“Good enough for Government Work”: Quality, cost, and gaming the system, Part 2 (of 4 parts)

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]

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[1] http://www.acog.org/About-ACOG/News-Room/Practice-Advisories/ACOG-Practice-Advisory-on-Annual-Pelvic-Examination-Recommendations

Rationing, Waste, and Useless Interventions

Most people, when they or those they love are sick, want things done for them that might be of benefit. Cost is a secondary factor, especially when it is not directly being borne by them because they have health insurance coverage (but if it is going to be costly, that insurance better be good). In general, the order of preference would be for: 1) things that will definitely help; 2) things that might help; 3) things that almost certainly won’t help-but-you-never-know and don’t cause serious harm; and 4) things that won’t help and may very well cause serious harm.

It might seem superficially as if most people wouldn’t want #4 interventions, but surprisingly people opt for them. This is particularly true when the expected outcome is death; if you’re going to die anyway, what harm could be greater? Besides, maybe a miracle will occur. Of course, there can be greater harm than simply dying – death preceded by increased suffering caused by futile attempts at treatment – but when confronting death, many people look at the positives and ignore the negatives. In addition, the decision may be different when made by the person actually facing death (provided s/he is conscious and competent – or has advance directives -- and isn’t doing what the family, not s/he wants, because s/he is used to caring for them) or by his/her loved ones.

This leads into a discussion about rationing of health care resources, which is, appropriately, achieving a lot of attention. Two “Perspective” pieces in the New England Journal of Medicine May 24, 2012, and a “Viewpoint” from JAMA, May 23/30, 2012, address these issues from slightly different, well, perspectives/viewpoints. Howard Brody, MD PhD, in “From an ethics of rationing to an ethics of waste avoidance[1], as a bioethicist, begins with providing the ethics of rationing: “First, rationing occurs simply because resources are finite and someone must decide who gets what. Second, rationing is therefore inevitable; if we avoid explicit rationing, we will resort to implicit and perhaps unfair rationing methods.” I’d say “certainly unfair”; while Brody is talking in the abstract, we need only look around at what is actually occurring in the world to know that we have rationing that is unfair. He adds “The main ethical objection to rationing is that physicians owe an absolute duty of fidelity to each individual patient, regardless of cost. This objection fails, however, because when resources are exhausted, the patients who are deprived of care are real people and not statistics. Physicians collectively owe loyalty to those patients too.”

Brody addresses the current importance of this discussion given recent studies that show that as much of 30% of health care expenditures are “waste”, as opposed to less than 10% that might be attributed to “deliberate fraud.” Eliminating fraud is important, but it is a “one-time” saving, whereas eliminating waste not only represents a bigger number, but, because doing more and more tests is a major driver of rising health costs, may represent a way to “bend the cost curve.” Of course, as I noted, what is “waste” can depend upon ones perspective, values, and even degree of selfishness. Certainly because, as Brody notes, one person’s health expense (even if it is “waste”) is another person’s income, this is not going to be an easy discussion.

Brody cites the case of treatment of advanced metastatic breast cancer with high-dose chemotherapy followed by autologous bone marrow transplantation, which was “…initially thought to offer perhaps a 10% chance of a significant extension of life for patients who would otherwise be fated to die very soon. Insurers’ refusal to pay the high costs of this last-chance treatment did much to torpedo public trust in managed care during the 1990s. Data now suggest that the actual chance of meaningful benefit from this treatment is zero and that the only effect of the treatment was to make patients’ remaining months of life miserable.” However, it could have gone the other way; maybe longer experience would have shown it to be more effective. The “torpedoing of public trust” was surely enhanced by protests from advocacy groups as well as from physicians and hospitals that benefited financially from these procedures. Another result, noted by Volpp et al., in JAMA “Assessing value in health care programs”^[2], is that “Many insurers, including Medicare, are continuing to cover bevacizumab for metastatic breast cancer, despite the unanimous recommendation by a US Food and Drug Administration panel that it not be covered because it is not helping patients to live longer, does not control their tumors, and exposes them to serious adverse effects, and despite an average annual cost of $99,000.”

Volpp and his colleagues  argue that, in health care, return-on-investment (ROI) cannot always be measured directly as positive in dollar terms, and is less so as the pool (everyone, a big company, a small company, an individual) is reduced:

“What would happen if the rule were applied to every health care decision that is made? Besides childhood vaccination and flu shots for the elderly, few health care services save money. The positive return-on-investment criterion is not applied to most health care services because almost nothing satisfies it. Medicare is prohibited by law from considering cost in coverage decisions, and other insurers tend to follow suit, even if the benefits are small and the costs very large. Would anyone ever ask, ‘What is the return on investment in treatment of this patient’s cancer?’ This is not a meaningless question, but almost certainly one that most people would think inappropriate to ask.”

They add “It certainly does not make sense to use one criterion—Are there clinical benefits?—for coverage decisions for treatments and a different criterion—Are health care savings greater than program costs?—for preventive services or for delivery system innovations designed to improve health;” however, we certainly do.

The third article, “Beyond the ‘R Word’? Medicine’s New Frugality”[3] by M. Gregg Bloche MD JD, takes a more policy, political, and law-oriented approach toward understanding what might happen in limiting health care expenditures. He discusses the medical “luxury tax” (on “Cadillac plans”) and notes that while this is not having a big impact now, with the threshold at $23,000 a year, it will in the future because costs of medical care (and insurance) rise faster (at least 2% and often more) than the consumer price index (CPI), while the threshold for the tax is 1% above CPI. He suggests that “Employers

will pay the tax, but workers will bear its burden as firms shrink salaries to cover the cost.”

This is really important, and it is another strong argument for a single-payer health insurance program that will cover everyone. Costs do – and will continue to need to be – controlled, and this will result in continued rationing. But that rationing is only ethical when it is explicit and based on medical need, not the character of one’s insurance or socioeconomic status.

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[1 Brody H,”From an ethics of rationing to an ethics of waste avoidance”, NEJM 24May2012;366(21):1949-51

[2] Volpp  KG, G Loewenstein, DA Asch, “Assessing value in health care programs”, JAMA 2012May23/30; 307(20):2153-4.

[3] Bloche MG, “Beyond the ‘R word’: medicine’s new frugality”, NEJM 24May2012;366(21):1951-3.