Breaking: Senior Vice President of Doctoring

It's a job description for "Senior Vice President of Doctoring", being advertised by the American Board of Internal Medicine.  Remarkably, the position requires no patient care whatsoever. 

It's interesting how history repeats.

If you wonder why your health care costs are so high, consider what's happening in our new era of highly-paid Physician Inquisitors.

-Wes

Social Media at Scientific Sessions

More and more physicians are entering the social media space - so much so that even our more classic academic physician colleagues are joining in.  But there can be challenges that arise at scientific sessions when the old way of professional discourse meets the new way of social media.

Robert A Harrington, MD (Chair, Dept of Medicine, Stanford University, CA) and Clyde W. Yancy, MD, MSc (Northwestern Medical Center, IL) discuss these challenges nicely at theheart.org and offer some interesting insights and tips for doctors, both young and old, as they consider entering the social media space.

-Wes

P.S.: Then again, if you're still unsure how Twitter even works, consider this Twitter primer.

Fixing the Wholesale Destruction of the "MD" Designator

Thanks to the unrelenting march of regulatory affairs in medicine, the MD designator (Latin: Medicinae Doctor) has been completely devalued for patients.  No longer does "MD" mean you care for patients.  Instead, "MD" could mean many things: like you work for an insurance company.  Or it might mean you sit in a fancy building lined with marble floors in Washington DC writing legal briefs and laws to torment other doctors.  Or it might mean you kill rats for a living. 

What patients need, and want, is a way to determine who is a "real doctor" that cares for and makes the majority of his income from actually seeing, touching, and treating real live patients.

For this, what is needed, like the Good Housekeeping Seal of Approval, is a "Real Medicine" seal of approval.  It could be appended to every clinical MD's signature.

The seal would mean an MD (or DO) spends over half his or her time, and earns the most of his or her income, directly caring for patients.  It also means that the doctor who uses this designator attached to his MD also is willing to work outside the normal 8am - 5pm business day and even takes call for clinical patient care (available 24-hours/day) on a regular basis annually.

So I have made a "Real Medicine Seal of Approval" for real doctors (as defined above) to use, free of charge:

So patients, the next time you need a "Real Doctor,"  look for the Real Medicine Seal of Approval:*

-Wes

* Non-clinical doctors who use this logo will be summarily humiliated publically by any means real doctors worldwide choose.  Doctors are advised to use this logo with the utmost caution and respect for the real profession of clinical medicine.

This Christmas, Look Up

I sit before the computer screen this morning, wondering "What should I write?"  Yet as I thought about this, I realized I should really write about why I'm thinking about this.

My journey in this space of social media has been a bumpy one, full of ups and downs, ins and outs, obsession and indifference, all rolled up into one.   Yeah, this sums up health care social media now, at least for me.

I began writing here in November 2005, not really knowing what I was doing.  I thought of this space as a marketing space, then an information-to-patient space, then a social space ("gee, so many interesting people here!) and even an "inside view of medicine" space.  In reflection, I really didn't know what the hell this space should be.

But then came 2006 and 2007, my father became gravely ill, and social media was a wonderful outlet for me to reflect on all of the emotions, memories, and experiences that such an event invokes.  I found I loved writing.  To this day, I use this space as a diary of that time in my life, and even found my eyes blurring a bit this morning as I re-read my earlier Christmas reflection of the events that occurred that year.  Blogs, I've found, are really a good space for remembering certain events, certain times.

Later, I'm not sure where I went with social media.  I signed up for Twitter during the Twitter-craze and learned about "tweets" and "hashtags" and all that stuff.  I was amazed at how "up-to-date" I could be with the latest rage, outrage, sound bite and scandal in medicine.  Heck, it my cell phone would come alive!  Medicine is so, *ping* , i-n-t-e-r-e-s-t-i-n-g again!  *ping* *ping*

As if the latest cell phone vibration, chirp, and flash was really what mattered and dull ol' medical care was just, well, glacially stimulating by comparison.  What's not to like, right?  You could be a teacher, provocateur, and health care social media detective!  You, dear doctor, could make a difference!

But in reflection, reality's been very different than that.

I realize now that I am just one voice, one small individual in a the overcrowded mess that is the internet.  Everyone is trying so hard to be heard.  Entire social media companies are developed just to make sure you pay attention to your cell phone - just look at SnapChat, where if you don't immediately attend to your cell phone, the image, message or 10-second video is gone, never to be seen again.  Pay ATTENTION, people!

This is not to say people's voices aren't important.  In fact, many in this space say incredibly powerful things here.  But I am seeing something very interesting on social media now, especially as it pertains to doctors' participation in this space: propaganda.

There are very savvy, well-organized forces on social media now.  Everyone knows this is where the battleground of public opinion rests.  So forces are marshaled, teams assembled to make sure the party line is towed.

I ask you, dear doctor, who much time do you have?  So it is with social media in health care.

But recently in my evolution in this space, I realize I have matured.  I don't come into health care social media starry-eyed any longer.  It has a purpose.  You can meet some remarkably thoughtful and insightful individuals here.  You can make some pretty amazing friends.  And you can get lost.

But I realize there's a purpose, too.  People can tell a single, quiet, story  here - a small, transcendent one, too.

Nowhere was this more visible than in the recent quiet, painful reflections of a young boy suffering with leukemia and the wonderful stories he and his parents shared in their blogs.  These are not people providing propaganda, these were people with a purpose.  These were people who realized what mattered.  These were people who were an inspiration to us all.

As I reflect on all of this at Christmas time, I find it's more important to spend these short, dwindling, yet cherished moments with real life, not one manufactured by the media companies.

Time is precious.  Family is paramount.  And social media is, well, social media.

This holiday season I hope all of us will take time to pull our heads from our cell phones and computer screens.  There some amazing things going on around us, some amazing stories of hope and courage, and things we really need to appreciate.  Most of those things aren't represented by bits and bytes on an iridescent screen, but rather what we take for granted every day, if we dare to look up.

Merry Christmas.

-Wes

Obamacare 2016: Happy Yet?

From Bradley Allen, MD in the opinion section of the Wall Street Journal this morning:

"The forecast shortage of doctors has become a real problem. It started in 2014 when the ACA cut $716 billion from Medicare to accommodate 30 million newly "insured" people through an expansion of Medicaid. More important, the predicted shortage of 42,000 primary-care physicians and that of specialists (such as heart surgeons) was vastly underestimated. It didn't take into account the ACA's effect on doctors retiring early, refusing new patients or going into concierge medicine. These estimates also ignored the millions of immigrants who would be seeking a physician after having been granted legal status.

It is surprising that the doctor shortage was not better anticipated: After all, when Massachusetts mandated health insurance in 2006, the wait to see a physician in some specialties increased considerably, the shortage of primary-care physicians escalated and more doctors stopped accepting new patients. In 2013, the Massachusetts Medical Society noted waiting times from 50 days to 128 days in some areas for new patients to see an internist, for instance.

But doctor shortages are only the beginning.

Even before the ACA cut $716 billion from its budget, Medicare only reimbursed hospitals and doctors for 70%-85% of their costs. Once this cut further reduced reimbursements, and the ACA added stacks of paperwork, more doctors refused to accept Medicare: It just didn't cover expenses.

Then there is the ACA's Medicare (government) board that dictates and rations care, and the board has begun to cut reimbursements. Some physicians now refuse even to take patients over 50 years old, not wanting to be burdened with them when they reach Medicare age. Seniors aren't happy."

Medicaid in 2016 has similar problems. A third of physicians refused to accept new Medicaid patients in 2013, and with Medicaid's expansion and government cuts, the numbers of doctors who don't take Medicaid skyrocketed. The uninsured poor now have insurance, but they can't find a doctor, so essentially the ACA was of no help.

The loss of private practice is another big problem. Because of regulations and other government disincentives to self employment, doctors began working for hospitals in the early 2000s, leaving less than half in private practice by 2013. The ACA rapidly accelerated this trend, so that now very few private practices remain."

Read the whole thing (subscription required, sorry).  Not surprisingly, it's not pretty.

-Wes

Physician Blogger Insights On Social Media

A recent e-mail exchange between myself (WGF) and fellow-physician bloggers John M. Mandrola MD (JMM), Edward J Schloss MD (EJS)  and Ves Dimov MD (VDMD) resulted in some interesting insights about how physicians are using social media tools today.  The following is a lightly edited version of the thread (used with permission). It began with an e-mail from Dr. Mandrola:

JMM: "In prep for our Social Media session at HRS2103. I was just wondering…

Do you guys keep a list of favorites on Twitter? I have lists--but they aren't very effective logistically. I was wondering if I designed a list--say the Mandrola-twenty--of folks I did not want to miss, I might be able to use a column on TweetDeck. Right now, I follow 350 people--and it's unwieldy. But yet I have trouble parsing because I'll look at an acct and say to myself, "this one's pretty good; I don't want to unfollow." Also, I find TweetDeck sometimes intrusive. I use the reg Twitter app and often post with Hootsuite--because it allows me to link to 4 social networks at once--LinkedIn, FB, Twitter etc.

What Twitter app do you all use on Computer? On smartphone?

Do you have thoughts on Facebook (FB)? I see from the WSJ they are making a comeback so to speak. For a while there, I thought they might be dead.

Do you agree that Twitter seems more amendable to professional needs--the sort we all use it for: things like links, communication with colleagues, filtering of important medical news. I tend to use FB, the little that I do, for real life things like family, in-real-life friends and cycling stuff, for instance. I wonder whether this is a correct distinction, as most of the major journals and medical society have a FB presence. And likewise, Twitter has plenty of willy-nilly stuff like Hollywood, Athletes etc. The young people I know use Twitter more like I use FB."

* * *

EJS: "I also use Twitter almost strictly for professional stuff, especially my posts. I follow a few non-professional accounts, but am really choosy in general about followers. For my own posts, I try to picture someone looking down my timeline and trying to decide whether I'm worth their time to follow. If I put a bunch of cr*p up, I figure they'd move on. Twitter is also the predominant source of my online persona, and I'm really careful about maintaining this.

Right now I follow 239 accounts and not all are terribly active. That keeps the stream manageable. I actually get a popup on the laptop for every thing that posts to my timeline. Because I use my laptop for all hospital charting, this means I see A LOT of tweets. That setup is clearly not for everyone, but I've gotten good at just glancing up to see who is posting before I commit to reading. The tweets fill the dead and mindless spaces we get during EHR data entry (which are a lot). At any given time I'll also have 5 or 6 searches running that also generate popups. Right now these include meaningfuluse, St Jude Riata, Barry Meier, EHR, @burbdoc, #HRS2013 among others. All of these also generate popups.

If you want to filter down you list to highlight your most important accounts, you can set up a list in Tweetdeck (and I'm sure in the other clients, as well). That will become a column, and you could turn on alerts for just this stuff if you're not at ADD as me. I have a friends/family list that shows up on my front page so I can quickly see if I missed anything good without having to obsessively scroll back through everything.

On the laptop, I use Tweetdeck. The old version before Twitter bought it is the best, but will stop working in a few days. I've put up the new version, but don't like it as much. The biggest drawback is not having the profile photo on the popups. With the old Tweetdeck, it was easier to see who was posting with just peripheral vision.

On the iPhone and iPad I use Tweetbot. It's really good and worth the few bucks it costs.
I'd tell any cardiologist starting on twitter to follow a bunch of health care journalists, along with you guys. The interactions you get with the journalists are really rewarding, and truly are a two way street.

I really don't see much professional purpose for Facebook for an EP doc. If you were a plastic surgeon or ortho, maybe there would be a role. I'm actually trying not to market directly to patients, given the nature of my practice. Maybe you could pick up some AF that way, but I suspect a lot of nervous people with sinus tach or PACs would clog up your office if you did that.

* * *

VDMD: Hi John and colleagues,

Here are my answers:
re: "Do you guys keep a list of favorites on Twitter?" -- yes, I have 2 lists - 1. list of favorite tweets that I use as bookmark, 2. list of "allergists on Twitter".

re: "Mandrola-twenty--of folks I did not want to miss" - yes, KevinMD has that - top 20 Twitters he doesn't want to miss. I follow few people - less than 100, I think, and only 50 of them tweet regularly.

re: "What Twitter app do you all use on Computer? On smartphone?" - I use TweetDeck on my home PC, HootSuite at work (TweetDeck is blocked), and mobile Twitter on my Android phone. I "favorite"/bookmark the links I want to check later.

re: "Do you have thoughts on Facebook?" - Facebook (FB) is here to stay - until a new network replaces it. You have to use it to stay relevant if you have a blog. In addition, people look at the number of your likes to see how large a following you have as a blogger. FB has limitations and can be annoying but Google Plus is not a replacement yet. FB will evolve for sure, they are a young, aggressive company, and will keep searching for ways to combat "user fatigue".

These are some quick thoughts. Please let me know if you would like me to expand on any of these.

* * *

WGF: "Twitter is for the person with ADHD while blogs are for the obessive compulsive.

Twitter, by its very nature, has a low barrier for entry and can serve as an information "gatherer" initially. I'd encourage people to LURK first. It's easy to use and feeds lots of information of interest quickly to docs. As a "MUST HAVE" for doctors, they should follow the journals they subscribe to: Heart Rhythm, NEJM, Circulation, JACC, etc, as well as major news orgs: WSJ, CNN breaking news, local newsorgs or radios, etc. I also follow Steve Colbert for a laugh once in a while.

Twitter is also VERY useful for collaboration (as we have seen) and for "hunters" of information by using your network. I especially encourage follows of docs of the same subspeciality.

Facebook is for family/personal friends for me. No patients there. I find it's the best way to stay connected with my kids after they're out of the house.

As far as lists are concerned: I think they're a waste of time. I tried it, but since you cant send a targeted message or "tweet" to a list, it's only a way to group accounts.

I use Echofon on my iPhone (like it better than Hootsuite) - easy user interface and free. I use Tweetdeck on my PC and MAC.

I follow 446 people - probably too many - but it's a broad group that includes right and left-wing health care thinkers, IT nerds, politicians, bloggers, and you guys, and Steve Colbert. :)

Perhaps the most amazing use for Twitter (recently) was the immediacy of info provided there during the Boston bombings. It was unbelieveable how quickly updates happened and totally smoked the main news organizations. Imagine if doctors had a similar network at times of crisis! That's why I think it would be VERY cool to push that concept with our audience. Consider, for example, the need to get an EKG interpretation immediately (check my recent Twitter stream to see an example of just that) - lots of folks weighed in with ideas - some good - some bad - but in the end it was vetted pretty well.

Looking forward to this..."

* * *

VDMD: re: Journals on Twitter - I'm not a big fan of these. It's mostly the administrative staff pushing some articles they have picked. RSS feeds for the journals are much better, in my opinion. They save time and include most (all) articles of each issue.

So there you have it.  A sneek peak behiund the social media physician curtain on their take of current software, apps, and uses they find for social media in health care today.

For those attending the 2013 Heart Rhythm Society Scientific Sessions in Denver, CO next week, Drs. Schloss, Mandrola and myself (as well as Robert Coffield, Esq. of the Health Care Law Blog fame) will be speaking at the Rhythm Theatre at 3:15pm on 10 May 2013 on Physicians in Social Media.

Hope to see you there!

-Wes

PS: For doctors considering the leap to social media, here's a basic Twitter Primer.

Story Lines

Doctors are trying to rationalize our current story line:  the loss of autonomy and pay cuts are a necessary evil for the greater good.   We're taking one for the excess-health care cost team.  We're willing to take this personal sacrifice for our fellow man and woman.   It is the noble thing to do.   It will be good for America's healthcare system if we do our part, work harder to improve inefficiencies.   There are even doctors in leadership positions who reflect in their three-year "honest assessment" of our current health care law that higher taxes and near-30% rise in insurance premiums are a necessary evil for extending insurance to 30 million more Americans.  "I am glad to do my part," they comment.  How could anyone argue with such beneficence?

Doctors who sacrifice and give tirelessly to their patients are our storybook ideal; what every American loves to envision.  But we should also acknowledge that there is another story line: that many physicians are deeply concerned with the realities of what's taking place in health care lately.

Doctors are witnessing health care costs greatly outstripping inflation, especially since our new health care law was put in place.

• People aren't using their coverage because they fear the cost of their much higher deductibles.


• Insurance companies have created their own convenient loophole to avoid the consequences of their own new law.


• With the initial deployment of the law only eight short months away, the promised insurance "exchanges" have yet to be fully deployed nor explained to the public.


• The small business health care program has been delayed.


• People with pre-existing conditions stopped being covered in February, 2013  because the government agency responsible for this portion of the law ran out of funds.
 
• More concerning for those who are budget-minded, as of today, not a single member of the the law's Independent Payment Advisory Board, the 15-member panel that is supposed to recommend cuts to the Medicare program beginning 1 January 2014 to maintain its solvency, has been selected, much less approved.

Meanwhile, our nation's leadership is enjoying the black-tie White House Correspondent's Dinner in appreciation of those who serve as our Great Distributor of Washington story lines, aptly named "Nerd Prom."

Perhaps I shouldn't be so harsh.  After all, it was just in the spirit of poking fun.  I should also accept that since American Medicine is our largest employer and nation's largest business, American Medicine will forever be tainted by politics.  But as we have seen time and time again, it is common in politics to sell Story A when, in fact, the real motivation for something is Story B. When political initiatives are deployed that are uncomfortable there has to be something that people will emphatically rally behind.  How else could we send our children off to war, for instance?

And so it has been with health care.

Story A was that this whole health care story line was about the uninsured.

Yet people were never waving flags and demonstrating in the streets for wellness initiatives with free mammograms, physicals and flu shots.  People were not looking for more and more middle layers of bureaucracy, red tape, and management.   People are not demanding that first-year medical residents see patients for only 12% of their day because of training rules. People were not looking for their doctor to become a nursing supervisor, medical coder or typist.    People were not picketing the Supreme Court for double-digit insurance company stock market returns so they could enjoy higher premiums and deductibles.    People were not hoping for $100-million golden parachutes for pharmaceutical executives. People were not lobbying for bigger hospitals competing with other hospitals for wealthy patients, each filled with outdated computers, waterfalls, big screen TVs and kiosks in "anticipation" of what was to come.   And people were REALLY not expecting the government to burn through their cash so fast that they'd be asking for more money so soon.  

Yet here we all are, realizing our new, disturbing story line.

Doctors, patients, ...

... and Nerd Prom.

-Wes

The Physician Payment Reform I'd Like to See

In case you missed it, the "National Commission on Physician Payment Reform" issued their glossy, industry-produced white paper on 4 March 2013 containing twelve recommendations to provide a five-year "blueprint" for transitioning physician payment methods to a "blended payment system that will yield better results for both public and private payers, as well as patients."

Rules Are Only for the Little People

I was alerted to the presence of this report after an "Online First" article entitled "Phasing Out Fee-for-Service Payment" by Steven A. Schroeder, M.D., and William Frist, M.D. for the so-called National Commission on Physician Payment Reform was published March 27, 2013 in the New England Journal of Medicine.  (So much for Journal's Ingelfinger Rule that prevents the publication of works previously published elsewhere.  It is interesting that Dr. Schroeder, the lead author of this New England Journal of Medicine article, failed to disclose that he currently serves as an editor for the New England Journal of Medicine.  No doubt he "exempted" his own piece from the Ingelfinger Rule because this 5-year, 12-step program [pun intended] was felt to be "public-health information that needs to be brought to the public's or profession's attention without delay.")

But the concerns about this article and its authors' backgrounds go much further.  We should realize that this 14-member "National Commission on Physician Payment Reform" was supposedly created out of thin air by an obscure general internal medicine group called the Society of General Internal Medicine (SGIM) comprised of approximately 3000 academic internists. We are led to believe the SGIM doctors chose their 14-member National Commission with physician payment reform solely as their guiding light.  And why not?  What physician wouldn't want to enjoy not being paid for the work they do?

Whose Interests Are Served By Physician Payment Reform?

So let's look at a few of the members of their "National Commission."

First and foremost is the "honorary" commissioner and former US Senator, William H. Frist, MD.  Doctors should ignore Dr. Frist's deep, deep ties to Hospital Corporation of America (HCA), the largest operator of health care facilities in the world.  After all, he only held a few blind trusts that his 2005 financial disclosure form valued between $15 million and $45 million.  And we should ignore the fact that he sold his interests in those trusts just one month before HCA stock price precipitously fell in 2005 and was subject to a SEC investigation.  To be fair, no wrongdoing was ever found.  But that hasn't stopped our "own" Dr. Frist from serving as partner and Chairman of the Board for Cressey and Company, LP, a private investment firm based in Chicago and Nashville "focused on the health care industry."

I'm seeing this effort for physician payment reform as being all about patients, aren't you?

But there's more.

Another member of the 14-member commission is none other than Dr. Troyen A. Brennan.  Dr. Brennan is Executive Vice President and Chief Medical Officer of CVS Caremark, the nation’s largest pharmacy health care company.  In this role, he oversees the company’s MinuteClinic, Accordant Health Care, clinical and medical affairs, and health care strategy.  CVS was so happy about his appointment to this National Commission that it even sent out a press release!  While I have no idea about Dr. Brennan's salary with CVS, I'd bet my medical degree that his salary is higher than that of most US physicians.  One only has to look at the relative salary and benefits that CVS Caremark's Chief Executive Officer earns and you see why I am confident about Dr. Brennan's relative salary.  I mean, who wouldn't want that private jet?  No doubt America's doctors will feel nothing but goodwill and fuzzy feelings about helping to fund the nice retirement package CVS routinely gives to its chairmen as a result of Dr. Brennan's efforts on the Commission.

Another member of the Commission is none other than Dr. Lisa Latts.  Dr. Latts also serves as the Vice President of Public Health Policy for WellPoint, Inc, the largest managed health care, for-profit company in the Blue Cross and Blue Shield Association.  They insure nearly 11% of the US population.  But one could argue, cheap doctors should mean cheaper insurance, right?   I don't think so.  After all, it's not easy to keep paying for retirement packages for your retiring CEO's that cost $20.6 million.  But no worries.  Wellpoint's new CEO's compensation will include just an annual base salary of only $1.25 million with eligibility clauses for an incentive bonus of up to 300% of that amount, not to mention that he is also getting equity-incentive grants for 2013 with an $8 million target value, restricted shares with a grant date fair value of $1.5 million as "an inducement to joining" the company and a "make whole" payment currently estimated at almost $3.6 million for compensation he'll forfeit in switching jobs.   Poor guy. 

So physician payment problems really ARE a major cause of those high health care prices today, doctors, don't you see? 

So let's hear it for the Society of General Internal Medicine and the New England Journal of Medicine for providing their white paper to America on how to implement physician payment reform!  I'm so glad to see that all of the members of the National Commision of Physician Payment Reform were willing to do their part to sacrifice part of their hard-earned salary on behalf of our national health care cost crisis, too, aren't you?

Oh, wait...

A Solution?

Look, here's my idea: stop redirecting the truth about what's really eating up the cost of health care.  It's time we address the excessive costs of all of these excessive middle management healthcare leeches.  If you want physician payment reform, stop creating ridiculous fronts called "National Commissions" of doctors that act has our modern-day Physician Inquisitors.

Instead, pay us what we're each worth (trust me, it's not that hard to find out and it sure as heck doesn't take a year of meetings held at expensive hotels that results in just one white paper with 14 co-authors that carry innumerable conflicts of interest into the discussion.)  Pay us by the hour at our fair rate. And pay us for everything we do for our patients: every minute we type at the computer, answer a health-related e-mail, sit on a phone, sit at their bedside, remove an brain tumor, teach a medical student, look up labs, grow our practice, explain a procedure, or care for your mother after hours, too.  Then pay us double for every minute we take call after hours. 

Dissolve the RUC.  Flush the SGR formula that is never followed anyway and wastes too much time and money each year.  Rid us of stupid proprietary CPT procedure codes that must be linked (properly, mind you) to a ridiculous list of ICD-10 procedure codes so we can be paid.

Keep it simple, stupid. It's not that hard to do.

It's only hard to make changes to our current physician payment system when everyone that wants "physician payment reform" also wants to make sure they get their part of our already dwindling pay.

-Wes

Health Care Reform Three Years Later - An Insider's Assessment

It’s been three years since the Patient Protection and Accountable Care Act (PPACA) became law.  There have been widely divergent opinions published by journalists on the impact of the law for Americans: from a rose-colored account from the New York Times, to a not-so-peachy account published at Reason.com.  Few doctors have ventured into this discussion.

The Need for Health Care Cost Reform

I should start by saying that I am biased.  I grew up in the days of an idealized image of the physician –where doctors were still held in relatively high esteem by our society.  I had to think this way for I was joining the system.  Back then, like now for the younger doctors, medicine was a still considered a calling, not just a job.  The unspoken code was that it was the patient above all else: screw the establishment, screw hospital loyalty, screw the drug company – if they couldn’t help your patient, you’d take them elsewhere.  So hospitals courted doctors.  Drug companies courted doctors.  Insurance companies courted doctors.  But the truth be known, doctors weren’t the apple in everyone’s eye, patients were.  And doctors enjoyed the limelight – so much so, that a few in our ranks succumbed to the greed, too.  After all, like now, patients paid everyone’s bills.

But health care costs for patients became increasingly hard to cloak.  Insurance companies, in the business of making the expensive seem cheap, needed an exit strategy.  The new hospital buildings, multi-million dollar corporate earnings, drug innovations costing tens of thousands of dollars, and the aging population that was growing too quickly weighed heavily on the entire system’s sustainability.  Something had to be done.

The First Steps

So without belaboring the obvious: we created Health Care Reform as we know it.  Health Care Reform wasn’t just the PPACA, though, but rather a carefully orchestrated series of legislative achievements that laid the groundwork for payers to offload the costs of health care on to the only other entity that could pay these high costs: our government. 

The process (as we have seen) first involved an expensive, multibillion computer roll-out that was part of the American Recovery and Reinvestment Act.  These computer systems promised “cost savings” by “improving efficiencies” of care.  Information systems were sold as our salvation from cost excesses like $15 Tylenols.  Corporate America (and their political lobbyists) bought it and so did the government.  To keep doctors quiet, doctors were promised $44,000 a piece to install computers in their offices.  Little did they realize their payments from government to private offices were to be slashed forty percent in the same legislation and computers would be required to bill the government.  So, the $44,000 actually went to doctors’ new employers.  Doctors were thanked for their services with a new $700-dollar iPad and a treasure trove of Meaningful use regulatory benchmarks that slowed patient care rather than sped it.

Our New "Reform"

Next came the PPACA, our signature health care law.  The law was spun as a way to save health care costs while adding 34 million more uninsured patients to the system.  Pulling heart strings was much more palatable politically than the much needed reality of fiscal restraint.

But we should admit that our health care system has flaws when it comes to the uninsured.  To prove the health care reform’s benefits, the easy-to-sell low-risk coverage for young adults was given as a loss leader to the new health care law's Health Care Happy Meal.  This benefit was universally welcomed by all because it was needed.  Yeah, it cost a bit more to provide this insurance, but in the scheme of things, the cost of this health care was relatively cheap to provide.  It was (and remains) a win-win. But our attachment to this part of the law may be a clever way to buy us off.

Preventative services, provided for free, were also included in the PPACA.  But this is a problem because nothing is free in health care.  Proving preventative services for free perpetuates an expectation that everything will be free in health care and have no consequences.  After all, preventative services take time and time for care providers overloaded with more and more patients entering the system is our most precious commodity.   Others argue that catching problems early will save money but the proof that this makes a difference to health care costs is really just a delightful narrative.  In fact, even the annual physical’s benefit to our health care has been called into question – especially when we recognize its value to the system compared to the benefits derived for the patient.

And people have argued that the PPACA has already reduced costs.  While I am not an economist, I really can’t speak to this.  I am just a worker and observer.  These days I see four or five administrators where, just a few short years ago, we had one.  I see fewer nurses with less experience caring for more patients now.  I see bigger buildings but fewer patient beds as wards are consolidated.  I see hospital-system employers with hiring freezes that are laying off workers in anticipation of upcoming costs imposed by the new law. 

How's the Quality?

And then there’s the overall quality of care.  I can’t say I really see a difference from five years ago.  Sure, I see things being done faster by fewer.  I see computers moving information around like never before.  But is the care to our patients really better?  I see reams and reams of documentation made not for the patient’s benefit, but for bureaucrats and bean-counters more interested in our use of computers than our patients.  I see better communication between doctors improved with the EMR, but has this translated to better care delivery? Not always. And when it comes to quality, the New York Times editors cited the example that health care in America is cheaper because Medicare patients have fewer re-admissions since the PPACA was enacted.  But they also failed to note that hospitals receive financial incentives to reward this behavior.  They claim this is “better coordination of care” while ignoring the fact that patients are labeled with scarlet A’s and shunted to health care facilities that don’t "count" as re-admissions.  They also failed to mention the effects of the higher costs that patients see from their higher insurance premiums.  Cha-ching.

What's Ahead

In the end, health care reform is still about the money for the system rather than the real needs of most patients.  We are cutting costs to corporations by inflating our Health Care Hindenburg with cheaper hydrogen.  We have spun a narrative of providing more care for more people with less cost while ignoring the shear forces and telltale weather patterns of cost concerns that blow our way and threaten our ship's buoyancy.  

Some doctors have leapt from the ship.  More will certainly follow.  Others remain silent yet quietly discontented; they do their job as just job now, marking time with little incentive for doing more.  They have become the common workforce drone  increasingly asked to do more by those who go home at 5pm and have no liability for the care they provide.  More risk with less reward has been the mantra for care providers in health care reform.  The stress is growing for everyone.   Unfortunately, the doctors that leave will soon be back-filled by well-meaning young physicians with fewer hands-on hours of training that have been sculpted by an educational system dependent on tenured med-school professors complicit with our new progressive mindset. 

Health care reform is here, alright, doing what it's always done: spinning reform without real reform for three years (so far) and counting.

-Wes

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.

-Wes

My Three Minutes of Fame

Dr. Seth Bilazarian of Haverhill, MA (a cool, rare-breed, private practice cardiologist) and I were interviewed by veteran health care reporter Shelley Wood from TheHeart.org on the use of social media for cardiologists.  (To their credit, Seth and Shelley are much better looking.)

Hopefully this will inspire other physicians to consider social media, irrespective of their specialty.

-Wes

When the Government Puts Prices on Patients' Heads

Recently, another predictable Trojan-horse provision of the Patient Protection and Affordable Care Act appeared that promises to pit doctor versus patient by literally placing a price on patients' heads:

Twenty-thousand physicians in four Midwest states received a glimpse into their financial future last month. Landing in their e-mail inboxes were links to reports from Medicare showing the amount their patients cost on average as well as the quality of the care they provided. The reports also showed how Medicare spending on each doctor’s patients compared with their peers in Kansas, Iowa, Missouri and Nebraska.

The “resource use” reports, which Medicare plans to eventually provide to doctors nationwide, are one of the most visible phases of the government’s effort to figure out how to enact a complex, delicate and little-noticed provision of the 2010 health-care law: paying more to doctors who provide quality care at lower cost to Medicare, and reducing payments to physicians who run up Medicare’s costs without better results.

Of course, no real assessment of physician "quality" is taking place with this scheme nor any outcome assessment.  "Quality" as it is defined in this scheme consists of only an electronic review of patient costs, doctor billing codes, and the patient characteristics of  age, gender, Medicaid eligibility, and medical conditions.   No government entity will actually observe and assess any physician in practice to determine their "value" to the system.  Instead, patients electronically determined to be "low-cost" will be heralded as favored electronic "value" benchmarks.   Even the health care law's original physician cheerleader, former Administrator of the Center for Medicare and Medicaid Services Donald Berwick, MD, was taken back:

“We do have to be cautious in this case. It could lead to levels of gaming and misunderstanding and incorrect signals to physicians that might not be best for everyone.”

Ya think?

-Wes

Doctors Passing Fake Sick Notes Get Reprimand

From the Wisconsin Journal Sentinel:

The Medical Examining Board reached stipulations with seven doctors Wednesday in which they were formally reprimanded for failing to make adequate records on the patients they saw during the protests. The stipulations also required the doctors to pay $225 to $350 each for costs and take four hours of continuing education courses within 90 days on medical record keeping.

The reprimands will stay on the doctors' records permanently and will show up in a national database of physicians, Murray said. The doctors' reprimands would be a factor in determining discipline in future cases if any of the doctors come before the board again, he said.

A mere hand slap.

Pity.

-Wes

h/t: Instapundit

A Few Aphorisms to Remember

A week ago I had the pleasure of attending a party to commemorate the remarkable achievements and character of a cardiothoracic surgeon who will put down his scalpel at the end of this month. Anyone who has worked with or been cared for by this man can attest to his fortitude and commitment to both the art of medicine and his patients. He is the kind of guy who would walk in to a patient's room after open heart surgery, glance down at them with a twinkle in his eye and a bit of a southern North-Carolinian drawl, and ask, "How's the suffering?"

While this question startled those who had never experienced his candor before, it always served to remind his staff and colleagues of his patient's post-operative reality and his sensitivity to it. Invariably, his post-op visit would be concluded with "Ya know, you're gonna be alright."

And ya know, more often than not, he was usually right.

Needless to say, he made quite an impression with people over the years. No one worked harder or worked crazier hours: transplant services, heart attacks, shootings and motor vehicle accidents have a way of doing that to you.

But he was always a man who lead by example, never from above.

As a testament to his leadership, friends, colleagues, co-workers, former trainees and patients all came to thank him. One of his perfusionists brought and amazing hand-carved centerpiece (see here) in honor of the man. We all wanted to thank him but usually noted that our words suddenly seemed insufficient. Words at such times usually are.

But later in the evening there came a point where this man wanted to say a few words of thanks himself to those with whom he had had the pleasure to work with over the many, many years. As he said, "There are two ways to talk about things like this, one a somber, melancholic reflection and what this all means, or as I'd like to prefer right now, a reflective, more lighthearted way. I think I'll stick with the more lighthearted way tonight."

He reached in to his pocket and pulled a small green notecard, but dusk had given way to dark at the outdoor affair and reading was nearly impossible. Several people sprang forth with a Tiki-torch and and a flashlight app to assist his vision because everyone wanted to hear what he might say.

He began:

"Thank you all for coming. It is wonderful to see so many colleagues, nurses, trainees, and former patients here. My wife will soon be happy knowing that hers will be the only woman's voice that I'll be talking to in the middle of the night from now on."

When the laughter subsided, he continued:

"I'd like to share a few aphorisms with you. For those unfamiliar with what an aphorism is, it's a little saying that usually has a meaning that goes beyond the saying itself. They're what has guided me and things that I want to leave with you.

First, medicine is a contact sport. It's one thing to get in there and play the game, but more often than not you're going to get knocked down. It's how people get back up and overcome their disappointments that will determine their success.

Second, medicine is a full-time job. Medicine knows no day and no night. Time in medicine is not measured in minutes or hours, it is measured in years.

Third, have courage. Try new things. Stretch yourself. There will come times when you have to do things that no one else will. Have courage.

Fourth, when you call me in the middle of the night remember, keep the 'crit over 30 and I'll sign just about anything you want in the morning.

Also, I've found a little saying that works pretty well in the ICU when I sign out to my team and colleagues at 10PM: "Go ahead, take the rest of the night off."

Finally, if you remember nothing else, remember this:

You're in charge."

Thank you, John, for everything.

Oh, and one more thing:

Go Duke!

:)

-Wes

How the Housing Market Is Affecting Doctors

Six years ago:

Low-interest loans, virginal credit records, an MD degree.

Need a home, doctor? No problem! How about one of these super-duper snazzy townhomes in a nice neighborhood. Just sign here!

Now:

A marriage, a young family. Perhaps time to buy a new place?

Oops. They can't. The townhome next to them is priced for a short sale at 60% of their purchase price and hasn't had an offer in a year.

Can you say, "under water?"

"Walk away from the mortgage!" many say. "It's not worth it!"

Until they realize they won't have any credit for about, oh, nine years.

Or maybe they could try one of these options.

It's not just about higher medical education expenses and lower salaries for our younger doctors. Like many others in today's economy, it's about the housing crisis, too.

-Wes

Cornered

Every day, doctors do risky things for their patients, often because they have no other options. Today is such a day for me.

I don't know how it will go, and because of privacy laws I really can't tell you about the case, I'm sorry. (Nor will you get an epilogue, that's not the point of this post). But let's just say that any normal person would consider the case I'm about to perform very high risk because of the patient's condition. Even though you tell people they could die and take care to mention that fact time and time again, you wonder if they really can comprehend the significance of what you're saying - after all, there is a fine line between being reassuring in a time of crisis and telling it like it is.

I've spoken with the family and kids at length, I've answered their questions, I've even asked that only one of them serve as a spokesperson for the entourage of family members who have come to the hospital and flown here for this day. And yes I've documented, documented, documented. I can only hope everyone knows how serious this is. Certainly the patient does.

But I also realize I assume a tremendous risk professionally doing this procedure. I've done what I feel is everything short of today's procedure in the hopes it could be avoided, to no avail. I've amassed an army of individuals to help. Monitors and medications will be assembled to counter every contingency, but there will still be the possibility that something will arise I have not considered. Most of us would rather be doing something else, but all realize there's few options than to proceed.

I know I'm not unique. This happens all the time in America in hospitals big and small: where doctors are pulled into circumstances like this as reluctant dragons, with a patients who trust in them to such an extent they'd have no one else do it but you.

Scary, really.

I hope and pray that all goes well. But as hard as this is, I wished like hell I didn't have to worry about the 800-pound gorilla who'll be in standing in the corner watching me today.

And trust me: every doctor in America knows who that is.

-Wes

Doctor-Bashing Headlines

While I know it grabs the eye, it really didn't matter what the article was about:

Click image to enlarge

... the headline says it all: doctors are the problem, not the system, right?

-Wes

What's Next, Carding Doctors?

It was en international doctors' meeting and had been a long morning of running between sessions. The brief break before the late-morning sessions was underway and doctors were streaming into the exhibit hall. The Merck booth was spacious and had a pleasant gentleman wearing a conventional hall uniform with white gloves behind a counter with two ornate large coffee pots and small cups behind the counter. The line of conference-goers stretched some distance, as the bleary-eyed and shoulder-bag-laden attendees waited for their cup of "joe."

And there it was, a sign, prominently displayed at the corner of the counter:

While I never saw the poor guy behind the counter card a doctor who approached his counter, I wondered how this law for physicians from the great states of California, Massachusetts, Minnesota, or Vermont was to be enforced exactly.

Oh yeah, the honor system.

Who knew?

-Wes

Should Doctors Join Social Media?

The pros and cons of social media for physicians are nicely reviewed by a number of prominent medbloggers (including yours truly) by Bonnie Ellerin in her recent white paper (pdf).

-Wes

h/t: @hjlucks on Twitter via Smartblog On Social Media.

The Townhall

They can from far and wide, this evening after. Cordial pleasantries were eagerly extended, like soldiers in a foxhole, I knew I was with friends. These were faces I'd seen a thousand times before over the years, but in very different circumstances. No young faces, mind you - they never bothered to check their e-mail: too busy, they'd say.

"Wes, damn good to see you! Thank for your help with Ms. Smith. Don't you love it when medicine comes together to save a life like that? I mean, damn, that's why we all do this right?" he said jovially.

"Wes, have you met Dr. Fatchamata Cheesedip?"

The young face approached bearing a platter of some sort: "What can I get you?"

Beautiful venue. People on their best behavior.

Or not.

Herding cattle, in the nicest of ways, came to mind.

For there they were, a sea of faces sitting at the table facing down shadowed by the faint glow of a cellphone sending texts or Twittering or emailing: "Take out dog. Get to ur homework, k?" "Oh, sure, 24.9% pay cut 1 January, WTF?" "After elections! Time to f-in' quit."

The gavel descending to bring the meeting to order.

"Aye," the back table mumbled, anticipating the first order of business as people chuckled. With a collective average MCAT score of 13, they knew the protocol: review the minutes, vote on bylaws, give some awards, appoint the head Puh-bah. Thank the organizers. Take one or two ideas from the floor. Thanks for coming.

Of course the room grew quiet when health care reform was mentioned. "We're uniquely positioned." "New era." "With our innovative EMR..."

Nothing new.

Like eerily awaiting the thinning of the herd.

"Think they'll have those yummy sandwiches next year?"

-Wes