and the FLY in the OINTMENT
Edward Kaplan and Paul Meyer came up with an elegant
solution in discussing outcomes. They created the Kaplan-Meyer Estimator; a
non-parametric estimator of survival function using timed data. Each entity
logged in as present, absent or deceased. No gimmicks! A treatment for cancer
would be graphed on an X-Y axis and the survival data would lend itself to an
easy view. Each step-wise ladder would denote those that perished to the disease
and those still surviving or censored as little tick marks on the steps. Comparisons with superimposed
placebo survival curve identify the benefits or risks (as in the graph below) of the new treatment.
But here we are embarking on this lauded “Outcomes” as a
metric to determine quality. I don’t know about you, but I have few misgivings
about this form of measure. Actually I have two problems to be exact; a) How
does one define Outcome and b) how does one define quality?
In a timed data if one were to treat pneumococcal pneumonia with
Penicillin and the fever, chills and the chest XRay improved, then one could
consider that as a good outcome. Easy peasy! However throw in the mix of
fungus, immunological deficiency from age, disease, cancer and what you have
putting it mildly is a major conundrum. No easy cure! Now let us bring in a patient with cancer
into the equation. Is survival a good measure? If you say yes, then I have a
bridge in Brooklyn available for sale. You see survival is not a simple measure in
cancer care either. There are many tiny incalculable genes mutating as they play
their game of life. The whole biology of the cancer and its rate of growth thing is a
complex dance filled with many characters. There is no one character that
struts on the stage momentarily to signify nothing. Every moving and non-moving genetic construct signifies something in the life of a human being. The many that are involved have each a
bucketful of colorful lives and a plethora of epigenetic sauces to create the
soup of life. So will the individual physician’s entire caseload of patients with a
certain diagnosis be put through the K-M curve and compared to the national
average? If we do that, even then we might be flawed in our thinking, especially
if the physician has a disproportionate number of African American, or
Hispanic or Asian patients or older or younger or more females than males, or
right-handed than left-handed, or more artists than scientists, or movie-goers
vs. internet-obsessed in that population (you get the drift).
Survival Curves 20-100 years & % of Survivors
A: White women in US (1939-1941)
B: Women in India (1921-1938)
C: Theoretical Population with half-life of 18 yrs.
Where exactly do Behavioral Modification and Behavioral Economics intersect?
At the expense level or at the payer level? Or at the arbitrariness of the
expert level, where most things today seem to live and breathe? Your guess is as good as any!
Now imagine given these simple scenarios that the elite
experts who reside in those vaunted ivory towers consider outcomes as a measure
of a good doctor and make payments predicated on such faulty thinking? Now
before you go saying that cannot happen. No one would be so stupid to accept
that? Guess what? That is exactly where we are today. “Outcome” is the new big
buzzword. And CMS is trying mightily to convince the “Gruber’s Stupid” that, "this is the way it should be."
We are not done yet. Now add to it some “Satisfaction Scores”
from the patients and we have a whole new enchilada in front of us. Say a
patient perceived your smile as a cynical one. There goes your score. Or
imagine you prescribed a medication that cost him or her more money than
anticipated, or you did not recognize him at a department store, or your receptionist missed calling him or her on the specified
time, or you as a physician had an emergency and the waiting room with five
patients turned into one with ten patients sitting and filling out the “satisfaction
Score” form? Any doubt that your “Reimbursement” from the Insurance would be
returned “denied.” And you will have to jump through hoops to get a fraction of
that expense 3 months later. That would constitute a certain Win-Win for the
Insurer, wouldn’t it?
Ah the cleverness in it all!
Breathe!
Breathe!
The fly in the ointment continues to flutter its wings,
trying mightily to get out, but the ossified mindset seems unlikely to remove it because
that mindset believes in that removing the fly means failure and more arduous hours of toil to rework a new flawed concept from inception. And
guess what, according to them, the fly is part of the ointment and therefore makes for a perfect recipe.
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