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BLOGS: THCB sells out!

Well not exactly, but I have taken a first tippy-toe in the commercial water by putting Google Ads down in the left column. No idea how it’ll play out but maybe I’ll cover some of my costs. Because of the nature of the program I have no control over the ads in it. Let me know what you think, and of course I’ll be reviewing it to see how it goes.  If you are interested in advertising/sponsoring the site, please let me know. (But I’m not expecting to get rich off this!)

Meanwhile, all of the back posts moved over from the old site have now been indexed into their correct category (doing that was a mind-numbing but  necessary task!).  So you should be able to see all the posts in a category that you’re interested in by clicking on the category in the left hand column.

HEALTH PLANS: Kaiser/Gadfly update, Fri, with early afternoon UPDATE

So today brings a couple of new wrinkles to the KP story.  First, following the initial meeting with the Judge after KP looked for an injunction asking the Gadfly take down the site which allegedly holds the 140 patients’ data, according to her version of events, the Gadfly voluntarily acceded to a request from the Judge to take the site down while the case was being decided.
Nonetheless, the Department of Managed Healthcare, which has basically been acting as a lap-dog to for-profit health plans since  Arnie became Governor, decided to intervene by issuing a press release this evening  giving the Gadfly 15 days to take the site down. Given that a judge will be ruling on this within seven days you’d think that the DMHC would have better things to do with its time, like ignoring the potential damage to the state by the local Blue’s licensee becoming part of a major monopoly and having its executives becoming gazillionaires in the process–luckily insurance Commissioner Garamendi was at least partially awake to that last year, even if he too was easily bought off in the end.

Still while the grandstanding by the DMHC is not particularly impressive,  in the press release they also seem to be stating that they are also investigating to see whether KP was guilty of posting this information before the Gadfly did. If they really are dong that, then this whole incident still has the possibility of hurting KP legally and reputation-wise, and it at the least gives the Gadlfy another venue in which to make her feelings about Kaiser known.  Although it’s probably at this stage pointless for me to say this again, KP would have been much better off if it had calmly and quietly dealt with the Gadfly’s complaints about her firing.

So what happened there?  Well there’s no sure way to know.  The Gadfly has put the long explanation of her version on her web-site. It appears that she got caught in a political infight between two managers, and then in attempting to get out of that problem, made a misstep which somehow signaled to their manager that KP would be better off getting rid of her, despite her work performance, which apparently seems to have been good.  But KP is known for being pretty political internally so I’m inclined to believe that there were things going on that were beyond the Gadlfy’s control. I’m also personally a believer in a greater level of trust and honesty being shown between employer and employee, and having seen a copy of the final termination letter from HR at KP, it’s clear that they at the least acknowledge that her version of events didn’t  square with that of her managers’. Now she was within her probationary period, and California is an
at-will employment state which means that anyone can be fired for any
reason at any time, but you’d hope two things.

One, that KP would have the decency to get to the bottom of this, including having a fair internal review process. Two, realizing that this firing put the Gadfly’s life into a tailspin and made her a KP enemy for life, you’d hope that KP would look to find a sensible way to settle the problem rather than ignoring her efforts and seeing her get all the more desperate and dangerous to their public reputation (not to mention having her dump the cost of her health problems on the goodwill of non-Kaiser providers and the taxpayer).

There’s even a bizarre twist that, according to the Gadly in order to get Kaiser’s attention, she tried to post some other Kaiser documents — not apparently the ones in dispute in this round of the story — on eBay. Although apparently nothing ever came of it,

Quite where all this goes I don’t know, but I suspect that the downside for the Gadfly is modest, as she’s clearly at the bottom and at the end of her rope and so has nothing to lose. The outcome for KP is probably modest too, but there’s a wildcard that this whole affair may become a bigger distraction than they’d like, and even that some genuine complaints are raised over their handling of patient data which might even result in penalties.

Somehow you have to feel that this could have been headed off at the pass if the Gadfly had been given a different assignment within Kaiser, or even a half-decent exit interview.

UPDATE: Over on her Corporate Ethics site the Gadfly details her problems with the DMHC which she claims failed to interview a doctor involved in her complaint about care she received when she was a Kaiser member and closed the complaint, and also that the DMHC seems to believe that she put the original site up.  She has continually stressed that she found the data online several months after she left Kaiser and never had access to it when she was there. The original site was taken down several days after this story was first featured in THCB in September 2004, but the Gadfly’s mirror stayed up. I cannot believe that the Gadfly was sneaky enough to steal the documents, stick the original site up, and then mirror it and take it down.  Much more likely, KP found out about the original error by their staff or consultants via the THCB posting and took it down themselves. (I have several Kaiser contacts and I know some of them read THCB). Obviously mistakes happen, and given the complexity of finding the patient data in those diagrams (I looked quite hard and I never saw any!) and the relatively few people who paid this any attention till this week, it seems like relatively little harm was done.  But KP should be trying to blame the original breach on the Gadfly if it’s not her fault. 

And as I’ve said for the nth time, there had to be better ways of dealing with this….

 

PHYSICIANS/QUALITY: Now it’s smoking too many old doctors kills you, by The Industry Veteran

A recent study instead of looking at specialists versus generalists showed that there’s a strong correlation that the older physicians get — and the further away from medical school — the worse the outcomes for their patients. While you may see this as an inevitability or a trick of the data, The Industry Veteran suggests that there are more malevolent factors at work:

My clients are blithely perceiving this news as confirmation of the admonition from Marketing 101 that they should segment physicians by age in addition to their usual criteria of specialty, Rx writing volume, current product preferences and so forth.  By contrast I perceive the news in a more dour fashion, taking it as further confirmation of the medical profession’s malevolence. Organized medicine’s failure to institute and enforce rigorous standards of continuing medical education is a menace to public health. Their failure reflects all pernicious elements of the guild mentality and the sense of entitlement that we perpetually see in physicians. Once they have completed that residency, they are as regents of the kingdom, set loose upon a defenseless public.  The fact that the profession exempts its practitioners from self-funded CME requirements virtually invites some of the worst excesses of pharmaceutical and other manufacturers. The companies provide continuing education programs that just happen to serve as promotional platforms for their respective products.  The added incentive of these company sponsored programs also providing mini-vacations for physicians and their families/mistresses is a mere incidental. Perhaps George Bernard Shaw used a bit of hyperbole in saying that every profession is a conspiracy against the public, but his language is a strict, empirical description of reality in medicine.

HEALTH PLANS: Kaiser Gadfly update

For those of you following along at home….

Today Kaiser sought an injunction against the Gadlfy asking her to take down the web site that supposedly contains the confidential information.  The Gadfly has just emailed me telling me that the judge did not grant that order, but instead set a hearing for next week.

POLICY/PHYSICIANS: Smoking too many specialists will kill you

Health Affairs is out with one of its fun articles looking at the physician labor force. Here’s the press release which basically explains that on a county level  and controlling for a bunch of other confounding variables (like race, income, etc), places with more specialists have higher mortality rates than those that have relatively more primary care doctors.  Here’s the full article from Johns Hopkins’ workforce specialist Barbara Starfield.

There are also some follow up articles with commentary. One by David Goodman, another of those socialist reprobates at the Dartmouth School who’ve been causing trouble in this arena for a long time, asks that given that we test the health impacts of every drug on the market extensively based on studies, why don’t we similarly seem to care in any empirical way about the health impacts of our structuring of the physician workforce? To be fair he does point out some limitations of the county-based study (e.g.. in California, Los Angeles county is huge, Placer County is not), but overall he thinks that COGME and others backing physician (and specialist) workforce expansion should do more to justify themselves.

The group from the Robert Graham Center in Washington DC point out the relatively obvious–specialists make (and generate) more money for themselves and the economy, and therefore you can argue that the creation of a specialist is better for overall economic growth than that of a generalist. I think their tongue is firmly wedged in their cheek, but surely a bright economist in the THCB reader corps can remind us of the "products versus services" argument from Econ 101–after all as it said in the Hitchhikers Guide to the Galaxy, the telephone sanitizers aren’t that productively useful no matter how much they get paid. (Until of course the civilization dies out from a disease caught off a dirty telephone)

Finally Edward Salsberg is director of the Center for Physicians Workforce
Studies at the Association of American
Medical Colleges. In other words he represents the
status quo of the current residency and training environment. He
thinks that any number of factors but not necessarily an "excess" of
specialists are to blame
for this mortality differential, and that we should reorganize the system to better integrate PCPs and specialists. Somehow I suspect that by "reform" he doesn’t mean getting rid of specialists or reducing the residency places provided for them and the money the taxpayer provides to the AAMC members for those places!

Let’s all be real for a moment. Every doctor with a quarter of a
brain who is going through the hassle of med school and residency
realizes that for a couple more years in fellowship they can double or
triple their salary if they reject pediatrics and general practice and
head to orthopedic surgery or diagnostic radiology. Even with the
downturn in some specialist’s income in some parts of the country in
the 1990s that’s still the case as this list  shows. So the demand for those residency
slots is high.

Furthermore because specialists can create their own demand (see
Fuchs et al ad nauseam for this) and we have in a system where payers
are prepared to stick in 15% more money each year apparently ad infinitum, there’s no real incentive for
the specialists themselves to limit their own numbers. And of course
the government is paying, and paying alot, to subsidize those
residency slots (at least $22,350 per slot per year), and the US government will almost always do what its
interest groups, in this case medical schools, AMCs and their students, want.
In other countries, the money available for specialty care is centrally
limited, and so the specialists are happy that their supply is limited,
so they and the government are happy to keep those specialist residency
slots down.

The current Administration is unwilling to take on the AMA, or the specialty societies over physician income, or the AAMC over residency slots, or today’s medical students and their families who want their son to be the highly-paid sub-specialist. And it would also be unwise for the Administration to take them on directly given that it has no real reason to care much about the overall state of the physician workforce compared to the myriad other things wrong with the health care system that it blithely ignores. So the top down approach of limiting residency slots is not going to happen.

So I’m left with two questions. First, does this have any minor impact on the whole pay for performance notion?  And can Medicare start thinking about this "impact of specialty mix on outcome measure" as something that far down the road it might think of "rewarding", in order to have a very, very long term impact on specialty mix. Second, if the answer is no, as I’m sure it is, why does Health Affairs keep on pissing into the wind by printing this stuff, if no one is going to take a blind bit of notice!

 

 

HEALTH PLANS: Kaiser patient data release spat update

Sigh.  Well KP, an organization that (I repeat) I have much respect for, is not taking my advice in the tawdry little business of whether they or the Gadfly released patient data onto the Internet. If you go to the Gadfly’s website you’ll see both that she has received a notice from Kaiser’s lawyers about an impending court date which presumably will order her to take her mirror site down (something that should please Kaiser), and has requests from two more journalists for interviews (something that probably won’t please Kaiser).

Can calmer heads prevail here? Are there any on either side?

BLOGS/QUALITY: More ego surfing–me on DM in Pharma Executive

Just in case you missed it, Pharmaceutical Executive interviewed me about a whole range of stuff. Out of that they chose some allegedly wise words I had about Disease Management and EMRs in a feature in the February issue. Interestingly enough they were a little dubious about my statements (that didn’t make it into print) about the coming reduction in the salesforce workforce, and that was a couple of weeks before Pfizer said it was canning 30% of its salesforce.

 

POLICY: The NY TImes tries to make Cutler a star

There’s a long and not too revealing article about Harvard health economist David Cutler in the NY Times magazine. It’s called the  The Quality Cure? and I will try to get to some comments on what’s wrong with it later today.  Meanwhile here’s what I said about it in my FierceHealthcare newsletter

Unlike most critics, Cutler doesn’t think high healthcare costs are necessarily a problem. After working on the failed Clinton effort, Cutler teamed up with another young economist named Mark McClellan to study the economic costs of heart disease. Their contrarian conclusion: Americans are getting their money’s worth when it comes to their healthcare costs, at least in cardiac care. The Times fails to note, however, that many of Cutler’s concepts are either not that new or are contradicted by several other leading health economists.

BLOGS: Grand Rounds up

Grand Rounds is up over at Orac’s blog and it’s done in the style of a TV narrative called What to watch this week. My post is part of Boston Legal, which apparently has James Spader and Captain Kirk in it these days.  I should watch more TV!

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