Friday, March 03, 2006

A(nathe)MA, part the second

I received a very interesting e-mail in response to the AMA rant I posted a few days ago. It came from Dr. Richard Dolinar, an Arizona endocrinologist who is a senior fellow in health care policy for the Heartland Institute. He pointed me towards a few excellent articles he has penned for the Heritage Foundation that have a lot more factual information regarding Medicare's P4P plans. They are well worth the time to read, and basically say (in a much more eloquent fashion than my rant) that we will gain nothing from the current plan being promulgated by Medicare with the back door assistance of the AMA. Another article he wrote with S. Luke Leininger of the Heritage foundation can be found here.

What is particularly insulting about the whole P4P initiative is that this is an exercise in "pseudo" market reform; the folks who are promoting it state that undoubtedly, care will improve (and we physicians will be rewarded) when a whole series of "quality" benchmarks are achieved. Unfortunately, as Dr. Dolinar points out, that has never been shown to be the case:

While federal lawmakers are rushing to implement “values-based purchasing” in Medicare, they ought to take a closer look at the professional literature on the topic, including the limited uses of “evidence-based medicine” underlying this approach. For example, Harvard University’s Meredith B. Rosenthal and her colleagues recently published “Early Experience with Pay for Performance from Concept to Practice” in the Journal of the American Medical Association in an attempt to fill the void of published research on this physician payment strategy. Curiously, the accompanying JAMA editorial rightly notes that in health care there have been “only nine randomized controlled trials of Pay For Performance…reported in the literature.” In reviewing those studies, we note that the review by the Agency for Healthcare Research and Quality (AHRQ) concluded that “little unequivocal data” supported this approach.
In my experience, the physicians and nurses who provide the best, and most cost effective, care are those who spend the least amount of time worrying about whether all of the little boxes in their sheets have checkmarks in them. We are in the business of caring for sick people, not of filling out forms in the realm of "cookbook" medicine. To put it another way, if 80-year-old diabetic GrandMa shows up in the ED with an INR of 6 because she is taking too much Coumadin, which she was prescribed for "evidence-based" reasons, bleeding from a newly diagnosed colon cancer, and needs a whole lot of intense care to get her through her hospitalization, do you really think her survival depends upon whether or not she is on the antihypertensive that some guideline has decreed is "appropriate" for her --- which she will be given in a "cookbook" fashion, just so that the physician and hospital won't get dinged in a review?

What is most disheartening to me is that Medicare, and the AMA, has already won the PR battle. There is no question that our current system does not allow every patient to receive the best and most cost effective care; nobody is more concerned about this than the physicians and nurses who are caring for them. With the inevitable imposition of the P4P plan, I predict that we will see reporting of ever-improving "results" but no true improvements --- sort of how the Soviet bureaucrats would report "record" production each year, while utterly failing by any reasonable calculation. In my opinion, until market forces are allowed to be applied to the field of health care, we will continue to see spiraling costs, poor reporting of bad outcomes, poor quality improvement and process improvement, and a culture of increasing government regulation in physicians' offices and in hospitals --- all masked, albeit temporarily, by a false sense of security generated by the "quality benchmark achievement" buzz. It has been said many times, but the old adage is true: if you like how the Post Office is run, you will love government-run health care.

I learned one additional thing from Dr. Dolinar --- AMA membership has fallen to 24% of practicing physicians in the US. Are you one of the 24%, and if so, why?