The Maze – Part 3
Medical Coding: Diagnosis Coding

This is a continuation of a series on medical coding, billing, and reimbursement.

Previous posts are here:

mazeI had planned to move on to federal monitoring and enforcement of health care reimbursement, but decided I would be remiss not to spend a little time on the diagnosis system and how it relates to medical billing and reimbursement. For those of you weary and bleary-eyed from the last two posts, this one will be a bit less insane–our friends over at ShrinkWrapped, Dr Sanity, or SC&A would probably diagnose this system as merely neurotic, rather than psychotic. But crazy it is, nevertheless.

When you submit a claim for health care services to a federal agency (e.g. Medicare or Medicaid) or a private insurance company, you must identify not only the service which you have provided, but the reason for which the service was performed. To do this, you use a system called the ICD-9 codes. ICD stands for the International Classification of Diseases, a system initially developed by the World Health Organization for epidemiology purposes–in other words, to track and categorize diseases in different parts of the world. The “-9” part indicates the revision number, and the ICD-9 has been around for quite a few years–at least 8 to 10 years to my recollection. The system, designed for tracking epidemics and targeting world health resources, has been adopted by health care payors to standardize reimbursement, similar to the CPT service codes spoken of in the first two parts of the series (CPT=current procedural terminology, the codes used for procedures and E&M services). There are plans for an ICD-10 which have been bandied about, but their implementation date is uncertain.

If you’re thinking that a system designed to send vaccines to Africa and track outbreaks of Dengue fever may not be ideally suited to health care reimbursement in the U.S., you’re showing great promise as a student of medical coding.
Continue reading “The Maze – Part 3
Medical Coding: Diagnosis Coding”

The Maze – Part 2
Medical Coding: E&M Guidelines

mazeGood–you’re back. Grab some coffee and head for your seats–the captain has turned on the seat belt sign, since there’s some rough flying ahead.

Before the break, we were discussing medical coding, billing, and reimbursement, in particular how procedures (surgical and otherwise) were handled. Now for the real fun: how do you decide the proper code for so-called cognitive services: the collection of medical history and data, physical examination, test and diagnostics, and medical decision-making? In coding parlance, these are called evaluation and management services, or E&Ms.

An encounter with a physician–in or out of the hospital–involves two broad tasks: information gathering and decision-making. On the information side, physicians use medical history (information about your present symptoms and illnesses, past illnesses, habits, and genetic risk factors); observational information, primarily from the physical exam; and diagnostic studies such as lab or x-ray. On the decision-making side, there are deductions about what problem or illness you have; judgments about the need for additional diagnostic studies or consultation by other physicians; and decisions about treatment such as medication or surgery.

As you can imagine, there are countless variations on this process, both in terms of the extensiveness of the evaluation, the investigative methods, and the complexity of the decision-making process. And so you can assume that quantifying this process objectively, in order to establish proper payment for services is a daunting task indeed. So the Feds, in conjunction with the AMA, came up with “guidelines” for establishing the level of E&M services–actually, 2 sets of guidelines, one in 1995, and a second in 1997. The 1995 guidelines were widely criticized as being too vague and difficult to interpret–a problem which was solved in 1997 by massively increasing their complexity. (Never, ever, suggest to the government that its regulations aren’t clear enough–the resulting deforesting required to supply paper is a principle cause of global warming).
Continue reading “The Maze – Part 2
Medical Coding: E&M Guidelines”

The Maze – Part 1:
Medical Coding: Intro & Procedures

Hedge mazeI won–I think.

George was a Vietnam vet, a grunt who served honestly and well. Drank hard and smoked, got hosed with Agent Orange like many, got discharged and went on with life. Settled down, stopped smoking, got married, a solid citizen.

In his early 50’s, he presented with an advanced, aggressive form of bladder cancer, the payback of choices both honorable and foolish. Too advanced for surgery, he underwent chemotherapy and radiation, and initially did well. At his interval cystoscopy–a visual exam of his bladder–I saw some changes that were troubling, suspicious for recurrent cancer. After the exam, we sat and talked–about the findings, the need for further evaluation with CAT scan, which was scheduled, and additional treatment options, including major surgery, should the cancer have recurred. It was a good 30-40 minutes after the exam before he and his wife left. That was last July–nine months ago. I just got notified that I will be paid for his visit.

Now, this is not really about George–it’s about his insurance company, and the Feds, and many other insurance companies just like his. And to explain the issue, and how insane and perverse it is, you will first need to go to school. So take your seats, sharpen your No. 2 pencils, open your spiral notebooks, and listen up: I’m gonna teach you about how George’s medical charges and billings–and yours, and millions like you and him–really work. This course is called Medical Coding and Reimbursement 101. Ready? I knew you were (except for those who thought you were auditing Transgendered and Feminist Perspectives on War, Rape, and Postmodern Literature: next classroom, please). So lock the door — no smoking, you in the back–and let’s get started.
Continue reading “The Maze – Part 1:
Medical Coding: Intro & Procedures”

Quality in Medicine – Pt 2:
Transparency

This is the third post of a series on issues related to improving quality in medicine (so why is it named “Part 2”? Don’t ask… ). The two previous posts addressed a new proposal for reimbursement called pay-for-performance:

Masquerade maskLast year, my trusty 1995 Acura Legend began to have baffling problems with intermittent overheating. After multiple trips to the shop for new hoses, a new water pump, radiator repair, new thermostat, and other fairly costly fixes–none of which resolved the problem–I decided it was time for a new car. I wanted to get a recent model coming off lease, and still on warranty, rather than a new vehicle. So I fired up my browser, and went shopping. I looked at the reliability of models in which I was interested, whether there had been any recalls, auto reviews, average gas mileage, and blue book prices. I browsed at several local car dealerships online, made a few calls, found a car, and did a Vehix search on its history. I then drove to a local dealership, and drove home with my new car a few hours later. The online investigation took less than 2 hours.

The last time I changed primary care physicians, I picked up the phone and called an internist friend of mine, and asked him whom he was seeing, then made an appointment with his doctor. The car will get me around town; the doctor may save my life.

Does anyone else think there’s something wrong with this picture?

As a physician, I have much more inside information than the average patient. When I need an orthopedist or surgeon, I can talk with the OR nurses who work with them day in and day out, and get a very good idea of their technical skills. I know many physicians personally, and have mutual patients, and therefore have a good feel for their intellectual wherewithal and interpersonal skills. But that’s about as far as I can get, and it’s still basically a crap shoot when picking a doctor. I know little or nothing about their complication rates, clinical skills, how current their medical expertise may be, how many malpractice suits they’ve had filed against them, the competence of their office staff.

And most patients looking for a doctor know far less about their choice than I. Why is this?

The answer is a lack of transparency.

Transparency is a term most often applied to the personal rather than the professional. It speaks to the wholeness of personal integration, the ideal state of being: what you see on the outside is what exists on the inside. Like a grand masquerade ball, we live life parading the beauty of our ball gowns and the cleverness of our costumes, while hiding our dark insides–our shame–behind exquisitely-crafted masks. Complete transparency is an unattainable goal–but when approached in some small measure, is one of the most liberating experiences in life. When we get honest about our own imperfections and shortcomings, and share them with others who recognize their own weakness and care for us despite ours, we begin to experience grace. The vast energies we have put forth maintaining our shields of deception can instead be diverted to addressing our own failings–often recognized for the first time–and giving of ourselves to others.

So what does this have to do with health care?

Professions by their very nature–requiring long training, utilizing a language unique to the craft, by their very nature embracing a highly specialized subset of knowledge not generally available to those outside the profession–tend to be somewhat closed and secretive. This is, by and large, not some nefarious plot to exclude the ignorant masses to preserve one’s power and wealth, but is rather a function of time, inertia, and the complexity of one’s field. It is far easier to do what you understand well, and have been highly trained to perform with little or no effort or forethought, than to explain your complex thought processes and instincts gained by years of experience to one without your training.

But the control of knowledge, given our human weakness, tends towards arrogance and defensiveness–as Paul of Tarsus observed many centuries ago: “Knowledge puffs up.” This is nowhere more evident than when, despite our knowledge, skill, and expertise, things do not turn out as expected. When challenged, we circle the wagons, employ defensiveness, rationalization, and self-justification. Whether or not the problem is self-engendered or the result of circumstances beyond our control, our natural instincts are to hide the ugly child, stuffing it in a closet while we move on, ignoring its cries, pretending all is well. And lest you think I’m singling out the medical profession, all professions–indeed all individuals in every walk of life–suffer from this tendency, to greater or lesser degree. You will find this process alive and well in the welder’s shop, at your car mechanic, at your bridge club and in your classroom. The problem in medicine is that the consequences of such cloaking behavior are potentially so great. If your bridge partner is lousy despite claiming otherwise, you will be angry and look foolish; if your car mechanic is not up to snuff, it may cost a lot of money and frustration, but is unlikely to otherwise harm you. If your doctor’s skills or knowledge are not up to par–whether he or she recognizes it or not–the impact on your life can be profound.

So how might this transparency thing make a difference?

Call me crazy, but here’s how it should work in my perfect world: When I need to see a surgeon, I go to the web, lookup his name, find his schooling, fellowships or other post-residency training, and how long he has been in his current practice. If I need my gallbladder removed, I can see statistics on how many he has performed, his incidence and type of intraoperative and postoperative complications; average, maximum, and minimum pain assessment levels at five days postoperatively; average length of stay in the hospital; and number of patients requiring re-operation. If I am looking for an internist to manage my hyperlipidemia, I can find out how many such patients he has managed, and how many have achieved their ideal lipid profiles, in what time frame, on which drugs. I want to see patient feedback on education about diet and lifestyle counseling, waiting times for appointments, waiting times in the waiting room, callbacks for lab results and questions. For my oncologist, I want to know her experience with my type of cancer, side effect incidence and profile for the chemotherapy administered, survival rate, pain management policies, availability of investigational protocols if needed, who’s on call when she’s gone or on the weekend.

As the patient, I find the thought of this kind of access to information exhilarating; as a physician, I find it highly problematic. It is not that I believe I would fare poorly by the release of such information — on the contrary, I am inclined to believe I would do well in most areas in contrast to my peers (which is no doubt my large ego at work). But I would fare poorly in other areas, which is an uncomfortable but necessary consequence of making this kind of information available. Oddly enough, this is not why the thought of such openness is frightening. The fear comes primarily from concerns about how the information is acquired, and how it will be used.

In the realm of the personal, transparency cannot take place without certain preconditions. First and foremost, one must be willing to be open and honest about both strengths and weaknesses–a vulnerability which can engender significant fear. This requires a willingness to admit one’s imperfections and shortcomings–which runs hard against both individual pride and denial, which are manifest in all of us. Secondly, the disclosure of potentially risky information about oneself must occur in a safe environment–the information must not be used against me, and must be protected from those who would so use it. And lastly, the point of such openness is the willingness to change–no point disclosing such information unless there is a desire to improve.

At the professional level in health care, the same conditions apply: willingness to disclose information openly and honestly, safe handling of information without retribution, and willingness to alter behavior based on such disclosure. There are significant problems with each of these preconditions for transparency in health care, however. Of the three, the elephant in the living room is the second: is there a safe way to release and distribute this information, so that it can be useful to patients (and to health care analysts and policymakers) without it coming back to bite hard at health care providers and institutions? I think the answer is a qualified “yes.” The willingness to release the information, and the ability to change behavior based on this information, will depend in large part on how the health information is handled.

Several criteria seem to me to be critical for the safe release and handling of detailed health statistics from providers:

  • The information must be stripped of all patient-identifying information.
  • The released health information must not be discoverable; i.e., it cannot be used in lawsuits against individuals or institutions.
  • The information must be excluded from medical disciplinary processes.
  • The information must be detached from decisions about reimbursement by third party payors and federal health programs.
  • The information must be broad-based: ideally most or all providers in all specialties.
  • Data comparisons of providers should be specialty-specific.

Physicians must also be able to comment on or amend this information. If my patient has surgical wound infection, but is diabetic and on prednisone, I need to be able to provide these details. Patient non-compliance, co-morbidities, or other circumstances determining treatment results are necessary details to flesh out the raw data about complications or other bad outcomes.

Without such safeguards, providers will be very reluctant to release such health care data. But there are other barriers to willingness as well. First and foremost, every physician reading this is asking, “Who’s going to generate and report this voluminous information?” The idea of massive reams of paperwork reporting clinical outcomes on most or all of their patients will drive a physician to early retirement, or the bottle–or both. This–along with concerns about who will access and use the data–will be the biggest hurdle to implementing any such system.

But it may be time for a reality check: pay-for-performance — a freight train already rumbling toward your medical practice — is going to require exactly this kind of information. And even if this payment scheme proves ineffective–as capitation, vertical integration, HMOs, and a host of other failed payment ideas have–once the data collection is in place, it will never go away. We should be thinking of how to do it correctly, so it benefits both our patients and our profession.

The use of an electronic medical record would greatly facilitate this data exchange. But EMRs have limited penetration in the health care arena–less than 15% of physicians use one. But recent decisions by Medicare to provide free, open-source EMR software to physicians–based on the robust system in use in the Veteran’s Administration hospitals and clinics, may well breach the dam of costs and vendor longevity which have proven impediments to widespread adoption of EMRs by physicians. Since this software is open-source, modules for the necessary data tracking and transmission could be developed with relative ease.

Who will manage and control this data? Government and insurance companies want this control, but here’s a better idea: rather than have a mandatory, government-run repository geared toward micromanaging health care, why not have a private organization or business manage the data, funded perhaps in part by government, but largely by subscription. Patients, health care researchers, media, third-party payers and government would subscribe to this service, with various levels of subscription fees based on the quantity and detail of information needed. These fees would support both data collection and IT costs, and allow physicians to be paid for providing the information, with contractual agreements allowing auditing to ensure that data provided by physicians was accurate and complete, and to discourage reporting fraud. Mandating that physicians provide detailed health information to government and insurers — while paying them less–will be as popular as a cellophane burqa in Mecca. Paying physicians to provide reliable information which will benefit their patients and their profession is a much more palatable and attractive concept.

Consider the benefits of having this quantity of health care data available. Most medical studies are performed using a few hundred, or at most a few thousand patients. Imagine the value of having access to the outcomes of millions of patients undergoing surgery, or management of heart disease, or cancer prevention. This is the power and potential of transparency. Will physicians and health care change as a result? I cannot imagine that the change would be anything less than tectonic. Competitive pressures will encourage physicians to improve their care. Large data sets will make it far easier to determine what works and what doesn’t, providing vastly more raw data than that currently provided by the medical literature–and without the potential conflicts of interest from pharmaceutical or medical device company sponsorship of such studies.

Anyway, that’s my dream. Like Samuel Coleridge, perhaps I have taken one too many puffs on my opium pipe, and shall awake to find this wishful thinking and fanciful visions. But before we can change, we must first begin to dream. We as health care providers can watch our patients search the web — where fruitcake herbal cures and quackery have equal voice with legitimate health care — and we can continue to base our treatment decisions on limited information — or we can begin to provide extensive health information ourselves, to improve our care and that of our patients.

Seems like an easy choice to me.

Quality in Medicine – Pt I

IrisA commenter on my previous post on pay-for-performance asked an excellent question:

So, if it were your job to implement a “quality assurance” system in health care (or specifically in your part of the health care system), where would you start?

Whining is easy in medicine — as in most areas of life — and I generally try to avoid posts which don’t provide some answers or direction to problems detailed. Being part of the problem is easy; being part of the solution more challenging. So I’ll try to collect a few thoughts on how best to achieve quality in medicine. These are very much “If I were King” solutions–in real life, they may pose insurmountable difficulties from an implementation, political, or practical standpoint. But it’s time to pencil outside the lines–our health care system is in serious trouble in many ways, and we cannot keep doing what we are doing forever before a true crisis arises. So here’s a few principles which I believe would make a major difference in health care quality and delivery.

First, let me say a few final words about pay-for-performance, discussed in my previous post. This whole concept strikes me as a solution looking for a problem. Is there really evidence that a significant quantity of the health care paid for by federal programs or private insurance is substandard, and needs incentives to improve? If there is a significant percentage of such care (and who has determined this?), is it the role of government or insurance carriers to improve this quality through their payment mechanisms? And if it is, how likely is it that they can achieve this goal? It would seem that clear answers to such questions should be given before launching out on a potentially gargantuan overhaul of health care reimbursement, with highly unpredictable results.

Even if the answers to the above questions are affirmative (a dubious assumption, at best), quality depends not merely on the facility or health care provider’s performance as individuals (and therefore potentially changeable by incentives), but in many cases depends on socio-economic factors not under the influence of payer incentives. For example, if you are hospitalized in a major city for severe pneumonia or asthma, and require a ventilator to breathe, you will very likely be cared for by a specialist in pulmonary medicine — or at least by an internist with extensive experience in such care. The nurses in your intensive care unit will have abundant experience with ventilators, sophisticated monitoring equipment, and the care routines (regular suctioning, for example) which greatly reduce your risk of complications and increase your chances for a good outcome. If you are hospitalized in a small town hospital, many of these advantages may not be available. How will pay-for-performance change the lack of availability of a pulmonary specialist, the limited nursing experience with ventilator care, unavailability of some monitoring equipment, and other liabilities which are more more likely to be a problem in a small community hospital?

Secondly, when Medicare and third party insurance companies start talking quality, you’d better lose weight, exercise, stop smoking, and hold on to your wallet: what really drives their locomotives is costs, not quality. The underlying presumption here is that by improving quality by monitoring adherence to standards, the costs of health care will decrease. But this is by no means true in every instance; in fact, higher-quality care is commonly more expensive — often quite a bit more. This reality is one of the main factors driving up health care costs. An MRI is a vastly better tool for diagnosing a ruptured disc than a spinal x-ray or a myelogram — and also far more expensive. Minimally invasive surgery which speeds your recovery often involves expensive technology–endoscopes, digital cameras, costly video systems–which exceeds the costs of traditional surgery. New drugs and chemotherapy are much more effective than older ones–and frequently stunningly expensive. We know that preventive medicine works well in some areas — good prenatal care, weight loss, exercise, drug and alcohol avoidance, smoking cessation — but how will paying providers more achieve these notoriously difficult changes in patient behavior?

I have tried to think of any health problem, any type of patient for whom I would significantly change my medical or surgical management based on a financial incentive — I can honestly say I cannot think of a single instance. This is not because my medical management is perfect by any means, or because I am a superior moral being — I most certainly am not–but rather that as a physician I constantly strive to do the best thing for my patients. Part of this drive is idealistic, part ethical, professional, and moral, and part simply the satisfaction and gratification of seeing my patients do well, of a job well-done. I do not believe I am unique in this regard: I am quite sure most physicians operate out of similar motives. Financial incentives to alter care, if anything, exert a pull toward providing care which is less ideal–either for the patient or for society as a whole. The only time I have to pause and ask myself whether I am doing the best thing for a patient is when there is a financial incentive to follow a certain course: am I doing this because of money, or because it is the best thing for the patient? Such distinctions can be surprisingly difficult to discern–my motives are best tested when I go contrary to financial incentives to do the right thing.

Well, enough on pay-for-performance for now. I had planned a single post to put forth some ideas on achieving quality in health care, but I have barely touched on the topic. This topic will work best, it appears, as a series of posts. Here’s a summary of some topical areas I am planning on covering:

  • Transparency–why is it easier to buy a used car than to select a physician?
  • Reforming the legal system–how the medical malpractice system degrades medical quality
  • Reforming the payment model–financial incentives which undermine quality, and how time often equals quality
  • Peer review–why it doesn’t work and what to do about it

I suspect other topics may come along as this evolves, so stay tuned. And I’d love to get feedback on these ideas from both health care providers and the folks who see them.

And lest you be bored by health care topics, coming soon will be more on the new Narrows Bridge construction, a puppy update, as well as special treat: Tall Ships Tacoma. Take care, and God bless.

Pray for Performance

GivernyThere has been growing interest in a significant change in payment methodology in health care, one called pay for performance. It’s a simple and alluring concept: physicians and other health care organizations will be paid better when their care meets or exceeds certain as-yet-unspecified quality indicators. The medical blogs, such as Medpundit, DB \'s Medical Rants, and Galen’s Log, have been discussing this issue for a while. In general, there is some interest among physicians in the idea, although the wariness is high. Most concerns revolve around the variables in the physician-patient relationship (the non-compliant patient, the patient who cannot afford their medications), the specifics of the quality standards, and concerns about another bureaucratic boondoggle adding mountains of paperwork to physicians’ desks in return for meager increases in reimbursement–or no reimbursement, with cuts for those not meeting the QA standards. Access issues have also been discussed: will physicians start avoiding or dumping their higher-risk or less compliant patients in such a system? The law of unintended consequences (a corollary of the Law of Rules) seems certain to result in unexpected–perhaps disastrous–sequellae to such a large systemic change in payment for health care services.

A recent situation raises another aspect for concern under this payment system: the problem of systemic variables. Consider the following scenario which recently affected the care and outcome of one of my patients:

  • Local hospital–a member of a small non-profit chain–has been contracting with a single service provider for mobile surgical laser services. High quality equipment, superb technicians, prompt service and excellent outcomes are the norm for this business. Business provides service at only two of the chain’s three hospitals, however, because of logistical and distance constraints.
  • Hospital middle-managers decide, for reasons of contract pricing and simplicity of negotiations throughout the chain, to contract with a larger competitor for laser services. This process occurs at the administrative level only, with no input from the clinicians who utilize the services. It is presented as a fait accompli. Numerous physicians complain, but are assured that this is a high quality service and that their feedback is “valuable” and “appreciated”. But no trial period is written into the multi-year contract; it’s a done deal.
  • Uncomplicated cases appear to go smoothly with the new service: so far, so good. Techs are spotty but generally competent.
  • Mr. Jones (not his real name), an 81-year-old gentleman, presents to me with blood in the urine; evaluation reveals an enlarged prostate and a very large bladder stone–larger than a golf ball. Surgery is scheduled, requesting the laser service, which will be used to break up the stone, avoiding open surgery. He is a relatively high-risk surgical candidate, with a history of recent heart attack and angina.
  • The OR scheduler notifies the laser service, but does not mention the stone is a large bladder stone, rather than a much smaller ureteral stone. The laser service also does not ask about the type or size of stone.
  • Patient undergoes anesthesia, and laser service arrives–with a woefully underpowered laser. After a few minutes of use at full power, the laser overheats and shuts down, requiring 5-10 minutes to cool before restarting. This happens repeatedly. Not dangerous as such–but very time-consuming.
  • The procedure–normally taking 30-45 minutes, takes over 2 hours to complete. Consideration for early termination of surgery is given, but this would require another surgery–with the risks of another general anesthesia in a high-risk patient–and the risk is judged to outweigh the benefit of stopping surgery.
  • Because of the markedly prolonged surgery, the patient absorbs a large amount of hypotonic fluid–a problem which never occurs in shorter cases. This results in low serum sodium and other problems of blood electrolytes, hemolysis (breakdown) of red cells, acute renal failure, mental status changes, several consultants required to manage the resulting problems. The patient leaves the hospital 12 days later–rather than the next morning, as would be the norm. Fortunately, there were no permanent medical impairments.
  • Cost of hospitalization is at least 10-12 times the norm. In any QA system, this qualifies as a very poor outcome. Had I terminated surgery early, he would have gone home the same day, but required another surgery for the same problem–another adverse outcome–and perhaps had cardiac complications under a second anesthesia. Checkmate.

Herein lies one of the many difficulties with the concept of pay for performance: not merely the variables of physician or hospital care, or patient compliance, or co-morbidities (other health problems affecting the management of the primary problem), but systemic problems which are entirely outside the control of the health care provider, and which are notoriously difficult to track down and eliminate.

Let’s take the above case as an example. In any well-run business, the process would go something like this: You are evaluating a change in contracted service, required in the production of your primary product, to see if you can cut costs while improving–or at least not damaging–the quality of your core product. You take historical information about the costs of your existing service, both direct and indirect. In other words, you look not only at the direct costs of paying for the product or service, but at the costs incurred by using this service–how many defective items need to be returned? How often did the contracted business fail to provide timely service, or provided inferior quality or defective goods? What are the costs associated with such shortfalls, and do they fall within an acceptable range?

In health care, however, evaluation mechanisms such as these do not exist–or when they do, function imperfectly, examining at only a small portion of the larger process. The mechanisms are further constrained by the nature of health care. You may accept a 1% rate of defective widgets components, knowing that your internal QA will catch most of those and your core widget product will remain at acceptable quality. How many additional deaths or complications are you willing to tolerate when changing medical services or supplies, in order to save money which may be used to provide care to other patients? Who is even willing to do this kind of analysis, knowing that hordes of lawyers are hovering, panting at the opportunity to find evidence that the evil greed of your hospital contributed to Aunt Nellie’s early demise?

My patient’s case illustrates this problem in multiple ways. The decision to change surgical laser services was made at an administrative level–no physician who actually uses the service was consulted. The contract change was made on the basis of up-front costs (how much is paid for each instance of the service) and administrative efficiency (having a single contract covering multiple hospitals rather than multiple, separately-negotiated contracts). The contract will likely have some clauses paying homage to “quality of care”–a pure CYA maneuver, which does not specify what constitutes “quality” care. Good thing, too–since the laser service has little or no access to outcome data for the services it performs. In over 15 years of using contract laser services at multiple hospitals, I have never once been asked by these services–or by the hospital–to provide outcome data, such as complications, mechanical problems during surgery, re-operation rates for poor outcomes, etc. Even if they started today demanding such accountability from contract services, there would be no historical data with which to assess the quality of a new service provider in contrast to the old.

At the clinician and hospital level, quality feedback breaks down again. Several years ago, a local hospital decided to change brands of urinary catheters–a medical supply used in great quantity in hospitals, where the savings of even a dollar or two per unit can result in millions of dollars annually in cost reductions. On a day-to-day basis, the minor reduction in product quality was insignificant: they worked fine for Aunt Millie when she need a catheter for a few days to monitor her fluids accurately while managing her congestive heart failure. But when Uncle Ernie had prostate surgery, and developed a few small clots from bleeding, the inexpensive soft-walled catheters failed miserably, their sides collapsing like a shantytown in an earthquake when irrigated–greatly increasing the chances that old Ernie would have to be returned to surgery to be rid of his clots, rather than have a simple procedure by the nurse in his hospital room. It’s the outliers that kill you in these situations, and they’re devilishly hard to predict when a middle-manager sits down to save a few cents on a high-volume supply item. And even when they’re detected, they are easy to blame on other factors–the patient’s condition, nurse or physician error or neglect, etc. And they’re even harder to change once problems arise.

The urologists who need the higher-quality catheters on a regular basis screamed bloody murder from the outset: their patients’ care was hugely affected by this seemingly benign change–but no one was listening. Or perhaps more accurately: no one was responding. The hospital set up an 800 line for physician complaints–but years later, the lower-quality catheters remain a stock item. Like the button on a streetlight at the crosswalk, pressing it made you feel like you were doing something–but the light changed at the same time regardless of how often you pressed. The physicians who did complain were dismissed as troublemakers, or whiners. No one knows how many patients suffered needless discomfort, or unnecessary returns to surgery, because of this simple, seemingly cost-effective change–which has almost certainly cost the hospital far more than it saved in hidden costs, not to mention harming patient care quality. And that’s exactly the problem: no one knows.

So there you have it–pay for performance is a noble idea destined to fail in the health care system. The necessary means and mechanisms do not exist to monitor quality in a whole host of areas–and in areas where they do, conflicting factors such as patient privacy, medical liability risk, and the inertia and nearsightedness of large organizations will thwart any progress toward actual quality improvements using financial incentives. Slapping a “free market” reform as a band-aid on the huge, micromanaged, economically-handcuffed health care system dinosaur is an invitation to create a new Jurassic Park. But of course, that is unlikely to prevent it from taking place.

Coming soon, to a hospital near you…

The Pioneer Spirit

Note: The following post was written shortly after the November 2004 election, and has been edited from the original to make it less time-dependent.

I bear good news: the Pioneer Spirit is alive and well in America.

True, the American frontier was conquered long ago. But ancestors of those intrepid explorers are setting out anew to explore the unknown, the uncharted, to brave the savages and convert the heathen. To wit: Blue-staters are hitching up their wagons and heading Red. They may be coming to a town near you.

Two recent articles tipped me off to this modern-day Manifest Destiny movement, one on each coast, from the Washington Post and the Seattle Post-Intelligencer. One can only speculate on the motivation for such intrepid ventures: perhaps the electoral drought and near-dust bowl voter yields have prompted the search for more fertile land (although it is rumored that Seattle has genetically engineered new loss-resistant voter ballots, which may help avert the impending famine). But whatever the reasons, there is a spirit of adventure in the air.

David Von Drehle, writing in the Washington Post Sunday Magazine, begins with a tale of his journey to the Red Sea:

Early in December, with a photographer and his assistant, I drove from Nebraska, near the geographical center of the United States, to the heart of Texas — more than 700 miles, through empty spaces and sprawling cities and all or part of four states. We headed pretty much due south, no dodging or weaving. And never did we pass within 100 miles of a county that voted for Democrat John F. Kerry in the recent election.

We were voyaging on the Red Sea.

Drehle actually paints a surprisingly balanced view of what he found on his journey – albeit in language whose flourish contrasts sharply with the simplicity of middle America. (“The sun was low in the south; its rays arrived languidly and aslant through the gray, tufted stubble of a cornfield.”) He seems encouraged to find people who voted for Bush, even though they disliked him (as if this were an unusual phenomenon in national elections), but periodically reveals his confusion about Red America as viewed through his dark blue sunglasses:

Kern returned several times to his belief that cities have become dangerous, expensive, disorderly places, in contrast with the safe and dependable countryside. And he seemed convinced that there is some causal link between the unpleasantness of that other America — the one beyond the Red Sea — and the variety of people who live there. The idea of diversity appeared to be meshed in his mind with the specter of change, and change is clearly something he prefers to avoid. Monochrome Nebraska, as he put it, is “the last frontier. Where else do you have a place where you don’t have to worry about crime, about juvenile delinquency, where you can leave your doors unlocked?”

Drehle seems unable to grasp that cities generally are dangerous, expensive, disorderly places (although obviously not without offsetting benefits for many), and that most Red state residents don’t frame their view of the world through the lens of “diversity” (much less think of Nebraska as “monochrome”). And change — that bogeyman that Mr. Kern is thought to dread — is not an inherently good thing when it brings about crime, personal risk, and social disorder.

Far from home and feelin’ Blue, Drehle is mystified and intrigued by these strange Red ciphers he has unearthed. He finds his Rosetta stone in a small Midwest bookstore:

I heard a lot about a book that claimed to explain how people … have been tricked by the moneyed class into voting against their own best interests. I found a copy of What’s the Matter With Kansas? at a bookstore in Ada and began reading it as we resumed our southward journey.

The author, Thomas Frank, grew up in a wealthy suburb of Kansas City and received a PhD in cultural criticism from the University of Chicago. … In Frank’s view, if Red Sea residents knew what was good for them, they would vote for capitalist-scourging Populists today. But they don’t know what’s good for them, Frank explains, because of ‘a species of derangement.’ The deranged people of the Midwest are no longer able to make ‘certain mental connections about the world,’ because those once-‘reliable leftists’ have been deluded into caring about moral issues … Frank kept me reading until it was too dark to read anymore.

It doesn’t get much deeper blue than a Ph.D in cultural criticism at Chicago University, now does it? Drehle has found comfort, like a kid reading a letter from home at camp, in his bunk, flashlight under the blanket.

He seems perplexed when encountering an Oklahoma woman who opposed Kerry for his position on abortion and gay marriage:

She was too polite to say, in so many words, that she felt John Kerry was a man of bad morals. Instead, she put it this way: ‘When Kerry said he was for abortion and one-sex marriages, I just couldn’t see our country being led by someone like that.’

Later, I double-checked what Kerry had said on those subjects. During his campaign, he opposed same-sex marriage and said that abortion was a private matter. But Joyce Smith heard it the way she heard it, and voted the way she voted.

Doesn’t the poor woman understand that a Democrat man’s word is his bond? Except when its not, of course. Sometimes eyes and ears comprehend things which Google searches don’t disclose.

On the Left coast, another journalist in Seattle hitches his Conestoga to the Google search engine in search of the abominable snowman of electoral politics: the Christian voter (“I’ve seen their footprints in the snow, Myrtle, but have yet to spot the beast!”). Tony Robinson, in Who Are Those Christians?, rapidly dismisses the vile misconception that Christians are all narrow-minded, hate-filled moronic drones:

For some today, all Christians are closed-minded religious bigots whose politics are somewhere to the right of the Terminator. For others, Christians can be explained in terms of two-party theory: There are liberal and progressive Christians on one side and the conservative and evangelical Christians on the other.

Both explanatory frameworks are inadequate to the diverse and complex reality of Christianity in America today. Like much else in post-modern America, the situation is wonderfully messy. It doesn’t lend itself to neat explanations or to a simple duality of liberal and conservative. Post-modernity is transgressive, that is, given to crossing boundaries. So today you have progressive evangelicals, theological post-liberals, the new orthodox, as well as ancient-modern Christians. Such stereotype shattering and boundary crossing strikes me as promising.

It is reassuring to know that Christians are not merely closed-minded religious bigots with bulging muscles and German accents, but rather boundary-crossing, stereotype-smashing, post-modern transgressives. Robinson finds this promising — as do I. I think. And as any good teacher, he does not simply leave us wondering what such wonderfully messy transgressiveness implies, but expands the outline in exquisite detail. He has discovered that Christians fall into different categories: mainline, evangelical, fundamentalist, charismatic and, yes — Catholic!

One can almost hear the audible gasp from Belltown readers, sipping their not-too-hot Chai lattes as they gaze over Elliott Bay: “There are different types of Christians — who knew? Say, what time is that Mapplethorpe exhibit at the Seattle Center?”

Robinson’s depiction reads like an African safari adventure written by a National Geographic reader: one gets the sense — unlike Drehle — that he’s never actually met the people he’s describing.

From a sociological point of view, his overview of Christianity in America is reasonably accurate. But as an overview, it approaches being entirely meaningless — or at least irrelevant. He divides two broad stereotypes into five broad stereotypes — then tells us that these stereotypes are, well, not stereotypical. For example, when contrasting the mainline churches with the fundamentalists, he says:

One broad-brush way to differentiate the dominate Christian groups is how they relate to modernity or what some call ‘The Enlightenment Project,’ with its hallmark values of reason, progress, optimism, individualism and tolerance. Mainline Christians have been open and receptive to modernity, working to accommodate Christianity and modernity. By contrast, fundamentalists circled the wagons against modernity, which they perceived as a threat.

Aahh, modernity — who does not desire to be thoroughly modern, Millie? The red flag here is the “Enlightenment Project” — a key element of postmodernism, which emphasizes, in essence, opposition to all forms of darkness and superstition, as exemplified by religion:

Enlightenment was defined as the project of dispelling darkness, fear and superstition. It was the project of removing all the shackles of free enquiry and debate. It opposed the traditional powers and beliefs of the church (branded as ‘superstition’) and raised questions of political legitimacy.

Without plunging the depths of the contrasts and conflicts between the relativism of postmodernism and the centrality in religion (especially in Judeo-Christianity) of an absolute Truth over and above imperfect human reason, it suddenly becomes clear why this sort of generalization about Christianity is so vacuous: the labels are meaningless. If the mainline churches espouse postmodern skepticism, rejecting ideas of absolute truth of divine origin (a characterization not far off, in many cases), then they are no longer Christian in any meaningful sense, other than by name.

Herein lies the source of enormous confusion for our intrepid explorers: you cannot rely on descriptions, like “Christian”, or “fundamentalist”, or “evangelical”, because their meaning has become so amorphous, and they are overlaid with ambiguity and inferences which cripple their utility as vehicles of fact. For example, “fundamentalist” originally referred to Christianity’s emphasis on absolute, transcendent Truth as opposed to relativism. While the specifics of exactly what that Truth entails remains controversial to a degree, even to this day, within Christianity, the fact that there is an absolute truth of divine origin is undisputed in the faith. Yet “fundamentalism” has become a societal codeword for rigid intolerance, ignorance, anti-intellectualism, and even violent repression. It has been linked by common usage to Islamic terrorism, adding additional baggage, though the two religions could not be more different. While many devout Christians acknowledge the fundamentals of belief in absolute truth and Christian doctrine, few today will publicly admit to being a “fundamentalist”. The connotations of the word are too profoundly negative in our modern society.

To understand Christians, or those mysterious Red state middle Americans, you have to get down to individuals, without preconceived notions carried forward from the lofty towers of intellectualism and social theory. The fruits of postmodern relativism and social concepts, detached from the real-life problems and solutions of everyday living — which many understand to require transcendent Truth and reliance on divine strength and guidance — are increasingly seen as empty and destructive by a growing plurality of Americans. It is this, perhaps more than anything else, which divides Red and Blue in America today.

The AMA Conspiracy

Milton Friedman, in his influential work Free to Choose, puts forth the premise that restrictions on medical licensure and the numbers of physicians in training by the AMA is one of the principal reasons for spiraling health care costs and diminishing quality. In a truly free health care market, the consumer would be free to choose from a large number of health care providers – physicians, non-physician health care providers such as nurse practitioners, midwives, chiropractors, and alternative medicine providers. Competition would drive down prices, and those providers with the highest quality and best service would succeed.

While I respect Milton Friedman, and believe in the power the free market, the law of supply and demand only works in a truly unrestricted free market.

American medicine is far more regulated than Soviet state industry ever was. The idea that physicians fees and resulting healthcare costs will magically drop if somehow the AMA loosens up the supply of physicians (which I am not all convinced is done for purely economic reasons, although no fan of the AMA in general — and not a member) is a fantasy. The vast majority of physicians fees are fixed either by federal regulation or contractual agreement with insurance companies. At the same time, physicians are businesses like any other, with rapidly escalating overhead costs which are beginning to bump against their virtually fixed – or falling – receipts. The reasons for this have been well described, and include spiraling malpractice premiums, unfunded federal mandates such as federal compliance and HIPAA, increasing health insurance costs for employee benefits, as well as a relatively scarce pool of highly qualified employees such as nursing and billing specialists. Opening the floodgates of physician supply will not drop prices, since prices are not determined by the usual supply and demand principles, but rather by federal law and an increasingly monolithic health insurance industry.

In my state, Washington, there were over 80 insurance carriers providing health insurance in the late 1980s. There now are three or four. Single insurers now cover huge swaths of the patient market, and therefore physicians have no flexibility to negotiate contracts. Imagine walking away from a bad insurance carrier contract, when 40-50% of your patients are covered under that plan (and will switch doctors if you’re no longer on their plan), and you begin to get the idea. Keep in mind that doctors are currently prohibited from collectively bargaining with insurance carriers under antitrust laws, and you can see how unbalanced the marketplace truly is.

Increasing the supply of physicians would in fact likely result in a rise in healthcare costs, as desperate physicians increase volume in an attempt to compensate for worsening financial viability.

Another myth related to the economic arguments for licensure liberalization is that of alleviating the problem of physician shortages in underserved markets, such as rural America. No offense to folks who live in small towns, but I doubt that physicians will flock to tiny rural villages simply because the AMA lets more doctors be trained. Cities have large populations precisely because they offer greater benefits to those who live there — financial, cultural, convenience, lifestyle. While the urban lifestyle is not for everyone, economics and personal lifestyle preference dictate physician distribution far more than absolute numbers.

Licensure restrictions — while certainly having the potential for conflict of interest and market domination – do in fact serve to standardize quality and predictability of physician care, albeit imperfectly. Anyone who has struggled to figure out who a good physician might be for their particular medical problem can imaging the situation when all bets are off — is the physician you selected adequately trained to bypass your coronary arteries, or remove your brain tumor, or simply a charming, good-looking con man? A low-cost brain surgeon somehow doesn’t sound like such a great bargain. Airline fares would drop, too, if you loosened the license requirements for pilots and flooded the market. No more overpaid pilots. All aboard, anyone?

Further undermining this argument is the fact that a vibrant market in alternative health care already exists. Billions of dollars are spent on remedies, herbs, manipulations, and treatments which are rarely beneficial, often worthless at best or harmful at worst, promoted using misleading advertising or by playing on false hopes or patient desperation (how many weight-loss products are there? How many work?) This is the free market at work, at its best – unregulated, unlicensed, unrestricted, unaccountable. Let the buyer beware.

There is no free lunch. Quality health care is expensive, and requires reasonable regulation — and therefore restriction – of providers to minimize the risks associated with highly complex advanced health care. Conspiracies about the AMA are superficially attractive, but it’s time to look elsewhere for answers to our growing health care crisis.