Thursday, February 19, 2009

Cardiologists Do Too Much


My laziness in blogging today is your win as I refer you over to Dr. Rich's Covert Rationing blog.
Dr. Rich writes a provocative piece on Cardiologists and their propensity to perform cardiac caths and place stents in patients...despite the evidence that stenting blocked coronary arteries does not prevent heart attack or prolong life.

Drug eluding (coated) stents cost from $15,000 to $30,000 to place and the data shows that medication (cholesterol lowering drugs and aspirin) are equally effective in patients who have stable blocked arteries and chest pain. So why are 70% of these patients treated with stents? Read Dr. Rich's blog for an eyeopener. It gets better as you read longer and see what patients erroneously expect the stent will do for them.

You can't blame the cardiologists...they are only responding to perverse incentives that pay them handsomely for doing more and more.

It's the American Way.

9 comments:

Anonymous said...

"You can't blame the cardiologists...they are only responding to perverse incentives that pay them handsomely for doing more and more."

I read the original posting.

I completely disagree. This is a terrible attitude. Part of going into the profession of medicine is thinking about your patient's needs. For doctor's it should not be "it is just about money." Perhaps these people should have gotten an MBA instead and worked on Wall Street.

It is a pity these cardiologists can't be taken in front of state licensing boards for doing unnecessary treatment.

I am certain there are those cardiologists that are not responding in this MBA manner and I wish there was a web site that listed who are the conscientious ones for any given demographic region.

Please comment on this Tracy...Thanks!

ERP said...

Well, here is the thing. The COURAGE trial did not use many drug-eluding stents since they were not approved for use until the very end of the trail. I wonder if you looked a patients that can take Plavix indefinitely with these new stents (as has been shown to be necessary to prevent acute clots) and compared it to people with medical therapy alone. It may turn out to be better. We shall see.....

tracy said...

....Who me??? All i can say, Anon, is that i totally agree with you...especially the part about doing unnecessary treatments...just for the big bucks..although, as deep in debt as i am, i can certianly see the incentive, sadly... "thinking about the patient's needs...". Yes, just where has that attitude gone...?

anon...who are you...????? :)

Anonymous said...

Hi Tracy,
I meant Toni, the author of the posting to comment but your name stuck in my mind because you seem to be a frequent blog poster.

I'm an MD with an BS in Elect Engr/Comp Sci working in medical technology.

On the one hand docs don't want to have to worry about being second guessed for approvals for procedures by insurance companies but then you have this sort of nonsense...there must be some sort of policing of the profession so as not to do this sort of thing.

David MD

Toni Brayer MD said...

David MD and Tracy: The policing should come from the professional specialty societies but, alas, that is not happening.

Even today there is an article in the NYT that compares drug eluding stents with bypass and shows pros and cons on both sides.

Medicine, like all science, is constantly changing and evolving and we try to be evidence based as much as possible. The real culprit is the perverse payments from Medicare and insurers that pay for more care, more technology but do not value time spent with the patient evaluating which treatment is best for that patient. Cookbook medicine does not work because every persons genetics are different and treatment must be individualized to get the best result.

Currently, doctors and hospitals are paid to do more. Patients all want more so there is nothing standing in the way of doing everything technical (ie: expensive) for everyone...even if it is not the best choice for quality of life and longevity.

Anonymous said...

Toni Brayer, MD said: "The real culprit is the perverse payments from Medicare and insurers that pay for more care, more technology but do not value time spent with the patient evaluating which treatment is best for that patient." [snip] "Currently, doctors and hospitals are paid to do more. Patients all want more so there is nothing standing in the way of doing everything technical (ie: expensive) for everyone...even if it is not the best choice for quality of life and longevity."

I'm sorry but I don't agree with this. I fondly remember reading in high school Lewis Thomas's "The Youngest Science: Notes of a Medicine-Watcher" (you can read the first few pages on Amazon.com) about his father's and his own experience as a physician.

The imbalance in compensation between PCP/cognitive medicine and specialty/procedural medicine is determined by physicians themselves (a note to the non-MD out there -- and not the government, not the insurers) through the Relative Value Update Committee (RUC).

Most countries have a 70/30 PCP/specialty ration. In the US we have a 30/70 ratio and it is largely because of the decisions of the RUC.

Certainly there are a lot of problems with medical care in this country where physicians have no control but this is not one of them in my opinion.

David MD

tracy said...

Hee, okay, Dr. David...now i'm totally embarassed, but oh well...wish i was Dr. Toni...really!

Toni Brayer MD said...

David MD: We disagree. Medicare fees to physicians are capped by congress via a complicated formula that is different in each state and locale. The RUC (authorized and formed by the government and AMA) determines what proportion of the capped money goes to primary care vs. the thousands of procedures that are part of Relative Value Scale (RVRUS). The RUC is made up of mainly specialists that are very narrowly focused (urology,vascular surgery, etc). For the past few decades, this group has set rates that favor procedures and punish cognitive (thinking, talking, planning) specialties financially. the insurance companies follow these same metrics.

It is clear that this system of underpayment has gotten us just where we are...a disproportionate number of specialist to care for the Nation. In many cities a Medicare patient cannot find a primary care doctor to care for their hypertension, arthritis, rash, sprained ankle. They go to specialists who are reimbursed at much higher levels for tests and procedures. The cost (and poor quality) of healthcare is skyrocketing and this is one of the reasons.

Primary care is underfunded and underpaid and we are reaping the end result of this cascade. I agree that the RUC is a major culprit but there seems to be no push to change that system.

Anonymous said...

Toni Brayer MD:
I think we agree in much it is just that I didn't communicate my point of view well enough. For certain the overall compensation pie for Medicare (and even more so Medicaid) is not sufficient, yet in my view the specialists through RUC which as you point out is dominated by specialists could ensure that primary care physicians and cognitive medicine get a larger percentage of that pie. I really feel that many of these specialists with their procedures -- some specialties more than others -- are making enough money (on average) to shift some of that compensation to primary care and cognitive medicine. In Japan the ratio of compensation for primary care and cognitive medicine to specialists and procedures is much higher than the US and I don't see why RUC can't move more in that direction *if* they are thinking of the patient (population) ahead of their pocketbook.

I feel that if someone of Lewis Thomas's character was doing what the RUC physicians currently do that she/he would ensure that the ratio of compensation was more towards cognitive medicine.

I'd strong suggest that readers of this blog read his books (many of the articles originally appeared in the New England Journal of Medicine).

Tracy -- I'm very sorry to have accidentally singled but I do like you comment much :-)

David MD