Taking Care of Numbers

Medicare is talking once again about value based purchasing in home health.  This is another name for pay-for-performance which was all the rage ten or so years ago and later, fell off the radar. Basically,  Medicare wants to increase payment to providers for being good providers and reduce payment to ‘bad’ providers.  Tonight’s post is about just one of many reasons why I do not like Paying for performance or outcomes.  Read between the lines and see if you can imagine home health and hospice providers chasing numbers when value based purchasing comes around.

My mother had a heart attack several years ago.  My father, an engineer and manager by education called me that Mama was having chest pain but that when he took her blood pressure it was fine.  I told him to take her to the hospital.  He proceeded to tell me that her blood pressure on the other arm was quite different.  A significant difference in readings between the two arms is characteristic of an aortic aneurysm so I told him even more emphatically to take her to the hospital.  He insisted on giving me the actual readings which were off by four millimeters of mercury easing my mind about aneurysms and such but I had not had any coffee so I hung up and after telling him I would see him at the hospital.

At the hospital, he asked me what MI was.  Mama had just been taken in the back and there was no credible information that she suffered an MI.  After a detailed explanation, he asked why they put it on the form between first name and last name.  Still no coffee.  This was going to be a long morning.  Daddy can’t hear very well and in his anxious state, I hated to leave him in search of caffeine.

I spent many years working in a cath lab.  Even looking at the clock, the number of minutes seemed excessive although not as excessive as the number of hours it felt like waiting.  Finally, the doctor called me back and showed me the films.

Nothing.  All I saw was wide open vessels.  Mind you, I’m good at this.  I can spot a diseased vessel that most people miss.  I did not see anything.

He repeated the films several times and challenged me, ‘You still don’t see it, do you?’  Grinning like the winner of an Easter egg hunt who found the golden egg, he showed me the culprit.  The tiniest branch of a branch of a branch at the apex of her heart originating at the right coronary artery was occluded.  He explained he couldn’t find it either which accounted for the delay.  He had to review the films and reshoot a couple of times to be certain.  Even with coffee and even if I had seen it, I might have written it off to a flaw in the images.

I was relieved.  Mama felt stupid as though she should have known that it was insignificant and Daddy continued to wax eloquently about the variable blood pressure readings.  All was well except my son was very angry that we forgot to tell him that his favorite person in the world had a heart attack.

A couple of days later, Daddy called to say Mama was tired and cranky and not able to do her stuff at church.  I went to see what was up and found that she had been placed on a beta blocker, aspirin and a statin drug because it was hospital protocol for anyone with a diagnosis of MI.  Mama is petite on good days and just short on other days and 25 mg of Lopressor was taking it’s toll on her.  She was fine after she stopped it.

She did not need any of the three.  Her drug of choice for pain is old fashioned Bufferin.   I have almost had to admit her to detox for it any number of times.  Her cholesterol is within normal limits and her coronary vasculature was award winning.  She exercises regularly and eats so well, I imagine there is an ICD-9 code for her self-imposed dietary restrictions.

Meanwhile, the hospital’s outcomes are keeping up with the Jones’s.  In the wisdom of evidence based practice my mother was prescribed three meds that would do her no good.  Granted, they were cheap and if I had to choose, I would prefer a global policy of prescribing them for everyone rather than miss a few who needed the medications.

I don’t have to choose as it turns out.  Medicare has already determined what pretty much every heart attack patient in the country needs.  With all of the critical thinking required to open a refrigerator door, our physicians order medications for all patients according to pre-printed recipe. The hospitals and the physicians with privileges at the hospitals are chasing numbers instead of taking care of individual patients.

What bothers me the most about treating the numbers is that although minor, there are side-effects to the medications prescribed to my mother as she was discharged from the hospital.  There was a potential for dizziness and orthostatic hypotension resulting in a fall from the beta blocker.  There are side effects of statins including memory loss.  An aspirin a day shouldn’t hurt anyone but nobody stopped to ask Mama what she ordinarily took for pain and too much aspirin can cause problems as well.  The chances of side effects for Mama outweighed the benefits of treatment.

Treating the hospital’s outcomes should never be mistaken for quality care of individuals.  This is something we need to remember when our reported data is being evaluated for purposes of payment.