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Tag: Anish Koka

In the Land of the Health Care Experts

Arguably, the most consequential moment of the nascent Trump administration will take place later today when Congress Votes on the first iteration of the bill known as the American Health Care Act (AHCA). If the success or failure of the bill to this point is to be judged by its reception from policy thinkers on most sides of the political spectrum, it is already an unmitigated failure.

It should be worth noting, however, that healthcare in America is a massive business accounting for 3 trillion dollars in spending with powerful stakeholders. Any real attempt at reform is bound to be opposed by those who would naturally resist attempts to dam the river of dollars that flows to them. The resistance from these parties always comes in the form of entreaties to think about patients harmed by whatever change is trying to be made.

Figuring out which stakeholder actually has the patients best interests at heart is akin to playing a shell game. All the cups look the same and its entirely possible the marble is underneath none of the cups. As a physician, I am of course, another stakeholder with inherent bias but I would submit that practicing physicians, among all the players at the table, have their interests most aligned with the patients they must directly answer to every day.Continue reading…

Randomized Trialomania

This story is old, but the age of the story should not detract from the lessons of the story.

It was 1982, the place was Tsukuba, Ibaraki Prefecture, Japan. Workers at Fujisawa pharmaceuticals began testing fermented broths of Streptomyces species that had been retrieved from soil samples at the base of Mount Tsukuba.  They were working to solve the remaining achilles heel of organ transplantation – effective suppression of the immune system that would prevent the body from attacking its new guest.  It had quickly became apparent to the medical community that the key to long term survival of patients now lay in the development of effective, non-toxic immunosuppressive agents. 

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After two years of testing, isolate no. 9993, which later came to be named FK506, or Tacrolimus, showed promise in inhibiting lymphocyte reactions.  First reports emerged in the literature in 1987, and were impressive.  The agent appeared to suppress mixed lymphocyte culture at concentration 30 to 100 times lower than the gold standard at the time: cyclosporin.  (1)

The father of organ transplant, Thomas Starzl was in Pittsburgh at the time, and quickly seized on the potential of this new agent.  By 1990, he had used the drug successfully in patients who were rejecting their liver transplants on conventional cyclosporine based immunosuppression. The positive results of the ‘rescue’ trial prompted initiation of a randomized control trial in Pittsburgh that compared cyclosporine to FK506 from the time of transplant.
At the time, the randomized control trial was in its relative infancy, and had not yet achieved the hallowed status it has today.  This, of course, was changing rapidly. Physicians recognized the fallacy of epistemology sourced purely from intuition and tradition, and sought the shelter of certainty that randomized control trials (RCTs) promised with the random allocation of patients to treatment and control arms.  The Pittsburgh team thus randomized 81 patient, 40 to cyclosporine – the conventional treatment – and 41 to FK506, the new kid on the block.  Investigators studied patient mortality and survival of the transplanted organ at various time points.  By convention, results were analyzed using statistical hypothesis testing – and to the lay person would seem to be underwhelming.  

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Death and Readmissions

Eugene’s wife is on the phone.  She has been taking care of Eugene for 41 years.  I supposedly take care of his heart, weakened by two prior heart attacks.  I say supposedly because his wife does all the heavy lifting.  She makes sure he takes his medications when he should.  She watches his weight every day and occasionally administers an extra dose of diuretic when his weight climbs more than a few pounds in a day.  And perhaps most importantly, she calls me when Eugene’s in the hospital and things seem wrong to her.  This is one of those phone calls.  They were in the ER, Eugene hadn’t been responding to his diuretic as he normally does, and his breathing seemed more labored to her.  The ER physician wanted to send them home – she was hoping I would weigh in.  Not surprisingly, she was right, Eugene needed to come into the hospital.  I used to be surprised when the ER wouldn’t call me for complex cardiac patient having an acute cardiac problem.  Not any more.

There is a clear culture shift that is obvious to those who have spent any time in the ER over the past ten years.  Low risk patients used to be managed and discharged from the ER, and higher risk patients were quickly admitted to the hospital for management by specialists.  This used to be a source of tremendous friction with the ER in my younger years, as I would try to explain to ER physicians that every single chest pain in a patient with known coronary disease did not deserve admission.  I seldom have this conversation with the ER anymore.  What changed?

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The Physician’s Case For Trump

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Brexit has been hailed as a turning point in the history of Western Democracy by a collection of liberal and conservative elites that decry the vote of a disenchanted and ignorant populace.  The greatest threat to democracy in the modern age turn out to be the very same people that make up the democracy.  We are told these are the same forces that propel Donald Trump forward.  It is a convenient narrative that extinguishes any real debate on policy.  If you support Brexit or Donald Trump you are an uninformed, xenophobic bigot.  Yet here I am – an Indian immigrant, a physician, and a lifelong democrat to boot, who sees no other choice than Trump this election cycle.

I must confess that I have no emotional connection with Mr. Trump – his public demeanor, braggadocio, and above all, the coarseness of his manner when he engages opponents are not what are familiar or soothing to eye or ear.  Yet, as a physician who has struggled through the last eight years of policies and regulations that have made my ability to take care of patients more and more difficult, Mr. Trump has taken on the form of an orange-tinged life preserver.

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ACO 101: Koka Completely Misses The Mark on Medicare ACOs

flying cadeuciiRecently, Anish Koka, MD, a Cardiologist from Pennsylvania, posted his anti-Accountable Care Organization (ACO) manifesto here on The Health Care Blog. [1] Koka argues that ACOs don’t work and are doomed to fail because they were designed by non-practicing physician policymakers and academics in ivory towers. He appears to be basing his judgment on a commercial ACO contract that only pays him $4 per month extra for care coordination and requires that he meet specific quality measures. He is also conflating his experience in a commercial ACO with Medicare ACOs, and interprets the initial results of one Medicare ACO program to mean that all ACOs are a failure. Finally, he relays an anecdote of caring for one of his patients, Mrs. K, a patient with chronic illness who doesn’t want to take her medication.

In his post, Dr. Koka calls out “well-meaning, hard-working folks that own a Harvard Crimson sweater…[whose] intent is to fundamentally change how health care is provided.” As luck would have it, I do own a Harvard Crimson sweater, and I’d like to respond.

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The Angry Physician

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I think I speak for most physicians when I say that we did not choose to go into medicine to shape health care policy.  Medicine is a calling, and I treated it as such.  I immersed myself with taking care of patients, and keeping up with the ever changing knowledge landscape that is medicine. I left the policy making to the folks I voted for the last 8 years. These were the adults, the intellectuals –  they would take care of the task of taking out the bad elements of our healthcare system and leaving the good.  I truly believed.  I eagerly began the ehr/meaningful use saga believing this would result in better care for patients.

It took me two years to realize the meaninglessness of meaningful use.  I still can’t believe how long it took me to realize that creating a workflow in my office to print out and deliver clinical summaries to patients didn’t do anything other than fill the trashbin. I still held out hope.  I thought – this was a first draft, improvements would come.  What came instead were positively giddy announcements of the success of the meaningful use roll out. The administration was actually doubling down.  There was no acknowledgment for the mess that had been created – onward and forward on the same road we must continue to march.  Except the road would no longer be paved and we would be walking uphill.

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The ACO Delusion

flying cadeuciiAccountable care organizations (ACO’s) promise to save us.  Dreamed up by Dartmouth’s Eliot Fisher in 2006, and signed into law as a part of the Patient Protection and Affordable Care Act (PPACA) in 2010, we have been sold on the idea that this particular incarnation of the HMO/Managed Care will save the government, save physicians and save patients all at the same time.  I dare say that Brahma, Vishnu and Shiva together would struggle to accomplish those lofty goals.  Regardless of the daunting task in front of them, the brave policy gods who see patients about as often as they see pink unicorns, chose to release the Kraken – I mean the ACO – onto an unsuspecting public based on the assumption that anything was better than letting those big, bad, test ordering, hospital admitting, brand name prescribing  physicians from running amuck.

I realize I am being somewhat harsh towards the creators of the ACO morass.  But, while they all may be well-meaning, hard-working folks that own a Harvard crimson sweater, their intent is to fundamentally change how health care is provided – this mandates a withering evaluation.  As Milton Friedman aptly said, “One of the great mistakes is to judge policies and programs by their intentions rather than their result.”  Thus, with little regard to intent, and with an eye on the end result, I say unequivocally : ACO’s do not work.Continue reading…

In Defense of Small Data

flying cadeuciiI read with interest a recent editorial that opined on the poor evidence for screening in cancer trials. The evidence was judged poor because apparently no screening trial has demonstrated a clear reduction in all-cause mortality, only disease-specific mortality.  One example discussed in the analysis reviews the data for colon cancer screening and notes that, while there were a statistically significant lower number of deaths related to colon cancer in the screened group, the total mortality in the two groups was no different.  The authors posit that the study is either underpowered for total mortality or that the screened patients may have more deaths due to the ‘downstream effects’ of screening.  The provocative conclusion by many a tweet and retweet is that cancer screening has not been shown to save lives. Apparently the path to progress in medicine now must be paved by studies with millions of patients.  I understand the desire for more and more data, but I see danger in the sanctimonious protestations of those who can only find truth within the confines of a million-person, randomized control trial.  This approach ignores the history of advances in clinical medicine, most of which live far outside of the boundaries of million-strong randomized clinical trials.

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Risk Scoring and Value-based Payments Haven’t Worked: The Medicare Advantage Story

Mrs. Cassidy slowly walks into my office one busy afternoon.  I see her out of the corner of my eye because she is hard to miss.  Mrs. Cassidy has some serious style.  She has a deep orange dress with a bright blue blazer on.  There aren’t too many folks that can pull that outfit off, but she can.  She has a wide slow smile, and she speaks with a slow southern drawl that belies her southern roots.  This was supposed to be a routine follow up visit for a 67 year old woman with a history of a mechanical mitral valve replacement and coronary disease.

Unfortunately, she tells me a story that is concerning for angina.  I think she needs a stress test. I slide over to the insurance tab on the EMR and I let out a somewhat audible groan.  She has a Medicare Advantage (MA) plan.  I explain to Mrs. Cassidy that we will need to go through an extra step to pre-certify her stress test.  She expresses surprise and asks me what she should do.  I will tell you what I told her, but first, let me tell you why.Continue reading…

The Magical World of ACA Funding

Congressional leaders just agreed to a budget that would keep the government open through September 2016. I was happy to hear the government was not going to shut down. I was much less happy to hear about the fate of provisions supposed to fund the Affordable Care Act (ACA). The ACA – costing $1.2 trillion over 10 years – was supposed to ‘mostly’ pay for itself.  Revenue was to be generated (in large part) by a series of taxes on a variety of different sources. These taxes did not fare so well in the current budget.

‘Cadillac’ Tax

The ACA took aim squarely at high cost employer-sponsored plans.  Economists believe that since employer health insurance is tax deductible, high cost plans proliferate as a mechanism to provide a tax free benefit to employees. These expensive plans are expensive because they cover most of the cost of medical care, insulating the patient from the actual cost of medical care. The ACA imposed an annual 40% tax on plans with annual premiums exceeding $10,200 for individuals and $27,500 for families to be paid by the insurers. The results were to be two fold: One, create a disincentive for employers to offer ‘cadillac’ plans, and two, generate revenue to pay for the ACA. A broad coalition composed of democrats and republicans lobbied to defeat this tax.

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