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Welcome to the Health Wonk Review. Rather than following my usual hosting path of pithy commentary on each post, I’m letting the bloggers tell their own stories. Enjoy!

Health policy

John Goodman’s Health Policy Blog explores the phenomenon of people seeking jobs based on the health benefits.

Under federal law, employers are treated just like insurance companies: They can’t deny employment or health insurance to people on the grounds that they are likely to need a lot of medical care. Nor can they charge a higher premium to employees based on their health status.

Colorado Health Insurance Insider points out some unintended consequences of high-risk pools.

The requirement that applicants be uninsured for six months prior to applying for coverage is a barrier that keeps people from applying.  I understand the idea behind the six months without coverage requirement (to limit enrollment in what Congress thought would be a very popular plan), but it seems that the provision is actually causing  adverse selection instead:  People have to be uninsured at least six months before they can apply, but once they qualify, they have coverage for pre-existing conditions right away.  That’s likely to encourage people to go more than six months without coverage and wait until they are in need of care to sign up.

Managed Care Matters analyzes the Super-Committee and concludes:

There’s some hope that statesmen-like traits will somehow take hold in the group and we’ll actually see them arrive at a grand bargain. If such a happy event occurs, expect to see subsidies for Medicare Advantage programs cut, a potential increase in eligibility age for Medicare recipients, decrease in hospital reimbursement under Medicare and means testing premiums for Medicare

The John A. Hartford Foundation is in the midst of strategic planning for 2013, and would love some help to fill in the blank:

Because the number of older adults is growing rapidly (some 10,000 turn 65 each day) and, therefore, rates of chronic illness and health care use/spending are increasing rapidly, we must ____________________________________.

The Apothecary decries a “ridiculous” move by the federal government to block modest Medicaid reforms in Illinois.

Block grants are the fulcrum of Medicaid reform. By giving states control over Medicaid dollars, the program can be run more efficiently, directing more resources to those who they’re actually meant for, thereby improving Medicaid’s disastrous health outcomes. Progressives regularly express concern about wasteful health-care spending. So why not let those closer to the problem try to do something about it?

Wright on Health argues that strange as it may seem –and hard as The Apothecary tries to prevent it– ObamaCare may become popular over time.

When it was first passed, Medicare was hugely unpopular among the public. Over time, public acceptance grew, to the point that Medicare’s popularity was actually one of the biggest political obstacles to the enactment of the ACA. Perhaps people will passionately support “Obamacare” decades from now. After all, the case of Medicare shows that it can happen–and has happened before.

InsureBlog wants to make clear where it stands on PPACA, before offering his thoughts on a Kaiser Health News roundtable.

The Obamneycrap evil mandate will probably come to a head next spring, just as the 2012 campaign is heating up. This should make an interesting sidebar.

Health Care Renewal examines the weird beast that is ALEC:

Reporters and bloggers have been probing ALEC (American Legislative Exchange Council), a shadowy non-profit organization known to be funded by the rich, right-wing Koch brothers.  Now it turns out that ALEC has been involved in health policy, and that it’s backers include numerous large corporations, leading to some amazing  juxtapositions.  The organization was involved in transforming the recent US health care reform effort into a means to enrich commercial health insurance, in part by backing the infamous “mandate” for all US citizens to buy commercial health insurance.  However, the Tea Party and other ALEC-backed right wing organizations are now attacking this provision as against personal liberty and unconstitutional.

Cost containment

Health Beat argues that contrary to the conventional wisdom, Medicare spending is not doomed to grow fast forever. Providers can trim the fat.

It appears that Medicare’s outlays are now growing at  4 percen a years. As the provisions in the ACA that will rein in Medicare spending begin to be implemented (cutting overpayments to Advantage insurers, and reducing those annual updates to institutional providers by 1 percent a year), it is quite possible that annual growth in Medicare reimbursements will fall to 2.50 percent– just 0.50 percent above growth in GDP. The aging of the boomers is not likely to reignite Medicare inflation anytime soon.

New Health Dialogue writes of the lack of magic bullets and what to do about it.

Recapping Don Berwick’s keynote: the current system of medical care is based on treating infectious diseases and other acute-care instances–a situation in which there is often a single, simple cure. That medical system doesn’t work well for the challenges we’re facing now–managing and preventing chronic illness. Dr Berwick drew on an idea from the response to climate change to illustrate how we can move to a more effective system and stabilize costs.

Healthcare Economist writes of Spain, making me realize his is the only non-domestic contribution to this edition.

How is an economic crisis affecting hospital staffing levels in Spain? The Healthcare Economist reports.

The delivery system

Healthcare Recon’s analysis suggest a slow rollout of ACOs is the ideal outcome.

A relatively small share of initial ACO participation in the CMS program is desirable, not a sign of failure; too fast an uptake can disrupt the economics of the rest of the provider system, encouraging undesirable capacity exits (given looming baby-boomer demand) or, worse, provoking crippling provider resistance to the overall program. In this context, the rather laborious rules CMS has offered may have had an incidental – even semi-intentional – benefit.

Information technology

Disease Management Care Blog frets that the shift away from PCs may alter the imperatives for Meaningful Use.

Dr. Sidorov examines the commoditization of the personal computer and the implications for the electronic health record.  The Feds have invested a lot of our nation’s treasure in the electronic health record, and just when that investment is gaining steam, the PC tower is giving way to handhelds and “the cloud.”

The Healthcare IT Guy has some soothing words for the rest of us.

Regulatory compliance officers need not fear open source in medical devices or mission-critical healthcare IT projects.

Healthcare Technology News brings us word of Query Health

Query Health will establish standards for distributed population queries of electronic health records and other sources of health information. The ultimate success of the effort relies on the participation of a wide range of stakeholders including patient advocates, clinicians, health IT experts, health systems, payers and other interested parties. The Query Health Initiative is an Open Government Initiative that is consensus-based, transparent, and open.

Drugs and TV

Workers’ Comp Insider takes note of Florida’s efforts to close down the pill mills.

Florida doctors bought 89% of all the Oxycodone sold to practitioners nationwide last year and thousands of outside visitors flocked to the state to buy drugs at the 1,000+ pain clinics. But armed with new legislation, the state is cracking down hard by shutting down pill mills and suspending the licenses of about 80 physicians who were high-volume prescribers.

Gary Schwitzer’s HealthNewsReview Blog provides more evidence of why you can’t trust what’s on TV.

[I offer] criticism of what NBC’s Andrea Mitchell said on the air when she announced that she had breast cancer.  Many other women with breast cancer reacted with constructive criticism about what they thought were misstatements in her televised message.

Consumer engagement

Healthcare Talent Transformation says physicians should not fear the engaged patient:

Doctors should be appreciative, not be intimidated by a patient who wants to be involved in his/her own care. Here is my first-hand account of participatory medicine and its impact on the patient.

Health Access Blog argues that at least when it comes to PPACA, ignorance is not necessarily a bad thing.

A new KFF poll shows that as time goes on, people actually become less knowledgable about the Affordable Care Act. That could be good, to the extent that means less misinformed and less opinionated. But it raises the question of what policies and practices are needed to inform people about the law–especially those who would directly benefit.

Meaningful Health IT News is enthused about Care for Your Care, a public/private initiative to raise awareness about the quality of health care and teach consumers how to seek out better quality.

I truly hope people will view this campaign for what it really is, an effort to engage patients in their own care and open some eyes about the quality problem, not an insidious plot. Unfortunately, in a society that values sound bites over substance, this may be a losing battle.

Prepared Patient Forum notes that we like health care numbers but that we place too much emphasis on them.

Advances in technology have made it possible to quantify – and thus monitor – a seemingly infinite number of physiological and psychological health-related states…Most of these numbers represent a marker that is potentially modifiable by some action we can take, often with guidance from and in collaboration with our clinicians. But while a change in a number may affect the course of treatment or indicate a higher or lower risk, it doesn’t guarantee a certain effect or outcome, as much as we would like it to.

And that will do it for this edition, folks.

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Two stores in the latest Today’s Hospitalist caught my eye.  The first, Making Headway with Difficult Patients discusses “how to defuse tension, cope with patient fears, and have less stress.” The second, Breaking the Foley habit illustrates how unnecessary catheter use climbs back up to its baseline level after intensive interventions are ended.

I wonder if there is some relationship between the two.

The difficult patients article is a good one because it encourages physicians to look at their own personalities to see if these might be a contributing factor, and to take more seriously patients’ concerns about inadequate pain management. It also recommends bringing in psychiatrists and social workers to deal with some of the most challenging cases, and to work as a team.

I know that quite a few patients can be “difficult” and even disruptive. Many of these behaviors are attributable to the stress of being sick and being in the hospital. Assuming patients can control themselves, it’s probably a smart strategy to keep quiet rather than be labeled as difficult. And yet, maybe more patients than the article acknowledges have a real justification for being such a challenge.

The catheter article reports how nonindicated Foley use in the hospital dropped from 15% to 1.2% but then drifted back toward the baseline after the dedicated “Foley nurse” who checked up on everyone daily was withdrawn.

“Team members are still giving sporadic feedback on Foley use to units, and a patient safety officer is making sure that electronic alerts to discontinue a Foley reach the right provider. But Dr. Johnson admits those efforts, ‘are not having nearly the effect that having the Foley nurse had.’”

“One of the unexpected results of the study was identifying a significant problem: Foley related trauma. While nurses recognize catheter-related injuries, those are rarely brought to doctors’ attention“. (emphasis mine)

“According to Dr. Johnson, not only is trauma common, but in some cases it can be dramatic and include false passage and bladder perforation. Even the act of removing Foley catheters can cause trauma to the urethra and bleeding.”

Do you think this kind of indignity and injury –that the doctor is unaware of– would be enough to cause a patient to qualify as difficult in the mind of his clinicians? What if we add to the mix other common problems such as a noisy environment that prevents sleep, medication errors, and failure to follow infection prevention procedures such as handwashing?

It’s actually surprising that more patients don’t get tagged as difficult.

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The wild attacks on Social Security by Republican presidential candidates including Rick Perry’s famous characterization of the program as “a Ponzi scheme” are amusing, but are a serious distraction from the real fiscal issues facing the country. Rather than attacking a fundamentally sound 75 year old program with a specified revenue stream, it would be a lot more honest to admit that a Republican Congress and President were responsible for a much more recent and reckless expansion of Federal spending in the form of the Medicare Part D drug benefit.

As explained by the North American Securities Administrators Association:

“The Ponzi scam amounts to little more than robbing an army of Peters to pay a handful of Pauls. As the number of initial investors (the Pauls) grows and the supply of potential new investors (the Peters) dwindles, the Ponzi bubble bursts under the pressure of meeting the promised returns.  While some initial payments are made to drum up new recruits, the vast majority of investors in a Ponzi scheme end up losing all or most of their money.  As in the case of simple pyramid recruitment frauds, a point is inevitably reached where the con man simply cannot keep up with the required payments.”

So Social Security is not a Ponzi scheme at all. It doesn’t promise amazing, rapidly compounding returns on investment. It doesn’t depend on drumming up new investors. Instead, it’s a pay as you go system that mainly taxes today’s workers to pay today’s retirees (that’s where 82 percent of funding comes from). If nothing’s done to rejigger the system, Social Security can still pay out 75 percent of what’s expected even once the so-called “trust fund” is extinguished. Modest adjustments have been made in the past and can be done again: some combination of raising the retirement age, increasing the maximum income on which Social Security taxes are levied, and adjusting benefit levels are enough to keep the program solvent essentially forever. Becoming more open to immigration would also improve the prospects for Social Security by bringing in younger workers. But trying telling that to the Republican candidates!

What about the Medicare Part D drug benefit? Unlike Social Security, there is no dedicated funding stream at all for this $62 billion per year program. And when it was passed there was no provision to make it revenue neutral; the cost went straight to the deficit. Today 83 percent of Part D is funded through “general revenues,” 11 percent through beneficiary premiums and six percent through state payments. Part D is not a Ponzi scheme, but it’s a redistribution of wealth from taxpayers as a whole to senior citizens and pharmaceutical companies.

I’d like to hear the candidates explain why Part D should stay and Social Security should go. Personally, I can’t see the logic of it.

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I got a chuckle out of a Wall St. Journal article (State-Run Drug Maker Answers Outrage Over Opulent Palace) and accompanying photos of the over-the-top interior of Harbin Pharmaceutical Group Sixth Pharm Factory in China featuring extravagant rooms lined with gold and marble, featuring crystal chandeliers and fancy furniture. It’s something one might expect in a Saddam Hussein palace, not a Communist owned factory with a fuddy duddy 1950s style name. To make things worse, these photos weren’t leaked by a whistle-blowing employee or ferreted out by a  muckraking journalist. Instead, they were featured on the company website. Once the company started taking flak it yanked the photos and asserted that the pictures were really of a”wood-block-printing art museum” in their headquarters building, as though that were a plausible use of corporate funds.

Running a successful pharmaceutical company creates a big problem: where to stuff all the cash it can generate. Western firms solved this problem a long time ago, but since they apparently forgot to pass along the pointers to their nouveau riche rivals, allow me to relay some “best practices” I have observed in my travels:

• State of the art air forces of jets and helicopters (without corporate logos for “security” reasons)
• Collections of paintings, antique furniture, sculpture and tapestries in the executive suite, but nothing so bright, gaudy and attention getting as gold
• Housing the chairman’s personal art collection in a company-owned stately home, which also relieves him of the burden of paying for round-the-clock security
• Understated but luxurious headquarters in out-of-the-way locations

And of course this stuff is never, ever photographed and displayed on the Internet. How tacky would that be!

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The Health Business Blog is hosting the Health Wonk Review this week. Please submit through Blog Carnival or email by Wednesday, September 14 at 9 am EDT.

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This is the transcript of yesterday’s podcast interview with Dr. Albert Tzeel of Humana.

David E. Williams:            This is David Williams, co-founder of MedPharma Partners and author of the Health Business Blog.  I’m speaking today with Dr. Albert Tzeel, National Medical Director of HumanaOne in Wisconsin.

He’s co-author of a study of the Wisconsin Health and Information Exchange (WHIE) in Milwaukee, which documents the cost savings to health plans when emergency department physicians use a Health Information Exchange.

Dr. Tzeel, thanks for being with me today.

Dr. Albert Tzeel:            Thank you for having me.

Williams:            What is the context for this study and why was Humana interested?

Tzeel:            Humana became involved as a part of the WHIE board of advisors with me as the representative back in 2007. Early in 2008, Kim Pemble Executive Director of the WHIE and a couple other folks approached me and said, “We really believe that there’s a great ability to impact costs, especially with what we’re doing in the emergency department linking program. We really need the opportunity to get our message out there and see what we can do to help plans save money and more importantly coordinate care for members.  Are you interested in possibly working with this on that?”

I said of course I’d be interested in doing that.

Then I took the idea and helped flesh it out and came up with an internal business case that we took through our internal processes.  Humana decided to provide an incentive to the exchange to help promote the querying of the Wisconsin Health Information Exchange by emergency department clinicians as they take care of our Humana members.

We thought that if payers could get some benefit maybe this could turn into a way of providing sustainability for exchanges. But in order to get payers to buy in, we had to show the business case.  So we went and created a pilot.  We looked at methods of what we would ultimately do to evaluate whether or not this made a difference and what this meant.

Lo and behold the paper that was published was the outcome of all that.

Williams:            What are the key findings of that paper? In particular I know that you did identify some fairly robust savings. What is the source of those savings?

Tzeel:            As we evaluated the data we determined that as a health plan we would save $29 per each individual ER visit for members that went to a facility where the Wisconsin Health Information Exchange was queried by doctors or clinical staff as part of the workflow, versus when our members went to facilities where there was no querying done.

I agree with you in what you said David, that’s a pretty significant savings.  The drivers of that are both improving coordination of care by providing a medical history at the point of care, but also decreasing redundancy of testing.

Typically if someone shows up in the emergency department in one facility and has a battery of tests done and then within a couple weeks or months shows up in another emergency department, if there’s no access to those tests, they’re going to be repeated. That just becomes wasted dollars to the system.

Our data showed that some pretty significant tests did decrease: laboratory tests and EKGs, but also just diagnostic imaging and even CT scans decreased.  Giving a CT scan in the emergency department setting is huge.  So being able to see that those types of tests were not needed to get the coordination of care that was provided to our members where the WHIE was queried was good.

That was very, very impactful.

Williams:            You mentioned a couple words I want to come back to and put them together.  One, you talked about an “incentive” and the other you talked about the “workflow.”

I’m familiar with some similar approaches that have been tried elsewhere that haven’t demonstrated savings. Often the issue has to do with integrating the data querying into the workflow of a busy emergency department. My guess is that the incentive is part of it, but there are probably some other elements to it as well.

Can you explain what really happens in the emergency department and what leads them to query the database versus not?

Tzeel:            Typically as individuals seek care in the emergency department, there’s triage done to see the severity of the condition and then a history is done.  A physical exam is done and then perhaps some laboratory data or whatever’s needed to help confirm the diagnosis and get a better idea of what’s going to be the ultimate disposition of this member.

Is it someone that can be sent home?  Is it someone that needs to admitted?  Depending on the complaint for which that individual comes to the ER, it can end up being fairly intense.  If it’s something non-specific like abdominal pain, there are a lot of different things that can potentially cause that so it becomes incumbent upon the physician to really be able to take a look.

I’ll give all the credit in the world to Kim Pemble and to the folks at the Wisconsin Health and Information Exchange.  They were able to establish relationships with the various facilities where WHIE access was going to be provided, and encourage providers to make this a part of the workflow because ultimately it will make the clinician’s job easier.

I will say that emergency department physicians here in Southeast Wisconsin, want to leave a track record of providing good care in our community. So the more information they have that allows them to make an informed decision, the better the care they can provide to the patient that’s lying down in front of them. In the paper we referred to a comment from one of the emergency department physicians who said that the information provided to emergency department physicians is like gold because it provides so much value to what they’re ultimately trying to do.

So the idea became that it almost became second nature for them in that the physician could access the WHIE database to see background information on the patient that they were seeing. Some of the facilities even had a clerk in the emergency department access the database and provide a printout that they could put right with the medical records, so when that doctor is seeing the patient they’re able to see what’s there and get a better idea of whether or not there’s more information needed, to follow up on or specific things they need to ask about.

So it became really like anything else that becomes ingrained as a habit. It was second nature to make it part of the workflow, to the point that when querying the database wouldn’t occur, I think that the physicians would be quite cognitive of that.  That’s really how it became ingrained.

With respect to the incentive portion, Humana wanted to make sure that the folks at the Exchange were able to be persistent to get the doctors to listen to their message and to be able to really work with them quite well.  So that was what led to our providing an incentive.

Although we set this up as a pilot with a finite time frame, now that we’re seeing a great return on investment this is something that we want to continue doing. And perhaps we can look at what other opportunities we have to expand.

Williams:            This study was conducted in Southeast Wisconsin on a fully insured population of commercial patients.  Do you consider these findings to be generalizable or do you think there are specific things about the geographic area or the patient population that would make you wonder about whether the results could be spread further?

Tzeel:            My opinion is that overall the findings can be generalizable.  When we looked at the data that we had, these were folks by definition had to have at least a couple ER visits and sometimes more than just two, so it wouldn’t be for someone who  just happened to come to the ER for one acute trauma and then wasn’t seen again.  These are folks that had a history of utilizing the emergency department for care.

The second thing is that one of our goals (and I don’t mean to digress) is to make sure that the exchange is queried for every patient.  We felt that it would be easiest for us to work on our fully insured population because Humana was willing to assume the risk. It wouldn’t have been fair to put our self-funded clients at risk if we didn’t see the cost savings.

The Business Health Care Group of Southeast Wisconsin, which is a very large client of ours that we’re the administrator for, heard about this and were very supportive. Even though they weren’t included in the analysis, they also helped support the WHIE through the same program that we were providing.

The question would be if we’re using a fully insured population, what does this mean for members that perhaps have government sponsored insurance: Medicaid, Medicare?  I would think that contractual reimbursements may be different in that respect but ultimately everything cancels out.

I do believe that given the types of conditions, and the fact that we’re seeing ER utilization increases just the same way that other major cities in the country are seeing, I think that it would be generalizable.

Williams:            As you mentioned, there has been an increase in the use of emergency departments for various reasons that you described in the paper, and that are not unique to your region or to Humana.  How does the use of a Health Information Exchange fit in with some of the other approaches that I assume Humana must employ in order to try to control the overall emergency department expense?

Tzeel:            It fits in quite well.  I believe that in a lot of respects it actually complements some of the other things that we do.

For example, certainly we’re trying to promote appropriate utilization of the emergency department.  There are some things that are emergencies and there are a lot of things that aren’t.  Some of the studies show that between 37 and 75 percent of visits to an emergency room are not truly emergencies.

So we want to make sure that folks use the ER appropriately. But whether they do or whether they don’t, if they do go to the emergency room, they will end up getting seen, so it behooves us to make the visit as efficient as possible for the physician by providing information that can be obtained through the WHIE and to encourage that doctor to utilize that information.

It’s neat in that a lot of data from hospitals can become available to that physician who’s taking care of the patient right in front of him or her. Some of the hospital systems here have also –because they’re already hooked up with a common Electronic Medical Record—started to provide data from their employed physicians to the WHIE.  Or if there’s a Federally Qualified Health Center or other entities outside the hospital, they can also provide data so that that gives more information to the emergency room physician who’s taking care of a patient.

Additionally there’s the ability to help with care management by providing comments about specific things about the patient. Things such as: “This is a patient that is in a care management program.  Please contact the following care manager.”

Williams:            The study is focused on the emergency department and that’s an obvious place to start. But is there value that’s broader if you look at it from the health plan perspective where you think you could save money if you go beyond the emergency department?  If we look three or five years down the road, would a lot of the value be elsewhere?

Tzeel:              As you said, I think some of it is actually related to timing.  Right now the main value is the emergency department.  I believe Willy Sutton said, “Why do you rob banks?  Because that’s where the money is.”

Why did we start with the emergency department?  Because that’s where we’re seeing a lot of utilization and can potentially make a big impact.  That’s where it is right now, but I do agree that there’s definite application beyond the emergency department especially for health plans.  I think that there is the ability to coordinate care.

We certainly have a lot of personal nurses or care managers that interact with our members and can help reinforce a lot of what’s going on.  The more information they have regarding conditions that a member has and where a member has gone to seek care the better.  There are some definite opportunities.

There are also going to be more opportunities for health plans to interact with facilities with the common goal to ultimately improve the health of our membership.

Williams:            Humana has been out in front in providing financial support to the WHIE. It sounds as though you’re building your business case and will perhaps be able to continue and extend the financial support.

Are you seeing other health plans follow the lead that you’re taking?  Are they seeing things in the same way?

Tzeel:            I think so to some extent.  I think it depends on where.

We got on board early.  I wasn’t really aware of many plans that were involved prior to our starting this three years ago.  Other health plans are starting to get engaged in certain geographies; California and Rochester, New York for example, and I think it’s all for the same reason.  The health plans believe that there’s opportunity to not just save money but to really improve the health of members that we serve.

My goal in trying to create the business case is to get the ones that are standing on the sidelines to come on board.  I will readily admit that, not for lack of trying, several of my counterparts here in Southeast Wisconsin haven’t come on board.  I think they agree with what we’re trying to do in principle, but they haven’t stepped up in terms of helping to create a sustainable model for a group like the Wisconsin Health Information Exchange.  I’m hoping that this helps bring them forward.

Williams:            I’ve been speaking today with Dr. Albert Tzeel.  He is National Medical Director of HumanaOne in Wisconsin.  Dr. Tzeel, thanks so much for your time.

Tzeel:            Thank you very much.

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The financial viability of Health Information Exchanges (HIEs) and their antecedents (RHIOs, CHINs, etc.) has always been shaky. Grant funding often carries these organizations through their early years and then dries up without anything robust to replace it. Attempts to demonstrate return on investment are often unpersuasive, and governance issues, rivalries among participants and perverse incentives can spell doom.

But I believe that this time around things really may be different. As an example of why I feel this way, I can point to a new journal article on a Humana pilot with the Wisconsin Health Information Exchange (WHIE) that tells an encouraging story of cost savings and makes a the case for ongoing financial support of HIEs by health plans. The Business Case for Payer Support of a Community-Based Health Information Exchange in American Health & Drug Benefits cites “an average cost savings of $29 per emergency department visit compared with the control group.”

In this podcast interview, lead author Albert Tzeel MD MHSA discusses the findings of the study and explains why he believes the results are generalizable beyond the study population.

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David Williams interviews HumanaOne National Medical Director Albert Tzeel [ 21:19 ] Play Now | Play in Popup | Download

Recently I heard a Rabbi discuss the prohibitions against bribes in Jewish law. He shared the Talmudic insight that “a gift blinds the eyes of the wise” and taught that this refers not just to obvious bribes but even to small, innocent-seeming gestures that appear too insignificant to influence another person but that actually do cause a conflict of interest. I told him this sounded very similar to contemporary relationships between pharmaceutical companies and prescribing physicians, where small gifts like pens and take-out lunches are tools of the trade –viewed as innocuous by their recipients but seen as a good investment by the givers.

I revisited a blog post I wrote on the topic back in 2006 along with a JAMA article (Health industry practices that create conflicts of interest: a policy proposal for academic medical centers) by Brennan et al. from the same era. I looked at the list of articles citing the Brennan piece to see if I could find something more current. Lo and behold I discovered Unconscious conflict of interest: a Jewish perspective by Gold and Applebaum in the Journal of Medical Ethics, which probes this issue in more depth. They write:

To me this is fascinating stuff and suggests that to truly avoid the unconscious conflict of interest in the pharma/physician relationship it would be necessary to cut off all contact between pharma rep and doctor. Even when a drug rep is prohibited from distributing tsotchkes or tapping his restaurant budget, the physician still knows the rep would give him things if he could. Under this logic, the “no see” policies of some physician organizations toward pharma reps make good sense.

There is another solution, which is to educate physicians about unconscious biases and the objectives and tactics of pharma companies, device companies, health plans, and other would-be influencers. Even better would be to couple this education with conscious efforts to counteract any biases that are introduced.

Physicians are notoriously skeptical of the notion that they are influenced by gifts large or small. Therefor the article wisely concludes:

For those disinclined to accept either the insights of sociologists and anthropologists or the findings of modern neuroscience on the tendency towards reciprocity in response to the receipt of gifts and favours, perhaps the wisdom of the ancients provides a reason to rethink the unconscious influence of even small benefits on physician behavior.

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A lot of my business school classmates had worked as engineers. They were drawn to the intellectual challenge and rigor of the engineering field and liked the relatively high salaries for engineering jobs coming out of college. But after a few short years working as engineers they realized the real decisions and the real money were made by business people, many with MBAs from top schools. So rather than putting up with the frustrations and plateauing compensation of the technical track, they took the business route.

Now they run companies, are partners in professional services firms, and work in private equity, hedge funds, venture capital and investment banking. Many still consider themselves engineers and use some of what they learned in school. But let’s face it, they’re not doing engineering.

Adjusting, More M.D.’s Add M.B.A. in the New York Times has a promising start:

Under heavy pressure from government regulators and insurance companies, more and more physicians across the country are learning to think like entrepreneurs…

Mark V. Pauly, a longtime leader of the health care management program at the Wharton School at the University of Pennsylvania, said, “A light bulb went off and they realize that health care is a business.”

Good, I thought. I’ll be reading about how practicing physicians are becoming more business aware.

But no. All the examples are MD/MBAs who sound a lot like my engineering classmates. These aren’t “physicians thinking like entrepreneurs” as advertised in the article’s lead. Instead the various pharma company execs, venture capitalists, and professors are MBAs who happen to have medical degrees, too. Some are graduates of the many  joint MD/MBA programs that are springing up. Others decided to get their MBAs after starting or completing medical school or even practicing medicine.

Have you ever heard of someone going back to medical school after getting their MBA? Now that would be a story.

Next time the Times examines this topic I would encourage them to pursue a more productive path and write about:

• How practicing physicians are incorporating business thinking into their work
• Whether and why physicians are leaving the practice of medicine to pursue business degrees and careers
• What medical schools should be doing to prepare doctors for business forces in health care
• How some MDs manage to simultaneously engage in patient care and a business venture
• What practicing physicians (without MBAs) think of MD/MBAs and whether they consider them to be peers

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