Industry, Beauty and Environment

On our drive across the country, we took a little detour into a West Virginia canyon. The New River Gorge is full of great views and spectacular rapids (including a few class V's that got my former paddler heart palpitating). Winding our way between the New River and Charleston West Virginia, we found ourselves driving through an environment I had not previously been familiar with, although I had gotten inkling over the years.

It is the riverine industrial environment.

I say this tongue in cheek. The roads looked a little muddy, like a mudslide had been recently cleaned up. I did not pay attention to the piles of black gravel by the river banks until we passed what could only be a coal-fired power-generating plant. The smokestack was less than half the height of the mountains in that tight little valley. A fine soot was collecting on roofs, and on cars. Although it was a crystalline clear afternoon, I wondered about the health of people exposed to burning coal. There is a little pocket of northwest Georgia where air quality downstream from a massive power plant. Not surprisingly, "respiratory ailments" are high in the area.

It is perhaps, a truism that ecological degradation and poor health go hand in hand. The reasons why are not as simple even, as a chicken and the egg paradox. The simplest way I have come to understand it is that rich people move away to better areas when an environment starts become unhealthy. But poor people cannot leave, or else their jobs maybe attached to that area. It's not as simple as that, of course, but it's a simple way to think about it.

Of course I know about silicosis in coal miners. I am aware of general lung function deterioration in areas of poor air quality and the notorious London fogs of the late 18 th and early 19th century. I know of the drop of longevity that was the hallmark of the Industrial revolution in Europe and the US.

We all have to make a living; economic production is as much an issue for the poor of these areas, unable to move out due to financial conditions or ties to the land that go far beyond anything I have experienced in my own peripatetic life. Have we sacrificed vast swaths of the American landscape to industrial production? As resilient as Mother Nature is, are some areas no longer fit for habitation? Are some parts of this country too plain, thinly populated and of little biological importance that they can be sacrificed?

Perhaps it is not unreasonable to say that once toxic kinds of industrial activity is underway, people should not live in those areas. Bring them in by truck or bus or train, but do not allow them to live in the vicinity of these environmentally decrepit areas. This is the ‘nanny state’ at its best: allow economic activity, recognize that if social accounting systems reflected all the true social and environmental costs, there could be no profit, therefore no incentive to invest, therefore no jobs for the handful who need them. Government can and should mandate what areas people may not live because of environmental deterioration, but in the interests of creating economic value, can allow that certain parts of the country be destroyed in the interests of industry.

Concentrate industrial activity in the interests of limiting the areas where environmental degradation is a problem.

It is an outrageous idea, but seriously, is the landscape around Evansville, Indiana attractive enough to save for a park?

There are many problems with this idea, like, for example, who would decide? The cost and risks of transportation of raw materials and people are an issue. The only mechanisms of transferring the costs associated with such a radical way of running industry are via government, and I am not a proponent of big government.

But the biggest question may well be why some centers of the industrial economy are located near some of the most picturesque landscapes on the continent? West Virginia is a spectacle of Appalachian beauty and yet its riverbanks are spoiled (in my eyes) by 100-foot mounds of coal. Louisville's riverfront is dominated by highways and infrastructure. Most of the waterfront in Jacksonville, FL is dominated by the port.

Maybe I'm just a sentimentalist tourist, expecting natural beauty in places where the business of human life is more important than the exigencies of beautiful vistas.

The Great American Desert

Posting has become spotty, not due to traveling and the holidays, as much as the fact that this morning, my wife and I begin our 3500 mile coast-to-coast drive. The packing has been intense, shoehorned as it was between jobs and graced by the festivities of the season.

We will spend New Year's on the road and the details of the road trip must be shrouded in the veil of my anonymity, which is becoming more fragile and more difficult to justify as this blogging gig is spilling over into print.

It has been 5 months since this blog began and it is moderately successful. I have surprised myself with how much I had to say. I am more pleasantly surprised by the extent of the positive response. What began as an exercise in self-expression has become a way of clarifying my own convictions, less self-indulgence and more exploration. I am impressed that anyone at all has been interested in what I had to say, and humbled by the quality, sensitivity and intelligence of my readers.

Wish us good luck and know that, even if the missives become less frequent for a time, there are more interesting changes coming in 2008.

See you on the road.

Christmas and Change

Merry Christmas. Christianity was seen by Bertrand Russel as an excuse for mediocrity. I think this perception can arise from Christianity's insistence on the potential for change.

Christianity is (or at least should be) about forgiveness and redemption above all. That means no matter how inadequate we are, how erroneous our ways, how mediocre our performance, there is always the opportunity for improvement. This position can sometimes seem to excuse past mediocrity, perhaps even celebrate it and reward it.

I was an awkward child, and a certain social awkwardness has penetrated into my adult life. But I am getting better. I have made many mistakes and continue making them. But I need to be free of the baggage of past errors in order to progress. For this reason perhaps, Christianity seems so ready and willing to forgive everything, in heaven if not on earth.

There can be no redemption without guilt. There can be no change without mediocrity. They are the catalysts for change.

Have a warm and happy day.

Doctors and Customer Service

Because The Physician Executive is leaving Maryland, headed to the Great American Desert, he has been spending an inordinate amount of time talking to other companies' customer service experts. When a customer calls to cancel their service, they usually are shuffled off to some of the better folks at handling customer service issues.

My response to this experience is to wonder how, for a service economy, you can't get any. Service, that is. Maybe health care is not doing so badly after all.

Gas and electric handled my departure with grace. Dish Networks offered options that didn't make sense and made me feel like a heel. Verizon (as usual) transferred me to four different people before they hung up on me when I expressed some frustration with the process. After going through three more people and a total of 1 1/2 hours on the phone, I finally understood that they intended to extract as much money from me as possible with lame justifications of service contracts for internet service, which now apparently renew annually instead of just expiring after the one-year term.

And we worry about transparency in health care?
We feel we are not getting good outcomes?
We worry that physicians do not provide adequate customer service?

Of course, there are lapses in any industry as large as this. No single company could hope to go through even a year without a significant lapse in customer service. I know there are stories out there... But overall, my impression is that physicians, nurses, pharmacists and all other allied health staff are generally professional. Do not forget that it is frequently a physician's job to refuse care; as in narcotics, excessive testing and unnecessary treatments. Somehow we manage to convince most of our patients that there is a better way.

We use the principles of shared decision-making, patient-centered care and self-management to come to reasonably satisfactory solutions. Using the parlance of customer service, the customer's experience is necessarily negative to begin with, since many clients are sick, afraid and upset due to their illness or condition. As an industry, we generally manage to treat people with compassion, caring and a modicum of dignity.

We drop the ball sometimes, especially in hospitals where the urgency of care sometimes leads to a neglect of personal propriety. When we need access to someone's neck veins in a hurry, we don't worry about what body parts are really naked. Privacy has always been an issue around the break room (and HIPAA is inadequate to the challenge). We have trouble dealing with drug-seekers and malingerers, who represent a betrayal of the compassion and skill with which we approach sick people (i.e. difficult patients are difficult.)

Apart from the odd scalpel-throwing surgeon or consultant-on-a-soapbox, I can't think of too many instances of internal customer catastrophes. In other words, we even manage to treat each other with some respect the vast majority of the time.

Customer service skills (or bedside manner, as it used to be called) are distributed as a bell curve in any random population; some do better than others. But overall, as a profession, as a group of professions and as an industry, don't we really do better than folks like Verizon and the cable company? On a risk-adjusted basis (adjusting for the fact that most patients are grumpy about even having to be a patient) we may, in fact, be stellar.

Not every problem needs fixing. Sometimes, no matter where you sit on the bell curve, your eyes are fixed on improvement. But little by little, we raise expectations and diminish our ability to provide any return on investment or effort.

We can lose sight of the fact that, compared to the level of service received in retail, business services, financial services, hospitality, IT and others, health care does reasonably well. We can lose sight that the law of diminishing returns dictates that significant improvements from here will be prohibitively expensive and pack only a small punch. Sometimes, the emphasis on customer service can belittle a worthy industry and its workforce.

Personally, I think we are doing well, and our weaknesses come to rise from the expectations that grow as a consequence of our success.

A Marketing Tool for Physicians and Policy Makers

Back when I got my management degree, albeit at a school of public health, I noticed how many approaches to understanding management involved divisions by four. The two-by-two matrix seems an easy way of characterizing the world and the approach has made many a career.

Take for example the service process matrix and the BCG matrix; even a SWOT analysis can be interpreted as a 2x2 box.

It always seemed to me to be an extension of the dualism that affects early human intellectual development, but aside from the obvious fact that two dualistic axes is better than one, splitting the world into two is a useful didactic tool.

So why should health care be any different? The Harvard Business Review reports on a study that divides health consumers into four, along financial and health spectrums. One thing I love about this type of exercise are the colorful descriptives that creative types can come up with.

• The first group is characterized as Healthy Worriers who have nothing to worry about but their growing inability to pay for future health care. This is probably the largest segment in the US.
  
• The Healthy, Wealthy and Wise have the resources not only to take care of their future illnesses, they are also motivated to maximize their current functioning, a different take on health.
• The Unfit and Happy don't recognize their risks and the significance of their actual health status. They mistrust the health system and justified or not, probably represent the bane of most physicians and providers.
  
• The Hapless Heavyweights. This is my segment, unhealthy and impotent to change anything, they need external support and motivation to lose weight, quite smoking, take their pills and actually show up for their next appointment. Come to think of it, a significant proportion of public health activities are focused on this group.
  

I suspect that the movement of consumer-directed health care was conceived to help the Health Worriers, but it seems to appeal the most to the Unfit and Happy. A parallel may be drawn to the rise of discount brokers in the 90's and the rise of do-it-yourself investing.

Mistrustful of the lack of apparent value in bad broker's advice over the years, I started finding information on the nascent web and making my own decisions. I found inexpensive sources of information, inexpensive trading platforms and made a small fortune. I also underestimated my risk and took a bath when the market collapsed. I have since rebuilt my portfolio by seeking out the professional advice I once eschewed, but continuing to use the internet to find that information. I still rely on my own judgment of Lehman or Prudential's research, but I have also learned where the holes are and use Google as my best overall financial adviser.

So in health care, some patients, mistrustful of the apparent lack of value in physician services, seek their own information and make their own health care decisions. Impaired by a lack of experience and perspective, they make errors and suffer health consequences. Eventually, this group learns how to use professional opinion and improve their decision-making, continuing to use alternative information resources to make better purchasing decisions.

But one way or another, efforts to reform the health care system tend to address the concerns of one or another of these groups. It rarely encompasses all groups. Not everyone was ready for discount trading in the 90's, not everyone is ready for consumer-directed health care today. Improving conditions for Hapless Heavyweights is decried as "nanny-state" interventionism by the Healthy Worrier. Reducing anxiety for the Healthy Worrier is met with accusations of freeloading from the Healthy, Wealthy and Wise.

And so on. The California debate will probably demonstrate these schisms yet again, but this HBR article may help us understand the market a little better.

Segment and conquer.

Billing Fraud Incentivized By Coding

I'm not sure what to make of this post at "Every Patient's Advocate." It follows up on a Steven Cole OpEd in the Dallas News, in which he points out that doctors prescribe medicines and order tests just to justify higher reimbursing billing codes.

There are certainly some medicolegal reasons for ordering tests and prescribing medications, many of which can be addressed by working on the communication skills of physicians.

But billing?

Poppycock!

The codes in question are 99213 and 99214. The principle is that you're pretty poorly remunerated for these visits, so you may as well capture what you've already done; document up to the code appropriate for the complexity of your patient.

Studies show that most primary care physicians underbill 99214. This is an established patient code; new patients have a higher documentation requirement and physicians tend to overbill the equivalent codes.

Get that; physicians underbill the one and overbill the other because the documentation requirements are different and they generally do not make the effort to learn all the details of billing. Physicians do not generally consider documentation and billing important parts of their calling.

So that must be why they prescribe drugs and order tests to get paid more... Yaaaaaa, riiiiiight!

Well, Dr. Cole is an allergist. I don't know how his colleagues behave, but I certainly know about primary care physicians. It's not what he describes. But even if we were to accept the notion that physicians practice patterns are affected by reimbursement rules, then all I have to say is "the trouble with incentives is that they work."

The CPT coding system was devised to distribute resources according to the effort required. Somebody underestimated the effort required by primary care and most especially the degree of risk assumed in primary care. But fraud is not worth it at our compensation rates. Physicians are smart enough to figure out whatever stupid system of regulations is thrown at them. Don't blame the physicians, blame the inadequacy of the regulation.

And as far as patient advocates are concerned, you have just shown me yet another ugly aspect of consumerism in medicine. Throw your efforts at improving the medicolegal environment, increasing transparency of the charges, and use primary care docs as your best advocates to guard against the worst that American medicine brings to bear.

We Need Votes

MedGadget is running the 2007 Medical Blog Awards. I think I'll nominate myself, but it would be so much cooler if you did.

Change in Health Care: Government or Corporate?

There is a great phrase I hear frequently on financial news programs. Usually it is from the mouth of a CEO, like Lily's new chief being interviewed this morning, and it goes something like this, "We will continue to drive change."

It sounds like a sports athlete coached to use canned sound bites like "our goal is to play hard and come together like a team."

The question that comes to mind listening to CEOs, who have become true celebrities in the last decade or so, is whether driving change has anything to do with playing like a team.

Change is not something capital can typically accomplish. Most often, the "change" is a fundamental change in the environment or the landscape. In a more Buddhist vein, I would suggest that change occurs in the river. Corporations/capital is like a canoe in the river. If the stream goes one way and the company goes another, someone's going to get wet.

Companies do not drive change. They navigate change something like shooting rapids.

Of course, some companies catalyze change. Microsoft was successful because the product they offered fundamentally changed the way America ran their businesses. But companies rarely, if ever, actually drive change.

I may have confidence in the power of markets, certainly as opposed to central planning of economies or government regulation. This approach tends to reflect a knee-jerk response to a perceived problem, thereby not accounting for the inevitable unforeseen consequence. You can't take just one noodle out of a bowl of sloppy spaghetti without making a mess.

On the other hand, I am losing confidence in the ability of capital to innovate (it would rather diminish risk), to drive change (the status quo always reflects less risk) or to self-regulate (there is altogether too much corporate influence in US governance, don't you think Dick?)

Change is much needed in health care. Will it come from well-meaning activists who would use the levers of government and probably make things worse? Will it come from capital whose interests, like pigs at a trough, compete for a limited amount of feed? I don't think capital can do it especially because the interests of pharmaceuticals and devices, hospitals, insurance, specialties and primary care are typically at odds with each other. And they resist change.

I hope activists who would use government as an instrument will remember to use the markets to their advantage and not to over-regulate. Government can work, just not the way folks are talking now.

The Meaning of Life

With all due respect to one of my former colleagues (who shall remain nameless), we recently got into a discussion regarding my future work plans.

She told me that she did not believe in God or an afterlife and figured what she was going to do with the last few years of her work life and into retirement was based on an accounting of what she valued. It's from zero to 10, she said, there's nothing after.

Of course, I do not wish to contradict anyone's beliefs because I do believe in God and an afterlife. The literality and inerrancy of the Bible are just sad remnants of a humanity that forgets meaning is in the eye of the beholder.

What occurred to me is that, in ethics as in life, there could be very little difference on our decisions based on our belief in God. Those who would believe feel they have to justify their life to God in faith and actions that reflect the faith. "What have you done with your life, dude?" is the question I am preparing for. If I didn't believe in God I would still want to maximize the value of my life. As an atheist, what standard would I use to measure myself?

Even though the "value" could be centered differently according to which ethic I prefer, a Christian or an atheist one, there remains the very concept of ethics. Embedded in the very need for the word to exist is a notion that there is a greater good than that which can be defined by the individual. Even if one was sufficiently egotistical to believe that their set of values was all that mattered to the entirety of creation, it remains that these ethics are all that matter to them.

I wonder if it isn't possible to perceive a kind of spirituality in atheism, that Christians are often too blinkered to see. I suppose I might say the same for Jews and Muslims, since my point is that spirituality transcends religion and may well exist as long as we speak of ethics.

The existence of the concept of ethics represents to me a basic human need to see a finger of creation behind the random events which make up our lives. I conceive God in the traditional Christian "person", but even if I didn't, I would still feel the need to justify my life to myself or even to a random Brownian universe. The process is the same, the name differs, as does the lord, the prophet or the energy.

St. Catherine of Siena, a mad-as-a-hatter nun if ever there was one, expressed this wisdom to the Pope once in her own defense.

It didn't fly and she had to recant to avoid excommunication. How sad the world of religion, rather than the full spirituality which we need, atheist or not, to make sense of this random world. Perhaps this is why St. John Chrysostom wrote about the gift of tears which affects those who discern the state and health of the human condition.

Chronic Pain, Malingering and the Difficult Patient

There have been some recent storms in medical blogdom over physicians refusing to prescribe pain medication. It seems some patients, especially someone named 'Anonymous Anonymous,' have taken exception, vomited vitriol and demonstrated that action and reaction are most visible at the point of conflict.

Consider the following:

Scalpel or Sword original Letter From a Chronic Pain Sufferer and a response in the Angry Migraineur.
White Coat on The Great Pain Debate and an observation in Disturbing Conversation.
Dr. Val's November post critical of physicians.
Consider understanding posts by a nurse and an English EMT

Let's call these people difficult patients; crazy or not, we need to deal with them. Here are a couple of great articles on the Difficult Patient in AFP, FPM and Medical Economics. There is a difference between the malingering patient (the one who storms out of the ER to get a heroine fix at her sister's) and the somatizer (often an unhappy middle-aged woman with abdominal pain migraines and a high depression score, but no insight).

We all know and hate the malingerer. In fact, it can even be fun to catch them in the act and watch them as they play up their dignity and indignation, as they slink out knowing not to mess with you again. But the somatizer is a type of difficult patient who we sometimes lump in with the malingerer. This person, I have some sympathy for, although rarely the patience to deal with effectively. They will counteract your every action, negate all help and have probably been their own worse enemy since long before you ever met. Sometimes all you can do is make your suggestion, smile and say you're sorry for what they're going through. Sometimes that's all their looking for, a sympathetic ear.

I even wonder about the people with real disease, such as sickle cell, who come in with marginal crises on occasion, planting yet another seed of doubt to infect my interactions with other patients.

Yes, our jobs are difficult all around, and ER physicians have reason to be frustrated by certain aspects of their jobs. But we need to learn to deal with the fact that about every 7th patient encounter (15% estimate quoted in the Med Ec article) will raise our blood pressure with some kind of manipulation, lack of insight or just plain dysfunction on the part of a patient.

No, we don't have to prescribe narcotics in inappropriate settings. Indeed we should prescribe narcotics as little as possible.

No, we don't have to argue with patients who are in need of deeper emotional care than their insight allows them to recognize.

No, we don't have to treat these people as GOMER's ("Get Out Of My Emergency Room") even as we show them the door.

But we can upgrade our skills. I for one, need better strategies to remain calm, especially when I know I'm being manipulated.

And if you're a patient who is tempted to flame me, read this:

There is a reason you need a prescription. There is a reason you need to see us. Don't forget, many of us have pain too. We don't let it stop us. We do want to treat it well. There are alternatives to medications. But the expectation of a painless existence is no longer a credible or reasonable expectation for you. Work with us and do not put yourself in the position of being lumped in with the malingerers.

Granny Can't Die [UPDATED]

Have you ever thought about how we die in America?

I guess there are occasions that a certain latent anger disturbs my usually inscrutable internal peace. Such as this earlier post, for example...

An off-line commenter (nobhilltreehouse) chastised me, saying the following:

Comes across callously and jaundices other posts. I know what you mean but I would have preferred: '"cause these days a dignified death comes with an all expenses unpaid trip to the ICU, replete with tubes, moving parts and tubes ad infinitum" or something like that.

Indeed, it comes across callously and for that, I apologize. Most especially, I am sorry because it deflects attention from an idea worthy of it's own post: how poorly we die in America and how much it ends up costing us.

In fact, my experiences with medical technology have highlighted for me the difficulty of deciding when medical heroics are futile. I really should know better.

I once felt the speed of the losing elderly family members as a blessing in disguise, a kind of nostrum against grief. A couple of years ago I lost a friend to cancer, in part because I couldn't convince her to undergo chemotherapy rather than the naturopathic remedies she preferred. Later I stared at that fearsome suffering we dread and found that technology can diminish as well as create it. For all the suffering, there are people in my life today who wouldn't be there otherwise.

This New Yorker article describes a medical miracle, such as those that frequently grace our televisions achievements that are actually mundane and unimpressive. But consider this amazing story of a 3-year old girl that fell into a frozen Austrian lake and disappeared under ice for over half an hour and was demonstrably brain dead early in the weeks-long efforts to save her life and then rehabilitate her. She is now a normal 5-year old.

Our ICU's are choked with people whose survival prospects are somewhat slimmer, to say the least. The Happy Hospitalist described a man with lung cancer and emphysema/chronic bronchitis who was receiving significant medical care. Would it be reasonable to undertake an effort as complex and resource-intensive as would be necessary to save this man if he had drowned under a frozen Austrian lake? I wouldn't want to be the one trying to say 'no.'

The story of the young Austrian girl carries with it a touch of the magical which is hard to separate from the cold scientific reality of day. But who is to judge? I am far enough away from my days in the ICU to shake my head with the same sense of awe my father, a physician who trained in the 1920's, had as he heard about my experiences in medical school.

I have pointed out in the past that the need for health care is an emotional one. The clinical economic term of "health care purchasing decision" does not speak to the panic a parent would feel if their child slipped into an icy tomb. That panic is no different if it is one's father; cancer and COPD and having lived a full life are pleasantries for the wake, not useful in the moment.

My close personal knowledge of the emotional aspects of health care decisions makes my apparent callousness and cynicism all the more inexplicable. Physicians do not make life and death decisions; typically it is the families that do so.

They need guidance on alternatives to heroic treatments and how realistic it is to expect recovery, so they can weigh it against the granny's wishes and her suffering while under treatment. An army of well-paid counselors and ethicists would cost us less than what we are spending on end-of-life care that I would judge as futile from my comfortable and sometimes jaded perspective. Presumably, a hospitalist and a critical care specialist would have a more aggressive perspective than mine. I would certainly seek out their advice and counsel to make up for my more recently acquired ignorance of the capabilities of a well-trained ICU team.

The problem is that specialists in intensive care can be unnecessarily optimistic at times. They hate losing a patient as much as anyone else. Consider also that their training is focused on saving lives, not letting them go. Our perceptions can shift according to who we're speaking with. If a family member is ill and you have a well-trained, compassionate physician, you will hear a lot about the possibilities that sound as miraculous as an Austrian child who died for several hours, but nobody gave up. Even talking about the risks and the expenses sound like so much fine print disclaimers on a credit card application that no one ever reads.

Problem is that it is expensive. Nobody should have to face the emotional agony of making a life and death decision based on money. Thus health care consumers expect all efforts to be made for our families. This impulse is so strong that we sometimes even make heroic efforts to save the lives of patients with living wills that explicitly limit such efforts. Thus, the bulk of Medicare expenditures are "wasted" on the last year of life.

It is end-of life care, after all. An economist may well define this care as expensive with no discernible return (but I doubt they would slip up so badly). If we define quality as "right care, right time, right person" then we must also define the "right perspective." That would be the perspective of the patient and the family.

This is where individual values are at odds with societal ones and there is no happy medium. Somewhere in the debate over paying for uncompensated care, we need to recognize that patients must get accustomed to being told that they cannot have care they perceive as necessary, because the odds are not good. And anyone who says 'no' is likely to get strung up and shot by a frantic, grieving family member who feels wronged.

UPDATE: Same day, similar thoughts, different blog. Actually, it looks like Panda Bear posted on the same subject yesterday before me, but we must have been working in parallel.

In addition, yesterday's Globe & Mail highlights the conflict between the abilities of medical technology and a cherished Orthodox Jewish value of never giving up hope, no matter how grim or how much it costs. Some may view this point of view as completely untenable from a resource perspective, but it is as old as Maimonides. It is the story of Samuel Golubchuk, a Winnipeg man whose family prevented withdrawal of life support by appealing to Manitoba court. The legal issues in Canada are related to the need for consent to actually remove someone from life support.

Think It Out Loud

Jerome Groopman's book How Doctors Think is doing really well and is on Amazon's Best of 2007 list.

I came across this article in one of my literature scans and thought about how we use the technique of "thinking aloud" in teaching residents. Clinical reasoning can only be taught if the learner's reasoning is made explicit for the purpose of evaluation, reinforcement and occasionally correction.

So how would patients respond if they were included in the "think aloud" exercise? I have been both criticized and praised for the fact that I tend to share my thinking with the patient. In fact, I usually get in trouble for taking up too much time. Joint decision-making and evidence-based medicine take a lot of time in practice, so one must wonder if it is possible to invest time sharing our reasoning and still churn 20 - 30 patients a day.

An article from Health Services Management Research would suggest otherwise. I think I'll just order another CT scan! Yes, this is how cutting Medicare reimbursement to cognitive specialists could increase health care costs.

Pay us for thinking and involving the patients in decision-making and maybe we won't just refer, test and follow-up in two weeks.

Health Wonk Review Closes Out 2007

HealthBlawg presents the latest Health Wonk Review, an end-of-year, Happy Holidays wonkfest. It is heavy on politics, given current action on the hill and approaching primaries. Rob Laszewski's Huckabee analysis is most welcome (that man frightens me).

The Happy Hospitalist: Why is Health Care So Expensive?

Health care is expensive. Making use of people's expertise and motivating them to take on responsibility and risk is expensive. Having a workforce belonging to a licensed healing class is expensive, whether you call them doctors, nurses or PA's. The more educated, the greater the number of years in training and the greater the debt, the more expensive they will be.

The Happy Hospitalist shows us some reasons he has uncovered for health care being expensive:
The Happy Hospitalist: This Is What Chronic Illness looks like

Happy, you missed one: dying in America is expensive, 'cause granny just can't die!

Mass Customization in Health Care

Mass customization is a concept which, more than any other in the business world, has the potential of reaching physicians.

Attempts to improve health care quality and performance have relied on ideas imported from the business world, most specifically from manufacturing. Mass customization comes from that environment, but is also increasingly applied in the service industry.

The first system that I came across was Six Sigma. The attempt to reduce a defect rate to 1 in a million or 1 in ten million provoked ridicule among my physician colleagues in class. Eventually it sinks in that the defects in question are process defects: charts, weights, temperatures, getting medications given at the right time. It had little to do with what we physicians recognized as our jobs. Instead, Six Sigma referred to everything that went on around our jobs, enabling or obstructing our efforts.We were thinking health outcomes, they were talking process outcomes.

This is how a group of skeptical physicians and a diverse group health professionals, including pharmacists, nurses, program managers, administrators and epidemiologists, all got on the same page. I would never have imagined something like this was possible until I saw it for myself in my Master's class.

After all, if you think about the complexity of flying planes, and applied the same rigor as a pre-flight checklist to medicine, it would be a miracle if any metaphorical flight would ever take off. Flying planes is not as complicated or as filled with uncertainties as providing health care.

Years after my MPH, I recalled how the physicians, including myself, came around and thought there was an important lesson to be had. Physicians can become so insular as to reject the contributions of very smart people from outside health care, "because they just don't understand."

Well, personally, I'm a "lumper". I see more similarities in things than differences. All the while I try to respect the differences between people and their experiences, deep down inside, I know the differences are only superficial. Medicine is like any other industry, except that we deal with more uncertainty and do so almost automatically, by virtue of our training.

As an aside, I believe that this ability to handle uncertainty that should be our greatest strength and selling point, but somehow physicians manage to stumble over it. It seems that we become vulnerable to uncertainty when the link between what we do and health outcomes is questioned. However that is a property of the battlefield terrain, not of the soldiers that tread fearlessly on to battle on it. But enough of the battle analogy; let's move on to cars.

Later in my career, I came across the Toyota Manufacturing Process, also know as the Lean Methodology. This is rising in popularity in health care today. One of the first principles is that we don't know anything. None of the people at Toyota knew anything about building a car and decided to break the process down to its quantum bits and figure it out.

I don't think physicians would object to someone approaching them with that attitude. In addition, the physician would have to accept that they know nothing about all those little bits of process that surrounds everything they do (i.e the paperwork).

Physicians inherently recognize the amount of resources wasted, spinning wheels, waiting and delaying because there is always something that prevents them from getting done what needs to be done. As an intern, I used the age-old techniques of schmoozing and being nice to people to get scans done on my patients at the drop of a hat. My length of stay was the envy of many a supervising resident, who then proceeded to give me a hard time about why I couldn't get a nuclear scan for one patient (when I had reservations) but could get anything on anyone at any time.

I was just schmoozing and found efficiencies beyond the imagination of my supervising residents. And that was eighty years ago when there was very little we could do for patients compared to today. [OK, I'm not that old, but I am thinning out lately.]

"Lean" aims to make the system surrounding the actual delivery of care (in a physician's eyes) as waste-free and seamless and possible. I think the docs would buy into this one, but would hold back over the fact that they will remind us how their patients are different.

Everyone who has ever had to manage physicians is smirking right now. Riiiiight. Every doctor's patients are different.

Mass customization addresses that concern. Every patient is different and gets to choose from their incoherent Chinese menu of options under a physician's guidance. Every physician has their preference in treatment or test. Erythromycin or penicillin can be a gut call. Stress echo or PET scan should not be. Sometimes, the preference is just too expensive to be tolerated.

But every patient is different, or at least different enough to feel that their specific concerns are being addressed. Physicians generally do that very well, though probably not as well as the legion of customer-service-savvy alternate medicine providers like chiropractors and naturopaths. Going through a hospital or large clinic should not be an alienating, frightening crap-shoot. Will the nurse be nice? Will the radiologist know how to read the film? Does the surgeon know right from left?

Every patient is unique and must be treated that way. The systems the patients travel through are not unique and need to be smoothed out, made predictable for both the patient and the physicians who ultimately will provide the revenue stream for the entity. All of this depends on obsessive attention to processes that physicians do not traditionally view as their purview. But if we are forced to take a minute prior to a procedure to make sure we have the right patient and the right equipment for the right procedure, we will get safety right each and every time. Also efficiency will rise as the incidence of screw-ups (defects) declines.

That means more money, lower costs and better outcomes.

Literate Medical Blog Posts

Sitting in Denver is called catch-up time. All things considered, there were a lot of interesting articles along the way and a few reached the level of this weekly award's criteria: well-written, good/atmospheric vignette or clear brief essay.

My selections for the top 3 this week:

1. james gaulte @ retired doc's thoughts on The Good Doctor Worries About His Patient
2. Bob Wachter @ Wachter's World on Adventures in Bizarro Land: My Don Imus Interview
3. Val Jones @ The Voice of Reason on Breast Augmentation: Mixed Emotions

How about insuring providers instead of patients?

The Economist's take on the US health care debate makes the assumption that the lack of universal coverage is an anomaly for so wealthy a country. The concerns about mandates is prominent, especially given the general lack of information as yet about the success or failure of the Massachusetts plan, which relies so heavily on the individual mandate.

Maybe a scaled-down employer mandate would work with the government contributing to the rest? It's not really the patients we really want to insure. It's the doctors, hospitals and labs. Right now, uncompensated care is disproportionately affecting all our costs. Maybe this would be a better place for a government bail-out.

The Economist adopts a position of detached bemusement.

Dr. Greenspan and the health insurance debate

I am stuck at the Denver airport in the snow. Our plane was delayed for two hours at the gate in Baltimore which means we missed our connection. Now, it's getting dark and the flurries are threatening a good old fashioned blizzard. We're still scheduled to get out of here by 6:30 this evening.

One good side of airport delays is the opportunity to read more print text than I have in the past three months (the totality of which has been a slim book by an Egyptian Jesuit). I finally got into Greenspan's Age of Turbulence. It's a surprisingly easy read (especially if you've listened to his congressional testimony) and came across a notable quote:

The existence of a democratic society governed by the rule of law implies a lack of unanimity on almost every aspect of the public agenda. Compromise on public issues is the price of civilization, not an abrogation of principle.

The current debate on universal health coverage [note, I did not say government controlled, single payer or insurance] has left me flummoxed by the lack of consistency and logic on both sides of the debate. It is good to be reminded that market-based solutions and a responsible approach to health care costs are important in an effort to increase wealth and the fairness of its distribution. If I have previously had trouble articulating the purpose of health care coverage, Dr. Greenspan has shown me the words and reminded me how the process is really a rugby scrum of competing interests pulling and pushing in different directions (image stolen from James Gaulte, as promised).

At least I finally found free internet in Denver.

Medicare Reimbursement, Physicians, Hospitals and Your 401K

Wow! Is there any reason to believe that between physicians and business interests, physicians will ever get it together enough to win?

I have been looking at the Medicare payments reduction of 10% with dismay, knowing full well that an increasing number of physicians are dumping Medicare. I always thought the major problem would be in rural areas where physicians dedicated to their communities cannot survive without the dominant insurer. Rural practitioners are folding their practices into large hospital-run groups or merging with FQHC's. A large reduction in Medicare payments would force a significant proportion of rural practitioners out of business or into groups.

But it took a GoozNews article for the light to go on! President Bush has threatened to veto any plan that cuts Medicare Advantage payments (Democrats take note, you can probably tie our fearless leader up in court for the duration of the next presidential term if you can figure out where the payments went). As long as Medicare Advantage plans are strong, physicians simply don't have a choice. Any physicians who tries to contract with a managed care company will be told "take them all or take nothing at all." Those physicians who can afford to drop Medicare cannot afford to be entirely cut out of the insurance market.

Actually, they can, but it is frightening to consider a cash-only model when you've been processing insurance for eons. Certainly the large groups have to eat the decreased reimbursement.

Take Goozner's analysis the next step and it becomes obvious that if you can't cut deeper into physician reimbursement and you won't touch Medicare Advantage, then the only place the money can come from is hospital reimbursement. This will hurt the cities, not the rural areas, because rural hospitals benefit from cost-based reimbursement. Inner city hospitals have had to become more efficient or close. On the other hand, rural hospitals have benefited from more money and many have milked it for all it's worth. The perversity is that semi-rural critical access hospitals un suburban and urbanizing areas stand to benefit the most, while inner city poor people's hospitals like Grady suffer.

In other words, the goal of improving the population's health does not receive much attention. The goal of protecting the health insurance industry's profits appears close to being accomplished, at least for the next fiscal year. I know where I'm putting my 401K money.

Cavalcade of Risk

This biweekly collection of matters related to risk, including insurance of the health type, is a fascinating window into a world outside medicine, which mysteriously and ineffably alters how medicine is practiced. As such, I recommend this week's Cavalcade at Joe Paduda's ever-opinionated, erudite and intelligent blog. I particularly like Lisa Emrich's take on Montel and big pharma.

Pharmacy Wars

So what happens when a retail pharmacy chain and pharmacy benefits manager merge? [PBM's are used by your managed care company to handle the pharmacy benefits side of the insurance.]

A war breaks out between retail chains, that's what.

CVS and Caremark are among the largest retail pharmacy chains and PBM's respectively. they also became one company in March of this year. So Walgreen's terminated their agreement over poor reimbursement. Nice try CVS/Caremark.

Physicians (and payors) take heed. Nobody told you to accept poor reimbursement. Reject the contracts and see what happens.

[UPDATE 12/5/07 1:45 PM: This is what happens.]

Canada and Health Care

I've been approached recently by a couple of Canadian mags about my American experience. It got me thinking about Canada's contributions and got me reading some Canadian content online.

I came across this article. It seems that Canada's scientific contributions have accelerated of late, despite a highly socialized system and government-run health care. Highly accretive societies like the US can quickly forget that some of their greatest heroes are "foreigners." So in the spirit of international cooperation and the remembrance of our common human nature, may I remind my adoptive fellow Americans that Neil Young and Bryan Adams are as Canadian as insulin and blood testing for cancer.

How Emotion Leads to Health

The Harvard Business Review has a feature on how people who feel strongly about their choices make better business decisions.

I can think of a couple of former bosses who could have benefited by not crowding out the emotionality with which I have approached key decisions in the past. I do my best not to say "I told you so" because I know there are other occasions that an apology would be more in order.

But the times I was most chastised for being emotional with respect to a business decision were the same times I was most committed to the best course for the organization.

This applies in other aspects of health care as well. Most health care purchasing decisions are made by the physician, the patient and the patient's family. Public health experts tend to miss the fact that these decisions are inherently emotional and resist the imposition of analytic processes based on measures such as cost-effectiveness, medical necessity and a paternalistic intervention by an impersonal and well-meaning body of reason.

Economists would say value is best determined (in aggregate) by how much a person is willing to spend for a given benefit. In any market where the real cost to the consumer is minimized by insurance and government-sponsored coverage, "value" becomes difficult to determine and extensive distortions give rise to what we have now: a crazy patchwork system of competing interests struggling against common goals.

Public health is impaired by thinking in the vertical silos of disease processes. There is a program for TB control, another for heart disease, yet another for accident prevention... Health care delivery must be better integrated by context: eg. school health, primary care, diagnostic and therapeutic intervention, and hospital-based care.

Health economists are impaired by not thinking enough about the range of potential economic benefits of interventions for specific diseases and conditions within those environments.

Many people appear to be missing the point that health care is not something anyone wishes to use, with the possible exception of preventive care. When someone is sick, health care consumption decisions are made in the context of emotionality, not reason and, if the HBR article is correct in its assertion, those decisions are made better by their lack of rationality [assuming that reason and emotion rest in opposition].

How Loneliness Relates To Health

This weekend we decided to make a visit to the National Gallery of Art to see the Edward Hopper exhibit.

The Nyack, New York painter came to fame between the two wars of the past century and came to represent introspection and solitude. "The loneliness thing is overdone," he once said.

Perhaps he was right, but the element of loneliness is recurrent precisely because so many people seem to respond to that element in his work. Loneliness and alienation have been buzzwords for the past hundred years and more.

We find ourselves living within the same spaces, crowded in big cities, shoulder to shoulder with other human beings and yet we crave relationship. I have always thought it ironic that the father of existentialism was almost a pastor, but in my mind, I originally associated the movement with Sartre and Camus and the 'ungodly' notions of boredom, dread and nothingness.

Humans have been grieving the passing of relationship and community since agrarian societies melted into the haze or urban life. We are disconnected from each other and it can affect how you feel about yourself. Self-perceived health status is related to feelings of loneliness. Social isolation is increasing.

We are complete biological, social and psychological organisms and what happens in one area affects the others. Mechanisms have not been elucidated, so there is speculation of which there are examples here and here.

We want health care to keep us healthy. It won't work. Medicine is at its best taking care of disease. It will do nothing for our connectedness, or lack thereof.

As Edward Hopper said, "If you could say it in words there would be no reason to paint."

Top Literary Blogs

This is probably the longest I have gone without a post since I started this blog! But The Physician Executive is winding down his old job and preparing for a cross country trip. Sometimes you just got to take some time out for local recreational activities which will not come around any time soon. Museums, Belgian restaurants were on the menu and our entire CD collection has now been ripped. That's 100 GB, if you can believe it, several hundred hours of music. For for the drive, you understand.

My top blogs of the week focus on medical writing, by anyone in the field. I am looking for quality of writing, evocative stories and well constructed essays. The criteria are inherently subjective, but I am shying away from journalism, rants and pure opinion, although the line between these forms and a literate essay is pretty fine.

1. Maria at intueri: Proofreading, Labels and Emotions
2. HalfMD: Every Time A Homeless Person Is Admitted To The Hospital, An Angel Gets His Wings
3. Sidney Schwab of Surgeonsblog: Thought Process
(Dr. Schwab posted a link on his blog. The story is good, so I threw it in the mix.)

Enjoy, and as always, I'm looking for help. Just comment if you're tempted.