. On the other hand, human beings can also be unduly influenced by just a few experiences, like the treatment of an especially memorable patient. As a result, different doctors frequently end up coming up with different answers to the same question….
    […]
    …guidelines are also embedded in the hospital’s computer system. Doctors and nurses are presented with a default choice — how much of a given drug to prescribe, for example — and have the option of overriding it. Most important, the electronic records system allows both committees and doctors to track patient outcomes. Doctors with consistently poor results can expect to be pulled aside for a collegial conversation with a supervisor about what they might be doing wrong. Doctors with the best results can expect to be asked what they are doing right. Doctors in many areas are also eligible for bonuses of up to about $2,500 a year if their outcomes are good.

    Lots more at the link.
    Pretty exciting stuff to me.

  25. “What Barry says about Kaiser is incorrect.”
    “Meanwhile, many of Kaiser’s for-profit competitors are selling much less expensive plans that are cheaper because they are filled with holes–holes that you don’t discover until you get sick and find out what isn’t covered.”
    Many large employers including the federal government, state and local government, the University of CA system, Stanford University, Disney, the large defense contractors, etc. offer their CA employees several or numerous health insurance choices. Some of those are high deductible plans. Probably none are low benefit plans such as hospitalization only policies or plans with a very low maximum benefit payment which, I assume, are the plans that Maggie characterizes as “full of holes.”
    If you compare comprehensive PPO and non-Kaiser HMO plans to Kaiser, the benefits are essentially comparable and the premiums are comparable or within a few percentage points of each other as well. Historically, HMO’s offered a lower premium in exchange for less provider choice or a narrow network vs. a broad network. With salaried doctors and electronic records, which is the direction reformers want to move in, there should be cost advantages. If there are, they should be easy to demonstrate and should be reflected in lower premiums charged to members. I think it would be interesting, for example, for each of the major insurers in CA, including Kaiser, to break out by age cohort their hospital inpatient bed days per thousand members.
    I have nothing against Kaiser. Indeed, I would prefer it if most doctors worked on a salaried basis instead of fee for service. When I or my family members need healthcare, we want competent, cost-effective care. We don’t want CYA defensive medicine and we don’t want money driven medicine. Maggie said Kaiser was not successful in NC. Nate said it wasn’t successful in OH. Different geographies have different preferences, and we shouldn’t try to oversell the Kaiser model. We’re a big, diverse country. A one size fits all approach is not the answer.

  26. I printed out the Intermountain story and read it carefully. As a layman I am forced to concentrate on the writing of professionals because there are so many specialized terms and acronyms. But I can assure whoever is reading this comment that following protocols was important but it was not binding on any doctor on the staff. Every doctor was encouraged to follow guidelines but was always free to depart from them, even if the reason may have been nothing more than a gut feeling.
    It was also pointed out, however, that the results of individual doctors were tracked along with a pile of other data and if someone was consistently getting worse outcomes than their peers that doctor was likely to have a conversation about it. I believe the term for such counseling was “collegial.”
    I was very impressed with what I read and was glad to find out there was yet another blue ribbon example of good outcomes at lower costs than the usual handful mentioned. The marked improvement in the reduction of C-sections and neonatal complications was also impressive. Those who have yet to read it should do so. I noticed no link in Dr. Reece’s post but I’m sure it’s easy to find.

  27. There are many patient’s who want a PSA test and subsequent biopsy. If found to have prostatic adenocarcinoma, they then want a prostatectomy despite the attendant consequences. So what do you tell the patient? No? Maybe if a patient wants PSA testing they pay out of pocket for the test and surgery.

  28. The bounds to which providers will go to defend the status quo and refute any suggestion that improvement is possible is breath-taking. Why are the voices for improvement from within the profession so scarce? Why isn’t every doctor more like Brent James? Instead we treat him and Wachter and Berwick and Wennberg (and the integrated systems) as freaks and come up with every reason why the rest of us do not deserve this level of care.

  29. Barry, Dr. Reese, Margait
    What Barry says about Kaiser is incorrect.
    Please see the comment that I just posted at the end of the comment thread on my InterMountian piece below —
    Nov. 10 “InterMountain Care” (Sorry I didn’t respond earlier; I didn’t realize that Matthew had cross-posted it.)
    Just by Googling, you can find an excellent, in-depth case study of Kaiser done by the Commonwealth Fund last June.
    In that study Commonwealth points out that
    Kaiser has kept healthcare inflation down to 6% a year (while the average among for-profit providers is 8% a year for the last 10 years.)
    Meanwhile, kaiser provides much more comprehensive care and better chronic disease management, greatly reducing hospitalizations and deaths as a result of heart disease.
    Kaisers patients are getting a better value for their healthcare dollars. The report points out that Kaiser has not been able to lower premiums in recent years because it is still paying for its capital invesmtent in electronic health records– the biggest integrated EHR in the civlian world. Meanwhile, many of Kaiser’s for-profit competitiors are selling much less expensive plans that are cheaper because they are filled with holes–holes that you don’t discover until you get sick and find out what isn’t covered.
    See my comment on the Nov 10 post below.
    Dr. Reese–
    Perhaps you have never heard of the Cochrane Collaboration– the largest database for evidence-based medicine in the world?
    Good doctors do not resist protocols. Good doctors resist errors. See Dr. Atul Gawande’s New Yorker article, “The Checklist.” See also Dr. Don Berwick’s book “Escape Fire” and his description of how dedicated health care workers in many hospitals have raised the quality of care by “measuring”–and then improving how they do things, improving results for patients.
    This doen’t happen by “being deferential to doctors.”
    (Have you ever visited Intermountain? )
    Of course there is much ambiguity in medicine .
    But in many cases we DO know what works best for patients who fit a particular profile–and what doesn’t.
    For instance, we know that PSA testing for prostate cancer does not reduce mortalities–and it does expose an enormous number of patients to treatments with life-changing side-effects. (incontinence and importence).
    We also know that there is no medical evidence that any of those treatments save lives.
    This why both the National Cancer Society and the American Cancer Society no longer recomment routine PSA testing.
    Yet doctors who prefer to follow their own “instincts” and ignore science and medical evidence continue to recommend PSA tests–which then can lead to some lucrative, if ineffective treatments.
    We know that more than half of all angioplasties, and a great many bypasses provide no benefit to the patient.
    (See Dr. Nortin Hadler’s very well-docoumented “Worried Sick” )
    We Know That OutComes are Better In Many Other Countries For Many Important Diseases. In these countires, doctors follow evidence-based guidelines. I went to an int’l medical conference in Germany a couple of years ago, and doctors from Europe were shocked that we still do PSA tests.. See Dr. Donald Berwick’s writing on how outcomes in the U.S. compare to other countires as well as Dr. Atul Gawande’s books and articles.
    We know that doctors following their gut instinct are performing more surgeries every year. As Dr. Atul Gawnade points out in his landmark June 1 New Yorker article, the number of surgeries has been spiraling, yet there is no indication that our heatlh has improved as a result. (Though health care spending has spiraled.
    As Dr. Don Berwick points out, “We don’t have the best medical system in the world, but we do have the most expensive.)
    Each year, Dr. Gawande notes, more Americans die of complications following surgery than die in car accidents. What we don’t know, he writes, is how many of them actually needed the surgery.
    The U.S. spends far more on medical care than any other country in the world– in large part because in our fragmented system, too many doctors working solo do what they are accusomted to doing–without consulting medical evidence. See the film, “Money-Driven Medicine” produced by Alex Gibney, the Academy-award winning documentary film-maker best known for “Enron: The Smartest Guys in the Room” and “Taxi to the Dark Side.” You can view the entire film, at no charge,
    online at http://www.moneydrivenmedicine.org. (See “Watch-In” on front page.)
    The film is based on my book, but I make no money from the film.
    Finally, practicing and promoting good medicine means holding two distinct ideas in hour mind at one time:
    a) there is much ambiguity and uncertainty in medicine
    b) there is much that we can measure, and good medicine is about continuously improving –not just doing things the same old way, based on habit, experience–and failng to keep up with evolving knowledge.
    Finally, doctors need to work together in collaborative groups so that they can share that knowledge.
    Margait–
    I can’t help but notice thar your comment is filled with “I would assume’s” and “Probably.” I guess you have as little respect for reserach and fact as Dr. Reese.
    Why not read the NYT article, Google Intermountain, and learn something about how the place actually works?
    You complain about insurance hassles in private practice.
    Don’t you understand that doctors who work for large multi-specialty integrated medical centers on salary don’t have to have to worry about hte paper work and hassles? A large back-office takes care of the business end of things. They just focus on caring for patients.
    OF course they can’t just do as they please –following their “instincts.” They are collaborating with other doctors who are all looking at the same chart. If one doctor is practicing bad medicine 00doing things the same way they ‘ve been doing them for the past 25 years, without keeping up with medical evidence– others will say to him: “Excuse me doctor, but haven’t you read . . .”

  30. The real proof of the pudding for Inter-Mountain would be for it to also become an insurer. With its hospitals, salaried doctors, labs and clinics all on the same team as the insurer, it should be able to provide comprehensive care to members for less than anyone else in its market. Presumably, it would outsource any complex care that it could not provide within its system. Kaiser, even in Northern CA where it is well regarded and has a significant market share, has not been able to offer health insurance for meaningfully less (including member co-pays and deductibles) than its traditional competitors, both for profit and not for profit. Let’s see if Inter-Mountain can provide more cost-effective and better quality healthcare to its members while taking on the actuarial risk inherent in a fixed insurance premium, even if it includes risk adjustment payments. I would actually like to believe that they can do it, but Kaiser’s experience suggests otherwise.

  31. Dr. Reece,
    I couldn’t agree more with your beautifully written assessment.
    I am also not certain that when we measure the differences between integrated health systems like Intermountain, and the rest of our care delivery system, we are actually measuring everything.
    I would assume that the physicians and staff at Intermountain are different than the average practitioner. I would also assume that Intermountain screens their prospective employees so that they fit the philosophy of the establishment.
    That “flame” that Dr. James is talking about is probably a prerequisite to working at Intermountain.
    While I believe that many a medical student graduate possessed “the flame” when fresh out of school, years and years of dealing with the mundane aspects of medicine in private practice probably extinguished most of it.
    It is hard to maintain a burning “flame” when you have to see thirty patients per day in order to survive. I wonder what the workload of a salaried Intermountain doctor is?
    It is also hard to keep the “flame” going when a large portion of your day is devoted to insurance hassles and paperwork. Do Intermountain doctors even care about medical billing? Are they concerned about Medicare cuts? Do they have to make the “flame” reducing decision of whether to take Medicaid or not?
    I guess the lesson from Intermountain is that we may need lots and lots of Intermountains. I don’t think the lessons can be easily applied to the rest of health care as it is delivered today.

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