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Physicians and the Business & Professional Community
Restoring Accountability in HealthCare & Medical Practice
Tuesday, August 13, 2002
Are Variations in HealthCare Bad?
The New York Times reported last week on the “unexpected” findings of a Dartmouth study which showed that people in Miami cost twice as much in Medicare funds as the patients in Minneapolis. They couldn’t understand why people in Miami went to a doctor up to six times as often and to the hospital twice as often as the people in Minneapolis. They attributed this to the fact that there are more specialists available in Miami, which then is construed as bad. The AMA complimented the excellence of the scientists and felt cultural preferences and underlying health were also factors. The Institute for HealthCare Improvement in Boston stated that if you want to predict the amount of HealthCare use, you just have to know the HealthCare supply. The implied correction was to police and limit the supply of doctors, health personnel and facilities in order to decrease costs.
John C Goodman, in his recent volume on “The American Experience with Managed Care” (www.ncpa.org) cites the RAND researchers who found wide variations in 123 medical procedures for Medicare patients in various parts of the country. He noted that RAND convened a panel of experts to judge the appropriateness of three of these procedures. Although the panel judged a fifth of the cases as inappropriate and unnecessary, they neglected to consult the medical literature. Once the experts were convened, they were far less unified than media reports suggested. The panel desired consensus and pressured members to change their minds. By showing the results when 7 of 9 agreed, Goodman found only 12 percent of the procedures were deemed inappropriate, not 22 percent as the report suggested. Goodman felt that the most remarkable fact about the RAND study was that even with all of those efforts to arrive at a definitive judgment, 7 of 9 experts agreed less than half the time that the procedures were either definitely appropriate or definitely inappropriate. Others have found the same variations of care in Canada despite the regimentation of its Medicare. Anecdotal information from colleagues in UK and Europe suggests similar variations. Protocols and practice guidelines have not changed this characteristic of practice.
Can Deviations from the Standard
Sometime be a Higher Level of Care?
In the 1950s and 1960s, medical students were taught never to give penicillin, with its risks of anaphylaxis, for a sore throat unless Streptococcus infection was first documented to justify these risks. However, missing a Strep throat could cause rheumatic heart disease (RHD) and renal disease as a long term consequence. I remember an attending staff physician during my internship stating that the GP’s disregarded this and gave penicillin, perhaps somewhat indiscriminately, to most patients with a sore throat and essentially wiped out rheumatic valvular heart disease. Furthermore, many patients were unwilling to pay $40 for a throat culture before the $5 penicillin shot. Thus inappropriate care in going against what an expert panel would have recommended, was felt to be appropriate care in the personal physician’s view of the patient’s long term risk/benefit interest.
Variations in Care can also be
Not to be overlooked is the fact that if one million patients would have developed RHD and required a mitral valvuloplasty (open heart surgery), at a cost of more than $100,000 (Sacramento rates), that is a $100 billion cost savings that inappropriate health care may have provided over appropriate health care.
Variations in Care are Actually a
Normal Process and may Reflect Progress
As a pulmonary consultant, my associates and I have seen more than 27,000 pulmonary consultations over thirty years from a variety of primary care physicians. The variations in primary care are almost unbelievable at first glance. Some of my pulmonary colleagues have labeled family doctors as providing poor or even detrimental health care. The referring physicians, however, represent several generations of medical care which is in a dynamic state. Some have stated that when the current class of residents have completed their training, the entering freshman in medical school will have a curriculum that has changed about 50 percent during that 8 years. Hence, with medical knowledge advancing and changing so rapidly, a medical generation has frequently been defined as about 8 years. My referring physicians represent approximately five medical generations. Approaching it from this point of view, I’m amazed at the industriousness of physicians to keep up with these changes. As a consultant, my job is to add to the level of care of the patient referred, which in turn further improves the level of care the referring physician gives, which by extension increases the level of care in his entire practice. I feel this approach has improved the quality of care more effectively than medical protocols and practice guidelines which reduces to rote what should be an intellectual process. If any feel that they can obtain better health care in any other country of the world, I have enough friends to provide a one way ticket to that country with two caveats: They must give up their American Passport and Citizenship permanently. They can never return to live in this country. If they return even for health care, they would have to pay a 10-fold reimbursement.
Committee or Expert Panel Medicine is
During my pulmonary fellowship, Professor Robert Greene of the University of Michigan remarked that much of tuberculosis care was run by committees and committee medicine was generally poor medicine. He stated that patients needed a personal physician who was the sole determinant of their treatment. Exposure to the various members of the Chest Conference was an important medical exercise, but it was for the benefit of the physicians and by extension to the patient, not directly to the patient. This was dramatized to me in my rotation through Weimar Medical Center, a TB Sanatorium, during my training when I saw committee medicine in action. The committee had different members present for the weekly meetings. If the driving forces of one week were absent the next week, the recommendations were vastly different. If the committee was actually writing the doctor’s orders, the weekly changes would affect patient therapy directly, which could have been disastrous in many cases. The personal physician being in charge was critical to appropriate focused comprehensive care.
Variations in Medical Practice may
lead to a Higher Quality of Care
Unfortunately no one in the Dartmouth or in the RAND study could see that if this variation occurs in an open Medical MarketPlace, there isn’t any problem. If the people in Miami want to spend twice as much on their HealthCare, they should be free to do so as long as they are not using other people’s money, whether taxpayers’ or premium payers’ funds. The problem is that in a highly regulated HealthCare environment, every variation impacts on someone else’s freedom of choice. If HealthCare functioned in an open Medical MarketPlace, the self correcting forces would allow for individual or cultural or geographic differences to occur without using funds obtained from premium payers or taxpayers. If some are very frugal in what they purchase for themselves, isn’t it highly unethical for others to utilize their premiums or tax dollars to purchase health benefits that others consider unnecessary or even extravagant? Haven’t we all had patients where no matter how much we spent on their behalf, it was never enough in their estimation?
At the University of California at Davis medical grand rounds last week, Faith Fitzgerald, MD, MACP, gave a masterful Clinical Pathologic Conference (CPC) discussion on a very challenging disease process. The auditorium was filled with residents, interns, staff physicians and clinical faculty members from the community overflowing into the hallways, aisles, and sitting on the floor in front of the first row. I see many of my referring family doctors present for this weekly conference on Thursday mornings as well as the Grand Rounds at Mercy San Juan Medical Center, my primary hospital, on Friday noon. That’s eighty hours of continuing medical education before our yearly medical and specialty conventions. What other profession has this thirst for knowledge and desire to keep current with modern medical advances? Certainly not the MBAs, CPAs, Actuaries, and bureaucrats that keep telling us we’re doing all of this wrong. The personal physician, with the breadth of knowledge and the depth of decades of experience over five generations of medical care, is still the patient’s best deal in health care. It is also superior to the physician assistants and allied health personnel who are treating patients by rote according to protocols and guidelines.
The Medical MarketPlace
MedicalTuesday recommends the Greg Scandlen Health Policy Comments as a serious exposition of market based medicine. You may log on to NCPA (www.ncpa.org) and register to received Greg’s weekly report. In the last issue we quoted Lew Rockwell, president of the Ludwig von Mises institute. Please log on at www.mises.org for some great reports on market medicine. Also log on to Lew’s premier free market site at www.lewrockwell.com.
MedicalTuesday recognizes HealIndiana as a supporter of market based medicine. Visit their website at www.HealIndiana.org. You will be able to informally meet Kim West, Executive Director, & Christopher Jones, MD, President, at the annual meeting of the Association of American Physicians and Surgeons in Tucson on September 18-21, 2002. You may register on the AAPS site at www.AAPSOnline.org. This meeting will also feature Ann Coulter, JD, who will sign her recent book, Slander, and give an address on Big Brother and the Future of Medicine; Wesley Smith, MD, who wrote Culture of Death and Forced Exit, will speak on the New Bioethics; Lawrence Stratton, JD, coauthor of The Tyranny of Good Intentions, will speak on the New System of Justice and Its Impact on Medical Ethics. The AAPS is probably the only remaining medical practice organization that totally supports market based private practice.
Tuesdays were the evenings that doctors formerly met to eat together, get to know each other as colleagues, share ideas, and obtain and discuss the latest medical information. (Mondays and Fridays are busy days in any practice. Wednesdays or Thursdays, doctors took a half day of compensation time off. Hence, Tuesdays were the logical days for get-togethers) With the advent of administrators and others who became proactive in telling doctors how to practice medicine, these meetings were deemed to be counterproductive to the mission of managed care or single-payer medicine. The meetings essentially disappeared.
MedicalTuesday will now become our nationwide and global network using the advantages of the electronic age to restore our colleagueal relationships and reestablish the doctor-patient relationship as our primary function and loyalty; by dialogue and discussion it will ward off those who wish to reduce the quality of healthcare under the guise of control and quality improvement. Send your ideas and anecdotes to Info@MedicalTuesday.net
Stay Tuned to the MedicalTuesday.Network twice a month and have your business and professional friends do likewise. This message reaches the Physicians and the interested Business/Professional community in 15 states, 10 countries, on 5 continents. Each person was either personally known, requested to be placed on our mailing list, or was recommended as someone interested in our cause of making HealthCare affordable to all. If this is not correct or you’re not interested in or sympathetic to a Private Personal HealthCare system, send an email to me at DelMeyer@MedicalTuesday.net and we will sorrowfully removed your name.
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Del Meyer, MD