A One-Size-Fits-All Approach to Determining Clinical Effectiveness Versus Shared Decision Making

The Disease Management Care Blog recently attended a physician meeting that keynoted a U.S. Senator.  In his prepared comments, he admitted that he knew little about controlling health care costs.  Unfortunately, that didn't stop him from humbly paraphrasing the testimony of a famous economist:

"Find out what works," said the expert, "and do that."

Maybe some of the physicians' silence that followed was an "aha!" reaction to the Senator's insightful nostrum.  Some of it may have also been out of respect. 

The DMCB is sure, however, that most of the docs in the room were quietly thinking "You must be kidding me."

Such is the approach of the mandarins leading our federal health care institutions.  "Science and existing literature" says HHS Secretary Sebelius.  "Effectiveness" is the mantra of the Center for Medicare and Medicaid Innovation.  "Improving health care" is now part and parcel of CMS. 

Unfortunately, applying scientific evidence to the economics of health care delivery sounds easy enough until you get down into the weeds.  For a perfect example of that, consider the common condition of painful spinal stenosis among Medicare beneficiaries. According to this JAMA article, there were over 37,000 operations in this population at a national cost of $1.65 billion. 

Which begs the question: does spinal surgery "work," is "effective" and "improves health care?" Can the "science and existing literature" help us decide?

To get an idea of just how complicated the answer is, check out this Agency for Healthcare Research and Quality (AHRQ) research review on Spinal Fusion for Treating Painful Lumbar Degenerated Discs or Joints.  The conclusions from the abstract are:

Overall, limited evidence suggests that spinal fusion compared with physical therapy improves pain and function for adults undergoing fusion for low back pain due to disc degeneration. Because of insufficient reporting and variation in surgical methods used in the different studies, the incidence of adverse events (serious and minor) associated with fusion could not be determined conclusively. The evidence was insufficient to draw evidence-based conclusions for the benefits and harms of spinal fusion for patients with degenerative stenosis or degenerative spondylolisthesis of the lumbar spine. The evidence was also largely insufficient to draw conclusions about the benefits and harms of fusion compared with other invasive treatments or different fusion approaches or techniques.

In other words, there is some evidence that, compared to conservative treatment, surgery helps.  After that, it's the stuff of caveats, statistics, evolving technique and myriad study limitations.

In fact, it's so complicated that the only way it can be applied is by helping patients understand how the science applies to their unique circumstances and values.  Once the patient understands things, it's a matter of letting that patient and doctor jointly decide on the best course of action.

That approach - in contrast to U.S. Senators musing on how we need a one-size-fits-all approach to what works - is called shared decision making and it can be applied to back surgery with considerable cost savings.

"What works?" asks the Senator?  The answer is for you to consider staying out of the way.

Taking Patient Preferences Into Account When It Comes to Pursuing and Measuring Quality

Here's a thought: ask them what they want

One of the intellectual underpinnings of population health management is that the biopsychosocial dimensions of care is a huge determinant of real-world outcomes. As any doctor who takes care of flesh-and-blood patients knows, national treatment guidelines like these typically fall short of taking the human dimension into account. While there are plenty of good and bad reasons why docs are failing to take advantage of guidelines, one is their sterile one-size-fits-all approach that often fails to account for physician awareness of their patients' risk tolerances and economic circumstances. What's more, many widely promoted treatments only offer a small absolute benefit.

Fortunately, this disconnect is bubbling up into the mainstream scientific literature. The latest example is this Viewpoint that appears in the October 28 issue of JAMA. The authors point out that the perspectives of expert physicians who develop guidelines are typically different than the general public, caregivers or persons with a disease. For example, while the NCQA promotes an A1c threshold as a important measure of diabetes care quality, a compelling survey of patients with diabetes suggests that that emphasis may be displaced.

Where to from here? The JAMA authors offer three commonsense recommendations. Future guidelines should:

1. be developed with the input of patients and frontline clinicians.

2. encompass the full range of patient experiences, not outcomes. This means accounting for the  burden, impact on quality of life and role function dimensions of any treatment recommendations.

3. avoid strong recommendations when the best course of action depends on the patients' context, goals, values and preferences.. Lacking a clearly advantageous outcome with minimal side effects, guidelines should offer a conditional suggestions.

The DMCB modestly offers up three additional suggestions for the population health community and other stakeholders:

1) Absent a satisfactory guideline process from the usual national organizations, it would not be a bad idea to take this bull by the horns and develop a parallel set of guidelines that meet the principles outlined in this JAMA article.

2) Organizations like the NCQA and NQF need to be more flexible in promoting evidence-based guideline-based metrics by moving away from a reliance on their monodimensional clinical measures and toward more nuanced measures of meeting patient preferences.

3) Finally, while national variation in health care delivery is a huge challenge as we continue to build a coherent health system, it may be time to reconsider the notion that all variation is bad. Human beings are variation, and the likelihood of imposing local "best practices" across the U.S. will not be in the best interest of patients with different views of what it best for them.

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Of Risk Stratification, Health System Variation and "Stupid" Decision-Making

A fly in the ointment

Years ago, a middle-aged Population Health Blog patient came in for a routine follow-up appointment.  Since his last visit, he had developed iron deficiency anemia. Since slow blood loss can be a sign of an early and curable cancer in the gastrointestinal tract, the PHB recommended a series of unpleasant tests. After a rather routine explanation of the time, expense and inconvenience of those tests, the patient surprised the PHB with a one-word answer: "No."

He went on to live for decades.

Which brings the PHB to this JAMA article on individually-tailored screening for another type of cancer. While even screening for prostate cancer is controversial, it's possible to stratify a man's risk of the condition with some questions, examination data and test results.  That risk can be portrayed in lay terms (there is a "42-in-100 chance" that cancer is present, but doing a biopsy has a "4-in-100 chance of causing an infection..."). 

The points of the well-written article is that 1) risk-stratification can be used to identify persons at high vs. low risk, 2) the decisions to screen, perform additional testing and embark on treatment can be, based on that risk, "tailored" to maximize a good outcome and 3) patients can use their level of risk to ultimately decide how they want testing and treatment to achieve the outcome they want.

Bravo, says the PHB.  While we're on the cusp of understanding whether a more sophisticated approach to screening ultimately leads to better outcomes than the standard all-or-none guideline (USPSTF "recommends against prostate-specific antigen (PSA)-based screening for prostate cancer"), there is enough face-validity to believe that patients will ultimately benefit.

But there is a fly in the ointment and a monkey in this wrench.

The fly? Variation will not go away. While health system bureaucrats everywhere would prefer that 0% of men undergo prostate screening, that 100% women over 50 get mammograms, and that 0% of us have a body mass index in excess of 25, individuals - after looking as the risk-benefit here, here and here, may choose otherwise.  We don't know what the "right" screening rates are.  In fact, we may not be asking the right questions.

The monkey?  Some "bad" decisions will occur. Once persons truly understand the benefits, risks and alternatives (including not dying prematurely of a preventable illness and side-effect risks that are less than driving in a car), they are allowed to make "stupid" decisions.  Physicians and bureaucrats may not like it when anemic patients, like the one described above, refuse no-brainer recommendations, but in a free country that's the price we pay. Our challenge is to make sure that our patients have all the information they need (which is apparently not the case here) to make a truly informed decision.

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Shared Decision Making for Hip and Knee Replacement Candidates

Osteoarthritis (a.k.a "degenerative arthritis) of the hip and knee just... sucks. Characterized by activity-related pain in the affected joint, many otherwise physically fit persons have to resort to pills, injections and, finally, an appointment with an orthopedic surgeon to talk about joint replacement surgery.

What is less appreciated is that osteoarthritis can have a waxing and waning course with periods of relative remissions. What's more, conservative treatment options can lessen or delay the need for surgery. Last but not least, the surgery itself involves months of recovery and the possibility of a nasty complication.

The primary care physician Disease Management Care Blog presided over this many times with its arthritis patients.  It was generally reluctant to refer a patient to an orthopedic surgeon because it knew that the patients would be more interested in the potential benefits and pay less attention to the downsides of surgery.

Enter shared decision making (SDM). Defined as care that is respectful of and responsive to individual patient preferences, needs, and values and ensures that patient values guide all clinical decisions, the premise is that by giving patients the information they need, they'll be able to ultimately determine the course of their care.  That would include patients with severe hip or knee osteoarthritis who are thinking about surgery but who also need to consider the option of conservative management.

That's why this just-published Health Affairs study is noteworthy. All the 27 orthopedic surgeons in the 5 Group Health Cooperative clinics introduced shared decision making (SDM) for patients who were being evaluated with knee or hip osteoarthritis.  The intervention consisted of DVDs and booklets (from this company) that were ordered by the surgeon prior to an appointment.  The materials could also be viewed on Group Health's website at any time.

The study itself was quasi-experimental.  To be included in the study, patients had to 1) have knee or hip arthritis, 2) ) be continuously enrolled in the Group Health Plan for 12 months prior to the orthopedic clinic visit and 3) have a visit itself that was first index visit by the patient for that problem being evaluated by that particular specialty.

Outcomes from the 18 months of the SDM intervention period (January 2009 through July of 2010) were compared to the observation period of January 2007 through July of 2008.

Recall that the surgeon had to proactively order the SDM prior to the visit.  As a result, only 41% of the hip patients and 28% of the knee patients received the DVD, pamphlet or viewed the on-line materials.
 
Nonetheless, during the 6 months after the initial visit, the SDM patient population had 0.34 hip operations per 180 person-days (your DMCB offers an explanation of this counter-intuitive metric below*), compared to the control population of 0.46.  The difference was statistically significant. 

There was also a statistically significant reduction in knee operations: 0.09 per 180 person-days vs 0.16 per 180 person-days. 

All the differences held up after the authors statistically adjusted for differences in age, sex, obesity, co-morbid conditions, use of prior x-rays, joint injections, insurance factors and the clinic site.

Like all good authors writing in a high quality journal, they point out that this research was not pristine. The comparison period may not have been a representative baseline and, from 2008 to 2009, other factors may have caused a drop in hip and knee surgeries.

Nonetheless, this is an example of a "real world" study that credibly demonstrates that when osteoarthritis patients are exposed to SDM, more will opt for conservative management.  While that helps decrease health care utilization and ultimately costs, that's not the most important point: the patients who really wanted surgery got it and the patients who were less sure about the benefits of surgery chose not to have it.  What's more, this didn't involve a lot of expensive face-to-face care management, it involved some DVDs.

The DMCB cautions that this successful study was carried out in a highly integrated delivery system and may not be transferable to other practice settings.  That being said, as Accountable Care Organizations struggle to meet their patients' expectations and save money, this application of SDM may represent an important option.

*The DMCB interprets "180 patient days" as one patient being followed for the entire 6 months of the study.  If that's correct, the average SDM knee patient referred to a Group Health orthopedist had a 34% chance of getting surgery versus a 46% chance in the prior control group.  For the knee patients, it was 9% vs. 16%

What the White House's Diffidence Over Syria Teaches Us About Complex Medical Decision Making

Talk about a no win situation.  After seeing his "red line" go rudely unheeded, the President is facing the prospect of appearing weak if he does nothing or warmongering if he launches an attack.

Medical decision scientists ask: how did it come to this?

Mr. Obama is correctly admired for his "no-drama' informed style of decision-making.  And good physicians, says medical science, should operate the same way.  According to this recent New England Journal article, consciously deliberative and logical approaches to diagnosis and treatment selection are far more reliable than the intuitive shoot-from-the-hip pattern recognition that used to rule the bedside.

Psychologists describe the latter as "Type 1" processing while the former is "Type 2."   Think George W. Bush's gut instincts over Iraq's weapons of mass destruction versus Barack Obama's disciplined rationality when he decided to attack the Bin Laden compound. He undoubtedly used the same methodology when he was pondering Syria.

But, thinks the Disease Management Care Blog, there are limits to brainy decision-making when the choices are overwhelmingly numerous.  In this retail business-oriented TEDTalk, Sheena Iyengar points out that dozens of options lead to procrastination followed by bad choices followed by low satisfaction. 

It can also apply to foreign policy. Given the vast array of pieces and potential moves on the Middle East chess board, little wonder that Mr. Obama would procrastinate for days saying he has "not made a decision," then apparently select an attack option disdained by even the New York Times and then engender even more second guessing by the very Congress that the President has repeatedly criticized as unreliable.

Ditto health care.  The downside to shared decision making is that an overwhelming number of testing and treatment options can lead befuddled patients to a "you decide, doc" mentality that leads the physician to regress to "Type 1" decision-making.

The DMCB isn't too sure how TEDTalk's Dr. Iyengar's suggested solutions can help the folks in the White House Situation Room, but the DMCB wonders if the national security staff shouldn't have done a better job of presenting the Commander in Chief with 1) a limited number of choices that were 2) more "concrete," as well as 3) arranged into categories with the 4) low complexity options offered first. 

That 4-fold approach could help docs and patients too.  The DMCB looks forward to additional research in the area.

In the meantime, there is one additional medical rule that has withstood the test of time that may also be useful in dealing with Syria. The DMCB offers it up to business and politicians alike: primum non nocere.

The Politicizing of Preventive Health Care: Whither the US Preventive Health Services Task Force?

Here comes the camel nose!

Kudos to JAMA for tackling what the Disease Management Care Blog has been saying for years: now that the Washington DC's camel nose is under the tent, there is no way health insurance coverage - and the care it pays for - isn't going to become politicized.

That's the bigger issue in this just-published article by Steven Wolf and Doug Campos-Outcalt. They're focusing on the political pressure that is being brought to bear on US Preventive Services Task Force (USPSTF). As readers may recall, the Affordable Care Act requires health insurers to fully cover screening services that are deemed effective by the USPSTF. Drs. Wolf and Campos-Outcalt point out that politics rudely intruded on the USPSTF's determination that the evidence supporting mammography for women under age 50 years was lacking. The resulting firestorm not only prompted Congress to not only waive the USPHSTF recommendation, but led some of its members to question the Task Force's integrity.

As academics writing in peer-reviewed journals are wont to do, the authors suggest that this can be remedied by another layer of bureaucracy. They want a new "firewall" committee to be inserted between the "pure" evidence-based USPHSTF and the "political" fisticuffs of the public square.  It'd be the job of this a new entity to insulate USPHSTF by reconciling the proof and the politics prior to the upload of the final recommendations to the mandarins that are running CMS.

"Another committee?" asks the dismayed DMCB. While that would end the Obamacare fiction that health reform was ever going to be truly "based on science," the real Achilles heel of the JAMA proposal is that it literally doubles the opportunity for political meddling. The smartest political operatives will see this as a target-rich environment and naturally seek to influence all of the committees with any jurisdiction over the medical-industrial complex of laboratory medicine, radiological imaging and medical devices.

The DMCB has bad news for its colleagues who thought that they could have the Washington DC "cake" of enlightened government involvement along with the "icing" of scientific independence. Uncle Sam's been given a clinical inch and now he'll take a political mile to influence clinical guidelines and define standards of care with a one-size-fits-all mentality sprinkled with a healthy dose of cronyism.  Surprise!

The DMCB has an alternative solution: CMS should tread very carefully when it comes to insurance design.  Congress needs to reengineer the preventive health part of the ACA. Instead of building new infrastructure to make up for the emerging failures of the old infrastructure, Washington should be pushing benefit design down, not up, to the local level. It can partner with commercial health insurers to assure that the USPSTF recommendations are considered, but with local committee assessments of market demand, provider opinion and community input to determine what's best for its covered population. It should do this while simultaneously promoting the use of shared decision making to help every patient ponder for themselves when testing is in their best interest.
 
Let a thousand flowers bloom.

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Obesity Surgery in Diabetes Mellitus: A Three Year Trial Shows High "Cure Rates." The Implications for Population Health

In case there is any doubt about the long-term efficacy of obesity surgery for diabetes, check out this three year study that was just published by the New England Journal of Medicine. 150 persons between the ages of 20 and 60 years with an A1c greater than the recommended target of 7% and a BMI greater than 27 were randomly assigned to either gastric bypass, sleeve gastrectomy or intensive medical therapy. 8 persons dropped out after being assigned to medical therapy and one patient had their surgery cancelled. Over the next 3 years, 4 persons were lost to follow up.

Of the remaining participants, two thirds were women and three quarters were white. The mean age was 48 years, the average BMI was a prodigious 36 and the mean A1c was a poor 9.3%, with an average duration of diabetes of just over 8 years. 

Of the 40 medical patients, 5% ended up with an A1c of 6%, versus 38% of the 48 bypass and 24% of the 49 sleeve patients.  The average weight loss was 4.3 kg in the medical patients vs. 26 and 21 kg in the bypass and sleeve patients. While only 2% of medically treated patients were able to stop their diabetes medications, 69% and 43% of the bypass and sleeve patients were able to do so. Only four patients in the surgery groups required additional surgery for the treatment of complications.  None died.

The Population Health Blog finds the results compelling enough to believe that the surgical option for obesity-related diabetes mellitus may be turning out to be a first line option.  The complication rate is acceptably low and the "cure" rate of up to 70% (if defined as not having to take medications) is likely to be welcomed by patients facing a lifetime of otherwise chronic illness.

Criticisms?

Critics may worry that any long-term economic benefits at a population-based level may be cancelled by the cost of surgery.  The PHB understands that, but doesn't believe that obesity surgery should be viewed through a "return-on-investment" lens.  Rather, the value assessment of "outcome" (in terms of diabetes and obesity cure) per unit of cost (dollars spent) is a as good as an investment compared to, say, coronary artery bypass grafting or a knee replacement.

Critics may also worry that obesity surgery is more of a symptom of an overfed society and that our national treasure would be better spent on understanding our dietary dysfunctions.  The Population Health Blog cannot disagree, but doubts that our national health spending can be wired so that every dollar spent on the promotion of nutritional wisdom will reduce the near-term health care cost crisis from diabetes.  We need to be prepared to invest in both.

Implications for Population Health

It appears to the PHB that this was a single site "efficacy" study involving an academic medical center.  We don't know if the low complication rate observed here is typical of other hospitals that offer obesity surgery.  In addition, this study did not examine the impact of the more popular approach of banding surgery.  That being said, this three year trial suggests that bariatric surgery should be offered in the suite of options for persons meeting the criteria above.

The good news is that shared decision making has already been evaluated in this setting.  While the majority of participants are more likely to chose conservative treatment, the point is that a 40-70% chance of cure over three years should be raised in the course of patient-centric coaching.  Population health vendors in the diabetes-obesity "space" should be prepared to engage patients on this treatment option and help them decide if surgery is the right choice for them.

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The Rise of the Non-Physician Expert and Implications for Care Management

The Disease Management Care Blog remembers when one of its patients with coronary artery disease suggested that he be given a course of an antibiotic to lower his future risk of a heart attack. The patient had done his homework, quoting literature that pointed to a possible infectious link to atherosclerosis. He also was aware of the theory that aspirin's benefit had less to do with blood thinning than reducing underlying inflammation.

Fast forward to the Feb 2-8 Economist that has an editorial pointing out that U.S. legal expertise may not require the completion of three years of law school. Why not, it asks, cut the requirement back to two years or, even better, skip the school requirement entirely and license anyone who can pass the bar exam?

And then there's the Feb. 11 Wall Street Journal, where "Notable and Quotable" refers to the "BA Bubble." Charles Murray argues that a looming oversupply of college graduates may portend a decline in the employment value of a liberal education. Work careers may consist of serving as "apprentices" and "journeymen" before becoming "craftsmen."

All of which makes the DMCB wonder if the vaunted Doctor of Medicine degree may be vulnerable.

Why should physician education be immune from a perfect storm of over-priced graduate education, "alternative" web-enabled learning with on-the-job-training? The declining value of the formal credential may be less about the university degree and more about competency, turbocharged by flexible licensing and a discerning consumer.
 
Non-physician health care professionals are arguing that their expertise is enough to enable them to deliver babies, administer anesthesia, prescribe drugs and perform surgery. The DMCB's traditionalist colleagues argue that patient safety is at stake and that lay persons may not be able to discern all of the possible risks, benefits and alternatives. When things go occasionally wrong in the delivery suit, operating room or with a drug, they say a credentialed and experienced doc can make the difference between life and death.

The DMCB also remains impressed by the ready availability of medical information in the public domain that is enabling some laypersons to become astonishingly expert.  In addition to the patient above, think about the self-taught parent of a child with a rare condition or the plucky cancer patient who guides the oncologist toward choosing the right life-saving therapy.  Imagine what happens when IBM's Watson is fully commercialized and available to anyone at anytime.

The physician DMCB understands all the perspectives above, but given the decline of the BA and the law degree, it worries that the medical traditionalists may ultimately end up being on the wrong side of history.

While regulators and the markets sort all this out, this may open another business proposition for care management. As patients with chronic conditions continue to seek ways to better share in their self care, they'll also be seeking providers that best suit their needs and expectations.  In other words, the population health vendors can not only help with shared decision making, but provider selection making. 

More on this in a future post.

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Implementing Shared Decision Making In The Real World

You read the Disease Management Care Blog and use its literature-based links.  As a result, you know a lot about shared decision making (SDM).   Based on the randomized control clinical trial data that are regularly linked by the DMCB, you're ready to implement it in your network of primary care clinics.  You call your physicians together for a meeting, explain SDM is the best thing since the invention of the Woods lamp and ask them to refer patients to the program.

Except for the part about the DMCB, that's what basically happened at the eight highly regarded medical institutions: Dartmouth-Hitchcock Medical Center, MaineHealth, Massachusetts General Hospital, Mercy Clinics in Iowa, the Oregon Rural Practice–Based Research Network, the Palo Alto Medical Foundation, the Stillwater Medical Group in Minnesota and the University of North Carolina at Chapel Hill.  The decision aids covered approximately 50 common conditions such as knee arthritis and prostate enlargement

And it didn't work out.

To investigate what happened, investigators at RAND interviewed 23 "key informants" from the 34 primary care sites that had implemented the Informed Medical Decision Foundation's shared decision making program. The interviews were conducted between December 2010 and March 2011.  Their study is published in the February issue of Health Affairs.

Three barriers were identified:

Overworked physicians: given all the other health care needs of their patients, it was difficult to count on physicians to distribute the decision aids.  As a result, only 10%-30% of eligible patients participated.

Overconfident physicians: many doctors felt that they were already providing sufficient patient education or that their patients would not benefit from the decision aids.  Just telling the docs that this worked was not enough.

Underperforming EHRs: the state-of-the-art information technology could not flag potential patents, remember which individuals had been exposed to the decision aids or record the patients' preferences.

The answers?

Well, if the someone from the eight institutions had simply called the DMCB and asked, it would have told them about the many times it explained stuff to a roomful of physicians and had zero impact.  There also good peer-reviewed literature on why it's so difficult to change physician behavior. 

The DMCB ultimately found the answer is to take physicians out of the work flow.

That's what the RAND researchers found.  Based on their interviews, they recommend that if you're going to implement SDM in your clinics:

 Automate the process as much as possible and remove human decision-making from the process the triggered the decision aid.  That could be done on the basis of pre-existing clinical criteria or when a specialist referral had been arranged.

 If automation was not feasible, rely on non-physicians to trigger the decision-aid.  For example, office assistants could offer SDM to patients in the course of check-out.

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The Centers for Medicare & Medicaid Services (CMS) Gets Nudged to Do Something About Shared Decision Making (SDM)

Medicare tackles the shared decision
making requirement in the ACA

In a recent New England Journal of Medicine article, Emily Lee and Ezekiel Emanuel point out that it's high time for the Centers for Medicare and Medicaid Services (CMS) to wake up and do something about Section 3506 of the Affordable Care Act.

That's the section of the law that deals with "shared decision making" (SDM):

"The Secretary shall establish a program to provide for the phased-in development, implementation, and evaluation of shared decision making using patient decision aids to meet the objective of improving the understanding of patients of their medical treatment options...."

In particular, they argue that CMS should expedite the creation of an independent entity that would certify and implement patient decision aids and begin piloting SDM among Medicare beneficiaries who are contemplating having one of the 20 most frequently performed procedures (a list can be found on page 3).

And they don't stop there. 

They recommend that Medicare's coverage for the "top 20" should be made contingent on the documented delivery of SDM to the beneficiary

"To give such a requirement teeth, full Medicare reimbursement could be made contingent on having documentation in the patient's file of the proper use of a decision aid for these 20 procedures. Providers who did not document the shared-decision-making process could face a 10% reduction in Medicare payment for claims related to the procedure in year 1, with reductions gradually increasing to 20% over 10 years. This payment scheme is similar to that currently tied to hospital-readmissions metrics."

In contrast to the NEJM readership, the thousands of regular visitors to the Disease Management Care Blog aren't surprised. They've known all along that "shared decision making was an important if unknown part of the Affordable Care Act.  To them it's not news that SDM is an evidence based approach that combines patient engagement with physician participation to optimize the utilization of potentially harmful therapies.

Pity that CMS leadership isn't regularly reading the DMCB.  Whether a NEJM article by one of D.C. health care mandarins spurs CMS to action remains to be seen.

Stay tuned!