Evidence Based Medicine, Medical Malpractice and Incentives

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A recent Dustin Comic like all good comics hit the proverbial nail on the head







Unfortunately the healthcare reform fails to address key aspects to the incentive problem in healthcare. The system remains centered on measuring what we do for patients rather than the end result.



There are moves by employers and the insurance industry to incentives patients towards healthier behavior. This approach is not without problems as highlighted in this piece in the New England Journal of Medicine "Carrots, Sticks, and Health Care Reform — Problems with Wellness Incentives" where the authors highlight the challenges for employers, employees and insurance in creating incentive and how this can introduce inequities that do more harm than good. As they point out

If people could lose weight, stop smoking, or reduce cholesterol simply by deciding to do so, the analogy might be appropriate. But in that case, few would have had weight, smoking, or cholesterol problems in the first place

There is no doubt that patient incentives must be part of the solution but require thoughtful design and implementation to avoid the pitfalls

Incentives for healthy behavior may be part of an effective national response to risk factors for chronic disease. Wrongly implemented, however, they can introduce substantial inequity into the health insurance system. It is a problem if the people who are less likely to benefit from the programs are those who may need them more.

But incentives aligned to the practice of evidence based medicine and in particular the financial challenges facing the ever increasing ordering of tests is where there seems to be significant progress. The announcement of a statewide adoption of Radport by the Institute of Clinical Systems Improvement (ICSI), a nonprofit comprising 60 medical groups, 9,000 physicians, and six payers and health plans was covered extensively at RSNA 2010 in Chicago this year and featured in this piece in Information Week "System Helps Doctors Pick The Right Tests" demonstrating a saving of $27 Million over the preceding year

During the yearlong pilot involving more than 2,300 ICSI-member physicians, ICSI saw no growth in the number of high-tech diagnostic imaging tests ordered. In previous years, the number of tests ordered grew about 8% annually...The lack of growth translates to a savings about $28 million for the year

But any discussion on incentives needs to include the issue of malpractice - liability drives behavior in the same way as incentives do (in some respects its incentive in another from). Peter Orszag opinion in the NY Times Malpractice Methodology makes the point that

The health care legislation that Congress enacted earlier this year, contrary to much of today’s overheated rhetoric, does many things right. But it does almost nothing to reform medical malpractice laws. Lawmakers missed an important opportunity to shield from malpractice liability any doctors who followed evidence-based guidelines in treating their patients.

President Obama weighed in on this issue in June 2009 when he spoke to the American Medical Association when he highlighted the "unnecessary tests and treatments (ordered by doctors) only because they believe it will protect them from a lawsuit" and as he put it

We need to explore a range of ideas about how to put patient safety first, let doctors focus on practicing medicine and encourage broader use of evidence-based guidelines

Medicine remains "more evidence-free" than should be the case:

One estimate suggests that it takes 17 years on average to incorporate new research findings into widespread practice

Addressing the issue of liability can take the traditional approach of limiting punitive damages but as Peter Orszag said "provide safe harbor for doctors who follow evidence-based guidelines" is a much better idea and one that would sit well with patients and doctors alike (I'd be interested to hear from lawyers who agree or disagree on the merits of such an approach).



There are some initial moves in this direction and a need to implement technology to help guide the treatment (as we see with ICSI) and all this would also lead to higher quality of care for everyone and possibly a new system that reimbursed based on the quality of care delivered versus the quantity of care.

Cricket WC 2011: Huge security clampdown!

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DHAKA: The opening game of the World Cup Saturday sees a huge security operation swing into action designed to prevent any repeat of the deadly 2009 attack on the Sri Lankan team that still haunts the sport.



Around 20,000 members of Bangladesh's elite paramilitary force the Rapid Action Battalion and regular officers have been deployed in Dhaka for the first match, police spokesman M. Sohail told AFP.



"All cricket venues, airports, the nine official hotels and transport for all the teams and officials fall under our security blanket," Sohail said as India and Bangladesh prepared to open the event.



Memories are still fresh of the attack in Lahore in March 2009 when gunmen ambushed the team bus carrying Sri Lanka's Test squad in the Pakistani city of Lahore.



Eight people were killed and seven Sri Lankan players and their assistant coach injured.



The attack led to Pakistan's removal by the International Cricket Council (ICC) as a co-host of the World Cup.



The Federation of International Cricketers' Associations (FICA) in a statement on Friday said its security consultants -- Eastern Star International (ESI) -- had "found proposed security arrangements to be sound."



"ESI informed they were confident that provided the plans are implemented in a professional manner the risk to the players in this event will be minimised as far as possible," the Australia-based association added.



It said that security was "a massive challenge" with 14 teams moving around the co-hosts Bangladesh, Sri Lanka and India, South Asia's biggest country, which has a long history of militant violence.



Tim May, the FICA chief executive, said security was still a major concern for players despite reported comments from ICC chief executive Haroon Lorgat that security was a "non-issue."





"I have spoken to Haroon, so as to gain an understanding of the context of his comments, and remain confident that the ICC shares FICA's concerns regarding the importance of security measures at the World Cup," said May.



The World Cup in India has so far avoided much of the anxious discussion that surrounded the hosting of the Delhi Commonwealth Games in October, which saw leading countries question India's suitability as a location.



India has a host of home-grown militant groups from Maoists to separatists and is also targeted by Islamists from neighbouring Pakistan who reject New Delhi's presence in the disputed region of Kashmir.



Islamist gunmen in November 2008 laid siege to Mumbai, India's financial capital, leaving 166 people dead in attacks on two luxury hotels, a rail station and a Jewish centre.



"Security concerns will always be there but how you plan to face it is the issue," said security specialist Medha Chaturvedi of the Delhi-based Institute of Peace and Conflict Studies think-tank.



The United States on Thursday urged its citizens to be vigilant about terror risks if they are in the three host countries of India, Bangladesh and Sri Lanka during the World Cup.



Bangladesh has a history of political violence, but far less militancy than India, while Sri Lanka is now at peace for the first time in decades after the end of its ethnic war.



India's celebrated police officer K.P.S. Gill, who crushed a Sikh rebellion in Punjab state in the 1990s, said his country was ready for the task.



"India proved it during the Commonwealth Games that it can handle mega-events and in my opinion Bangladesh has handled the issue of terrorism in a much better fashion than Pakistan," Gill told AFP.



International experts say that the handling of security was essential, pointing out that there is no shortage of manpower.



"The implementation of a security plan is the most critical aspect," Jake Stratton of London-based Control Risks security consultancy firm told AFP.



"Some of the venues have been planning it for years and so they had plenty of time to put the necessary security into place and train the security staff," he added on the eve of the six-week tournament.



Sri Lanka, where government troops last year defeated ethnic Tamil Tiger rebels, ending the island's 37-year-old separatist war, said it was ready with its plan for the tournament.



"We are giving maximum security and we want to have an incident-free tournament," said Sri Lankan police chief Mahinda Balasuriya.



Resource:economictimes.indiatimes.com