PookieMD's Blog: Where Physicians Learn About the Business of Medicine

My parents are both over the age of 65 and recently retired.  They are now on medicare, and have supplemental insurance as well.  Both have some health issues and have long term relationships with their doctors.

Well, not anymore.

The large Medical Center that services most of the well heeled, small city where they live doesn’t accept medicare.  Patients may continue to see their doctors at the Medical Center once they turn 65, but 15% more is added to the bill, and the patients are expected to pay in full at the time of service.  The Medical Center will not submit claims, or do any paperwork on behalf of the medicare patient.  Getting payment is the responsibility of the patient once they are lucky enough to be on medicare. As you probably have guessed, most patients can’t afford to do this and seek care elsewhere.

The closest place to get care is another city, approximately 20 miles away. There, the physicians take medicare.  Most of the physicians in my parent’s city are employees of the Medical Center, and the Medical Center has enough non-medicare patients and doesn’t feel socially responsible enough to take in a portion of medicare patients.  Basically, the Medical Center has a monopoly as  most of the city’s physicians are employees, and the Medical Center’s position is of profitability at all costs.

The Medical Center has a stranglehold as most physicians are employees, and the city’s urgent care centers are owned by the Medical Center. The Medical Center, by turning away patients once they turn 65, demonstrates the worst model of profit driven behavior in the medical world.  Rather than accepting a certain percentage of medicare patients, which is what most socially responsible physicians, the Medical Center forgets they are in the socially responsible business of health care.  They elect to dump patients on the physician groups who are socially responsible.

I don’t think I would go so far as to mandate that physicians must accept a certain percentage of medicare patients.  I think this would be akin to forcing car dealers to accept less for a car from those over 65 years.  Instead I advocate that medicare reimbursement increase to fair market levels such that physicians are not forced in to dumping long term, long standing relationships in order to keep the doors of their practice open. And to the CEO of the Medical Center, I say–how do you sleep at night?

PS: out of respect for my parent’s privacy, I have deliberately not named the city where they live.  I wish I could have, as I think this would have more impact.

A good friend loaned me a book called The Information Cure.  It is written by Jeff Margolis, who is the CEO of the TriZetto group,  which provides “enterprise information solutions to U.S. healthcare payers.”  (I’m not sure what this means.)  However, there is was an enlightening section on how insurance companies view physicians and health care providers when a patient status post hip replacement gets what appears to be MRSA.

Mr. Margolis faults the hospital for the infection. “If the hospital had known in advance that it would be paid only for the original planned hospital stay and hip replacement procedure, would that have made the hospital more likely to follow evidence-based medicine protocols?  What if we paid doctors and hospitals for the procedures they were supposed to perform in the first place and not for the care that resulted from medical?”

The view is that infections, errors and bad outcomes occur because physicians and hospitals get paid more if there are complications.  He makes the case that we don’t pay attention to details such as clean hands because we don’t get dinged monetarily for infections, rather we are “rewarded” by making money off of complications.  Margolis claims that if we were paid for performance we would rapidly eliminate errors, infections and bad outcomes.  He completely disregards the fact that things go wrong, in spite of our best efforts.  He implies we are only motivated by money, not that we personally care about the health of our patients.

It is sad how easily we distrust each other.  The insurance industry so easily points fingers at physicians,  claiming that rising health care costs are the responsibility of the germy, unclean physicians that care not a whit except for the money earned, and that physicians greedily anticipate making more money from the complications they so easily induce.

Don’t get me wrong–many errors and bad outcomes can be avoided with proper procedures.  But to think that physicians care not about bad outcomes is ridiculous.  Yes, we care about the bottom line, but more importantly, we really do care about our patients.

I am reading the fascinating book, The Healing of America,by T.R. Reid.  I will review it more detail later but was very much intrigued by a mention of Dr. Ernst Wynder.  Dr.  Wynder is my new hero.

In the May 27, 1950, Journal of the American Medical Association, Dr. Wynder published his findings that smoking causes cancer.  Dr. Wynder studied 604 non-smokers, “moderate” smokers and “heavy smokers” based on patient interviews.  He examined, retrospectively, 20 years of smoking behavior.  He found statistical correlation between cigarette use and lung cancer.  Dr. Wynder also developed a machine that would smoke cigarettes.  He then painted the residual tar on to mice, and with in one year, 44% of the mice developed cancers.  Tragically, Dr.Wynder’s mentor and co-investigator, Dr. Evarts Graham, a heavy smoker, died of lung cancer.

This single study probably has done more for American public health than any MRI, transplant surgery, or medication created during this same time.  Yes, we hear all about the famous surgeons and scientists (think DeBakey, Watson and Crick, Jarvik)  but truly, Dr. Wynder is an unsung hero, and has had immense influence on America’s health.

“It should be the function of medicine to help people die young as late in life as possible.”–Dr. Ernst Wynder

Who is your medical hero?

Tweenager Daughter has a new accessory–a bright red long arm cast, applied at her orthopedic surgeon’s office. The past three days have been full of compassionate people that have cheered up T.D. (Tweenager Daughter!) immensely, with a single small exception.

Her appointment with the surgeon was smack dab in the middle of a swing shift I was supposed to work . I called four of my partners and EVERYONE of them said they would cover my shift so I could go the appointment. It was just a matter of picking which one! Wow! One of them even called back to make sure I got the shift covered.  What a great group!

T.D. was apprehensive before the appointment, as we all were, because there was a concern that she may require surgery.  (Dodged that bullet!)  Instead the cast was to be applied.  It was applied by  a “crabby” (T.D.’s word) lady who told T.D. that there was no way she could have a green and red cast for Christmas–one color only. The cast was applied in cherry red.

Later that night we went to T.D.’s gym, where her team mates rushed up to her, hugged her, and exclaimed over her cast.  Her coaches came over, hugged her and me, and anxiously asked for the report.  The gym owner reminded T.D. that the holiday party was coming up, and not to miss it. They were all so glad to see T.D. that it warmed me and took away some of the sting of the wounded wing. 

Looking at all of this, I am reminded to be compassionate.  It’s hard at the end of the day to muster enthusiasm for applying a two color cast, but sometimes it is these simple acts that go a long way.  Just as the hugs, phone calls and cards from T.D.’s friends helped patch a hurting heart, so do the simple acts we do as physicians every day.  I will try to remember that as I admit the alcoholic that broke his hip falling off a bar stool, and the COPD patient for her 10th admission who won’t stop smoking. I will try to push myself, and am greatful for those that were so compassionate to me these last several days.

Through a series of unfortunate events, I spent a fair amount of time in my local ED and pediatrician’s office. Tweenager Daughter broke her arm at gymnastics, with just one week to go before the state championships.  Needless to say, there are a lot of long faces at my house, including my own.  Watching her compete this season has been a joy, as it has lifted me up just watching her.

The ED visit was a complete disaster.  We waited for an hour and a half in an empty ED  before being seen.  I looked at the Xrays with the ED doc, and we both noted the fracture.  The radiologist at the hospital called while we were there and confirmed the break.  The ED doc sent her home in a sling, with an instruction sheet on “sprains”!  No splint was applied, no pain medications given, no warmth to a young girl whose entire season concluded with a misplaced hand on a vault table.  The nicest person to us was the lady who took our registration information and handed us some warm blankets as we waited in the cold, empty lobby. 

The next day I came to my senses and called Tweenager Daughter’s pediatrician. By some miracle, he was in the office on the Saturday after Thanksgiving.  He told us to come right in.  The good doctor applied a splint, gave a prescription for pain medication, and applied a soothing balm to the soul. 

Tweenager Daughter is still horribly depressed about missing the state championships.  However, she is in less pain, and actually slept last night.  Thank you Dr. W. for that!

I am a fanatic about discharges.  Of all the hand offs we do in medicine, this one seems to be the most dangerous, with discharge medications being the road side bomb of hospital medicine.  A recent article in Archives of Internal Medicine examined the effectiveness of a pharmacist performing medication reconciliation, patient counseling and education and then making a follow up call at 72 hours.  The study examined ED visit and readmission rates at 14 and 30 days, and found no difference between intervention and control groups.

Important highlights of the article:

• one fifth of patients were found to have omitted medications.
• a phone call after discharge reduced readmission risk at 14 days, but the benefit of a post discharge call is not well defined–some data has shown a post discharge call leads to higher utilization of health care resources!  (Perhaps these calls identify other issues that require clinical follow up…)
• only 43% of patients were reached with a post discharge call, so the phone call data is limited.
• the article doesn’t mention how many medications were on the medical reconciliation at discharge.
• it took the pharmacist 87.5minutes to perform the reconciliation and “other discharge activities.” There is no way a discharging physician could spend this much time.  The article doesn’t mention what exactly the pharmacist was doing in these 87.5 minutes!

My (unscientific!) take away: patients with long medication list, lots of changes including stopping old medications and starting new ones, are at the most risk of errors and medical mishap.  These patients are probably older, have limited eye sight and hearing, and may not comprehend the changes.  Additionally, they may be on narcotic pain relievers, “sleepers”, and antidepressants, as well as a plethora of beta blockers, anticoagulants and oral hypoglycemics.  I think that this group of patients deserves their medications to be combed through with a fine tooth comb, and reviewed and reconciled with the family, the patient and other caregivers.  AND, for pity’s sake, the primary care doctor has got to be kept in the loop!  I would like to see a study that focuses on the elderly, and those who go home on 5 or more medications, as well as those on coumadin and diabetes agents.  I bet we would see a large improvement if these patients were the ones studied to examine effectiveness of pharmacist medical reconciliation at discharge.

Anyone interested?

 The November 23 issue isn’t on line yet.  Here’s the citation: “Impactof a Pharmacist-Fracilitated Hospital Discharge Program: A Quasi Experimental Study”, P.C. Walker, PharmD, et al, 2003-2010.

In the November 2 edition of BusinessWeek, a plan by United Healthcare to reduce the cost of diabetes is explored and lauded as a way to lower health care costs.  Here are the nuts and bolts of the plan that will only be offered to large payors as a way to reduce the cost of taking care of diabetic patients:

• The plan requires patients to follow treatment plans and agree to be tracked by United to make sure the are compliant.  They must agree to see their doctor two times per year.  (Interestingly, every three months is what is common practice.)
• In return, the patient will have discounts on medications for diabetes (co-pays would be waived) and deductibles may be lowered.
• If patients fall off the wagon, and are non compliant, they will be moved back in to their company’s standard plan.
• United will be tracking these patients in a secure database, and may roll out similar programs if the diabetes plan demonstrates improved outcomes and lower costs.  BusinessWeek  cites a statistic that it costs $30,000 to treat a diabetic patient who “suffers complications.”  (No word on what those complications are.)

Aetna insurance has a similar plan which provides prescription discounts to patients with diabetes, hypercholesterolemia, and asthma, among others.  Aetna notes that people are filling more prescriptions, but it is too early to measure improvement in outcomes and reduced expenses.

Sad as it is, I think that this is the only way American health care consumers will finally start taking care of themselves.  Clearly, rants by physicians to patients to take better care of themselves are useless!   It appears as if the only way we change our health habits is by taking  a hit in the pocket book.  So, as hard as it is for me to actually agree with health insurance companies, I think United and Aetna are on to something.  I’ll keep you posted.

Annals of Internal Medicinehas a nice study on the ability of ”structural capabilities” to improve  primary care.  Let me translate: structures are systems implemented in a practice, such as EMRs, paper based reminders, on site language interpreters etc.  They are mechanisms a practice puts in place to improve quality and efficiency of care.

So what works?

An EMR is helpful to bring up scores on some HEDIS measures such as: screening for breast cancer, colorectal cancer, and chlamydia, and diabetic eye care and nephropathy monitoring.  Even at that, it only improved scores if it was a “frequently used multifunction” EMR–meaning that xray reports, labs, med lists, problem lists and specialist notes were ALL on the EMR.  If the EMR was underutilized, or not as functional, it would generate lower HEDIS scores.  So, if your practice is getting an EMR, better make sure you get a highly functional one and actually use it!

Systems to remind patients to obtain necessary screening  improved HEDIS scores, but paper notes to physicians were not helpful.  (Now why is that?  The authors speculate that is may represent practices that have barriers to optimal care.)  Having an interpreter on sight wasn’t particularly helpful either, nor was a multilingual practitioner.

Having frequent (at least quarterly) meetings where quality of care was discussed led to higher HEDIS scores as well.

So simple steps to improve quality of care at your practice:

1. If you are getting an EMR, get a highly functional one that includes multiple functions such as labs, x-rays, medication lists, notes etc, and use it.  Best if subspecialists use it as well.  (Don’t ask me how you are to accomplish that!)
2. Have frequent meetings on how to improve HEDIS measures such as screening for cancer and diabetic monitoring.
3. Send reminders to patients to get their screening done.

Right now, that’s all that has been studied and shown to work.  What works for your practice?

The next time you write for a prescription narcotic pain reliever, ponder the following facts:

• 9.7% of all 12th graders admit to non medical use of vicodin in 2008.
• Teenagers believe that prescription medications are safe and “responsible.”
• Girls are more likely than boys to intentionally abuse prescription drugs.
• The majority of teens and young adults get prescription medications for free from their friends and families.
• Almost 3 of 10 teenagers do not believe that prescription pain medications are addictive.
• Most young users (62%) get prescription pain relievers from their parents’ medicine cabinets.
• A third of 14-20 year olds claim to order prescription drugs on line or via phone.
• 8th graders report using dextromethorphan (from cough syrup!) to get high.
• Abusing prescription drugs before the age of 16 has a greater risk for dependency in later life.
• The number of accidental deaths directly attributable to opioids has tripled  from 1999-2006, with prescription narcotics over taking illegal drugs such as heroin as the culprit drug in accidental overdose.

So, the next time you write for that vicodin or oxycontin prescription, think carefully who it is for, and how much to prescribe.  For more information on this problem that affects all physicians, visit the National Drug Intelligence Center website.

PS: I am sick to DEATH of on line drug companies spamming my blog!

On August 20th I went to a version of a town hall meeting with our representative, Mr. Jared Polis.  It was set up in front of a Whole Foods, and featured a table with seven chairs.  You got to sign up to chat with Mr. Polis, and were arbitrary placed in groups with 6 other people.  Each participant was to be allowed one minute to ask a question or air a view point with the congressman.

It was packed.  What surprised me was the amount of people there and the depth of their passion about health care reform.  What was scary was the vehemence that some expressed with their views, and also the blatant propaganda that some attempted to spread.

As I waited in line here is what I heard people say:

• Doctors got a “kick back” each time they (we!) referred some one to a specialist. (I actually spoke up to this person and told them that was not only not true, it was against the law!)
• Doctors all owned parts of MRI companies, drug companies and they like, and we were all over paid.
• Doctors were incredibly rich and deserved to have their salaries cut–”just like the rest of us.”  (I also mentioned I have NEVER had a pay raise since completing residency 14 years ago, but kept mum on my Subaru with over 200,000 miles on it!)
• The elderly and poor loved Medicare and Medicaid, and we should have a health care system based on this.
• All Americans love their private health insurance.
• There was actually only “6 million uninsured–and most of them were undocumented aliens, anyway” so health care reform wasn’t needed.
• We should tax the wealthy who have been on a “free ride for the last 1o years anyway” to pay for health care reform.
• Health care in Canada and the UK was “horrible” and “exactly what we need here.”
• Corporate America is responsible for all our woes.

People carried placards, wore “single payor now!” hats, and handed out sheets of paper bearing their views. One person was dressed in a white coat and carried a sign stating “Another Physician For Health Care Reform.” 

Wow–American activism at it’s best and worst. There were no fisticuffs, and people were civil.  It seemed to me that most people wanted a government option side by side with private pay.  Seems reasonable.  People also understood that taxes would need to be raised, and favored taxing the wealthy, and/or a sin tax on tobacco, alcohol, soda and candy.  I felt a bit sorry for Mr. Polis as he patiently heard it all and repeatedly answered the same questions, criticisms and statements calmly, fairly and succinctly. 

Hats off to our democratic nation, and to the people that took the time to participate!