This is part two of the Charles Odegaard Lecture, delivered at the 27th National Conference on Primary Health Care Access, April 6, 2016
We have all heard the business
mantra “do more with less”, which, on the face of it, is either absurd or,
perhaps, a very cynical indictment of how much is currently being “wasted”,
waste being differently defined depending upon the point the user wishes to
make. I, for example, would consider “waste” to be money designated as “health
care dollars” going to excessive profits for private corporations rather than
actually being spent delivering health care; others, perhaps in the insurance
industry, might consider “waste” to be an excessive “medical loss ratio”, their
quaint term for the money that they actually have to spend delivering health
care and don’t get to pocket. Politicians, of course, are more malleable;
“waste” is whatever is being spent on what they don’t like, provided of course,
it doesn’t get them into trouble with their constituents (like the VA scandal),
in which case switching definitions is always an option.
What might be waste in the
provision of health care? One is providing, and charging for, services that are
unnecessary or possibly even harmful. A current example is the performance of
pelvic examinations (as distinct from collecting Pap smears) in asymptomatic
women (without pain, discharge, or bleeding) just to see what we can find. The
American College of Physicians (ACP), the internists’ group, recommends against
them. ACOG, the American College of Obstetricians and Gynecologists, recommends
doing them, or at least leaving it up to the physician. Guess which group stands to lose
more financially? ACOG’s position includes the statement that “…the College continues to firmly believe in
the clinical value of pelvic examinations, through which gynecologists can
recognize issues such as incontinence and sexual dysfunction. While not
evidence-based, the use of pelvic exams is supported by the clinical
experiences of gynecologists treating their patients.”![1]
Hm. Maybe the best way to discover issues like incontinence or sexual
dysfunction is not to put one’s hands inside a woman, but, perhaps, to ask her!
The US Preventive Services Task
Force (USPSTF), of course, makes no recommendations on whether to do a
particular exam or procedure, as its recommendations are for or against
screening for particular diseases (with, in that context, exams or procedures
discussed). It recommends against (“D” recommendation) screening for ovarian
cancer, a major “benefit” cited by some ob-gyns, because it is inadequately
sensitive and specific and doesn’t save lives. In a recent survey of ACOG
members, the “potential benefits” of pelvic examination in asymptomatic women
were cited, but not the costs – in dollars or to patients in terms of
discomfort and morbidity.
This is relevant here because when
costs, both potential for harm as well as dollars, are not considered,
everything could be potentially of benefit. Another recent study showing mild
benefit from the use of the diabetes drug pioglitazone to prevent strokes or
TIAs in people who have previously had them shows some benefit, but at the cost
of an increase in the number of fractures requiring surgery or hospitalization;
the editorialist in Journal Watch General
Medicine emphasizes the benefit rather than the risk of harm, but is a
neurologist, not an orthopedist. Should we do an MRI on everyone every week,
just to see what we can find? Certainly there could be some things found! What
about CT scans for screening for lung cancer (USPSTF “B” rating)? The best
study, from the US, shows absolute risk reduction for death in 6.5 years of
0.33%; some smaller recent studies from Italy and Denmark show no benefit for
mortality, and even in the US the frequency being recommended is moving to less
than annually. Should we be on track to
weekly MRIs?
So, I just wanted to be clear that
it is not true that I am for anything that could improve quality whatever the
cost. That is ridiculous. But there is a baseline of quality which not only
can, but regularly is, compromised when there is a potential for financial
benefit from doing so.
More recently, and wildly popular
in health care, is the Triple Aim. The
idea is to improve quality, improve patient satisfaction, and cut costs, all at
once. It is difficult to find anyone, regardless of political affiliation or
medical specialty, politician, provider, or consumer advocate, who doesn’t
think that this is a good idea. To some degree, even I think this is a good idea, but I also believe that, like a lot of
good ideas, the devil is in the details, the proof is in the pudding, where the
rubber meets the road, or whichever is your favorite saying. While I am certain
that many well-meaning pundits and providers, such as the leaders of family
medicine, the experts at the Institute for Healthcare Improvement (IHI) and
others are serious about improving quality, the reality, as M. Gregg Bloche notes in his NEJM piece (see Part 1, ref #3), is
that almost all of the rewards are for cost-cutting. Yes, ACA has given us some
modest revenue enhancements for meeting quality goals, although in general they
are either very broad or very precise, and in either case poor measures of
actual quality, and thus of limited impact. But almost all of the rewards, on
either side of the Atlantic, in the NHS, or the VA, or for the ACOs created by
the ACA, are for reducing costs. And it is almost always in the public sector
that the impact is the greatest.
For example, outside the VA, we
have our RACs, the bounty hunters licensed by Medicare to come into hospitals
to find “fraud and abuse”. This usually manifests as discovering that some
Medicare patients have been “admitted” to the hospital, rather than placed on
“observation” status, which costs Medicare less. We have been well-socialized
by our institutions, prompted by Medicare, into ensuring that we have reason to
believe a patient will be in for “two midnights” (a bizarre conception with
regard to health, much easier to achieve when a patient is admitted at 11pm
than at 1am!), but how many of us realize that it is our patients who pay,
literally with dollars? The excess cost is because “observation” is officially
outpatient and paid by Medicare Part B, which requires much higher co-pays than
the Medicare Part A that covers admissions. I have to admit that it was only
relatively recently, when I heard a cousin being admonished by a friend to
“make sure that your mom is admitted, not put on observation, or she’ll go
bankrupt”, that I realized this.
[part 3 next week: The VA, the private and public sector, and the profit motive]
[1] http://www.acog.org/About-ACOG/News-Room/Practice-Advisories/ACOG-Practice-Advisory-on-Annual-Pelvic-Examination-Recommendations
