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Can you say 9 Sigma?

Rich

_________________
Member of the world's premier gun club, the USMC!

Is that one defect per billion?

I do not remember off hand but to get an engine approved for use on a commercial two engine plane used for overseas flights required that kind of reliability. The likelyhood of two engines failing on the same flight was somewhere in the one in a billion range. I no longer have access to the data but the engines were built to meet what was considered astronomical odds.

This is even more impressive if you have ever seen what is under the hood so to speak. There are hundreds of blades alone and countless sub systems. Each component had to be so good that the individual part reliability could not be measured with instruments or gauges. It was done using statiscal processes based on all of the actions taken on it.

One blade had over $1,000.00 of value in it so it was not practical to destroy a lot of them in destructive testing to insure a good product. I wandered the factory floor at the engine plant in Cincinnati for about 8 years and was always amazed at the design and manufacturing processes they employed.

Rich

_________________
Member of the world's premier gun club, the USMC!

"Apples and oranges again. How are you different from the chemists and the scientists at Merck?"

They have NOTHING to do with the actual selection of care and NEVER see the face to face consequences of illness or questionable business. I am the SINGLE individual on the medical team MOST responsible for the selection of care and MOST likely to see the consequences of illness. I see patients they see test tubes. If you cannot see this distinction there is no reason for me to elaborate.

"I still want to know how your medical center gets reimbursed."

Like all medical centers probably. We get paid largely by DRG. Fees for illnesses are negotiated with different ensurers; medicare pays what medicare pays; medi-cal pays what medi-cal pays. There are systems to capture all the illness in the language of the coders so we get paid for the work we do and the complexity of illness. It's too complicated to get into in detail, and luckily the physicians are kept from most of it. Closest we come to being bugged is my bills are monitored for accuracy. Lsat check was 100%.

"Also, "free" care isn't free."

Clearly. But administered by people without conflicts of interest.

"You are very blind to hospital administrators, Ian."

Oh? I haven't spoken much on the matter, so you must be surmising. I'll leave it at this: physicians who work under administrators have infinitely more freedom to determine how care is delivered than do pharmacists or other individuals at Merck etc have freedom to determine if the public is notified of a concern or a drug pulled. My decisions are almost never second guessed; theirs ARE. This is the difference, it's clear, and if I'm blind perhaps you are also reading the "braille" on the computer screen.

"What about all the HIV drugs going at cost or cheaper to Africa? It's being done because it's the right thing to do. Sound familiar?"

HUGE resistance from the same types of corporate lawyers who brought you the Merck debacle. HUGE. And right, or best for image, are diffrenet things. Please refer back to my eflornithine example somewhere in my alphabet slew of questionable pharmaceutical decisions.

As for the fact that airplane safety is better than hospital safety:
--you can call off a flight, but not medical care, if the plane, but not the patient, is in suboptimal shape.
--flights, but not most hospital care, can be planned and scheduled. A mechanic, but not a well rested physician, can always be found who is deeply familiar with the issue at hand (or takeoff can be delayed).
--flights and planes have great similarity; patients are diverse and individual.
--planes don't suffer, balk, or scream when you take them apart to look at the inner workings.
--planes are made out of defined alloys and other materials, rather than extremely complicated organ systems we have but a few lab tests to measure.
--planes are more reliable at sticking to maintenance schedules and taking their pills, if you will. Patients smoke, drink, skip meds, don't report complaints, etc.

Now that's an explanation, not an excuse. If you look at prior threads, including on your forum, you'll see that while I submit there is a reason for our greater errors, we absolutely have to embrace change and improve things. Some docs, for example, think I'm a nazi for believing that physicians who can't use antibiotics correctly shouldn't be able to use them at all. And for the billionth time, I'm working on several hospital safety projects RIGHT NOW to improve the situation. So you really can't change my mind by arguing for my previously state position.

Ok, and back to the issue--drug safety. As promised, a review on NSAIDS follows, and I will leave this matter (whether physicians are just as conflicted as pharma employees, such as the ones who told me with a straight face that azithromycin improves bronchitis despite the well known fact that it doesn't) to others and the record of previous posts.

_________________
--Ian

For interested parties, I searched naproxen rofecoxib cardiovascular on pubmed and excerpted the most interesting hits. The matter gets complicated and there are conflicting views. Summary: take your old NSAIDs and worry about ulcers and renal impairment, but without much cardiovascular worry. Take a cox-2 if you fail your other options, including failing NSAID plus ppi. Don't take any pills you don't have to take. See your doctor first.

In reverse chrono order.

Motsko SP. Temporal relationship between use of NSAIDs, including selective COX-2 inhibitors, and cardiovascular risk. Drug Safety. 2006;29(7):621-32. Compared with long-term ibuprofen use, long-term use of celecoxib (adjusted hazard ratio [HR] 3.64; 95% CI 1.36, 9.70) and rofecoxib (adjusted HR 6.64; 95% CI 2.17, 20.28) was associated with a significant increase in cardiovascular risk. When restricted to patients >or=65 years of age, the cardiovascular risks associated with long-term celecoxib (adjusted HR 7.36; 95% CI 1.62, 33.48) and rofecoxib (adjusted HR 13.24; 95% CI 2.59, 67.68) use increased. Short-term use of celecoxib (adjusted HR 0.75; 95% CI 0.42, 1.35) and rofecoxib (adjusted HR 0.85; 95% CI 0.39, 1.86) was not associated with any significant change in cardiovascular risk when compared with short-term ibuprofen use. Neither long- nor short-term exposure to naproxen and etodolac was associated with cardionegative or cardioprotective effects when compared with ibuprofen.

Solomon DH. Cardiovascular outcomes in new users of coxibs and nonsteroidal antiinflammatory drugs: high-risk subgroups and time course of risk. Arthritis Rheum. 2006 May;54(5):1378-89
RESULTS: We identified 74,838 users of NSAIDs or coxibs, and 23,532 comparable users of other drugs comprised the reference group. Adjusted models demonstrated a significant elevation in the event rate for rofecoxib (RR 1.15, 95% confidence interval [95% CI] 1.06-1.25) and a significant reduction in the rate for naproxen (RR 0.75, 95% CI 0.62-0.92). No other coxib or NSAID was associated with a significant increase or decrease in cardiovascular event rate. The increased rate associated with rofecoxib was seen in the first 60 days of use (adjusted RR 1.14, 95% CI 1.01-1.29) and thereafter (adjusted RR 1.14, 95% CI 1.02-1.28). Kaplan-Meier event curves showed a similar pattern of risk (early and persistent separation of the event curves) among long-term rofecoxib users at low or high baseline cardiovascular risk. CONCLUSION: We found an increased cardiovascular event rate among users of rofecoxib, and a decreased rate with naproxen use. Other coxibs and NSAIDs did not appear to be associated with a difference in event rate compared with users of other drugs. The increase in rate associated with rofecoxib was seen within the first 60 days and persisted. There was no important modification of the event rate based on the patient's baseline cardiovascular risk.

Ardoin SP. Update on nonsteriodal anti-inflammatory drugs. Curr Opin Rheumatol. 2006 May;18(3):221-6 SUMMARY: Nonsteroidal anti-inflammatory drugs have been in the spotlight this year. While preliminary evidence has supported novel roles for these drugs in ankylosing spondylitis and in cancer prevention, accumulating evidence shows that some cyclooxygenase-2 and perhaps all nonsteroidal anti-inflammatory drugs are associated with cardiovascular toxicity. Further research is needed to understand the magnitude and mechanism of this risk. Clinicians are compelled to weigh carefully the benefits and risks of therapy. Concerns about safety are balanced by optimism about their potential role in delaying the progression of ankylosing spondylitis.

James MJ. Cyclooxygenase-2 inhibitors: what went wrong? Curr Opin Clin Nutr Metab Care. 2006 Mar;9(2):89-94. RECENT FINDINGS: The elucidation of differences between the active sites of cyclooxygenase-1 and cyclooxygenase-2 allowed the targeted design of the selective cyclooxygenase-2 inhibitors known as coxibs. These were developed and marketed as non-steroidal anti-inflammatory drugs (NSAIDs) that had improved upper gastrointestinal safety compared with older non-selective NSAIDs. A large-scale study with arthritis patients to evaluate upper gastrointestinal safety, however, demonstrated that celecoxib was not superior in terms of upper gastrointestinal safety compared with the older non-selective NSAIDs that were used as comparators. In an equally large study with arthritis patients, a more selective cyclooxygenase-2 inhibitor, rofecoxib, did have improved upper gastrointestinal safety compared with the non-selective non-steroidal anti-inflammatory drug naproxen. Although concomitant clinical trial evidence emerged that rofecoxib increased cardiovascular risk, this was discounted by its pharmaceutical company owner. Despite the lack of improved upper gastrointestinal safety with celecoxib and the evidence of cardiovascular risk with rofecoxib, both agents had widespread clinical use for 4-5 years. This was not diminished by the publication of plausible eicosanoid-based biological mechanisms whereby selective cyclooxygenase-2 inhibition could increase cardiovascular risk. Finally, clinical trials involving patients with colorectal cancer and post-operative pain revealed increased cardiovascular risk with all members of this class of drug. SUMMARY: These events provide a case study of a failure of the medical journal literature to guide drug usage.

Velentgas P. Cardiovascular risk of selective cyclooxygenase-2 inhibitors and other non-aspirin non-steroidal anti-inflammatory medications. Pharmacoepidemiol Drug Saf. 2006 Jan 4; [Epub ahead of print]RESULTS: Compared with ibuprofen or diclofenac use, the relative risk (RR) of ACS during periods of current rofecoxib use was 1.35 (95%CI 1.09-1.68). For current use of celecoxib, the RR was 1.03 (95%CI 0.83-1.27). Risks in the first 30 days of rofecoxib and celecoxib use were modestly elevated. Rofecoxib use at the 25 mg/day (modal) dose was associated with an elevated risk of ACS (RR 1.54, 95%CI 1.15-2.04), while use at 26-50 mg/day (>modal) was not (RR 0.81, 95%CI 0.41-1.60). There were no increased risks with modal or greater than modal doses of celecoxib or naproxen compared with all doses of ibuprofen or diclofenac combined. CONCLUSIONS: The incidence of ACS was 1.35 times greater during rofecoxib use than use of ibuprofen or diclofenac. No statistically significant elevation in risk was observed with celecoxib use. Naproxen use was not associated with risk of ACS. Copyright (c) 2005 John Wiley & Sons, Ltd.

Hippisley-Cox J. Risk of myocardial infarction in patients taking cyclo-oxygenase-2 inhibitors or conventional non-steroidal anti-inflammatory drugs: population based nested case-control analysis. BMJ. 2005 Jun 11;330(7504):1366.RESULTS: A significantly increased risk of myocardial infarction was associated with current use of rofecoxib (adjusted odds ratio 1.32, 95% confidence interval 1.09 to 1.61) compared with no use within the previous three years; with current use of diclofenac (1.55, 1.39 to 1.72); and with current use of ibuprofen (1.24, 1.11 to 1.39). Increased risks were associated with the other selective NSAIDs, with naproxen, and with non-selective NSAIDs; these risks were significant at < 0.05 rather than < 0.01 for current use but significant at < 0.01 in the tests for trend. No significant interactions occurred between any of the NSAIDs and either aspirin or coronary heart disease. CONCLUSION: These results suggest an increased risk of myocardial infarction associated with current use of rofecoxib, diclofenac, and ibuprofen despite adjustment for many potential confounders. No evidence was found to support a reduction in risk of myocardial infarction associated with current use of naproxen. This is an observational study and may be subject to residual confounding that cannot be fully corrected for. However, enough concerns may exist to warrant a reconsideration of the cardiovascular safety of all NSAIDs.

Johnsen SP. Risk of hospitalization for myocardial infarction among users of rofecoxib, celecoxib, and other NSAIDs: a population-based case-control study. Arch Intern Med. 2005 May 9;165(9):978-84RESULTS: Current users of rofecoxib had an elevated risk estimate for hospitalization for MI compared with nonusers of any category of nonaspirin NSAIDs (adjusted relative risk [ARR], 1.80; 95% confidence interval [CI], 1.47-2.21). Increased risk estimates were also found among current users of celecoxib (ARR, 1.25; 95% CI, 0.97-1.62), other cyclooxygenase-2 selective inhibitors (ARR, 1.45; 95% CI, 1.09-1.93), naproxen (ARR, 1.50; 95% CI, 0.99-2.29), and other conventional nonaspirin NSAIDs (ARR, 1.68; 95% CI, 1.52-1.85). The highest ARRs were found among new users of all examined drug categories. CONCLUSIONS: Current and new users of all classes of nonaspirin NSAIDs had elevated relative risk estimates for MI. Although the increased risk estimates may partly reflect unmeasured bias, they indicate the need for further examination of the cardiovascular safety of all nonaspirin NSAIDs.

Spiegel BM. Minimizing complications from nonsteroidal antiinflammatory drugs: cost-effectiveness of competing strategies in varying risk groups. Arthritis Rheum. 2005 Apr 15;53(2):185-97CONCLUSION: Generic nonselective NSAIDs are most cost-effective in patients at low risk for an adverse event. However, the addition of a PPI to a nonselective NSAID may be the preferred strategy in patients taking aspirin or otherwise at high risk for a GI or cardiovascular adverse event.

Kimmel SE. Patients exposed to rofecoxib and celecoxib have different odds of nonfatal myocardial infarction. Ann Intern Med. 2005 Feb 1;142(3):157-64RESULTS: The adjusted odds ratio for MI among celecoxib users, relative to persons who did not use nonaspirin nonsteroidal anti-inflammatory drugs (NSAIDs), was 0.43 (95% CI, 0.23 to 0.79) compared with 1.16 (CI, 0.70 to 1.93) among rofecoxib users. The use of rofecoxib was associated with a statistically significant higher odds of MI compared with the use of celecoxib (adjusted odds ratio for rofecoxib vs. celecoxib, 2.72 [CI, 1.24 to 5.95]; P = 0.01). Nonselective NSAIDs were associated with a reduced odds of nonfatal MI relative to nonusers. Comparisons of COX-2 inhibitors with nonselective NSAIDs were the following: rofecoxib versus naproxen (odds ratio, 3.39 [CI, 1.37 to 8.40]) and celecoxib versus ibuprofen or diclofenac (odds ratio, 0.77 [CI, 0.40 to 1.48]).

Juni P. Lancet. 2004 Dec 4-10;364(9450):2021-9 METHODS: We searched bibliographic databases and relevant files of the US Food and Drug Administration. We included all randomised controlled trials in patients with chronic musculoskeletal disorders that compared rofecoxib with other non-steroidal anti-inflammatory drugs (NSAIDs) or placebo, and cohort and case-control studies of cardiovascular risk and naproxen. Myocardial infarction was the primary endpoint. FINDINGS: We identified 18 randomised controlled trials and 11 observational studies. By the end of 2000 (52 myocardial infarctions, 20742 patients) the relative risk from randomised controlled trials was 2.30 (95% CI 1.22-4.33, p=0.010), and 1 year later (64 events, 21432 patients) it was 2.24 (1.24-4.02, p=0.007). There was little evidence that the relative risk differed depending on the control group (placebo, non-naproxen NSAID, or naproxen; p=0.41) or trial duration (p=0.82). In observational studies, the cardioprotective effect of naproxen was small (combined estimate 0.86 [95% CI 0.75-0.99]) and could not have explained the findings of the VIGOR trial. INTERPRETATION: Our findings indicate that rofecoxib should have been withdrawn several years earlier. The reasons why manufacturer and drug licensing authorities did not continuously monitor and summarise the accumulating evidence need to be clarified.

Ray WA. COX-2 selective non-steroidal anti-inflammatory drugs and risk of serious coronary heart disease.Lancet. 2002 Oct 5;360(9339):1071-3 Results of premarketing and postmarketing trials have raised doubts about the cardiovascular safety of the non-steroidal anti-inflammatory drug (NSAID) rofecoxib, especially at doses greater than 25 mg. Between Jan 1, 1999, and June 30, 2001, we did a retrospective cohort study of individuals on the expanded Tennessee Medicaid programme (TennCare), in which we assessed occurrence of serious coronary heart disease (CHD) in non-users (n=202916) and in users of rofecoxib and other NSAIDs (rofecoxib n=24 132, other n=151 728). Participants were aged 50-84 years, lived in the community, and had no life-threatening non-cardiovascular illness. Users of high-dose rofecoxib were 1.70 (95% CI 0.98-2.95, p=0.058) times more likely than non-users to have CHD; among new users this rate increased to 1.93 (1.09-3.42, p=0.024). By contrast, there was no evidence of raised risk of CHD among users of rofecoxib at doses of 25 mg or less or among users of other NSAIDs

_________________
--Ian

Whew.... that is a tough read.

However, I detected the phrase that pertains to me:


OK Ian, based on all of the above, what is your take on my situation of 100mg of Celebrex 4 or 5 times a week?

Rich

_________________
Member of the world's premier gun club, the USMC!

Unfortunately from the first paper there's another phrase that also pertains to you:

"Compared with long-term ibuprofen use, long-term use of celecoxib (adjusted hazard ratio [HR] 3.64; 95% CI 1.36, 9.70) and rofecoxib (adjusted HR 6.64; 95% CI 2.17, 20.2 was associated with a significant increase in cardiovascular risk."

These are complicated relationships to tease out, and the absence of risk in one study doesn't provide any guarantees. The sum of the studies is the key and the summary appears to be that COX 2's appear to increase risk, vioxx more than celebrex, and the older NSAIDS may increase risk, but not as much. Plus there's one line there about celebrex not having a gastrointestinal benefit. So what I do is tell people to avoid drugs if possible, and if not, take a traditional NSAID unless they have a real reason not to. If they've had a bleed they can take a Cox-2 or take an older nsaid with a ppi. If they've got to take a cox-2 they can try to keep other cardiovascular risks down.

_________________
--Ian

Thanks Ian.

_________________
Member of the world's premier gun club, the USMC!

Realized a little key might be of some help. This is a simplification, but think of an odds ratio (OR) or hazards ratio (HR) as being your "fold" risk for the comparison. If the OR is 2, you have a two fold risk. If the OR is .5, the risk is halved. These are estimates which are done with imperfect data, so the stats come with a 95% confidence interval (CI). When an author tells you the OR is 2 but the 95% CI is 1.01 to 32, you only are 95% sure that the true OR is between those values and may be negligible or huge. Not very helpful but if its statistically significant its publishable. If the CI is .98 to 5, then our CI includes 1, which designates no increased or decreased risk--and so the result isn't significant (by convention).

_________________
--Ian

In the conflict of interest debate, you're talking about different entities. Ian (and I) are talking about the actions of the corporation, which are really the actions of the executives. Bill, you're talking about the actions of the chemist, who are more analogous to the doctor.

At Merk, the chemist is not paid more or less whether he alerts the public to safety risks of the drugs. That's not his job. In fact, if he did go beyond his job description to hold a press conference or make a press release, he'd probably be fired. The chemist has no conflict of interest. On the other hand, the executives do have a an conflict of interest if they believe that they'll be making more money for the company by concealing risks associated with their products.

Now one thing I'm ignorant on is the specifics of how doctors are paid; Are they paid hourly, or per-service or some combination? I know the services are billed individually to patients, but is the doctor profitting directly for each service performed? If so, then doctors do, in fact, have a conflict of interest. If a doctor gets paid for each test ordered then there exists a temptation to order superfluous tests.

If doctor's have no conflict of interest, the comparison to a chemist is fair. If they do, then the doctor really is more comparable to an executive for the purposes of this discussion. However, I personally think there's a big difference between having an incentive to perform unnecesary (but harmless) services, thereby wasting the customers' money, and having an incentive to conceal risks, thereby doing physical harm to customers. The conflict of interest for doctors is really just to make the system less efficient, to make hospital visits more expensive and so on. This isn't negligible by any means, but I think it's less of a concern than the fact that our system may be creating incentives to essentially kill people for money, which is what intentionally concealing a known risk does.

_________________
- Justin Powell

Ka-ching!!!!

http://abcnews.go.com/Business/wireStory?id=2325100

Sure, the chemists at Merck can be compared to the doctors at a healthcare corporation, each supervised by executives that might do the wrong thing because of the competing interests of serving their company and the stockholders, and the customers who take their drugs or receive their healthcare. But that would gloss over some key differences. As I mentioned before, the primary goal of the healthcare organization is to provide care, and they're legally and ethically obligated to provide required care. Merck may have some rebate programs to help lower income people take their drugs, but they sure don't hand them out to everyone who comes knocking, and they're not legally required to do so. The chemists may not have a conflict of interest, but then their unconflicted interest is in serving the company, not the customer; the doctors are told to take care of the patients, first. While they are asked--rather indirectly--to use cheaper means when they are equivalent, they are expected to provide any necessary care. And there are layers of supervision between chemists and customers; no decision they make gets directly to a patient. At the hospital, its a mirror image, as the doctors make all the decisions at the bedside, and if executives make a decision, its filtered down and ultimately implemented by doctors. There is cash and people in both systems, and that can screw things up. But the ability to compare them doesn't mean we should think they're comparable.

But enough of that. As for payment......

Some doctors are paid hourly--random shift coverage, jail clinics, etc. Others are salaried and required to work a certain number of hours, which is similar.

Some doctors are paid fee for service, whether you're a cash pay plastic surgeon or psychiatrist, or solo practioner in Smallville. Others--many--generate their money that way but share the ups and downs in small corporations.

Kaiser collects insurance, pays for necessary care, including meds and clinics and hospitals, and pays other organizations to do such things as transplants or other specialty work. It profits if it collects more than it pays out. At the end of the year, vested physicians vote on whether to receive the surplus or reinvest it in computers or paperclips or what have you.

In england they're salaried; they just shifted to a partial "pay for performance" model where they earn points for meeting goals and receive more money that way. England expected a fraction of the points would be earned, instead, it was 95%, and there were a lot of inconvenient patients excluded from the tallies to ensure good performance. Many hospitalists in the USA are salaried plus they get productivity incentives, which entices them to see more patients a day. I'm not a fan.

Some salaried US doctors can convince their University to pay extra monies to them that are many times greater than the usual physician payscale, because of their ability to take their research elsewhere at a moments notice.

Others are paid a lump sum to care for a patient by an insurance company. If they never come in, the doc keeps it all. If the doc spends a million on the patient he or she loses money. The idea is to reward the doctor for decreasing utilization.

The occasional doc has invested in, say, an MRI scanner. S/he gets paid each time its used. Guess what? Use goes up. This is shady.

I hate selling stuff, at least, selling stuff for profit, or feeling conflicted. So I work salaried with set duties--staffing the ward service 50% of the days of the year and some smaller tasks--and if I have 2 patients life is better than when i have 18. What I "sell" to patients is my advice, and I get to give it knowing it doesn't influence my compensation. If I want, I can do extra shifts where I'm paid by the hour at the jail (this is where system constraints REALLY kick in as we routinely / probably appropriately deny care all the time*), or overnight elsewhere. And ~4% of the salary comes as a bonus for meeting objectives for the group that the hospital selects.

Note: doctors can't game the system by making hospital stays more expensive. While there is a professional fee submitted for each patient each day, the doctors of the old model were thrown out because hospitalists (that's me) can shave an average half day off each hospitalization without compromising other outcomes. That's big money. Not as much as it should, but increasingly, costly errors and bad practice are catching the attention of the bean counters and resulting in individual and institutional pressure to improve.

*for example, why would the taxpayers want to excise a lipoma or replace glasses that have both been needed and not pursued by the inmate for FIVE years, until they're convicted of a crime, and when the care is essentially free, they want to see the doctor within a week? Jail will not pay for that stuff.

_________________
--Ian

Good posts, Ian and Justin.

Actually you just convinced us that they can and they do.

Data wonks carefully monitor statistics such as days per 1000 members, and see how that varies by facility reimbursement method. If you pay a facilty a "case rate" (by DRG or diagnostic-related category), then you get several activities going on.

• You get "DRG creep." In other words the coders game the coding system to make a patient appear as sick as possible so they get classified as being in the most expensive disease category. The coders get sent to classes where they learn how to maximize return on coding.
  
• Doctors are pressured to write as many diagnostic codes as possible in the record so that a patient appears as sick as possible. Gotta keep that paper trail... Creative coding borders on and ventures into out-and-out fraud. The federal government estimates that as much as 15% of health care dollars are fraudulently obtained by myriad methods. They actually took Columbia HCA to court (and won) for their activities.
  
• Physicians can be pressured by the hospital bean counters to get people out the door ASAP. Those beds cost money, and you want them in-and-out as fast as possible. Outfits such as Milliman and Robertson (M&R) invest millions of dollars of time, effort, and information supplying information to various sources to show them percentile distributions of hospital stay by DRG so the bean counters can keep the pressure on.
  
• Hospitals find ways to parse services off to outpatient where they get additional reimbursement. For instance they may choose to have various radiological services done on an outpatient basis and billed separately. Insurance companies ultimately get in a war with them about these "unbundling" practices. They have software that rebundles, and the hospitals have business types that scream bloody murder when they do.
  
• Hospitals tell the patients that the insurance company is making them send mama and baby home. No, the hospital is getting paid by C-Section or vaginal delivery, and they make more if they boot mama and baby out early. Then they blame it on the insurance company. I know, because they do this to mothers who work at those very insurance companies. Needless to say, that doesn't go over well...

If you pay by per diem (per day), then

• foot-dragging goes on at the hospital while the insurance companies get on them with the days per thousand and M&R stats. Patients stay longer than they should, which causes them unnecessarily to be exposed to antibiotic-resistant nosocomial infections. You do NOT want to get an infection in a hospital.
  
• Hospitals employ various tricks such as releasing a patient a minute past midnight to get an exta day. They can get double-paid for that bed this way. I've seen it...
  
• Hospital errors result in longer lengths of stay. Longer lengths of stay mean more money when you are paid on a per diem basis. So bad medicine = more money.
  
• There is no financial incentive to get nosocomial infection rates down, and that kills patients.

Medicine isn't the saintly industry some make it out to be any more than any other profit or non-profit business is. Ultimately ethics need to be trained and applied at the individual level. And as Ian pointed out, people need to be trained that quality business is good business. It gets repeat customers. Just ask GE and Toyota.

- Bill

"You get "DRG creep." In other words the coders game the coding system to make a patient appear as sick as possible so they get classified as being in the most expensive disease category. ... Doctors are pressured to write as many diagnostic codes as possible in the record so that a patient appears as sick as possible. Gotta keep that paper trail."

The creep is towards accuracy in my experience. At the Beth Israel, doctors were routinely coding all their care 1/4-1/3 too low for fear of overcoding. They were losing millions every year--millions they, according to the insurance company rules, had earned. The same thing was happening at UCSD. The doctors are given an insanely complicated list of things they must write in a note to bill for X or Y level, and its basically too hard to ever sit through and compute so doctors throw up their hands and underbill. Have you seen these silly rules, Bill? If you have you know exactly why we have billing seminars and reminders from the coders, and implying that the existance of these things equals doctor trickery is disingenuous. Desperate hospitals then harrass us to do better and force us to go to billing seminars. The coders have to review the language we use in the chart and when I write "dry," "cachectic," "urosepsis," or "low Na" they come by and ask me to write (if and only if its true) "dehydrated," "malnourished," "uti complicated by sepsis" and "hyponatremia." Then we improve and we're cast as gaming the system? You think I enjoy tallying up the number of systemic inflammatory response syndrome criteria and organ dysfunctions so I can bill for severe sepsis or septic shock when the patient has it? The lies that I've told on forms have been limited to situations where insurance companies--and I am not making this up--will not release the antibiotic my patient needs unless I say its for a UTI, etc.

It is a game--but the doctors didn't create it. I did have a bunch of doctors advise me, while I was in college, that the explosion of paperwork, billing BS, prior authorizations, and other BS was so unpleasant that I shouldn't go to medical school. Gaming the insurance world? What do you call it when a patient is on a lifesustaining medication that's propping up his bone marrow, is getting worse despite that, comes into the hospital for two days, I write him for a refill on his way out, and his insurance company takes the opportunity to do a review, denies the med, and makes me fill out forms and talk to bean counters for 3 hours before he can get it, to "prior authorize" a med he's been on for a year? Like my other patients prefer I spend my time jumping through hoops like that? Like the lawyers, bean counters, and executives I'm being compared to ever have to apologize to their patients or take care of them with their hands tied? It does ******, but its all I've known so I'm used to it. I haven't, however, taken so much flack for it before. I try to paint complex pictures here sometimes, such as:

--merck didn't behave perfectly and should have anticipated trouble, but the lawsuit craze is inappropriate
--doctor reimbursement is complex and those who put themselves in sketchy positions should be accountable, but most are trying to do the right thing

But somehow the replies always come back without any moderation or qualification...

--merck 100% blameless, lawyers 100% awful
--doctoring, and me, exactly the same as merck cashmaking and corporate conflicts of interest

it's as likely to be true as:

--Iraq war 100% good, France 100% bad.

And this stuff I no longer feel a need to explain away. Since it came up elsewhere: Occam's Razor--people have a sense for the way it actually plays out and its never as cut and dry.

Oh, and once again, I'm not paid based on my billing performance. I do it as accurately as I can because part of my job is to bring in the funds for the work I do so my hospital, which deal primarily with the underserved and underfunded patient population here in san diego, stays open. Find fault in that? Name me in a class action suit or something.

_________________
--Ian

Sigh... Well that was entertaining, if nothing else.

You need a little humor, Ian. Perhaps this will shed light on what drives it all.



- Bill