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Thursday, May 2, 2013

Money, medicine and myopia

An opinion piece in the New York Times of April 4 makes the case that health care policy tends to lag well behind the imperatives of practice. The particular example highlighted is bariatric surgery. Bariatric surgery, so goes the argument, is now extremely prevalent and of proven value in the treatment of severe obesity yet still subject to antiquated restrictions.

The case made is that bariatric surgery became increasingly popular before much research was done. When research caught up, it showed a relatively high rate of complications. This, in turn, led to restrictions in Medicare reimbursement in 2006 so that bariatric surgery would be covered only at Centers of Excellence.

But a recent study in JAMA, featured in the New York Times piece, shows that complication rates since 2006 for privately-insured patients do not differ between such Centers of Excellence and their counterparts. Centers of "Mediocrity," I guess. The apparent reason for the absence of any gap is advances in surgical technique since 2006 that makes the Medicare restrictions obsolete.

Dr. Pauline Chen lays out just this case in her column in the New York Times. The punch line is that a "Center of Excellence" designation may outlive its utility. If bariatric surgery is every bit as excellent at centers with, and without, such a designation, the designation is at best useless and at worst misleading.

But while this is where Dr. Chen's argument ends, it's where mine begins. Because there is far more wrong here than a label of "excellence" that outlives its utility.

First, how do we account for the fact that over a span of years and decades, bariatric surgery did, indeed, become increasingly prevalent--the rate of operations rose "exponentially"--before systematic study and publication of outcomes and complications? How, in particular, do we account for this in an age of so-called "evidence-based" medicine?

The answers aren't hard to discern, but they are disturbing. One is that--and most colleagues with whom I've discussed this tend to concur, provided the conversation takes place in a cone of silence--we don't really have evidence-based medicine. We have reimbursement-based medicine. What gets studied is what gets done, and what gets done is what gets paid for. We like to think we figure out what works and then cover it. But we can't figure out that something works if it never gets any traction in the first place. In the pursuit of evidence, cart and horse routinely swap positions, and money cracks the whip.

A serious and fundamental problem resides where the tendency to medicalize meets inside-the-box myopia. That tendency to medicalize, symptomatic no doubt of living in an age of technology and pharmacology advancing much faster than wisdom, is a matter of increasing attention and concern. A poignant column in the New York Times of April 1 made that very point. I have long lamented the modern inclination to bolt normally rambunctious children to chairs all day long, then prescribe Ritalin when they can't sit still. Yes, there really is ADD/ADHD that warrants medication. But the proper remedy for rambunctiousness in young children is recess, not Ritalin. And yes, we have actual data to show the substitution can work.

The related myopia is that once we medicalize everything from restlessness to weight gain, we tend to look for solutions within the walls of medicine -- and neglect the world of opportunity outside that box. The reality is that lifestyle is the best and most powerful medicine we have. But it tends not to be on the Medicare radar.

So, for instance: Why is it that bariatric surgery was routinely reimbursed long before data collection was robust, but a boarding school that can produce comparable or better results at lower overall cost won't be? Because our culture has told us that all health problems are medical problems, and medical problems warrant medical solutions. Despite our ostensible fervor for evidence, we are culturally indoctrinated to presume that drugs and operations are the right ways to fix health problems. They are to some extent presumed effective until proven otherwise.

The very opposite is true of non-medical, lifestyle-based interventions that are ultimately far more powerful. One good example is the widely-known heart disease reversal program developed by my friend, Dr. Dean Ornish. Some 15 years of study were required to establish this as a reimbursable alternative to coronary bypass surgery. In contrast, coronary bypass surgery was reimbursed from the start. There are many other examples, but no need to belabor the point.

Back to bariatric surgery. I would like to be clear that I support its availability to all who need it; that position is long a matter of public record. Bariatric surgery is effective and often works when nothing else does. If anything, reimbursement for it is, as Dr. Chen argues, unduly restricted. But I oppose a cultural orientation that seems cavalier about rerouting the gastrointestinal tract to fix what a genuine commitment to better use of feet and forks could prevent. If we can, for instance, impart to our teenage sons and daughters the skillpower to lose weight and find health through education, should we really be so willing to send them through the OR doors instead?

If there is a counterargument of any merit, it's that we have too little evidence to support the real-world utility of lifestyle-as-medicine approaches. That's true, but it is a symptom of our medical myopia, not an excuse for it.

And so the second great conundrum here is a potentially massive misallocation of money. It's not just that we reimburse for surgery while neglecting non-medical approaches that could work as well or better. It's that our entire system of biomedical advance, and the investments that underlie it, favor the ... well, biomedical.

What I mean is that the somewhat more than $30 billion annual budget of the National Institutes of Health is overwhelmingly directed at promoting basic science advances and clinical intervention trials. Another huge sum of money is provided by pharmaceutical and device companies to study, you guessed it, drugs and devices.

A vanishingly tiny portion of the NIH budget is allocated to figuring out how to turn what we already know into what we routinely do. Since what we already know would allow us to eliminate fully 80% or more of all chronic disease, heart disease, cancer, stroke, diabetes, dementia, that seems a potentially serious oversight.

I am a scientist--I run a clinical laboratory--and so I don't just trust my intuition and convictions; I respect the need to verify. To that end, colleagues and I, including one of the world's preeminent health economists, developed a protocol to study allocations of NIH money and determine how they might best advance the human condition over some specified time horizon (e.g., a decade, or two, or three). So far, we haven't been able to get funding for the study.

So I can't say, on the basis of evidence, that NIH is misdirecting vast fortunes from where they could do the most good within our lifetimes. But I certainly do believe it. What I can say is that biomedical research dollars are subject to the same myopia that tends to dominate our personal lives. There is a saying of uncertain origin that most of us spend more time planning a two-week vacation than the upcoming decades of our life. In the case of the NIH, I can say, as both a grant applicant and reviewer, that individual research applications are scrutinized just like that vacation. But the whole budget is rather like those decades. To the best of my knowledge and that of every expert colleague with whom I have conferred, there has been virtually no systematic study of how the whole sum is allocated across an array of potential projects to establish what would do the most good.

The restriction of Medicare reimbursement for bariatric surgery to Centers of Excellence may well be obsolete, and that's a problem. But fussing over which centers to reimburse for weight loss surgery while neglecting the opportunities to prevent that weight gain in the first place is a far bigger problem. Worrying about how best to direct scalpels while neglecting opportunities to make better use of feet and forks routine is a far bigger problem. Choosing among biomedical solutions while ignoring all options outside those walls is a far bigger problem.

The bad news is we have bigger problems. The good news is we have corresponding solutions. But we will find our way to them only if we climb the entanglements of money and medicine, overcome our prevailing myopia, and take in the landscape of neglected opportunity outside the box.

David L. Katz, MD, FACP, MPH, FACPM, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care. He is a board certified specialist in both Internal Medicine, and Preventive Medicine/Public Health, and Associate Professor (adjunct) in Public Health Practice at the Yale University School of Medicine. He is the Director and founder (1998) of Yale University's Prevention Research Center; Director and founder of the Integrative Medicine Center at Griffin Hospital (2000) in Derby, Conn.; founder and president of the non-profit Turn the Tide Foundation; and formerly the Director of Medical Studies in Public Health at the Yale School of Medicine for eight years. This post originally appeared on his blog at The Huffington Post.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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