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    "When many cures are offered for a disease, it means the disease is not curable" -Anton Chekhov

    ''Once you tell people there's a cure for something, the more likely they are to pressure doctors to prescribe it.''
    -Robert Ehrlich, drug advertising executive.

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    Monday, July 25, 2005

    Reward and Punishment: The Washington Post launches the media campaign to promote Medicare's new pay-for-performance initiatiatives. Suggesting, in the process, that Medicare should stop paying doctors to treat complications:

    In a four-year period, 106 heart patients at Palm Beach Gardens developed infections after surgery, according to lawsuits and government records. More than two dozen were readmitted with fevers, pneumonia and serious blood infections. The lawsuits included 16 patients who died.

    How did Medicare, the federal health insurance program for the elderly, respond?

    It paid Palm Beach Gardens more.

    Under Medicare's rules, each time a patient comes back for another treatment, a hospital qualifies for an additional payment. In effect, Palm Beach Gardens was paid a bonus for its mistakes.

    If the hospital was as dirty and nasty a place as the hospital suggests, then it should be shut down by the health department. But, what if, instead, Medicare just refused to pay for the treatment of complications? Then, hospitals and doctors would be reluctant to treat them. "Bouncebacks" are already viewed as something of a black mark by doctors. Many hospitals have quality review boards who keep track of such things and reprimand doctors for them. And so, you will sometimes see said doctors trying to divert the patients away from their own services to those of others (i.e. the primary care doctor.) Adding a monetary penalty will only make it worse.

    But, then, the article veers away from a punishment system to a system of rewards, arguing that a certain Medicare HMO in Minnesota should get higher payments than a Medicare HMO in Miami because its patients are healthier:

    One of the losers in Medicare's payment system can be found near Minneapolis. Amid supersize bookstores and upscale coffee shops, doctors and nurses at the suburban Woodbury clinic tend to nearly 23,000 patients belonging to HealthPartners, the highly ranked Medicare HMO.

    As a Medicare HMO, HealthPartners receives a flat fee from the federal health program to provide care to each member, unlike traditional Medicare, in which doctors and hospitals are paid each time they provide a service. Medicare bases that HMO fee in part on what it pays for its traditional fee-for-service members in that region.

    The result is that HMOs that happen to be in areas where patients use more services and overall Medicare spending is high are paid thousands more annually per member than HMOs in low-cost areas such as Minnesota -- regardless of how the patients fare.

    For example, WellCare, a Miami HMO, receives $11,834 to treat each of its Medicare members. HealthPartners: $7,851 -- a difference of $3,983 per patient per year.

    Yet HealthPartners outperforms WellCare on 13 out of 14 Medicare quality measures.

    More of its patients get flu shots and colorectal exams. Turnover among HealthPartners' doctors is lower. And patients of the Minnesota HMO -- whose average age is 78 -- report being happier with their care.

    It's normally not wise to make assumptions, but in this case, we'll go out on a limb and guess that the Miami HMO has a larger population of immigrants, and poorer people in general than the northern HMO located amid "supersize bookstores and upscale coffee shops." Affluent 78 year olds tend to be more health-conscious, eager consumers of preventative medicine - the measures of quality that this article lauds so highly. Those kinds of measures are a much tougher sell to poor, inner city immigrants whose culture may not place such a high value on allowing doctors to probe dark recesses of the body in the absence of symptoms.

    The article's assertion that Medicare ends up paying more in areas with higher densities of specialists, however, is quite right. It necessarily that doctors intentionally refer to specialists needlessly when there are so many of them in one spot. It is instead, a medical cultural phenomenon. It becomes the standard of care to have a nuerologist for all strokes - even those "mini-strokes" that resolve after a few minutes or hours, a cardiologist for all chest pain, and an infectious disease specialist for every pneumonia. Failure to involve a specialist is then seen as a dereliction of duty - by patients, by nursing staff, and by other doctors. And if - God forbid - something goes wrong and there's a lawsuit, well, how are you going to defend not calling in a specialist for granny's pneumonia when everyone knows that that's the standard of care in the area? Short of turning all the Miamis in the country into Cicelys, it just isn't going to happen in any short order. It would require a cultural revolution.

    But, the most disturbing idea in the article is this one:

    Medicare has a pilot program to reconfigure how it pays for patients with chronic conditions such as diabetes, heart disease and kidney failure. While relatively small as a percentage of all patients, these beneficiaries account for about half of all money spent. Medicare is testing the idea of paying doctors a single, all-inclusive fee for managing each patient's care, linking the payment to whether the patient gets better.

    People who are at the ends of their life - as so many Medicare patients inevitably are - don't "get better" from chronic disease like kidney failure, diabetes, and heart disease. They die from them. Eventually. But, then, maybe that's the idea. It tilts the balance in Medicare's favor. They'll never have to pay a cent.

    Addendum: For an idea of just how ephemeral this thing called quality can be, consider these two studies from last week's New England Journal of Medicine. In the first, researchers looked at hospital improvement in bevahiors they knew to be targeted by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) - measures such as smoking cessation counseling, giving patients with certain conditions certain drugs (aspirin for heart attack patients, ACE inhibitors for heart failure patients, etc.) They found that all hospitals improved those particular behaviors when they knew they were being observed. And those who were performing the worst at the beginning made the most improvement by the end. However, it didn't seem to make much difference to the patients. Mortality was the same regardless of how many quality points the hospital scored.

    The second study, using data from Medicare, found that hospitals may be very good at meeting checklists for one disease but not another, making it difficult to rate their overall quality without assessing every single disease they treat.

    Both studies (and monitoring bodies) by the way, consider only three diseases worth examining when they talk about quality hospital care. Those diseases are heart attacks, congestive heart failure, and pneumonia - the three most common diseases treated in hospitals. However, as the an accompanying editorial points out:

    We have no idea whether care for other conditions has deteriorated, even while care for acute myocardial infarction, congestive heart failure, and pneumonia has improved. It is even possible that unmeasured aspects of care for these three conditions have deteriorated. Williams and colleagues' inability to find any decrease in inpatient mortality related to acute myocardial infarction, neonatal mortality, or obstetric lacerations (unpublished data) suggest that the effect of the reported improvements on public health may be modest.

    In other words, we have no idea if we're actually measuring "quality" or just our ability to follow a check list.

    posted by Sydney on 7/25/2005 08:06:00 PM 0 comments


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