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.
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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.