The Weekly Roundup…

Stuff this week that caught my eye: Does medical tourism harm the natives? Are all those CT scans destroying more than our budgets? Are nocturnalists at risk for more than decubs? Will Medicare need to cut hospital payments to fuel P4P?

Answers: yes, yes, probably, and duh.

Yesterday, NPR’s All Things Considered described the dark side of medical tourism: some Thai patients are now having a hard time finding docs. This is an old complaint, of course – docs (and nurses) leaving their native lands to come to the US or Western Europe for more lucrative practices in more modern facilities. What’s new? The Thai docs aren’t leaving Bangkok; they’re leaving the public hospitals to go across town to the hospitals that cater to foreigners. Some of these places, like the iconic Bumrungrad Hospital with its sushi bar and VIP suites, are the Thai version of the Cleveland Clinic. But even the big public hospitals are now creating fancy rooms and concierge-type care, sometimes to cater to foreigners, and sometimes to attract better paying locals. Just one more window into the consequences of the flattening of the healthcare world.

Second, an article in this week’s NEJM documents the public health costs of all of those CT scans (an estimated 62 million this year in the US, up from 20 million in 1990). The authors, medical physicists from Columbia University, estimate that nearly one-in-50 cancers in the US may now be attributable to radiation from CT scan exposure (!), up from one-in-250 15 years ago. The risk is particularly high when the scan-ees are kids.

This is scary stuff. But will this induce us to do fewer scans? I doubt it, though it will give us some more ammunition for the informed consent discussion we should be having before we order the CT scan in the patient with a benign-sounding but persistent headache. Today: “I’m pretty sure there’s nothing to worry about, but if you’re concerned we can get a CAT scan to be sure.” (Translation: I have essentially no concern about intracranial pathology, but I need to cover my tush. I fully expect that you, being a normal risk-averse, technophilic American, will choose to have the scan; and that the payer, having no way of knowing whether the scan is indicated or not, will fork up the $1500; and that the hospital and the radiology department, both with a strong financial stake in doing more studies, will make obtaining the scan as easy as possible). Now add: “… and if we get the scan, there may be a small increased risk of cancer.” My guess is that a few patients will say no, but most will shrug and sign, favoring current certainty in their anxious moment-of-truth over a tiny risk somewhere beyond a distant horizon.

What’s interesting about this, of course, is the tension between individual and aggregate decision-making. From the standpoint of an individual patient, the risk of a single CT scan (or unnecessary antibiotic, for that matter) doesn’t seem like a big deal. For a population, it is huge concern, whether the cost is an increase in cancer risk or, in the antibiotic analogy, antibiotic resistance. How to make this a fair food-fight – to balance the scales so that we fairly weigh aggregate impact against individual impact – is one of the great health policy questions of our time. (For further insights on this tension, see this classic NEJM article on the individual-aggregate discrepancy by my friend Don Redelmeier of Toronto. Sorry, it is pre-Web; you’ll have to go to the library to get it. Remember libraries?)

Speaking of risk, based on a surprisingly robust series of studies, next month the International Agency for Research on Cancer, a branch of the WHO, will add overnight shift work to their list of possible carcinogens. As reported by CNN (in anticipation of a soon-to-be published article in Lancet Oncology), the pathophysiologic mechanism for this seemingly bizarro association is that the night (I won’t call it “graveyard” anymore) shift disrupts the circadian rhythm. This disruption lowers the production of the hormone melatonin, which appears to have some role in scavenging wannabe cancers. Solution: there is some indication that melatonin can be partly replenished by sleeping in a very dark room after the night shift. There’s no evidence that toggling between day and night shifts helps, and some weak evidence it might even be more harmful. And you thought it was hard to fill your night shifts now!

Finally, every month CMS seems to announce yet another tactic in its ever-increasing transition from agnostic bursar to activated promoter of quality. This week’s announcement (described here on the Wall Street Journal’s excellent health blog) was a stunner: a proposed cut of 2-5% in the base payment rate to hospitals, the saved dollars to be used to pay P4P bonuses for better performers (split Solomonically between the best and the most improved). As I previously discussed, this move was entirely predictable. With both CMS and GM lurching toward bankruptcy, only Rip Van Winkle would have thought that payers would find new money to pay quality bonuses.

This will get discussed and Harry-and-Louise’d in the political arena for a while, but the tea leaves are unmistakable: Medicare will continue to put more and more skin in the quality game (will hospitals ultimately need to add a CDO – Chief Dermatology Officer – to the C-suite’s alphabet soup?), hospitals will be under more and more pressure to measure up, and physicians will be increasingly “counseled,” bagel-and-loxed, threatened, bonused, or pay-cutted to ensure that they’ll play ball. As I noted previously, although simply installing an IT system with reminders won’t do the trick, hospitals will look for more and more ways to hardwire better performance. And, through it all, there will be bellyaching about the clunkiness of the quality measures, the documentation burden, the inadequacy of case-mix adjustment… in short, the ruination of medicine, as it transitions from magnificent human art to a robotic, cookbook business run by “those damn MBAs.” As always, some of the skepticism will be right, but remember, the status quo aint nuthin’ to be proud of.

In any case, the Quality Revolution is really picking up some speed. Fasten your seat belts.


Thanks to Brad Flansbaum and Larry Wellikson for bringing two of this week’s articles to my attention. Assuming that there are items that are “blog-worthy” – the blogospheric equivalent of Elaine Benis’s “Is he sponge-worthy?” litmus test for prospective dates on Seinfeld – I’ll plan on doing this roundup every week or so. So if you see items that you’d like me to look at, please feel free to email them over.

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