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Category: Medical Practice

PHYSICIANS: CYA Healthcare By Eric Novack

Dr. Eric Novack, THCB’s resident orthopedic surgeon and spokesphysician is an angry   man today. He is angry about people who go around blaming physicians for high healthcare costs. And he’s got something to say about it. What’s the real problem? Eric thinks its CYA healthcare. If you want to hear more from Eric, fire up your PC speakers and go have a listen to an archived webcast of one of his interviews on KKNT 960 AM radio in Phoenix.      

Thanks to all who participated in the ‘debunking’ of the “3% Myth” about Medicare’s efficiency. In other earlier posts, I have tried to address other great myths and misperceptions about the US healthcare system—see “an outcomes primer” and “association v. causation.” Another source of confusion and misperception is the statement that “doctors perform unnecessary tests and procedures simply for financial gain.”  Implied in this statement—and the basis for the ‘Stark Laws’ as well as single-payer proponents of government micromanagement of healthcare delivery—is that MOST physicians engage in this behavior MOST of the time, bilking patients and insurers, and substantially driving up healthcare costs.

I disagree. Before I get a wave of comments about how lab utilization decreased 25 years ago after Stark was introduced, read on. Did the introduction of Stark regulations (laws against self-referral for certain healthcare services) work?  Answer—NO.  If they did, why are we having the robust discussion here at THCB and throughout the country about healthcare?  Healthcare costs have continued, with few reprieves, to increase at faster than inflation rates for years.  The solution for the single-payer crowd—more regulation of providers and price fixing for service delivery.  It has not worked until now, and will not work into the future.

A much greater driver of costs today are patient-demanded healthcare and CYA healthcare.  It is difficult to quantify these costs, but the costs are huge.  Patients often come in ‘demanding’ an MRI or other test.  Accompanied with the demand is almost always the statement ‘well, I have insurance’, and ‘it is covered and will not cost me anything’.  These demanded test and procedures dovetail with CYA costs—fear of not getting a certain test and then discovering later a condition or problem needs treatment.  That ‘delay in diagnosis’ is one of the leading causes of medical liability claims.

The real culprit here, of course, is the 3rd party payer system that divorces patients from costs and risks—and places those risks squarely on the shoulders of healthcare providers.  Even for many of the chronically ill, the knowledge that someone else is picking up the tab alters behavior.

Changing the system so that 3rd party (insurance, government) payment is minimized will provide real market forces to reduce excessive healthcare costs.  Blaming doctors for the problem of ‘unnecessary’ healthcare, while failing to recognize the role of patients in driving costs is another area of distortion and misconception that clouds and confuses an intelligent discussion about healthcare.

PHYSICIANS/INTERNATIONAL: GPs making hay in the UK

My dad told me never to become a doctor. As I failed physics "O" Level and wandered off into social sciences that was probably sound counsel for me, but in general his advice may not have been correct. With the bonus payments and a bunch of other incentives, it looks like British GPs are really making out these days. Apparently average income is now north of 100K GBP, which is far in excess of income for primary care docs over here (if you take it at the $2 to 1GBP exchange rate).

And they are pretty happy about it, or as we Chelsea fans say "top of the league and having a laugh"

TECH/PHYSICIANS/INDUSTRY: Now the Communists have infiltrated the officer ranks!

Back_surgery
(Speaker adopts very pompous tone) You may remember a little while back that some left wing seditious journalist criticized the sanctity of our free and opaque market system. He claimed that a leading back surgeon at the Cleveland Clinic — the Cleveland Clinic, I say, yes, the very epitome of all that is good and great about American capitalist medicine — was somehow putting his own interests above that of his patients as he used a surgical device that he and the clinic both promoted.

Well this rabble rousing has got completely out of hand. Now a presumably Frenchy cheese-eating surrender monkey type who claims to be a surgeon also specializing in back surgery is also on the hunt. The "surgeon" in question, one Aaron Filler, makes outrageous claims about surgeons — including those who’ve been to medical school and therefore have unimpeachable ethics. He even suggests that those involved in developing and marketing devices claim that they get better results using them that are not replicable by other surgeons.

Nonetheless, concern about an ethical crisis affecting patients was
reinforced by discussions at various professional meetings during 2006.
Formal scientific publications on a new type of spinal device had
revealed extraordinarily high success rates and explicitly reported
“zero” device-related complications (Schnake et al Spine Journal 3:159S
2003). However, a separate study involving only surgeons with no
financial interest revealed an unusually high rate of “device related”
complications and failures (Grob et al, Spine 30:234, 2005). <SNIP>Differences in reported scientific results seemed to reflect the
difference between conflicted versus non-conflicted investigators.

He also casts aspersions on the completely above-board and reputable relations between professional societies of surgeons and their respectable colleagues in the medical device industry.

Many surgeons receive manufacturer funds to attend training meetings in
places like Vail, Cancun and Las Vegas, advertised as academic medical
education events. I recently organized a session at one such meeting
that brought in several nationally respected neurosurgeons to teach new
diagnostic techniques and treatments to reduce the use of implants. Meeting sponsors from the device industry objected and the session was canceled.

Hang on a moment. He said "surgeonS". That means there’s an epidemic of Frenchies breaking out in the ranks.

But I’ve figured out this so-called surgeon’s motives! He’s too lazy to do any surgery! Instead he’s written a book called "Do You Really Need back Surgery". Well it’s not too hard to see his game! Instead of getting up early and cutting away in the great tradition of American capitalist physicians, he wants to sit on his rear and collect royalties. Well, that’s not the spirit of grit and true enterprise that this country’s medical care establishment was built on.

I suggest that the North American Spine Society quickly sets up a Committee on UnAmerican Spine Surgical Activities and drags this Filler, and his fellow travelers like Association of Ethical Spine Surgeons‘ President Dr. Charles Rosen, into hearings where their true Frenchy leanings can be exposed to the world. Then the real American back surgeons can thankfully go back, undisturbed, to operating on anyone who’ll lie down.

PHARMA/PHYSICIANS: Big joke-Free CME: Pharmed out doesn’t impress The Industry Veteran

THCB regulars will be missing the delicate tones of The Industry Veteran. But never fear, he’s back and none the less caustic for his lay-off from these hallowed electrons. Here’s his take on the new CME for doctors.

No doubt you saw this article in the Washington Postdescribing the efforts of PharmedOut to make no-cost, continuing medical education sessions available to physicians.  As pharmaceutical companies sponsor a large proportion of CME sessions for physicians, the ostensible purpose of PharmedOut’s campaign lies in removing Pharma’s undue influence on prescribing behavior.It seems PharmedOut.org was created through a $21 million grant from Warner-Lambert (now Pfizer).  The money represents part of Pfizer’s 2004 settlement of the whistle-blower suit involving W-L’s off-label promotion for Neurontin.

Now it’s inevitable that if pharmaceuticals are discovered and distributed through a competitive market and a gatekeeper system, the competitors will try to influence the decision makers and compromise the latter’s fiduciary responsibilities in the process.  Is it too simple to suggest, however, that regulation should remove CME as a means for undue influence over prescribing by making the damn physicians pay their own way?  Do any of the influentials who peruse THCB see a sick absurdity in the fact that physicians need to receive their CME free if they are to remain current?  I’m not aware of settlement grants going for the continuing professional education of lawyers, accountants, or other self-employed professionals.  Instead of using that $21 million to pay for health care programs for the indigent, someone thought it a good idea for six-figure physicians to receive free CME. I’ll wager a used examination glove that physicians will irrationally offer more resistance to paying for their own CME than to many other things that have a far larger impact on their wallets.  The reason is their sense of entitlement. The boys and girls who cloak their black souls in white gowns feel they’ve worked so hard and “sacrificed their 20s” (as one cardiologist told me), that society owes them and should cover their CME.I’ll say it again.  At some point genuine health care reform will require breaking the power of organized medicine, making the profession overwhelming female, and reducing it to the status of government paid professionals akin to school teachers.  Until then, efforts to control cost, increase access and improve quality will have marginal results at best.

PHYSICIANS: Remember, it’s a FFS world

Remember kids, almost all physicians work in a FFS world. HSC reminds us:

While the proportion of physicians in group practice whose compensation is based in part on quality measures increased from 17.6 percent in 2000-01 to 20.2 percent in 2004-05, far more physicians face financial incentives tied to individual productivity, according to a national study released today by the Center for Studying Health System Change (HSC).

Despite the small but statistically significant increase in quality-related physician compensation, financial incentives tied to physicians’ individual productivity continued to be much more common, consistently affecting about 70 percent of physicians in non-solo practice since 1996-97, the study found. Nevertheless, nearly all physicians with quality incentives also face productivity incentives.

So don’t be surprised about what’s happening.

TECH/POLICY/PHYSICIANS:American medical care, or Larry Weed on Speed

Denver
(This one is long on links and short on explanation….sorry, but it’s all old ground here on THCB).

Larry Weed was at IHI last week using the same line that he was using in 1998 and was probably using for years before that.

"What’s the point of outcomes data?" Weed wonders. So what if there are four times the rate of prostate surgeries in Salt Lake City as in Denver? "I wouldn’t know whether I should move to Salt Lake so they don’t miss my cancer of the prostate or move to Denver so I wouldn’t have unnecessary surgery."

That statement has been true for a while, but Eliott Fisher et al are basically now showing that care is better in Salt Lake City. As Fisher says in the roundtable in the Health Affairs blog

The increasing fragmentation — almost atomization — of medical care, and a payment system that rewards commercial behavior on the part of physicians that, from all of my work, looks as if it’s on average certainly wasteful and quite often harmful.

The situation is certainly worse in Miami (and the rest of Florida), and it costs a hell of a lot more there. I know that’s true because Brian Klepper says so too! (read down in the article for his quote). And even the pestilent sore-lickers at the NY Times have finally figured it out.

And much of the reason is the inconsistent incentives that, Jeff Goldmsith points out in a recent Health Affairs article, are making the physicians primarily in the Sunbelt leave their compact with the hospitals and open up their own shops/heart hospitals—all of which are turbocharging the natural incentives that FFS gives them to do more anyway. Not that this is exactly hurting all hospitals; some of the biggest of which are having banner years. But while everyone in the business makes hay, there are those who suffer as a consequence.

And we’ve known about this for thirty years and nothing has been done to stop it.

PS. “Larry Weed on Speed” is an Ian Morrison line about the future of the EMR. 25 years later no one is using the Problem Knowledge Coupler. Which is a pity and a problem.

TECH/PHYSICIANS/INDUSTRY: Communists in press stirring up trouble

Cypho
So a disgruntled reporter is stirring up trouble by daring to question the way medical advances happen in this great nation. Apparently this Joel Rutchick character is suggesting that when respected surgeon Dr. Isador Lieberman and his organization the Cleveland Clinic began pushing a new type of back surgery, we are supposed to be surprised he didn’t plaster memos about his stock options and holdings in the company that made the device all over the foreheads of his patients.

Lieberman did not tell his patients about his financial conflict of interest unless asked, the Clinic acknowledged. According to Plain Dealer research, he also did not reveal his stock holdings in numerous articles he wrote about kyphoplasty.

Bunkum! Does every computer come with a message that you’re making Bill Gates richer every time you turn it on? Of course not.

And when he (Lieberman) testified to the treatment’s benefits at a government hearing last year, he did not divulge past stock interests in Kyphon Inc. and other device makers – even when explicitly asked to disclose such holdings.

Well he was correct. He had apparently sold the last of his stock a few months before the Congressional hearing. Like any good capitalist Dr Lieberman is onto the next pony. As he told the commie rag The Plain Dealer

"I strive to be transparent in my disclosures and believe that I have disclosed my interests within the guidelines and policies of the Cleveland Clinic," Lieberman said in a written statement. He declined to be interviewed.

Who needs an interview in the face of that transparency!

Didn’t Rutchick know that unlike a bum masquerading as a reporter Dr Lieberman had been to medical school and therefore knew all about ethics? And didn’t Rutchick also know for there to be great inventions like this it’s required that not just the inventor but anyone who uses it gets rich? Otherwise what incentive would physicians have to help patients and save lives! After all who except some communist would disapprove of such a system?

When Kyphon officials took their company public in May
2002, they disclosed in a filing with the Securities and
Exchange Commission that they had offered stock options to
the eight members of their advisory board. All took them
except Dr. Joseph Lane, a New York orthopedic surgeon who
teaches at the medical school affiliated with Cornell
University. "I felt it was very awkward for me to be honest about
these things if I owned stock in the company," Lane
said last week.

Yeah, and we know what color state this Dr. Lane character is from, don’t we?! Enough said on that topic. Honestly, virtually every great medical advance absolutely requires this kind of capitalist incentive for those using them. After all, most other medical advances come about the same way. The important thing is that there’s clear evidence of an improvement.

On the SpineUniverse Web site, Lieberman, Kyphon co-founder
Reiley and three other doctors published a four-paragraph
synopsis of their initial experiences with kyphoplasty
involving 26 patients. "These results support further
use of kyphoplasty," the March 2000 summary concluded.

What possible other evidence than this initial, non-per reviewed disinterested study could be needed? None, of course! The important thing is to get the new procedure into as general use as quickly as possible for the betterment of patient care and to save lives!

Before 2004, there had been only one reported death
associated with kyphoplasty and seven with vertebroplasty.
Since then, the numbers have changed dramatically. From 2004
through September, 16 deaths involving kyphoplasty were
reported to the FDA versus three vertebroplasty-related
fatalities. Experts agree that vertebroplasty is used more
frequently than kyphoplasty, although the gap has closed in
recent years. “These sorts of complications are extremely rare,” said
Julie Tracy, a Kyphon vice president. “These are procedures
that are very safe and do a lot of good for these patients.”

In a study published two years ago, researchers at the Johns
Hopkins Hospital in Baltimore also concluded that
kyphoplasty was more closely associated with serious
complications than vertebroplasty. Lieberman led the rebuttal for kyphoplasty proponents,
challenging the methodology of the study and completeness of
the data. However, those deaths and other complications underscore a
fundamental flaw of kyphoplasty: the risk of subjecting an
elderly patient to trauma and a general anesthetic, said Dr.
Kieran Murphy, one of the authors of the Hopkins study.
Murphy has disclosed that he receives royalties from one of
several manufacturers of the equipment used in
vertebroplasties.

Exactly, it’s clear that the naysayers are paid off by the communists. And at least we know that the insurance industry and the government are getting better value for money from the new procedure.

Murphy and other critics of kyphoplasty say hospitals need
the fees from general anesthesia and admission to recover
the costs of the equipment used in the procedure. That
equipment averages $3,500 to treat a single fracture,
according to Kyphon; vertebroplasty kits generally cost $500
to $600. Costs vary, but all told, vertebroplasty was found
to be $6,000 cheaper for each fracture treated, according to
a research report.

Well obviously those insurers must think it’s a better deal! Who could imagine insurers or Medicare just paying more for a new procedure without careful vetting it. After all they’re the end payer aren’t they? And they’re really strict about containing costs, as anyone paying insurance premiums knows! And if they weren’t so tough on containing costs for consumers and taxpayers, then why would we have a national clinical cost-benefit analysis center researching all these new treatments and being "transparent" about which ones cost what?

Answer me that, you Cleveland commie reporter, eh!

The only slightly disquieting aspect of this whole article is that the procedure concerned was invented in France. I know it’s a free market and all that, next time I hope that a red-blooded American like Dr. Lieberman could have been a little more patriotic. We don’t want those people with nice new backs only able to run backwards, do we?

 

PHYSICIANS: Barry Bonds and the AMA’s still got management where they want them

Dilbertlie
The irony is quite staggering. On the same day that Barry Bonds gets the San Francisco Giants to bid against themselves–appalling the local baseball columnists–and give him $16m for one season in his tarnished chase of Hank Aaron, the Congress after a lot of high falooting talk, cancels the fee cut for Medicare Part B and gives a tiny P4P boost. Obviously like Bonds and the Giants management, the AMA still has Congress where it wants it — even though Bond’s numbers for the last two years have not exactly been worth $6m a year let alone $16m, and the cost to Medicare of Part B physician services has gone up despite previous fee cuts, while all the wonks agree that access to physicians for Medicare patients is not a problem (or at least not one affected by across the board fee increases or decreases).

Still let’s not look to baseball teams or Congress for rational decisions, especially with other people’s money. And I won’t even comment on the potential abolition of the limit to which people can put tax-free money in HSAs, other than to note that as they can be used for any spending after age 65 Congress may have just created the biggest tax avoidance scheme of all time!

PHYSICIANS/POLICY: NY Times is surprised about its Ps and Qs in Prostate Cancer Therapy

Das KapitalSo there are three treatments for prostate cancer. Medicare pays physicians a whole lot more for one (new snazzy non-invasive one that patients prefer too)  than the other two. So they rush off to get the necessary equipment and staff-up to perform the new procedure. Then they start doing that rather more than they others. And the NY Times is surprised!

Wow. Just wait till they hear about chemotherapy, and how much of that treatment “choice” is based on incentives to physicians. (Cue Greg to tell us!)

Just another reminder why non-globally budgeted FFS in a system with no mandated technology cost-effectiveness assessment does not work. And that’s roughly what Medicare provides. Instead we should be trying to figure out what is the best patient long-term outcome is for a pre-determined amount of spending.

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