JAMA Watch Jan. 4, 2012: I read what the AMA is writing so you won't have to.
In the interest of the public health, I am going to start posting summaries of significant articles from JAMA the Journal of the American Medical Association, because it is widely read by U.S. physicians, and it has lots of influence on physicians in the U.S.--and sometimes the lay public. Recall that the editor of JAMA was given the boot during the Lewinsky Hearings for publishing a study done at a southern college which revealed that the majority of bright, educated southerners really do think that oral sex is not sex. Overnight, the Internet went from "Only a moron would try to claim that oral sex isn't sex" to "Of course, in some parts of the country 'sex' does not mean 'oral sex'. That is a scientifically proven fact."
Most of the stuff in JAMA isn't that much fun. A lot of it goes something like "Rhesus monkey pancreatic RNA useful in decreasing human aveolar diffusion in vitro tests" and crap like that.
Here are this weeks offerings of stuff you might want to know. There is a four article special on controlling health care costs.
1. "Reversal of Established Medical Practices: Evidence to Abandon Ship" In a nutshell, lots of things that doctors have been doing for a long time are not doing their patients any good, but people keep having them done because they are "The standard of medical care." The authors site the example stenting diseased coronary arteries that are not causing any symptoms. 84% of the stents performed in this country are of this type--and studies show that they do not do the patient any lasting good and probably isn't any better than placebo procedures at reducing angina (non fatal chest pain). The near universal use of hormone replacement therapy in any woman who had insurance is another example cited. So is verterbroplasty. These are treatments doctors have used for years because they ought to work, if you think about the physiology. However, health often does not make sense. There are too many factors at play. Sounding good does not take the place of clinical studies--and I am not talking the kind of sham circus performances that the company with the patent often stages with the help of a highly paid physician investigator.
Moral. We waste an awful lot of money on snake oil.
2. "What are the Health Care Cost Savings?" Did you know that if our health care spending continues at its present rate, one of every two dollars in the U.S. will be sucked up by the Medical Industrial Complex in 2080? Did you know that U.S. health care spending is the world's fifth largest economy?
Yeah, I agree. It is time to trim the fat. But where do we start? Malpractice caps, limiting insurance company profits, increasing use of generic drugs, letting preemies die (eeks!) will not do the trick.How do we start? The authors suggest tertiary prevention. Tertiary prevention means going after the cow when it is out of the barn and attempting to lasso it before it can run across the road and get run over by an eighteen wheeler. It makes good money for the cowboy doctors riding the horses in chaps and spurs carrying the lassos, but it would still be a lot cheaper to hire one pimple faced teenager to keep the barn door closed. That is what is known in the public health profession as primary prevention. The problem is primary prevention does not do anything for the years of medical neglect that our nation's middle aged and elderly have already suffered. The implication of tertiary prevention is you pay the family doctors to keep the patients from needing the much more expensive care of the specialty doctors. However, family doctors will have little control over whether or not the new patients 50 pack/year smoking history has given him a bad heart, emphysema and lung cancer. Meaning that the only way to give the appearance that you are "saving" money is to make sure that you do not accept any sick patients. See article 4 below.
3. "How will the affects of the Affordable Care Act be monitored?" Good question. The author suggests measuring how much preventable mortality drops----not the easiest thing to do, since sudden access to health insurance will not reverse a lifetime of health neglect. The drop in preventable hospitalizations should occur more rapidly as more of us get our diabetes controlled in an office rather than an emergency room when we finally go into diabetic coma. Third, how many people will actually get health care that they can afford to use out of their new health insurance? I'm betting that there will still be a huge number of people who will not be able to get the care they need, thanks to high deductibles, co-payments and limited provider directories. Fourth does the cost of health care per person go down to Western European levels? As with one above, expect a lag.
4."Withholds to slow Medicare spending: A Better Deal Than Cuts" A better deal if you belong to a huge multispecialty medical practice that cherry picks healthy, rich elderly patients, maybe. Remember HMO withholds? I do. They were a crock of shit. Doctors were told "We will reduce your fees by (anywhere from 5-50%) and if you are very frugal, you will get that money back. " Doctors are no fools. Indeed, they are some of the brightest folks you will meet. Tell them something like this and they immediately go full Titanic mode, jettisoning the sick folks from their practice and hanging onto the healthy. Yes, they do. My practice absorbed a lot of these orphan cancer and heart patients in the mid-nineties when their regular family doctors suddenly discovered that they did not have the skills necessary to treat these kinds of people. Or, they suddenly had the skills necessary to take the place of the oncologist and cardiologists. Remember, referral denials are not intended to make patients do without necessary care. That would lead to malpractice suits. Docs who refuse to refer knows that their patients will get on the phone to their insurer and find a doctor who will.
OK, I will get down from my soapbox. What do the authors suggest? One, base payments on the cost savings (or excessive spending) of care providers in a specific geographic region. Which is bullshit. Who is going to set up practice in an area with a lot of poor folks, knowing that poor folks are also sick folks, and therefore the doctors who spend long agonizing hours trying to improve the lives of America's least fortunate---like the minorities that live in the petrochemical industry's pollution---will be penalized for doing so? This is nothing but regional discrimination. Boundaries would be drawn to keep the poor and minorities in areas that would remain woefully under served. Second option? You guessed it. Let savvy doctors join huge multi-specialty groups that will vow to keep down costs by eliminating waste but which will actually cherry pick their way to riches.
Moral: watch out for financial arrangements suggested by doctors (Yeah, I am one. Want to make something of it?) They are not ready to give up on their six and seven figure salaries yet, and if they can find a way to get rich quick and then quit practice, many of them will do it.
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