Posts Tagged ‘waste’

DOC-IN-A-BOX

December 9, 2013

A small study, unlikely to garner much media attention, may be one of the first salvos in the war against medical waste.

Recently published in Circulation: Cardiovascular Imaging, the trial studied the impact a web-based computer program might have on decision-making in the emergency room. About 500 patients presenting with chest pain or a sensation of shortness of breath, something doctors call dyspnea, were randomized to an active group that had a computer gauge their medical risk and prescribe the necessary testing. The doctors in the control group decided in the usual fashion, without computer help. The investigators found that the program lowered the patients’ radiation exposure (i.e., fewer tests) without a significant difference in the rate of return to the emergency department for care or occurrence of adverse events.

Watching the geometric progression of technological evolution, it seems inevitable that someday the line will be crossed where computers become more accurate diagnosticians than people. Whether you believe that day is 25 years away, 50, or 100, is irrelevant. The importance of this study lies in the fact that, properly applied, even present-day computer programs have the potential to cut waste (and increase patient safety).

Whatever your view of Obamacare, it is evident that universal coverage and no exclusions for pre-existing conditions are good things. It is also evident that good things come at a cost. The only immediate way to get a good thing at no cost is by removing fraud and waste. Having practiced in the medical field for decades, my impression is that there’s probably a lot more waste than fraud. Figures of 20-30% of our medical care dollars have been bandied about, which jives with my admittedly subjective impression.

Eventually, the march of technology and knowledge will lower costs in other ways, by allowing more effective treatments and perhaps even curing chronic illnesses that, at present, we can only effectively manage to the point of bankrupting the health care system. In the meantime, it behooves us to put a lot more effort into studies like the one above, the primordial germ of artificial intelligence, that will ultimately make my job obsolete.

Someday, perhaps sooner than we think, the only “doc-in-the-box” you’ll ever need will be attached to a touchscreen with circuits linked to what is now known as the “cloud.”

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THE GOD OF WASTE

May 19, 2013

A couple of weeks ago I received a report from an out-of-area cardiologist regarding a mutual patient who spends part of the year in another state. The note referenced a 3-year-old cardiovascular test ordered by me with intent to repeat. There was no record of the more recent study done a few months ago, perhaps forgotten by the patient. I contacted the patient only to learn the repeat study has been completed a day earlier.

If you think this unnecessary duplication of effort is an isolated event, think again. It’s just another example of the 20-30% of the waste in the system. An industry characterized by third-party payers and often little to no patient out-of-pocket expense lends itself to this scenario. The insurers don’t have the ability to track all of this, and perhaps lack the incentive as well, as long as they can raise premiums and maintain robust profit margins. Usually the quick fix is employed—the blunt instrument of progressive reductions in reimbursement for the most commonly employed tests and procedures, regardless of their appropriateness or complexity.

If you think this is isolated to the heath care industry, think again. Waste is the new god of Western society. Its worship takes the form of long-term government guarantees of retirement benefits regardless of market conditions, funded by loans and wave after wave of “quantitative easing,” the green ink flowing like a verdant waterfall. The largesse even spills into the private sector, from time to time. When General Motors decided, at the behest of the union leadership, to emulate the government’s modus operandi with unsustainable retirement guarantees in the form of defined benefits, the ruling class stepped in with freshly printed and borrowed money to prevent the inevitable implosion. The move was applauded by many; the alternative would have been near-term hardship on a major scale. The future fall-out from this is … well, in the future.

A majority of the electorate is perfectly happy to allow this state of affairs to continue. Retirement, unemployment and welfare benefits provide comfort, and a reasonable standard of living. It’s also comforting to attribute the current economic malaise to the failure of the wealthy to pay their fair share, rather than indiscriminate borrowing and unbridled printing. Some believe it will all heal when the economy magically recovers. Others don’t think about it at all. The more informed and cynical will try to get whatever they can before the end of the road is reached.

I don’t know how long the road is. Perhaps it ends when our debt-to-GDP ratio reaches 170%, as in Greece. I do know that history, ancient and present, proves that it is not infinite.

So clink your glasses in salute to the new god. Green beer is a one day event—green money is forever. Or is it?

EUPHEMISMS

September 24, 2012

Quantitative easing. It has a nice, soothing quality to it. In its third iteration it has the friendly, familiar nickname, “QE3.” I don’t know who coined the term, but I hope they got paid well. It’s brilliant. Unfortunately, what they paid will certainly be worth less tomorrow than it is today.

It isn’t only the name that’s brilliant. The concept itself shines. What other ploy robs you of your hard-earned money so elegantly, all the while making you feel as if you have more? If they called it by its real name, “inflation,” you’d be furious. So they’re going to “quantitatively ease” you. It’s the equivalent of the king’s executioner twisting the vise screw against your temples and telling you he’s “supporting your aching head.”

Of course, before a major election, it pays to “ease” things a bit. Each injection of cash makes things better, for a while, kicking the can down the ever-shortening road for an ever-briefer euphoric fix. But it’s enough to create the illusion, at least for half the nation’s voters, that the Obama economic plan is making a dent in the failing economy.

Meanwhile, the only dent our enemies in the Middle East see is in our armor. Because an economically weak U.S. is a vulnerable U.S. For those apologists who think we’ve been too big a presence in the world, wait and see what it’s like with someone else (perhaps China?) at the forefront. Not a pretty picture.

That’s not to say we haven’t been as poor a steward of our military resources as we’ve been with every other aspect of the economy. Waste has been a way of life for us. Now it’s payback time. Either we do it or our children and grandchildren will.

Unless our enemies cancel the debtor.

I HATE TO SAY I TOLD YOU SO …

September 10, 2012

Well, maybe not. There is a perverse pleasure in seeing one’s assessment, even when it comes to bad news, validated. It’s human nature. To that end I present a recent excerpt from the ACC News Digest that references several sources analyzing our health care spending:

IOM Says US Health System Wastes $750 Billion Annually.

The AP (9/7, Alonso-Zaldivar) reports that yesterday the Institute of Medicine issued a report finding that “the U.S. health care system squanders $750 billion a year – roughly 30 cents of every medical dollar – through unneeded care, Byzantine paperwork, fraud and other waste.” The conclusion drawn is that while both “President Obama and Republican Mitt Romney are accusing each other of trying to slash Medicare and put seniors at risk … deep cuts are possible without rationing, and a leaner system may even produce better quality.” That’s because the IOM’s “one-year estimate of health care waste is equal to more than 10 years of Medicare cuts” under the ACA and “more than enough to care for the uninsured.” The report also “identifies six major areas of waste: unnecessary services ($210 billion annually), inefficient delivery of care ($130 billion), excess administrative costs ($190 billion), inflated prices ($105 billion), prevention failures ($55 billion) and fraud ($75 billion).”

The Washington Times (9/7, Cunningham) reports in its “Inside Politics” blog, “The report highlighted flaws that have long plagued the U.S. health care system, which is relatively slow to adopt new technologies, lacks incentives for doctors and hospitals to keep costs down and doesn’t encourage all of a patient’s providers to coordinate care.”

ABC (9/7, Wong) in its “Medical Unit” blog says that “the money squandered on services that failed to improve Americans’ health could have provided health insurance for more than 150 million workers or covered the salaries of all of the nation’s first responders for more than 12 years.” Author Dr. Mark Smith, president of the California HealthCare Foundation, said, “We’re spending money in ways that don’t seem to improve people’s health.”

I began this blog a few years ago with the health care system as its initial focus. My estimates were based on my personal experiences but I suspected, correctly it seems, that my observations were generalizable. There is a silver lining to this bad news: With this much waste, theoretically we can dramatically improve our health care delivery and its cost by waste cutting alone. The devil’s in the details of ferreting out the problems and realigning the incentives.

In early 2010 I whittled down my 15 recommendations for a healthier health care industry to what I felt were the most crucial 5:

  1. Tort reform. Without it we’re banging out heads against an endless testing and retesting wall.
  2. Increase competition by allowing patients to obtain coverage from out-of-state insurers, possibly in conjunction with nonprofit health cooperatives owned by the patients. Mandatory minimum coverage for those that can afford it has to be part of this.
  3. Establish a centralized medical records database.
  4. Immediately halt the arbitrary reimbursement cuts (actually, they seem to be based solely on volume and cost, rather than utility and appropriateness).
  5. Notify physicians and providers that are utilization outliers (and by that I mean beyond two standard deviations from the mean) of their status, without penalties.

Since then I’ve become less sanguine about the value of tort reform as a means of reducing cost, considering its impact (or lack thereof) in California, where we’ve had it for decades. Its benefit lies in its ability to bolster physician access by limiting the bloated malpractice insurance premiums that drive doctors away from essential specialties. In any case, little has progressed in this arena. Likewise, numbers 2 and 3 have seen little change, although isolated EMRs are springing up like poorly programmed weeds due to government incentives, which is a first step toward more universal connectivity. Reimbursement cuts are proceeding, although haltingly, so as to keep physicians from bolting from Medicare. I haven’t seen even a mention of number 5.

Will Obamacare be the answer? I know people who think so. I’m skeptical that a complex law no one fully understands, and which the legislators haven’t even read, can increase the extent and scope of medical coverage by increasing taxes without further driving us to the brink of bankruptcy, but we’ll see. Unless it’s repealed.

The only thing for certain is that the only road to “something for nothing” is waste management.

SOME ROADS LEAD TO ROME

December 12, 2011

A recent post in the ACC News Digest recently proclaimed:

Berwick Says As Much As 30% Of Health Spending Is “Waste.”

The New York Times (12/4, Pear, Subscription Publication) reports that Donald Berwick, in an interview on his last day as head of the Centers for Medicare and Medicaid Services, said “20 percent to 30 percent of health spending is ‘waste’ that yields no benefit to patients, and that some of the needless spending is a result of onerous, archaic regulations enforced by his agency.” Berwick “listed five reasons for what he described as the ‘extremely high level of waste.’ They are overtreatment of patients, the failure to coordinate care, the administrative complexity of the healthcare system, burdensome rules and fraud.”

The Hill (12/5, Baker) reports in its “Healthwatch” blog, “Berwick came to the job with a passion for delivery-system reform, and in roughly 18 months as CMS administrator he oversaw an aggressive push to implement pieces of healthcare reform that matched his vision.” Sen. Tom Harkin (D-IA) remarked, “This is a missed opportunity to have someone who really understands the healthcare system, who understands quality of care rather than volume of care, which has been his hallmark. I’m just so sorry to see this end like this.”

The actual articles are brief and worth reading. Dr. Berwick, a pediatrician, and I have reached strikingly similar conclusions about the state of health care. The 20-30% number for waste  and the remark, “The decision is not whether or not we will ration care — the decision is whether we will ration with our eyes open,” will sound familiar to those who have read my past rants on he health care crisis. Despite our areas of agreement, I find it harder to swallow the premise that the massive, complex law we’ve dubbed “Obamacare” is the road to our salvation. Forgive me if I also gag on his view that “[t]he government, unlike many private health insurance plans, is working in the daylight. That’s a strength.” The same article quotes him as stating, “Government is more complex than I had realized. Government decisions result from the interactions of many internal stakeholders — different agencies and parts of government that, in many cases, have their own world views.”

We’re dealing with a complex, multifaceted issue involving many people and institutions with their own agendas and are trying to regulate it with a complex, multifaceted institution with many people and institutions with their own agendas. Toss in a large dollop of corruption in both pots, and we have a recipe for disaster. Unfortunately, as with the overarching economy, we need real change, fast, because we’ve kicked the can down the road for too long. But change of this magnitude, implemented incorrectly, may sink us faster. Are we doomed? Maybe. But a good start would be to examine all the pieces, as I’ve done when I began this journey over two years ago, and set realistic goals.

Yes, Dr. Berwick, we will be rationing care. We always have, poorly. Now we have to do it rationally.

WASTE AND WHAT-NOT

November 2, 2009

When I witness waste in the system, almost daily, and then listen to things like Speaker Nancy Pelosi’s speech on the proposed health care reform bill a week ago, it becomes a herculean effort to avoid succumbing to the dual demons of cynicism and resignation. Her words were like those radio commercials for one of the myriad “miracle cures” I hear every Sunday. “Guaranteed to work.” “No side effects.” Please. 

This week I got to provide a little exercise for a prisoner sent for stress testing for chest pain he’s had for years that was textbook-classic for acid reflux (“I don’t think it’s my heart, doc”) but who is at risk for coronary artery disease because he’s HIV-positive. The test, as anticipated, was negative. It seems the heightened scrutiny the penal system docs have been given over the past year is having its desired effect—contributing to the state’s bankruptcy. 

Meanwhile, over in the private sector a patient of mine who had been doing well and relocated to Bakersfield for a year had an evaluation by his new doctor 6 years post his bypass surgery. The physician was “concerned” that there had been no recent stress testing, so he obliged, irradiating him first for a “technically difficult” heart scan that showed a possible problem and then with an angiogram that showed the blood flow to his heart was intact. The patient still felt well. 

Another patient went to an emergency room in Riverside after forgetting to take his pills with him and developing chest pain related to medication withdrawal. He was appropriately evaluated and observed for threatened heart attack. He also was irradiated with a CT scan of his chest to exclude pulmonary embolism, or clot to the lungs. There’s a blood test called a D-dimer that is used to screen for clotting abnormalities seen in the presence of pulmonary embolism. I often joke it was developed by a radiologist because it has very good negative predictive value, meaning if it’s normal, you can rule out clots with a high degree of certainty. However, if it’s elevated, and minor elevations aren’t uncommon in patients visiting the ER, most of them will be false positives (meaning a lot of normal CT scans). This patient of mine had a normal D-dimer, but it didn’t save him from a chest CT. Ka-ching! 

The government is a blunt instrument when dealing with high costs driven in part by waste and in part by, well, the high cost of treating the elderly and infirm. It slashes reimbursement across the board, wounding the thoughtful, cost-effective provider and the knee-jerk or greedy diagnostician alike. 

We need a more surgical approach. Even if Nancy promises a month of free health care if I call within the next ten minutes.