The roadwork

Joe Frazier passed away last night. He died, at the age of 67, of liver cancer. Among many accomplishments, the great heavyweight champion uttered the best quote about medical education (or any other sort of preparation) I have ever heard:

You can map out a fight plan or a life plan, but when the action starts, it may not go down the way you planned, and you’re down to your reflexes – that means your training. That’s where your roadwork shows. If you cheated on that in the dark of the morning, well, you’re going to get found out now, under the bright lights.

- Joe Frazier

Keeping people healthy saves money. Duh.

Tell me something I don't know:


Ellen, an 82-year-old widow, lives in Anaheim, California. One Wednesday morning last year, she got on her scale, as she does every morning. One hundred and forty-six pounds—wasn’t that a little high? Ellen felt vaguely troubled as she poured herself a bowl of oat bran.
Half an hour later, the phone rang. It was Sandra at the clinic. She too was concerned about Ellen’s weight, which had jumped three pounds since the previous day. Sandra knew this because Ellen’s scale had transmitted its reading to the clinic over a wireless connection.

Given that Ellen had a history of congestive heart failure, a three-pound weight gain in 24 hours was a potentially dangerous development, a sign of possible fluid buildup in the lungs and increasing pressure on an already stressed heart. Sandra wanted her to come in for an immediate visit: the clinic would provide a car to pick her up and bring her back home. Ellen’s treatment began that very morning and continued for two weeks until she was out of danger. Had the warning signs not been noticed and addressed so quickly, she might easily have suffered a long, painful, and expensive hospitalization.
Dan, a retired letter carrier, is a patient at a clinic in the same system. At 87, he is decidedly frail, his once-sturdy legs now weak and unsteady. He is a classic candidate for a fall of the kind that has injured many of his friends, in some cases leading to weeks in the hospital and months of rehab. The elderly are prone to falls for many obvious reasons, including weak limbs, impaired vision, and medication side effects. But Dan’s doctors knew that some less obvious causes included shag carpets and long, untrimmed toenails. Because of this, they’d sent someone from the clinic to visit Dan’s apartment and make sure that his daughter replaced the 1980s-vintage carpets with low-pile rugs. Dan also visits the clinic regularly for light muscle-training sessions and periodic toenail clipping. Due to these preventive measures, Dan and his fellow clinic patients are one-fifth as likely as comparable patients elsewhere to suffer falls.
Joe, a 79-year-old diabetic, cut his foot when he banged it against a door. When it didn’t heal after a couple of days, he limped into the office of his family physician. After glancing at the cut, his doctor immediately sent Joe to a clinic in the same system as those that treated Ellen and Dan. For diabetics, even small cuts can be a serious matter: untended, they can become infected and contribute to an alarmingly high rate of amputation.
At the clinic, a nurse practitioner cleaned and dressed the wound, and told Joe she wanted to see him there in two days so she could inspect and treat it again—and two days after that, and two days after that, until it was fully healed. The clinic would arrange for transportation if needed. Thanks to the steady, regular care, Joe’s foot healed without any infection or threat of amputation.
Ellen, Dan, and Joe are all real people, though their names have been changed. The clinics that serve them are all affiliated with CareMore, a company based in Cerritos, California, that operates 26 care centers across the Southwest, serving more than 50,000 Medicare Advantage patients. Those numbers are likely to grow, perhaps dramatically, in the next few years: in August, CareMore was acquired by the insurer and health-services provider WellPoint, which serves 70 million people nationwide directly or through subsidiaries, and has plans to expand the CareMore model.
CareMore, through its unique approach to caring for the elderly, is routinely achieving patient outcomes that other providers can only dream about: a hospitalization rate 24 percent below average; hospital stays 38 percent shorter; an amputation rate among diabetics 60 percent lower than average. Perhaps most remarkable of all, these improved outcomes have come without increased total cost. Though they may seem expensive, CareMore’s “upstream” interventions—the wireless scales, the free rides to medical appointments, etc.—save money in the long run by preventing vastly more costly “downstream” outcomes such as hospitalizations and surgeries. As a result, CareMore’s overall member costs are actually 18 percent below the industry average.

Excuse my cynicism. But we know these kinds of measures work. And we know why they are not standard practice. Take it away, Dr. Berwick:

The access we need to create is access to help and healing, and that does not always mean—in fact, I think it rarely means—reliance on face-to-face meetings between patients, doctors, and nurses. Tackled well, I believe that this new framework will gradually reveal that half or more of our encounters—maybe as many as 80 percent of them—are neither wanted by patients nor deeply believed in by professionals. This is an example of a problem so big that we have trouble seeing it. The health care encounter as a face-to-face visit is a dinosaur. More exactly, it is a form of relationship of immense and irreplaceable value to a few of the people we seek to help, and these few have their access severely curtailed by the use of visits to meet the needs of many, whose needs could be better met through other kinds of encounters.
The alternatives to visits in the escape fire are many: self-care strongly supported and unequivocally encouraged; group visits of patients with like needs, with or without professionals involved; Internet use for access to scientific and popular information; e-mail care between patients and clinicians; and well-managed chat rooms, electronic and real, for patients and significant others who face common challenges.
Payers should take careful note: Most of you still pay only for Pulaskis. The greatest potential for reducing costs while maintaining and improving the lot of patients is to replace visits with better, more flexible and fine-tuned forms of care. But almost all current payment mechanisms, whether enforced by the market or mapped into organizations by internal compensation systems, use impoverished definitions of productivity that actively discourage the search for and incorporation of non-visit care. 

Every single country in the industrialized world spends less on healthcare than we do, and most have better outcomes. This is not an exaggeration, or a statistical trick. We have fallen behind and are going broke because we are pissing away money on poorly coordinated expensive interventions instead of cheap, proven approaches.

The proximal cause of this is the reimbursement system, the madness of the RVU model. This system pays us for doing stuff, and it pays us a lot more for stuff that involves technology, cutting and sewing, labs, scans, and specialist care. This is exactly the reason we ended up with a system with a death of primary care and an abundance of technology, cutting and sewing, labs, scans, and specialist care. We designed the system that way. Practice has followed compensation.

The VA saves money and improves outcomes the same way -- they are stuck with the person for life.

Technology has become a driver of costs, rather than a source of cost-savings, as a result of being yoked to this dysfunctional system of payments. You can check a patient's weight at home and intervene before their CHF exacerbation sends them to the ED? Say goodbye to the ED billing, the chest X-ray, the IV lasix and nitro paste, goodbye the bill for the hospital bed, the itemized charges, the bedside echo. Thousands of dollars saved by the healthcare system are thousands of doctors lost to the healthcare worker or the healthcare institution.


CareMore can do this because they get a flat fee for each patient, adjusted for their demographics and preexisting conditions. So every dollar they save is a dollar they save, rather than a dollar they lose. And the savings they are reporting are the tip of the iceberg, if we learn to follow the simple principle that we pay once, for a person's overall care -- their health -- and not piece by piece for every intervention, which rewards disjointed care and rewards failure -- sickness.

Kaiser succeeds by making its money on the insurance side -- again, they get a lump sum per patient.

I'm glad CareMore was able to strike this deal with Medicare Advantage -- it's about time that big, fat, juicy piece of pork was used for good rather than evil. But at some point can we stop being surprised by this -- stop treating it as a bold outside-the-box experiment that might go either way? It's freakin' Capitalist Economics 101: if you pay doctors to do things, and pay the most for tests and procedures and scans, they will do more things, and especially more tests and procedures and scans. If you structure the compensation to align the incentives for the individual provider or hospital with those of the patient -- who wants to be well, not sick, and have few medical interventions, not many -- you get a system that is better for patients, for caregivers, and more society as a whole.

It's time to stop gawking at the pioneers and run our whole healthcare system on this basis.

Abraham Verghese damns the physical exam with faint praise

Dr. Verghese, above, gives us a fun and seemingly unobjectionable TED talk calling for the revival of the physical exam -- one that unfortunately illustrates why the physical exam is dying of neglect.The TED audience seemed to like it, but I feel like I have heard this lecture with slight variations every year since the start of med school.

Doing medicine from behind a computer is condemned. Traditional rounds with extensive histories and physical exams are praised. The glorious history of the physical exam is recounted. Said history always includes allusions to Arthur Conan Doyle and Auenbrugger tapping wine barrels, Laennec watching children play, and so on.

While they touch on the diagnoses missed and patients harmed by hasty or sloppy exams, the lion's share of the talk is always devoted to how the exam makes the patient feel -- how it helps or harms the patient's emotional connection with their doctor, how the exam reassures, how it conveys the unironically invoked "healing touch."

None of this is wrong, but it damns the exam with faint praise. It skirts past and implicitly concedes the question of what actual, reliable, actionable information can be obtained by the physical exam. How good is the physical exam at achieving its declared goal of giving us useful information about illness?

The problem of time is also intertwined with this, and also is ignored by Dr. Verghese, who speaks rapturously of splitting an exam off into its own half-hour appointment so that he can discuss the history uninterrupted during the first half-hour appointment. How does this anecdote help me in the emergency room, in the ICU, or on the wards? Fuck you very much, Dr. Verghese.

But it's not really his fault; he's just carrying on a proud tradition of unreality surrounding medicine at the bedside. How many prescribed work-ups open with this infamous phrase: "Do a complete history and physical exam." Anybody do that? Or anyone? Ever?

And that's the problem with those teaching rounds, too. So you want the hospitalist attending, with 20 people on their service, to interview and examine every patient, every day, with Q-and-A with the residents at bedside?

If you really want to promote the physical exam, the way to do so is exactly the opposite of Dr. Verghese's method. Enough about the exam's noble history. Bleeding has a noble history in medicine, too, but that didn't save it from the dustbin. The physical exam will rise or fall based on its clinical utility, which is determined by:

1. The sensitivity and specificity of particular maneuvers for particular conditions (see the Rational Clinical Exam series or Physical Diagnosis Secrets for examples of this research). Stuff that is not sensitive or specific needs to go (bowel sounds, I'm looking at you). There are 1440 minutes in every day and God's not making any more time.
2. To make this research applicable to the bedside, we need to agree on a standardized technique for performing a given maneuver. Students need to be taught a consistent method; students and residents need to be regularly supervised and evaluated in their performance of the exam.
3. Students should learn how to do a comprehensive exam, but textbooks and instructors need to acknowledge the reality of limited time and state explicitly what parts of a comprehensive exam can be safely omitted in which patients. Do you need a heart and lung exam in a healthy 20-year-old with a sprained wrist and no other complaints? Obviously not, but common sense is often ignored in the teaching of the physical exam.

If I were to sum up my program here in a single sentence, I would say: To restore the respect for the physical exam vis-a-via tests and scans, we must apply all the same principles that guide our use of tests and scans:

1. What we do should be evidence-based.
2. We shouldn't be indiscriminate or unfocused in our application of these tools. Our time is as precious a resource as the time of the MRI scanner.
3. We should use sensitivity and specificity to guide our use of these tools in making a diagnosis. Some will rule in, some will rule out, some will be used in parallel, some in series.
4. How we do a test/scan/exam may vary from place to place, but it should be, as far as possible, standardized around best practices, so we know the research we are using applies, and we can trust the results reported to us from elsewhere.

There is no question that the act of touching the patient deepens our relationship with them, and has an intangible value. That is a given. But it is also, if performed properly, a ruthlessly effective way to gather critical information about multiple systems simultaneously without exposure to radiation or expensive and time-consuming blood tests. The exam is fully capable of justifying itself within the paradigm of scientific medicine,  and can be optimized for that task without losing any of its -- literal -- touchy-feely bona fides. What we must not do is strive to preserve an idealized and historically driven vision of the physical exam, which will lead to an impractical mess -- heartily praised and rarely performed -- that it is not subject to investigation and systematic improvement because it is justified in the first place as relationship-building, as emotional or spiritual comfort, a performance rather than an investigation.

The physical exam is not the ground on which to fight a battle over medicine as art versus medicine as science. The physical exam -- the act of looking, listening, feeling, and make decisions on the basis of the empirical evidence gathered -- belongs wholly to science. Appealing to art, like appealing to the notion of emotional and spiritual comfort, is not factually wrong, but is an act of self-defeating desperation.

The exam needs to be continually tested and improved by scientific investigation and critical judgement, or it will fall hopelessly behind blood tests and scans, where such continuous improvement is routine. Loving the physical exam, as I do, means not fearing for its fate at the hands of evidence-based medicine. It is a powerful and practical tool, and we can continue to prove that as we continue to improve it.

Looking to Save Money, More Places Decide to Stop Fluoridating the Water

By LIZETTE ALVAREZ

MIAMI — A growing number of communities are choosing to stop adding fluoride to their water systems, even though the federal government and federal health officials maintain their full support for a measure they say provides a 25 percent reduction in tooth decay nationwide. 

We're going to have to open another kit

"My OB said WHAT?!?" is a site which is basically devoted to hating on obstetrics, physicians and Western medicine in general. Along with a bunch of mildly insensitive comments and a few that are truly outrageous, a few of the stories are really funny caregiver wins:

OB: “Would you rather be cut or tear?”

Mother: ‘Neither!”

OB: “Nurse, hand me my magic wand.”

Should NPs call themselves doctors?

No. It's confusing. There, that was easy.

The NYTimes opened this bag of worms recently. The blogosphere took the cue. For me the question itself fails to excite. Nurses are more trusted as a profession than doctors. Few of them are going to want to be confused with a doctor. Among those that do, most will have the common sense to realize that in the common usage, a medical doctor is a DO or an MD, and regardless of what brilliant etymological arguments one can bring to bear to illustrate that this should not be the case, it is so and a non-physician introducing themselves as the patient's doctor is going to destroy trust with that patient, who will feel deceived.

The story is more interesting for what it says about the state of healthcare today than the question getting all the attention. For instance, consider this fun fact:

For decades, a bachelor’s degree was all that was required to become a pharmacist. That changed in 2004 when a doctorate replaced the bachelor’s degree as the minimum needed to practice. Physical therapists once needed only bachelor’s degrees, too, but the profession will require doctorates of all students by 2015 — the same year that nursing leaders intend to require doctorates of all those becoming nurse practitioners.

Doctorates for all! And you're welcome to 'em. But might I ask, what for? As the article points out:

Nursing is filled with multiple specialties requiring varying levels of education, from a high school equivalency degree for nursing assistants to a master’s degree for nurse practitioners. Those wishing to become nurse anesthetists will soon be required to earn doctorates, but otherwise there are presently no practical or clinical differences between nurses who earn master’s degrees and those who get doctorates.

We have a huge labor shortage barreling down on us in healthcare, as the baby boomers move out of their healthcare jobs and into the stretcher in the hallway. Is this really the time to be raising barriers to those entering the profession?

 It would be one thing if those extra months and years were to be spent running codes in the sim lab, treating hundreds of standardized patients, or drilling deeply into pathophysiology or pharmacology. But that's not what they are doing:

While instruction at each school varies, Dr. McCarver took classes in statistics, epidemiology and health care economics to earn her doctor of nursing practice degree. These additional classes, at Vanderbilt University, did not delve into how to treat specific illnesses, but taught Dr. McCarver the scientific and economic underpinnings of the care she was already providing and how they fit into the nation’s health care system.

Nursing phD degrees focus on research skills, administration, public health. They don't go back to the basics and forge exceptional clinicians; they're not for that. It's hard to escape the gnawing sense that these are advanced degrees mostly for the sake of advanced degrees; mail-order MBAs for the ambitious and upwardly mobile healthcare worker.

I think a lot of this is about credential inflation; the tendency to value and require more and more postsecondary education regardless of whether it actually effects the person's ability to do their job. And the artificial scarcity of physicians that creates and maintains a massive hunger for mid-levels; that's in there too. I mean, if you have bright people who want to study for eight years to go work in a primary care clinic and call themselves doctors, the $64,000 question is why you don't just train them as doctors.

But those are posts in themselves, so stay turned for part two: Credential inflation in healthcare.

The Hazards of Hospitals

Created by: Medical Billing and Coding

I tell people this stuff in the emergency room, straight up, when they want admission to the hospital and it's not indicated. A hospital, I say, is a great place to be if you're critically ill, and a terrible place to be if you can be treated safely at home, keeping you within your family, familiar surroundings, and the flow of your life.

There are no Dilaudid PCAs at home, though, so I lose that argument more often than not.

The trouble with blockbusters: expensive, crappy sequels

h/t My Strong Medicine:

April 20, 2011 — The 10 most prescribed drugs in the U.S. aren’t the drugs on which we spend the most, according to a report from the IMS Institute for Healthcare Informatics.

…

Out of the $307 billion we spent on drugs in 2010, we spent most of our money on the following:

Lipitor, a cholesterol-lowering statin drug — $7.2 billion
Nexium, an antacid drug — $6.3 billion
Plavix, a blood thinner — $6.1 billion
Advair Diskus, an asthma inhaler — $4.7 billion
Abilify, an antipsychotic drug — $4.6 billion
Seroquel, an antipsychotic drug — $4.4 billion
Singulair, an oral asthma drug — $4.1 billion
Crestor, a cholesterol-lowering statin drug — $3.8 billion
Actos, a diabetes drug — $3.5 billion
Epogen, an injectable anemia drug — $3.3 billion

What struck me was that with the exception of Epogen and (for certain indications) Plavix, every single one of those drugs is a variant on an older, now generic drug, which works for all intents and purposes just as well.

Crestor? Really? Nexium? Actos?

If you wanted to shave a quick $20 billion off the government’s healthcare costs, you could just announce that the VA formulary are now the only drugs Medicare or Medicaid will pay for.

When “Transformers 3″ comes out I will go see it, despite the fact that I’m shelling out money for a slight variation on a winning formula. But when the pharmaceutical industry is making its money off tired knock-offs, that’s more of a problem.

Making healthcare cheaper

Making healthcare cheaper is not, actually, a particularly difficult problem. It requires political will, not theoretical innovation. It can be arrived at via many routes, provided they observe a simple principle:

We must pay for health, not for sickness. For outcomes, not for methods. For the totality of a life, and not a particular crisis.

There are many ways in which this could be accomplished. A national health service, responsible for the health of the entire population, is one. A more market-driven approach would be to have a number of necessarily large healthcare organizations who would "bid" for patients, likely in lots, the contract for life-long health services going to the lowest bidder.

If we prefer to nibble around the edges of the problem first, there are a number of small, commonsense reforms we could implement. We could cut reimbursement for diagnostic studies and all procedures by 20%. We could require all Medicare and Medicaid recipients to fill out an advanced directive (we aren't going to tell them what to put in their advanced directive, only require that they have one).

Medicare could announce that it will automatically deny any claims by a physician who exceeds the census-adjusted rate of billing for a given code by more than 200%, excepting things like health maintenance or counseling. So if you, as an EM physician, order five times as many cervical spine CTs as your peers, Medicare will deny them all and require you to justify them one by one.

Medicare and Medicaid could carefully chose a subset of the best-validated, evidence-supported practice guidelines, and automatically deny any claims not in accordance with those guidelines.

Another money-saving and quality-improving device would be to rigorously limit the amount of documentation by health care professionals to the absolute minimum that can be shown to substantially improve safety and continuity of care. Fines for overcoding and fraud should be increased by orders of magnitude, forcing organizations to police themselves.

It is almost too obvious to say Medicare should only cover treatments which are effective. That this is a matter of some controversy cannot help but raise the question of whether Americans are, as a nation, too stupid to survive. A NICE-style board, calculating cost per DAYL, is the best way to calculate effectiveness. I would go a step further, and have too sets of calculations; one for people over the age of 60 with two or more chronic health problems; one for everyone else. Because we need to stop pissing away hundreds of thousands of dollars a case to no purpose but to torture some poor benighted soul for three or four weeks in the ICU. If you want that (and no one but no one who has seen it at the bedside and knows what it is wants it) you can pay for it yourself.