Financial Incentives, maybe; corporate profit, no!

If we truly wish to move toward a healthcare system which delivers high quality in a reliable manner, one of the great flaws of our current system is that incentives are not always lined up to achieve that goal. Indeed, we could make a strong argument that incentives, particularly financial incentives, often lead healthcare providers (sometimes individuals, but certainly large organizations such as hospitals, nursing home and hospital chains, pharmaceutical companies, device manufacturers) in the wrong direction. That is, they pursue financial profitability rather than the highest quality of care for our people.

Sometimes these two run together, and sometimes they do not. If the disease you have is one that is well-provided for and you have the money or insurance to pay for it, you are in luck. If you don’t have financial access to care, or your disease’s “product line” was not one deemed financially profitable enough for your hospital or health system to invest in, you are not. Similarly, if you have a disease that lots of others share, pharma is always ready to provide a drug for it – particularly if it is still patented; if you have an “orphan” disease, you may not be able to get treatment, or it can cost (truly) more than $100,000 a year.

The federal government, through Medicare, has sought to use financial incentives to (most often) control costs and (sometimes) to encourage quality; this occurs under both Republican and Democratic administrations, but is also a big feature of the Affordable Care Act (ACA). One example going back to the 1980s, is the reimbursement of hospitals for what Medicare has figured is the appropriate cost of care for a particular set of diagnoses, rather than by whatever the hospital charges. Under ACA and in incentive plans in place from private insurers, doctors get more money if they do more of the “right” things and fewer of the “wrong” things. Financial incentives can also be used by organizations to encourage certain types of performance in its employees or contractors. Examples include incentive payments for generating more revenue, or financial penalties written into a contract for poor performance. Financial incentives are not unique to health care and, in fact, have been used and studied in many other industries. Their use in health care is not unique to the US.The question is, however, “do they work?”

This is the question that a group of Australian scholars led by Paul Glasziou sought to answer in an “Analysis” published in the British Medical Journal (subscription required), “When financial incentives do more good than harm: a checklist.”[1] Glasziou and his colleagues review the data on the effectiveness of financial incentives in both health care and other industries, and focus upon a meta-analysis by Jenkins et al.[2], and two Cochrane studies, one an analysis of 4 systematic reviews (? a meta-meta analysis?)[3] by Flodgren et al., and one looking at primary care by Scott, et al.[4] Basically, the results were mixed; sometimes they worked (to achieve the desired ends) and sometimes they didn’t. Glasziou observes: “While incentives for individuals have been extensively examined, group rewards are less well understood….Finally, and most crucially, most studies gathered few data on potential unintended consequences, such as attention shift, gaming, and loss of motivation.” (Again, see Daniel Pink, “Drive”, on Motivation).

In an effort to help identify what works, Glasziou has developed a 9-item “checklist” for financial incentives in healthcare that is the centerpiece of this article. Six items are related to the question “Is there a remediable problem in routine clinical care?”, and 3 are related to Design and Implementation. The first six are:

1. Does the desired clinical action improve patient outcomes?

2. Will undesirable clinical behavior persist without intervention?

3. Are there valid, reliable, and practical measures of the desired clinical behavior?

4. Have the barriers and enablers to improving clinical behavior been assessed?

5. Will financial incentives work, and better than other interventions to change behavior, and

why?

6. Will benefits clearly outweigh any unintended harmful effects, and at an acceptable cost?

And the 3 regarding implementation are:

7. Are systems and structures needed for the change in place?

8. How much should be paid, to whom, and for how long?

9. How will the financial incentives be delivered?

They provide explanations of each of these and include a useful table that uses real life positive and negative examples to illustrate their points. For example, regarding #1 they note that the UK has provided financial incentives to get the glycated hemoglobin level in people with type 2 diabetes below 7%, despite several studies showing no patient benefit. (This is an example of “expert opinion” governing practice ever after contradicted by good research.) #2 means some behaviors occur or extinguish if effective processes are put in place without financial incentives. #3 is important because of the cost of implementation (“We found no studies on the cost of collecting clinical indicators.”); one of the great complaints of providers is that they spend so much time providing information to various oversight bodies that they haven’t sufficient time to provide good patient care.

Criterion #5 relates to the issue of “what, in fact, motivates people?” Criterion #6 is, I believe, relates to the greatest flaws in most of our financial incentive (often called “pay for performance” systems. The four behaviors most often creating harmful effects have all been discussed in this blog:

Attention shift (focusing on the area being rewarded distracts from attention to other areas);

Gaming (a huge negative especially for large organizations). This specifically refers to manipulating data to look “good” on the measurement, but also includes upcoding and what might be called intentional attention shift, where the organization focuses, on purpose, on to the areas that make it the most money and neglects others;

Harm to the patient clinician relationship, when the patient, often correctly, feels that it is not her/his benefit but some external target that is motivating providers;

Reduction in equity. This is extremely important. I have written extensively about health disparities; this point is meant to drive home the reality that this inequities, or disparities, can persist even when there is an overall improvement in the areas being measured.

Most of these issues and several others derive from the simplistic application of financial rewards to complex interdependent systems. Financial incentives assume that paying more for a service will

lead to better quality or additional capacity, or both. However, because money is only one of many internal and external influences on clinical behavior, many factors will moderate the size and direction of any response. The evidence on whether financial incentives are more effective than other interventions is often weak and poorly reported.”

These authors are from Australia, which like most developed countries, has a national health insurance system. (See the map[5]).  The data they cite is world-wide, but largely from their country, the UK (which also has a national health system) and the US (which does not). The real problems of health disparities and inequity are enormous in our country. They are not modified by the presence of a national health system, which reduces many of the financial barriers to health care; indeed they are exacerbated by a make-money, business-success psychology of providers that may be worse in the for-profit sector but essentially drives the non-profit sector as well.

 

The application of a simplistic corporate psychology to health care delivery can lead to poorer quality and greater inequity in any country. In combination with an entire system built on making money, gaming the system, and excluding the poor, and making corporate profit (see graph) it is a disaster. Our disaster.

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[1] Glasziou P, et al., When financial incentives do more good than harm: a checklist, BMJ 2012;345:e5047 doi 10,1136/bmj.e5037, published August 20, 2012

[2] Jenkins GD, Mitra A, Gupta N, Shaw JD. Are financial incentives related to performance? A meta-analytic review of empirical research. J Appl Psychol 1998;83:777-87.

[3] Flodgren G, Eccles MP, Shepperd S, Scott A, Parmelli E, Beyer FR. An overview of reviews evaluating the effectiveness of financial incentives in changing healthcare professional behaviours and patient outcomes. Cochrane Database Syst Rev 2011;7:CD009255.

[4] Scott A, Sivey P, Ait Ouakrim D, Willenberg L, Naccarella L, Furler J, et al. The effect of financial incentives on the quality of health care provided by primary care physicians. Cochrane Database Syst Rev 2011;9:CD008451.

[5] Interestingly, this map, from the Atlantic, may make us think that the aloneness of the US in not having national health care is less serious than it is. Most adults are used to seeing map projections that inflate the size of Europe and North America. This is a geographically more accurate map, but if it were in our “accustomed” projections would be even more green.

Quality and price for everyone: Bigger may be better in some ways, but not all

Atul Gawande, MD, a Harvard surgeon at Brigham and Women’s Hospital in Boston, regularly contributes significant and provocative articles to the New Yorker under the head “Annals of Medicine”. In recent years I have written about several of these, including the “The Cost Conundrum”, June 1, 2009 (my comments in Medicare Costs: "All Politics are Local", June 11, 2009), “The Hot Spotters”, January 24, 2011 (Freedom abroad, health at home: experiments in preventive health care, February 13, 2011 and Camden and you: the cost of health care to communities, February 18, 2011), and “Cowboys and Pit Crews”,  May 26, 2011 (EMRs and Primary Care: The good, the bad, and the challenges, June 11, 2011 and Physician Oaths and Social Responsibility, July 11, 2011). His latest contribution, “Big Med”, August 13, 2012, continues his outstanding tradition of thinking outside the box, making important connections, and writing for a popular-but-educated audience.

“Big Med” starts with a visit to the popular restaurant chain, The Cheesecake Factory, and proceeds with his investigation into how it works and works effectively. This chain provides an enormous variety of menu choices, high quality both in terms of ingredients and taste (perhaps not the gourmet’s standard, but really good food), excellent consistency, and reasonable prices. It does not take a huge step to understand the relevant metaphors for health care, and in particular hospital care. Hospitals provide a huge menu of services, and we would all like them to be consistently of high quality and available at a reasonable cost. Unfortunately, they’re not. Gawande searches for how The Cheesecake Factory does it, and comes up with some excellent suggestions for health care.

He starts with the key ideas mentioned above: people should be able to go into a hospital and expect the best care and the best possible outcomes. These should be consistently delivered, and delivered at many locations (not necessarily every hospital for every procedure – to extend the analogy, The Cheesecake Factory has lots of restaurants, but not in every town) and done in a cost-effective way. While with restaurants, each of us knows what we like and whether something tastes good and whether we think we have gotten value for our dollar this is not true for health care. Most people (including physicians outside their own specialty) have little idea of what is quality in medicine. They can tell if they had a good outcome (“I’m better”), but not if it was the intervention that made it better, or perhaps just speeded up – or retarded – natural healing. They can tell if they had a bad outcome (or their survivors can), but not if this was unavoidable. (The current method we have for adjudicating this – malpractice suits – is entirely invalid.) They do not know if their outcome would have been better in a different hospital or with a different doctor or team, or even in the same hospital with the same doctor on a different day. They certainly don’t know whether what they, or their insurer, are paying is appropriate for the value.[1]

Gawande writes that “Big chains thrive because they provide goods and services of greater variety, better quality, and lower cost than would otherwise be available. Size is the key…We can bristle at the idea of chains and mass production, with their homogeneity, predictability, and constant genuflection to the value-for-money god. Then you spend a bad night in a “quaint” “one of a kind” bed-and-breakfast that turns out to have a manic, halitoxic innkeeper who can’t keep the hot water running, and it’s right back to the Hyatt. Medicine, though, had held out against the trend. Physicians were always predominantly self-employed, working alone or in small private-practice groups. American hospitals tended to be community-based. But that’s changing. Hospitals and clinics have been forming into large conglomerates. And physicians—facing escalating demands to lower costs, adopt expensive information technology, and account for performance—have been flocking to join them.”

He goes on to describe examples of how American medical care is changing, focusing on the experience of his mother getting a knee replacement at his hospital by a surgeon (not the most famous) who has organized a standardized system for delivering this care, using a (large) team. This surgeon has also accomplished the remarkable (to anyone who knows surgeons) feat of getting all the prima donna orthopedists at his hospital to agree to use the same prosthesis. The principle, just as in the casual dining area, is find out who does it best, identify the characteristics that make it so (removing the chaff and nonsense that may be associated but are just noise, often costly noise), and replicate it.

Applying this principle requires not only standardization, but size. Every hospital cannot be a mom-and-pop store, and the cost savings from scale are what make the whole thing possible. Yes, medical care cannot be completely reduced to recipes, and this can be a real danger. Individual doctors are different, and their skills are different not only by specialty or subspecialty, but in the way they interact with their patients. Some people may like a doctor who is older, or younger; a doctor who is a woman, or a man; a doctor who is more formal, or more casual. Some want a doctor who will explain things to them and elicit their beliefs and desires, and make them the educated “decider”; others want a doctor who is more didactic and authoritative. None of these is the “best” for someone who does not share those values; each is the “best” for those of us who do. The only caveat is when a particular approach actually makes a difference in the health outcomes for all people, not just those who “like” the doctor’s style.

Another danger in size and scale is that many of the processes and procedures that are put in place by these big, standardized organizations do not improve health outcomes, and may even limit them by taking time and energy from the things that do. Management in health care is still very much tied to “Motivation 2.0” (see “Drive”, by Daniel Pink[2], and my comments in The Primary Care Conundrum, August 18, 2012).  Many big food, or hotel, or hospital chains do not provide quality, and most certainly do not contain costs; see, for example, “A giant hospital chain is blazing a profit trail”, by Julie Creswell and Reed Abelson in the New York Times August 14, 2012, about Hospital Corporation of America (HCA). Like HCA, “big” is not a panacea, and can be a negative for social values and social justice.

Gawande includes important cautions:

"Yet it seems strange to pin our hopes on chains. We have no guarantee that Big Medicine will serve the social good. Whatever the industry, an increase in size and control creates the conditions for monopoly, which could do the opposite of what we want: suppress innovation and drive up costs over time. In the past, certainly, health-care systems that pursued size and market power were better at raising prices than at lowering them….

“The vast savings of Big Medicine could be widely shared-or reserved for a few. The clinicians who are trying to reinvent medicine aren't doing it to make hedge-fund managers and bondholders richer; they want to see that everyone benefits from the savings their work generates-and that won't be automatic….

"Our new models come from industries that have learned to increase the capabilities and efficiency of the human beings who work for them. Yet the same industries have also tended to devalue those employees. The frontline worker, whether he is making cars, solar panels, or wasabi-crusted ahi tuna, now generates unprecedented value but receives little of the wealth he is creating. Can we avoid this as we revolutionize health care?"

I don’t know, but I hope so. Holding on to old ways of doing things when they are not the best (or even very good), or the idea that each doctor can use a different prosthesis and they are all the best, is bad. Devaluing individual workers, whether they are physicians or technicians or cleaners, is bad. Developing ways of delivering high-quality care which is what both individual people and the whole society needs is good.

Good outcomes will certainly not come from the drive to maximize profit. To get truly good outcomes, we must put people and put social justice at the center of any change.

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[1] I love this part: “Historically, doctors have been paid for services, not results. In the eighteenth century B.C., Hammurabi’s code instructed that a surgeon be paid ten shekels of silver every time he performed a procedure for a patrician—opening an abscess or treating a cataract with his bronze lancet. It also instructed that if the patient should die or lose an eye, the surgeon’s hands be cut off. Apparently, the Mesopotamian surgeons’ lobby got this results clause dropped. Since then, we’ve generally been paid for what we do, whatever happens.”

[2] Pink, Daniel H, “Drive: the surprising truth about what motivates us”, Riverhead Books, New York 2009.

So, two things.
1. I changed the blog template. I hope you like it; I'm not sure I do, but it seems that blogger doesn't actually offer the old one anymore anyway.

2. I still, despite changing my pw and using Google "verify" am getting what I interpret as hacked spam -- items I obviously didn't create appearing in my "draft blog" list. I'll change pw again, but don't know how this is happening, and apparently no one else does either.

The Primary Care Conundrum

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The primary care conundrum:

We need more primary care doctors.

We treat primary care doctors relatively poorly, thus discouraging medical students from entering the field.

This issue has been one of the recurring themes in the discussion of health reform, and I have written about it often. People argue around the edges of the conversation:

·         It is not only primary care doctors that are relatively underpaid; so are many non-procedural specialists.

·         There is not going to be an increase in the payment to physicians, so higher-paid specialists are going to have to take less money.

·         It is not just about money; it is about lifestyle. Primary care doctors have to work too hard.

·         It is not just about money; it is about status. Primary care doctors have lower status.

·         It is not just about money; it is about intelligence. Primary care is just too easy.

·         It is not just about money; it is about unrealistic expectations. Primary care is just too complex.

And on and on. These are not silly or spurious or even inaccurate statements, although the last two might be considered another “primary care conundrum”, the one to which medical students are often subjected. All of these are things that family medicine and other primary care specialties have to think about, and address to the extent that it is within their control. I have, for example, talked about the selecting medical students who are likely to be more interested in primary care and underserved (both rural and urban) practice, as well as about making the curriculum more supportive of primary care. However, it is, ultimately, not the responsibility of the primary care specialties, or even the medical educators, but rather of the overall society to develop policies of reimbursement that encourage primary care – if that is what the society wants and needs.

Thus “Payment reform for primary care within the Accountable Care Organization”,[1] by Goroll and Schoenbaum in the August 8, 2012 JAMA is appropriately subtitled “A critical issue for health system reform”. While it may not really be all about the money, a good part of it certainly is. One doesn’t have to be an economist who believes that everything can be reduced to, or expressed in terms of, money, to recognize that lifestyle and status are just other manifestations of money. If you make more (or, more to the point, if the services that you render are reimbursed at higher levels), you can work (if you choose) less, or a health system employing you can hire more people to do that work. Status is measured by many yardsticks, but most of them, at least in our society (since we do not have inherited titles) have to do with money.

Goroll and Schoenbaum, from, respectively, the Massachusetts General Hospital and the Josiah Macy, Jr. Foundation, focus their discussion on Accountable Care Organizations, or ACOs. These are a centerpiece of the health reform law (ACA), but most experts believe that, whether ACA survives or not (it has survived the Supreme Court, but there will be continuing challenges, particularly if the Republican Party takes the Senate and/or White House in 2012) it is the wave of the future. This is because it is both a framework for increasing quality and for saving money; saving money is the main thing that virtually all politicians and pundits talk about in regard to health care. Even providers do so, although they mostly focus on saving it on other aspects of the health system.

In a sense, this last is what ACOs seek to avoid; by assigning patients to an ACO that provides comprehensive care – ambulatory, hospital, post-hospital – for lives (in insurance parlance) or people (in English) it seeks to avoid “blaming the other”:

·         We took good care of them, but when they went to the hospital they received poor care or unnecessary procedures.

·         The “local doctor” didn’t provide adequate care, but luckily we in the hospital could save the patient.

·         We did great care in the hospital, but the nursing home (or patient’s family) didn’t, so the patient suffered, or had to be readmitted, or died.

·         They discharged the patient – home or to the nursing home – too soon, so despite our excellent care the patient suffered, or had to be readmitted, or died.

The devil, as always, is in the details. How will this be different from the managed care of the past? (“I heard this all back in 1995,” says a colleague.) In order to avoid some of the politically unpopular characteristics of “managed care”, the ACA does not contain a requirement that patients receive care only from the ACO to which they are assigned. However, if they are cared for elsewhere, how can the ACO ensure either the quality or the cost? Who will care for the uninsured? How will (and they will) providers (including hospitals, doctors, nursing homes) game the system to maximize their advantage by passing the buck, cherry picking the relatively health, emphasizing high-reimbursement and de-emphasizing low reimbursement care? How will (and here “Will it?” is still a question) that be rectified?

The important point of the JAMA article is made in the beginning: that “Primary care, the foundation of the ACO, requires payment reform to enable and make durable its transformation into a high-performance model such as the patient-centered medical home.” Primary care is the foundation of the ACO, just as it is the foundation of any effectively-functioning health system. The authors cite 3 main obstacles to increasing payment for primary care: 1) Inertia. It is not the way our incredibly elaborate and expensive payment system is currently structured, and changing it will be hard; 2) Resistance. The development of new systems and funding will require, particularly in a setting in which overall funding will not appreciably increase, the reallocation of money from one set of groups to others, and this certainly will (and already has) meet with resistance by those who will lose money. 3)  “Motivation 2.0”. “…many health care executives (including some physician managers) believe that physicians work harder under fee for service and that productivity is at risk of faltering under payment systems that do not maintain a strong, volume-based incentive.”

The first two are obvious and will have to be strongly and persistently addressed if there is to be any success in re-engineering the health care system; there is no one who will fight so hard as a group whose privileges, no matter how unfairly earned, are being threatened. However, the third is more questionable. Another colleague asked “is there any evidence that this is not true?” Indeed, there is some evidence that it is; in the 1990s when hospitals and health systems bought out physician practices, they often found that the physicians, now salaried, were less productive than when they were in practices where their income came from productivity. The flaw there is that the same standards were being used for measurement: how many patients were seen, how many wRVUs (a measure, albeit imperfect, of physician productivity). It was not measured by whether the quality of patients’ health was improved. Perhaps by seeing fewer patients-per-day, for longer visits when they need them, or providing care in teams and by phone and email when appropriate, fewer return visits would be needed (bad if reimbursement is all fee-for-service) and delivered in teams.

Goroll and Schoenbaum do not, actually, use the phrase “Motivation 2.0”. This comes from Daniel H. Pink, a business management author, from his book “Drive”, published in 2009 and one of the most influential management books in recent years.[2] Pink contrasts the management style based on this sort of motivation (2.0, not the “1.0” that was ancient man’s – survival), the dominant one of the 20^th century and into the 21^st with a new understanding of what motivates people and what kind of management is most effective. He draws on decades of psychological and sociological and business research, as well as actual implementations in management practice, to clarify what this new appreciation, “Motivation 3.0” is. I recommend reading the book, quite short and easy.

But understanding and implementing effective motivational practices will certainly not, in itself, solve health care. Making sure that there are systems to ensure quality, and that they are available to everyone, is the sine qua non.

  

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[1] Goroll A H and Schoenbaum SC, “Payment reform for primary care within the Accountable Care Organization”, JAMA 8Aug2012;308(6):577-8.

[2] Pink, Daniel H, “Drive: the surprising truth about what motivates us”, Riverhead Books, New York 2009.

Medical errors: to err may be human, but we need systems to decrease them

An op-ed by Sanjay Gupta, MD, the Atlanta neurosurgeon and CNN medical correspondent, appeared in the New York Times on August 1, 2012. “More treatment, more mistakes” makes the case that medical errors are common and that they are largely due to the pressure to “do more”, to do more tests, to do more x-rays, to do more surgery. This is not news in itself; the Institute of Medicine (IOM) of the National Academy of Sciences published its study “To Err is Human” in September 1999, observing that between 44,000 and 98,000 deaths occurred per year as a result of medical errors (full text available at http://www.nap.edu/openbook.php?isbn=0309068371).

To Err is Human itself was not the beginning of the study of medical errors. It uses a taxonomy dividing errors into “Diagnostic”, “Treatment”, “Preventive” and “Other”, published 6 years earlier in a study by Lucian Leape, et al., in the Quality Review Bulletin.[1] To Err is Human detailed the variety of types of medical errors that could occur, the relative frequency with which they occurred, and the reasons why they occurred, and provided suggestions as to how to prevent them from occurring. The Institute for Healthcare Improvement (IHI), founded by Leape and former CMS director Don Berwick (who were among the authors of the IOM report) has been working on this issue for more than 25 years. Its “100,000 lives campaign” sought to save that many lives by having hospitals sign on to implementation of certain strategies that had been shown to reduce errors. These included “timeouts” in surgery to be certain that everything was correct (right patient, right part of the body, etc.) before beginning, particular ways of managing people on breathing machines in intensive care units to prevent “ventilator associated pneumonia”, and the like.

A key point is that very few of these errors are intentional – they are not malpractice in the traditional sense, they are rarely the result of physicians being “bad doctors” – and yet people, avoidably, die from them. A key part of the strategies promulgated by people like Berwick and Leape, IHI, by the IOM report, and others working in the field is to employ the systematic approach to error reduction developed in other industries, such as airlines. (A common trope is that if airlines had errors as frequently as medicine, a jumbo jet full of people would be crashing several times a day.) Continuing follow-ups have looked a “how we are doing”, such as in “Five years after ‘To err is human’: what have we learned?” by Leape and Berwick in JAMA in 2005[2] and the summary of it by the Commonwealth Fund.

It is in the context of this history that Gupta’s article appears. Its main significance is that it brings to public (New York Times) attention the fact that these problems still exist, and that despite progress (and there has been much) there is much that still needs to be addressed. It is a balanced presentation, but does emphasize the point in the title – that more treatment leads to more errors, or, to put it another way, that more is certainly not always better. He cites “Rule #13” from the novel “House of God”, written by Stephen Bergman, MD (under the pseudonym Samuel Shem) in 1979: “The delivery of medical care is to do as much nothing as possible,” a restatement of the dictum primum non nocere, first do no harm.

An interesting series of letters responding Gupta’s paper appeared under the heading “Taking steps to reduce medical errors” in the Times on August 4. One of them is from Bergman, who echoes Gupta’s concept that fear of malpractice suits (the “whining motor behind doctors’ ordering unnecessary, pricey tests,”) is the cause of many errors, and applauds interventions such as surgical time outs. However, another letter, from Niall O’Dowd, the uncle of Rory Staunton, the 12-year old boy who died after being treated for a “minor” scrape in the NYU Hospital emergency department (see Jim Dwyer, “An infection, unnoticed, turns unstoppable”, NY Times July 10, 2012 and many follow-up articles including a column by Maureen Dowd “The boy who wanted to fly”, 3 days later), points out that there are also dangers, as in his nephew’s case, from doing too little.

Mr. O’Dowd focuses, naturally, on the emergency department, which is where his nephew was treated, inadequately as it turns out. Emergency departments are seeing more and more patients, and are responsible for a very large and increasing number of admissions to hospitals, as detailed in a recent New England Journal of Medicine article by Schuur and Venkatesh, “The growing role of emergency departments in hospital admissions”.[3]  They identify a number of trends that tend to increase the use of the emergency room as a source of care, particularly for acute conditions. These include the lack of availability of acute-care appointments in primary care practices, and the lack of the high-tech instruments such as CT scanners that permit EDs to rapidly diagnose and admit – or rule out and then discharge – conditions such as heart attack and stroke.  They also include public education campaigns that urge people to go to the ED when they have symptoms that could be heart attack or stroke, and, of course, the fact that lack of insurance prevents people from accessing health care in most other settings (federal law requires EDs to assess anyone who presents there). While the fact that the increase in admissions from the ED may have something to do with their “lower threshold” (“…emergency physicians are trained to assume the worst and are more likely to admit patients with uncertain diagnoses and with whom they don't have an ongoing relationship, and that they are unwilling to discharge patients when they cannot guarantee outpatient follow-up,”) it is also possible that in their pressure to diagnose and admit the most sick, they could possibly undertreat some, like Rory Staunton, who do not appear to be so ill.

Mr. Staunton may have benefited from antibiotics he did not get. Other letter writers speak of both the dangers of underusing antibiotics and overusing them; however, the settings they describe (critical care units in the first case, treating viral syndromes in the second) are very different. Doing a lot is not necessarily wrong, or right. Doing little is not necessarily wrong, or right. Both can cause errors, and both can save lives. Yet a fifth letter writer suggests “our mission is clear: if it’s right for the patient, it’s the right thing to do.”

This is true as far as it goes; the difficulty is in ensuring what is right for the patient. But systems, checklists, timeouts, and consistent rules can go a long way to making this be the case. And if people with non-acute, non-emergent conditions can get in to see their doctors, and as important, have doctors and can have the health insurance that allows them to be seen, it would help even more.

This is something that we must not lose sight of; as Schiff, Bindman, Brennan et al note in a 1994 JAMA article, denial of care is the “gravest of all quality defects.”[4]

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[1] Leape L; Lawthers A, Brennan, T, et al. ,“Preventing Medical Injury”. Qual Rev Bull. 19(5):144–149, 1993.

[2] Leape L, Berwick D, “Five years after to err is human: what have we learned?” JAMA. 2005;293(19):2384-2390

[3] Schuur JD, Venkatesh AK, “The growing role of emergency departments in hospital admission”, NEJM 2Aug2012;367(5):391-3.

[4] Schiff G, Bindman A, Brennan T, et al., “A Better-Quality Alternative: A Single-Payer National Health System Reform”, JAMA. 1994;272(10):803-808.

Doctor shortage or shortage of the right doctors?

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The lead article in the New York Times (right column, front page, by Annie Lowrey and Robert Pear) on Sunday, July 29, 2012, has the provocative headline “Doctor shortage likely to worsen with health law.” My first instinctive reaction was “What? I don’t know of any part of the new health law, the ACA, that will reduce the number of doctors!” Then, reading the first sub-head, I realized what they meant. “Primary care is scarce”, something I well know and have written a lot about, and then, in smaller type, “Expanded coverage, but a greater strain on a burdened system.”

What they are saying is that the shortage of physicians, especially primary care physicians, will effectively increase (get worse) as millions more people gain insurance coverage under ACA. This will happen both through expansion of Medicaid coverage or through health insurance exchanges that will permit both individuals and small companies that have not previously had or offered health insurance to buy it at much lower rates. The expansion of health insurance coverage to these groups is a good thing; it will eliminate a major barrier to quality health care, itself a component of good health. Unfortunately, phrasing the problem in the way that the NYT headline does is likely to inflame displeasure with the law among those who, through ignorance or selfishness or both, are happy to draw up the bridge behind themselves, not wishing to share their, often limited, access to doctors with the newly insured. Surely, this is not an acceptable reaction.

The problem is that there are too few doctors to provide each person with full access to care, especially in an aging population because, as noted in a quote from Dr. Darrell G. Kirch, president of the Association of American Medical Colleges (AAMC) “Older Americans require significantly more health care…Older individuals are more likely to have multiple chronic conditions, requiring more intensive, coordinated care.” It is, however, much more about the poor distribution of doctors by specialty (too few primary care physicians, too many of many varieties of subspecialists), by geography (too few in rural and poorer areas, too many in more affluent and suburban areas), and by the insurance status of the patients that they care for (too few who take Medicaid, and even Medicare, and too many willing to care for only those with insurance that reimburses more). And, relevant to the cost of care, too many whose business model is built upon doing high-cost, high-profit procedures even when they are marginally (or not at all) beneficial to the patient, rather than providing the comprehensive care needs of people.

Sadly, and for the wrong reasons, some of this may not come true, so some of the fears of the already-insured may be mitigated. Many states have indicated their plans to not participate in Medicaid expansion despite the financial incentives to do so (the federal government will pay 100% for the next several years, and 90% thereafter). These same states, as well as others, also pay so little under Medicaid that many doctors won’t see Medicaid patients. Unfortunately for that ignorant-or-selfish-or-both minority of seniors who say “keep the government’s hands off my Medicare!”, many of those same doctors are now refusing to accept Medicare patients. Hey, if they can make a big living without it, why should they take care of your mother? So if you are not on Medicaid OR Medicare maybe you’re safe – if you live in a relatively affluent part of an urban area, and have private insurance, and especially if you are in an integrated health system such as Kaiser that provides a strong primary care base.

The NYT article indicates that “Physician compensation is also an issue. The proportion of medical students choosing to enter primary care has declined in the past 15 years, as average earnings for primary care doctors and specialists, like orthopedic surgeons and radiologists, have diverged. A study by the Medical Group Management Association found that in 2010, primary care doctors made about $200,000 a year. Specialists often made twice as much.” In fact the gap is much greater than that between primary care physicians and specialists “like orthopedic surgeons and radiologists”; it can be several times greater. (This is because “specialists” includes, in addition, doctors like psychiatrists and some pediatric and medical subspecialists who earn much closer to what primary care doctors do, and thus bring down the “specialist” average.) A recent estimate was that an anesthesiologist can anticipate earning $7 million more in a career than a family physician!

I woke the other day to NPR to hear Republican senator Orrin Hatch saying “To be clear, it is a disgrace that so many American families go without health insurance coverage.” I was nearly ecstatic; to agree that something is a problem is the first step to getting together to solve it. And, surely, that something is “a disgrace” is even worse than being a problem. I turned up the radio to find out how Sen. Hatch and the Republicans were going to solve it. Unfortunately, that was not to be. It was a sound bite in a story by Julie Rovner titled “GOP Says Coverage For The Uninsured Is No Longer The Priority” (July 27, 2012). I hadn’t known it ever was a priority for the GOP, but this piece laid any doubts to rest. Worse than the double-talk from Hatch was Senate majority leader Mitch McConnell, in this excerpt:

McConnell: "Let me tell you what we're not going to do. We're not going to turn the American health care system into a Western European system. That is exactly what is at the heart of Obamacare. They want to have the federal government take over all of American health care."

By "Western European," McConnell means government-run or primarily government-run. Western European countries also pretty much don't have people who don't have health insurance. And by the way, there are closer to 50 million Americans without health insurance; 30 million is the number the health law is estimated likely to cover.

McConnell never says what the GOP is going to do, but you can be sure it will not have anything to do with covering everyone. This is too bad; there are possible solutions, and many of them are even based in the marketplace. Step one is for Medicare to completely revamp its reimbursement policies. This is because, to a large degree, Medicare reimbursement is the basis for all insurance reimbursement; while they may pay more (say, 1.5x Medicare) the ratios are the same, so if Medicare changes what it reimburses for primary care relative to subspecialty care, other insurers will follow.

In biological systems, the normal situation is to have “negative feedback loops.” For example, if the thyroid gland is producing enough thyroid hormone, it shuts down production in the pituitary gland of another hormone that stimulates the thyroid. When there is not enough thyroid hormone in the blood stream, the low levels stimulate the pituitary to become active, activating the thyroid gland. This is functional. Imagine how dysfunctional a “positive feedback loop” would be – the more the thyroid produced thyroid hormone, the more the pituitary would produce its stimulant, creating yet more thyroid hormone, and soon we’d all be hyper-thyroid and dead!

This is like the current medical reimbursement system. We pay doctors more to do procedures, pay them more to take care of only a few diagnoses in a limited organ system, pay them more if they live in an expensive area, and even more if they refuse to care for those on government insurance. This is a positive feedback loop where you economically do the best being a medical “partialist” in a nice suburban area taking care of relatively well-off people, and worst being a generalist in a rural area taking care of people who need it. Or, if you choose, work less than full time and still make a good living.

Medicare should immediately begin reimbursing primary care at a higher rate, including for the effort and cost of managing chronic disease, so that the income differential between generalists and specialists largely disappears. Then it should increase payments for doctors working in more rural and remote areas, not for “desirable” urban and suburban areas. Doctors practicing in urban underserved areas should get smaller incremental payments (after all, they can live in a “good” neighborhood and commute).

We will still have a shortage of doctors until the pipeline fills, but such a system will decrease the financial impetus to be yet another subspecialist in a metropolitan area that already has enough, and increase the impetus to become a generalist in an underserved area. If we are to depend on the market, this is the kind of market-based approach we need.

Variations in the cost of medical care: Sense and sensibility

The cost of medical care gets a lot of attention from politicians and policy pundits (including both the influential and people like me); we are often told that Medicare is going to bankrupt the nation, that people are getting unnecessary, expensive, and potentially harmful services (except, of course, when those services are being received by the speaker or writer or those they care about). We are also told that quality and cost control can go hand-in-hand. While sometimes they can, they do not always. As I have noted in the past, prevention does not always save money in the long term. (I guess if we wanted to save money on health care, we’d encourage people to smoke, eat fatty food, and not exercise, so they could have their heart attacks young – and of course not treat them – so they’d never get old enough to be the multi-morbidity high cost patients!)

Two recent “Perspectives” in the New England Journal of Medicine address this from different angles. “Cents and sensitivity: teaching physicians to think about costs” (July 12, 2012), by Rosenbaum and Lamas, looks at the education of physicians (students and residents) in terms of how they are taught what medical tests cost, and conclude that it is very little. They open with a typical rendition of a student presenting a new patient to residents and attending (faculty physician). As the student painfully proceeds with identifying less-and-less probable diagnoses for the person who almost certainly has pneumonia, this list of expensive tests to be done to “rule out” the improbable grows. “Our profession has traditionally rewarded the broadest differential diagnosis and a patient care approach that uses resources as though they were unlimited.” The issue is not that we should only consider one diagnosis; it is that expensive tests to look for the most unlikely diagnoses need not be done immediately, but only when a patient is not responding to therapy for the most likely (including after testing to “rule in” or “rule out” common, not rare, competing diagnoses). We certainly do not need to do every possible test that can be done to make a diagnosis even after the first, best, test confirms the clinical suspicion; this is the basis of an educational model that the authors cite by another scholar, Chris Moriates.

Radley and Schoen, from the Commonwealth Fund, write in the July 5, 2012 issue about “Geographic Variation in Access to Care — The Relationship with Quality”.  This draws on data from the most recent Commonwealth Fund Scorecard “Rising to the Challenge”, published in March, 2012, and examines how health care quality varies dramatically depending upon which area you live in. This is largely regional, but there are also “sub-regional” differences. They discuss a number of the common areas in which quality can vary, including adults with a usual source of care (93% best, 59% worst), high-risk adults who visited a doctor for a checkup in the past 2 years (95, 67), adults over age 50 who received recommended preventive and screening care (59, 26), and adult patients with diabetes who received recommended diabetes care (69, 27). They note that “…when we look beyond state averages, there are staggeringly wide gaps in people's ability to gain access to care in different communities around the country. We also find a strong and persistent association between access and health care quality, including the receipt of preventive care. Simply put, where a person lives matters — it influences the ability to obtain health care, as well as the probable quality of care that will be received — though it should not matter in an equitable health care system.”

But the most important contribution that they make is to, matter-of-factly, state that not having insurance is a negative quality indicator, that there is “even [my bold] variation on such fundamental measures as having health insurance or a connection to a regular source of care.” The attached map shows the regional and sub-regional variations in health insurance; white areas have the lowest level of uninsurance (5-14%, Massachusetts lowest), and black areas (on the Texas-Mexico border) the highest, >50%.

The article by Rosenbaum and Lamas cites the views of a number of medical ethicists, including several who believe that it is an abrogation of the Hippocratic oath to limit the care provided to the individual patient in front of you based on cost. I do not agree; while the primary criterion should be a consideration of the cost-benefit ratio (how much will this help the patient per dollar of cost), it is also true that there are certain interventions for certain conditions that are too costly to provide for everyone who needs it equally. And that is the crux of the issue. While one can (if a bit disingenuously) say “I cannot worry about ‘society’, I have to care for the patient in front of me,” the fact is that the patient in front of you for whom you may be considering an expensive intervention is not randomly selected. At least in the US, it is probably someone with health insurance that will pay much of the cost. It is certainly someone who has made it through the medical maze to get your attention. If the person in front of you can afford to pay for any service, whether they need it or not, but there are others who cannot pay for even the services they most definitely require, this is not coincidence nor is it irrelevant.

Perhaps the primary responsibility for cost-control should not be at the individual doctor-patient level, but at the societal level, such as is done in Great Britain through the National Institute for Health and Clinical Excellence (NICE) that evaluates interventions and decides, based on cost-benefit ratios, whether the National Health Service will pay for them. However, as individuals’ out-of-pocket expenses for employees’ contribution to insurance premiums, deductibles, and co-pays continue to increase, more and more people are finding that, insured or not, cost is an issue. Remember that “low cost” is relative; most “low cost” interventions are still a lot of money, easily moving into 4, 5, or 6 digits, for folks to pay out of their pockets. Rosenbaum and Lamas end their article with “Protecting our patients from financial ruin is fundamental to doing no harm.”

We may have different perspectives on where the limits are in providing costly care to an individual, but making sure that everyone, wherever they live, has access to quality care is critical. And ensuring that it is not financial or insurance status that limits access is the first step.

The Oregon Lottery: Far from enough, but at least they are doing something

On June 22, 2012, the New York Times published an article on the results of the Oregon lottery. No, this was not your “pick 3” or “powerball”; this was a lottery to get publicly funded health insurance. “In Oregon, Test Case for Health Overhaul, Better Care at a Cost”, Annie Lowrey describes the outcome of Oregon conducting, in 2008, an actual lottery for working-age adults living in poverty to get on to Medicaid. It was not, presumably, intended as an experiment (although certainly people knew that it would end up being one), but rather the result of the state not having enough money to enroll everyone in that category.

The results, after 4 years, should surprise no one. The study “has found that gaining insurance makes people feel healthier, happier and more financially stable,” and that “The insured were 25 percent less likely to have an unpaid medical bill sent to a collection agency and 40 percent less likely to borrow money or skip paying other bills in order to cover their medical costs.” First of all, it is obvious. Having coverage makes it possible to go to the doctor to care for chronic disease and actually get better, or keep it from getting worse, it means you don’t have to forgo paying the rent or electric bill or buying food to get care, and it saves you from bankruptcy when you do have to go to the hospital. Second of all, a similar study was done before, the RAND Health Insurance Experiment of the 1970s and 1980s, which followed the result of giving free care or care with a co-pay to previously uninsured adults. A large number of publications resulted from this study, which was led by Joseph Newhouse. A key finding was that people with free care used more care than those who had to pay a co-payment (and much more than those with no insurance). This included care such as going to doctor for minor conditions (something many health care pundits consider “inappropriate” use of care, except, of course, when they are doing it). It also, however, included care that everyone agrees was “appropriate” – that cured acute conditions, controlled chronic disease, and prevented death.

Newhouse, along with Amy Finkelstein (“… the most recent winner of the John Bates Clark Medal, an economic prize considered second only to the Nobel”), was the evaluator of the Oregon Study; their high credentials lend credibility to results which would only have been incredible if they had gone the other way. Another obvious finding is that the insured spent more on health care than those who were uninsured. This finding, Ms. Lowrey says, was “dashing [to] some hopes of preventive-medicine advocates who have argued that coverage can save money — by keeping people out of emergency rooms, for instance.” Well, I’m sorry that getting care didn’t cost less than not getting care, but it is very hard to argue that this is a credible argument against helping people get health care. Besides, neither the total amount spent by the newly insured, nor the difference was very much:  “…the newly insured spent an average of $778 a year, or 25 percent, more on health care than those who did not win insurance.”

Note the phrase “win insurance.” Not “had insurance.” It was a lottery, remember. The winners did a lot better than those folks who didn’t win. It’s kind of like being the third-world kid who is lucky enough to “win” by living in the “right” village where a “mission” trip comes to do surgery for your congenital anomaly. The Oregon lottery, even if it wasn’t intended as research, does illustrate why some people fear participating in research. They think that they will be “experimented on” and that they may not get treatment that will work and save them. It is often had to explain to people that we, the researchers, don’t know what works, what will save them, until after we have done the study. The legacy of the Tuskegee syphilis study continues to poison the well in terms of recruiting study participants, especially among minority groups like African-Americans. In Tuskegee, poor black men in the South were followed for four decades to determine the “natural history” of syphilis. Most outrageous, of course, was that the study continued for decades after effective treatment for syphilis, penicillin, was available, and they were not treated.

The Oregon health lottery is, in many ways, not like Tuskegee. It selected people randomly, through a lottery, not targeting any particular racial group. Of course, by its nature, it targeted poor people – working age adults who did not have health insurance. One can imagine Tuskegee researchers saying that they weren’t really racist, that if they wanted to study the natural history of syphilis they had to study the population that had it – poor black men in the South. Of course, it was racist.

The most important similarity between Tuskegee and Oregon is that we withheld treatment that we knew would work in both. The previous work done by the RAND Health Insurance Experiment (HIE) proved what was obvious even before – that having health coverage would improve people’s health. The Times notes that many of the Oregon winners “…said that Medicaid had made a significant — even transformative — difference in their lives.” It would have made the same difference in the lives of the lottery losers. Of course, this is the nature of a lottery; the winners do better than the losers. But this is a lottery about people’s lives and health.

I realize that what I have written might be seen as an attack on Oregon, saying that it did something bad. Quite the contrary; at least Oregon, for the second time in the last 30 years, has made an effort to do what it could to help as many uninsured poor adults as it could, and did it in a reasonably fair way, by a lottery. Compared to most states, certainly including my own, Kansas, it is an admirable effort that has transformed the lives of many people that the rest of our states seem to not care about. But it is beyond the time for such experiments; the results are in. It is time to cover everyone. It is time to go beyond what an Affordable Care Act rescued by the Supreme Court will provide. It is time to expand Medicare to everyone.

Because that’s the least we can do.

Multimorbity, primary care,social determinants, and universal insurance: where they all come together

Tinetti, Fried, and Boyd, writing in JAMA June 20, 2012, discuss “Designing health care for the most common chronic condition – multimorbidity.”[1] They note that adult patients with only a single chronic disease are the exception (e.g., only 17% of people with coronary disease have that as their only chronic condition) and the rate of multi-morbidity increases with aging. However, the medical system is organized around individual diseases, both in terms of reimbursement (based upon International Classification of Diseases, 9^th Edition, or ICD-9, codes) and in terms of specialty structure. Thus, cardiologists care for heart disease (only), oncologists for cancer (only), endocrinologists for diabetes and thyroid disease, etc.

Moreover, they observe that even more recent efforts to reward quality have been single-disease focused, with metrics related to acute myocardial infarction (heart attack), pneumonia, and particular surgical procedures. This is added to the fact that these criteria focus on hospitalized patients, rather than on efforts to keep them well. They state that “To align with the clinical reality of multimorbidity, care should evolve from a disease orientation to a patient goal orientation, focused on maximizing the health goals of individual patients with unique sets of risks, conditions, and priorities.”  This is a long way of saying care should be patient-centered. They also say that “The process for assigning responsibility for providing clinical care also needs redesign, perhaps beginning with a systematic process for determining which clinician should have primary responsibility for helping patients make decisions,” which is a long way of saying people need generalists, or primary care physicians.

This group does not want to call them generalists, though. Perhaps this is because they are from Yale, a school well-known for its research and for its high-tech tertiary and quarternary care capability, but woefully weak in training physicians to provide general, or primary care. It doesn’t even have a Family Medicine department, despite the fact that this is the specialty that provides the largest number of primary care physicians, so these authors are from Internal Medicine. They have suggested that such physicians be called comprehensivists rather than generalists because the latter term “fails to capture the breadth of skills and expertise required”  to care for patients with multiple comorbidities.

While this article suggests nothing new (for example, I have addressed these issues several times, including Primary Care: What takes so much time? And how are we paying for it?, May 21, 2010 and Primary Care’s Image: A Problem?, November 17, 2009), it is good that it keeps these issues on the table. Providers, particularly hospitals, want to be paid for metrics that are easily identifiable and relatively easy to achieve. Students choosing careers often want to pick a field in which they can feel that they are masters of a limited field of knowledge.Patients sometimes want to get help for a specific problem from a particular specialist. But everyone is better served if there is coordination of care and decisions regarding the care of one condition take the others into consideration. This means that medications which have negative interactions or countervailing effects are less likely to be prescribed. It means that the difficult decision about whether or not to have a particular surgical procedure is taken in the context of all of the health issues confronting the person. It means that decisions about interventions in desperate situations or at end of life are made wisely, and in full possession of the available information, without bias toward treatment of a particular disease regardless of its impact on others.

In a recent “Doctor’s Blog” on the British Medical Journal’s (BMJ) “doc2doc” site [disclaimer: I also blog at this site] one doctor presented their thoughts on “Is prevention ALWAYS better than cure?”. I do not agree with all of Dr. Lush’s points, and am not sure I even understand them all, but that “…as we get older the risks of many diseases increases so that many patients end up on a cocktail of preventative drugs, probably 2 antihypertensives, aspirin, beta blocker, statins, anti-inflammatory medications, diuretic, asthma treatment, type 2 diabetic treatments, analgesics, etc etc.” is a fact. Many of these medications can be for either prevention or treatment or both (remember the concepts of secondary and tertiary prevention, so that treatment of one condition – say high blood pressure – can be prevention of another – say heart attack), but they often lead to patients saying “too much!” Worse than that, some may have opposing effects – the anti-inflammatory medication you take for your arthritis can lead to GI bleeding and kidney failure. The narcotics you take for your pain, in addition to the more well known negatives of addiction, cause constipation so serious it may well be the source of even worse symptoms.

Even the presence of a National Health Service is not sufficient. A study from Scotland published recently in the Lancet, “Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study”, demonstrates an extremely high rate of multi-morbidity in that county, with much higher rates in poorer communities. The “[O]nset of multimorbidity occurred 10–15 years earlier in people living in the most deprived areas compared with the most affluent”. The authors conclude that their findings “…challenge the single-disease framework by which most health care, medical research, and medical education is configured. A complementary strategy is needed, supporting generalist clinicians to provide personalised, comprehensive continuity of care, especially in socioeconomically deprived areas.”

Of course, unlike Britain, which has a National Health Service, the US does not cover everyone. A Kaiser Family Foundation (KFF) “health reform subsidy calculator”, cited by Don McCanne in his Quote of the Day, demonstrates the amazing out-of-pocket costs for health insurance that come with slight incremental increases in family income, and would be mitigated, although not eliminated, by the Affordable Care Act. This creates a real difference in our two health cultures, because many people in the US do not seek care because of the financial barriers, and then only for acute episodes.

In terms of having a supply of physicians who can fill the role of caring for multiple morbidities, Britain has much more extensive primary care base than the US. It is possible that their system has as great a risk as ours of generalists not being sufficiently “comprehensivist”; our system, with more hospitalists, is moving in the British direction of having primary care doctors who do not follow their patients into the hospital. But in the US, we are without a sufficient number or percent of primary care doctors altogether.

The reality is, as I have often observed before, is that a comprehensive national health insurance system is a necessary, if not sufficient, component of a plan to actually ensure health. Two other major components are also necessary. The first is addressing the social determinants of health, which are largely associated with class/socioeconomic status, and the second is having an adequate primary care base, And, while, as the Scottish study indicates, the national health service in Britain does not guarantee either, it does provide a vehicle for addressing the second and mitigates the impact of the first.

The absence of such a system in the US makes the problems of an inadequate primary care workforce and the impact of socioeconomic disparities much worse.

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[1] Tinetti ME, Fried TR, Boyd CM, “Designing health care for the most common chronic condition – multimorbidity”, JAMA 20Jun2012;307(23):2493-4.

The "Annual Physical": Screening, equity, and evidence

Three articles in the NY Times over a two-day period addressed the circumstances of a person’s (or, in medical parlance, “the patient’s”) visit to the doctor and their expectations. On Sunday, June 3, “Let’s (not) get physicals” by Elizabeth Rosenthal called into question the American habit (?) belief (?) that there is something called an “annual physical” that everyone should get to maintain their health, even if they are not having any symptoms. Rosenthal says that they are not necessary, and can even be harmful, and that the US is virtually alone in the world in perpetuating this idea.

She supports her argument by going through a list of tests frequently done at these visits that are not recommended by the US Preventive Services Task Force (USPSTF) and many other expert bodies. These include screening for prostate cancer with prostate-specific antigen (PSA) tests, routine electrocardiograms (EKGs, or sometimes more correctly, ECGs), Pap smears (should be done for most women every 3 years, and not at all for women under 21, or for those over 65 if they have had 3 previous normals). She doesn’t specifically address the actual physical examination part of the “physical” but there is little to no evidence to support this either. (And that is pretty much true of pre-participation physicals for school and sports also.) She indicates that the Canadian government recommends against these exams, noting that they are “potentially harmful,” and discusses the “Choosing Wisely” campaign of the American Board of Internal Medicine Foundation, which I recently discussed ("Eggs Benedict" and "Choosing Wisely": often the best thing to do is nothing,” April 14, 2012).

“Potentially harmful”? Yes, of course. When a screening test is positive, it is then necessary to do a confirmatory test (usually more difficult, expensive, uncomfortable, risky or all of the above than the screening test, which is why it wasn’t done in the first place) and this may lead to other procedures – biopsies, surgery, etc. We tend to think of this as good if we have the disease, but if we don’t we incur cost, risk, and sometimes actual harm in looking for it. Indeed, sometimes even if we do have the disease, the complications of the investigation can lead to worse outcomes that the disease we are looking for. Which is why no test should be ”routine”.

The right term is “screening,” which means testing for something for which you have no symptoms, and it should be reserved for conditions that are potentially serious, can be identified by testing before symptoms appear, and for which there is an intervention that is not only effective but is more effective when done before the symptoms appear. None of this relates to tests done when you have symptoms, or have a diagnosis, and are being tested to follow up on treatment. For example: a screening blood count (CBC) to look for anemia in asymptomatic people is not indicated, but it might be if you are tired and pale. And if you are anemic and are treated (say, with iron), further testing to see if it worked – if you are no longer anemic – is appropriate.

The next day (June 4) two pieces appeared in the paper. In “The trouble with ‘Doctor knows best’”, Peter Bach also discusses screening tests that are not indicated and the puzzling fact that many doctors do them anyway. He attributes this to a combination of 1) this is what they learned from their teachers, 2) their concern because of “bad things” they have seen before in their practices, and 3) our instincts that make us “apply these [cancer screening] tests as if they were treatments, as if getting a mammogram were somehow like prescribing an antibiotic.” He shows how all of these are, or can be, wrong. The first should be obvious to all of us: the state of the art and of medical knowledge has often, indeed likely, changed from when we learned from our mentors. We need to keep up with current information, based on the most recent data available.

The second and the third are maybe a little harder to understand. With regard to #2, we, even doctors, remember what is unusual, not what is usual, and we tend to think that “had we only done that test, the bad outcome might have been prevented” when it usually would not have. #3 has to do with the difference between treating a condition that we have diagnosed and screening asymptomatic people. For almost all conditions, the percent of people who actually have them is so low that a majority of the people who have positive screening tests will actually be false positives. The physician’s anecdotal experience, never a substitute for the actual population data, may have value in the treatment of a condition she sees frequently, but virtually none with regard to screening.

The third article, “Afraid to speak up at the doctor’s office” by Pauline Chen, which was published also on June 4 but originally appearing earlier on Dr. Chen’s blog, talks about the reticence of people (even, as she describes, intelligent, successful, and generally empowered people) to not only not question their doctor’s recommendations, but to not even ask questions. This is something I have seen over and over again with friends and relatives, who don’t want to bother the doctor, or, worse, have gotten the message that Dr. Chen’s friend did that “’I don’t really feel comfortable bringing it [her concern about her symptoms] up,’…While her doctor was generally warm and caring, ‘he seems too busy and uninterested in what I feel or want to say.’”  Dr. Chen cites an article from a recent Health Affairs, “Authoritarian Physicians And Patients’ Fear Of Being Labeled ‘Difficult’ Among Key Obstacles To Shared Decision Making”[1]which shows this is a really common problem.

How much this is due to doctors being “authoritarian” rather than simply “authoritative,” or due to the physician being very busy (despite being “caring”) and wanting to cut short potentially time-consuming conversations, I do not know, but it is not a good thing. Nor, of course, is it good for patients to be hostile or to treat the physician as if she were a retail store where you just put in an order for what you want. Shared decision making requires collaboration, but, as in all situations with unequal power (student-teacher, employee-employer, etc.) it is primarily the responsibility of the party with greater power – in this case the physician – to take primary responsibility for ensuring that they are open to and welcoming of sharing. This is not the same as becoming a rug for a demanding patient to walk on, just as a patient being aggressive is not the same thing as being assertive. But as this study shows, the absence of shared decision making is much more often a failure on the part of the physician to encourage it.

Annual exams are more complicated. Dr. Rosenthal is absolutely right in pointing out the lack of indications for many of the screening tests that we often do, and in the incorrectness of the myth of the “annual physical”. On the other hand, such visits, whether annual or less often, serve another purpose. They offer the physician a chance to talk to the patient, to ask questions about real or potential health risks that the patient may not have bothered to bring up because it didn’t seem “worth bothering the doctor about” or because they weren’t sure that they could talk to the doctor about it. The latter includes “sensitive” topics such as domestic violence, abortion, sexual health, drugs, etc. It also is a time that doctor and patient can discuss health risks and what the patient can do for themselves to minimize their risks, from smoking and alcohol and drugs to safe sex and bicycle helmets and healthful foods.

Indeed, this is the main use of a “school physical” for sports – not to really identify physical problems that put a student at risk, but as an opportunity to talk to adolescents, a group that doesn’t often come to the doctor, about their health behaviors. Dr. Rosenthal says “I respect my doctors, but I see them only when I’m sick.” But she adds “I religiously follow schedules for the limited number of screening tests recommended for women my age — like mammograms every two years and blood pressure checks — but most of those do not require a special office visit.” However, she is a doctor; a lot of people don’t know what is indicated without guidance, and may not be so “religious” about doing those things without encouragement.

The biggest problem, as I have said many times, is that do these unnecessary-and-potentially-harmful tests for patients with good insurance, going to extremes with even more and more expensive and more un-indicated tests for “executive physicals” when a company is paying, but not do even the most strongly-recommended tests for poor and uninsured people. These people may never get to the doctor until they are very sick.

This absurd inequity, too much testing for some and too little for others, based not on patient preference but class, income and insurance status, is the true scandal. While there is clearly much else to do, a universal health insurance program is the obvious first step.

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[1] Frosch DL, et al., Authoritarian Physicians And Patients’ Fear Of Being Labeled ‘Difficult’ Among Key Obstacles To Shared Decision Making, Health Affairs May2012;31(5):1030-8.