Letters
might not represent an abrogation of responsibility so much as the general discontent and frustration with the “daily grind” of medical practice, administrative burdens, bureaucracy, and the lack of authority or capacity to lead in a rapidly changing health care system. Indeed, our aim in carrying out the survey was to move beyond the speculation of academics and policy makers to hear the voices of physicians in the trenches. Jon C. Tilburt, MD, MPH Matthew K. Wynia, MD, MPH Susan Dorr Goold, MD, MHSA, MA Author Affiliations: Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota (Tilburt); Institute for Ethics, American Medical Association, Chicago, Illinois (Wynia); Department of General Internal Medicine, University of Michigan Medical Center, Ann Arbor (Goold). Corresponding Author: Jon C. Tilburt, MD, MPH, Mayo Clinic, 200 First St SW, Rochester, MN 55905 ([email protected]). Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Tilburt reported receiving a grant from the Greenwall Foundation. Dr Goold reported receiving a grant from the Greenwall Foundation; honoraria for lectures from University of Texas Southwestern and Gila Medical Center; and travel expenses from the American Medical Association. No other disclosures were reported.
In Reply The survey conducted by Tilburt et al asked physicians to “rate the degree of responsibility (if any) each of these [various] entities should have in reducing the cost of health care.” Only 36% of the respondents indicated that physicians have a major responsibility to reduce costs. Even though nearly all of the respondents (95%) indicated that physicians do have at least some responsibility to control costs, they consistently apportioned greater responsibility to other actors in the system. Trial lawyers, insurance companies, drug and device manufacturers, hospitals, and even patients all ranked higher on the responsibility scale. The data make clear, as Tilburt explained, that physicians believe that “they are, if anything, a little bit less responsible for fixing health care cost than other key stakeholders.”1 Even if, as Ms Weiner suggests, physicians misread the survey and gave their opinions of who bears responsibility for the increase in costs (as opposed to responsibility for reducing costs), which is unlikely, this too would be discouraging. As is often said, the first step in solving a problem is acknowledging that one exists. If physicians deflect blame for increasing costs, surely they will deflect responsibility for controlling them. The reality is that physicians direct roughly 80% of health care spending. Their authority in medical decision making is not, as Dr Korula asserts, “curtailed.” Physicians decide which patients are seen in the office and how frequently; which patients are hospitalized and which are treated at home; which laboratory tests, diagnostic procedures, and surgical operations are ordered and administered; which medications are prescribed; and which other practitioners are recommended and referred. This is hardly curtailed authority. jama.com
However, physicians are clearly not the only ones responsible for controlling health care spending. Real cost containment requires an all-hands-on-deck approach—one in which all relevant stakeholders are mobilized in pursuit of more cost conscious, patient-centered care that keeps people healthy and out of the hospital. Trial lawyers, insurance companies, pharmaceutical companies, and the like will all play a role in that transition. But physicians cannot be absent; indeed, they must lead. There are clear, viable steps that can be taken to realign incentives and create downward pressure on costs. Bundled payments, which is one such step, have been shown consistently in demonstration projects to improve cost efficiency while maintaining and even improving quality. In Medicare, implementing a bundled payment system for coronary artery bypass graft operations reduced costs by 10%.2 And the Acute Care Episode bundled payment demonstration has yielded encouraging data that show potential for reducing costs while increasing quality for procedures like cardiac pacemaker implants and hip or knee replacements.3 What proportion of physicians voiced their support for bundled payments in the Tilburt et al study? A paltry 6%. Leadership will require much more than 6%. If improvement in cost control is expected, all hands will be needed on deck. Ezekiel J. Emanuel, MD, PhD Andrew Steinmetz, BA Author Affiliations: Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia. Corresponding Author: Ezekiel J. Emanuel, MD, PhD, Department of Medical Ethics and Health Policy, 122 College Hall, Philadelphia, PA 19104 (zemanuel @upenn.edu). Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Emanuel reported receiving payment for speaking engagements unrelated to this letter. No other disclosures were reported. 1. Gholipour B. Who should contain health care costs? doctors weigh in. http://www.livescience.com/38384-doctors-health-cost.html. Accessed July 23, 2013. 2. Cromwell J, Dayhoff DA, Thoumaian AH. Cost savings and physician responses to global bundled payments for Medicare heart bypass surgery. Health Care Financ Rev. 1997;19(1):41-57. 3. IMPAQ International LLC. Evaluation of the Medicare Acute Care Episode (ACE) demonstration. http://www.impaqint.com/project-showcase/impactevaluation-studies-projects/default.htmlhttp://www.impagint.com/projectshowcase/impact-evaluation-studies-projects/default.html. Accessed September 9, 2013.
Pitfalls of Population-Based Preventive Medicine To the Editor In a Special Communication, Dr Fineberg 1 explored pitfalls of population-based preventive medicine. Although unintended, the article confirmed for me that cardiovascular prevention practiced by clinicians today is far different from classic prevention. Fineberg distinguished 2 medical approaches, curative and preventive. My practice, and that of many other clinicians, is actually a hybrid, and interventional prevention solves several problems cited by Fineberg. A hypothetical case helps elucidate this. JAMA November 27, 2013 Volume 310, Number 20
Copyright 2013 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a Penn State Milton S Hershey Med Ctr User on 05/23/2015
2201
Letters
An asymptomatic 60-year-old obese woman with a family history of premature cardiovascular disease presents for evaluation. The standard workup reveals borderline levels of triglycerides, high-density lipoprotein cholesterol, and fasting blood glucose. Her 10-year Framingham risk score is 1%. Understanding the limitations of the Framingham risk score,2 her physician does not simply admonish her to exercise and lose weight but instead looks deeper by performing imaging with carotid intima-media thickness (CIMT) and coronary artery calcification and examining blood and urine for apolipoprotein B, C-reactive protein, lipoproteinassociated phospholipase A2, and microalbumin. Age- and sex-matched CIMT and coronary artery calcification results categorize her in the worst 10% and 1%, respectively. Blood and urine biomarkers are also abnormal. Imaging proves the existence of premature vascular disease; biomarkers reveal the presence of active metabolic derangements. The physician has discovered invisible but real and threatening disease and consequently can more effectively address the patient. In the context of Fineberg’s 4 approaches to curative vs preventive medicine, this patient’s disease can now be cured rather than her hypothetical risk of developing disease simply prevented. Pathology (not simply risk) was identified; health can now be restored (not just reduced risk); her individual responsibility to follow prescribed therapeutic lifestyle changes and accept medications can be promoted, moving beyond population-based advice; and individualized clinical recommendations can be established, not just broad-brushed behavioral advice. This stratagem also solved 4 prevention difficulties cited by Fineberg: success is no longer invisible as biomarkers and CIMTs change with interventions3,4; there is no longer a lack of drama—demonstrating disease through personal images and blood work produces visceral and motivating responses; the emotionless world of statistics has been supplanted by the reality of self-danger; and the barrier inherent in delay of results has been breached because biomarkers can rapidly right themselves.5 Embracing interventional prevention adds a vital dimension to the construct of population-based prevention. The 2 systems are not mutually exclusive; they complement and support each other. Seth J. Baum, MD Author Affiliation: Department of Medicine, University of Miami Vol Miller School of Medicine, Miami, Florida. Corresponding Author: Seth J. Baum, MD, Preventive Cardiology Inc, 7900 Glades Rd, Ste 400, Boca Raton, FL 33434 ([email protected]). Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and reported being a consultant to Solstas and Diadexus. 1. Fineberg HV. The paradox of disease prevention: celebrated in principle, resisted in practice. JAMA. 2013;310(1):85-90. 2. Simprini LA, Taylor AJ. Cardiac CT in women: clinical application and considerations. J Cardiovasc Comput Tomogr. 2012;6(2):71-77. 3. Peters SA, Grobbee DE, Bots ML. Carotid intima–media thickness: a suitable alternative for cardiovascular risk as outcome? Eur J Cardiovasc Prev Rehabil. 2011;18(2):167-174.
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4. Nemet D, Oren S, Pantanowitz M, Eliakim A. Effects of a multidisciplinary childhood obesity treatment intervention on adipocytokines, inflammatory and growth mediators. Horm Res Paediatr. 2013;79(6):325-332. 5. Esposito K, Marfella R, Ciotola M, et al. Effect of a Mediterranean-style diet on endothelial dysfunction and markers of vascular inflammation in the metabolic syndrome: a randomized trial. JAMA. 2004;292(12):1440-1446.
In Reply As Dr Baum notes, the opportunity to individualize preventive measures to meet the clinical circumstances of each patient may be an important strategy to make prevention more meaningful, tangible, and acceptable to a patient. One means to accomplish this goal is to identify the subset of general preventive care guidelines that offer the greatest benefit to a patient’s specific clinical circumstances.1 Baum describes another means that relies on biomarkers that can be targets for preventive measures, and changes in biomarker status give tangible evidence of an improving risk profile. As genomic and related research identifies more molecular targets for prevention, this type of precision medicine will be expected to expand and may help overcome some of the obstacles to prevention outlined in my article. Over time, precision medicine can exert a profound effect on the choice of treatment for disease, and this may be accompanied by an even greater effect on personalizing population-based strategies for prevention of disease. Harvey V. Fineberg, MD, PhD Author Affiliation: Institute of Medicine, Washington, DC. Corresponding Author: Harvey V. Fineberg, MD, PhD, Institute of Medicine, 500 Fifth St NW, Washington, DC 20001 ([email protected]). Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. 1. Taksler GB, Keshner M, Fagerlin A, Hajizadeh N, Braithwaite RS. Personalized estimates of benefit from preventive care guidelines: a proof of concept. Ann Intern Med. 2013;159(3):161-168.
Sharing of Medicare Claims Data To the Editor In their Viewpoint, Drs Toussaint and Berwick1 discussed the qualified entity (QE) program authorized by §10332 of the Affordable Care Act. I agree that the QE program is an important avenue for sharing information about quality and efficiency with both providers (eg, hospitals, skilled nursing facilities, physicians, and other practitioners) and the public. The Centers for Medicare & Medicaid Services (CMS) currently has 11 organizations participating in the QE program and anticipates additional organizations will be selected to participate in the future. However, I would like to clarify certain statements regarding reuse of CMS data provided to QEs. It is possible for QEs to qualify to receive CMS data for another purpose unrelated to the QE program. In these cases, the CMS generally does not ask the QE to pay for data that it already has or require it to reobtain that data from the CMS. Instead, the CMS would enter into a second data use agreement (DUA) with the organization to govern the use of the data for the non–QE-related purpose. Data use agreements are important because they establish rules that ensure CMS data are used appropriately and patient privacy
JAMA November 27, 2013 Volume 310, Number 20
Copyright 2013 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a Penn State Milton S Hershey Med Ctr User on 05/23/2015
jama.com
might not represent an abrogation of responsibility so much as the general discontent and frustration with the “daily grind” of medical practice, administrative burdens, bureaucracy, and the lack of authority or capacity to lead in a rapidly changing health care system. Indeed, our aim in carrying out the survey was to move beyond the speculation of academics and policy makers to hear the voices of physicians in the trenches. Jon C. Tilburt, MD, MPH Matthew K. Wynia, MD, MPH Susan Dorr Goold, MD, MHSA, MA Author Affiliations: Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota (Tilburt); Institute for Ethics, American Medical Association, Chicago, Illinois (Wynia); Department of General Internal Medicine, University of Michigan Medical Center, Ann Arbor (Goold). Corresponding Author: Jon C. Tilburt, MD, MPH, Mayo Clinic, 200 First St SW, Rochester, MN 55905 ([email protected]). Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Tilburt reported receiving a grant from the Greenwall Foundation. Dr Goold reported receiving a grant from the Greenwall Foundation; honoraria for lectures from University of Texas Southwestern and Gila Medical Center; and travel expenses from the American Medical Association. No other disclosures were reported.
In Reply The survey conducted by Tilburt et al asked physicians to “rate the degree of responsibility (if any) each of these [various] entities should have in reducing the cost of health care.” Only 36% of the respondents indicated that physicians have a major responsibility to reduce costs. Even though nearly all of the respondents (95%) indicated that physicians do have at least some responsibility to control costs, they consistently apportioned greater responsibility to other actors in the system. Trial lawyers, insurance companies, drug and device manufacturers, hospitals, and even patients all ranked higher on the responsibility scale. The data make clear, as Tilburt explained, that physicians believe that “they are, if anything, a little bit less responsible for fixing health care cost than other key stakeholders.”1 Even if, as Ms Weiner suggests, physicians misread the survey and gave their opinions of who bears responsibility for the increase in costs (as opposed to responsibility for reducing costs), which is unlikely, this too would be discouraging. As is often said, the first step in solving a problem is acknowledging that one exists. If physicians deflect blame for increasing costs, surely they will deflect responsibility for controlling them. The reality is that physicians direct roughly 80% of health care spending. Their authority in medical decision making is not, as Dr Korula asserts, “curtailed.” Physicians decide which patients are seen in the office and how frequently; which patients are hospitalized and which are treated at home; which laboratory tests, diagnostic procedures, and surgical operations are ordered and administered; which medications are prescribed; and which other practitioners are recommended and referred. This is hardly curtailed authority. jama.com
However, physicians are clearly not the only ones responsible for controlling health care spending. Real cost containment requires an all-hands-on-deck approach—one in which all relevant stakeholders are mobilized in pursuit of more cost conscious, patient-centered care that keeps people healthy and out of the hospital. Trial lawyers, insurance companies, pharmaceutical companies, and the like will all play a role in that transition. But physicians cannot be absent; indeed, they must lead. There are clear, viable steps that can be taken to realign incentives and create downward pressure on costs. Bundled payments, which is one such step, have been shown consistently in demonstration projects to improve cost efficiency while maintaining and even improving quality. In Medicare, implementing a bundled payment system for coronary artery bypass graft operations reduced costs by 10%.2 And the Acute Care Episode bundled payment demonstration has yielded encouraging data that show potential for reducing costs while increasing quality for procedures like cardiac pacemaker implants and hip or knee replacements.3 What proportion of physicians voiced their support for bundled payments in the Tilburt et al study? A paltry 6%. Leadership will require much more than 6%. If improvement in cost control is expected, all hands will be needed on deck. Ezekiel J. Emanuel, MD, PhD Andrew Steinmetz, BA Author Affiliations: Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia. Corresponding Author: Ezekiel J. Emanuel, MD, PhD, Department of Medical Ethics and Health Policy, 122 College Hall, Philadelphia, PA 19104 (zemanuel @upenn.edu). Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Emanuel reported receiving payment for speaking engagements unrelated to this letter. No other disclosures were reported. 1. Gholipour B. Who should contain health care costs? doctors weigh in. http://www.livescience.com/38384-doctors-health-cost.html. Accessed July 23, 2013. 2. Cromwell J, Dayhoff DA, Thoumaian AH. Cost savings and physician responses to global bundled payments for Medicare heart bypass surgery. Health Care Financ Rev. 1997;19(1):41-57. 3. IMPAQ International LLC. Evaluation of the Medicare Acute Care Episode (ACE) demonstration. http://www.impaqint.com/project-showcase/impactevaluation-studies-projects/default.htmlhttp://www.impagint.com/projectshowcase/impact-evaluation-studies-projects/default.html. Accessed September 9, 2013.
Pitfalls of Population-Based Preventive Medicine To the Editor In a Special Communication, Dr Fineberg 1 explored pitfalls of population-based preventive medicine. Although unintended, the article confirmed for me that cardiovascular prevention practiced by clinicians today is far different from classic prevention. Fineberg distinguished 2 medical approaches, curative and preventive. My practice, and that of many other clinicians, is actually a hybrid, and interventional prevention solves several problems cited by Fineberg. A hypothetical case helps elucidate this. JAMA November 27, 2013 Volume 310, Number 20
Copyright 2013 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a Penn State Milton S Hershey Med Ctr User on 05/23/2015
2201
Letters
An asymptomatic 60-year-old obese woman with a family history of premature cardiovascular disease presents for evaluation. The standard workup reveals borderline levels of triglycerides, high-density lipoprotein cholesterol, and fasting blood glucose. Her 10-year Framingham risk score is 1%. Understanding the limitations of the Framingham risk score,2 her physician does not simply admonish her to exercise and lose weight but instead looks deeper by performing imaging with carotid intima-media thickness (CIMT) and coronary artery calcification and examining blood and urine for apolipoprotein B, C-reactive protein, lipoproteinassociated phospholipase A2, and microalbumin. Age- and sex-matched CIMT and coronary artery calcification results categorize her in the worst 10% and 1%, respectively. Blood and urine biomarkers are also abnormal. Imaging proves the existence of premature vascular disease; biomarkers reveal the presence of active metabolic derangements. The physician has discovered invisible but real and threatening disease and consequently can more effectively address the patient. In the context of Fineberg’s 4 approaches to curative vs preventive medicine, this patient’s disease can now be cured rather than her hypothetical risk of developing disease simply prevented. Pathology (not simply risk) was identified; health can now be restored (not just reduced risk); her individual responsibility to follow prescribed therapeutic lifestyle changes and accept medications can be promoted, moving beyond population-based advice; and individualized clinical recommendations can be established, not just broad-brushed behavioral advice. This stratagem also solved 4 prevention difficulties cited by Fineberg: success is no longer invisible as biomarkers and CIMTs change with interventions3,4; there is no longer a lack of drama—demonstrating disease through personal images and blood work produces visceral and motivating responses; the emotionless world of statistics has been supplanted by the reality of self-danger; and the barrier inherent in delay of results has been breached because biomarkers can rapidly right themselves.5 Embracing interventional prevention adds a vital dimension to the construct of population-based prevention. The 2 systems are not mutually exclusive; they complement and support each other. Seth J. Baum, MD Author Affiliation: Department of Medicine, University of Miami Vol Miller School of Medicine, Miami, Florida. Corresponding Author: Seth J. Baum, MD, Preventive Cardiology Inc, 7900 Glades Rd, Ste 400, Boca Raton, FL 33434 ([email protected]). Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and reported being a consultant to Solstas and Diadexus. 1. Fineberg HV. The paradox of disease prevention: celebrated in principle, resisted in practice. JAMA. 2013;310(1):85-90. 2. Simprini LA, Taylor AJ. Cardiac CT in women: clinical application and considerations. J Cardiovasc Comput Tomogr. 2012;6(2):71-77. 3. Peters SA, Grobbee DE, Bots ML. Carotid intima–media thickness: a suitable alternative for cardiovascular risk as outcome? Eur J Cardiovasc Prev Rehabil. 2011;18(2):167-174.
2202
4. Nemet D, Oren S, Pantanowitz M, Eliakim A. Effects of a multidisciplinary childhood obesity treatment intervention on adipocytokines, inflammatory and growth mediators. Horm Res Paediatr. 2013;79(6):325-332. 5. Esposito K, Marfella R, Ciotola M, et al. Effect of a Mediterranean-style diet on endothelial dysfunction and markers of vascular inflammation in the metabolic syndrome: a randomized trial. JAMA. 2004;292(12):1440-1446.
In Reply As Dr Baum notes, the opportunity to individualize preventive measures to meet the clinical circumstances of each patient may be an important strategy to make prevention more meaningful, tangible, and acceptable to a patient. One means to accomplish this goal is to identify the subset of general preventive care guidelines that offer the greatest benefit to a patient’s specific clinical circumstances.1 Baum describes another means that relies on biomarkers that can be targets for preventive measures, and changes in biomarker status give tangible evidence of an improving risk profile. As genomic and related research identifies more molecular targets for prevention, this type of precision medicine will be expected to expand and may help overcome some of the obstacles to prevention outlined in my article. Over time, precision medicine can exert a profound effect on the choice of treatment for disease, and this may be accompanied by an even greater effect on personalizing population-based strategies for prevention of disease. Harvey V. Fineberg, MD, PhD Author Affiliation: Institute of Medicine, Washington, DC. Corresponding Author: Harvey V. Fineberg, MD, PhD, Institute of Medicine, 500 Fifth St NW, Washington, DC 20001 ([email protected]). Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. 1. Taksler GB, Keshner M, Fagerlin A, Hajizadeh N, Braithwaite RS. Personalized estimates of benefit from preventive care guidelines: a proof of concept. Ann Intern Med. 2013;159(3):161-168.
Sharing of Medicare Claims Data To the Editor In their Viewpoint, Drs Toussaint and Berwick1 discussed the qualified entity (QE) program authorized by §10332 of the Affordable Care Act. I agree that the QE program is an important avenue for sharing information about quality and efficiency with both providers (eg, hospitals, skilled nursing facilities, physicians, and other practitioners) and the public. The Centers for Medicare & Medicaid Services (CMS) currently has 11 organizations participating in the QE program and anticipates additional organizations will be selected to participate in the future. However, I would like to clarify certain statements regarding reuse of CMS data provided to QEs. It is possible for QEs to qualify to receive CMS data for another purpose unrelated to the QE program. In these cases, the CMS generally does not ask the QE to pay for data that it already has or require it to reobtain that data from the CMS. Instead, the CMS would enter into a second data use agreement (DUA) with the organization to govern the use of the data for the non–QE-related purpose. Data use agreements are important because they establish rules that ensure CMS data are used appropriately and patient privacy
JAMA November 27, 2013 Volume 310, Number 20
Copyright 2013 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a Penn State Milton S Hershey Med Ctr User on 05/23/2015
jama.com
