If The Hunger Games Came to Medicine

““A totalitarian state is in effect a theocracy, and its ruling caste, in order to keep its position, has to be thought of as infallible. But since, in practice, no one is infallible, it is frequently necessary to rearrange past events in order to show that this or that mistake was not made, or that this or that imaginary triumph actually happened.”
                                               - George Orwell

* * *

The brushed, steel belly of the scalpel blade pressed down on the orange antibacterial film and released the subcutaneous yellow fat globules surrounded by small beads of red blood.  The movement of his hand was fluid, purposeful, and without hesitation.  The electrocautery pen carefully seared the points where blood appeared.  A retractor was installed to spread the tissues farther apart as he worked quickly to gain access to the tissue plane just above the muscle.  His movements were deft for he knew they were watching.

The Capitol's campaign to ensure perfect outcomes was well underway. They had installed cameras throughout the hospital just four short years before: in the halls, the changing rooms, at the scrub sinks, and in the operating rooms.  The Capitol had discovered that the operating room was like yesterday's boxing ring, or even farther back in the mists, the Coliseum.  In the New World unpredictable events and venues that stirred primitive passions were few - and yet they were longed for as they were feared.  This context explained the popularity of the annual Hunger Games, created as punishment for the destruction of District 13 by a failed patient uprising after the health care financial apocalypse.  Each year, one male and one female physician "tribute" from each of the surrounding twelve Districts were selected by lottery and performance metrics to fight each other to the death. Providing spectators with a window into the drama, and ensuring that drama by creating just the right conditions, gave spectators a sense of aliveness that they barely remembered, and just enough to stimulate fear.  The Games also served as the perfect venue to deflect blame from the Capitol's expedience in sacrificing people for their own avarice.   

The call had come after a full, exhausting day.  The patient had presented to the Emergency Room only two weeks after open heart surgery for coronary disease and to replace his critically-narrowed aortic valve.  The surgeon-tribute wasn’t sure why his conduction system should fail this late after surgery but it didn’t matter; his heart rate had slowed to a dangerous 19 beats per minute. His blood pressure, while low, remained stable.  A quick review of this medication list disclosed the mandatory heart medications that included an anticoagulant for the heart valve and antiplatelet agents for his coronary disease.  No heart rate slowing medication was being used so the Capitol's appropriateness indication to proceed with the procedure was indisputable.  It was also fortunate that the anticoagulant the patient was taking hadn’t thinned his blood too far.   He decided to take him to the operating room directly.  It was 3 am.

Meanwhile, back at the TV studio:  “I tell you, Frank, every year the footage gets better and better!  How did your team know that these untenable circumstances would result in such great late night viewing?  This is so exciting!” 

The call team had been called, but was short-staffed.  Efficiency meant lower cost, fewer people, and longer work hours.  The designated scrub tech had car trouble and would be delayed.  So the other technician and nurse worked feverishly to ready the room.  The call had already been made to the device representative who brought the new pacemaker hardware, but he was barred from entering the operative suite for he was not part of the medical team.  Rules were rules.   The patient, of course, was agitated, gasping for breath.  The doctor worked as fast as possible to establish pacing – the air was tense.

“Are you kidding?  I love seeing this, don’t you?  The nervousness of his voice!  The anxiety!  The skeleton crew at night!  Beautiful!  I’m not sure it gets much better!”

John had no idea why his car wouldn’t start that night (but the spectators did).  He turned the key again and again, only to hear the engine spit in return.  He slammed his hand against the steering wheel, frustrated that he was unable to keep his car tuned for poor weather.  But such concerns were luxuries now that hospital budgets were tight thanks to the Capitol’s Bundled Payments for Care Improvement campaign.  Finding a ride to work became the imperative.  He raced back into the house to wake his wife in a panic, asking her whom he might call to give him a ride – they each knew the consequences of failure.  They called their neighbor and woke him from a sound sleep.  The pressured nature of their voices convinced him to loan them his car and five precious minutes later, he was off to work calling ahead to notify them of the delay.

At the hospital, Chloe answered John's call as she sat behind the monitoring console.  She was one of the best young technicians to graduate from her training school.  Still, her hospital’s equipment was not up to date because maintenance contracts were left to expire in these cost-saving times.  Still, although the software it ran was now several versions old, it still reliably fed data to the Capitol's chargemaster.  She looked down at the dust on the keyboard.  Seeing this, it was clear she couldn’t enter the room to assist because the risk of surgical contamination was too great.

The surgeon-tribute was glad he’d placed two venous sheaths to gain vascular access, rather than just one.   He had successfully placed both pacing wires through the sheaths to the patient’s right atrium, ready to be secured to their appropriate chamber.  But he needed a softer shaping wire – the stylette – to insert into the inner lumen of the pacing wire.  Without the stylette, the pacing wire had the consistency of a well-cooked spaghetti noodle.  With it, he could place the pacing wire to its appropriate chamber.    As he turned, his eyes left the surgical field for just a moment.  He scanned the table crammed with scattered instruments and hesitated briefly as he located the proper stylette. 

A hush fell over the audience as they saw the opening.  They leaned forward in anticipation, reveling in their luck to see such a careless mistake.

John leaned his head in the room to notify them he’d finally arrived and would assist as soon as he could change.  The surgeon smiled, acknowledging his dogged efforts to arrive as quickly as humanly possible.  He turned to the field and shaped  the stylette to the perfect curvature that would allow him to affix the pacing wire to the lower, primary pumping chamber of the patient’s heart.  He focused his blurring vision to place the tiny stylette in the endhole of the pacing lead.   Chloe broke the silence of the moment: “Hey guys, did an electrode fall off?”

The doctor looked up briefly to see atrial P waves dancing across the monitor screen without any corresponding ventricular electrical activity. With that, his worst nightmare was realized.  The patient began posturing on the table, his head thrown back beneath the drapes, his arms slowly but powerfully raising.  The surgeon leaned forward to grab the patient while trying to control the leads, stylette, and surgical wound sterility.  The patient began violently thrashing beneath the drapes, his face turning blue and lips crimson as saliva and exhaled gases mixed into a frothy spraying mess.  He was seizing uncontrollably.  His once steady escape rhythm had chosen this unfortunate moment to stop. 

If the surgeon was expecting help from a sponsor it was unlikely to be forthcoming.  Just yesterday, the tribute's most likely supporter/sponsor, Sylvia, a well-to-do matriarch from the Central District, had noticed an incipient sign of aging on her neck – subtle crepe-like thinning of her skin, this despite her  rigorous adherence to all of the Wellness Initiatives the Capitol had advertised.  She had reason to hate, didn't she? She'd  been failed one too many times.   She remembered sitting with her 65 year old mother gasping for air in one of those infernal assembly-line clinics with the young doctor glancing at the red, flashing "Do Not Admit" guideline on the computer screen as he sent them home with morphine with that flat, dead, passive expression on his face!  He didn't care then and so she wouldn't care now!

Seconds felt like hours as the patient's body slowly twisted sideways.  The nurse did all she could to support his weight and keep him from falling.  The surgeon, too, felt helpless as the powerful frame shook uncontrollably beneath the drape.  The restraints tethered his arms but his involuntary leg movement forced him further sideways.  John felt powerless as he watched from the door.  Finally, he could watch no longer and ran into the room just as the patient fell to the floor.

Four cannon blasts were heard in the distance.  The spectators roared.
 

-Wes

So Much For Paying Me for Keeping You Healthy

Okay, America. Stay healthy. Eat only two thousand calories per day, exercise five times a week, don't smoke, keep your body mass index at an appropriate level and for goodness sakes, don't let me find your hemoglobin A1C over 6.5, ya hear? I demand it.

Okay, Mr. Hospital-Employer, I did my part, now pay me, okay?

What? You won't? What do you mean when you say I haven't DONE anything?

I have just broadcast to the world (via the internet, no less) exactly what I should be doing to keep people healthy. Isn't this payment-for-keeping-people-healthy thing supposed to be our new payment model going forward? We're all in this together, right? You know, one big happy Accountable Care Organization. Accountable for the quality of care we provide and for our ability to keep people out of our doors. What's better than preventing illness for lowering our costs to the health care system?

What's that you say?

What do you mean I have to work nights and weekends now? I've been your stalwart foot-soldier! I've done everything our administrative directors and the government has asked me to do: click questionnaires, completed my charts, looked at patients in the eye when I care for them, even went above and beyond to blast sincere public service announcements on your behalf!

What's that? They're getting sick anyway?

No way. They can't! They've done everything right! They've followed my every message! People don't just get cancer! We can STOP that, darn it. Maybe we can issue a few more sincere press releases and policy ideas...

Yes, sir. Sorry, sir. I'll try to do better. No problem going to another hospital that you bought. Really. No that's fine. What's a few more RVU's, right? Yes, sir, I understand.

* pause * (Reaching for his cell phone)

"Honey, I'm going to be a bit late tonight. Looks like I have to see a few more consults..."

-Wes

What Quality Means Now: Checkboxes

With the news that Wellpoint, one of the largest insurance companies in America, will cut off annual 8% payment increases to about 1,500 hospitals if they fail to "test" high enough on 51 quality measures, they have officially defined "quality" health care as checkboxes.

Yep, checkboxes.

You see how do insurers know if we offer each of our patient's nutritional guidance or exercise counseling?

Well, they check to see of doctors have clicked on a yellow warning box advising we do this. If we have, then not only is that doctor a fine, "quality" doctor, but the hospitals (and it's computer system and scores of administrative staff that compile and submit this data) are real, fine, "quality" hospitals.

That's all there is to it.

Never mind if we don't have time to actually perform the counseling.

* click * * check * * click *

Simple as pie. Efficient, too.

Beautiful bureaucratic quality.

Good luck with that.

-Wes

In Comparing Hospitals, What If They're All the Same?

Quality measures. Patient satisfaction surveys. With our new health care reform law, these "performance measures" are the new black in health care.

Hospitals are currently spending, conservatively, tens of millions of dollars to bolster these "performance measures" in hopes of securing a refund of a mere 1% of payments that CMS will soon withhold from them in the name of "assuring" quality improvement.

But what if, nationwide, there wasn't a big difference in these measures between hospitals? What happens then? Might payments then be made on political grounds?

Performance measures have been collected for some time now in anticipation of this new payment initiative by the government, so data exist to evaluate. In fact, Kaiser Health News was nice enough to aggregate the findings from our government's Hospital Compare website for my review.

So I calculated the mean, median and standard deviation of the results of all of this data collected across 50 states and 2 territories and found very little difference in measures collected between states:

MEASURE	Nurses Always Communicated Well	Docs Always Communicated Well	Always Got Help When Needed	Pain Always Well-controlled	Staff Always Explained Medications
Median	76%	80%	65%	70%	61%
Mean	76.06%	80.31%	64.42%	69.29%	60.71%
Std Dev	2.99%	2.84%	4.85%	2.19%	2.89%

MEASURE	Room & Bathroom Always Clean	Always Quiet at Night	Given Info for Recovery	Hospital Rated 9 or 10	Definitely Recommend Hospital
Median	72%	58%	82%	67%	69%
Mean	71.44%	57.67%	82.00%	66.85%	69.25%
Std Dev	3.86%	6.14%	2.95%	4.38%	3.78%

Perhaps most remarkable is the fact that none of these data are skewed (means are virtually identical to the medians) and that there is very little variability (2-6%) between the data sets.

The fact that these data are so similar across states is a testament to the nationwide health care quality that US citizens can currently expect in America.

But these data also lead to a disturbing question: if the data are so similar across every state or territory, will similar findings hold true between hospitals? How is the average Joe or Sally (or Joe or Sally government worker) going to see a meaningful difference in performance measures between states OR hospitals when they show performance differences of as little as ±3%?

The realistic answer?

They can't.

-Wes

Co-Opting the History and Physical Examination

This week, new "performance" guidelines were published for adults with peripheral artery disease (or as one drug company brands it, "PAD.")

Interestingly, in explaining the rationale for these performance measures, these guidelines state:

Despite the overwhelming evidence that patients with PAD are at a markedly increased risk of myocardial infarction, stroke, and death, these patients are often undertreated, in that they do not receive antiplatelet therapy or statins with the same frequency as do patients with coronary artery disease (19).

Thus, these PAD performance measures are directed at strategies to improve diagnosis and treatment of patients with PAD with an overall goal of improving patients' walking distance and speed, improving their quality of life, and decreasing cardiovascular event rates.

And we should add, giving them appropriate pharmachologic and interventional therapy.

Fair enough.

But the guidelines push for the performance of an ankle brachial index, or ABI (a part of a thorough cardiovascular physical examination), in all patients determined on the basis of a questionnaire to be at risk for peripheral vascular disease. And they push hard, with statements simultaneously published the the Journal of the American College of Cardiology, Circulation, and reportedly also later in the Journal of Vascular Nursing, the Journal of Vascular Surgery and the Vascular Medicine Journal. The ABI is nothing more than a calculated ratio of blood pressures of the lower extremety systolic pressure divided by the upper extremity systolic blood pressure. A ratio of 0.9 or less is thought to suggest significant "PAD." To speed measurement of both arms and legs simultaneously, fancy new machines have been developed and costs about $75-110 to have performed by ancillary personnel.

Now don't get me wrong, I do think we can do a better job of detecting and treating peripheral vascular disease, but I have to ask several questions:

First, if "8 million persons in the United States are afflicted with PAD" and "the prevalence of PAD is approximately 12% of the adult population, with men being affected slightly more than women," how much will these screenings cost? Cost and the issues of dealing with false positive findings were part of the reason why screening EKG's were not recommended for all high school athletes in the American Heart Association's earlier guidelines. Should we not have a similar discussion for ABI screening?

Secondly, since when did we allow portions of the history and physical examination to be co-opted into billable procedures by professional organizations interested in promoting "quality care?"

How about a few more minutes in the exam room instead?

This is not just a rhetorical question any longer. Doctors are constantly being pushed by more and more "performance measures" to focus on things that might not have anything to do with the patient's chief complaint. Like bugs to a light, we are re-directed by these performance measures, soon-to-be mandated by Medicare, to direct our thinking away from patients toward the bureaucrats in the name of professional organizations' turf preservation.

Every screening measure amplified by millions of people has the potential to raise costs, not reduce them. And this era of a real need to significantly reduce costs of health care delivery, maybe we should have an honest discussion of the costs of these "performance measures."

-Wes

Health Care Utopia's First Great Challenge

Welcome to Health Care Utopia, young doctor-to-be!

Now that you've completed medical school and post-graduate training, we've decided that you'll be the perfect candidate to join in our government-directed social experiment. You see, we've decided that all doctors straight out of medical training (irrespective of subspecialty) should make the same Perfect Starting Salary of $200,000. No need to fuss over medical specialty, no. We've taken those discussions out of the picture, because irrespective of the speciality you decided to pursue, everyone in Health Care Utopia makes the same starting salary!

Now, to keep it simple, you only have two choices about where to practice after you've completed your training: (1) Socialist Hospital in lovely city of Mount Pleasant or (2) Capitalist Hospital in the thriving city of Prosperity. To keep your decisions simple, every state in the Utopian Union has only these two cities. Also, we mean no offense, but you're just too green-around-the-gills to be subjected to the challenges of private practice and have no money to buy our required electronic medical record that holds the key to all health care payments in Health Care Utopia).

Now, the only difference between the two hospitals in which you will be an employee is their compensation model. These, we have learned, can be very sensitive subjects for our doctor-employees. Since we're not quite sure which model to impose nationally, young doctor, we're going to insist you become part of our Great National Experiment.

So here's the deal: Socialist Hospital pays all their doctors the same amount by pooling all their revenues and dividing them up at the end of the year evenly. This way, everyone is happy. Well, at least at first. If all the doctors work harder each year, we'll pool those earnings for them, divide it up evenly, and everyone makes more money! Isn't that great? No more fuss and muss with productivity bonus earnings here. If everyone keeps working hard, you'll all make a bit more money year after year. If someone is a slacker, well, you all might not get paid more even though YOU worked harder, but hey, this is Socialist Hospital! It's how they work. They'll be able to follow each and every one of your work schedules because they follow our perfect Work Unit measures and eventually fire the slacker-doctor, really they will. Now you might not make as much money as those guys at Capitalist Hospital, but you might have a life outside the hospital here. And you know what's great? I've heard some doctors in this model can even work really hard four days a week and sometimes just take the fifth day off (although some of their colleagues seem a bit perturbed by this, since they have to be at work when you're not).

Capitalist hospital, on the other hand, works on a slightly different model. At Capitalist, the harder you work, the more you'll make, irrespective of what your colleagues do. If you want to make a lot of money, just work harder! The sky's the limit! It's really simple at Capitalist: more Work Units means more money. So if you work really hard, take call as often as you want (even ever other night, if you want), and keep your clinic visits to just 5 minutes instead of seven, you can see more patients and see a TON of income! Be careful not to give too much work to your colleagues, though, or you might not make as much money since they'll earn those Work Unit points instead of you. The challenge at Capitalist will be if you want a life outside the hospital. In that case, your Work Units are likely drop quite a bit, a so too, your salary. I mean, that's the way it goes. But that's how things work at Capitalist Hospital: every man for himself.

So tell me, young doctor-recruit, which will it be?

-Wes

Evaluation Time

This week several evaluation requests from insurers appeared in my mailbox at work. One from UnitedHealthcare and the other from Blue Cross and Blue Shield of Illinois (BCBSIL). No doubt there will be others.

Most doctors I know ignore these surveys. I, for one, have never filled one out. Usually such notices are relegated to the circular file. Maybe a few physicians are brave enought to turf them over to their already overburdened office managers who could care less about such a survey, scribble a response if required, and move on. But no doubt a few well-meaning individuals complete these - and probably say relatively nice things like "my patients never complain" or "my hospital seems pretty good at what they do." More likely they complete them without ANY data before them, like how many of their patients have been denied payment and how long reimbursement rates for services rendered actually took. And even after the survey is completed (and, if lucky, mailed) we are left to wonder, what's riding on these rarely-completed surveys? So I spent a minute looking at them.

UnitedHealthcare wanted me to sign on to a computer with this survey address: http://www.msisurvey.com/H07162a. They gave me a tip about this address:

TIP: Do not enter the survey web address into a search engine or search function on your browser, as it will not find the survey Web site. Use only the Address or Location line located at the top of your web browser window.

Thanks to web-crawlers, I added it in this little tip into my blog to be SURE to correct this problem. I wonder why they want to keep their UNITEDHEALTHCARE SURVEY so secretive in this era of "consumer empowerment" in healthcare? By the way, the server was down when I tried to log in this morning stating:

The system is unavailable at this time, please try again after 6am EST. We appologize for the inconvenience and appreciate your patience.

That was at 7 am CST (8 am EST) today - maybe because the computer clocks are screwed up due to ending Daylight Savings Time today - but I digress.

Here's a sample of the letter from Blue Cross Blue Shield of Illinois:

"The BCBSIL Quality Improvement Plans require measurement of physician satisfaction with procedures for utilization management, referrals (if applicable), appeals, claim payment, continuity and coordination of care, and various services including BCBSIL services and hospital information."

I'm not good at business double-speak. What is "utilization management?" And since when do insurers perform "referrals" or assure "continuity and coordination of care" for a patient? Is it just me or do insurers now think they are "care providers?"

And the cover letter from BCBSIL says something else:

The Hospital Information section, found on the last page of the Satisfaction Surveys, is important to BCBSIL, as results (will be) analyzed for the BCBSIL Annual Hospital Profile. We strongly encourage you to provide feedback on your primary hospital. Responses are only analyzed and presented at the aggregate level. Therefore, all the individual responses are kept strictly confidential.

The questions for the hospital survey include things like scoring the overall quality of the hospital, timeliness of imaging reports, adequacy of the number of nurses, quality of discharge plans, etc. Wow. Not only do I get to care for patients, but I can be Zagat for hospitals, too!

Or am I being asked to be a mole? Are such "hospital quality" questions really because they care about improving quality in hospitals? Or is there another motivation like: "We want to use your less-than-perfect aggregate responses against your hospital during negotiations with them." At least this would be honest and make more sense why these data are so "important." They are, after all, interested most in their bottom line as a business.

But let's not be quite so negative. No doubt the insurers take the three or four responses (not the real number, mind you, but certainly a minority of the total surveys distributed), and show their leadership and stockholders their beneficience in all things insurable. Surely they raise self-congratulatory data up their PR flagpole and to Congress and CMS as justification of their existence.

All from three or four survey responses.

Ah, the beauty (and shame) of healthcare bureaucracy...

-Wes

The Challenges of Measuring Outcomes with Guidelines

In Circulation’s published-before-print edition this week, results of the CRUSADE trial (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the ACC/AHA Guidelines) were published.

This trial compared the care received by patientswas with acute coronary syndromes (unstable angina, non-Q wave myocardial infarctions) admitted to a specialty cardiology service versus a general medical service. Patient characteristics, the use of American College of Cardiology/American Heart Association guidelines class I recommendations, and in-hospital outcomes by the specialty of the primary in-patient service (cardiology versus noncardiology) in patients from 301 tertiary care hospitals were compared. A total of 35 374 patients (63.2%) were primarily cared for by a cardiology service, and these patients had lower-risk clinical characteristics, but they more commonly received acute (<24 hours) medications, invasive cardiac procedures, and discharge medications and lifestyle interventions.

Their findings? While non–ST-segment elevation acute coronary syndrome patients primarily cared for by a cardiology inpatient service more commonly received evidence-based treatments and had a lower risk of mortality, these patients had lower-risk clinical characteristics (healthier patients did better).

This, then, leads to the question, were the improved outcomes an effect of application of guideline-based therapies, or just selection bias (healthier patients were referred to cardiology because they had fewer co-morbidities)? It was impossible to tell by the data collected.

So why is this study important?

Because performance measures (as determined by application of Class I guideline recommendations for the management of acute coronary syndromes), while measurable, were still unable to determine if improved outcomes were from the application of guideline recommendations, or just a matter of the healthier population to whom these guidelines could be applied.

This throws in to doubt the legitimacy of CMS’s pay for performance initiatives using the application of lock-step guidelines to measure outcomes, since these guidelines are applied disproportionately to healthier patients.

-Wes

Image credit.

Proving Our Worth

I just don’t get it.

Here’s how we attempt to control the costs of healthcare in America.

First, we must prove to the medical consumer that we have good healthcare in the US and that Medicare is getting their money’s worth, so we assemble TONS of people in the form of associations including: the American Hospital Association (AHA), Federation of American Hospitals (FAH), Association of American Medical Colleges (AAMC), Centers for Medicare and Medicaid Services (CMS), the Joint Commission, the American Medical Association, the American Nurses Association, the National Association of Children’s Hospitals and Related Organizations, American Association of Retired People, American Federation of Labor and Council of Industrial Organizations, the Consumer-Purchaser Disclosure Project, the Agency for Healthcare Research and Quality, the National Quality Forum, the Blue Cross and Blue Shield Association, the National Business Coalition on Health, General Electric, and the U.S. Chamber of Commerce.

Next, we give them a nice marketing name like the “Hospital Quality Alliance.”

Then, they then make sure the hospitals and care providers know the “74 answers” to the tests that they’ll be tested on.

Next, they collect scads of information on every patient admitted to nearly 5000 hospitals across the country.

They spend countless hours of personnel time, intellectual energy, and human resources.

Then they crunch the data.

They spit this data out on a website paid for by the consumer by tax dollars on yet another government department database owned by the Department of Health and Human Services.

And when they reviewed heart disease care statistics, they only find that 17 centers (0.4%) provided exceptional care and 35 (0.8%) provided “substandard” care. Gratefully, they can now justify to those lackluster performers that they will withhold some of their Medicare reimbursements to them and save the government (and taxpayers) a bit of money.

After all, 99.2% of hospitals, they found, are doing a “good” job (at least when it comes to heart disease) by upholding their measures of “good” care.

So what have we learned?

We have now learned that there are millions and millions and millions of dollars of health care and association resources being expended to collect data that might mean something to 0.8% of the hospitals in America and to a tiny fraction of the medical consumers out there.

And will these data really effect care outcomes? For instance, should the ambulance carrying a person with chest pain bypass a hospital with a poor door-to-balloon time in favor of one that meets the standard? Or might this delay care further? Who will decide?

The real outcome question I’d pose is this: Is all of this retrospective review of health care delivery in America worth its cost to gather and process the data when we find it changes how only 0.8% of the hospitals in America will be reimbursed?

Or might our time, energy, and efforts be better expended improving health care facilities, providing programs for the poor, and taking care of patients?

But then, think of all the administrators who might become unemployed, eh?

-Wes

Doctors' Scarlet Letter: The Big Blue Dot

Today the New York Times reported that there is a wide discrepancy in reimbursement rates of private insurers from hospital to hospital for patients in need of open heart surgery in Pennsylvania. (Medicare rates are relatively fixed and only vary slightly based on geographic location). They based their report on Pennsylvania’s Health Care Cost Containment Council’s report published today.

While the information is interesting and serves as a reasonable overview, it has no “drill down feature” to look a specifics of the data collected. Instead a complicated, obfuscating, and proprietary weighting scheme (see the last page of these technical notes) was used to determine measures such as expected mortality rates. Cardinal Health claims the trademarked Atlas Outcomes™ methodology has been verified, but then they stand to profit from the data, don’t they?

But what was not discussed in the Times report was that physican mortality data was also presented in the Pennylvania report. Simply. Graphically. You see, rather than reporting an actual number or percentage mortality with details to view, various graphics analogous to Consumer Reports methodology were printed representing mortality data: an open circle (better than expected), dotted circle (expected), or Big Blue Dot (higher than expected).

For Pennylvania physicians that performed with in-hospital mortalities higher than their colleagues in 2005, they are branded with this scarlet letter of health care on the report: the Big Blue Dot. It becomes clear that even one of these Blue Dots might spell disaster for future referrals for a physician. But administrators, insurers, and likely patients will praise the simple graphic.

But health care is anything but simple. Just look at the letter one surgeon in Pennsylvania sent in to the Health Care Cost Containment Council in an attempt to explain his higher mortality rate (looks like three of 43 patients put him at the Blue Dot level). These folks were sick! But his explanation, while posted on Pennylvania’s website, did nothing to change his label.

His Big Blue Dot still stands for eternity for the world to view.

So what will happen with this doctor next year? Surely he will hope to avoid the Big Blue Dot again.

And so, this surgeon might hesitate just a bit before offering surgery to complicated patients with multiple medical problems. It’s not because he wants to be mean-spirited. No, it’s just that now he has to manage the risk to his reputation in concert with the risks of the procedure to the patient. Hopefully, by caring for patients who are less sick, his Blue Dot will be revoked next year and his name cleared. And the sick patients? They’ll either be left to fend for themselves medically, or referred to higher volume centers where, perhaps, the risk will be better absorbed.

And if every surgeon does this, there will be no more Blue Dots. Health care will be better, right?

Well, at least the report will look better.

But for the sickest of patients, they may stand to lose.

-Wes

More Benefits of Pay-for-Performance

Here's the performance that pay-for-performance has brought to our patients.

-Wes

Dear Patient: P4P is Here

Dear Mr. and Ms. Patient,

I regret to inform you that I will be spending less time focusing on your heart problem because I have decided to focus on the heart and medical problems that Medicare deems important to assure I get paid. They call this initiative "Pay for Performance (P4P)."

You see they published a list of 74 criteria that will be measured to see if I give good care, so I will get paid appropriately. Fortunatelty for cardiologists, we only have to do four things:

The ACC (American College of Cardiology) is asking cardiologists to report on these Physician Consortium for Performance Improvement (PCPI), National Quality Forum (NQF)-endorsed measures, which include at this time:
• ACE or ARB therapy for heart failure patients with LVSD (left ventricular systolic dysfunction)
• Antiplatelet therapy prescribed for CAD (coronary artery disease) patients
• Beta-blocker therapy prescribed for CAD patients with prior MI (myocardial infarction or heart attack)
• Beta-blocker therapy prescribed for heart failure patients with LVSD

And the specifications for how we should do this providing and documenting good care can be found here (Caution, this pdf file is 181 pages long!).

So, dear patient, I'm sorry if you have pericarditis or heart block. I'm gonna need to focus on my heart attack and heart failure patients a bit more to make sure my office staff can still return your calls.

I hope you understand.

Sincerely,

-Wes

The Dark Side of Pay for Performance

The pay-for-performance nerds are in a tailspin.

Yesterday’s JAMA article, co-authored by Drs. Rachael Werner and Eric Bradlow, compared the World’s Best Hospitals (top “75th percentile”) to Johnny Q Public hospital (bottom 25th) and found that, gee, people die at about the same rate at hospitals in the US. Amazing. But what was beautiful about this study, was the data mining of the data came from The Centers for Medicare and Medicaid Services (CMS)’s own Hospital Compare website. Hospital performance measures that were supposed to ferret out the good boys from the bad boys were found to be crummy measures and only predicted small differences in hospital risk-adjusted mortality rates.

But to the quality nerds that want to use such statistics to form pay incentives for physicians and hospitals, this presents a dilemma. What do you do when everyone does a good job? Or, as the quality nerds would like to say, what do you do everyone in the United States is performing in the same mediocre fashion?

Why, it’s easy! Make more measures! The quality nerds responded:

… Michael Rapp, director of CMS's quality measurement and health assessment group, said the researchers most likely would have found bigger differences between hospitals if they'd examined all 22 quality measures used on Hospital Compare. Finding only slight differences when using a few measures is not surprising, Rapp said.

Whoa there, Mr. Rapp. If I have a heart condition and want to find out about the World’s Best Hospital caring for heart disease, why do I need 21 or more other measures? But I know how you will clarify it for me:

Still, Rapp said he agrees that more quality measures are needed to evaluate hospitals. "CMS is actively working to expand quality measures used on Hospital Compare," Rapp said.

Please, Mr. Rapp, give me more data do I can be even more confused. Give our patients more measure to make this “clear.” If the public can’t figure out Medicare Part D, how the heck are they going to decipher the 22 measures you already have, or 100, 200, or even 1000 measures? Is this how we're going to give “power to the people?”

While carefully-controlled drug trials have demonstrated the effectiveness of aspirin or a beta-blocker therapies at reducing mortality after a heart attack, to suggest that measuring compliance with a medical regimen will translate to improved patient mortality outcomes after heart attack in the uncontrolled real world is a leap. Patients are not homogenously selected like they are for such trials. Every patient is unique and every patient’s problem list different. Medicine is complicated, not cookbook.

When a good researcher stops and wonders why his experiment failed, he gains valuable information to steer him in the right direction to test his next hypothesis. CMS does not seem capable of this. Rather, their answer is to develop still more convoluted “measures” rather than focusing on other, more urgent matters that might save the health care system.

I would suggest that CMS cut costs by focusing stricter guidelines for insurers dealing with Medicare patients by restricting overpaid insurance CEO’s and board members and require liability reform nationwide for any state desiring Medicare or Medicaid funds, rather than leaving the insurance, regulatory and legal interests to cripple our health care system further and price our patients out of the health care market.

You see, measuring performance measures by its very nature has a more sinister side, especially if one gets the evaluation measure wrong. Tacitly stated, measuring “performance” differentials implies one must also measure ”non-performance.” And you might as well call it “incompetence.” Doctors, hospital administrators, and people in general don’t like being called, or even considered, incompetent - especially by a governmental body that demonstrates its own inability to get the measure(s) right.

-Wes

Played for Performance

Pay for Performance: To think our government, legislators, and insurance yahoos want to implement this for Medicare payments to physicians and hospitals. Look what it has come to in England.

Yuck.

-Wes