Employed Physicians

I had an interesting conversation with a feller from Texas the other day. I was telling him how I had formed my impressions of docs in employed situations from my experience on the East Coast. It just seemed that the solo practitioner was almost dead, if not completely so. Even in rural Maryland, it was more likely to find groups of two or three docs in private practice fiercely holding on to their independence in the face of large single- or multi-specialty groups encroaching from the suburbs. Many of the large groups have found Stark-compliant ways of working with nearby hospitals, or, in some areas, are outright owned by the hospitals.

I reflected to my acquaintance how different it was out here in the Western desert regions, where it seemed the employed docs sometimes felt they could act like it was their own shop and close up with less than a day's notice to stay home with the kids or go duck hunting or take whatever break is justified by a hard-working, highly-valued provider of a needed service by a grateful community.

You can't do that when there are 50 physicians and 300 employees whose work schedules are dependent on physicians providing billable services on razor-thin margins.

Well, maybe you can. It's all about the supply and demand equation, isn't it? If there aren't enough primary care physicians to go 'round, the tolerance for behavior inconsistent with a larger organization's overall well-being is better tolerated. And certainly the local physicians' culture has an important role to play. Texas docs, I was told were nearly never in large groups and they never tolerated overbearing administrative intrusions to their clinical or vocational independence.

I walked away from my conversation with a tall and lanky Texan (sorry for the cliche, but he was tall and nearly lanky), with an understanding of how different the situation is for physicians across the country and how my approach to change management and performance management is colored by my East Coast experience.

In areas where managed care penetration is high, employed physicians predominate by choice, and a high regard for academic analysis output exists, there is an atmosphere of understanding and willingness to work within a corporate environment. Evidence-based medicine, quality and performance improvement are all perceived as methods to improve health care delivery systems for the betterment of the community. Physicians understand the choice to enter employed positions and accept the trade-offs, giving up some independence for the sake of fewer administrative headaches, better benefits and perhaps, a reasonable lifestyle.

In areas where one or more of these conditions do not hold, physicians resent encroachment on their judgment, style or authority and mistrust the motives of administrators of all stripes. EBM, QI, and PI are bridles of control to be avoided at all costs and administrative entities are regarded to exist for their personal betterment and not the benefit of communities nor the doctors, Such physicians enter into an employed arrangement begrudgingly and only if they feel that their work is not subject to the kind of oversight that will reduce their independence.

OK, I'm dumb. I didn't realize the obvious until now. I have grown up in academic environments which are so dominated by various stakeholders that the independence of the community physician a distant recollection from the stories of William Carlos Williams; the vague memory of a historical work of fiction read in childhood. The East coast and its large cities are places where independent practitioners are abberations or mavericks worthy of awe, disbelief and admiration.

Elsewhere in the country, in smaller cities and younger landscapes, the independent practitioner has thrived and the battle for physicians' independence is much more vigorous.

It is possible to engage physicians any number of ways in future improvements to health care. The lessons of the East tell me that the best way is not confrontational. Without physicians, no meaningful reform is possible, despite the best efforts of other stakeholders. On the East Coast, docs have been beaten into submission. It took a long time, created a lot of ill feelings and did not accomplish much. The rest can do it faster, more collaboratively and with greater focus. The first step is to get a clear understanding of the situation and adapt to local environments.

Wonderful Wonks

The venerable Mr. Hank Stern has The Health Wonk Review again. A terrific job, for the fourth time, I understand. I never fail to learn something.

Another State Ranking Report

The Commonwealth Fund reports (it's a big file) on Child Health, ranking states according to access, quality, cost and other factors (check out the map).

Number 1 is Iowa, a state with a great family practice residency and a primary care oriented medical school, along with a quality research university. Good access to top-notch reasonably-priced health care probably trumped the reputation of places like Massachusetts, that suffer from high costs.

So much for branding. After all, the two most important people who went to Harvard dropped out before graduating.

Even Vermont could not come in first, given their unparalleled social programs, but cost was factor there as well. Washington and Wyoming were the only western states that came in the top half (remember I live in The Great American desert... think West). My biggest surprise is seeing Minnesota in the 2nd quartile. I would have expected the State to rank in the top 10. Managed care has negative its effects on physicians, provider organizations and the pharmaceutical companies but it represents a way of providing more rational care to patients. Minnesota has the greatest managed care penetration in the country, but the majority are for-profit entities.

Just musings... but one might wonder if managed care, a dirty word to physicians and patients alike, may lose any purported benefits in the hands of a for-profit entity. Perhaps it is another example of an academically brilliant concept that gets distorted when handed over to real people. Kind of like God!

Of course the problem with rankings is in the detail. The indicators include equity, which is notoriously difficult to define (which income cutoffs do you use) and something called "potential to leave healthy lives". Let's not lose sight of what these rankings tell us:

1. There is way too much variation across states (but perhaps this is what the founding fathers would have wanted.) Let the states decide if they care about kids or health care.
   
2. It is possible to score very high as well as possible to hit rock bottom. In other words, the rankings can distinguish between states. In addition, there is internal consistency and, I suspect, some degree of external validity also.
   
3. A very interesting observation emerges from the executive summary; quality and access correlate strongly. I recently heard from a CEO who was referring to managing physician performance that productivity was inseparable from quality (productivity=access). Even a clueless doc can do a great job, given three or four hours for a single patient. A physician's value to a community is measured differently than when measured one patient at a time. On a state level, quality is meaningless if there is no access.

The rankings are interesting, and it points to one incontrovertible fact: we could do better.

QI: Alienating Physicians

The most remarkable thing... I found an article that says cost reduction efforts don't work and tend to alienate physicians.

The final paragraph of the article is particularly enlightening:

Judgmental programs tend to interfere with quality improvement. They score but do not support physician work and therefore are perceived by physicians as disempowering. Accountability combined with perceived inability to improve is a formula for creating frustration and antagonism. We propose instead an approach that identifies specific wasteful practices and then engages physicians in changing them.

So it appears to be possible to engage physicians in quality improvement (QI) and achieve goals of cost reduction and reducing overuse, as long as it is in the context of improving care, something most physicians care passionately about. As long as they are cast as part of the problem, why would they do anything other than sabotage the solution?

I do not know many physicians who are heavily involved in quality improvement, but I have learned from recent experience, that physicians who have been beaten up by QI programs are very likely to resist and attack anyone who comes to them with a quality agenda, irrespective of their credentials. That is to say, the stupidity of others impairs quality-committed physicians ability to effect change and that needs to be part of an environmental assessment for any new quality management project.

OK, it seems obvious, but I'm human too!

Hospital Merger Trends

Hospital chains have been consolidating for years. Given how tight capital markets are these days one would expect that there would be fewer deals now.

Bzzz. Wrong answer.

The large chains are having less trouble dealing with their debt than smaller rivals, so it is easier for them to snap up relatively smaller entities opportunistically. The Tennessean (courtesy FierceHealthcare) suggests it may be partly due to the increase in un-reimbursed services to the uninsured. But a Chicago Tribune article points out that the kinds of savings you would expect from economies of scale do not appear in hospital charges. While prices have not gone up (that would get regulators paying attention), it is possible expenses have gone down. Increased margins means dividends for stockholders and cheap capital for not-for-profits.

The FTC is looking at unfair market practices in Evanston, Illinois and Virginia and even in rust-belt Pennsylvania, questions are being raised. The FTC's effectiveness is in question and vulnerable to counterattacks that the mergers are necessary for the health of the population and the area's ability to attract doctors.

Since primary care doctors do not usually practice in hospitals and primary care is the only segment of medical care (as distinct from public health) that improves the health of populations (as opposed to individuals), I would submit there is no impact of hospitals on the health of the communities where mergers leave a single dominant hospital provider, nor are the kinds of doctors they attract relevant.

The FTC should shut down bad mergers. On the other hand, the government could support market forces by encouraging better management and easier access to capital for community hospitals.

Cause for Celebration

It looks like regulation that could hurt the nation's safety net has been killed for now (reg required). The AHA has weighed in (reg required) on the underserved rule. With a new administration coming in a few months, I wonder if anyone believes the threat is gone for good.

CMS was going to reduce payments to safety net institutions and close so-called loopholes that allowed states to invest heavily in expanding coverage in their jurisdictions with assurances of federal matching payments. Needless to say, the nouveau riche that run the right wing don't feel it's right to invest in low-income Americans. CMS started to create regulation that would cripple critical access hospitals and community health centers.

So perhaps we should celebrate that this round of attack is over, but vigilance is wise.

Have a great Memorial Day weekend!

We cherish too, the Poppy red
That grows on fields where valor led,
It seems to signal to the skies
That blood of heroes never dies.

Massachusetts Lawsuit

I am always impressed by good quality management and amazed that there isn't more of it. Physicians have decided to sue a Massachusetts insurance oversight agency over physician rankings.

The agency freely admits their ratings are faulty, but docs should just suck it up because it's a step in the right direction. However, despite the flaws, patients are charged different copays according to the rankings. In other words, although they know they don't really know what they're measuring, if they are measuring the right thing and if they can effectively differentiate between providers of different quality, they'll just use their system anyway and work on it later.

How about a little transparency here? Not to mention a little common sense? Perhaps it would have been a little more acceptable to run the system for a couple of years and refine it until it could be reasonably used to make decisions that involve money. No wonder doctors fear the concept of quality in health care. It appears to be a blunt instrument designed to further bludgeon a profession that has suffered much over the last two or three decades.

I went back to school because I recognized that I did not have the management skills I needed to succeed without upgrading. Too bad the managers already in place have not realized the same.

Here's a Shocker About Breast Cancer Testing

Sorry, the sarcasm is out of control lately...

This recent JAMA article (subscription required) carefully studies the role of adding ultrasound to mammography in breast cancer screening. They found that the combination picked up more cancers but also increased the false positives. In the parlance of clinical epidemiology, it increased sensitivity but decreased specificity.

Or as Homer Simpson would say: DUH!

It is not uncommon that the two co-vary in opposite directions. You can virtually manipulate the sensitivity and specificity of a test by carefully choosing your cutoffs for indicating the presence of absence of disease. The test ends up performing according to your needs. Our purpose in combining tests is to maximize both sensitivity and specificity. HIV is a case in point, since it is an over-sensitive antibody test (won't miss anyone) followed by an extremely specific confirmatory Western blot (won't wrongly diagnose anyone). Most labs won't report a positive antibody unless the Western blot is also positive.

I wish the results of the breast cancer study would have shown a reduction in false positives by the addition of ultrasound. This has always been my fervent hope whenever I have added an ultrasound to a mammography. The lesson of the report is that ultrasound doesn't help that much and must be used with caution and judgment.

Journal Watch reports a JAMA editorialist pointing out that

despite the high number of false-positives, what high-risk women "probably fear most is a late diagnosis." That, she continues, is "the real threat they want to be protected against, not false-positive diagnoses."

Again I must say, DUH!

This study is meant to help guide us through the emotionally charged fear of breast cancer. It packs a huge punch for any woman even suspected of having the disease. On the other hand, we need to know the real (scientific= truth) value of doing a test. Perhaps the editorialist is saying that since it is an emotional matter, neither the data nor the truth matter, as long as we only detect more stuff, cancerous or not.

The original article is very detailed and a great read for those with an interest in how to crunch numbers to guide investigative decisions. The editorial set me off!

Employed Physicians

What have we given up?

I have been an employed physician for going on 15 years and an independent contractor for a handful. I enjoyed the contract years the most, but it was not a settled lifestyle and something told me to do what everyone else was doing. You know, settle down, get a job, travel on two weeks off a year like the rest of humanity.

Teaching was fun and it could only be done in a large institution. Eventually, I settled for a large University setting in the south. Yes, my ego was part of it. Everyone in the region was always impressed by credentials as a professor from the Harvard of the South. After all, I had come from the Harvard of Canada. (I won't dwell on the sarcastic undertone, but if it is subtle, please note it!)

The main arguments for a physician to enter into an employment agreement are for lifestyle (you don't have to cover everything in your practice), convenience (no hassle of being responsible for your own books, payroll and so on) and for leverage (negotiating better terms with insurances.) Maybe there are others and you're free to add them.

But that means you have to give up some autonomy. Unlike the rest of the work-a-day world, I wonder if physicians expect to continue having all the freedoms they associate with their own practices: make your own schedule, close up shop as needed according to immediate priorities, refuse to take direction to meet the needs of the organization...

Most administrations are respectful of the fact that their physicians and other providers are the backbone of any clinical services organization. Of course I have met some pretty untrustworthy people and entities along the way, full of backhanded politics, unreasonable requests and frank incompetence.

But my question is what did the physicians expect when they entered into employment agreements???

Balance Billing

This one is a bit of a bother; my conscience versus insurance company shenanigans...

The LA Times reports that consumer groups are getting their noses out of joint about the practice of balance billing, where a health care provider tells the patient that the insurance company did not cover the fee and charges the patient directly. If you're a patient, that's a pretty scary prospect. The San Diego Union-Tribune reports on the state's attempt to outlaw the practice.

We all must know by now that primary care is under-reimbursed, so I see an opportunity to charge what we are really worth as primary care providers by balance billing. But let's face it; primary care docs are mensches. We won't do it, but the emergency rooms and hospitals will. In the absence of any price transparency, hospitals can get away with extra billing whatever they want and pretty much make up what they please.

Too many hospitals' bills read much like a work of fiction. This household has never yet received a properly itemized ICD, CPT and HCPCS coded bill. Although mistakes appear to be few and far between, it is hard to tell without the detail. I guess I can trust the insurance companies not to overpay! But can I trusty the large health care delivery entities any more???

Ingenix Lawsuit

There is a perverse pleasure seeing health-care leadership get some of their own. Ingenix is a subsidiary of United Health Group and is a prime resource for health plans and administrators in a score of lines of work related to health. One of the things they do is determine pricing by collecting fee schedule data... you know, that troubling little piece that the consumer-driven health care people want to be able to provide directly to consumers. Who better to collect fee schedules than a subsidiary of an insurance company, eh?

So a patient decided to sue them (reg required), citing low reimbursement to his provider as a result of a manipulated database leaving him on the hook for the balance of what he was charged. Here is another brief article on the matter.

We could have a field day blaming people, but I am still having a belly laugh over the AG's response:

Cuomo announced in February that he intended to sue Ingenix and said he was investigating what he called an “industrywide scheme perpetrated by some of the nation’s largest health insurance companies to defraud consumers.” So far his office has not filed a complaint.

Providers versus industry versus consumers! Take your pick!

Accountability

Kevin, MD's recent posting of an anonymous primary care physician from the heartland seems to have struck a cord with a whole lot of people, judging from the comments.

Let me tell you how much it resonates with me.

Our own administration is pretty incompetent and think it knows all that is required to run a community health center without the physician leadership. But I'm not sure. Our chief executive is a nurse who once told me she did not want the providers' input. Power relationships reign supreme and integrity is scarce.

But frankly the biggest problem is two physicians bred and steeped in a traditional specialty philosophy which seems oddly out of date, but apparently still prevalent in some areas. They are both sub-specialties with their training overseas, who came to this primary care facility on J-1 visas. Their feeling about primary care is similar to a Greek doctor who responded to my explanation of what a primary care doctor is by saying, "I think we have some in the villages, you know, in the mountains."

Many of US doctors feel that primary care is the choice of students with no other choice. Even Canada's social conscience cannot mask the prejudice entirely. I was once recruited by a cardiovascular surgeon who said I was too good to settle for family practice. It is a nearly universal phenomenon in a world where progressively greater expertise gets more respect than being a generalist. Why else would family physicians so urgently proclaim that they are specialists and not generalists? Paul Starr characterized physicians as inveterate social climbers. A disregard for fellow human beings, especially well-educated colleagues, is a hallmark of the need to climb a social ladder.

My personal value system is to give the generalist at least as much respect as the boring old, extreme and arcane specialist, to provide the poor as well as the rich and to try and love people who are hard to love as much as people who's company everyone seems to enjoy. But such is the world and I wish I'd known then what I know now. Wealth is built by having uncommon skill or knowledge, especially in a cut-throat capitalist culture.

Medical science at the turn of the last century had so much promise. As a profession, we are accountable, but we lost our way during the 50's, 60's and 70's. Medicine got more technical, more complicated and we forgot that William Osler human ability to listen to the patient's story and consider the context of a life before recommending treatments. We did not meet the expectations of many stakeholders, no matter the fact that some of those expectations were unreasonable to begin with. Some of us sacrificed the profession's autonomy and its beneficent role in society, with full wallets and a family legacy, but not much else.

So disease management, patient navigators, care managers and medical homes are all "new" ideas supposed to help this ultra-specialized medical world provide coordination of care and help combat increasing fragmentation. Although I grieve for this mess of a system, I must reluctantly acknowledge that the world must be unfolding exactly as it should. For those who care, having an impact is no simple task.

New Medicaid Rules: Attacking the Safety Net

Under new CMS rules, low income individuals will probably have as much help in the US as the mentally ill; that is to say nothing.

There are seven new regulations being floated at CMS attracting a lot of attention and push-back. The net effect of each of these regulations is to reduce the federal health care budget. The two proposed regs that caught my eye were the one altering the byzantine rules of matching state Medicaid funds and the one redefining health profession shortage areas (HPSA).

The first reg is one I do not completely understand, but appears to limit some safety net hospital ability to qualify for higher reimbursement due to their critical access (or some other status) that allows them to charge cost-plus.

The regulatory territory at issue is already a bloody battleground. The Government Accountability Office repeatedly exposed state plans that essentially reused federal dollars to pad their own contribution to the Medicaid burden. Enhanced payments were made to public hospitals under the upper payment limit, which allows states to pay some providers higher rates than others as long as the aggregate doesn’t exceed what Medicare would pay. A portion of the enhanced payments would then be returned to the state through intergovernmental transfers, contributing to the local contribution for a new federal match.

The second rule refers to something I am much more intimately familiar with, since it relates to the trajectory of my career; I have only ever worked in areas with some sort of shortage designation since I came to the US. A shortage area should bring rural areas to mind first, sparsely populated places where there is a real difficulty attracting and retaining physicians. You may be surprised that HPSA's exist in many urban areas as well, such as inner city Atlanta and just outside the beltway in the very urban Langley Park area (technically an MUP, for those to whom it matters). There are simply more under-served individuals in inner cities and urban areas than there are in sparsely populated places.

The new rules will sharply change the weights of factors going into a HPSA calculation, increasing the importance of population-to-provider ratios to the point that nearly any populated areas will lose their top HPSA status. The rule also proposes three levels of FQHC based on the HPSA score. Only 25% of the country's safety net will retain its top level status. CMS counters saying that only 1.6% of health centers would lose their designation entirely. Since achieving one of the two new designations has unclear implications for future funding, there is reason for FQHC's to be anxious. Meanwhile both sides are lobbying with their best argument, neither of which relates directly to the other.

This government's unblushing ability to distort reality comes across in a press release stating that the new rules increase state's flexibility in designing their own Medicaid systems. I guess if you get less money from the feds, you are proportionately less accountable. I'm sure that will come as a comfort to those safety net and community hospitals that will close due to a lack of funding.

Cost effectiveness of well child visits

Immunizations are simply the best and most cost-effective intervention ever conceived by the science of medicine. They are so important that health care providers have toyed with various techniques to improve immunization rates. For example, my current facility has a full-time immunization nurse who can give missing vaccines to children following a sick visit (as long as they don't have a fever.)

The principle of vaccinating when you got 'em in the clinic is common in many developing countries and under-served areas, since you never know when you will see these children again.

Now the practice is being questioned. According to an article in Pediatrics, some parents don't bring their children back for well visits. The well-child visit includes a brief developmental assessment, physical examination and anticipatory guidance. These aspects of the visit have great value, especially for the young, low-income mothers who are the most likely to conflate a well visit with a shot.

As a clinician, I understand the value of well child visits, but my public health degree must question the data. There is insufficient evidence to support annual adult examinations. Studies with children are naturally more likely to yield a benefit, but I just haven't seen them. After all the well-child visit schedule is tied to... you guessed it, immunizations.

It's good to know that there is documentation of the downside of opportunistic immunization (which has been our experience). I am not sure it matters in the big picture.