Wednesday, April 16, 2014

The Woo-O-Meter

There's a lot of garbage on the internet.  A lot.  My patients are constantly bringing in things that they print off the web that sound great- supplements, weight-loss drugs, cancer cures.  When you read it, it all sounds amazing.  I'm just grateful that they trust me enough to get my opinion before they go wasting money on many of these things.

The problem is that any idiot can write anything they want and get it out on the internet.  And once it's out there, it can get picked up and repeated again, and again and again...until what was once fiction starts to take on the veneer of fact.

It can be difficult to tell truth from fiction, or, as I like to say, true from woo.  What is woo?  I'm not really sure of the origins of the word, but most people think of it as pseudo-scientific thinking.  It's not just someone throwing out a line of bull.  It's bull that is cloaked in a shroud of scientific-sounding words and phrases.  This often makes it sound just plausible enough that you might fall for it.

Therefore, to help you all figure out True from Woo, I've created the Woo-O-Meter.  It takes 18 separate criteria and uses them to calculate a score of "True" or "Woo".  A few criteria might require some defining.  The "Quack Miranda Warning" is the standard disclaimer that claims have not been evaluated by the FDA and that the product is not intended to treat, prevent or diagnose any disease. Woo purveyors seem to think this gives them carte blanche to make all sorts of outlandish claims.  PubMed is a database of basically all published journal articles.  A link is provided in the table.  Impact factor is a measure of how prestigious a journal is (because there are a lot of journals out there that are crap and will publish anything).  The table has a link to a database of impact factors.

So, to use the Woo-O-Meter, all you need to do is find a questionable article/blog post/advertisement, plug the information into the table below, and read the meter!

Let's give it a try, shall we?

Check out this blog post.  The blog came to my attention because of some rather extreme anti-vaccine views the writer was expressing.  While reading more of her blog, I came across this post about curing ADD and bipolar disorder with essential oils.  It's a moving testimonial about a mother stopping her son's psychiatric meds and using essential oils instead.  Per her report, her son was completely cured.  The blog author then goes on to say this:
Wow! I love this testimony. I love that this sweet boy is happy and healthy and whole again. This testimony is what Young Living Essential oils are all about. Health and healing using God’s medicine!
One of the most effective approaches to treating ADD and ADHD – without drugs – is the use of pure, therapeutic-grade essential oils per a study conducted in 2001 by Dr. Terry Friedman that compared the effects of lavender, vetiver, and cedarwood essential oils in improving focus and learning in ADD and ADHD kids.
One of the oils Rebecca mentioned above is called Vetiver. Vetiver oil is psychologically grounding, calming, and stabilizing. One of the oils that is highest in sesquiterpenes, vetiver was studied by Dr. Terry Friedmann for improving children’s behavior.
“The American Medical Association Journal published a two year case study (1999-2001). Stating that Dr. Terry Friedmann M.D. found children who previously had been diagnosed with ADD/ADHD were administered therapeutic essential oils by inhalation that got noteworthy results. The essential oils used were Lavender, Cedarwood and Vetiver”
Dr. Friedmann found a 53% performance increase with Lavender, 83% performance increase with Cedarwood, and 100% performance increase with Vetiver.

I mean, wow.  That sounds pretty impressive, doesn't it?  I'm practically ready to go order some oils, and I don't even have ADD.

However, before we whip out our credit cards, let's fill out the Woo-O-Meter.  We're going to add points for mentioning Western Medicine and pharmaceuticals.  We also have to give a point for the Quack Miranda Warning, as it appears at the end of the blog post.  Of course, another point for using testimonial and for linking to a sales site.

Now, you'd think we could also add a point for the amazing sounding study.  However, no citation is given.  A quick search in PubMed confirms that no only does no such study exist in the Journal of the American Medical Association, but there are actually no studies at all published by a Dr. Terry Friedmann.

Our final Woo-O-Meter verdict is this:

And there you have it.  Something that sounded terrific, when looked at critically, is clearly woo.

So, please, don't allow yourself to be taken in by woo.  Feel free to use the Woo-O-Meter for yourself- the spreadsheet can be downloaded.  Share far and wide, and don't forget to think critically!

Wednesday, April 9, 2014

How Rich is Your Doctor?

Those damn rich doctors.  Bilking Medicare for billions a year.  Driving their Porsches and BMWs everywhere.  At least, that's what the New York Times and most media outlets would have you believe.

Today, to great fanfare, Center for Medicare Services (CMS) released the billing data of over 800,000 doctors.  This was done in the name of transparency.  Unfortunately, the data is anything but clear, helpful, or correct.

I looked up several doctors that I refer to.  There is no way their data is correct.  For example, one oncologist that I frequently refer patients to only had data for 10 patients.  I'd guess that I alone send her more than 10 Medicare patients a year.

I found my data somewhat depressing.  My reimbursement for an average visit with a Medicare patient is $47.  My reimbursement for a complex medicare patient is $73.  Those visits typically last about a half hour.  Keep in mind that that $73 has to cover my office's overhead, which runs...high.  Really high.  It also covers the work I and my staff do later on, like refilling meds over the phone, filling out the various forms that I'm always complaining about, reviewing lab and radiology results, consulting over the phone with other doctors...still think that doctors get paid too much?

Well, plenty of the commenters at the NY Times do.  What frightens me the most about the release of this data is that it is completely misunderstood.  For example:

What I learned about my opthamologist from this release is telling. That she alone in her practice of several was reimbursed close to $300K just for medicare reveals the tip of an iceberg. This is a small part of her practice, which suggests that her income is well into seven figures. While I’m all for her “right” to make as much money as you want, at what point does that become too much when it becomes an unreasonable burden on healthcare costs?

I recently switched to an ACA plan. I recently learned that this doctor’s practice is dropping two major insurers (including mine - all plans, not just ACA conforming.) I can only assume that the practice is gaming the system, pulling out to renegotiate compensation by these insurers, and in the meantime leaving their patients insured by these plans in the dark, not to mention in the lurch. All this for the sole sake of maintaining their very high compensation?

Many doctors have pulled out of ACA and Exchange plans altogether because the small percentage of patients seen under these plans have (relatively) low reimbursement rates. But, since this is fractional to their overall practices, they stand to lose little, if anything, considering some of these may be new patients.

Doctor’s carte blanche to opt out of these plans might well doom the independent insurance aspect of ACA altogether. Is it any wonder that the AMA was so staunchly opposed to the ACA?

Maybe I should bring a chicken to barter with on my next visit.
This commenter, like many, seems to think that her ophthalmologist actually was paid and got to keep  $300,000 from Medicare.  In fact, ophthalmologists have really taken a beating today.  However, one must keep in mind that most of these billings are for injections of Lucentis (I covered this in an earlier blog post).  The doctor has to buy the drug in advance, and actually only gets paid about 6% of the cost of the drug.  The rest of the money goes right out to the pharmaceutical company.  And that's before they even tackle their office overhead.

Then there's this one:

Medicine used to attract people who cared mostly about alleviating human suffering. The data has clearly shined the line on the lack of ethics among practicing physicians. Why the decline in ethics and medical ethics in particular? The profession's resistance to transparency, the false worship of technology, the lack of independent auditors to prevent or minimize fraud and waste, and the self-serving fee-for service practice. Can this nation ignore the threats of sickness-for-profit enterprises?
Ouch.  That hurt.

And this one:

I've been reading a number of responses here, allegedly from doctors themselves, that appear to care more about the billing and what they are paid per visit than patient outcome. (I'll bet they deal mostly with seniors too because the inevitable outcome is finite.) I have worked in the medical industry for years. This is a word of advice to all of the patients reading this column. The next time you go to your doctor, specialist or primary care, take a look at the car parked in the doctor's reserved spot n the parking lot, usually behind the office out of sight, then look at the doctor's trophies (photos, plaques, etc.) around his/her personal office. You'll be able to quickly determine what this doctor is really in the business for ego or patient outcome. You would not believe how many luxury cars and pictures of ski trips, fishing trips, etc. are out there.

These are the same providers who are also supporting the efforts to repeal the Affordable Care Act. Always follow the money trail. Those most fervently against reform are those profiting the most in the first place. 
Hmm.  Well, I don't have a reserved spot.  In fact, all of us who work in the building are told to park towards the back of the lot, so as to leave closer spots for patients.  I also don't ski.  Or fish. I seem to be doing everything wrong!

Now that we've thoroughly vilified physicians, I suggest we look at the bigger picture.  Payments to physicians were $77 billion.  Total Medicare expenditures were $600 billion.  That means the physician payments made up a measly 12% of total expenditures.  What about the other 88%?  Where is the transparency there?  Why have physicians been chosen as the scapegoat for out-of-control medical spending in this country?  If we want to have a true conversation about costs, lets look at the other culprits- pharmaceutical companies, medical supply companies, and hospital costs.

For the record- I drive a 2004 Honda with over 100,000 miles on it.

Thursday, April 3, 2014

Sunday, March 2, 2014

Wednesday, February 26, 2014

The "Patient Centered Medical Home": A Pig in a Poke

Some of my readers might find this post a bit dull, but as a primary care doctor I find this information fascinating.  It also took me an hour and a half to write it, so please, read on...

Some of you might be familiar with the concept of a "Patient Centered Medical Home," or PCMH.  This is something that was trotted out around 2006, and I'm both embarrassed and angered to admit that it was my own specialty organization, the American College of Physicians, that instigated it.  Now, in all fairness to the ACP, I think their intentions were good.  They saw that the cost of care in this country was rising in an unsustainable manner.  They saw that fewer and fewer doctors were entering primary care, frustrated with the low reimbursement and high paperwork demands.  They wanted a way to improve the primary care system.  But, you know what they say about good intentions. They pave the road to hell.

The American Association of Family Physicians jumped on the bandwagon the next year...and then in 2008 the bureaucrats joined the party.  A veritable alphabet soup of acronyms (The NCQA, JCHAO, AAAHC) began creating guidelines, accreditations, and payment schemes.  The Affordable Care Act specifically included provisions for PCMHs.

So, what's so great about a PCMH?  Here is the general idea, taken from the 2007 guidelines developed by the ACP and AAFP:

  • Personal physician: "each patient has an ongoing relationship with a personal physician trained to provide first contact, continuous and comprehensive care."
  • Physician directed medical practice: "the personal physician leads a team of individuals at the practice level who collectively take responsibility for the ongoing care of patients."
  • Whole person orientation: "the personal physician is responsible for providing for all the patient’s health care needs or taking responsibility for appropriately arranging care with other qualified professionals."
  • Care is coordinated and/or integrated: Care is coordinated and/or integrated between complex health care systems, for example across specialists, hospitals, home health agencies, and nursing homes, and also includes the patient’s loved ones and community-based services. This goal can be attained though the utilization of registries, health information technology and exchanges, ensuring patients receive culturally and linguistically appropriate care.[9]
  • Quality and safety
    • Partnerships between the patient, physicians and their family are an integral part of the medical home. Practices are encouraged to advocate for their patients and provide compassionate quality, patient-centered care
    • Guide decision making based on evidence based medicine and with the use of decision-support tools
    • Physician’s voluntary engagement in performance measurements to continuously gauge quality improvement
    • Patients are involved in decision making and provide feedback to determine if their expectations are met
    • Utilization of informational technology to ensure optimum patient care, performance measurement, patient education, and enhanced communication
    • At the practice level, patients and their families participate in quality improvement activities.[9]
  • Enhanced access to care is available through open scheduling and extended hours and new options for.[9][24]
  • Payment must "appropriately recognize the added value provided to patients who have a patient-centered medical home."
    • Payment should reflect the time physician and non-physician staff spend doing patient-centered care management work outside the face-to-face visit
    • Services involved with coordination of care should be paid for
    • It should support measurement of quality and efficiency with the use and adoption of health information technology.[25]
    • Enhanced communication should be supported
    • It should value the time physicians spend using technology for the monitoring of clinical data
    • Payments for care management services should not result in deduction in payments for face-to-face service
    • Payment "should recognize case mix differences in the patient population being treated within the practice"
    • It should allow physicians to share in the savings from reduced hospitalizations
    • It should allow for additional compensation for achieving measurable and continuous quality improvements

When I first read about this, I kind of thought, "OK?  How is this different than what I do now?"  The answer was that it really wasn't.  But if I wanted to be considered an Official PCMH, I would have to be accredited.  And in order to be accredited, I'd need to meet certain benchmarks, which basically are 10 standards that must be met:

ELEMENT 1A—Access and communication processes
The practice has written processes for scheduling appointments and communicating with patients.
ELEMENT 1B—Access and communication results
The practice has data showing that it meets the standards in element 1A for scheduling and communicating with patients.
ELEMENT 2D—Organizing clinical data
The practice uses electronic or paper-based charting tools to organize and document clinical information.
ELEMENT 2E—Identifying important conditions
The practice uses an electronic or paper-based system to identify the following in the practice’s patient population:
  • Most frequently seen diagnoses
  • Most important risk factors
  • Three clinically important conditions
ELEMENT 3A—Guidelines for important conditions
The practice must implement evidence-based guidelines for the three identified clinically important conditions.
ELEMENT 4B—Self management support
The practice works to facilitate self-management of care for patients with one of the three clinically important conditions.
ELEMENT 6A—Test tracking and follow-up
The practice works to improve effectiveness of care by managing the timely receipt of information on all tests and results.
ELEMENT 7A—Referral tracking
The practice seeks to improve effectiveness, timeliness and coordination of care by following through on critical consultations with other practitioners.
ELEMENT 8A—Measures of performance
The practice measures or receives performance data by physician or across the practice regarding:
  • Clinical process
  • Clinical outcomes
  • Service data
  • Patient safety
ELEMENT 8C—Reporting to physicians
The practice reports on its performance on the factors in Elements 8A.

Read these carefully, please, and tell me what you think might be wrong with these standards.  Well, aside from the bureaucratic gobbledygook, the vast majority of these standards only have to do with tracking data.  Elements 1B, 2D, 2E, 8A and 8C are about data tracking.  So 5 of the 10 "must have" standards for the Patient Centered Medical Home have nothing at all to do with patients.  They are just about data collection.

You can't just say that you're a patient centered medical home.  You have to apply to one of the 3 certifying agencies and do a ton of applications and undergo an on site audit, which can cost up to $8000.  You can't just say that you track referrals and coordinate care with specialists.  You have to hire a nurse case manage to do this or designate a staff member.  You can't just track data with a paper and pencil or Excel spreadsheet.  You have to purchase an EMR with special registry capabilities.

Therefore, the cost of becoming a PCMH is quite high.   Factoring in cost of the technology and electronic medical records along with the additional staff needed to be hired to perform "care coordination,"  it can be anywhere from $100,000 to $500,000 per physician.

Now, something that is so heavily promoted, so supported by every major medical organization, so expensive, must be good, right?  There must be a ton of data to support the effectiveness of the PCMH and its ability to improve health outcomes and reduce costs to the average American.  That would be the logical thought.  However, logic often plays no role in public policy.  In fact, there is very little evidence to support any of this.  A study released last year concluded that:
This evidence indicates some favorable effects on all three triple aim outcomes, a few unfavorable effects on costs, and mostly inconclusive results (because of insufficient sample sizes to detect effects that exist or uncertain statistical significance of results because analyses did not account for clustering of patients within practices).

This is in direct conflict to this report, which extols the virtues and success of the PCMH model.  Of course, that report is put out by the Patient Centered Primary Care Collaborative, which is an advocacy group whose stated agenda is to promote the PCMH model.  So, no conflict of interest there, right?  Plus, this report is based almost entirely on industry data from insurance companies, so again, pretty biased.

The fact is that there is a serious dearth of evidence to support the PCMH model.  Most of the "evidence" comes from extrapolating the better health outcomes from other countries that rely more on primary care rather that the fragmented specialist system we have here.  But that's comparing apples and oranges.

A great study was published this week in JAMA called, "Association Between Participation in a Multipayer Medical Home Intervention and Changes in Quality, Utilization and Cost of Care."  The study evaluated 32 primary care practices in Pennsylvania who voluntarily became PCMHs.  The data analysis compared their costs and quality outcomes to 29 non-PCMH practices.  It also compared their performance from before they became PCMHs to after.  Three years of data were analyzed.  The results were pathetic, to say the least.  Out of 11 quality measures, only one showed improvement in the PCMH group.  One.  Hospitalizations did not decrease.  Emergency room visits increased.  Specialist visits increased.  Total cost of care increased.   I mean, these results are bad.  Really bad.  Couldn't really be much worse.  In typical understated academic fashion, the study concludes, "These findings suggest that medical home interventions may need further refinement."

You think?

I'm not particularly surprised by results, and most of my colleagues aren't, either.  We haven't been buying what the PCMH is selling.  When you start concentrating on data collection instead of patient care, it should not be a surprise that outcomes are worse.  When you hire additional people to "coordinate care" instead of letting the patient's doctor do it, continuity suffers and care quality goes down.  When you are dazzled by e-technology and start letting electronic charts be the focus point of a visit instead of the patient in front of you, patient care suffers.

This is not rocket science, people.  Unfortunately, this is what happens when policy is put before practice.

Monday, January 20, 2014

I'm a real doctor, I don't play one on TV

I was watching TV this past weekend when a commercial for another latest-and-greatest drug came on. Have you ever noticed that on TV a doctor's office always looks something like this?

Neat and beautiful, with framed diplomas on the wall.  The TV doc is always in a crisp white coat, which matches his (and it usually is a man) distinguished white hair.  He peers out earnestly from behind his desk, comforting his nervous patient who sits before him (sometimes with adoring, anxious spouse).

But in real life...well, not so much.  Of course, no one is ever going to mistake me for a distinguished genteelly graying gentleman.  As a matter of fact, I once had a patient walk out of my office because I "look too young."  Here's my desk:

Shoved against a wall, no room for patients to sit in awe before me...I'm clearly doing something wrong.

No diplomas on my wall! Instead, we're featuring portraits.

Looks just like me, right?

No sedate, distinguished globe and pen holder for me!  Instead we have this:

The true essentials- lots of lip balm, hand cream, dental floss, and silly putty.  I know what's important to have at hand.

Wanna know where my diploma is?

It's crammed into a corner in the home office, on the floor next to the dog crate.  That's actually a step up for it- up until a few weeks ago it was in a closet in the basement.  Maybe one of these days I'll actually get around to hanging it up.  

But maybe not.  I'm in no rush.  Because it's not about appearances and outward trappings.  The fancy desk doesn't mean a thing.  I have to earn the respect and trust of my patients, because they deserve nothing less.

Sunday, January 12, 2014

Highway Robbery

I recently had a patient ask me to change his medication for his insomnia.  He had been using it on an intermittent, as needed basis with no problem, so I was surprised and asked him why he wanted to change.  He responded that he didn't want to, since it worked fine.  However the price for the medication was going up from $10 a month to $85.   He showed me what his insurance company had sent him:

His company "helpfully" suggested an alternative.  Just to be clear- trazodone is in no way a similar drug to temazepam.  They are not in the same class of medications, and have different efficacies and side effects.

Now, I was surprised that temazepam, a drug that has been generic for quite a while, was so expensive.  So I decided to find out what the retail cost was.  Sure enough, you can get a month's supply at Costco for $9.33.

What could possibly be the excuse for this?  I understand that a store like Costco might use cheap prescriptions as a loss leader for people to shop there (although anyone can use their pharmacy, you don't need to be a member).  However, I would like to point out that UnitedHealthcare Insurance Company had a 2012 profit of $5.1 billion.  That's $5.1 billion.  Just wanted to make sure you got that.

Most of us have noticed that our insurance premiums have gone up quite a bit this year.  That's why this stings even more- it appears that some insurance companies are actually profiting off of our medication expenses.

As for my patient, I kept him on his temazepam, and told him to fill the prescription at CostCo and to pay cash.