Blog | Monday, August 21, 2017

Unintended consequences of medical rants


When I started blogging in 2002, I did not understand where blogging would go. I took a rather vanilla name, Medical Rants, due purely to naivety. Perhaps if I could have seen the future I would have used the phrase “unintended consequences” in the blog's title.

Medical care in 2017 suffers often from the unintended consequences that government has induced. I have written about this problem many times over the past 15 years. This problem is not just an American problem, but seemingly a problem throughout the world.

Our jobs become unnecessarily complex when Congress passes laws and when the Centers for Medicare and Medicaid Services (CMS) develops regulations. Here are some examples:

The four-hour rule for giving antibiotics for community acquired pneumonia (CAP)

A retrospective “big data” analysis suggested that patients who received their antibiotics within 4 hours of reaching the emergency department had better outcomes than those who had a “delay” in starting antibiotics. What could go wrong?

The first most obvious problem was that hospitals “encouraged” the emergency department to err on the side of giving antibiotics if CAP was likely. But how do we define likely? Hospital administrators saw the money attached to this measure and decided (implicitly) that sensitivity trumped specificity. You cannot increase the percentage of CAP patients receiving rapid antibiotics without also increasing the percentage of non-CAP patients receiving antibiotics.

Several articles documented the problem of antibiotic overuse. Further analyses documented the flaws in the original study that spurred this rule. The patients who had delayed antibiotics actually had confusing presentations complicated by more comorbidities.

CMS wants to decrease costs (as do all insurance companies and most countries with socialized medicine). So they latch on to a study that suggests a way to decrease length of stay. But they do not analyze the problem carefully. The demonstrate H.L. Mencken's great quote, “For every complex problem, there is a solution that is simple, neat, and wrong.”

The EMR push

Robert Wachter, MD, FACP, has documented this story beautifully in his book “The Digital Doctor.” Adopting electronic medical records (EMRs) seemed like a no-brainer to Congress. EMRs would have better data, decrease order errors and make data sharing so much easier.

Again the wonks did not think through the unintended consequences. You can recite them. Physicians spend long errors with the electronic patient rather than the real patient. Notes become bloated and virtually unreadable. Order errors still occur. EMR systems do not talk with each other. The law writers forget to prevent the EMR companies for having proprietary data structures.

Now EMRs do have some advantages, but there are no incentives for the companies to make their product doctor and patient friendly. The companies are making huge dollars selling to administrators. Physicians have little input into program design.

We bypassed market pressures to induce development EMRs that improved the doctor patient relationship and the exchange of information. Those factors were apparently never considered.

CMS billing rules

Every day, every hour in offices and hospitals, physicians report complete review of systems and physical exams, without regard to the necessity for performing and recording the review of systems and physical exam. So every day, the housestaff regurgitate meaningless words in the chart. The history has not changed, the exam has no relevance, but the chart contains the check list.

The patient has a sore throat, so we record the heart exam, the abdominal exam, a complete neurological exam, etc. And the inclusion of this often meaningless data bloats the chart.

CMS developed these rules so that billing would have requirements. They adopted resource-based relative value units, despite the obvious consequence of the ability of many physicians to game the system. The system makes no sense, and decreases communication among physicians.

CMS requirement for three nights in the hospital prior to paying for a transfer to a nursing home/the observation rule/prior authorization requiring the physician to stay on hold

Please help me expand this list.

The problem is actually simple. The rule makers do not think about the consequences of rule adoption. They do not include intelligent practicing physicians to comment on the rules. They just make rules.

These rules are often dangerous and costly. They do not consider evidence. They do not study the potential impact of their rules. Technically they commit malpractice.

db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and is the Regional Associate Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds over 100 days each year. This post originally appeared at his blog, db's Medical Rants.