Saturday, December 23, 2006

Who Should Enforce Standards?

Those whose eyes are caught by such things will have noticed the recent mention in the press of a study indicating that physicians who spent more time performing colonoscopies found more polyps. I happened to see it in the December 19, 2006 issue of the New York Times.

According to the reported study, the critical time period was during the gradual withdrawal of the scope, when the physician is looking for the polyps. Those who spent at least six minutes at this had the best results.

The NYT article went on to discuss how colonoscopy patients might use this information to select a physician to perform the procedure.

I thought the report noteworthy for two reasons. One was the ease with which the public now engages in public evaluation of how medicine is practiced – an indication that the profession is gradually losing its mystique. As medicine loses its mystique, its claim to professional independence and immunity from supervision weakens.

The other was what it implies about consumerism in health care. There is never going to be an easy or gracious way for the ordinary consumer to find out whether a particular physician takes more or less than six minutes to withdraw a colonoscope, or whether the physician’s polyp discovery rate is 25% or more (the standard quoted in the article).

It would be much better, it seems to me, if hospitals and group practices took responsibility for monitoring and enforcing standards of practice. I would like to believe that if I get my colonoscopy at the Leahy Clinic in Boston, Methodist Hospital in Houston, the Henry Ford Health System in Detroit, or the Myrtue Memorial Hospital in Harlan, Iowa, the institution makes sure that the gastroenterologists on its staff are all practicing according to accepted standards.

Thursday, December 07, 2006

Not Quite Ready

Massachusetts health authorities have decided to publish mortality data for each of the 55 heart surgeons who perform cardiac bypass operations in the Commonwealth.

According to the article in the December 6, 2006 issue of the Boston Globe that reported this decision, this same data has been published in Massachusetts since 1991, but by hospital without identifying surgeons. During that time, one hospital temporarily suspended its cardiac surgery program because of high mortality and another suspended a surgeon, presumably for the same reason.

The article indicated that the first report will include some “outliers;” i.e., surgeons with high rates, but that those surgeons no longer practice surgery in Massachusetts. (Mortality rates will be reported as three-year moving averages and the data will be almost two years old by the time they are released.)

So if reporting by institution was working, why identify individual surgeons – particularly when an “outlier” not dealt with by a hospital could be killing people for two years before the numbers become public?

The authority interviewed was quoted as attributing the decision to “….the growing push by employers, insurers, the federal Medicare program, and the Romney administration to more fully disclose medical care data.”

My own interpretation is that while both logic and evidence indicates that properly run hospitals are our best assurance of quality health care, we are still not quite ready to put our faith in institutions rather than in individuals.

Monday, December 04, 2006

The Hazards of Reasoning by Analogy

It seems that Governor-elect Eliot Spitzer of New York wants to deal with rising health care costs in his state by closing a bunch of hospitals (NYT, November 26, 2006). One supposes that he is reasoning by analogy from companies like General Motors which, when they need to reduce cost, close assembly plants.

Unfortunately, the analogy doesn’t necessarily hold. One letter to the editor the following week (NYT December 3, 2006) pointed out that the patients in these so-called underutilized hospitals are likely to transfer to other facilities where costs are higher. The same letter suggested that the hospitals receiving those patients would thereby come to enjoy a stronger monopoly position, which they would use to negotiate higher rates with health insurance companies.

Comments in other letters ran the gamut. One writer put blame for the cost problem on the usual suspects like malpractice courts, insurance companies, HMO’s, and drug manufacturers. Another said that what was needed was more money (apparently 15% of our national wealth for health care is not enough for him).

All of this demonstrates the absence of any generally accepted understanding of how the economy of our health system works.

So my advice to the Governor-elect is to get an understanding of the economics of health care and reason from that, rather than by analogy.

Sunday, December 03, 2006

A Devil’s Bargain

A hot subject in health care these days is something called Pay for Performance, which has been given the clever acronym of P4P.

P4P is a scheme whereby health insurance pays higher rates to providers - mainly hospitals and doctors - who meet certain performance standards.

Providers have gone along, apparently being allured by the possibility of increasing their income.

It sounds like a good idea all around, but there is a catch.

Over the years, health care providers have been seen as dedicated professionals who can be trusted to do the right thing. That image has given them high social status, a great deal of independence, generous financial support, and more than a little power.

But they seem not to realize that the message implicit in P4P is that they can’t be counted on to do the right thing unless they get paid extra.

The risk is that once that comes to be realized, much of the justification for their status, independence, generous support and power will have been lost.

And the ironic thing is that the amount of money involved in P4P is not all that much.

It’s a devil’s bargain.

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