Physicians Behaving Badly

Can we trust physicians with the responsibility and the scope of practice society gives them? Do we need a 'systems approach' to help them manage their scope?

Physicians' scope of practice is increasing - driven by many big social drivers:

1. High technology health care.
2. Demand fueled by over-capacity but not by need for their services.
3. A Fee-for-service payment model that rewards doctors for doing 'stuff' unrelated to actual patient characteristics.
4. No naturally antagonistic professional group applying 'top-down' political pressure to limit increasing scope of physician practice.
5. Expansion of American healthcare system under Obama's heath care reform.
6. Medicalization of social ills (eg: alcoholism and 'medical marijuana').

Are physicians qualified to handle this increased scope? Is public safety assured? Can we help them behave better?

Evidence over the last 10 years indicates that the American health care system kills 98,000 Americans per year and loses $60 billion to thieving Medicare pirates every year.

I think we're throwing good money after bad by trusting physicians to lead the way. The current private practice model - where 70% of American healthcare happens - is analogous to the "airplane pilot flying the plane and serving us drinks, too".

The difference is pilots, airplanes and airports have adopted a 'systems approach' that makes flying much safer than 20-years ago. Without a similar safety approach to healthcare patients will keep dying, getting poor outcomes and spending our money.

A systems approach places more power into process measures that define 'how' healthcare happens - but not process measures defined by centralized Medicare policymakers. The process measures that lead to better outcomes need to be defined by clinicians that see the patients and the managers that take care of the clinicians.

For our purposes, process measures are a specific type of healthcare quality measure encompassed by the term 'systems approach' that tries to lower cost and improve care without blaming the people involved in the care.

But, speaking of blame, here are examples of how physician (and physical therapist) bad behavior over the last two decades have wasted our money.

Excessive diagnostic variation

Song et al in the May 2010 NEJM examined the diagnostic variation in 306 hospital regions in the United States from 1999-2006. Diagnosis drives procedures so the finding of diagnostic variation is not particularly surprising given the wide variation in costs and intensity seen in other studies.

The worrisome feature is that diagnostic intensity will affect future payment using risk adjustment. The Dartmouth group has consistently managed to highlight an embarrassing feature of American healthcare: differences in how folks are diagnosed and treated is not driven by their clinical characteristics.

Increasingly complex fusion surgeries

Dr. Richard Deyo et al published a follow-up study in 2010 to Dr. Weinstein's study (see below) that showed COMPLEX fusion surgeries (more than 2 levels, 360-degree operations, etc) increased FIFTEEN-fold in five years, from 2002-2007. That's 300% per year!

What's more, most of these surgeries are being done on the oldest, sickest Americans - Medicare beneficiaries who may have an outdated trust in their physician. Life-threatening complications increased from 2.3% for simple spinal decompression to 5.6% for the complex fusion surgeries.

Dr Deyo states:

"Financial incentives to hospitals and surgeons for more complex procedures may play a role..."

Increased costs but decreased outcomes for spine problems

Martin et al in Spine Magazine (2009) describes outcomes from ALL spinal treatments during the period from 1997 to 2006...

"...the proportion of patients who reported any limitation in physical functioning increased steadily and significantly..."

Costs, however, increased between 37% and 134% for outpatient settings, prescription drugs, inpatient and emergency settings.

Rapid increase in spinal fusions

Weinstein et al in 2006 in Spine found a 500% increase in lumbar fusion surgeries from 1992 to 2003. There was a 20-fold variation from high- to low-intensity regions that may not have been driven by patient need. Spending for spinal fusion increased from $76 million to $482 million over this period - consistent with Dr. Martin's 2009 study should we anticipate getting more VALUE for our dollars?

Its not that we don't trust these PEOPLE - physicians and physical therapists - but that these aren't PEOPLE problems, they're problems with the system.

Maybe its time to put our trust in systems that help physicians and physical therapists better help people.

What kinds of processes do you use at your work that lead to better outcomes?