My thanks to Marilyn Mann and Jerry Hoffman for the contents of this post.
Marilyn sent me a very nice blog posting:
http://www.straightstatistics.org/article/how-overtreatment-diabetics-may-have-cost-lives
--in which is described the backtracking of the British NHS after one year from a practice guideline that called for GPs to try to control their diabetic patients' blood sugar so tightly that the hemoglobin A1C level (a measure of long term control of sugar) would be below 7.0%, down from a previous target of 7.5%. These guidelines are used to determine financial bonuses for GP practices for "quality" care and failing to meet this guideline could cost a GP practice 3000 pounds annually.
At the time this guideline was announced, there were already studies published in the literature making it clear that tighter control of blood sugar in Type 2 diabetes was not helpful in improving patient outcomes and was instead associated with greater risk of harm (as I've covered in several previous posts). So there were loud critics when the guideline first went into effect; and those same critics, while glad that the NHS guideline people have backed off (returning to the 7.5% target) point out that almost certainly, patients died during this past year due to the application of this inappropiate guideline.
What does any of this have to do with ethics and Pharma? Here we come to a comment Jerry Hoffman made to me some time back that is pertinent--that the whole idea of "pay for performance," which the NHS has embraced eagerly and which bandwagon US insurers including Medicare are now eager to jump onto, has obvious advantages but some downside risks that are often hidden. Specifically, in the olden days, if drug companies wanted to sell drugs, they had to figure out a way to influence 800,000 free range US physicians. They figured this out, of course, quite well, but it cost them a ton to hire the 100,000 detail people (at the peak of their population) thought to be needed to do the job. If pay-or-performance comes to be, we have made Pharma's job much easier. They will simply have to figure out a way to influence 1000 or so physicians--the ones who write the guidelines on which the P4P targets are based. As I've pointed out before, there is a huge accumulation of evidence that the name of the game in treating Type 2 diabetes ought not be blood sugar control; yet we keep hearing of new drugs designed to provide better blood sugar control, and guidelines keep being written (usually by authors with financial conflicts of interest) advocating better blood sugar control. If that all seems like a way to sell drugs rather than to treat patients properly, we might wonder how that could have come to pass.
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2 comments:
So we make it easier for the crooks to control the warden, sort of speak. You describe very well the problem with cookbook guidelines tied to reimbursement.
The physician may pause longer to study the data when his/her pay is based on the ability to make a judgement, rather than having to worry about how many targets they hit. Even in the face of a noble target such as benchmarking critical values, the drawbacks are quite evident.
Obviously, there are good and bad outcomes to both sides of the argument. However, we could hold the physician accountable in the old system, this new pay for performance system has useless finger pointing, and no accountability.
The Mafia Rule of "follow the money" has durable explanatory power.
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