Medical Technologies - Notes of a Medical Technology Realist

I’m a realist about technology use in American health care. Given the American culture and its belief that solutions to complex problems lie in technology just beyond the next horizon, I believe it's difficult, indeed, nearly impossible, to effectively suppress technology use.

Those in power tend to believe they can control medical technologies, bring in experts to figure out what needs to be done, conduct large scale studies to assemble evidence to decide what to pay for, set pre-authorization standards to rein in abuses, and limit available technological installations.

This belief sounds logical. But in America these approaches may not work. Why not? The problem is that complex technologies and their uses and abuses are…..well, complex.

At the market level in a complex capitalistic society that believes in innovation and entrepreneurship and choice, there are simply too many interacting variables, vested interests, market-driven forces, permutations and combinations among interacting individuals and entities, connections at the edges of practices and inside and outside organizations, financial and emotional incentives and considerations, hospitals and doctors who see technologies as a means to increase marketing clout, bring in more revenues, enhance prestige, and improve care: and too much pressure to generate additional sources of money to compensate for decreased reimbursements, patient desire to access the best and the latest, hype and hope generated by ubiquitous media.

Complexity doen’t end there. Once the technological genie is out of the bottle, and hospitals, specialists, and supply chain companies taste fruits of technology, there’s no going back, no way to stop, step back, and re-assess hard evidence whether a technology actually works to improve outcomes..

Take the case of imaging. Once CT and MRI scans hit the marketplace in the early 1970s and doctors recognized computerized imaging was a superior technology that allowed doctors to look inside brains, hearts, body cavities, and joints, there was no retreat. Marketing forces were simply too powerful.

Howard Hiatt, MD, dean of the Harvard School of Public Health, wrote in 1976 in the Wall Street Journal that there was far too much medical technology, and there ought to be a National Technology Assessment Institute to establish irrefutable proof that medical technologies improved care before they hit the market. His idea never got off the ground. Imaging flourished. Indeed, by 2001, a survey published by Fuchs and Fox in Health Affairs, among 225 internists indicated the number one innovation over the previous decade was CT and MRI scanning.

Consequently, imaging, in all of its variations and configurations, has become the fastest growing single cost component of the health system, with growth rates
of 16% to 18% per annum.

Health plans and Medicare have tried to contain imaging growth without avail. This year Medicare drafted a proposal saying it would only pay for CT angiograms if a large scale study proved their worth in improving care. The proposal met with fierce resistance from cardiologists and industry CT suppliers and lobbyists.

Medicare backed down. Two comments on why Medicare blinked, cited in a June 29 New York Times piece, “Weighing the Costs of a Look Inside the Heart,” are worth quoting and tell the technology tale..

• Said Barry Straube, MD, Medicare’s chief medical officer, “There are a lot of technologies , services, and treatments that have not been shown to improve health outcomes in a definite manner,” in announcing Medicare had changed its mind and would pay for CT angiograms, designed but not proven to rule out heart disease and to identify calcified arterial plaques.

• Noted Dr. Redberg, University of California San Francisco cardiologist, “Once the train leaves the station, once the technology gets into the marketplace, we don’t get the evidence. We’re spending a lot of money on technology with unclear benefit and risk.” And so CT angiograms are destined to continue, in ever increasing numbers.

The Web of Ideas to Limit Technology Costs

Here, briefly, are pros and cons of a web of ideas, many based on the Web itself, to reduce and untanglesoaring costs of technologies and to curtail the thirst and dependence of American health providers and consumers on technologies.

• Place doctors on salaries to end incentives to use medical technologies for personal gain from self-referral. This is so-called Mayo Model. It has two problems – one, only 10% to 12% of American doctors practice in Mayo type environments; two, the economic success and growth of hospitals employing doctors depends of ordering technologies offered by the hospital, thereby increasing costs.

• Reward only technologies that are “evidence-based.” Sounds good, but evidence-based research is in its infancy and “evidence” too often rests in the eyes and spins of beholders, outcomes based on patient behavior and compliance, not on actions of doctors. Few treatments have “absolute” evidence of cost effectiveness and reside in that “vast gray void” devoid of scientific proof and more on incentives of doctors and expectations of consumers. Besides where is the evidence to pay for "social visits," which account of about half of patient visits to the doctor.

• Compel health consumers to pay for a growing portion of costs using health savings accounts, high copays, and high deductibles in a consumer-driven environment using health savings accounts, with unspent tax-free money carrying over to subsequent years in a 410J type of arrangement. Consumers spending their own money will spend it widely, conventional wisdom says. The trouble is it’s hard to wean paternalistic pundits, politicians, and policy wonks, and consumers off idea that health care ought to be essentially “free.”

• Develop sophisticated algorithms using artificial intelligence and predictive modeling and aggregate pricing techniques to identify those technologies that offer proof of value and avoids unnecessary duplications and medical expense. Requires widespread computer systems, “fully operative” electronic medical records and personal health record systems that talk to one another and are trusted and used by physicians and hospitals.

• Introduce a single-payer system, as in Canada or the United Kingdom, that minimizes administrative expense and controls technologic use and installations by fiat and command and control methods. In America, socialism and capitalism don’t always mix, particularly when they restrict freedom to choose and exercise options.

• Modify the malpractice environment to end practice of “defensive medicine” so doctors are not punished for failure to diagnose using advanced medical technologies . Believe this will happen, and I will be glad to sell you a time-share in North Dakota in January.

• Have physicians spend more time with patients and pay them well to patiently to explain risks and benefits and options of technologies versus less expensive and more conservative wait-and-see approaches. This is difficult in our fast-paced society looking for immediate answers and gratifications, often for life-style enhancement and advancement rather than diagnosis and treatment of life-threatening disorders.

Oh, what a tangled web we weave then we try medical technology costs to relieve.

Medicare Pay Cuts Imminent

Doctors Outraged;
Seniors See Prejudice against Aged;
Democrats Sense Potent Campaign Issue

“Time after time, Congress has jumped in at the last minute to block Medicare payment cuts to doctors. Will this be the time when time runs out?”

Jacob Goldstein,” Bill Blocking Medicare Pay Cuts to Docs Stalls in Senate,” Wall Street Journal Health Blog, June 27, 2008

“President Bush had threatened to veto the bill, in part because it would reduce federal payments to private Medicare Advantage plans, offered by insurers like Humana, UnitedHealth and Blue Cross and Blue Shield companies.”

Robert Pear, “Doctors Face Payment Cuts for Patients on Medicare, “New York Times, June 27, 2008

July 29, 2008 - On June 26, Tuesday, a handful of Republican Senators handed Democrats a campaign issue by voting against calling up a bill that would have blocked a 10.6 % cut in Medicare pay for doctors, thus killing it. Senate supporters fell two votes short of the 60 needed to close debate. The vote was 58 to 40. Senator Obama voted to block the bill. Senator McCain, who was campaigning, and Senator Kennedy, who is ill, did not vote
The House had voted overwhelmingly 355 to 59 to pass the bill the previous day.

Cuts are scheduled to start on Tuesday, July 1, while Congress is taking a July 4 recess, making a last minute reprieve unlikely.

On Campaign Trail

On the campaign trail, Democrats will argue Republican Senators’ vote favors big business, i.e. the private for- profit Medicare Advantage HMO industry and the unpopular President Bush. This tactic will anger 44 million Medicare recipients, a potent voting bloc, and 500,000 or so practicing physicians..

Physicians, and anyone else with eyes to see and minds to think, knows Medicare is the Sheriff of the health system and sets rules and precedents on health plan payments. Health plans obey those with the Medicare badge. Health plans follow Medicare in lockstep, especially when it benefits their bottom lines.

Consequences, Expected and Unintended

What are expected and unintended consequences of the Senate action?

On the “expected” side, you can expect

1) “Compassionate” Democrats will seize a wedge campaign issue against “Heartless” Republicans, who, they will say, care only for profit-making enterprises.

2) The senior vote. led by AARP and the like, will swing to Democrats,

On the “unintended” side, you can expect

1) Outrage among doctors and seniors: already Sermo.com has 1174 messages among doctors, some threatening to boycott Medicare and others saying they shut down practices to new Medicare patients.

2) Widespread protests among seniors, already upset about higher Medicine copays, increased premiums, and complaints of doctors about unfair Medicare restrictions and expenses.

3) Less access to primary care physicians, and specialists who conduct Medicare based practices.

4) Loss of morale among doctors, who will retire earlier, restrict access, cut Medicare services, and seek careers outside of private practice.

5) Cries of dismay among those unable to find a doctor and among doctors unable to afford to care for them.

6) These messages will become common, “Where have all the doctors gone?” “Will the last doctor in America please turn off the lights?” and among doctors, “We no longer accept new Medicare patients.”


In Short

This Medicare crisis will engage all politicians, Republicans, Democrats, and independents. This crisis will be about what you can expect, who will be the most politically correct. Expect an unprecedented wide protest among clinicians, who depend on Medicare to meet economic conditions. Expect outright outrage among Medicare patients, who depend on predictable physician relations. Expect campaign talk on what’s good for business ganders isn’t necessarily good for the physician and patient bystanders. Expect frequent reportage on the physician shortage. Expect Obama moral stigmas on McCain health plan market-driven enigmas. Expect a campaign battle for the minds the public who want choice and freedom and who aren’t mindless cattle. Expect patients to take sides on health plans versus doctors with whom their care resides

Clinical Innovation - Disruptive Innovation Takes Time

While in route to a recent retreat to speak about disruptive healthcare innovations, I picked up a copy of Harvard Business Review on Managing Health Care, which contained several articles about disruptive innovation and the changing healthcare landscape.

As I read the book, two questions popped into my mind:

If disruptive innovations are so hot, why aren't they working to lower overall health costs?

And if prices are so high, why are hospitals in such hot water?

Health costs ballooned by 4.4 times the rate of general inflation from 2002 to 2007. In "Will Disruptive Innovations Cure Health Care?"—an article featured in the compilation—Clayton Christensen, who popularized the term "disruptive innovations" in The Innovator's Dilemma (Harper Business, 2000), explains why healthcare costs may remain so high:

"Nurse practitioners, general practitioners, and even patients can do things in less-expensive, decentralized settings that could once be performed only by expensive specialists in centralized, inconvenient locations. But established institutions—teaching hospitals, medical schools, insurance companies, and managed care facilities—are fighting these innovations tooth and nail. Instead of embracing change, they're turning the thumb-screws on their old processes—laying off workers, delaying payments, merging, and adding layers of overhead workers. Not only is this at the root of consumer dissatisfaction with the present system, it sows the seed of its own destruction."

Christensen's comments may be true, but the medical establishment is unlikely to change. Its leaders are heavily invested in specialized facilities, and specialists (two-thirds of all doctors) are accustomed to having things their way and of dictating who can do what to whom.

Resistance to Change
The healthcare establishment is strong. It has lobbying power. And it can always claim only it has the stature and legitimacy to deliver quality care and set standards. For these reasons, disruptive solutions have been slow to come and to bring down health costs. These innovations have been marginally effective.

Sure, there have been signs of progress. Since 2000, Congress has made high deductible plans with HSAs widely available, consumer-driven care has chugged ahead, hospitals have started to decentralize, doctors have invested in specialty hospitals and other physician-owned facilities, large employers have set up worksite clinics, big retailers—Walmart, CVS, and Walgreens—have gotten serious about retail clinics, medical tourism has been born, and some have became delirious about health 2.0 as the do-all and be-all to re-organizing our dysfunctional system.

And the hospital establishment has shown signs of failure and panic. The fear of failure is out there. Michael Sandnes, director of healthcare services for the Executive Sounding Board in Baltimore, writes in a recent column, "Is The Tidal Wave About to Wipe Out the Health Care Sector?":

"Many hospitals and healthcare facilities have come face-to-face with the reality that factors largely out of their control, like insurance reimbursement and government funding, will ultimately determine whether they survive—perhaps in a different form with a new owner or in a downsized facility—or shut down."

Hospital challenges include

Competition from freestanding, investor and physician-owned diagnostic and treatment facilities.
Cost and complexity of technology and IT infrastructure.
Constant need to improve quality and patient safety.
Labor supply shortages
47 million uninsured Americans.
Questions about not-for-profit status
Pressures on Medicare and Medicaid reimbursements.

There are signs hospitals are awakening to the reality the status quo will no longer work. Hospitals are rapidly decentralizing to form their own outlying facilities, or creating partnerships and alliances with physicians groups. A good example of hospital decentralization is partnering with Walmart to own, oversee, and staff retail clinics in the 400 retail clinics Wal-Mart plans to open in the next two years.

The role of physician leadership
As these disruptive changes are underway for hospitals, pundits tend to disregard innovations on the physician side of the equation, perhaps because of physicians' fragmented, disorganized, independent nature. In the managerial and venture capital world, physicians tend to be viewed as organizational mavericks and therefore may receive little respect.

This is a mistake. Physicians know that without physicians, hospitals would be nothing but empty shells of buildings with mediocre food. They also know physicians flooding into hospitals for employment may ultimately rise to top leadership positions, as they have at Johns Hopkins, Mayo, the Cleveland Clinic, Duke, Emory, and Health Partners in Boston.

Finally, physicians know the future lies in detached facilities—emergency rooms, diagnostic centers, surgicenters, big MACCs (multispecialty ambulatory care centers), imaging centers, surgicenters, specialty hospitals, specialized chronic care facilities—established and controlled by physicians, and in their own revamped, rewired, and retooled practices, delivering care outside established institutions.

These shifts are underway, but they sometimes lack overall physician leadership. Needed now are new business models, new ideas, and new innovations. Ideas for these may emerge of such knowledge exchange sites as Sermo.com, which now has 65.000 doctors submitting ideas and suggestions, or the Physicians Foundation for Health System Excellence, whose constituency consists of state medical society leaders representing 300,000 practicing doctors. New consulting firms, focusing on physician innovation, are springing up to provide new directions.

The physician culture as a whole must coalesce around central disruptive ideas that make healthcare more convenient, cheaper, better, and more adoptable by generalists and the public at large. Rather than turnaround firms, practicing physicians need organizations and leaders with market insights, strategic and development skills, and ability to help physician execute through innovation in rapidly changing markets.

I conclude with this cautionary note from Clayton Christensen, Richard Bohmer, and John Kenagy in the Harvard Business Review on Managing Health Care:

"If history is any guide, the established high-end providers of products and services are likely to be articulate and assertive about preserving existing systems in order to ensure patient-well being. Very often, however, their eloquence reflects concerns about their own well-being. Customers have almost always emerged from disruptive transitions better off- as long as the disruptions are not forced into an old mode, but instead enable better service to be delivered in a less-costly, more convenient contract."

Maybe in the end, those at the bottom of the healthcare food chain—patients and primary care doctors, will set the pace for change. But we're not there yet.

Massachusetts 2 1/2 year old of Universal Coverage Pan

Observations about progress to date.

1. At its onset, Massachusetts was a state unusually positioned for universal coverage, a liberal populace, a low rate of uninsured (552,000 of 6.4 million, 8.6%) and the highest health premiums in the land, roughly 30% above the national average.
2. Other states are unlikely to follow Massachusetts because of different demographics, e.g., California has more uninsured, 6.7 million, than the entire Massachusetts population of 6.4 million.
3. Universal coverage is more expensive than originally projected and is growing faster than anticipated because of record and growing enrollments.
4. The plan has successfully newly insured 350,000 residents, 5.5% of the state population.
5. Universal coverage requires a large and complicated bureaucracy (The Connector, rules for tracking who gets subsidies and how much, tracking who is getting enrolled, and Medicaid tracking and adjustments).
6. Monthly costs per subsidized member are $352.43 per member.
7. The individual mandate is enforced through state income tax returns.
8. In 2008, the maximum penalty for not having insurance was $912.
9. In 2008, for most citizens health insurance is now considered affordable.
10. Universal insurance coverage is not the same as universal access, :many citizens are having difficulty finding a primary care physician and primary care practices are overloaded.
11. Cost control is an overriding issue (according to John Kingsdale, executive director of the Commonwealth Connector, “To maintain public and financial commitment. Controlling costs is 110% of the challenge over the next several years.”)
12. he legislature is considering new cost controls, and Blue Cross Blue Shield may initiate a plan combining payments combining pay-for-per-performance and capitation.
13. The Massachusetts experiment is a work in progress, is popular among the public and its politicians, and will continue as long as the State and the federal Medicaid program is willing to pay the ever-increasing bill
14. Universal health reform takes more time and more money than expected, evening an overwhelmingly liberal state with the best intentions of all participating parties.

Reference

Robert Stein brook, M.D. “Health Care Reform in Massachusetts – Expanding Coverage, Escalating Costs,” New England Journal of Medicine, June 26, 2008.

Electronic Medical Records, Internet, Limits of Technology - EMRs and Consumer-Internet Use

I have a confession to make. I don’t use ATMs. I don’t shop online. I don’t deposit online. I don’t go through electronic shopping center check-out counters. I don’t seek out doctors with EMRs for my personal care.

The New York Times, that fount of national health system wisdom, disagrees with me. In a June 24 editorial, “Our Pen-and-Paper Doctors,” the Times opines that every American doctor ought to have an EMR, just like doctors in Australia, New Zealand, the Netherlands, and Denmark do. The Times cites a Mass General survey of 2700 doctors and laments that only a “paltry” 4% of doctors have “fully functioning” EMRs. The Times concludes, “It is time to drag private physicians out of the paper age.” Presumably public doctors, bought and paid for and supported by government, would have EMRs.

In fairness, the Times does mention that American doctors think EMRs cost too much to buy and maintain, don’t fit their needs, and become rapidly obsolete. What the Times doesn’t say is that studies to date in the U.S. indicate no significant differences in quality, safety, outcomes, and productivity in doctors with or without EMRs.

Nor does the Times say anything about consumer Internet attitudes and actions. Surveys indicate consumers would like to communicate with doctors by e-mail and regularly surf the Net for information about signs and symptoms and treatment of disease.

But, as it turns out, consumers don’t pay much heed to doctor rankings and choosing a doctor. According to a 2007 survey of 1007 California adults, only 1-2% use doctor online rankings to choose or change doctors. Consumers prefer word of mouth referrals from friends, relatives, and neighbors and personal stories. When it comes to choosing doctors, the Internet is not yet that Great Global Positioning (GPS) in cyberspace for steering , influencing, and telling patients where to go for care.

I suppose it is contrary, ornery even irreverent, for me question the notion that this nation’s health system and its doctor choices, are not yet ready for e-prime time, or that our medical system doesn't have to run on Internet time, or that myself and 98%-99% of other consumers, still prefer to choose caregivers the old-fashi0ned way, word of mouth and local and regional reputations, rather than Internet rankings, but that’s what blogs are for – to keep readers and the Times in touch with reality.

References

1. New York Times editorial , “Our Pen-and-Paper Doctors,” June 24, 2007.

2. Pamela Lewis Dolan, “Patients Rarely Use Online Rankings to Pick Physicians,” AMedNews.com, July 23/30, 2008.

3. California Healthcare Foundation, “Just Looking: Consumer Use of the Internet to Manage Care,” Harris Interactive Survey of 1,007 adult Californias form Nov. 5 to Dec. 17, 2007

Poem Call to Babyboomers

Operator, please connect me to America’s babyboomers
Yes, those 78 million soon to be health care consumers.

All born after the year of nineteen forty six,
Now about ready to qualify for a Medicare fix.

Pause…

Hello, all you baby boomers
Have you heard the rumors?

That as you grow old and startto age
You’ll turn over a new health page.

That you will be much more demanding,
To avoid a life style crash landing.

That you will flock to cosmetic operations,
To lookyouthful for all possible occasions.

That you will seek new hips and knees,
To remain free of any over-use disease.

That at all costs you will avoid unseemly unsightliness,
No contacts or bifocals, but lasers to hid nearsightedness.

That you will come to doctors’ offices with e-downloads,
Gathered during your many trips down electronic roads.

That you will examine doctor data outcomes,
To comparison shop for the best value sums.

Most doctors know these rumors are misleading,
Indeed, that many are simply not worth heeding.

Like all patients you’re looking for best advice,
Not necessarily the best price or latest device.

Life, health, prevention, imagined and real disease
Are so complicated no single approach will all please.

Keep your faith in doctors, be reasonable.
For you they will do whatever is feasible.

In the end, it’s all about options and choices,
And about physicians listening to your voices.

For your care you deserve freedom and to be in charge,
To partner with doctors in a relationship writ large.