I don’t know, but this week she’s in Newsweek.
You’ll see more of Amy at the Health 2.0 conference…and we think she’s wonderful too!
THCB Reader Mail (from Maggie Mahar & Jeff Goldsmith)
Frequent THCB contributor Maggie Mahar responds to Matthew’s post last week on decision aids:
"Too often, "patient satisfaction" is based on trivial things that have little or nothing to do with the quality of care. For example, a patient may have to wait two hours to a see a doctor because the doctor was called into surgery, because earlier in the day what he thought would be a routine 20 minute visit turned into an emergency. Or maybe he just spent 10 or 15 minutes longer with each of 5 patients because they had questions.
I once spent five hours listening in while the head of cardiology at a major medical center saw patients. All of these things happened except being called into surgery. One patient showed up, without an appointment, who had begun losing his vision in one eye that morning. A very bad sign. He needed immediate attention.
Another patient’s test showed that his carotid artery was totally blocked. In other words, he shouldn’t be alive. (The doctor was completely shocked). But there he was, sitting there, 85 years old, with a flock of his octogenarian relatives. It took a while to explain to all of them what was going on and why he needed immediate surgery.
Then there was the CEO scheduled for a bypass in four weeks who wanted to put it off because he wanted to wait three months until the end of the golf season. (He had already collapsed on the golf course, which was when he was diagnosed.) He also wondered why he couldn’t have the surgery at a hospital near his home in the surburbs rather than at the medical center in NYC. "It’s so hard to park here," he explained. "And it’s expensive." I wanted to stand up and scream: "You’re having open-heart surgery! Hire a car!"
POLITICS: Whisper it quietly…
But some on the left are begging to realize that health reform, post an assumed 2008 Democratic victory, is still a very, very big assumption. On liberal blog Daily Kos, DemfromCT uses the recent polling data from Bob Blendon’s group at Harvard MollyAnn Brodie’s team at KFF and an editorial from Columbia’s veteran health policy prof Larry Brown in the NEJM to help his colleagues understand why health reform is so hard. Of course you sensible folk already know.
Families USA: Tom Daschle on Health Care Reform – Brian Klepper
Former Senator and Majority/Minority Leader Daschle gave the opening address on the 2nd day of the Families USA Health Action conference. Mr. Daschle has a new book coming out in March on America’s health system and our past efforts to fix it.
I was honestly impressed with Mr. Daschle’s grasp of the sweep of health care problems and how they play out. Mostly importantly, he was clearly aware of the deep challenges associated with getting meaningful change, given the industry’s control of Congress and the policy-making process.
QUALITY: Decision aids in the real world
Most of this morning at the FIDMD meeting has been largely technical stuff about setting up decision aids. Shannon Brownlee suggests that the name should be changed to “personalized medicine” which has been nicked by the bio-tech crowd for now.
There is progress in better patient information around systematically including patient preferences, values & desires at the point of care—particularly in prostate screening & breast cancer. (Good programs at Dartmouth, the VA local UCSF, Group Health of Puget Sound, and several other primary care programs in academic medical centers).I won’t bore you with the technicality of the decision aid methodology (because I didn’t understand much of it!)
All good stuff and all leading to the question, what happens when this starts to get mainstreamed because, (of course) better informed patients tend to desire less aggressive care? (Although interestingly there were actually several anecdotes about cancer surgeons & radiologists now pushing lumpectomy on some women who actually want the radical masectomy—so even when “do less” becomes the mantra it may not fit what patients want). But overall, this is a threat to the ability of patients to entreprenurially do what they want and get paid for it.
QUALITY: The sociology & economics of practice patterns & decision aids
More from Matthew at the FIMDM conference
David Jones, Harvard medical historian on revascularization
Why do you need a randomized clinical trial (RCT)? From the 1960s surgeons could show that CABGs opened veins (removed plaque) so why was there a need? As it turns out, it’s not the large plaque in the vein that kills you but instead it’s the smaller “fragile” plaque which ruptures & causes heart attacks—it’s not the big blockage that causes the heart attack. Angioplasty (PCI) doesn’t get that fragile plaque out, so it shouldn’t be used as much as it is. Of course that’s not what happened. We’d already been shown that by Lee Lucas that there was lots more angioplasty when this theory became well known
However in fact the theory about these fragile plaque rupture was in the obscure cardiology pathology literature in the 1960s but didn’t break through to the mainstream cardiologist opinion until the late 1990s.
POLICY: The Lessons of ’94
Ezra Klein, who I think is hanging with Brian Klepper at Families USA — where Don Berwick is hopefuly showing the link between system reform and insurance reform Friday— has a nice article out on the The Lessons of ’94. I, being biased and an arrogant git, slightly prefer this take on the matter.
But the basic question is, will things be bad enough to override the coming opposition of the health care industry to going after their goose? Remember that we need three convergent factors to actually get health care reform that means anything. 1) The Democrats to win big enough in November to both take White House in a canter, and a bigger chunk of the Senate. 2) A new spirit of political ruthlessness (perhaps they could hire Karl Rove, who seems to have time on his hands?) and 3) radical increase in middle class and more importantly middle-class voter insecurity about their continuity of insurance coverage. Translation for #3 is a bad mother of a recession that seems to have no end.
I don’t think we get any of the above….but at least one guy who seems to understand markets a little better than I (around $6bn better) thinks that #3 is coming.
QUALITY: Foundation for Informed Medical Decision Making research conference
While Brian is hanging with the politicos down in Washington DC, I’m in Boston at a meeting looking at the research funded by the Foundation for Informed Medical Decision Making. This is the group that looks at practice variation and how to inform patients about treatment options and is funded (in part) by Health Dialog which uses their decision tools. Health Dialog (recently bought by UK insurer BUPA)’s Analytics Group is headed by David Wennberg, Jack Wennberg’s son. Jack is of course a major hero on THCB so expect me to be in agreement with most stuff! (They were nice enough to pay my way out here, full disclosure).
Eliot Fisher, famed Dartmouth doc who is no doubt on the AMA hit list, introduced a panel on small area variation. There’s lots of very, very new (and unpublished in academic terms) data released. Most confirming everything Jack Wennberg said in 1973 (yes he’s in the room—I’m only moderately afraid of a mysterious breakout of food poisoning in the hotel!)
First up was a Brit, Klim McPerhson who was looking at surgical intervention rates in different countries. (There’s lost of issues with data being differently collected from different countries needing clinical experts and experts on data sources in international variations to work it out. It’s a big work in progress(not that’s that’s stopping Rudy Giuliani)
So what did he find? For Cardiac rates, America is high, everyone else lower save Australia. Back surgery, America much much higher for spinal fusions, and much higher for elderly people. Hysterectomy rates, greater “excess” of hysterectomy for young women in US and Canada increases meaning that the number of women with hysterectomies greater than others, but everyone overall is having a downwards trend. But it’s gone down because of increased rate of endometrial ablation and making it a second line therapy.
Overall in differences between countries? There’s high variation in the amount of variation between procedures (only hip replacement is very standardized)
What’s the difference between the UK (traditionally at the bottom) and the US? Klim thinks that its conservative medical practice in the UK, but also that we may be missing some of the data in the UK due to private surgery
Note that the data sources miss proportions in different countries (may miss outpatient surgery in US, may miss private surgery in the UK).
Lee Lucas, Maine Medical center, Lee Looked at rate of cardiac procedures in the Medicare population, and (true to the Foundation’s mission) could somewhere there be between shared decision making as part of the process. She starts with the assumption that there’s no difference in impact of either medical or interventional therapy in terms of heart attacks—proved by the fact that AMI rate has stayed flat over 1993–2001. Meanwhile stress testing has gone up very fast, revascularization (that’s actual procedures doing something to fix the heart) has gone up, but actually CABG has gone down but angioplasty (PCI) and cardiac cath (invasive imaging) has gone up. Most of the south & Florida is higher than average use. Increasing PCI rates are related directed to increasing cardiac cath rates (more caths done, exponentially more PCI.
She did a cohort study in Medicare population in 2005 (Part A & B not in HMOs). She found that there was 3 times more PCI, than CABG. AMI is common on admission (but only 12% of all PCI). She’s now looking at where they would put in decision support—for non-emergent patients about 1/3 had a hospital stay. But only 60–50% had a stress test before, and only 28% had a card cath BEFORE they had the PCI, which means the rest went in for a cath and came out with a stent. So how could we intervene for those people? Or should there be better shared decision making about the cath?
Why did the explosion in doing the cath image and the stenting (PCI) at one time? Dave Wennberg says that a) payers wouldn’t pay for two procedures, so they forced docs into making the choice—and they get paid 6 times more to do that and b) when they asked cardiologists ad hoc decisions were much more likely to include “stenting” than if they considered it over more time later (pressure to act)
Amy Aldredge is a plastic surgeon who was looking at Mastectomy vs Lumpectomy with radiation (breast conservation) for early stage breast cancer. In both cases the outcome as shown by a mid 80s random clinical trial is the same. In the 1908s and 1990s there was no change in rate of overall mastectomy despite the revelation of the trial. Jack Wennberg says that this was the the biggest failure of the lack of inclusion patient choice in decision.
Again there are more data problems—it’s hard to pick lumpectomy from other procedures (biopsy) on an outpatient basis, and hard to pick an initial action from an incidental procedure to a case already in process (may be 5–10 years). In other words she had to do lots of methodological screwing around to get to her data.
The good news is that of the breast cancer cases; mastectomies have gone down to 19%. Within lumpectomy (BCS) still similar wide vary between 69–97%. So in 20 years we have done a complete 180 change. Now BCS is preferred to mastectomy. But there are several interesting characteristics associated with increased likelihood of mastectomy. Biggest variation how sick the patient is. OK, that’s probably fine. But after that the age of surgeon matters. Surgeons above 40 20–30% higher more likely to do mastectomy and female surgeons 25% less likely to perform mastectomy. Presumably surgeon choice shouldn’t be the driver, but it is…
Concierge Medicine From A Doctor’s Perspective – David R. Donnersberger, MD, JD
Call it boutique medicine. Retainer medicine. Platinum care. Evoking the pastoral image of a sturdy black doctor’s bag and spectacles, concierge medicine is a small but growing trend among over-worked and over-booked physicians. The practice essentially offers a limited number of patients the opportunity to pay a fixed annual fee in exchange for premium services and attention. Fees can range anywhere from $1,000 to $20,000. Concierge medicine has been dubiously received while transition necessitates limiting a physician’s patient base significantly. Imagine receiving a letter from your doctor of 30 years demanding an annual fee on top of the cost of your normal visits. Hurry your check, and you may be one of the lucky ten percent the practice will keep. Thousands of patients have been outraged to receive just this kind of letter from their family doctor.
I believe concierge medicine can indeed offer significant advantages if mixed with a dose of good, old-fashioned business practice. There exists a happy medium that allows physicians to spend increased time with patients without alienating long-term clients. In our practice, we demand no annual fee. We ask that Medicare patients pay out of pocket for their wellness visit; such payment is only covered when the patient turns 65. The patient can in turn be reimbursed on the insurance provider’s schedule.
TECH: Google Health getting closer
Those purists who spend their time pondering Google’s next move have found a login page for Google
Health….
Here’s what it says Google will do (no, the page itself doesn’t work!)
With Google Health, you can:
- Build online health profiles that belong to you
- Download medical records from doctors and pharmacies
- Get personalized health guidance and relevant news
- Find qualified doctors and connect to time-saving services
- Share selected information with family or caregivers
Hat-Tip: Tech Crunch
