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

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.

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!

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!

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?

Annals of Internal Medicine (July 21 volume 51, number 2) has an interesting article on trans fats, and an accompanying editorial.

I bring it up because of two things: 1) in this culture of health care reform, we need to look at the low lying fruit and 2) the accompanying editorial is ridiculous.

The New York City Board of Health mandated in 2006 that artificial trans fats be removed from restaurant food.  By November, 2008, use of trans fats in restaurant foods had fallen to 2%.  Trans fats are largely manufactured or modified fats, but naturally occur in small amounts in foods.  Initially, restaurants were urged via an educational campaign to voluntarily remove trans fats from use. Trans fat use in restaurants remained unchanged in spite of the educational efforts.  (Please see my post on “Influencer” as to why education as a mode of behavior change doesn’t work.)

However, once the mandate (and accompanying fines for non compliance!) went in to effect, use of trans fats fell to less than 2%. Now, long term effect on lipid profile has yet to be seen, but it seems a relatively painless step in creating a healthier population.

NOT SO, according to an accompanying editorial by Julie Louise Gerberding, MD, MPH, former director of the CDC.  She states that implementing a nation wide ban on trans fats (as they have in Denmark) is “impractical if not impossible” for several reasons. She claims:

1. Consumers will “inadvertently” substitute foods with saturated fats or higher carbohydrate loads
2. Corn oil is limited secondary to the “strong biofuel market”
3. There is not enough healthy oils and development is too slow to make this viable
4. “Pushing too quickly could do more harm than good, if producers are forced to resort to products high in saturated fats…”

Dr. Gerberding suggests instead that physicians inform and encourage patients to avoid trans fats.  She states that the FDA “urge clinicians to encourage awareness of the important influence of diet on heart health.”

Bull pucky.

Patients do not change their habits because of a once a year “physical” in which physicians urge them to eat better, exercise more, stop smoking, wear their seat belts, wear sun screen, get a colonoscopy, get a mammogram, get a flu shot, get an H1N1 shot, get a tetanus shot, get a bone density, eat calcium, and make sure the guns in the house are stored safely.  They are NOT going to eat less trans fats because I tell them it is bad for them.

Please Dr. Gerberding, use your considerable influence for the common good.  Eliminating trans fats is an easy fix.  Stop pushing it off on clinicians, and stand up for the American public, and for appropriate public health care.

What if physicians were reimbursed for talking about end of life decisions with patients? What if there was a code, say 99000-000.00 for the office based or bed side based talk with families and patients about end of life care? What if we could bill for one of the most important conversations we could ever have with patients?

Health care costs would fall and patient satisfaction would go up.  We could bring the patient and family to the office, have copies of medical power of attorney and “living will” paperwork available.  We could talk about where the patient is with their disease and life. We could take the time necessary to make plans to do what the patient wanted when the end of life neared, and stop doing the testing and treating that some patients (read many!) don’t want at the end of life.  Instead we could focus on what patients do want: dignity, friends and family, and freedom from pain.

So, maybe, there should be a place for the “99000-000.00″ visit in this climate of health care reform.  Think of the benefits for all, most importantly, the patient.

PS: in the meantime, consider handing out a copy of this article from MSN Money to patients.  Maybe it will convince them to move forward on their own to get an advanced directive.

Because I love you, I have gone to the ends of the internet to find definitions of weird EMR terms. I found this at a website, edited it, and hope you will book mark it for future reference!  Check out the definitions of  ‘Snomed’ and ‘Thin Client’.  Like it or not, EMRS are coming your way!

ADSL:  A type of DSL that uses copper telephone lines to transmit data faster than a traditional modem. ADSL only works within short distances because it uses high frequencies with short signals.
ASP:(Applications Service Provider) A business that provides computer based services to customers over a network. Also know as SaaS (Software as a Service)
ASP:(Active Server Page) A dynamically generated web page with ActiveX scripting, which executes on the server instead of on the Web browser (HTML). The Server executes the file and generates an HTML formatted page for Search Engine Spiders or Web Browsers for proper display.
BMI charts: Charts within EMR systems, which can manipulate data, perform calculations, and adapt to user preferences and patient characteristics; users may expect greater functionality from electronic BMI charts

CCHIT: Certification Commission for Healthcare Information Technology, the recognized certification authority for electronic health records and their networks, and an independent, voluntary, private-sector initiative.

Citrix Server: A server solution, similar to Microsoft Terminal Services that provides remote access to clients via the web or to dummy terminals in a network.
Clearinghouse: A company that provides clearing and settlement services for medical financial transactions. Some of the more popular clearinghouses include Emdeon/WebMD, McKesson and THIN.
Client-Server: A network architecture which separates the client (often an application that uses a graphical user interface) from the server.
Computerized Patient Record (CPR):  Also known as an EMR or EHR;.a patient’s past, present, and future clinical data stored on a server.
Computerized Physician Order Entry (CPOE): A system used by physicians to electronically order lab tests, imaging and prescriptions
Continuity of Care Record (CCR): A new XML standard being developed for EMR software vendors to follow which will theoretically allow patient data to be easily moved from one EMR vendor to the next in a structured database format.
Digital Imaging and Communications in Medicine (DICOM): A standard to define the connectivity and communication between medical imaging devices.
Drug Formulary Database:Used for electronic prescribing, electronic medical record (EMR), and computerized physician order entry (CPOE) systems to present formulary status to the provider while during the prescribing decision.
EDI: Electronic Data Interchange. Electronic communication between two parties, generally for the filing of electronic claims to payers.
Electronic Medical Records (EMR):  Electronic Medical Records. A computerized record of a patient’s clinical, demographic and administrative data. Also known as a computer-based patient record (CPR) or electronic health record (EHR).
Electronic Eligibility: An EMR feature which gives a payer access to deliver up-to-date insurance benefits eligibility information on patients.
Electronic Health Records (EHR): See Electronic Medical Records (EMR)

First Data Bank: The leading provider of drug information. Provides context and integration information for heathcare of every type at every level.

HCFA (CMS-1500 Form):The insurance claim form that a healthcare provider turns in to an insurance company.

HL 7 (Health Level 7):Part of the American National Standards Institutes accredited Standard Developing Organization (SDO);the Health Level 7 domain is the standard for electronic interchange of clinical, financial and administrative info among healthcare oriented computer systems. A not-for-profit volunteer organization, it develops specifications, the most widely used of which is the messaging standard that enables disparate health care applications to exchange key sets of clinical and administrative data. HL7 promotes the use of standards within and among healthcare organizations to increase the effectiveness and efficiency of healthcare delivery. HL7s international community of healthcare subject matter experts and information scientists are dedicated to the creation of a standard architecture for the exchange and transmission of clinical data.
Hybrid Record:  Describes a provider using a combination of paper and electronic medical records during the transition phase to EMR.

IEEE:  the Institute of Electrical and Electronics Engineers.

Legacy System:Term used to describe an outdated system (usually hardware and software), ie. old medical billing software system.
MEDCIN:  Clinical documentation nomenclature designed to provide E&M level coding assistance to providers through the use of a extensive database for documenting patient encounters.
Multum:  A popular drug formulary and alerts database.
Picture Archive Communication System (PACS): Used by radiology and diagnostic imaging organizations to electronically manage information and images.
Patient Portal:  A secure web-based system that allows a patient to register for an appointment, schedule appointments, request prescription refills, send and receive secure patient-physician messages, view lab results, pay bills, and access physician directories.
RAID (Redundant Array of Independent Disks):  A way of storing the same data in different places on multiple hard disks. Often used on servers to provide redundancy in the event of a hard drive failure.
SNOMED:  (SNOMED CT) Systemized Nomenclature of Medicine Clinical Terms. The medical language standard which details health care terminology, providing comprehensive coverage for procedures, diseases, and clinical data. SNOMED CT helps to structure and computerize the medical record while allowing for a consistent means of indexing, storing, retrieving and aggregating clinical data across sites of care (i.e. hospitals, doctors offices) and specialties. Snomed CT, in standardizing clinical vocabularly reduces the disparity resulting from the way data is captured, encoded and used for clinical care of patients and research. It allows for more accurate reporting of data and is currently available in English, Spanish and German.
SQL:  Structured Query Language: A computer language aimed to store, manipulate and retrieve data stored in relational databases.
Stark Law:  Part of the Omnibus Budget Reconciliation Act or 1989 the Stark Law prevents hospitals from purchasing EMR software and other equipment for private practice physicians in an effort to atract referrals.
SureScripts:  Electronic exchange that links pharmacies and healthcare providers. Founded in 2001 by NACDS to make the prescribing process safer and more efficient.
T1, T3 line:A high-speed internet connection provided via telephone lines often used by businesses needing internet connection speeds greater than DSL/Cable.
Terminal Services: Microsoft’s method for remote administration tasks that delivers the Windows desktop and Windows-based applications to nearly any personal computing device, even devices that can’t run Windows.
Thin Client:  Also known as a Dummy Terminal; a network computer without a hard-drive which requires a constant connection to a server for operation.
UB-92 Form:Form designed for hospitals to file a medical claim with the patient’s insurance carrier.
UNIX: A network capable, multi-user operating system used for workstations and servers. Many old practice management, medical billing and EMR software were originally designed under the UNIX operating system.

Web-based EMR: See ASP (Application Service Provider)
XML (Extensible Markup Language):  Used for defining data elements on a Web page and communication between two business systems. Example: Standard messaging system for and EMR to integrate with other software such as a practice management or drug formulary database.

Last night I ditched my tennis team practice and instead went to the Colorado Foundation for Medical Care “Launch of A Community Health Endeavor” meeting on how the community can/should reduce re-admissions to the hospital.  As you are hopefully aware, the CMS (Centers for Medicare and Medicaid Services) has mandated that the amount of re-admissions of medicare/medicaid patients must go down–approximately 20% of these patients are readmitted in the 30 days following their hospitalizations.  One of the hospitals I work at has been chosen to be part of a pilot study on decreasing re-admissions; CMS has picked 14 areas with in the country to take part in the initiative which CMS is funding.

There was a fair amount of finger pointing by some parties, a lot of talk, some power points, brochures and introductions, but not a lot of concrete planning.  I suppose it is early yet, but I was hoping we could get down to concrete tasks rather than the usual “it’s broken and has to be fixed.”  There was a panel discussion which contained the chief medical officers of the two hospitals involved, the director of the Center to Improve Care of the Dying from GW Medical School in Washington, D.C., a professor of medicine from the U–an expert on “care transition intervention”, two state representatives, a community liaison, and the chief medical officer of the Colorado Foundation for Medical Care.  There were no hospitalists on the panel.  The physicians on the panel were not “in the trench” physicians, but rather CMOs or University Professors.

Here are the general points that were made:

• Medication reconciliation is onerous to all, and the primary care physician doesn’t enough time to reconcile a med rec from a discharged patient.
• There needs to be a standardized form for all transfers.
• Hospitalists don’t pay for themselves, and make transfers even harder and more complicated.  They have some value however in that they are “enthusiastic” about making changes.
• Patients should have a Personal Health Record, (PHR), whether it is paper or electronic.  (No word on how we will access this–?from a memory stick?  Do I hear “computer virus”?)
• Nursing homes receive patients from hospitals/hospitalists “all the time” with out receiving proper discharge paperwork and medical reconciliation.
• Hospitals/hospitalists do not prepare patients for “the next care situation.”  One physician panelist asserted that hospitals and hospitalists “lie” to patients about nursing homes to get them out of the hospital.
• The way to fix all of this is by “Care Transition Coaches.”  These are non medical coaches are charged with visiting the patient in the home or nursing home.  They are to make sure the correct medications are being taken, and incorrect medications are NOT being taken, check that the patient knows who to call for problems (not necessarily the PCP), and that follow up appointments are made and that the patient has a way to get to them.  Additionally, Care Transition Coaches are to role play with patients so they know when to ask questions or bring up concerns at the follow up doctor visit.  (Example given: when following up with the cardiologist, the patient should not wait until “the door handle moment “to tell the doctor they are short of  breath when they lay down.)
• “Care Transition Coaches save $300,000 per coach.”  (Please do not ask me for the data on this number as I don’t have it!)

Hmm. The take away for me:

1. Transfers do indeed need to be standardized.  (I have ranted on this before.)
2. Medical reconciliation is paramount.  (I have ranted to hospital administrators on this, and am told it costs too much to do it effectively!)
3. We have got to do better at calling PCPs and SNIFs.  (And vice versa!)

As to the health transition coach: I’m not so sure.  I think the better solution is SLOWING DOWN HEALTH CARE.  Make it so we have time to contact each other, explain things to the patients, and review with the family what is next.  I don’t know that introducing yet another person into the mix –the “coach” is the answer.  I do believe that having the time to effectively communicate with patients, families and other care givers is!

And you? What do you think we should do to fix this problem?