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.

For-Profit Hospitals

Readers’ comments online regarding The New York Times article, “A Giant Hospital Chain Is Blazing a Profit Trail” (Creswell and Abelson) express disgust at HCA’s prioritization of financial gain. However, given that all health care facilities struggle with the often competing demands of serving patients and generating revenue, I’d like to dedicate this post to examining more closely just what I find problematic with HCA’s approach and how it compares to the other hospitals' practices.

First, there’s the concern that profit-seeking will continually come at the expense of patient care. Patients have been wrongly screened out; those who are admitted have been treated inappropriately as doctors make decisions based on what will generate hospital profits (e.g. ordering unnecessary cardiac surgeries); and these instances have given people reason to question HCA’s priorities. HCA appears to be giving improper attention to customers presumed to not be “profitable,” and is willing to cut corners, safe in the knowledge that even if negative outcomes result the money lost in settlements will be more than repaid in profits. Both of these problems have been true of businesses in other industries as well. When I’m at a restaurant, waiters often notice my age (and my standard “just water for now”) and proceed to be inattentive to me for the remainder of the meal, seeking out their big tips elsewhere. (My friends and acquaintances have described similar treatment, which anecdotally suggests that I don’t just happen to frequent snooty restaurants or to have a particularly unfortunate rapport with waiters.) And Walmart has been a frequent recipient of allegations regarding bribery, corruption, discrimination, employing illegal immigrants, overtime, gender bias, and destruction of evidence. Though having an inattentive waiter isn’t life-threatening, having an inattentive nurse is. And though Walmart’s unethical actions have had a negative impact on thousands of employees, they haven’t led to significant physical damage or death. Government officials can attempt to hold businesses accountable, but if their attempts come too late in the case of HCA people’s lives are at stake in a way that is unparalleled in other industries.

Then there’s the added problem of HCA leadership associating success with instating effective regulations, requiring its employees to move away from making independent judgments in favor of compliance. HCA leadership consists of members of the Board of Directors, whose members also serve on the Audit & Compliance, Compensation, Nominating & Corporate Governance, and Patient Safety & Quality Committees respectively, and only one of whom holds an M.D. (Stockholders also get to approve how these Committees are structured.) Regulations are inherent in the legal framework that dominates the health care industry, and most hospitals are governed by an administration of non-M.D.s. However, at HCA the policies are more clearly aimed at efficiency and profit gain: they have used a successful ad campaign to increase their number of clientele, serve only those who can pay, and keep operating costs to a minimum. From the perspective of these board members, further success depends upon emergency room doctors following screening policies more consistently rather than overriding them; nurses increasing their efficiency in order to meet quality expectations with minimal staffing; and all employees working toward meeting hospital-defined targets. Patients too will have to give up their desire to be treated as unique individuals in favor of being lumped into categories based on diagnosis. These measures appear practical, but frustrate health care professionals who want to treat patients their way (a way often based on knowledge and varying amounts of personal experience) and patients who want personalized treatment. Some may equate these frustrations with self-centered stubbornness on the part of physicians, and excessive neediness in patients. But health care is complicated, and it’s hard to trust that all its nuances can be appropriately responded to by following protocols.

A related problem is the business model: HCA’s decisions are made without input from its employees, and its large profits aren’t felt equally by all its employees either.

In the December 2011 edition of Harvard Business Review, the cover article was about Morning Star, a large producer of the canned diced tomatoes and tomato paste found in cafeterias, schools, and businesses across the United States. Written by Gary Hamel, “First, Let’s Fire All the Managers” describes how the company has achieved success not despite but rather because of its lack of top-down administration. He writes of the inefficiency of a “top-heavy management model that is both cumbersome and costly,” describing how hierarchy “systematically disempowers lower-level employees,” shrinking their “incentive to dream, imagine, and contribute,” (4). At Morning Star, every employee writes a personal mission statement that outlines how he or she will contribute to the company, and negotiates Colleague Letter of Understandings (CLOU) annually with associates who are most affected by his or her work. Though this organization may appear disorderly, it has led to a flexible organization that better reflects the needs of the company—while fostering the personal engagement of employees. Additionally, all employees can issue a purchase order (though colleagues buying similar items meet to maximize buying power) and colleagues are responsible for hiring new staff when they feel overworked. At the end of the year, every employee gives and receives feedback from colleagues and every unit of the business explains its performance to the rest of the businesses; individual pay is dictated by how much value you add to the company. The result is a company with inventive, collaborative employees who take initiative and hold each other accountable, making well-informed and timely decisions that are rarely unilateral.

Hamel’s critique of businesses with a hierarchy of managers is an attack of HCA’s business model—and those of all large hospitals where physicians’ practices are increasingly regulated by hospital administrators. And his description of the “risk of large, calamitous decisions” for businesses with a management hierarchy is particularly significant as it relates to HCA, whose top management includes stockholders like Bain Capital. Morning Star’s business model sounds like a better fit. The medical community has already recognized the importance of collaboration, and doctors are increasingly working as members of teams alongside nurse practitioners, physician assistants, nurses, physical therapists, and social workers. But without an equal stake in the outcomes, and with others dictating protocols and standards of care, there is less incentive for personal investment in the quality of care delivered.

These problems—a lack of focus on quality patient care, overemphasis on adherence to hospital policies, and a top-down administration—aren’t unique to HCA. In a recent article in The New York Times, “Rationing Healthcare More Fairly,” Eduardo Porter described a recent study of hospital emergency rooms in Wisconsin that found that “victims of severe traffic accidents without health insurance got 20 percent less care… [and] the uninsured were 40 percent more likely to die from their injuries,” suggesting that linking hospital services with patients’ ability to pay is not unique to HCA. While at the Brigham and Women’s Hospital this week, I overheard nurses and doctors discussing whether or not to follow a hospital protocol that they deemed unnecessary (they opted not to). And in another recent Times article entitled “Should Hospitals Be Run by Doctors?” Tara Parker-Pope writes: “Among the nearly 6,500 hospitals in the United States, only 235 are run by physician administrators,” despite the fact that findings in the journal of Social Science & Medicine last year found that “overall hospital quality scores were about 25 percent higher when doctors ran the hospital, compared with other hospitals; For cancer care, doctor-run hospitals posted scores 33 percent higher.” I wonder how much higher the same quality scores would be if hospitals were run equally by all members of health care teams.

Questioning HCA’s practices is appropriate and warranted. But the concerns raised cannot be confined to HCA hospitals alone. 

A Response to Atul Gawande's "Big Med"

In Atul Gawande’s latest article for The New Yorker, he writes about the benefits of “Big Medicine,” anticipating that hospitals will increasingly give out medical care to patients as The Cheesecake Factory gives food to customers—efficiently and with high customer satisfaction at a low cost. He rightly notes that medical facilities are moving in this direction, citing Partners Healthcare and its competitors (Care Group and Steward Health Care System) as examples of large healthcare chains overtaking community-based hospitals. And this change makes sense, given that this increase in scale lowers costs while offering hospitals access to the up-to-date (expensive) technology we have come to rely upon. However, patient care would be better improved without the formation of these conglomerates, and without perpetuating our problematic reliance on medical interventions to fix personal, multifaceted problems.

Though Gawande mentions possible problems involved with the growth of large healthcare chains, these significant issues are mentioned only cursorily—and there are still others left unsaid. As he mentions, there is the significant problem of the savings from Big Medicine being reserved for the few, contributing to the ever-widening gap between the rich and the poor. As hospital chains expand, they will gain power over individual health care employees and patients, who will have trouble finding employment opportunities or services elsewhere (should they so desire). And they may want to if employees are treated similarly to the “frontline worker” Gawande mentions, who follows exact orders—creating the successful outcomes he touts—without reaping any of the financial benefits.

Having set standards of care, and people like Christina Monti (the Steward tele-I.C.U. nurse) checking in to make sure they are followed, is more than an annoyance; it may change the way health care professionals think for the worse. In “Don’t Fear The Cybermind,” a recent New York Times opinion piece, Daniel Wegner (professor of psychology at Harvard) explains how human minds remember only information that they alone are responsible for: his wife remembers where house things are while he remembers where care and yard things are, and they rely on each other to fill in individual deficits. He uses this evidence to describe how our computing devices help us to specialize, rather than hampering our capacity for storing information. But I wonder how it applies to jobs in which people are intently supervised. If doctors know someone else is checking to make sure everything is done properly, will they (intentionally or not) be less diligent and more careless? Who will ultimately take responsibility for ensuring patients are tended to? While having safety checks in place is a good thing (especially in vulnerable patients), if they come at the expense of initiative and thoughtfulness in those personally administering the care, they aren’t serving their purpose.

More important than hiring outside administrators to ensure procedures are followed is determining what mistakes are being made, and preventing them. If the issue is one of attentiveness, one fix would be to follow the advice outlined in Gawande’s The Checklist Manifesto: How to Get Things Right: have every employee write down a list of tasks to complete before, during, and after entering a patient’s room (a list that could be evaluated and updated at set intervals to ensure that it was up to date). If long term problems are due to employees avoiding inconveniences in place of caring for patients (another problem Gawande mentions), then employee training and workplace culture must be altered considerably.

The incentive to adapt and improve practices would be much stronger if patients could make informed decisions regarding where they sought care, and took responsibility for their own health. For example, what if patients had access to information regarding the possible hospitals and doctors they could visit prior to making an appointment? People other than Gawande’s mother should be able to select a talented doctor that matches their needs. Granted, the information sharing would have to be done carefully, so as not to unjustly inflate the successes of physicians practicing in wealthy areas on patients with fewer concurrent issues. And the focus should be on finding a doctor that matches a patient’s needs and priorities—maybe someone with experience in integrative medicine for someone interested in complementing traditional Western medicine with Eastern practices, for example—rather than on constant, unjust questioning of doctors’ capabilities. But with patients (and their families) more involved in their care—aware of their needs and willing to hold care teams accountable for meeting them, or else seek them elsewhere—these workers may be more motivated to make important improvements.

Please don’t equate my promotion of patient empowerment with requiring hospitals to achieve high “customer satisfaction,” as though healthcare is comparable to a business abiding by the Golden Rule “the customer is always right”. The fact is patients often aren’t right: they want to be able to eat before a procedure, even if it requires fasting for several hours beforehand; and they want enough medication to feel no pain, forgetting that pain is an important gauge of the body’s internal state and functioning. And some people are just more content than others, who (especially in stressful circumstances) may be prone to finding issue with everything and anything. To ask hospitals to please these people is to ignore what they were hired to do in the first place: to heal patients, even if at the expense of temporary discomfort. Though doctors would do well to listen to their patients—and some empathy and reassurances couldn’t hurt either—patients should also trust their respective doctors; the patient-doctor relationship is just that—a relationship.

This discussion of patient involvement leads to a larger discussion of patients’ role in their health—something fundamental to Gawande’s piece that is never addressed explicitly. When someone goes to The Cheesecake Factory, they choose to order whatever they please, whether or not the choice is good for their health. They may enjoy this freedom, and I don’t doubt that the food tastes good, which is certainly pleasing. But using this scenario as an analogy for healthcare is problematic. Healthcare isn’t about delivering patients what they want (though some would argue with me here); it is about facilitating healing and promoting health. Many people want to look and feel young indefinitely—a desire that is not only unachievable, but also works against their ability to deal realistically with the natural evolution in their capabilities that comes with age. Many people also want quick fixes to their problems, choosing to take medication for their chronic fatigue and stress-related diseases rather than work to improve their quality of life. Some want more than they need—more scans, more medications, more attention—while others (out of stubbornness or fear) avoid seeking out help. The doctor’s role is to recognize these differences in desires and behavior, and to work with each individual to improve their health appropriately.

The Wikipedia page for The Cheesecake Factory includes a category labeled “Controversies,” in which is written the following: “The Cheesecake Factory has been criticized for their heavy promotion of large servings of high calorie and high fat foods, and a corresponding lack of healthy menu options. For these reasons, the chain was dubbed the ‘worst family restaurant in America’ for 2010 by Men’s Health magazine. The average sandwich at the restaurant contains 1,400 calories.” People have the right to consume however many calories they choose, and to eat wherever they please. But, as this controversy demonstrates, catering to people’s immediate, instinctual desires (i.e. good tasting, inexpensive food) can have negative consequences in the long term. The Cheesecake Factory isn’t meant to engage in conversation with its customers about the potential issues resulting from their choice of menu item—that’s not why customers choose to eat there, and that’s not their role. Healthcare professionals are.