Re: a cautionary tale about medical practice
- From: "Imno1" <whoha@xxxxxxxxxx>
- Date: Tue, 9 Sep 2008 13:15:10 -0700
piece of information and a thought that are of practical value to older
people.How unusual for this board. If the ideologues weren't so busy
screaming at each other they would accuse you of wasting band width.
Speaking for the (few) rest of us
thank you
"arthur wouk" <awouk@xxxxxxxxxxxxxxxxx> wrote in message
news:1220986433.274908@xxxxxxxxxxxxxxx
defensive practice, that is. it harms the patient.
The Pitfalls of Linking Doctors Pay to Performance
By SANDEEP JAUHAR, M.D
Not long ago, a colleague asked me for help in treating a patient with
congestive heart failure who had just been transferred from another
hospital.
When I looked over the medical chart, I noticed that the patient, in his
early 60s, was receiving an intravenous antibiotic every day. No one
seemed to know why. Apparently it had been started in the emergency room
at
the other hospital because doctors there thought he might have
pneumonia.
But he did not appear to have pneumonia or any other infection. He had
no
fever. His white blood cell count was normal, and he wasn't coughing
up sputum. His chest X-ray did show a vague marking, but that was
probably just fluid in the lungs from heart failure.
I ordered the antibiotic stopped -- but not in time to prevent the
patient
from developing a severe diarrheal infection called C. difficile
colitis, often caused by antibiotics. He became dehydrated. His
temperature spiked to alarming levels. His white blood cell count almost
tripled. In the end, with different antibiotics, the infection was
brought
under control, but not before the patient had spent almost two weeks in
the
hospital.
The case illustrates a problem all too common in hospitals today:
patients receiving antibiotics without solid evidence of an infection.
And
part of the blame lies with a program meant to improve patient care.
The program is called pay for performance, P4P for short. Employers and
insurers, including Medicare, have started about 100 such initiatives
across the country. The general intent is to reward doctors for
providing
better care.
For example, doctors receive bonuses if they prescribe ACE inhibitor
drugs
to patients with congestive heart failure. Hospitals get bonuses if they
administer antibiotics to pneumonia patients in a timely manner.
On the surface, this seems like a good idea: reward doctors and
hospitals
for quality, not just quantity. But even as it gains momentum, the
initiative may be having untoward consequences.
To get an inkling of the potential problems, one simply has to look at
another quality-improvement program: surgical report cards. In the early
1990s, report cards were issued on surgeons performing coronary
bypasses.
The idea was to improve the quality of cardiac surgery by pointing out
deficiencies in hospitals and surgeons; those who did not measure up
would
be forced to improve.
But studies showed a very different result. A 2003 report by researchers
at
Northwestern and Stanford demonstrated there was a significant amount of
"cherry-picking" of patients in states with mandatory report cards. In a
survey in New York State, 63 percent of cardiac surgeons acknowledged
that
because of report cards, they were accepting only relatively healthy
patients for heart bypass surgery. Fifty-nine percent of cardiologists
said it had become harder to find a surgeon to operate on their most
severely ill patients.
Whenever you try to legislate professional behavior, there are bound to
be
unintended consequences. With surgical report cards, surgeons' numbers
improved not only because of better performance but also because dying
patients were not getting the operations they needed. Pay for
performance
is likely to have similar repercussions.
Consider the requirement from Medicare that antibiotics be administered
to
a pneumonia patient within six hours of arriving at the hospital. The
trouble is that doctors often cannot diagnose pneumonia that quickly.
You
have to talk to and examine a patient and wait for blood tests, chest
X-rays and so on.
Under P4P, there is pressure to treat even when the diagnosis isn't
firm,
as was the case with my patient with heart failure. So more and more
antibiotics are being used in emergency rooms today, despite
all-too-evident dangers like antibiotic-resistant bacteria and
antibiotic-associated infections.
I recently spoke with Dr. Charles Stimler, a senior health care quality
consultant, about this problem. "We're in a difficult situation," he
said.
"We're introducing these things without thinking, without looking at the
consequences. Doctors who wrote care guidelines never expected them to
become performance measures."
And the guidelines could have a chilling effect. "What about hospitals
that
stray from the guidelines in an effort to do even better?" Dr. Stimler
asked. "Should they be punished for trying to innovate? Will they have
to
take a hit financially until performance measures catch up with current
research?"
The incentives for physicians raise problems too. Doctors are now being
encouraged to voluntarily report to Medicare on 16 quality indicators,
including prescribing aspirin and beta blocker drugs to patients who
have
suffered heart attacks and strict cholesterol and blood pressure
control for diabetics. Those who perform well receive cash bonuses.
But what to do about complex patients with multiple medical problems?
Forty-eight percent of Medicare beneficiaries over 65 have at least
three
chronic conditions. Twenty-one percent have five or more. P4P quality
measures are focused on acute illness. It isn't at all clear that they
should be applied to elderly patients with multiple disorders who may
have
trouble keeping track of their medications.
With P4P doling out bonuses, many doctors have expressed concern that
they
will feel pressured to prescribe "mandated" drugs, even to elderly
patients
who may not benefit, and to cherry-pick patients who can comply with
pay-for-performance measures.
And which doctor should be held responsible for meeting the quality
guidelines? On average, Medicare patients see two primary-care
physicians
in any given year, and five specialists working in four practices. Care
is
widely dispersed, so it is difficult to assign responsibility to one
doctor. If a doctor assumes responsibility for only a minority of her
patients, then there is little financial incentive to participate in
P4P.
If she assumes too much responsibility, she may be unfairly blamed for
any
lapses in quality.
Nor is it clear that pay for performance will actually result in better
care, because it may end up benefiting mainly those physicians who
already
meet the guidelines. If they can collect bonuses by maintaining the
status
quo, what is the incentive to improve?
Doctors have seldom been rewarded for excellence, at least not in any
tangible way. In medical school, there were tests, board exams and lab
practicals, but once you go into clinical practice, these traditional
measures fall away. At first glance, pay for performance would seem to
remedy this problem. But first its deep flaws must be addressed before
patient care is compromised in unexpected ways.
Sandeep Jauhar, a cardiologist on Long Island, is the author of the
memoir
"Intern: A Doctor's Initiation."
Copyright 2008 The New York Times Company
--
"be wary of mathematicians..especially when they speak the truth."
--sT. Augustine
to email me, delete blackhole. from my return address
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