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Archive for September, 2012

Sunday, September 30th 2012

Money & Medicine

PBS has a series called Need To Know as part of their coverage for the 2012 elections. Last week they aired, as part of this series, an episode titled “Money & Medicine.” You should watch it.

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Saturday, September 29th 2012

Next Great Debate Issue: Autism & Vaccines

If the above poorly focused image of a Romney/Ryan campaign mailer from Virginia is confusing you then join the club. But it appears the mailer is real and as Mother Jones points out,

[I]t turns out that Romney has, over the last few months, actually made Lyme disease—the bacterial disease transmitted to humans from deer ticks—part of his pitch to suburban Virginia voters.

In a letter to Virginia Represenatives Smith and Wolf from August, Romney’s campaign chastised the Obama administration for not doing enough in the fight against Lyme disease and says,

I know that Lyme disease is a problem.

[...]

More needs to be done. As president, I will work to ensure that more attention is focused on this important issue…We need to ensure that all scientific viewpoints concerning this illness can be heard.

It isn’t that this is a bizarre niche campaign issue that this is concerning. It is that last quoted sentence above and the contents of the campaign mailer which should raise some eyebrows. You see the issue of chronic Lyme disease is at a surprising cross roads between medical science and politics. Lyme disease itself is an obvious clinical entity with a well established etiology. Chronic Lyme disease on the other hand is a poorly defined condition consisting often of vague, chronic symptoms, described by a review in the New England Journal of Medicine as a term used by

a small number of practitioners (often self-designated as “Lyme-literate physicians”) to describe patients whom they believe have persistent B. burgdorferi infection, a condition they suggest requires long-term antibiotic treatment and may even be incurable.

Although chronic Lyme disease clearly encompasses post–Lyme disease syndrome, it also includes a broad array of illnesses or
symptom complexes for which there is no reproducible or convincing scientific evidence of any relationship to B. burgdorferi infection.

It may indeed be that these symptoms are sequalea of the previous infection but it remains that there is strong evidence against continued treatment for infection in randomized studies here and here. Despite that there continues great argument that the medical community is ignoring or outright suppressing evidence for chronic Lyme disease and for the long term use of antibiotics in such cases. The proponents of such a view have demonstrated considerable political clout, especially in Virginia,

Virginia Gov. Bob McDonnell assembled a governor’s task force on Lyme disease. He appointed Michael Farris as its chair. Ferris is a lawyer and the chancellor of Patrick Henry College, aka God’s Harvard, whose motto is “For Christ and for Liberty” and whose “Statement of Faith” holds that the “Bible in its entirety” is “inerrant.”. The school isn’t known for its biology department.

You can read the full report from the task force here, but Laura Helmuth in the above Slate article quotes it, concerning chronic Lyme disease,

“There is no scientific basis for concluding that 30 days or less of antibiotics is sufficient treatment for every case of Lyme disease.”

The NIH and CDC disagree. Pandering to those who would agree with the Virginia task force is a low play from the Romney-Ryan campaign.

I imagine next they’ll have Jenny McCarthy on the campaign trail with them, making a further political issue of the unfounded vaccine-Autism link.

Saturday, September 29th 2012

How Many Medical Schools Does Texas Need?

The state of Texas is very close to opening two new free standing medical schools. One in the Rio Grande Valley and one in Austin. While still hurdles to jump through for these two new schools they look to be part of Texas’ relatively rapid expansion in undergraduate medical education capacity. In the past two decades Texas has seen both new schools and an aggressive expansion of the capacity of its current schools. But such is of questionable necessity. Below is data from 2006 U.S. Census Bureau estimates of state populations and 2006 AAMC medical school enrollment numbers for public medical schools.

State 2006 Public Medical School Enrollment 2006 Estimated Population Public Medical School Seats Per 10000 Population
Alabama 971 4599030 2.11
Arkansas 605 2810872 2.15
Arizona 492 6166318 0.79
California 2899 35457549 0.79
Colorado 611 4753377 1.28
Connecticut 346 3504809 0.98
Florida 1283 18089888 0.71
Georgia 749 9363941 0.8
Hawaii 255 1285498 1.98
Iowa 630 2982085 2.11
Illinois 1722 12831970 1.34
Indiana 1164 6313520 1.84
Kansas 703 2764075 2.54
Kentucky 1026 4206074 2.44
Louisiana 1122 4287768 2.61
Massachusetts 450 6437193 0.7
Maryland 650 5615727 1.15
Michigan 2363 10095643 2.34
Minnesota 924 5167101 1.79
Missouri 767 5842713 1.31
Mississippi 427 2910540 1.47
North Carolina 1024 8856505 1.15
North Dakota 246 635867 3.87
Nebraska 491 1768331 2.78
New Jersey 1402 8724560 1.6
New Mexico 329 1954599 1.68
Nevada 218 2495529 0.87
New York 2480 19306183 1.28
Ohio 3908 11478006 3.4
Oklahoma 617 3579212 1.72
Oregon 516 3700758 1.39
Pennsylvania 1236 12440621 0.99
South Carolina 931 4321429 2.15
South Dakota 207 781919 2.64
Tennessee 861 6038803 1.42
Texas 5243 23507783 2.23
Utah 429 2550063 1.68
Virginia 1803 7642884 2.35
Vermont 426 1945482 2.2
Washington 805 9047320 0.89
Wisconsin 664 5556506 1.19
West Virginia 663 1818470 3.64

Texas public medical school numbers include Baylor College of Medicine which recieves some public funding in return for giving preference to Texas residents.
Washington’s population includes Alaska, Idaho, Montana and Wyoming. Residents of those states receive preferential admission to the University of Washington School of Medicine.
Vermont’s population includes Maine. Residents of that state receive preferential admission to the University of Vermont.

While Texas does not top the list in per capita public medical school seats it isn’t far behind.

    States With Most Per Capita Medical School Seats
    1. North Dakota
    2. West Virginia
    3. Ohio
    4. Nebraska
    5. South Dakota
    6. Louisiana
    7. Kentucky
    8. Virginia
    9. Michigan
    10. Texas

It is slightly disingenuous to compare a state like Texas with smaller states on the list above including Nebraska, South Dakota, North Dakota and West Virginia. There are considerable relatively flat infrastructure costs to running an institution like a medical school. If those states with small populations are going to make a commitment to public undergraduate medical education it is nothing to say they’re going to enroll 200 students instead of 30, and so of course their per capita rates will be higher. In light of that Texas’ per capita numbers are even more favorable.

Texas has the most public medical school students in the country and, perhaps more importantly, the most public medical school campuses in the country. While I don’t have the data, with so many freestanding health science campuses and so many medical students it would not surprise me if Texas already spent more on public undergraduate medical education than any state in the union. And while Texas population continues to grow so has the number of medical students enrolling in the state with every medical school increasing its class size since 2006 and a new medical campus opening in El Paso since the data above.

In 2011 the growth in medical school enrollment in Texas had more than kept up with Texas’ impressive population growth and left the state with 2.36 medical school seats per 10000 population. The new slots in the Rio Grande Valley and Austin promise to continue that trend and boost Texas’ per capita numbers higher. I would argue that while we need to prepare our undergraduate medical education capacity to keep pace with our growing population, that the number of current graduates, even for the foreseeable future, is completely adequate for the health care needs of Texas.

The more substantial problem may be in training these medical students after they graduate. The 2010 medical school graduating class in Texas had 1404 medical students competing for 1390 first year resident positions. Nearly half of Texas medical school graduates, their education subsidized considerably with Texas tax payer dollars, leave the state for residency and are unlikely to return. Texas’ contribution to graduate medical education is abysmal as compared to many other states. From the Houston Chronicle article linked to above,

[T]he state’s coffers are a relatively small part of funding — $79 million was allotted last session. The lion’s share comes from Medicare, which is, if anything, in potentially worse shape than Texas.

Unlike many states the medicaid program provides no direct graduate medical education funding in Texas.

There are many arguable benefits of medical campuses. They bring a likely economic benefit to the local economy and they promote prestige and contribute to the local academic community. They also likely help promote community health. But their primary mission, indisputably, is education and undergraduate medical education is not something we need more of in Texas. The press for these medical schools represents local politics and activity within the university system they are poised to be a part of; egos from Austin and the Rio Grande Valley looking at these campuses as a matter of benefit for their local communities.

[T]o hear [state Senator Kirk Watson] speak these days, nothing is more important — and, perhaps, more career-defining — than establishing a medical school at the University of Texas, as well as a new teaching hospital, comprehensive cancer-care center and other elements of what supporters call “Watson’s 10 in 10” — 10 health care goals to achieve in 10 years.

“We have so many good people ready to do it that success is immensely possible, and to not do it and not get started on the path would be extraordinarily regrettable,” Watson said last fall. “This is big. It’s going to be hard. But it needs to be done.”

Some of the costs of these academic healthcare endeavors will be borne by these communities – Travis county’s health district is asking voters in November for a property tax increase – but plenty of money will come from state general revenue afforded to the university systems. That is money from tax payers across the state who are likely to see no to nominal benefit from these new schools.

New medical schools in Texas are unlikely to improve our statewide physician shortage and may even do little to correct disparities in the communities they’re joining. We’re already graduating enough medical students and in a strong position to continue to do so for our growing population without new medical campuses. The schools will bring new graduate medical education funding, in the form of new Medicare dollars but such will not keep pace with the new medical school graduates they promise. The costs of these new medical schools would be much better put towards improving graduate medical education in the state. That is something that would truly improve Texas’ doctor shortage and potentially the public’s health.

Friday, September 28th 2012

Dr. Berwick Talks The ACA So Far

Just watch Donald Berwick, former CMS director, speaking on the Affordable Care Act.

Friday, September 28th 2012

Is The Ideal of Evidence Based Medicine Foolhardy?

The Guardian has an excerpt from Dr. Ben Goldacre’s book Bad Pharma. The piece in The Guardian looks at how negative data for treatments, specifically commercialized ones, is suppressed and how that severely skews the ideal of evidence based medicine.

Negative data goes missing, for all treatments, in all areas of science. The regulators and professional bodies we would reasonably expect to stamp out such practices have failed us. These problems have been protected from public scrutiny because they’re too complex to capture in a soundbite.

[...]

In 2003, two [systemic reviewes] were published. They took all the studies ever published that looked at whether industry funding is associated with pro-industry results, and both found that industry-funded trials were, overall, about four times more likely to report positive results. A further review in 2007 looked at the new studies in the intervening four years: it found 20 more pieces of work, and all but two showed that industry-sponsored trials were more likely to report flattering results.

[...]

How do industry-sponsored trials almost always manage to get a positive result?

[...]

You can compare your new drug with something you know to be rubbish – an existing drug at an inadequate dose, perhaps, or a placebo sugar pill that does almost nothing. You can choose your patients very carefully, so they are more likely to get better on your treatment. You can peek at the results halfway through, and stop your trial early if they look good. But after all these methodological quirks comes one very simple insult to the integrity of the data. Sometimes, drug companies conduct lots of trials, and when they see that the results are unflattering, they simply fail to publish them. Because researchers are free to bury any result they please, patients are exposed to harm on a staggering scale throughout the whole of medicine.

The book is yet out and won’t be, in the United States at least, until January. When it is I’m inclined to pick up a copy based on the above.

Wednesday, September 26th 2012

Flip & Flop

You’d think political candidates, even conservative ones opposed to the expansion of the government roll in healthcare would avoid the oft repeated, and oft chastised, claim that America already provides a health safety net for all in the form of the emergency room. And yet here is Mitt Romney fumbling around with such an answer.

Why Romney persists so far to the right on an issue like this, with the nomination secured, is beyond me in terms of political strategy. It’s difficult to call his recent comments sincere. As recently as his last campaign for president he made contradictory statements,

During a GOP presidential primary debate in 2007, Romney said: “Look, the best kind of prevention you can have in healthcare is to have a doctor. And if someone doesn’t have a doctor, doesn’t have a clinic they can go to, doesn’t have health insurance to be able to provide the prescription drugs they need, you can’t be healthy. And you need to have health insurance for all of our citizens.”

And when arguing for his Massachusetts’ reform effort Romney was even more explicit. Sarah Kliff at Washington Post’s Wonkblog links to two op-eds during the period, one in the Wall Street Journal and one in the Boston Globe. Although behind a paywall, Kliff quotes Romney’s WSJ editorial as,

By law, emergency care cannot be withheld.

[...]

Why pay for something you can get free? Of course, while it maybe free for them, everyone else ends up paying the bill, either in higher insurance premiums or taxes.

Uncompensated emergency room care is expensive for society. It also provides a poor avenue for dealing with non-emergent issues which may in the future lead to more costly care. For instance, a patient presenting symptomatic with a headache from poorly controlled hypertension has his blood pressure acutely controlled and then is sent out the door without access to outpatient antihypertensives, other therapy or follow up and returns with a primary intracranial hemorrhage a month later. As Romney claims the emergency room treats true emergencies well, if at great expense. But outpatient emergency room care is a poor alternative to more substantial access. Even insinuating that the ER represents a legitimate safety net is irresponsible and has drawn ire when claimed by others than Mitt Romney. You think he would’ve learned. You think he would’ve remembered his experience in Massachusetts.

Wednesday, September 26th 2012

Lost In The Monotony

Residency is a period of survival, even in the age of duty hour restrictions. It is a period of sometimes putting your head down and going one day to the next which, can often, run together. And depending on how the call schedule comes together it can be difficult to recall fully your responsibilities. Am I on call today or tomorrow? This weekend? So I know I’m not alone in showing up to one of the hospitals we cover yesterday promptly at 4 pm to take overnight call and realizing to my embarrassment that I was 24 hours early.

Once when I was a medical student doing a general surgery rotation I stayed overnight for “call” and then went home in the morning at about 10am. I quickly fell asleep. I woke up to the sun on the horizon from my bedroom window and a bedside clock that read “7.” I jumped up, forwent a shower and raced to the hospital. Out of breath, at the end of the stairs I found the team’s work room empty. Frantically I dialed my fellow medical student on the service to ask her if the team was already on the floors rounding only to learn she was at home making dinner and I was twelve hours early. I had mistaken 7 pm for 7 am. That truly would’ve been a feat to sleep 20 hours straight instead of the actual 8 hour nap I had pulled.

Shift work does this to you I suppose.

Tuesday, September 25th 2012

When More Is Not Better

San Antonio is no longer the largest city without a freestanding children’s hospital. It will soon be the proud owner of two freestanding hospitals dedicated solely to pediatrics and a third substantial pediatric operation within a larger hospital campus. For the effort that went into establishing a children’s hospital in San Antonio the city now looks to have three.

The editorial board of the San Antonio Express News has described this development as “exciting.”

Competing health systems working to provide the best pediatric care possible will benefit the community, the children in need of the services and the students receiving their training here.

A more realistic view is that of John Hornbeak, the former CEO of Methodist Healthcare in San Antonio, who said in his own editorial,

[T]here are more than enough egos and resources to put on quite a show and produce a children’s medical arms race on steroids. All three plan to be No. 1. This promises to be a war of attrition, long and tortuous.

[...]

But the worst of it all is that, for all the added expense, the health status of children will only be marginally better. All three combatants will have to battle for the best paying patients, the highest margin services and give short shrift to the low or no pay kids and money losing services. There will be many protestations to the contrary, but splitting the business three ways requires this. That’s what competition looks like in health care.

The idea that competition amongst so many pediatric hospital beds will drive quality is a hopeful one but naive. It is hardly borne out in data where no evidence exists for children’s hospitals and the studies of competition of hospitals in general shows a mixed bag.

Not to deny the full flesh of arguments for children’s hospitals but the measurable clinical benefits are a little bit difficult to tease out in the literature. That said, if there is one place where a single freestanding children’s hospital would have indisputably improved the care of the children of south Texas it would’ve been in the tertiarization of complex cases. In this I disagree with Mr. Hornbeak who has concluded that the enormous costs going into these three children’s hospitals would’ve been better spent on community and primary care instead of on “the one little Jimmy out of a million getting his surgery.”

The brain tumors and the congenital heart defects and the solid organ failures make an exceedingly compelling case for bringing inpatient pediatric care in San Antonio and south Texas under one roof. These complex diseases, and so many more, have incredibly strong evidence that higher volumes within a system, within a hospital, lead to better outcomes.

And yet, the various health systems of San Antonio now promise great expense to keep pediatric care competitive and disparate. A promise to keep all of their complex programs adequate but none of them great. It’s bad for San Antonio.

Tuesday, September 25th 2012

Incentivizing Savings

Some prominent voices in health care reform have a new editorial in The Wall Street Journal today.

Pilot programs under the Affordable Care Act, such as Medicare’s Acute Care Episode Demonstration in the Baptist health system in San Antonio, have produced 15% to 30% savings in hip and knee replacements.

[...]

We also recently proposed letting market competition determine prices for many health-care goods and services. Rather than have the government set prices for things like laboratory tests, manufacturers and suppliers should compete to offer the lowest prices. Where it has been used, competitive bidding has reduced Medicare spending by 42%. Does this sound like government-controlled health care — or a market-friendly policy?

I appreciate the attempt to pitch current reform efforts as part of the conservative ideal. But the pilot program referenced is likely neither sustainable nor generalizable from the participants I’ve talked to. The Acute Care Episode Demonstration has shown some cost savings, at least in its orthopedic wing, but those savings seem a novelty.

The pilot has two key components.

  • Medicare beneficiaries are being being paid up to $1100 to go to ACED pilot participation sites, as long as those sites are meeting certain quality measures. So, if grandma gets her hip replaced at Hillcrest Medical Center as compared to St. Francis hospital she is paid.
  • CMS is bundling payments for these surgeries to hospitals. Hospitals then turn around and reimburse the surgeons. As long as the hospital is meeting certain quality metrics, then CMS is allowing the hospital to share cost savings, up to 125% of the Medicare fee schedule for the surgery, with the surgeon

Providers are a large component of both quality and cost. There are gains in both to be had by procedural and process changes but substantial gains are obviously impossible without physician engagement. So an attempt to incentivize physicians towards such goals is not new. Where those incentives are coming from may be the largest problem with the Acute Care Episode Demonstration.

At Baptist Health System, which is cited in the editorial, for all intents and purposes all of the cost savings in the orthopedic wing have come from negotiation on implant costs. The hospital went to the surgeons and essentially said, “I know you’re using Company X artificial hips right now but we can get Company Y for cheaper. Would you start using Company Y artificial hips if we paid you more?”

Cost savings elsewhere throughout the process have been elusive. This one time jump to reduce costs raises questions about the sustainability of the program. In conversation, the increased reimbursements for surgeons are tied to savings in a set fiscal temporal period and don’t carry forward. The surgeons helped the hospital save money in the first fiscal year of the pilot but they did so almost entirely by agreeing to use low bid implants. That is not a repeatable trick. The surgeons have to help the hospital find new savings on the same order the next year, otherwise their compensation starts heading back towards the baseline Medicare fee schedule. Everyone is working against a new benchmark. That’s at least how I understand it.

As well, while not mentioned in the editorial, the payments to Medicare beneficiaries don’t appear to be driving them to pilot program participants.

Explain to me if I’m wrong but I have serious doubts about the Acute Care Episode Demonstration and all of CMS’ pilots looking at incentivizing savings and quality.

Monday, September 24th 2012

Maybe This Will Promote Adoption

Despite meningful use bonuses from CMS, electronic medical records remain highly contentious amongst physicians and their implementation remains sluggish.

The most recent CDC data would seem to be encouraging for EMR adoption, with EMR use (finally) passing 50%.

Too bad there is more to the story.

If you look at adoption rates for so called “fully functional EMRs,” the adoption rate remains in the low teens (full data for 2011 is not yet available). So why is there an almost 4-fold discrepancy between “any EMR” and “fully functional EMR”? If EMRs are so great, why does the government have to essentially “bribe” physicians to adopt them through incentives such as the meaningful use incentive program? Why is this so important to them that they didn’t even wait for the healthcare affordability act to implement this “incentive”?

The effect of EMRs on quality care measures remains dubious and the effect on productivity, and thus presumably, income is likely even more in question. Physicians skeptical of the adoption of electronic records should probably pay attention to a new analysis from the New York Times. Although some of it attributed to questionable practices it appears that the implementation of electronic medical records is associated with increased billing and reimbursement.

Over all, hospitals [and presumably physicians] that received government incentives to adopt electronic records showed a 47 percent rise in Medicare payments at higher levels from 2006 to 2010, the latest year for which data are available, compared with a 32 percent rise in hospitals that have not received any government incentives, according to the analysis by The Times.

[...]

Some experts blame a substantial share of the higher payments on the increasingly widespread use of electronic health record systems. Some of these programs can automatically generate detailed patient histories, or allow doctors to cut and paste the same examination findings for multiple patients — a practice called cloning — with the click of a button or the swipe of a finger on an iPad, making it appear that the physicians conducted more thorough exams than, perhaps, they did.

[...]

Many hospitals and doctors say that the new systems allow them to better document the care they provide, justifying the higher payments they are receiving. Many doctors and hospitals were actually underbilling before they began keeping electronic records, said Dr. David J. Brailer, an early federal proponent of digitizing records and an official in the George W. Bush administration.

There’s no doubt that it’s easier to check a set of boxes than write out a detailed review of systems on a chart. I’m inclined to believe that more thorough documentation is the result of the ease with which the documentation can now be made and not a matter of documenting unperformed history and exam. It may indeed be roundabout evidence of increased productivity that we’ve been waiting for.