My discussion of the reporting on the extremely high rate of major spinal fusion surgery in Louisville has generated its own follow-up. On Jan 17, Courier-Journal reporter Patrick Howington contributed a front-page article about the legal battle of five Louisville orthopedic surgeons over an estimated $60 million in royalty fees.
Wow! The Chamber of Commerce must be proud. This is the kind of big-time health care and research money on which Louisville’s city fathers, and its business and university communities have pinned their hopes for the future. So why am I embarrassed over this? Should I be? Would I be if the money were coming to me? I think there is plenty of embarrassment to go around.
It is embarrassing for me as a physician to see other physicians fighting so publicly over money. While certainly within their legal rights, this dispute over money by these professionals reminds us that even for physicians, the practice of medicine is at its base a business. There has always been an inherent tension in the patient-physician relationship: what is best for the patient may not always be what is best for the physician. The professional ideal resolves any such conflicts in favor of the patient. As more and more outside players insert themselves between and around the patient-physician relationship, the vectors of tension become more complex and more difficult to resolve. I predict we will increasingly appreciate such policy difficulties as the structure of our healthcare system changes. Our debates over capitation, managed care, or physicians as employees provide examples where the nature of the patient-physician relationship has been tested. During the last year in Louisville, several prominent contract battles between insurance companies, doctors, and hospitals continues to disrupt the vulnerable contract between patients and their physicians. Continue reading “Battles Royale in Louisville”
On the second day of the new year, the front page of the Courier Journal highlighted the fact that one of our local hospitals was third in the United States in the number of spinal fusions performed. Since the Louisville business community has identified generating healthcare revenues as a top long-term strategic priority, the headline could easily be interpreted as a success story. However, the full-page article by John Carreyrou and Yom McGinty reprinted from the Wall Street Journal was not very flattering. (The article is not present on the Courier Journal website, but is available on the Wall Street Journal’s.)
The article emphasized the multibillion-dollar annual market and the medical controversy over when and if this extremely expensive major surgery should be done. Also highlighted were the large amounts of royalty money paid by the manufacturers of surgical equipment directly to surgeons who make the decision to operate. The article reported that five of the surgeons at my local hospital received more than seven million dollars in less than a year from the manufacturer of the implants used in the surgery. This was in addition to the clinical charges billed. It was reported that total Medicare reimbursements for spinal fusion at my local hospital were almost $48 million. The article proposes, and I and would have to agree, that the amounts of money involved are enough to distort the medical decision-making process. Since the hospital and doctors involved are part of our academic medical center, one might also reasonably assume that young physicians in training will perceive these activities as the standard of care.
There is not room here today to summarize the medical literature pertaining to spine surgery for disc disease and arthritis. Suffice it to say, most national organizations of general physicians and rheumatologists are arguing for fewer operations than in the past. In my own career as a rheumatologist, I personally recommended spine surgery for only three patients with arthritis. It is possible for you to suspect that I think too much spine surgery is being done in general. The hospital and doctors involved will likely offer their own explanations: indeed I think they will need to.
What I do want to talk about today, is the methodology that brings such observations to the forefront. It has been called study of “small area variations.” You see these kind of studies all the time. They were popularized by Dr. Jack Wennberg and the group at Dartmouth. I have always been drawn to this approach because the mapping of results appeals to my visual sense. For example, here is one of the earliest health policy studies I ever did. Continue reading “Area Variation. Is Doing the Most a Good Thing?”
Courier-Journal reporter Darla Carter led off New Year’s Day with a front page article “Health news [is a] prescription for confusion.” I agree with her. Is coffee bad for you of not? Should postmenopausal women take estrogens or not? Should men get a routine PSA test for prostate cancer or not? When and how often should I get a mammogram? Should I get chest x-rays to screen for lung cancer or not? Should my child get immunized or not? Our daily media is full of headlines and stories that address medical scientific issues and their application to medical care. Even if one is not paying attention, it is obvious that the recommendations appearing in these news articles and segments conflict with each other on a regular basis.
It is this article that stimulated me to get off my duff with this blog. For years I have been pulling my hair out about the way medical information is presented to the public. The volume of health and medical information presented to the lay and professional public daily is overwhelming. I don’t know about you, but I can hardly stand to watch television any more because of all the drug ads. The only thing that is worse are the campaign ads, but at least these are with us only part of each year.
We are assaulted by print, broadcast, and electronic media everywhere we go. The nature of the information ranges widely. It ranges from “news,” advocacy sponsored material, through press releases supporting every possible position. The content passes further down the social-value scale through entertainment, snake oil, and outright fraud. The overwhelming volume of health-related material with which we are sandbagged is advertising: somebody is trying to induce us to buy something that will translate into income for them. There is nothing wrong with information: more and better information is badly needed. But we live in a time when food is sold like medicine, and medicine sold like soap powder. Which hospital in my town really has an infection control problem? What is the basis of a claim that a given product or service is the “best,” or even works at all for that matter? Such information is hard to come by– if it is available to the public at all. Continue reading “Does Medical Reporting Help or Hurt?”
When I began this site, I intended a companion blog in which I could comment on news and policy, and to stimulate discussion among others. It was my conceit that because of the broad range of medial professional activities I have enjoyed, that I might have something to contribute! Without making excuses, this did not come to be! In the spirit of a New Year’s Resolution but with a hope of greater persistence; and with the philosophy of not letting the “Best be the Enemy of the Good,” I want to try my hand at a health blog. I cannot predict how this will evolve, but to learn what can be done, I need to start.
My intention is to try to react each day to some health-related item in my local newspaper (to honor the my Kentucky home and the tagline of this site,) but I will also draw on items from the national media.
I invite any potential readers to join the discussion, present alternative viewpoints that I fail to mention, or to help me get all my facts right. This blog uses the WordPress software that I confess I am still learning to master. I do know that the blog will fill with spam and unrelated material unless I require you to register in order to comment. I hope you will feel comfortable in doing so. I promise that I will never share any information about you in any way. Let me know if the site is not working the way it should. Use the “Contact Us” link in KHPI.org homepage.
While I hope you will find that I have a sense of humor, I am worried about our health care system. It deserves serious discussion. Obscenity or abuse aimed at others will not be tolerated. Offending posts will be deleted and their authors blocked from future participation.
Having said that, I do hope to have some fun doing this. Although my intention is to present as many sides to a given issue as I am aware of, I do have opinions of my own. I have never been very good about hiding either my opinions or my feelings. In the spirit of full disclosure, my basic perspective is that our health care system exists entirely for the benefit of people who are ill, or who are at risk to become ill. To serve this need is a privilege.
Enough procrastination for now!
Jan 1, 2011
Has anything in health care improved for the better for us patients… for anyone?
Over 10 years ago as we approached the new millennium I was finishing an intensive Health Policy Fellowship. As a synthesis of all I had seen and learned from an insider’s perspective, I penned a vision of what I thought healthcare should look like in the next century. It was more a statement of some twenty principles and directions rather than specifics. We are now a full decade into the 21st century so it seemed a good time to take a look at my old roadmap. Perhaps it is a measure of my current pessimistic state of mind, but I am not immediately able to declare progress towards any of the goals I envisioned. In fact, it seemed at first blush that despite all the money and best efforts of public and private interests, that most of the items on my wish list were getting worse.
What do you think? Please prove me wrong. Help me indentify something good that has happened to us as collective patients. Is anyone better off? If so, who? Convince me that we are not irreversibly lost in a status quo of decreasing access to healthcare of uncontrollable cost, and of unknowable quality.
This observational study of local variation in hospital charges arose in the environment of one of the most comprehensive state attempts at health care reform. In the early 1990s, at the same time the Clinton health care reform plan was being debated in Washington, the Commonwealth of Kentucky enacted into law a comprehensive reform plan that in many ways was modeled on the Clinton strategy. Alas, we will never know what parts of this state experiment would have succeeded. It was largely repealed two years after enactment due to withering opposition by the health care industry. I have no way of knowing if the situation regarding hospital charges that I present on the KHPI site has changed from 1996. My informed suspicion is that it has not. To this day I still cannot understand my personal medical bills– and I used to be a health executive!
Certainly the same problems of quality and affordability are still with us. Indeed, for affordability, the problem is worse. With respect to quality it is difficult to know whether there has been improvement or not because of the related barrier of non-transparency. Certainly tremendous effort and much money have been put into attempting to measure quality, but I am not personally enthusiastic about the usefulness of the information received. For all the money Medicare and the hospitals themselves put into measuring hospital quality, it could recently be concluded that only a handful of hospitals have a mortality rate for heart attack that is either better or worse than average! I have to ask, why bother measuring at all if your method of study cannot find any difference? Measure something else or measure it differently! It is not true that all hospitals provide care of equal quality, and certainly not for the same cost.
Proposals to make health care information about cost and quality more public are still part of today’s ongoing public policy debate. For that reason, I dusted off this old study. I was an old laboratory scientist back then and this was one of my very first forays into health policy research. I am the first to admit that it was, and is not cutting edge research, but I found it of great interest personally at the time and believe others will too. I abandoned efforts to publish it back then because of objections from my University. Even though such studies of institutional or regional variation make no initial value judgments, this kind of information is embarrassing to some hospitals. I regret that I was not in a position to further test the limits of my academic freedom at the time.
Kentucky’s effort to provide more information to the public in 1995 did not work as planned. It was too easy to ignore by providers, it may not have asked the right initial questions, and the public was not assisted in transforming the information into something they could use. The same forces resisting change then still operate today. As I write this, the outcome of “National Health Care Reform 2010” in Washington is unknown to me. I will not be surprised, but will be disappointed if we are left as a nation with the status quo of declining access to a health care system of unknowable quality.
Peter Hasselbacher, MD E-mail
When I worked in Government and later as a health care lobbyist, I often heard it said, seemingly in the jest of desperation, that the only way we were going to be able to “fix” the health care system was to wait for an economic or other meltdown such that a new health care Phoenix could arise from the ashes. I must confess that this did not seem so outrageous to me at the time, nor does it now. Just as the “Technology Bubble” burst, and then the “Housing Bubble,” and then the “Banking Bubble,” so do I see the pin approaching the “Health Care Bubble.” The unintended consequences of doing something different are less scary to me than the both obvious and unintended consequences of staying the course.
Ten years ago I dreamed (halucinated) a vision of what I thought healthcare should look like in this new mellineum. We are now approaching the end of its first decade and as I plan to update my Vision, I am hard pressed to see that we have made any progress at all. In many ways we are worse. Since few, if any, others think our health care mission has been accomplished, I assume my dreams are shared by at least some others, perhaps even by Dr Scott whose principled (perhaps courageous given the setting) comments stimulated this posting.
I would like to use this occasion to kick-start the interactive aspects of this Website and to augment its content. You can respond to this posting by clicking the “Comments” link just below. I am new at managing this Blog function, but we can learn together and I will profit from your guidance. Please register and add to the discussion. If you wish to contact me directly, email me here.
Peter Hassselbacher, MD