Friday, June 21, 2013

Obesity as a Disease: All About the Economics

The American Medical Association has decided to recognize obesity as a disease.  This is a mistake, but not for the reasons you might initially think.

Let’s establish the logic behind the AMA’s decision.  There is no new study, no new statistic, no new discovery that has led the AMA to this decision.  This is about money, plain and simple.  And while I don’t object to the decision on these grounds (economic incentives can be powerful tools for behavior change), I’m not convinced the AMA has thought this all the way through. 
There is increasing frustration in the physician community around the expectation of doctors to “treat” what was previously the symptom or co-morbid condition known as obesity.  The time spent counseling patients on diet, exercise, weight loss programs, and underlying behaviors impacting weight has not been adequately reimbursed by government or commercial payers.  Thus, physicians are left with the need to treat a condition without an explicit payment mechanism for such treatment.  I understand and acknowledge that this has a negative impact on physician practice economics and/or on the overall health of obese injured workers and other patients. 
But calling obesity a disease will result in a plethora of unintended consequences. 
First, we risk creating a new fee stream to doctors that may yield little progress in the fight against obesity.  Altering physician behavior through economic incentives doesn’t necessarily translate to altering patient behavior.  This decision by the AMA (and the subsequent legislation introduced in Congress to mandate Medicare coverage of obesity treatments) is emblematic of the most basic flaw in our health care system: placing the physician at the center of the system instead of the patient.  We've been on this path for several decades now and it's not working for us.  If we're going to have a discussion about economics and obesity, let's center that discussion around the patient, not the doctor.    
Second, the economic basis for this decision is deeply rooted in the fee-for-service world in which we currently live.  While I believe the death of the fee-for-service model is greatly exaggerated by some, there is an undeniable movement toward outcomes-based payment structures for providers, both hospitals and individual doctors (the rise of the Accountable Care Organization being the most notable among such structures).  I don't know how long the transition will take, but I do believe the AMA will some day regret the classification of obesity as a disease.  When the time comes that physicians are paid NOT for mere diagnosis and treatment, but rather based on the actual weight loss of obese patients, doctors will face the harsh reality that physician accountability and patient accountability are not one in the same. 
Most physicians (but not all) would rather get paid for the treatment they render or suggest.  In a fee-for-service model, obese patients aren't likely to experience issues with provider access.  But when payment streams are linked to outcomes, will that remain the case?  When a physician's paycheck is subject to whether a 300 lb. patient can drop meaningful weight, how many physicians will be willing to see that patient?  Accountable Care Organizations will develop risk-adjusted models for measuring outcomes, but these models will be inherently complicated and difficult for the average physician to grasp.  The point here: in an attempt to create access and funding for the treatment of obesity in a fee-for-service world, the AMA may have inadvertently thwarted future access and funding for obesity in an outcomes-based payment environment.
The fight against obesity should be about accountability and responsibility, but we should be focused on the accountability and responsibility of the patient, not the doctor. 
On Twitter @PRIUM1

Monday, June 17, 2013

September 16, 1877: The Ghosts of Opioid Addiction

September 16, 1877
A letter written by Tom Barlow, catcher for the Hartfords:
“It was on the 10th of August, 1874, that there was a match game of baseball in Chicago between the White Stockings of that city and the Hartfords of Hartford, now of Brooklyn. I was catcher for the Hartfords, and Fisher was pitching. He is a lightning pitcher, and very few could catch for him. On that occasion he delivered as wicked a ball as ever left his hands, and it went through my grasp like an express train, striking me with full force in the side. I fell insensible to the ground, but was quickly picked up, placed in a carriage, and driven to my hotel. The doctor who attended me gave a hypodermic injection of morphine, but I had rather died behind the bat then [sic] have had that first dose. My injury was only temporary, but from taking prescriptions of morphine during my illness, the habit grew on me, and I am now powerless in its grasp. My morphine pleasure has cost me eight dollars a day, at least.  I was once catcher for the Mutuals, also for the Atlantics, but no one would think it to look at me now.”

Sound familiar? 

Tom Barlow (who is credited, by the way, with the invention of the bunt) was hurt on the job, received care from a physician that, while well intended, resulted in dependence and addiction.  The only difference is that, in 1874, his employer didn't pick up the tab for his addiction like employers do today.

While the scope of the issue is broader and more complicated today, we would do well to keep in mind that addiction is not a new phenomenon - and that we have a responsibility to stop it before it starts or, once a patient is in its grasp, to do everything we can to treat that addiction. 

On Twitter @PRIUM1

Wednesday, June 12, 2013

Opioid Education Resources

[Guest post from Scott Yasko, PRIUM Account Executive]

The work comp industry is a relatively small universe and one where a lot of us are very familiar with each other. So I am sure that a lot of you who read this blog received the same email recently from Phil LeFevre of the Work Loss Data Institute. Perhaps the most notable work that this organization does is with the Official Disability Guidelines (ODG) with which we at PRIUM utilize on a daily basis.

LeFevre’s email begins with the line, “I’ll sum up the statistics on opioids in two words: Ruined Lives.” The purpose of his email was to promote ODG’s Opioid Flyer (found here) and at the same time raise continued awareness for the epidemic our industry and this country is currently facing. ODG are of course evidence based guidelines and Michael Gavin has written on this same page a handful of times about how important it is to utilize evidence based medicine as a baseline for care.

But what struck a chord with me and what compelled me to want to share my thoughts is the passion and frustration that shows through in the way in which it was written. This is the same passion and frustration I know that a lot of us share on a daily basis when dealing with this issue. An issue that is front and center in our little corner of the world, and one where the problem is well documented everywhere else, but yet the adherence and desire to work together to combat the opioid epidemic is surprisingly lacking in our society.

It pains me to know that Missouri still does not see the necessity of having a prescription drug monitoring program.  It is frustrating that there are still physicians out there passing out painkiller prescriptions to patients’ outstretched hands as if Rx Halloween comes once a month. Especially considering the well documented cases of bad actors like Dr. Lisa Tseng who was arrested on murder charges and linked to at least 19 overdose deaths; or that of Dr. Rolando Lodevico Atiga who was arrested after writing a prescription for an opioid and a muscle relaxant to an undercover agent who presented him with an x-ray showing injuries to the neck and back … of a dog.

Perhaps what motivates me (and comforts me) is the fact that there are those willing to raise their hand when the questions is posed: What are we going to do? Dr. Andrew Kolodny, President of Physicians for Responsible Opioid Prescribing (PROP) is one such individual taking action against this epidemic. This group’s mission? “To reduce morbidity and mortality resulting from prescribing of opioids and to promote cautious, safe and responsible opioid practices.” We need individuals and organizations like this and we need more calls to action like the one that was expressed in Phil LeFevre’s email. And this is the advice given to the readers about the opioid flyer: “Share it, save it, print it, tape it to the wall if it helps you, your MPN providers, or your loved ones.”

That’s good advice because if you needed a reminder - this IS an epidemic and it is one that dwarfs the size of any we have seen in this country. Prescription drugs are now responsible for more overdose deaths than heroin and cocaine combined. But the transformation of this industry even in just the last couple of years to recognize this issue is commendable. And there is definitely a long way to go and a lot more that needs to be done, but every small effort like forwarding an email or typing up a blog rant is a step in the right direction.

Scott E Yasko
On Twitter @PRIUM1