What are tomorrow’s policy problems?

by Allan Joseph

In a few weeks, my institution is hosting the AMA’s Northeast-region meeting for medical students who are interested in policy and advocacy, among other topics. I’ve been asked to give a presentation on the policy problems of the future, and ways for the attendees to prepare for those problems and to help shape their solutions.

I thought I’d take an informal poll to help guide my talk. So what do you see as the biggest healthcare policy problem of the next 1 year, 5 years, 10 years, and/or 25 years? What can medical students do to prepare for them, and how should physicians shape the solutions?

Send me your answers to any or all of those questions via email, on Twitter, or in the comments below.

Thanks!

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Allan Joseph is a second-year medical student at the Warren Alpert Medical School of Brown University, where he is pursuing an MD/MPH. You can follow him on Twitter @allanmjoseph.

Has med school changed for the better?

by Karan Chhabra

 

Every third-year has heard it.

…When I was in your position, I was taking 24-hour calls every other night. If my resident was there, I was there….

We’re regaled about the glory days, without shelf exams, without phlebotomists, and—by god—without those work-hour restrictions. The days when medical students wouldn’t dare ask their residents for help, or residents their chiefs, or chiefs their attendings, and so on. I hear a bit of romance: the heroism of providing total patient care, exactly when the patient needed it, unfettered by handoffs or outside interference. I envy the skill required to practice medicine almost-literally in one’s sleep.

As the veteran doc continues his (yes, usually his) soliloquy, he may admit that it wasn’t the safest model for patients, or the most humane for trainees. He may today be a better doctor for it, but he’s a bit ambivalent about whether it should remain exactly the same today. Presumably he wasn’t alone, because since the good ol’ days, the third year of medical school has morphed into something barely recognizable.

Now, rather than arriving before our residents and leaving after, our time is “protected” in many ways. We have lecture days devoid of patient care, service-learning commitments, and other activities designed to expand our learning beyond the hospital’s four walls. We have shelf exams demanding a much broader scope of knowledge than a typical day on the floor. Occasionally we’re granted a bit of time to study for said exams. Sometimes, we even have weekends.

This is progress, in many ways. Teachers with the right training are supervising patient care. We’re gaining exposure to ambulatory care, where the bulk of American medicine takes place. We’re acquiring the research skills to practice up-to-date medicine as it evolves, rather than learning from sheer repetition. We’re learning how to communicate humanistically and practice ethically. And, in fits and starts, each generation is learning a bit more about how the many pieces of the healthcare system fit together.

But I wonder how much has also been lost. Residents’ duties have gone from the bedside to the computer, where information flows in and orders stream out. We can “round” on vitals and labs at the nurses’ station without ever laying eyes (let alone hands) on the patient. Nurses, phlebotomists, and other members of the workforce have taken over so much of what we formerly called “patient care”—which in turn has evolved from a tactile task to a cognitive one. It’s no surprise that medical students’ experience has followed suit. By the end of a clerkship, we can rattle off pathology, pharmacology, and differential diagnoses till even the attendings fall asleep—but heaven forbid we’re asked to start a difficult IV. I worry I’ll end up in a new generation of well-read, friendly, ethical, system-conscious doctors who’ve learned the textbook but forgotten the patient.

As a student, the times when I’ve lacked longitudinal patient contact have been the most taxing. The hours spent chasing labs and consults or “rounding” at the nurses’ station are the ones that leave me wondering what medicine has become. And I have to ask if the apparent epidemic of physician burnout is really about too little human contact rather than too many hours on the floors. Some have decided that rather than returning to patient care, we should be learning on simulators instead. But to me, that would represent the pendulum swinging even farther away from those we must eventually serve. Lest the establishment forget, we will someday be treating patients rather than machines and multiple-choice problems. Will we be ready?

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Karan is a third-year student at Rutgers Robert Wood Johnson Medical School and Duke graduate who previously worked in strategic research for hospital executives.

Follow him on Twitter @KRChhabra or subscribe to the blog.

How my PCP alerted me to the potential for abuse in telehealth

by Tom Liu

I recently called my primary care physician (PCP) for the first time in years to get my immunization records, and encountered a strange message saying he was not currently seeing patients. My mom had apparently encountered the same message weeks ago. “Maybe he retired,” she suggested.

I did a quick google search of my PCP’s name to find an alternate contact number, and instead found a shocking article from the local newspaper. Apparently my PCP has been indicted for falsifying tax returns and participating in an online pharmacy organization that provided prescription drugs without an in-person physician examination.

Remote Prescribing: Lucrative, Pervasive, and Very Illegal

I did a quick search online and confirmed that the practice of offering prescription drugs through a “cyber doctor” prescription, relying only on a questionnaire is indeed very illegal.

It is also very pervasive. The National Association of Boards of Pharmacy (NABP) reviewed 10,700 websites selling prescription drugs and found that 97% of them were “Not Recommended”. Of these, 88% do not require a valid prescription and 60% issue prescriptions per online consultation or questionnaire only.

What struck me was how this appeared to be a case where the market came together to produce a “triple win” for profit-seeking internet pharmacies, shady physicians (such as my own), and a subset of patients willing to pay a premium to access drugs (most commonly weight loss drugs, erectile dysfunction drugs, and commonly-abused antidepressants and painkillers).

According to one analysis, one such website offering prescriptions from its own doctors listed prices for fluoxetine (brand name Prozac) and alprazolam (brand name Xanax) that were roughly 400% to 1800% higher than prices from a more traditional Internet pharmacy not offering prescriptions. The fact that such “remote prescription” websites remain in business despite the huge price differential suggests that they are attracting patients willing to pay that premium to avoid seeing their regular doctor. And as for where that money is going—well, my doctor was alleged to have received roughly $2.5 million over six years.

Similar Incentives Could Exist for Telehealth Writ Large

Given the clear business case driving abuse in this model of “remote prescribing”, I wondered about the risks of overuse and abuse in the rapidly burgeoning field of telehealth more broadly. After all, one of the promises of telehealth is its ability to make the delivery of services more convenient for both patients and providers. A physician could vastly expand the number of patients he/she sees without leaving the office—which has been identified as a potent way to alleviate the physician shortage problem.

But that would only hold true if the proliferation of telehealth does not generate additional, potentially unnecessary demand. And substantial evidence points to the presence of physician-induced demand under a fee-for-service system. Currently, Medicare pays for a limited set of telehealth services under the same fee-for-service payment model used for in-person visits. Within Medicaid, while select states are experimenting with bundled or capitated payments that include telehealth, others are retaining their fee-for-service model.

In a testimony before the House Energy and Commerce Committee last month, Dr. Ateev Mehrotra, an expert on telehealth, noted, “To reduce health care costs, telehealth options must replace in-person visits.” I’m not convinced this is the case—especially when there is a clear financial incentive to provide more care.

“The very advantage of telehealth, its ability to make care convenient, is also potentially its Achilles’ heel. Telehealth may be ‘too convenient.’” — Ateev Mehrotra

In some cases, fee-for-service payments for telehealth may result in outright fraud, as my physician may have done. In others, it may simply encourage providers to err on the side of providing more care given uncertainties in a practice environment. In fact, a study led by Dr. Mehrotra found that PCPs were more likely to prescribe antibiotics during e-visits than in-person visits.

As various constituencies continue to debate the best approach for paying for telehealth, it is imperative for us to better understand how the incentives and convenience of telehealth interact to affect overall utilization. Blindly carrying our existing fee-for-service system into the new world of telehealth options may produce some unintended consequences.

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Tom is a healthcare researcher with experience in public health and blindness prevention. Follow him on Twitter at  @tliu14 or check out his blog.

Is “progress” in medical education backfiring?

by Karan Chhabra

A good bit of fuss surrounds the evolution of medical education. The way we’re taught sometimes seems as susceptible to trends than the clothes we wear—one decade trumpets the “integrated,” systems-based curriculum, the next decade moves to the “flipped classroom,” and the cycle continues. Of course, these changes are based on educational theory, and their outcomes are often studied rigorously. But every now and then, when I rotate with a doctor trained the old-fashioned way, I wonder what has really been gained—and whether something has been lost—since the days they were taught.

I’ve seen how older physicians recollect tidbits from their preclinical years (decades ago) that my classmates and I can’t seem to remember past a few months. I wonder how much of this is the result of the way they were taught. Of course, there are many confounders here: our own intelligence versus those physicians’, our generation’s perpetual state of distraction, and perhaps the volume of material we’re expected to retain. The “old way” of teaching by discipline (anatomy, pathology, pharmacology, etc.) seems far less intuitive than the way we’re currently taught, by organ system (cardiovascular, gastrointestinal, etc.). To mentally switch from psoriasis to anti-arrhythmics in the same day seems like work.

But that may in fact be the secret to its success. I’m referring to research on “massed practice,” rapidly learning subjects en bloc, as opposed to “interleaved practice,” switching between learning tasks rapidly and revisiting the same topics day after day. A recent article (thanks Skeptical Scalpel) shows a relevant example:

 

Consider this study of thirty-eight surgical residents. They took a series of four short lessons in microsurgery: how to reattach tiny vessels… Half the docs completed all four lessons in a single day, which is the normal in-service schedule. The others completed the same four lessons but with a week’s interval between them.

 

…The difference in performance between the two groups was impressive. The residents who had taken all four sessions in a single day not only scored lower on all measures, but 16 percent of them damaged the rats’ vessels beyond repair and were unable to complete their surgeries.

 

Why is spaced practice more effective than massed practice? … Rapid fire practice leans on short-term memory. Durable learning, however, requires time for mental rehearsal and the other processes of consolidation. Hence, spaced practice works better. The increased effort required to retrieve the learning after a little forgetting has the effect of retriggering consolidation, further strengthening memory.

 

This effect isn’t limited to technical skills. The article also references cognitive tasks, like geometry problems. I wonder if it’d extend to preclinical medical education as well. I can personally relate to how a disease seen in one organ system, say in November, may literally never be seen again under an “integrated” curriculum.  It’s far easier to learn the pathogenesis of strokes and their treatment in the same week—but easier is not always better. Perhaps a trickier, thornier learning process is also sticker in the long run.

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Karan is a student at Rutgers Robert Wood Johnson Medical School and Duke graduate who previously worked in strategic research for hospital executives.

Follow him on Twitter @KRChhabra or subscribe to the blog.

Saving money in healthcare, PCMH edition

by Allan Joseph

I wanted to quickly follow up on Tom’s excellent post from yesterday on patient-centered medical homes (PCMHs), which nicely outlined some conflicting results from recent research on the model. (Edited to complete the sentence.)

It really shouldn’t surprise us that PCMHs only saved money in the 10% of patients with the highest risk. Why? Take a look at this chart from the NIHCM, which is one of my favorites in all of health policy:

Distribution of Healthcare Spending

Notice that the top 10% of spenders (not the same as the top 10% of risk scores, but pretty close) account for just about two-thirds of healthcare spending. The vast majority of patients account for very little spending — there’s no savings to be had there. Healthcare spending is highly concentrated at the top.

Now let’s look at spending from another angle. According to the Robert Wood Johnson Foundationtwo-thirds of healthcare spending is on patients with multiple chronic conditions. That means at minimum, roughly one-third of healthcare spending in America is spent on those patients in the top 10% with multiple chronic conditions. (To get even deeper, at least 16% of spending is on patients in the top 10% with three or more chronic conditions.) Of course, that’s only a lower bound — I’d be surprised if the number wasn’t much higher.

So what does this have to do with PCMHs? Well, the core idea behind a PCMH is greatly increased care coordination. That’s precisely the type of intervention that will help sick patients who have multiple chronic diseases — or the very group that accounts for a huge portion of our healthcare spending. No wonder the investment in PCMHs paid off for the sickest patients. They’re the ones where all the money to be saved is.

Given that the vast majority of patients who might use PCMH services account for little health spending, we should expect spending money to build a broad PCMH structure to save money on net. Nor should we be surprised that there’s money to be saved by better coordinating the care of the sickest patients. That’s the whole idea of the “hotspotting” movement. That’s also why Tom was spot-on to focus on the idea of “risk-adjusted population health,” such as focusing care managers on the sickest patients or designing separate clinics that focus exclusively on high-risk patients.

Sometimes it’s worth stepping back and taking stock of our intuitions about what might reduce healthcare costs. If an intervention isn’t aimed at the sickest patients, it’s probably not going to save a lot of money. Don’t be surprised when it doesn’t.

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Allan Joseph is a first year medical student at the Warren Alpert Medical School of Brown University, where he is pursuing an MD/MPP. You can follow him on Twitter @allanmjoseph.

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