Thoughts and Thoughts

One of the best articles I’ve read in a while:

Providing health care is like building a house. The task requires experts, expensive equipment and materials, and a huge amount of coördination. Imagine that, instead of paying a contractor to pull a team together and keep them on track, you paid an electrician for every outlet he recommends, a plumber for every faucet, and a carpenter for every cabinet. Would you be surprised if you got a house with a thousand outlets, faucets, and cabinets, at three times the cost you expected, and the whole thing fell apart a couple of years later? Getting the country’s best electrician on the job (he trained at Harvard, somebody tells you) isn’t going to solve this problem. Nor will changing the person who writes him the check.

via Annals of Medicine: The Cost Conundrum: Reporting & Essays: The New Yorker.

Link to Story

Writing in the journal Academic Emergency Medicine, lead author Dr. Carlos A. Camargo of Massachusetts General Hospital estimates that it would take until 2019 to find enough fully-trained, board-certified emergency physicians to work in the 4,828 emergency departments that are open 24 hours a day. And that best-case projection assumes that no current doctors who meet those qualifications die or leave their jobs.

The Institute of Medicine said in 2006 that ERs should ideally be staffed by doctors who had spent their residency training in emergency medicine and had later passed tests to become certified in the specialty. But only about 55 percent of doctors working in ERs meet that standard, Camargo and his co-authors write.

Does any other field have such a low percentage of physicians that are not board certified in the field of practice?  I know some of this has to do with the recent certification process, but that is pushing nearly 20 years now, and grandfathering options were available for those who were practicing before that.  What makes this worse, these calculations were done under the rosiest of scenarios where the doctors do not burn out and leave the field… good luck with that.

I’m not sure there is an easy solution to this problem.  I don’t think anyone is (or shoud be) suggesting we lower the standard of being qualified as an emergency medicine specialist.  There are already over 1000 residents trained a year, and at some point you run out of quality facilities to train residents (getting the right amount of volume with broad, well-rounded training isn’t possible just anywhere).  Decreasing the meteoric rise in ER visits in the past decade will also help a whole lot.

As China Roars, Pollution Reaches Deadly Extremes
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One of the hardest things to try to explain to people when discussing various kinds of institutional or governmental policy is the law of unintended consequences. It basically says the policy can have effects that are very different than what one expects. History is full of examples, yet people continue to believe that the idea/policy is smart enough to prevent thousands or millions of people from figuring out a way to mess it up while imaginatively trying to better their lives. It shouldn’t scare someone from trying to change things, but steps need to be taken to measure the change in order to ensure that what was intended to happen is indeed happening.

Glen Whitman, an associate professor of economics at California State University, Northridge, wrote a very nice article on this topic, linked here. It is worth a read, as it explains an idea which can be difficult to explain in a nice, accessible way.

The article is also saved after the break for archival purposes.

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Adam Bosworth, VP of Google recently has posted a few items on their blog regarding health care and the poor information transfer withiin the field.  I can only imagine that Health Informatics must seem truly backwards when one comes from a place like Google.

His first post is here:

http://googleblog.blogspot.com/2006/11/health-care-information-matters.html

And there is a second post, including a link to a transcript of a keynote address regarding this very issue.

http://googleblog.blogspot.com/2006/12/thoughts-on-health-care-continued.html

There are a number of obstacles to overcome, and the technical limitations are only a part of them. The bigger problem is that people working in the field are so fearful of litigation from a privacy breach, especially when it gets released to the “net.”  Some of this is because people are afraid of increased insurance rates, and many of these concerns are legitimate because information is just SO easy to duplicate a million times over once it is digitized.

Another article from the New York Times.

A product sold by Neurometrix, called NC-stat, is the topic of an article today’s New York Times, in particular the way it shows the problems with how doctors are reimbursed for the care that they provide.

Also provided here, is a link from Medgadget, and their review of how the NC-stat device works.

The interest for me, however has less to do with the device itself, but the following paragraph near then end of the piece:

For physicians, who might be able to bill only $80 or so for a routine 30-minute office visit, Neurometrix’s promise of a profit as high as $250 for 15 minutes, is compelling. So was a customer-referral program in which physicians could receive hundreds of dollars in free products for steering other doctors to Neurometrix.

….

For some health policy analysts, the popularity of such procedures illustrates why primary care doctors should be paid more for basic office visits and less for money-making procedures. Earning $250 from a diagnostic test “is obviously out of line with what physicians can earn from office visits,” said Paul Ginsburg, the president of the Center for Studying Health System Change, a Washington research group.

The reality is that doctors are simply not paid very much for spending time with patients, particularly in comparison to doing some fancy procedure.  The Medicare payments system that prices things based on the amount of resources it uses encourages people to use resources.  It seems obvious, but if one creates an incentive, one shouldn’t be surprised if people take it.  In this case, one shouldn’t be surprised if the entire medical industry is geared toward using more resources.

In fact, the expert doctor who can accurately diagnose people quickly is actually paid less, because, well, they’re too fast.

Anyway, the complete article is below.

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Arthur L Kellermann is a role-model to many of us who have earned or aspire to MD-MPH degrees. Having met him, he speaks with uncommon insight and wisdom. He has written a valuable editorial in the New England Journal of Medicine this week regarding the rising problem of crowding in the Emergency Department, particularly regarding disaster capacity. The Journal has been good enough to offer the editorial for free on their website.

When crowding reaches dangerous levels, hospitals often divert inbound ambulances to other facilities. In 2003, diversions occurred more than half a million times — an average of once per minute.³ Diversion may provide a brief respite for a beleaguered staff, but it prolongs ambulance transport times and disrupts established patterns of care. It also creates ripple effects that can compromise access to care throughout a city. Because crowding is rarely limited to a single hospital, one facility’s decision to divert ambulances can prompt others to follow suit. When that happens, a city may experience the health care equivalent of a “rolling blackout.” Everyone’s access to care is affected — the insured and uninsured alike.⁴

The complete article can be found here.

An article in the New York Times presents a microcosm to a phenomenon that occurs throughout medicine.  In Public Health school we call this “small area variation,” and it drives insurers completely nuts.

When it comes to treating blocked arteries, there are no definitive studies showing which approach most benefits patients in the long term. And some local insurers agree that the Elyria hospital provides high-quality care.

But there is little doubt that hundreds of Elyria patients each year are getting angioplasties that they would not be getting if they lived elsewhere in Ohio — or in any other part of the country for that matter — at a cost of millions of dollars a year to Medicare, the federal insurance program for the elderly. Elsewhere in the state, some of the sickest of these patients might have received bypass surgery, while many others might have simply been treated with drugs. Or, for those whose conditions were not diagnosed or were not deemed serious enough, there might have been no treatment at all. .

Experts know that changing the financial incentives can change the way medicine is practiced.

A major problem, as cited above, is that often times medical technology and approaches change so fast that it is very difficult to have definitive studies.  At the same time, many doctors are not comfortable with the fiscally conservative approach which demands that the cheapest method be used unless a more expensive option is proven to be more effective.  The truth is that many other industry have practices that don’t demand clear undisputed evidence, and medical practice will often not advance without it.

Still, small-area variation clearly is evidence that a problem exists.  Both groups of doctors can’t be right, and extreme variation like this only make it obvious the degree to which we simply don’t know.

complete story below

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An excellent post from a fantastic blog, Get Rich Slowly:

Beggars are a moral quandary for me. I want to help. In an ideal world, I’d help them all. Or I’d at least help those who are legitimately in trouble. But how can I tell which beggars are truly needy, and which are just going to use the money for booze or pot? Does it matter? And who am I to judge?

It might seem silly to write about this — it’s such a trivial part of personal finance (if a part of it at all) — but I think it presents important moral implications. I know many people are opposed to giving money to beggars ever, and I cannot blame them. I’m always reminded of one of my favorite Bible passages, the parable of the Sheep and the Goats (Matthew 25:31-46), which reads in part:

For I hungered, and ye gave me no meat: I was thirsty, and ye gave me no drink: I was a stranger, and ye took me not in: naked, and ye clothed me not: sick, and in prison, and ye visited me not. Then shall they also answer him, saying, Lord, when saw we thee hungered, or athirst, or a stranger, or naked, or sick, or in prison, and did not minister unto thee? Then shall he answer them, saying, Verily I say unto you, Inasmuch as ye did it not to one of the least of these, ye did it not to me.

The comments I posted in that blog:

The Sheep and Goats parable is troubling. It is easily to justify not giving by making judgments like “they probably use it for drugs,” but I don’t think that is what God intended. The Bible doesn’t tell us to try to figure out the scammers, it just asks us to give what we can. There is an ultimate judge, and I try to trust that the scammers will get what they deserve, and those who are not scammer will find some measure of comfort.

The New York Times is reporting today about how Medicare changes that were planned are being reversed.  I guess it’s a fancy way of saying that nothing has changed.

The “scale back” (lack of change) was argued as being a good thing.  In particular, the new payment system would have made heavy cuts into the payments for cardiac coronary artery drug-eluting stents, defibrillators, and other “newest technology.”  The New York Times cites a number of analysts:

“The final rule significantly moderates proposed cuts for cardiac procedures,’’ Citigroup said in a note to investors. Lehman Brothers described the final rule as “a win for cardiac and orthopedic device companies, specialty hospitals and general acute care hospitals.’’ The Prudential Equity Group said the final rule, which takes effect on Oct. 1, was “favorable for device manufacturers’’ like Boston Scientific, Medtronic and St. Jude Medical.

The part that concerns me, however, is what follows:

“Under the final rule, hospitals will receive much smaller increases than originally proposed for treating some conditions, like pneumonia and chronic obstructive pulmonary disease.”

The issue I have is with the assumption that the newest technology represent the best of medicine.  As a self-proclaimed gadget geek, this might surprise you, but it is not entirely clear that the latest findings are the best and most accurate.  In particular regarding devices, very few of these have good long term studies showing safety and efficacy.  In fact, by their very nature, because they are new technologies, nobody truly knows what is going to happen 20 years down the road.

Medical devices, unlike other technologies, don’t automatically improve.  Windows XP (no matter how bad) is better than Windows 95, is better than Windows 3.1, but it’s not clear if the new hip device is worth 50% more than the old hip device.  This goes hand-in-hand with the fact that a major reason for rising health care costs in this country for the past 20 years is due to medical technology such as these.

I’m not down on medical devices in general.  The innovation of these companies is commendable.  I just worry that the “new technology” is taking precedence over tried and true technology such as antibiotics.  I worry that innovation is being steered away from less profitable fields like pulmonology and into fields flush with money such as cardiology and orthopedics.  In my hospital, I can already see that the patients who have “high-paying” problems generally get preference, and these payment structures only exaggerate the multiple-tier system.

I suppose these payment systems are examined by people smarter and better informed than me.  I am happy that the health care field is getting money, I just wonder if it is going to the right place, and whether we are creating the proper incentives for innovators within our field.
The complete article, as usual, is below:

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