Cookbook Medicine

Would you like the government to tell your doctor how to take care of you? That possibility is not as remote as you may think.

Medicare recently announced it will start paying more to hospitals that follow a dozen procedures, including administering antibiotics prior to surgery and anti-clotting medication to heart attack patients. It will pay less to hospitals that don’t comply. The same thing is about to happen to doctors. Those who comply on up to 194 different metrics— including adopting electronic medical records — will get higher fees. Those who resist will get lower ones.

These are examples of a much larger trend: Washington telling the medical community how to practice medicine. Even though a recent study finds little relationship between the inputs Medicare wants to pay for and such outputs as patient survival, and even though the latest pilot programs show that paying doctors and hospitals for performance doesn’t improve the quality, we are about to usher in the era of big brother medical care.

Remember these words: “evidence-based care.” They are likely to be very much a part of your future.

To its advocates, evidence-based care follows medical treatment guidelines and protocols developed by experts, based on the scientific literature — as reported in medical journals and scholarly reports. If all doctors follow the same protocols, they argue, patients with similar conditions will be treated the same way. Wide variations in the practice of medicine would be replaced by uniform, standardized treatments. This view is about to dominate the entire health care system.

If you are elderly or disabled, Medicare will probably refuse to pay for any procedures that aren’t evidence-based. If you get health insurance at work, your employer will probably do the same. If you buy your own insurance, you won’t have much choice about the matter. The only health insurers that will be allowed in the new (ObamaCare) health insurance exchanges — certainly the only ones that survive — will be those that limit coverage to evidence-based care.

Before long, virtually all doctors will be practicing only the kind of medicine the health plans cover. After all, most doctors like to get paid for what they do. If that’s not incentive enough, the Obama administration has a medical malpractice carrot and stick it wants to try out. If doctors follow protocols and guidelines developed by committees of experts, they will be immune from lawsuits. If they don’t, they will have to take their chances.

So what’s wrong with that? Don’t you want your doctor’s advice to be based on scientific evidence? Don’t you want her to follow guidelines that have been written by reputable scholars who have surveyed all the relevant literature?

So what’s not to like? A lot, it turns out.


Don’t you think maybe

We could find us a

Brand new recipe?


Think about the calendar you keep on your laptop or your cell phone. It’s probably an invaluable aide to help you organize your life. Now suppose that instead of being your servant, the calendar becomes your master. What if there were a rule that says you can’t do anything during the week unless it is on the calendar by Sunday. Call this “calendar-based scheduling.” Instead of being an aide, the calendar would quickly become an oppressive barrier to your freedom of action.

The same principle applies in medicine. Protocols and guidelines can be helpful or harmful, depending on how they are used. And there are six reasons why such guidelines — in the wrong hands — can reduce the quality of care you receive.

First, in most areas of medicine, there are no treatment guidelines; and where there are, they are often unreliable, conflicting and incomplete. Even for something as straightforward as deciding when women should get mammograms there is conflicting advice. (See here, here, here and here.) If insurers have to choose among conflicting and inconsistent guidelines, which ones do you think they will choose? The ones that cost them less money, of course.

Second, even where there are well established guidelines, they are inevitably written for the average patient. But suppose you are not average. Is your doctor free to step outside the protocols and give you care based on her training, knowledge and experience? Or will she be pressured to stick to the cookbook, regardless of how the patient fares? Health plans always say that doctors are free to step outside the guidelines if they have good reason for doing so. But if the doctor is forced to fill out multiple forms and jump through lots of hoops, many will conform to the guidelines even if that’s bad for you.

Third, guidelines are often written by people who are not disinterested. One study found that 56% of the doctors who helped write guidelines for treatment of heart ailments had potential conflicts of interest. These conflicts are more common than is generally realized. Writing in The New York Times, University of Texas law professor Ronen Avraham notes that:

Guidelines produced by insurance companies sometimes put their interests first. Malpractice insurers, for example, may recommend yearly mammograms, even if they are not necessary, because they bear the costs of lawsuits for late diagnoses of breast cancer — and not the costs or health risks of the extra mammograms. Moreover, the nonprofit groups behind many other guidelines have traditionally depended on pharmaceutical and medical device companies to finance their work. Last year, the Council of Medical Specialty Societies issued a new code of conduct seeking to stop these industries from sponsoring the development of guidelines, but there are still too many loopholes, and thousands of guidelines produced before the reform are still in circulation.

In one particularly egregious case, Eli Lilly and Co. funded medical guidelines created for the treatment of a deadly infection in an effort to boost sales of a drug with questionable benefits. (See David Williams and this story in The Boston Globe.)

Fourth, evidence-based guidelines are based on studies; and these studies often exclude entire segments of the population. For example, a large number of studies of patients with heart failure excluded elderly patients even though most of the people who have this problem are elderly! If you are an elderly patient do you want your doctor to follow procedures that were based on studies of patients 30 or 40 years younger than you are? According to Don Taylor (Incidental Economist) it is not at all unusual to exclude patients with characteristics and conditions from clinical trials who are then subjected to the guidelines after the trial is over.

Fifth, the “gold standard” of medical research is the randomized controlled trial (RCT). But Steven Goldberg has catalogued all kinds of reasons why even these experiments are often poor guides for practitioners dealing with real patients.

Finally, the whole idea behind guidelines and protocols is that it is appropriate to treat patients with similar conditions the same way. But individuals are individuals. They don’t always respond to treatments the same way. For substance abuse, for example, there apparently is no such thing as a protocol that works for diverse groups of patients.

Like electronic medical records and computerized protocols, evidence-based guidelines could be a boon to medical practice, helping doctors do their jobs. But when these tools substitute for the doctors’ judgments, patients are likely to be the losers.

Comments (30)

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  1. Tom says:

    Insightful. I don’t think I’d like calendar-based scheduling…

  2. ralph weber, says:

    Soon, we’ll all be calling a call taker in India who will triage us using a symptom checker before you can get a referral to a nurse practitioner. Don’t think it will happen? Canada has a nurse help line as the first step of triage! Washington has a HUGE database of “evidence based medicine”, which is the basis of this cookbook, and sadly many doctors have been hoodwinked into cooperating in their own extinction.

  3. Eric says:

    An interesting take. But given how many patients presently receive unnecessary or inappropriate care (and suffer harm as a result) it seems like a necessary step to take. Just as the government and insurers would have incentives to choose lower-cost procedures, practitioners presently have incentives to provide more invasive, costly care (both because of personal/hospital profits and fear of malpractice) that doesn’t necessarily help patients.

    For conservatives who complain about wasted spending and like financial incentives, this seems to be a reasonable solution. Much will depend on who develops the guidelines, but if an independent scientific body with no financial interest develops the guidelines, wouldn’t the rationing problem be mitigated?

    I agree practitioners need flexibility to practice and take care of a diverse patient population, but I don’t think that freedom extends to providing care that is unnecessary, inappropriate, and not supported by evidence. Given the multitude of problems that the present paradigm of “freedom” is causing the US health care system, I think it’s time to look into other methods.

    The status quo is clearly unacceptable, and I don’t think it’s reasonable to expect the system to change without changes to the reimbursement system.

  4. Jay A. Huminsky, RHU, REBC says:

    Like Eric, you have an interesting take John, but a bit over the top. From a FAR right winger like me that should say something. We all know that special interests exist in the healthcare delivery system: the government, the insurance industry, the hospital systems, Rx companies, provider groups, practice management, and the individual small town provider. Sadly do less and charge more has pushed out reasonable and prudent as a goal for all. If reasonable and prudent was applied by all we would still have a problem…no standard.

    Evidence based medicine, when executed properly, uses a global matrix that determines most effective treatment patterns. This does not mean one treatment fits all. There is a “Step” process in some cases, so long as the “Steps” do not adversly increase cost.

    Evidence based medicine will suffer that same problem that the overall delivey system suffers. Too much self interest and not enough patient interest. Evidence based medicine, in its purest form, “IS” in the best interest of the patient.

  5. Allan says:

    Eric writes: “Much will depend on who develops the guidelines, but if an independent scientific body with no financial interest develops the guidelines, wouldn’t the rationing problem be mitigated?”

    I wonder if Eric can mention a few groups that have existed for long periods of time that don’t have any “financial interest” and are totally “independent”. I will assume that if there is no list presented that none exist or are extremely rare. That negates his point.

  6. Robert says:

    I mostly agree but how will the independent body be paid for their work, will they do it for free? How do we define “independent” or keep them that way?

    The other method we could look into is allow people seeking medical services control over their own money and they can ask physicians up front about the costs associated with the services and if they want to pay them.

    Perhaps they could even ask which “indepednet body” is recomending that procedure and why, or what other independent bodies say about procedure.
    That way if a person wants “unnecessary or inappropriate care” or choses the “lower-cost procedures” it is strictly between themselves and physician.

  7. ralph weber, CLU, ChFC, CFP, GBA, REBC says:

    Price fixing is still price fixing even with incentives.

    Pay $13,000 for a Kia, and it’s a Kia. Pay $50,000 for the same Kia, and it’s STILL a Kia.

    The price fixing in the system is a disease in the heart of they system. Change it to an ACO, ICD 10, ICD 11, change it to anything you want and it will STILL fail, because it is based on economic philosophies which will NEVER work

  8. Eric says:

    It’s definitely a good point that a truly independent organization will be tough to find/fund. PCORI and the Cochrane Collaboration are two kinds of groups that could potentially be suited for such a role. It may be difficult or impossible for such an organization to make guidelines without government funding, but I still think that they can operate independently if they are lead/directed by an independent board of directors without government involvement.

    And Jay, great point. Alarmists are trying to spin evidence-based medicine as a dirty word, but the fact of the matter is that all good medical practice is evidence-based, and the goal of all providers should be to provide the best care for their patients, as supported by evidence. Grey areas will exist when there are limitations to such evidence, and these grey areas are potentially problematic. That does not mean we should forgo evidence-based medicine altogether, but instead, work to expand the knowledge base to fill in those gaps. To dismiss evidence-based medicine as “cookbook medicine” does a disservice to one’s credibility in being able to have a serious discussion about health care.

  9. Allan says:

    Eric, note how you are unable to list any groups that “have existed for long periods of time that don’t have any “financial interest” and are totally “independent”. Instead you had to rely upon an existing group (that you personally favor) to fill the position you mention. I believe this group mostly developed in the market place and had to satisfy a wide group of interests that guarantee their existence. People have a tendency to do a good job doing so in the market place. But, once the group has a mandate from government the incentives change and that group has to answer to the government. If the government can so easily grant a mandate it can just as easily take it away.

    Regarding your comment to Jay, a lot (possibly most) of medical care doesn’t have strong evidence backing it up. Not only that but the evidence for many things done changes faster than the guidelines can be written. By the way physicians use guidelines all the time, but they choose them based upon the newest things written in the journals and texts.

  10. John R. Graham says:

    In what other endeavor do we allow government regulators to define “evidence”? Nowhere: Even in criminal proceedings, the weighing of evidence is done in front of a jury by adversarial attorneys.

  11. Linda Gorman says:

    Evidence-based medicine is a term invented in the late 1980s to justify the use of RCTs to guide the practice of medicine. It is a very specific term. It is not necessarily about making the practice of medicine use all available information to improve decision making. It does give academic medicine a lot more power to control medical practice.

    EBM is not particularly scientific as it rates some types of information above others. It hugely downgrades clinical observation. Real science looks at all kinds of information.

    RCTs may or may not be well designed and may or may not have reasonable endpoints that measure anything that anyone cares about. They take forever and are very, very, expensive. They may or not have enough power to avoid making a type II error. They may or may not have a representative sample, as we know very little about how genetic differences interact with various kinds of medical practice. We also know nothing about the people who simply refuse to participate in trials.

    One of the biggest RCT debacles in the last decade or so was the ALLHAT trial which ended up recommending diuretics as first line treatment in hypertension based on a flawed sample and serious questions about the endpoints. The hormone replacement results form the Women’s Health Initiative are another case of testing drugs that aren’t prescribed for patient populations that don’t take them. More recent evidence suggests that the conclusions were incorrect due, once again, to a flawed sample asking the wrong questions.

    The discovery of h. pylori by Barry Marshall and J. Robin Warren is a good cautionary tale about over dependence on the formal structures of evidence-based medicine, or comparative effectiveness research, as people are now trying to call it (just like global warming got a bad name and has been morphed into climate change). Careful observation and testing discovered h. pylori and developed the treatment for it, not RCTs.

  12. Eric says:

    Allan, I’m not totally sure why existing for a long time is an important criterion for a group that evaluates existing evidence for the purpose of creating clinical practice guidelines. While you are correct that PCORI is new, Cochrane has been in existence since 1993, and is completely independent. It could be an interesting model to replicate, with some modifications. PCORI was established by the ACA, but is also an independent organization.

    I agree that guidelines are not the be-all and end-all, and will definitely have to evolve to keep up with expanding knowledge. I don’t subscribe to the slippery-slope logic that guidelines will lead to bureaucratic rationing of care and government death panels, and I would want these guidelines to be created by independent scientists who are experts in their field and who have thoroughly reviewed the available literature (as opposed to government bureaucrats with an interest in cutting costs).

    I don’t necessarily agree with your assertion that physicians operate based on the most recent scientific evidence. It often takes many years for new findings in the literature to make their way into clinical practice (some delay is certainly warranted to verify the evidence, but still…). Anecdotally that may be true but on the whole there are way too many instances of care being provided that runs counter to the most current evidence (such as PSA testing on older men) that have been shown to have no benefit, and possible harms.

    There is certainly no easy fix to the current problems in the US health care system, but to dismiss possible solutions based on ideology is short-sighted. Guidelines are certainly not a perfect answer (as Linda describes), but they are definitely a move in the right direction toward reducing the frequency of inappropriate or unnecessary care that patients receive.

  13. Frank Timmins says:


    “Evidence based medicine, when executed properly, uses a global matrix that determines most effective treatment patterns.”

    Jay, your caveat, “when executed properly”, preempts any argument for its use as a third party benefit determination tool. It actually can never be executed properly unless human procreation suddenly morphs into a humanoid/robot manufacturing process that neatly blueprints all operating systems with manuals for repair and upkeep, and a formalized recall system for faulty parts (like a Chevy Tahoe). I don’t think we are quite that far along in understanding our biology. It’s absurd to defend “best practices” as a fair and logical benefit determination when it is really no more than an excuse for cost control.

    I have a recent personal experience to validate how silly this stuff is. I had to go see a sports Orthopod because of a messed up knee (no Jay, I wasn’t sky diving), and he said he pretty much knew what the problem was but could only confirm with an MRI. I said fine. I have an HSA through our local version of the blue monolith, and I just need to get them to reprice the MRI so that it can apply to my HSA deductible.

    Well guess what? They refused to “approve” the MRI because a clerk in the insurance claim office determined that “protocol” required several other procedures (including cortisone shots) before doing an MRI. This guy has not only been my doctor for 20 years (and knows my creaky body ailments very well), he is good enough to do all the orthopedic work for one of our local professional sports teams as well. He rolled his eyes and explained that all the protocols would be a waste of not only time but money. If the issue were a life threatening one it could be a waste of a lot more. I went ahead and had the MRI, paid for it out of my HSA and didn’t even turn it into the carrier. Anyone who couldn’t afford to do that is a casualty of third party management stupidity.

    The bottom line is this little adventure is not an isolated anecdote, but more the rule than the exception. We simply don’t know enough to make this kind of thing work other than as helpful guidelines to doctors.

  14. David C. Rose says:


    This was an excellent post. I agree with all of it. I would like to add two points.

    First, what actual doctors understand but bureaucrats don’t is that treating a patient is not like fixing a car. With a car we can usually make a clear diagnosis and then decide on a repair. But in medicine doctors often begin treating a problem before they know for sure what it is. This is why an indemnity model will never work for health care. But more to the point, standard treatment protocols will have the effect of driving doctors to consider following such protocols first, but not just because doing so pays better. Making matters worse, such protocols will soon become de facto standards by which doctors can defend their actions ex post. This will drive the art of diagnosis to the science of rule following but since the most efficient practice of medicine is both art and science, we’ll get worse care in the process. I want a doctor, not a bureaucrat.

    Second, things change. In a free market economy when things change competitors respond to those changes in a variety of ways. The greater the number of competitors and the more freedom they have, the greater will be the diversity of responses. The greater the diversity of responses, the closer one will come to the very best response. Soon everyone else will copy the best response. That will then become an organic standard upon which subsequent evolution of the practice of medicine is based. We have the best health care in the world for a reason.

    Diversity is a beautiful thing. It’s a pity that those who claim to love it don’t fully appreciate it. In any case, a free market economy is not a toaster that can be reverse engineered, fully understood, then repaired or modified as we see fit. A free market economy is much more like an ecosystem that is constantly evolving so even if we have a strong command of the details (our understanding of DNA, for example) we have no idea when a new species will pop up. We can’t even predict the population distribution over existing species over time in the near future. Too many moving parts, as it were.

    Many amazing things in a free market economy would have never happened in a centrally planned economy, even if the latter were run by only 180+ IQ people. The reason why is that there is no substitute for a diversity of experiments responding to each and every change, responses that are then winnowed by the discipline of competition. It’s a beautiful thing. It produced the American healthcare system. I recommend the government allow the American healthcare system to reacquaint itself.


  15. Frank Timmins says:


    “…Guidelines are certainly not a perfect answer (as Linda describes), but they are definitely a move in the right direction toward reducing the frequency of inappropriate or unnecessary care that patients receive.”

    Trying to solve the problem this way is like blaming the ice berg for the titanic disaster. Why is it so hard to accept the fact that inappropriate and unnecessary care is the result of the absence of the payer at the site of the service. People have an amazing ability to “smarten up” about the service they are buying when they are reaching into their own coin purse for the payment.

    Why don’t we try the simple solution before we take the presumptuous step of trying to categorize the nuances of the medical profession and the ailments of the human body?

  16. James says:

    Mr. Timmins,
    RE: your comments: “They refused to “approve” the MRI because a clerk in the insurance claim office determined that “protocol” required several other procedures (including cortisone shots) before doing an MRI.” and “The bottom line is this little adventure is not an isolated anecdote, but more the rule than the exception.”
    You are making an excellent argument for single-payer Medicare-for-All universal health care. For-profit private insurers care only about one thing: making a profit. So, they will focus on “not approving” health care services whenever they can, especially if they’re expensive. Under Medicare, if your doctor ordered the MRI for the medically-necessary condition you described, it would have been done (and paid for), period.
    Also, your comment “I went ahead and had the MRI, paid for it out of my HSA … Anyone who couldn’t afford to do that is a casualty of third party management stupidity” also supports single-payer reform, because what you call “third party management stupidity” is really a rational profit-oriented activity and “anyone who couldn’t afford to do that” applies to the majority of Americans. Most Americans don’t have HSAs. MRIs are expensive. Therefore, unless it’s a true medical emergency (in which case they can get it for “free” in the ER), they won’t get their MRI if they have to pay for it.

  17. Neil H. says:

    James, what kind of fantasy world are you living in? All Medicare enrollees are soon to be enrolled in ACO-type HMOs, where they will be denied access to all kinds of tests and other care. And yes, that includes MRIs.

  18. Tom says:

    John: Your anecdotal article on cookbook medicine does doctors and patients a disservice. Your reference to pre-operative antibiotics contradicts your message in that adherence to this guideline has dramatically reduced post-operative infections. Likewise, measures to reduce post-operative venous thrombosis and pulmonary emboli have proven efficacy. The treatment of asthma has been improved by standardization Emergency room responses to acute coronary and cererovascular events have been disseminated from acute care centers to rural hospitals where there may be no physician available. As a practicing physician, I have witnessed a massive increase in medical knowledge and its complexity in the past 40 years. Packaged as evidence-based medicine, it is delivered to my doorstep for the benefit of my patients. I still have the responsibility to apply it appropriately to each one.

    Jay: Did the MRI for which you paid the absurd retail price confirm the orthpod’s diagnosis? Second, did it alter how he would have treated you without it? Was your final treatment the steroid injection suggested by the insurance carrier? An MRI is a wonderful diagnostic tool but very expensive if all it provides is reassurance.

    David: Diversity may be a beautiful thing but not in your doctor’s office. Let your personal physician apply the knowledge amassed over the past 100 years and now available in collated form as evidence-based medicine. Leave experimention to the laboratory or organized clinical setting. It works better that way. Witness the four new cancer treatments announced at the ASCO meeting last week.

    As always, this is a stimulating forum.

    Tom Newsome, M.D.

  19. Linda Gorman says:

    Dr. Newsome: Say I have 5 children under 7. Two of them have strep. The three others show all of the physical symptoms of strep. Are you going to follow the guidelines and make me pay more than $100 for strep tests?

  20. Allan says:

    Mandated groups as opposed to market based groups: I think you completely missed the point. Once Cochrane is mandated to have exclusive power, assuming your assessment of Cochrane to represent perfection is correct, they now have a change in their incentives so they are no longer the identical entity they were before the mandate. Cochrane is an example of an entity that may be good but once it is a mandated government entity their independence becomes questionable and the likelihood of their quality or effectiveness degenerating is almost assured. So far you have not mentioned an entity that has been mandated by the state and has proven to be as beneficent as it seems you think they need to be. All the entities I can think of have failed over time.

    Independent: When you use the word “independent ” remember there is a difference between the use of a word and its actual deeds.

    Slippery slope argument: If you “I don’t subscribe to the slippery-slope logic that guidelines will lead to bureaucratic rationing of care” believe what you say then IMO you do not understand how decisions in medicine are made. If one doesn’t fit into the guideline one might be denied payment for something that may save that person’s life and because of that the person might die. Maybe that is a social good, but that means that rationing does occur and can cost someone their life.

    Guidelines: You are correct that it takes time for all physicians to incorporate new knowledge into their treatment program and sometimes that is to the advantage of the patient. But what we are talking about is creating guidelines based upon studies that will take years to produce and years to be peer reviewed and published during which time medicine will have advanced making many of those guidelines obsolete.

    Specifics: Tell us what the guidelines should be for a person with mitral valve insufficiency and when they should be operated upon. The insurance companies might want to wait (the US government acts as an “insurer”) until the symptoms are well developed to save money. But that might mean that the heart already changed and will negatively impact the patient for the rest of his life. The medical decision is made based upon risk/benefit calculations which depend upon the individual patient, the technology available at the time and a whole host of other things that might change tomorrow.

    Additionally would you like to tell us at exactly what age PSA testing is indicated since you drew such direct and specific conclusions? “Older men” is very vague and really shouldn’t be used.

    Statins and NICE: Guidelines are OK as long as they are voluntary. Look at the Statin guidelines. I think Britain has a so called beneficent group that you might feel is independent. It’s called NICE, but I believe they do not follow those guidelines. Why? Because they might feel it costs the government too much money. That is known as rationing.

  21. Frank Timmins says:

    @ James

    James, I don’t think you understand what the ACA is all about. The techniques of third party managed care are the model for the new law. The implications of the “profit” motivation of the insurance company will be multiplied by the bureaucrats who will restrict benefits and access with impunity in order to keep costs down. The insurance carriers (even in the quasi competitive environment we now have) have to answer to their clients, and they can be removed and replaced.

    Of course, the new law is merely a gateway to the inevitable “single payer” scenario you suggest. How do you think the bureaucrats in charge of such a program will control costs? Medicare? Soon Medicare benefits will be doled out in a way that would make the stingiest of insurance companies look generous.

    If we have a true competitive market for healthcare, the “profit” impact on overall costs will be irrelevant. Health insurance markets are no different than any other product or service when competition is allowed to flourish.

    By the way, you are right that “most Americans do not have HSAs”. Who do we blame for that?

  22. Frank Timmins says:

    Tom, to answer your question the MRI confirmed the suspicions of the doctor – medial and lateral meniscus tears. Cortisone was not a good option. X-rays, one of the other suggested prerequisites to the MRI, would have shown nothing and been a waste of time and money. Now I know what I need to do to get the most mileage possible out of that knee before having it fixed. The MRI was the only way to do that.

    The bottom line here proves the most effective cost control management was mutually determined between my doctor and myself, and the time and money waster was the third party interventionist.

  23. Tom says:

    Linda: Appropriate question from a skeptic. Admittedly, I am a surgeon and would defer to a pediatric collegue, but it would seem logical to treat the others without further testing. I would expect a payor to approve, saving money and facilitating care. Testing the first two kids was good medicine. As in most cases, rules are generally good, but their application requires judgement. The old adage regarding the baby and the bath water would apply. Don’t throw out the protocol just because you are concerned about its potential misapplication.

    Frank: Clearly, the MRI was the correct first step in your case. Xrays are rarely useful in soft tissue injuries of the joints but are almost always ordered prior to an MRI, even by orthopedists. The MRI usually gives the answer but is so expensive that private payors and individual patient payors shudder. Also, it is often noted that the orthopedist owns the MRI machine. If yours did, it benefitted him to have you pay retail for the MRI rather than have the payor pay a greatly discounted price for the xray and MRI. One answer to the external protocol issue would be to pay for diagnoses rather than procedures. The orthopedist in this instance could order whatever test or perform whatever procedure he felt was indicated without affecting his payment from the payor. He would have a financial incentive to provide high quality care as efficiently as possible. That is one of the presumed benefits of Obama’s ACO’s. Note, however, that the regulations, protocols, and financial risks associated with these has made them a non-flyer with physicians and hospitals. Still, this type of bundled payment would put protocal development back into the hands of physicians and cap the financial exposure of the payor.

    Tom Newsome, M.D.

  24. Earl Grinols says:

    Altering payment to control the practice of medicine is a chilling and dangerous road to turn onto. Medicare did not begin as a program whose purpose was to control the nature of health care, but that is what it is doing. We can also predict in what ways its preferred protocols will begin to increasingly diverge from what free medicine would have been.

  25. Virginia says:

    I have to agree with Eric on this one. The post presents some interesting point about why we shouldn’t have rigid protocols. However, I’m not sure we should throw the baby out with the bath water.

    The idea of an objective treatment guideline for most diseases is a good one. Most docs don’t have the time or the energy to chase down the latest and greatest in treatment guidelines. I would hope that in the future there are independent companies where docs pay for weekly updates that are specific to their area of practice and give an overview of the latest data. In an ideal world, the physician wants to use these tools because he wants to do the best for his patient. I know that’s a little naive, but the better your data gets, the more achievable that is.

    In the real world, I don’t think we have the data to do that yet. We have a lot of work to do before we reach true evidence-based medicine. But, frankly, I’d prefer that my doctor be more of a mechanic and less of an artist. While there are problems with checklists and one-size-fits-all medicine, most people hate to admit just how average they are.

    I read Deming and Juran this semester as part of my health admin degree. The approach they take to medical care (and process improvement in general) is fascinating. Why is there so much variation? What can we do to fix it? (Voluntary) Evidence-based guidelines are a place to start.

  26. Chris Ewin, MD says:

    Clinical perspectives:
    H.pylori…I had the privilege to hear Dr. Marshall present his case in 1984 while studying in Adelaide, Australia. Packed auditorium. The old Docs sitting next to me thought he was a kook…(they also cut out half the stomachs for treatment of ulcers).. Researchers and physicians have a passion/curiosity to investigate new diseases and develop treatments for clinical use. You can’t legislate curiosity of doctors (Phd’s physicians, etc). Polio vaccine, treatment of depression/substance abuse/psychotics, HIV and now 104H4 E coli.

    Frank is correct: These are guidelines. This will never be like McDonalds where french fries are all cooked at 185 degrees for 137 seconds. It’s simply never going to happen, although a great goal, is detrimental to patient care and is impractical. Further, to get paid for outcomes is a poor solution. We are becoming data collectors like our colleagues (pharmacists, nurses) and obstructs their ability to take care of patients…It’s time consuming so don’t complain when your child has a fever of 104 and can’t get her antibiotics or you are waiting such a long time to get a nurse in the hospital for your grandmother needing pain meds.
    All physicians have been trained differently and have different skill sets. Some brilliant physicians have no bedside manner and vice versa…Those that have both are restricted b/c of more and more regulations and time constraints.

    James….You make assumptions….and understandably…you may not be a physician on the front lines who has the difficulties dealing with workflow like those of us on the frontlines. correct me if I’m wrong but it’s hard to comment on all of these questions that John poses week after week when you are not subject to these challenges.
    I don’t take Medicare, medicaid nor insurance as a primary care Concierge physician. MY prices are cheaper then McDonalds. I can only take care of so many people and do it well. Further, when I deal with insurers to get approval for studies, I speak directly with the physician who makes the decision. Speaking clinician to clinician has posed zero problems. When I had my previous cattle call practice, I didn’t have the time to call. If you divide 3,000 by 365 days you will see the dilemna in just giving a physical to every patient in a practice. People wonder why the divorce rate is high and some Docs’ kids grow up without seeing their parents’ who are Docs.

    This should give all of you pause for thought in the practicality of the direction this country is headed towards.

    Stay out of the way of people (clinical physicians) who know what they are doing…..

  27. Allan says:

    Virginia, I don’t think anyone is against voluntary treatment guidelines. The problem begins when guidelines become mandated and represent a political or business interest.

    Let me correct a few of your misconceptions. There are many guidelines that are published by all sorts of groups including the sub-specialty groups. There are journals today that do exactly what you are asking for in the future. There are other journals that have intense reviews of singular subjects etc.

    Medicine faces the problem of n=1 because each patient is different though frequently they can be placed in groups. That placement frequently can cause bitter debates. Humans differ by age, sex, genetics, location, what they eat, what they do, etc. so that one size fits all is impossible and variation must exist. You might have seen this variation in the way your doctor prescribes antibiotics. In some locations there is resistance to certain antibiotic and in some locations there isn’t.

  28. Devon Herrick says:

    It is difficult to reduce the influence of drug and device companies over protocols. One reason there is conflict of interest is because the researchers that are experts in their respective fields depend upon funding from companies selling therapies in that field. This is not bad. A drug company wants to create drugs that benefit patients and needs the participation of researchers who test and monitor the chemical compounds (and patients’ reactions to those compounds). You would not want someone with no knowledge of a given treatment to recommend treatment protocols. But it’s also problematic to have researchers who as so wedded to the companies that produce therapies.
    Anytime someone else is paying the bill it is ludicrous not to think the payer would want some say in what they will (and will not) pay for. That’s the nature of third-party payment. If you want patients to retain control over which services are purchased and which one don’t hold value, then patients need to control more of the funds that pay for their health care.

  29. Linda Gorman says:

    “…but it would seem logical to treat the others without further testing. I would expect a payor to approve, saving money and facilitating care. Testing the first two kids was good medicine. As in most cases, rules are generally good, but their application requires judgement. The old adage regarding the baby and the bath water would apply. Don’t throw out the protocol just because you are concerned about its potential misapplication.”

    Voluntary guidelines allow logic and good judgment. Involuntary, government required guidelines do not. Under involuntary guidelines it would be illegal for a payer to agree to circumvent the guideline. This debate isn’t about a potential for misapplication, it is about the certainty of misapplication.

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