Posts Tagged health care quality

Affordable Care Act — the right to health care

boxersPresident Obama vs. Republican Congress.  Another grudge match, the sweaty pugilists in the corners, puffs of smoke from the cigars in the front row, the referee  holding the mike, saying  it’s the 8th round, the clang of the bell, the jabs, the left hook, bam – a hard right to the teeth, finally the round ends with a flurry of punches under the belt.  We now interrupt the show for an important announcement.

HEALTH CARE IS NOT A CONTEST.  We are not in a reality show, this is real life.   The consequences are life and death.  Why is there an argument or a fight?

The sky-box view.  Look down at the basic arguments of the two sides:

  • Obama — health care is a right
  • Republican congress — health care is not a right
  • Both agree — health care costs too much

The punches and counter punches.

Punch:  The southern US has poor health care
Counter:  Not our problem, don’t fix it with our money

Punch:  Insurance companies are unethical
Counter:  They are just businesses trying to make a profit

Punch:  Primary care is better and more efficient
Counter:  The market determines what is better or more efficient

Punch:  Everybody should have access to health care
Counter:  Only those who have money should have access

Punch:  If everybody has insurance the system would be more fair
Counter:  Don’t tell me to buy insurance, I will do what I want.

Punch:  Raise taxes to pay for the uninsured
Counter:  We can’t afford higher taxes

Punch:  We already pay enough to provide good health care for everybody
Counter:  We don’t want regulations.  Some of us get great health care already

Punch:  U.S. health care only ranks 30th in the world
Counter:  Poverty and old age are the fault of individuals, don’t count them

Punch:  We need government oversight of health care quality
Counter:  That’s what lawyers are for

Punch: Women need care for female health problems
Counter:  What is good enough for men is good enough for women

Punch:  The constitution gives the right to life, liberty and the pursuit of happiness.  You can’t have any of those things  without being healthy.
Counter:  The Constitution says nothing about a right to health care.

Punch:  All this fighting makes me forget about poor health care quality and high cost
Counter:  Me too.

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Lack of Consistency — medical care variability

Combined target graph

An Interim Report from the Institute of Medicine (IOM) about geographic variations in care was just released.   This is a very scholarly report with massive statistical analysis.   The basic idea was to review what Medicare paid for various types of medical care, devices and drugs across the US to see if some pattern could be identified.  The hope was to find some way to alter the payment scheme to improve the value of health care.  Alas, they could not find a pattern, only wild variation.  An individual doctor might be cost-effective for one disease and a money-waster in another, doctors within a group would range from  judicious to wildly profit-motivated and the variations between hospital referral areas show the same scatter.

The graph.

The holes in the target above are an example of wide variation.  The archers did not hit the bulls-eye  very often — there is a lot of variation.  A particularly interesting graph from the report is redrawn above on the right.  This is about how often gastroenterologists in an unnamed state perform a stomach scope (EGD) with the billing diagnosis of heartburn  (i.e. gastroesophageal re-flux) .

The vertical axis is the number of EGD procedures per 100 diagnoses of heartburn (the procedure rate).  The horizontal axis is the ordered list of 403 gastroenterologists in the state.  The list is in order of the lowest to highest rate of performing EGD.  The ovals placed on the s-shaped curve represent 17 different doctors all in the same group.  The remainder of the 403 gastroenterologists are plotted as dots on the curve.  If all the gastroenterologists approached heartburn in a consistent and reliable manner the graph would just be a horizontal line somewhere in the lower part of the graph.  Instead we see some gastroenterologists performing a scope on 100% of people they see who have heartburn — to be clear, this is the picture of unnecessary procedures or “padding” the bill.

What does it mean? 

Gastroenterologists are poor marksmen.  No, no, no.  It means they are shooting at different targets.  Some aim to maximize revenue,  some aim to follow evidence based (lower cost) guidelines and some aim in-between.   Keep in mind that a gastroenterologist is paid about $200/hour for clinic visits and about $1000/hour when doing procedures.   The doctors on the right side of the graph clearly have targeted the high paying procedures “scope first and ask questions later!”

The IOM claims no insight into the mysterious variation.  It is not necessary to study this more!  Look at other countries, they don’t have this problem because other countries don’t pay doctors by the number of procedures performed.   Simply pay the gastorenterologist the same hourly wage for seeing patients in the clinic as doing a procedure.  In the big picture, the variation can be markedly reduced by having doctors employed by an accountable care organization (ACO).  The ACO sets the salary, pays the malpractice insurance and provides the office to practice — a doctor in an ACO just has to focus on doing what is right for the patient, not what is most profitable for the gastroenterologist.

What should be done?

Although the graph puts gastroenterologists in the spot light the data show the same scatter across the spectrum of doctors.  US health care is sliding more and more into the swamp of poor quality and high cost.  The US needs doctors to aim for the right target and to aim for reliability, which means to consistently hit the bulls-eye.   Hopefully the IOM will have the strength to recommend strong action to change the whole system of  payment for US doctors, hospitals, drug companies and equipment manufacturers.  Instead of trying to make a perfect system we need a good system that can be adjusted as needed to achieve both high quality AND low cost care.

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Second Opinion — really?

marcus welby 2nd opinion

Dr. Kiley asks Dr. Welby for a second opinion (circa 1970).  What was the story?  A crusty patient does not believe Dr. Kiley’s diagnosis and demands a second opinion from Dr. Welby.  Oh, the drama, the crushed feelings of Dr. Kiley, the wisdom of Dr. Welby, and the horror that neither knows how to use a microscope!

Holly Finn wrote an article today in the Wall Street Journal “First of All, Get a Second Opinion” (WSJ March 23, 2013).  She is strongly in favor of second opinions for two basic reasons:  there are now more successful companies that specialize in second opinions and 60% of people who seek a second opinion obtain recommendations which are less invasive and less costly.  But, she is taking the statistics out of context.  99% of people do not get a second opinion but the 1% who find a problem with the first opinion are often correct another solution is better.  The take-home lesson, like many things in life,  if something does not sound right,  it’s probably not.

Contrary to popular belief most physicians are very happy to help a patient get a second opinion.  Why?  Because a patient who feels uneasy with a situation will not follow directions, will not take prescribed medications, and will be hyper-critical if the outcome of treatment or surgery does not meet their expectations.  So, all a patient has to do to get a second opinion is to ask the provider (“do you think a second opinion would help us?”).

It is important to keep the primary care provider “in the loop”.  The best consultations or second opinions happen when there is a good exchange of information — what has been done, what tests show and what medications have been tried.

When should a person ask for a second opinion?

  • When a provider is unable or unwilling to discuss your questions or the information you have found in books or the Internet.  An unending barrage of questions is counterproductive — be prepared by doing your homework and ask a few good questions.
  • When you simply do not understand the diagnosis.
  • Give your provider an opportunity to adjust medications if side effects happen or if medications are not working as expected.  A second opinion is a good idea if the treatments and modifications are not working.
  • When the provider is unable to make a diagnosis of a problem.
  • When you have been diagnosed with a life threatening condition — you may not get a second chance for a second opinion so don’t wait.  Sometimes a bad situation can not be cured — at least you will have some comfort that what can be done is being done.
  • When your doctor is not giving you more than one option for treatment — there is always an option (perhaps not a good one, but there is always a choice)
  • When you are uneasy about the need for any surgery.  A CNN report  lists 5 surgeries that should trigger a second opinion:
    • Heart bypass surgery (get a second cardiologist opinion)
    • Hysterectomy (often not needed)
    • Pregnancy termination for fetal abnormality (because the diagnosis can be difficult)
    • Surgery for varicose veins (often not needed)
    • Treatments for brain tumors (a really big step)
  •  Sometimes insurance companies require a second opinion for certain problems.  Listen carefully to that second opinion even if you were happy with the first opinion.  There is indeed a lot of unnecessary testing and surgery which can be  dangerous for you and expensive for the insurance company.

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S is for Specialist


An expert is someone who has succeeded in making decisions and judgments simpler through knowing what to pay attention to and what to ignore.
(Edward de Bono)


There are about 50 common types of  medical and surgical specialists.  The list runs from allergists to vascular surgeons.  So, in the big picture of health care where do they fit?  Do they add to health care quality?  Are their services cost-effective (as you might evaluate a drug or device)?  When should a patient see a specialist (or not)?  Why are specialists happier than primary care doctors?

Many years ago there were no specialists.  Doctors delivered babies, set broken bones and used leaches.  Treatment of war wounds with amputation heralded surgery as a specialty in the latter part of the 19th century.  As time went by other specialties came into being mostly because specialists were the conduit from research to clinical practice.  As medical information was more widely available specialists simply had more experience with uncommon or difficult problems.  Specialists led the way for new treatments .  Pulmonary doctors treated consumption (TB).  Cardiologists studied EKGs.  Obstetric specialists invented forceps for difficult births.  Now there are at least 50 varieties of specialists.

The specialist world is divided between procedural (surgical) and medical (expert advice) specialists.  A cardiac surgeon is a good example of a surgical specialist.  An endocrinologist is a good example of a medical specialist.  Some specialists do a little of both like cardiologists who do heart catheterization procedures and provide expert advice for treatment of heart disease.  Medical research has exploded to such an extent specialists still maintain an edge by focusing on smaller and smaller areas of expertise.

One might be led to believe every condition should be evaluated by a specialist.  But, there is good evidence to the contrary.  Based on Medicare data:  Areas with more specialists spend more on health care for Medicare beneficiaries but see no improvement in the quality of care, mortality, or patient satisfaction.  The foundation of modern American medical care is being questioned.  What went wrong?  Is it Kryptonite?  How can this be?

 

There are two answers to what went wrong.  First, knowledge about a disease does not always lead to cure but always runs up the bill for tests.  Second, medication and surgery do have complications that can be serious to the point of shortening a person’s life.  In aggregate the specialty world “hit the wall”.  The positives could not offset the negatives.

The foregoing indictment of specialists really put the wind to the sails of primary care.  In fact, treatment of most common ailments is well established with what are called “evidence based guidelines”.   Quality, safety, cost-effectiveness, and patient satisfaction thus depend on a good process to implement the known guidelines rather than special knowledge.  Until recently primary care providers had the lowest job satisfaction of any provider group.  Now, with a new sense of importance and purpose they seem to be personally happier.

The specialty world is fighting back by addressing cost-effectiveness.  Cardiologists have devised cost-effective strategies for treatment of heart attacks (evidence based guidelines) with dramatic improvement in survival.  Oncologists are following guidelines for treating many cancers and engaging hospice at a more appropriate time.  Gastroenterologists have found they can prevent colon cancers by following evidence based  guidelines for doing colonoscopy.   The world’s specialists are not all on board with the idea of being  cost-effective.  Those who do procedures are still criticized for doing them too often (if you have a hammer everything looks like a nail).

THE BOTTOM LINE:

  1. If you have health problems then have regular visits with a primary care provider.  They usually do have good advice about going to specialists.
  2. Do your homework.  Search the Internet about your problem.  If there are ideas you find then discuss them with your primary care provider.
  3. There is still some “ego” challenge for a primary care provider to ask for help in difficult situations.  The simple question: “Do you think a specialist could help us with this problem?” is usually well received.
  4. If you have a life altering problem or are hospitalized more than once for  the same disease a visit to a specialist is certainly reasonable.
  5. If you do go to a specialist make it clear you want your primary care provider kept informed.  Likewise, make sure the primary care provider communicates with the specialist (sends periodic updates) and follows the recommendations primary care actually  requested.

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The Culture of Quality – Priceless

There is no question that health care costs money.   But like anything we purchase we would like to get a quality product.  All the States in America pay for health care and to some extent are responsible for the quality of care in each State.  Control over quality is exerted through licensing and through medical and pharmacy boards.  Management of the Medicaid program is very directly the responsibility of the State.  How well do the States provide quality health care?  The chart below shows quality and cost rankings of the States.  The casual observer would conclude: the more money spent on health care the worse the quality.  Does money corrupt health care or is there some other answer?

Quality and Cost Rankings of States

The New England Journal of Medicine reports a reduction in death rate in States where Medicaid has been expanded.  This seems contrary to the previous data.  The more money spent by expanding Medicaid improves quality.   So does money corrupt or cure quality?

The answer to the previous question is simple:  it depends on management.  An effort to follow evidence based quality guidelines is usually rewarded with lower cost (see the example of asthma).   It does no good to stay within budget but fail to deliver quality (money “down the drain”).  The expanded Medicaid programs were showing better management and higher quality than some other State medical programs.

Sometimes, even with the best of intentions, health care money is wasted and poor quality results.  Dr. Donald Berwick, previously the head of the US Department of Health and Human Services, commented on the 5 main causes of waste in health care:

  1.  overtreatment of patients
  2. the failure to coordinate care
  3. the administrative complexity of the health care system
  4. burdensome rules
  5. fraud

Connecting the dots:

If a State contracts for a highway project there are engineering based  specifications on the final product.  Failure to have specifications for a highway leads to a bumpy road.   Failure to adequately specify evidence based health care  leads to waste, high cost and low quality.

The culture of health care in some states is collaborative and quality driven, and in other states the culture  is competitive and profit driven.  The Midwest tends to be the former (see the chart at the top).  The outcome for patients is better in a collaborative and quality driven environment.  Not just anybody can lead a health care organization.  The ability to build a culture of quality is essential for a government administrator or  a health care CEO.

The cost of US health care is about $8000 per person per year.   Other advanced countries achieve higher quality at a cost less than $5000 per person per year.   Excessive health care waste (Chalice, Robert. Improving healthcare using Toyota lean production methods : 46 steps for improvement — 2nd ed. Page 21) accounts for at least 30% of the cost of US healthcare.  The US must attack the problem of waste to reduce overall cost and at the same time foster a national culture of health care quality so all the States have similar high quality levels.

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