The Growing Culture of Hostile Dependency Toward Caregivers

Not long ago in this blog, I wrote about one of my colleague's tears as she hung up the phone after a bitter patient  berated her for making a surgical schedule change.   Tired and exhausted and still with consults and pacemaker checks to perform, she was returning a series of phone calls at the end of the day long after most people had already headed home.  She tried to maintain control, but after that call, the damage was done.

I have seen this happening over and over again recently.  The stress is palpable in our profession that cares for people's most prescious commodity, their health, while under extreme pressure to do more with less.

For businesses everywhere, the balance of costs with productivity to assure profit is nothing new. But in health care where people's lives are in the balance, the stress to health professional personnel is particularly palpable, especially now as huge transformative shifts are underway in how health care is being delivered in America.

So it was from this background that I struggled to understand why an exerpt from a heavily promoted book on patient safety appeared recently in the Wall Street Journal.  Why should an article about five simple steps to "keep hospitals from killing us" bother me so?  After all on the surface, it's such an important concept.

Perhaps I was bothered that "killing" was used in the byline when there are so many of us trying to prevent harm or do good for patients.  Perhaps it was because some of the insinuations made in the book lacked a national perspective.  Perhaps it was because some of the suggestions made were just more top-down Big Brother ideas that detract from actual patient care.  Perhaps it was all of these.  But after considerable reflection, I realized there was something else: a another overriding phenomenon that I was having a hard time putting my finger on. 

I submitted the following letter to the Wall Street Journal Wednesday.  They elected not to publish it.  This really did not come as a surprise since it was quite critical of their coverage of the patient safety issue.   But after showing the letter to a number of well-respected colleagues, they all encouraged me to publish it here.   Hopefully it will make people think about the complicated psychology of what's happening on the front line of health care these days.

Holding the Wall Street Journal Accountable

Since when does a book promotion get a full page and a half of prime news print in one of the most respected business newspapers in the world?  Usually a story that commands that much newsprint in the Wall Street Journal is written by one or more seasoned journalists to make sure all sides of the story are reported.



Full-page WSJ Story 21 Sep 2012

 So why the Wall Street Journal's recent coverage of Marty Makary's newly released book "Unaccountable?"   Not only has the Wall Street Journal devoted a full page-and-a-half article by Dr. Makary (who we find on Twitter describes himself first as a "medical commentator and author" and second as an Associate Professor of Medicine at Johns Hopkins School of Medicine), but they have now allowed him to host a special electronic blog platform called an "Ideas Market" on their website.   As news coverage of Dr. Makary's book spread this week, we learned from CNN that this same doctor described his fellow surgical colleagues as "Fred Flintstones" in his book because they don't use the latest laparoscopic techniques. 

Doctor versus doctor: it just doesn't get any better for Main Stream Media. 

But did anyone think to ask Dr. Makary if maybe the reason those older doctors don't use laparoscopic techniques is because they work at an inner city hospital with a limited budget without all the trappings of an academic medical center? 

No.  That would be reporting.

I am trying to understand the Wall Street Journal's motivation for their recent move.  It is both puzzling and concerning.  But at its core, it's probably quite simple to understand.  I should probably follow the money.  After all, we're all aware of the problems print media is having these days.

My bet is there's Big Business behind the Wall Street Journal's journalistic move. 

And who's Bigger Business or Bigger Money than the insurance industry or the hospital industry?  After all, medicine is the Biggest of Businesses in America.

Now before you go laughing at my conspiracy theory, ask yourself if there might be a problem with the perfectly even 98,000 number of deaths caused by medical errors touted by the Institute of Medicine in 1999 and highlighted in the Wall Street Journal's patient safety piece.  Ask yourself why a professionally-produced book trailer promoting Dr, Makary's book that HAD to cost upwards of a quarter million dollars to produce winds its way on to the Internet.  Ask yourself why no one would research the background of the players in that video and their motivations to appear in it.  Was their motivation truly altruistic?  Or in this era of the creation of Big Box medical care delivery, might there be another reason?

These days, the majority of today's American doctors are in the unenviable position of trying to be true patient advocates while promoting a Big Box medical model that has been foisted upon them and, for the majority of us, serves as our employer.  The world loves idealists and none more so that Big Box Medical Center administrators and thought-leaders.  Getting a physician leader spokesperson to forward a business agenda that serves the interest of its cash-paying customers is about as sweet as it gets.  Better yet, using patient safety as a means to influence doctors' behavior is ideal because it is professionally unassailable.  What doctor in his right mind would ever dare to think, let alone put in writing, that there could ever be a down-side to assuring perfect patient safety?

But is this new paradigm of journalistic reporting and wholesale promotion of one doctor's five ideas for patient safety without consequences? Can we afford perfect safety and all of the costs it entails while throwing our doctors under the documentation bus (or Big Brother camera) as they are asked to take incredible risks on behalf of their patients, be omnipresent, omni-available, impeccably skilled, omni-credentialed, omni-sympathetic all while seeing more patients in less time?  Must we be made to believe, without reservation, that doctors (or any of the hundreds of people who work on each doctor's behalf) aren't human and subject to error?

I am seeing a culture of hostile dependency growing toward caregivers.  The theme is like an adolescent who realizes his parents have feet of clay.  He comes out of his childhood bubble and realizes his parents have failures and limitations because they are human beings.  This results in the adolescent feeling unsafe, unprotected and vulnerable.  Since this is not a pleasant feeling, narcissistic rage is triggered toward the people he needs and depends on the most.  None of this occurs at a conscious level.  Most of us understand this behavior simply as "adolescent rebellion," not understanding the powerful issues at play.  So when we spotlight one side of the patient safety story without acknowledging the realities health care workers face like looming staffing shortages and pay cuts, we risk fanning the flames of narcissistic rage against the very caregivers whom we depend on the most - the very caregivers who are striving to do more with less, check boxes while still looking in the patient's eyes, meet productivity ratios, all while working in a highly litigious environment.  Why would we do this and why would we allocated money as Dr. Makary suggests, for punitive top-down solutions instead of spending that same money on supporting and educating our frontline providers?

A good journalist would investigate all sides of the story and understand its impact.  A one-sided full-page book promotion by a non-journalist in the well-respected Wall Street Journal that reduces the serious patient safety issues in today's Big Box medical organizations to "5 simple steps" is nothing more than a cheap shot at the majority of  doctors who choose to carefully and tirelessly treat their patients as safely as they can without basking in the glow of Main Stream Media.

-Wes

On The Promotion of Hospital-Based Killing

It's an interesting world in medicine these days.  What I read in papers and see in flashy professionally-produced book trailers about hospitals as killing fields boggles the mind.  Imagine: there are even full page spreads in papers as influential as the Wall Street Journal carrying headlines like "How to Stop Hospitals From Killing Us."

It is, of course, nothing more than a book promotion for "Unaccountable," written and heavily promoted in the main stream media and TV circles by the surgeon Marty Makary, MD from Johns Hopkins, who's parlayed his public policy interest in safety into a money-making PR campaign based on fear.

There is no question that there are issues in major medical medical centers with preventable mistakes that can lead to patient death.  I would be a fool to think that the pharmaceutical and medical device industries haven't used shady marketing techniques to sell their products in our very lucrative growth industry called health care.  (I would also be a fool to think it hasn't happened with the Electronic Medical Record industry or on Capitol Hill, either).  And I would be a fool to think that we shouldn't always be striving to avoid any patient errors.

But when we see book trailers with fancy aerial shots flying above big cities, close-up cameos of doctors doning face masks, and gushing teaser quotes from provosts of the very university where Mr. Markal practices, editors of the New England Journal of Medicine, a medical journalist, and even the President of the Institute of Medicine (none of whom actually cares for patients), we should ask: Why now?  Why here?  Who paid for this?

There is money in fear.  Big money. 

And one hell of an industry that caters to safety training.

But these fear tactics are not without their costs to our patients and health care system.  When we pull back the cover on what Dr. Mackary's solutions for our "current crisis" are, we see that the solutions he proposes are actually quite thorny.

We once again see the number "98,000" touted as the number of deaths each year at hospitals when the actual value is unknown. The number came from The Institute of Medicine's 1999 report on medical errors which estimated the number from 44,000-98,000. But this is unimportant.  Big death numbers sell.

Data dashboards are heavily promoted as one of Dr. Mackary's paths to transparency, but we should ask ourselves how much this data collection costs.  We should ask if it has affected outcomes.  As Dr. Mackary acknowledges, patients make decisions on which hospital to go to based on personal choice, not data.  Since we've been collecting these data on quality, has it impacted costs one bit?  The answer, actually, is no.

And then there's Dr. Mackary's idea of using cameras in hospitals to improve transparency.  In his article in the Wall Street Journal, Dr. Mackary justifies this approach by telling us an anecdote about a gastroenterologist who filmed his colleagues doing colonoscopies "without telling his partners."  (I'm not kidding).  There was no attempt at education between colleagues.  There was no attempt at professional discourse.  Just a camera secretly filming colonoscopies.  Images of the Orwellian book "1984" flashed in my head when I read this.   How much time might I soon be required to review the films we make of our colleagues if we chose such a path?  How much time will it take from me seeing patients?  Who will own the films?  Where will they be stored?  Who will pay for the filming?  And let's not even speak of the liability implications to physicians when these films are discoverable.  It is hard to see how this will constructively correct patient safety in hospitals and won't further add to doctors' burnout with the system.  Is this now going to be our path to patient safety salvation, fear-based medical practice?

Not all of Dr. Mackary's ideas are crazy: his idea for Open Notes and lessons about the importance of transparency in medicine are valuable.  His ideas of cherishing the input of every member of the care team in a patient's care is spot on.  But if we are going to be fully transparent, then we should be transparent about costs at all levels of patient care.  We should recognize that there large hurdles to accomplish transparency and accountability in medicine when the legal risks of slander and libel can be so easily invoked when a junior physician dares to buck a financially-flush system hell-bent on maximizing revenues.  Yes, we have problems, but the solutions are complicated and risky for those already ultimately legally on the line for every patient who enters our health care system.

Finally, we should ask how our younger doctors (who are training and more likely to make mistakes) how they would feel practicing in such a Orwellian, fear-based system.  Might we be compromising our ability to recruit new doctors? 

From a business sense, I wish Dr. Mackary all the best in the sales of his new book.  No doubt his sales will soar thanks to the cleverness of this sales campaign. 

I just hope that the Grand Thinkers in our legislative and health policy circles have enough marbles in their heads to not be influenced by all of Dr. Mackary's proposed grand schemes for improving our patient's safety.

If they do, they may be causing more harm than good.  Then who will be accountable?

-Wes

The Other Cause of Sudden Cardiac Arrest

All too often we associate sudden cardiac arrest (SCA) with tachyarrhythmias post-infarction.  Sometimes, there is another cause for post-infarction SCA that is forgotten:



Click image to enlarge

The above EKG was acquired four days following an anterior myocardial infarction during a pre-discharge submaximal (modified Bruce) stress test after walking 1.3 MPH for 5 minutes.  Note the bifascicular block (RBBB, LAFB) and lack of PR segment prolongation (with the exception of the PAC) just before the event, suggesting an infra-Hisian location of the eventual AV block.

Needless to say, the patient's discharge was postponed.    (We're still waiting word from the doctor who ran the above test as to the condition of his underwear.)

-Wes

Another Friday Chest X-Ray

Click image to enlarge

Just your basic Friday chest x-ray on an asymptomatic patient with hypertension and atrial flutter.

Any thoughts?

-Wes

Our Problems With Codes

Oh, that clever Center for Public Integrity.  Look what they've gone and done now!  My, oh my.  According to the article, doctors are much of the the problem, billing "billions" of Medicare upcharges according to the center.

But what if the medical coding game itself is flawed?  Stop for a moment and imagine what it would look like if lawyers billed like doctors.  Suddenly, we see how bizarre the world of government billing codes and chart-completion mandates has become.

Not long ago I asked the blog-o-sphere what my time is worth on a per-hour basis.  Collectively and independently, the blog-o-sphere settled on a number of about $500/hr (see the comments).  Now look for a moment at what Medicare pays, even at its highest level of billing for a physician's time for evlauation and management of a medical problem: for 40 minutes of a physician's time, it's $140 (or $210/hr) before taxes.  Again, we see another disconnect as to how doctors are valued in our current system.

Doctors are working long hours to collect these fairly low fees from Medicare while jumping more hoops than ever to do so.  They have become pseudo-experts at the coding game, trying to get as much money for their extra efforts as legally possible.  But these fees paid by Medicare do not cover payments for time spent on phone calls, e-mails, and working insurance denials.   These services are still considered by our system as gratis. To partially counteract this coding problem, doctors realized (and the government insisted) that doctors use electronic medical records.  But when independent doctors set out to implement these records they quickly discovered that the expense and long-term maintenance costs of local office-based EMRs could not compete with more sophisticated systems already in use by their neighboring large health care systems.  Because of ever-increasing cost-of-living and overhead costs, not to mention the threats of large fee cuts, doctors have migrated to large health systems faster than ever.  With the fancier electronic record at those systems (streamlined for billing, collections, and marketing) fields required for higher billing codes (but not always material to the problem at hand) are completed in less time.  So are doctors really the problem?

It depends on who's looking.  Since every medical test and order is tied to a doctor's name, then of course it looks like doctors are the problem.  And yet it's the government who has mandated the codes, the requirements for chart completion, and the electronic records to which our electronic signatures are attached.  But we should ignore these facts; in the eyes of the Center for Public Integrity, of course its the doctors' and hospitals' fault. 

And what do you think the government's response is to all of this? 

Why, get get ten times the number of billing codes, of course!

So take a moment and imagine a world without codes might look like.  A world where doctors are paid for their level of expertise, time with patients, time with communication for those patients, and time their connected to the EMR to enter codes, document, e-mail, and care for patients.  No codes, just time-based billing at a level of commensurate with their skills.  If we can track billing codes, we can track doctors' time.  Gosh, it's sounding sane isn't it?

If we really want out of this coding and billing conundrum, we should stop the coding schemes.  Pay doctors for what they are worth in today's market.  Pay doctors for their time as well as their productivity.  Throw away the codes, the consultants, the code licensure fees, and the nonsense.  Compared to current administrators of these coding schemes, people might actually discover that doctors and hospitals are the path to salvation for excessive health care costs rather than the instigators of coding fraud.

-Wes

Out-of-the-Box Thinking on Avoiding Hospital Readmissions

As a cardiac electrophysiologist, I'm pretty far removed from public policy.  But I have to admit that I was interested in the latest move by CMS to cut their Medicare payment rates to hospitals by invoking pay cuts for hospital readmissions.  The Chicago Tribune's article is enlightening and filled with some interesting anecdotes after the first round of pay cuts were implemented:

(1) The vast majority of Illinois hospitals were penalized (112 of 128)
(2)  Heart failure, heart attack, and pneumonia patients were targeted first because they are viewed as "obvious."
(3) "A lot of places have put a lot of work and not seen improvement," said Dr. Kenneth Sands, senior vice president for quality at Beth Israel.
(4) Even the nation's #1 Best Hospital (according to US News and World Report) lost out.

So what's a hospital to do?

I have a suggestion based on other observations in regard to government-imposed pay-for-performance measures that have cost hospitals and clinics across the land untold billions to implement and still have failed to demonstrate even a break-even financial proposition for hospitals.

Stop trying.

From the looks of things, Medicare's going to cut even the finest hospital's pay.  Everyone will suffer, just some more immediately than others, but woe to the hospital that works to understand why.  This is not the intent of this measure.  The intent of this measure is to cut payments.

Therefore, if we do not commit excessive funds to this endeavor and instead work to support the people on the front lines as they do their job, cost savings will more likely be realized than if 500 more administrators and nurse coordinators are put on the job.  Like putting cash under your mattress in a down market, they'll be way ahead.

Hiring more people are expensive because of their salaries and benefits.  Writing programs to do this is also expensive.  All kinds of people are expensive because of the training they require for new government initiatives like Pay for Performance (which has NOT been shown to affect outcomes by the way) and avoidance of hospital readmissions (little proof of sustainable goals can be achieved, a la quote #3 above).

So just help the professional people you already have do their jobs caring for patients to the best of their ability.  Make this the mantra rather than new unproven approaches. 

Call me silly, but my bet is that hospitals would do WAY better off financially in the long run if they stopped trying so hard to follow unproven legislative initiatives.

-Wes

Schedules

It started as big day in the lab: six cases. Actually, my partner and I were eventually able to split the load over two labs.

But I screwed up.

I took too long putting in a device - WAY too long.  Four hours too long.  Since it was the first case of the day, it backed everything up. People had to work very late - some even had to dip into overtime.

But  I was impressed that no one said a thing.  In fact, everyone that I worked with was incredibly supportive.  After it was over, one of my nurse practitioners even bought me a salad on her own dime before she laid into me with a ton of pending questions about outpatients and the new consults upstairs.

Why?

Because my colleagues know about schedules in medicine.  They know that some things we do can be incredibly challenging due to anatomic variables that aren't always there in the normal individual.  They know that sometimes we work on sick folks, young and old, who really have no other options - that a particular procedure might be their one best and only shot at getting better.  They know that many other times, the cases go faster.  They know that these things can happen.  So they remain professional and make a their calls home to say they'll be late.

Schedules, I'm finding, are getting more complicated in our consolidated new health care world.  So much so that administrators are turning to computers to help.  And who can blame them?  Different cases, different time allotments, different hospitals, different doctors, different equipment needs, different drive times between facilities, different days for clinic, different insurance, different staffing needs.  It's simply getting too complicated for any one person to keep it all straight in their head. 

But computers rely on logic.  Computers rely on criteria on which to make decisions - they must have an estimated procedure time to go with every procedure.  Computers don't incorporate variations in physician skill level, technique, or a person's individual anatomy into their scheduling algorithms. Computers don't know about a son's baseball game.   Computers don't factor in the frustrations of traffic.

I never like making that call home when I am running late.  I never like to hear the sighs, the disappointment, to learn what I'm missing.  But I have also learned that it is far worse not to make the call.  My family's schedule and psyche demands it.

But as the day's work is algorithmically sliced across increasingly geographically-dispersed larger and larger health care systems with schedules more and more compressed, I wonder if computers will ever be able to explain to our families why we keep running late.

-Wes

The Irony of Why EKG Class Was Cancelled

I look forward to teaching our housestaff the basics of EKGs each year. Moments where I can leap from worker-bee clinician to the quiet confines of a lecture hall is rejuvenating. Seeing eyes widen as they grasp basic insights to the wealth of information contained in biologic signals even more so. So I carve some time at the beginning of each year with the chief residents to commit to this endeavor far in advance.

This year, I arrived a little early for my lecture with a stack of EKG’s, ready to bring down the screen, load the Powerpoint presentation, and collect my thoughts. Unlike most lecture days, the lecture hall door was closed when I arrived. I quietly cracked the door and peered in: there, in their new, carefully pressed white coats, was a sea of residents. I was elated, expecting that attendance at this lecture would be especially high since I already had a captive audience.

So I closed the door quietly and paced in the halls waiting for the lecture before mine to conclude.

The nearby secretaries noticed me and politely said hello and I, in turn, smiled and acknowledged their greeting. I grabbed a quick cup of coffee from the coffee pot and sipped the nectar in my quiet moment of reverie before class.

But something was askew. The secretaries seemed a bit uncomfortable.

“Doctor Fisher? Oh, I’m so sorry, the lecture hall is being used today for our annual Transitional Residency program review. Let me see if I can find another lecture hall for you.”

She logged on her computer and scanned the available spaces. She clicked and clicked and clicked.

“Well, there is a room on the fifth floor…. Um, maybe not. I see there’s only 15 chairs in there… Let me keep trying.”

“Thanks so much,” I said.

About this time, the doors from my previously-arranged lecture hall opened and a sea of smiling residents poured out from the room. Some headed to the washroom, others checking their beepers. Others appeared to be heading back to the wards. I was puzzled.

I glanced in the lecture hall to see several well-dressed women sitting before a pile of 3-ring binders full of papers, one of which was opened. They chatted with each other, occasionally giggling, but very professionally so. There behind them was a tray of uneaten donuts and other treats and a coffee dispenser neatly arranged on a tray behind them.  Boy, those looked tasty!  I smiled as I thought to myself: “No wonder their attendance was so good.”

A few moments later, one of the Chief Residents came to me with his tail between his legs and apologized profusely. “I’m SO sorry, Dr. Fisher, we forgot to call you about this change of schedule!”

The poor guy. Sent with full flak jacket in place to take the hit. But I knew exactly how he felt as he tried to keep all the various clinical and administrative scheduling balls in the air.

“No problem,” I said. “We’ll do this another time.”

But as I walked back to my office, I couldn’t help but wonder what we’re creating as housestaff are corralled before bureaucrats who ask them how their residency is going while their own residency's EKG training was silently sabotaged. 

It’s kind of like those uneaten donuts behind those well-dressed ladies: food for thought.

-Wes

Why Patients Will Need Influence Peddlers

"Hello, Dr. Fisher this Dr. Schmo.  I have a special (friend, patient, secretary - insert your title here) that I'd like to see you but your next new patient appointment is in about 2-3 months.  Could you see him/her sooner?"

It's a call that's becoming increasingly common.

In the past, this was a request that was fairly easy to fulfill for a friend.  But this week this has already happened three times.  I wonder (a) how many times I can realistically expand my clinic hours and (b) how many follow-up patients I'll soon stop seeing to make room for the masses as pressure to see more people in less time continues and (c) how many patients will use this approach to leverage access to health care?

The days of long-term relationships between patients and subspecialists seem to rapidly be coming to an end - our new model increasingly rewards proceduralists.

But such an approach is not without its consequences.  Doctors and patients both lose when we lose closure with our patients.

-Wes

The Empty Chairs

It's the skit I would have liked to see by either political party:

The Independent Payment Advisory Board

Eastwood: "So, would each of you like to introduce yourself to the American Public?"

* silence *

Eastwood: "How many of you are licensed physicians?"

A few raise their hands.

Eastwood:   "Really, that's all?  (Mumbles under his breath, "Wow."   He continues:  "How many of you are men and how many are women?"

* silence *

Eastwood: "Given there are 50 states in the United States, could you tell us in which state each one of you live?"

* silence *  As if no one wants to admit where they live...

Eastwood: " If one of you gets sick, are there only 14 people who vote or does someone else gets picked?"

* silence *

Eastwood: "How many of you have parents still living over 75?"

A few hands are raised.

Eastwood: "How many of you are less than 35 years of age?"

* silence *

Eastwood:  "How many of you have ever told someone they have cancer and then cared for them?"

* silence *

Eastwood:  "How many of you received grants of any kind from the US government?  Any of you stand to receive benefits from the US government of any kind?  Might one of those benefits include health care for you or your family?"

* silence *

Eastwood: "Do any of you carry the BRCA1 or BRCA2 gene for breast cancer or does anyone in your family?"

* silence *  Some appear confused by the question.

Eastwood: "Would each of you share your religious affiliation with America?  Any atheists amongst you?"

* silence *

Eastwood:  "Well, it seems we're not getting too far.  I guess we'll conclude there and ask the American people what they'd like to ask you..."

* Opens microphone to responsible voices... *

-Wes

EKG Du Jour #27: Caught in the Act

I've been looking at EKG's for over 20 years and I'm not sure I've ever seen this captured on a 12-lead electrocardiogam outside the EP laboratory. 

The patient was admitted with some vague chest discomfort.  The initial EKG and troponins were normal, but they decided to admit the patient anyway for observation.  Once on the ward after being given some heparin and aspirin, the patient was feeling perfectly fine - wanted to go home - but the second set of troponins returned positive.  The first year resident decided to order a second EKG. 

The EKG technician came dutifully, performed the EKG, and before she knew it, all hell broke loose:

Click image to enlarge

Fortunately, the patient did well after a quite bit of work in the cath lab.

Remember this story.  It might just save a life.

-Wes

On Outcomes

A new patient consult, "Typical atrial flutter, age 65" the schedule said.

With a history of renal cell and a nephrectomy,
And an bleeding ulcer while on aspirin,
And a stroke (now better),
And polycythemia vera,
And a monoclonal gammopathy,
And a "low grade" lymphoma,
And a history of "bleeding" with the tiniest of scratches while on warfarin,
And a history of a hemolytic transfusion reaction,
And an EKG of atrial fibrillation a year ago,
And an EKG of typical atrial flutter now,
On no anticoagulant or aspirin,
On dialysis,
In in a patient who doesn't feel the arrhythmia and is feeling fine.

"Management?" the consult read.

This should be easy, right?  Just "Get With the Guidelines!"

More often than not, it is difficult to follow pre-defined guidelines (as the above case demonstrates). 

More often than not, there are many, many independent variables that weigh on patient management decisions.  Despite this reality, there has been a growing call for treatment standards, guidelines, protocols, and checklists by those tasked with paying for health care.  Payers want perfect outcomes or they will not pay for care, as if people are widgets on a production line with interchangeable parts. 

But how may people exist in the center of a Bell curve?  How many more do not?

Current models for health care delivery attempt to make generalizations about treatment regimens for as many people as possible because payers want to receive as much value as possible for every dollar spent.  On the surface, such an approach seems so logical.  But for the majority of individuals who fall outside the center of normative data sets upon which standards, guidelines, protocols and checklists are based, the doctor and patient must face the reality that there are often no perfect answers for treatment.

In these cases we look into each others' eyes, weigh what we know and what we don't know together, then join hands and walk into the uncharted treatment waters of real life. 

This is OUR standard, our expectation, our reality...

... and one that clashes head-on with pre-specified guarantees of outcomes.

-Wes

DOJ Hands Heart Rhythm Society and Hospitals Its Decision on Defibrillators

Today, the Heart Rhythm Society issued the following cryptic email to its membership explaining the results of the three-year investigation by the Department of Justice (DOJ) audit of implantable cardiac defibrillator (ICD) implantation procedures:

Over the past three years, the Heart Rhythm Society (HRS) has served as an advisor to the Department of Justice (DOJ) on the issue of implantable cardiac defibrillator (ICD) procedures. We made this difficult decision to work with the DOJ to protect patient access to life saving therapies, and to ensure that the federal government was aware of and considered evidence-based medicine and the realities of clinical practice during their investigation. Given that this process would have proceeded with or without HRS involvement, we believe that acting in this capacity was in the best interest of our members, patients and of the profession.

As a result of input from HRS and others, the DOJ has created several categories that contain clinical scenarios that fall outside of those covered by the National Coverage Determination (NCD) for ICD therapy but that the DOJ will be excluding from enforcement in this investigation. Unfortunately, in some circumstances our counsel was not accepted, and we are troubled by some aspects of the final decision. However, we believe the receptiveness to our counsel regarding the application of ACC/AHA/HRS guidelines for ICD implantation helped to mitigate the number of clinical scenarios considered inappropriate and therefore, subject to penalties.

Our priority moving forward will be to assist the heart rhythm care community to manage the patient care pathway in the post-DOJ decision environment and address its limitations. The misalignment between the Medicare NCD and the ACC/AHA/HRS guidelines creates gaps between the payment policy and clinical decision making and places our physicians and their patients in an untenable position. We will continue to work in partnership with the American College of Cardiology (ACC) and other key stakeholders to address this problem and to align payment policy with evidence-based medicine.

Changing Medicare policy is a lengthy process. In the meantime, we encourage physicians to work with their hospitals to improve transparency and documentation of clinical decision making. Our guiding principles should be accurate documentation; clear thinking about alternative strategic approaches; and working with our hospitals to ensure our patients' needs is the first priority. HRS will keep you informed in the months ahead on our progress to address the clinical indications that permit payment for these life-saving therapies as well as make educational tools available to respond effectively.

So what have doctors like me learned from this notice? 

First, the investigation of ICD implantation criteria and the Heart Rhythm Society's involvement in the investigation began long before it was announced to the general HRS membership on 20 January 2011.

Second, specifics of what the DOJ's actual decision were lacking in this email.  After doing a bit of digging on the interwebs I found a copy of this e-mail (pdf) that was sent to hospitals by the DOJ.  In it, we find that the DOJ was willing to permit certain clinical scenarios outside the 2005 National Coverage Decision for ICDs, provided doctors clearly document the rationale for the ICD and it falls within one of their clinically reasonable "buckets."  If not, penalties will be likely forthcoming.

Third, the American Heart Association (AHA) noted there were problems clarifying the DOJ's decision, stating:

However, this proposed settlement framework, as we understand it, does leave one area that may be problematic.  The American Heart Association believes that some situations, categorized in the DOJ's proposed settlement as "previously qualified," would be justified even though technically in violation of the National Coverage Determination.  In this category, a patient meets criteria to have an ICD implanted but it is not implanted.  Subsequently, the patient has a new cardiovascular event that resets the NCD's time limitation but the physician makes the medical judgment that implantation of the ICD is medically necessary and justified even if not within the NCD timeline.

Fourth, the message for the ICD market in particular and other expensive medical technologies is chilling.  It is clear that any high-cost technology that is utilized outside a National Coverage Decisions may be subject to DOJ audit, irrespective of a local physician judgement or updated professional society guideline recommendations.

Most concerning for doctors in general, however, is how the DOJ made up its own new rules that it calls clinical "buckets" (with the secretive help of chosen "professional" societies) to apply on top of outdated Center for Medicaid and Medicare Services (CMS) MS National Coverage Decision rules, rather than asking CMS to update its anitquated rules to reflect changes in the current standards of care.  While the DOJ's Resolution model claims their model "does not replace, update or interpret NCD 20.4 and should not be relied upon or utilized in any manner to determine whether an ICD is payable by Medicare," it most certainly does.  With this new secretive rule-making approach, doctors are rendered powerless to adapt their practice medicine to its latest state of the art without later fear of retribution from the long arm of the law.

So dot your i's and cross your t's, good doctor.  Document everything, not once, but twice, and scan the strips of the arrhythmias into the medical record.  After all, if it ain't in the old CMS National Coverage Decisions or now, one of the DOJ's specially-created new "buckets," it ain't getting paid for.  Capisce?

And patients, expect to hear some more strange rules as to why you can't that defibrillator even though your doctor says, based on evidenced-based medicine, you need it, okay?  This is the way things are likely to be from now on it seems...

... more hoops, more random jumping, for all of us.

-Wes

Addendum 14 Sep 2012:  When the Feds Come Knocking - prior piece outlining my concerns with the DOJ's actions.

On Labor Day

She hung up the phone and stared at the screen, her eyes red, swollen.  There before her were message upon message, email upon email - her work queue.  Others around her tried not to notice.  But it was clear that something was wrong.  Some had tried a box of caramels, others a Kleenex.  Finally, the screen became blurred as her eyes became flooded.  She whispered, "I'll be okay," as she tried not to be noticed.  "Really,  it's just been a bad day.  I'd rather not talk about it."

Was it a phone call?  A patient, frustrated with the schedule?  Was it the realization that one more schedule was being changed at the last minute?  An impossible amount of work still to go? Maybe something at home or about a friend?

Perhaps it was all of these.

Every day, every hour, there are health care workers across this land and around the world feeling the strain.   They are swimming upstream constantly.  Things aren't getting easier.  They must do more with less.  They are the quiet, small ones - the ones who never complain - the real workers that care.

According to the U.S. Department of Labor, "Labor Day ... is a creation of the labor movement and is dedicated to the social and economic achievements of American workers. It constitutes a yearly national tribute to the contributions workers have made to the strength, prosperity, and well-being of our country."

In a way, that's too bad.

Labor Day should really be about the workers, not the collective output of those workers.  Too often we don't acknowledge the value of these caring individuals over their "social and economic achievements."

Enjoy your time off today because, really, this day is about you.

-Wes

Nurse Practioners Owning Cardiologists?

Asking the important questions: "Can a Nurse Practitioner open/own a cardiology practice?"

"Technically, I can. The problem is getting a consulting physician to sign on. You aren't going to get a Family Practice MD to agree to that. You're also probably not going to get a Cardiologist to agree to that as you'll be competing with a specialist who might like APNs, but isn't going to give you the piece of the pie that pays for new boats, jet skis, etc."

Yep, it's hard to make this stuff up.

-Wes