Saturday, January 30, 2010

Healthy Incentives: Paying doctors bonuses in bid to reshape medicare - National Post

Jay Mercer's efforts to get more of his patients to undergo cancer screening are starting to pay off: Early detection resulted in one woman having her cervical cancer cured and gave another high hopes for recovering from a breast tumour.

The screening push is also paying off, literally, for the Ottawa family physician. His preventive campaign is partly driven by a little-known recent trend in the Canadian health-care system: incentive payments, or bonuses, paid to doctors to encourage better health care.

If he pushes a set percentage of patients through cancer screening, Dr. Mercer is rewarded with a sizeable annual bonus.

Ontario doctors can also earn bonuses of up to $5,000 for visiting patients at home; specialists in Nova Scotia receive thousands of dollars extra a year to simply stay in a rural location; and GPs in British Columbia are paid $2,100 annually just to keep delivering babies.

There are also bonuses for convincing people to have flu shots, better treating high blood pressure and merely taking on patients who have gone without a family doctor.

Such payments -- which come on top of regular fees for performing specific services -- have proven costly and controversial in the U.K., where they were pioneered. Doctors in some of the four provinces experimenting with the concept here, however, insist bonuses are already reshaping Canadian medicine for the better.

"This stuff works," Dr. Mercer said. "What these incentives do is translate into better outcomes. You've got the funding to do the extra work ... to start chasing down the [patients] who don't come in."

British Columbia introduced its incentives in part to convince doctors to operate full-service family practices with rosters of patients attached to them, rather than gravitate to the production-line -- but more lucrative -- medicine of walk-in clinics.

In just a couple of years, the bonuses appear to have stemmed the exodus from family medicine, says Dr. Brian Brodie, president of the B.C. Medical Association.

"In 2006, before these incentives started to roll out, it was so bad. People were leaving the hospitals, they were leaving family practices. It was dead, dead," he said. "[But] that conversation is done ... There's been a huge difference."

Patients whose doctors received the incentive payments -- designed partly to encourage better treatment of chronic diseases such as hypertension and diabetes -- also cost the medicare system less money, according to a report released last year by a consultant working for the province and the medical association. The theory is that they were less likely to need pricey hospital care.

The Hollander Analytical Services report was not all positive, however. A survey found that patients whose doctors claimed incentive payments were no more satisfied overall than those whose doctors did not.

The idea -- sometimes called pay for performance or quality-based incentive payment -- began appearing in other jurisdictions in the mid-2000s, a response to the pressures of a sicker, aging population, and evidence of inappropriate use of medical care.

More ...

Thursday, January 28, 2010

The Decision Tree - Thomas Goetz

The Decision Tree idea: 

What's a decision tree? Well, basically it's a flow chart. So what does that have to do with health? The idea is this: Our health doesn't happen all at once; it's a consequence of years of choices – some large and some small – that combine to make up our health. Sometimes we've chosen wisely and we enjoy good health; sometimes we choose poorly and we suffer the consequences. A decision tree, then, is a trope; a device that can make these decisions more explicit and more obviously something we are actually choosing – it's a way to externalize the choices that we otherwise make without much thought at all. Research shows that when we actually engage in a decision (when we think it through, even if just for a moment) we tend to make a better decision, defined both as one that we're more comfortable with in hindsight and one that potentially bodes a better outcome. By engaging with our health consciously and explicitly as a series of decisions, one leading to another, we can become "smarter" and enjoy better health.


The Decision Tree: Taking Control of Your Health in the New Era of Personalized Medicine

The Health Care Blog

This blog, billed as "Everything You Always Wanted to Know About the Health Care System, But Were Afraid to Ask," is published by Matthew Holt, a consultant and publisher of an email digest of health-care news for executives and hospital administrators. Mr. Holt uses his blog to draw attention to health-policy articles in other publications and on other blogs, and share his thoughts about Medicare policy, health insurers, electronic medical records and doctors.


Sermo is the largest online physician-only community, where over 112,000 practicing physicians collaborate on cases and exchange observations about drugs, devices and clinical issues.

Wednesday, January 27, 2010

Editorial - Radiation Therapy’s Harmful Side -

Radiation treatments have helped save the lives of countless cancer patients, but when medical personnel get sloppy and manufacturers fail to provide technical safeguards the results can be devastating. Two tragic cases at hospitals in New York City illustrate the dangers, and a look at cases elsewhere reinforces the feeling that much more needs to be done to protect patients.

The dark side of radiation therapy in an age when the technology is getting more powerful, complex and medically useful was laid bare in two investigative articles in The Times this week by Walt Bogdanich.

The first, published Sunday, described the plight of two patients who died in New York City after receiving extremely high doses of radiation from linear accelerators. In the first case, a man being treated for tongue cancer at St. Vincent's Hospital in Manhattan was subjected to high-energy radiation that was supposed to be directed precisely at the tumor but blasted his brain stem and neck for three days because of a computer problem. Technicians did not notice the warnings on their computer screens.

In the second case, a woman being treated for breast cancer at the state's Downstate Medical Center in Brooklyn got three times the prescribed radiation for 27 days because a therapist programmed a computer improperly, a vital filter was not activated and therapists again failed to notice indicators on their screens.

Wednesday's article described cases in several other states where patients were overradiated because medical teams made mistakes or failed to detect errors.

Radiation oncologists typically respond that such accidents, while heartrending, occur in only a tiny fraction of the radiation treatments delivered annually. But no one really knows how often radiotherapy accidents occur because there is no central clearinghouse of cases. Accidents are thought to be hugely underreported.

Manufacturers need to develop software that will shut down the linear accelerators before they can deliver extreme amounts of radiation. Medical teams that deliver the radiation must be far better trained than many now are. Surely it should be standard procedure to run a test before the first treatment to be sure the computer is programmed correctly. Once the damage is done to a patient, there is little that can be done to correct it.

Tuesday, January 26, 2010


Your Guide to Quackery, Health Fraud, and Intelligent Decisions

Pain and dying are explored by doctors in new books

Pain and dying are explored by doctors in new books

By Perri Klass
Tuesday, January 26, 2010; HE04 

Pain and death are the physician's familiars, reminders always of the limits of medical capacity and the parameters of human mortality. The desire to prevent or at least alleviate pain and to evade or at least postpone death guide medical practice, yet doctors have often been accused of failing to take pain seriously and treat it effectively. And when it comes to taking care of patients at the end of their lives, once again doctors don't always do well, either at discussing the realities with their patients or at administering treatment at that critical juncture.

It is this need for proper care at the end of life that has given rise to David J. Casarett's specialty: He is a palliative-care specialist and the director of research and education for the University of Pennsylvania's hospice, and so he consults on a range of dying patients. "Last Acts: Discovering Possibility and Opportunity at the End of Life" is his rogues' gallery of last-act stories and his attempt to make sense of the variety of ways in which human beings react to the knowledge that death is near.

David Biro, author of "The Language of Pain: Finding Words, Compassion, and Relief," sees the subject of pain not only as a physician but also as a patient: After finishing his residency training, he developed a blood disorder that ultimately put him in the hospital for a bone marrow transplant. "At its most intense, the pain literally strangled my vocal cords," he writes. Recalling Edvard Munch's painting "The Scream," he continues, "Silenced, I felt just like Munch's sufferer: wanting to scream as loudly as I could but unable to make a sound." His book is a journey through art and literature as well as medical experience, seeking ways of understanding, articulating and relieving pain.

Casarett sorts his stories of patients into a set of fascinating conundrums: "Maybe there is an overarching organizational structure -- a taxonomy -- of the last acts that people pursue near the end of life." Thus, his book is organized by category, each defined by a signature story: Danny, who faced his advanced cancer with a round of wild partying and high living; Marie, who wanted to disinherit her family; Tom, who buried himself in the budgets and spreadsheets of his office job.

Many of these stories are not heroic; these are patients who are refusing to die what might be called a "good death" by literary conventions, which demand heartwarming family tenderness or nobility at the gates of eternity. Further, as the author notes, these patients often reject the more modern medical ideal of a "good death" that has given rise to the hospice movement of which Casarett is a part. His medical team is profoundly troubled when Jacob, rapidly dying of leukemia, insists that he wants to be placed on a ventilator, even though it will prolong his life for only a few hours and rob him of the possibility of spending his final moments awake with his family. When Tom focuses only on his work, the team wants to know why: "This was a patient, they thought, who should be saying goodbye to his family. So why was he filling out evaluations of assembly-line employees and estimating his department's computer budget for the coming year?"

The gradual journey toward understanding this highly unsatisfactory patient is detailed with self-awareness and humor. As he drives back from visiting Tom, Casarett begins to see himself in the patient's place, facing imminent death and "finishing a last paper or two. And wrapping up the data analysis for a study so a colleague could write it up." This sense of identification brings him into some conflict with his team, when he tries to argue against the idea of work as denial. And as he pursues Tom's story, and stories of other patients who fill their last days with their regular jobs, he finds himself wondering about the different functions that work may serve: Is it a distraction? A comforting habit? A source of identity? ("So what sort of person would be compelled by his sense of his identity to continue working . . . . Such a person would be a writer, a researcher, a thinker, naturally. It would be someone, I thought -- untroubled by modesty -- like me.") The author's willingness to analyze himself and his colleagues and to confess his many false starts gives his narrative an appealing quality. There is no omniscience here, just experienced and well-meaning people attempting to understand and help.

The stories in "Last Acts" are unexpected and often quirky. Casarett's taxonomy includes Lacy, who was desperate to write a novel and leave it as her legacy, and Ladislaw, who wanted only to enroll in a clinical trial so his illness could be useful. And there is Jerry, a hospital employee "widely known for a combination of laziness and boorish behavior that made him widely feared and universally hated," whose refusal to apologize, even when seriously ill, prompts an examination of why the dying may or may not seek to make amends.

At times, the team of hospice experts are shocked at what seems selfish or irresponsible or unappealing behavior by the patients. But in fact, this is a big part of Casarett's point: that our collective sense of the "good" death can prevent us from seeing the individual realities of people's lives. It's a lesson he learns as a doctor, over and over, delineating the stubbornly individual imperatives that drive people who know they are close to death.

Biro, on the other hand, sees a unifying experience in the complexity of pain. In his erudite and ambitious book, he writes about the ways that artists, poets and novelists have described pain; he considers physical pain and psychological pain and argues that the isolation that comes with pain, especially when it cannot be described, contributes to the agony. He invokes philosophical reflections on pain by Elaine Scarry and Susan Sontag, along with personal accounts by writers ranging from Fanny Burney, who underwent surgery for breast cancer in the days before anesthesia, to Virginia Woolf and William Styron on illness and depression, to James Joyce describing Stephen Dedalus's ear infection to fictional characters suffering and dying beside Mount Kilimanjaro (Hemingway) or in the wilds of the far north (Jack London). "The Language of Pain" investigates not one single vocabulary but a complex syntax of suffering.

In a wonderful chapter called "The Weapon," he takes us from a teenage boy in the emergency room who compares his abdominal pain to a knife, to a larger discussion of disease viewed through the metaphor of war and combat: "We feel as if there must be an agent moving against (and threatening) the body: Burney's poniards, Daudet's pen-knife, Price's eel, John's knife, Rachel's volcano, Mr. H's fire. Or, more elaborately . . . an enemy or alien force marches against and attacks the body's interior, like the advance of the secondaries in Solzenitsyn's novel, tearing the cancer patient's defenses to pieces as if they were tanks."

Considering pain in terms of agency, he continues, offers a kind of answer to the helpless question: Why is this happening to me?

Eventually he turns to the consideration of "good pain, " the pain in a Jack London story that reassures the character that he is in fact still alive and intact, and to the philosophical, metaphorical and even clinical implications of describing and expressing pain: "Pain is not an aberration in human experience but a routine, inescapable part of life . . . . It affects us all at one point or another. How, then, can we let it pass without trying to share it? How can we keep silent?"

Biro brings an extraordinary range of voices into this silence and moves through a huge variety of experience and narrative, without straying too far from the bedside.

Both books draw strength from this, from the sense that these are real, everyday situations that nevertheless require responses outside the traditional pharmacopeia. Both these books resonate not only with the common certainties of pain and death but also with the infinite individuality of human life and human voice.

Klass, the author of "The Mercy Rule: A Novel," is a professor of journalism and pediatrics at New York University.

Clinical Cases and Images: CasesBlog - Medical news and social media

A Tour of my Brain | Dustin Curtis

In April of 2006, when I was 19, I suddenly started getting painful headaches. Over the course of several weeks, they increased in intensity until the pain was unbearable. I saw a neurologist, and he ordered some tests including an MRI series.

Thankfully, the MRIs showed nothing wrong, and we later found the cause of the headaches to be my murderous car emitting carbon monoxide into the cabin. But one good thing did come out of the whole experience: I now have a complete series of MRIs showing my real, actual brain. I'd like to show them to you (and maybe try to remember some random neuroanatomy facts).