Sunday, April 27, 2014

Why Your Doctor Doesn’t Work For You

Many doctors are ambivalent about the Affordable Care Act. This is not due to the primary aims of the bill- after all, more people with health insurance means more paying patients, so what’s not to like? Rather, doctors are worried about the other, less publicized pieces of the bill, and related changes to Medicare and Medicaid that have quietly reshaped medicine- and often not for the better.

Over the years, there has been a big push by the government and private insurers to pay for “quality” instead of “quantity”. You may have heard of some of the programs and organizations being set-up as part of this drive: Accountable Care Organizations (ACOs), Patient-Centered Medical Homes (PCMHs), and Value-Based Purchasing (VBP). All these programs have laudable goals: they are trying to pay doctors to keep patients healthy instead of paying them to perform procedures and manage problems. But they frequently backfire, and hurt patients more than help them.

Some background here is essential to understanding how this came about. Healthcare was (and largely still is) structured like so: A patient develops a problem- from the common cold to abdominal pain. They go to see a doctor. That doctor diagnoses what is wrong, and performs certain procedures. The patient’s insurance company pays the doctor based on what procedures were done and how difficult the problems were to diagnose. A 45 minute long visit paid more than a 15 minute one, and a large surgery paid more than antibiotics. As you can imagine, this created something called a “perverse incentive”. Doctors would be paid more for doing more procedures- regardless of whether or not the patient needed them. A minority of doctors responded to this incentives, and performed procedures that weren't always indicated (though typically helped along by unclear science). A prominent example is back surgery. Spine surgeons found that they were paid over $10,000 per back surgery. Consequently, they ended up recommending and doing a lot of them. At the time, doctors didn't know much about back pain- using new MRI imaging techniques they saw broken structures in the back, and thought: if we fix the structures, the pain would go away. This turned to be wrong in most (though not all) cases. But, we only figured this out after hundreds of thousands of people went under the surgeon’s knife unnecessarily. A combination of a bad incentives ($10,000 per spine operated on) and unclear science (thinking that fixing the bones and structures would take away the pain) resulted in a terrible outcome: Medicare and insurance companies spent billions of dollars on a surgery that wasn't useful and often made patients worse.

This problem affected a minority of doctors carrying out a minority of procedures- and they were frequently fixed over time by the profession itself. In this case, science caught up with the surgeries, and most surgeons stopped reflexively recommending the procedure. But, many politicians, academics, and bureaucrats used problems like these to accomplish something that even they didn't intend to do: take away control of a person’s medical care from the individual in consultation with their doctor, and reassign it to the system. How was this done? Through a drive for “quality”.

Let’s go through an example. Suppose a middle-aged man, let’s call him John, lives in New York City and has diabetes. But, John can’t quite kick the habit of picking up a donut whenever he stops into Dunkin Donuts for coffee on the way to work as a stock broker (I certainly wouldn't be able to). This is 1990. The donut (and diet in general) causes the amount of sugar in John’s blood to go up, and over time this causes his heart’s arteries to harden, choking off the blood that keeps his heart pumping. 24 years later, John has coronary artery disease, with damage to his kidneys and liver as well. He can barely get out of bed, can barely move without collapsing from the strain on his heart. Statistically, he will die within the new few months of a heart attack. What now?

Cardiothoracic Surgeons have come up with a way to help John- they can perform a surgery called a Cardiac Artery Bypass Graft (aka a “CABG”, or a “Bypass”). This operation bypasses clogged arteries and gives John’s heart more blood. It is not without risks- there is a significant chance that John can die from the surgery. John, because of the damage to his kidneys and liver, is at especially high risk of not surviving the surgery. However, this chance is far less than the chance that John will die in the next few months of a heart attack. While precise statistics are impossible, let’s say he has a 20% chance of dying during the surgery, and an 80% chance of dying in the next few months. What should John do? I can’t say- the choice is up to John. But most patients opt for the surgery, and the chance of living for years more.

If this had happened in 1990, John would have had the surgery, and probably lived for a decade or more. But this is 2014. In the mid 90s, the government of New York decided that they wanted quality in medicine, and picked Cardiothoracic Surgery as their first target. They decreed that all surgeons and hospitals would receive grades based on how many of their patients survived the operation or experienced complications. This program seemed (and is still touted by New York) as a great success. The number of surgeries dropped sharply, patients who did have the surgery were more likely to survive, and Medicare and New York saved a lot of money. This was high quality medicine!

Except- the gains were illusory. Researchers from Stanford and Northwestern found that the total number of deaths increased. Patients like John would be denied the surgery because they were too sick. They stood such a high chance of dying that no surgeon wanted to operate, and thereby risk lower their grade if John died. Even if a surgeon wanted to do the surgery, the hospital he or she worked at would fire them, so as not to decrease the hospital’s grade. Instead, John would sit at home and die within the next few months- but it wouldn’t count against the grade of the surgeon who said no, or the hospital that threatened the surgeon with a pink slip if they did operate. Were there positive effects? Of course- some unqualified and incompetent surgeons were put out of business. But at the cost of a lot of patients being denied life-saving procedures.

What happened? The drive for quality and publication of grades transformed cardiothoracic medicine in New York. Whereas before surgeons worked for the patients, now they effectively worked for whoever issued the grades- in this case, the government.

This is what is happening in medicine today, only not just in cardiothoracic surgery. Patients like John are being denied tests and procedures, forced to use inferior drugs, and seeing their care worsened because their doctor is being measured and held “accountable” by the government and insurance companies. Doctors are not working for John anymore. The Republicans have raised a great hue and cry about how the Democrats want the government to take over healthcare, and create socialized medicine. They’ve missed the fact that it’s already happened- as part and parcel of the drive for “quality”. Only, it isn't just the government, but rather a myriad of insurance companies, private ratings agencies (ask any doctor, and they will tell you that they would rather make a deal with the devil than be subject to the tyranny of a group called Press-Ganey), and others. Patients lost control of their healthcare long ago.

How do we get it back? How do we change the system to avoid the earlier problem with spine surgeons, but also prevent the horrors of John’s case? Thankfully, modern behavioral psychology has come to the rescue. Professor Dan Ariely is a prominent researcher in the field. His research and the work of many others has shown that using intrinsic motivators is a far safer, and more effective way to motivate healthcare providers than grades and money. In other words, doctors want to help their patients, and harnessing this ‘intrinsic’ drive is a lot better than rating and paying doctors based on criteria that could easily backfire.

How would this work? Imagine a system like this. John from the previous example goes to see a surgeon, let’s call him Dr. Smith, recommended by John’s Primary Care Physician. John has the surgery. Unfortunately, John dies on the operating table. Soon afterward, a meeting is held. Dr. Smith is there, as is John’s primary care physician, perhaps members of John’s family, and many other surgeons and primary care providers. Dr. Smith goes through the case, details exactly what they did. The surgeons present confirm that Dr. Smith’s technique is appropriate. Dr. Smith’s statistics are compiled, and shared in this meeting. It is revealed that the surgeon’s patients die more often than average. However, other primary care physicians speak up. They state that they send their worst patients to Dr. Smith- because they know Dr. Smith trained at Cleveland Clinic (a very prestigious center of cardiothoracic medicine) and is comfortable taking care of very, very sick patients like John. While John died in this instance, he received the very best care possible from an outstanding surgeon. The family (and John’s Primary Care Physician) are all ultimately satisfied that the care John received was good, despite John’s unfortunate death.

Do you see the benefits of this system? There are no direct penalties. Instead, the immense variation in human medicine and outcomes is taken into account, and properly used to evaluate Dr. Smith. Patients like John continue to receive the treatment that they decide upon with their doctor- without grades influencing the decisions made. Are there problems? Of course- starting with the need to pay surgeons and primary care physicians to take a day off and come together to evaluate each other holistically. But the benefits are certainly worth it.

Why not pay for a system like this, with safe, intrinsic motivators? Perhaps because a sound, self-regulating medical profession is not what the politicians want. They want to save money, and to achieve control over notoriously independent doctors. Now, is this what they intend? Of course not- they legitimately want to improve quality, and feel that the only way to do it is to force measurement of quality. But their actions are having effects that they do not intend. Are there problems in medicine? Certainly, and they are vast. But the current methods and tactics are not the answer. These tactics were born in corporate boardrooms, where businessmen were accustomed to measuring everything with numbers, punishing failure and rewarding profits.  They tried to apply the tools they used to build machines to the profession that deals with something infinitely more complex than any machine imaginable- a human being.  The drive for quality is an illusion, masking the reality that vast organizations are now dictating the decisions that should be made by a patient and their doctor.

Profession after profession that deals with humanity in all it's infinite complications is being devastated by this attempt to strangle independence and to measure performance and quality. First they perverted police work.  Then, they attacked education. Now, they've come for medicine.

I'd like to make it clear that I'm not against all forms of measurement/quality improvement- I'm only against unsafe and ineffective ones.  For example, I think measuring handwashing rates in hospitals is fine, as is measuring Central Line and other Hospital Acquired Infection rates (though that has to be properly risk-adjusted to take into account hospitals that see the elderly/the immunocompromised to a far greater degree).

I also have no problem with internal tracking and collection of statistics for the sake of quality improvement.  Kaiser Healthcare does this pretty well- they track rates of CT scans ordered, and if a doctor is significantly over the average they'll have a chat- but won't deny the next scan ordered.  There's no demand from the payer or the public- it's an internal matter.  Kaiser will seek to understand: is this just a function of the location of the hospital in question, or variations in the patient population, or just natural variation over time?  It's holistic review triggered by statistical measurement.