Saturday, January 31, 2015

Accountable Care Organizations, Hospitals, Primary Care, and Ptolemy vs. Copernicus

In a very interesting post, Paul Levy wonders if Accountable Care Organizations will really be the panacea for cost containment and more rational and organized medical care that some people are hoping for:

His skepticism is well founded, I think. The basic idea of ACOs came from the Dartmouth researchers, who started in the 1970's studying rural New England medical neighborhoods located around a single hospital, and found that there were small area variations in the customs of treatment. Some areas had lots more tonsillectomies than other areas, for instance, with no difference in the population. They posited that having lots of ENT doctors in an area led to more tonsillectomies, and found other such correlations as well. This was great research!

From there the concept has expanded, and every area of the country is now viewed as having the same organization as rural New England, centered around a hospital. The idea of ACOs is to take this putative neighborhood – and if there is no such neighborhood, to try to make it into one – and organize it differently, so that if a more formally organized group of doctors and hospitals can rationalize the care and make it less expensive, they can save the country money and make a little bit more themselves, by being well-coordinated and abstemious in their care.

This insight is that of corporations. If one brings all participants in a system under one roof, the processes can be rationalized, and the increased profits shared among the participants. The opposite theory is that of a market, where all elements are independent and competitive horizontally with one another, leading to more efficiencies not by corporate regulation, but by decentralized invention. Sometimes one theory works, sometimes the other theory works. The main variable in deciding which one is better is transaction costs: if they are high, it's better to go with a corporation; if they are low, a market is better.

Personally, I like a competitive market. I think a corporation should always be the second choice, because I think people will do what is comfortable for them personally unless they are forced to compete. But I have to admit that sometimes corporations can be great. Which should it be for the medical neighborhood?

The ACO concept is corporate, and indeed, the FTC needs to give ACO's a pass on anti-competitive practices for them to be established. My concern is that the way hospitals and specialists (who will most often be in charge of the ACO's) view the world is Ptolemaic. They see hospitals and tertiary centers and the specialists – the high priced elements of the system – as the center. Is this as it should be? Should these elements who drive the high cost of care, the high price of care, be at the center of power? 
Let us recall again the parable of the blind men and the elephant, each describing the whole as being the part that they are feeling. To hospitals and specialists, what they do is the core of medicine. The way they do it is the core of medicine. Put hospitals in charge and we will find ever more administrators populating the system, producing more of the same cost escalation, just as higher education costs are fueled by more and more university administrators. Put specialists in charge, and they will be driving primary care by their own lights, dishing out more and more of the current tasks of specialty clinics for the primaries to handle. The cost of care might well be reduced, and certainly the cost of specialty clinics will be reduced, and they will thus be paid more. But, they haven't thought things through. If the specialists dump more of their work on the primary care practices, what primary care tasks will these specialty tasks displace?

Little understood and valued by the hospital hubs, primary care has its own agenda. Primary care is the place where patients and doctors interact most constantly and most intimately, over a long term and many different issues great and small. Primary care is where prevention and health promotion take place. But here is where the blind men and elephant come in. Do the hospital and specialty hubs realize and value this? Not really. They call it “hand holding.” Well, yes, we do hold hands at times. That's valuable; that's important; that's human. That's what doctors are supposed to do.

But the medical care system does not value primary care services highly, literally. There is a system called RBRVS, that puts a value on everything medical. Unfortunately, specialists run the RBRVS system, and mirabile dictu, it turns out that specialist procedures are valued more highly than primary care. So specialists earn more. And since money measures all, it turns out that specialists are more valuable than primaries. It must be, then, since they are worth more, that specialists are smarter, and therefore they are worth more. And that primary care isn't worth very much, so why not have them do more specialty care?

But that's not all there is to it. People are concerned that primary care will not do their job properly under ACO's – not because they will be doing specialty work, but because the payment will be changed from fee for service to capitation. So, how do they defend against primary care dereliction of duty? Measure primary care performance! 
Well, one might think that this would indeed ensure that good primary care work was being done. And it would – if the “quality measures” worked. But they don't. They suck. People have tried, and there are many, many measures – too many, actually, and different ones employed by different measuring agencies so that there is now a movement to consolidate and have all agencies measure the same thing. But that really doesn't matter, because they only measure what is measurable, and most of the most important elements of primary care are not measurable. It is a common problem: "Not everything that counts can be counted, and not everything that can be counted counts."  (William Bruce Cameron.) 
Here's a good example: one of the most important functions of primary care is making a good diagnosis. This is completely unmeasured, yet what could be more important? I had a young mother in my office on Tuesday whose own mother just died last year at the age of 43. The story was that she seemed to have thyroid deficiency that was untreatable, no matter how many pills she took. A new doctor took over and just followed the old doctor's regimen and the patient still was no better. Then the diagnosis finally declared itself: disseminated ovarian cancer. The young mother in my office is completely devastated by the loss of her mother, and the incompetence of the care. She said she was going on a doctor strike, not seeing anyone herself, and seeing one for her son only reluctantly. She was relieved to meet me as someone who practiced in a practice with a strong reputation,and as someone whom she could obviously trust, because I was a mensch, I listened and understood and was empathetic and talked to her in the right way -- I've been at this a long time and I have learned. 
How would quality of care assessment work in the case of her mother? Not at all – they don't do diagnosis. How would it work in assessing my work in reassuring my patient (mothers are actually our patients, as you know)? Not at all, or maybe very indirectly with some general patient opinion surveys, which are in the main completely unreliable and structured for coding of answers so that promptness is equal to “listened to me,” and empathy doesn't appear. So, are we really going to count on “quality measurement” to ensure that primary care thrives in ACO's?

I'm not saying that ACOs can't work, but if they are to work, there has to be a Copernican revolution. Primary care needs to have its own center of power within the new organization. In addition, primary care needs to find its roots and find its leadership based on those roots. Its roots are in the personal relationship of trust and intimacy between doctor and patient, and in healthful guidance and advocacy from the doctor to the patient. This is just not easily measurable at present. One can't measure the end results of this process well, it's too hard to do so. If there is to be measurement, and I guess there should be, then it needs to be a process measurement. What values permeate the practices? What procedures are undertaken to ensure that positive reinforcement of these values takes place? What leadership is in place? There are lots of objective measures that can hit on this, but no one is using them now, but they should. And, we need the primary care leaders within the organizations to give the stories, give the anecdotes, promote the values, and get the rest of the system to appreciate what primary care does. 
And then finally, we need the primary care leaders to get more money for their doctors, more money for their practices, and then attract the medical students and residents to primary care, so there can be someone there to do the jobs they are promoting as so important. That's what has to happen if ACO's are going to do some significant good. The odds on this happening. Low, sorry to say. But stranger things have happened. Copernicus did emerge, and there was a revolution in his wake.

Budd Shenkin

Friday, January 16, 2015

Selma - Not One for the Ages

We saw “Selma” last night. It is a powerful movie. Young as we are as a country, our mythical events are mounting steadily: Roanoke; the Pilgrims; the American Revolution; the Founding Fathers; Lewis and Clark; Lincoln and the Civil War; FDR and the Great Depression; the assassination of JFK; the Civil Rights Movement; a man on the moon. A short history compared to other countries, but with a sense of mythical mission and many enshrined moments.

I don't know if we have more myths than other countries – probably not, I probably just know them more because I'm an American. We are certainly a self-conscious nation, and it seems a nation given to drama. But in contrast to other nations, we have a command of media that no other nation has in the present day, and certainly far beyond any nation in the past.

Think about the ancient Greeks, just for contrast. They were a people filled with mythology, not just the gods, but the historical Trojan War, and the historical House of Atrius. In that time of low technology, how amazing it is that they preserved their myths for all time. For the Trojan War, they preserved it by oral tradition – oral tradition! They made it into a coherent story, and then they had to remember it, so they used repetitive phrases (“rosy colored dawn”) and most importantly, rhyme – rhyme is beautiful, but it is most importantly an aid to memory. That was their technology in the Mycenaean civilization. The oral tradition preserved the Trojan War epics until papyrus emerged in the classical ancient Greek world half a millennium later, and miraculously, the epics were thus preserved in written form.

At the same time, classical Greece had performance art to present and preserve their myths, not only of the Trojan War, but of the House of Atrius. Luckily for us, although the actual performances of their plays were themselves evanescent, the scripts of perhaps 1% of their plays were preserved on papyrus. It was a small sample, but it is enough for us to appreciate their dramatic sense of themselves.

Then, with the technology of writing on papyrus at hand, the classical Greek world invented history with Herodotus and Thucydides. Without the need for gods, drama, and rhyme, facts as the writer knew them could be approached directly, and causes postulated and probed. The search for facts wasn't then what it is now, but at least direct experience could be accurately transcribed.

Contrast the Mycenaeans and the Greeks to us. How easy it is to collect facts; how easy it is to write about what people have done with a fair degree of accuracy; and how incomparably powerful it is to convey visions with the most powerful instrument for conveying someone's vision that has ever been invented, the movies. A play is one thing, it allows one to imagine that the abstraction one sees on the stage is truth. But a movie is something far more powerful -- it shuts you in a room, dampens any other sensory distractions, focuses your attention on colors and giant images that are as clear as can be, and envelopes you in surrounding sound. There is nothing like a movie. Movies are the most persuasive, impactful, and indelible of any media ever invented. Movies are not only powerful, they are so easily accessible; more people see movies than read books or see plays by orders of magnitude.

So, where does that leave us with the movie Selma. It is, as I said, a very powerful movie. It is professionally done, with some excellent performances, and I think especially excellent camera work. It is impactful. It is in service of one of our most important myths, the Civil Rights movement, and one of our most important heroes, Martin Luther King. The problem with Selma, however, is that it contains a horrible lie. It is factual with the African-American protagonists, but it is terribly wrong in the way it treats Lyndon Johnson. It casts LBJ as an adversary to MLK, when in fact he was an ally. The story of the Voting Rights Act in fact has two heroes, and the film proffers only one.

Now, if you are trying to remember the Trojan War and you have only an oral tradition to use, you might well have to simplify, you might have to create a drama that centers on a central truth, and to invent and distort other truths so that the epic can be remembered and retold. It's something you might have to do. Your mission might not be history, but eternal truths, and to get there you might distort facts, but everyone knows who listens that this is the case.

If you are a historian of the Peloponnesian War, many facts might not be available to you, and you might have to tell only the part that you know to be factual. You might seek to highlight some eternal truths, but you do it within the facts as you know them.

Here in modern day America, we have different conditions from the Greeks. Both traditions continue, drama and history. We have new technologies that make drama more compelling (at least technologically), and we can ascertain historical facts as never before. We also have some of the same limitations – a movie like Selma has to make its money back, and so it needs to be dramatic. It also wants to make its essential points of bravery, glory, personal foibles, internal differences of opinion, etc.

But how far do you have to go in this mission? Do you have to lie? Does drama inevitably have to distort reality? Does drama have to disserve history? And if so, how much? What does “artistic license” entitle you to? (And, how much does artistic license act as camouflage for poor artistic ability?)

I can see the need sometimes to collapse two characters into one memorable character, if they are not the main roles. Maybe it's even OK to say Connecticut was against the Emancipation Proclamation when it wasn't (I actually don't think it's OK, but maybe I'm wrong). I definitely don't think it should be permissible to say that torture evokes information to locate Osama bin Laden when it didn't, that's really a lie that's too important to justify.

The issue is this: in the modern world, drama morphs into history. So many more people see a movie than read the books, and a movie is by nature so powerful, that the movie's “facts” are what people remember as truth. So you can say you have a drama, but you really need to act with the constraint of being reasonably close to history. What is “reasonable” is the point of contention.

To my mind, the lies of Selma are so profound as to be infuriating. They shouldn't have done this. What they have done is to sully the reputation of a great if terribly flawed man, Lyndon Johnson, when what he deserves is the exact opposite.

Selma doesn't shade the truth – Selma lies. Selma depicts Johnson telling Martin Luther King, “Not now. Wait.” This is simply untruthful. We have documentary evidence, we have recordings(!) of their conversations where LBJ tells MLK to find the best examples he can of the injustices laid on the African-Americans and publicize them, and the people will see, “That's not fair!” And then Johnson can deliver. That's what LBJ says.

We have the truth from Robert Caro's LBJ books – the truth is more than available. LBJ rose from poverty and the disgrace and financial decline of his father, from his own deficient education, to become adopted by the Southern masters of the Congress, and to lead and command the Congress as no one ever had. He worked as hard and as skillfully as anyone has ever worked in politics, and when he got to the top, he double-crossed his mentors. While they supported continuing the status quo and segregation, the LBJ of his boyhood turned on them, skillfully and with some compassion, but he turned on them for what he knew was right. Having risen by dint of their patronage, he now led the nation not toward their way, but toward the way of Martin Luther King. He threatened and cajoled and got the most significant civil rights legislation passed in over 100 years – and anti-poverty legislation as well.

But what do we see in Selma? We see a limited, self-interested man in cahoots with J. Edgar Hoover, of all people, which is just not true. In fact, Hoover was an insubordinate opponent to be outwitted and ultimately overpowered, with great skill and even bravery from LBJ.  We don't see the conjunction of two stars, the preternatural leadership genius of the young MLK who has known only one way, and the older genius LBJ who has led the more tortured and circuitous way to greatness. I'm sure it's harder to make a drama with two stars coming together, rather than one star with an adversary. Maybe the writers of Selma weren't up to it. But the way it is, it's a distortion, it's a desecration of LBJ, and it's a desecration of the truth. Even if our view of LBJ doesn't have the policy implications of Zero Dark Thirty's utility of torture distortions, it's still important.

It's true that the Civil Rights movement deserves to live in the mythology of the nation. The Black heroes of Selma deserve to live in history and myth. But because of taking the easy way out and gratuitously desecrating a white man who was a true hero of civil rights, this film is truly, truly misbegotten.

The Greeks would have done it better.

Budd Shenkin

Saturday, January 10, 2015

A Prominent Academic Specialist Denigrates the Periodic Physical

Is the advice of a skilled medical professional who knows you, cares about you, and sees you regularly, worth anything? According to one of the NYT's anointed medical columnists, Ezekiel Emanuel, the answer is no.

It will be hard for me to obscure my disdain for Zeke Emanuel. His arrogance is apparently familial. He doesn't seem to question his blinkered viewpoint of an academic administrator, an academic specialist as an oncologist, and his reflections on his role in shaping Obamacare seem always to be defensive – what we did was unalloyed good, and the best that could be had. He must be a politician of the “admit no mistakes” school. Although everyone does admit that he is smart, I have to say.

Zeke argues in this article that the yearly physical is an invalid procedure, something to be avoided. He says that “research shows” that little significant disease is discovered – “the annual physicals did not reduce mortality overall or for specific causes of death from cancer or heart disease.” He casts doubt on the value of early detection of disease. He implies that too many tests and studies are ordered by the doctors at a yearly physical. He says that these visits drive up health care costs. He compares the visit to an automobile service, but with fewer positive results. He denigrates the value of the doctor-patient relationship.

What a turkey he is.

First, let's look at research. If you want to prove something is worthless, the best tactic is to posit an end result that is either impossible, impossible to measure, or just not the reason that the thing is done in the first place. And if you are to practice sophism, make sure you simply assume that the goal of the procedure is what you want, not what the practitioners want it to be.

So, Zeke – remember, he is an oncologist who treats severe disease – assumes that the primary goal of the annual physical is to detect cancer (or, possibly, heart disease or something else) early. Then he says there is no evidence that the annual PE does this, and that screening asymptomatic populations is not a good procedure. Yes, Zeke, it's not good for cancer detection – except for mammograms and Pap smears, and I would say PSA in the hands of good doctors. Not that early detection doesn't happen – it does, it does, and it can save lives. Maybe not “cost effective,” but that's another argument. But Zeke – that's not the purpose of the periodic PE.

The purposes of the periodic PE are several. Health promotion and prevention are important objectives – maddeningly derided by Zeke as something he can do himself. Surveys show that the leading motivation for smoking cessation is recommendation by a doctor. Yes, we know “we should.” But when a doctor talks, we listen. Likewise for weight loss, exercise, and healthy eating. Zeke might say “I don't need no stinkin' primary care doctor,” but most of us really do.

Moreover, where exactly are we supposed to find out if our cholesterol and/or our blood pressure are too high? Careful questioning and screening can reveal depression, a condition with high prevalence, and eminently treatable. Alcohol addiction can be detected and discussed and treatment begun. Even as a general pediatrician I routinely inquire about the state of the parents' marriage, knowing that this is the most consequential condition for child health, and that once again, intervention can make a difference.

Measuring the results of health promotion and prevention is terribly difficult. In cancer it's pretty easy to distinguish useful from worthless therapies. But healthier lives are hard to identify in themselves, and the effects of prevention can be felt so far in the future that research can fail to find it. No one has done in depth studies of the results of close relationships with a primary care doctor, and I don't know how it could actually be done. For Zeke to place the onus of proof of effectiveness of primary care on those who practice it, according to his own rules of science, is outrageous. Prove that a caring parent is necessary for a child, why don't you, and banish them all to orphanages if you don't find that it is cost-effective. His “science” is suited to him, and he wants to use it on everything, which just coincidentally puts him in the driver's seat.

Actually, probably the worst sin of Zeke's jeremiad against PE's is his denigration of the doctor-patient relationship. Particularly in our world today, what is the value of being cared for? What is the value of having a serious professional who knows you well and who cares, who is on your side, paying attention to you, and helping you with your health in sickness and in health? The cyber-billionaires contend that 80% of what a doctor does will be supplanted by computers – you think? You think that what a doctor does is to reason all day? This is personal, gentlemen. We have a need to be cared for, and this is not irrational. There are choices to be made, there are feelings to be accounted for, and one size does not fit all, at all.

Finally, how specious is the cost of care argument! One of the first things I learned in the Public Health Service was, if someone says they can't do something “because of the budget,” it means they don't want to it. The budget is generally an excuse. In health care, we know that high costs reside in specialist care and hospitals – and remember, “costs” are related to “price,” which is highest by far in the US compared to Europe, probably especially in cancer care for all I know – not in primary care. Cut costs in primary care and you have accomplished very little except degrading quality, Zeke. Look to your own institutions if you want to cut costs. Gore your own calf, why don't you.

Let's once again revisit where Zeke sits – he is an influential voice in establishment medicine. All too many establishment policy makers truly believe his self-interested point of view. Prevention and health promotion are not sexy and not remunerative, and not what the academic centers interest themselves in. Training for prevention and health promotion in internal medicine and even family medicine are usually deficient. Even in these potentially primary care producing training programs, more and more subspecialists continue to be churned out, with fewer and fewer primary care docs. As a result, fewer and fewer practicing primary care docs have less and less time, training, and attention to spend on periodic PE's.

The biggest structural problem in the health care system of the United States is too much specialty and not enough primary care. Zeke Emanuel would do well to support primary care docs in their tasks rather than to attack their rationale.

Budd Shenkin