Sure, I’ve always wanted to write a clickbait headline that sounds like a promo for the bastard child of Buzzfeed and the Federal Register. But, seriously: you will not believe what Medicare just did about patient engagement in a draft new rule dramatically changing how doctors are paid.
And, depending upon the reaction of the patient community, you definitely won’t believe what happens next.
The annual Lown Institute Conference advocates for the “right” kind of patient care, as in “the correct course of action.” But the political meanings of “right” and “left” also echo, sounding like a healthcare version of the recover-lost-glory demands of Donald Trump and the moral crusade of Bernie Sanders.
The program for this year’s meeting, held in Chicago, urged attendees to “take back health [care];” you could almost hear a Trumpian, “Make medicine great again!” In an opening address, the institute’s senior vice president, Shannon Brownlee, proclaimed, “We are gathered out of a shared sense of moral purpose and a shared sense of outrage at the state of American healthcare.” The targets of that outrage that “we” need to take back healthcare from comprised a Sanders-type litany of the “pharma, biotech and device companies…[who] have illegally marketed products.”
There was one more villain, very carefully defined. That would be “a culture of overtesting and overtreatment…[that] harms patients, clinicians and communities.” Got that? While Brownlee’s acclaimed 2007 book, Overtreated, repeatedly highlights the abuses of fee-for-service medicine, the Lown Institute’s namesake founder and its president are academic physicians. And so, the doctors and hospitals responsible for and often profiting from overtreatment magically become just one more set of victims of the “culture.”
Ideological blinders notwithstanding, the institute’s work celebrates and highlights an impressive array of individuals working diligently for every conceivable kind of “right care.” There was Dr. Jeffrey Brenner, a Camden, NJ family physician whose description of his dogged, data-driven efforts on behalf of the poor and sick brought a standing ovation. And Dr. Joanne Lynn, a long-time advocate for the frail elderly, explaining why a MediCaring community model that mixed medical and social services was what the vulnerable old and their families really needed.
In my three-part series on why we know so little about ACOs, I presented three arguments:
We have no useful information on what ACOs do for patients;
that’s because the definition of “ACO” is not a definition but an expression of hope; and
the ACO’s useless definition is due to dysfunctional habits of thought within the managed care movement that have spread throughout the health policy community.
Judging from the comments from THCB readers, there is no disagreement about points 1 and 3. With one exception (David Introcaso), no one took issue with point 2 either. Introcaso agreed with point 1 (we have no useful information on ACOs), but he argued that the ACO has been well defined by CMS regulations, and CMS, not the amorphous definition of “ACO,” is the reason researchers have failed to produce useful information on ACOs.
Another reply by Michael Millenson did not challenge any of the three points I made. Millenson’s point was that people outside the managed care movement use manipulative labels so what’s the problem?
I’ll reply first to Introcaso’s post, and then Millenson’s. I’ll close with a plea for more focus on specific solutions to specific problems and less tolerance for the unnecessarily abstract diagnoses and prescriptions (such as ACOs) celebrated today by far too many health policy analysts.
Summary of Introcaso’s comment and my response
I want to state at the outset I agree wholeheartedly with Introcaso’s statement that something is very wrong at CMS. I don’t agree with his rationale, but his characterization of CMS as an obfuscator is correct.
The eminent physicians Martin Samuels and Nortin Hadler have piled onto the patient safety movement, wielding a deft verbal knife along with a questionable command of the facts.
They are the defenders of the “nobility” of medicine against the algorithm-driven “fellow travelers” of the safety movement. On the one side, apparatchiks; on the other, Captain America.
They are the fierce guardians of physician autonomy, albeit mostly against imaginary initiatives to turn doctors into automatons. By sounding a shrill alarm about straw men, however, they duck any need to define appropriate physician accountability.
Finally, as befits nobility, they condescend to their inferiors. How else to explain the tone of their response to the former chief executive officer of Beth Israel Deaconess Medical Center, Paul Levy? As for patients, Samuels and Hadler defend our “humanity.” How…noble.
To me, healing the sick is an act of holiness, not noblesse oblige. Fortunately, we Jews cherish a long tradition of arguing even with God Himself. A famous Talmudic story ends with God acknowledging that even Divine opinion isn’t enough to override the rule of law. Let’s take a closer look at Samuels’s and Hadler’s opinions in relation to the rules of medical evidence.Continue reading…
Among the 200 demos, 60 exhibitors and more than 100 speakers at the annual Health 2.0 conference on digital health, a critical insight for succeeding in this burgeoning market might have gotten lost in the noise.
The crucial advice came on separate days from two of the savviest digerati doctors in Silicon Valley. Not coincidentally, both Dr. Robert Wachter and Dr. Michael Blumpractice at the University of California, San Francisco (UCSF) Medical Center.
Wachter, an internist, was an early and eloquent advocate of the potential of electronic health records (EHRs) to improve the safety and quality of care. Actual EHR implementation, however, brought not nirvana, but a jarring number of “side effects.” Not least was the way the technology often distracts, confuses and complicates the lives of clinicians, endangering patients in the process.
To understand how a landmark new report on diagnostic error breaks the mold, go past the carefully crafted soundbite (“Most people will experience at least one diagnostic error in their lifetime, sometimes with devastating consequences”) and rummage around the report’s interior.
You can’t get much more medical establishment than the Institute of Medicine (IOM), also called the National Academy of Medicine, author of the just-released Improving Diagnosis in Health Care. Yet in a chapter discussing the role played in diagnostic accuracy by clinician characteristics, there’s a shockingly forthright discussion of the perils of age and arrogance.
“As clinicians age, they tend to have more trouble considering alternatives and switching tasks during the diagnostic process,” the report says. Personality factors can cause errors, too: “Arrogance, for instance, may lead to clinician overconfidence.”
Wow. Sure, both those assertions are extensively footnoted and hedged later with talk of the importance of teams (see below). Still, given the source, this practically qualifies as “trash talking.”
Of course, those quotes didn’t make it into the press release. There, inflammatory language was deliberately avoided so as not to give opponents any easy targets. (Disclosure: I was an advocate of an IOM report on this topic while consulting to an organization that eventually helped fund it. After testifying at the first committee meeting, I had no subsequent involvement.)Continue reading…
Your doctor believes he’s “patient-centered” because he wants to provide the the treatment he thinks you need as quickly as possible. Or as the fictional Dr. Heart tells his chest pain patient right after recommending a stent, “As it happens, I can do the procedure for you next week. Does that work for you?”
Before giving in to the gurney, what questions should patients ask? One data-driven script was presented in skit form at the recent Health Datapalooza 2015 meeting in Washington, D.C. The drama was light-hearted; the clinical and financial issues underlying it are not.
Dr. Heart was played by Glyn Elwyn, a theater student-turned-family practitioner recognized as one of the world’s leading researchers in patient preferences and values. Casey Quinlan, a writer and activist widely known for her unfiltered expression of those preferences and values, played the patient.
In the skit, a persistent Quinlan keeps pestering the doctor with questions about what a stent will accomplish that changing her medications won’t. At first glance, a stent sounds appealing because it props open the blood vessel. What could be better? However, when Quinlan asks directly about the effect of meds versus stenting on preventing a heart attack, the doctor admits that data show medication lowers the odds but stenting does not.
Twenty years ago this month, the Boston Globe disclosed that health columnist Betsy Lehman, a 39-year-old mother of two, had been killed by a drug overdose during treatment for breast cancer at Dana-Farber Cancer Center. In laying out a grim trail of preventable mistakes at a renowned institution, the Globe prompted local soul searching and a new focus on patient safety nationally.
Although I didn’t know Betsy personally, we were about the same age, had two kids about the same ages and were in the same profession. (I, too, was a health care journalist.) That’s why I was particularly disappointed by a recent conference celebrating the reopening of the Betsy Lehman Center for Patient Safety and Medical Error Reduction. It was heavy on statistics and poll results; e.g., one in four Massachusetts adults say they’ve seen an error in their own care or the care of someone close to them.
While it’s true that Boston is the epicenter of thinking, writing and speaking about patient safety, words do not always translate into deeds.
A few years ago, I was upgraded to First Class on a flight from California back to Chicago. Not long after I settled in, a tall, muscular man easily four inches taller than me walked up to my aisle seat in the first row and prepared to sit by the window.
I envisioned him spending hours hemmed in by the bulkhead and offered to switch places. We began to talk, and soon he shared that his seatmates often hesitate to engage him in conversation. Women and even some men will turn or stiffen in their seats in order to send a clear body-language message.
That’s what happens when you’re a large, physically imposing black guy. People make assumptions. When it comes to patient engagement, we often make assumptions, too.
We minimize the influence of race, gender and ethnicity, or we confuse it with socio-economic status. We assume that “people like us” have communication preferences like us. We downplay the doctor-patient relationship and overemphasize technology.
Race and Ethnicity Matter
In truth, race and ethnicity matter as much in medicine as in the rest of the society. For example, whites, African-Americans and Latinos share the same expectations of their physicians, a study in Health Services Research found, but “patients from different racial and ethnic groups report differing experiences…when using well-validated measurement tools.” Translation: the perception reflects reality.
I was reading a medical home advocacy group’s upbeat approach to a recent JAMA study that had found scant benefit in the concept when, suddenly, we tumbled into Alice in Wonderland territory.
The press release from the leadership of the Patient-Centered Primary Care Collaborative (PCPCC) started out reasonably enough. The three-year study of medical practices had concluded that the patient-centered medical home (PCMH) contributed little to better quality of care, lower cost and reduced utilization. This was an “important contribution,” said the PCPCC, because it showed “refinement” of the concept that was still necessary.
That was just the set up, though, to this challenge from Marci Nielsen, chief executive officer of the group. “It is fair,” said Nielsen, “to question whether these pilot practices (studied) had yet transformed to be true medical homes.”
Where might one find these true medical homes? The answer turns out to be as elusive as a white rabbit. Formal recognition as a medical home via accreditation “can help serve as an important roadmap for practices to transform.” However, accreditation as a PCMH “is not necessarily synonymous with being one.” Conversely, you can be a “true PCMH” without having received any recognition at all!
But maybe the true medical home does not yet exist, since, “the evidence base” for the model “is still being developed.”
In Through the Looking Glass, Humpty Dumpty scornfully informs Alice: “When I use a word, it means just what I choose it to mean – neither more nor less.” And so we learn that a true medical home means just what the PCPCC says it does.
It’s confusing. If the truly transformational medical home lies in the future, why does the PCPCC chide the JAMA researchers in this “otherwise well-conducted study” for failing to “reference the recent PCPCC annual report which analyzed 13 peer-reviewed and 7 industry studies and found cost savings and utilization reductions in over 60 percent of the evaluations”?