Monday, November 24, 2014

Coming Up Empty. Does The Government Look Before It Leaps?

A few months ago I assessed a patient with dementia.  I dutifully ordered the appropriate blood testing and MRI.  As I delved further into the history, I was concerned that there may be a component of depression.  Pseudodementia (memory disturbance and dementia like symptoms caused by depression) can often mimic classic Alzheimer’s disease, but resolves with proper treatment.  The best way to differentiate these two syndromes is neuropsychological testing.  I decided to send my patient to a colleague whom I had been working with for years.  He had recently joined a large multi-specialty group owned by the major hospital system in our area.

The patient returned to my office a few weeks later.  Not only did he get the consult, he also was sent directly to the neurologist next door (who worked for the same medical group/hospital), and had all his blood work and MRI repeated.  He was placed on a dementia medication called Aricept.  Now most primary care physicians can manage run of the mill dementia without a neurologist’s input, and many agree with The American Geriatrics Society’s Choosing Wisely campaign that Aricept should be used sparingly.  So it seems my innocent and appropriate neuropsychology consult turned into a very expensive episode fraught with repetitive and unnecessary care. 

What gives?

A recent study in JAMA by James C. Robinson and Kelly Miller examined per patient expenditures for hospital-based practices in comparison to those that are physician owned.  They found that hospital practices were 10.3% more expensive and multi-hospital system owned practices were 19.8% more expensive then private physician practices in the period from 2009-2012.  The goal of the study was to examine the effects of work force consolidation among providers that was occurring at a breakneck pace as a result of Obamacare (for a good discussion of consolidation and Obamacare see Scott Gottlieb's article in Forbes).

Whether intended or not, this is just another example of how governmental policy is both failing to bend the cost curve, and having a neutral if not negative effect on healthcare quality.   In fact Washington has been dead wrong more times than not.  There is no better example than the Medicare demonstration projects.  Lauded as government innovation, these projects were set up to test the most "prescient" beltway policies.  In January 2012 the Congressional Budget Office produced a memo titled: Lessons from Medicare’s Demonstration Projects on Disease Management, Care Coordination, and Value-Based Payment.  They concluded that of the ten projects to date,  the improvements in cost and quality had been negligible.  

More recently there has been a much hype about pay for performance.  Aaron Carroll does a nice run down of how it has failed to show benefits in his New York Times piece.   The promise of electronic medical records and meaningful use was just another disappointment as documented by the RAND Corporation's most recent analysis.  The Bundled Payments For Care Improvement initiative is now well under way and is the next in a long line of "innovations" which is expected to fail.

Looking into the future,  I am strongly in favor of the governments ability to form and test hypotheses.  Demonstration projects can help us predict which policies may actually lead to improved healthcare.  The problem is the government tends to look before it leaps.  Healthcare consolidation,  pay for performance, PQRS, and meaningful use are already prime time even as the studies to prove their effectiveness are coming up empty.

Tuesday, November 18, 2014

The Not So Humorous Unintended Consequence of Healthcare Reform is Monopoly


The administrator's voice wavered as I picked up the phone.  He was calling about the nursing home patient that I admitted the day before.  While normally forthright, I could feel the discomfort in his tone as he danced around the issue.  The patient's insurer had called.  Apparently they made an "arrangement" with the Mega ACO owned by the latest consolidation of Goliath health systems.  They wanted my patient transferred to another doctor.  Apparently the insurer now required all it's patients to be seen by only medical group physicians.

The administrator was almost whispering now.

The truth is, if it was up to me, I would have you see all our patient's!

The medical group doctor hardly ever rounded.  She was almost never available for urgent calls.  Her patients were transferred out to the hospital at the drop of a hat.  Yet, incredibly, she was managing three quarters of the nursing home population.   But the medical group physician had one advantage that trumped clinical quality or even cost of care.  She was measurable.  Her every move was recorded in an electronic medical system that could be beamed into the greedy hands of administrators, case managers, and insurers at whim.  This data could be analyzed and assessed, and spit back at her with ultimatums and extracted promises.

We sat silently on the phone at a loss for words.  The nursing home could not dare damage the fickle relationship with the ACO.  Otherwise the growing stream of patients coming from the local hospital would diminish.  It had been that way for some time now.  The threat was implicit to the arrangement.  The not so humorous unintended consequence of healthcare reform is monopoly.  And there is a power grab by huge expansive hospital systems for the billions of dollars, I mean patients, ripe for the picking. Physicians and nursing homes, doctors and nurses have all become pawns.  They are fodder for a game playing out around the country.

The administrator was the first to speak.

You know that the ACO will be merging with your other hospital systems soon.

He was right.  It was only a matter of time before they would be kicking me out of the nursing home business and replacing me with some no named company man.  As I began to hang up I sensed a ring of optimism bouncing over the phone line into my unwilling ear.

You might want to join the medical group, we really need you to see more patients here.

I hung up.


Monday, November 17, 2014

You Are Not Your Data

A few weeks ago, @drmikesevilla (Mike Sevilla) live tweeted a slide from Eric Topol’s (@EricTopol) talk at the American Academy of Physicians' 2014 annual meeting. The slide, a picture of a young man with transparent numbers and data points outlining his face, is silhouetted by words in bold black print: YOU ARE YOUR DATA. This sentiment was a throwback to Dave deBronkart’s (e-Patient Dave’s) 2009 keynote address for the Medicine 2.0 Congress in Toronto titled “Gimme my damn data, because you guys can’t be trusted.”
The idea is that a person’s ability to understand and control their medical records, previous lab results, and even biometric data will lead to more engaged patients and better outcomes. While enticing to blindly follow this logic, there remains a fallacy to such arguments...

Please read the rest of my post at The Medical Bag.

Tuesday, November 11, 2014

My First Patient Was A Mouse

I didn't think much of it at the time.

Most physicians can trace back and recall their first patient.  For some, it is a clinical encounter the third or fourth year of medical school.  The more creative may point to their cadaver during first year anatomy and nod knowingly.  My first patient was a mouse.   Or shall I say a group of them?

My freshman year of college, I volunteered in the lab of a prominent endocrinologist and studied a new drug to reverse the course of type 1 diabetes.  We monitored genetically bred, non obese, diabetic mice.  Every day we would reach into their cage and grab them as they scurried about.  Then we would rub their bellies inducing urination, swab the urine, and test for glucose. The unlucky creatures with a positive urine test needed to have blood drawn.  The thing about mice is that they don't have obvious vessels like you and I.  In order to get a drop of blood, we had two choices: either cut a portion of the tail or tap the choroidal plexus behind the eye.  The latter approach, while more brutal, was less maiming.

I would take a swab and dip it in ether.  The swab would be applied to the mouses nose inducing anesthesia.  The tough part, while applying pressure to the orbit causing the globe to pop out of the socket, I would slip a pipette behind the eye and turn until blood shot up the tube.  Then, if we were lucky, the mouse would wake up.  If not, we used our fingers to compress the chest performing mouse CPR.  Those mice proven to have diabetes would be randomized to two separate groups.  One would get the experimental injection while the other would get placebo.

I passed many days and weekends alone in the lab.  One sleepy Saturday,  I approached a mouse in preparation for a blood draw.  Mice can be slippery creatures.  The technique most favored was to grab them by the scruff of the neck with the thumb and forefinger, and hold the back tightly with the base of the hand.   So I thrust forward like I had done dozens of times.  I got a good hold, and flipped the mouse around to face me.  But something went terribly wrong.  I must have grabbed too high, or maybe too roughly.  The mouse's body quivered and then shuddered in such and odd and frightening manner.  I reflexively released as the mouse fell to the table.  Dead.  With horror, I realized that I accidentally snapped it's neck.   I will never forget the feeling of life passing so quickly and unexpectedly in my hands.

I occasionally think about this as I watch family members cradle their loved ones in those passing moments before death.  Do they feel the shudder?  Do they experience revulsion or relief?

And I sometimes have fevered dreams about that mouse.  When I toss and turn, unable to sleep because of the crushing pressure of some clinical decision or another.  That poor creature.

That poor creature who succumbed under the weight of my thick, clumsy hands.

Tuesday, November 4, 2014

Sadness On The Side

The calls came simultaneously.  One from the hospital and the other from a nursing home.  Two deaths separated by fractions of a second.  My heart swelled.  For a moment.  The pile of papers on the desk softly whispered.  My mobile howled jealously vying for my fragile attention.   I could feel the emotion drain as I turned back to the task at hand.  Unexpectedly, my mind wandered back to the wedding in California.

It was a spectacle.  Pre-ceremony hors d'oeuvres with sushi stations and Kabobs.  An open bar long before the utterance of the first I do.  The wedding party bespectacled in gowns and tuxedos danced down the isle as the gala began.  I felt the joy, in every corner of the room, soak the participants in a  humid haze.  It was heavy but far from suffocating.

I held my wife's hand as first the groom and then the bride sauntered down the isle.  The groom paced the full length but then circled back as his bride reached the middle section.  They walked together to meet the Rabbi.  My wife glanced in my direction and saw the tears welling in my eyes.  She looked quizzically before turning back to the ceremony.  I was far from surprised.  

I have been crying a lot lately.  At weddings, during movies, or while watching television  It's something that has grown exponentially over the years.  The barriers of my heart have become weak and the tide crashes into the breakers and spills shockingly on the barren land below.

I have lost control.  And I know exactly why.

It's just that I see so many awful things.  My daily menu consists of death and destruction with a healthy serving of sadness on the side.  I swallow these whole, rarely having the time or energy to chew properly.  Yet all that is pushed down must eventually be digested.  I no longer mourn, for after all these years mourning would have morphed from a hobby to a full time profession.  I neither grit my teeth nor curse a deity that often seems indifferent to the suffering of us poor plodding humans.

Instead I cry.  When it's safe. When the joy becomes overwhelming.