Stand Out from the Crowd? Think Again

February 3, 2015
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Health Care Reform As Crowd Control

Persuading your doctor to care about you just got harder. People want docs who care about them. Nothing matters to people as much as doctors who listen and form genuine bonds with their patients. But another health care reform decree is sucking up your physician’s attention: Population health management.

Health Care Reform As Crowd Control

Persuading your doctor to care about you just got harder. People want docs who care about them. Nothing matters to people as much as doctors who listen and form genuine bonds with their patients. But another health care reform decree is sucking up your physician’s attention: Population health management.

Packed appointment schedules, electronic medical records, seven-minute visits and meeting insurance company “quality measures” are already enough. Now insurers command doctors to squeeze out more time to monitor “populations” of patients. Diabetics (perennial favorites), heart patients, people who go to the ER too often, asthma patients, chronic pain sufferers, fat people. Anyone who costs the insurance company too much money.

Population health was recently defined by the Institute for Health Technology and Transformation (iHT2). They describe it as “. . .the health outcomes of a group of individuals, including the distribution of such outcomes within the group. . .”  Health outcomes here means: Patients who are too costly to treat.

The new focus on “population health” is a chicken or egg riddle. Did population health come first? Or computerized charts? Several years ago, population health was the lonely playground of statisticians and epidemiologists. Typical clinicians spent their days caring for patients the old-fashioned way. One by one. Getting to know them, what ailed them and how they could best help. Each person. Quaint.

Electronic health records or EHRs showed up early in the 21st century. Their amazing abilities were trumpeted through the land. Computerized charts would revolutionize medicine! Electronic records revolutionized medicine all right, but not the way tech-besotted doctors or geeks foresaw. Electronic health records are an unmitigated disaster according to critics. Or a disappointing experiment in marrying technology and care. Even die-hard EHR supporters admit misgivings. The federal government committed to spending $36 billion on technology that may have minimal value for most Americans.

So now doctors have billions of dollars worth of technology sitting around. What to do? Use it for something else. Re-purpose it, in corporate speak. Use EHRs to track clusters of expensive patients for the insurance companies. Then the insurance companies can manage them—insurance lingo for denying care.

Population health management crept into medical journals a few years ago. (Population health management is a different critter from public health though the fields overlap.) The topic first appeared in the venerable New England Journal of Medicine in 2011. Dr. Ann O’Malley writes of the havoc electronic records wreak in patient-doctor relationships. She glides past those with impractical suggestions, zipping on to the need for electronic records or health information technology (HIT) in population management:

Primary care practices increasingly must focus not just on individual patients [emphasis mine] but on whole populations…A new orientation and effective methods for shifting practices from reactive and acute-symptom care to…care for both healthy and chronically ill populations will be needed. Without HIT [health information technology], it’s difficult to provide effective population-based care and report quality metrics….But most…EHRs currently cannot help identify which patients in a population may need particular services. Registries are another critical tool for population health management and an area where HIT applications could be better developed and integrated with EHRs.

Corrupted Care

Physicians aren’t able to ignore population health management as bureaucracy run amok though it is that. Population management is the camel’s nose under the flap. Its required treatment protocols and guidelines are the whole shaggy beast standing in the tent.

Many commercial insurance companies and Medicare now tie clinicians’ payments to whether they’re treating their patient populations according to the guidelines du jour. Guidelines change often as scientific understanding changes. Rules engraved in stone today are discarded as dangerous tomorrow. No matter for insurers. They get updates in the quality metrics data analysis— from health care behemoths like Optum—and move on.

But population management can trigger disasters in patients’ lives. Those matter. And patients don’t move on so fast.

A quartet of physicians, outraged enough by this miscarriage of care, published three opinion pieces in the New York Times in the past several months.  Pamela Hartzband, an endocrinologist and her husband, Jerome Groopman, well-known author and oncologist wrote the first. “How Medical Care Is Being Corrupted” appeared last November. The doctors describe the “financial forces” that pressure physicians to pay attention to “strict metrics…[that]…are population-based”.

The metrics, tied to guidelines, ignore the preferences and idiosyncrasies of each patient. The metrics substitute generic edicts for clinical skill, devaluing the patient and the physician. Worse, physicians are coerced by insurance companies and hospitals. The pressure threatens the financial health of their practices unless they yield.

Hartzband and Groopman sound a warning about health policy experts who believe that, “… it is obsolete for the doctor to approach each patient strictly as an individual; medical decisions should be made on the basis of what is best for the population as a whole.”

Health care reform as written by George Orwell.doctor frustrated by health care reform

Guidelines Know Best. Not!

Sandeep Jauhar detailed similar frustrations about a month later in “Don’t Homogenize Health Care”. Dr. Jauhar, a cardiologist, laments that “‘variation’ has become a dirty word” in American health care.  Variation is banished by increasing reliance on treatment guidelines for maladies ranging from asthma to urinary incontinence. He acknowledges many treatment guidelines reflect good evidence. Patients may recover faster and maintain better health when their treatments have solid science foundations.

Jauhar observes “…the effort to homogenize health care presumes that we always know which treatments are best…”. Typical patients are surprised—and disconcerted—that many treatment recommendations are wobbling on flimsy evidence. So-called evidence-based medicine is often a euphemism for an expert’s opinion. Opinions of experts spin with the wind…or the funding. Eradicating variation is impossible.

Further, Jauhar mentions the danger lurking in ill-considered adherence to guidelines. He describes the now-notorious (well, among us medical types) insistence that low-risk patients receive a certain drug during surgery to prevent heart complications. Instead, these hapless souls had a much higher chance of suffering a stroke. Jauhar “shudders to think” how many people were disabled, or died, because of guideline-induced strokes.

He finishes, saying that treating each patient differently didn’t work well. Treating all patients the same way isn’t yielding great results either. At least for patients. Jauhar believes medicine “needs another way”.

Up A Tree

Kasia Lipska’s “When Diabetes Treatment Goes Too Far” appeared in the print edition of the Times on January 13, 2015. Dr. Lipska specializes in treating people with diabetes. Not diabetics. Her opinion piece makes that refreshingly clear. She tells the story of an elderly patient she treats for diabetes. He uses insulin to keep his blood sugar in check. Several years ago, his blood sugar dropped too low, a well-known insulin risk. Lightheaded while driving, he lost control and plowed into a tree.

There are two common ways to measure blood sugar. One is a serum blood sugar or glucose. It’s a snapshot of the person’s blood sugar level the minute the blood was drawn. It’s used by people with diabetes for day-to-day decisions on medication doses. The other is a “hemoglobin A1c” or just A1c. It’s a virtual photo album or average of the person’s blood sugar for the past three months or so, a more useful test for long-term treatment choices.

Treatment guidelines infested diabetes care long before the population management crusade. Drug and medical device foxes (also here) were in the American Diabetes Association henhouse writing guidelines years ago. The aggressive move to population management is a heaven-sent gift for the drug and device industries. Their greatest success was convincing policymakers that every person with diabetes needed to force his or her A1c below seven percent. Even elderly patients for whom there was no proof of benefit.

Quite the opposite. Several studies showed danger to older patients when their A1c’s were driven lower than seven percent. One study was stopped early because people in the intensive treatment group were dying at a faster clip than the those whose blood sugars remained higher.

Despite, yes, more guidelines that direct clinicians to exercise caution when caring for older people with diabetes, more than half still are subjected to zealous treatment to push their A1c’s below seven. Even patients with other illnesses, at greater risk of harm from low blood sugars, still get overtreated. Lipska and her colleagues published a study this month chronicling the problem.

Lipska quotes the delicious (sugar-free) fact that revenues from diabetes drugs just about equal the combined take for the National Football League, Major League Baseball and the National Basketball Association. That’s a lot of bank as economists say. The folks who sell the drugs have plenty of incentive to keep every diabetic person’s blood sugar in the cellar.

Health Reform Menace

Themes run through these opinion pieces. The dehumanizing results of population health management. Hidden financial motives of its proponents. Harms, even death, suffered by patients when clinicians thoughtlessly follow guidelines.

I don’t trust coincidences, unrepentant reader of murder mysteries and cop procedurals that I am. The Times parceled out coveted real estate on its Op/Ed pages to four authors who all condemned some failing of population health management. All lamented the devaluation of human bonds in medical care. The paper published these articles within the short space of two months.

The Times took a clear stand on the importance of respectful care given to individual patients by doctors who have their patients’ interests at heart. Against the corrosive effects of herding people into “populations” and foisting crowd care on them.

The paper is sending a message: population health management is a personal health menace.

Insurance companies and EHR peddlers are sending messages, too. They don’t care whether folks stroke out on the operating tables. Or wrap themselves around trees. They follow excellent treatment guidelines for themselves. The ones that prevent money hemorrhaging and keep share prices healthy.