He was nonetheless unapologetic about the time he had invested.
“Real life is all about the narrative,” he said. “It’s sitting down and talking about bowel movements with a 79-year-old woman for 45 minutes. It’s not that interesting, but that’s where it happens.”
.. Outsourced hospitalists tend to make as much or more money than those that hospitals employ directly, typically in excess of $200,000 a year. But the catch is that their compensation is often tied more directly to the number of patients they see in a day — which the hospitalists at Sacred Heart worried could be as many as 18 or 20, versus the 15 that they and many other hospitalists contend should be the maximum.
.. If you talk to them for long enough, you get the distinct feeling it is not just their jobs that hang in the balance, but the loss of something much less tangible — the ability of doctors everywhere to exercise their professional judgment.
.. “It became difficult to plan your day,” said Dr. Frank Littell, a Sacred Heart hospitalist who has been practicing in the area since the 1980s. “If a patient needed to be admitted to the E.R., you had to cancel all your afternoon appointments.”
Gradually, it became clear that it would make more sense for a subset of internists to be based at each hospital, where they would handle the care of all the patients on site.
.. Asked if health outcomes had improved as a result, Mr. Higman said, “Readmission rates have been reduced — we can show it.” Costs are rising more slowly too, he said, no small thing in a country where many people are bankrupted by medical expenses. But, he added, “as to whether you as an individual are seeing better quality in health care — I think there’s some question there.”
.. The basic accounting problem for hospitalists is that they are not a profit center. That is, when they treat patients, the amount a hospital can bill Medicare and insurance companies is typically less than what the hospital must pay them. The opposite is true for other specialists, like surgeons.
The Hidden Financial Incentives Behind Your Shorter Hospital Stay
What is clear is that hospital stays used to be a lot longer. In 1980, the average in the United States was 7.3 days. Today it’s closer to 4.5. The difference isn’t because hospitalized patients are becoming younger and healthier; by and large, today’s patients are older and sicker. Yet they’re being discharged earlier.
One big reason for the change came in the early 1980s. Medicare stopped paying hospitals whatever they claimed their costs were and phased in a payment system that paid them a predetermined rate tied to each patient’s diagnosis. This “prospective payment system,” as it is called, shifted the financial risk of patients’ hospitalization from Medicare to the hospital, encouraging the institutions to economize.
.. The prospective payment system pays a hospital the same amount whether a Medicare patient stays five days or four. But that extra day adds costs that hit the hospital’s bottom line.
.. A physician who practices at a Boston-area teaching hospital told me that hospital administrators exert social pressure on doctors by informing them that their patients’ stays are longer than that of their peers.
A disturbing report from the front lines of the war on cancer.
“The Death of Cancer” is an angry book, in which one of the critical figures in twentieth-century oncology unloads a lifetime of frustration with the obduracy and closed-mindedness of his profession. DeVita concludes, “There are incredibly promising therapies out there. If used to their fullest potential for all patients, I believe we could cure an additional 100,000 patients a year.”
.. Baffled, he asked one of the hospital’s leading oncologists, Barney Clarkson, to explain exactly how he was administering the MOPP protocol. Clarkson answered that he and his colleagues had decided to swap the nitrogen mustard in DeVita’s formula for a drug called thiotepa. This was a compound they had developed in-house at Memorial Sloan Kettering and felt partial to. So MOPPwas now TOPP.
.. “Why in God’s name have you done this?” he asked.
A voice piped up from the audience. “Well, Vince, most of our patients come to us on the subway, and we don’t want them to vomit on the way home.”
Here were physicians at one of the world’s greatest cancer hospitals denying their patients a potentially life-saving treatment because their way felt better. Stories like this are why DeVita believes that a hundred thousand cancer patients in the United States die needlessly every year.
.. The angriest chapter of “The Death of Cancer” is devoted to the Food and Drug Administration, because DeVita believes that it has fundamentally misunderstood the trade-off between diffusion and innovation. The agency wants all new drugs to be shown to be safe and efficacious, to be as good as or better than existing therapies (or a placebo) in a randomized experiment involving the largest possible number of patients. For example, the F.D.A. might ask that patients getting an experimental treatment have better long-term survival rates than those receiving drug treatments already in use. The F.D.A. is the country’s diffusion gatekeeper: its primary goal is to make sure that good drugs get a gold star and bad drugs never make it to market.
.. A given tumor, for instance, can rarely be stopped with a single drug. Cancer is like a door with three locks, each of which requires a different key. Suppose you came up with a drug that painlessly opened the first of those three locks. That drug would be a breakthrough. But it can’t cure anything on its own. So how do you get it through a trial that requires proof of efficacy—especially if you don’t yet know what the right keys for the two remaining locks are?
.. Drugs are now approved not for a specific cancer or for general use in a variety of cancers but for a specific stage of a specific cancer and specifically after and only after patients have had all current treatments, which are listed drug by drug, and the treatments have all failed. Doctors risk F.D.A. censure if they use an approved drug under any other circumstances, and patients are penalized because insurance companies won’t pay for treatments not approved by the F.D.A.
The vital insight gained by using an approved drug in a different way for a different tumor has been lost.
Working to Lower Drug Costs by Challenging Questionable Patents
Through the Coalition for Affordable Drugs, a company they formed this year, Mr. Bass and Mr. Spangenberg identify pharmaceutical patents that they consider weak or abusive. Then they request that a unit of the United States Patent and Trademark Office review the legitimacy of the patents.
By mid-November, the firm had filed 33 requests for patent reviews, targeting 13 drugs from a dozen companies.