Doctors and hospitals nowadays are being asked to demonstrate the value of the health care provided to patients. Value is defined as the relationship between cost and quality. In very qualitative terms, value is the ratio of quality to cost. In other words, as quality increases relative to cost, value increases. Looked at from the cost perspective, if quality is held constant while costs are reduced, value increases.
This would all be well and good if it were a simple calculation - which would be the case if all of these elements were well understood and easily measured. One might think the easiest to tackle would be cost, as that seems an easy number to capture. Even there, however, it is complicated by the nettlesome issue of cost versus charges: the difference between what it costs to provide a service and the price one tries to collect from the customer for that service.
A familiar example of this can be found in the airline industry. I flew to San Diego this past summer for a wedding. I will be making the same trip for Thanksgiving. The cost of my transportation via airplane will surely be about the same, allowing for changes in the price of fuel. But the ticket prices are wildly different, because the airlines can charge whatever they want, and they gouge passengers who want to travel for holidays.
Hospitals exhibit large differences between costs and charges, not because they take advantage of those who get sick during periods of peak demand, but because they have to make up for the people who cannot pay by charging much more than cost to those who can. This is called cost shifting. Everyone in the health care and health insurance industries knows all about it, and nobody likes it, but until everyone has health insurance that pays enough to cover costs, that's how it will be. And by the way, the government programs that cover the poor and the elderly (Medicaid and Medicare) do not pay enough to cover costs, so the rest of us are paying for the health care of these patients both through our taxes and through cost shifting.
How does this affect the value calculation? If Hospital A has more patients with no insurance or with Medicaid and Medicare than Hospital B (which has more patients with real insurance), Hospital A will have to charge higher prices to the insured (unless it wants to go out of business). That will make Hospital B look like a better value, which is hardly fair.
If you are now dismayed that measuring the element of cost in the value equation is not as simple as it should be, wait until you see what happens when we attempt to measure quality!
The Centers for Medicare and Medicaid Services (CMS - don't ask what happened to the extra "M") has many "quality measures" for doctors and hospitals. These are things they expect us to measure and report to them. As you might guess, measuring all of these things is rather labor-intensive, which adds to costs. To make it appealing, they start out by providing a small monetary incentive (pay for reporting) for doing this, but over the next few years that goes away and is replaced by penalties for not reporting.
In addition to penalties for not reporting, CMS also penalizes hospitals for failing to hit targets for the quality measures. This would seem to be a good thing, as it gives us a financial incentive to improve quality. But that assumes the "quality measures" imposed by CMS actually measure quality.
Most of us in healthcare think the important thing to measure is patients' health outcomes. And some of the quality measures actually get at this. For example, CMS thinks patients should not acquire infections while in the hospital. I agree. While rates of hospital-acquired infections probably cannot be reduced to zero, we can get pretty close, and we have good evidence of best practices that will help us to get there.
But many of the other measures are related to processes rather than outcomes. So we are expected to do certain things for patients being admitted to the hospital for treatment of pneumonia. These are things you might think would result in better outcomes, and so it might seem reasonable to measure how good we are at doing those things consistently and reward (which means not penalize) us for that. But here is the problem. First, the connection between processes and outcomes is often surprisingly loose. Second, CMS uses quality measures based on processes that have never been shown to improve outcomes. Why would they do that? Maybe you weren't even asking that question, because you know it's a government agency, but the answer is simple: like everyone else, they do things that seem to make sense, even when there is no evidence to support intuition. Then, when presented with evidence to the contrary, they change their approach only with great reluctance, and resistance, and lengthy delay.
So we find ourselves doing many things that we know contribute nothing to improved outcomes because of government mandate. This, as I'm sure you will understand, is very frustrating. The folks at CMS claim to want to improve quality and reduce cost, thereby increasing value, but instead they cause us to waste resources doing useless things, thereby reducing value.
Fasten your seatbelt, because it gets worse. There are actually things they want us to do that may reduce quality and cost lives.
My favorite current example is what they are telling us about ordering CAT scans of the head for patients who come to the emergency department (ED) with headaches. They have established a set of criteria they want us to follow. If the patient doesn't meet the criteria, we shouldn't order a CAT scan.
By now, you have surely predicted the problem. Yes, you guessed it, the criteria are not scientifically valid. There are ED patients who do not meet the criteria who should get CAT scans. And some of those patients, because of the CMS "quality measure," will not get CAT scans. And some of them will have serious conditions that will go undiagnosed.
These "quality measures" adopted by CMS are typically endorsed by an outfit called the National Quality Forum (NQF). NQF endorsement is by no means a guarantee that a quality measure is good, but they try. This new "quality measure" related to CAT scans for headache patients was rejected by the NQF. And yet it was adopted by CMS anyway. They are convinced that it will save money and improve quality by sparing patients needless and potentially harmful radiation exposure, and that we will not, by following their criteria, miss any important diagnoses. If that were true, it would be great. Why, you may ask, has CMS not been dissuaded by the lack of scientific evidence to support this "quality measure?"
A dear friend and colleague once (many times, in fact) said that CMS makes up the rules not to improve health care but to fit the amount of money they want to spend. This is a very important truth to keep in mind. And it's not just CMS. Any time you read or hear statements about value in health care, maintain a healthy skepticism. Ask whether the better value being promised is really about the ratio of quality to cost, or whether it's really just about cost, with quality only an afterthought (if it is a thought at all). All too often, as the "value equation" is addressed, cost is the focus, and quality is ignored or sacrificed.
Saturday, October 22, 2011
Sunday, October 16, 2011
Hope for the Future of the Medical Profession
The American College of Emergency Physicians is holding its annual Scientific Assembly in San Francisco. Preceding the educational conference there was a two-day meeting of the organization's national, representative, deliberative body (called the Council). I had the opportunity to visit with the delegation from Texas. One of the topics of conversation was the future of the medical profession - specifically the attraction of the profession to young people.
I have worried about this for many years. I believe it is very important for the medical profession to attract the best and brightest of our nation's youth. I don't know about you, but I realize I'm getting older. I'm not old yet, but I can see it on the horizon. And while I hope to be old and healthy, I know I may not be so lucky. I may be old and sick some day. I may even have the misfortune to be afflicted with the medical equivalent of the ancient Chinese curse.
You know the oft-quoted ancient Chinese curse: "You should live in interesting (or exciting) times." The medical equivalent of this curse is, "You should be an interesting case." I guess for those of us in emergency medicine, "You should be an exciting case" would be an appropriate variation, but I've not heard that version.
If I am ever unlucky enough to be an interesting case, I know who I want to be my doctor. Gregory House, as portrayed on the television show by Hugh Laurie, is the guy. I don't care about bedside manner. I want a brilliant diagnostician. Emphasis on the word brilliant - which brings me back to wanting the best and brightest to choose medicine over the many other professional careers open to them.
Many factors enter into a young person's choice of a career. Medicine appeals to those with superior intellect and strong academic aptitude in the sciences and mathematics. It appeals to those who want to help their fellow man, who want to spend their days curing the sick, saving lives, comforting the afflicted. It attracts those who want to devote their professional lives to something the value of which to society is unquestioned.
Those it attracts must be willing to work hard. Entering the profession requires eight years of post-secondary education (college and medical school) followed by three to eight years (depending on specialty) of post-graduate training, for a total of 11-16 years after high school. And then there will be several decades of hard work. Yes, doctors in some medical specialties work harder than others, but there are few really easy ones, and even those are easy only by comparison with the others. Slackers need not apply.
What is the reward? Most of what's really important, I think, is knowing every day that one's work has helped others and made a difference in their lives. And there is a reward in being a member of a profession that is respected and admired by one's fellow citizens. Finally, the profession does provide a comfortable income, an enviable standard of living, an economic position in the top five percent or so of income earners in the US. That matters in an economic culture that typically rewards hard work with financial success, especially when you consider that most young physicians accumulate substantial educational debt from college and medical school.
If you spend a little time crunching the numbers, you see that physicians' incomes, in inflation-adjusted dollars, have been on a slow but steady decline over the last generation. That doesn't mean we really have anything to complain about, as we are still doing just fine, but the trend is worrisome. And, coupled with that, many physicians perceive a variety of other currents that make the practice of medicine less appealing. There is far more government regulation. There are far more outside entities telling us how to practice medicine and interfering with medical decisions that really should be made within the physician-patient relationship, based on the medical information provided by the doctor coupled with the patient's personal values. And we have an absurdly flawed system for addressing harms that come to patients as the result of medical error. I will write more about that in the future, but the system we have of litigating medical negligence claims does a terrible job of fairly compensating patients who are deserving and is poisonous to the doctor-patient relationship.
Surveys of physicians conducted in recent years reveal that more and more of us, severely frustrated by these trends, actively discourage our children from seriously considering following in our footsteps. So, if we want to make sure the medical profession continues to attract the best and the brightest of our nation's youth, we have our work cut out for us.
My own career in emergency medicine, after medical school and residency training, began in 1985. In those early years I had the privilege of working with a colleague named Ken, a warm and jovial Irishman, who taught me much about emergency medicine - and about life. Ken and I shared many of the same concerns about the future of the medical profession. If you had listened to some of our numerous conversations on the subject, you would have predicted that we would be among those who would steer our own children away from medicine.
Last night I attended a social event for registrants here at ACEP Scientific Assembly. Soon after my wife and I took our seats at one of the tables, the remaining seats were filled by a group of young doctors who are in training in the emergency medicine residency program at Wright State University in Dayton, Ohio. Not long into the conversation, I learned that one of them was Ken's daughter Brooke. You can imagine how delighted I was to meet her, after hearing so much about her from her dad when she was a little girl - and to realize that Ken had, after all, not steered her away from our profession.
My younger daughter is a freshman in college, and she aspires to enter the medical profession. She has the intellect and the drive to accomplish that goal. Equally important, she has the warm and caring personality her patients will need, because she wants to be an oncologist. And she has my full support and encouragement, because I know she is exactly the kind of person our nation needs to be choosing medicine over all the other things she could do with her life.
As a nation, we are struggling to make difficult decisions about reforming our health care system. We should be focused on what is best for patients. We must also keep in mind that the doctors trying to help those patients need health care reform to make their work easier rather than harder. At the same time, it will help if legislators, regulators, and policymakers understand that an inexorable trend of expecting doctors to work harder for less money, year after year, is undermining the cause.
I have worried about this for many years. I believe it is very important for the medical profession to attract the best and brightest of our nation's youth. I don't know about you, but I realize I'm getting older. I'm not old yet, but I can see it on the horizon. And while I hope to be old and healthy, I know I may not be so lucky. I may be old and sick some day. I may even have the misfortune to be afflicted with the medical equivalent of the ancient Chinese curse.
You know the oft-quoted ancient Chinese curse: "You should live in interesting (or exciting) times." The medical equivalent of this curse is, "You should be an interesting case." I guess for those of us in emergency medicine, "You should be an exciting case" would be an appropriate variation, but I've not heard that version.
If I am ever unlucky enough to be an interesting case, I know who I want to be my doctor. Gregory House, as portrayed on the television show by Hugh Laurie, is the guy. I don't care about bedside manner. I want a brilliant diagnostician. Emphasis on the word brilliant - which brings me back to wanting the best and brightest to choose medicine over the many other professional careers open to them.
Many factors enter into a young person's choice of a career. Medicine appeals to those with superior intellect and strong academic aptitude in the sciences and mathematics. It appeals to those who want to help their fellow man, who want to spend their days curing the sick, saving lives, comforting the afflicted. It attracts those who want to devote their professional lives to something the value of which to society is unquestioned.
Those it attracts must be willing to work hard. Entering the profession requires eight years of post-secondary education (college and medical school) followed by three to eight years (depending on specialty) of post-graduate training, for a total of 11-16 years after high school. And then there will be several decades of hard work. Yes, doctors in some medical specialties work harder than others, but there are few really easy ones, and even those are easy only by comparison with the others. Slackers need not apply.
What is the reward? Most of what's really important, I think, is knowing every day that one's work has helped others and made a difference in their lives. And there is a reward in being a member of a profession that is respected and admired by one's fellow citizens. Finally, the profession does provide a comfortable income, an enviable standard of living, an economic position in the top five percent or so of income earners in the US. That matters in an economic culture that typically rewards hard work with financial success, especially when you consider that most young physicians accumulate substantial educational debt from college and medical school.
If you spend a little time crunching the numbers, you see that physicians' incomes, in inflation-adjusted dollars, have been on a slow but steady decline over the last generation. That doesn't mean we really have anything to complain about, as we are still doing just fine, but the trend is worrisome. And, coupled with that, many physicians perceive a variety of other currents that make the practice of medicine less appealing. There is far more government regulation. There are far more outside entities telling us how to practice medicine and interfering with medical decisions that really should be made within the physician-patient relationship, based on the medical information provided by the doctor coupled with the patient's personal values. And we have an absurdly flawed system for addressing harms that come to patients as the result of medical error. I will write more about that in the future, but the system we have of litigating medical negligence claims does a terrible job of fairly compensating patients who are deserving and is poisonous to the doctor-patient relationship.
Surveys of physicians conducted in recent years reveal that more and more of us, severely frustrated by these trends, actively discourage our children from seriously considering following in our footsteps. So, if we want to make sure the medical profession continues to attract the best and the brightest of our nation's youth, we have our work cut out for us.
My own career in emergency medicine, after medical school and residency training, began in 1985. In those early years I had the privilege of working with a colleague named Ken, a warm and jovial Irishman, who taught me much about emergency medicine - and about life. Ken and I shared many of the same concerns about the future of the medical profession. If you had listened to some of our numerous conversations on the subject, you would have predicted that we would be among those who would steer our own children away from medicine.
Last night I attended a social event for registrants here at ACEP Scientific Assembly. Soon after my wife and I took our seats at one of the tables, the remaining seats were filled by a group of young doctors who are in training in the emergency medicine residency program at Wright State University in Dayton, Ohio. Not long into the conversation, I learned that one of them was Ken's daughter Brooke. You can imagine how delighted I was to meet her, after hearing so much about her from her dad when she was a little girl - and to realize that Ken had, after all, not steered her away from our profession.
My younger daughter is a freshman in college, and she aspires to enter the medical profession. She has the intellect and the drive to accomplish that goal. Equally important, she has the warm and caring personality her patients will need, because she wants to be an oncologist. And she has my full support and encouragement, because I know she is exactly the kind of person our nation needs to be choosing medicine over all the other things she could do with her life.
As a nation, we are struggling to make difficult decisions about reforming our health care system. We should be focused on what is best for patients. We must also keep in mind that the doctors trying to help those patients need health care reform to make their work easier rather than harder. At the same time, it will help if legislators, regulators, and policymakers understand that an inexorable trend of expecting doctors to work harder for less money, year after year, is undermining the cause.
Thursday, October 6, 2011
The Apple of My Eye
For many years I regarded Apple as a cult. People who bought the company's machines seemed to be a large group of devoted followers. A colleague at work could often be seen reading a trade publication called MacAddict (later MacLife). It was my sense that Apple had a relatively small share of the personal computing market, but what it lacked in market share was overshadowed by the passion of those who believed in the company and its products.
My experience with personal computing was limited to personal computers - by which I mean the original IBM PC, my first one, acquired in the early 80s, and its descendants. The early PCs were not what I would later call user-friendly. Everything I wanted the computer to do had to be entered as a command from the keyboard.
Meanwhile, a company called Apple was revolutionizing personal computing with something called a graphical user interface, which was remarkably intuitive and easy to learn. Microsoft was trying to stake out its own territory with the earliest versions of Windows, but it seemed Windows was a poor attempt to make the Microsoft operating system look and work like the Macintosh OS, and it fell far short.
Each version of Windows seemed to bring with it new maddening flaws, while each new version of the Mac OS seemed a real advance over the last, and the Mac always functioned beautifully, never inciting its users, with infuriating error messages, to throw it out of the window of an apartment on an upper floor. But I didn't know about any of that. I plodded along using Windows-based computers (after I traded "up" from my original IBM PC), unaware that it wasn't really necessary for my computer to enrage me periodically.
I came late (2005) to the everyone-owns-a-laptop trend. It was a Toshiba PC running Windows XP. It lasted a bit more than four years. Early on it had a hard drive failure, but the data turned out to be salvageable, and a new hard drive kept it going another few years before it started doing things that made me wonder if I could find an exorcist for a computer. By then I had taken note that more and more of my friends were using the MacBook. In June of 2009 my older daughter bought one. Two months later my Toshiba PC died, and Diana enthusiastically endorsed the idea of replacing it with the latest MacBook Pro.
More than two years later I am pleased to report that there may be no such thing as "Error Message Withdrawal Syndrome." I can't really be sure about that, because while I never get error messages on my Mac, I still use Windows-based computers at work, and they fill the void - some days often enough to make me glad I don't have ready access to a sledge hammer, because I'd probably get fired, or at least tranquilized.
Steve Jobs, the driving force, the genius, the wizard at Apple, is gone now. And everyone is talking and writing about him and his extraordinary contributions. He changed the world, they say. He was the most important force in technological advancement since Thomas Edison and Henry Ford. He believed that the machines his company built should be physically beautiful and function flawlessly, with seamless integration of software and hardware. He was not interested in giving his customers what they wanted. Like ice hockey legend Wayne Gretzky, whose famous statement (about skating to where the puck was going to be) Jobs liked to quote, his approach was that Apple should build the things its customers would want if they could envision them, and they would prove him right by buying Apple's new products once they learned about them.
I've always been a bit - sometimes more than a bit - behind the curve. Never an early adopter. When the iPhone was introduced in 2007, I sat back and watched - at least partly because I was a loyal customer of a wireless carrier that didn't offer it. And the most interesting part of watching was how other players strove mightily to bring to market something that could compete with the iPhone. The first device that was a legitimate contender, I think, was the Droid X. From there the proliferation of 4G smartphones that offer serious competition for the iPhone just took off.
Some day I may buy a tablet, either an iPAD or one of its competitors, if I ever become convinced that a device that falls somewhere between my MacBook Pro and my smartphone would fill a void that I currently do not perceive. We shall see. My future smartphones may be iPhones, or they may (like my Droid Bionic) be competitors that measure up. After two-plus years with a Mac, I cannot imagine ever buying another Windows-based computer.
I suspect this is the contribution made by Steve Jobs for which I will always be most grateful: producing machines that show what the state of the art can be and driving the competition to try to emulate his vision of perfection.
Thanks, Steve.
My experience with personal computing was limited to personal computers - by which I mean the original IBM PC, my first one, acquired in the early 80s, and its descendants. The early PCs were not what I would later call user-friendly. Everything I wanted the computer to do had to be entered as a command from the keyboard.
Meanwhile, a company called Apple was revolutionizing personal computing with something called a graphical user interface, which was remarkably intuitive and easy to learn. Microsoft was trying to stake out its own territory with the earliest versions of Windows, but it seemed Windows was a poor attempt to make the Microsoft operating system look and work like the Macintosh OS, and it fell far short.
Each version of Windows seemed to bring with it new maddening flaws, while each new version of the Mac OS seemed a real advance over the last, and the Mac always functioned beautifully, never inciting its users, with infuriating error messages, to throw it out of the window of an apartment on an upper floor. But I didn't know about any of that. I plodded along using Windows-based computers (after I traded "up" from my original IBM PC), unaware that it wasn't really necessary for my computer to enrage me periodically.
I came late (2005) to the everyone-owns-a-laptop trend. It was a Toshiba PC running Windows XP. It lasted a bit more than four years. Early on it had a hard drive failure, but the data turned out to be salvageable, and a new hard drive kept it going another few years before it started doing things that made me wonder if I could find an exorcist for a computer. By then I had taken note that more and more of my friends were using the MacBook. In June of 2009 my older daughter bought one. Two months later my Toshiba PC died, and Diana enthusiastically endorsed the idea of replacing it with the latest MacBook Pro.
More than two years later I am pleased to report that there may be no such thing as "Error Message Withdrawal Syndrome." I can't really be sure about that, because while I never get error messages on my Mac, I still use Windows-based computers at work, and they fill the void - some days often enough to make me glad I don't have ready access to a sledge hammer, because I'd probably get fired, or at least tranquilized.
Steve Jobs, the driving force, the genius, the wizard at Apple, is gone now. And everyone is talking and writing about him and his extraordinary contributions. He changed the world, they say. He was the most important force in technological advancement since Thomas Edison and Henry Ford. He believed that the machines his company built should be physically beautiful and function flawlessly, with seamless integration of software and hardware. He was not interested in giving his customers what they wanted. Like ice hockey legend Wayne Gretzky, whose famous statement (about skating to where the puck was going to be) Jobs liked to quote, his approach was that Apple should build the things its customers would want if they could envision them, and they would prove him right by buying Apple's new products once they learned about them.
I've always been a bit - sometimes more than a bit - behind the curve. Never an early adopter. When the iPhone was introduced in 2007, I sat back and watched - at least partly because I was a loyal customer of a wireless carrier that didn't offer it. And the most interesting part of watching was how other players strove mightily to bring to market something that could compete with the iPhone. The first device that was a legitimate contender, I think, was the Droid X. From there the proliferation of 4G smartphones that offer serious competition for the iPhone just took off.
Some day I may buy a tablet, either an iPAD or one of its competitors, if I ever become convinced that a device that falls somewhere between my MacBook Pro and my smartphone would fill a void that I currently do not perceive. We shall see. My future smartphones may be iPhones, or they may (like my Droid Bionic) be competitors that measure up. After two-plus years with a Mac, I cannot imagine ever buying another Windows-based computer.
I suspect this is the contribution made by Steve Jobs for which I will always be most grateful: producing machines that show what the state of the art can be and driving the competition to try to emulate his vision of perfection.
Thanks, Steve.
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