More is Not Better

It is customary to believe that more is better. Higher availability and more access = better care...right? Wrong! A recent interaction at the pediatricians office amplified the point and the influence that the patient can have. In a case of extended week long general malaise some level of investigation and therapy was warranted and we agreed on some basic blood work. But in the conversation with the pediatrician she explained that many of her patients were insisting on "Lyme Titre's" based on local reporting of "huge increases in Lyme disease". Nationally the incidence runs around 0.04% and is considered "rare". I could have insisted but logically it made no sense - there had been no possible instance of exposure to risk factors (tick bites) so what would that test bring. But my choice was clearly not the norm.

It is this excess utilization driven by the system that is detailed in in Atul Gawande article penned a another insightful piece in the New Yorker that shreds the notion that we are getting better care just based on higher access. "The Cost Conundrum" is the talk of the town and rightly so.

In his tale of two cites - 800 miles apart in Texas the data available on healthcare costs and results shows that McAllen, Texas is spending approximately twice the cost (~ $15,000 per enrollee). Currently Medicare income per capita is $12,000....! In El Paso - some 800 miles away the costs are half as much running at around $7,504 per enrollee. Similar mix of demographics and public health statistics.

His discussions with local residents and providers was revealing in the wide variation of possible causes:

• McAllen is providing unusually good care (it's not)
• Better technology availability (it's not)
• More doctors (no difference)
• The service is better
• Malpractice is a bigger problem (not based on the recent Texas law capping malpractice claims)

In Fact on the quality metrics published by Medicare:

Nor does the care given in McAllen stand out for its quality. Medicare ranks hospitals on twenty-five metrics of care. On all but two of these, McAllen’s five largest hospitals performed worse, on average, than El Paso’s.

Not only is the cost troubling but the outcomes show that the population is not getting value for their expenditure. As is so often the case if you follow the money" the answer becomes evident. Our system incentivise use not results. As the cardiologists put it when asked about a hypothetical patient with chest pain that goes away and has no associated family history or other clinical indicators to suggest heart disease...

“Oh, she’s definitely getting a cath,” the internist said, laughing grimly.

And for many patients this would be a great outcome. They got the test they needed and ruled out heart disease. Not so for the sub group who are unfortunate to suffer complications some minor and transient and some major and permanent (you can get a good overview of the procedure and complications here):

The1-2% of people who get major complications from the procedure, the 0.08% who die from the procedure, the 0.03% who have a myocardial infarction precipitated by the procedure, the 0.06% who have a devastating stroke or the 0.62% or 0.06% depending on the approach Hospital Acquired Infection, the 1% who have an allergic reaction to one of the many agents used, the 1% who may go on to develop renal dysfunction....still feeling good about the investigation?

In McAllen the analysis of the Medicare data revealed some troubling variation compared to El Paso:

Between 2001 and 2005, critically ill Medicare patients received almost fifty per cent more specialist visits in McAllen than in El Paso, and were two-thirds more likely to see ten or more specialists in a six-month period. In 2005 and 2006, patients in McAllen received twenty per cent more abdominal ultrasounds, thirty per cent more bone-density studies, sixty per cent more stress tests with echocardiography, two hundred per cent more nerve-conduction studies to diagnose carpal-tunnel syndrome, and five hundred and fifty per cent more urine-flow studies to diagnose prostate troubles. They received one-fifth to two-thirds more gallbladder operations, knee replacements, breast biopsies, and bladder scopes. They also received two to three times as many pacemakers, implantable defibrillators, cardiac-bypass operations, carotid endarterectomies, and coronary-artery stents. And Medicare paid for five times as many home-nurse visits.

As Atul Gawande put it:

The primary cause of McAllen’s extreme costs was, very simply, the across-the-board overuse of medicine.

The good news is that just having the technology does not necessarily translate into over use. The Mayo clinic in Rochester has some of the highest levels of technological availability but one of the lower rates of Medicare spending (in the lowest 15% of the country at $6,688).

At the core of this story is data - the lack of insight and availability of data was troubling:

It was a depressing conversation—not because I thought the executives were being evasive but because they weren’t being evasive. The data on McAllen’s costs were clearly new to them. They were defending McAllen reflexively. But they really didn’t know the big picture of what was happening.

The most expensive piece of equipment in the hospital is a doctor's pen. But this tool has been heavily influenced by knowledge and availability of best practices. Where best practices are well defined there is close alignment in the clinical choices. Where the science is unclear the variations arise from high levels of investigation (in areas of low cost healthcare delivery) to low levels and conservative treatment (in areas of low cost healthcare delivery). Overall the intent is not to over charge or provide more care but the underlying drivers change behavior for clinicians who try to cope with a complex and overwhelming system that they have little training to deal with.

To borrow form the Six Sigma and Deming's "Plan-Do-Check-Act" Cycle Six Sigma attacks problems with DMAIC

• Define high-level project goals and the current process.
• Measure key aspects of the current process and collect relevant data.
• Analyze the data to verify cause-and-effect relationships. Determine what the relationships are, and attempt to ensure that all factors have been considered.
• Improve or optimize the process based upon data analysis using techniques like Design of experiments.
• Control to ensure that any deviations from target are corrected before they result in defects. Set up pilot runs to establish process capability, move on to production, set up control mechanisms and continuously monitor the process.

Rinse lather and repeat. Critical to this process is developing measures and collecting the data to measure. But healthcare has lived in a wilderness of data both clinical and financial. Everything about the current system is focused on increasing volume in part to offset the decreasing levels of reimbursement. Creating systems like the Mayo that deliver care where "the needs of the patient come first" is at the core of the changes necessary. What is interesting is that most here would love access to the Mayo care but in the political battlefield the concepts and ideas are tainted as rationing and limits to our supposedly great service.

Everyone likes to bash the NHS in the United Kingdom and roll out the legion of complainers who list the reasons why the system is not working while failing to acknowledge the integrated care and access helps deliver better care. While the NHS may not be the perfect system it does encompass elements that we should learn from. I know which care I'd prefer to receive - that of the Mayo style; balanced and high quality. I avoid the McAllen experience where possible recognizing that the "MD" at the end of my name can influence the clinical interaction positively or negatively. I can invariable force the investigation or test if I choose to but I elect to be far more conservative in my approach for me and my family. As I did with the Lyme Titre and do repeatedly - I remain conservative bucking the trend.

Do you? Would you have insisted on the Lyme Titre or just accepted it when it was mentioned simply because you had heard about Lyme disease, were worried and your physician had mentioned it? More is not always better. What's your experience?