Pay for Performance: Peril for Patients

I’ve written before of the perverse incentives created by the price-fixed healthcare insurance model which reimburses every doctor the same fee for each service provided, promoting quantity rather than quality.  Recently, policy makers and insurance companies have noticed this problem too (over 30 years after they caused it).  They are slowly realizing that they are paying doctors to treat as many patients as they can, but not to treat them well.

There is now a major drive by policy makers for state and federal health systems and by private insurers do develop criteria by which to measure the quality of care that is delivered and to base payments to physicians and to hospitals on these measurements.  The various plans are called “pay for performance”.

Wednesday’s Wall Street Journal featured an op-ed by Dr. Jerome Groopman and Dr. Pamela Hartzband, faculty members of Harvard Medical School, who explain the terrible consequences of Massachusetts’s “pay for performance” programs.  Doctors are publicly scolded for failing to meet arcane criteria.  Rigid guidelines are inappropriately applied to complex patients.  Recommendations that are out-of-date are used to measure physician performance and to determine reimbursement.  The op-ed argues powerfully that these efforts are harmful to patients.  I urge you to read the op-ed (link below) for a frightening look at the growing medical bureaucracy.

The underlying assumption that prompts these misguided efforts to measure medical quality is that healthcare is too complex a field for the patient to figure out.  How can someone with no medical training possibly be a sophisticated healthcare consumer?  And if she can’t, shouldn’t we have policy makers define and demand quality for her?

But this assumption is false.  Savvy consumers shop for products and services all the time despite the fact that they don’t have specialized training in that field, and some of these products are far more complex than healthcare.  Customers with no technical knowledge can be very discriminating shoppers.  We buy cars, video game consoles and computers and hire architects and lawyers without a detailed understanding of the product or service we’re receiving.  How?  By using well-established markers of quality that don’t rely on expertise.  We read reviews; we look for businesses with long traditions in the same location and widespread positive reputations; we look for objective certifications of high quality.

Similarly, in healthcare, savvy patients insist on a physician who is board certified.  They check for complaints against a doctor’s license.  They ask for hospital and university affiliations, knowing that elite institutions will exercise some scrutiny over their staff.  Since patients have no way to test a doctor’s training directly, they expect ongoing education (and preferably teaching) as evidence of current knowledge.

In every other marketplace it’s the customer who pays for performance.  Excellence and affordability will be restored to healthcare when patients are allowed to keep and spend their own healthcare dollars and shop around.

Learn more:

Wall Street Journal opinion article: Why ‘Quality’ Care Is Dangerous

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Staying Healthy Abroad

or, Malaria Makes a Bad Souvenir
or, I Went on Safari and all I Got Was Hepatitis A

We Americans take for granted much of what keeps us healthy.  We expect our food and water to be uncontaminated.  We expect the neighbor’s dog to have had all his shots.  We expect that if we get sick we will receive prompt and excellent care.  Then, when we travel to the developing world, we forget that none of our expectations apply.  We plan our itinerary, our meals, even our web access, but we forget to plan for our health.

But staying healthy abroad requires planning.  Some of the required vaccines take a month to be effective.  So see your doctor at least a month before you travel.  Before the visit review the Centers for Disease Control recommendations at their Traveler’s Health website (link below).  The website allows you to enter your destination and then gives you up-to-date recommendations for vaccinations, preventive medications and other precautions for that part of the world.  Besides recommendations for your physician, the website has very important recommendation for you, such as how to avoid mosquito bites, reminders to avoid pets (that cute puppy may have rabies!), and advice for avoiding contaminated food and water.

If you take prescription medications, make sure you have enough with you for the whole trip.  (I’m happy to fax a prescription to Tanzania for you, but I’m not sure where the great pharmacies are.  By “great”, I mean pharmacies with a fax machine.)  Since travelers and their checked luggage occasionally get separated, essential medications should be in your carry-on luggage.

So please remember, jaundice and fever do not make for happy leisure time.  Plan ahead to make your vacation memorable and healthy.

Learn more:

The Centers for Disease Control and Prevention Traveler’s Health website

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How to Break an Already Dysfunctional Marketplace

I haven’t made it a secret in these posts that I’m a big fan of electronic health records (EHRs).  I think they improve patient care, and I think that paper medical charts will eventually go the way of the vinyl LP.  (For those of you born after 1980, I’m referring to an archaic music recording medium.  Yes, even more archaic than the CD.)

I’ve also written before about the very slow rate of adoption of EHRs by physicians.  Well, it turns out hospitals are no better.  A study in this week’s New England Journal of Medicine surveyed American hospitals for their use of EHRs.  The results were underwhelming.  Fewer than 2% of U.S. hospitals have electronic records in all clinical units.  Another 7.6% of hospitals have EHR in some units and not in others.

The barrier most frequently cited by hospitals for EHR adoption was, not surprisingly, the same barrier physicians cited: cost.  EHRs cost money, and in a marketplace which reimburses for quantity, not quality, who is going to make a major investment in better patient care?  Insurance companies pay a fixed price for each service provided, whether the outcome is fantastic or marginal, whether the patient is delighted or frustrated.  The financial incentive in such a market is to increase quantity as much as possible and to provide quality that is only good enough to avoid lawsuits.

Policy wonks and politicians (in both the current and previous administrations) hope to solve this problem by government subsidies for EHR adoption.  An article in yesterday’s Wall Street Journal cites a Congressional Budget Office estimate that over $20 billion will be spent by the federal government on health-information technology between 2011 and 2015.  EHR companies are naturally delighted as it will increase their revenue enormously.  Most physicians and hospitals won’t object either, since they will be handed a valuable tool at taxpayer expense.

I think patients (not to mention taxpayers) should be more skeptical.  First of all, the price of EHRs will skyrocket if they are subsidized.  (See the price of healthcare after Medicare was enacted.)  Second, there is little reason to believe that those who are handed a “free” EHR will use it as productively as those who invested their own resources to buy it.  After all, those who see the most value in it have already voted with their dollars; those who see the least value in it will require the largest subsidy to buy in.  So the cost will inevitably be greater than expected and the benefits to patients much less.

CDs replaced LPs because music fans were willing to pay a few more dollars for better music.  EHRs will inevitably replace paper charts.  But it will happen when patients (not insurance companies or government) are allowed to pay a little more for better care.

Learn more:

Wall Street Journal article: U.S. Hospitals Slow to Adopt E-Records

New England Journal of Medicine study: Use of Electronic Health Records in U.S. Hospitals

My previous post on EHRs: Only 4% of American Physicians Have Electronic Health Records

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Screening for Prostate Cancer May Harm More than Help

About 20 years ago a blood test called prostate specific antigen (PSA) was developed with the hope that it would help in the diagnosis of prostate cancer.  Since then, countless healthy men have been tested for prostate cancer with a PSA and a digital rectal exam despite the fact that there has never been convincing evidence that diagnosing prostate cancer saves lives.

The reason for the controversy about prostate cancer screening is that prostate cancer is a very slowly growing cancer which usually takes a decade or longer to be life-threatening.  Prostate cancer also occurs in older men.  So many cases of prostate cancer never cause symptoms and do not shorten lifespan.  The treatments for prostate cancer, on the other hand, can involve serious and permanent side effects, including urinary incontinence and erectile dysfunction.

The most important question about prostate cancer screening has always been does it save any lives?  And if it does, is it worth putting men through potentially harmful treatment now for the possibility that we’re saving their lives 10 years from now?

Two studies released this week in the New England Journal of Medicine unfortunately don’t help clear the fog, and have generated much media attention.  (See links below.)  The first study was a randomized trial in the US which showed that prostate cancer screening did not prevent any deaths from prostate cancer.  This study, however, had some serious methodological flaws.

The second study randomized over 100,000 men in Europe into two groups: one which received periodic prostate cancer screening, and one which did not.  The results showed a tiny mortality advantage 9 years after being screened.  There was one life saved for every 1410 men screened for prostate cancer and for every 48 men treated for prostate cancer.  That’s not a very compelling benefit.  It means that 47 men are harmed by prostate cancer treatment for every life saved and that screening an individual has a smaller than 0.1% chance of helping him.  Given this tiny benefit, it’s difficult to say if more harm was done than good.

The US Preventive Services Task Force states that the evidence is insufficient to recommend for or against screening for prostate cancer in men age 50 to 75.  It recommends against screening men older than 75.  For men between 50 and 75 that still means a discussion with their physicians about the possible risks and uncertain benefits of screening, and then making a personal decision without much scientific guidance.

Learn more:

NY Times editorial:  The Prostate Cancer Muddle

LA Times article:  Studies cast doubt on prostate cancer screenings

The US Preventive Services Task Force recommendations regarding prostate cancer screening

The two New England Journal of Medicine articles: Mortality Results from a Randomized Prostate-Cancer Screening Trial and Screening and Prostate-Cancer Mortality in a Randomized European Study

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The Challenge of Sobriety

Three weeks ago I wrote about the difficulty of quitting smoking.  This week I’m writing about an even harder habit to break – problem drinking.

Our understanding of alcohol use and abuse is evolving.  Alcoholism or alcohol abuse is defined as continued alcohol drinking despite negative consequences, whether those negative consequences are to one’s work, relationships or health.  Alcohol abuse happens to different people at different quantities of drinking, so the amount of drinking was never the focus.  It was the fact that drinking continued despite bad consequences.

A valuable article in the Wall Street Journal this week reviews the change in thinking about alcohol abuse and points to a useful new website for patients from the National Institute on Alcohol Abuse and Alcoholism (NIAAA).  We now know that even without adverse consequences, people who drink more are at much higher risk of progressing to alcoholism that those who don’t.

The NIAAA definition of low-risk drinking for men is 14 or fewer drinks per week and 4 or fewer drinks on any day.  For women it’s 7 or fewer drinks per week and 3 or fewer drinks on any day.  For men and women over 65, low-risk drinking is defined as no more than 1 drink daily.  For other groups of people, including patients taking medications that interact with alcohol, pregnant women, and patients with liver disease or heart disease, complete abstinence is recommended.  Only about 2% of low-risk drinkers go on to alcohol abuse.  Those who exceed either the daily or weekly definitions of low-risk drinking have a 20% chance of developing alcohol abuse.  And 50% of those who exceed both the daily and weekly limits develop alcoholism.

If you’re curious about whether or not you should drink less, I urge you to follow the link below to the NIAAA website and enter your drinking pattern.  It’s completely anonymous, so it’s a safe way to see how you compare with the general public and what risk your drinking pattern poses.  You’re the only one who can decide whether or not to make a change.  The NIAAA website is just an educational place to start.

Learn more:

Website from the National Institute on Alcohol Abuse and Alcoholism:  Rethinking Drinking

Wall Street Journal article:  To Your Health: New Web Site Helps Predict Alcohol Problems

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Everyone March to Your Colonoscopy

I don’t know about you, but whenever I think of March, the first thought that springs to mind is National Colorectal Cancer Awareness Month.

Patients frequently ask me to be tested for whichever cancer they are particularly anxious about.  “Is there a test to make sure I don’t have early ovarian cancer?”  “Pancreatic cancer?”  “Lymphoma?”  I have to explain that for healthy people without any symptoms, there is no test that has been proven to find these malignancies early or save lives by finding these diseases.  In fact, for most cancers we don’t have accurate screening tests, and for some cancers it’s not even clear that finding the cancer early saves lives.

Colon cancer is a major exception.  There is very solid evidence that testing for colon cancer in healthy people with no symptoms catches colon cancer early and saves lives.  That’s why I bug my patients relentlessly about having a screening colonoscopy.

Who should be screened?  Everyone between the ages of 50 and 75, but those with a family history of colon cancer may benefit from earlier screening depending on the details.  And particularly healthy people aged 75 to 85 may benefit from screening as well.  For more details, I encourage you to click on the link to the US Preventive Services Task Force recommendations below.

Screening is usually done by a colonoscopy, and if the colonoscopy is completely normal, it need not be repeated for 10 years.  Though lots of my patients dread their first colonoscopy, they invariably tell me afterwards that it wasn’t that bad.  Anyway, a procedure once a decade in return for a practical guarantee not to die of the second leading cancer killer in the US is a pretty good deal.

I think what National Colorectal Cancer Awareness Month needs is a snappy slogan, like “A Colonoscopy a Decade Keeps the Oncologist Away” or maybe “The Light at the End of the Tunnel is a Colonoscope”.

Learn more:

CDC Features:  March is National Colorectal Cancer Awareness Month

US Preventive Services Task Force recommendations on colorectal cancer screening

US News article:  Colon Screening: 5 Things You Need to Know

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Scientifically Proven Weight Loss Method: Eat Less

Few things captivate the public more than a new diet.  From Atkins to Ornish to the Mediterranean diet, each new theory attracts attention and true-believer adherents and generates lots of book sales and interviews on daytime TV.  People passionately argue about whether a diet low in carbohydrates or low in fat is best for weight loss.  But until now no large trial has ever been done to answer the question.

This week’s New England Journal of Medicine published the largest study that directly compares different diets to measure which yields the greatest weight loss.  Over 800 overweight adults were randomized to one of four different diets.  (Importantly, diabetics were excluded.)  They were all given diets calculated to provide 750 calories fewer than they were burning daily, but the four diets differed in the percentage of calories from fat, protein, and carbohydrates.  Two of the diets were low-fat and two were high-fat.  Two were average-protein and two high-protein.  And the four diets provided a broad range of carbohydrate intake from low to high.

The participants were also asked to participate in periodic group counseling sessions and were instructed to do 90 minutes of moderate exercise per week.  They were followed for 2 years and their compliance with group attendance, diet and exercise was tracked.

Interestingly, the four diet groups lost weight at the same rate.  Six months into the study the participants lost an average of 13 lb, 7% of their body weight.  After that, on average, they slowly regained weight, so that by two years the average weight loss was 9 lb, the same in all four groups.

So diet and exercise lead to weight loss, and whichever low-calorie diet you can stick to is as good as any other.  So get started.  You can still buy the latest diet book and swear that it’s the best because your favorite actor lost weight on it.  Only you and I will know that you owe your success to the New England Journal of Medicine.

Learn more:

New England Journal of Medicine article:  Comparison of Weight-Loss Diets with Different Compositions of Fat, Protein, and Carbohydrates

NY Times article:  Study Zeroes In on Calories, Not Diet, for Loss

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Mind if I Don’t Smoke?

Quitting smoking is probably the hardest thing I ask my patients to do.  (Losing weight is probably the second hardest.)  Smoking is a profound addiction.  Smoking feels good, and countless smokers have told me the calming pleasure they get from a cigarette.

Despite the health risks and financial costs associated with smoking, medications aimed at helping smokers quit have been only modestly successful.  A very helpful article in Monday’s Los Angeles Times reviews the medications available to assist in quitting smoking.  If you smoke, I urge you to read it.  (See the link below.)

The oldest quitting aid is nicotine replacement.  Nicotine is available over-the-counter as a patch, gum, lozenge or inhaler and has long been known to help some smokers kick the habit.  There is some new information that makes nicotine replacement even more effective.  It was previously thought that smoking while using nicotine replacement (for example smoking while wearing a nicotine patch) was very dangerous.  It turns out to be quite safe (or no more dangerous than just smoking).  The reason this option is helpful is that new studies show that many smokers prefer to quit slowly, by gradually decreasing the number of cigarettes smoked.  So smokers can now use nicotine replacement during the slow weaning period rather than have to quit smoking abruptly.  A recent study in the American Journal of Preventive Medicine showed that for smokers gradually decreasing their cigarette use over an 8 week period, nicotine gum during that time led to more successful tobacco abstinence than placebo gum.

There are also newer prescription medicines for tobacco cessation.  Zyban (buproprion) is the same medicine as the antidepressant Wellbutrin.  Studies have shown that it helps smokers quit more than placebo.  Like all antidepressants it can have some side effects.  The newest option for smokers is Chantix (varenicline) which I wrote about when it became available in 2006.  Chantix, however, is plagued by new reports of psychological side effects, like depression.

The bottom line is that neither of these medicines is spectacularly effective.  In the studies proving their effectiveness, most smokers in both the placebo and medication group went back to smoking, but the medication group did better than the placebo group.  So you have to be determined, and you have to try more than once to finally quit successfully.

If you’re a smoker, discuss these options with your doctor, and take a look at the articles below.  2009 may be your year to quit.

Learn more:

Los Angeles Times article: Ready to quit smoking?

American Journal of Preventive Medicine article: Quitting by Gradual Smoking Reduction Using Nicotine Gum: A Randomized Controlled Trial

New England Journal of Medicine article: A Randomized, Controlled Trial of Financial Incentives for Smoking Cessation

My post about Chantix:  Chantix is Modestly Helpful for Quitting Smoking

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Would You Like Some Salmonella With That?

Our modern hyper-efficient means of producing, processing and distributing food has made hunger virtually extinct in the developed world. (In fact obesity is a much more pressing problem.) But our modern food production network is revealing an increasingly dangerous cost. Because food from any one farm or any one plant is frequently distributed nationally or even internationally, contamination with a foodborne infection can sicken thousands before the source is identified.

Two years ago Escherichia coli from contaminated spinach caused a nationwide outbreak. This spring and summer an outbreak of Salmonella traced to contaminated peppers imported from Mexico led to over 200 hospitalizations and 2 deaths. Most recently, in an outbreak that is still ongoing and is receiving heavy media coverage, Salmonella linked to contaminated peanut butter and peanut paste has caused hundreds of hospitalizations and at least 8 deaths.

A perspective article in the New England Journal of Medicine attempts to propose sensible solutions to an increasingly dangerous, expensive, and frequently lethal problem. The author is dismissive of organic back-to-nature fantasies:

To those who believe that the solution is a return to a pastoral, early-20th-century model with millions of small farms producing more “natural” food, I would point out that even if the millions of farm workers who would be required were available to produce food on a quasi-boutique scale, the costs would be enormous; it would be impossible to feed 300 million Americans, let alone the rest of the world. Efficient, industrialized production of huge quantities of food is an inescapable necessity to avoid food shortages and global famine. The challenge is to enhance the quality and safety of industrially produced food.

Instead he proposes improved inspections, information technology for foodborne infection reporting to allow rapid identification of an outbreak, and bar-coding of perishable foods so that the farms and factories that grew and processed the food are immediately identifiable.

He also recommends an idea that I wrote about last summer which would prevent up to a million cases of foodborne illnesses in North America annually. All high-risk food should be irradiated. The only obstacle preventing this is widespread public misunderstanding and fear of irradiation.

Learn more:

Track the latest recalled products on the US FDA Salmonella page

Associated Press article: Texas recalls all items from plant over salmonella

New England Journal of Medicine article: Coming to Grips with Foodborne Infection — Peanut Butter, Peppers, and Nationwide Salmonella Outbreaks

My previous post on food irradiation: Gamma Rays are Good for Your Veggies

Tangential miscellany:

Two extraordinary men were born 200 years ago yesterday. One was Abraham Lincoln. If you haven’t read it recently, take this opportunity to read the Gettysburg Address.

The other man was Charles Darwin. I’ll close with a quote from the last page of his landmark work On the Origin of Species which was published in 1859.

It is interesting to contemplate a tangled bank, clothed with many plants of many kinds, with birds singing on the bushes, with various insects flitting about, and with worms crawling through the damp earth, and to reflect that these elaborately constructed forms, so different from each other, and dependent upon each other in so complex a manner, have all been produced by laws acting around us… Thus, from the war of nature, from famine and death, the most exalted object which we are capable of conceiving, namely, the production of the higher animals, directly follows. There is grandeur in this view of life… that … from so simple a beginning endless forms most beautiful and most wonderful have been, and are being evolved.

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The Flu: Good News, Bad News

The good news about this flu season is that so far, both nationally and in California, it has been a mild one, with a relatively small number of people infected.  The weekly trends are still increasing, so the worst is still ahead of us.

The bad news is that one of the major strains of the flu virus this season is resistant to Tamiflu, the most frequently prescribed and safest anti-flu medicine.  In response, the CDC has issued an Interim Antiviral Guidance statement, which recommends which antivirals should be used this season.  The recommendations are impractically complex, and depend on the availability of rapid testing to identify the strain infecting each patient.

The most practical solution for this flu season is to use Relenza, an inhaled anti-flu medicine that is as effective as Tamiflu and to which this year’s strains are all sensitive.  Relenza should be avoided, however, in patients with asthma or emphysema.  Like Tamiflu, Relenza should be started within the first 48 hours of symptoms.  So if you get a high fever, diffuse aches, and a cough, call your doctor right away.

But the good news is that it’s not too late to get your flu shot.

Learn more:

Track the influenza season in California:  California Influenza Surveillance Project

Tack the influenza season nationally so you can warn Aunt Martha in the Midwest:  Centers for Disease Control Flu Activity and Surveillance

Follow the epidemic on Google which detects flu activity about two weeks earlier than traditional surveillance:  Google Flu Trends

LA Times article:  Tamiflu no longer works for dominant flu strain

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