Monday, February 24, 2014

Maintenance of Certification: The Noose Tightens

Center for Medicare and Medicaid Services (CMS) displayed it's enmeshed ties with the American Board of Medical Specialties (ABMS), a private non-profit with its 24 Subspecialty Member Boards, by agreeing to provide "incentive payments" of 0.5% for 2014 as part of its 2014 PQRS quality reporting initiative.
In accordance with section 1848(m) (7) of the Act (“Additional Incentive Payment”), Centers for Medicare and Medicaid Services (CMS) is continuing the Maintenance of Certification (MOC) Program Incentive that began in January 2011. Eligible professionals (EP) who were incentive eligible for the Physician Quality Reporting System (PQRS) could receive an additional 0.5% incentive payment when Maintenance of Certification Program incentive requirements were also met.


In order to qualify for the additional 0.5% incentive payment for the 2014 PQRS based on the 12-month reporting period (January 1, 2014 through December 31, 2014), the physician will need to complete the following:

• Satisfactorily submit data, without regard to method, on quality measures under PQRS, for a 12-month reporting period either as an individual physician or as a member of a group practice.


The Maintenance of Certification Program will need to submit to CMS, on behalf of the physician the following information:

• That the physician more frequently than is required to qualify for or maintain board certification status, participates in the Maintenance of Certification Program for a year and successfully completes a qualified Maintenance of Certification Program practice assessment for such year;
• Information on the survey of patient experience with care; and
• The methods, measures, and data used under the Maintenance of Certification Program and the qualified Maintenance of Certification Program practice assessment.

As defined in section 1848(m) (7) (C) (i) of the Act, a “Maintenance of Certification Program” is a continuous assessment program that advances quality and the lifelong learning and self-assessment of board certified specialty physicians by focusing on the competencies of patient care, medical knowledge, practice-based learning, interpersonal and communication skills and professionalism. In order to qualify for the additional 0.5% incentive payment in 2014, physicians will be required to participate more frequently than is required in at least one of the following two parts of the Maintenance of Certification Program, as well as “more frequent” successful completion of a qualified maintenance of certification program practice assessment as follows:

• Participate in educational and self-assessment programs that require an assessment of what was learned; and
• Demonstrate through a formalized, secure examination, that the physician has the fundamental diagnostic skills, medical knowledge and clinical judgment to provide quality care in their respective specialty.

A “qualified Maintenance of Certification program practice assessment,” as defined in section 1848(m)(7) (C) (ii) of the Act is one that includes an initial assessment of a physician’s practice that is designed to demonstrate the physician’s use of evidence-based medicine; includes a survey of patient experience with care; and requires the physician to implement a quality improvement intervention to address a practice weakness identified in the initial assessment. The practice assessment must also require the practice to reassess performance improvement after the intervention.

The phrase “more frequently” may be interpreted differently by different Maintenance of Certification Programs. CMS is looking to see an attestation from a Maintenance of Certification Program entity that both the Maintenance of Certification Program itself and the practice assessment are completed once more by a physician than is required by a specific Maintenance of Certification Program.
This is, of course, the start of the end-run to tie Maintenance of Certification requirements (as defined solely by the ABMS) to Maintenance of Licensure for physicians to be able to practice medicine. Employer-based physicians will have no choice but to agree to pay into this certification cartel as money-squeezed hospital systems look for ways to improve their bottom line. For doctors, this process is nothing more than a "pay to play" scheme that backs a union-like serfdom with leaders that idealize their self importance and exorbitant salaries more than patient care.

This CMS PQRS incentive payment scheme incentivizes those who make the tests, track the results, and then post them online, rather than improving the quality of patient care. The onerous MOC process as devised by the ABMS has never been independently shown to improve patient care or quality outcomes but rather detracts from patient care in favor of payments required by the regulators.

Where's the quality in that?


Christman KD. Maintenance of certification (MOC), maintenance of licensure (MOL) and continuing medical education (CME): how the regulators prosper. Journal of American Physicians and Surgeons. 2012.17(3):76-79.

Benjamin Rush Society's MOC Bibliography.

Saturday, February 22, 2014

The Unintended Consequence of Free Preventative Care

Be careful when hoping for "free" preventative care. From the Charlotte Observer:
I have learned since that it’s not unusual to get this extra charge with a preventive exam.

In the past year or so, primary care doctors say they have struggled over how to manage their time during preventive visits when patients bring up questions about chronic medical problems. If the discussion in a preventive exam turns to previously diagnosed conditions, the code for that signals the insurance company to pay for an “office visit,” which usually means a co-pay from the patient.

“It’s very confusing, even for the doctors,” said Dr. Dino Kanelos of Carolina Family Healthcare in Ballantyne. “I just finished (a preventive exam) with a lady who had 15 medical problems she wanted to discuss.”

There are multiple factors at work here. This practice of billing for an extra visit began before the Affordable Care Act’s insurance mandate took effect Jan. 1. But some doctors and insurance companies may be using this opportunity to more strictly follow guidelines about what qualifies as a preventive service under the act, and must be covered 100 percent without patient cost-sharing.

In addition, doctors are under pressure to document everything appropriately in the electronic medical record or they could be subject to Medicare reimbursement cuts in the future. That takes more time, so they have less time to handle extra questions from patients. And with the growing prevalence of high-deductible insurance policies, patients may save their questions for the preventive exam, hoping they can avoid paying the full cost of a separate medical visit.

“It’s a Catch-22,” Kanelos said. “I want to be able to say, ‘What’s going on? Is there anything wrong with you?’… In the old days, that’s the way I picked up a lot of problems. ... Now, it is hard to figure out what to do.”

Friday, February 21, 2014

What Is "Non-Valvular" Atrial Fibrillation?

With the recent heavy marketing of the relatively new novel oral anticoagulants dabigatran, rivaroxaban, and apixaban, a new marketing phrase has been born: "non-valvular" atrial fibrillation.

What, exactly, is "non-valvular" atrial fibrillation?

Is it atrial fibrillation without any valvular heart disease like a teeny, tiny bit of functional mitral insufficiency? Or should doctors "ignore" the degree of mitral insufficiency when prescribing these medications? What about mitral valve prolapse patients with severe prolapse?

Is it atrial fibrillation without the presence of any prosthetic heart valve? What about a valve ring placed when a mitral valve is surgically "repaired?"

Is it atrial fibrillation without any rheumatic heart disease? What about mild mitral stenosis compared to moderate or severe mitral stenosis? If there's a difference, what valve area should we use to judge safety of prescribing the novel oral antiocoagulants?

Or is it some combination of one or more of these above patient groups?

For doctors who manage patients with atrial fibrillation and are considering if they should offer a novel oral anticoagulant to a patient in lieu of warfarin, this issue is not a trivial question.

To answer some of these questions, we should turn to the RE-LY, Rocket AF, and Atristotle Trials. But these trials offer only minimal guidance to today's practicing physicians.

For instance, in the RE-LY trial, only patients without "History of heart valve disorder (i.e., prosthetic valve or hemodynamically relevant valve disease)" were studied. What, exactly, do they mean by "hemodynamically relevant heart valve disease?" Does any valve qualify or just the mitral valve?

The Rocket AF trial describes their "non-valvular" heart disease patients a bit better as those with "(1) Hemodynamically significant mitral valve stenosis or a (2) a prosthetic heart valve (annuloplasty with or without prosthetic ring, commissurotomy and/or valvuloplasty WERE permitted)" but were mild mitral stenosis patient's included? What, exactly, defined "hemodynamically-significant" mitral stenosis patients?

The Aristotle trial defined their excluded valvular heart disease as patients as those with "moderate or severe mitral stenosis, or conditions other than atrial fibrillation that required anticoagulation (e.g., a prosthetic heart valve). (The reader must assume that surgically-repaired mitral valves were okay, but were they included or excluded from this trial - we're not sure.)

For doctors on the front line of medicine who might want to prescribe these new drugs to their patients, the term "non-valvular atrial fibrillation" seems to mean different things to different people.

Common sense would dictate that any patient with mitral stenosis (of any severity, in my opinion (be it rheumatic or post-surgical) or patients with prior placement of a prosthetic heart valve (either bioprosthetic or mechanical) should not be considered for these agents. But this is just my wild-ass guess. After all, there is no clear consensus on what really defines "non-valvular" atrial fibrillation, especially when we examine the evidence-based data available to doctors on this issue.

But beyond this, as researchers testing new therapies, we should be careful not to coin confusing new marketing terms to describe a complicated constellation of patients. Otherwise, we might risk injuring those we really are trying to help.


Thursday, February 20, 2014

St. Jude Issues "Dear Colleague" Letter Regarding Older Pacemakers During Surgery

On 29 January 2014, St. Jude Medical issued a "Dear Colleague" letter regarding their review of incident reports on older-model pacemakers (Affinity, Entity, Integrity, Identity, Sustain, Frontier, Victory and Zephyr models) that occasionally dropped their output voltage during surgical electrocautery. (Here's a publication describing two such cases.)

Several issues regarding this advisory letter are troubling.

First of all, according to the St. Jude letter: "Placing a magnet over the device or programming to an asynchronous pacing mode will not prevent this temporary reduction in pacing output." Consequently, St. Jude advises that pacemaker-dependent patients with these older pacemakers consider undergoing surgery without the use of electrocautery or to "employ appropriate precautions to ensure that the heart rate will be supported in the presence of electrocautery. Consideration of placing a temporary transvenous pacemaker is appropriate. (Emphasis mine)"

Typically, placing a magnet over pacemakers causes them to pace at a default "magnet rate" and pace at the programmed output voltage. This is such a common feature among pacemakers that it formed one of the cornerstones of the 2011 guidelines for peri-operative pacemaker management. While electromagenetic interference on older pacemaker models has been seen due to the device being reset, it is unusual for pacemaker output voltage to drop briefly. Furthermore, the recommendation to place a temporary pacing wire before surgery where electrocautery use is anticipated in pacemaker-dependent patients suggests there is no programmable "work-around" for this problem.

Secondly, while it seems an effort has been made to notify physicians about this problem with certain older St. Jude pacemaker models, it is concerning that I could not find the notice on St. Jude's Healthcare Professional website at the time of this writing, nearly three weeks after date of the original notification letter. Furthermore, it is concerning that such an unusual (and potentially fatal) failure mode of these older models of pacemakers has not been made more public to patients with these older St. Jude pacemakers so they can serve as their own advocates when surgery is in its planning stages.


Wednesday, February 19, 2014

Are Drug Letters Harming Our Patients?

One week's worth of drug letters
Now that a new year has come and gone, I have been swamped with letters from pharmacy benefit manager and insurance companies.  Piles of them.  Not only do these letters consume hours of time each week to address (so much for the "efficiency" of the electronic medical record), I am worried some of the latest practices of these companies might be endangering my patients. 

Here's a typical (paraphrased) letter that has me most concerned:
"Dear Mr or Ms Patient:

This letter is to inform you that Insurance Plan XYZ ("the plan") has provided you with a temporary supply of the following prescription:

(Insert your favorite novel oral anticoagulant name/dose here)

As described in more detail on the following page, this drug is either not included on our covered drug list (formulary) or included on the drug list, but has certain limits on it.

Because you are within the first 90 days of coverage this plan year, TooBig Insurance Company is required to provide you with at least a 31-day supply of this drug.  The supply is less if the prescription is written for less and does not have refills...

It is important you understand this is a temporary supply of this drug.  Before this supply ends, you should talk with your doctor to decide if you should change your prescription.  (Emphasis mine) If your doctor feels that the coverage options listed on the following page are not clinically appropriate for your situation, your doctor can request a formulary exception from TooBig Insurance Company to continue coverage of this drug.

If you need help requesting an exception, please call TooBig Insurance Company Customer Service listed on the back of your member ID card."
Note that all novel oral anticoagulant medications carry a very specific black-box warning from the FDA regarding discontinuation of these medications. Here's the black box warning for rivaroxaban (Xarelto):

Premature discontinuation of any oral anticoagulant, including XARELTO®, increases the risk of thrombotic events. If anticoagulation with XARELTO® is discontinued for a reason other than pathological bleeding or completion of a course of therapy, consider coverage with another anticoagulant.
Should insurance companies be allowed to restrict the dispensing of any medication where doing so puts patients at risk of injury?  Why are insurance companies allowed to potentially violate FDA-mandated black box warnings if they do so?   How many lives are being placed at risk by this practice?  What about the patients that are blind or can't read?  What happens to them? 

On a more selfish note: why must the physician suffer the liability consequences of an insurer's profit-driven  actions that disregards the safety and well-being of our patients? 



Sunday, February 16, 2014

Patient Safety and Medical Professionalism: How Far Do the Conflicts Go?

Recently, the US Department of Justice levied a 40 million dollar fine against CareFusion, makers of ChloraPrep® surgical skin antiseptic agent, because of kickback money paid to one member of the National Quality Forum's board, Dr. Charles Denham, MD.  As a result, it's become clear that much of the physician demonizing and marketing hoopla surrounding the patient safety movement might not be just about patient safety, but rather more about a money grab.  And it hasn't stopped there.

We have now learned that Christine Cassells, MD, former President of the American Board of Internal Medicine (ABIM) and the current President and CEO of the National Quality Forum has her own conflicts of interest since she was also serving as a paid consultant to several organizations who stand to benefit from the patient safety and quality initiatives created by the National Quality Forum.

Fool me once, shame on you.  Fool me twice, shame on me.

Given these ongoing revelations, it seems only logical to investigate if other conflicts might exist with these same doctors who make their living in these professional society circuits, especially when they serve as authors of papers outlining how doctors should behave professionally.  After all, the seemingly well-intentioned paper entitled "Medical Professionalism in the New Millenium: A Physician Charter" was published by Ms. Cassell's former organization that she lead at the time, the American Board of Internal Medicine (in conjunction with the American College of Physician-American Society of  Internal Medicine (ACP-ASIM) and the European Federation of Internal Medicine).

Not surprisingly, the current analysis is stunning.

For instance, remember the recent announcement from CVS Caremark about no more sales of tobacco products in CVS Stores splashed far and wide in the media - even by the President of the United States and the head of the Department of Health and Human Services?  Well guess who now serves as the Executive Vice President and Chief Medical Officer for CVS Caremark?  Troy Brennan, MD, JD, the lead author of the medical professionalism paper published in 2002.  While employment in the private sector after a lifetime in medicine does not violate current ethical standards, we have to wonder if it's medically professional to leave the medical profession itself to a greener, more lucrative pasture sculpted by one's papers that now are seen to serve corporate (and perhaps self-) interests more than patients, especially when they invoke the relatively new ethical requirement for social justice: that is, the needs of the collective should supersede the needs of the individual patient in the name of cost savings.

Another author of the medical professionalism paper, Walter McDonald, MD, also seems to feel it's medically professional to serve as executive vice president and CEO of the ACP-ASIM while also  serving as the senior vice president for QHc Advisory Group, LLC.

Double-standard, anyone?

Finally, let's not forget about Lisa J Lavisso-Mourey, MD, another of the paper's authors, who is President and CEO of the Robert Woods Johnson Foundation itself created from the riches of one of the sons of the Johnson and Johnson, Inc. fortune.  According to the organization's 2012 Form 990, Dr. Lavisso-Mourey pulls in a cool $918,519 in salary and benefits as its President and CEO.  Not a bad day job.  But why was she authoring an article on medical professionalism?  Shouldn't she have recused herself when not actually practicing medicine?  We should note that before joining RWJF, Dr. Lavisso-Maurey was senior vice president of the Health Care Group and member of the Clinton Task Force for Health Care Reform, so a political motive might have superseded a truly medical motive.  And since she was a co-author with Dr. Troy Brennan on the medical professionalism paper cited above, we should not be surprised that Dr. Lavisso-Mourey's had nothing but a glowing endorsement of the CVS Caremark decision to abandon tobacco sales.   After all, the back-slapping by these old pals goes way back.

For patients and hard-working doctors in the trenches, what does all of this really mean?  Can anything our professional organizations say to us and the public be trusted any longer?  Are edicts on medical professionalism, patient safety, prevention, EMR order sets with their "meaningful use" requirements,  more about a power and money grab than real ideals for patient care?

We have to wonder.

When any organization tolerates board members receiving kickbacks and ignoring cushy consultant positions that have clear conflicts of interest, a good, thorough, house-cleaning is needed.  And that house-cleaning should start at the top.  Anything else is window-dressing.

Without such a dramatic move, our professional organizations' credibility with those they pretend to serve will never recover.


Saturday, February 15, 2014

What the Collapse of Big Law Can Teach Big Medicine

An important read from The Atlantic:

With each passing year, Big Med is following Big Law. Physicians, medical schools, and hospitals all proudly trumpet their standing in national rankings. Efforts to preserve and augment revenue streams produce a less patient-centered and more business-oriented approach to organizing the practice of medicine. Physicians are more and more commonly referred to as healthcare providers. And billboards hawking the services of injury attorneys are being crowded out by hospital ads touting high-margin service lines.

Many clients, patients, and legal and medical professionals regard the erosion of the professions as the equivalent a tidal wave—deeply regrettable but utterly unstoppable. But this is not so. It is possible to reverse the tide and restore a sense of what it really means to be a professional—to be devoted to the service of others and the ideals of a noble profession. Collaboration can supplant competition, and the best interests of clients and patients can regain their rightful primacy.

Who would gain from such a restoration of professional integrity? First, the professionals themselves, who could still go to work in the morning and lay their heads down at night knowing that they are serving something beyond their own narrow self-interest. Another group of beneficiaries would be clients and patients, who would be able to trust that the professionals serving them are truly following their hearts and doing what they believe to be right.

And third and most importantly, society itself would benefit from such an example. In the short-term, to strive to be anything other than number one is foolish. But in the long term, life need not be a zero-sum game. There are many opportunities for each of us to serve others and enjoy long and richly rewarding careers without always maximizing our incomes at other’s expense. As the story of Big Law indicates, competition can be good, but only when it truly brings out the best in us.
Read the whole thing.


Monday, February 10, 2014

CABANA Trial Morphs from Mortality Trial to Composite Endpoint Trial

Major changes are underway for one of the signature comparative effectiveness research trials promoted by government interests on Capitol Hill as a critical path forward to controlling costs in health care. It seems such research might not be so easy and "cost-effective" as some had hoped.

The Catheter Ablation Versus Anti-arrhythmic Drug Therapy for Atrial Fibrillation (CABANA) trial was slated to have total mortality as its primary endpoint, but with the trial's most recent revision, the primary endpoint will instead become a composite endpoint of 1) total mortality, 2) disabling stroke, 3) serious bleeding, or 4) cardiac arrest.

While some may not see this as a significant development, we should understand that clinicians will be left without a definitive answer to which therapy, catheter ablation or anti-arrhythmic drug therapy, will prolong life the best in symptomatic patients with atrial fibrillation. Instead, doctors will have to read tea leaves based on a composite score of several endpoints to make their own personal judgment.

Changes to the protocol from its original design have occurred because (1) there was a lower-than-expected mortality rate seen in the trial so far and 2) (and perhaps most importantly) accrual of patients worldwide was occurring at a lower rate than expected. Careful consideration of these issues led to a decision by the study leadership to (a) change the primary endpoint in the trial from total mortality to the new composite endpont described above and (b) to reduce the sample size from 3000 to a number (2000-2200) with longer follow-up (5-7 yrs) to shorten the study duration and more realistically achieve the new endpoint within the study's funding.

While these develops are disappointing to many of us who serve as regional investigators for this trial, this study remains our best chance to get closer to determining which therapy for symptomatic patients with atrial fibrillation and CHA2DS2-Vasc scores > 2 is most likely to reduce death AND/OR stroke.

As the CABANA Trial has now clearly shown us, the realities of conducting proper research to make definitive claims about patient care are much more difficult to prove than our politicians and policy wonks on Capital Hill would like us to believe.

On a larger scale, we should remain skeptical that comparative effectiveness research (CER) is necessarily the best and most cost-effective means to determine the best therapies for our patients. This is especially important to grasp since the Patient Care Outcomes Research Institute (PCORI), formed by the 2009 Stimulus Bill and quietly funded by patient fees attached to their new insurance premiums, necessarily involves insurers and other "stakeholders" in this CER research initiative. Their participation worries me that spectrum, reporting, analytical and data-snooping bias can be introduced when interpreting such imperfect CER trial results. After all, the fox is irrevocably in our CER research henhouse.


Saturday, February 08, 2014

What One Cardiologist Thinks About the CVS Caremark Decision to Ban Cigarette Sales

By now the world has heard the remarkable news: that CVS Caremark will no longer be selling its tobacco products in any of its stores.  Locked and loaded with the news, the American Heart Association, American College of Cardiologists, local public health experts, Phillip Morris, and even the former-smoking President of the United States was quick to applaud the news by publishing press releases. 

But when press releases and major announcements of a single company's business decision floods the airwaves, newsfeeds, and radio spots, my bullsh*t antenna goes up. 

This is not to say that CVS Caremark's announcement wasn't nice to hear.  It was.  But making me feel better isn't going to stop people from smoking.   Is pulling the supply of cigarettes from one pharmacy/convenience store chain really going to affect the incidence of smoking in America?  Is it really going to "send a message" to other convenience stores and states who make billions of dollars from the sale of cigarettes each year?  Can we really sit and applaud this action while more and more states (like Illinois) seem to feel that smoking marijuana is just fine for our health?  


After all, despite the public's widespread knowledge of the dangers of smoking, being ridiculously taxed, stored behind counters, and withheld from minors for years, tobacco smoking is seeing a huge resurgence in both the young and old in America.

But politicians and public health experts, reeling from this reality, are desperately in need of some good news to spin.  They need to show the world how their self-righteous drum beats of preventing disease by restricting the supply of cigarettes at one business will make a difference to people's consumption behavior. 

It seems these same people have forgotten Prohibition.

To understand smoking in America, you have to meet smokers where they are - specifically their social circumstance.  People are growing up in a time of unprecedented pessimism in America.  They can't get jobs.  They are incredibly anxious, fractionated, and uncertain about their futures.  They are desperate to belong, to gain their own identity, to feel imporant, and to belong to a set of peers.  If smoking helps them achieve their own set of personal, social, or professional needs, no feel-good corporate policy announcement is going to change their minds about using cigarettes.

Supply-side public policy edicts will never affect psychology.

How do I know this?  Because I see people who smoke despite knowing these risks every day.  I know this because I am one of the most argent anti-smoking promoters to my kids.  As a cardiologist and father, how else could I be?  Throughout my entire career and my kids' entire lives, they've heard about the dangers of smoking, the addictive potential of nicotine, the poisons in the smoke, and the horrible cases I saw of lung, oral, and bladder cancer in my training.  My wife and I have never allowed cigarettes to be smoked in our house and have we have never smoked.

But despite all of our harping and example-setting, I recently learned that one of my young-adult kids has started smoking.  He felt so conflicted about this decision that he knew he was making, he recently met with my wife and me over dinner to explain.  His reasons were specific to him and him alone.   He just didn't want to lie to us about his decision and I know for certain that this decision wasn't because he didn't know the dangers of smoking or what it could do to him.  Were we happy about this? Of course not.  But the decision is his and I know that if he wants something, he's going to get it, even if CVS Caremark doesn't carry cigarettes any longer.  Hopefully, as his life circumstances change, he'll quit.

This is why we need to get over ourselves about the CVS Caremark business decision to stop selling cigarettes - there are just too many other confounding variables and mixed messages out there that are bringing people to smoke.  Sure the CVS Caremark announcement was good news but good news and one pharmacy chain's decision to not sell tobacco products won't really affect the booming incidence of smoking in America.  CVS Caremark's announcement has already come and gone.  Smoking, however, is still here.

To me, when we start focusing on why people are smoking despite the known well-known dangers of this habit we'll be much closer to gaining a real foothold on this public health problem.

Anything else is just spin.


Thursday, February 06, 2014

When Academic Medical Centers Allow Double-Dipping

When leaders of public universities that receive their income from both tax payers and private industry interests, ethical lines become blurred when expensive technologies or industry-sponsored research protocols are promoted by that university.  Are patients' best interests sufficiently protected?

Paul Levy, former CEO of Beth Israel Deaconess Medical Center and blogger over at the Not Running A Hospital blog, has broken the Chicago story that is ongoing at the University of Illinois which came to light after an advertisement promoting robotic surgery at the University was paid for by the robotics company.  Today, Mr. Levy asks if the dean's disclosure documents filed with the Secretary of State (specifically the Statement of Economic Interests) are (1) sufficiently reviewed and (2) enforced to prevent such conflicts of interest inherent to such double-dipping. 

Is the public being served best when conflicts such as these are ignored?

Mr. Levy deserves praise for his dogged coverage of this issue.  Hopefully the Secretary of State and the University of Illinois (that is already reeling from earlier exposure regarding the University's former policy of admitting students based on patronage criteria), will resolve to commit to appropriate oversight and end such conflicts.  As Levy points out: the silence has been deafening.


Sunday, February 02, 2014

Talking Heads

February, in case you haven't noticed, is "Heart Month" full of associations with Valentine's Day, love, peace and tranquility.  It's also a month to sell cardiovascular health care.

Everywhere you look these days are advertisements for the latest and greatest heart care, finest heart care facilities, touching stories of the latest cardiovascular intervention saving a life at this medical center or that.  Go ahead.  Type in "heart" as your Google alert phrase to see what I mean. 

Heart month, you see, is business month for most medical centers since the cardiovascular disease product line is sold more often than any other in medicine.  But what is good for the business of medicine is not always good for the reputation of physicians.  As one surgeon has wisely pointed out, physicians are devalued when breathless claims of magical health care delivery promised on TV can't be delivered. 

Most doctors say little about the problems inherent to this advertising trend.  We see no problem with advertisements for the latest drug or procedure on TV or the radio.  That's because doctors are becoming comfortable with their new subliminal marketing role for their new employers and as figureheads to quality.  

I worry that we doctors, overburdened with our new reality of declining pay, seemingly bottomless administrative meetings, data entry, coding requirements, and the million other regulatory changes that are detracting from direct patient care, are becoming comfortable (and worse, complacent) in our new role as talking heads.   We pretend that really there's no problem with "innovations" to care, when deep in our souls we know otherwise.    I get that we're all in survival mode right now, and perhaps this is why I'm concerned.

Recently the Wall Street Journal discussed the business case for using lower level providers in lieu of physicians.  The article discussed the "clash on proposed oversight" that exists when a less costly nurse anesthetist is substituted for a fully-trained anesthesiologist.  These capable nurse anesthetists don't want oversight.  They feel they can do their job just fine, thank you.  After all, they're the one's at the patient's side most of the time as the anesthesiologist flits in an out of several operating rooms instead of sitting in just one.  Is this the best quality for the individual patient to have a person with only two years' experience working independently?  Probably not.  Is it fiscally innovative for both doctors and hospitals to do anesthesia this way?  Absolutely.   Consequently, I wonder if tomorrow's "Top Doctor" will be a much-heralded clipboard-carrying oversight manager of an army of lesser-trained health care providers.

Perhaps these changes are inevitable given the realities of American health care delivery today.  In our rush to get more work done faster than ever, we use physician extenders to see patients first, then make cameo appearances at the patients bedside, more for PR (and billing purposes) than real clinical discovery.  Is this quality?  It seems that in our new world of upcoming Press Ganey patient satisfaction surveys linked to hospital payments, inpatient medicine is evolving to PR.  During the brief patient interactions, doctors had better smile, look good, and wash their face and hands lest the facade of quality fade.  After all, good doctor, big screen TVs, marble foyers, and extensive menu selections at the bedside can only get your hospital so far.  Yet if this trend is allowed to go to its next iteration, will image consultants be the next recertification requirement for physicians?

I wonder….

Sadly, conflicts such as these are only the tip of the iceberg.   For instance, instead of insisting that information technology giants and bureaucrats correct he horrible data entry requirements imposed by today's electronic medical records, many of us have succumbed to hiring costly scribes.  We justify the benefits of these scribes because they allow us to see and touch more patients, while not admitting that we have thrown up our hands to the root problem that created this mess in the first place.  Likewise, when physicians allow their administrators to purchase cheaper, inferior equipment or allow maintenance contracts to lapse in the name of "alignment" of doctors' and hospitals' financial interests, who are we serving?  Or as personnel ranks are slashed from hospital payrolls and patient wards consolidated, are our patients being served best? Can a nurse used to caring for post-surgical patients really manage a cardiac patient as well?

The list goes on and on.  While employee-physicians are losing our autonomy and ability to provide direct one-on-one patient care in all cases, there's a growing need to educate those who don't have a clue about patient care in hopes of improving that care without compromising its quality (if that is possible).  Perhaps more than ever, doctors are needed to fulfill a leadership role in the education of all factions involved in patient care - from administrators to ancillary care providers - about what is needed for their patients and when.  Doctors need to push to dismantle what is broken and organize those systems that work.  Being railroaded by a system that has changed way too soon and way too fast thanks to forces outside our control won't help anyone.

But before we embark on this seemingly impossible task, physicians will first need to ask themselves a very important question, one that strikes to the very core of being a doctor: will we dare to speak up as advocates for our patients and as advocates for each other as doctors, or will we just become a talking head?

Given what's transpired to our health care system so far, I'm not sure I really know the answer.