White Coat Underground

Health care reform, Part II

In part I, I presented you wish some admittedly artificial categories of problems in our health care system. First we discussed patient-centered problems. Today, we’ll look at problems posed by medical science and practice itself.

Medical science

The science of medicine is not always compatible with the practice of medicine. Medicine is still largely a cottage industry, with hard-working, independent practitioners working in small or medium-sized practices. Aside from licensing statutes, there are no official guidelines that doctors must follow to be officially “certified”. Once a doctor has a license, they can pretty much practice as they see fit, with only the threat of litigation or the less realistic threat of medical board censure to rein them in. Is this a good thing, a bad thing, or doesn’t it much matter? How does this affect the health care system as a whole?

  • Quality: The quality of medical practice is essentially unregulated. There is no objective way for a patient to judge the care they receive. There is a patchwork of systems that grade doctors and hospitals on various measures, but these are rarely patient-centered. Many HMOs, for instance, track how much money their doctors spend, and rate the doctors based on this. This can even lead to doctors being dropped from health plans, independent of the quality of care they provide. There are also statistics gathered on complication rates in hospitals and other related statistics. None of this data is centralized and available to help guide health care decisions.

    In medicne, it’s not clear what quality measures should be followed or how these measures should affect individual doctors or hospitals. Medicare is now penalizing hospitals whose medicare patients suffer complications. Is this a good thing? Will this cause hospitals to cover up or otherwise misrepresent complications rather than investigate and mitigate problems? Does this type of penalty have any benefit?

  • Evidence and Outcomes: What is it to be a “good” doctor? How can we measure this, and what should we do with the data? Because human beings are inexact, so is medical science, but some things can be measured. For example, the success of certain surgeries can be measured by complication and reoperation rates, but this has huge pitfalls; many doctors see a healthier or higher risk population, so using success rates to compare doctors can be invalid. What might be more useful to both patients and doctors is making evidence for certain practices available, and tracking the use of these practices.

    For example, I treat many diabetics. Evidence shows that diabetics who have blood sugar, blood pressure, cholesterol, eye, and foot checks do better. A system could track me to see if I actually order these things (and take into account whether patients follow through). This would be much better than tracking how good my diabetics’ blood sugars are, since I shouldn’t be “graded” on my patients “failures”. This type of thing is already being done by some insurance companies, but there is no good system in place. To continue the example, I belong to a physicians’ group that gets money back from insurers for tracking these measures. But to track them, they give me a bunch of forms and ask me to find time to fill them out on each patient. If my EHR would simply collect the data automatically (which is technically feasible), the data could be transmitted to the relevant party.

Many of these potential solutions require the collection and dissemination of outcomes data, tort reform, mandatory reporting, and a willingness of doctors to give up a measure of autonomy. These are not changes that can be made piecemeal.

Next up, the doctors’ sob story.

Comments

  1. #1 Donna B.
    July 29, 2009

    When medicine becomes 100% science, then I can see objective ratings, perhaps. That won’t (scratch that… make it SHOULDN’T) happen because doctors will still be dealing with the very messy reality of human bodies, minds, environments, and cultures.

    I am not dismissing the huge and priceless contribution that science has made to the overall health of humans, especially ones in advanced technological countries. BUT, ratings, evidence, outcomes, etc., are not science. They are measurements, measurements are mathematics.

    Measurements are surely a good thing, but I don’t want my doctor to treat me by measurement alone. I want a doctor that understands medicine is still very much an art and even though he has many more tools to use in his PRACTICE of this art, it will not (in our lifetimes) be reduced to simply checking items off on a list and running it through a computer program.

    When evidence-based medicine becomes the norm, the need for doctors is reduced isn’t it? What could be a better cost-cutting measure than to cut out one of the highest paid jobs in the industry?

  2. #2 PalMD
    July 29, 2009

    Donna, I think you misunderstand. One way to apply science is to “incentivize” doctors to follow evidence-based practices, like proper diabetic care. That has nothing to do with what you describe.

  3. #3 Donna B.
    July 29, 2009

    Side note on the art of medicine and the production of a medical masterpiece:

    Yesterday my husband had an outpatient surgical procedure done. We were warned that it could possibly require an overnight stay and to come prepared for that.

    The most likely outcome — the one we expected — was that my husband would come home with a catheter in place to be removed in the doctor’s office the next afternoon.

    The surgeon talked to me as soon as my husband went to recovery and the guy was grinning from ear to ear – he said everything went absolutely perfectly and there was no need for the catheter at all! We were in the car on the way home three hours later.

    I was ecstatic and my husband was still high on demerol. We had a highly entertaining evening. Possibly the neighbors did too because at one point, my darling walked into the front yard, raised his hands, and hollered “I can piss!” Who says old folks don’t have fun?

  4. #4 Donna B.
    July 29, 2009

    Well, it wouldn’t be the first thing I’ve misunderstood today!

    But what I was criticizing was the idea that the evidence is scientifically generated when it’s actually merely a measurement. There’s a huge difference in my mind.

    It wasn’t until I was made to understand how mathematics and measurement work, that I understood where this could lead doctors astray sometimes.

    It’s valuable in that it provides a “best practices” to try first in most cases and diabetes is a disease where that probably works very very well. Especially when you have a motivated and compliant patient.

    What I’m saying is that when bureaucrats, whether private insurance or government, get hold of the mathematics, they can’t think beyond them. Doctors will suffer as much as patients.

    If I’m still misunderstanding, please have hope that someday I’ll get it, okay?

  5. #5 Whitecoat Tales
    July 29, 2009

    Donna I think we have different concepts of what evidence based medicine is.

    Every day, when I see a patient, I have questions.
    For example, there are numerous drugs for high blood pressure – beta blockers, thiazide diuretics, calcium channel blockers, ACE inhibitors, ARBs, the list goes on. Within those classes of drugs there are number of different drugs to consider. They all have different benefits and risks, and work best for certain people. So I walk into a patients room, and I walk out and ask myself “so which high blood pressure medication is right for this person?”

    Evidence based medicine is a way to find answers to that question, and others. Instead of trusting the drug rep (who will doubtless recommend one of the more expensive options), or the opinion of some other doctor, or just guessing, evidence based medicine gives me good ideas, guidelines. It doesn’t force me to practice “cookie cutter medicine,” instead it helps me personalize my care to the patient in front of me.

    So if I walk into a room and have a diabetic patient, I know the evidence says a good medication for him/her is an ACE inhibitor or an ARB – the evidence says that either of those medications protects the kidneys of a diabetic.

    On the other hand, in a patient with no other medical problems, a good medication is the thiazide diuretics – they work very well for blood pressure, and are inexpensive for the patient on a budget. The evidence says they work just as well for uncomplicated patients as more expensive drugs.

    That doesn’t force me to pick those drugs, in my diabetic, I might choose to add, or use a number of other drugs, a beta blocker to protect their heart perhaps.

    It doesn’t stop me from practicing the art of medicine, but it answers the questions that I would otherwise have to struggle with every day!

  6. #6 Donna B.
    July 29, 2009

    Whitecoat Tales — do we then agree that evidence-based medicine is a powerful tool?

    I did not mean to imply otherwise. If I did, I apologize.

    What I did mean to say is that tools are to be used in producing the art of good medicine — and I think you’ve illustrated how they do.

    What I am worried about is bureaucratic interference which dictates that the tools surpass the art. I suggest it is happening now and that it undermines a doctor’s expertise which includes more than the use of tools.

    I suspect I’m much older than either you or PalMD. This is not a criticism, as I admire and am in awe of what the generation following mine has become and has accomplished.

    BUT, we remember “evidence-based” guidelines from years past through today and we can’t make sense of them… and we wonder.

    For example: I gave birth between the years of 1975 and 1982. The “evidence-based” guidelines for immunizations of each of my children was vastly different — and the difference between those and what my grandchildren are vaccinated under are even wider.

    And let’s not forget to mention the guidelines on what to feed an infant when… good grief!

    Now, I won’t say that today’s guidelines are worse than yesterday’s. Honestly, I don’t believe they are. (I’m not so sure on feeding guidelines, I’ll have to get back to you on that.)

    What bothers me is that guidelines become corporate policy. Policy is much more difficult to change than guidelines are. Guidelines can be updated with new research. Policy requires much more effort.

    And if the policy is set by a government instead of a private corporation, the effort to change it multiplies by 547 (Congress, the President, and the Supreme Court) at a minimum.

    Measurements should be updated regularly and evidence-based medicine should reflect such updates. BUT, once any given evidence-based treatment is set in policy stone, it’s much more difficult to update… and frankly it’s much cheaper not to try.

    Medicine, I think, is at its best when it’s practiced as an art and as a science. When it’s practiced as mathematics… I’m not so sure.

    I’m not saying ignore measurement-based medicine, I’m just cautioning against giving it more importance than it warrants.

  7. #7 David
    July 30, 2009

    Pal, great post.
    One drawback to quality metrics is they focus attention on the metric to the exclusion of other patient care issues. If hospitals are penalized for IV line infections, nurses will be told to spend disproportionately more of their time on IV lines, and other aspects of nursing care, not covered by a quantitative measure, will suffer. The PCP’s incentives to assess sugar, eyes and feet might distract you from a serious discussion of the patient’s alcoholism, for which you’re not reimbursed.
    Medicare’s E&M rules have led to mechanization of visits: many doctors follow a checklist of minimum activities required to justify a certain billing level, leaving little residual time for actual history-taking and counseling.
    You get what you pay for.

  8. #8 Whitecoat Tales
    July 30, 2009

    @Donna B.

    I think we’re in agreement on EBM as a tool. Perhaps where the disconnect is regards “EBM as policy.”

    None of the plans or ideas on the table will require a specific EBM guideline to be always-prescribed, in such a way as to take that decision making-based-on-the-art-of-medicine away from doctors. Doctors just wouldn’t be able ot get behind a bill that did that.

    My understanding of the way guidelines will be used is making and funding an extra resource to be available for physicians. I also was under the impression that the government wouldn’t be making the guidelines, so much as using the guidelines already being created by experts, and possibly incentivizing doctors to follow those guidelines where possible.

    I admit, I could be wrong, I still haven’t had time to read all the way through any of the full 1000 page draft bills floating around teh interwebz.

    @David
    I agree with you that the implementation of some quality metrics hasn’t been stellar. It’s difficult to find the right metric and implement it the right way.

    I disagree with the implication of your comment that “You get what you pay for,” the problem you described is a problem of implementation of a specific idea in one system. It’s not a necessary consequence of a socialized, or government run/subsidized healthcare system.

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