Wednesday, January 30, 2013

Your Blog, Your CV, and Academic Promotion

"Doctor, could we have a copy of your most recent CV."

"Sure," I said, realizing it hadn't been updated recently. 

It is interesting how I approach my academic pursuits now.  It used to be that it was "publish or perish" in the world of academic medicine.  Of course, even now the only "publishing" that counts to the academic world is that of conventional peer-reviewed journals with high impact factors (or grant applications that bring in dollars).  But publishing for the sake of publishing may have its limits, too, since some researchers chose to publish the same research data in many publications and in different formats just to pad their curriculum vitae (CV).

We're seeing a new era of complete disruption in medicine.  Scientific publishing is no different.  Peer-reviewed journals, while still considered most "scientific" by the academic community, are finding their relatively long turn-around times and paywalls competing against more nimble peer-reviewed open access journals that foster and promote broad commentary across disciplines for free.  Blogs, too, encourage open, free communication and, because they are often syndicated using RSS feed, can have a significant "impact factor" to not only the public, but more conventional main stream media.

It is no secret that I have published MUCH more on this blog's pages than I ever would have via peer reviewed journals.  After all, it can be enjoyable and there is virtually no barrier to entering a discussion here.  I have enjoyed the to and fro commentary here and found there are many insightful individuals that greatly enrich not only this blog's content, but my perspective.  In effect, writer and reader both learn here.


But there's another interesting thing I've come to find as a result of my work to publish here that academic centers who want to influence discussions should know: I am certain that several topics I have covered in these pages have had MUCH more influence on my chosen field than they they would have had I published just in a closed access, peer-reviewed journal.  Hyperlinks can substantiate claims.  As such, blogs can be change agents and influence action.  In return, I find the process of researching and publishing in this forum increasingly worthwhile professionally.  Writing here can also keep me sane when I need it most.

Sure, there are legal risks to publishing a blog.  HIPAA rules, the permanence of this record, the need to avoid defamation, etc. are critical aspects of working in this public space.  But opinions and unique perspectives that are freely searchable on the internet can spark other ideas or areas for analysis not previously considered in the fixed black-and-white world of print media.  Discussion threads, while now more commonplace behind journal paywalls, remain restrictive to public discovery and review there. 

Currently, a link to my blog exists on my curriculum vitae.  I realize it may never be reviewed by the academic medical world nor might it facilitate my academic promotion.  For me, I won't be crushed if that's the case.  But for younger doctors just getting started, their efforts at maintaining a well-written scientific blog should be rewarded academically in my view, just like a scientific paper.  After all, a good blog can contribute to important scientific and educational discussions.
Perhaps it's time academic centers routinely include social media contributions as a regular part of their academic promotion criteria.  It's not everything, certainly.  But careful, thoughtful, and responsible online writing and interactions should be valued and promoted formally by academic centers in this internet age.


Sunday, January 27, 2013

By the Numbers

Diagnosis codes: numbers.
Procedure codes: numbers.
Speadsheets of one's "productivity:" numbers.
Spreadsheets of RVU's: numbers.
Spreadsheets of total office visits: numbers.
Speadsheets of new office visits: numbers.
Spreadsheets of complications: numbers.
Spreadsheets of new codes on top of old codes: nothing more than more numbers.

Then numbers converted to numbers.

Speadsheets of revenue: numbers.
Spreadsheets of accounts receivables: numbers.
Spreadsheets of patient satisfaction scores: numbers.
Number of Patient calls: numbers.
Number of Staff messages: numbers.
Miles traveled: numbers.
Continuing Medical Education credits: numbers.
National Practitioner Identifier: numbers.

Letters typed, converted to bytes, then bits, then zeros and ones.

Fingers numb, eyes searching.  Unable to find a number...he stopped and looked up.

He wondered.

Where are the codes for color, for smell, for sound, for touch, for tears, for fear, for terror, for pain, for exhaustion, for laughter, for teaching, for listening, for learning, for love, for patience, for tenderness, or for grace?

"They paved paradise and put up a parking lot," he thought as he marveled at the revery of medicine's latest myopic trend:

cold, raw, unemotional, unassailable, yet remarkably error-prone,



Saturday, January 26, 2013

Ectopia Cordis

If a baby is born with a portion of her heart outside the chest, what do you do?

Why, make a new chest, of course (video).


Thursday, January 24, 2013

Dr. John M: Health Care Reform -- The New Baby

"Blissful life for real-world doctors is over. The days of running on time in the office—gone. The days of having enough time to chat and get to know patients—gone. The days of doing one thing at a time—gone. This one hits yours truly the hardest: The days of crafting a narrative to a primary care doctor on a patient—gone. Now it’s a sterile environmentally abusive multi-page list of bullet points included as protection against medical fraud. These are just a few of the new rules. The suffering of course is that many doctors were attached to these self-evidents of good doctoring. Attachment always causes suffering.

Life is changed. The new child has rocked a once happy family. ..."
Read the whole thing.

Sunday, January 20, 2013

Patient Safety and the Ethics of EMR Implementation

“An experiment is ethical or not at its inception, it does not become ethical post hoc – ends do not justify means. There is no ethical distinction between ends and means.”
-- Henry K. Beecher, MD
 New Engl J Med 274(24) June 16, 1966 pp 1354-1360.

"When everything is digitalized, all your records - your privacy is protected, but all your records on a digital form - that reduces medical errors. It means that nurses don't have to read the scrawl of doctors when they are trying to figure out what treatments to apply. That saves lives; that saves money; and it will still ensure privacy."

The implementation of the electronic medical record (EMR) in American medicine gained a powerful foothold in medical care with the passage of the American Reinvestment and Recovery Act (ARRA) in 2009. With the passage of this act came the promise of improved efficiencies, safety and ultimately reduced cost delivery for health care. Also, some $18 billion dollars in financial incentives were offered to physicians to offset costs to deploy these systems nationwide. To assure adoption, if the systems were not implemented by 2015, doctors and care providers will suffer payment penalties from the government. For physicians who care for Medicare patients, there was no alternative than to deploy these systems.

In 2010 alone, the EMR market was pegged at $15.7 billion dollars, a cost that is ultimately passed to all Americans. In addition, despite all of the changes that health care reform has brought to date, people in some states continue to see their insurance premiums mushroom over 20% in 2013 from the preceding year. Simply put, patients are finding health care anything but “affordable.”

We should acknowledge that there might be cause, ethically, to deploy a technology that truly benefits patients at some cost. After all, you have to break a few eggs to make a good omelet. If interoperability of EMR systems between facilities were commonplace and clinical data were shared with ease while patient privacy was vigorously upheld flawlessly, the cost of these systems might be ethically justified.

But the promise of improved efficiencies to our health care system, improved patient safety and (especially) reduced cost for our health care system remain elusive. More importantly these goals remain unproven. In fact, examples that the opposite is occurring abounds as doctors struggle to enter ever-increasing amounts of information of no relevance to the patient’s presenting problem just to prove they’re using the EMR in a “meaningful” way, health data security breeches continue, errors are growing instead of shrinking, data-mining of patient information is occurring not just for patient care but for marketing purposes, and the direct costs of health care for patients continues to rise, not fall. Proponents of these systems will argue these issues are nothing more than “growing pains” of these novel systems.

So should we step back for a moment and ask ourselves if we are being ethical to patients with the deployment of this technology? Does the ends of presumed cost savings to our national health care system justify the deployment of poorly integrated, difficult-to-use systems? Are patients being subjected to new risks heretofore never considered with the adoption of this technology? Could a tiny programming error occur that negatively impacts not just one patient, but millions? If so, what are the safeguards in place to prevent catastrophic error? Who will be responsible? Who is the oversight body that assures the guiding principles of the Belmont Report (respect for persons, beneficence and justice) with respect to EMR deployment are followed? The Secretary of the Department of Health and Human Services or a more nebulous body like Congress?

If we accept that the benefits of the EMR are at least uncertain to patients in terms of risk and cost, we should demand they be studied before deploying them. The guiding medical ethics tenets would demand nothing less. So, would not such study qualify as human research? After all, we should remember that the United States and other countries have a precedent of human research programs performed by government agencies that were usually highly secretive, and in many cases information about them was not released until many years after the studies had been performed.

From a sentinel paper in 1966 by Henry J. Beecher, MD on Ethics in Research:

"I should like to affirm that American medicine is sound, and most progress in it soundly attained. There is, however, a reason for concern in certain areas, and I believe the type of activities to be mentioned will do great harm to medicine unless soon corrected. It will certainly be charged that a mention of these matters does a disservice to medicine, but not one so great, I believe, as a continuation of the practices cited.

Experimentation in man takes place is several areas: in self-experimentation; in patient volunteers and normal subjects; in therapy; and in the different areas of experimentation on a patient not for his benefit but for that, at least in theory, of patients in general."
While Beecher’s paper was addressing ethical research errors in general, his words are oddly prescient for EMR development. Ethical errors, as he pointed out, “are increasing not only in numbers but in variety.” He points to one of the biggest drivers of ethical conflict: money.

“Of transcendent importance is the enormous and continuing increasing in available dollars for research, as shown below:

Money Available for Research Each Year
YearMassachusetts General HospitalNational Institutes of Health

These data, rough as they are, illustrate vast opportunities and concomitantly expanded responsibilities.

Taking into account the sound and increasing emphasis of recent years that experimentation in man must precede general application of new procedures in therapy, plus the great sums of money available, there is reason to fear that these requirements and resources may be greater than the supply of responsible investigators.”

The need for “responsible investigators” remains significant; funding for all of the National institute of Health in 2011 was $142.5 billion dollars. Annually, EMR companies have received the equivalent of 11% of the entire NIH annual research budget from US citizens without having to prove their safety or value to patients.

Again, from Beecher’s paper:

“The ethical approach to experimentation in man has several components; two are more important than others, the first being informed consent. The difficulty of obtaining this is discussed in detail. But it is absolutely essential to strive for it for moral, sociologic, and legal reasons. The statement that consent has been obtained has little meaning unless the subject or his guardian is capable of understanding what is to be undertaken and unless all hazards are clear. If these are not known this, too, shall be stated. In such a situation the subject at least knows that he is to be a participant in an experiment. Secondly, there is the more reliable safeguard provided by the presence of an intelligent, informed, conscientious, compassionate, responsible investigator.”
Because EMR deployments are cloaked in intellectual property, non-disclosure and restrictive hospital employment agreements, doctors are often prohibited from voicing specific concerns about an EMR system publicly. In addition, by adopting EMR systems as cornerstones of the American health care system, Congress, the President and the ARRA side-stepped patients’ informed consent regarding the short-comings of these systems, advertising only their desired benefits instead. Furthermore, rather than Congress turning to “conscientious, compassionate, responsible investigators,” they turned to lobbyists when deciding to fund the deployment of unproven EMR systems. As a result, doctors were relegated to becoming nothing more than stewards of data entry subject to new, ever-evolving documentation requirements as these systems evolve for cost-saving benefits and care "efficiencies."

Patients and doctors alike understand the need for improved efficiencies and value in our era of exploding health care costs. We must strive to find a solution to our health care cost crisis that is transparent, cost-effective and ethical. Without such an effort, our health care system will collapse. Only recently has the Office of the National Coordinator of Health Information Technology recognized the problem and opened their Health IT Patient Safety Action and Surveillance Plan for public comment. This plan asks the EMR companies and interested stakeholders to develop their own methods to assure patient safety and reporting systems – a move that approaches the same ethical standards as equivalent of asking the foxes to watch the henhouse. Nonetheless, we should acknowledge their efforts.

But we should be cautious of EMR systems as we move forward. After all, these clinical systems have not been subjected to the same cost-benefit and ethical scrutiny as other clinical tools we use in health care. The scrutiny of EMRs should be no different than that found with pharmaceutical or medical device research where Institutional Research Board approval and proof of no conflict of interest is demanded. Why should clinical EMR systems be any different?

Given the profit motives and market consolidation occurring amongst the purveyors of these EMR systems and the potential for lethal EMR errors both from software and human interface issues, doctors and patients must especially question the ethics of the movement to deploy untested, novel technology on our patient population under restrictive covenants. As part of informed consent, patients should have full understanding of how and where their clinical data are used, including when it will be used for direct-marketing campaigns, prioritizing care delivery, or for research. Patients should be able to opt out of the use of their clinical data for these or any other purpose if desired, without restricting payment for care. Finally, physician and patient concerns about EMR systems should be allowed to be vetted publicly and without threat of professional or personal reprisal or the withholding of payments for care rendered, especially and particularly if these disclosures are performed in the best interest of patient care.

To do otherwise is unethical for our patients and the public at large.


Friday, January 18, 2013

If EMRs Were Research, Would They Pass IRB Muster?

Imagine for a moment that you were a principal investigator who wanted to study your independently-developed electronic medical record system for clinical use.  You have spent billions developing your system, housed it in a high-security fortress with its own power grid, power backup-system, multiple fiber-optic T3 lines that dovetail with large communications contractors. Your experimental system is outfitted with the latest and greatest software innovations to chart patient encounters, transmit lab data and post results, interact with other vendor software manufacturers, and bill patients for procedures performed while collecting huge volumes of patient data in data repositories.  You want to prove the EMRs ability to safely care for patients, lower health care costs, and prevent errors.  Your hypothesis is that your EMR system does all of these things.

But to gain approval for your study, you must bring it before an Investigational Review Board (IRB) for approval before you can begin your research project.  For those unfamiliar, an IRB is a committee that has been formally designated to approve, monitor, and review biomedical and behavioral research involving humans. They often conduct some form of risk-benefit analysis in an attempt to determine whether or not research should be done. The number one priority of IRBs is to protect human subjects from physical or psychological harm. In the United States, the Food and Drug Administration (FDA) and Department of Health and Human Services (specifically Office for Human Research Protections) regulations have empowered IRBs to approve, require modifications in planned research prior to approval, or disapprove research. IRBs are responsible for critical oversight functions for research conducted on human subjects that are 'scientific', 'ethical', and 'regulatory'.

Interestingly, billions and billions of dollars ride on your study being shown true. You are convinced, I mean convinced, that your EMR will do all the beneficial things your hypothesize with little to no downside. After all, you have strong political and financial backers that agree with you.  You have deployed your experimental system to over 40% of the entire US population in preparation for your study. It's time to start, you say.

I wonder, if the readers of this blog were members of the IRB and this study was presented to you, what safeguards would you insist upon to protect patients?  Would the study, as proposed, pass muster?


Wednesday, January 16, 2013

Meaningful Abuse

Sometimes, the money made for pursuing bureaucratic pursuits is not worth the time required to fulfill them.  This is becoming especially true for "meaningful use" criteria that have been developed by the government to penalize doctors if they don't use the Electronic Medical Record in a "meaningful" way.  The roll-out of punitive measures to "encourage" doctors use of EMRs began with varying "stages" of required compliance and threatens to implode upon itself:
For Stage 1, physicians have to meet a total of 15 core (required) measures, select five measures of their choice from a menu set of ten, and also meet six clinical quality measures. For Stage 2, physicians are required to meet more measures: 17 core measures, an additional three measures of their choice from a menu set of six measures, and starting in 2014, meet nine clinical quality measures. The Health IT Policy Committee’s proposal for Stage 3 would nearly double the number of measures physicians would have to meet for each patient in order to avoid meaningful use financial penalties. Failing to meet just one measure by  one percent would make a physician ineligible for incentives and face the same financial penalties during the penalty phase as those physicians who make no effort to adopt EHRs.
You read that correctly.  If you do all the clicky computer things the government wants with each patient visit, you will not have time to care for your patients.  So never mind if you don't have a clue what all these "stages" of computer use actually mean because I can help you:

With the proposed Stage 3 Meaningful Use criteria coming down the pike, you will be penalized for using the Electronic Medical Record because you don't use it well enough no matter how hard you try.  After all, patient care is not the priority, computers are. 

Any questions?

(Yeah, it's hard to make this stuff up.)


Reference: AMA Letter to the Office of the National Coordinator for Health Information Technology

Monday, January 14, 2013

Illinois Funding Cuts Threaten Physician Licensure

The Illinois Department of Financial and Professional Regulation (the Illinois physician licensure body)  has had to cut their head count from 26 to eight due to state funding cuts.  As a result, there will be only ONE employee to handle all physician licensure in Illinois.

Residents and fellows will have their training delayed as they wait for their licenses.

Physician's current licenses will expire before a renewal can be processed.

Best of all, doctors will have to stop practicing at a time when the demand for practitioners will be higher than ever.

Well done, legislators!


Cost Savings from EMRs: A Path to Salvation

The Electronic Medical Record (EMR)'s promised contribution to health care cost savings got a second look recently, and the results were poor at best.  But what I found interesting was the "second look" was from the same organization that did the first look: the corporately-funded, non-profit think-tank called the RAND Corporation.  From their second and more recent report:
"A team of RAND Corporation researchers projected in 2005 that rapid adoption of health information technology (IT) could save the United States more than $81 billion annually. Seven years later the empirical data on the technology’s impact on health care efficiency and safety are mixed, and annual health care expenditures in the United States have grown by $800 billion."
Who would have thought that such a prestigious organization like the RAND Corportation could have made such a teeny, tiny multi-billion dollar mistake? After all, their 2005 study was funded entirely by several of the major EMR manufacturers who have reaped billions in revenue on EMR sales since.  Is there any wonder that now the same RAND Corporation felt that the EMRs the lack of cost savings is really the end-users' fault?

"In our view, the disappointing performance of health IT to date can be largely attributed to several factors: sluggish adoption of health IT systems, coupled with the choice of systems that are neither interoperable nor easy to use; and the failure of health care providers and institutions to reengineer care processes to reap the full benefits of health IT."

What a shallow assessment.  There is no mention of the cost of these systems, their maintenance, lack of interoperability, poor user-interfaces, and in many cases, lack of graphics support.  Even more ironic, there was no consideration that someone might actually figure out a way to efficienctly skirt the government's arcaine documenttion requirements for reimbursement that would permit MORE health care spending.  No, those assessments would have been too obvious.  Instead, the Rand Corporation tells us that there were no cost savings with the EMRs is because doctor- and hosptial-customers didn't re-engineered their care processes or "adopt" substandard first-generation systems.

Give me a break.  At least the Congressional Budget Office saw through the Rand Corporation's ruse in their scathing report (pdf) from 2008.

Even so, at this point it doesn't matter.  Doctors and patients alike understand that there was too much corporate money involved and too many politicians' campaigns happily funded as the Stimulus Bill that implemented the EMR nationwide was crafted.  As a consequence, little will be done about either of the Rand Corporation's erroneous and over-zealous EMR cost-saving predictions now.  Whether we love it or hate it, the Electronic Medical Record is here to stay.   Government incentives have made it so and are still slated to grow.  More to the point, our lack-of-cost-savings epiphany came so late that most of our newly-graduated doctors have never used a paper chart and likely never will.

So now that the whole EMR implementation and cost charade has been exposed (and a blind eye permanently cast), what should doctors do now?

First, doctors must demand value for the money wasted spent on the multitude of EMR systems out there.   No where would that value be more evident than if interoperability standards were required within two years, especially when different health care systems use the same EMR system.  This is especially so with EPIC Systems, the largest EMR nationwide that is thought to contain patient records, at last estimate, some 40% of the nation's hospitalized patients.  Right now, this minute, most of the major medical centers in Chicago use EPIC.  There is simply no excuse any longer that doctors from one major medical institution shouldn't be able to view clinical records at another institution, especially when they use the same software.  Silo-ed patient data is not a value-driven proposition for the patient but rather a profit-driven proposition for hospitals.  As such, transferability of patient data between hospitals and health care systems should become one of the highest "quality standards" for hospitals to achieve and (perhaps) stiff payment penalties applied if this goal is not met. Patients (and the doctors trying to care for them) deserve nothing less.

Second, open avenues of communicating concerns about EMR functionality and safety should be mandated  and not restricted to conversations moderated behind secured web-based firewalls hosted by twenty-something computer nerds with no clinical experience.  Social media involvement by companies, be it by way of blogs, Twitter, LinkedIn, or Facebook, should be the norm.  Such open discussions encourages constructive, transparent and understandable transmission of tips, tricks, and (most importantly) needed improvements as EMRs mature.  After all, there's nothing better than a screenshot or picture(s) (devoid of patient information, of course) published for all to see to make a point and affect change. A grass-roots critique of EMR systems by doctors is long overdue.

Third, EMRs should not try to be all-encompassing.  They should stick with what they know.  Do not try to be a graphical user interface when you write in MUMPS, for instance. It's embarrassing.  If you can't do graphics, pictures or difficult multi-layercalendars, then dove-tail with someone who can.   To do otherwise creates unfamiliar non-standardized interfaces that invite treatment errors and inefficiencies rather then correcting them.

Today the sad reality is this: EMR interactions consume more of the physician's time than direct patient care.   EMR companies should realize that as long as doctors are challenged by data entry and the ever-increasing documentation and verification requirements to maintain their livelihood, they will speak out on the new challenges posed by the the EMR publically.  Companies that embrace and respond effectively to constructive criticism openly and honestly are much more likely to be viewed favorably by the health care marketplace and (who knows?) might even help to save a buck some day.


Saturday, January 12, 2013

The New Cognitive Dissonance of Medicine

The 30-something teacher stood before a room of leaders, neatly dressed, wearing black-rimmed hipster glasses, articulate, poised.  He never stuttered, his words precise.  His expertise was educating big rooms of leaders - it was all he knew: summa cum laude, three majors, and impeccable youthful credentials for a corporate consultant.  Meeting rooms and corporate board rooms were his theater and comfort zone,  flip charts and Powerpoint graphics his instruments.

Before him sat two sets of leaders - each neatly assembled, restless.  One group was unaccustomed to fluorescent light, snack tables, and colored markers.  Instead, their productivity comfort zones were in swabbing the back of throats or reaching within the abdomen.  For the other group of leaders, productivity was defined by human resources, spreadsheets, e-mails, agendas, meetings, and time cards.

It was a strange juxtaposition of leaders, each seated side-by-side now, awkwardly struggling with the cognitive dissonance engendered by learning from a babe as they were forced to embrace change.  A new world order thrust upon them now, a world where of ideals of William Osler had irreversibly shifted to the ideals of Walmart, FedEx, UPS, and The Cheesecake Factory.

"Stakeholders." "Customer service." "Product lines." "Efficiency," "Service values."

Bracing for impact.

They sat quietly absorbing it all with knots in their stomachs realizing that these corporate intangibles are now what matter.   Challenging decisions are to be made simple by nothing more than numbers, spreadsheets, and scoring thresholds.  Each leader there had an eerie sense of being comforted by the facade of feeling included, yet quietly realizing just how outside the mainstream they were.  The good girls and boys of medicine, so easily fooled.

Then a page pierced the air: "Please call the ER x 1155 Re: consult: New-onset atrial fibrillation."

A reality that was anything but simple, anything but linear.

Lead, dear doctor, lead.


Tuesday, January 08, 2013

You Know You Need a Pacemaker When...

... your pause, when held vertical, exceeds one third of your height:

Strip recorded 1.5 years after implant of an implantable loop recorder showing new 27-second pause (Period between large black boxes on the strip represent six seconds each - click to enlarge).

Sunday, January 06, 2013

The Hospital Pension Problem

The issue of looming pension fund shortages will be the final death knell to academic medicine's resistance to joining the 21st century's shared-risk of the 40-3b/401-k retirement funds.  From Chicago Business:
Already caught between flattening revenues and rising costs, many hospital CEOs are confronting a looming pension fund gap.

The University of Chicago, which includes the university and the medical center, and Resurrection Health Care Corp. were among the most underfunded pension funds for hospitals in the country, according to a study of 550 health systems by Standard & Poor's Ratings Services, based on 2010 financials.
While U of C's and Resurrection's retirement funding has improved, they are part of a group of five Chicago-area hospitals and health care networks whose pensions are less than 80 percent funded and are considered at risk of default, according to federal regulations. NorthShore University HealthSystem and Provena Health, which merged with Resurrection in 2011 to form Presence Health, also are below the threshold. The others are Northwest Community Hospital and Elmhurst Memorial Healthcare.

The five most underfunded hospital pension funds are among 10 major hospitals and health care networks in the Chicago area that owe a total of $1.12 billion to their pension funds, according to a Crain's analysis of the most recent financial statements.

Saturday, January 05, 2013

The Costs of Not-so-Shared Decision Making

This week's New England Journal of Medicine contains a perspective piece by Emily Oshima Lee, M.A., and Ezekiel J. Emanuel, M.D., Ph.D. entitled "Shared Decision Making to Improve Care and Reduce Costs." The original paragraph of the piece sets the tone:
"A sleeper provision of the Affordable Care Act (ACA) encourages greater use of shared decision making in health care. For many health situations in which there's not one clearly superior course of treatment, shared decision making can ensure that medical care better aligns with patients' preferences and values. One way to implement this approach is by using patient decision aids — written materials, videos, or interactive electronic presentations designed to inform patients and their families about care options; each option's outcomes, including benefits and possible side effects; the health care team's skills; and costs. Shared decision making has the potential to provide numerous benefits for patients, clinicians, and the health care system, including increased patient knowledge, less anxiety over the care process, improved health outcomes, reductions in unwarranted variation in care and costs, and greater alignment of care with patients' values.

However, more than 2 years after enactment of the ACA, little has been done to promote shared decision making. We believe that the Centers for Medicare and Medicaid Services (CMS) should begin certifying and implementing patient decision aids, aiming to achieve three important goals: promote an ideal approach to clinician–patient decision making, improve the quality of medical decisions, and reduce costs."
What a nice, lovely, fuzzy bunny.  Who couldn't want such "shared" decisions in complex medical care?  Especially nice simple teaching aids for Medicare's top 20 procedures printed at the "8th grade level" that are "brief?"

Doctors, don't you know that this will become simply another box to check on your EMR for Medicare reimbursement? 

And yet the benefits of cost savings that these "shared" decision making tools' will have on health care are assumed, especially when deployed nationwide, despite what the authors claim.  Note that the 2011 Cochrane Collaborative review of the 86 studies they reference said nothing about cost savings.

Doctors know this and so do the authors.

Why else would the authors require a cudgel to impose their "shared" decision making benefit if other real life clinical doctors fail to follow along?
"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."
Ms. Lee and Dr. Emanuel, in their zeal to impose their Progressive mindset upon America's physicians have forgotten several important tenets of health care delivery:
  • First, decisions made in medicine are each unique to a patient's constellation of medical problems, socioeconomic and cultural background, age, gender, religious beliefs, etc.  In other words: decisions are made in concert with an individual's situation, and not based on the government's desire (necessarily) for cost savings (even if it is couched in euphemisms such as "shared decision making").

  • Second, actual cost information (both out-of-pocket and real health care system costs) for patients and doctors will remain shrouded  in secrecy since payers rely on obfuscation of actual cost information to extract their portion of fees before patients receive any value for their dollar.  Also, other similar pay-for-performance measures have already uniformly flopped at demonstrating cost savings.  Then imagine for a moment if the cudgel for shared decision making is imposed.  The potential for a 10-20% Medicare physician fee cut on top of a 30% Sustainable Growth Rate cut that is likely to reappear in 2014 will be untenable for US physicians. 

  • Third and very importantly, the ACA legislation has created a whole new "institute" of salaried individuals within government called the Patient-Centered Outcomes Research Institute (PCORI) to develop the authors' soon-to-be-mandated decision aid materials while another branch of government already exists to produce such education aids called the Agency for Healthcare Research and Quality (AHRQ).  Wouldn't our health care system benefit far greater from cost savings by not duplicating services already performed by another government agency? How much, exactly, will the PCORI cost us?

  • Fourth, the push to re-invigorate the mass-production of physicians via three-year medical school curricula while simultaneously failing to increase residency slots assures poorer trained, inexperienced doctor-patient discussions about complicated medical issues, not better ones. Shared does not mean better.

  • Finally, liability risks remain for doctors caught in these unenviable mandates that fail to recognize the individual complexities of an individual patient's care.  Until doctors sense a modicum of effort for liability reform, they will continue to offer care that exposes both themselves and their patient's to the path of lowest legal risk, irrespective of what teaching aids they give to patients.
Doctors and the AMA should demand transparency in the cost of creating and funding the PCORI and its shared decision making materials, yet another layer in the runaway middleman health care behemoth emerging as the front lines of health care delivery are systematically decimated. 

If that doesn' t matter to all of us, then share away.


Thursday, January 03, 2013

To EPs: Happy Coding New Year!

Well, well, well.  It's another year and another chance to enjoy new procedural coding changes for electrophysiologists in 2013!  In case you missed it, the old catheter ablation codes for supraventricular and ventricular tachycardia ablations (93651 and 93652) have been deleted effective 1 Jan 2013.

That's right:  Gone.  Kaput.  Fi-ne. 

In their place we now have five new codes, two of which are specific for atrial fibrillation ablation:

  • 93653 - For use with SVT/WPW/Focal ATach/IVC-Tricuspid annular-dependent flutter ablations - Don't even THINK about coding separately for transseptal catheterization with this one - it's now bundled.  (If 3D mapping is needed, it looks like it's still okay to add 93613 to this code - for now.  Also, for Afib ablations, do NOT use this code, but rather a separate code (See 93656 and 93657 below)). RVU Value: 15.

  • 93654 - For use with Ventricular Tachycardia Ablation - This includes everything from placement of catheters, to the transseptal (if needed), AND the use of 3D mapping, and the ablation of VT.  (Remember: no separate code of transeptal and 3D mapping with this code.) RVU Value: 20.

    • If there is a SECOND arrhythmia focus that is ablated during EITHER SVT or VT ablation codes above, you can use add-on code 93655 but must specify the second arrhythmia targeted.  Total RVU value: 7.5
  • 93656 - For use with Atrial Fibrillation ablations - This includes the placement of catheters, the transseptal, pacing, mapping, giving meds, etc. up to and including isolation of the pulmonary veins.   (It appears 3D mapping (93613) can be billed separately for this code, unlike for the VT ablation)Total RVU value: 20.02.

    • 93657 - Used in addition to the Afib ablation code, 93656, if linear lines are developed in the atria following pulmonary vein isolation procedure. Total RVU value 7.5
Full details on these new codes, how they were developed, and how they should (really) be applied can be found on the Heart Rhythm Society website. (Please take what I say with a grain of salt).

Happy coding!


Wednesday, January 02, 2013

The Fix That Failed

The new "fiscal cliff" legislation hailed by some as a "one-year doc fix" of the scheduled 26.5% sustainable growth rate (SGR) cut that was scheduled to take effect on 1 January 2013, has passed the Senate and House as part of the American Taxpayer Relief Act (HR 8) goes to President Obama for his likely signature.

But was this "one-year doc fix" really a fix?

Not at all.

In fact, once again Congress has failed to resolve the ever-present sustainable growth rate cuts that repetitively surface year after year by kicking the proverbial can down the road another year.

The cost of the one year patch will be $25.1 billion dollars over 10 years and will be paid for almost entirely by health care cuts in other areas.

  • Hospitals (increasingly doctor-employers now, remember?) will see audits of their billings increase as efforts to recoup some $10.5 billion of "overcoding" charges are seen as the largest source of revenue for the one-year "fix."

  • Hospitals will also see an extension of lower Medicaid payments to hospitals that treat a high number of uninsured or low-income beneficiaries, known as "disproportionate share hospitals" to find savings of about $4.2 billion.

  • Another $4.9 billion offset will be applied to the lowered bundled payments given for patients with end-stage renal disease - some of the sickest people receiving services from Medicare.

  • Also another $1.8 billion will be "saved" to offset the "fix" by reducing payments for multiple procedures that are performed on the same day with patients.  Look for more ICD-9 (or ICD-10) code changes for the new year. 

  • Also, look for an even greater crackdown on imaging studies as another $800 million has to be found to pay for the "fix."

  • And there's more: the complete list of payments for the "fix," drawn almost exclusively from health care alone, can be found here.

  • Finally, doctors can expect revenue to stay flat result of this "fix" from Medicare, meaning that the payments received will not address costs imposed by annual inflation.  (You well-paid primary care doctors, are you listening?)
So you see, the "doc fix" is in for another year alright ...

... one that is assured to get even harder to really fix next year.