A number of services like HealthGrades and RateMDs allow patients to rate their doctors. Most of these ratings are based on things like “ease of scheduling an office visit,” “Wait time before seeing the physician,” or “Helps patients understand their medical conditions.” Fair enough things to grade a physician on.

A number of services like Medicare’s Hospital Compare or Cal Hospital Compare allow patients to compare hopsitals based on a set of standard “quality indicators” for things that we know will help patients do well — things like making sure patients with heart attacks get the right medicines or treatments in the right amount of time, or giving older patients pneumonia vaccines. Not only are hospitals publicly evaluated on these indicators, but Medicare is considering paying hospitals (and doctors) based on standard indicators. This is know as “P4P” or “Pay for Performance.”

However, physicians and hospitals rightfully argue several things:

• You’re only going to get the extreme patients to evaluate you (and often the unhappy ones
• The unhappy patients will have the opportunity to publicly say how terrible the doctor is, but because of privacy rules, the doctor or hospital cannot comment or defend him or herself
• There is too much emphasis on bedside manner and convenience, and not enough information on outcomes — “How Good A Doctor Am I?”
• Even if there is information on outcomes (like in the hospitals’ cases) if this determines payment or discourages future patients because of a bad rating of outcomes, the physician will be much less likely to risk treating a very sick patient, who will likely have a bad outcome no matter what
• These systems also ignore where a hospital operates or where a doctor works — hospitals with large populations of poor patients are likely to be sicker than hospitals in affluent areas. Academic hospitals which often care for many incredibly complex, sick patients might be compared to relatively straightforward, simple patients at another hospital down the street.

Medicare has run a trial of this P4P stuff, and it’s been written up in the New England Journal, called Pay For Performance: At the Tipping Point . Let’s look at the some of the outcomes — they took hospitals and either paid the hospitals for their quality improvements, or told the hospitals their outcomes would be publicly available online:

Now, some might say, “Wow, look at that, if you pay people for doing better on quality, they get better!” But the keen observer would point something else out: “Wow, even if you don’t pay people, but make results publicly available, people do better, too!”

Folks (and by folks, I mean doctors and hospitals), this stuff isn’t going away. If you don’t have patients blogging about their encounter with you by name, it’s only because they’re in their 20s or 30s and are young and healthy. (I happen to be friends with one Dr. Gilbert, who is mentioned on the Stanford Hospital Yelp page as the Stanford ER’s McDreamy.) Seriously. The personal evaluations about you are coming, whether you like them or not. It’s in our best interests to argue for the best, most objective and accurate standards. If you’re one of the people that says “Medicine is a business above all,” (I’m not) then fine, but look at every other business in the US: it’s getting revolutionized, criticized, and evaluated online.

We don’t need less transparency, we need more. And the only way we’re going to get there is by having more data.

Physicians and hospitals should certainly be judged by if they’re taking good care of their patients. That means a lot of things: patient rapport, having a “good experience” (whatever that means), but more importantly, outcomes and guidelines. These are, however, guidelines, not rules. It should be simple and straightforward for the hospital or physician to not follow a guideline: if the patient’s heart rate is already 40, they shouldn’t be getting a beta blocker, which slows the heart rate, for example.

For physicians: do patients want the gruff surgeon who’s the best, or the one who’s pretty good but is kind and nurturing (I swear, there’s nurturing surgeons out there)? This data will soon be out there–but in subjective form. “I saw Dr. Green and two weeks later, my cancer had metastasized!” We need accurate, fair standards to examine how we’re doing as doctors, that take into consideration things like patient complexity and compare apples to apples .

For hospitals : I think a lot of the P4P and outcomes and quality indicators stuff for hospitals is worthless for the public. Hospitals get patients for primarily two reasons:

1. The patient comes to the hospital’s ER and gets admitted.
2. The patient has a particular doctor who has admission privileges at Hospital X, so the patient gets admitted to Hospital X.

Patients, when sick, do not launch a web browser and see which hospital was more likely to give an ACE inhibitor to its diabetics. They go where their doctor tells them, or barring that, wherever is closest or where they’ve had a good experience before.

P4P and Incentives
One of the big concerns in P4P is “how do we define good, and how do we reward that?” Do we pay the doctors who are really crappy, but then start to improve, while ignoring the docs who are already outstanding? Both? Neither?

For physicians: It’s a little frustrating that we would have to pay physicians to practice appropriate medicine, instead of expecting them to simply keep up with modern medicine, no? Isn’t that what CME requirements are for? I’m not talking about the cutting edge, latest-issue-of-NEJM stuff, but stuff that we’ve known for 10 years? ACE inhibitors, beta blockers, aspirin?

For hospitals: It’s a bit more complex to improve indicators in hospitals, because there’s so many different steps involved to coordinate successes, so hospitals should be rewarded handsomely. But hospitals shouldn’t be competing for patients. They should be competing with other hospitals. Perhaps we create “reward funds” for 3 hospital types: community, academic, and county. And hospitals compete with each other for “most improved,” “best indicators, etc,” — again, apples to apples hospital comparisons. Each 6 months, the top hospital in each category gets a reward that gets split up between the hospital and its staff; this would create innovation between hospitals, everyone trying to do better a job. And let’s say the winning hospitals have to give away their secrets to “best pneumonia vaccine rate” to everyone else.

Perhaps for the next 5 years, we start with carrots. If you’re either improving or continuing to do a good job (as compared to your equals), you get a bonus. 5 years after that, if you’re not improving, or doing significantly worse, in comes the stick, with some sort of punishment.

(Look, I’m well aware that the indicators aren’t always practical or the best, and they certainly need to be improved drastically, taking into account the differences between community and academic medical centers, etc, but the evaluations and ratings are coming. I’d much rather setup a system that is created by health care providers and reasonably fair than be evaluated by the subjective masses whose opinions are often muddied by sad, tragic bad outcomes.)

Update: Case in point, I just last night got an email from a close friend who sent a group email to have us “check out this new site that shows hospital ratings on Google maps.” How are they determining who’s red and who’s green? The data I discuss above.

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EMTALA , the law that requires ERs to evaluate and stabilize everyone who shows up, is a good law. (There went half my readers right there.) If you’re still with me:

I would argue (as would the writers of EMTALA) that we are so advanced a nation that patients should not be dying on the streets because of their inability to pay for emergency medical care. The problem with EMTALA is that it provides too much potential for abuse. This is the fundamental art of social policy — how do I put together a rule to maximize its use for its intended purposes, yet minimize the opportunities for abuse and loss of personal freedoms for whom the rule applies? (Note: unfortunately many policy makers do not seem to follow or care about this. They trust lobbyists to do this.)

If you were to look online or eavesdrop in a doctor’s lounge, likely “abuse of medical resources by certain patients” would be near the top a frequency-of-complaining list. However if you were to look at how much, in reality, these patients actually cost the system, it would be a tiny percentage of that compared to the truly sick. So it’s more a matter of wasting a doctor’s time and energy — these patients are truly draining : they frustrate physicians and nurses greatly.

The other problem is that EMTALA is an unfunded mandate. This means that hospitals are required to follow the rules of EMTALA no matter what the cost may be to the individual hospital.

Often it depends on why the patient is there — which often is near impossible to discern in the first place. Others are straightforward: hypochrondriacs? Easy. Refer to psych. For drug seekers (note: boy would these patients be easier to spot a mile away if we had some sort of national medical record), make sure they’re only drug-seeking, and get them out.

Others seemingly have nothing better to do. While I’d argue that perhaps job resources, education, and opportunities in the long term and for future generations might be a better solution, I’ll stick to health care for now.

If we want these patients to either stop seeking care altogether (not good to alienate people from the health care system, I’d argue, see my other posts in this series) or start seeking more appropriate care, then we’ve got to use our carrots (rewards) and our sticks (punishments) to lead the donkey.

Maybe we just need to offer better options. For some patients who simply don’t know any better, and for whom a stern lecture by a doctor isn’t going to educate them, they just need another place to go besides the Emergency Department. For these patients, we should be supporting our community health centers for after-hours clinics. They’re usually just as well-placed and located as hospitals, they provide more appropriate care settings at much lower costs, and they would also get a patient tied in for follow-up at the clinic, maybe even start seeing a physician on a regular basis. These after-hours clinics should be funded, like EMTALA (see below).

For other patients, they need a stick, as the niceities of education and better options simply don’t appeal to their finer sensibilities. Two possibilities here: perhaps it’s three strikes out at the olllld ballll game. Once a patient has been seen for non-urgent care (which would obviously need to be defined) three times, they no longer qualify for EMTALA at the hospital. If they return, they get a vital signs screening by a triage nurse, and barring no abnormal vitals or other gross, obvious issues, they are turned away. Another possibility would be charging a patient for non-urgent issues. We say, “Sure, we’re happy to evaluate you,” but if you are not even urgent (remember, you’re at an Emergency Department), you’ll be charged. (Note: this latter option I don’t support if there are no other options for these patients, which is why I think we should offer after-hours clinics.)

Finally, funding. A colleague of mine likes to say that a heavenly program can be hell if not funded appropriately, and maybe this would lead to a chain reaction of EMTALA fixes. If the federal government (read: taxpayers) had to start paying for EMTALA care (note: we already are, in the prices of higher costs to subsidize unreimbursed care), we would immediately see the true costs, and take actions to fix it. Currently, it’s all just buried in inflated prices and percentages of costs and losses in hospital account ledgers. Either way, EMTALA care needs to be funded. Some states are trying to partially fund this effort by passing certain taxes, but a national source makes more sense, since it’s a national law.

(Note: “Repeal EMTALA” enthusiasts are either kidding themselves, heartless, or living on Mars. If you believe that Emergency Departments in the United States should check for insurance in the ambulance bay or require a funds verification before they see a septic patient or one after a bad car accident, like they do in India, you might as well stop reading. We’re not going to see eye-to-eye anyway. For-profit hospitals would have no problem doing this, and it’s unethical and immoral.)

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(If you’re just joining us, here’s the introduction .)

People die.

I wish it wasn’t so.

Over the next 30 years, America is going to be seeing its population growing in the older age groups more than the younger ones. We will see a massive increase in our elderly population, who tend to be sicker, have more chronic diseases complicating their care, and have weaker immune systems, making them more likely to get sick with an infection in the first place. And as people will be living longer, they will have increased years for possible health expenditures, including medical interventions that may or may not be necessary.

At present, our health care system already appears to be unable to handle this load of patients. It will not improve with a higher quantity of patients. While we can certainly build more beds and more hospitals, we run into a more serious supply problem: doctors and nurses to staff them. (Taking Jack Wennberg’s Dartmouth Atlas of Health Care only complicated the issue further, showing that less health care = healther patients, that there are huge regional variations in care patterns with little change in outcomes by region, and that 30% of Medicare’s budget is spent on the last year of someone’s life .)

We also currently have a system where, due to legal fears (and the fact that Medicare will pay for it), doctors and hospitals end up providing ultimately futile care (ie: using health care resources that will not ever be able to meet the goals of care for a patient) due to either a) lack of an advance directive stating the patient’s wishes, b) family disagreement over the patient’s wishes, with threats of a lawsuit, and c) no standard by which to determine how to proceed in these situations. This is often ultimately bad for the patient, and is certainly not without harm: all interventions carry risk, and most cause at least some degree of pain or discomfort. Add in the oft-quoted Hospice statistic that while 90% of patients, when asked, want to die at home, 90% currently die out-of-home.

I’m certainly not ready to say that “at age 80, you get no more health care, and if you die, you die” as some have proposed. If you spend even a day in a hospital or medical clinic you see the broad, broad variation of what 80 means. 80 can be fully, 100% functional, with energy and vibrance of a 25 year-old; 80 can mean severe, advanced Alzheimer’s with 3 heart attacks and the inability to dress or feed oneself.

What we need is a better prognosticator. Some way to figure out when a person’s last year of life will be. (I worry this may never come; we humans are just too damn unique, complex, and confusing, and the awesome human spirit often beats the actuarial tables in the betting game.)

In one corner, we have the elderly patient. He doesn’t want, in general, to die in a hospial, connected to ICU tubes, fingers and tubes in every orifice. It is not a dignified death. In fact, in retrospect, when most people finally learn about and enroll in hospice, their reaction is “I wish we would have known about this sooner.” In the other corner, we have the health care system, which can’t figure out how to balance the needs of society. So what do we do? We do what any American would do: we offer choice.

Experiment: we offer people, say, 90 and above $30,000 and 100% free hospice care. In exchange, they agree to seek simple or comfort care only. See, those “last 6 months” costs or “last 1 year” costs are worth real, American dollars. And my guess is if you ask these people what they want with their final time, it’s not to spend it in a hospital or a doctor’s office. Maybe it’s to see Italy or France. Or to take a vacation with their great-grandchildren to Disneyworld. Or buy a fast car. Or invest it in the stock market. Who knows? I certainly don’t pretend to know what you want.

Again, this would not be a Draconian requirement, merely an option. If you’re going to be spending your hard-earned insurance dollars on something, perhaps you should get a choice–hospital food and IV sticks daily, or Paris? Sure, maybe you die a little sooner because you’re not seeing every doctor every month, but we certainly allow people to die sooner by smoking cigarettes or ride a bike without a helmet, right?

Even if this isn’t the option you choose, I strongly believe that Hospice should be free. Not only because it’s a simple, humane, dignified, cost-effective way to provide closure to people’s lives, but that it is what most people want at the end of life. It makes people comfortable and addresses their symptoms while giving them the needed medical follow-up to meet the goals they want for their short time remaining: often peace, closure, and time with the ones they love.

Second, I believe everyone with Medicare (or perhaps everyone with insurance, or everyone admitted to the hospital?) must have an advance directive. Even if it’s “I want everything done,” everyone must have something . Say we tell everyone they must have one by 2010, and if they have one by 2009, they get an extra $200 tax credit (first carrot, then stick). There are too many people who ignore the fact that they will die (see above: everyone does) and it causes problems for the entire society. (Remember, we’re all in this together.) From the family members it tears apart to the doctors and nurses who feel they are providing futile care, to your loved one who needs a hospital bed but cannot get one because the hospital is full. I believe we are truly disrespecting and taking the dignity from our loved ones by not knowing what they would want. We owe it to our parents, spouses, and loved ones to be able to represent them and their wishes correctly. We’ve now had ventilators and life support systems for what, 50 years? — but we still can’t seem to face up to the fact that many of our loved ones will spend time incapacitated at some point in their lives and we should know what to do when they are.

Third, we must recognize that often, family bickering about what a parent or other loved one “would have wanted” is not truly bickering, but more often a stage in the grief process — denial (“Mom is not going to die, do everything!”), anger (“How *dare* you say that mom is dying! Do everything!”) or bargaining (“Can we just try chemotherapy for two more weeks? Do everything!”). If we understand them from this perspective, it may be easier to resolve these issues.

Note: I toyed with the idea of “cost-sharing” for futile care, but I believe this to be a cruel way of enforcing policy–that “mom is going to die because I can’t afford to pay for her care.” I’d much rather setup a system that makes it “okay” for mom to die than “forcing” her to die. (See my upcoming post on Patient Autonomy.)

Finally, language affects the way we understand our world. I wholely support the efforts to change terms “do not resuscitate” to “allow natural death,” and “life support” to “artificial organ support,” as often our tools are merely preserving organs, not a patient’s life. As Reverend Chuck Meyer discusses the former terms :

An order to Allow Natural Death is meant to ensure that only comfort measures are provided. By using the AND, physicians and other medical professionals would be acknowledging that the person is dying and that everything that is being done for the patient–including the withdrawal of nutrition and hydration–will allow the dying process to occur as comfortably as possible. While a DNR patient in Intensive Care might be put on a ventilator, given artificial hydration, or have a feeding tube inserted, an AND patient would have all of those things withdrawn, discontinued, or not even started, since such treatments are painful and burdensome for the terminally ill. The AND would prevent this unintentional pain and simply Allow a Natural Death.

( Image Creative Commons licensed at Flickr. )

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Health care resources should go to those who most need them.

Welcome to “Health Care’s Broke,” my series of thoughts on what’s ailing the health care system, and what needs to happen to solve the problems we’ll face in the next century, as we face an aging population and workforce, a changing physician workforce, and new technologies and therapies that improve the lives of patients. Our health care system was created to deal with the acute illnesses, while our patients and providers now deal with chronic ones. Our health care system — and few others in the world — have adapted in response.

I’ll be tackling everything from health care financing to HIPAA and privacy, from malpractice to direct-to-consumer marketing, and everything in between.

The goal? To create some constructive dialog from both sides of the political aisle on what should happen. And to that end, I welcome your comments, but only if they’re of a constructive nature . While my undergraduate background was in Health Policy, and my graduate training is in Medicine, I make no claims to be the ultimate in health wonkery. To that end, I’d love to hear why you think my ideas would or wouldn’t work, or how they might be improved. They are, to some degree, brainstorms straight from the Half-Bakery, and while I think many are unique or different from what’s already been tried or suggested, maybe they’re brilliant. Maybe they’re idiotic. I am simply trying to understand why each of the players in the health care system act/behave as they do, and then provide possible fixes based on these motivations.

I’ll be posting one to two topics a day, if I can keep up. (I already have 9 written.) I look forward to the dialog. My goal is to keep it as apolitical as possible, focusing on the health care side of things as much as possible. But again. It isn’t a political diatribe. It’s a series of reasoned arguments to provide health care resources to those who most need them.

The perspective I take here is a mix of wonk and physician. In some areas, I may see more of the individual physician’s or patient’s perspective. In others, I may look more toward what would be best for society, not best for each individual person: patient or physician.

I am also a firm believer in the fact that if we do not make efforts to change, progress, and improve in areas that we know can and need to be improved, Congress or JCAHO or some other regulatory body will step in and pass some probably-well-meaning but ultimately-terrible-for-docs-and-patients law to try to remedy the problem themselves. Privacy was a concern of patients, doctors didn’t do enough to self-regulate, and we got hit with the hell that is HIPAA.

Regulatory bodies and Congress are, for the most part, reactionary. If a problem comes up, and is not solved, they will respond by imposing regulations. Look at any JCAHO regulation, and I guarantee there’s a history behind it. Do I think that a nurse and a doctor can’t talk to each other over the phone without a verbal readback by the nurse? Of course not. But somewhere along the way, enough verbal orders got screwed up that someone decided to do something about it. Why do chart regulations now stipulate that you have to write out morphine, instead of MSO4? Because doctors’ handwriting was bad enough that people were getting magnesium instead. I dislike regulations entirely, and don’t believe that an administrator at a desk knows more than I do about taking care of the patient in front of me, but if those of us in health care aren’t critical of ourselves in figuring out what’s going wrong and how we can fix it, inane, silly, wasteful and potentially dangerous regulations will keep coming down the pipeline.

I do not believe that just because doctors mostly control health care (really, we do) we have the right to be stuck in our ways while every other industry adapts and progresses. I understand the reasons behind stuck-in-our-ways, but they seem to be a bit out of sync with the 21st century.

Why Am I Doing This?

We spend plenty of time debating health care financing (which is certainly important), but as many people have already noted, we have many other major issues in health care that aren’t being addressed or even discussed. While Americans view health care as a major issue, the presidential candidates (and politicians in general) have largely ignored anything besides health care financing. So I figured I might as well try to do something about it.

And with that, we’re off to the races with one of the least publicly-discussed and probably most important topics for the next 30-plus years in health care: End of Life and Futile Care . To keep up with the series, they will all be listed in their own category together if you please.

(Note: if you’re interested in linking to this series, I’d love the help getting the discussion going! Copy this code below to your blog, and it’ll link to the category archive with the image and look like this:

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