Tag: Physicians

PHYSICIANS/INDUSTRY: Notes from my wanderings on EBM and malpractice

Apologies for the lack of posting. When you read the first paragraph you’ll figure out why. I’ve been touring around the East Coast talking to various people in the health care business and then on Thursday went to the UK. Or more accurately got on a plane, which sat on the runway at JFK overnight before deciding that it didn’t want to go and dumping all its grumpy passengers on the next plane. I have a few observations about the state of play with physicians, and Medicare.
I spoke with a group of physicians and a separate group of managers and clinical managers in a rural health system in Pennsylvania, and with various industry watchers and participants on New York and Philadelphia. The doctors are (not surprisingly) concerned about malpractice….given the current deal in Pennsylvania where the governor has decided to pay their malpractice insurance for the current year by raising the cigarette tax. If this goes through it’s a temporary win for the Pennsylvania Medical Society, which has billboards up across the state reading “when the last doctor leaves the state the malpractice crisis will be over”. While this may solve some of their problems immediately, it doesn’t resolve the longer-term issues. In my Q&A with the doctors three major points emerged.
1) There was broad if grudging acceptance that though malpractice reform was needed (from the doctors point of view) simply saying that we need a cap on awards for pain and suffering of $250,000 is not good enough, and that some more valid solution needs to be proposed. On physician told me that 20 years ago both sides of the malpractice equation were taken care of– Anyone hurt badly by the system was looked after institutionally (e.g. a child with brain damage from a “bad birth”) Now the parents only option is to see a lawyer and go after the poor OBGYN who just happened to be there at the time. On the other side, the physician I spoke with is so scared of lawyers that he will not give any kind of a reference about a doctor or nurse, especially a bad one, for fear of being sued by that clinician. That’s one reason why it took so long for the New Jersey “Angel of Death” to be discovered). So lawyers are the problem but also for many patients the only solution. I believe that this view romanticizes the “good old days” especially as way back then doctors’ incomes were lower in real terms and the communal support for victims of poor care wasn’t that great. However, we did agree that lawyering may remain the only solution unless physicians do something constructive about it.
So what might that something be? Well, physicians, nurses and pharmacists have a huge amount of public trust. Amazingly enough, politicians, lawyers and HMO managers do not. As a profession, doctors need to spend some of that “trust capital” by developing education for the public about what evidence based medicine is, and also amongst themselves by showing that they are working to implement it. I appreciate that following evidence-based medicine is very tricky, but the profession needs to level with the public about the fact that not every doctor is practicing state of the art medicine, and that although agreeing on what constitutes EBM is complicated, physicians as a whole are dedicated to working towards that end–rather than simply telling the public that “we have the best health care in the world” and ignoring Don Berwick, the IOM and Michael Millenson.
The real issue is how to do that and to some extent whether they already are doing that. I was accused, perhaps accurately, of identifying organized medicine as only being the AMA. But of course the IOM and the IHI is composed of doctors too, and their work is beginning to have an effect. Many dedicated physicians are working hard to promote the understanding and application of evidence based medicine both among the public and among physicians. The question is how will the public understand this issue and how will that interact with the malpractice issue. If doctors are perceived as simply covering their own rears, and not seen as promoting the best science in the interest of their patients, that “trust capital” may not be there to be spent in ten years time.
2) There were several comments about how much is “too much”. The specter of the Oregon Medicaid insurance experiment (organized rationing for the poor) was invoked. I’d introduced the QALY notion in my talk and one comment I heard was that “we have to get away from the concept that any procedure, test or pill that shows a statistically significant improvement should automatically become standard practice now matter what the cost.” Cost efficiency as a rationale for new Rx introduction has been introduced in the UK, which recently said no to various new drugs for MS and osteoporosis. The concept of introducing that type of assessment to the US is still light years away–we love technology too much for that. But a couple of factors suggest that a compromise might be developing here. First is the slow growth of shared-decision making. Frequently that ends up with a less aggressive course of treatment, because the patient tends to be less interested in a heroic procedure than the physician. The other is the long range state of Medicare, which is eventually going to have too may people at too high a cost to be able to say yes to absolutely everything.

INDUSTRY: Malpractice & EBM, a modest proposal from Matt Quinn

Over at DB’s Medical Rants and at the Bloviator there’s been a continued interesting debate on Malpractice.  I suggest that you read DB’s post here, which as a bonus gets you two long comments from Ross (who writes the Bloviator).  The crux of this issue is how do you shoehorn what we theorists know about evidence-based medicine into the ill-fitting shoe of the American court system. Presumably the AMA and organized medicine should be doing something here.  Matt Quinn, who’s been absent from this column working on an interesting new project at Intermap Systems, has some ideas:

    The medical profession needs to spend its time and energy fixing the problem (i.e. care that does harm and/or doesn’t follow institutional best practices) rather than protecting itself from the consequences of bad care.

    I think that a constructive role that the AMA and the various clinical professional associations can play is in establishing evidence-based guidelines for care.  I know – easier said than done.  But every doc in the country doesn’t need to agree on what appropriate care means.  A 2/3 solution is better than none at all and professional associations – in an activist (versus protectionist) role – can drive this.  If I (or another non-clinician) were serving on a jury in a malpractice case, having evidence-based (professional) guidelines would make understanding whether care was appropriate much easier (and perhaps quicker and cheaper) to determine.  Without good (i.e. evidence-based) reasons to deviate from  guidelines – and an adverse outcome for a patient, fault is obvious. 

    Further, clinicians can use the guidelines (perhaps built into EMR systems) to know when the care that they are providing deviates from evidence-based best practices.  If they feel the necessity to deviate, they should justify themselves.  While this might increase the prevalence of "defensive medicine" in exceptional cases, it would largely eliminate the necessity for "defensive medicine" for most cases.  It is incumbent on professional organizations and the physicians who compose them to ensure that their guidelines are updated to reflect the standards by which they will be judged.   

    There isn’t, of course, a direct correlation between proper care and malpractice liability.  Most malpractice victims neither bring suit nor are compensated.  Some people who receive proper care receive malpractice awards.  Limiting liability robs justice from those who were wrongfully harmed and successfully prove their cases – while protecting the
    perpetrators.  And does nothing to address those who received a judgment but weren’t wrongfully harmed, those who were wrongfully harmed and didn’t bring suit, or the incentive for the medical profession to hold itself to its own oath.

Of course Matt nails the real reason for the rise of malpractice in the Administration’s agenda

    I view Bush’s (Rove’s) preoccupation with Tort Reform as a way to damage the political opposition and not a way to "fix" medicine.

As I mentioned in comments over at DB’s my British heart tells me that you shouldn’t be suing someone who’s trying to help you (which I assume is the case in all malpractice cases). My American head tells me that that’s the way things are here, and the end result, as Matt points out, makes a lottery of the medical system. I have no firm opinions about how to solve the malpractice problem, but I do think that a no-fault error reporting system, or a separate medical court system, should be investigated. Unfortunately this is an arena in which none of the protagonists–organized medicine, trial lawyers, both political parties and the corporations looking for immunity from litigation who are hiding behind the medical profession for political reasons–is looking out for  anything other than their basest self-interest. The public good and patient safety are way down the list.

INDUSTRY: Boutique medicine emerges as an on & off-line niche. Will it be turbocharged by HSAs?

I’m preparing a speech I’m giving next week and I’ve gone back to some of my old charts which essentially said that over time Americans would have less time and more money to deal with our health care (and lives as a whole).  The cause of the less time and most of the "more money" is the disappearance of the (voluntary) stay-at-home spouse.  The additional cause of the more money is the growth in incomes and wealth of higher paid Americans versus the average.

As part of the medical profession’s attempt to deal with the new reality of a higher-end consumer, and as part of the rejection of managed care, some of those physicians who can have made the move towards "boutique medicine". Essentially what that means is they charge an upfront fee for some set of enhanced services to patients that is not billable to an insurer, and thus is paid in cash by patients.  The leading example of this is Howard Maron, M.D., MD2’s founder and ex-team doctor for the Seattle Supersonics who apparently has enabled himself and three colleagues to bill over $1 million each annually by taking care of 100 people at $10,000 each (or $20,000 depending on who you believe)–the patients still carry insurance for labs, hospitalization and other expensive stuff.

    MD2 physicians deliver care not available elsewhere, such as appointments often lasting an hour, extensive preventive care, thorough annual physicals, and even advocacy for patients with payers and other providers. MD2 doctors practice a "proactive, preventive" approach to health, he adds. They also provide the full range of primary care.

    MD2 doctors don’t bill insurers or participate in insurers’ networks, Moses notes. "We encourage the patients to have insurance for everything else" besides primary care, he continues, including hospitalization, specialists and drugs. "This is not a replacement for insurance in any way."

 It sounds great for the docs as the overhead is lower and the revenue is higher than typical primary care.  It doesn’t sound so great for the patients, unless the price of doctor visits is much higher in Seattle than I’ve understood.  But if they can get people to sign up for it, good luck to them–it’s the American way.

More realistically The McKinsey Quarterly had an article a while back about Virginia Mason (also in Seattle) which charges $3,000 a year and has over 850 people signed up.

    For $3,000 a year, it offers individual subscribers 24-hour access to internists by mobile telephone or e-mail, as well as house and office calls by physicians. In addition, the Dare Center’s doctors who see 3 to 8 patients a day, compared with 20 to 25 for their colleagues at health maintenance organizations (HMOs) spend more time with each subscriber. Revenue from subscriptions easily fills the gap between the higher fees charged for the longer, off-hour, off-site consultations and the insurers’ reimbursement payments, which are based on the standard charge for an office visit to an internist during normal hours.

    About 850 people, mostly over 60 years of age, have subscribed, far exceeding expectations, and the Dare Center plans to expand. On average, members use it 7 or 8 times a year, while people in their US age cohort make an average of 6.8 visits to clinics a year.

This may work for some clinics and systems, and they may manage to sail around Medicare laws that ban balanced billing.  But it strikes me that that’s a little too much money to become mainstream.  Some other clinics are offering similar services at a lower price–you can get extended phone and email consults, plus the promise of an appointment the next day from GreenField Health Systems for a mere $350 a year, so long as you move to Portland, Oregon! That seems to me to be closer to what most people might find reasonable to pay, if they are regular visitors to their doctor.  For those who want these type of "concierge services" a company like Health Dialog, which uses the Wennberg technique of Shared Decision-Making. Shared Decision Making "presents patients with evidence-based, unbiased views of their healthcare options, and encourages patients to work with their doctors to choose the healthcare options that are right for them". It also tends to make patients use less health care, and so health plans and employers are happy to pay for it, which is why Health Dialog is growing quite fast and why the other DSM companies like LifeMasters and American Healthways are growing quite fast.

There’s a very limited market of people who can or will pay $10,000 or even $3,000 a year for primary care services.  But $1,000 or $1,500 which covers, say, 10 doctor visits, emails, phone calls, and all the hand-holding you can eat, may be attractive to consumers–especially if doctors stop making phone calls for free (mine does, thanks Dr…no I won’t say his name!). The question I don’t know the answer to is whether people will be able to use their yet to be set-up HSA or Consumer-directed health plan accounts to pay for these boutique care services.  But if the fees counts against the HSA and the deductible, then anything else (more or less) hits against the catastrophic insurance.  So the boutique service is more or less free (assuming that the patient would be making those visits any way). And if a primary care doctor can get 3-400 patients to pay it, well that’s a nice bonus.

So watch this one shake out as doctors try to set up to get into the boutique game at a bargain price and make it work for CDHPs and HSAs. Of course the insurers will try to wriggle out from having these payments count as co-pays or against deductibles.

The bigger question is that, as employers and plans push "consumer choice" onto patients (what Ian Morrison calls "You’re on your own pal!"), how big a phenomenon will boutique medicine be? Or will consumers/patients who are already getting aggravated with having to contribute more for their insurance at work, get really mad when they are asked to pay more for the services that they thought they were already getting from their physicians?


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