Friday, May 30, 2014

Death by a Thousand Clicks

The Giant Experiment That is Killing Medicine


What if you and everyone you know were the subject of a giant medical experiment? What if no one warned you or asked your permission before including you? What if that experiment drastically changed everything your doctor did? Guess what? That's exactly what started in 2009, when Obama passed the Health Information Technology for Economic and Clinical Health Act (HITECH Act). This is not the same thing as the Affordable Care Act (a.k.a., Obamacare), and I think it is far more ominous.

The HITECH Act allocated $44 billion of Medicare and Medicaid money to subsidize the adoption of privately-made, government-certified ‘Electronic Health Record’ (EHR) systems, and encourage (bribe and penalize) medical practices and hospitals to use them to carry out certain tasks in patient care. These tasks are called 'Meaningful Use' (MU) of the EHR as defined by regulation.

As time progresses, the bribes will taper to nothing and become penalties levied on practices or hospitals that do not reach these goals will have to pay penalties. So, effectively, HITECH is forcing doctors and hospitals to adopt these private programs for all of their patients or stop accepting Medicare and Medicaid--which means stop serving most of the sickest patients.

Based on my personal experience, I think this program misses the forest for the trees and sets up a series of incentives that impair doctors’ abilities to help patients. It is a reckless, unethical experiment, which, if it were a pharmaceutical, would be illegal. No one should have the authority to impose such a change on the entire system without scientific evidence that it will improve the concrete outcomes of longer, healthier, and happier lives.

Part 1. The Mismeasure of Medicine

There are dozens of Meaningful Use goals. Many seem appropriate for individual patients. Some seem deeply flawed to begin with. The sum of all of them may do more harm than good.

One Meaningful Use measure that at least seems sensible, at least in individual cases, is the requirement to document smoking status. But does documenting in the medical record the smoking status of every single patient lead to fewer patients smoking over all? Does it lead to fewer heart attacks and cancer and extend lives? How do you know the documentation is accurate? Are there more efficient ways to approach smoking? Apparently, nobody has tried systematically to find out.

There are Meaningful Use measures that are based on science that is in dispute or becomes obsolete before regulators can adapt the regulations. For instance, blood pressure control is one Meaningful Use measure, but acceptable systolic blood pressure for a diabetic patient over the age of 60 has gone up by 10 points since I have been in practice. So steps I took a few years ago trying to comply with this goal may have actually harmed my patients.

Meaningful Use does not necessarily measure real world activity. It is data entry, and data entry can be manipulated to suit the person entering the data. I can meet Meaningful Use goals to minimize inappropriate antibiotic prescription by describing the same symptoms as ‘cough’ instead of ‘bronchitis.’

Meaningful use takes money and resources away from interventions proven to work. There are hundreds of thousands of bureaucrats dedicated to implement this program that has no proven positive impact. In a world of limited resources wouldn’t it be better to improve access to prenatal care or life-saving medications? How about reimbursing mental health work decently?

Most personally galling to me, my time spent even on worthy Meaningful Use goals may take away from my time spent pursuing goals that are more important but not measured or even measurable.

There is the time learning these measures that I could otherwise spend learning more medicine. Lunch meeting after lunch meeting is taken up with Meaningful Use lessons. I would rather discuss the evidence behind new hypertension recommendations, or how I can best care for a difficult case.

And there is my time with the patients. I get 15 minutes for most visits. Many doctors get as few as 8 minutes. The average is 12. Meaningful Use takes a lot of that time. When can I comb through the record and catch mistakes or opportunities to improve care? When can I listen closely to my patient and examine them carefully? When can I look into their eyes and explain my reasoning in plain language? When can I practice meaningful medicine?

I am ready and willing to learn new rules and do boring, repetitive tasks, but only if they lead to meaningful outcomes for my patients—years of happy, healthy life. Until Meaningful Use has been proven to do that, it is a game for harvesting government money at the expense of patient care and the biggest unethical experiment of our time.

Next: Part 2. Electronic Health Records, the Hope, and the Reality

Center for Medicare and Medicaid Services Guidance on Meaningful Use

Campbell-Scherer, DL, et. al., ACC/AHA Guideline Update for the Management of ST-Segment Elevation of Myocardial Infarction, Am Fam Physician 2009:79(12)1080-1086.

Wednesday, May 7, 2014

Everyone Should Take This Pill!

Just kidding. Such a pill has yet to be discovered, and I increasingly doubt it ever will. Nevertheless, every so often, the medical community settles on some supplement or pharmaceutical that everyone (or everyone past a certain age) needs to be on. For a while, it was vitamin C. Then it was a multivitamin a day or maybe just anti-oxidants. But every time this happens, it seems, later studies are published that show the superpill of the month actually does not have any measurable positive effect and may even cause a little harm. The lay press usually never gets the retraction. Meanwhile, many in the 'alternative medicine' community will adopt it as a cause. So people accumulate more useless pills that they dutifully take every day.

The latest to go the way of the dodo is the daily aspirin. The US Preventative Task Force has recommended for years that men over 45 and women over 55 should take a daily aspirin prevent heart attacks. Now, the FDA has warned that for people of any age not at high risk, the small risks of aspirin outweigh its small benefits.*

I say it all the time, and I'm beginning to believe it. Healthy people should not take pills.

*Thankyou, Dr. Zachary Sholem Berger for posting this article on Facebook.

Tuesday, May 6, 2014

Blue Cross Blue Shield's Medicare Blue: Another Member of the Insurance Hall of Shame

My patient has had two heart attacks. You would think that his insurance company would try to prevent him from having another one. After all, you might say, heart attacks are expensive, and they wouldn't want to pay for that. You would be wrong on both counts.

Medicare does not pay for outpatient medications. This may have made sense when Medicare was created, since the cost and number of medications for the elderly were relatively low. However, nowadays, it's very tough to pay for the average senior citizen's medications. Hence, the Medicare Part B plans. These were put in place by the Bush Administration to encourage private companies to offer medication insurance for Medicare beneficiaries. Perhaps one problem with these plans is that they have less of an incentive to pay for prevention than traditional plans. After all, why pay for a medication to prevent a heart attack if you don't have to pay for the hospital stay or the bypass surgery? At least, that what I think is happening.

 So, back to my patient. As overused as they may be for other indications, statins prevent heart attacks in patients who have already had one or more heart attacks. (Statins are cholesterol-lowering medications such as atorvastatin, a.k.a. Lipitor.) The American Heart Association and the American College of Cardiology recommend only the two most potent statins, atorvastatin and rosuvastatin, for these patients.

My patient had severe muscle aches on atorvastatin, and it barely touched his cholesterol. He tolerates rosuvastatin, and it is the more potent drug. There is no question that he should be on it. Yes, it's expensive, but he needs it, and it costs less than a bypass. Medicare Blue won't pay for it. I've appealed twice, and the second time, their letter basically said, "we'll cover this when hell freezes over."

Keep it classy, Blue Cross, Blue Shield.

Saturday, April 12, 2014

United Healthcare Strikes Again!

As I said in a previous post,*  United Healthcare is the worst in the rogue's gallery of modern health insurers. Last week, I got another confirmation of this fact. One of my patients came in for his history and physical exam and had not gotten his blood drawn in advance. Why? Because United Healthcare will not pay for labs that associated with a history and physical unless they are drawn on the very same day as the visit.

When my patients come in for a History and Physical, I try to have them get their labs drawn before they come in. That way, we can have a face-to-face talk about what diet might lower their cholesterol or why they might be anemic, or whatever. I can also get any follow-up labs drawn on that day. It makes everyone's life easier, and, sometimes, it even saves the insurer money. Some lab results might require a face-to-face discussion instead of a phone call, and, if I don't have the labs on the day of the physical, the patient will have to come in for another visit, which means another bill to insurance.

I don't know why United Healthcare does this. Probably, some deranged actuary has convinced them that it makes financial sense, even though none of their rivals appear to think so. I don't believe that United Healthcare is consciously vindictive, but they sure do good impression of it.

Saturday, April 5, 2014

Comment on "How Doctors Choose to Die"

This reminds me of one of my last nights in residency. (Details changed to protect privacy.) As I signed on, I saw that I would be responsible for a very sick, 100-year-old man. I had a sinking feeling that he was going to die that night, and, if he did, I would have to do horrible things in a fruitless attempt to bring him back. He was demented and unable to speak for himself, so I told the family what I thought might happen. I asked their permission to allow him to die if it came to that.

They refused. He was from a foreign country, and his family mistrusted our medical system, since, where they were from, doctors had abused people like them. They weren't about to let a man in a white coat stint on their venerated grandfather. So I went to the call room and tried to sleep, fearing the inevitable beeper interruption.

A few hours later, it came. The 100-year-old man had stopped breathing, and his heart had stopped. Someone had 'called a code.' I came downstairs to find my team around his bed. Looking at each other sheepishly, the interns, nurses, and I stabbed him with a large needle to place a central venous line, pounded his brittle ribs, and shocked his withered heart into a few more beats. As I jammed the endotracheal tube down his throat as gently as I could, his dying eyes glared at me, and his face contorted in a rhythmic, reflexic scowl of brain death. His heart stopped again. Finally, I decided we had played the charade long enough. I pronounced him dead.

I cannot dismiss the effect the family's collective history had on their priorities. Perhaps there was no other way for them, but, to me, this whole effort had been a horrible crime.

Calling a code is not always pointless. Chances of survival are bleak, but a previously vigorous person who makes it through a code has a reasonable chance of walking out of the hospital on their own two feet and in good mental shape. On the other hand, once someone is frail and fatally ill, cardiac resuscitation is practically useless.

Resuscitation for all cardiac arrests is still the default in fact, though not in law (at least in my state). This is for bad and good reasons. Doctors are afraid of lawsuits, and some salvageable lives have been forsaken out of prejudice or base motivations. A family's wishes cannot be dismissed lightly.

But, if you don't want this to happen to you, please plan for this. If and when you are fatally ill, make sure everyone in your family understands that you want to go peacefully when it is time. If you don't, some prodigal son might return and demand that everything be done to 'save' mom to assuage his own guilt. Or your spouse, not knowing your wishes, might be unwilling to deny you the 'best' care. Give them permission to let you go.