A NYT op-ed the other day,”How Medical Care Is Being Corrupted” (by Pamela Hartzband and Jerome Groopman, physicians on the faculty of Harvard Medical School), gives a good sum-up of what I fear is becoming the new normal, even under so-called “personalized medicine”.
“It is obsolete for the doctor to approach each patient strictly as an individual; medical decisions should be made on the basis of what is best for the population as a whole.”
Remember that when they tell you you’re getting your very own, individualized, custom-tailored, personalized medicine!
I see a future role for independent experts in medicine and medical statistics to whom individuals and consumer groups could turn to get the real scoop, as well as to critically assess the statistics of any clinical trials that bear upon their treatment decisions.(Remember the Potti case.) No wonder I hear of so many doctors getting out of the field. Perhaps some of them,along with interested medical statisticians, can put out their shingle for a company of advisors. I don’t see this as far-fetched [i]
Here’s the main article
WHEN we are patients, we want our doctors to make recommendations that are in our best interests as individuals. As physicians, we strive to do the same for our patients.
But financial forces largely hidden from the public are beginning to corrupt care and undermine the bond of trust between doctors and patients. Insurers, hospital networks and regulatory groups have put in place both rewards and punishments that can powerfully influence your doctor’s decisions.
Contracts for medical care that incorporate “pay for performance” direct physicians to meet strict metrics for testing and treatment. These metrics are population-based and generic, and do not take into account the individual characteristics and preferences of the patient or differing expert opinions on optimal practice.
For example, doctors are rewarded for keeping their patients’ cholesterol and blood pressure below certain target levels. For some patients, this is good medicine, but for others the benefits may not outweigh the risks. Treatment with drugs such as statins can cause significant side effects, including muscle pain and increased risk of diabetes. Blood-pressure therapy to meet an imposed target may lead to increased falls and fractures in older patients.
Physicians who meet their designated targets are not only rewarded with a bonus from the insurer but are also given high ratings on insurer websites. Physicians who deviate from such metrics are financially penalized through lower payments and are publicly shamed, listed on insurer websites in a lower tier. Further, their patients may be required to pay higher co-payments.
These measures are clearly designed to coerce physicians to comply with the metrics. Thus doctors may feel pressured to withhold treatment that they feel is required or feel forced to recommend treatment whose risks may outweigh benefits.
It is not just treatment targets but also the particular medications to be used that are now often dictated by insurers. Commonly this is done by assigning a larger co-payment to certain drugs, a negative incentive for patients to choose higher-cost medications. But now some insurers are offering a positive financial incentive directly to physicians to use specific medications. For example, WellPoint, one of the largest private payers for health care, recently outlined designated treatment pathways for cancer and announced that it would pay physicians an incentive of $350 per month per patient treated on the designated pathway.
This has raised concern in the oncology community because there is considerable debate among experts about what is optimal. Dr. Margaret A. Tempero of the National Comprehensive Cancer Network observed that every day oncologists saw patients for whom deviation from treatment guidelines made sense: “Will oncologists be reluctant to make these decisions because of an adverse effects on payments?” Further, some health care networks limit the ability of a patient to get a second opinion by going outside the network. The patient is financially penalized with large co-payments or no coverage at all. Additionally, the physician who refers the patient out of network risks censure from the network administration.
When a patient asks “Is this treatment right for me?” the doctor faces a potential moral dilemma. How should he answer if the response is to his personal detriment? Some health policy experts suggest that there is no moral dilemma. They argue that it is obsolete for the doctor to approach each patient strictly as an individual; medical decisions should be made on the basis of what is best for the population as a whole.
Medicine has been appropriately criticized for its past paternalism, where doctors imposed their views on the patient. In recent years, however, the balance of power has shifted away from the physician to the patient, in large part because of access to clinical information on the web.
In truth, the power belongs to the insurers and regulators that control payment. There is now a new paternalism, largely invisible to the public, diminishing the autonomy of both doctor and patient.
In 2010, Congress passed the Physician Payments Sunshine Act to address potential conflicts of interest by making physician financial ties to pharmaceutical and device companies public on a federal website. We propose a similar public website to reveal the hidden coercive forces that may specify treatments and limit choices through pressures on the doctor.
Medical care is not just another marketplace commodity. Physicians should never have an incentive to override the best interests of their patients.
Error Statistics Philosophy 
The same pressures exist everywhere, but they seem to be much worse in the USA. where health care costs twice as much as in the UK (for which you get shorter life expectancy). The problems of over medicalisation, over-prescribing and excessive testing are, unsurprisingly, worse when the prescriber makes money from them.
The other side of the coin is that much talk about personalised medicine is pie in the sky. Even for whole populations, it has proved very hard to define the risk-benefit ratio for very highly-prescribed things like statins and anti-depressants (probably because the benefits are quite small). The problems of sub-group analysis make personalisation very hard. Genomic analysis has had very limited success so far.
The problem for personalised medicine is that, with a few exceptions, the knowledge doesn’t exist to do it. Likewise, prevention is undoubtedly better than cure, or it would be if we knew how to prevent things. Apart from vaccines, we usually don’t. Most of the rest depends on dubious and ever-changing dietary advice based on observational data (e.g http://www.dcscience.net/?p=6300 ).
None of this detracts from the value of a physician who thinks about caring when, as so often, they can’t cure.
It is undoubtedly essential that patients should be aware of how their physician makes money. Some have subscribed to http://www.nofreelunch.org/index.htm But not enough. The ultimate irony is that medicine, the caring profession, has become one of the most corrupt.
Hi David: Drug salesmen have been around forever, what I’m alluding to now are things like policy determinations of aggregate statistical goals, then translated into what’s best for “you”. I’ve had enough discussions with my doctor of many years on matters of philosophy of statistics that he generally lets the cat out of the bag. The next generation of doctors will be trained on groupthink. Individuals can rarely get the information needed to challenge recommendations. I don’t think the idea of private medical advocates is so far-fetched. They’d have to be independently certified in some manner.
I wonder what this new motto does for the “first do no harm” pledge: Will it become “no harm to the population, as computed by one of many max-utilitarian cost-benefit algorithms?”
Let me be clear, there ARE considerations that can’t avoid and should take into account what is best for the population as a whole (e.g., quarantines), but those are not the cases being discussed in the article.
> aggregate statistical goals, then translated into what’s best for “you”
But we only get evidence for aggregates of individuals, even that pie in the sky (so far) personalized genomics medicine will be at some level of aggregation.
Now what to make of and how to act on that available aggregate level of evidence is never very clear and so we need really smart groups of people to help sort that out.
Its almost never a individual clinician on their own. Certainly we don’t want those groups to have the wrong incentives and we do want them to have competition (i.e. critical review, second opinions). Managing health care is incredibly difficult to get less wrong.
There are massive amounts of publicly available drug development data from the FDA as well as a vast array of publicly funded published study data (here some think most of that is misleading) that one can try to make sense of. The idea of a clinician on her own being able to make the best decision for an individual patient, if it ever made sense, does not today.
Keith: But the point here is that there are situations where the doctor knows or has excellent evidence for some preferred treatment and yet because it runs counter to the aggregate recommendations, may be pressured to go against it.
The issue is the tension that arises between competing masters. My doctor always tells me when this is so—he’s a maverick–and admits he might get a less good grade for doing what’s right for the patient. Future doctors will likely be more robotic, if they are not robots altogether.
Medical care in the USA is already corrupted – this is exactly why we needed the Patient Protection and Affordable Care Act, before America ran into the economic ditch that overpriced medicine was driving us towards. Excessive drug prices, overstocked hospitals, and 40 million uninsured Americans unable to access any of it until they have to go to an emergency room with advanced disease is no way to ethically care for a large group of people. It doesn’t work financially either.
Doctors have been coerced to modify their practices for centuries. Snake oil sales and the like have been legislated against, and we now have the Food and Drug Administration and other agencies to oversee some kind of sensible delivery of medicine.
It is really unclear to me from this opinion piece as to what these two doctors are complaining about. I think they are just nervous and confused by the necessary changes coming into place.
A current problem in American health care delivery is that it is remunerated on a fee-for-service basis, so doctors and medical supply businesses make more money by prescribing more services and products, not by improving public health. This is one of the reasons prevention is so poorly performed in America. Businesses don’t want a Surgeon General telling people not to smoke, or not to eat piles of edible food-like products heavily laden with high-fructose corn syrup – they just want a drug to be available to cure whatever mischief the cigarettes and sugar cause. Just look at how much lung cancer research goes on at Duke University, an institution built with tobacco profits. And notice that we don’t even have a Surgeon General at present, thanks to corporate funded politicians holding up any appointment.
So one of the lessons learned in comparing health care delivery in the USA versus so many other countries with far lower per-capita medical costs is that these other countries pay doctors a base salary, plus some bonuses for positive results across groups of patients, the “pay for performance” these op-ed authors are so concerned about. Health outcomes and cost metrics in other countries clearly show that pay for performance yields better outcomes than pay for service, so such provisions were worked into the Affordable Care Act and we can begin to see these appearing in practice, as noticed by these op-ed authors.
The outcome of an individual patient’s treatment yields an anecdote, not information that can improve outcomes for many people. This is why randomized clinical trials work, and are necessary. Evidence across large numbers of people is the only reasonable way to judge whether medical progress is being made.
I love the last sentence of the Op-Ed: “Medical care is not just another marketplace commodity”. Of course it is – did these two Op-Ed authors not notice how well they are doing financially in America? Does their hospital take in anyone off the street and provide service for free? The problem in the USA is that medical delivery has been a marketplace pushed by its industry leaders to make double digit profits over the last several decades – even the Affordable Care Act only restricts the insurance marketeers to 20% profit, with mandated rebates required if this cap is exceeded, which happened regularly in years past, often well above 20%. That’s the real corruption in American health care delivery. Human health should be a non-profit endeavour, as it is in many other countries. Making piles of money off of human suffering is truly corrupt.
Steven: There’s a difference between using aggregate information from RCTs and insisting your patients have an aggregate value on some measure when doing so requires them to take other drugs that may have negative side-effects. That’s the point of the article. It’s the tension between following a course of treatment known to be less good for patient X so that a doctor’s overall numbers on one preferred measure–picked by the issuance company/regulator– attains some cut-off value. As if they even know in many cases whether lowering the particular aggregate is a definite good–we are always hearing of reversals (and remember, costs are taken into account). And think of them insisting on continuing to use morcellators in hysterectomies to save time, even after it was evident that it spread hidden cancer, putting the patient in Stage 4 cancer immediately. (Largely ended, only recently, and only because of an outspoken critic who refused to be shut up.)
http://www.medscape.com/viewarticle/831267#vp_1
Doctors already hand out excessive drugs to patients that have negative side effects – witness the current heroin epidemic spawned by excessive prescribing of oxyconton and relatives. Doctors have overprescribed antibiotics for decades. They are incentivized to do so via several mechanisms that need addressing. Doctors can hold stock in drug companies so have a conflict of interest when prescribing certain medications. This is why pay for performance is preferable to pay for service. Doctors should earn a bit more salary when many of their patients do better in terms of measurable health outcomes. A doctor who successfully institutes prevention manoeuvres that yield measurable health improvements will make little money in a fee for service payment model, but will do well in a fee for performance model.
Nobody makes a doctor give a patient a treatment that the patient does not want or has problems tolerating. Even on RCTs, a patient who reacts badly to meds is taken off the meds (though proper intent-to-treat analysis will record that patient on the treatment arm of the study). A doctor may decide to give a patient an untoward treatment because of certain perverse incentives, in which case those incentives need to be addressed. That’s part of what is happening now.
We can’t just base all of a doctor’s pay on the doctor just showing up and prescribing snake oil at an exorbitant cost. Doctors are just people after all, subject to influence, and we need to set up influences that yield measurable improvements in health across the population served. There will always be doctors willing to take money from rich people to do just about any kind of treatment, Michael Jackson provides a recent example. But for the rest of us getting by on modest incomes, we have to figure out how to implement health care delivery that gets better performance from our limited resources. Better incentives than drug company stock profits and visits by pharma-babes are needed. This is why Cuba, which spends something like 300 dollars per person annually on health care, works so hard at prevention, and achieves many health outcomes at levels similar to those seen in the USA where we spend thousands of dollars per person annually. They have few resources, and prevention is generally cheap to implement and deliver.
The power morcellator issue is quite a conundrum. Early adoption of the procedure showed promise because there was a measurable drop in complications and infections since the procedure is less invasive. The tragic consequence of a small number of women having a contained cancer spread about presents a moral dilemma indeed. Do more women need to die of infection so that fewer die of stage 4 cancer? This is similar to the conundrum for prostate cancer in males. Do you perform more prostatectomies to save a few men from stage 4 prostate cancer, while killing other men via infection and other complications when those men would have lived just fine with an indolent prostate tumour? PSA tests and excessive use of prostatectomy surgery are currently being re-examined, with opinion generally shifting to a strategy of watchful waiting for more men with prostate lumps. Similar re-examination is now starting with the power morcellator issue.
Unless they can do a MUCH better job of testing for cancer ahead of time, or if the women is quite young and is clear about the morcellator risks,I say “never” to power morcellators to remove fibroids/hysterectomies.I hope they do a detailed study of how many women were given stage 4 cancer over the past x years.