Wednesday, July 23, 2008

The DMCB Comments About Comparative Effectiveness Research, Payment for Quality, Measuring Resource Use & Physician Payment

The Disease Management Care Blog participated in an interview about some of The Big Medical Questions Of Our Time and, in typical media fashion, adhered to a superficial‘ drive-by shooting’ approach in its responses. This is less about accuracy or thoroughness but more about covering as wide an area as possible and then exiting quickly. So here’s the short and sweet of it:

What is the role of Comparative Effectiveness Research?

It’s suitable for drugs, devices and relatively circumscribed medical interventions. In the CER universe, an academic/research medical-industrial complex approach of head-to-head randomized clinical trials will be a virtue. That’s fine, but the DMCB doubts complex ‘packages’ of interventions that are interdependent and synergistic (like the Medical Home or Disease Management) lend themselves too well to prospective trials because they are hard to randomize, hard to blind, difficult to shield from other sources of bias and certainly hard to pay for.

The key question for readers of the DMCB: If CER determines there is no evidence that an intervention “works,” should that result in 1) no payment, because there is no evidence, or 2) payment until there is evidence that something else works better?

What is the role of Linking Payment to Quality?

While this has yet to really be applied to physicians, in order to discern levels of clinical quality ('high,' warranting payment, versus 'low,' warranting non-payment), the ‘law of large numbers’ requires that a valid statistical sample be used. Most individual physicians in most practice settings don’t have sufficient numbers of patients with a condition in which quality can be confidently assessed. This is an insurmountable problem, unless the solution is “close” is good enough. By the way, even if a sufficiently large sample becomes available, a p value of .05, means 5% of the payments are probably in error.

The key question for readers of the DMCB: A common solution is to aggregate physicians’ data and let the physicians distribute the payment. Is this a conscious or unconscious early step in the aggregation of physicians into groups, PHOs, accountable health systems or integrated health systems – and the demise of the small independent practice?

What is the role of Measuring Resource Use?

Since the subsequent use of resources (back imaging studies and a visit to a specialist or hospital) following an index encounter (the first visit for back pain) is part of the resource consumption, most measures of resource use rely on ‘episodes of care,” which the DMCB thinks of as a packaged timeline with a start (index visit) and a finish (resolution of the condition). The good news is that otherwise independent providers involved in the episode of care can have a stake in optimizing resource use. The measures, if done right, can get them to cooperate and integrate.

The key question for readers of the DMCB: Is measuring resource use around an episode of care the first step in a road that will lead to paying for episodes of care, using a payment mechanism similar to capitation?

What is the role of Medicare Payment Updates from the RUC?

Mainstream primary care physicians are confused by the RVU methodologies, disenchanted with the competing specialties in the process, distrustful of the politics surrounding them and disdainful with the RVU conversion to dollars and payment. While policy, economic and physician experts are grappling over tenths of an RVU, the street level PCPs have become disengaged.

The key question for readers of the DMCB: While us do-gooders in the population-health biz have GREAT ideas on how to make life better for physicians and their patients, why should docs, given their experience with RVUs (and capitation and P4P) believe that we aren’t offering more disappointment?


Off topic, but DMCB is having an 'egads, what were you thinking!?' moment over the bad Gator behavior of young and future physicians. A study from the Journal of General Internal Medicine:


Aim To measure the frequency and content of online social networking among medical students and residents.

Using the online network Facebook, we evaluated online profiles of all medical students (n = 501) and residents (n = 312) at the University of Florida, Gainesville. Objective measures included the existence of a profile, whether it was made private, and any personally identifiable information. Subjective outcomes included photographic content, affiliated social groups, and personal information not generally disclosed in a doctor–patient encounter.

Social networking with Facebook is common among medical trainees, with 44.5% having an account. Medical students used it frequently (64.3%) and residents less frequently (12.8%, p < .0001). The majority of accounts (83.3%) listed at least 1 form of personally identifiable information, only a third (37.5%) were made private, and some accounts displayed potentially unprofessional material. There was a significant decline in utilization of Facebook as trainees approached medical or residency graduation (first year as referent, years 3 and 4, p < .05).

While social networking in medical trainees is common in the current culture of emerging professionals, a majority of users allow anyone to view their profile. With a significant proportion having subjectively inappropriate content, ACGME competencies in professionalism must include instruction on the intersection of personal and professional identities.

According to MSNBC:

'Erick W. Black, one of the researchers, said he found pictures of students grabbing their breasts and crotches, posing with a dead raccoon and multiple photos of residents and medical students drinking heavily.

Many students had joined Facebook groups that could be considered sexist, racist or downright nasty, with many using vulgar language. Some of the tamer groups included 'Physicians looking for trophy wives in training' and 'PIMP' (Party of Important Male Physicians).''

The DMCB asks if instruction in the use of common sense might also be in order. DMCB spouse opines 'they should not be allowed to graduate!'

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