Is this double dipping? A new bipartisan House bill on oncology reimbursements

Here is another gem from the House of Representatives: a bipartisan bill to increase Medicare reimbursements to community oncology practices. While at first glance this seems like a reasonable idea, this detail is puzzling:

The so-called "prompt pay" legislation excludes certain discounts extended to wholesalers when calculating Medicare reimbursements and is strongly supported by oncologists.

Confused? Met too. Here is how I understand it. Many community oncology practices have set up infusion clinics, where they administer intravenous chemotherapy on site to their patients. To stock these infusion centers they deal with drug manufacturers and distributors to purchase the drugs at wholesale prices. The bigger the buy, the bigger the manufacturer discount. To the best of my knowledge these discounts are proprietary information, guarded like state secrets. Yet despite these discounts, the clinics charge Medicare a premium for the drugs themselves as well as for the service of administering. The way this legislation looks to me is that it will completely eliminate any reduction in reimbursement related to these discounts. Double dipping, anyone?

Now, I have many friends who are oncologists, and this is really not a slur against them. But these infusion clinics have always represented a cash cow for these practices. And who would not want to have a steady source of income to maintain a robust practice and have some money left over for a life? Again, this is not an indictment of community oncology practices. If, however, one takes an external perspective, this bill becomes something of an anathema to improving efficiency of healthcare delivery. If the reimbursement rates for administering these already exorbitantly expensive drugs improve further, will it not become even more difficult for an oncologist to tread the fine line of the conflict of interest between treatment only when it is in the patient's best interest and treatment for income optimization? Again, I want to point out that I am not singling out oncologists, as it is a part of the human condition to rationalize our selfish decisions by putting them in an altruistic light. And given the amount of uncertainty about who might respond to these drugs, it is easy to convince oneself that a trial of a therapy may be a reasonable idea, with the reimbursements providing a nudge in that direction.

A couple of quotes from the sponsors of the legislation are also worth reprinting:

"On any legislation today, you have to find a way to pay for it. And like any legislation, that's an issue with this one," Whitefield said. 

"But to be truthful, because of the oncologist groups and patient groups and others, we think that there may be some provisions in the healthcare bill that passed last year that we may be able to utilize some of those funds for this. All of it's about healthcare, and if we can convince people that this is more important than the others then we can do it."     

On any legislation today? You mean it has not always been like this? I guess we have all gotten used to credit as a life style, and now it is time to pay the piper.

Now, what about this: "Because of the oncologist groups and patients groups and others..."? Are they saying what I think they are saying? That because groups are likely to benefit are saying that this is vital, it is in fact vital? I also have to wonder who those "others" are. Hmmm, I wonder...

And this: "All of it's about healthcare, and if we can convince people that this is more important than others then we can do this." OK, so the statement is so grammatically abominable and non-sensical that I can interpret it any way I like. And it seems to me that they are implying that increasing these already hefty reimbursements is more important than stuff like paying for prenatal care and immunizations to the poor? And other essential services to the Medicare population? Well, if this is not the a poster child for why we need to be articulating the value of healthcare, I do not know what is.  

Why easy is not always good

My mother-in-law is a typesetter. She will not read a book unless it is not only appealing in its content, but also pleasing to the eye. When I was in medical school, she did quite a bit of work for medical textbook publishers. Comparing books typeset by her to what I was grinding through on a daily (and nightly basis) incensed her: unwieldy tables appearing three pages away from the corresponding text, small letters crammed to capacity onto oversized pages, few illustrations -- all baffling, annoying (and easily fixable) transgressions against readability. Yet, like all budding docs of all generations, I plowed through these morasses of knowledge without giving its readability much thought -- this was just what you did to get to your goal.

Yesterday I was listening to a program where the author Amy Chua was interviewed about her (ahem) embattled autobiography Battle Hymn of the Tiger Mother. Ms. Chua, though evenly humored throughout the interview, was on the defensive nearly the entire time, explaining how the intent of her opus has been grossly misunderstood by the public, thanks to attacks by critics on her parenting style. And granted, looking at the book as a parenting manual through the prism of our Western parenting norms is a bit disturbing. Yet putting its events in a culturally appropriate context, as well as looking at the content as a narrative rather than a guide, leads to completely different conclusions.

Why am I bringing up Amy Chua's interview after talking about my conquest of the unreadable? Well, it seems that ease is what we have come to expect from everything. What I mean by this is that not only do we expect easily readable texts, but we also expect people to present themselves in such a way as to make it easy for us to like them. Why else change your appearance through life-threatening eating disorders and grueling surgeries, get coached on how to make friends and influence people, and comment on how unlikable some of our female politicians are? Is this not a triumph of form over substance?

Amy Chua clearly bucks this trend in her book and is paying the price. But what worries me is that we are all paying a price. By creating another false dichotomy of "she is nice" or "he is nasty", we have eschewed a more realistic view of our human foibles. We are all nice sometimes and nasty at others. Yet this dichotomy has proven supremely fruitful to our political discourse, where for 30 years this new reality has been taking root. And it has born fruit, so that now people who do not hold similar opinions to ours are summarily dismissed as "nasty" or idiotic, and we are satisfied to surround ourselves with "nice" like-minded sycophants. How primitive it renders our political and social interactions!

Ms. Chua's immigrant parents' philosophy resonated with my upbringing. Coming from lands of uncertainty and deprivation, as immigrants, our parents subscribed to Maslow's pyramid and taught us that economic security trumped everything else. This is why only certain career choices were acceptable, while others were relegated to the back burner of a hobby. These choices were not about ease, but about doing what we were taught was the right thing. As John Adams said:

I must study Politicks and War that my sons may have liberty to study Mathematicks and Philosophy. My sons ought to study Mathematicks and Philosophy, Geography, natural History, Naval Architecture, navigation, Commerce, and Agriculture, in order to give their Children a right to study Painting, Poetry, Musick, Architecture, Statuary, Tapestry, and Porcelaine.

We all set priorities, and some of them may not be easy. I myself still read books even if they are not all that well presented; my priorities are content and writing style, though, to be sure, I do not frown upon the beauty of the visual form. I even enjoy characters who in, their multidimensionality, are a challenge to like. And I have learned in the rest of my life to enjoy people who do not necessarily hold easy or quick appeal for me, yet in the long run prove to add unimaginable richness to my life. Nietzsche coined the famous quote "What does not break you will make you stronger." In all aspects of our lives, while, based on Nietzsche's statement, adversity is a sufficient but not necessary road to strength, pushing ourselves a little bit out of our stuporous ease may prove to be one timely remedy.

The value of a test

Reading this vintage paper on C diff from the Archives of Pediatric and Adolescent Medicine, I came upon this irresistible conclusion:

Priceless!

Quality or value? A measure for the 21st century

Fascinating, how in the same week two giants of evidence-based medicine have given such divergent views on the future of quality improvement. Here (free subscription required), Donald Berwick, the CMS administrator and founder and former head of the Institute for Healthcare Improvement, emphasizes the need for quality as the strategy for success in our healthcare system. But here, one of the fathers of EBM, Muir Gray, states that quality is so 20th century, and we need instead to shine the light on value. So, who is right?

Well, let's define the terms. The Merriam-Webster dictionary defines quality as "the degree of excellence." The same source tells us that value is "a fair return or equivalent in goods, services or money for something exchanged." To me "value" is a holistic measure of cost for quality, painting a fuller picture of the investment vis-a-vis the returns on this investment. What do I mean by that?

Simply put, the idea behind value is to establish what is a reasonable amount to pay for a unit of quality. Let's take my used 1999 VW Passat as an example. If my mechanic tells me that it needs to have some hoses replaced, and it will cost me under $100, and the car will run perfectly, I will consider that to be a good value. However, if my transmission has fallen out in the middle of Brookline Ave. in Boston (really happened to me once, many years ago and with a different car), and it will cost me $5,000 to fix, I may say that the value proposition is just not there, particularly given that the car itself is worth much less than $5,000. Given that my budget is not unlimited, I have to make trade-off decisions about where to put my money, so I may instead spend the money on another used Passat that has good prospects.    

But in medicine, we routinely avoid thinking about value. There seems to be an overall impression that if it out there on the market, and especially if it is new, it is good and I am worth all of it. This impression is further enabled by the fact that CMS has no statutory power to make decisions based on value of interventions -- they are legislatively mandated to turn a blind eye to the costs. Does this make sense? How toothless is our comparative effectiveness effort likely to be if it has to ignore half of the story?

Let us now look at my favorite sticky wicket, ventilator-associated pneumonia, or VAP. Now, the IHI bundle aimed at eliminating VAP consists of 5 points of intervention: 1). semi-recumbent positioning, 2). daily screen for readiness to get off mechanical ventilation, 3). daily sedation vacation, 4). prophylaxis against GI bleeding, and 5). prevention of clots. As I have mentioned before elsewhere, adherence of 95% to all these measures is deemed compliance and may be ultimately used as a quality measure by payers to determine levels of reimbursement. And while each of these interventions is basically "motherhood and apple pie", applying them blindly and in toto to 95% of intubated patients may be a strategy for disaster. But what is even clearer is that, in order to implement this and all of the other quality improvement strategies, systems need to be put in place that will safeguard against failing to implement these quality measures. The time and resource expenditures needed to institute and maintain these systems, which have not been described in great enough detail as far as I am concerned, have never been quantified. So, what we are left with is a bunch of interventions that, while looking OK individually in clinical trials (until you really start looking at them critically), are likely providing small, if any, gains in quality at the margins, whose investment-return equation has not even been disclosed, let alone balanced. And because budgets are necessarily limited, as are clinicians' time and cognitive capacities, we need to select a sensible menu of interventions from this practically unlimited feast.

This is the quality conundrum, a clear case of chasing our tails to achieve perfection at the expense of good enough. And while no one in their right mind will argue with the language of improved quality in healthcare, I do think that Muir Gray and his camp are on to something that has been a long time coming. At this time of shrinking budgets, competing priorities and tightening resources, does it not make sense to look at value as a package deal, rather than merely at quality in isolation from its context? Instead of being bombarded by ever-increasing volume of quality measures coming from many directions, would it not be more sensible to prioritize these interventions based on the value that they bring rather than merely on their projected outcomes benefits, so frequently estimated based on data that have very little applicability to the real world? Let's start asking the question: how much quality and at what price? Without paying attention to this critical balance, we will not only bankrupt the system, but also worsen outcomes paradoxically, as we continue to overwhelm clinicians with infinite minutia that may or may not be generating helpful outcomes.

So, in my book, Muir Gray: score; Berwick: keep trying.