Paid NEJM Subscriptions: There's No Such Thing As A Free Lunch

My hospital system, like many hospital and academic medical centers in America, provides an open-access journal subscription to the New England Journal of Medicine (NEJM) for it's doctors on their private intranet. While I do not know the price of this subscription (I'm sure it's substantial), in the past I have thought it was a nice gesture by our hospital staff to keep doctors current with the latest medical information from the medical journal with the highest impact factor.

Now, I'm not so sure.

New conflict of interests between the NEJM and my hospital have arisen that make me question the wisdom of this policy of free subscriptions provided to doctors, not only our institution, but all other medical centers that offer such an free subscriptions to their medical staff.  As they say, there's no such thing as a free lunch.

Especially when the lunch being served supports tying Maintenance of Certification to maintaining doctors'  hospital privileges.

On 7 April 2014, the New England Journal of Medicine launched their NEJM Knowledge+ website, a product of the NEJM Group, a division of the Massachusetts Medical Society, that breathlessly markets their own costly version of preparing for the ABIM's MOC process to their readership.  A tiny sliver of their exhaustive marketing even promotes the use of their product during the few remaining non-medical hours of a physician's day:

"Whenever you’ve got a moment to lean back and reflect, Internal Medicine Board Review is there with you — whether it’s in line at the supermarket, in the parking lot while waiting for your child’s soccer practice to let out, or during an unplanned minute between patients."

Seriously?

Never is there a mention what NOT passing the ABIM MOC testing means to doctors and their families.   Never is mentioned that since the advent of MOC re-certification, the financial reserves of the ABIM and ABIM Foundation have increased substantially; in 2006 and 2007, the ABIM transferred $13 million to its "foundation."  Never is there a mention that reserves of this magnitude demand accountability to physicians upon which their system has been foisted without any unbiased scientific evidence of its merits.  Never is there a mention of the cozy financial relationship that exists between Area9 Labs (the manufacturer of the NEJM Group's new Knowledge+ website), McGraw-Hill publishing, and the NEJM. Never is mentioned how Area9 distributes and markets the web-based physician learning data it collects on the Knowledge+ website.

Most of all, there is never a mention of the ABIM's unrelenting efforts to link their MOC process to doctors' hospital privileges and their ability to practice their trade - hence where my concern with the conflict of interest exists when hospitals and medical centers purchase the NEJM free of charge for their physicians. Hospitals don't need to buy into this manipulation of their staff.  Almost every medical group has mechanisms to acquire continuing medical education for their staff that are open and not restricted to the ABIM's costs and onorous re-certification process.  By purchasing paid subscriptions to the NEJM, are our hospitals supporting the ABIM's proprietary, self-mandated and scientifically unproven educational process that ties passing a test to the maintenance of hospital privileges?

It is very troubling that the NEJM Group has decided to ally with the ABIM in its MOC efforts.  The ABIM leadership continues to exist under a non-transparent and unethical conflict of interest policy.   The ramifications of the conflicts that existed with former and current members of the ABIM leadership are only now coming to light. This leaves the ABIM's professional credibility seriously in question with physicians.  Is the money that the NEJM Group receives from doctors of all levels of training on their Knowledge+ website worth the damage to their credibility as they ally with the ABIM?

It seems so.  After all, the NEJM seems more concerned about its educational subscription fees than the ethics and scientific integrity of the training process they're promoting.

Because of the clear and present danger that the promotion of the ABIM's MOC process presents to physicians' reputations and their ability to practice sound medicine, I recommend immediate termination of free paid subscriptions to the NEJM for physicians at our institution and others like it until the NEJM Group abandons its support of the ABIM's highly-flawed and manipulative MOC process.

After all, the conflict of interest problems inherent to this cozy institutional arrangement between the ABIM, NEJM Group, and the nation's hospitals far exceed anything that existed when pharmaceutical representatives supplied doctors with free pens.

-Wes

The Physician Payment Reform I'd Like to See

In case you missed it, the "National Commission on Physician Payment Reform" issued their glossy, industry-produced white paper on 4 March 2013 containing twelve recommendations to provide a five-year "blueprint" for transitioning physician payment methods to a "blended payment system that will yield better results for both public and private payers, as well as patients."

Rules Are Only for the Little People

I was alerted to the presence of this report after an "Online First" article entitled "Phasing Out Fee-for-Service Payment" by Steven A. Schroeder, M.D., and William Frist, M.D. for the so-called National Commission on Physician Payment Reform was published March 27, 2013 in the New England Journal of Medicine.  (So much for Journal's Ingelfinger Rule that prevents the publication of works previously published elsewhere.  It is interesting that Dr. Schroeder, the lead author of this New England Journal of Medicine article, failed to disclose that he currently serves as an editor for the New England Journal of Medicine.  No doubt he "exempted" his own piece from the Ingelfinger Rule because this 5-year, 12-step program [pun intended] was felt to be "public-health information that needs to be brought to the public's or profession's attention without delay.")

But the concerns about this article and its authors' backgrounds go much further.  We should realize that this 14-member "National Commission on Physician Payment Reform" was supposedly created out of thin air by an obscure general internal medicine group called the Society of General Internal Medicine (SGIM) comprised of approximately 3000 academic internists. We are led to believe the SGIM doctors chose their 14-member National Commission with physician payment reform solely as their guiding light.  And why not?  What physician wouldn't want to enjoy not being paid for the work they do?

Whose Interests Are Served By Physician Payment Reform?

So let's look at a few of the members of their "National Commission."

First and foremost is the "honorary" commissioner and former US Senator, William H. Frist, MD.  Doctors should ignore Dr. Frist's deep, deep ties to Hospital Corporation of America (HCA), the largest operator of health care facilities in the world.  After all, he only held a few blind trusts that his 2005 financial disclosure form valued between $15 million and $45 million.  And we should ignore the fact that he sold his interests in those trusts just one month before HCA stock price precipitously fell in 2005 and was subject to a SEC investigation.  To be fair, no wrongdoing was ever found.  But that hasn't stopped our "own" Dr. Frist from serving as partner and Chairman of the Board for Cressey and Company, LP, a private investment firm based in Chicago and Nashville "focused on the health care industry."

I'm seeing this effort for physician payment reform as being all about patients, aren't you?

But there's more.

Another member of the 14-member commission is none other than Dr. Troyen A. Brennan.  Dr. Brennan is Executive Vice President and Chief Medical Officer of CVS Caremark, the nation’s largest pharmacy health care company.  In this role, he oversees the company’s MinuteClinic, Accordant Health Care, clinical and medical affairs, and health care strategy.  CVS was so happy about his appointment to this National Commission that it even sent out a press release!  While I have no idea about Dr. Brennan's salary with CVS, I'd bet my medical degree that his salary is higher than that of most US physicians.  One only has to look at the relative salary and benefits that CVS Caremark's Chief Executive Officer earns and you see why I am confident about Dr. Brennan's relative salary.  I mean, who wouldn't want that private jet?  No doubt America's doctors will feel nothing but goodwill and fuzzy feelings about helping to fund the nice retirement package CVS routinely gives to its chairmen as a result of Dr. Brennan's efforts on the Commission.

Another member of the Commission is none other than Dr. Lisa Latts.  Dr. Latts also serves as the Vice President of Public Health Policy for WellPoint, Inc, the largest managed health care, for-profit company in the Blue Cross and Blue Shield Association.  They insure nearly 11% of the US population.  But one could argue, cheap doctors should mean cheaper insurance, right?   I don't think so.  After all, it's not easy to keep paying for retirement packages for your retiring CEO's that cost $20.6 million.  But no worries.  Wellpoint's new CEO's compensation will include just an annual base salary of only $1.25 million with eligibility clauses for an incentive bonus of up to 300% of that amount, not to mention that he is also getting equity-incentive grants for 2013 with an $8 million target value, restricted shares with a grant date fair value of $1.5 million as "an inducement to joining" the company and a "make whole" payment currently estimated at almost $3.6 million for compensation he'll forfeit in switching jobs.   Poor guy. 

So physician payment problems really ARE a major cause of those high health care prices today, doctors, don't you see? 

So let's hear it for the Society of General Internal Medicine and the New England Journal of Medicine for providing their white paper to America on how to implement physician payment reform!  I'm so glad to see that all of the members of the National Commision of Physician Payment Reform were willing to do their part to sacrifice part of their hard-earned salary on behalf of our national health care cost crisis, too, aren't you?

Oh, wait...

A Solution?

Look, here's my idea: stop redirecting the truth about what's really eating up the cost of health care.  It's time we address the excessive costs of all of these excessive middle management healthcare leeches.  If you want physician payment reform, stop creating ridiculous fronts called "National Commissions" of doctors that act has our modern-day Physician Inquisitors.

Instead, pay us what we're each worth (trust me, it's not that hard to find out and it sure as heck doesn't take a year of meetings held at expensive hotels that results in just one white paper with 14 co-authors that carry innumerable conflicts of interest into the discussion.)  Pay us by the hour at our fair rate. And pay us for everything we do for our patients: every minute we type at the computer, answer a health-related e-mail, sit on a phone, sit at their bedside, remove an brain tumor, teach a medical student, look up labs, grow our practice, explain a procedure, or care for your mother after hours, too.  Then pay us double for every minute we take call after hours. 

Dissolve the RUC.  Flush the SGR formula that is never followed anyway and wastes too much time and money each year.  Rid us of stupid proprietary CPT procedure codes that must be linked (properly, mind you) to a ridiculous list of ICD-10 procedure codes so we can be paid.

Keep it simple, stupid. It's not that hard to do.

It's only hard to make changes to our current physician payment system when everyone that wants "physician payment reform" also wants to make sure they get their part of our already dwindling pay.

-Wes

A Million Hearts or A Million Dreams?

Yesterday, Thomas R. Frieden, M.D., M.P.H., and Donald M. Berwick, M.D., M.P.P. used the bulliest of scientific pulpits, the New England Journal of Medicine, to announce their "Million Hearts" initiative aimed at "preventing" heart attacks and strokes.

Now I do not hold a Masters in public health or public policy, but I do know a thing or two about evidenced-based medicine and cardiology. So it seems only appropriate that a cardiologist should comment on the proclamations made by an infectious disease specialist and pediatrician who promise to "save a million hearts," especially when we consider the billions of taxpayer dollars that have been or will be allocated to their programs.

I suspect neither of these highly accomplished men from public policy circles knows if, or exactly how, they will save a million lives nor how they should appropriately measure the effect of their initiative. That is not the point. Sexy program names are the point and making sure those names appear in a scientific journal within reach of treating cardiologists is especially the point.

We should acknowledge that the authors have been very good at dangling statistics of death and destruction caused by heart attacks and stroke to drive their policies. After all, while cardiovascular disease has remained the number one killer of Americans year after year, it is also the biggest driver of health care costs in America. I have no doubt these two non-cardiovascular specialists are proposing their initiative as a straw dog in an effort to gain the public's favor while simultaneously working around the clock to reduce cardiovascular spending. This is, after all, about a money shift, not just about more good ideas for improving cardiovascular outcomes.

How do I know?

I know because you will not hear from these men about the changes underway to limit access to cardiologists by forcing their consolidation with larger health care systems. I know because doctors are scrambling to these systems in an effort per preserve their income in a system intent on cost cutting. I know because government regulators are also working to restrict access to technologies have proven efficacy at saving lives and prolonging life for our older seniors, like wearable defibrillators whose use is being "reconsidered" and percutaneous aortic valves that still wait to gain approval (likely with significant restrictions to their use) here in the US. I also know because even with all the waste, fraud, and abuse measures underway to the cost of health care delivery in America, there will still be a need to cut America's health care system payments by at least 10-20% over the next ten years to maintain the program's fiscal solvency.

So given these overriding needs to cut costs, Americans should expect there are rock-hard data upon which the authors have based their need to start such a "million heart" initiative. Sadly, there are not. In fact, when we dig deeper we find the health care dollars spent on many of the cornerstone programs that serve as the foundations to their theories have lacked sufficient data to even justify their continuation. Yet, they ignore these data.

Let's look closer at the six cornerstone "principles" upon which their "million hearts" initiatives rest:

• Principle 1: Focus - The authors claim that "communication, clinical measurements, reporting by physicians and health care facilities, and health care systems will emphasize improving ABCS (Aspirin therapy administration, Blood pressure management, Cholesterol lowering, and Smoking cessation)." Few data support this claim. In fact, clinical measurement programs, like pay-for-performance measures, have failed to affect outcomes in smaller pilot programs here in the US and in a larger population studies overseas. Despite this, additional money for these programs continues to be promoted by these authors. We should really ask why.
• Principle 2: Health Information Technology (HIT) - The authors claim that "HIT enables providers and facilities to provide cardiovascular care and target intervention to patients in need of intensified care through registries and EHR (electronic health records) functions used at the point of care." While this sounds great, the data so far do not support this assumption when outcomes are actually measured:

  In fact, EMRs (electronic medical records) were associated with significantly improved performance in only one measure — giving diet advice to high-risk adults. They didn’t improve performance in things including giving aspirin for coronary artery disease, depression treatment or blood-pressure measurement.

• Principle #3 - Clinical innovations - The authors claim: Innovations such as team-based care, patient-centered medical homes and interventions to promote adherence will be supported, evaluated, and disseminated rapidly to increase the effective use of ABCS practices." In other words, they haven't figured out if any of these "innovations" actually work. Truth be known, patient-centered medical home pilot projects have been a bit of a disappointment so far. Still, our authors press on absolutely convinced, (convinced I tell you!) that these measures will work despite data to the contrary.
• Principle #4: Policies and programs to reduce smoking and effects of second-hand smoke - This program is likely to be cost-effective. But we should temper our enthusiasm for these efforts now that the anti-smoking message is firmly established in our schools and public consciousness.
• Principle #5: Policies for reducing sodium content of food - While it is one thing to project the number of lives saved from modest sodium restriction in the diet, its an entirely different thing to suggest public policy will change people's individual lifestyle decisions. Good luck getting Americans to restrict sodium to 3 grams per day, especially when people can buy a salt shaker. If Drs. Frieden and Berwick could also impact the farm subsidies for corn that have been criticised as a significant contributor to our current obesity epidemic, they might gain favor with cardiologists, but politics are not likely to permit such a move.
• Principle #6: Policies at eliminating artificial trans fats in the diet - The authors expect to "further reduce the level of trans fats that increase LDL cholesterol levels, lower HDL cholesterol levels that increases the risk of heart attacks." This principle requires the authors to accept the cholesterol theory of reducing heart attacks, but recent studies are debunking that theory. Take the recent high-profile NIH-sponsored AIM-HIGH trial comparing statin to statin plus niacin therapy in patients with cardiovascular disease and low HDL levels. (This study was designed to show that increasing HDL levels with niacin would improve heart attack and stroke outcomes.) This study was stopped 18 months ahead of schedule not only because it was determined to be extremely unlikely that the increase in HDL produced by niacin would improve outcomes, but also because of an unexpected increase in strokes among the patients receiving niacin, a drug known to increase HDL. Support for the results of this study come from earlier trials on non-statin cholesterol lowering medications that lowered cholesterol but never reduced the outcomes of heart attack and stroke. Only statins as a class of drugs have shown such a benefit. So what gives? Doctors are not sure, but it's more about the statins than it is about the cholesterols. Still, such analyses are unimportant to our policy-makers intent on moving their agenda forward. You see it is far better to espouse non-factual takes in the New England Journal of Medicine unencumbered by critical discussion. Worse, given what we now know about elevating HDL levels from the AIM-HIGH trial, their programs could even have a deleterious effect to public health.

Most of the best ideas for improving the public's health will come from those on the front lines of specialized medical care and not those who dictate unproven policy initiatives from a place of theories, inexperience, and assumptions. Like the 90-minute door to balloon time, an idea stemming from the professionals in the field with hard data to suggest its benefit to our patients, these are the initiatives that save real lives.

But we should realize what these feel-good perspective pieces are really about: they're about the money. More specifically, this perspective piece serves as a distraction to the money cuts and a money shifts from real-life proven therapies to mostly unproven, costly initiatives based on dreamy projections of public good rather than actual patient outcomes. As a result, we are now seeing the modus operandi of our government health care leaders of the future: placing feel-good happy-face programs in place based upon mostly unproven, theoretical data in favor of funding more expensive, better-proven therapies that really do save lives.

-Wes

Addendum: John Mandrola, MD offers his more heart-healthy take.

JACC to Appear on the Kindle

This Christmas, I bought my wife, an unmitigated book-lover, a new Kindle 2 from Amazon. While she's a bit of a Luddite when it comes to technology, she has quickly become a believer - uploading three books at a time to bring with her on weekend trips. (She's even one of my three subscribers to this blog on the Kindle!) My only regret is hearing the soft "*click* ... (pause) ... *click*" in bed as she turns electronic pages at bedtime.

While hard copy books will still be great permanent reference sources, the plethora of fast-moving printed journals seem ripe for electronic disruption. I wouldn't be surprised to find that most journals as we know them eventually go the way of the dinosaur. As proof comes this from the ACC:

The Journal of the American College of Cardiology (JACC) will be available on the Amazon Kindle e-book reading device starting this March. JACC is the first cardiovascular journal on the Kindle platform and the second medical journal after the New England Journal of Medicine. Visit the Kindle store on amazon.com beginning on March 12 to order and learn more. Also, bring Kindle to ACC.10 in Atlanta to download the meeting abstracts and final program.

Welcome to the 21st Century!

-Wes

Is There Something in the Water?

I don't know what it is, but it's been ridiculously busy around here. It's like someone put something in the water... Blogging, unfortunately, has suffered. I'll be back as time permits. I realize there's lots of controversy about the Avandia meta-analysis that showed up in the New England Journal of Medicine this week.

Unfortunately, I can offer litle to what's already been said. I only know that if I had submitted a meta-analysis to the New England Journal of Medicine regarding any other drug, it likely would have been summarily rejected due to methological flaws inherent to such studies. While the study certainly raises important questions, it still leaves open the possibility that there might be one or more confounding variables to explain the cardiovascular risks with this drug reported.

But it is also important to realize that people much wiser than me had an opportunity to critically review the study and, perhaps due to the inability of the investigators to acquire the raw ("patient-level") data, felt the implications of the findings were important enough to publish. There can be no denying that the Journal is taking a stand on how to manage patients with heart disease taking this drug. But I question whether these results really required an "Online First" designation (meaning the results were important to disseminate quickly). I could see this if there were a prospective randomized trial sufficiently powered to make a claim about changing treatments, but a meta-analysis as "Online First?" Have we lost our minds?

-Wes

Addendum: 2158PM 23 Mar 07: Some saner minds prevail:

To avoid unnecessary panic among patients, a calmer and more considered approach to the safety of rosiglitazone is needed. Alarmist headlines and confident declarations help nobody.

22:23PM 23 Mar 07: Hmmm... it seems some folks are happy with the way this study was presented. And we wonder why the cost of healthcare is skyrocketing?

Martin Leon, MD the Scapegoat

Poor Marty Leon, MD. Dissed by the New England Journal of Medicine.

I never understand this stuff. Why pick on just him? Oh sure, this was a big "no, no" to leak embargoed trial results early, but others hinted at tidbits from this big trial, too. This is not the first time scientific meetings have had to deal with leaks in the age of the internet. Why single him out? What about this from the Wall Street Journal Health Blog at 25 Mar 2007 @ 11:38 PM:

Interventional cardiologists the Health Blog spoke with – including Leon’s colleague Gregg Stone of Columbia University, who ran major Boston Scientific and Abbott Labs stent studies; Donald S. Baim, the chief scientist at Boston Scientific, and Barry F. Uretsky, who co-chairs part of the confab here – echoed this analysis. Hip replacements don’t decrease deaths either, Stone pointed out, but they’re still worth doing in many patients to improve quality of life.

Note that these comments were also made before the COURAGE trial was released. Not that I really care. But should they be reprimanded, too? They were big dogs in this trial, weren't they? Or was the reprimand less about Marty Leon and more about the New England Journal of Medicine?

Maybe the real reason Martin Leon, MD was singled out was another reason: the Journal's impact factor.

Dr. Leon is well known in Cardiology circles. Dr. Leon knows people and industry. He is likeable. When Dr. Leon speaks, people listen. And people write articles. And articles that reference the New England Journal of Medicine are what are needed to increase the Journal's impact factor.

(British Medical Journal - 3/07) The impact factor has become the global currency for a journal's scientific standing and, by implication, of the papers it publishes. Available at the click of a mouse (http://scientific.thomson.com/isi/) from the Institute of Scientific Information and updated every year, the impact factor has three decimal place precision and an impressive range from close to zero to over 30. Some journals delight in flaunting their impact factors, and when the big names such as Nature do this you could be forgiven for believing that the impact factor is both credible and important.

Sadly, this is not the case. Even superficial scratching beneath the hype shows this currency to be so seriously debased that only the naive could attach any value to it. A journal's impact factor is derived as the total number of citations of all its eligible articles (full papers and reviews) published during the previous two years, divided by the total number of eligible articles. The basic assumption that this ratio reflects the journal's scientific quality has been challenged on many counts, including the heavy citation of reviews, self citation, and period of measurement. It doesn't even matter if a paper turns out to be rubbish—or even if the only reason for citing it is to point this out—because all citations count and contribute equally to the journal's impact factor.

And the worst point of all of this, is that the impact factor can be manipulated during a rebuttal process sanctioned by the ISI:

This system of negotiations—or, as (the Institute of Scientific Information) ISI's Ms McVeigh prefers it "discussions or clarifications"—has made journals far more cognisant of how editorial decisions can affect impact factors. As well as monitoring cases in which ISI gets it wrong, editors are using this knowledge to their advantage. By keeping the numbers of scholarly articles as small as possible, journals can maximise their ranking. "Every time you get a number you get people working out how to make it work to their advantage", admits Dr (George)Lundberg (editor of JAMA). Several artefacts can influence a publication's ranking in journal lists. Review articles or letters are generally cited more than research papers, so boosting review content can make journals perform better in the ranking. Inclusion of news articles, editorials, and media reviews that are among articles considered "non-source" by ISI can win a journal citations without increasing the denominator. And journals can, of course, deliberately try to inflate self citations by asking authors to reference papers in their journal.

The need for inflating impact factors in journals that report clinical research cannot be overstated:

There has been a haemorrhage of clinical academic staff from universities during the past 10 years—mirroring the existence of the research assessment exercise—and wide ranging cuts in specialist teaching available in medical schools, with some subjects now completely absent. Professor Rees says 1000 members of staff have been lost from medical schools, most of them clinical researchers. He attributes this damaging decline to the fact that papers reporting laboratory based research get published in journals with generally higher impact factors than their clinical counterparts, so universities selectively return those sorts of papers for departmental evaluations in the research assessment exercise and funding for clinical investigation decreases as a result.

What is clear is that in the age of the internet, print journals, like newspapers, are losing readership. The internet is fast becoming doctors' source for information. So journals are eager to keep up their relevance in such a wired world.

And nothing sells news like bad news - and drives up an impact factor - like the reprimand of one of their own.

-Wes

23 Apr 2007 - Update: It seems others realize that Wall Street always seems to know the results of these trials before they're released:

But Dr. Kaul said doctors talking about the New Orleans incident were more concerned about whether medical companies or Wall Street analysts had been alerted to the medical study’s results well before Dr. Leon’s reported lapse. “It’s very common,” Dr. Kaul said, “to hear rumors that companies are in the know about trial results.”

-Wes