The Covert Rationing Blog

Back Next Week - Emptying the Nest

August 27th, 2008 by DrRich

DrRich will be preoccupied for the next week or so, packing, driving, unpacking, etc. his youngest child off to year 1 of college, then trying to come to terms with the utter strangeness of how quickly it all goes by.   Before too long, he hopes, he will come to see blogging as an aid in his recovery process, and at that point he will return.

Posted in Uncategorized | 4 Comments »

Taxpayer Support of the Evil Drug Companies

August 25th, 2008 by DrRich

Demonizing the drug companies is a necessary and indispensable strategy under a healthcare system that covertly rations healthcare. Quite simply, it is necessary because drug companies are in the business of developing expensive new products that doctors and sick people will demand for themselves.

If we can paint the pharmaceutical industry as being sufficiently evil and corrupt, then we can justify constraining drug companies so as to limit the introduction of these expensive new products. We can, for instance, build daunting regulatory hurdles or legislate “windfall profits” penalties. Fortunately for us, drug companies are indeed not the most fastidious members of the corporate community, and their actions and methods provide us with many fruitful avenues for demonization.

One such avenue is to show how the corrupt pharmaceutical industry feeds at the trough of the American taxpayer. As an example of this reprehensible behavior, the New York Times has pointed us to the case of Dr. Laszlo Bito and the anti-glaucoma drug Xalatan.

In the early 1980s Dr. Bito, a researcher at Columbia University, made a key discovery about a new class of substances that could potentially treat glaucoma. His research was funded with American tax dollars through the National Institutes of Health.

Subsequently, the pharmaceutical giant Pharmacia purchased the rights to Bito’s discovery for a mere $150,000. Based on Bito’s tax-supported work, eventually Pharmacia released the anti-glaucoma eyedrop preparation Xalatan. Xalatan rapidly became a worldwide best-seller, yielding as much as $500 million in sales per year. For their part in this wondrous success story, Columbia University has netted over $20 million in licensing fees and royalties, and Bito himself became a millionaire.

Meanwhile American glaucoma sufferers are forced to spend upwards of $50 every six weeks for a tiny vial of the drug, which costs the company only a small fraction of that amount to produce, and whose discovery the glaucoma sufferers paid for with their own tax dollars. And, as if to guild this already brazen injustice, Pharmacia makes Xalatan available in Canada, France, and most other countries around the world (where taxpayers decidedly did not support the discovery of the drug), for less than half what American patients pay for it.

It seems, the Times points out, that the American taxpayers are the only parties in this little scheme who reap no financial return on their investment. All they got were some expensive eyedrops.

And so, drug-company demonizers would have us conclude, this is a particularly egregious example of how the evil pharmaceutical industry is ripping us off. Not only are the drug companies mercilessly profiteering from sick Americans (which, after all, is their openly-admitted business model), but they are also picking the pocket of every American by using our tax dollars to invent new drugs, then selling those drugs back to us at exorbitant prices. This, one could reasonably argue, is at least as sociopathic as anything the tobacco companies ever did. (The tobacco companies, in contrast, at least had the good graces to eventually stop claiming that they were a major boon to the public health.)

And (we are all supposed to agree), if this reprehensible behavior doesn’t give our government the right to control the prices charged by drug companies, one would be hard pressed to say what does.

To all this, of course, DrRich says, “Bosh.”

DrRich certainly doesn’t want to absolve the pharmaceutical industry of all responsibility for drug prices that seem obviously too high, or for the striking pricing disparities we see between the U.S. and other countries. He has read the complex justifications, published by apologists for the pharmaceutical industry, as to why drugs in Canada cost so much less than in the U.S., and why a drug that costs $.05 a tablet to manufacture is sold to the elderly sick for $5.00. DrRich thinks that, despite all the pretty explanations for these “seeming disparities,” drug companies simply do what every other industry does - they charge the highest price that the market will bear, for each market in which they participate. If they didn’t do this, they would be abrogating their fiduciary responsibilities to their shareholders.

There is much not to like about high drug prices, or the fact that people in other countries reap the benefits of American research for far lower prices than Americans do. And it is reasonable for us to seek to address these pricing issues. But as we address certain inequities in drug pricing, we should be careful that in doing so we don’t throw the baby out with the bath water. So if we’re going to alter the arrangement we have with the pharmaceutical industry, let’s be clear on how that arrangement works, and why we set it up in the first place to operate as it now does.

Consider once again the glaucoma drug Xalatan, and consider how Dr. Bito’s discovery was actually used by Pharmacia.

Bito did not discover a finished product. Instead he discovered a new concept for reducing intraocular pressure (that is, for treating glaucoma), and demonstrated that it could be effective - but the specific compound he discovered was not marketable. In fact, it was so highly irritating when applied to the eye that it was simply not suitable for clinical use. Indeed, Bito’s discovery was offered to and rejected by a host of drug companies as being completely infeasible.

When Pharmacia finally agreed to pay for the rights to Bito’s patent, they took on an expensive risk that, some estimated, had less than a 5% chance of achieving success. Pharmacia assumed the difficult task of developing a brand new synthetic molecule that would have all the benefits described by Bito, but at the same time would not have the prohibitive side effects. There was no assurance that such a molecule could be found. Then, they would have to shepherd their new compound through a time-consuming and costly regulatory gauntlet that proves fatal to most new drugs, and pray that it would gain FDA approval. That their efforts were ultimately successful does not diminish the fact that, when they agreed to invest the time, money and opportunity cost to develop Dr. Bito’s discovery, they were taking on a large risk with no assurance of making a profit or even recouping their losses.

Bito’s (tax supported) idea was a promising one, but the challenge of developing that idea into a product that was useful to patients and that could be brought to market was very expensive and highly risky. Pharmacia took on that risk (all of which was borne by its shareholders, and not by taxpayers) only after difficult, internal corporate soul-searching. If not for the prospect of making enormous profits if this risk worked out, the company (like several other drug companies did in this particular instance) certainly would have walked away.

Before 1980, it is likely none of this would have happened. The Bayh-Dole Act of 1980 was passed expressly to encourage the further development of federally financed, university-based basic research. Until then, a large proportion of basic university research was never “translated” into useful medical products. Such translation of basic research was recognized by Congress to benefit society not only by advancing the practice of medicine, but also by stimulating the overall economy. So industry was actively encouraged to take on the risk of developing promising ideas that came out of federally-funded research. And the profit that greeted successful enterprises was designed to be the one thing that would lure industry into taking that risk.

So when the Times “discovers” a company “profiteering” from work done with tax dollars, it should not be a revelation, nor should it be an unmistakable sign that the company is inherently evil or dishonest, nor does the company’s activity in this regard give us the right to arbitrarily restrict its profits. Rather, that’s simply the deal we taxpayers made with the drug industry (through our elected officials). We made this deal because we felt, in the long run, that it would benefit American society, and quite probably, us as individuals. If we want to change that deal now, so be it. It is within our rights to do so.

Without Bayh-Dole, perhaps patients with glaucoma would still be getting surgical therapy and wearing those coke-bottle lenses instead of just using eyedrops. And if we want to put the brakes on such medical advances (in order to prevent unseemly profiteering), we certainly can.

But we shouldn’t vilify the drug companies for taking us up on the deal we offered them.

Posted in Evil Drug Companies | 2 Comments »

The End-Of-Life Movement and Medical Ethics

August 18th, 2008 by DrRich

Last week DrRich offered some friendly advice to health plans that would like to take advantage of the cost-saving potential of assisted suicide. DrRich was moved to help in this way upon witnessing the initial, typically ham-handed forays which health plans are making into this promising new arena of High Quality and Efficient Healthcare.

Among the sage recommendations which DrRich so kindly provided to directors of American health plans was the admonition to tone down their overt enthusiasm for assisted suicide, and to let the robust end-of-life movement do the selling for them.

DrRich finds the end-of-life movement to be an extremely interesting social phenomenon. These folks purport to act solely on the behalf of the autonomy of the individual, that is, to help people to preserve their freedom of choice, sense of control, and personal dignity when faced either with inevitable death, or with a life that is no longer worth living. They see the medical-industrial complex as an insensate machine which, for its own purposes (i.e., profit), will inevitably act to prolong the suffering and indignity of these unfortunate patients for as long as possible, long past the point where the individual sufferer would wish it to stop.

As with most passionate social movements, there is more than a grain of truth to their underlying premise. However, their own actions with regard to the three major issues they have taken up – assisted suicide, advance directives, and medically futile care – should make us suspicious of their true dedication to the precept of individual autonomy.

The stance the end-of-lifers have taken on advance directives and assisted suicide, of course, is entirely consistent with supporting the autonomy of patients who wish to forgo aggressive medical treatments, or even to hurry death along. It’s with the issue of medically futile care that the end-of-life movement reveals that its true motivation lies elsewhere.

For, when patients or families insist on continued medical care that even the insensate healthcare machine agrees is very likely to be unavailing, an end-of-life movement dedicated to preserving the autonomy of the individual would want that care to be offered anyway (since that is the explicit desire expressed by the affected individual). But instead, the end-of-life movement strongly favors withholding such care from these individuals, and indeed, seems anxious to expand the sorts of medical services that are to be considered futile.

One can argue logically about whether the position of the end-of-life movement with regard to medical futility is reasonable or not. But one cannot argue logically that this position is based on preserving individual autonomy. It is not.* Instead, their position is most consistent with wishing to limit spending on healthcare. Cost cutting, and not individual autonomy, accurately predicts the position the end-of-life movement takes on all three of its signature issues.

When reducing cost and preserving individual autonomy work in the same direction (as they do with advance directives and assisted suicide), it is easy for them to claim that they are motivated by their passion for individual autonomy. But when reducing cost and individual autonomy are at odds (as with medical futility), they immediately side with reducing cost, and not with autonomy.

(DrRich chooses to attribute the specific positions taken by the end-of-life movement to a desire to control costs, rather than to the other possibility suggested by their actions. Namely, he is reluctant to consider these fine people to be a death cult, of simply being in favor – due to some pathological or morbid fascination with death – of whichever action hastens it. DrRich is far too charitable to believe that.)

DrRich understands utilitarianism, though he most often does not agree with it. However, he finds it dangerous, and nearly reprehensible, to disguise utilitarianism as an ethical argument. If we as a society want to debate the hastening of death as a method of reducing spending on healthcare, then let’s have that debate.

But what the end-of-life movement seems to be doing is attempting to cut off this debate before it starts by claiming an ethical high ground that is actually inconsistent with its own positions. We should not treat the ethical argument advanced by proponents of the end-of-life movement any more seriously than they do themselves.

And we should avoid embracing assisted suicide (and other end-of-life solutions to the problem of healthcare rationing) until we’ve carefully considered the real ethical implications of doing so.

*Medical ethicists are actually much more subtle than this argument allows, and indeed have come up with an ethical system that permits us a way of preserving individual autonomy by (get ready) ignoring the clearly expressed desires of individuals! DrRich will address the medical ethicists’ support of the end-of-life movement in a later posting.

Posted in General Rationing Issues | 4 Comments »

How to Sell Assisted Suicide

August 10th, 2008 by DrRich

In July, the Oregon Health Plan injudiciously sent a letter to lung-cancer patient Barbara Wagner denying coverage for the expensive chemotherapy her doctor had recommended, and offering instead to cover palliative care “including doctor-assisted suicide.”

The firestorm of outrage this letter triggered (to see the outrage for yourself, simply Google the search terms “Barbara Wagner” and “suicide”) penetrated even the dulled sensibilities of the Oregon insurance executives. One Jim Sellers, a spokesman for the Oregon Health Plan, admitted to ABC News that “the letter to Wagner was a public relations blunder and something the state is ‘working on.’”

DrRich expects that the Oregon Plan executives must feel at least a little blindsided by the general reaction to their ham-fisted denial letter. Denial letters, after all, routinely list (as an aid to the patient) services which the insurance company judges to be reasonable alternatives to the denied care. While in this case the denied service offered some reasonable hope for prolonged survival, and the service being offered as an alternative (to say the least) did not, that’s really not so much different from the content of more “routine” denial letters. The difference is one of degree, and not of substance. So, Oregon Plan executives might be thinking, “What’s the big deal?”

One must try to be understanding of such insensitivity. It is a fundamental task of health plans to deliver unpleasant news to people whose lives are at stake, and it is normal – even necessary – for those who are charged with this task to grow thick skin. It is perfectly predictable that such thick skin might dull one’s ability to discern subtle differences in degree between various denials of services, subtle differences that might call for more artful phraseologies than those employed in this instance by the Oregon Plan. The failure to recognize the need for a more artful denial letter, Mr. Sellers appears to say, is the problem in the case of Ms. Wagner. The solution, consequently, is not a substantive change in any policy, but better public relations.

Those who run the Oregon Health Plan must be particularly disheartened to learn that even vocal proponents of physician-assisted suicide are criticizing their ill-considered denial letter. To so blatantly juxtapose healthcare rationing with the “option” of assisted suicide seriously undermines the chief argument advanced publicly by the end-of-life movement, namely, that assisted suicide is primarily an individual autonomy play*, and not primarily a cost-saving mechanism.

In other words, whether or not you embrace physician-assisted suicide, everyone seems to agree that offering it as a covered medical service immediately after denying potentially life-prolonging therapy is both insensitive and unseemly.

And so – as a public service to insurance executives in both the government and the private sector who are severely challenged by trying to understand simple human emotions, to patients like Ms. Wagner who may suffer true physical harm by exposure to such institutional callousness, and to the rest of us who simply would appreciate not being confronted so blatantly by the dark abyss that underlies our healthcare system – DrRich offers some friendly advice to health plans on the right way to sell physician-assisted suicide.

How Health Plans Should Sell Assisted Suicide

1) Don’t be so anxious.

Sure it’s easy to get excited about physician-assisted suicide. All you need to do is look at your own data. Whatever sort of health plan you are running, it’s likely that a huge proportion of your spending goes to patients who are in the last year of life. Enticing these end-of-lifers to choose assisted suicide (which you can accomplish in a sufficiently tasteful way for about $100) is such an attractive proposition that it’s indeed become very hard to make yourself appear reasonably circumspect about it. At the very least, it’s difficult not to push the idea out there to your subscribers. Otherwise how can you be sure they know all their options for end-of-life care?

But doing even that much is a mistake. If you don’t believe that, simply look at the small firestorm the Oregon Health Plan created with their simple and helpful “reminder” letter to Ms. Wagner. As a result, neighboring states that appeared ready to pass their own assisted-suicide laws are now having second thoughts about it. It is clear that for a health plan to seem overly interested in assisted suicide, or even to mention the option to their subscribers, is a very counterproductive idea.

A much more subtle approach is required.

2) Publicly disown assisted suicide.

Think about Tom Sawyer whitewashing the picket fence. Ole Tom didn’t get all his friends to paint that fence for him by asking for their help, or by overtly trying to sell or cajole them on the idea. Instead, he got them to do the job by pretending he wasn’t the least bit interested in having them do it, by ignoring them altogether, and making himself seem completely absorbed in the delightful task. By the time Tom was done, his friends were begging for a turn, and even giving him wondrous gifts (such as dead cats on a string) to bribe him for a chance to participate.

What you need to do is pretend that encouraging assisted suicide – even if it’s a covered service that patients ought to be made aware of – is the farthest thing from your mind. Instead, you are completely invested in and insistent upon providing full-service end-of-life care, with all the bells and whistles and no holds barred; and – while patients of course have the option to exercise their individual autonomy as they see fit – you take great pride in squeezing every last instant of life out of those elderly, used-up, chronically ill bodies that present themselves in your ICU, no matter what the cost to the patient and family in terms of pain, suffering, humiliation and anguish. It is your mission to stave off death to the bitter end, come what may, and you’re proud of it.

3) Have somebody else push it.

In the meantime, clear the path for agencies and interest groups which are dedicated to the end-of-life movement. There are plenty of them out there. Have them do the selling for you.

Make sure they have access to your patients and patients’ families, especially in the ICU setting. Allow them space for educational displays; provide them some private space where they can talk to interested patients and families; see that hospital social workers are aware of their presence. In the meantime, make it clear you do not endorse or encourage their efforts, and indeed wish they would go away, but are providing such groups with access in the interest of full transparency and your dedication to patient choice. If patients choose to avail themselves of such information, you will do nothing to stop them.

4) Make the advantages to assisted suicide seem real.

There’s no need for you to talk up the advantages of assisted suicide – let the end-of-life proselytizers do the talking for you. All you have to do is to make their arguments seem accurate. The great part is, that’s just a matter of maintaining business as usual.

The end-of-life zealots will tell patients that assisted suicide is a way of asserting some measure of control over the dying process, of holding on to some level of personal dignity at the very end. So simply make sure your end-of-life care continues robbing patients of any semblance of dignity and control.

They’ll tell patients that assisted suicide will end pain and discomfort and suffering when all hope of recovery is gone. So simply continue with inadequate pain control** and half-hearted comfort measures, and keep the ICU as hectic, loud, scary and impersonal as possible.

They’ll tell patients that assisted suicide will finally bring comfort to their long-suffering family and friends. So make sure family and friends suffer long, by keeping those ICU waiting rooms hot, cramped, noisy, uncomfortable and smelly.

You get the idea. Simply make sure the arguments of the end-of-lifers have teeth. You’re good at that.

5) Tell patients to consult with their doctors before making this choice.

That’s right. Refer patients to their doctors, their supposed personal advocates, the selfsame individuals you yourself have long since fatally compromised (by grabbing control of their individual professional viability). Assuming you have placed sufficient cost-cutting pressures on your doctors, then their willingness to encourage (or at least not discourage) assisted suicide will increase substantially. So when patients do consult with their doctors, the doctors will not undermine your subtle efforts, but will be your partners in convincing those approaching end-of-life to just be reasonable.

6) Make physician-assisted suicide legal, but not reimbursable.

You’re going for the Botox model here. You do not want physician-assisted suicide to be merely another hush-hush medical procedure, conducted quietly and almost secretly in a typical doctor’s office, so that people can pretend it doesn’t exist. Rather, you want to establish it as something that’s front and center, something people will want and ask for and go out of their way to seek. You want to encourage doctors to establish inventive business models for assisted suicide, just as dermatologists have done for Botox clinics.

Accomplishing this, of course, will require assisted suicide to be made legal everywhere (and not just in Oregon and a few other progressive states), but at the same time will require you to NOT make it a reimbursable medical service.*** For once it’s made reimbursable it will become subject to typical healthcare price controls, and you will severely limit the possibilities.

Think of those possibilities: One envisions physician-assisted suicide becoming established as a “life cycle event” like a wedding or Bar Mitzvah, where the right atmosphere, the right spirituality, and the right tone come together to create an unforgettable, uplifting experience for everyone. Some assisted suicides will take place in a doctor’s office, of course, but why not in a place of worship, a favorite city, a resort, a mountain top, a rocky coast, a casino? Why not allow the prospective decedent to actually hear the eulogies and experience the tearful tributes before actually engaging (ritually) in the Act? Why not partner with the deathcare industry to wrap the final healthcare service into a comprehensive package with funeral services? Why not engage American media to celebrate the event with a new mode of reality programming (one that is sure to garner a massive share of viewers)? Why not convert what is today an antiseptic, impersonal and frightening process into one that makes everybody present say, “Yes! That’s the way to go!”

The beauty is that this sort of model will convert what is today, at best, merely the option for assisted suicide into something that’s expected – a true destination event, a natural part of life. Indeed, not opting for assisted suicide, at a certain point in one’s life, will come to be seen as being unreasonable, greedy and selfish. And when granny begins to spend more time in a doctor’s office or (worse) in a hospital where frequent visitation is expected (and other family inconveniences are generated), some loving grandchild will pat her precious wrinkled hand, and say, “Granny, you know, it’s getting to be about that time. Wouldn’t a last weekend in Vegas be just the thing?”

So, if you play your cards right - passively encouraging the end-of-life movement in its effort to spread the word, while making the alternative (i.e., not committing suicide) as nasty and foul an option as possible, and also while coercing doctors and encouraging families to view assisted suicide as the most advantageous modus exodus one could ever imagine – well, the “right” to assisted suicide will shortly become the expectation and even the duty for assisted suicide.

And if those who run health plans will just follow DrRich’s program, you will have accomplished all this without seeming crass and self-serving as you most certainly do each time you send somebody a letter like the one you sent the unfortunate Ms. Wagner.

*Preserving the ethical precept of individual autonomy is the basis upon which modern utilitarian ethicists build their defense of physician-assisted suicide, passive euthanasia, active euthanasia, and even involuntary, secret euthanasia. DrRich will elaborate on the ethicists’ defense of doctors killing people in a future posting.

**This will simply require the government to continue severely and very publicly prosecuting the occasional pain-management doctor. Whether the target physician is actually engaging in analgesic excesses is unimportant to the goal of making any American doctor afraid of aggressively controlling their patients’ pain, for fear of becoming a target themselves.

***You may need to fashion the payment model so that assisted suicide is paid for in the case of hospitalized patients, and for patients in Medicaid programs. The point is to make assisted suicide a highly-desired self-pay service for anybody with enough money for a decent car or central air conditioning.

Posted in General Rationing Issues, New business models for healthcare | 3 Comments »

More Guidelines - Fighting For the Children

August 4th, 2008 by DrRich

A few months ago, DrRich addressed certain disadvantages that will arise from a policy of forcing physicians to practice medicine by guidelines. Essentially, once we decide to measure physician quality and determine physician pay according to how well they “perform” in following handed-down clinical guidelines, we will open a Pandora’s Box of dysfunctional and contradictory guidelines that will make the IRS code - or even the Medicare policy manual - seem straightforward and logical.

Payers are placing much hope in guidelines. They envision great cost savings through the simple expediency of adopting guidelines that leave out certain medical services they would like to avoid paying for.

But the payers have made the grave strategic error of fully embracing the “guideline movement” before securing for themselves control of the guideline development process. Apparently they missed the obvious fact that, if the practice of medicine is is reduced to following sets of guidelines, then any healthcare group and any medical organization with any stature whatsoever will begin manufacturing guidelines that direct doctors to do whatever it is that advances that organization’s agenda. That is, if guidelines determine who gets paid for what, then guideline development will become the chief byproduct of the healthcare system. We are beginning to see this chaotic process in action now.

DrRich, who delights in attempting to tease order from chaos, has suggested several specific categories of the dysfunctional guidelines that will inevitably flow from such a process. One of these categories he labeled “predatory guidelines.”

As an example of predatory guidelines, DrRich pointed to the recent recommendations advanced by the American Heart Association (AHA) urging that children with ADHD be screened with ECGs before they are placed on stimulant medication. Those ECGs, the AHA went on to explain, should be interpreted not by the pediatrician, but instead by “a pediatric cardiologist or a cardiologist or a physician with expertise in reading pediatric electrocardiograms.”

In making this recommendation the cardiologists of the AHA have attempted to encroach upon the turf of the pediatricians, ostensibly to save the lives of innocent children, but in a manner that will inevitably increase business for cardiologists by a) generating hundreds of thousands of ECGs for them to interpret at $25 - $50 a pop, and b) generating tens of thousands of echocardiograms and other cardiac tests that will be necessary to evaluate all the equivocal (and to a very large extent false positive) ECGs that will result from this routine screening, while c) explicitly leaving the pediatricians themselves out of the process.

DrRich predicted at the time that the pediatricians would not allow this invasion of their turf to stand, and that they would find it necessary to counter with their own set of guidelines. And so, what began as “predatory guidelines” from cardiologists would likely degenerate into “dueling guidelines” between cardiologists and pediatricians.

DrRich is delighted to report that his prediction has now come to pass.

The American Academy of Pediatrics (AAP) has just released a policy statement suggesting that the AHA is guilty of promulgating bad advice. Indeed, the AAP finds, it is not necessary to perform routine ECGs on children with ADHD prior to giving them stimulant medication. Further, the AAP pointedly demonstrates that the AHA’s recommendations were based on faulty science (that is, the AHA failed to follow the principles of evidence-based medicine), and that those recommendations give at least the appearance of being self-serving. Finally, the AAP notes that since routine ECG screening produces many false positive results, which themselves require further cardiac testing, this screening actually produces more harm than good. So, the AAP concludes, not only is there no need to do routine ECG screening, but also doing the screening would produce net harm. The AAP statement stops just short of accusing the AHA of malfeasance.

And so, DrRich would like to thank the AAP for so clearly bearing out his prediction that “predatory guidelines” will always tend to yield “dueling guidelines.”

Needless to say, the cardiologists are not happy about this new development. Dr. Steven Nissen (famous of the Cleveland Clinic, and also famous for producing inflammatory statements pretty much on cue) tells TheHeart.org (professional registration required) that “the AAP statement is misguided.” Nissen also suggests, perhaps a bit gratuitously, that the pediatricians (and their friends, the detestable shrinks) are tossing amphetamines around like candy. He says, “This is the second time in a few weeks where the AAP has issued poorly thought out guidelines that promote inappropriate drug use in children. The previous statement promoted statin use in children as young as 8 years of age.”

(DrRich is sympathetic to the notion that the diagnosis of ADHD might be a tad overdone these days, to the point where being a boy is all but an official disease, for which drug therapy is frequently urged and often prescribed. But still, in the debate over whether children diagnosed with ADHD should have ECG screening before being drugged, the assertion that they are being overtreated in the first place is actually beside the point.)

Both sides in this now-very-public debate seem to have some valid points, and to DrRich’s estimation neither side is obviously completely right or completely wrong. Cardiologists are correct in pointing out that stimulant drugs do have cardiovascular effects, and it is logical to think that kids who are susceptible to cardiac arrhythmias might be at higher risk on these drugs, and that screening these kids might save some lives. But the pediatricians are correct in pointing out that the data that has been collected so far does not show any increase in sudden death in kids on drug therapy for ADHD when compared to the general population, that the same cardiovascular effects caused by these drugs are also caused by everyday activities such as running, jumping, and the sort of emotional outbursts that children with untreated ADHD may have from time to time, and that, besides, doing ECGs on all these kids has a known downside in terms of unnecessary procedures and increased cost.

So, in addition to being unseemly, these dueling guidelines create a dilemma (instead of guidance) for doctors who are actually attempting to care for children with ADHD. One set of guidelines says that screening is necessary to save lives; the other (from an equally regarded professional organization) says that not only is screening unnecessary, but also harmful. Whatever the doctor does, if there is a bad outcome the plaintiff’s attorney will come pre-armed with one set of guidelines or the other which will prove that, no matter what the doctor did, it was the wrong thing.

These dueling guidelines also demonstrate that many important medical questions are simply not suitable subjects for guidelines. Guidelines are fine when a medical issue is resolved, that is, when there is substantial agreement among experts (of all relevant factions) as to how patients with a certain medical condition ought to be managed. But guidelines are helpful only when the clinical question is sufficiently ripe. Premature guidelines - the ones promulgated for some other reason than that the optimal clinical pathway has been resolved - will cause harm (and often, ironically, will increase cost).

Nonetheless, the notion that the practice of medicine can be completely reduced to sets of guidelines (a notion vitally attractive to insurance companies and government bureaucrats), now has been broadcast with great fanfare across the land. It is through guidelines that we will finally homogenize healthcare, and establish the tools by which clinical excellence can be tabulated and costs can be controlled. So, as a consequence of this generally agreed-upon fiction, swarms of guidelines are now flying out of the medical establishment like bats out of a cave. We can expect many of these guidelines to be created not because clinical science warrants them, but instead to covertly ration care, to protect professional turf, or to aggressively extend one’s interests onto entirely new turf.

And so, spectacles like this one, where cardiologists and pediatricians have become engaged in a rather nasty turf battle (fighting for the children, as it were), will be repeated countless times across the medical landscape.

Cry havoc, and let loose the dogs of guidelines!

Posted in Guidelines, Abuse of | 5 Comments »

Skin in the Game

July 30th, 2008 by DrRich

The New York Times recently took dermatologists to task for creating a two-tiered system of dermatology - one for patients with skin disorders, and one for “cosmetic dermatology.”

As the Times describes it, patients who wish to see a dermatologist for, say, possible skin cancer are put on a waiting list, and when their appointed time finally arrives (generally months later) they are subjected to modern medical hell. To wit: Upon arriving in a lackluster office, the patient is shelved for a while in an unattractive, poorly lit waiting room equipped with a broken TV, old magazines, unruly children of other patients, and surly office personnel. Eventually her name is called by a not-necessarily-pleasant nurse practitioner who will “triage” her to the appropriate category (e.g., acne, fungus, cancer, warts- you know, dermatology stuff), have her strip in order to fully expose the large surface-area organ (the skin) for which she has sought assistance, give her a scratchy yellow paper gown to cover her nakedness, and have her wait for some time in a chilly exam room to see the actual doctor. At last the dermatologist arrives, mutters a greeting (or some other ritual uttering), glances at a clipboard, and announces, “Show me your [acne, fungus, cancer, warts];” whereupon, having regarded the cause of cutaneous concern and having made a professional determination, he either signs the prescription that has been pre-written for him by the nurse practitioner, or schedules a procedure. Then, shoving into the patient’s arms her bra and other structural and non-structural equipage, the doctor pushes her out into the hall, as the formal interview is over.

Presumably, one hopes, some dermatology practices not visited by the New York Times might not be quite so bad. Still, anyone who’s been seen by an American PCP lately will nod sympathetically at the dermatology patient’s ordeal.

Now observe what the Times observes when the patient, instead of having an actual skin problem, merely is sagging here and there and wishes to be shorn up. That is, the patient has a cosmetic issue. That is, the patient wants Botox.

The same dermatologist will often have an entirely different setup for these patients. This time the patient is seen immediately, possibly the same day, as dermatologists are sensitive to the needs of those who are about to appear in public, say, at an impending dinner party. If this patient is to wait at all, she will wait in a modern, tastefully decorated private room. She will then be seen not by a mere nurse practitioner but by an aesthetician, who will do a formal assessment of the sagging parts, and, aside from suggesting more injection sites than the patient might originally have had in mind, will offer a complete program for long-term cosmetic maintenance, which naturally will include quarterly Botoxification. At just the proper moment the dermatologist comes in, greets the patient warmly and reassuringly; then reviews the recommendations of the aesthetician and discusses those recommendations at length with both the aesthetician and the patient, studying the patient’s face in depth as he does so, pointing, nodding, agreeing, adjusting, all the while smiling confidently. Yes, he indicates, we will all be very happy indeed with the results. Finally the doctor begins to make the now-thoroughly-discussed-and-agreed-upon injections, doing so with the greatest solicitation and sensitivity. The patient is then given as much time as she needs to collect herself, and is invited to “recover” in a room set aside for this purpose with flattering lighting, soft music, a cappuccino machine, and perhaps a glass of wine. She leaves the office a new person. And, just as the dermatologist has promised, all are indeed very happy with the results.

Naturally, the New York Times is scandalized by the dichotomy which its discerning readers will note here. Why should a patient with a mere cosmetic issue be treated so well, when a patient with an actual medical problem, possibly even skin cancer, is treated so shabbily? How can dermatologists openly encourage such a two-tiered system?

DrRich has a word of advice for the commentators and reporters of the New York Times and any other concerned Americans worried that dermatologists, by setting up separate-but-not-equal practices for their two kinds of patients, are moving us one step closer to the dreaded two-tiered healthcare system we all abhor. That word is: Chill.

Allow DrRich to support this friendly recommendation with two observations.

1) We already have a multi-tiered healthcare system, and little or none of it is the fault of dermatologists. It is the fault of human nature. All countries have at least a two-tiered healthcare system, including countries (like Cuba and China) that have specifically embraced egalitarianism (rather than individual autonomy) as the fundamental operating principle. The second tier, like the poor, will always be with us.

2) When a dermatologist spends Tuesday afternoon in her run-down office, treating people who come to her for bona fide skin disorders like they’re widgets on an assembly line, then goes to her other, better office on Wednesday, treating the merely cosmetically-challenged like minor nobility, she is not really engaging in two-tiered healthcare. Not at all. Instead, she is practicing real, true, prescribed-by-society, by-the-book American healthcare on Tuesday, and doing Something Altogether Different on Wednesday.

Injecting Botox is officially and formally not part of American healthcare. How do we know this? Because it is not covered by Medicare or health insurance. If you want Botox you’ve got to pay for it your own self, just as you do if you want a TV or a car. So by all that is sacred, injecting Botox is NOT American healthcare.

Furthermore, when one looks objectively, injecting Botox is not even really practicing medicine, at least not in any true sense. In actual truth, it takes very little training or expertise to inject Botox. There’s no reason one must go to college, graduate from medical school, or do several additional years of training in dermatology (or any other specialty) to do this. Anyone with a needle and syringe, an alcohol wipe, and access to Botox could do as well. Just find the wrinkle and stick it. If they made the materials available over-the-counter, folks would do just fine with it.

Of course, doctors in general (and dermatologists in particular) have legally cornered the market on Botox injections. So it’s not like you could just set up a booth at the Mall and hire high school students to do this (as you can for, say, ear-piercing - which, in contrast to Botox injections, is an actual surgical procedure which results in a permanent structural change in a body part). If you set up a chain of Botox Booths, you would be practicing medicine without a license, which is a serious offense.

And consider this. Dermatologists could just as easily have taken up a somewhat different well-known cosmetic procedure, one that also involves injecting substances through the skin via needles, and that has much more to do with the skin itself than Botox injections (which actually do not affect the skin itself at all, only the muscles under the skin), but they chose not to. DrRich speaks, of course, of the tattoo. But unlike making Botox injections, tattooing requires real skill, knowledge, training, expertise and artistic talent. Most dermatologists simply could not manage a highly-technical skill like that.

The point, of course, is that injecting Botox does not involve intrinsic skill, knowledge, difficulty, risk, or any other objective characteristic that necessarily renders this a medical procedure while ear-piercing and tattooing are not. Viewed from this perspective, one must conclude that declaring the injection of Botox to be a medical procedure, which cannot be performed by anyone not having a medical license and years of specialty training, is an entirely arbitrary determination.

Fundamentally, then, while performing Botox injections may have a certain legal status, in any true sense it is not really practicing medicine. Rather, it is simply an activity some dermatologists may choose to do when they’re not doing real dermatology.

Doctors engage in this sort of thing all the time. That is, they partake in activities other than practicing medicine when they could, in fact, be seeing more patients. Some have taken up golf. Others have started side businesses such as restaurants or software companies. Some go to graduate school (usually for MBAs). Still others have opted to work part time in order to raise their families.

Society generally finds such activities acceptable, and - to this point - does not insist that all doctors forego all other human endeavors in order to see as many patients as humanly possible, during all their waking hours. While society seems to be moving closer to declaring that doctors owe this duty, it has not reached this point quite yet.

Until society sees fit to legislate otherwise (which, DrRich supposes, could happen as early as the next president’s administration), doctors will continue to spend some of their time engaging in hobbies and business or family activities outside of the formal healthcare system. Some may even leave the formal healthcare system altogether in favor of these other activities. DrRich himself has done this. And until society renders it officially illegal for doctors to do so, DrRich respectfully asks that doctors be left alone to celebrate their individual autonomy as granted to them under America’s founding documents, whether it’s by establishing authentic Indian restaurants, setting up Botox clinics, or even becoming retainer practitioners.

One last word of advice for dermatologists: Have fun with your Botox clinics, fellas, but please don’t become too invested in them. Injecting Botox is not exactly cardiac electrophysiology. This is definitely a shallow-moat business, and the only thing that gives you any protection at all is your aura as highly trained specialists, with special and secret knowledge about an organ (i.e., the skin) which visibly droops when the underlying muscles become lax with age and gravity. A single action by forces entirely out of your control - say, Congress or the FDA - could render your monopoly entirely moot overnight, and you will be instantly priced out of business by hordes of PCPs, nurse practitioners, Botox booths in Walmart, and even home Botox injection kits. So please remember to at least keep your hand in genuine dermatology, or get your MBA, or perfect your long iron shots - but do something that will provide you with a Plan C. Because Plan Botox is definitely a high risk endeavor over the long term.

Posted in New business models for healthcare | 12 Comments »

Is Treating Cancer Worth It?

July 24th, 2008 by DrRich

Yesterday, Jacob Goldstein of the Wall Street Journal Health Blog pointed out the financial dilemma that has been created by evidence that a new cancer drug, Nexavar, is effective in treating liver cancer.

Most liver cancers are particularly impervious to chemotherapy, and until Nexavar came along no chemotherapy had ever been shown to significantly prolong survival. So when Nexavar improved the overall survival of a subset of patients with liver cancer in a well-designed randomized clinical trial (RCT) last year, the FDA (recognizing a true breakthrough when it sees one) quickly approved the drug.

The problem? Nexavar costs over $5000 per month. That, DrRich points out, is even higher than your average monthly health insurance premium. This means that any insurance company (or government) that agrees to pay for Nexavar is going to be out some big bucks.

(The good news for the payers, if there is any good news, is that Nexavar only prolongs survival by an average of three months, and the one-year survival of a population of patients with liver cancer on Nexavar is still less than 50%. Just think of the damage if Nexavar prolonged survival by several years!)

The economic question created by drugs like Nexavar - which result from extremely sophisticated and costly research and development processes, and whose benefits are undeniable but perhaps marginal - is likely to be asked several times over the next few years. We are also hearing those questions expressed, for instance, regarding the drug Avastin, which is used for lung, colon and breast cancer. Like Nexavar, Avastin has clear-cut and undeniable benefits that have been proven in RCTs. Like Nexavar it is very expensive. And also like Nexavar the duration of its benefits are measured in months, not years.

The form this economic question usually takes is: Should we really pay for extremely expensive cancer drugs like this when the expected benefit is so transient? While DrRich does not pretend to have the best answer for this question,* he will make two observations.

First, the reason it is so difficult to answer questions like this is that we in America (citizens, the government, and the insurers) refuse to acknowledge that there are limits to what we should expect from our healthcare system. We expect to receive any bit of healthcare that offers even a possibility of benefit, even if that benefit is likely to be marginal or transient. We expect our researchers to work day and night to cure every disease, no matter how rare, and we become indignant when progress does not seem rapid enough for our particular disease; indeed, death itself is merely a manifestation of insufficient research. In other words, where healthcare is concerned, there are and can be no limits.

Given this “no limits” paradigm, when our society is faced with the inescapable need to ration healthcare, that rationing can only be done covertly. There’s no other way to do it.

And under covert rationing (whose very purpose, again, is to preserve the illusion of “no limits”), there’s simply no mechanism, or even justification, for addressing questions like the one raised by Nexavar and Avastin. Our procedure is: we do the RCT, and if the RCT shows any measurable benefit, we pay for it. End of story.

So the insurers and the feds won’t be able to base their payment decision on some objective and transparent cost-benefit analysis for Nexavar, evaluating where this analysis falls in relation to all the other cost-benefit analyses they perform for all the other forms of therapy. Rather, they’re simply going to have to announce they’re paying for it. They have no other choice, because to do otherwise would question the “no limits” paradigm.

And then they’ll perform the unavoidable rationing by some covert means probably having nothing whatever to do with this particular therapy, or of any particular therapy, but rather, according to whatever means they can get away with, wherever in the healthcare system and with whichever patient that might be. That’s the job we’ve assigned to them. And they’re very good at it.

Second, the financial questions raised by Nexavar, Avastin, and similar therapies point out yet again that the Axiom of Industry often invoked by healthcare policy experts - that is, that improving quality will always reduce cost - simply does not work in healthcare. There are many, many times when achieving the best possible clinical outcomes (i.e., optimizing quality) greatly magnifies the cost of medical care.

The real problem with Nexavar and Avastin is not that their beneficial effect is just transient. That fact, to be sure, gives insurers and commentators a convenient handle, some basis for whining about these drugs that will engender sympathetic murmurs from certain quarters (though, as we have seen, it will ultimately not get them out of paying for them). But it’s not the problem. Indeed, the fiscal challenge for the payers would be much worse if these expensive drugs resulted in very prolonged survival. The real problem is that some of the stuff that works really well in healthcare is just really expensive, you see, because a lot of expensive research and technology went into developing and producing it. It just costs a lot.

So when some expert comes along and tells us that achieving a cost savings resulting from some brilliant new initiative - such as pay for performance, disease management, medical home, etc., etc. - will necessarily and directly yield an improved quality of care from that same initiative, we can immediately dismiss him or her as being either disgracefully ignorant of his or her chosen field of study, or disgustingly deceitful. In DrRich’s experience, the odds of any particular policy expert being disgraceful vs. disgusting is roughly 50-50.

* He does, however, pretend to have a transparent and equitable process for getting to a reasonable answer, which can be found in his book.

Posted in General Rationing Issues | 11 Comments »

Fun With Randomized Trials, and Breasts

July 18th, 2008 by DrRich

The Cochrane Collaboration has created something of a stir with its latest review on the advisability of doing breast self-examinations, which concluded, in essence, that they’re not advisable. Specifically, they found that women who perform breast self-examinations end up producing more harm than good, so women should be discouraged from the practice.

The Cochrane Collaboration is a highly regarded resource for those who value evidence-based medicine, medical guidelines, and the randomized clinical trials that support such tools. The experts at Cochrane conduct reviews of all randomized clinical trials (RCTs) that meet their strict criteria for scientific and statistical robustness, and periodically publish summaries of the scientific evidence thereby derived, on particular clinical topics. Cochrane reviews are thorough and straightforward, and virtually always present an accurate reflection of the up-to-date evidence as supported by RCTs.

Despite the respect in which the Cochrane Collaboration is held, DrRich finds it at least mildly interesting that their conclusions regarding breast self-examination have not been generally construed as being politically incorrect. After all, several aspects of political incorrectness, ones at least as incorrect as your more standard species of political incorrectness, can be readily identified within the Cochrane review. For example, one could easily allege that anti-women, anti-self-empowerment, or anti-early-detection thinking riddles this report. And if the review had emanated from say, the White House, one almost certainly would. But in fact most media reports, while expressing a certain amount of surprise, have seemed very reluctant to criticize the Cochrane Collaboration’s conclusions. And physician experts who have been excavated by the media for their comments have also given at least tepid support.

(Not all commentators have blindly accepted Cochrane’s recommendations. DrRich refers you to his colleague Trisha Torrey, for example, who expresses an appropriate amount of skepticism. But the traditional media, and their Rolodex physicians, have on the whole swallowed it. See here and here.)

The general support for Cochrane’s report on breast self-examination, DrRich submits, is a direct reflection of the exulted position that RCTs have achieved today all across the modern medical (and media) landscape. If a statistically legitimate RCT reaches some conclusion, no matter how strange, counterintuitive, or wrong that conclusion might seem, it is a conclusion that must be accepted. That this belief in RCTs trumps even the powerful social force of political correctness speaks to its ultimate strength.

DrRich has previously observed that our widespread belief in RCTs can be reduced to three main tenets:

1) Data derived from randomized clinical trials represents Truth.
2) Data derived from non-randomized trials represents Falsity.
3) If you don’t believe this, you are a heathen.

Objective observers will find it at least a little ironic that an attempt to claim the scientific high ground has so obviously resulted in a new religion, replete with its own dogma. True Believers will not see the irony, thus providing even more evidence that what we’re dealing with here is indeed a religion and not objective scientific thought. (Religions deal in mystery, and not irony.)

The sad truth is that the results of RCTs are invariably dependent on the bias built into their design, and even if internally they are statistically legitimate, they can often send us down the wrong path.

Those who design RCTs (the smart ones, at least) know this. They are like smart trial attorneys, in that they know the answer before they ever dare to ask the question. So they tailor their “question” in such a way as to yield the answer they want to get. Indeed, if a lawyer should end up asking a question that produces an unexpected answer, he or she is completely incompetent and ought to be sued for legal malpractice. In more cases than one might think, the same is true for those who design RCTs.

So, for instance, if you are a payer and want to limit the use of an expensive therapy, you design your RCT so that enrolled patients likely to respond to the therapy are diluted with lots of enrolled patients much less likely to respond, to assure that the average response of the whole population will be quite small. (In many instances the clinical characteristics of the likely responders and the likely non-responders will be reasonably apparent.)

On the other hand, if you are a company that wants to encourage the use of your product, you design an RCT that preferentially enrolls patients who are very likely to respond favorably, and then trust the marketplace (with a tweak from your DTC advertisements) to “extrapolate” the results to broader categories of individuals.

So RCTs do not in any way eliminate statistical bias, as most seem to think. Rather, they simply offer an opportunity to control the statistical bias in your favor. Since most doctors (and most regulators, guideline writers, and reporters) don’t seem to get this, it becomes relatively easy to fool them.

DrRich does not know if the people who designed the RCTs looking at breast self-examination tried intentionally to bias the results against self-examination, or if it was an accident. But that is what they did.

The RCTs which the Cochrane Collaboration reviewed looking at breast self-examination indicate that, in large populations of women in Russia and China, who go on to receive Russian and Chinese healthcare, breast self examination did not improve overall survival. And since those who did self-examination underwent twice as many breast biopsies, many of which revealed benign lumps, they experienced net harm. DrRich does not quibble with any of this. It is almost certainly true.

On the other hand, while most RCTs do not reveal it (since they look at aggregate results and not individuals), it is most often the case that some individual participants in even a negative study will experience benefit from the intervention being tested. In the breast-self examination studies, for instance, it is a certainty that individual women benefited at least to the extent that their breast cancers were detected earlier than they otherwise would have been. (In the Russian study this was proven to be the case.) These women had at least a shot at better survival by virtue of their earlier detection.

But whatever the overall results of these RCTs conducted in such exotic locales, they can have nothing whatsoever to do with women in America in 2008, who receive far more aggressive, tailored, and sophisticated therapy for breast cancer than women in virtually any other country in the world. (The optimal treatment of breast cancer depends on correct staging, on correct genetic testing of the tumor, and on optimizing the individual’s surgical and medical therapies, often employing very new drugs.) In any case, earlier detection of breast cancer is far more likely to be a significant factor in determining outcome in the U.S than it is in recently (or presently) Communist countries with 3rd world healthcare systems.

To be sure, DrRich does not pretend to know anything about the various specific institutions in Russia and China where these studies were conducted. Perhaps they were conducted in those rare showcase institutions that appear here and there under authoritarian regimes, of the sort Michael Moore frequents when he goes to Cuba, and where the level of medical care is said to more nearly approximate medical care in the United States. (Occasional institutions like this will survive even in the U. S. after Healthcare Reform, so that our Congresspersons will have someplace to go.) While this seems very unlikely - could a few showcase hospitals really accommodate the nearly 400,000 women enrolled in these studies? - one must suppose it is possible.

But even if all 400,000 study participants received showcase healthcare, advances in the therapy of breast cancer since the 1990s, when these women were studied, would likely yield different (and better) results today. Does any American oncologist believe that the early detection of breast cancer in 2008 does not improve a woman’s prognosis?

In light of such considerations, why are American doctors apparently so ready to accept the results of the Cochrane review, and to stop recommending breast self-examination? The answer is clear: It is because the data came from RCTs, and since RCTs always yield the truth (you heathen), all other considerations must fall away. Such is the depth of our faith.

DrRich will leave it for another day to discuss the favorable implications to the healthcare system of discouraging breast self-examination (such as having to pay for fewer biopsies), or the lessons that ought to be learned from this example about the advisability of blindly accepting formal guidelines just because they are derived from RCTs, and instead will simply give some friendly advice to the women who might be reading this blog:

First, it is probably a good idea to continue with your breast self-examinations. The downside of doing so is that you may be subjected to a breast biopsy for a benign lump. So take that into consideration. But the upside is that self-examination offers the (proven, according to the RCT data) potential for earlier detection, and therefore offers better odds of long-term survival if cancer is present.

And second, if breast cancer is diagnosed, try to get your therapy in the U.S. rather than in Russia or China. For the average patient in those countries, it would appear that cancer therapy sucks.

Finally, DrRich will close with this plea: Can our guideline writers, at least in the U.S., please refrain from creating new guidelines that are suitable for 3rd world healthcare systems, at least for the year or so it might take for the American healthcare system to actually be reduced to those levels?

Posted in General Rationing Issues | 9 Comments »

Throwing It To The Dogs

July 15th, 2008 by DrRich

Robert Pear reported this week in the New York Times that, in narrowly averting the scheduled 10.6% pay cut for doctors (and in the process taking the popular Medicare Advantage program away from seniors), congresspersons of both parties have come to recognize that “the formula for paying doctors is broken.” For their insight in reaching this conclusion, we all should be proud of the cleverness of those whom we persist in electing.

Doctors now have an 18-month reprieve before the next round of pay cuts are scheduled to kick in. And members of Congress, who were unable to stomach the blowback that would have occurred if they had allowed the relatively “small” pay cut this year, fully realize that they’re not going to get away with the next one either, which is scheduled to come in at 20%. This gives them 18 months to find a solution to the physician reimbursement mechanism which, DrRich reminds you, they all agree is broken.

That reimbursement mechanism, of course, is so fundamentally ridiculous that it can only be understood by recognizing that it is a fairly typical bureaucratic attempt to covertly ration healthcare. Covert rationing requires systems that maximize complexity and inefficiency. So, while regulators might have achieved the desired cost cutting by the simple expediency of declaring an arbitrary series of pay cuts for doctors, they instead saw fit to conjure up a truly Byzantine system of rules, formulas, regulations and calculations, whose machinations are somehow linked to projected changes in GDP, which themselves are the product of arcane and mystical divinations made by such prevaricators as econometricians. This sort of “system” serves covert rationing well. It allows Congress to represent the physician pay cuts as being the result of a scientifically derived and economically justified process, which is so finely calibrated as to make it nearly a crime for Congress (or anyone else) to “adjust” it .

We aren’t supposed to notice that the physician reimbursement mechanism fails to recognize even the most basic principles of economics. And if doctors point out that neither the number of sick people nor the overhead of medical practices track in any way with the projected GDP, they reveal themselves as being either unsophisticated or greedy. Either way, they can be safely ignored.

At least, that’s how the process is supposed to work. With this latest round of scheduled pay cuts, however, while Congress did its best to take the issue to the wall, in the end our elected representatives were forced to admit that the physician reimbursement system simply doesn’t work. By this admission we can only conclude that the reimbursement system at last has become politically infeasible. .

Infeasible though it might be, Congress is far from prepared to come up with a substitute. As Mr. Pear reports, “Democrats and Republicans agree that. . . fixing it would be phenomenally expensive.” For instance, if Congress were to do what at first blush seems to be the most logical thing, that is, to simply repeal the current mechanism and allow payments to doctors to grow at the rate of medical inflation, the Congressional Budget Office estimates it would cost Medicare $65 billion in the first five years and nearly $200 billion in the next five years. You go tell the voters that doctors are worth that kind of money.

The bottom line: Paying doctors in some reasonable manner is simply not an option.

The solution Congress is turning to, according to Mr. Pear, is to assign the job of figuring out physician reimbursement to the doctors themselves: “Lawmakers are pleading with physicians’ groups to come forward with a comprehensive proposal.”

We have seen, of course, the sort of thing that happens when you turn over to “physician’s groups” the honor of figuring out how the limited physician reimbursement pie is going to be divvied up. The RUC is the result of such an effort, and there, as one would expect, the powerful specialists have completely overwhelmed the voice of the relatively weak primary care physicians, much to the detriment of not only the PCPs, but also of patients, the healthcare system, and the healthcare budget itself. (While some may consider it ironic that a process initiated in an effort to covertly ration healthcare ends up increasing costs, this is actually the most common outcome of the programmed inefficiencies that invariably accompany covert rationing efforts.) In any case, Congress now proposes more of the same - that is, let the doctors figure it out.

DrRich has pointed out many times that doctors really do want to do what’s best for their patients, and that indeed, wanting to do what’s best for their patients is as high as number three on doctors’ priority list. Priority number one is maintaining their individual viability as practitioners (a priority that requires them to keep the payers happy above all else). And priority number two is protecting the integrity their professional turf, that is, maintaining the prerogatives of their specific medical specialty. (Cynics should recognize that no doctor who ignores priorities one and two will very long be in a position to exercise priority three.)

Congress is now proposing to remake the physician reimbursement system by turning it into a turf battle among physician groups. The battle will be bloody.

Congress is faced with a kennel full of starving dogs, of many various breeds, and has decided it will feed them with a single lamb shank. Rather than figuring out how to distribute the lamb shank so that smaller (yet valuable) dogs will not be torn apart in the struggle, they have elected instead to just go ahead and toss the shank over the fence, and let the dogs figure out how to divide it up. The result will not be pretty, nor will it be hard to predict.

DrRich would rather not watch. He merely (as a courtesy, no more), shouts this new warning to PCPs (the smallest dogs in the kennel). He will then hide his eyes from the carnage.

Posted in Healthcare economics, Primary Care in America | 8 Comments »

Getting Square With the Nurses

July 9th, 2008 by DrRich

Last month, DrRich wrote about how “doctor-nurses” are fixing to displace primary care doctors, and how the noble American Medical Association – champion, as always, of the American PCP – is mobilizing with decisive action to prevent this tragedy from taking place.*

One of the more remarkable responses to this article came in the form of a blog entry by DrRich’s colleague Annie, an entry which was, let’s say, critical.

DrRich is very sorry to have raised Annie’s ire, especially since Annie represents a combination of two of DrRich’s favorite kinds of people – nurses, and students of the Constitution. It is in this latter capacity that she writes for the blog Home of the Brave, a site that, if a bit leftward-leaning for DrRich’s tastes, is nonetheless dedicated to the very worthwhile goal of discussing “U.S. history, the state of the union, the state of the U.S. Constitution.” DrRich even gave top billing to one of Annie’s posts last week in Medical Grand Rounds – her nicely tuned article showing what the Founders might have said about the current sad state of the American healthcare system, an article which he now recommends again to everyone.

This public recognition of Annie’s obvious merits, despite the article she had written in response to DrRich’s posting on doctor-nurses, ought to attest to DrRich’s essential fair-mindedness and objectivity. For in that article Annie was less than kind to DrRich’s sensibilities. For instance, referencing DrRich, Annie said,

A few physicians are skeered of a new demon. They’ve got their Salem witch hunter judicial robes on, and they’re ready to order the press, the pyre or just a good old pompous piosity to their screed. What has their panties all in a bunch?

Doctorally educated nurses. I. am. not. making. this. up. They’re afraid of nurses.

What nurse bashing this is and based on what? Fear of competition?

Annie goes on some more about DrRich’s manhood and such (for the record, DrRich does NOT wear panties), but you get the idea.

More relevantly (more relevantly, at least, to everyone else if not to DrRich), Annie’s post points out that: a) nurses with doctorate degrees are not a new phenomenon; b) the vast majority of nurses are not out to displace physicians, or to usurp the title “doctor;” c) since there is an acknowledged shortage of PCPs, surely something has to be done to fill the void, and nurses – working in full partnership with doctors, as always – can help; d) the formidable Mary Mundiger (formidable, at least, to the lily-livered DrRich) does NOT speak for the large majority of nurses; and e) the organization that actually does speak for most nurses is the very reasonable American Association of Colleges of Nursing (AACN).

And the AACN is greatly disturbed by ideas, put forth by misguided paranoids like DrRich, that doctor-nurses may be getting ready to take over for actual physicians, and is distressed by the blowback that has already been experienced by the nursing profession as a result of such ideas. Indeed, Annie points out, the AACN is so alarmed by the resolutions being considered by the AMA (described here) - resolutions that, if passed, would potentially result in sending nurses a strongly worded letter - that it has issued a white paper itself urging the AMA not to take such drastic action.* This white paper passionately expresses

concerns regarding Resolutions 303 and 214, which are coming forward to the American Medical Association (AMA) House of Delegates. . .AACN is distressed by the tone of these resolutions, which may weaken the good working relationships established between many physicians and nurses….AACN requests that the AMA withdraw Resolutions 303 and 214, and if that is not possible, we urge members of the AMA’s House of Delegates to vote against these measures.

That is (Annie assures us, and the AACN certainly confirms), nurses, even most of the doctorally trained ones, want to play nice with physicians. And DrRich’s screed on the impending take-over of American medicine by hordes of aggressive nurses is both overdone, and very counterproductive.

In response, DrRich can only offer that he fervently desires that Annie, and any others who may have been offended by his earlier post, go back and read it again, but this time read it keeping in mind the following prompt: Irony. For DrRich’s comments were mainly aimed at satirizing the response of the emasculated and morally bankrupt medical establishment to the inevitable encroachment by nurses on what has traditionally been medical turf. DrRich was attempting to be ironic. (A colleague of DrRich’s, reading Annie’s posting, commented that those who miss the poorly-hidden subtleties of irony also may be likely to miss the well-hidden subtleties of difficult medical diagnoses. But this is unkind and likely incorrect, and DrRich chooses not to subscribe to it. Besides, this snide comment presupposes that DrRich does irony well, which may not be a good bet.)

Furthermore, DrRich would like to go on record to say that virtually everything Annie says (except for the personal stuff about his cowardice, Puritanical judgmentalism, exaggerated piety, panties, etc., much of which is simply not true) is pretty much correct. DrRich agrees that the large majority of nurses have no intention or desire to fundamentally displace American PCPs. And DrRich further agrees that doctors who resent nurses because they think they’re after their jobs are badly misguided.

But it’s not because ascendant nurses aren’t about to displace them that they’re misguided. They are indeed about to be so displaced. Rather, they’re misguided because most nurses don’t want any part of it either, just like Annie says.

Anyone who had read DrRich’s earlier articles on the plight of the PCP would understand that he does not consider the prospect of nurses encroaching on the turf of PCPs to be evil or bad, but simply the normal pattern in a modern society wherever advancing technology enables lesser-trained individuals to do things that in the past required highly-trained specialists. DrRich would never bash nurses for simply playing their natural part in the evolution of a technological society. He would sooner criticize a grizzly bear for dining on the entrails of an elk which had died of the mange.

The quotation Annie provides from the AACN white paper, protesting because the AMA is accusing nurses of doing what nurses are, in fact, doing (however involuntarily it may be) is quite telling. The train is leaving the station. The writing is on the wall. While it is clearly not Annie’s intent, or the AACN’s intent, or the AMA’s intent for nurses to replace PCPs, it’s happening just the same, as the night follows the day. Neither the PCPs, nor the nurses who may be startled and intimidated by the prospect, can ultimately stop it.

Those doctors who do view the encroachment by nurses as an unadulterated evil deed will see the protestations of innocence by the AACN - while events on the ground so clearly contradict them - as something similar to the soothing murmurings of the Japanese Ambassador while preparations for Pearl Harbor were in their final stages. They will see it as disingenuous at best, treachery at worst. But viewing it this way is simply wrong.

The posting by Annie and the white paper of the AACN are actually indications that most nurses are as apprehensive as are the PCPs they are displacing. And why shouldn’t they be? Look at the new responsibilities and risks the nurses will be acquiring - medical, moral, legal, financial and otherwise. Historical upheavals like this are often unkind to all parties involved, even the supposed “winners.”

If further evidence is needed that DrRich is correct (beyond simply studying the history of technological societies), simply read the July 2008 Update of the Hospital Outpatient Prospective Payment System issued by CMS. This document (if you can get through it) among other things removes language from the Medicare Benefit Policy Manual that had required that “services furnished in provider-based departments of hospitals must be rendered under the direct supervision of a physician who is treating the patient.” That is, non-physician care providers are now allowed to provide care for Medicare patients in a hospital outpatient department without any supervision by any physician who is caring for the patient.

CMS is already there, and is very obviously clearing the path for the inevitable. Everybody needs to get ready for this - the PCPs, and the patients, and even the reluctant nurses.

* This is an example of irony.

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