If you like Healthcare, etc., please consider a donation (button in the right margin) to support development of this content. But just to be clear, it is not tax-deductible, as we do not have a non-profit status. Thank you for your support!
Showing posts with label healthcare policy. Show all posts
Showing posts with label healthcare policy. Show all posts
Friday, September 7, 2012
What does $750 billion in wasted spending look like?
Here is an infographic (I know) from the Institute of Medicine who just released this report. According to it, we are wasting $750 billion annually in unnecessary healthcare costs, and here is the breakdown. Note the ~$250 billion on overdiagnosis and overtreatment. Now,what are we going to do about it?
If you like Healthcare, etc., please consider a donation (button in the right margin) to support development of this content. But just to be clear, it is not tax-deductible, as we do not have a non-profit status. Thank you for your support!
If you like Healthcare, etc., please consider a donation (button in the right margin) to support development of this content. But just to be clear, it is not tax-deductible, as we do not have a non-profit status. Thank you for your support!
Wednesday, July 25, 2012
Medicine as the trolley problem
Are you familiar with the trolley problem? It is an ethics dilemma first formulated by the great Philippa Foot as a part of a series of such dilemmas. Her formulation goes roughly like this. Imagine there is a tram hurtling down a track. If it keeps going straight, it will hit and kill 5 people who are working on that track. The conductor is able to throw a switch and divert the train to another part of the track, where 1 single worker will be killed by the trolley. The question is what should the conductor do? Most people when asked respond that yes, he should throw the switch and sacrifice 1 life to save 5. After all, the net benefit is n=4.
There are literally thousands of alternative formulations of this problem, but one of them from the philosopher Judith Jarvis Thomson merits special consideration. The problem starts out similarly, with 5 lives on a track in potential peril. The vantage point and the solution are quite different, though. Now there is a bridge over the rail track, and a very large man is looking at the tracks from the bridge. One way to stop the train is to throw a heavy object in its path, like this large man, for example. You are on the bridge standing behind the man. Would you be justified in pushing him off the bridge in front of the tram to meet his death in order to spare the 5 workers down the tracks? Most people when faced with this formulation say an emphatic "no." This is somehow puzzling, since the net benefit is the same, n=4, as in the original Foot formulation.
Philosophy professors have puzzled over this difference for decades, and there are several potential explanations for why we respond differently to the two scenarios. One explanation has to do with the proximity of the operator (conductor in the first case and the person doing the pushing in the second) to the sacrificial lamb -- in the first case one is enough removed from the action of killing by merely redirecting the tram, whereas in the second the action is, well, more active, and the operator is actually pushing an innocent person to his death.
Though in some ways the scenarios seem to bear no practical distinction from one another, we see the morals and ethics of each differently. This difference in the view point is instructive to the field of medicine, where it has implications to how policy relates to the individual patient encounter. Here is what I mean.
Suppose you are a policy maker, and you recommend that every woman at age 40 start to receive an annual screening mammogram to reduce deaths from breast cancer. At the population level, if we screen 1,000 women for about 30 years, we will save approximately 8 of them from a breast cancer death. (Yes, it's 8, not 80, and not 800). At the same time, among these 1,000 women, there will be over 2,000 false alarms, and over 150 of these will result in an unnecessary biopsy. Some of these biopsies will incur further complications, though currently we do not seem to have the data to quantify this risk. But what if even one of these biopsies were to lead to death of or another dire lasting complication in a woman who turned out not to have cancer? And by the way the accounting is not all that different when applying the new USPSTF mammography screening recommendations. Well, then we have the trolley problem, don't we? We are potentially sacrificing 1 individual to save 8. And who does the sacrificing is where the variations of the trolley problem come in.
Payers levy financial penalties on primary care physicians when they fail to comply with screening recommendations in their patient panels. The payer certainly sees this issue as the original formulation of the problem: Why not throw this financial switch to achieve net life savings? But for a clinician who deals with the individual patient this may be akin to pushing her over the bridge toward a potentially fatal event. Because we don't have a crystal ball, we cannot say which woman will die or incur a terrible complication. But the same population data that tell us about benefits must also give us pause when reflecting on the risks. Add the ubiquitous uncertainty (and lack of data) into this equation, and the implications are even more shocking. So, while making policy recommendations based on population data is sensible, policing uniform application of these recommendations to individual patients is fraught: of course, clinicians and patients need to be cautious about making individual decisions even when in population data benefits outweigh risks.
On the surface risk-benefit equations for many interventions may appear favorable, leading to blanket policy recommendations to employ them on everyone who qualifies. In the office, the clinician, caught in a tug of war between mountains of new literature and the ever-shrinking appointment times, is hard-pressed to take the time to consider these recommendations in the context of the individual patient. And furthermore, financial incentives from payers act as a short-hand justification, a "nudge," for doing as recommended rather than for giving it thought. So, who must look out for the patient's interest? The patient, that's who. Who understands the patient's attitude toward the risks and the benefits? The patient, that's who. Who now has to be responsible for making the ultimate informed decision about which track to stand on? The patient, that's who.
For me the trolley problem gives clarity to the reservations that I walk around with every day. I have done a lot of soul searching about why it is that, even if the benefits seem to outweigh the risks, I am still more often than not skeptical about whether a particular intervention is right for me. And since every intervention in medicine has a real risk, though mostly quite low, of going terribly awry, my skepticism is justified. This is my approach to evaluating these risks and benefits, based on my values and my understanding of the data as it is today.
What's the answer to this ethical conundrum in medicine? I cannot see that policy makers will stop throwing the switch in the near future, and so as a society we will be forced to accept the tram's collateral damage. And while this may make sense in an area such as vaccination, where thousands of lives can be saved by sacrificing a very few by throwing the switch, in most everyday less clear-cut medical decisions the answer is less clear-cut. Will doctors rebel against being forced to throw some patients on the tracks in order to save some marginally larger number of others? I don't think that they have the time or the energy or the incentive to do this, since the framing of the switch-throwing is through the rhetoric of "evidence." Right or wrong, doctors are shackled by the stigma of ignorance that comes with not following evidence-based guidelines, and this may act to perpetuate blind compliance. This leaves the patients, for some of whom the right thing will be just to get themselves off the tracks altogether, far away from the hurtling trolley until its brakes are fixed.
If you like Healthcare, etc., please consider a donation (button in the right margin) to support development of this content. But just to be clear, it is not tax-deductible, as we do not have a non-profit status. Thank you for your support!
There are literally thousands of alternative formulations of this problem, but one of them from the philosopher Judith Jarvis Thomson merits special consideration. The problem starts out similarly, with 5 lives on a track in potential peril. The vantage point and the solution are quite different, though. Now there is a bridge over the rail track, and a very large man is looking at the tracks from the bridge. One way to stop the train is to throw a heavy object in its path, like this large man, for example. You are on the bridge standing behind the man. Would you be justified in pushing him off the bridge in front of the tram to meet his death in order to spare the 5 workers down the tracks? Most people when faced with this formulation say an emphatic "no." This is somehow puzzling, since the net benefit is the same, n=4, as in the original Foot formulation.
Philosophy professors have puzzled over this difference for decades, and there are several potential explanations for why we respond differently to the two scenarios. One explanation has to do with the proximity of the operator (conductor in the first case and the person doing the pushing in the second) to the sacrificial lamb -- in the first case one is enough removed from the action of killing by merely redirecting the tram, whereas in the second the action is, well, more active, and the operator is actually pushing an innocent person to his death.
Though in some ways the scenarios seem to bear no practical distinction from one another, we see the morals and ethics of each differently. This difference in the view point is instructive to the field of medicine, where it has implications to how policy relates to the individual patient encounter. Here is what I mean.
Suppose you are a policy maker, and you recommend that every woman at age 40 start to receive an annual screening mammogram to reduce deaths from breast cancer. At the population level, if we screen 1,000 women for about 30 years, we will save approximately 8 of them from a breast cancer death. (Yes, it's 8, not 80, and not 800). At the same time, among these 1,000 women, there will be over 2,000 false alarms, and over 150 of these will result in an unnecessary biopsy. Some of these biopsies will incur further complications, though currently we do not seem to have the data to quantify this risk. But what if even one of these biopsies were to lead to death of or another dire lasting complication in a woman who turned out not to have cancer? And by the way the accounting is not all that different when applying the new USPSTF mammography screening recommendations. Well, then we have the trolley problem, don't we? We are potentially sacrificing 1 individual to save 8. And who does the sacrificing is where the variations of the trolley problem come in.
Payers levy financial penalties on primary care physicians when they fail to comply with screening recommendations in their patient panels. The payer certainly sees this issue as the original formulation of the problem: Why not throw this financial switch to achieve net life savings? But for a clinician who deals with the individual patient this may be akin to pushing her over the bridge toward a potentially fatal event. Because we don't have a crystal ball, we cannot say which woman will die or incur a terrible complication. But the same population data that tell us about benefits must also give us pause when reflecting on the risks. Add the ubiquitous uncertainty (and lack of data) into this equation, and the implications are even more shocking. So, while making policy recommendations based on population data is sensible, policing uniform application of these recommendations to individual patients is fraught: of course, clinicians and patients need to be cautious about making individual decisions even when in population data benefits outweigh risks.
On the surface risk-benefit equations for many interventions may appear favorable, leading to blanket policy recommendations to employ them on everyone who qualifies. In the office, the clinician, caught in a tug of war between mountains of new literature and the ever-shrinking appointment times, is hard-pressed to take the time to consider these recommendations in the context of the individual patient. And furthermore, financial incentives from payers act as a short-hand justification, a "nudge," for doing as recommended rather than for giving it thought. So, who must look out for the patient's interest? The patient, that's who. Who understands the patient's attitude toward the risks and the benefits? The patient, that's who. Who now has to be responsible for making the ultimate informed decision about which track to stand on? The patient, that's who.
For me the trolley problem gives clarity to the reservations that I walk around with every day. I have done a lot of soul searching about why it is that, even if the benefits seem to outweigh the risks, I am still more often than not skeptical about whether a particular intervention is right for me. And since every intervention in medicine has a real risk, though mostly quite low, of going terribly awry, my skepticism is justified. This is my approach to evaluating these risks and benefits, based on my values and my understanding of the data as it is today.
What's the answer to this ethical conundrum in medicine? I cannot see that policy makers will stop throwing the switch in the near future, and so as a society we will be forced to accept the tram's collateral damage. And while this may make sense in an area such as vaccination, where thousands of lives can be saved by sacrificing a very few by throwing the switch, in most everyday less clear-cut medical decisions the answer is less clear-cut. Will doctors rebel against being forced to throw some patients on the tracks in order to save some marginally larger number of others? I don't think that they have the time or the energy or the incentive to do this, since the framing of the switch-throwing is through the rhetoric of "evidence." Right or wrong, doctors are shackled by the stigma of ignorance that comes with not following evidence-based guidelines, and this may act to perpetuate blind compliance. This leaves the patients, for some of whom the right thing will be just to get themselves off the tracks altogether, far away from the hurtling trolley until its brakes are fixed.
If you like Healthcare, etc., please consider a donation (button in the right margin) to support development of this content. But just to be clear, it is not tax-deductible, as we do not have a non-profit status. Thank you for your support!
Friday, May 11, 2012
Blind and toothless: The future of middle class in America?
Since it's Friday, we'll steer clear of academic subjects and just tell a story. This is a story of a good friend of mine who works in an editorial position for an interdisciplinary humanities journal. This journal is based at a prestigious private liberal arts institution, and thus she is on staff at that institution. This story is about her, but also about how well the Massachusetts health law is working for people like her. I will call her Jo.
Jo is in her early 50s, a single mom of two lovely teenage boys. Their father who is separated from Jo, although in the picture, does not provide any child support for various reasons. Thus she carries sole financial responsibility for her family.
Well, you say, she is on the journal's editorial staff, she is loaded, right? Nah, surely you are not so naïve as to think that this is a high-paid position at a humanities publication. Let's just say that she is not the 1%; why, she is not even in the top one-half. Would you believe me if I told you that a high-ranking editorial staffer gets a salary that is only 2x above the federal poverty level threshold? So much for those wealthy elite academic East Coast types! But she does get her healthcare insurance through her employer, and this is fortunate, right? Well, here is the rub.
Jo has a complex health condition that affects her entire body, including skin, teeth, eyes, heart, lungs and viscera. Despite this, she is optimistic, upbeat and one of the most patient parents I have ever met. But here is what gets her goat: it is the very fact that she gets her health insurance through her employer! How can this be?
Here is how. The cost of her basic restrictive HMO insurance through her employer is over $5,000 per year. And this flat rate is not affected by the salary level of the employee; in other words, the janitor and the university president get to pay the same amount of money for the same plan. In addition to this, her office visit copay is $20, and her medication co-pays are between $10 and $30 for a month's worth of medication. As you can imagine, for someone with a complicated chronic condition, these co-pays can add up quickly, and they do, to a shocking $2,500 per year. And this is before any allowance for the boys' medical needs or dental or eye care for any of them. Once you add everything up, Jo spends over 1/4 of her entire not-so-stellar income on healthcare. But if we do add dental and eye expenses into the mix (remember, her condition affects these organ systems as well), her healthcare expenditure comes to 40-50% of her annual income! And this is just for draconian restrictions of an HMO! AND, this does not cover all of the time that she spends on the phone finding providers that take her insurance and on schlepping miles away to see that single specialist that the HMO will pay for.
But wait, you say, you live in Massachusetts, the land of socialism, gay marriage and healthcare for all. Why can't she just dump this lousy and expensive employer-provided coverage and go to the Mass Connector, where everyone is equal and all get what they need for what they can pay? And furthermore, you say, isn't the PPACA, the new healthcare law of the land that is fashioned after Romneycare in MA, going to take the choice away from people and MAKE them get insurance through these exchanges rather than through their employers? Jo must be an idiot not to be taking advantage of this communist healthcare state! Hmmm, let's see now.
Jo has had a number of discussions with the staff at the Connector. And yes, you are right in that, if she switched to one of their plans, she would qualify for a plan very similar to her present one for about 1/5 of what she pays now. And the co-pays? Why those would shrink to $0 to $10. How's that for a deal? But here is the catch: According to people she has spoken with at the Connector, a person who has health insurance offered through her employer is not permitted by law to take advantage of the Connector deals if the employer plan offers coverage that meets the minimum standard in the law. And hers does. Ironic, isn't it?
So Jo goes on struggling with the financial burden of her crappy and expensive employer-provided insurance, only now she has to pick and choose: Can she afford to replace her failing dental bridge ($4,700) or should she just choose something so frivolous as feeding her children instead? This is a choice that is not a choice at all, is it? And if these are the choices that we can expect with the PPACA, well, then, we have the law that we deserve: one that will make sure that the investors in the "healthcare" marketplace continue to get handsome returns. But start getting used to people who cannot see their computer screens showing up to work without their teeth!
If you like Healthcare, etc., please consider a donation (button in the right margin) to support development of this content. But just to be clear, it is not tax-deductible, as we do not have a non-profit status. Thank you for your support!
Jo is in her early 50s, a single mom of two lovely teenage boys. Their father who is separated from Jo, although in the picture, does not provide any child support for various reasons. Thus she carries sole financial responsibility for her family.
Well, you say, she is on the journal's editorial staff, she is loaded, right? Nah, surely you are not so naïve as to think that this is a high-paid position at a humanities publication. Let's just say that she is not the 1%; why, she is not even in the top one-half. Would you believe me if I told you that a high-ranking editorial staffer gets a salary that is only 2x above the federal poverty level threshold? So much for those wealthy elite academic East Coast types! But she does get her healthcare insurance through her employer, and this is fortunate, right? Well, here is the rub.
Jo has a complex health condition that affects her entire body, including skin, teeth, eyes, heart, lungs and viscera. Despite this, she is optimistic, upbeat and one of the most patient parents I have ever met. But here is what gets her goat: it is the very fact that she gets her health insurance through her employer! How can this be?
Here is how. The cost of her basic restrictive HMO insurance through her employer is over $5,000 per year. And this flat rate is not affected by the salary level of the employee; in other words, the janitor and the university president get to pay the same amount of money for the same plan. In addition to this, her office visit copay is $20, and her medication co-pays are between $10 and $30 for a month's worth of medication. As you can imagine, for someone with a complicated chronic condition, these co-pays can add up quickly, and they do, to a shocking $2,500 per year. And this is before any allowance for the boys' medical needs or dental or eye care for any of them. Once you add everything up, Jo spends over 1/4 of her entire not-so-stellar income on healthcare. But if we do add dental and eye expenses into the mix (remember, her condition affects these organ systems as well), her healthcare expenditure comes to 40-50% of her annual income! And this is just for draconian restrictions of an HMO! AND, this does not cover all of the time that she spends on the phone finding providers that take her insurance and on schlepping miles away to see that single specialist that the HMO will pay for.
But wait, you say, you live in Massachusetts, the land of socialism, gay marriage and healthcare for all. Why can't she just dump this lousy and expensive employer-provided coverage and go to the Mass Connector, where everyone is equal and all get what they need for what they can pay? And furthermore, you say, isn't the PPACA, the new healthcare law of the land that is fashioned after Romneycare in MA, going to take the choice away from people and MAKE them get insurance through these exchanges rather than through their employers? Jo must be an idiot not to be taking advantage of this communist healthcare state! Hmmm, let's see now.
Jo has had a number of discussions with the staff at the Connector. And yes, you are right in that, if she switched to one of their plans, she would qualify for a plan very similar to her present one for about 1/5 of what she pays now. And the co-pays? Why those would shrink to $0 to $10. How's that for a deal? But here is the catch: According to people she has spoken with at the Connector, a person who has health insurance offered through her employer is not permitted by law to take advantage of the Connector deals if the employer plan offers coverage that meets the minimum standard in the law. And hers does. Ironic, isn't it?
So Jo goes on struggling with the financial burden of her crappy and expensive employer-provided insurance, only now she has to pick and choose: Can she afford to replace her failing dental bridge ($4,700) or should she just choose something so frivolous as feeding her children instead? This is a choice that is not a choice at all, is it? And if these are the choices that we can expect with the PPACA, well, then, we have the law that we deserve: one that will make sure that the investors in the "healthcare" marketplace continue to get handsome returns. But start getting used to people who cannot see their computer screens showing up to work without their teeth!
If you like Healthcare, etc., please consider a donation (button in the right margin) to support development of this content. But just to be clear, it is not tax-deductible, as we do not have a non-profit status. Thank you for your support!
Friday, March 30, 2012
My solution to the healthcare crisis
Here is my talk from Ignite Boston last night -- I solved the healthcare crisis!
If you like Healthcare, etc., please consider a donation (button in the right margin) to support development of this content. But just to be clear, it is not tax-deductible, as we do not have a non-profit status.
Thank you for your support!
Zilberberg igniteboston2012
View more PowerPoint from murzee
If you like Healthcare, etc., please consider a donation (button in the right margin) to support development of this content. But just to be clear, it is not tax-deductible, as we do not have a non-profit status.
Thank you for your support!
Wednesday, March 28, 2012
Why the PPACA hearing is the very definition of insanity
I haven't said much about the SCOTUS hearing of the PPACA, but it is time to break my silence. I have been listening to some of the details of the arguments, and I cannot help but be nauseated. It feels to me like the Justices are behaving like my teen: they take literalness to its absurd limit. Health insurance and cell phones, really? This betrays a complete disregard for probability. What are the chances that you will within your lifetime in the US need to dial 911 in the absence of a landline or another human with a cell phone within shouting distance? And what are the odds that you will at some point in your life require a medical consultation? I rest my case.
The more I think about it, the more convinced I am that the bill should have introduced single payer a priori -- funding our access to medicine through a tax. Yes, a tax. Perhaps the government is not the most efficient agent of this, and the overhaul could have been accomplished through some public-private hybrid model. In the end, as I have said here, our priorities are misaligned, as are our perceptions of what is important in this debate. We spend 97% of all the healthcare money on medicine, and we spend well over 97% of our national discussion about health on access to healthcare and medical interventions, which can only make a 10% difference in our health. The real money, so-to-speak, is in public health, which contributes 60% to our true health and gets only 3% of the expenditures and practically no conversational energy.
So, once again I find myself turning to the wisdom of Albert Einstein, who defined insanity as "doing the same thing over and over again, and expecting different results." The SCOTUS circus is the poster child for this insanity. Whatever the outcome, and I am not at all optimistic about the individual mandate, my sense is that nothing will change until we start paying attention to the root causes of our collective illness.
If you like Healthcare, etc., please consider a donation (button in the right margin) to support development of this content. But just to be clear, it is not tax-deductible, as we do not have a non-profit status.
Thank you for your support!
The more I think about it, the more convinced I am that the bill should have introduced single payer a priori -- funding our access to medicine through a tax. Yes, a tax. Perhaps the government is not the most efficient agent of this, and the overhaul could have been accomplished through some public-private hybrid model. In the end, as I have said here, our priorities are misaligned, as are our perceptions of what is important in this debate. We spend 97% of all the healthcare money on medicine, and we spend well over 97% of our national discussion about health on access to healthcare and medical interventions, which can only make a 10% difference in our health. The real money, so-to-speak, is in public health, which contributes 60% to our true health and gets only 3% of the expenditures and practically no conversational energy.
So, once again I find myself turning to the wisdom of Albert Einstein, who defined insanity as "doing the same thing over and over again, and expecting different results." The SCOTUS circus is the poster child for this insanity. Whatever the outcome, and I am not at all optimistic about the individual mandate, my sense is that nothing will change until we start paying attention to the root causes of our collective illness.
If you like Healthcare, etc., please consider a donation (button in the right margin) to support development of this content. But just to be clear, it is not tax-deductible, as we do not have a non-profit status.
Thank you for your support!
Friday, March 23, 2012
How our healthcare spending is like that drunk joke
You know that joke about the drunk crawling around under a street light? A cop comes up to him and asks what he is doing. The drunk explains that he is looking for his wallet. The cop, getting ready to help the man, asks where exactly he dropped it. The drunk points to a distant corner of the dark side of the street. The cop, baffled, inquires why the man is looking here. With inimitable logic the drunk responds, "This is where the light is."
What does this story have to do with anything? Well, I went to a great HIT tweet-up in Cambridge yesterday, organized by Scratch Marketing and led by Janice McCallum. No, they did not at all remind me of the drunk in the joke. But the lively discussion about data by about two dozen attendees inspired by Janice's thoughtful presentation certainly made me realize that our healthcare policy is like that drunk. Here is what I mean.
So, if the probability of premature death due to a public health-related condition is 60%, why are we only spending 3% of all the healthcare dollars on fixing it? Another way of posing this question is, if the probability of premature death from issues related to access to adequate medical care is 10%, why are we spending 97% of all the NHE on that piece of the pie?
If this isn't just like that joke, I don't know what is. Only in this case it is much less funny than in the case of the drunk.
If you like Healthcare, etc., please consider a donation (button in the right margin) to support development of this content. But just to be clear, it is not tax-deductible, as we do not have a non-profit status.
Thank you for your support!
What does this story have to do with anything? Well, I went to a great HIT tweet-up in Cambridge yesterday, organized by Scratch Marketing and led by Janice McCallum. No, they did not at all remind me of the drunk in the joke. But the lively discussion about data by about two dozen attendees inspired by Janice's thoughtful presentation certainly made me realize that our healthcare policy is like that drunk. Here is what I mean.
Our healthcare expenditures are completely devoid of any attempt at probabilistic thinking. I thought about the old Rand Corporation data, which I have presented here before. Juxtaposing them with the data on our National Healthcare Expenditures really drives home my message that we need to get a whole lot better at applying probabilities to our decisions. And this specifically applies to policy.
Just look at the glaring imbalance: while fully 60% of all premature deaths are due to behavioral, social and environmental factors which reside in the realm of public health, 97% of all NHE is spent on the medical side. If I add the 2% of the total NHE spent on research into the public health piece of the pie (this is exceedingly generous, as public health research gets a bafflingly tiny portion of the total US research budget), we still have 95% spent on personal health and its administration and only 5% on public health.
So, if the probability of premature death due to a public health-related condition is 60%, why are we only spending 3% of all the healthcare dollars on fixing it? Another way of posing this question is, if the probability of premature death from issues related to access to adequate medical care is 10%, why are we spending 97% of all the NHE on that piece of the pie?
If this isn't just like that joke, I don't know what is. Only in this case it is much less funny than in the case of the drunk.
If you like Healthcare, etc., please consider a donation (button in the right margin) to support development of this content. But just to be clear, it is not tax-deductible, as we do not have a non-profit status.
Thank you for your support!
Friday, March 16, 2012
Time to get the goblins out of our healthcare system
Just when you thought you could predict my blog topics, I am going to foil you and not do a post on the rice study in BMJ. I feel like after the last two days with the "meat kills" and "PSA screening saves lives but does not reduce mortality" posts you are not only fed up, but also competent enough to do your own debunking. Let me know if you need any help with that, by the way.
No, in honor of Friday, I will do a fluff post about a show that my family and I are hooked on. Yes, we are addicted to the BBC series "Merlin." Guess what it's about. The new twist is that it is set when both Merlin and Arthur are young men, and it is Merlin's job to keep Prince Arthur from succumbing to his enemies or to his own folly, so that he can lead Camelot forever and ever amen. It has everything you would expect: castles, bloody sword-fight scenes, dragons. Its heroes and villains are an epidemiologist's dream, since they are all evil or all good with nothing in between. It has magic, though that mostly stays in the closet, as Arthur's misguided father King Uther is quite magic-phobic.
Well, last night we witnessed a first in the Episode 3 of Season 3 -- a mischievous goblin got inadvertently released from his lead-lined wooden box and invaded the body of the court physician and Merlin's mentor and friend Gaius. As we all know, of course, goblins are hungry for gold (almost literally -- you'll have to watch the episode). Normally a caring and reasonable man, the pillar of his community, the elderly physician became a raucous and self-centered party animal in search of gold coins at all costs, so-to-speak. In one scene while making a house call to a sick peasant he indicated that the man would die without the potion that Gaius was holding in his hands. Yet he would not part with the potion unless the sick man and his wife produced a gold coin as payment. "But we are so poor," the family explained, " and you have never charged us before." Well, the new and improved market-driven Gaius could not be swayed, and the family ended up giving up their meager wealth to "cure" the husband, who incidentally was merely suffering from a broken rib.
In the next scene, in his continued search for gold coins, Gaius-come-goblin is accosted by Guinevere (in this version she is merely a servant to Lady Morgana -- long story), who is suffering from some ill-defined but clearly innocuous symptom. He takes this opportunity to sell her a potion without which he claims she will succumb to the deadly infection that is gripping Camelot. And despite her obvious skepticism, she is so driven by the fear of the "what if," that she hands over her coin for the tonic and peace of mind.
If all of this seems familiar, but you just can't put your finger on how, I'll give you a hint: our US healthcare "system." It's like there is a goblin in it, who in his relentless pursuit of gold is bankrupting the nation and disease-mongering to increase profit. Of course this allegory has no nuance, and why should it: this is after all a TV series about a magical medieval kingdom whose name itself has come to mean "utopia." Yet it is jarring to realize just how close to our reality this story is.
I am sure you are all anxious to find out how the episode ended. Did the peasant survive? Was Gaius able to regain his body? Did the goblin get back into his box? For answers to all these questions you can go to Netflix. As for our healthcare system, isn't it time we chased the goblins out?
No, in honor of Friday, I will do a fluff post about a show that my family and I are hooked on. Yes, we are addicted to the BBC series "Merlin." Guess what it's about. The new twist is that it is set when both Merlin and Arthur are young men, and it is Merlin's job to keep Prince Arthur from succumbing to his enemies or to his own folly, so that he can lead Camelot forever and ever amen. It has everything you would expect: castles, bloody sword-fight scenes, dragons. Its heroes and villains are an epidemiologist's dream, since they are all evil or all good with nothing in between. It has magic, though that mostly stays in the closet, as Arthur's misguided father King Uther is quite magic-phobic.
Well, last night we witnessed a first in the Episode 3 of Season 3 -- a mischievous goblin got inadvertently released from his lead-lined wooden box and invaded the body of the court physician and Merlin's mentor and friend Gaius. As we all know, of course, goblins are hungry for gold (almost literally -- you'll have to watch the episode). Normally a caring and reasonable man, the pillar of his community, the elderly physician became a raucous and self-centered party animal in search of gold coins at all costs, so-to-speak. In one scene while making a house call to a sick peasant he indicated that the man would die without the potion that Gaius was holding in his hands. Yet he would not part with the potion unless the sick man and his wife produced a gold coin as payment. "But we are so poor," the family explained, " and you have never charged us before." Well, the new and improved market-driven Gaius could not be swayed, and the family ended up giving up their meager wealth to "cure" the husband, who incidentally was merely suffering from a broken rib.
In the next scene, in his continued search for gold coins, Gaius-come-goblin is accosted by Guinevere (in this version she is merely a servant to Lady Morgana -- long story), who is suffering from some ill-defined but clearly innocuous symptom. He takes this opportunity to sell her a potion without which he claims she will succumb to the deadly infection that is gripping Camelot. And despite her obvious skepticism, she is so driven by the fear of the "what if," that she hands over her coin for the tonic and peace of mind.
If all of this seems familiar, but you just can't put your finger on how, I'll give you a hint: our US healthcare "system." It's like there is a goblin in it, who in his relentless pursuit of gold is bankrupting the nation and disease-mongering to increase profit. Of course this allegory has no nuance, and why should it: this is after all a TV series about a magical medieval kingdom whose name itself has come to mean "utopia." Yet it is jarring to realize just how close to our reality this story is.
I am sure you are all anxious to find out how the episode ended. Did the peasant survive? Was Gaius able to regain his body? Did the goblin get back into his box? For answers to all these questions you can go to Netflix. As for our healthcare system, isn't it time we chased the goblins out?
Thursday, February 16, 2012
Medicine: The art of applied science
I read this NPR article this morning and had to do a post in response. The gist is that the military is turning to what we might call the less conventional (for us in the West) medical modalities to deal with the injuries sustained by the current crop of vets. Instead of getting them hooked on pain meds for life (we saw plenty of this in the VAs in the '80s and '90s among Vietnam vets), they are turning to stuff like massage and acupuncture. And, predictably, it is stirring up controversy.
The story that is told is of a Sgt. Rick Remalia who fractured his back and pelvis in Afghanistan:
I am well aware that a group of anecdotes does not amount to science. And I am also well aware that what we are hearing here are anecdotes. But here is the thing: when your kid tells you that she likes chocolate ice cream better than vanilla, do you ask for evidence that chocolate is better than vanilla at the population level? No, that's absurd! OK, you say, but this is a strawman: nobody is going for a claim of superiority of chocolate ice cream over vanilla. That is true, but is this about the science or about being able to make a claim? If my kid likes chocolate, why not let her have that when ice cream is on the menu? If acupuncture seems to provide some relief to Sgt. Remalia, why not let him have that relief? After all, whose opinion about what works counts in this individual example, ours or the patient's? And if the ethics of using placebo are the concern, there is nothing wrong with letting him know that in large clinical trials the evidence is equivocal, which means that it may work for some and not for others. In fact, this might be a good disclaimer to make before commencing any treatment, one with the right to claims and one without.
Another argument is that there is no way that insurance (or our taxes) should pay for this unproven treatment. Still about science? Do any of you want to stand up and tell Sgt. Remalia, who fought for our freedom, that we will not pay for the only thing that seems to help him, that is pretty cheap and safe and that has very few, if any, long-term adverse effects, in stark contrast to pain killers? Yes, I understand that this is not science, but is there no room for humanism in the practice of medicine? After all we have throaty debates as to whether or not it is ethical to deny a $100,000 payment for a treatment that, on average, prolongs life by 2 weeks. Surely, denying Sgt. Remalia access to this relief would diminish our humanity. And what about the costs of treating addiction to pain killers?
So, here are my points:
1. I completely agree that that acupuncture "works" for Sgt. Remalia, does not mean that "acupuncture works" in the scientific sense. It may or may not work; furthermore, our current models of the universe do not allow us to have an adequate mechanistic explanation. But that is not the point -- it works for this young man whose life will never be the same because he signed up to defend his country. To this extent his "claim" has all kinds of internal validity.
2. Making claims is subject to legal and regulatory frameworks that have very little to do with science. I have done much blogging on clinical vs. statistical considerations in clinical research that feeds regulatory approvals and hence claims, and I remain of the opinion that a lot of the acceptable claims are specious. I know, I know, this is a "tu quoque" argument, but if we are talking about the goose and the gander, well...
3. Whether or not a treatment should be paid for is more prone to political than evidence-based decisions. Given that most medicines work in a minority of patients, and none comes without adverse events, the extent of which remains largely unknown because of our negligence to build real regulatory systems to quantify them, we are spending a lot of dollars on stuff that does not work at the individual level.
Medicine has to be part science and part art; in fact the art is in how and when to apply the science. That latter portion must be about humanism.
The story that is told is of a Sgt. Rick Remalia who fractured his back and pelvis in Afghanistan:
Remalia broke his back, hip and pelvis during a rollover caused by a pair of rocket-propelled grenades in Afghanistan. He still walks with a cane and suffers from mild traumatic brain injury. Pain is an everyday occurrence, which is where the needles come in.And lately he has been receiving acupuncture treatments, with this result:
"I've had a lot of treatment, and this is the first treatment that I've had where I've been like, OK, wow, I've actually seen a really big difference," he says.And incidentally, her gets these treatments from a military physician, who, herself a skeptic, admits to perceiving a personal benefit from her own exposure to it:
"I actually had a demonstration of acupuncture on me, and I'm not a spring chicken," she says, "and it didn't make me 16 again, but it certainly did make me feel better than I had, so I figured, hey ... let's give it a shot with our soldiers here."So, all good so far, right? Well, Harriet Hall is quoted in the same article, and to her this falls right into what she likes to call "quack-ademic" medicine. She says,
"The military has led the way on trauma care and things like that, but the idea that putting needles in somebody's ear is going to substitute for things like morphine is just ridiculous," Hall says.Now, as you know, I have had some debates with the SBM crowd in the past, and as it turns out, we agree on the science more than we disagree. However, I am thinking that this argument is not about science, but about politics.
I am well aware that a group of anecdotes does not amount to science. And I am also well aware that what we are hearing here are anecdotes. But here is the thing: when your kid tells you that she likes chocolate ice cream better than vanilla, do you ask for evidence that chocolate is better than vanilla at the population level? No, that's absurd! OK, you say, but this is a strawman: nobody is going for a claim of superiority of chocolate ice cream over vanilla. That is true, but is this about the science or about being able to make a claim? If my kid likes chocolate, why not let her have that when ice cream is on the menu? If acupuncture seems to provide some relief to Sgt. Remalia, why not let him have that relief? After all, whose opinion about what works counts in this individual example, ours or the patient's? And if the ethics of using placebo are the concern, there is nothing wrong with letting him know that in large clinical trials the evidence is equivocal, which means that it may work for some and not for others. In fact, this might be a good disclaimer to make before commencing any treatment, one with the right to claims and one without.
Another argument is that there is no way that insurance (or our taxes) should pay for this unproven treatment. Still about science? Do any of you want to stand up and tell Sgt. Remalia, who fought for our freedom, that we will not pay for the only thing that seems to help him, that is pretty cheap and safe and that has very few, if any, long-term adverse effects, in stark contrast to pain killers? Yes, I understand that this is not science, but is there no room for humanism in the practice of medicine? After all we have throaty debates as to whether or not it is ethical to deny a $100,000 payment for a treatment that, on average, prolongs life by 2 weeks. Surely, denying Sgt. Remalia access to this relief would diminish our humanity. And what about the costs of treating addiction to pain killers?
So, here are my points:
1. I completely agree that that acupuncture "works" for Sgt. Remalia, does not mean that "acupuncture works" in the scientific sense. It may or may not work; furthermore, our current models of the universe do not allow us to have an adequate mechanistic explanation. But that is not the point -- it works for this young man whose life will never be the same because he signed up to defend his country. To this extent his "claim" has all kinds of internal validity.
2. Making claims is subject to legal and regulatory frameworks that have very little to do with science. I have done much blogging on clinical vs. statistical considerations in clinical research that feeds regulatory approvals and hence claims, and I remain of the opinion that a lot of the acceptable claims are specious. I know, I know, this is a "tu quoque" argument, but if we are talking about the goose and the gander, well...
3. Whether or not a treatment should be paid for is more prone to political than evidence-based decisions. Given that most medicines work in a minority of patients, and none comes without adverse events, the extent of which remains largely unknown because of our negligence to build real regulatory systems to quantify them, we are spending a lot of dollars on stuff that does not work at the individual level.
Medicine has to be part science and part art; in fact the art is in how and when to apply the science. That latter portion must be about humanism.
Monday, January 23, 2012
Physician Payment Sunshine Act: More marginal thinking
It never ceases to amaze me how we gravitate to the margins in our thinking: margins seem to have a centrifugal force that is nearly impossible to overcome in today's political discourse. Yet the truth almost always lies at the center, the place that does not generate Op-Eds or produce votes.
I have said this before, and I will say it again: industry-physician relationship is not all bad or all good, there is no one within this relationship that is all bad or all evil, and it does not always benefit or always harm patients! The truth, of course, is somewhere in the middle. Contrary to Stossel's thesis, there is plenty to worry about with respect to corruption promoted by the big money exchanging hands between Pharma and doctors. On the other hand, just because there are instances of corruption and its consequences, not all interaction, financial or otherwise, is counterproductive. I am the first to admit that the much-touted innovation in medicine is rare, and we have largely given up its pursuit in favor of predictable markets and returns. Yet without a robust and transparent collaboration between industry and practitioners there is not only little hope of innovation, but any innovation that may stand a chance is likely to be irrelevant.
Yes, I agree with Stossel that the new reporting regulation is overly punitive and will inevitably result in undue administrative burden. But it would be disingenuous of me to disagree with the fundamental idea that there needs to be at least some degree of transparency in the financial dealings between industry and clinicians, if only to avoid the appearance by the docs of serving two masters.
As in everything in life, the devil is in the details. And it is these details that get buried by the gravitational pull of peripheral thinking and discourse. The solution? How about we stop paying attention to these marginal fallacies and start putting our heads together for real to solve these significant problems? How about we start a rational discussion about what is best for the people and not for the corporations or the economy or reputations? The discussion has been subverted by extremism. It is time to give in to the centripetal pull of reason.
I have said this before, and I will say it again: industry-physician relationship is not all bad or all good, there is no one within this relationship that is all bad or all evil, and it does not always benefit or always harm patients! The truth, of course, is somewhere in the middle. Contrary to Stossel's thesis, there is plenty to worry about with respect to corruption promoted by the big money exchanging hands between Pharma and doctors. On the other hand, just because there are instances of corruption and its consequences, not all interaction, financial or otherwise, is counterproductive. I am the first to admit that the much-touted innovation in medicine is rare, and we have largely given up its pursuit in favor of predictable markets and returns. Yet without a robust and transparent collaboration between industry and practitioners there is not only little hope of innovation, but any innovation that may stand a chance is likely to be irrelevant.
Yes, I agree with Stossel that the new reporting regulation is overly punitive and will inevitably result in undue administrative burden. But it would be disingenuous of me to disagree with the fundamental idea that there needs to be at least some degree of transparency in the financial dealings between industry and clinicians, if only to avoid the appearance by the docs of serving two masters.
As in everything in life, the devil is in the details. And it is these details that get buried by the gravitational pull of peripheral thinking and discourse. The solution? How about we stop paying attention to these marginal fallacies and start putting our heads together for real to solve these significant problems? How about we start a rational discussion about what is best for the people and not for the corporations or the economy or reputations? The discussion has been subverted by extremism. It is time to give in to the centripetal pull of reason.
Tuesday, December 13, 2011
When end of life is not
Twenty years ago, I helped save a man's life.So begins this New York Times essay by Peter Bach, MD, where he talks about the inadequacy of resource use at the end of life as a policy metric. Now, I am not very fond of policy metrics, as most of you know. So, imagine my surprise when I found myself disagreeing vehemently with Peter's argument. Well, to be fair, I did not disagree with him completely. I only disagreed with the thesis that he constructed, skillfully yet transparently fallaciously (wow, a double adverb, I am going to literary hell!) Here is what got me.
He describes a case of a middle-aged man who was experiencing a disorganized heart rhythm, which ultimately resulted in dead bowel and sepsis. The man became critically ill, the story continues, but three weeks later he went home alive and well. This, Dr. Bach says, is why end of life resource utilization is a bad metric: if this guy, who had a high risk of dying, had in fact died in the hospital, the resources spent on his hospital care would have been considered wasted by the measurement. And I could not agree more that lumping all terminal resource use under one umbrella of wasteful spending is idiotic. Unfortunately, knowingly or not, Peter presented a faulty argument.
The case he used as an example is not the case. Indeed it is a straw man constructed for the cynical purpose of easy knock-down. When we talk about futile care, we are not referring to this middle-aged (presumably) relatively healthy guy, no. We are talking about that 95-year-old nursing home patient with advanced dementia being treated in an ICU for urosepsis, or coming into the hospital for a G-tube placement because of no longer being able to eat or drink. We are talking about patients with advanced heart failure and metastatic cancer, whose chances of surviving for the subsequent three months are less than 25%. And yes, we are also talking about some middle-aged guy with gut ischemia, sepsis and worsening multi-organ failure whose chances of surviving to hospital discharge are close to nil; but in his case, instead of being clear from the beginning, the situation evolves.
So, yes, the costs of end of life care, and specifically hospitalizations, are staggering. But more importantly, among patients with terminal illnesses like metastatic cancer, advanced heart failure and dementia, hospitalizations and heroic interventions at the end of life cause unnecessary pain and suffering, and without much, if any, benefit in return. Their families and caregivers suffer as well, and many studies suggest that these caregivers are not interested in prolonging suffering, provided they are aware of the prognosis. Unfortunately, just as many studies suggest that communication between doctors and patients' families about these difficult issues is less than stellar.
So, let me play the devil's advocate and pretend that I support end of life resource utilization as a quality metric. If I did, I certainly would not be interested in depriving Dr. Bach's middle-aged acutely ill patient of the chance to survive. In fact, my aim would be to make sure that we align resource use with where it can do most good, and turn away from interventions that are apt merely to prolong dying.
Friday, September 23, 2011
Clinician as the Politbureau of medicine?
Do you think that medicine in the US is centralized? I do, but not in the way that we generally understand centralization. And furthermore, it is this centralization that I believe is making the idea of shared decision making so intimidating to some. Here is what I mean.
If you read management texts, centralization refers to an organization that is run predominantly top-down. In other words, a couple of oligarchs at the top of the ladder make all the decisions without consulting anyone below. In this way all the power is concentrated in the hands of the few. In an antithesis to this, in a decentralized organization, grassroots input and initiatives are incorporated into the fabric of the organization. And while in the times of a great crisis, when rapid decisions are necessary, the benefits of centralization may outweigh its risks, during normal day-to-day operations, such unilateral power can result in obviously negative consequences, from discontent among the employees to making the wrong choices. Furthermore, as organizations grow in size, it gets that much more difficult to run them effectively within the centralized paradigm.
Now, let us look at medicine. The traditional model of the doctor-patient relationship relies on the clinician to know what is right for the patient: take this pill and don't worry about the side effects, dear. Now, clearly, when someone shows up to the emergency room in septic shock, there is very little room for a democratic process; we want the doctor to do rapidly what needs to be done to save the patient. But this is a catastrophic exception to the rule of what modern medicine cares for. From pre-diabetes to pre-hypertension to "borderline cholesterol" to osteopenia to mild depression, these are the "diseases" that are prevalent in the office of the 21st century. None of these is particularly urgent or life-threatening. And if we are honest with ourselves, even a devastating diagnosis of cancer does not demand an instantaneous intervention: in the vast majority of cases there is ample time for discussion and contemplation. So, the centralized approach is the wrong way to go. Thus enter the robust discussion about shared decision making.
Another reason that centralization of medical decisions is crumbling is the expanding patient panels that clinicians need to engage with in order to stay solvent, all within the context of increasing compliance and regulatory burdens along with decreasing reimbursements. Without an equal growth in one's cognitive ability to multi-task, this escalating imbalance is creating a rising risk for unilateral decisions to be plain wrong.
So, in my mind, this is yet another argument for all parties to embrace shared medical decision making to the extent we as patients are willing and able to do so. Because what is the alternative?
Subscribe to:
Posts (Atom)