A rare entry in the good policy column. I heard from Propublica and NPR yesterday that some major manufacturers of drugs have cut down the amount of money they spend paying doctors to speak about their products by half. These companies include Eli Lilly, Novartis, and Pfizer, among others. Now, this reduced spending is valued in the area of 15-20 million dollars per company, chump change for Big Pharma. Still, good progress, right? These companies are seeing the error of their ways…
Well, not quite. Big Pharma has had, for some time, a loose relationship with the truth and a very cozy one with some physicians. Ten big pharmaceutical companies have been fined a total of 13 billion dollars in the last few years for fraudulent marketing. Ten of them. Most of the fraud involved mislabeling drugs, failing to list side effects, and most often, marketing drugs for inappropriate or off-label uses. So the marketing problems have not been in relation to physician compensation per se. Since physician compensation for drug speeches comes under the label “marketing”, it’s hard to see how doctors could have been totally innocent in these cases.
But there might be another reason payment for doctors to do drug speeches and dinners is going down. The ACA. Obamacare. Yes, that hated piece of legislation. I know, health insurance exchanges and the problems therein have made the headlines, but did you know there’s a provision in the act called the Physician Payment Sunshine Act? No? There is. And guess what? It goes into effect this September. I love love love this act! If it works the way it’s supposed to. Here’s what I suspect: any pharma CEO worth his salt is going to look at his budget for marketing and simply move physician payment money to another, murkier, marketing strategy. And why? Does this CEO have something to hide? Something he doesn’t want the sun to shine upon? Otherwise, why the cut in spending? The pharma companies say the decrease is the result of an unusually large number of drugs going off-patent. Meh. Not totally buying it.
There is a big truck-sized hole in this sunshine act. Pharma does not have to report payments to NPs and PAs. I’m sure our CEO can find a way to work this. There is only one way to stop pharmaceutical companies from spending some of patient’s money to compensate doctors. Doctors have to say NO. NO, NO, NO. There is absolutely no reason doctors should be involving themselves in the marketing of any drug, I don’t care how fabulous or life-saving. That is not our job. It demeans our field, makes our patients mistrust us, and detracts from our ability to take care of people. Please, colleagues and friends. Just don’t.
My dear friend Paul Ryan, who has his eyes firmly glued on the white house, recently released a 200-page report with lots of figures and references and ibid’s claiming that all the anti-poverty programs run by the government are worse than useless and should all be scrapped. He’s got some ideas on why people are poor: they come from or create broken homes. They have no education. They don’t work. They work part-time. They receive medicaid. Wait, what? Here’s what the report claims:
“Medicaid coverage has little effect on patients’ health,” the report says, adding that it imposes an “implicit tax on beneficiaries,” “crowds out private insurance” and “increases the likelihood of receiving welfare benefits.”
Is this true?
There’s a lot of references listed at the bottom of the page. Let’s look at some of them.
1. the Medicaid and CHIP Payment and Access Commission. Children on medicaid or CHIP are more likely than privately insured or uninsured children to be in fair or poor health…and to have more problems like asthma, ADHD, autism, etc. Well, yeah. Medicaid helps poor people. Poor people often have poorer health. That doesn’t mean that medicaid causes poorer health.
Oh, and I love this one. Adults younger than 65 who are enrolled in medicaid are sicker than those who are privately insured or uninsured. That’s because you have to be disabled to get on medicaid if you are younger than 65!
2. A study out of Stanford by Baker and Royalty: Medicaid Policy, Physician Behavior, and Health Care for Low Income Population. Medicaid patients are more likely to be treated in hospitals or public clinics than in private physician’s offices. OK, that’s true. Medicaid pays 70% or so of what Medicare pays, which is way less than what private insurers pay. Baker and Royalty assert that this is not an efficient source of care. But it’s the cheapest. One could argue that if reimbursement was better more patients would get treated by private physicians. Assuming that really is better.
3. The Oregon Health Insurance Experiment. Medicaid patients use more health care than uninsured patients. Well, duh. What, the goal is to keep people from using health care at all? If that were the case we’d be spending all our money on promoting exercise and salads, not invading countries. And the report chooses to ignore the rest of the story, which is that the medicaid patients also had lower out-of-pocket expenses, lower medical debt, and better physical and mental health.
4. The Oregon Health Insurance Experiment II. Medicaid coverage does little to improve people’s health. That’s because health care does not improve people’s health. People do. Poor people have fewer options for healthy lifestyle choices. Mr. Ryan’s report also plays down the rest of the story, which is that having medicaid also increased the use of preventive services and eliminated out-of-pocket catastrophic debt. Which is what insurance is supposed to do.
5. Rachel Rapaport Kelz in an article entitled Morbidity and Mortality of Colorectal Carcinoma Surgery differs by Insurance Status. Medicaid patients are more likely to get sick during their hospital stay. This is another entry in the duh category. This is not because they have Medicaid. It’s because they are poor. And because they are poor, they have fewer healthy lifestyle options. Because they have fewer healthy lifestyle options, they’re sicker. Put them in the hospital, they’re sure to get sicker yet.
How about that “implicit tax?”
6. The Interaction of Public and Private Insurance: Medicaid and the Long-Term Care Insurance Market, by Brown and Finklestein. ”The premiums that one might have paid for existing private policies go to pay for benefits that would have otherwise been provided by Medicaid.” I have no idea what that means.
And finally, the topper: Being on medicaid increases the likelihood of receiving welfare benefits.
7. Moffit and Wolfe: The Effect of the Medicaid Program on Welfare Participation and Labor Supply. A rise in medicaid benefits increases the likelihood that a person is on AFDC (welfare) and decreases the likelihood that the person has a job. Somebody needs to explain cause and effect to Moffit and Wolfe.
This is all to say that medicaid does not cause anyone to be poor, be on welfare, have poor health, etc. Medicaid is a health insurance program for the poor. Being poor therefore increases the likelihood that you’ll be on medicare. It’s not a great system and the care isn’t that good, but it’s not a failed program. The war on poverty may indeed be lost, but not because of medicaid. It’s being lost in spite of medicaid.
If you follow your local healthcare marketplace even superficially you have probably noticed that everybody is merging with everybody else. Hospitals, physician groups, and even insurance providers are combining themselves in various ways, ostensibly for the purposes of either making money or helping people, or both. The Affordable Care Act has had something to do with this by agreeing to pay these groups in specific ways, depending on a set of performance measures. There are three broad categories of such groups: Physician Quality Reporting System (PQRS), Group Practice Reporting Option (GPRO), and Accountable Care Organization (ACO).
ACO’s in particular have gotten a lot of attention because the payment system rewards cost-savings and makes the group pay for cost overruns. For example, medicare will pay $X to ACO Y for all their medicare patients. If the total cost for care of all the medicare patients in ACO Y is lower than $X, the members of the ACO keep the change. If the total cost is higher, the members lose money. In order to prevent wily hospital CEO’s from skimping on care and pocketing the dollars, 33 performance measures are followed to ensure care is adequate. Forgive me if all of this is review. I’m getting to my point.
Last Friday the government released performance numbers for five of these measures for 141 ACOs in 2012. The five they chose were, essentially, the easiest to understand and the least controversial. Four deal with diabetes and one with vascular disease. Here are the measures:
1. Controlling blood sugar levels in patients with diabetes
2. Controlling blood pressure in patients with diabetes
3. Ensuring that patients with diabetes do not smoke
4. Prescribing aspirin to patients with diabetes
5. Use of angiotensin-converting inhibitors (ACE-I) or angiotensin receptor blockers (ARB) in patients with diabetes and weakened left ventricles.
According to the Kaiser Family Foundation analysis, ACO’s accomplished these 5 measures satisfactorily 65-75% of the time. OK, not bad. The groups varied widely, however, from 9% on some measures to 97%. The other two types of group payment systems, PQRS and GPRO, did a little better. I’ve been searching around but I can’t find any data on how all individual groups within the ACOs did on these measures before they joined the ACO. That would be nice to know.
The thing is, I’m not sure why consumers need this information, at least on an individual basis. You see, patients don’t choose a specific ACO. Chances are you are in one and you don’t even know. You can’t shop around for an ACO, or a PQRS, or a GPRO. You the patient don’t know how your personal doctor fares on these metrics. What is important to know is how your doctor is getting paid, or not. It’s important because, if you look at those quality measures above, you notice that one of them is a personal behavior that has little to do with your doctor (smoking), and two others require significant patient cooperation (controlling blood sugar and blood pressure). So, in very real way, the behavior of you the patient determines how much the doctor gets paid. Imagine if a group of, say, plumbers got together and persuaded 5,000 customers to pool their money and pay them a set rate for any plumbing problems that occurred in a given year. Say 100 or so of those customers hate all plumbers. Or are just really irresponsible. Those people could, with their behavior (clogging drains, putting hair in the toilet, letting the pipes freeze, etc.), decrease the pay for all the plumbers in the group. Plumbers are smarter than doctors and would never put up with pay being dependent on someone else’s behavior. That’s what your doctor faces. Just so you know.
Henny Penny is right. The sky is falling. Our assumptions are being challenged all over the place. Received wisdom is being called into doubt. Derek Jeter is retiring. Mammograms don’t decrease mortality. Now this: It turns out that SAT scores make exactly zero difference in college success. (http://www.nacacnet.org/research/research-data/nacac-research/Documents/DefiningPromise.pdf). Oh man! All that money my mother spent at Kaplan! Actually my mother spent no money at Kaplan which is why my SAT scores were, well, what they were. Doctors and physicists with low SAT scores are vindicated! In any case, while there had been rumblings about this from colleges and industry groups for awhile, this was the big study that confirmed the hunch.
Studies like this are scary for a lot of people. Not just for the test-prep folks or the people that administer the tests. It’s scary for people who’s job or inclination it is to impose control on the world. It threatens the idea that everyone can be scored and categorized, put in his or her proper place. It threatens the comfort of knowing where everybody stands. It threatens imposed order. This sort of study, and to a lesser extent the mammography study, implies that it might be OK to refuse to conform. Just a little bit. It suggests that everyone saying something “must be done” doesn’t actually end the conversation. It suggests that people with skills and opinions that don’t fit into neat multiple-choice niches might have a place in a carefully guarded meritocracy. It suggests that it’s OK to be a little bit naughty.
When I was growing up there were a lot of things you “just did”. You went to school and sat quietly. You got good grades. You took your SATs. You went to college. You did what you were told and the implication was that if you conformed in all these ways you were safe from…what? Safely on the “good” side of the line, the responsible citizen line. And you would be happy. Same thing in medicine. It used to be that you got your yearly physical, you did what the doctor said, you got your cholesterol checked, you got your mammogram and your PSA and your PAP, you did your 30 minutes of exercise, and all this put you safely on the responsible side of the line, where it was safe. Very simple. Very comforting.
It turns out that a lot of us got sold a load of crap. I went to medical school and came out miserable. Matt Damon dropped out of Harvard and is, to all appearances, happy as a clam. One person from a prosperous home gets perfect SATs but it’s the minority student on the next street over who succeeds at the college they both go to. One violinist plods along faithfully, practicing 8 hours a day, but the violinist who gets the symphony job is the one who never set foot in a practice room. One person has 12 letters after their name but it’s the guy with the high school diploma who creates Facebook. One woman never gets a mammogram and lives to be 100 and another gets hers at age 40 and is dead 2 years later.
Life is much messier than we would like it to be. We live in a great world where we can make choices. We can challenge the received wisdom. We can use our actual talents, rather than manufacturing talents we don’t have in order to fit the picture we are supposed to present. We can succeed in a way that feels like our personal definition of success, not someone else’s. We can refuse to conform and live with the consequences. But we have to think a little, and we have to choose. It’s so much easier to just do what we’re told.
Most of you don’t know this, but I have been invited to write for the blog Wright on Health, started by Brad Wright at the University of Iowa. It’s a health policy site mainly, so I’ve been trying to speak intelligently about health policy, at least to Brad. A few weeks ago I wrote a piece for him about the “doc fix”. Here’s what I said:
Let’s talk about the Doc Fix. No it doesn’t mean that surgeons will get any less cranky or that your urologist will improve his bedside manner. What I am talking about in this case is the Sustainable Growth Rate formula. You see, the Center for Medicaid and Medicare Services, or CMS, has to figure out every year how much it’s going to pay for things. The SGR is supposed to ensure that as fees for everything in healthcare go up, the rate of increase does not outpace the growth of GDP. In a complicated middle-man maneuver, CMS sends a report to the Medicare Payment Advisory Commission, which in turn advises Congress on how much medicare spent last year and how much it’s targeted to spend next year. There is a conversion factor that adjust payments based on how much over or under the target cost was the previous year. The SGR is that conversion factor, and believe me unless you have the beautiful mind of John Nash you don’t want to know how it’s calculated. The SGR was formulated in 1997 and, put simply, is a way to control costs.
So the SGR is a formula to control medicare costs. OK. So what’s the problem? The problem is that as healthcare spending has outpaced GDP, every year since 2002 physician reimbursement has gone down. The SGR demands it, because every year cost is over the target. And every year Congress, under the heavy lobbying of the AMA, passes short-term overrides to prevent these cuts. And why is THIS a problem, since everything Congress does these days is emergency short-term fixes? Money. The gap between what the SGR says we should pay for medicare and what it actually costs is about $300 billion. The gap will get bigger and bigger.
You can read the rest at wrightonhealth.wordpress.com. If you do, you will find that I predicted that the alternative to the SGR would have something to do with physician performance measures. Medscape Medical News, an industry news feed, has just informed me that I was right. Unfortunately. A new hammer has been proposed with which to bludgeon us called the Merit-Based Incentive Payment System (MIPS). It’s not really new, it’s just three smaller hammers put together: Meaningful Use, Physician Quality Reporting System, and the Value-Based Payment Modifier. Yeah, those all exist. You didn’t know?
Here’s how Robert Lowes, the author of the Medscape article, explains MIPS:
“The proposed MIPS program would assess physicians in 4 categories: the quality of their care, EHR meaningful use, use of healthcare resources (eg, ordering too many tests), and activities undertaken to improve clinical practice. Physicians would receive a score of 0 to 100, according to their performance in each of the 4 categories. Medicare would compare a physician’s composite core with a performance threshold that would be either the mean or the median of the scores for all clinicians subject to MIPS. In a zero-sum game, clinicians who score above this threshold would receive bonuses funded by the penalties imposed on physicians who fall below the threshold. Bonuses would max out at 3 times the penalties, which are capped at 4% in 2018, 5% in 2019, 7% in 2020, and 9% in 2021. The law would award an additional $500 million per year from 2018 through 2023 to exceptional performers.”
I feel like a figure skater. Ooh! I hope I can be an “exceptional performer!” I really want to get bonuses funded by penalties lowered upon my colleague next door for failure to ask enough people if they smoke or for failing to prove that they use their computer meaningfully.
I’ve been thinking about Canadian women’s breasts. Well, not their breasts individually, and not for aesthetic evaluation. I’m talking, if you haven’t heard, about the big study out of Canada that failed to show mortality benefits from mammogram. This post is actually not about the results of the study. For my purposes the results are irrelevant. This is about Data. Evidence. And how we get it.
First of all, that Canadian study could never have been done here in the US. You’d never find 45,000 women to consent. You’d never get it past the institutional review board. Because mammograms are now what we call “standard of care”.
But let’s talk about the greater issue of randomized clinical trials (RCTs) in general. The Innovation Center got criticized recently for not doing enough RTCs in its effort to find more efficient and cost effective ways to deliver health care. I think I talked about some reasons why that might be. But here’s another reason. In this country policy comes before data.
A couple of examples. Take the whole Time Out movement. Someone thought we could prevent more wrong-side surgeries or wrong-patient surgeries if we implemented a Time Out, in which every member of the surgical team has to stop before incision and review the patient’s medical record number and correct side. Got national attention and everybody implemented it. No one said “Hey, that’s a great thought. Let’s see if it is actually true that time outs reduce medical error!” We did it backwards. Now we can’t do 100,ooo surgeries and randomize them to time out or no time out. The policy is already in place. And even if someone did such a study, people who are invested pro or con in time outs wouldn’t change their minds, or their policy.
So thats Time Out, but TO just costs a few seconds and a bunch of educated people standing around with an intubated and draped patient with a bone sticking out of his leg intoning medical record numbers and agreeing that, yes, it is the right leg that’s broken. Some policies have environmental implications, if you care about that sort of thing. A few years ago a hospital got criticized by the accrediting organization for not having post-operative anesthesia notes on out-patient, ambulatory surgery patients. Someone decided it would be good for everybody having a knee scope to get a note in the chart from an anesthesia provider that said everything went fine. Now, everything was going fine before, mind you. No one had been sent home inappropriately, no one complained, no one felt ignored. But there was a policy. No one said “Hey, that’s a great thought. Let’s see if it is actually true that anesthesia post-operative notes improve patient outcomes.” Uh uh. Backwards. Now we generate, lets see, conservative estimate 40 patients per day, 20 days a month, 12 months a year, thats…(I hate math) like, 10,000 pieces of paper. Per year. Policy before data.
I could go on. Let’s take a slightly different approach. On a national scale, CMS (Center for Medicare and Medicaid Services) has decided that one of the quality measure for anesthesia is whether or not patients were adequately warmed in the OR. OK, fine. I want to be warm if I’m operated on. CMS feels so strongly about this measure that they won’t pay you for doing the anesthesia for the surgery unless you can prove you addressed the warming issue. To be fair, there is plenty of evidence that warm is better than cold for surgical patients. So anesthesia departments everywhere put a little check mark in their EMRs saying “patient appropriately warmed” or something to that effect. Fine. Except that’s not a measure of how many patients got warmed. It’s a measure of how many people clicked the box. In this case, we have data, we have policy, but the policy is based on flawed or meaningless data.
The problem with health care in this country is not data. We’ve got data. We’re drowning in data. This data has very little impact on what people believe or what they do. More importantly, we are in danger of implementing policy with bad data, or no data at all. A good idea is not proof.
There are many provisions in the Affordable Care Act that people don’t know about. Everybody is familiar with the health insurance part of it, but did you know the Centers for Medicare and Medicaid services (CMS) is giving $10 billion dollars to an organization called “The Innovation Center”? The Innovation Center is charged with researching ways to most effectively deliver health care. Good goal. The center’s website says “The Innovation Center develops new payment and service delivery models”. Oh. Well, still good goal.
Here’s what the definition of a “model” is, according the the free online dictionary: A schematic description of a system, theory, or phenomenon that accounts for it’s known or inferred properties and may be used for further study of its characteristics. So a model is not the thing. It’s a smaller or schematic representation of the thing. So what the Innovation Center is supposed to do is find or come up with schemes of payment and service delivery and try them out. It has been doing this, so far, largely with “demonstration projects”. A demonstration project tests an idea or group of ideas that might improve either payment systems or delivery systems, and then uses some complicated math to determine if things were better or worse before and after the idea is implemented. Therefore, CMS is not looking for proven methods of improving payment or services, but testing ideas that might work.
There’s nothing wrong with this, by itself. My 2-year-old does this all the time. She peers up at the kitchen counter, determines she can’t see, drags a chair over, gets on it, and compares the view with the chair vs. the view without the chair. Over time this has allowed her to develop a policy of always getting a chair if she wants to see what I’m doing. She wouldn’t go get the chair if I just said “be a good girl and go get a chair” and then praise her and give her a cookies if she does it. If you go the the Innovation Center website what you mostly see is incentive programs for good behavior. For example: The Comprehensive Primary Care Initiative is one of the Innovation Center’s projects. This is how CMS describes this program:
“The Comprehensive Primary Care (CPC) initiative is a multi-payer initiative fostering collaboration between public and private health care payers to strengthen primary care. Medicare will work with commercial and State health insurance plans and offer bonus payments to primary care doctors who better coordinate care for their patients. Primary care practices that choose to participate in this initiative will be given resources to better coordinate primary care for their Medicare patients.”
Here’s another: The Physician Group Practice Transition Demonstration:
‘The PGP Demonstration was the first pay-for-performance initiative for physicians under the Medicare program. Under the PGP Demonstration, physician group practices continued to be paid under regular Medicare fee schedules, but earned incentive payments for offering patients high-quality, coordinated healthcare that resulted in Medicare savings for the patient population they served.”
Another, the Medicare Health Care Quality Demonstration, goes straight to performance measures. Three hospital/physician care systems in the US are being given money to test ideas that will improve performance measures. Performance measures are not “performance” measures. They are “quality” measures. Doctor’s get up on stage and perform certain things, and judges evaluate whether their performance is a quality one. As I have said before, measures of quality are things that are easily measured, quantifiable, and easy to find in an electronic medical record.
OK, to summarize so far: CMS, i.e the federal government, is funding the Innovation Center, which is supposed to find better ways to pay for and deliver health care, but which is mostly doing pay-for-performance stuff. Fine. There are some people doing some fine work in health care delivery who could use the funding. Some people are complaining that all the studies that the Innovation Center are doing are demonstration studies, not randomized controlled trials (RCT). RCT’s are the medical gold standard for proof, essentially. It’s not true until an RCT says it is. Why isn’t the Innovation center doing more RCTs?
I postulate several reasons: 1. RCTs take a lot of time. CMS, under the gun from ACA opponents, wants quicker results. 2. A good RCT has a very narrow research question, usually one or maybe two interventions compared to no change. The researchers have to settle on a promising intervention and follow it up long-term. It’s hard to decide what promising intervention is going to give the best results given how long the question will take to answer. 3. There are so many moving parts in health care. It’s very hard to control for everything. Some large RCTs that have affected national policy, such as the Tennessee study in the 1980′s, which found that smaller class sizes in early childhood translated into better long-term outcomes, changed only one variable and kept everything else the same. Tennessee public schools are a closed system with relatively little short-term variability and relatively predictable human behaviors. An RCT that, for instance, studies the effect of a specific intervention on re-admission rates to hospitals has to deal with the variability of disease process and progression, human behavior, emergency situations, dubious quality measures, record-keeping inconsistencies, the list goes on and on. 4. CMS is a political animal. Politics and RCTs do’t readily mix.
So, should the Innovation Center be doing RCTs? Absolutely. Is CMS funding the way to get that done? Probably not. But you have to give the ACA an A for effort on this one. Hopefully the demonstration studies will demonstrate that one or two of the ideas are worth pursuing with an RCT.