The Infinite Loop

Doctor's can't help fix the health care cost problem because they are kept uninformed about prices or (worse) not allowed to disclose prices to patients or journalists (or health care researchers) once those prices become known to them lest they lose their job.

So, for example, there might be a technology a doctor wants to use to make a diagnosis on one of his patients.

Later he learns that his patient was charged many thousands of dollars for that simple diagnostic test because his patient informs him that the insurance company considered the test "unproven or experimental" and refused to pay for it.

Not only is the charge for the test exorbitant relative to the work required to perform it, but the doctor also learns that every local insurer will not pay for the simpler test he ordered but will pay for an invasive surgical procedure to gather the same exact same data at ten times the cost.

What should the doctor do now?

Should they refer future patients for the diagnostic surgical procedure that pays him and his employer well yet costs the patient very little, or should they do the least invasive and safest test to gather the data knowing their patients will be left with a hefty overpriced bill that will not be covered by their insurer?

For the solution to this problem, I'd refer the reader to the first sentence of this piece.

* * *

In the past when the majority of doctors were independent from large health care systems, doctors could advocate for their patients and move them to other centers that offered cheaper prices or had superior services.  Now it is estimated that nearly 75% of physicians will be employed by hospitals or large health care systems by 2014.  This may sound reasonably benign and irrelevant until patients contemplate what they are trusting their doctors to do.  

If the issue of quality and price transparency are important parts of our health care reform discussion, then another solution for reform than our present construct will have to be developed.

After all, with the passage of our new health care law (and its "accountable care organization" construct), it is becoming crystal clear that we have approved a system that perpetuates the impossibility of doctors serving as true advocates for their patients.

 -Wes

Judgment versus Big Data

Knowledge in Numbers?

Decisions in medicine are supposed to rest on concrete obervations and hard evidence. 

Often, hard evidence does not exist or when it does, it isn't used.  Why is this? 

Concrete observations, too, are increasingly missed as we stare at computer screens longer and patients less.  Yet we persist. Why?

This is our reality now; our evolving medical world.

But if we stop and think about it, medicine, by definition, is a world of technological faults, systemic frailties, and human inadequacies.  We are convinced we know how a patient dies, for instance, thanks to the wonders of unprecedented imaging capabilities but stand slack jawed when an all-too-underperformed autopsy discloses a surprise cause of death that was completely missed by all.

And our answer to these inadequacies?  Stop doing autopsies.  Even though autopsies have consistently shown that one in four deaths occurs from an unexpected outcome or complication of care.

Why did we stop doing them?  Let me count the reasons: we are human, you see.

History repeats. 

Increasingly we are foregoing clinical judgment and intuition in favor of "Big Data" to make decisions.  We construct 70-page Appropriate Use Criteria for ICD documents that cover (really) just a few special clinical circumstances for patients, as if the authors ever really know a patient's clinical circumstance.  Ask yourself how good we are at predicting the day a person will take their last breath?  Like the weather, life is impossible to predict even when you have a billion data points or more.

Big Data and its certainty are our hottest trend in medicine and academics right now.  We know why this is: we love technology.  It is rational.  It is understandable.  It is linear.  We want, desperately, to understand and compartmentalize our human condition, to minimize its variability, so we can ration our resources logically.  But rather than acknowledging the limitation of such an approach, we forge ahead and create logic from dissociated databases with incomplete or empty data fields based on highly-selected patient populations to make our points.  Outliers are considered nothing more than acceptable loss rations.  We manipulate and massage the incomplete or erroneous data using statistics to make our points seem more valid.  Then, like the azithromycin folly, we extrapolate that data and transmit our firmly held beliefs through government agencies to the masses.  We feel good about our myopic analyses and are happy our academic salary was secured for another day.  In return, the importance of medical judgment, experience, and intuition to medicine are cast aside by our fervent belief that trials, databases, and data manipulation are always free from bias and the influence of greed.

More inadequacies.

But in the face of medical uncertainty, what other than judgment and intuition does a physician have - or a patient have, for that matter?  The real patient that sits before us demands an answer where, more likely than not, no real answer exists. Real concrete clinical challenges are rarely represented in a clinical trial or computer database. So we listen. We observe. We review data. Perhaps we get a second opinion. Patient judgment, life experiences, and intuitions are factored, too. Then we decide, together. Medical judgment and intuition are like that: not all luck, not all logic.


But now with Big Data, the new requirement for wellness and fitness is going to be for patients to keep proper symptoms that stay within the lines.  Symptoms and findings must fit new rubrics.  If they don't, your "caregiver" won't know how to treat you, the computer won't know how to treat you, and the rubric won't know how to treat you.  Who are you to say your symptoms are unique? Who are you to deserve a special look?  In the great cattle call of commoditized medicine created by Big Data, who do you think you are?   A liability risk?  Please, stay normative; align your symptoms with Big Data.  And be happy about it, dear patient, because the ends justifies the means.

Ironically, the folly of man has always been that we think we can have all the answers.  Perhaps we should stop for a moment and really think about what we're creating, courtesy of Big Data.

-Wes


 

Need an Expert? There's an App for That!

"Sally, we need an EP consult on Mr. Smith here. He has some trouble walking now due to pain from his multiple myeloma, but he also has a history of a heart attack, left bundle branch block, some non-sustained VT on his telemetry monitor, and is still a pretty young guy..."


"No problem!" said Sally, reaching for her iPhone. "I think there's a app for that!"

She scoured the apps on her iPhone 5. She clicked on her Heart Rhythm Society Sudden Cardiac Death Primary Prevention Protocol app walked through the algorithms there.

"Hmmm. Looks like I need to order an echo," she thought. * Click click * “Echo ordered! Damn I’m good,” thought Sally.

She continued with her Heart Rhythm Society app. "Says something here NYHA Class? I wonder how I figure that out....Wait! I have a MedCalc app for that, too!" A few taps later, "Looks like NYHA Class II!"

"Let's see, back to the Heart Rhythm Society app..."

A few more clicks and...

"Yipee! Looks like he qualifies for one! But wait, will the government pay for it? Let's check the CMS ICD app!"

A few more clicks and then...

"If we wait ninety days... he might get it paid for... but will I be investigated by the DOJ because I ordered it inappropriately? Hmmm. Oh, wait! There's an app for that, too! I can just use the American College of Cardiology Foundation's Appropriateness Use Criteria (AUC) app© ..." she thought to herself, “After all, it covers 369 clinical scenarios… Wait, looks like there’s an update to the app. This is only Version 1.1… I think I'm going to need Version 1.2…”

She left the "AUC app©" and went to the App Store icon on here phone. She waited a few seconds while the screen refreshed and then:

“There it is: the latest update!. Seems those guys update these scenarios every week. Wouldn’t want to be out of date on this.” She clicked the “Update” button. “I sure like how those clever app developers have all he right data I need right here at my fingertips,” she thought.

After it updated, she went back to the American College of Cardiology Foundation’s "AUC app©" on her iPhone and began entering the patient's scenario...

"Wow," she thought. "This is making it so easy for me! There's nothing to this! Hmm, can't seem to find anything in here about multiple myeloma ... Oh, heck, I'll just click on the 'no' button ... There we go, I got a green box! Looks like we'll still be okay to implant his ICD and stay out of jail." She turned to the resident, beaming.

"Well, did you get that EP consult I asked you to get on Mr. Smith?" the resident asked.

"I didn't need to, it looks like he's good to go!" Sally announced.

"Great!" said the resident, impressed with Sally's performance. "So when does the device go in?"

"I'm not sure.  As soon as the next iOS version becomes available I'll check the new software updates." said Sally.

"Awesome.  You think his low grade fever will be a problem?"

"Let me check," said Sally, reaching for her iPhone again...

-Wes

Our Inappropriate Appropriateness Criteria

Ladies and gentleman, if there is any question that clinical judgement has been relegated to the back bowels of medical care, a new breed of healthcare-payment-denial-criteria-for-insurers has been born: so called "appropriateness" criteria for cardiac revascularization.

Actually, it started for cardiac imaging, and somehow, some way, our cardiovascular leadership who cozy up to our well-intensioned-but-clueless legislators on the Hill thought it would be a good idea to (QUICK!) develop even more complicated "appropriateness" criteria for cardiac revascularization!

I mean, what kind of word is "appropriateness?" Shouldn't it just be "appropriate" criteria?

But alas, just as we have seen the invasion of the word "wellness" into our health care lexicon by insurers, so too comes "appropriateness."

As if I can have more "appropriateness" than my other colleagues. Nah-nah-na-nah-nah.

In an absurd and utterly shameful attempt at categorizing every permutation and combination of coronary disease that comes our way and categorize it into three levels of judgments regarding care (Appopriate, Uncertain, and Inappropriate), the authors have succeeded in dispensing with what really matters in treating patients: clinical judgement.

That's right, your "score" will mean more than your judgement. Just get over it.

As if such a scoring system will keep the less-than-honest amongst our ranks from making sure their patient qualifies as "appropriate."

Please, spare me.

But what's really ironic (and telling) is that cardiologists don't need these criteria clinically. We can define if a patient needs revascualization MUCH better than any "score" or table ever could. That's because we can actually see and examine the patient. We can appreciate the myriad of confounding co-morbidities that shape clinically relevant treatment recommendations, like cyanosis, severity of heart failure, pulmonary disease or peripheral access issues.

But that's not good enough for insurers - especially Great Big Governmental Ones that are convinced (and I mean convinced) that Doctors Are The Evil Ones when it comes to cost overruns. Doctors are out to scalp the system, relentlessly. We never have the patients' best interest at heart. It's always about our wallets, right?

Give me a break.

Week after week we sit in cath conferences with our surgical collegues and discuss in great detail not necessarily if an individual needs revascularization, but which form would be more appropriate: bypass or stenting. Do these so called "appropriateness" criteria for revascularization help us with that decision? Not at all!

Really, how "appropriate" is that?

But maybe, just maybe, my keeping these criteria "appropriately" vague and limited to "only" 4000 potential permutions, the authors tacitly achnowledge the limitations of their efforts. Unfortunately, by creating these inappropriate "appropriateness" criteria, they have helped the insurers grant more reasons for denial of payment than they have helped their collegues manage patients. They have virutally guarenteed that in the end, as the ongoing battle between those that deliver care and those that pay for it continue to lock horns, the patient will bear the brunt of the battle and remain the most confused about their obligated portion of their health care bill.

And to me, that's what's really inappropriate.

-Wes