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Curbside Consult with Dr. Jayne 10/14/13

October 14, 2013 Dr. Jayne 1 Comment

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I was hanging out this week with my nephew, who introduced me to Mega Shark vs. Giant Octopus, which if you haven’t seen it, explains what happened to Lorenzo Lamas and Deborah Gibson after they left the limelight. There are so many “attack of” movies but this one is truly larger than life. If you don’t believe it, you’re welcome to check out the trailer featured at the link above.

Having to confront things enormous and/or ridiculous reminds me of the daily grind of office practice. There are so many things to worry about from regulatory hurdles and payer nitpicking to patient satisfaction, patient engagement, and quality care. Many of them are important but some are just tiresome. It feels like there is always some shark waiting to eat you or an octopus intent on squeezing the joy out of patient care. I shouldn’t have been surprised then when I started reading a journal article and Top 20 Reasearch Studies of 2012 for Primary Care Physicians turned into “Attack of the Killer Guidelines.”

This is the second year that American Family Physician has worked to summarize the top research studies in primary care. Having been a practicing family doc in a small practice, I know how hard it is to keep up with the literature, and articles like this are very helpful. I don’t have time to read through the 100+ clinical research journals that the authors did in order to find the top 20 studies with the potential to change primary care practice. Having them summarized in a way that makes sense to the clinician in the trenches is key. As primary care docs, we don’t have time for esoteric studies or case reports featuring zebras and unicorns. We need help solving the bread and butter problems we see every day in the office, and help solving them in the most effective and efficient way possible.

Some of the points featured this year are serious game-changers when you’re looking at delivering cost-effective care that makes sense. To some degree, though, they go against the conventional wisdom and if physicians start following them, they’re going to get “dinged” on quality reports and payer metrics. Let’s look at a couple of them:

Diabetes. Does home monitoring of blood sugars lead to better management of Type 2 diabetes in patients who are not treated with insulin? The short answer is no. Hemoglobin A1C levels (which are used to monitor average blood glucose) only came down 0.25 percent after six to 12 months of home testing. The reduction was not clinically significant, but the discomfort and cost that patients bear is certainly significant. How many obese patients are going to develop diabetes in the US? Lots of them. How many are checking their blood sugars for years with little change in their overall diabetes control? Plenty. The authors conclude that home monitoring should be reserved for patients on insulin.

What? What about those commercials with Wilford Brimley hawking diabetic testing supplies “at little or no cost to you?” What about the fact that Medicare pays for it? I’ve had patients argue with me about this before, stating that if Medicare pays for it they should be entitled to it simply because they’ve paid into Medicare, clinical appropriateness be damned.

Again with Diabetes. Do older patients who have functional or cognitive impairment and tightly controlled diabetes do better than those with less tightly controlled diabetes? Surprise, those with tighter control actually had a greater risk of functional decline than those with less tight control of their blood sugars.

It sounds like heresy, but maybe we don’t need to be driving all these blood sugars down as low as we thought we should in the past. And we certainly don’t need to be overly lowering the blood sugars of the octogenarian up the street who is starting to show signs of dementia. Relaxing his blood sugar control (and his wife’s also, for that matter) could reduce their medication bill by $150/month and might prevent secondary complications due to low blood sugar. Unfortunately their primary care physician still has them on multiple medications and has them checking their blood sugars several times each day.

Back to the category of things Medicare pays for, so it must be the right thing to do. Bone Density screening. Review of evidence indicates that women with normal or mildly low bone density can wait up to 15 years before a second screening and those with moderate loss of bone density can wait five years. So why does Medicare cover this every 24 months? I’ve been on the other end of this argument, with a patient who accused me of being in favor of “death panels” simply because I told her the test wasn’t indicated after two years because her bone density was normal and she had few risk factors.

I’m tired of CMS pointing the finger at providers accusing us of fraud and abuse all the time. They come after us for upcoding, but have you ever seen a giant refund to a provider due to the vast downcoding that many perform out of fear? They routinely deny payment for services when physicians fail to understand the arcane minutia of local billing rules, yet are perfectly happy to pay for annual mammograms in 90-year-old patients when the government’s own US Preventive Services Task Force recommends screening every two years for patients stopping at age 75 because “among women 75 years or older, evidence of benefits of mammography is lacking.”

I’d love to see CMS stop paying for services that go against the government’s own evidence-based guidelines. Although some may see this as a slap in the face of patient empowerment, it would be a great help to those of us who spend a lot of time trying to convince patients that just because services are covered by their insurance plan doesn’t mean they’re a good idea. Like personalized medicine, if patients want services that aren’t evidence based, they’re welcome to pay out of pocket. In the realm of non-CMS payers, I’m still dealing with insurance companies that refuse to cover all vaccines, so maybe we could shake enough money loose to prevent some cervical cancer with wider use of the HPV vaccine.

I’m tired and cranky after a gruesome shift in the ER and don’t feel like doing the math, but I bet cutting out unnecessary mammograms, premature PSA testing, aggressive diabetes treatment in the elderly, and a handful of other things would help the Medicare trust fund go a little farther. I’d like to see dollars go into research, subsidized continuing education for health care providers, and preventive medicine rather than paying for services that may be popular but don’t lead to better outcomes.

The burning question however is this: how rapidly can guidelines and protocols adjust to these changes? Similarly, how do we convince front-line physicians that they need to behave contrary to how they have been for decades? What do you think about a truly evidence based coverage revolution? Email me.

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One Response to “Curbside Consult with Dr. Jayne 10/14/13”

  1. 1
    FLPoggio Says:

    Dr. J,
    Great points…
    In case you haven’t figured it out yet it is really not EBM…it’s EBPM, That stands for evedienced based Political medicine. Your mamogram example is classic. When the feds study came out you would have thought that we were canceling the right to an elementary education, It got over riden by Sebelius in a NY second. Why?
    With the Komen foundation and the radiology mfrgs up in arms there was no way to argue for real EBM. Yet when the same federal tak force said no Pap smears, or no PSA tests for some patients…no screaming, no battle, no problem. Simply put if there is no medical industrial group getting gored and no strong special interest group, then drop the test, otherwise keep spending!

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