Thursday, April 09, 2009

The Doctor Regulator Will See You Now

As my wife and I waited at her OB-GYN’s office, we could hear the doctor on the phone across the hall speaking rather gruffly with someone that he obviously felt was trying to push him around. After slamming the phone down, he stormed into the room grousing that the insurance company’s hired doctor had no right to tell him how to practice medicine or determine what was best for his patient. After all, my wife’s doctor steamed, the man had had his license suspended as a result of his alcoholism. He hadn’t seen a real patient in over nine years and had no idea how to effectively treat patients in real life.

Third party bean counters have been able to improve medical outcomes up to a point. Doctors Jerome Groopman and Pamela Hartzband explain in this WSJ op-ed that “standardized protocols” developed as the result of research have remedied a number of sloppy medical practices that harmed people. These protocols include hand washing and catheter insertion routines, for example.

These successes have prompted many to assume that similar protocols could be successfully developed that would improve outcomes in cases of complex diseases by standardizing treatment and practices. Both government and private insurers have implemented “pay-for-performance” programs in recent years. You might think that this means that they pay more for better outcomes, but you would be wrong. Rather, they are paying for how well doctors follow guidelines developed by committees.

In some areas, extremely coercive means are used to force doctors to rigidly follow these guidelines. Actual outcomes don’t matter. Only compliance matters.

We all want our doctors to follow best practices, but when it comes to complex diseases, explain Doctors Groopman and Hartzband, flexibility is called for; not rigidity. After listing a number of situations where metric driven treatment has proven to be useless or harmful, they write:
“These and other recent examples show why rigid and punitive rules to broadly standardize care for all patients often break down. Human beings are not uniform in their biology. A disease with many effects on multiple organs, like diabetes, acts differently in different people. Medicine is an imperfect science, and its study is also imperfect. Information evolves and changes. Rather than rigidity, flexibility is appropriate in applying evidence from clinical trials. To that end, a good doctor exercises sound clinical judgment by consulting expert guidelines and assessing ongoing research, but then decides what is quality care for the individual patient. And what is best sometimes deviates from the norms.

“Yet too often quality metrics coerce doctors into rigid and ill-advised procedures. Orwell could have written about how the word "quality" became zealously defined by regulators, and then redefined with each change in consensus guidelines.”
Do you want your doctor to treat you according to what she thinks will truly be in your best interest, or do you want her treatment of you to revolve primarily around unseen regulators that demand exact compliance with general guidelines? Studies have already found that doctors are shying away from even lifesaving treatments in some cases “out of fear of receiving a low grade if the outcome is poor.”

I recently commented to a doctor that the pharmaceutical industry thinks that a controlled study where 56 percent of the patients have a somewhat positive outcome is stupendous. I complained to him that doctors often give the impression that a medication with such a success rate will be effective for everyone. He admitted that I was correct. He added that doctors are usually “just following guidelines.”

We want our medical practitioners to have the latest technology and medical information. But it is folly to create unyielding rules based on these this. Hopefully we are training medical personnel to employ good judgment. Turning them into automatons that unstintingly follow committee recommendations makes ill use of those skills and arguably leads to worse outcomes for non-average patients.


Charles D said...

I have to pass on this relevant story.

The President of a large California managed care company was also board chairman of his community's symphony orchestra. Unable to attend a concert he gave his tickets to the company's director of health care cost containment. The next morning the president
asked his associate how he enjoyed the performance. Instead of the expected usual, polite remarks the director handed him the following memo:

A. The attendance of the orchestra conductor is unnecessary for public performances. The orchestra has obviously practiced and has the prior authorization from the conductor to play the symphony at a predetermined level of quality. Considerable money could be saved by merely having the conductor critique the orchestra's performance during a retrospective peer review meeting.

B. For considerable periods the four oboe players had nothing to do. Their numbers should be reduced and their work spread over the whole orchestra, thus eliminating peaks and valleys of activity.

C. All 12 violins were playing identical notes with identical motions. This is unnecessary duplication: the staff of this section should be drastically cut with consequent savings. If a large volume of sound is required, this could be obtained through electronic amplification, which has reached very high levels of reproductive quality.

D. Much effort was expended playing 16th notes, or semi-quavers. This seems an excessive refinement as most of the listeners are unable to distinguish such rapid playing. It is recommended that all notes be rounded up to the nearest 8th. If this is done, it would be possible to use trainees and lower grade operators with no loss of quality.

E. No useful purpose would appear to be served by repeating with horns the same passage that has already been handled by the strings. If all such redundant passages were eliminated, as determined by the utilization review committee, the concert could have been reduced from two hours to 20 minutes with greater savings in salaries and overhead. In fact, if Schubert had attended to these matters on a cost containment basis, he probably would have been able to finish his symphony."

Scott Hinrichs said...

Awesome. I'm laughing myself silly.