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Monday, February 22, 2016

Fixing U.S. health care by "monetizing altruism"?

A week from today I'll be in Vegas to cover HIMSS 2016. Rather doubt that I'm going to encounter any discussions on "monetizing altruism."

A lot to discuss and consider in this post. I just finished Dr. Nortin Hadler's latest book.

"Figuring out a way to monetize altruism"

Chapter Nine: Medical Professionalism in the Twenty-First Century 
It is one thing to champion a trustworthy patient-physician relationship that promotes informed medical decision making and proclaim the physician to be the wise facilitator in such a relationship. But it is quite another thing to extricate such a relationship from the current dialectic, which is heavily funded to promote a systems approach to patient care. I find it impossible to remain passive in the face of this dialectic. There is an old proverb in medical circles that internists know everything but do nothing, and surgeons know nothing yet do everything. I am an internist. But I am a loose-cannon internist. 

There is a desperate need to position the patient’s narrative as raison d’ĂȘtre and a desperate need to provide wise ears to hear it. The only way that will happen is to create an atmosphere that demands it, an administrative structure that supports it, and a reimbursement scheme based on fees for serving. Getting there is an uphill battle, somewhat Sisyphean given the powerful push-back from stakeholders in the status quo, but it is not insurmountable. The top of the hill is the moral high ground. Medical professionalism must plant its flag there because there is no other way to serve patients well in the twenty-first century. 

Finding a way to plant that flag has been a twenty-five-year odyssey for me, but it has not been a steady upward climb. In fact, it was a gentle saunter for many years because there was neither urgency nor an obvious path of least resistance. Besides, these were years when I was focused on my career as an educator and clinical investigator while American medicine was reveling in its transformation into a behemoth. It was difficult to step aside long enough to effectively question the enthusiasm surrounding me. It became less difficult when I realized that the aspects of my career and my competence that I valued the most were losing value in the new version of American medicine. I felt little pain since other aspects of my career were thriving, but colleagues who were focusing exclusively on the bedside found themselves progressively disenfranchised. So about fifteen years ago, I started to climb with more determination. It was clear that the developing version of American medicine was no champion of my notion of excellence at the bedside. It was clear that prior versions of American medicine had too many flaws to bemoan their passing. And it was clear that American realpolitik would not countenance a national health-insurance scheme, not even the copying of elements of such schemes that were successful elsewhere. The hope was in finding a way to overlay the American approach with a layer of rationality and reestablish the patient-physician relationship at the center of American medicine. That would require figuring out a way to monetize altruism.

Hadler M.D., Nortin M. (2016-01-11). By the Bedside of the Patient: Lessons for the Twenty-First-Century Physician (pp. 159-160). The University of North Carolina Press. Kindle Edition.
I could not recommend it more highly. "Altruism," 'eh? A rather out-of-fashion concept these days during this time of our acrimonious neo-Randian/Tea Party/Trumpist "Selfishness Uber Alles" political idiocracy atmosphere. More on this in a bit, perhaps. For now, you might want to See my citation of Tomasello's fine book "A Natural History of Human Morality" (scroll down). The actual science is telling us that there's adaptive/evolutionary utility in prosocial, empathic, and altruistic conduct.

I took a rather odd path in reading Dr. Hadler's book.

I began at the introduction, then did a bit of keyword/phrase searching, highlighting and bookmarking the findings. From there I read "backwards," commencing with the final "Guideposts for Future Physicians" chapter, and thereafter reading chapters 9, 8, 7, 6, 5, 4, and 3 in that reverse order before finishing up with chapters 1 and 2 in sequence.

Yeah, odd. It's a time-saving tactic of mine (ended up not helping much this time, though). At a pace of about 80 books a year plus all of my periodicals and the endless wash of online stuff (like blogs such as THCB, Science Based Medicine, The Incidental Economist, etc, and now STATnews), many times I delve into a book and shortly think "yeah, OK, I get it, where's this going? Cut to the chase..." whereupon I'll read concluding material to determine whether I need burrow back into detail in the middle (aided by ad hoc topical keyword-searching).

I came by this book by way of a comment Dr. Hadler left under a THCB post entitled "Why We Have so Little Useful Research on ACOs."
"Excellent article and discussion.

In the current issue of the Annals of Internal Medicine ( doi:10.7326/M14-2633) Kern et al have published the results of the 5-year Hudson Valley cohort study comparing the “Patient-centered medical home” approach to practice with practices that utilized just the EHR or retained their paper charts.The study was supported by the Commonwealth Fund and the NYS Department of Health. It recruited 438 primary care physicians in 226 practices, with 136 480 patients across 5 health plans.

There was no clinically meaningful difference in health care quality or utilization between the 3 practice types.

No one should be surprised. Everyone should be disappointed. Some might be upset that prescience drives policy more than science. I am of all these persuasions:"
" clinically meaningful difference in health care quality or utilization..."

That stung. Was my time with the QIO during DOQ-IT and the REC amid the subsequent Meaningful Use initiative simply part of an enormous, expensive waste of time and money (or worse)? Is my interest in and advocacy of digital health InfoTech of nil value? Is my long experience with process QI irrelevant -- even that which took place in the health care setting? Dr. Hadler takes dour, iconoclastic pains to dump all over Health IT and what he calls "quality zealots" and the view of health care as a "system"/"industry."

I'm no unreflective "quality zealot," but I find efforts such as "Lean Health Care" rational and worthy. That it does in fact comprise a huge and growing "industry" is simply a fact. Pining for a more bucolic clinical time of yore is not likely to change that reality one iota.

Back to the present. Dr. Hadler:
"If there is a role for computers in decision making, it is to facilitate dialogue between patient and physician, not to supplant the input from either or to cut health-care costs." [op cit, pg 138]
Well, I've agreed with that sentiment all along. Moreover, the increasing "fragmentation" ("shards") we see in the health care space is not the fault of information technology. See, e.g., my cites of the work of Einer Elhauge ("Allocating Health Care Morally") here and here.

Dr. Hadler on the "ACO" thing:
Gatekeepers Since the attempt to target hospital systems for the sake of affordability has been largely co-opted by the costliness of the approach and the ability of hospital systems to game the system, policy experts have been tweaking the latest versions of the multispecialty clinic, even though the lucrative specialties have fled and the more viable of these clinics have been purchased by various health-care systems. The policy approach is based on a simple tenet: if disease can be managed efficiently in the outpatient clinics, the need for recourse in hospitals would be abrogated and their costliness circumvented. This is the reasoning that is driving some of the reforms in Graduate Medical Education we discussed previously. In an amusing gambit, the policy experts decided there must be another designation for these clinics to distinguish their novelty and desirability: 

Patient-Centered is one shibboleth, as if this is a radical innovation. Clinics have always been patient-centered. As with hospitals, the issue is whether the patients are advantaged by being the center of attention.

Medical Homes are another shibboleth, also touted as a radically new idea. However, it is really the However, it is really the idea embodied by the American “family practice” or, recently, the British “general practice,” where a “team” is the primary caregiver from cradle to grave. Usually, a physician is designated the responsible cognitive leader working with the administrator responsible for infrastructure. As has been true for some time, the roles played by the members of the team are in flux. Some “medical homes” assign an “intake” nurse responsible for asking the patient what’s wrong and directing him or her to what is presumed to be the person with the solution. Some larger “medical homes” have pharmacists, even pharmacists with a doctorate in pharmacy, monitoring prescriptions. Some make use of nurse practitioners more than medical doctors as resources. And some designate a single practitioner to the care of each patient with rules for cross-coverage. 

Accountable Care Organizations (ACO) are the most ludicrous of the neologisms because all they denote is another attempt at the promulgation of a Health Maintenance Organization (HMO). An ACO is a patient-centered medical home that is capitated, meaning it is given a fixed sum of money based on the number of enrolled patients and charged with living within these means. The better the ACO lives within its means, the less the allocated sum of money is expended, leaving behind a “profit.” In America, it is a viable model as long as the patients are not too sick and the means substantial. It is the business model for the Kaiser-Permanente organization. The Medicare administration is fostering ACOs around the country with the expectation that primary-care physicians can burden the “chief executive” function regarding expenditures and reimbursement while maintaining quality of care. Many in the policy world are applauding. 4 Of course, all are aware of the potential for perverse incentives in a capitated delivery model. Will care be withheld, or more expensive care withheld, to pad the pot at the end of the budgetary cycle? To do so overtly would be unethical, if not illegal, as the U.S. Veteran’s Administration is demonstrating. However, how can we develop some assurance that such false efficiency is not a subliminal action? 

Pay-for-Performance is proposed as a solution to maintaining the quality of care in ACOs (and elsewhere). Obviously, in an ACO, there is an incentive to offer care so efficiently that there are residual funds to disburse to the members of the staff at the end of the budgetary cycle. It is not clear how many and how often ACOs are even able to stay within their budgets, let alone have a surplus. It isn’t even clear how to distribute any surplus fairly among physicians, physician assistants, nurse practitioners, and others. 5 Should it be based on performance, or should some component or all be distributed regardless of performance in deference to a “team” spirit? If it’s by performance, what weight should be given to experience, clinical purview, and patient mix (relative degree of clinical challenge)? And what do we mean by “performance”? 

This last question is at the very heart of health care. What do we mean by “performance,” and can we measure it in order to value it? [ibid, pp. 152-154]
So, ACO's are really just HMOs v2.0?

I am reminded of a book published 20 years ago that I've long had in my stash.

From the opening chapter:
Introductory remarks
Medicine took an earlier flight

Henry Greenberg

This volume emerged out of the primary concerns of the hard physical and biological sciences. Proponents and organizing committee of the conference on which this volume is based reflects this. In the individual chapters concentrate on the threats to these disciplines. Although a majority of the authors come from a background in the social sciences, the issues under scrutiny relate to scientific reasoning, logical deduction, and professional expertise.

Let me take a brief look at a soft science that engages all levels of society — namely, medicine. Last year I organized the conference, sponsored by this Academy, that sought to enlarge the view of health care reform so that potential long-term results could be included in the debate. Its title was Beyond the Crisis: preserving the capacity for excellence in healthcare and medical science. In my talk I focused on threats to excellence in medicine. Toward that end, I explored the Genesis of the term healthcare provider, a description with which we are all familiar and one which infuriates positions. I tried to show that the apparent democratizing of the team, the cultural leveling of the peak usually inhabited by the physician, was a genuine threat to the professional uniqueness of the physician. The social construction of reality has come to medicine. Borrowing from Larry Churchill, I showed that without his or her own professional ethic, a physician who is dependent only upon the usual guiding ethics — law, custom, and common sense — would not be able to defend the best interests of his patient when law, common practice, and conventional wisdom defined a patient's interest in terms that best serves society and not the individual. The loss of the professional ethic will curtail the physician's ability to defend his patient's best interests.

Since then — and those of us in the East are behind — a new threat has emerged. The for-profit health maintenance organization (HMO) has arrived in Gotham. Everyone — hospitals, doctors, medical schools — is fighting to join. Packaging themselves in new organizations, bundling their services in financially pleasing ways, and then devaluing the services so as to be the lowest bidder, they are part of the great game to survive; at least we all think so. And the HMOs, with their $10 million CEOs, paying out $.68 on the dollar for care, understand and like what they see. With little extra effort they will reduce the physician to an employee. Again, the unique professional ethic will be stripped away, and the doctor will measure his life in degrees of compliance with cost driven algorithms and will hone his skills to reduce an office visit to seven minutes.

One HMO circulated a memorandum stating that it wanted all its specialists to have at least 20 office hours a week. Since a physician could arrange to see a patient within a day should the need arise, why are his 10 hours a week in adequate? I think I know the answer. He must have a financial base outside the office. If he does, he may not be as subservient to the HMO requirements as he should be. But if he is dependent upon his office practice, the HMO will gain the control it wants. The physician can be kept in place.

Medicine, then, is being put at grave risk by many strong forces. The social construction of its reality is only one of these forces. This ongoing assault has, however, weakened medicine. The professions inability or unwillingness to confront, let alone recognize, this attack has sapped it of much of its bigger. The other criticisms have a core validity. Because of accentuate it attention to these — arrogance, greed, and excessive paternalism — medicine feels constrained to defend itself and is paralyzed when it comes to speaking clearly about its strengths. The rare but highlighted focus on fraud and the less rare examples of marginally scrupulous positions feeding at the "pass-through" trough of Medicare and other insurance plans are commonplace headlines. However, the near comprehensive inability to distinguish the profession from the practitioner has inhibited the defense of professionalism. And yet when the profession is dead, it will be missed, warts and all.

There is a parallel development in the research science environment. If the incursion of attempted invalidation of scientific reasoning gains a foothold and then saps significant energy for its reputation, the body politic of science will be weakened. If the defense is incomplete or intellectually ineffective, the situation will be frighteningly similar to medicine's. Such a failure to defend science from its irrational critics can set the stage for a lethal blow when the real budgetary attacks arrive, and they are nearly upon us. Some would say they are here, but I am not so optimistic. If science cannot claim a preeminence for its intellectual virtues or in excellence for its methodologies and sense of design, then it will have great difficulty laying claim to rational share of the nation's resources for its perpetuation. This volume has an important role to play.
I dug this book out after reading an irritating THCB post entitled "Why I Don't Believe in Science" by one Michel Accad, MD. I noted in the comments that I had "reported" him to Science Based Medicine. He subsequently tried to weasel out and deflect from his phrasing choice, that it had been merely allusive and "in quotes" (which THCB had removed). In a word, "clickbait."


Speaking of old books on my library shelves.

Ever wonder about Princess Di's recent affair with Elvis Presley? You can read all about it on the front page of the supermarket tabloid. Elsewhere on the page appear stories of bizarre accidents and fantastic misadventures. An impact with a car's steering wheel causes lung cancer. Breast cancer is triggered by a fall from a streetcar, a slip in a grocery store, an exploding hot-water heater, a blow from an umbrella handle, and a bump from a can of orange juice. Cancer is aggravated, if not actually caused, by lifting a forty-pound box of cheese. Everybody knows, of course, that such stories are fiction. Falls and bumps don't cause cancer.

Other stories tell how a spermicide used with most barrier contraceptives causes birth defects. We know it doesn't. The whooping cough vaccine causes permanent brain damage and death. That's not true either. The swine flu vaccine caused "serum sickness." It didn't. A certain model of luxury car accelerates at random, even as frantic drivers stand on the brakes. Not so. Incompetence by obstetricians is a leading cause of cerebral palsy. It isn't. The morning-sickness drug Bendectin caused an epidemic of birth defects. It didn't. Trace environmental pollutants cause "chemically induced AIDS." They don't.

How can anybody be absolutely, positively certain about these didn'ts, doesn'ts, and don'ts? No one can. But the science that refutes these claims is about as solid as science ever is.

And yet all of these bizarre and fantastic stories-- Elvis and Di excepted--are drawn not from the tabloids but from legal reports. They are announced not in smudgy, badly typed cult newsletters but in calf-bound case reports; endorsed not by starry-robed astrologers but by black-robed judges; subscribed to not only by quacks one step ahead of the authorities but by the authorities themselves. They can be found on the dusty shelves of any major law library. The cancer-by-streetcar cases are decades old, but the others are recent.

When they learn of these legal frolics, most members of the mainstream scientific community are astounded, incredulous, and exasperated in about equal measure. Some now speak with open derision about tortogens, litogens, scientific bamboozlement, and the carcinogenic properties of insurance; others wonder why courts invite the inmates to run the asylum. The derision is understandable. Maverick scientists shunned by their reputable colleagues have been embraced by lawyers. Eccentric theories that no respectable government agency would ever fund are rewarded munificently by the courts. Batteries of meaningless, high-tech tests that would amount to medical malpractice or insurance fraud if administered in a clinic for treatment are administered in court with complete impunity by fringe experts hired for litigation. The pursuit of truth, the whole truth, and nothing but the truth has given way to reams of meaningless data, fearful speculation, and fantastic conjecture. Courts re- sound with elaborate, systematized, jargon-filled, serious- sounding deceptions that fully deserve the contemptuous label used by trial lawyers themselves: junk science.

Junk science is the mirror image of real science, with much of the same form but none of the same substance. There is the astronomer, on the one hand, and the astrologist, on the other. The chemist is paired with the alchemist, the pharmacologist with the homeopathist. Take the serious sciences of allergy and immunology, brush away the detail and rigor, and you have the junk science of clinical ecology. The orthopedic surgeon is shad-owed by the osteopath, the physical therapist by the chiropractor, the mathematician by the numerologist and the cabalist. Cautious and respectable surgeons are matched by some who cut and paste with gay abandon. Further out on the surgical fringe are outright charlatans, well documented in the credulous pulp press, who claim to operate with rusty knives but no anesthesia, who prey on cancer patients so desperate they will believe a palmed chicken liver is really a human tumor. Junk science cuts across chemistry and pharmacology, medicine and engineering. It is a hodgepodge of biased data, spurious inference, and logical legerdemain, patched together by researchers whose enthusiasm for discovery and diagnosis far outstrips their skill. It is a catalog of every conceivable kind of error: data dredging, wishful thinking, truculent dogmatism, and, now and again, outright fraud.

On the legal side, junk science is matched by what might be called liability science, a speculative theory that expects lawyers, judges, and juries to search for causes at the far fringes of science and beyond. The legal establishment has adjusted rules of evidence accordingly, so that almost any self-styled scientist, no matter how strange or iconoclastic his views, will be welcome to testify in court. The same scientific questions are litigated again and again, in one courtroom after the next, so that error is almost inevitable.

Junk science is impelled through our courts by a mix of opportunity and incentive. "Let-it-all-in" legal theory creates the opportunity. The incentive is money: the prospect that the Midas-like touch of a credulous jury will now and again trans- form scientific dust into gold. Ironically, the law's tolerance for pseudoscientific speculation has been rationalized in the name of science itself. The open-minded traditions of science demand that every claim be taken seriously, or at least that's what many judges have reasoned. A still riper irony is that in aspiring to correct scientific and medical error everywhere else, courts have become steadily more willing to tolerate quackery on the witness stand.
I first read this back during my 1980's time as a programmer and QC analyst in a forensic-level radioanalytic lab in Oak Ridge (e.g., evidentiary assays for dose and exposure litigation and regulatory enforcement). While I am not into "scientism" -- the notion that only reductive western science is epistemologically sound (I came away from my late daughter's illness unsure of what to believe anymore) --, the burden of proof is on the naysayers. I'm glad that Dr. Accad is not my physician.

While Dr. Hadler's new book is rife with appeals to the importance of "science," it does so in leavened fashion:
Humanism for the Patient with Symptoms That Defy Diagnosis 
Of the many shortcomings of a reductionistic approach to the care of the patient, few cause more consternation for the patient and for the physician than when no convincing cause for the patient’s symptoms can be discerned. Physicians have long been inclined to take the path of least resistance when faced with this conundrum, applying labels to this lack of explanation that range from the theoretical to the fatuous. Anything other than such obfuscating labels might be seen as an admission of the limitations of the physician’s competency or a confession about the inadequacy of the state of clinical science. In any case, these labels provide a way to dismiss the patient’s concerns without angering him or her or making the physician seem less all-knowing. Peabody, the humanist, was keenly sympathetic to the plight of the patient whose symptoms defied diagnostic acumen. He decried dismissing these patients with, “There really is nothing the matter with you. . . . I’ll give you a tonic to take when you go home.” Patients with symptoms of unknown origin were a challenge in Peabody’s time, just as they are today: “Numerically, then, these patients constitute a large group, and their fees go a long way toward spreading butter on the physician’s bread.” Peabody argued that dismissing them drives them to try “chiropractic or perhaps . . . Christian Science.” Besides, while not being a reassuring diagnosis, “nothing the matter” is also not a tenable concept because, “except for a few low grade morons and some poor wretches who want to get in out of the cold, there are not many people who become hospital patients unless there is something the matter with them. And, by the same token, I doubt whether there are many people except for those stupid creatures who would rather go to the physician than go to the theater, who spend their money on visiting private physicians unless there is something the matter with them.”...
Osler, Peabody, and Putnam are exemplars. They were leading advocates of a scientific basis for modern medicine a century ago. But they knew that science offered only a partial solution for the miseries that drove people to become patients. These legendary clinicians and teachers realized that the experience of illness is always contextual. Hopes and dreams are as susceptible to dissolution and damage as any organ system, or more so; in fact, they can suffer the harmful effects of illness even when organ systems are spared. Society may need practitioners who are skilled in techniques and others who are wedded to advancing technologies, but patients need physicians who are committed to their humanity. [Hadler, op cit, pp 13-15]
"Art of Medicine" stuff, anyone? Again, apropos of HIT,
"If there is a role for computers in decision making, it is to facilitate dialogue between patient and physician, not to supplant the input from either or to cut health-care costs."
Yes, but where do "Artificial Intelligence and Intelligence Augmentation" fit here?

It's useful also in this context to take seriously Margalit's lament "Are structured data the enemy of health care quality?"

Bit of a break here. More to say on these issues, but I'm gonna throw it out there at this point.


"the malignant granularity of EPIC, the antithesis of dispassionate information technology." [op cit, pg 177]

Any attempt to digitize the clinical record that denigrates the humanity of the clinical narrative is iatrogenic. The main reason for the clinical record is to remind you or a colleague, in the middle of the night or in six months, what you were thinking about and concerned about for the sake of your patient. Any other role for the digitized record is ancillary at best. [pp 177-178]
So, has Health IT become a massive case of "Tail Wags Dog"? Have the needs of the patient and the empathic humanist physician been relegated to the back of the bus?

Questions I will be asking at HIMSS16 next week amid all the well-funded, glitzy hoopla.

By the Bedside of the Patient: Lessons for the Twenty-First-Century Physician is a veritable gold mine of quotes (his takedowns of NQF and IHI alone are worth the ticket price). His recounting of his training and life as an eminent physician is priceless.

I've cited Dr. Hadler's prior book "Citizen Patient" before. See, e.g., "ICD-10: W6142XA, Struck by turkey, initial encounter."

I come away from this effort with profound new respect for the man, gotta say.

Just buy the new book, OK? (BTW, Amazon has lowered the price by ten bucks.  It's now $16.49 instead of the $26.60 I'd griped about. Gratifyingly, they gave me a differential refund.)

I could enthusiastically keep going, but I'll be pushing the "fair use" boundary.


More briefly on the ramble of one hapless patient caught in the maw...

Well, now that we've switched from our BCBS HSA coverage to full Medicare, we expect and hope there will be less of the frustrating no-value-add sand in the gears I began recounting here. But, some vestigial bozo-ness has recently come in the mail.

First, I just got a bill from my urologist's office for $40.11 net charges from "Date of Service 08/18/2015."

At first, I thought "WTF?" "CPT 76924, Sono Guide Needle Biopsy"? My prostate biopsy px was done on March 30th, 2015. August 18th? What? I had no "biopsy" in August.

It was my (woefully unpleasant) Calypso implant px for my ensuing IMRT tx. I guess they have no code for that. Great revenue cycle you have, folks, August to February. No wonder y'all are all going broke.

Then there was this little doozy, from BCBS.

OK. I was not involved in any "accident resulting in injury" on April 2nd, 2015 (Date of Service regarding this notice). That was the day I was admitted to Muir Hospital suffering from sepsis in the wake of my March 30th prostate biopsy (ugh).

The fully processed and settled claims for which are right there in your own dad-gumbed records.

Irritated, I started to fill out the form (concerned that they might be retroactively trying to claw back money from me), but stopped and called first, wading through all of the "Your Call is Important to Us" auto-attendant phone tree waste of time.

Finally got through. After I explained the details, I got "just ignore that letter; it was automatically kicked out by our system by the encounter coding. I have informed our Subrogation Unit of the error."

Shards of coding. Hmmm... Maybe I'll fill out the form anyway and send it back, late, replete with some "pithy" commentary. Just to reciprocate on the jerking around.


New post up at THCB, "Will Feeding Watson $3 Billion Worth Of Healthcare Payment Data Improve Its Decisions?"
"Physicians often don’t know what the heck is going on but are forced to enter specific diagnoses in the EHRs, which can’t handle probabilities or ambiguity."
Yeah. What was I just saying? My iatrogenic prostate biopsy sepsis morphs to "injury resulting from accident" and my Calypso implant px becomes "sono guide needle biopsy."

All they care about is getting paid.

I loved this:
Our question is whether healthcare payer data are so inaccurate and, worse, biased, that they are more likely to mislead than guide? Will the supercomputer’s semiconductors digestion of junk and contradictory information produce digital flatulence or digital decisiveness?
"Digital flatulence," LOL. Whole 'nuther nuance to the phrase "digital exhaust"?

I'll say it again; medical coding = "lossy compression."


Stay tuned...

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