Doctoring The Evidence

Accountable Care Organizations: "Accountable to Whom"

noreply@blogger.com (Randall Bock, MD) — Mon, 16 May 2011 15:25:00 +0000

At the heart of medicine is the relationship between a doctor and a patient. The more a doctor knows about his patients, the better. For instance, vision-changes with numbness might represent migraine in one patient, and stroke in another. Having followed patients through the stages of life, participating in their medical experiences firsthand rather than solely reviewing those as written case-files -- I can vouch that knowing a patient's personality, habits, and proclivities helps not only in diagnosis but in tailoring treatment as well.

Somewhere along the line, we have lost sight of this. Today, few patients have the opportunity to continue a relationship with a single doctor; conversely doctors may be losing the direct patient focus, as they deal with increasingly larger supervisory medical organizations:

independent physician associations (IPAs),
physician hospital organizations (PHOs),
integrated delivery networks (IDNs),
and soon the newest creation of the health-care system, accountable care organizations (ACOs).

ACOs will fundamentally change Massachusetts health-care providers' ability to organize their own businesses and will limit insurers' product-choices available to consumers. Instead of accepting fee-for-service, these new large, integrated systems will receive a predetermined compensation-amount for each patient under care. Medical providers would increasingly be asked to take on the role of insurance company: rewarded if they keep patient-care costs down, and put at financial risk if they exceed budget, having to cover excess costs out of their own pocket. Doctors could find themselves paying rather than being paid to provide medical treatment. Medical school curricula should start including “Medical provider as sub-insurance entity, taking on financial risk”. As focus diverges from consideration of patient health above all to financial concerns overall, the Hippocratic Oath could yield to the Hypocritical Oath.

Doctors, previously in compact with a patient together battling a disease, now will be held accountable for group-related “outcomes”. Rather than being rewarded for success in diagnosis, they may be punished falling short of metrics (as yet to be determined: by a state, a commission, or a consortium).

Will any given desirable outcome be permanent? Presume doctors succeed in organizing longevity, translating to greater nursing home fees. As those fees become their own burden, will doctors be pressured to pursue yet some other socially (not medically) determined outcome? Do people want government’s foot on the scale in the doctor’s office?

Transferring risk from insurer to provider is not altogether new. In the 90s, health maintenance organization (HMOs) tried a similar method called capitation. The system had its cost-benefit, but wasn’t across-the-board popular. Patients grew concerned that physicians were being paid to withhold care. They also wanted greater freedom to see specialists. Insurance companies responded, appropriately, creating different tiers of offerings, trading privilege for price, maintaining simultaneously HMO, PPO, and fee-for-service options.

The new ACOs (with their group-outcome risk-assumption by medical providers) figure to be HMO’s “on steroids”--in and of itself not necessarily a terrible idea; but quickly becoming just that -- if existing insurance products, as competitive ballast, are eliminated by fiat: what is proposed by the state of Massachusetts, as we write.

ACOs will be law, enforced by government that essentially stipulates its superiority in judgment to the peoples’ (given the previous popular rejection of HMO’s). The state, nonetheless, will impose its rules and limitations on insurers, henceforth able only to provide one anointed insurance-product. There will be no other option.

ACOs encourage market-consolidation. Hospitals, positioning themselves to become integrated systems join forces: purchase some physician practices ignoring others; choose separate, non-conflicting geographical areas -- spheres of influence, in a real-life version of the boardgame Risk. Crowding out the smaller hospitals and independent doctors will result in decreased competition and lessened innovation. These new larger entities, contrary to the stated designs of the ACO-plan, can use this greater leverage with insurance companies to drive health-care costs higher.

Community-based solo practices will likely be driven to extinction with the adoption of ACOs. In 25 years’ of practicing medicine (such as mine), doctors see parents' infants grow to parents themselves, dependable adults gracefully age to more dependent seniors, while providing attentiveness and personalized care considering personalities, families, and community. Long-term primary care clinicians (PCC's) tend to order fewer tests through more time in conversation, addressing not just the symptom, but the person’s reaction to it.

But even with this high level of care, smaller group PCC reimbursement rates are lower than institutions’ due to the latter's leverage over insurers; yet if not in a financial position to become an insurance-entity, any smaller practice will founder and disappear.

Six years ago, I began treating people struggling with narcotic-addiction. While many doctors use a replacement-narcotic therapy with no end, I focus on removing patients’ dependency, arming them with the skills and values needed to maintain drug-free life. These patients -- mostly on Medicare and Medicaid -- approach a time in which they no longer require treatment for addiction, decreasing the financial burden on these state-benefit programs and the taxpayers. This ability to tailor a unique, gently tapering, few-month program emanates from the independence of a small practice, in an environment of choice, not dictates. Smaller practice size affords an ability to adapt to the needs of patients, creating this innovate approach, allowing people get on with their lives.

Drug-users, a particularly needy population, present, as a very high-risk impediment for inclusion within an ACO. Drug users, hyper-utilizers of the medical system, periodically engender medical visits for detoxification, and in the meanwhile often manipulate multiple medical visits for secondary gain in pursuit of narcotic-prescriptions. Add in counseling, groups, x-rays and tests from injuries and diseases incurred from a drug-lifestyle, and “pretty soon you’re talking about real money” -- money an ACO might desire to retain over these wayward patients’ business.

Such patients may suffer as small, nimble, free-thinking practices, like my own, no longer are open to treat, avoiding the financial burden coincident with their profligate medical usage. Doctors will be required to take on more risk, while these patients may not be asked to take on additional responsibility, themselves, for their care and "outcomes". In fact, while receiving state-benefits, they are insulated from any understanding or absorption of the costs involved. Instead, they are offered endless and repetitive medical options at no cost instead of paying (even tolerable “cigarette-money” copayment-levels) for each individual service. People choose items differently at a buffet from à la carte, and arrive far more frequently when that buffet is free.

When we ask people to contribute, proportionally, to the costs involved for their medical treatment, e.g. $10 a sore-throat at the PCC versus $50 at an ENT, they make an adult choice. Under ACO, such choices will be restricted “by the system”. People capable of making positive health decisions will be penalized with decreased health-care options while (likely) subsidizing the costs of those who are engaging in the riskier behaviors that result in the frequent and expensive use of the medical system.

Removing patients, as ACOs do, from the equation of fixing their own health issues infantilizes them. Patients (in the child-role) will be hectored into (what is deemed) proper medical testing and personal behaviors by the (financially-at-risk parental) medical establishment. This will naturally lead to tension and unintended consequences, fraying the doctor-patient relationship, diminishing doctors’ currently high moral-standing and respect within the community.

Instead of further divorcing patients from the financial risks involved with their health decisions, we should return to a state closer that which pertains in their other investment- and life-decisions. Medical savings accounts directly reward patients’ keeping health-care costs down, additionally (over the long run) incentivizing those more time-consuming decisions to lose excess weight, stop smoking, and the like once rewards are in place that bring their own health-care costs down. This is the direction in which we should be headed.

Consider as example, briefly, public housing. Tenants have no financial investment in the buildings, which quickly become rundown, littered, and covered with graffiti. Conditions improve when tenants become owners, their property-value on the line. They will work to increase the value of their property: they monitor, no longer ignore, the common areas. They invest in improving and maximally maintaining the building because they are rewarded, simply and financially, themselves.

ACOs will naturally lead to a rationing of care. “Who-gets-what” options for everything from the flu to cancer will be decided by regulations decided, at a remove -- rather than by medical judgment, at a visit. Medicine changes faster than bureaucrats’ issuances -- so, even in the best scenario, any well-considered document outlasts its usefulness. ACOs discourage innovation, limit competition, decide medical-care- winners and -losers care, and usurp the popular will already shown to be wary of heavy-handed incursions on personal health choices. ACOs create a one-size-fits-all approach that will irritate patients, discourage innovation, infringe on business-rights across-the-board -- with no guarantee of decreased prices, given decreased competition via consolidation within each physical catchment area.

In Massachusetts, it is already hard to find a primary care doctor. If ACOs are put into place, this process will only get harder as these new layers of bureaucracy create obstacles to maintaining a successful practice. Doctors will vote with their feet. Massachusetts' fine medical schools will send doctors increasingly to less restrictive states of the union.

We need to foster communication and innovation, rather than drowning them in a sea of new guidelines and regulations.
We need to encourage people to take responsibility for their own health.
We need to get back to focusing on the doctor-patient relationship and making both parties more active in the process, not less.

"My Eyebrows Hurt"

noreply@blogger.com (Randall Bock, MD) — Tue, 09 Nov 2010 16:39:00 +0000

Sorry to start off with a bad joke here, but back in elementary or middle school some inquiring soul would ask, "does your face hurt?" If you were dim enough to answer at all (presumably in the negative), then the retort would be, "well it's killing me!": Laughs would ensue (with the laughter's being directed "at you", not "with you").

Today's first patient (who is undergoing a gentle narcotic tapering / detoxification process administered through my practice), stated, "my eyebrows hurt". He had been complaining of mild cold-symptoms, and I guess his audience (his wife and I) knew what he meant, some forehead pressure from sinus congestion. But shortly after he said this, we all started to smile, particularly after I mentioned that I had never heard, in 25 years of listening to pain-complaints, the particular phrase "my eyebrows hurt".

Earlier, his wife had been asking about his starting counseling in hopes of divining the reason for his previous narcotic usage. He has not been working although they have a three-year-old child. I mentioned one of my little homilies that "the best counseling (or group therapy) is a job", and recommended his pursuing employment over counseling, directing his efforts outward rather than inward -- with the goal of production, rather than introspection.

With a job, external challenges have to be met, internal issues have to be set aside. There is friendly chumming and social churning: getting out, getting lunch, keeping busy. The result is a lack of time to self-obsess: my recommendation in cases absent severe mental disturbance. Not returning to narcotics involves, IMHO, a step towards maturity: (in his case) knowledge of his place as father, husband, provider; evolving from current dependence.

Surely, then, there would be less time in which to worry over eyebrows' hurting. Before people excoriate for minimizing the medical problem at hand: testing and examination were done and pointed towards his having a cold, simply. Whether he can stay away from narcotics in the future is an open question, but success is anticipated, if his eyebrows stop hurting. Moreover, if his mind and body are busier focusing on the world just beyond those eyebrows

stop smoking, lose weight, get married!!! (at the church)

noreply@blogger.com (Randall Bock, MD) — Thu, 28 Oct 2010 21:30:00 +0000

Doctors have no trouble or compunction giving these good pieces of advice:

stop smoking
lose weight
eat less saturated fat
wash your hands
vaccinate
schedule your mammogram
get a colonoscopy

These all likely can augment both life-quality and -expectancy.

Do doctors, then, (in appropriate situations obviously) go the extra mile and tell a patient to "get married"? There are reasonable reports church-going adds to longevity, but with sensitivity to broaching religious beliefs, doctors may be reluctant to suggest Doctor Daniel Hall's advice "take two prayers and call me in the morning", even though actuarial death rates found that weekly worship service attendance could add up to three years to a person's life.

But what is holding them back about advising marriage? We are certainly at a juncture where this advice could prove a crucial difference in how well our society holds up in the upcoming decades. Even Social Security is worried about the relatively poor health of the unmarried, and never married.

Studies show that people live longer married. And that's not even a joke (you remember this one: "do married people live longer?, No, it only feels that way" ). That's the sentiment of the popular culture: movies, TV shows, magazines, MSM. Marriage is there to be mocked.

Not only does do people live longer married, but they live wealthier and happier, and this conclusion remains even after you factor out preselection towards marriage people you could argue that maybe those destined for poorer life expectancies never marry in the first place but probably the opposite is true, people who need care and caring tend to marry at a higher frequency.

A 22-year-old woman was in my office yesterday. She has a 1.5-year-old baby, lives with her own mother, is on state-benefits. The infant's father lives in the next town over, works, and had asked to marry her. She said, "I'm thinking of going back to school at some point"... "so, I'm not ready yet."

But is her baby ready, yet? Children in married households have more resources, not just physical resources, but emotional, instructional, and familial. In this case we're not talking just about the patient's health, harmful activity avoidance and longevity; but, in the long-run, probably those of the offspring as well.

So "take two wedding-rings and call me in the morning"

Postscript: this note was partly inspired by the occasion of the visit of the 22-year-old quoted above. She was in for a visit to "meet the doctor". She had a little bit of back pain and a fair amount of obesity, which we addressed with standard medical advice. It was during this visit that I tried the "health intervention" advice of suggesting to this young lady to consider the beneficial social and general health aspects of solidifying her ongoing relationship with the child's father. She seemed to acknowledge this and consider it in a reasonable fashion, and we had what I had thought was a productive conversational visit. She called a couple of days later announcing she will never be coming back, so perhaps take what I say above with a grain of salt until this concept percolates through to society with the same weight and force of other standard medical advice dicta, or don't attempt this until many visits have transpired.

Will Your Surgeon be "Socially Just" or "Highly Skilled"?

noreply@blogger.com (Randall Bock, MD) — Thu, 30 Sep 2010 19:32:00 +0000

((((bravo and kudos to Doctor James Gaulte. ))))

First of all doctors (or, in their tadpole-form: medical students ;-) ) should be welcome to have whatever political opinion they choose, not be funneled or channeled into some predilection of a particular power-elite du jour; nor by similar justifications be given preferential (ab initio) medical school admission.

Medical school should be about teaching medicine, and the techniques and science behind it. If and when there are strong compelling political arguments of the day (i.e. always), let's not presume patients are ignorant, and let's not presume patients, when they are having (say) their diabetes treated need to hear our political points of view. Certainly if they ask, we are welcome to supply our own opinions but emphasizing that it is merely just that: our own opinions.

When someday you or I get old (you first please), and need a cataract removed. I hope that the doctor with laser or blade in hand got to that position directly above the waiting eyeball not because of affirmative action, social justice, political opinion, or anything but competence, knowledge, and expertise.

Ironically, just earlier today, I was reading a great post by Thomas Sowell: Using words to confuse , wherein he touches on the concept that "social justice" may be neither very socially redeeming, nor very just.

Warm, fuzzy words and phrases have an enormous advantage in politics. None has had such a long run of political success as "social justice." The idea cannot be refuted because it has no specific meaning. Fighting it would be like trying to punch the fog. No wonder "social justice" has been such a political success for more than a century... There is a strong sense that it is simply not right – that it is unjust – that some people are so much better off than others.... Is the person who has spent years in school goofing off, acting up or fighting – squandering ...dollars ...spent on his education – supposed to end up with his income aligned with that of the person who spent those same years studying to acquire knowledge and skills that would later be valuable to himself and to society at large?

Dying for a Smoke? Cigarettes versus Mevacor; can't wait until you pay for it

noreply@blogger.com (Randall Bock, MD) — Fri, 10 Sep 2010 21:00:00 +0000

Earlier this week, I had a patient in, visiting me for the first time. He basically a "syndrome X" type of guy: middle-aged, overweight, high cholesterol, high blood pressure. He's not the most personally careful individual, with a history of domestic altercation, some prison time. Almost goes without saying he drinks too much and smokes cigarettes.

Well, now, he wants his cholesterol medication restarted since he has just now started receiving "insurance", i.e. Masshealth, Massachusetts' state welfare benefits program. He tells me he couldn't afford cholesterol medication on his own, notwithstanding a "heart attack scare" a year ago -- and stopped it, after having had it prescribed a few years prior.

Couldn't afford cholesterol medication on his own? Well, a bit of simple calculation shows that he spends about five dollars per day on cigarettes, and at least that much per day on alcohol. If he had chosen to purchase generic Mevacor for his cholesterol -- a fine, cholesterol-lowering, statin medication for the most part, although not state-of-the-art -- he probably would have been out about $.50 per day.

Now that he has "insurance" (call me old-fashioned, but I see insurance as a policy that you actually have to spend on in advance as a gambling hedge against later infirmity while you're actually young and healthy; not a gifted grant of benefits unpaid-for), he is happy to have the other citizens of Massachusetts take care of his cholesterol issue, now five years worse than it would have been had he been able to take some of his cigarette- or alcohol-money -- really only 1/10th of it, and invest it in himself.

How do we get people to properly invest in themselves? Probably there has to be some downside to ignoring one's health problems, rather than having your problem just drop into the laps of your more conscientious fellow citizens. Can you help me with this conundrum?

THE PRESSURE TO KEEP PRICES HIGH AT A WALK-IN CLINIC, see below for my more recent commentary

noreply@blogger.com (Randall Bock, MD) — Tue, 24 Aug 2010 18:15:00 +0000

The Pressure to Keep Prices High at a Walk-in Clinic

N Engl J Med 1989; 320:183-185January 19, 1989

SOUNDING BOARD

THE PRESSURE TO KEEP PRICES HIGH AT A WALK-IN CLINIC

A Personal Experience

It would be difficult today to be connected to medicine as either a provider or a consumer and not be aware of the existence of free-standing ambulatory care centers. Their usual habitat is along a suburban commercial strip, and their presence is generally announced by a well-lit sign displaying a hyphenated medical name, corporate-logo style. The ambulatory care center, known to much of the public as the “walk- in clinic,” is less well known to much of the medical community, perhaps because of its newness and the tendency of doctors and their families to visit their colleagues' well-established offices.

I intend to describe my experience at one such clinic so that the reader may understand the problems that I experienced personally as a “franchise doctor.” I want to show how the clinic’s management tried to keep the charges to patients higher than necessary, and how I was finally dismissed for not generating enough charges per patient. My dismissal and these pricing practices may be of general interest, because they bring into focus the relation between two necessary aspects of clinical medical practice — ethics and business — in a medical setting in which that relation is still evolving. It is important to emphasize that what follows occurred at one particular franchise within the corporation; however, colleagues with knowledge of other franchises have told me that my experiences were not unusual, especially for a comparatively large franchise.

For nearly four years, I worked full time in an ambulatory care center in a middle-class suburban town. I had six “permanent” physician partners, one after the other, and a score of part-timers, and the franchise had three different owners. Stated corporate philosophy evolved during this time from emphasizing “episodic care” along emergency room lines to stressing “continuous care” along primary care lines. Physicians today are asked to consider the clinic practice as their own and to make it grow and prosper as they would an ordinary community practice of primary care.

Many ambulatory care centers flourish in this mold. Patients enjoy the clinic’s accessibility and the doctor’s availability. The waiting time is rarely more than a half hour, and usually less than 10 minutes. The walk-in approach accommodates acute, relatively minor illnesses extremely well. The urgently ill come only rarely and are triaged. and those with severe chronic illness usually come only for peripheral problems, because they are already integrated into an institutional medical system. Referrals are made to internists or surgeons for hospitalizations and to specialists when warranted. General medical follow-up at the clinic is encouraged. When they work well, these clinics resemble the English model of general practice. And many do work well, providing efficient primary care of high quality.

Many doctors, including me, enjoy working at such clinics. The reasons include the absence of paperwork, billing hassles, scheduling rigidity, and on-call and hospital coverage, unless we desire it, and the presence of patient continuity, a well-trained staff, and a well-outfitted office.

The current trend in the business is to encourage the practicing clinic physician to purchase the rights to the franchise and become an owner-operator. The great majority of ambulatory care centers remain corporately owned, however, and pay the doctors a salary. In these clinics, the motivation to make a profit is greater for the corporation than for the doctor, yet the doctor effectively has the power of the purse in deciding the number and nature of medical tests and procedures and the cost of office visits. As if to counter this inherent difference in profit motivation, the ambulatory care center is structured so as to maximize corporate participation in the doctor’s decisions that bear on billing.

This is effected partly by splitting the nursing staff from the doctor administratively. At the clinic where I worked, only the nursing staff were corporate employees. The doctors remained outside the corporate structure because, technically, they were designated as independent subcontractors. Only a corporate employee — and therefore no doctor — could supervise the clinic.

The nurse-supervisor ordinarily took an interest in the revenue generated by the clinic, overseeing the accuracy of billing and the maintenance of proper corporate pricing. Last year, the nursing staff was empowered to assign the price level of an office visit on the basis of a corporate guide list (previously, designating the price per visit had been the doctor’s prerogative). The supervisor’s corporate credentials could be enhanced by greater clinic total revenue, the standard of a clinic’s value to the corporation. In addition, as a result of the comparisons and competition between clinics under the same corporate banner, staff morale varied with the generation of revenue. Monthly “bonus incentive” programs rewarded staff members of the clinic that had the best sales figures of one type or another. Such sales boosterism can lead to overzealous fee charging by the staff, especially when insurance eliminates price as a matter of direct concern to the patient.

Total revenue is of course the product of the number of patients and the average charge per patient. The number of patients is the less controllable variable and can only increase slowly, month by month, even in the best-run clinics. Therefore, many of the staff’s — and corporation’s — hopes for “better numbers” rely on increasing the charges per patient, something that, short of increasing prices, can only be achieved by performing more tests or upgrading the charge for office visits. With staff nurses and morale hanging in the balance, some doctors may feel pressured to keep charges up.

Doctors themselves are not neglected with regard to incentives. Their salary changes from an hourly wage ($28 per hour in 1987) to a commission (22 percent of the gross billing) once the latter amount exceeds the former. And beyond incentives, there lies persuasion. The doctor is visited every other month or so by the company’s medical director, whose principal duty in these visits is to educate the doctor about ways to increase charges. Such medical topics as quality of care are not ordinarily addressed in these meetings. A handful of practicing doctors known as “regional medical directors” perform a similar function by circulating memorandums with pricing tips and by holding informal staff meetings at local clinics. At one such meeting, the regional director pointed to the x-ray machine and exhorted the staff “I want to hear that baby humming!”

The corporate president and founder, a physician, led this boosterism by example. A memo he circulated told us that our corporation had been criticized by Blue Shield for not having ordered enough laboratory and x-ray tests. No other doctor to whom I have spoken has ever heard of Blue Shield’s requesting to be billed for more tests. At my first meeting with the corporate president, he said he expected that I would order chest films routinely on all patients with the diagnosis of bronchitis. Over my doubts he assured me that there was much written medical consensus on this point. At staff meetings, he reinforced the concept that we were much more likely to be sued and to lose lawsuits if not enough laboratory and x-ray tests were ordered. I do not recall his ever discussing the more basic aspects of medical-legal risk management.

The corporate predilection for testing was expressed in the idea that routine diagnoses should be accompanied by routine tests (and x-ray examinations). These tests, once defined from above as routine, could then be ordered by the nursing staff before the doctor saw the patient. Perhaps such an arrangement can work between a doctor and nurse who are familiar and comfortable with each other’s judgment; doctors reluctant to allow nurses this privilege were to be reported to the regional medical director, according to a corporate memo circulated to nurses.

Clinic doctors nevertheless remain the single most important factor in determining clinic revenue, through their discretionary power to order testing. This importance can be underscored by looking at the range of amounts doctors charged per patient. Until recently, corporate headquarters sent out a monthly list of the average per-patient charges billed by each of the 50 or so doctors working at the corporation’s 35 franchise clinics. The reported range (excluding the one or two most extreme) was about $54 to $80 — even wider than it might appear at first glance, because the irreducible minimum was $35 to $40, the fee for a standard office examination (titrated with some brief visits). Therefore, some doctors were adding in the neighborhood of $20 per patient in tests and visit fees, and others were adding twice as much or more. The upward pricing pressure here was subtle — the list ranked doctors in order of their charges, with those charging the least at the bottom. The doctors who seemed most in favor politically — the regional medical directors — were in the mid to upper part of the list. The message doctors were given may have been that to work one’s way up the corporate ladder, one had to work one’s way up the patient-pricing ladder. The message that one should avoid being at the bottom of the ladder was considerably less subtle. The three full-time doctors who were at the bottom of the list a year ago are now all gone. One was told he would be fired if his charges did not increase. He resigned. Two were fired. Of these two, one was given absolutely no explanation, verbal or written. I am the other. I was told directly (but never in writing) by the corporate president that I was being fired for not having charged enough per patient.

I am neither absolutist nor doctrinaire in avoiding laboratory tests. Like all clinicians, I order my share of x-ray films that I know will be negative, of cultures whose outcome will not necessarily change my treatment, and so forth. A test can be reassuring in its negativity and can reinforce the need for compliance when it is positive. By a standard of absolute necessity, I order too much. By the corporation’s financial formulas, of course, I did not order enough.

There was neither implicit nor explicit criticism of the quality of my professional care, as it was explained to me. A “bottom-line” financial assessment had merely been made. Another, more satisfactory doctor in my place would have had a lower threshold for testing and would have generated more money for the corporation.

This hypothetical replacement would not necessarily have been a worse doctor, for questions of when to test are delicate ones, without right or wrong answers, and subjective in the extreme. I make no criticism of and got along well with, almost all my fellow doctors whose charges exceeded my own. One would need to know a doctor’s actual clinical decisions intimately before any comment would have meaning. Indeed, knowing a doctor’s charges may be only slightly more important in determining his or her medical worth than knowing his or her shoe size. My objection is to the corporate view that such charges are, in effect, a measure of a physician’s medical worth.

In some ways, it is difficult to find fault with a corporation’s focusing on the bottom line to increase profits. Such is the nature of business. Such is also the crux of the problem. The ethos of medicine and the nature of its primary concern — human health and emotions — make medicine a commodity less amenable to harsh business realities than other economic goods such as automobiles, hair spray, or lumber. The question therefore arises, not whether a corporation is doing good business, but whether it is giving medicine and physicians proper respect when it considers a doctor’s pricing profile in its decisions on hiring and continued employment.

Granting, as I do, that good doctors can be found at all levels of the pricing spectrum, I nonetheless hold that medicine’s ethical pact with its public is subverted when higher-charging doctors are favored in hiring. Such a practice takes advantage of the relatively low price sensitivity of the typical clinic patient with health insurance. Medical consumers, enticed by convenience or advertisements to meet “today’s family doctor,’ are offered a product that costs more, on average, than it would if the corporation hired and employed doctors without regard to their pricing profile.

I imagine that every doctor in private practice can on occasion think of a patient as a dollar amount couched within a symptom, but I also imagine that doctors regularly pull back from such thinking by virtue of their education and morals. The dangers here are the institutionalization of the impulse to greed by the corporation and the individual physician’s subsequent removal from personal responsibility for carrying out the actions that follow from that impulse.

Lastly, these actions by my former employer occur at a time of much public discussion of high medical costs and possible ways to contain them. There is considerable doubt about whether medicine can get its own house in order or whether it needs some governmental coaxing. If the public and the third-party payers come to believe that they are being manipulated by the growing corporate segment of primary care, the desire for governmental intervention may build, to the detriment of doctors who act responsibly.

RANDALL S. Bock, M.D.

38 Athens St.

Boston, MA 02127

Massachusetts Medical Pharmaceutical "Gift Ban" ---------------- An argument for the the return of the medical informational dinner------------------

noreply@blogger.com (Randall Bock, MD) — Sun, 18 Jul 2010 18:42:00 +0000

Massachusetts is the only state that prohibits pharmaceutical-company-sponsored neutral-site educational lectures (with dinner) for physicians.

Quick, bullet point summary of the article below

Doctors are clearheaded enough to eat a meal and then still think through to the best medication choice.
Do politicians hold themselves to this same standard? Are politicians willing to give up their lobbyist-paid occasions?
These medications have passed FDA-scrutiny, a very high bar.
Lectures are sponsored by competitors within a given pharmaceutical class, so doctors are likely to hear many different perspectives.
Lectures won't be the sole place that doctors get information, with sophisticated knowledge-database availabilities currently.
In fact the lectures barely even mention the product and are well-balanced, given by the "thought leaders" who don't want to seem beholden to a pharmaceutical company.
It is a competitive world and Massachusetts needs to keep attracting the best doctors. Many doctors don't appreciate losing the collegial atmosphere of sponsored functions.
Your work and effort is needed to repeal this "gift ban". Please e-mail as below.

It is insulting to think that doctors who are ostensibly smart enough to save one's life are (at the same time) in fact so stupid, or (perhaps worse) merely gullible enough, to be swept away (or even swayed) by what is in actuality only a very weak potion of sales-presentation intermixed with and embedded within generally informative and pharmaceutical-balanced subject-focused medical lectures. Such lectures occur usually at a private function room at a restaurant or, in conjunction with a served dinner. It is the dinner-aspect that rankles the politicians, who are under the presumption that a served meal (or the associated thankfulness for same) will override doctors' better sensibilities at the time of later writing prescriptions.

These prescriptions will be written after evaluating patients, in consideration of best medical practice, desirous of success, yet under the eternal threat of malpractice or failure. Somehow though at the time of prescription-writing a long-ago-digested meal's meaning and memory will predominate over the preponderance of acute medical and clinical data, diagnosis, and thought.

Are our medical professionals so much more corruptible than our politicians? How is it that politicians are somehow able to sit through thousands of dollars worth of lobbyist-, or other political-contribution dinners without having their opinions or actions influenced (insert laugh track here) -- yet physicians are unable to maintain their balance and bearing, after the occasional dinner? At these dinners there is generally a group of a dozen or more physicians, whereas at lobbyists' convocations for politicians, the politician may be in fact the only person being fêted. In which situation is there a higher likelihood of monetary-influenced opinion-changing?

Where is the ban on politicians' attending lobbyist-sponsored dinners? Will politicians be clamoring for this anytime soon?

The pharmaceuticals associated with these dinners have already passed scrutiny by the FDA in order to reach market. This is a very high bar, a high standard to meet, and generally tens of millions of dollars have been invested in the pharmaceutical substance to bring it to market. It is sensible and necessary for future innovation and for current incorporation of information to have the prescribing population become aware of newer medications (and of utilization changes of older medications).

Politicians also ignore the fact that pharmaceutical companies don't exist in a vacuum (or as a monopoly... perhaps this is self-referential, the way they think of government, and the way government acts). Pharmaceutical companies, on the other hand, compete with each other. For every dinner that I went to in years past for promotion of (for instance) Viagra, I would also invariably attend dinners for competitors Cialis and Levitra. I would leave these lectures better informed about the ED-problem, the nature of PDE5 inhibitors, the possibility of side effects, but not "in the bag" for one brand or the other.

I have no doubt that physicians are adept enough, smart enough, and well enough balanced to make appropriate medical decisions based on the information out there (these days even more accessible , with so many instantly available medical-knowledge tools). These "live" (pharmaceutical-sponsored) educational sessions serve a useful adjunct function for dissemination of information, bringing physicians together and allowing physicians directly to question skilled and knowledgeable lecturers -- in my experience, with questions more about disease-states than about specific medications.

Physicians are quite busy and are also hard workers and high earners. Their working time is valuable and their free time is in a sense equally or more valuable. In order to bring doctors actionable and timely information, pharmaceutical companies knowingly and sensibly offer this non-monetary stipend of a sociable and social outing, a dinner. This is a nontransferable momentary benefit that is literally consumed at the spot.

I remember leaving these dinner lectures "full", but generally more nearly full of newly acquired subject-matter knowledge than abdominally full. The lectures themselves would barely mention a given sponsoring product, but even if they did, I would trust, and do trust , doctors during business hours to make their best decisions in accordance with the realities of a situation.

Even for the speaker, giving these lectures does not represent a "conflict of interest." The pharmaceutical company is simply happy to have the FDA-approved data presented to the audience. After that, the more thoughtful and neutral the speaker is with regard to the medication, the more credibility is maintained. Does the legislature want to keep suppressing the opportunity to hear truly balanced presentations?

Bringing back these sociable collegial events will help Massachusetts compete for "the best and brightest" physicians. Certainly we create a fair number here in our training institutions, but retention may be another matter.

The Massachusetts legislature holds a possibility in current session of repealing this "gift"-ban. Please do all you can in contacting your legislators to help further this process towards repeal.

Thank you very much for your consideration.

Sincerely,

___________________

Randall S. Bock, M. D.

for those interested in taking action, here is a quick addendum to help you focus your efforts:

The conference committee members who will be determining the fate of the “gift ban” repeal have been announced. please contact any/all of the below. Let them know your opinion on this matter.

· Sen. Karen Spilka – Metro West

· Sen. Ben Downing – Western MA

· Sen. Bruce Tarr – North Shore

· Rep. Brian Dempsey – Haverhill – Supported repealing the ban

· Rep. Garrett Bradley – Plymouth – Supported repealing the ban

· Rep. Viriato Manuel deMacedo – Plymouth – Not present

hearing aids versus reading glasses

noreply@blogger.com (Randall Bock, MD) — Thu, 15 Jul 2010 15:12:00 +0000

Hearing aids cost thousands of dollars. In my early dotage ;-) currently 53 years old, I recently found imperfection in my near-vision (as we all do, over time). Probably I was laboring for a year or so before caving in: purchasing reading glasses. I am using them right now and they have made all the difference.

In the space of a few months, this year, I went from no reading glasses to seven pairs. I bought all seven online together as a package recently, for the grand sum of $10.00. That comes out to less than $1.50 per pair. As a result I keep one set by my bedside, one in the kitchen, one at my office, one in the car etc.; always at hand.

Not so long ago, reading glasses would have been "fitted" by an optometrist much like prescription glasses would have cost potentially hundreds of dollars each pair, but the wisdom of the market prevailed, under the implicit acknowledgment that the vast majority of cases of people needing reading glasses doesn't require prescription-fitting. Pretty much everybody gets nearsighted in the same manner, albeit differing in gradation; so it's just a matter of finding the right amount of correction in purchasing the new reading glasses. You can try one pair and then another until you are comfortable. There's the possibility that one eye's visual correction need is different from the other 's, and for those people optometrist consultation might be in order; however for nearly everybody else, off the shelf reading glass purchases are adequate, after trying different diopter-gradations of the eyeglasses.

Age-related diminishment in near-visual acuity is a result of change in the shape of the eyeball, essentially the drying out of the intraocular gel. This is nearly uniform although some of us get it earlier than others. Because the problem is pretty much the same for everybody, although differing slightly in degree, the solution is nearly the same for everybody. As a result , there is a great economy of scale, and eyeglasse-fitting for hundreds of millions if not billions of people just a matter of choosing a correction-level and finding a nice style, really no harder than buying a pair of gloves and probably easier than buying a pair of shoes.

Along the same lines of losing our near vision gradually, pretty much much we all lose our hearing, or more harshly said "go deaf" in the same manner as each other (with aging that is).

If we can fit gloves, reading glasses, or shoes so easily: usually for relatively little indentation into our pocketbooks, why then do hearing aids cost thousands of dollars? I recently bought a replacement Bluetooth earpiece, and it cost me all of $20. This Bluetooth coordinates with a variety of telephones and computer and other devices. It is tiny and extremely complicated. It has volume adjustments, battery-saving mode and probably a bunch of other features that I have not figured out yet.

Why is this purchasing paradigm so different from that of hearing aids'? I know that a hearing aid has to augment sound yet not overdo it in case a loud sound occurs whereupon the hearing aid 's amplification could damage the eardrum. But really how much more complicated is a $2000 hearing aid than a Bluetooth earpiece?

I think the pricing has much more to do with lack of access on the part of the consumer to a free open market for same. Everyone is funneled through the audiology offices.

There was apparently some interpretation of a federal statute by FDA making hearing aids prescription devices. This apparently was a misreading of statute and the market is now opening up. Once this occurs we should be able to obtain hearing aids for prices similar to the more complicated Bluetooth devices, and maybe get more features too. Wouldn't it be nice if one could remotely control hearing aids; add GPS or item loss-prevention; replace them for tens of dollars rather than thousands?

Remember when contact lenses cost hundreds of dollars per pair? That market has totally turned inside out. We need to open up the market for hearing aids. I'm somewhat surprised that organizations supposedly advocating for the elderly, e.g. AARP, have not been more proactive in this area. The AARP wants its members to have hearing aids, promotes the benefits of hearing aids, but does not appear to have done very much to open the market. They have tried to promote a tax credit for hearing aids, but this only transfers the cost, the high cost, of hearing aids to other taxpayers effectively.

It would seem to me that the highest benefit from the current approach acrues to audiologists. Similar situations obtained previously vis-à-vis contact lenses for ophthalmologists, orthotic shoes for podiatrists, reading and other eyeglasses for optometrists, teeth whitening fittings for dentists, antisnoring mouthpieces for ENT's or dentists.

We have to flip this model inside out so that the greatest benefits accrue to those with the problem: in this case hearing loss. I have so many patients with hearing loss who can't afford to go the hearing aid route. When they can purchase these items freely, try them on, and choose openly between brands, prices will drop. The free-market rules!