By Evan Falchuk
The Jobbing Doctor, a primary care doctor in the UK, writes today about the British version of what Americans call “Pay for Performance,” or “P4P.”
He says something I’ve said many times before (like here, here, and here). Which is this: incentives fail because they try to treat medicine as an assembly line process, when it’s not.
But what’s most interesting about his post is that it could have been written by a doctor from anyplace on the planet Earth.
By Evan Falchuk
The American Cancer Society says that men over 50 need to seriously consider whether they really ought to get screened for prostate cancer. According to them, the risks of getting tested may outweigh the benefits of detecting the cancer, especially for younger men. They say it’s a “complex issue,” but they understate how complicated it really is.
Like the recent controversy over breast cancer screening, the new recommendations add to the swirling morass of conflicting messages and priorities around health care in America.
By Evan Falchuk
You can’t generalize about the medical profession from talking to just one doctor. But there are striking similarities in the ways the world’s best doctors think about medical care. I had the honor to meet such a doctor yesterday, Dr. Takeshi Kawase. He’s Professor and Chairman of the Department of Neurosurgery at the School of Medicine at Keio University in Tokyo, Japan.
Dr. Kawase is a neurosurgeon, who specializes in skull-base surgeries. Interestingly one of his major specialties is operating on patients with the exact same illness my brother dealt with recently.
I learned a lot from my talk with Dr. Kawase. What else would you expect from a talk with a renowned medical professor?
By Evan Falchuk
A new study out of Israel (h/t Robin Grantham via twitter) says that the kind of mood your doctor is in may significantly impact the quality of care you get.
On days the doctors felt positive moods, they spoke more to patients, wrote fewer prescriptions, ordered fewer tests and issued fewer referrals. However, when doctors were in a bad mood, they did the opposite.
Now, I bet this is true in any line of work. If you’re in a bad mood one day you probably aren’t as good at your job as on days you are in a good mood. Ok, well maybe not every line of work.
Still, if being in a bad mood leads to lower quality, higher cost medicine, let’s think about what the work life of a doctor typically looks like.
For starters, they often have to see 30 or 40 patients a day, and spend maybe 20 minutes with each. Private insurers and the government impose on them an increasing amount of administrative work. They’re also increasingly involved in the medical decisions the doctor works so hard to make. Doctors’ incomes aren’t going up, but the cost of their malpractice coverage is. Meanwhile, patients are increasingly demanding and sophisticated, the pace of change in diagnosis and treatment is accelerating.
It’s a set-up that seems exquisitely designed to create high levels of stress, anxiety, fatigue and burn-out, doesn’t it?
Of course, these were precisely the things the Israeli researchers said led to lower quality, higher-cost medicine.
The stress, anxiety, fatigue and burn-out we see, though, are just symptoms of a larger problem. Our system too often deprives doctors of the time and space they need to get to know a patient, think about their problem, consult with colleagues, and offer sound advice. These are the things patients want from their doctors. What’s more, doing these things are a big part of why people become doctors in the first place. Unfortunately, there isn’t much of anything in the health care reform proposals that addresses this deeply fundamental problem, and so it will continue, or get worse.
Which ought to create bit more stress and anxiety for the rest of us.
By Evan Falchuk
At the Wall Street Journal’s Health Blog, Jacob Goldstein writes that programs that pay more for better quality care are a “tricky proposition:”
Even if you can figure out what to measure, and how to account for differences between patient populations, you still need to have a decent sample size; anybody can have a bad (or good) day, so you need to measure a large enough number of events to minimize the role of random variation.
But 65% of primary-care docs work in practices that are too small to draw meaningful conclusions about the quality of care they provide (at least if you rely on Medicare data), according to a study published this week in JAMA.
Fair enough. But it begs the question: why would we need to pay doctors more for delivering quality service (whatever that term might mean)?
The hidden assumption in these kinds of programs is that quality problems in health care are caused by bad financial incentives. Since doctors are paid the same regardless of the quality of their work, they don’t care enough about whether they do a good job or not. Pay them extra if they do well, and you’ll see improvements as they try to earn that extra pay.
It might be true if the practice of medicine were like an assembly line. In that kind of work, the goal is to deliver large numbers of standardized products through a series of repetitive, simple tasks. People are good at this kind of work, and can be incentivized to deliver different kinds of outcomes, depending on how you pay them. Want more cars? Pay extra for hitting some production target. Want higher quality manufacturing? Pay extra for lower levels of defects. Robots do this kind of work even better, and you don’t even need to pay them anything at all.
But doctors aren’t robots, and this isn’t what medicine is all about. Of course, this hasn’t stopped the exact opposite from becoming the conventional wisdom about health care.
Costs are too high? Increase throughput and reduce unit costs. Or, in English, make the doctor see more patients and pay him less for each one he sees. Still too high? Get nurses to do some of the work so throughput can be increased even more. Oh, and let’s cut the pay, too. Meanwhile, let’s buy some new computer systems that will make work more efficient. Computer systems always do that. Let’s also come up with some quality measures, like maybe, 1,500 or so, and pay doctors a little extra if they meet some of them.
If it weren’t for all the politics surrounding health care, I think many people would find it amusing that anyone thought this was a very good idea. But it’s the state of the art in reform. And it’s characterized by a fixation on metrics that too often misses the bigger, more important, picture.
So what’s wrong? In health care, we do not have a consensus on what “quality” means. Some say quality should be measured based on outcomes, but even the very best doctor can’t ensure a good outcome. Sometimes the news is bad, and the outcome will be what it will be.
Instead, why aren’t we measuring quality based on what people really want from their doctors – the right diagnosis and treatment? As a patient, I would gladly pay more to go to a doctor who I knew was better at this than her colleagues.
As I’ve noted many times before, the fundamental mistake is prioritizing money over medicine. By focusing on ever more clever ways to design economic incentives, our system undervalues the very things that make it possible for doctors to deliver the right diagnosis and treatment. Things like time with the patient, thinking about his or her problems, consulting with colleagues, and coming up with sound advice.
If we want to remake our health care system, we need to start with the idea that the right diagnosis and treatment is the fundamental goal. Everything else we create should be based on whether it helps serve this goal, above all others.
By Evan Falchuk
I’ve spent the last few days with much of our European team, today in Madrid, Spain.
Here are a few quick observations, as the American reform process continues.
1. Every country’s health care system has developed in the unique circumstances of its history. That is, the health care system of each country is the result of a collection of changes, fixes, restrictions, reforms, market developments and whatever else has happened over the last several decades. The result in each country are systems that work better or worse, but which in most all cases are very confusing to the people that work in them or get care from them.
2. In my travels, when I talk to people about what it is like to get care in their health care system, everyone speaks highly of their doctors and poorly of whoever it is that pays for their health care. It’s true whether it’s the government paying or a private insurer. I think that, at least in the Western world, people just don’t like the idea that health care is an economic activity. There is, I think, a sense that there is a sense that there is something almost religious about health care. And so the idea that someone should pay someone else to deliver it seems, culturally, somehow distasteful. The trouble is, no matter what people have tried to do, health care is a business. I think some of the dissatisfaction people feel with their health care systems has to with how hard it is to reconcile these two conflicting ideas.
3. The experience of being sick, or caring for a family member who is sick is very similar no matter where you go. Most people feel that they can handle being sick; the part they can’t handle very well is the uncertainty about what to do next, and whether what’s being done to them is even the right thing. Everywhere you go people talk about the enormous amount of information available on the internet about their medical condition – but also about the insufficient time they get with their doctors to talk about what they’re finding, what they’re worried about, and how to deal with their anxiety around these things. There is, it seems a, growing sense that it is ok, and in fact important, for patients to educate themselves about their medical situation. And, certainly, a growing sense that it’s ok to ask your doctor questions, to want to be satisfied with the answers, and to make sure you have the best chance possible to get well.
In all events, here’s a photo of me with some of the terrific team in our office in Madrid:
By Evan Falchuk
There is a disturbing story in the Hartford Courant (via the WSJ Health Blog) on how Connecticut state lawmakers have helped hospitals keep medical mistakes secret from the public. It’s true:
The legislature in 2002 ordered hospitals to disclose all serious patient injuries “associated with medical management.” But after the first reports were made public, hospital lobbyists persuaded lawmakers to rewrite the statute in 2004, limiting the kinds of adverse events that must be divulged, and promising to keep reports secret unless they led to an investigation.
What happened next is predictable. According to the Courant, public access to data about hospital adverse events dropped by 90%.
Is this a good thing?
The state and hospitals seem to think so. They say that the more limited reporting requirements mean that reporting is targeted at serious problems. A spokesperson for a major Connecticut hospital agreed, saying that “questionable cases” are reviewed by senior management, and forwarded to the state if they meet the criteria for reporting. They also say that keeping the reports secret makes the hospitals more willing to report honestly on adverse events.
I don’t doubt the integrity of the people involved in these programs at the state or hospitals. But the system they have set up can be summed up as “trust me.” Trust me that I will know, as a hospital, when an event is serious enough to report to the state. Trust me as the state that I can figure out what’s important to tell the public what is and what isn’t important. Trust us that the quality of hospital care will be better if we can just keep you from knowing too much what happens when people are treated in them.
I appreciate that people like to manage bad news in private. In an organization, it can be an understandable instinct of self-preservation. But more broadly, hiding mistakes is a very bad thing.
Why?
First, it gives the impression that the hospitals, and the state, actually have something to hide. I mean, otherwise, why hide it? Maybe they are worried the public will misinterpret the data. But then why not spend a little bit of time educating people on the meaning of the data? That seems more productive than simply hiding it. And don’t the hospitals and legislators see that by hiding it in this way all they are doing is magnifying the importance of whatever it is they are hiding?
It also corrodes the trust people place in what ought to be trustworthy institutions. The data ought to just be the data. The state and hospitals should ensure the data is accurate, understandable, and consistent. By focusing on figuring out what is appropriate for the public to see or not the data becomes unavoidably tainted with politics. Worse, it creates a perception that certain public servants have special access to information, which the rest of us are not worthy to see. That’s not how America’s supposed to work, and one reason Justice Brandeis’ wisdom that “sunlight is the best disinfectant” is so timeless.
Finally, keeping these kinds of things secret robs all of us of the opportunity to learn from mistakes. Teaching hospitals and others commonly perform what are known as “morbidity and mortality” rounds. These are conferences in which doctors meet to discuss mistakes, bad outcomes, complications and the like. The purpose of these rounds isn’t to lay blame, but rather to try to figure out what went wrong, and how to learn from the mistakes.
Broader studies on misdiagnoses show that if you collect lots of data on what goes wrong you can discover interesting things that can improve the quality of care. For example, some researchers are categorizing how and why medical errors happen, helping avoid these kinds of mistakes in the future. But without data, you can’t do these good and valuable things.
So, yes, I understand the instinct to keep bad news secret. But our philosophy ought to be openness and transparency. Not only because it helps improve the quality of care but because it’s simply the right thing to do.
By Evan Falchuk
I’ve blogged for a long time (like here, here and here) about how the conventional approach to health care systematically devalues the thinking, processing and deciding aspects of medical decision-making. Among the symptoms of this problem is the limited amount of time doctors are expected to spend with their patients. For example, the latest government data show that the average doctor visit features face time with the doctor of less than 15 minutes.
Now, a new study is out. Some of those talking about it are saying the time problem is being solved.
Really?
According to the study, between 1997 and 2005, the average length of a doctor visit increased significantly. Well, statistically significantly. It went from 18 minutes to 20 minutes 48 seconds.
Does it mean anything? A study by ABC News earlier this year found that the number one complaint patients have about their doctors is the amount of time they get to spend with them. Patients don’t seem to be noticing much of a difference.
Still, the whole thing misses the point. You don’t go to your doctor to spend time with him or her. You go to the doctor to find answers to your medical problems. You go to your doctor because you want him to listen to you, answer your questions, and give you confidence about the next steps in your care. Having limited time with your doctor doesn’t help, but pushing the median to 22 minutes or 24 minutes or whatever isn’t the answer.
The answer lies in fundamentally rethinking our approach to health care. We need to move away from the fixation on units of health care and towards a focus on the needs of the patient. We need to have a profound respect for the doctor-patient relationship, for the time doctors are able to spend thinking about their patients. We need a system that puts these fundamentally qualitative measures of care at the center, and not the assembly-line metrics that have for too long moved health care away from serving the needs of patients and their doctors.
So, I guess it’s a good thing that patients have an extra three minutes of time. But health care shouldn’t be about reducing the rush your doctor is in to an acceptable level. It’s about things that are more fundamental, and more important, to patients and their doctors.
By Evan Falchuk
Last night, I saw a commercial produced by the federal government. Called “Questions are the Answer,” it’s a call for patients to be engaged in their medical care, to ask questions of their doctors in order to be sure of their medical condition.
The commercial was excellent – it showed a man asking dozens of increasingly arcane questions about a cell phone he was thinking of buying. Then, it showed him in his doctor’s office, apparently after getting a diagnosis. “Do you have any questions?” the doctor asks. “Nope,” says the man.
The government agency that produced the commercial is the Agency for Healthcare Research and Quality. There are a series of other videos and tools that can help you be a better, more informed consumer if you get sick.
The only catch: it’s almost impossible to find any of this great material. The front page of their web site – if you should somehow manage to find it – is an enormous list of bullets and subcategories. There’s a good consumer-oriented video on the right side (featuring Fran Drescher), but the screen is quite literally smaller than a postage stamp.
Those excellent TV ads? Hidden several clicks away from the front page. And what’s worse, you can’t embed or share them, they seem to only be available to watch locally. In other words, all this good work is going to waste. From a social media perspective, this most effective part of AHRQ’s web site pretty much doesn’t exist. I noted this back in May, and it’s unchanged since then.
But the AHRQ should know: it’s never too late to get involved in social media. Please, re-think your web site and get a social media strategy. It’s never to late to get this important message out there.
By Evan Falchuk
Some people are upset or wringing their hands about this bufoonish speech by little-known representative Alan Grayson from Florida. All of them – including Grayson – are taking themselves way too seriously.
And they – like reformers and their opponents – are missing what’s important in health care. They’re all fixated – as they have been from the beginning – on who pays for health care, and how. It’s a problem that long pre-dates this latest reform effort. Its impact was well documented in Atul Gawande’s (thoroughly misunderstood) article in the New Yorker.
Gawande showed how our fixation in America on money — rather than medicine — was creating the very problems we are trying to solve. Money has become the central organizing principle of our system and efforts to reform it. And so as reformers focus on ever more clever ways to pay for medical care, they continue to systematically undervalue everything that makes for high quality medicine. Things like time with your patient, thinking about his or her problems, consulting with colleagues, and coming up with sound advice.
So the focus on a “public plan” or the arcana of insurance underwriting completely misses the mark.
Your care may be paid for by a private insurer or a public one. Your coverage may be called a “Cadillac” plan or a high deductible plan. You may be uninsured. But there are some things that will be virtually certain if you get sick regardless of who and pays for your care and how:
The majority of your medical visits are going to feature face-to-face contact with your doctor of 15 minutes or less. Your care is going to be fragmented, with information about you stored in paper files, electronic records, and the memories of the doctors you have seen. You’re going to be on your own, facing important decisions, with too few places to turn to for help.
It’s bad, and in my experience, almost everyone I talk to on this subject has some personal experience with health care that looks just like this.
What’s even more troubling is what happens to many of them.
Studies show that 15% or more of patients have their diagnosis missed, delayed or wrong. Others have found that the biggest driver of this poor quality are the cognitive errors that happen when you make complicated decisions with fragmented information and restricted time. Our own data at Best Doctors show that more than half of patients end up with the wrong treatment.
It’s not clear if the current effort to focus on money over medicine will succeed or not. But for those who have become engaged in health care because of it, there is an opportunity to lead a renewal of thinking about health care in America. We need to refocus on what is really important when you’re sick. That your doctor is able to spend the time with you that you need. That he or she is able to think about you, answer your questions, help you understand your condition. That you are sure you have the right diagnosis and treatment, and the best chance to get well.
UPDATE: Dr. Bob Centor, who does some of the best blogging on this kind of ‘re-thinking’ of health care has a post up on this point that’s well worth reading.
