It is not hard to imagine an excellent system to rate how good a physician really is.  You want to test his or her knowledge of the illnesses and treatments that might affect you.  You want to know how well he performs against other physicians in treating real-life patients, those with diabetes, heart disease, and ear infections.  You want to know how thoroughly she informs her patients of what they really need to know, and whether she delivers the preventive care that you need to stay healthy.   And you’d really like to know if his patients are healthier and live longer than those of other physicians.

Unfortunately, that information isn’t available.  What is available isn’t even close to that ideal.  Mostly people rely on what their friends, family, or other physicians recommend, and there’s no evidence that is any better than flipping a coin when trying to identify a better-than-average physician.  What else can you do?

The answer is that patient opinions, for all their shortcomings and obvious problems, are one of the best answers we have today.  One example supporting this is the Consumer Assessment of Healthcare Providers and Systems, a system of scoring physicians and hospitals through patient surveys, which is being used by the US Department of Health and Human Services to improve performance.  Another example is California’s Integrated Healthcare Association, which rewards medical groups in part on the basis of patient assessment of physician performance.  No, it’s not ideal, but it’s a start.

Don’t make the perfect the enemy of the good.  Until we have real comparative information on physician performance and outcomes, consumer satisfaction is probably the best we can do to identify the physicians that most deserve our patronage.  

Yes. Through a remarkable partnership with the Drug Effectiveness Review Project (DERP) at Oregon Health and Science University, and the Agency for Healthcare Research and Quality of the US Department of Health and Human Services, Consumer Reports has access to the best available evidence on drug safety and effectiveness:

This information compares drugs in the same class (pain relievers, high blood pressure, diabetes, etc.) on all the published medical literature that examines their clinical effectiveness, mostly through clinical trials. This original source information is available to you online at

Unfortunately, you will not find the DERP information very useful – try reading the first report, “ACE Inhibitors.” It is 147 pages of dense medical analysis of high blood pressure drugs. It also has no information on the cost of the 11 different drugs in this group, which is very important to those who not only want a safe and effective drug, but also need to pay for it

That’s where Consumer Reports comes in. Taking the DERP findings, adding information on the cost of these drugs, and then publishing it in reader-friendly short reports, CR is making the best information easily accessible. And it’s free. They even identify “Best Buy Drugs,” those which consistently have the best quality-to-cost ratio. What could be simpler?

Can it save you money? The CR Best Buy drug could save you $1,900 a year if you’re taking Celebrex and $1,700 a year if you’re taking Nexium, to give you two examples.   Look at the CR site for your own medications to see how much you might save.

Does anyone else believe CR’s information? You bet – as reported in the Journal of the American Medical Association, this is a service which physicians applaud. And 15 states, including New York and Minnesota, use this information in deciding which drugs to offer their Medicaid beneficiaries. It has been endorsed by organizations as diverse as the American Public Health Association, the AFL-CIO and the Alliance for Retired Persons.

It’s free, it’s great information, and it will save you money. Any questions?

First, the facts.  Avandia was approved in 1999 after clinical trials with 5500 patients.  It was found to be effective in diabetics for controlling blood sugar.  It is a member of the same drug class as Rezulin, which was withdrawn from the market in 2000 because it caused liver failure.  Avandia was already known to increase the risk of heart failure, and evidence just published in the New England Journal of Medicine suggests that it increases the chances of heart attacks and deaths from heart disease about 40%.  Since diabetics already have twice the risk of heart disease and are a vulnerable population, this is a serious potential concern.

These are only preliminary findings.  When all the evidence is in, it might be possible that there is no increased risk.  How could the possibility that Avandia causes heart disease have been missed when the drug was approved?  Consider that millions now take Avandia, and that an infrequent side effect may not show up in the relatively small number of patients involved in FDA trials.  This has been the problem with other drugs that have been recalled after initial approval (think of Baycol, Redux, Bextra and others), and will continue to be a problem that can only be addressed with better surveillance after a drug is released.

Diabetics taking Avandia should talk to their physicians.  They are at more risk from not taking any medication than from taking Avandia, so the worst thing a diabetic could do is to stop taking their medication.  Are there other alternatives?  Yes, and very good ones.  In addition to other oral drugs, Actos (pioglitazone is the generic name) is a member of the same drug class, and there is some evidence that it may actually have a protective effect against heart disease, although this has not been proven.

Should a diabetic, knowing what we know today, take Avandia?  I think the answer is, “No.”

What happened?  Disease management can be a real help to people with chronic illness, and it can save claim dollars for employers and other payers.  That promise created a booming market for disease management, and a gold rush ensued as new entrants flooded the market and eroded the value of the service.  Suddenly every health plan offered a disease management program, and many did not bother building the solid nursing foundation needed to deliver real results.

The heart of disease management is a therapeutic relationship between a nurse and a patient.  That’s how you educate, change behaviors, assure quality care and create better outcomes.  It helps if you can enlist the patient’s physician as well.  Boxes full of literature, glitzy marketing campaigns and grandiose claims don’t do the difficult jobs of establishing that relationship, supporting patient education and self-care, and delivering better results.

Nurses are expensive.  If you are a disease management company, you can under price your competition by having fewer patients in nurse coaching.  And then don’t bother reporting that to the client – read a disease management activity report today and try to figure out how many health plan beneficiaries are actually getting nurse coaching.  It’s the critical metric, but most disease management vendors don’t report it to their clients.

What’s the right number of a health plan’s diabetics that should be in nurse coaching?  50%?  25%?  We can debate that, but I will guarantee you it’s not less than 2%, which is the result for some disease management programs today.  There is no possibility that touching so few beneficiaries will result in a meaningful impact or real program savings.  Unfortunately, disease management vendor estimates of savings and ROI are so mired in statistical problems, including selection bias and regression to the mean, that they cannot be relied on as a meaningful measure of the program impact.  The industry missed a chance to standardize measurements of results to report valid metrics and allow meaningful comparison across vendors.  This would have created a fair marketplace, assured accountability, and rewarded top performing organizations.  Accountability and transparency could have headed off the problem we are approaching when nobody believes disease management savings and ROI reports.

We know we have a problem as disease management vendors withdraw from the Medicare demonstration project and reports appear more frequently that question the value of disease management.  There’s a chance that this is simply part of a healthy shake-out in the marketplace, but those of us who see the real promise of disease management also fear that the coming backlash will go too far.

This development has taken a grim turn, though, with the rise of international trafficking in organ transplantation.  The reason for this development is clear:  there is a severe shortage of organs for transplantation in the US.  About 6,500 individuals in the US die every year awaiting transplantation, and there were almost 100,000 candidates for the estimated 29,000 organs that became available in 2006.  Organ transplantation has become safer and less expensive – a kidney transplant, for example, has a high success rate and costs much less than a single year of dialysis.  And the quality of life is much better with a transplant than with dialysis.

There are plenty of potential organs for transplantation in the US, but the vast majority are cremated or buried instead of transplanted.  Virtually every religion supports organ donation and transplantation, but administrative obstacles and failure to request donation by medical authorities make for increasing shortages.  Dramatically increasing the supply of organs for transplantation is as easy as making it an “opt-out” to decline donation rather than having to “opt-in” through finding and completing an organ donor authorization.

Instead, transplant candidates are increasingly going overseas to buy organs from indigent locals.  The World Health Organization

http://www.who.int/ethics/topics/human_transplant/en/

reports that people in Pakistan, Egypt, India and the Philippines are being persuaded to sell their organs to a broker, often for as little as $1,000.  These individuals receive inadequate medical care and risk death as a result, as described in an article published in the Journal of the American Medical Associations:

http://jama.ama-assn.org/cgi/content/abstract/288/13/1589/

This would be illegal in the US and most of the developed world. 

We can debate the ethics of paying donors for their organs, but we are instead preying on vulnerable populations as the price of our discomfort in confronting the issues of death and organ harvesting in the US.

More and more health plan participants are encountering exactly this scenario.  Welcome to “concierge medicine,” or retainer medicine, the latest trend among physicians to increase their incomes and reduce their workload.  Here’s how it works:  a physician office practice decides to become a concierge practice.  Each patient in the practice is approached to pay the annual fee and sign a contract.  In return for the annual retainer, physicians promise longer office visits, same-day appointments, shorter waiting times, and better access to the physician, sometimes including their cell phone numbers. 

Medicare, which is concerned about the legality and potential access problems, commissioned a study in 2004

http://www.gao.gov/new.items/d05929.pdf

which found several hundred physician practices nationally had already converted.  Since then, the number of physician groups becoming concierge has increased rapidly.  Most major health plans will not allow physicians to charge access fees to their members, so many of these physicians drop their health plan contracts, and many drop out of Medicare as well.  An employer’s health plan members who see one of these physicians must pay the annual access fee out of their own pocket and seek out-of-network reimbursement for physician services if they are enrolled in a PPO. 

What’s in it for physicians?  Their patient loads drop, from an average of about 3,000 to about 600, depending on the type of practice.  And their incomes soar – from an average of $150,000 per year to $400,000, according to one source:

http://www.aarp.org/bulletin/yourmoney/a2004-11-11-boutique.html

Instead of seeing more than 100 patients per week, they see about 30. 

So what’s wrong with a little physician entrepreneurship?  First, there is no evidence that patients in concierge practices have any better outcomes – they just pay more.  Second, we already have a shortage of primary care physicians, and each practice that converts to concierge leaves about three-fourths of their patients to seek coverage from a shrinking pool of physicians.  And finally, these same physicians were trained at huge public expense with their education heavily subsidized by the US public.  This is no way to repay our trust.

Credit for this idea should go to Pitney Bowes, which has been swimming upstream by reducing pharmacy copayments by employees for years, and finally eliminated them completely. As reported by the New York Times

This idea has started to catch on, and other employers like Marriott and Mohawk are taking the same step.

Here’s why. The first part of the answer is simple math and consumer behavior, tied to the fact that the employers are only reducing copayments to zero for certain drugs, predominantly generics and a few brand name drugs used to treat chronic illnesses, like asthma, diabetes, and heart disease. We’ll come back to those in a moment, but first the story on generics. 

An average generic prescription costs about $25 and an average brand name costs over $100. With a typical three-tier pharmacy benefit, say $10 generic, $20 brand, and $30 non-formulary, here’s the payment:

Now, lower the generic copay to zero, but raise the brand copay to $25

One more step. You’re an employee, and you get a letter from the pharmacy benefit manager saying you’re on a brand name drug that costs you $25 a month. There’s a generic alternative, which works as well, that you can get for free. Talk to your doctor and see whether switching to the generic will work for you.

Employees switch. Maybe as low as 10% over the course of the first year, but every time an employee switches, the employer saves $50 ($75 brand cost versus $25 generic cost). Depending on the generic utilization rate before changing the benefit design, that savings may be enough to pay for the change by itself.

But there’s even better news. The compliance rate for employees taking medication for chronic illnesses like high blood pressure, diabetes, heart disease and the like goes down dramatically if the out-of-pocket prescription costs go up. What Pitney Bowes and others showed was that the modest increase in pharmacy costs caused by employees actually taking their medications was more than offset by the savings on complications from those chronic health conditions. That shouldn’t be surprising because prevention costs a lot less than cure. The cost of high blood pressure medication, especially generic, is thousands of times less expensive than the cost of heart failure or a heart attack.

So you prevent complications and disease progression, save money, help your employees save money and have better health – why can’t you get free prescriptions, too?

Those scenarios are the driving force behind the Next of Kin Registry (NOKR):

The NOKR is a free, nonprofit, emergency contact system for both daily emergencies and national disasters. Here is how it works: you or someone in your family registers online at the NOKR web site. You can register multiple individuals as next of kin and emergency contacts, and you can enter information about medical conditions, medications and other important information. When that information is needed, it will be used up to contact you or your family member or to allow medical care during an emergency.

One way the information is used is to make it available to state agencies (sheriff, police, coroner, hospitals, etc.) during emergencies. There are multiple protections in place to assure that only qualified agencies are allowed to access the information, through a registration process that confirms their need to know. There are also safeguards so that no agency will be allowed to search the system for wanted felons, victims, witnesses or suspects to crimes.  What they will do is locate and notify those in the database that an individual has been located.

Here are other cases where NOKR information will be used:

• Missing or injured child, adult or senior
• Accidents while traveling
  
• Unconscious person unable to communicate
• Natural disasters (hurricanes, earthquakes, tornados, floods, tsunamis and fires)
• Terrorist acts
  
• Deceased person

There are testimonials on the web site that give dramatic illustrations, including NOKR’s help in locating relatives for over 500 victims during hurricane Katrina. There may not be internet access during every disaster, but it makes sense to take this step for the day when you or your family will need it.

When I first started reading reports linking oral health and other medical conditions, I was skeptical.  But as study after study comes out showing the connection, especially with cardiovascular diseases like strokes and heart attacks, it seems clear that there’s a connection, even if it seems bizarre.

If you have serious gum disease, you are twice as likely to have a heart attack, according to one study.  In another, treating gingivitis lowered C-reactive protein and fibrinogen, blood stream markers that are known to predict heart attacks.  Another study found that those with gum disease have more arteriosclerosis of the arteries to their brain, making them at risk for strokes.  Yet another study found that those with gum disease do indeed have more strokes.

The mechanism is not clear, but the suggestion is that infected gums permit the entry of bacteria and the body’s inflammation products to enter the blood stream.  Inflammation may damage the blood vessels directly, and bacteria may lodge in blood vessel walls.  These in turn result in irritation to blood vessel walls, with cholesterol deposits and narrowing as a result.

To make matters worse, gum disease appears to cause other medical problems as well.  Diabetes is much harder to control, and there are more complications in those with gum disease.  Gum disease in pregnant women?  They are seven times more likely to deliver premature babies with low birth weight.  And reports last week again noted that those with gum disease were almost three times as likely to develop cancer of the pancreas.

However unlikely it may be, wherever we look we find systemic medical problems resulting from gum disease.  While we may not have the full story on how periodontal disease causes these illnesses, the evidence points to your risk returning to normal if you treat gum disease when it exists.  It is even better, of course, to prevent it in the first place.  So there’s more reason than ever to listen to your dentist:  floss every day.

It wasn’t long ago that a person had no right to see his or her own medical record. That record was considered the property of the physician or hospital that cared for the patient. In most states a patient could not get access to his or her own records, even to correct an error. That changed with the Health Insurance Portability and Accountability Act (HIPAA), so that the right to request medical records was federally protected, and the revolution started.

For the first time anyone could see his or her diagnoses, look at the lab results or X-ray reports and evaluate the care they had received. Thanks to the explosion of medical information on the Internet, you can now evaluate for yourself whether the diagnosis makes sense and whether the care you received was appropriate. You can decide what other steps might be taken for your benefit. Effectively, this enables you for the first time to take charge of your own health care and to partner with your physician in determining your course of care. This has been a difficult transition for some physicians, but ultimately it acts to empower us as genuine medical consumers with knowledge and confidence, and that results in better outcomes.

But just as the Web has changed so many other areas of our lives, the changes have not stopped there. Some health plans are making medical records available online electronically, so you can see your lab results, often before your physician does. Since your medical information is now in a portable format, online and not buried in paper copies, you can easily share the information you want with experts anywhere in the world to get a second opinion or find other treatment options.

We are not far from the day when all of these results can be compiled to determine the best treatment for each medical condition, something that today is often based on guesswork. It will be possible to really measure how well a physician performs by the results his or her patients experience. We will also be able to support them through expert systems to bring the best and the latest information to your care.

We have already seen this kind of information revolution in banking and financial services – remember your savings account passbook? The promise is even greater in health care. Stay tuned.