Medical Technology and Personalized Medicine

I recently watched this NBC clip on advancements in medical technology, which demonstrated the capacity that doctors now have to remotely monitor patients and the expanding role of continuous data collection in personalized medicine. The segment suggests that technology can be used to increase efficiency, decrease costs, and improve the doctor-patient relationship. But the segment also made me wonder how widespread use of this technology would impact our societal conception of health. Would our desire to improve our health turn us into lifelong patients, reliant on data for our decision-making? Would we develop a false sense of control, and blame ourselves for any negative outcomes? At what point does preventing disease impede peoples' ability to live happy, fulfilling lives -- the very goal of medicine in the first place? Personally, though I'd like a diabetic to know what foods cause their insulin to spike and how to appropriately manage their disease, I'm not convinced that continual monitoring would empower them to manage their disease with peace of mind. And I don't consider "healthy" to be synonymous with making decisions based on medical data, since data cannot include so many of the factors that are essential to health -- including doing what makes you feel fulfilled and happy.

The segment also mentioned personalized medicine as the best approach to patient care, and described the current approach as one in which people are viewed as cattle, assessed and treated the same way despite individual differences. Though I sympathize with this sentiment, and like viewing each individual as just that -- an individual -- the most strategic way of approaching medical treatment is by researching how it works on a population level and beginning patient treatments based on these results. To treat everyone uniquely would also mean treating them arbitrarily; there's no way of drawing conclusive results with a sample size of one.

The Ethics of Free Clinics

At visits to medical schools during the application process last year, every school mentioned that they had free clinics. These clinics were touted as places of learning, offering medical students clinical experience dealing with a tough patient population. No one took a patient-centered approach to describing the clinics' benefits, which made me wonder just how great the clinics were for the uninsured.

The exception to this was one very frank conversation I had with a resident interviewer. He had started the free clinic at the school as a medical student there, and when I asked about how they operated he shared with me its benefits and draw backs. The organizational structure of the clinic was thoughtfully done and seemed to maximize good: the clinic had connections with local hospitals and could easily refer patients for specialty treatment as needed, and they had the resources to set eligible patients up with health insurance. But we both agreed that the need for free clinics in the first place was a problem.

I chose the medical school I now attend for many reasons, one of which was the student involvement in service projects. Virtually everyone volunteers at a free clinic, which I saw as an indication of student engagement with the needs of the community. During orientation all the first years went through an orientation program for volunteering at the clinics where we learned how to take a patient history, measure blood pressure, and administer a vaccine, and soon afterward my classmates began volunteering.

However, again the approach was medical student centered: we were encouraged to volunteer in order to learn, a reasoning that surely has truth but also conceives of the patients as practice specimens. Rather than the clinics being places of service, where students dedicated themselves to caring for the Chicago community, they felt like an extension of the curriculum.

I soon realized that I wasn't alone in having trepidations about volunteering at the clinics. One of my classmates expressed a similar discomfort, and we soon had a class-wide discussion about the ethics of the clinics. Those who had already volunteered expressed concerns: it's difficult to find doctors to volunteer so there isn't always adequate supervision; and our training wasn't sufficient to make us comfortable dealing with patients' multi-faceted medical problems. Others were more certain of the clinic's benefits: some care is better than no care; supervision is typically adequate; no one feels totally comfortable meeting with patients at first regardless of circumstance; medical students can't offer healthcare but we can listen, and that makes a positive difference;  and we can be educators for patients who are misinformed.

My initial qualms were related to how the clinics were approached, but once the perspective shifted to a patient-centered one, I still didn't feel comfortable with the rationale being used to justify our involvement. Is discovering patients' health problems beneficial without the capacity to appropriately respond to their subsequent needs? (I don't think so.) Though listening is indeed therapeutic, are we using this reasoning to justify our involvement in a system that perpetuates inequality? (To a certain extent, yes.) Are all the student volunteers knowledgable enough to educate patients on relevant topics? (I know I'm not.)

Despite all this, I still see a role for free clinics in our current healthcare system. Whatever the status quo may be, it is certainly possible to create a clinic that offers excellent care to the uninsured. A place where patients eligible for Medicare and Medicaid are aided in applying for and accessing services, where patients can find educational programs and assistance with psychosocial issues, and where diagnoses are follow up with high quality medical treatment. Until these same patients can access the same services as everyone else, that's the best we can offer.

Ultimately this is about a person's right to healthcare -- something that I didn't feel the true importance of until recently. Being poor, or homeless, or undocumented -- these are circumstances that no one would wish for; circumstances that often occur despite someone's best efforts to avoid them. And when anyone in our community is suffering, everyone suffers. When one person is too sick to work, but shows up anyway because they can't afford not to, her fellow employees and customers get sick. When one person is too downtrodden to keep a consistent job, our economy suffers. And when one person is ignored, his troubles accumulate until we are forced to contend with them -- and at that point, it's often too late.

Offering someone healthcare doesn't mean getting them access to prescriptions and medical treatment -- although that's part of it. It means offering everyone the chance to lead a healthy life. As we work to find a successful model of healthcare delivery, I hope that we will avoid using our energy to make judgements on who is deserving of our care, and instead focus on how to best foster a healthy, vibrant community.

Questioning the Price of Care

Why do hospitals argue that they need certain more profitable departments (like cardiology) in order to compensate for other money-losing departments? Why do doctors have an incentive to order one type of treatment over another? Since physicians and hospitals are reimbursed on a fee-per-service basis according to the cost of treatment, if the reimbursement rates are accurate no such discrepancies in profit gain should exist. But they do – in part because of the difficulty of determining accurate, generalizable prices for procedures, but also because of the competition for money between different specialties. Here I’d like to examine how Medicare Fee-for-Service rates are set for freestanding medical centers, as a way of offering insight into the distortions in price involved in the health care market.

Reimbursement rates are established by the Center for Medicare and Medicaid Services (CMS), which voluntarily relies on the American Medical Association’s (AMA’s) Relative Value Scale Update Committee (RUC) to determine the costs associated with each procedure. The RUC is made up of about 30 representatives of different medical specialties – the idea being that no one interest dominates and the group remains neutral overall. They collectively agree upon pricing based on physician surveys (audited by government-appointed consulting firms) and invoices (or other concrete evidence of costs, like salary). Beyond the cost of medical equipment, variable inputs like the amount of time a machine is used per patient and the number of medical staff involved in the administration of a treatment influence the cost estimation considerably – which is why the physician surveys are important. Once proposed rates are established, a “notice and comment” period begins for comment letters to be submitted. After these are reviewed, a final rule is determined, which becomes the Medicare Physician Fee Schedule.

In an ideal world, the cost of delivering care would be equal to the reimbursement rate in every case -- and patients would know the costs prior to deciding on treatments. But there is variability in cost even between patients receiving the same care at the same hospital, let alone different patients at different hospitals. Different machines, different numbers of hospital staff, different procedure times. Given the high price of medical technology and hospital staff, inaccurate estimation of any of these variables has a large impact on the cost to the hospital.

And there are a number of signs that these estimations are far from accurate. Rates typically increase with each annual reevaluation by the CMS, despite the fact that new procedures become more efficient with time. To ensure that the CMS spending doesn't increase more quickly than GDP, the Medicare Sustainable Growth Rate (SGR) is used to control spending. When the CMS sends an annual report to the Medicare Payment Advisory Commission (a group that advises the U.S. Congress on the previous year's total and target spending), the report has a conversion factor which is used to change reimbursement rates across the board in the coming year, such that they meet the target sustainable growth rate. As a result, reimbursements calculated from survey data and direct price inputs are typically cut in half across the board. If these rate calculations were accurate,  everyone would be reimbursed half of their actual costs and everyone would go out of business.

Whether intentional or not, certain specialties have done a particularly good job of inflating their costs in these calculations, such that some departments are overpaid. It is far harder to inflate the cost of annual physicals relative to that of cardiac surgery, for example, which involves ever-evolving technologies and techniques. With larger discrepancies in profit margins, physicians are more tempted to suggest the more expensive procedures, even when a cheaper procedure (or no treatment at all) may arguably be more beneficial. This is exactly what doctors were accused of in 2011, when urologists came under scrutiny for sending patients for radiation at centers where they had financial interests. These expensive radiation treatments were reimbursed at a high price, making them unreasonably profitable. 

But these updates to the fee schedule have yet to be implemented in the 16 years since the SGR was enacted by the Balanced Budget Act. Every year since 2002, with pressure from the American Medical Association and other physician groups, Congress suspends the updates, allowing spending to increase at a rate greater than the growth in GDP. This year the cost to overriding the updates was approximately $30 billion, paid for by hospitals and some Medicaid payments.

In a recent New York Times Op-Ed, Bill Keller underlines the importance of decreasing the cost of health care by cutting prices -- not through across the board cuts, but through effective bargaining. He accurately states that the most significant factor in our inflated health care costs “is that our system charges far more for each service – each office visit, each hip replacement, each day in a hospital bed, each dose of antibiotic” than other countries. As a result, we get the same amount of care for almost double the cost: though Americans “spend more than twice as much per capita as other developed countries on health care – a crippling 18 percent of the country’s economic output, and growing,” the volume of services provided are “not much different from other developed countries.” He cites our inability to bargain prices down as the main culprit – a problem he thinks we could fix by having one big payer (like the government or large hospitals).

Another solution that has been proposed is to bundle payments based on risk group. This would work well alongside Michael Porter's vision of health care, in which hospital departments are structured around disease groups rather than specialty. In this model, rather than having separate departments for Surgery, Radiation Oncology, and Medical Oncology there would be one department for patients with tumors in the Central Nervous System in which Neurosurgeons, and Medical Oncologists and Radiation Oncologists specializing in CNS saw patients together, attended relevant lectures, and met regularly to review cases. (Porter also argues that there should be less redundancy such that MGH and the Brigham and Women's Hospital shouldn't both have the same departments, although this assumes that better care would result from physicians collaborating in the same workplace rather than competing with each other for resources and patients.) In the primary care setting, this could mean physicians working alongside social workers, nutritionists, nurses, and others, each contributing their expertise in order to deliver high quality care.

Though having more people involved may seem more expensive (and it may be initially), the positive health care outcomes over time would more than pay for the costs. This structure would also allow primary care doctors to spend more of their time as leaders overseeing patient care, rather than trying to individually address the many factors (social, economic, etc) contributing to each patient's health in a brief office visit. I like the sound of that!

References:

Benjamin Falit, "The 2013 Medicare Physician Fee Schedule's Treatment of IMRT/SBRT: How we got there and Future Alternatives," (2012).

Robert Stein, "Doctor-owned centers spark criticism, scrutiny," The Washington Post, February 28, 2011.