The Tradeoffs of Obamacare

A few from above, from Saurabh Jha, MD (Twitter: @roguerad):

The biggest trade-off is between a constitutional republic, with all its checks and balances, and a centrally-planned healthcare.  The two are fundamentally incompatible.  The future will yield many more convulsions.  Many more Halbigs.

The optimism surrounding the ACA, summed up by President Obama's promise "if you like your doctor, you can keep your doctor," gave many the impression, myself included, that healthcare reform can be Pareto optimal; a win-win for all.

Regrettably, trade-offs are a fact of life.  Which means there are winners and there are losers.  This is not unusual.  But by not acknowledging the trade-offs we have created resentment in the losers, and widened the partisan chasm.

Read the whole thing.

-Wes

Rebuttal: The NEJM's Justification of Medical "Mystery Shoppers"

The proposed examination of access to primary care according to insurance status in nine representative states was largely derailed by physicians and other critics concerned about the potential for government invasion of physicians' privacy. They argued that less controversial survey methods would suffice or that additional studies of the well-known primary care shortage are a waste of public resources. I think these arguments are misguided.

- Karin Rhodes, MD NEJM, July 27, 2011 (10.1056/NEJMp1107779)

Fair enough, Dr. Rhodes. You certainly are entitled to your opinion.

But before I take on my rebuttal to your piece, let's both be clear on a separate issue: what is most misguided about your perspective piece in the New England Journal of Medicine was that comments were not allowed. If they were, the "physicians and other critics" could explain their aversion to these tactics.

So, let me be the first to state my position.

Covert, subversive tactics in research in an attempt to avoid bias carries the risk of introducing additional forms of bias. For instance, when a phone call is made to a doctor's office for a new patient appointment and the problem sufficienctly urgent that other real live patients are rescheduled to accommodate a mystery patient's needs, how, exactly are the affects and costs to the established patients compensated? How will those data be "counted" in your statistics when your one new patient's access if offset by the loss of two follow-up patient's access. Who will explain to those affected by these tactics why they were rescheduled? Will you?

You claim that "the study was intended to generate valid national estimates of primary care capacity before the anticipated expansion of private and public insurance to as many as 38 million currently uninsured Americans."

First, recall the problems with that "38 million" number. Wasn't that number "47 million uninsured not too long ago?" Right off the bat, we see how numbers can be spun in policy circles, Dr. Rhodes. Which leads to the most important question that remains unanswered regarding a study that uses these covert tactics: how will the data be used? Will the data (which most certainly are going to "discover" problems with access) be used to justify mandates to shorten office visits from 7.5 minutes per patient to 7 minutes per patient to improve access? Or might doctors be directed to see more patients that are not insured? Seriously. What policy directives can we expect from these data?

You justify the use of this deceptive practice saying "the use of masking and concealed allocation, widely endorsed for randomized, double-blind clinical trials, lends confidence to the interpretation of results." And yet in the circumstance of randomized, controlled trials, patients must sign informed consent to take part in such a study before they are randomized. Hardly a "mystery" process. Should patients and doctors of prospective clinics not be afforded the same respect who might be asked to take part in your study?

You also seem to feel that a sampling 18% of states (9 of 50) is adequate to formulate conclusions. I find this concerning. National policy development should have representation from all states affected, not a minority. To suggest that the concerns of states with relatively high congestion mirror those with more rural populations is certain to bias policy decisions going forward and, more likely than not, exclude the perspective of less populous states.

So these are just a few of my concerns. There are others. Please note that none of them even begin to address the privacy issues raised by "others." But given the flaws I've outlined, paired with the obvious shortage of physicians that we will encounter in 2014 when the full brunt of the Patient Protection and Affordable Care Act kicks in (not to mention our limited research funding these days), this study certainly does appear to squander our limited public resources. Must we spend our resources to become Masters of the Obvious?

No doubt others would like to share their views, so unlike the New England Journal of Medicine, I'll leave my comments open.

-Wes

New York's Dress Code Proposal for Doctors Doesn't Go Far Enough

From AMA Medical News:

New York physicians may have to take off their neckties, jewelry, wristwatches and long-sleeved white coats when caring for patients if a bill under consideration in the state legislature becomes law.

The bill, proposed in April in the state Senate, calls for a "hygienic dress code council" within the New York Health Dept. to consider advancing a ban on neckties and requiring physicians and other health professionals to adopt a "bare below the elbow" dress code in an effort to slash hospital-acquired infections.

Even though there's no data that this does anything to reduce hospital acquired infections.

But that doesn't matter.

So why stop there? I say, doctors should do the ultimate for their patients: the Full Monty.

-Wes

Numbers

Numbers. Lots and lots of numbers.

Increasingly, we are seeing the way numbers are used to direct patient care:

• Need a defibrillator? Check their ejection fraction.
• Have diabetes? What's their glucose level?
• Need a cholesterol-lowering medication? What's their LDL?
• Are you a good doctor? What's your patient satisfaction score?
• Are you using the computer in a meaningful way? Please, count the numbers.

Even some insurers have recently begun promoting "health in numbers" on big, splashy, television advertisements and on their self-promotional websites.

As if everything in medicine is linear, predictable, mathematical.

I recently saw a patient urgently because his ejection fraction number had declined and the patient who had a pacemaker implanted about 2 years ago felt fatigued. Sure enough, his number had declined from 0.56 on an echocardiogram to 0.40 on a nuclear scan. The referring doctor was concerned and thought he might benefit from upgrading his pacemaker to a more sophisticated biventricular pacemaker. Certainly, this might be a very appropriate referral. But the patient had a little caveat mentioned on the nuclear scan next to the 0.40 number and it said this: "This value might be an underestimation." Why? Because the patient was not in sinus rhythm at the time the study was performed. In fact, he's never been in sinus rhythm for years.

But the comment was not a number. Therefore, it never registered on a computer that tracks these numbers, nor entered the referring doctor's mind. Comments are like that - poorly quantifiable but remarkably important - numbers are not. Numbers are linear, predictable, unflinching, and some might say, wholey accurate.

Except when they're not.

All of us have seen numbers following blood tests that are "lab-omas" - lab values that make no sense when viewed with other numbers next to them and when related to clinical circumstances. Those labs are repeated and, more often than not, return very different than before. Or consider the automatic blood pressure cuffs and telemetry monitor that often give faulty "numbers."

So what gives? Shouldn't numbers be infallible and uniformly reliable?

Of course not.

Numbers are one piece of the grand puzzle called medicine. Numbers certainly can help us, spotting trends and quantifying, but they almost never conclude. For instance, a very high white count might be so for very different reasons: like pneumonia, leukemia, or steroids. Each of these medical problems demands a very different clinical approach irrespective of what might be the same elevated number.

But the message is everywhere. At home. In the hospitals. On Capitol Hill. Numbers are king. We're all about numbers. Especially in advertisements to doctors and patients via TV ads, drug reps, and hospital administrators. Numbers for cholesterol, one's prostate, ejection fraction, HbA1C, quality scores, numbers of procedures, duration of erections, and now, insurance 78,000 employees managing 70 million people. Numbers, you see, will help us save billions of other numbers, we are told.

Too bad no one talks about the numbers spent on the collection of all of these numbers that are used to justify the other numbers in health care.

That, you see, would be a VERY big number.

-Wes

The Importance of Our Health Care Myers-Briggs

With all the talk about special interest groups in health care reform, there is another force afoot that is much more influential: psychologic interest groups. Here I take a rough stab of characterizing those I've noticed in our ongoing health care debate:

The Libertarians (L)- "Let the Market Sort It Out"

Characteristics of this psychologic construct include:

• Free market sunny optimism
• Faith in human nature, against all odds
• Competition will assure price controls
• Complete denial of the human frailty and greed
• Cynical about humanitarianism

Fairy Tale Believers (F)- "I'm not comfortable with anyone going without anything"

• Insist on fear-based appeasement: if you don't give them what they want, the peasants will come knocking at your door.
• Secret elitist belief that I'll get what I want anyway
• Infantile inflexibility to alternatives from their beliefs
• I'll-hold-my-breath-until-you-cry-uncle form of debate
• Discomfort with their own aggression or shadow side
• Politically active

Distrustful (D) - "No stick is big enough"

Characteristics of this psychologic construct include:

• Aggrieved, victim mentality
• Some history of real inequities or being disenfranchised which colors all perceptions
• Safety first - no quality control will ever be enough
• Doctors are greedy and will work best a pernicious, punitive environment
• Group oversight is superior to individual oversight
• There can never be enough bean-counters
• Politically active - often protest marchers

Alfred E. Neumann (A) - "What Me Worry?"

This group never has health care issues until they do. Characteristics include:

• Immature, emotionally unmodulated
• Extreme anxiety/neediness in the hospital but complete denial when they hit the exit door.
• Discussions of doctor availability are of no relevance until they are pressing the nurse call button
• Politically inactive, rarely vote

So, which are you?

To date, many doctors have lived in our own fairy land when it comes to health care policy. We have preferred to insist that human beings will think in a fair-minded, scientific, data-based manner. Who would have known that we should have had a psychology or marketing degree? Perhaps this is why the debate has become so divisive.

Unless we address these powerful, subliminal psychologies head-on, our influence on the larger social policies influencing health care delivery in the future will remain limited.

-Wes

Clash of the Titans

After Northwestern Memorial Healthcare closed its acquisition of Lake Forest Hospital in the posh northern suburbs of Chicago this past Friday, they have officially leapfrogged the geographic stronghold formerly held exclusively by NorthShore University HealthSystem (disclaimer: my employer, so I tread lightly). What this means for the health care market in the north Chicago suburbs remains to be seen, but there is no denying that competition for patients between the large hospital systems will be keen.

After all, someone has to pay the bills.

So what will the competition look like?

First, patients like all things bright and shiny. So look for plenty of new construction. Nothing like a tasteful, brass-laden lobby with plenty of open air space and windows to bring in their distinguished "consumers."

Second, plenty of advertising. Get the word out: there's a new kid in town. And their competition won't like this so they'll shout, too. As a result, money will flow freely to marketing and ad agencies. Look for these folks to profit handsomely from this deal.

Third, court the doctors. This is likely to be their most challenging endeavor. No doctor wants to travel 45 minutes (one way, in good traffic) from the Chicago Loop (site of the Mother Ship) to the posh suburbs and back again. What a waste of time. Still, specialists will be "encouraged" to make the road trip to provide "unprecedented" service to the suburbs. At first doctors who reside in the area will be tasked with supporting the expansion, but as the need for a backup cavalry of physicians to assist with call schedules takes hold, specialists will feel the strain. As a result, more high-priced doctors will need to be recruited. While this will be a snap due to the hospital's location, those specialists will pine for the conferences and academic niceties of the Mother Ship. Geographic realities will once again come in to play.

Local private doctors eager to sell their practices like new buildings with prestigious names, too. But some might not be as eager to work for a large corporate structure after having the independence of their own practice. Look for plenty of practices to demand a hefty price tag to assure a golden parachute to their more resistant senior practitioners as they consolidate with the Mother Ship. Look for the Mother Ship to be choosey as they try to cut costs.

Fourth, insurers ever-so-happy when hospitals compete for their patients, will find two stubborn health care systems with huge overheads (Lake Forest Hospital's $400 million price tag did not come cheap). They may not see as dramatic price improvements as they had hoped initially. Still, pressure for patients will ultimately prevail so the hospitals will have to "improve efficiencies" (i.e., not rehire staff and run lean and mean) to remain solvent.

Fifth, the "Northwestern Lake Forest Hospital" will have to have a unified electronic medical record system with downtown. This is no minor issue, especially when the Mother Ship has yet to consolidate under "one EMR roof" compared to their more local competitor. But the whole EMR story is increasingly becoming a commodity rather than a market differentiator and the difference between health systems will likely be short-lived.

The real challenge will be for patients, as its quite likely that the two EMR systems used by the health systems competitors will not communicate with each other. What a mess. But this issue alone might become the fault in the EMR-exclusivity tectonic plates that our computer specialists will have to resolve to avoid liablity for health care malfeasance.

All in all, its tough to see where costs will fall to patients in the short term. Maybe, just maybe, we'll see the affects of real competition on health care prices eventually, but just don't expect to see the affects anytime soon.

-Wes

Think You Know Government Health Care?

Now you can prove it.

Bring friends and family together to tackle this crossword comprised of only five complete words and twenty common government health care-related acronyms.

Only the uniquely tolerant will survive:

Click image to enlarge

Have fun!

-Wes



Give up? Answers here.

Our Upside Down Medical Liability Crisis

I had an interesting visit with the husband of my niece last evening. He works as an ER doctor that is self-insured group of 60 physicians that cover the ER needs of four hospitals in Clark County near Las Vegas.

What is interesting is they are self-insured to save costs. As a group, then, they know how much per patient they must collect to assure liability care for every patient that comes to their emergency rooms.


That amount is $17 per patient per visit.

Guess how much their group receives for care they render to a Medicaid patient for a "level two" visit (minor problem: ear ache, sore throat, etc.)

Fourteen dollars per visit.

(Note: Medicare level two patients pay considerably better (about four times as much)).

When liability costs exceed the payments received for the care provided to those most in need, it's interesting that our legal and political forces in Washington see no need for liability reform as part of our larger health care reform efforts underway.

-Wes

Model Health Care System Drops Medicaid Patients

Yep, the Mayo clinic is refusing Medicaid patients from two states, citing poor payment rates.

So let me get this straight. The government sets the rates for the poor and disadvantaged and one of the President's model health care systems balks? How's this going to work when the government runs more and more of the health care delivery in the US?

Maybe this is why Mayo isn't too happy with the current reform plans.

-Wes

Drilling Down On Cardiology Cuts

Currently, cardiologists are on a treadmill of increasing patient visits to offset declining Medicare payments and increasing overhead. When the government plans on blanket cuts to cardiologists in favor of primary care, the impact will be felt first by those in rural areas that already have a shortage of cardiologists. Then will come pressure on small town practices as they are forced to close. Bigger cities with large health systems will be least affected.

But this is all part of the Grand Plan of health care physician reform: make sure everyone gets insurance so they can "prevent" cardiovascular disease while those that have it can't find a specialist.

I see how this works.

-Wes

On the President's Health Care Address

I just finished watching the well-delivered, but frankly heavily partisan, health care reform speech by President Obama. After seeing it, I did not think it was a game changer, but no doubt others will be wooed by the authoritative tone set by the President. The speech was clearly not aimed toward the Republicans in the Congress but rather appeared, in my view, to be a warning shot and "call to action" to the conservative and moderate Blue Dog Democrats as the President struggles to win their support of the Public Option and his plan for health care reform. Hard to see the Republicans nuzzling up to the President at this point and the strategy seems to have shifted to getting a bill through by reconciliation.

There were good points made early and late in the speech, like the need for reform and the need to provide insurance options to those who cannot afford it, making the denial of pre-existing conditions illegal, and even the requirement that insurers can't cancel coverage mid-way. But these reforms were no-brainers. And while there was no question that the best part of the speech was the heartfelt memory of Ted Kennedy through a letter he wanted opened after his death that reinforced his desire to define the "character" of the country through this initiative, there were some glaring problems with the speech as well.

First, I thought the President did a poor job as he spoke "directly" to seniors, convincing them how the hundreds of billions of cost savings he proposed to discover in Medicare and Medicaid would not affect their benefits in the program. Simply put, our seniors are smarter than that. This remains a major problem for the President and the reform efforts underway.

More importantly for doctors, there was the issue of medical malpractice reform. It was interesting to review what the President actually said:

Now finally, many in this chamber, particularly those of the Republican side of the aisle, have insisted that reforming medical malpractice laws will bring down the cost of health care. (Republican side of the aisle finally applauds, to which the President points out: "There you go. There you go." and then continues.)

Malpractice law is not a silver bullet. I have talked to enough doctors to know that defensive medicine may be contributing to unnecessary costs.

So... so, I am proposing that we move forward on a range of ideas to put patient safety first and let doctors focus on practicing medicine. I know that the Bush administration authorized demonstration projects in individual states to test these ideas. I think that is a good idea and I am directing my Secretary of Health and Human Services to move forward in this initiative today.

That was it. Medical malpractice reform by putting patient safety first. You could see the members of Congress sitting there somewhat stunned and with puzzled looks on their faces. They weren't sure if they should clap or not.

But a quick check on what the President was referring to can be found in the medical literature. In 2006, Hilary Clinton and Barack Obama co-authored a "perspective" piece published in the New England Journal of Medicine entitled "Making Patient Safety the Centerpiece of Medical Liability Reform." (Note: I have discussed my concern regarding the use of medical journals for political commentary previously). In this article, Clinton and Obama stated:

Instead of focusing on the few areas of intense disagreement, such as the possibility of mandating caps on the financial damages awarded to patients, we believe that the discussion should center on a more fundamental issue: the need to improve patient safety.

So there you have it. It will be medical liability reform through more safety supervisors, hand soap dispensers, operative "time outs" and hall monitors. No unseemly caps on financial damages. Boy, the Bar Association members must be giving each other "high fives" for how well the President handled that part of his speech, don't you think?

But despite all this, an even more surprising and memorable moment came when the President promised not to pay for coverage of illegal aliens in any government health care reform bill and a Republican Congressman blurted out so all could hear, "You lie!" The Democratic side of the aisle immediately booed the vocal Republican Congressman. The look on Nancy Pelosi's face as she sat befuddled behind the President following the outburst was, as they say, priceless. And while this was a tense moment that passed quickly, it reinforced the passionate nature of the debate for all Americans and served as a reminder of how hard it will be to pass any bill of this scope and magnitude.

-Wes

Photo credit: Whitehouse.gov

Saving Money: B.Y.O.P.

* bleeeeep bleeeeep bleeeeep *

It was 11:57PM on the alarm clock last night. I peeled my head from the pillow and felt my heart racing from the adrenaline surge that usurped by Stage IV REM sleep. I fumbled for the pacer and pressed the button. Glorious silence ensued as I caught my breath. Reading the pager, I noticed it was the nurse caring for my patient calling. I dialed the phone.

"This is Doctor Fisher. I'm returning Sally's call (not her real name)."

"Just a moment."

Some cheesy commercial played in the background with some canned music that I had heard a thousand times before. 'Damn, why don't they just play some soft classical music?' I thought to myself. Just then, a voice answered.

"This is Sally..."

"Sally, Dr. Fisher, returning your call..."

"Yes, Mr. Faachamatacheesedip is having trouble sleeping. Can he have a sleeping pill?"

My heart raced again, but I kept my composure and acquiesced. Sure." Then I prescribed a sleeping pill as requested and the nice nurse thanked me and I was back to lying an bed, staring at the ceiling, thinking about ways to cut health care costs. I do that sometimes. Especially when I've been awakened for a sleeping pill.

Every day, countless times across the country, thousands of doctors prescribe tylenol and sleeping pills and countless other "preventative" medications just so they don't get these calls at night. I wondered how many millions of dollars could be saved, but realized with the savings comes a price: the need to make another call to the doctor. Would this really save money? Hard to tell. Would doctors sleep worse? Probably.

Better still, what if we allowed patients to take their own chronic medications that they have been using for years when they have already paid for when they come in the hospital for routine procedures? These medications could be registered on the patient's electronic medical record and designated as "self-adminstered" to assure that the nurses and doctors caring for the patient knew which medications they were actively taking during their medication reconcilation process performed when they enter the hospital.

But alas, the hospital would lose money. "Patient safety might be compromised," they'll say!

But I say, maybe some simple ideas like this could save real money in the long run for our over-priced health care system. Call it "B.Y.O.P.:" Bring Your Own Pills.

And then maybe, just maybe, our system could save some real money, bit by bit. And patients could take their OWN sleeping pills so the doctor could get another wink of sleep each night.

-Wes

All the President's Men: Lipstick Cost Control

Representative Michele Bachmann (R - Minnesota, 6th District) referred to a quote by Ezekiel J. Emanuel, MD, PhD on the floor of the House before the House recess:

"Vague promises of savings from cutting waste, enhancing prevention and wellness, installing electronic medical records, and improving quality are merely lipstick cost control, more for show and public relations, than for true change."

He's right, of course. But what he proposes instead is threatening to the doctor-patient relationship, especially when the government intervenes in end-of-life decisions. Could government bodies ever understand the nuances of a patient's illness and family dynamic when a loved one is near death? It is hard to conceive how any doctor could take the Hippocratic Oath, as Emanuel states, "too seriously" at that time.

Maybe rather than taking away physicians' discretion regarding end-of-life decisions and care (especially when tort reform is not and has not been part of the reform discussion) we should ask why are we being smeared with the "EMR-Prevention-Wellness-Waste Reduction" lipstick as a means to justify significant cost savings if it's all a ruse. Might all those non-intercommunicating computer systems, drugs, testing, and wellness initiatives actually increase the costs of care delivery due to the large number needed to treat to save one life? Have these things really saved costs to our "system" or merely made healthy patients sick?

But then, serious discussion wouldn't be feeding our political constituents, would it?

Here's the video of Bachmann's comments:



-Wes

Addendum: This from the New England Journal of Medicine - Prevention might not save costs. Who knew?

On MedPac and Robots

Yesterday in our cath conference, we discussed the substudy from the prospective randomized trial called PREVENT-IV just published in the New England Journal of Medicine. That study evaluated the major adverse cardiac event rates of minimally invasive vein harvesting compared to open vein harvesting prior to coronary bypass surgery.

I was surprised to see that minimally-invasive vein harvesting had a higher combined complication rate of death, myocardial infarction (heart attack) and need for revascularization in the patients who received vein grafts harvested by the minimally-invasive technique. Following the presentation of the data, our surgeons were asked why this might be the case. While none knew for sure, they postulated that the art of harvesting vein-conduits using endovascular techniques might play a role (it's more difficult), or the effects of the thrombolytic state induced by on-pump bypass vs. off-pump bypass might create the discrepency in post-surgery vein survival, since patients are less likely to develop clinical thromboses in the post-open chest bypass population.

So this morning, I was surprised that President Obama toured Cleveland Clinic yesterday and had such an up-front experience with minimally-invasive robotic surgical techniques for mitral valve repair that hardly represents mainstream American health care. While the marvels of the technologyy cannot be disputed, like the endovascular vein harvesting study above, might we find that robotics could be as deliterious to patients compared to open chest techniques? After all, these techniques have yet to be compared in multicenter trials to more conventional open techniques for mitral valve repair. But more concerning as we move forward is this question: will academic centers be granted more funds to test comparative effectiveness research for robotics at the expense of front-line American health care? Surely, this won't be, will it?

Probably.

But when I see pieces like this I wonder why the article does not question the cost and risks of this technique compared to conventional open-chest procedures, especially in this era of touting the need for health care cost containment. How much is this piece about the marketing of this technique to the community (for financial gain) or to the President (for obtaining grants or political favors)?

Perhaps we should ask ourselves how many of the physicians and surgeons at Cleveland Clinic stand to earn a seat on the proposed MEDPAC board that will determine if Congress will approve payment for robotic techniques even when few data exist to show their superiority over conventional techniques.

Now that might make for some really interesting reading.

-Wes

The Biggest Threat to Health Care Reform: Physician Burnout

It was supposed to be delayed gratification.

After all, that's the American way: work hard, put your nose to the grindstone, get good grades, be obsessively perfectionistic, then you'll be rewarded if you just stay with it long enough. It's the myth that perpetuated through medical school, residency and fellowship. Our poor residents, purposefully shielded from the workload they're about to inherit, march on.

But then they graduate to find to find the population aging, chronic and infectious diseases are more challenging, and the number of complex health advances and therapies are exploding. Just then, we decide to launch a full scale attack on physicians and their patients with increased documentation requirements, call hours, larger geographic coverage of their specialties, reduced ancillary workforce, and shorter patient vists.

Physicians get it - burn out and dissatisfaction are higher now than ever before. This is probably the greatest real threat to the doctor-patient relationship and health care reform discussions don't even put it this on the table.

At the same time that we expect our doctors to be devoted, available, enthusiastic, meticulous and at the top of their game with perfect "quality" and "perfect performance," while simultaneously cutting their pay, increasing documentation reqirements and oversight, limiting independence, questioning their professional judgement, and extending their working hours. We must become more efficient!

Deal?

-Wes

Dr. Wes Goes to Washington

From Jessica, commenting on my "Are Doctors Sheeple?" post:

I for one want to hear what the physicians have to say and really, that's about the only group I want to hear from. It is beyond comprehension how people can condemn doctors/providers for health care costing too much. It makes me so mad - it is the best case of brainwashing I've ever seen and it would do us well to track that sentiment back to those who stand to gain the most from spreading such lies.

We are lucky to have the talented souls who go to work each and every day knowing the tape they have to work around and we need to stop now and listen to what they suggest. There is too many unnecessary layers between me and my providers, too much between me knowing how much something will cost so I can plan ahead, too many back room deals between unaffected players that help those who don't need it and hurt the ones that are dying for help.

While reading your post, I got this picture in my mind of like, all the great doctors in our country with their nose to the grindstone, doin' their thing, working their magic, not having the time to 'make deals' like power groups have time to - like you said, they are being the entrepreneurs, the innovators, the individuals who are healers and kind souls who set out on a mission to help people live their lives a little better than the day before. All the while, those who are not intrinsic to the provider/patient relationship are spending their time buying political capital. The individual-ness of doctors is what makes medicine in our country so great - your minds are free to work! No associations required, just more volume please!

Jessica, now's your chance to hear some doctors.

Dr. Wes will stop blogging briefly to participate in a press conference next week entitled "Putting Patients First", to be held at the National Press Club in Washington on 17 July 2009 from 9AM-12 noon EST.

Dr. Val Jones (of the blog "Better Health") has graciously invited me to participate along with other nurse, nurse practitioner and physician bloggers to discuss issues of health care reform that directly affect doctor/patient relationship from an "Outside the Beltway" perspective. The keynote speaker for the event will be Congressman Paul Ryan, (R-Wisconsin), ranking member, House Budget Committee and the moderator will be Rea Blakey, Emmy award-winning health reporter and news anchor, previously with ABC, CNN, and now with Discovery Health.

Participants will include:

Primary Care Panelists:

Kevin Pho, M.D., Internist and author of the popular KevinMD.com blog

Rob Lamberts, M.D., Med/Peds specialist and author of Musings of a Distractible Mind

Alan Dappen, M.D., Family Physician and Better Health contributor

Valerie Tinley, N.P., Nurse Practitioner and Better Health contributor

Specialty Care Panelists:

Kim McAllister, R.N., Emergency Medicine nurse and author of Emergiblog

Westby Fisher, M.D., Cardiac Electrophysiologist and author of Dr. Wes

Rich Fogoros, M.D., Cardiologist (and yes, another Cardiac Electrophysiologist) and author of The Covert Rationing Blog And Fixing American Healthcare

Jim Herndon, M.D., past president of the American Academy of Orthopaedic Surgeons and Better Health contributor

Better yet, you're also welcome to attend in-person. (Contact john.briley@getbetterhealth.com if they'd like to be in the audience. Seating is limited in the broadcast studio.) A video of highlights from the event will be created that I hope to embed in this blog or will link to after the event.

Got something you want said? Let me know.

- Wes

Are Doctors Sheeple?

Imagine a couple caught up in arguing about who should take out the garbage while there's a fire on the stove. The garbage may be a real source of conflict, but bickering about who's turn it is risks the house being engulfed in flames.

Such it was this past week when Daniel Palestrant, MD, Founder & CEO of the physician online forum Sermo, Inc., took a step in the wrong direction by deciding to stand in opposition (subscription) to the AMA:

As physicians, our first step in the healthcare debate needs to be clearing the air about who speaks for us on what topics. Today, I am joining the increasing waves of physicians who believe that the AMA no longer speaks for us. As the founder and CEO of Sermo, this is a considerable change of heart, given the high hopes that I had when we first partnered with the AMA over two years ago. The sad fact is that the AMA membership has now shrunk to the point where the organization should no longer claim that it represents physicians in this country.

While some of his points might be perfectly valid, we wonder how further division amongst our ranks will affect our ability to lobby effectively for the doctors and patients in the current era of health care reform. Do we have the time for such pissing matches? I understand the inherent opportunity for Dr. Palestrant to mobilize the online physician community, but how do we mobilize the majority of physicians and break out of our specialty silos to develop points of consensus? Needless to say, the other partner, the AMA, was none too pleased and shot back:

The AMA has decided not to continue its business relationship with Sermo.

The AMA is always looking for effective ways to communicate with physicians. After an evaluation of the initial relationship with Sermo, we have decided that the value was not there to justify the investment of AMA members’ dues dollars. We continue to explore ways to communicate more effectively with all physicians.

Meanwhile, the politicians and lawyers smile.

This is not about "he said, she said." While Sermo boasts over 100,000 physician registrants, neither organization can say it represents the majority of doctors. Further, to suggest Sermo is any less conflicted than the AMA when it comes to revenue generation is misinformation. But all doctors are keenly aware of the bureaucracy, the middle men, the excess, cover-your-butt tactics needed to shelter them from litigation, their increasingly demanding work hours, frenetic patient visits and diminishing professional payments despite all of their work.

But now, all the politicos see is this: "Look Joe: Sermo guys ain't talking to the AMA and the AMA ain't talkin' to Sermo! Poor bastards. Guess we don't have to worry about them if they can't even agree with each other."

We are, after all, surrounded by professional organizations that have not permitted themselves to devolve into silos. The American Bar Association. The pharmaceutical lobby. The medical device industries. The American Hospital Association, etc. They have political clout. They have a powerful voice on the Hill. They know how to play the game. They have differences in political bents (trial lawyers typically democratic and corporate lawyers typically republican, for instance), but they know how to minimize their internal differences to maintain political bargaining power.

We, on the other hand, are fiercely independent, entrepreneurial, and schizoid: conveniently parsed into our narcissistic silos of primary care, hospitalists, nocturnists, specialists and subspecialists. Some are hospital-employed and others in private practice, some are academic and others fiercely clinical, some are deeply conservative and others even more liberal.

I have to admit I'm still miffed at the CMS proposal to cut cardiologists' fees and shift funds to primary care. I'm miffed at the AMA, too: where was their condemnation of the proposal?

But is this the big issue? To pretend that the cost of doctors' services are the reason for excessive health care costs is a chimera. Look on your latest hospital bill at the exact line items for a health care charge. Look at the "adjustments." Look at what the doctor ends up clearing for that bill. And that's all they can think of to cut?

Enough said.

On the other hand, as one commenter mentioned at the Happy Hospitalist blog in a post on why doctors' salaries are so high:

Take, for example, the Navy SEALS. As an elite unit, their work demands nothing but the absolute best of the best soldiers. In the midst of a shortage and recruiting crisis, the last thing the Navy should do is lower its standards in BUD/S to get more graduates to fill the demand. Lives are dependent upon the quality of the work that the SEALS do. In order to meet the growing demand for the SEAL ranks, the Navy has gone to ultra-marathons, 24 hour adventure races, and Ironman-type competitions to recruit the kinds of people who can hack it as a SEAL.

Medicine is no different. At a time when there are shortages across the board, why does it seem like the government and the industry have created less and less incentive for the best and the brightest to join our ranks? Arduous paperwork, debt, lawsuits, lack of emotional reward due to minimal patient contact, and the ever increasing leftist drone to decrease our income are some extremely powerful motivators to keep the best of the best looking somewhere else for satisfaction in life.

Getting doctors to argue about which among us should get the fee cuts buys into a myth that doctors' fees are the first and foremost reason health care costs are so high. Have doctors insisted on an intelligent discussion about true health care costs in Washington? Why not? Why are we being such sheep buying into the premise that doctors are the problem? Don't tell me that a doctor's pen is the single most expensive piece of medical equipment. Did my pen charge a patient a ridiculous $179,000 gross charge with a $43,000 "credit" seen on a recent 23-hour admission for a biventricular defibrillator implant?

No way. That's because the doctor's fee wasn't even included in the bill.

And what about the "Just To Be Sure" mentality that pervades medicine today? You know the one: "Mrs. Jones, I know you feel fine, but I think we should order another echo this year just to be sure your aortic insufficiency isn't any worse" or "Mr. Jones, we'd better check those liver function tests just to be sure your statin isn't somehow affecting your liver, even though we checked that test 6 months ago." Does the lack of liability reform and exorbitant malpractice awards force this line of reasoning? Dare we hold the politician's feet to the fire on this issue or do we just let the legal status quo with its ridiculous malpractice premiums continue?

I do not know what critical line was crossed that spurred Dr. Palestrant to sever his relationship with the AMA. Perhaps the damage is done. If so, God help us. But at this exact point in time, perhaps reevaluating and reconsidering the potential for reuniting the power of his forum with the established political standing of the AMA might be in the best interest to our profession, however staid the AMA might seem to him. With vigorous effort and collaboration, doctors might then have the ability to collectively voice their concerns to our political establishment and force policies beneficial to all physicians and their patients, rather than splintering our collective voice into impotent fractals of discontent.

Can physicians move out of their silos and develop consensus points we all agree upon?

The house is burning.

-Wes

The Medicare Hatchet Begins

How's an 11% cut in a single year for cardiovascular services grab ya?

From CMS:

CMS is also proposing to stop making payment for consultation codes, which are typically billed by specialists and are paid at a higher rate than equivalent evaluation and management (E/M) services. Practitioners will use existing E/M service codes when providing these services instead. Resulting savings would be redistributed to increase payments for the existing E/M services.

And that's just the start.

-Wes

Reference: CMS Press Release.

More from BNET Healthcare.

President Obama Talks About Pacemakers

I was one of those who missed the "town hall" meeting aired by ABC on the 24th of June, but was nicely pointed to this video where President Obama speaks about placing pacemakers in 100-year olds by a loyal follower:



The video is remarkable on several fronts.

First, I was impressed with the remarkable footage that suddenly appears of the caretaker with her mother, demonstrating the staged nature of this "spontaneous" town-hall interview. No doubt, this question was asked to reassure our seniors about the choices that will soon be made by Washington.

Second, the number of times the elder woman presented to the Emergency Room for care. We are left wondering, did she have a primary care doctor? What were the other discussions that took place before?

Third, the issue of placing pacers in 100-year olds and the new, proposed reliance on bureaucratic "experts" in Washington that will tell the local doctors what the best course of therapy should be based on "research" (a reference to the 1 billion dollar research boondoggle that is comparative effectiveness research). To think that any research will occur on patients of this age is ridiculous. (I'll let others decide what this means for our elderly).

But this is not to say that we should not make choices in this instance. The issue of "cognitive ability" of the elderly, however, was conveniently dodged, and there was never a discussion about the centurion woman paying for her own pacemaker (seems in this case it would be less than a new car).

But whatever you think, these are choices doctors and patients will have to make head-on in the days of increased pressure on Washington to cut costs. The thought of unknown and poorly-defined "experts" (MedPAC?) making these decisions based on non-existent data, rather than the frank discussions between the doctor and their patients and their families, is what really concerns me.

-Wes

Biasing the Argument Against Specialists

In an article originally published in the Washington Post on 20 Jun 2009 and republished in the Chicago Tribune today, the national shortage of primary care physicians is highlighted and serves as a significant problem for health care reform efforts underway. The systematic devaluation of primary care relative to "procedural-based" medicine is again addressed:

The disparity results from Medicare-driven compensation that pays more to doctors who do procedures than to those who diagnose illness and dispense prescriptions. In 2005, for example, Medicare paid $89.64 for a half-hour visit to a primary-care doctor in Chicago, according to a Government Accountability Office report. It paid $422.90 to a gastroenterologist who spent about the same amount of time performing a colonoscopy in a private office. The colonoscopy, specialists point out, requires more equipment, specialized skills and higher malpractice premiums.

But, as mentioned previously, we should realize that Congress made attempts to correct this disparity though "fudge factors" to the RVU payment formula before:

In 1993, Congress declared a redistribution of funds from proceduralists to primary care physicians. Initially there were 2 conversion factors—1 for medicine and 1 for surgery. The conversion factor, ie, the multiple of the RVU for payment, had the added advantage of demonstrating where costs were increasing. The 2 conversion factors demonstrated conclusively that surgeons did not increase their utilization when reimbursement decreased (because, for example, patients have only 1 gallbladder, and the indications for its removal remain constant). Other specialties increased their utilization, a process that continues to this day. In a refining effort to shift money to primary care, a third and separate conversion factor was developed in 1995. By 1997, it was clear that separate conversion factors were not controlling utilization of primary care and medicine services, causing these 2 conversion factors to decrease. The 3 separate conversion factors were eliminated in 1998, resulting in a decrease for surgery and an increase for medicine and primary care. In addition, more surgeons' practice expense reimbursements are included under the indirect category, now reimbursed at 35% of cost; internists and primary care physicians have a higher percentage included as direct expenses, which are reimbursed at 66%.

But few mention these facts. Further, when payment differentials are cited between primary care and specialists (whom have been conveniently reduced to "proceduralists"), the 90-day global period (the surgery and all care related to the procedure for 90-days afterward) is rarely, if ever, mentioned in the discussion. Follow-up visits, dressing changes, wound checks, and management of complications - all conveniently ignored pre-paid for three months.

Without a clear understanding of all of the issues related to physician compensation and the problems with government's prior attempts at meddling with the system to correct the disparity between primary care physicians and specialists, we should understand that simply cutting specialists' fees in favor of primary care physicians might lead to not only additional primary care shortages, but an even more acute shortage of specialists as well.

-Wes