Monday, September 15, 2014

BREAKING: Patients Are Not Stupid

In a new Forbes article, David Shaywitz ponders whether patients are the best judges of physician quality. This is a very interesting question, not because the answer is elusive, but because the question itself is rather unusual, and may prove to be the harbinger of a new way of thinking about health care. The question raised by Dr. Shaywitz is not whether patients have enough damning information to select their doctors, which is the common drivel in the media right now. The question is whether regular people are mentally competent to make that decision. Responding in the negative to this question implies that someone, or something, other than the patient should be empowered to judge physician quality, and pick your doctor for you. 

It seems that Dr. Shaywitz was inspired to write this article in the wake of an opinion piece in the Wall Street Journal, where a practicing physician, Dr. Mark Sklar, is railing against the oppressive bureaucracy engulfing his medical practice today. Dr. Sklar offers several opinions, one of which is that “the patient should be the arbiter of the physician's quality of care”. Unfortunately for Dr. Sklar, his other prescriptions seem to be in opposition to some Obamacare tenets, and this is guaranteed to elicit kneejerk responses from Affordable Care Act supporting journalists, who have long ago ceased to even pretend to be impartial in matters of politics.

What I find exceptional about this Forbes piece is that Dr. Shaywitz’s first instinct is to solicit a response to Dr. Sklar’s complaint not from a famous Obamacare supporting physician (of which there are many), and not from the purveyors of rules and regulations at CMS, but from none other than Mr. Vinod Khosla, the billionaire venture capitalist who insists that 80% of doctors are middling and should be replaced with his computer driven algorithms. Of course, once Mr. Khosla gets his wish (and he will), Dr. Shaywitz’s question will become moot, and we will be relieved of another mental burden on our way to perfection, or perdition, depending on your point of view.

Perhaps, we shouldn’t be surprised by the appeal to Mr. Khosla’s informed opinion, since Dr. Shaywitz admits to sharing the modern disdain for physicians in general: “doctors don’t know what they don’t know, they often provide manifestly suboptimal care, and can get away with it so long as they sweet-talk the patient”. Sweet-talk? I thought we were going for the abrupt, dismissive, inconsiderate, aloof image, but either way they can get away with it, because we are all too dumb to know the difference (present company excluded, of course). Among some random thoughts about data collection, Dr. Shaywitz poses another quintessential question which never fails to materialize in this context: “Why should I know more about my mechanic than my doctor?” Note that as always this is a rhetorical question and an answer (other than duh…) is not deemed necessary.

I don’t really know what your car mechanic experiences are, but I can tell you that I know nothing about any of the various people who worked on my cars over the years. I don’t even know if they were mechanics. I don’t know if and where they went to mechanic school, and I have no idea how long they have been practicing mechanics (I assume that older ones have been in the business longer), I have no data regarding how many Jeep carburetors they fixed well and how many they broke, I don’t know how many times people had to come back for the same problem, and I have no idea if it takes six hours to replace ball joints, or maybe just two. Heck, most of the time I don’t even know their last name, and I certainly have no idea if they worked on my car themselves or delegated the work to some trainee on his first day on the job.

And yet, I would insist that I am the best judge of mechanic quality for my car, and I use information to render my judgment. I ask people I know for recommendations, and I ask the grease covered guy at my favorite gas station about the best body shop that’s not too far from my house, and then I pick one, go over and talk to the “guy”, and if I get a good feeling that the “guy” knows his stuff and is trustworthy, I let him fix my car. I have yet to make a truly horrific mistake. The tools and data I use to make my decisions were invented hundreds of thousands of years ago and honed to perfection by every human interaction over the millennia. I use similar tools all day every day, and I like that sometimes they are fuzzy, and I like that they are my tools to shape and alter as I please.

I use my tools to pick my lawyers, my accountants, my hairdresser, my plumber, my air-condition guy, painters, fence-builders, the tree guys, dry-cleaners, the lady that that does alterations, the fresh fish store, the stands at the farmer market, and a gazillion other products and services. Sometimes, I use customer reviews on the Internet in lieu of asking friends, but not very often, and never for personal services. I make lots of mistakes and sometimes I learn from them, and once or twice I rushed into some serious blunders, or procrastinated my way into disaster. It’s called life, and I insist on my right to make bad decisions, because it’s the only way for me to make the right decisions.

The Constitution of the United States of America gives us the right and the duty to judge the quality of the most powerful person on this planet, and we have to do that without any prior performance data and without ever meeting the candidate. We also have to judge the quality of the future executives of our respective States and towns, and from time to time we are called to actually judge the guilt or innocence of one of our peers. These are difficult decisions to make, and in spite of the seemingly egregious errors we are now making, I am not too terribly inclined to delegate these rights and responsibilities to Mr. Khosla’s computers, or the supreme intellect of the ProPublica editorial team.

We may be down and out. We may be disenfranchised right now, and plagued by broad daylight robberies, which we can’t fend off just yet, but we are not stupid. We know that the $2.8 trillion in our health care purse is enough to blind the righteous, and more than enough to attract the wicked. As a group, doctors are taking home a large chunk of that money, because we allowed them to do that in return for an ancient commitment, that means nothing to purveyors of machine ethics, but means a lot to us. We know that there are thieves and murderers among doctors, and some of us fall prey to those disturbed individuals, but as a group, physicians have proven worthy of our trust, and certainly more so than the corporate organized crime consortium and the sensationalist media outlets that serve them.

We don’t seem to be the best judges for picking our occupations, our food, our sports, our houses, our financial investments, how we educate our children, how we speak, and now how we pick our doctors and medicines. It would be so much more convenient and so much easier for all involved, if we just quit squirming and allowed the billionaires, with their computerized and biological overseers, to help us make all these complex decisions. For our own good, of course, so we can all lead happy and productive lives.

Tempting to be sure, and a merciful way to dispose of western civilization, but I’m afraid that the Reverend Dr. Martin Luther King's famous long arc of the moral universe is still bending towards justice, and away from slavery by any other name.

Wednesday, September 3, 2014

The Fallacy of Value-Based Health Care

Value-based health care is antithetic to patient-centered care. Value-based health care is also diametrically opposed to excellence, transparency and competitive markets. And value-based health care is a shrewdly selected and disingenuously applied misnomer. Value-based pricing is not a health-care innovation. Value-based pricing is why a plastic cup filled with tepid beer costs $8 at the ballpark, why a pack of gum costs $2.50 at the airport and why an Under Armour pair of socks costs $15. Value-based pricing is based on manipulating customer perceptions and emotions, lack of sophistication, imposed shortages and limitations. Finally, value-based prices are always higher than the alternative cost-based prices, and profitability can be improved in spite of lower sales volumes.

Health care pricing is currently a smoldering mixture of ill-conceived cost-based pricing with twisted value-based pricing components. For simplicity purposes, let’s examine the pricing of physician services. As for all health care, the pricing of physician services is driven by Medicare. The methodology is neither cost-based nor value-based and simultaneously it is both. How so? Medicare fees are based on relative value units, which are basically coefficients for calculating the cost of providing various services in various practices, of various types and specialties. The price, which is also the cost since it includes physician take home compensation, is calculated by plugging in a dollar value, called conversion factor. The conversion factor, which is supposed to represent costs, is not in any way related to actual production costs, but instead it is calculated so the total cost of physician services will not exceed the Medicare budget for these services. Buried in this complex pricing exercise is a value-based component. A committee of physicians gets to decide the requisite amount of physician effort, skills and education, for each service. Whereas in other markets the value decision hinges on buyer perceptions, in health care it is masquerading as cost.

The commercial insurance market adds a more familiar layer of complexity to the already convoluted Medicare fee schedule baseline. Unlike Medicare fees, which are nonnegotiable, private payers will engage in value-based negotiations with larger physician groups and health systems that employ them. Monopolistic health systems in a given geographical area can pretty much charge whatever the market can bear, just like the beer vendor at your favorite ballpark does, and brand name institutions get to flex their medical market muscles no differently than Under Armour does for socks. This is value-based pricing at its best. Small practices have of course no negotiation power in the insurer market, but as shortages of physician time and availability begin to emerge, a direct to consumer concierge market is being created, providing a new venue for independent physicians, primary care in particular, to move to a more profitable value-based pricing model.

Unsurprisingly this entire scheme is not working very well for any of the parties involved, except private insurers who thrive on complexity and the associated waste of resources. Upon what must have been a very careful examination of the payment system, Medicare concluded that it does not wish to pay physicians for services that fail to lower Medicare expenditures, and Medicare named this new payment strategy value-based health care, not because it has anything in common with value-based pricing, but because it sounds good. Another frequently used term in health care is value-based purchasing, which is attempting to inject the notion of quality as the limiting factor for cost containment. However, since Medicare is de facto setting the prices for its purchases, there is really no material difference between these two terms.

We need to be very clear here that value-based health care is not the same as quality-based health care. The latter means that physicians provide the best care they know how for their patients, while the former means that physicians provide good health care for the buck. To illustrate this innovative way of thinking, let’s look at the newest carrots and sticks initiative, scheduled to take effect for very large medical groups (over 100 physicians) in 2015. Below is a table that summarizes the incentives and penalties that will be applied through the new Medicare Value-based Payment Modifier.


There are several things to note here. First, if your patients receive excellent care and have excellent outcomes, you will receive no perks if that excellence involves expensive specialty and inpatient services, whether those are the accepted standard of care or not. You would actually be better off financially if you took it down a notch and provided mediocre care on the cheap. The second thing to notice is that you will not get penalized for providing horrendously subpar care, if you do that without wasting Medicare’s money.

Another intriguing aspect of this new program is that you have no idea how big the incentives, if any, are going to be. The upside numbers in the table are not percentages. They are multipliers for the x factor. The x factor is calculated by first figuring out the total amount of penalties, and that amount is then divided among those who are due incentives. If there are few penalties, there will be meager incentives. Lastly, those asterisks next to the upside numbers, indicate that additional incentives (one more x factor) are available to those who care for Medicare patients with a risk score in the top 25 percent of all risk scores.

As with everything Medicare does, this too is a zero sum game. For there to be winners, there must be losers. One is compelled to wonder how pitting physician groups against one another advances collaboration, dissemination of best practices, or sharing of information, and how it benefits patients. Leaving philosophical questions aside, the optimal strategy for obtaining incentives seems to be transition to a Medicare Advantage type of thinking: get and keep the healthiest possible patients, and make sure you regularly code every remotely plausible disease in their chart. Stay away from those dually eligible for Medicare and Medicaid, the very frail, the lonely, the infirm, or the very old, and don’t be tempted to see a random person who is in a pinch, because there is always the chance that he or she will be attributed to your panel following some hospitalization or other misfortune.

The Value-based Payment Modifier is for beginners. It is just the training wheels for the full-fledged risk assumption that Medicare is seeking from physicians and health care delivery systems in general. The grand idea is not much different than providing an aggregated and risk adjusted defined contribution for a group of assigned members, and having the health care delivery system absorb budget overruns, or keep the change if they come in under budget. There is great value in such a system for Medicare and commercial payers certain to follow in its footsteps, and perhaps this is why they decided to call it value-based. Ironically, the equally savvy health care systems are fighting back precisely by building the capacity to create a true value-based pricing model for their services through consolidation, monopolies, corralled customers, artificial shortages, confusing marketing, and diminished physicians.

It is difficult to lay blame at the feet of health systems for these seemingly predatory practices, because transition to a perpetual volume-reducing health care system is by definition unsustainable. The infrastructure and resources needed to satisfy all the strategizing, optimizing, counting and measuring activities required for value-based health care, whether the modest payment modifier or the grown up accountable care organization (ACO), are fixed costs added to health system expenses year after year. However, the incentives or shared-savings are temporary at best, because at some point volumes cannot be reduced further without actually killing people. Either way, in the near future, and for already frugal systems, in the present, all incentives will dry up leaving only massive outlays for avoiding penalties coupled with increased risk for malpractice suits. 

And as these titans are clashing high above our little heads, two outcomes are certain: individual physicians will be paid less and individual patients will be paying more for fewer services. This is how we move from volume to value. Less volume for us, more value for them.

Tuesday, August 26, 2014

The Study You’ll Never Hear About

According to a new Commonwealth Fund sponsored study published in Health Affairs, “Small Primary Care Physician Practices Have Low Rates Of Preventable Hospital Admissions”. The study of over one thousand practices of various sizes and ownerships, conducted by some of the most respected names in health care, found that the smallest independent primary care practices, that are physician owned, provide better care at lower overall cost. Considering the current, and rather belligerent, advocacy and policy efforts to eradicate small independent medical practice, and the massive move of physicians from private practice to hospital employment in the name of efficiency, quality, value and economies of scale, this study should have created quite the furor. It has not, and chances are excellent that it never will.

The study, consisting of 1045 practices and 284,000 patients, is a combination of survey responses regarding practice characteristics, and Medicare claims data used to calculate rates of ambulatory care-sensitive admissions (ACSA). As the title implies, Lawrence Casalino and colleagues found that practices with one or two physicians had 30% lower rates of these presumably preventable admissions. But this was by no means the only finding, because in general, physician owned practices, as opposed to hospital owned practices, regardless of size, had lower ACSA rates. Furthermore, the study also found that all sorts of innovative practice models foisted on physicians nowadays have marginal and sometimes negative effects on ACSA rates: “Neither the patient-centered medical home score, nor pay-for-performance incentives, nor the acceptance of risk for the cost of hospital care for the practice’s patients was significantly associated with the ambulatory care–sensitive admission rate … . Practices exposed to public reporting had somewhat higher rates.”

We should clarify here that the study uses a proprietary definition of “patient-centered medical home scores”, which is a narrow electronic-industrial subset of the broadly accepted comprehensive definition of the Patient Centered Medical Home (PCMH), and as such, unlikely to be implemented in small practices. Important PCMH aspects that are widespread among small practices are not included in these “scores”. For example, enhanced access to care is measured exclusively by availability of group visits and e-mail communications with physicians, without accounting for the more conventional same-day or after-hours appointments, and two fundamental aspects of classic PCMH, personal physician and whole person orientation, are inexplicably left out altogether. In addition, practices with 1 or 2 physicians are handicapped right out of the gate for being automatically deemed to lack “primary care teams”. Small practices also get dinged for lack of “rapid-cycle quality improvement strategy” and not participating in “quality improvement collaboratives”.

Another thing that should be noted is that this new study is based on 2008 data, so six years ago, physician owned practices were providing better care at lower costs, and the smaller the practice the more efficient it was. Between then and now, we enacted legislation and a slew of regulations pushing for massive consolidation of health systems, which in turn triggered a most spectacular shopping spree for private practices, converting large swaths of the health care delivery system into a less effective and more expensive model of care. To top it all off, we added, and are still enthusiastically piling on, regulatory requirements for all the things that Casalino and colleagues found largely inconsequential, and in the case of public reporting, somewhat detrimental to the outcomes we seek. We are spending billions of dollars on transforming our health care system into one that is more expensive and arguably of lower quality.

Previous studies (that you probably never heard of either), are somewhat inadvertently supporting the findings published by Casalino and colleagues. For example, a 2011 study by John Kralewski and colleagues showing that investment in improved quality of care for patients with diabetes can indeed reduce costs of care, reached several secondary conclusions that may have gotten lost in the shuffle. The study found that “[p]hysician-owned practices had significantly lower costs than hospital-owned practices”, and that “[l]arger practices and those with more on-site support services had significantly higher costs”. It also noted that neither the presence, nor the advanced expertise in use, of electronic medical records had significant influence on costs for the studied patients, while a “higher ratio of nurse practitioners and physician assistants in the practice increased costs”. Finally, a closer look at the results indicates that physician-owned practices “achieved more of their cost savings by providing higher-quality care than practices owned by hospitals or other agencies”.

In spite of the pretty straightforward evidence presented by Casalino and colleagues, and others before them, the authors seem troubled by the “unexpected” results, “since small practices presumably have fewer resources to hire staff to help them implement systematic processes to improve the care they provide”. And here we arrive at the crux of our health care dilemma. For decades, brilliant minds in health care have been consistently driving policy changes based on the assumption that health care is a “system”, and as such, it should be improved by well-established methodologies borrowed from other systems (e.g. Deming cycles, Lean Six Sigma, etc.). Small practices were obviously ill suited for such endeavors and hence the tacit agreement that most physicians should transition to larger medical settings, preferably hospital owned, so that improvement cycles can be uniformly applied across the factory floor. As a variety of integrated health systems began reporting success with these methodologies, the issue was considered settled and the “system” began moving full steam ahead.

Except that the baseline was all wrong. While millions and billions of dollars were being diverted from direct patient care and spent instead on industrializing health care, the much derided Marcus Welby model of care, in its stark simplicity, was running circles around the heavy machinery with gazillions of moving parts, put in place by health care reform. The only question remaining now is whether the damage is reversible. Obviously, the large amounts of money that were sent down the drain are not recoverable, but perhaps it’s not too late to cut our losses and stop throwing good money after bad. The Casalino study is a snapshot of the situation in 2008, but sadly the same may not be true today.

After years of trying to keep up with regulations, incentives, penalties, mandated clunky technology, performance reporting, overt and covert price discrimination, and increasingly untenable reimbursement complexities, all of which were shown to do nothing for effectiveness and/or efficiency, many physicians in small practice are demoralized, frustrated or have completely given up. As a group, independent doctors are getting older and medical schools, turned trade schools for “health care systems which are now the major employer of doctors” are busy preparing students “to focus on populations of patients rather than individual patients”, with full support from the American Medical Association..

It may very well be too late to recover what was lost, but this realization does not explain the conclusions reached by Casalino and colleagues from this, perhaps too little too late, study. In spite of the data presented, we are told that “[s]mall practices have many obvious disadvantages”, where none were discussed in the body of the article, and that “[i]t would be a mistake to romanticize them”. The article also suggests, and rightly so, that more research is needed, and perplexingly also that small practices should be helped with resources and services to implement precisely the processes that two paragraphs above were shown to make no difference in outcomes.

I do understand the difficulties inherent in reversing position on a long held belief, but just like romanticizing the country doctor of days gone by is indeed a mistake, dismissing the data based on romantic notions about Toyota’s car manufacturing business, is an equally grave scientific error. And in response to this study, the silence of the health care research community, as well as the mainstream media, which is supposed to act in the public interest, is outright deafening. I wonder why....

Wednesday, July 23, 2014

Introduction to Hypoliquidemia

The venerable University of Texas MD Anderson Cancer Center in Houston will accept patients with traditional Texas Medicaid health insurance, and some patients in Medicaid managed care plans. Memorial Hermann, another large health system in Houston, will accept traditional Medicaid patients and also those in Medicaid managed care plans. Neither institution will accept the Blue Cross Blue Shield HMO silver plan sold on the Affordable Care marketplace, according to NPR, and as clearly outlined on the MD Anderson website. As it turns out, the conservative state of Texas is able to obtain best in the world health care for its poorest and sickest citizens, while the private market representative, Blue Cross Blue Shield in this case, is barring its “customers” from the best and most popular Houston hospitals, including the public system (!), and all the doctors that go with these hospitals. This situation is hardly unique to the Lone Star state.

The Affordable Care Act (ACA) is mandating that insurance companies take as much money from people as they are presumed to be able to pay, then proceed to top it off with taxpayer subsidies to make up for any shortcomings, and engage in these activities without discrimination based on formerly diagnosed illnesses. For their part, the people are mandated to make these payments, whether collectively through the government, or individually through their own pocketbooks, or most often both. While the ACA prescribes in great detail the mandatory flow of money from the people to health insurance corporations, and the services due to the people in return, it leaves the definition of the means by which these services are to be provided largely to the wisdom of the corporations, as long as they can show that, theoretically, the services can be provided. And indeed in many cases, many people, in practically every state, are now receiving excellent theoretical coverage for theoretical medical services.

If you happen to have cancer, and are looking to purchase health insurance, no insurer can turn you down or charge you more because of your preexisting condition. Thanks to the generosity of the ACA, you can select any one of the diverse insurance plans offered by each payer. You can choose a plan with a tailored, high-performing network focused on keeping you healthy, which includes almost no cancer hospitals and no cancer specialists, or you can buy a lusher and more expensive plan that includes some cancer facilities and doctors, or you can buy an exorbitantly priced health insurance plan that includes the likes of MD Anderson Cancer Center. If your cancer is found after you enrolled in that affordable plan for healthy people, you can always decide to switch to a plan that treats cancer and pay the difference. It’s all up to you, and the cash in your wallet, because now you have choices you never had before the ACA was enacted. This has absolutely nothing to do with preexisting conditions. It has to do with high-performance, tailoring, focusing and all sorts of other patient-centered features and benefits.

With great choice, comes great responsibility. All but the most expensive plans available for your selection on the Affordable Care marketplace, and most employer based insurance plans as well, are consumer driven. Basically you get to make all the big decisions regarding your health care and you need to empower yourself to rise to the occasion if and when disease or accidental misfortune materializes in spite of the system’s best efforts to keep you healthy. For those with little expertise in insurance jargon the best illustration may come from the home mortgage market. See, your affordable health insurance plan is very similar to the pre-2008 affordable mortgage for your pre-2009 home. In addition to your affordable monthly payments, there is a balloon payment due the day you are diagnosed with cancer, heart disease, or just slip and fall while cleaning the gutters. This payment is also known as your high deductible, and unlike your mortgage balloon payment, your high deductible is a self-renewing source of anguish, which springs back to life every January 1st.

There are handy calculators available to let you estimate the size of your balloon payments, and hospitals are setting up specialty services to evaluate a new vital sign called “liquidity” before any procedures are undertaken. Think of it as an expanded pre-op clearance. If your liquidity is lower than the price of your treatment, hospitals may help you elevate liquidity levels through various financial instruments, such as credit card debt, and refinancing for your balloon payment. It is not by accident that entities with brilliant track records in financial markets, such as Citigroup, are seizing the emerging opportunities in the brand new health care financing market, and are introducing innovative solutions “designed to simplify and enhance the healthcare payment experience”.  Be on the lookout for more innovation here, since this market is projected to run into the hundreds of billions of dollars by the end of the decade.

To bridge the gap between our vibrant financial industry and our old and tired health care system, a new diagnosis seems to be in order. Hypoliquidemia is a disease of the financial system. It is characterized by low levels of liquid cash in your bank account, low credit scores and low socioeconomic status (SES). Other signs and symptoms may include anxiety, depression and various phobias. Hypoliquidemia is diagnosed through a series of evidence based standardized screenings, ported from the financial industry and administered by your whole-person oriented care team. Moderate hypoliquidemia is severely exacerbated by prolonged encounters with the medical system, and although not a life threatening condition in otherwise healthy individuals, it may be lethal when comorbid with other severe illnesses.  The secondhand effects of hypoliquidemia can be extremely debilitating to hospitals and physicians who fail to take the necessary financial stewardship precautions when treating large numbers of hypoliquidemic patients.

Physicians, primary care docs in particular, are at increased risk of being affected by the spread of hypoliquidemia, since they are usually the first point of contact for patients entering the health system, and also because they lack the sophisticated diagnostic tools needed to measure liquidity levels before medical services are provided. The most likely effect of treating low liquidity populations consists of increasing levels of uncollectable bad debt. The only known protection mechanisms for individual physicians are to require cash or credit card payments at the time of service, or to avoid encounters with potentially hypoliquidemic patients altogether, i.e. those with ballooning high deductible insurance plans. Finally, according to a must read article in Managed Care, hospitals are already setting up “financial screening techniques that stratify access to their services” because “having an insurance policy will not guarantee access to care in the future”.

Hypoliquidemia is reaching epidemic proportions in the U.S. and there is no cure in sight, and there will be no mercy either. For the desperate, there is an old folk remedy which has been used successfully by inadequately liquid citizens in need of nursing home care in their old age. To attenuate the effects of hypoliquidemia on serious comorbid conditions, you need to counterintuitively drive your liquidity levels to zero. You need to quit your job, assuming you have one, and deplete any and all meager assets you may still have. Since regulatory climate is extremely important to treating hypoliquidemia, you may have to move to a region with suitable environmental controls. Once all these steps are executed successfully, you should be able to qualify for Medicaid and gain access to academic centers of excellence, including places like MD Anderson Cancer Center, if that’s what you need to survive. The most common side effects of this remedy are: premature death before the course of treatment could be completed, persistent exacerbation of hypoliquidemic symptoms, suicidal ideations and universal health care delusions.

Friday, July 11, 2014

Health Care for the Poor: The Sequel

In a previous post, I described how the American health care system is morphing into a system designed to service impoverished populations, and concluded that the transition “will take time, thoughtful planning, lots of innovation and a carefully cultivated disdain for human life”. However, a new blog post from Dr. Peter Ubel makes me think that it may not take that much time after all. It seems that Dr. Ubel has been “writing a bit lately on the need for health care providers to talk with their patients about health care costs”, and it seems that some have pointed out that this sounds very much like rationing of care for poorer citizens.

In a Forbes article explaining why this type of criticism is “misguided”, Dr. Ubel is pointing out that individual patients may have different preferences and it is entirely possible that a “patient who pays 20% of the cost of a $100,000 chemotherapy treatment might decide that the potential benefits of the chemotherapy are outweighed by the $20,000 in out-of-pocket expenses they will incur”.  If the empowered patient has $0 in his wallet, division by zero would indicate that the potential benefits of life-extending or even life-saving treatment would be outweighed by a factor of infinity.

Having settled the rationing argument, Dr. Ubel is proceeding to suggest an innovation that should help “providers” bring costs into treatment decisions, not necessarily for everybody, but just for “those who are financially distressed by the cost of medical care”. Since most “providers” don’t know much about costs of treatment, the “financially distressed” will be directed to “walk down the hall and talk to one of the billing experts in the clinic”, because “meeting with this kind of a financial expert will help patients gain a fuller sense of the costs and benefits of their health care alternatives”.

I am not sure how the “billing expert” turns into a “financial expert” in the span of one short paragraph, or how one gains a fuller sense of treatment benefits after a conversation with a coder in the back office, not to mention the technical problems in clinics where the “financial expert” positions were outsourced to India through this or that cloud-based EMR company. Presumably to address these difficulties, Dr. Ubel proceeds to list all sorts of philanthropic Internet startup companies that will help patients figure out costs of care, largely out of the goodness of their hearts. Consistent with his other articles, Dr. Ubel is advising physicians to not “resist this inevitable trend”, but rather “embrace the opportunity to help their patients better understand the full ramifications of their healthcare alternatives”.

Since unlike Dr. Ubel, I don’t find it “relatively straightforward to imagine a shift in our clinical paradigm, where physicians alter the flow of patients in their clinic” to send poor people to the back, I would like to suggest a different solution which should require no imagination at all. Let’s make poverty a disease, most likely one of those “lifestyle” diseases. Instead of just V codes, let’s give it a few regular ICD-9 codes and plenty of ICD-10, and let’s add a special CPT code for ancillary “financial expert” services that can be billed incident to a physician visit for patients diagnosed with Poverty and proper manifestation codes of commercial insurance or no insurance (which is basically the same thing when you have Poverty). Note that publicly insured individuals can only be afflicted with unspecified Poverty, and do not have out of pocket manifestations, so their claims will fail medical necessity checks and will be denied.

If you think about it, Poverty fits very well in the documentation templates of any EMR. For the HPI section, Poverty can be acute or chronic and it can have date of onset and duration. It certainly has severity levels, and it can be better with some things and worse with others. Poverty has well known co-morbidities and you can even reasonably document previous treatments. Both the Family and Medical Histories can accommodate Poverty in relatives and previous bouts of Poverty in the patient. We will need to formally add an organ, or system, to both ROS and Exam sections, and the canned Normal findings could be something like “wallet plump to palpation, credit scores clear with no discharges and no late payments”.  

Poverty with commercial insurance or no insurance manifestations, is of course a secondary ICD code which cannot be billed on its own (you are a doctor, not an accountant), so before you can document your assessment and plan for the primary diagnosis, you will need to send the patient for a “financial expert” session, either in the back of your office, or at an outside facility, just like an x-ray or a cardiology consult. After the patient has been carefully made to understand that the benefits of $100,000 chemotherapy are outweighed by the lack $20,000 in her pocket and the unavailability of assets, loans or other debt instruments, you can complete your assessment and add orders for affordable hospice medications to her plan. This can be done remotely through secure email to save the patient the inconvenience of one more visit, and the care plan can then be shared with the rest of her care team via health information exchange facilities.

After five long years of political bickering, the solution to our health care problems now emerging from all our legislation, regulations, court battles and billions of dollars to "support transformation", seems to be one which requires doctors to take poor people to the back room, one by one, and educate them on the fiscal subtleties barring them from access to proper medical care. Why try to fight this brave new system? Why resist this inevitable trend, when you can embrace the opportunity?

And there is indeed great opportunity here. First, reimbursement rates for Poverty consultations are bound to be fabulous, and the prospects of “shared savings” are almost boundless. Second, the old coder in the back office may be a poor match for “financially distressed” people, and there is no denying that medical knowledge should help things along, and an MD could be the most effective consultant. So perhaps MDs with MBA degrees will finally be provided with a proper venue to exercise their craft, and perhaps a new specialty will rise to the forefront of value-based health care. May I suggest Paupertology (: the branch of medicine that deals with ability to pay disorders of the poor)?

Monday, June 30, 2014

The Ethics of Big Data Workers

A new study was published in the Proceedings of the National Academy of Sciences of the United States of America (PNAS). The study is titled “Experimental evidence of massive-scale emotional contagion through social networks”, and it analyzes an experiment on Facebook users conducted by Facebook, in collaboration with researchers from UCSF and Cornell, almost two years ago. The experiment was a success, as it showed that Facebook was able to alter the emotional state of its users by making subtle and deliberate changes to the content users were shown in their news feeds. The study was subsequently edited for publishing by a Princeton professor, and accepted for publication by the prestigious National Academies, which by the way include the Institute of Medicine (IOM).

The experiment “manipulated” the News Feeds of 689,003 people, randomly selected, and then measured the effect on the subjects’ own Facebook postings, due to increased exposure to either positive or negative content from their own friends. The results show modest but significant ability to affect people’s emotional state by ever so slightly altering what they see on the Internet. The study concludes by pointing out that “the well-documented connection between emotions and physical well-being suggests the importance of these findings for public health”. And if this line of thought leadership is not creepy enough for you, there is one more little thing to note here. The subjects of this bold experiment had no idea that their friend feeds were being manipulated and that they were being studied by Facebook.

According to The Atlantic, who first broke the story, neither Facebook nor the authors were available for comments. However, the Princeton professor who prepared the study for publication, Prof. Susan Fiske, agreed to talk with The Atlantic reporter. It seems that she had some initial concerns which were addressed by the authors when “they said their local institutional review board had approved it—and apparently on the grounds that Facebook apparently manipulates people's News Feeds all the time... I understand why people have concerns. I think their beef is with Facebook, really, not the research”. Yes, the research itself is "inventive and useful", according to Prof. Fiske, and its “originality” should not be lost because “ethics are kind of social decisions. There's not an absolute answer. And so the level of outrage that appears to be happening suggests that maybe it shouldn't have been done...”  As it turns out, now that we know about the study, Prof. Fiske is “a little creeped out, too”.

The idea here seems to be that the definition of ethics at any given time depends on the personal opinion of those in the know. So if you conduct experiments on human subjects in secret, it is only your opinion that counts towards the definition of ethics. If the study becomes public, and if the public has a different opinion about ethics, you just say oops, maybe we shouldn’t have done that, but the results are way too cool, so let’s use them anyway. If indeed the study was approved by the review boards at either UCSF or Cornell, and contrary to explicit PNAS policy, there is no note to that effect in the article, it also appears that institutional review boards at academic centers will approve experiments on human subjects without consent or notification based on a solid track record of similar transgressions that went unnoticed and unchallenged in the past. Stated discomfort and feelings of creepiness emerge briefly only after public disclosure, and then we move on to the next adventure.

This little experiment is a perfect illustration of what Big Data can do for us. Big Data can spread mass happiness without “in-person interactions and nonverbal cues”, which can in turn induce “physical well-being” and ultimately improve the health of the public, at presumably much lower per capita costs. Here you have it; two of the Triple Aim goals are easily achievable by technology alone. All we need to figure out now is how to hit our third goal of better care for the individual, and this too is amenable to Big Data solutions once we get past the “creepiness” hurdle.

A recent article from Bloomberg describes precisely how highly individualized care is already provided to more fortunate patients through the beneficence of Big Data. Mammoth hospital systems turned health insurers, or just apprehensive about having to accept risk for their patients’ outcomes, are purchasing information from Big Data brokers, including credit card purchases, household and demographic information, and who knows what else. When combined with clinical and claims data these entities already have, Big Data allows health corporations to profile their customers and identify not only the ones that may put them at increased financial risk in the future, but, according to The New York Times, also the customers most likely to bring in increased revenues. And just like any other big business, health systems can then devise marketing and outreach strategies to mitigate their risk and increase their profits. Or in terms better suited for public consumption, they can provide better patient-centered care to individuals to help them get healthy and stay healthy. Problem solved.

Big Data is by definition a weapon of mass destruction. Some have likened Big Data to nuclear power, which can be used for unspeakable horrors or for the public good. This is an apt analogy, if we remember that nuclear power was first used for mass destruction, then it was (and still is) used for terrorizing nations, and when it is used to generate electricity, mountains of safety measures must be employed, and even then accidents do occur with dire consequences. Following the public discovery of unprecedented government surveillance on citizens’ communications (yes, that is Big Data), President Obama asked us to remember that "the folks at NSA and other intelligence agencies are our neighbors and our friends", and that they “are not dismissive of civil liberties”. Of course not, and the folks working in nuclear weapons plants, or nuclear reactors are also our friends and neighbors, and they are not mass murderers either. And yet, we found it necessary to enforce strict regulations on their work, instead of trusting their better angels and personal ethics.

The Facebook trial balloon floated nonchalantly by the National Academy of Sciences to gauge public reaction to mass psychological experimentation on people is most likely indicative of a much larger iceberg in the making. Creepiness is not a legal term and right now we are allowing every garage entrepreneur, every corporate entity and every governmental department to collect, distribute, sell, purchase and utilize unlimited amounts of Big Data for any purpose they see fit, including mass deception of the public, with no legal guidance and no legal consequences. We would never dream of a similar arrangement for nuclear materials. The polite reactions from self-appointed “privacy advocates” urging “transparency” and “patient ownership” of their data are woefully inadequate, because they demonstrate an utter lack of understanding of what Big Data is, how Big Data works, and how Big Data is being used. Besides, this is not about “privacy” anymore. This is about freedom, liberty and the non-enumerated right to human dignity.

Monday, June 23, 2014

We are Number Last

The Commonwealth Fund just published its fourth Mirror, Mirror on the Wall study comparing the U.S. health care system with other countries, and as in all previous studies, we ranked as the absolutely worst health care system in the developed world, bar none. Yikes. The Commonwealth Fund studied many health care domains, and we didn’t rank in first place for anything. The best we managed to do is place a lackluster third in the subcategory of Effective Care. The United Kingdom, on the other hand, with its socialized medicine system, took first place in almost every category, and the Swiss came in second.  That’s almost enough to drive a proud American into deep despair, and as the report bluntly states, “The claim that the United States has “the best health care system in the world” is clearly not true”. To add insult to injury, ours is also clearly the most expensive system in the world, and no, that doesn’t count as being #1 for something.


The authors of the Commonwealth Fund report are gracefully doing their best to cheer us up and give us hope, by pointing out that “[s]ince the data in this study were collected, the U.S. has made significant strides adopting health information technology and undertaking payment and delivery system reforms spurred by the Affordable Care Act”. It may be okay to hope that the next Mirror, Mirror report will show us moving up a couple of notches, instead of continuing to be the laughing stock of all developed nations. So how do we go about improving our scores? Adopting health IT is obviously the first thing, and then we need to “encourage more affordable access and more efficient organization and delivery of health care, and allow investment in preventive and population health measures”. Sounds like a plan.

Except, one thing in that picture looks very peculiar. The United Kingdom, the poster child of frugal and immaculate perfection, scored almost as bad as we did in the only domain that can be regarded as an outcome: health. The bon vivant French people, with the worst access to care and horrific patient-centeredness, seem to enjoy the healthiest lives of all (and Jefferson is finally vindicated). Looking further, it seems that Sweden, where care is of abysmal quality, but most equitable and efficient, came in second in healthy lives and third overall. Can something even be simultaneously of low quality and very efficient? Can a country have dangerous, ineffective care, like Norway, and still be ranked comfortably in the middle of the pack? For inquiring minds of the confused variety, the study provides more granular data points to peruse, so let’s dive in.

Over at the Incidental Economist blog, Dr. Aaron Carroll is warning us to stay away from “Zombie arguments defending the US healthcare system”. Fair enough. Let’s not worry about the U.S. system, or any system, and let’s even hold back on questioning the much too flawless results of this or that system. Let’s just look at the data. There are four major domains in the study: quality, access, efficiency, equity and healthy lives. Without splitting hairs, healthy lives can be considered an outcome of efforts in all other domains, but of course, it shouldn’t be, and the study authors acknowledge that the health care system is “just one of many factors, including social and economic well-being, that influence the health of a nation”. Completely agree. In which case, it is unclear to me why healthy lives measures are factored into the rankings of health care systems, straight up with no weighting or adjustments.

Let’s dig in a little deeper.  The quality domain is divided into four subdomains: effective care, safe care, coordinated care and patient-centeredness. Without debating this particular definition of quality, let’s look at how effectiveness is measured on two axes, preventive care and chronic care, each one assessed based on a series of data points. So for example, the first three prevention measures are: 1) the ease of printing out lists of patients due for preventive care; 2) patients who received preventive care reminders; and 3) patients routinely sent computerized reminders for preventive and routine care. I would call this triple dipping, because the only measure that actually counts here is whether patients received reminders or not, and how they responded, which was not measured at all. Whether it is easy to “print out” lists, or whether people are bombarded with computer calls that nobody picks up the phone for, is irrelevant.

The U.S. was ranked 3rd for patients receiving reminders and 7th for the other two useless measures. The UK ranked 1st for the useless measures and 5th for the mildly pertinent measure. For the remaining preventive measures, dealing with lifestyle advice provided by physicians to their patients, the U.S. ranked 1st and 2nd overall. To assess effectiveness, I would have expected perhaps a ratio of reminders sent, to reminders acted upon by patients, or at least reminders received, instead of an average score for those two, plus some strange measure about printing lists to paper.

The chronic care portion of the effectiveness subdomain illustrates yet another logical flaw in the study. Similar to the preventive care measures, here too the U.S. scores decently on actual chronic care activities, and poorly on ease of producing lists. But the bigger issue is the one measure evaluating cost barriers to adherence, and as expected the U.S. scored poorly on affordability, which is what this measure is all about. It may be fine to blast the U.S. system for being expensive, but to say that we are paying too much for a bad system, while assessing badness based on the system being expensive, is circular logic that should have no place in serious scientific conversation. 

Another, rather perplexing methodology flaw, is the many repetitive questions with conflicting answers that were nevertheless dutifully added as is to the averages. Questions of this type are routinely included in surveys to validate answers, but are not meant to be independent data points. For example, how is it possible to have a bad score on primary care docs receiving discharge summaries in general, coupled with a good score on receiving discharge summaries in a timely manner? You can keep on digging if you are so inclined, but my general impression is that the data in the analyzed surveys are neither sufficient, nor pertinent enough to allow for meaningful rankings of national health care systems. Let’s also note that all data is derived from surveys. Even if surveys would be classified as objective observation, which they are not, how can we infer causality from a narrow observational study?

And here is my biggest problem with these rankings and the subsequent conclusions drawn by the Commonwealth Fund, i.e. more computerization, more preventive care, more population management, or in other words more corporate and data driven health care. The study authors are basing their findings on a subset of indicators subjectively selected by the survey designers. What about the heaps and troves of other indicators that may also be pertinent to these findings? For instance, the average primary care panel size in the UK is a little over half the average panel in the U.S., and most primary care is delivered in small private practice, by primary care physicians who are better paid than UK specialists. Are those things pertinent to the UK stellar performance on all study domains? I don’t know, and neither does anybody else until a proper study is conducted.

Looking under the lamppost for lost keys is not a scientific method of inquiry, and when we can’t find said keys, it is not proper to blame the low wattage of the lamp. There is nothing in those surveys supporting the conclusions and recommendations put forward by this report, other than faith and preconceived opinions which were neither validated nor disproved by survey responders. There is no indication that the U.S. is an outlier in health information technology, preventive care or population management, and there is zero indication that these factors are the most salient factors in the performance of a health care system.

Does the fact the U.S. is the only country in this cohort where poor people are segregated away into special insurance plans that pay doctors and hospitals below cost, have anything to do with our poor numbers for Equity and Access? Does the for-profit nature of our system affect the exorbitance of our costs and hence all study domains? Are these things perhaps a tad more important than the ease of generating and printing out lists of patients? We may never know….

It is proper to observe, as the Commonwealth study does, that all other countries have universal health care, while the U.S. does not. It may even be logical to assume that such a huge systemic difference must in some ways adversely affect our outcomes. But it is nothing short of perplexing to conclude that the remedy consists of mixing a tiny bit of our overpriced (and yes, best in the world) medicine, with lots of corporate run analytic dashboards, followed by universal administration of this homeopathic concoction to innocent people.