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

In my last post, I was a bit dark with the factory worker analogy.  However, this is status quo for primary care.  But, given my promise that if I complain about a problem, I will seek to find solutions. So here goes:

Physicians must become leaders and team players.  Sometimes, when I am wearing my EMR consultant hat, I have to remind myself that I am not the boss, I’m a team member, and not necessarily the most important team member!  (I think we physicians love to be the boss–after I told my daughter what I did at work, she commented, “so basically, you bossed people around all day.”  Ouch!) Being the boss is not the same as being a leader!

So what’s a physician leader? Here are things you don’t hear from a physician leader:

• “That’s not how we do things”
• “We’ve always done it this way.”
• “I don’t have time.”
• “You can’t teach an old dog new tricks.”
• “It will never work.”
• “That’s of no benefit.” (I think this was heard at the introduction of hand washing and sterilizing instruments!)

So what are what does a physician leader say?

• “Show me the data.” (We love data!)
• “How we will do this?”
• “Does it improve patient care?”
• “How much does it cost–in terms of time, money and will power, and what resources do we have for this?”
• “Who can I work with to get this done?”

So if you really want to stop being a factory worker physician, get out of your silo. Learn to lead, not to boss, open your mind to new ways of thinking and doing things, and learn to collaborate. And lastly, listen much, speak little!

On my quest to educate myself on the business of medicine, I picked up the April issue of the Harvard Business Review, which had a spotlight on health care.  Well, I want to fix health care as much as anybody, so I forked over the $16.95 for the issue.  Some of it was good (a review of Gawande’s Checklist Manifesto, already reviewed here) but other parts made my hackles rise.  (Yup, still got those hackles!)

Jeff Levin-Scherz, MD, MBA, assistant prof at Harvard Medical School and School of Public Health, was the chief hackle riser.He wrote an editorial on pages 72 and 73 on  5 items that “drives high health care costs–and how to fight back.”  Here are a few choice picks from his list:

• “Payment schemes that reward excess”: “he advocates that we all join HMOs because salaried physicians perform fewer procedures.  No matter that many patients and physicians hate HMOs and capitation. Dr.Levin-Scherz must not have practiced in these institutions.  Talk about another way to drive young doctors away from primary care! Practicing in capitated systems is very restrictive, and takes away a value that most physicians hold dear–autonomy! (Mentioned just earlier in the issue!)
• “Small practices, fractured care.” The good doctor states that small practices should  integrate in to large multispecialty groups to “improve communication and accountability.”  He also notes that such large groups are better able to leverage IT infrastructure, and use “non-physicians in a team approach.”  Basically, he sees the answer to rising health care costs is to make all physicians employees that can be forced to be the head of a “medical home” and supervise a group of health care extenders. (God, do I hate that word!)  Yes, large group have leverage in investing in items like EMRs (which by the way have NOT been demonstrated yet to improve health outcomes!), but the physician as employee model again shrinks one of  the hardest working, motivated, driven workers in the American system to that of line worker.  Physicians have huge intellectual capital, and minimizing that by enforced group membership lays waste to a huge resource.
• “A few patients cost a lot.” Yup, they do. He advocates that complicated patients go to”centers of excellence” to receive care from those with “disease specific expertise.”  Would those be the specialists that he says are costing too much money? (Yes, he decries specialists’ salaries, and suggests  that compensation be increased to “attract doctors to general medicine.” I am all for increasing internists and family practice compensation, but that is just one factor in why these specialties can’t attract young physicians.  To be honest, primary care can be a real drag, with relentless hours and countless regulations.  Dr. Levin-Scherz appears to ignore this fact.)

I do agree with some of Dr. Levin-Scherz’s observations and suggestions such as increasing transparency in pricing (a head ct in the US costs $950, but can be had in Canada for around $500.)  He also notes that the price of LASIK surgery has fallen because it competes on price. Dr. Levin-Scherz ignores the elephant in the room: Americans want “everything done”, and don’t care how much it costs, as long as it doesn’t cost them.  I am responsible for meeting this expectation, and am forced to abide by insurance regulations and malpractice pressures.  Dr. Levin-Scherz  neglects to mention that controlling these factors would go a long way toward controlling costs.

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I received a request to sign the following Letter to the Editor that will appear in the Denver Post on Saturday, March 14 edition.

“Doctors feel the consequences of unavailable or unaffordable health insurance every day. Uninsured and under insured patients forgo needed care, turning treatable conditions into complex and expensive health care events. Many can’t get insurance due to pre-existing conditions or over-priced individual plans. Our fragmented health insurance system creates administrative burden for patients and doctors alike, but does little toward improving quality, communications, or overall health in America. Our patients are seeing double-digit insurance premium increases and sky-rocketing deductibles.  More and more they cannot afford to come to the doctor.

Delaying health insurance reform would unnecessarily perpetuate lack of access to health care, financial hardship, and suffering. We urge passage of federal health care reform legislation immediately and call for continued executive evaluation and creative legislation until all Americans have access to affordable quality health care.”

Would you sign this? If you want to sign, go to http://bit.ly/aY9IuW.

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?

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.

Note from PookieMD: this is a blog post from Lila Rosenthal, MD.  She is passionate on the topic of health care reform.  She notes that physicians are a very silent group in this debate.  Below are her thoughts.

“May all beings be filled with compassion and kindness for one another.”  This blessing-turned-bumper sticker has been on my mind the past several months as I observe our collective national response to congressional proposals to reform our health care ‘system.’  It is on my mind when I go to work, as an urgent care physician, seeing patients who come to the clinic for reassurance, treatment, or a referral.  Some have insurance, but many do not.  The latter is starting to look more and more like middle class America, not just the ‘working poor.’ 

This past week, two young men came in on the same day — one a graduate of CU-Boulder business school, the other a recent law school graduate — both without health insurance.  The business school grad lost his job in December, and had descended into a deepening spiral of depression, insomnia, tremors, and occasional distorted thinking.  He needed some basic blood work, but the cost was out of reach after paying $150 out of pocket just for the consult.  He also needed a referral to psychiatry, but would surely not be able to afford the hundreds, if not thousands, of dollars the consult and treatment would cost. 

The law school graduate, living with type 1 (juvenile-onset) diabetes for many years, had symptoms of H1N1 influenza.  He had gone to a local drug store to ask a pharmacist what to take for his cough, figuring this would be cheaper than seeking care.  In light of his diabetes, the pharmacist urged him to be seen by a health care professional, since he was at high risk for flu-related complications.  Currently interviewing with several area law firms with prospects for a well-compensated career on the horizon, he was sure he wouldn’t be able to purchase health insurance, since no private health insurance company would take him on with his pre-existing condition.

As a physician it is gratifying to be able to mitigate patients’ suffering by treating illnesses such as mental health disease and diabetes.  It is also unbelievably painful when a lack of health insurance is the barrier to easing that suffering.  That’s why Doctors for America, a grassroots, nonpartisan, nonprofit organization representing more than 15,000 physicians nationwide, is speaking out in favor of proposed reforms.  We believe that it is a moral imperative that every individual has the opportunity to seek care and receive services without having to risk economic hardship.  We want it to be illegal for health insurance companies to discriminate on the basis of pre-existing conditions, or to drop coverage when patients get ‘expensive’ diagnoses.  We want comparative effectiveness research that helps us practice evidence-based, best-practices medicine that is cost-effective.  And yes, we want to see a public option as the mechanism for providing a safety net for folks who don’t have employer-based coverage and can’t afford other insurance.  We want reform that supports primary care as a backbone to an inclusive health care system, with an emphasis on prevention, screening, and quality of life.

I really want to believe that in their hearts, those who oppose these common-sense and moderate reforms have kindness and compassion for all beings.  I hope that we can shift the dialogue now to how, not whether, to accomplish what should be collective goals of universal coverage and access.  The question isn’t whether we can afford to do these things – it is, rather, how can we afford not to? 

 Lila Rosenthal is a family physician and the Colorado State Director for Doctors for America (DFA).  To learn more about DFA, please visit www.drsforamerica.org.

As a small business owner, I buy my own health insurance. Two and a half years ago, my husband went to work at a small cutting edge company that offered only one health insurance option.  It wasn’t a good option for us, so I made the fateful decision that we would pay for our own insurance, believing fervently that the freedom provided by the insurance we would buy would be worth it.

In reality, it was something out of the movie Sicko.

My husband had a screening colonoscopy and removal of two benign polyps.  He was deemed “uninsurable” by several insurance companies I contacted.  (Now, mind you, this is not a obese, tobacco spewing, french fry chewing middle aged man!  This is someone that plays hockey every Sunday with former NHL players, bashes down black diamond ski slopes and jumps out airplanes for fun!)

My daughter was diagnosed with reactive airway disease at age 3, and had 2 ED visits at that age.   Nothing since, and she is now 12 years old.  She was deemed uninsurable because she was on flovent and singulair.  At one time I remember saying to the faceless entity on the other end of the phone, “it’s not like she’s on a vent for God’s sake!  She’s a gymnast.”

Click. Dial tone.

So we ended up buying one insurance policy for my husband, and a second for my daughter and me.  Our combined deductible is $7500/year and we pay approximately $500/month in premiums.  According to NPR, since my husbands lay off, we are under insured as we now pay over 10% of our income to health insurance.

Yesterday we got a notice saying that my husband’s insurance would go up $200/year.  This is the second such notice we have gotten in two years.

So, yes, I support insurance reform.  I pay heartily for the coverage I have, and I have no other options.  I am not saying that all we should have is a single payor system, but I think there should be more options then what is out there.  Health insurance for 3 healthy people is the largest percentage of our budget.  Something needs to change!

Last night, as I worked out at the Y on the elliptical, I watched Larry King Live, hosted by Wolf Blitzer.  The topic for the evening was  (drum roll): health care reform.  Special guests were the following physicians: former U.S. Senator Bill Frist, cardiothoracic surgeon, Michael Roizen, “Chief Wellness Officer” at the Cleveland Clinic, anesthesiologist/internist, James Rohack, president of the AMA and cardiologist, Sanjay Gupta, neurosurgeon and Andrew Weil, founder of Arizona Center for Integrative Medicine.

Does anything strike you about the panel? Yes, they are all specialists and physicians to the rich and entitled.  Not one of them actually practices primary care amongst real people.  I found it ridiculous that these are the “experts” the American media uses to explain why we need health care reform, and particularly reform in primary care.

The only one that actually spoke up about Americans taking responsibility for their own health care was Dr. Roizen.  He pointed out that Americans eat too much, exercise too little, smoke and don’t wear seat belts.  He was promptly dismissed by Dr. Frist, who stated that healthy habits can’t be legislated.

Wrong, Dr. Frist.

We can legislate seat belt laws, tobacco taxes and physical education requirements in schools and government jobs.  We can follow New York City’s example on trans fats.  We can encourage walking and bicycling by offering tax credits.  Our entire country can become healthier almost immediately and our health care bills will drop.  However, fewer of us will need by pass grafts and carotid endarterectomies.  The rich can still go to special clinics and get health coaching and the latest treatments, however.  The rest of us normal folk would get healthier by default–forced elimination of the nasties of obesity, sugar and fat highs, tobacco and couch potatoism will go a long way to making us healthier.

Works for me! What do you think?