Several people are concerned about the integrity of our medical leaders, and the latest Cleveland Clinic spat has upset a few people, notably local MD Medpundit. I have a more jaded view. I liken it to when I heard that lawyers have to take an ethics test but are only not allowed to practice if they fail it, I assumed that any lawyer passing an ethics test lacked the aptitude required for the job! However, making a welcome return to THCB, even the usually cynical-beyond-belief contributor The Industry Veteran appears a little concerned. He writes:
I had previously viewed the tussle between renowned cardiologist Eric Topol and his boss at the Cleveland Clinic, Delos Cosgrove, as principally an academic spat whose significance did not extend beyond the personal fortunes and the organizational power positions of the two principals. The Times’s article, by contrast, suggests the Cleveland bash reveals that the integrity of academic/high research medicine is fundamentally compromised. Instead of remaining disinterested researchers who help to develop and evaluate new medicines and technologies, big time researchers and their institutions own equity positions in the companies whose products they evaluate. The very notion that medical researchers are gatekeepers for the public, motivated by professional ethics and the search for scientific truth, remains a fool’s myth. Who guards the guardians?I recently asked a friend who teaches marketing ethics at his university to tell me his views about the recent editorial in the New England Journal of Medicine. That was the one where the Journal’s editors belatedly said they were shocked, shocked by the fact that Merck’s shills neglected to include three instances of myocardial infarction among a sample of Vioxx users. The specific issue for which I sought clarity concerned the relative responsibility of the academic physicians who authored the study (or, more accurately, whose names appeared above the study, since Merck’s medical writers doubtlessly wrote the paper) versus that of Merck, who sponsored the research. My friend’s pontifications assigned the lion’s share of blame to the physicians. They must reasonably be expected to know that the first and final interests of any corporation’s operators lie in obtaining profit to satisfy shareholders. In this particular case, the academic physicians would have been psychotically detached from reality not to have known that Merck’s pursuit of Vioxx profits included a thoroughly unethical inclination to twist and hide data. “If they were willing to accept research money and sponsorship from known crooks such as Merck,” he wrote, “then they had a responsibility to act with the very highest possible standards of ethics, and my guess is that they fell far short of that.” The Times article flicks off the lid to reveal that these kinds of self-aggrandizing conflicts are the routine condition of high powered, medical research.
And from the THCB Japan bureau (well actually the Yomiuri Shimbun)….
It’s worth noting that the Japanese, who have one medical fee schedule for all of their multi-payers (and also a complex system of cross-subsidization between those payers), are about to cut fees and reallocate them. In Japan private doctors make lots and lots more money than hospital-based ones, and the government is slowly trying to move the incentives away from what’s traditionally been a system with a high-volume of office visits and prescriptions of dubious benefit.
We’re about to do the same here, calling it pay for performance. Like there it’s going to turn into a fight. Joe Paduda notes today that the AMA is having some success in its attempt to stop the 4% cut that’s scheduled to come into effect for Medicare at the end of the year. And is directly linking it with a demand to stop pay for performance.
The advantage that the Japanese have got is that there’s only one fee schedule to argue about. Here we have gazillions and no one really knows what they are…
Bob Wachter is probably the leading expert in the nation on medical errors and a great speaker.
He’s worried about the lack of budget for training, and that IT = Patient safety. But he does think that the IT/EMR movement is now tipping, especially as the disconnect between patient’s perception of being high-tech and what’s happening in the health care system is not tenable, and docs saying that they can’t do it is not credible even for the older docs
He talks a little bit about computer induced errors and problems. There’s a new literature replacing the Bates stuff about how great the Brigham’s system was, and now it’s all about how it’s going wrong. It’s not a mistake to computerize but you need to go in with your eyes open. You need to think about the process improvements…including the easy ability to cut and paste H&T and continuing on mistakes. What happened when the computer goes down? As at Beth Israel Deaconess. And then in the example for Childrens’ Pittsburgh, does CPOE kill people? Well the chaos still goes on and CPOE clearly gets in the way in ICUs. The critiques of this study are that they "didn’t do it right" but that’s what an implementation looks like. Plus what looks good in the demo doesn’t work per se in your local community hospital. Or the experience of the Brigham is not transferable …unless your hospital also has a 1,300 strong IT department.
The Cedars Sinai story: They built their own and they built in some decision support. But the medical staff revolted. Too many alarms, reminders, too many screens, etc, etc. But not just that, also a story about control over medical care. Cedars was exerting central control.
So the question is, who exerts control. He quotes Spiderman. "With great power comes great responsibility" Now there are institutions that are going to have to wrestle with this problem, and if you push too hard the backlash is very tough. get it implemented first, and do the control later…one little thing at a time. It’s like the Right Stuff which changed the test pilot from being a cowboy pilot like Chuck Yeager to being a goody two shoes Astronaut like John Glenn….it got more boring, but mortality rates fell dramatically. So this shift is coming too, and will be a huge shift.
Add to this the emergency dislocation of medicine, such as late-night radiology reading in Bangalore. This means that the world gets wired and we start to figure out how to provide care very differently. eICU from VISICU is another reason, seeing a real time data stream and facilitating the care remotely. One of the most profound affect is going to de-tether the assay from its interpretation.
The AMA — well after 100 years of hisory, we’d never have seen this one coming.
The American Medical Association has made clear that it will oppose efforts to link Medicare payments to higher-quality healthcare services unless Congress and Medicare permanently halt steadily declining payments to doctors.
MrHISTalk, who’s blog is fantastic, out-does himself in an article about the University of Pittsburgh Children’s hospital CPOE implementation, which has had so much publicity since the article was released on Monday.
His article is called, Does Cerner Millennium kill children? I don’t think so. It’s not betraying his anonymity to tell you that MrHISTalk is a hospital IT director with a great deal of experience in pharmacy. He’s an expert, so go read it.
I have little to add other than three quick thoughts:
1) The before and after study may have studied a period too early in the CPOE implementation. It takes time to get the new processes down, and things may have got better later. But not in the timeframe of this study, apparently.
2) Last weekend I heard a doctor complaining bitterly about having to use an EMR in the outpatient setting, claiming that it imposed secretarial tasks on him, and interfered with his relationships with his patients. I’d counter by saying that in ambulatory care the recording of what happens in the exam room and the presentation of information from there and other venues (labs, medication) etc matters more to the care of the patient than the information that the doctor actually imparts there, 90% of which the patient forgets about when they walk out the door — something physicians don’t on the whole realize. In the ICU, what happens in the room is often a matter of life and death, so the interference that the recording of the information puts in the way of the process may have a bigger impact.
3) IT implementations are not easy. Paper does kill. Of course it’s not just paper that kills, it’s poor processes with or without IT. But the option of ignoring IT is not an option. The industry needs to do much more work about getting this right.
We’re almost at the point that you know exactly what any study from the Dartmouth group is going to find before it’s published. Following the assessment last year that showed that the nations “Top 100” hospitals show a wide variety of difference in procedures in their ICUs, for no apparent difference in outcomes, the same result comes up again. This time (with Stanford’s Lauren Baker playing a starring cameo) Wennberg, Fisher et al looked at Medicare spending on patients in the last two years of life in hospitals in California and once again geography is destiny. (Health Affairs article here)
The study found that reimbursements ranged from $19,745 per Medicare patient at Redwood Memorial Hospital in Humboldt County’s Fortuna to $88,661 at Garfield Medical Center in Monterey Park in the San Gabriel Valley
Sacramento was cheaper than the Bay Area which was in turn cheaper than Los Angeles. And of course the outcomes were similar in all places and had little relation to the costs. Interestingly, hospital chain is also a predictor. Sutter, which isn’t exactly known by California’s health plans as being a low cost operator, did way less than Tenet. (although I don’t know if Redding Medical Center skewed the data by itself!)
Medicare spending was also higher in some large hospital systems. Sutter Health, which operates 27 hospitals in Northern California, spent $30,814 on average per Medicare patient in the last two years of life, compared with $46,323 at Tenet Healthcare Corp.
Given that these are the most expensive patients (the 10% that cost 50% of all dollars), and moreover “it’s my money dammit”, you’d think that our so-called conservative leaders would be seizing on this to try to do something about the practice variation problem. But it just seems to be accepted as some type of unintelligent design.
File this in the cleaning up my queue category, but there’s a pretty good article in last weeks NEJM about how a doctor judges himself. I’d submit that apart from baseball players, and call center customer service rep, most of us don’t get the regular metricized feedback that would help us improve.
This doc, Richard Baron, surveyed a small sample of his practice and discovered (and I’m sure that he’s not alone) that although he and his staff were doing OK in servicing patients, and keeping them clinically in good shape, he was not doing so well communicating to them about how to manage their disease. So he needs to import a good dose of information therapy.
But this is a start. The only company I’ve ever worked where there was serious consultation via survey with staff and customers was a survey firm. And to be fair, whatever the results of the survey, they didn’t seem to really change the organization’s behavior too much. Perhaps I should be surveying my clients and my readers….but I think many more doctors should be surveying their patients.
When Senate Finance Committee Chairman Chuck Grassley found out that the value of the approximately $300 million-a-year medicare chemotherapy demonstration project to report on a patient’s level of nausea, vomiting, pain and fatigue was for nothing (providers were being paid $130 to simply forward the data that is already collected), they hoodwinked Congress into additional reimbursement to oncologists that report whether their treatment adheres to practice guidelines published by either NCCN or ASCO.
Looks like cancer patients will have to continue overpaying their oncologists and not have access to cutting-edge cancer treatments, and continue to suffer side-effect consequences and even death. The system will continue to serve the clinical investigators and the clinical oncologists, but not serve the best interests of cancer patients.
I think that the concept that some "authoritative" organization (made up primarily of practitioners and researchers with built in conflicts of interest) should determine the "correct" approach to cancer treatment has been very harmful to progress.
oDr. Enoch Choi, a medblogger (and OT but BTW a liberal evangelical Christian just so you know there is one!) has packed up his black bag and spent the week in New Orleans following his medical calling. Go read his blog and scroll down to the October 1 entry — then read up. Doesn’t take too long as he’s posting via his Treo and he’s mighty mighty busy. It’s an amazing read.
It’s very clear that the return to New Orleans is fraught with similar perils to the evacuation. Plaudits to Enoch to heading out and putting his God-given talents to work in a crisis. They still need doctors desperately down there.
UPDATE: Enoch writes direct (promoted from the comments). Please consider donating once more to the organizations that are sending committed volunteers like him onto the very front lines.
thanks for the props, Matthew. i’ve come to new orleans with City Team ministries and serving under the local authority of Pastors Resource Council PRC Compassion, invited by the local churches in St. Bernard. Menlo Park Presbyterian Church MPPC paid all of our flights, expenses, medicines and supplies.
Any of those organizations would be able to immediately deploy your donations to people we’re seeing every day. Yesterday, one of our nurses gave us $1000 from their Kansas Church… Their entire disposable cash. We spent it today on natural tears, sunblock, nasal saline, sudafed, lozenges, cough syrup, hydrocortisone. We gave it away in 2 hours. There’s immesurable need here, and whatever you give to MPPC would be immediately consumed by that need by our medical team.
to give to MPPC:
to give to City Team:
to give to PRC Compassion:
This is so different than giving to Red Cross, what you give to them will be spent on the next disaster. The Red Cross doesn’t have physicians down here. I don’t see any other medical teams down here other than ours. There are plenty of individual physicians that have come down, and they’re very important, but as an organized group, we’re it.
Susan Sheridan, whom I wrote about last month, is even more famous. She and her son Cal who has kernicterus syndrome are the hook for a piece in The New Republic by Robert Berenson. (You may only be able to get to the first page…) It largely tells the truth about malpractice, but just to reiterate, my reading of the data is that:
1) The tort system only picks up about half of malpractice2) The medical system barely ever apologizes (Susan never got an apology), but when it does law suits are much less likely3) Too much of the money goes to lawyers and expert witnesses, and lawyers and Democrats don’t want to change that, but as they don’t hold power–so what.4) Doctors, whose Republican allies now do hold power, are only interested in reducing caps on damages, which may reduce their rates a bit but does nothing to help severely injured victims of malpractice and more importantly nothing much to reduce medical costs for the rest of us. (I live in California where we have the MICRA caps and my insurance premiums ain’t going down — sufficient proof to me that the Republican talking points about this are bunk).5) Defensive medicine makes the system and the doctors more money and until they stop getting paid for it, the whole "8-10% savings" concept is a myth6) Special courts, non-binding arbitration, apologies, openness, and a near-miss reporting system are all good ideas and are the eventual solution, but the AMA won’t back them, and their Republican allies won’t either. Why not? For them tort reform has nothing to do with patients, and not much to do with doctors, but much, much more to do with stopping what are mostly legitimate lawsuits against malfeasant corporations — and it’s much better if that all gets mixed up with an evil lawyer suing Marcus Welby MD in their PR campaign.
So unless there is some real concession from organized medicine, we’ll keep what we’ve got and it doesn’t work. The "good" news is that it’s only a minor issue compared to the complete morass of the rest of the health care system.
(Hat-tip to Brian Klepper for the article)