Saturday, June 21, 2008
Some things catch my eye, in both the medical and management literature that are worth passing commentary. I sometimes feel as though I have one foot in each of two different worlds, as though Alice were in both Wonderland and Kansas at the same time. These moments are probably not worthwhile subjects for a doctoral dissertation, but together I hope to generate some insights into both management and the practice of medicine.
That has always been the purpose of this blog.
A couple of medical management PhDs were writing in a journal for physician executives about core values required to be a customer-centric physician. Some of the core values are very familiar to physicians and easy to advocate. Those values include a belief in the importance of patient-focused service, patient-friendly service, listening to patients, working in a team, and the importance of people as individuals.
Mom and apple pie, right? Until you get to the last sentences: "You must remember that patients are honoring you with their care. You must convince them that you are honored to care for them."
This statement is true in almost every industry but medicine. Fact is that medicine has been sheltered behind a kind of social contract that, in the US, is in tatters. Physicians received several social and economic advantages in exchange for taking on some very difficult responsibilities.
Not only does policy have to take into account the fact that this contract no longer exists, but that its demise has left a wealth of bad feelings. Given the level of demoralization amongst physicians, it is difficult to feel honored about caring for a patient who does not really want your medical opinion or comes in demanding a service you don't believe is their best interest and moreover to do so in an environment of legal threat and diminishing reimbursement.
Given the deteriorating supply and demand equation in primary care, I am not so sure who should feel more honored to be in a physician-patient relationship. Frankly, I frequently work on empowering my physicians to say no. They will not face recrimination from administration if they refuse narcotic refills, unnecessary referrals or anything which goes against their better judgment. I have advised young providers reduced nearly to tears by dysfunctional patients not to waste their passion, energy and vibrancy on such patients.
For primary care to have an impact, it must be focused on people most likely to benefit. Motivating people (as in motivational interviewing) is necessary, but only in places where there are enough resources to meet the demand of already motivated patients.
Perhaps if the threats were minimized and morale improved, then it would be easy to engage physicians in being patient-centered and delve into the patients' unique perspectives. I firmly believe that physicians actually enjoy taking care of patients and would willingly explore ways of improving the care they deliver. What they don't enjoy is having to comply with external prescriptive recipes because being told they are doing a crappy job, all the while intuiting that they don't really control the outcomes they are being criticized for.
Perhaps policy and management stakeholders would do well to remember that it is ridiculous to talk of customer service when the second most important customer (the physician) is so poorly served by the system.
Thursday, June 19, 2008
She was a friend of mine.
We met at the University where she worked as a transcriptionist. She was quite a bit older than me, but we kept bumping into each other at coffee. I tend not to stand on protocol or social class, and shee seemed impressed that one of the the doctors would spend as much time talking to her. She mothered many of the staff and I was no different.
We bumped into each other outside work, in coffee shops, the more Bohemian restaurants in town and the occasional Tom Waits hangouts that have nearly disappeared from Atlanta's landscape in the years since I left. She would dress up as a tiger at Hallowe'en with what she called her tribe and they would march into Yuppie nightclubs, a motley crew of costumed animals, subversives and misfits.
I ran into her with various girlfriends during my exploring days and we had dinner to discuss them. I absorbed her advice and through the years, on reflection, her reflections were unerringly true. We discussed my dreams and plans and aspirations. Hers were limited somewhat, by her enviable ability to live vibrantly in the moment. I have never met a woman who lived more in the present.
She was a Buddhist who lived with a phone company technician in a gentrifying part of town. She loved to garden and occasionally offered me herbs she had grown, which I used (to cook with.) She had a big shaggy dog and two cats, her house smelled of incense and patchouli. She painted and I tried to encourage her. I asked to buy one of her paintings, but it was one of her favorites. She sold it to me a few years later when she needed money and she knew I wouldn't haggle with her.
Perhaps it was because of this relationship and my earnest innocence that I completely missed the flirtatious undertones of our conversations. In the end she remained a friend.
But I sometimes fear I am not a good friend.
Her friend called me once, not long after I met the woman who would become my wife. Toni had breast cancer. She was refusing treatment. I called, we caught up and the next thing I knew I was driving up to the mountain town she had moved to without her friend. I took my future wife in hand to meet my muse.
Toni was afraid, perhaps more afraid of the drugs than of the disease. It turned out she was in active treatment, if you want to call it that, with herbal treatments from an alternative medicine herbalist in the mountains. I knew where she was coming from given her personality and her beliefs. I felt it was her right... informed consent and all that, you know. I told her she really needed to think about medical treatment, but she looked so good and I was caught up in a relationship that was finally working, that I talked to her only once after that.
I got concerned when I started getting her answering machine and she didn't call back.
I was more concerned when I found that the number was disconnected.
I lost her friend's phone number.
I didn't keep in touch.
I got married.
I started a new job.
I found her obituary online. She had died the week I proposed to my wife, just a little over four years ago.
I think about Toni often, especially when I worry about why I don't keep in touch with my family or friends as well as I should. I think about her fears as I watch my wife make scary decisions of her own. Today, my wife is having her fourth breast biopsy in less than two years. She went through the chemo, radiation and drugs that Toni dodged. It's always a struggle and we have been blessed with good doctors, good coverage and no money concerns to affect our emotionally-laden and very scary decisions. They are difficult enough to make as it is, even if I am a medical person.
I pray that Toni is in the arms of the mother goddess, probably with a sad smile on her face, knowing that this is just one more thing that I need to go through for my own sake, even as it pales to what my wife is going through.
Wednesday, June 18, 2008
According to a June 11 CMS announcement, doctors will have to reconcile their NPI data with their IRS legal name data in order to get paid.
It is a befuddling regulation since, as an employed physician, 100% of my billings have gone to organizations that paid me a salary. Why check my provider identifier with my tax information. They don't correlate. I can pretty much promise you that they never have and sometimes the discrepancies have been fairly substantial. When I worked at a residency, I could bill enormous amounts of money for services I supervised, but was paid a pretty paltry academic salary for the privilege.
I am sure this will be a huge problem for docs in practice who bill under their name and get paid directly. Any discrepancy in any character in the field will ensure non-payment. This is not the kind of thing your laptop spell check will prevent. If this regulation is enforced to the letter, it will assure that services are provided free of charge.
I bet that this billing "error" can also be enforced as fraud and abuse, leading to criminal charges, treble penalties, and time in jail. I hear PhD nurses want to get into the practice of medicine... could you please remind me why anyone would want to do this?
And I thought insurance companies were the best at playing the game of using regulation as an excuse to get out of fulfilling their obligations. CMS must be attracting former insurance executives.
Monday, June 16, 2008
Some treat health care as an entitlement. It is the right thing to do because nobody should ever go without access to care in the face of illness. Illness is frightening, as are many other things in the world. But fear of getting sick is about as good a justification for universal health care as universal access to... say, attorneys. It may be a good thing to do, but I would rather push for universal access to information.
Many physicians see the health care system as a vehicle for the intellectual challenges and exercises in skill required of the practice of medicine. As an exercise in meritocracy, health care should be more available to those best able to pay for it. There has always been and will always be value in having uncommon skill or knowledge. I firmly believe that this drive, rather than the profit motive, is what pushes most physicians to specialize, sub-specialize and constantly and marvelously push back the limits of what can be done with the human body.
Health systems are also an opportunity to find a margin. Yes, health care is a business and in America, profit is not a dirty word.
Health care is also as "issue" for politicians, and to the extent that it affects voters, it influences the government agenda. It represents a way to get a vote.
Health care can be seen as a public health measure, which I tend to do. This suggests that those interventions that are most likely to help the health of populations (as distinct from the health of individuals) should get the most resources. With all due apologies to my sub-specialty colleagues,who are critical to our health care infrastructure from many perspective, it is here that primary care wins out hands down.
In fact, the broader the definition of health, the less medical it becomes. Securing water, adequate shelter, safe employment, reliable food sources, traffic safety and basic literacy are health issues that hardly fit into our usual conception of health care or the current reform debate. Immunizations, prenatal care and primary care are the most cost-effective things the medical world has to offer. PAHO and WHO publish guides for policy makers.
A health system like ours is at cross-purposes. Many advocate a total overhaul but that's not how change happens. Incremental change is more likely. Even if we were to reach some sort of tipping point in technology, or delivery, or insurance we will not likely see a complete change in a high resource service sector. Despite the complexity of the health system, care is still delivered one-on-one. All other discussions remain MBA-speak appropriate for the Harvard Business Review and little else.
Don't get me wrong, I like what I see in the health reform world. I like Dr. Val. I like Steve Case for that matter. I think what they are doing in consumer-driven health care is valuable. Jay Parkinson sounds like a smart guy and I might even ask him what he thinks about spreading his model to rural areas. I believe that the Future of Family Medicine project has enormous potential for change as evidenced by the TransforMED project and the rising popularity of the medical homes concept. PHR's have potential. RHIO's even more.
But none of these ideas are sufficiently transformative to represent the answer to a broken health system. Together, they represent a significant change in direction that incrementally may have an outsize impact.
The single notion that could have the greatest effect is the one that says we cannot and should not provide for every possible health benefit under the sun.
Rationing by cost (a barrier to access) is more acceptable than rationing by mandate, regulation, insurance company ruling or queuing. No rationing does not exist in any industry.
This means we must prioritize the things we cover. We make decisions all the time about what is covered and what is not covered, but we currently decide based on politics; that is to say the sum total of influence exerted by stakeholders and lobbies.
Frankly, it's not a bad way to do it; I don't believe in central planning. Look at Canada. But a better way to do it is follow the data. Otherwise every right wing crackpot and left wing entitlement-creator will have outsize say according to the way the political winds blow. Right now, we have two nutty ideas floating around: one way is expanding health care coverage under government tutelage and the other is giving tax credits to poor people to buy health insurance. As far as I'm concerned, government should only guide and create an environment for market forces to accomplish common goals (in this case, health.) Expanding government programs is not the way to do it. Tax credits for poor people are ridiculous; I can't get my poor patients to spend on bus fare if there is no IMMEDIATE benefit.
McCain is also promoting an idea to allow insurance companies to compete across state lines. Bob Vineyard at Insureblog seems to feel it won't work because of differing state mandates (the analogy is with credit card companies). In other words, states are already making choices about which benefits are to be covered. This may be viewed as rationing, or alternatively, choosing which parts of health care to subsidize. In fact, I prefer the subsidy position, because it puts us on more firm moral ground. If we chose to subsidize any industry, we should do it on the basis of data and a specific goal in mind. A utilitarian like me will view government's responsibility as creating the greatest common good i.e. the most wellbeing. This merges nicely with the broader definitions of health.
What I like about the McCain idea is that it represents incremental change. To address Vineyard's correctly pointing out that state mandates represent a serious obstacle, they are not insurmountable. A federal rule for companies selling insurance across state lines could be that they meet or exceed the benefits coverage of most states. These policies will be more expensive than policies sold in low-mandate states, but provide useful alternatives for those willing to pay. They will represent real competition in high mandate states, which are sufficiently populous to get people asking questions. There are other legislative and regulatory hurdles to get over, but ideas should not be discarded before a full and public airing.
Transparency in the insurance industry and in hospital pricing, expanding coverage for the uninsured and under-insured, a more flexible tax code to allow for the purchase of alternative insurance products, increasing adoption of IT and maximization of its potential in measuring and affecting quality, aggressive changes in models of care delivery and defining different levels of coverage according to health impact analysis are all a small part of the solution. Overall, there is a tremendous amount of value yet to be unlocked in the US medical system, but tearing a system apart to rebuild it from the ground is not a good option. Revolutions tend to be more destructive than creative.
Sunday, June 15, 2008
My experience has been one of utter frustration with maternity nurses, who should know better, but frequently feed their wards sugar water for no reason. Some kids can get hypoglycemic, but certainly not three quarters of the nursery. Some kids may lose weight, but that is a normal phenomenon, with the natural history of birth being a decline in weight and return to birth weight by day 10. It is not abnormal to lose weight, but it is abnormal to get formula or D5 on day 1.
These practices appear to me (on an anecdotal basis) to be widespread in places I have worked in the US, but they would be unacceptable in other places of which I have some knowledge: Montreal, England, or France. I understand from a cousin in Dubai that at least one hospital reflects the US's breastfeeding dysfunctions, so I am sure there is tremendous variation from country to country, especially by socio-economic class.
The harm done is that by allowing alternatives to breast feeding, we don't give a woman a reasonable chance of establishing her breast milk in the first place. To establish breast feeding, you need an infant sucking on a nipple, which provides the hormonal stimulus to produce milk in the first place. The more concerned you are that the breast milk may "not be enough", the more you assure the fact.
The problem with personal observations is the tendency to generalize. Finally, the CDC surveyed hospital infant feeding practices, as reported in MMWR. American hospitals persist in providing alternatives to breast feeding to infants, such as sugar water and formula. I am sure that most well-meaning maternity ward nurses will explain that they are trying to make sure babies gain weight or not become hypoglycemic. Unfortunately, entire wards of infants are not likely to suffer from the risk factors for hypoglycemia and weight loss in the first three days is a natural phenomenon that does not get babies in trouble if skilled observation and timely intervention is available.
So breast feeding suffers for entire populations as we chase the shadows of unusual and uncommon poor outcomes that rattle us to the point that it is easier to just chuck formula into every crying newborn's mouth.
Hopefully there will be more Edwinas around to take up the cause.
Tuesday, June 10, 2008
Dr. Val (via Joe Paduda) reports from "Fighting Chronic Disease: The Missing Link In Health Care Reform" conference that 50% of the (? adult) population has a chronic disease. In addition, chronic disease accounts for 75% of health care costs.
No wonder we can't afford health care in this country.
USA Today (via Kaiser Daily) reports that the lifetime cost of obesity is about 5 to 30 THOUSAND dollars.
The number of under-insured are rising. The Seattle Times coverage lingers on the plight of those with chronic disease who chose not to fill prescriptions due to the cost. If we focused on chronic disease care (i.e. secondary and tertiary prevention) to determine the impact of nearly 75 million uninsured and under-insured on the US health care tab, we could calculate an ROI. It would be a theoretical exercise to estimate the economic impact of universal health care.
It may not be a reason to do it; I was once told by an health care economist that some things that should not be subject to economic impact analysis. I think he found it morally repugnant. I agree, but finding dollars and cents calculations objectionable is not a reason not to do the calculation.
Maggie Mahar is right. Statistics and stories both inform policy in a way that neither alone can do adequately. There are thousands of moving stories of people in need (and a few stories of others taking advantage). Finding an acceptable way of providing universal coverage is the right thing to do. But we also deserve to know what the net effect is on our economic engine, even if it is an estimate or a guess.
Saturday, June 7, 2008
I guess it may have been apparent to a few that the new job in the Great American desert is not going well. When I took the job, it looked like a turn-around was well under way and the group was ready to establish a quality and improvement agenda.
I was wrong.
The CEO was fired six weeks into the job, the board is locked in a self-destructive lawsuit driven by ego and an attorney running for public office with a platform of attacking corruption in institutions.
The details of why I'm leaving this new job only sounds like sour grapes and so should be subject to a little self-editing. I have bad feelings about more than a couple of people, but they will fade in time. Hopefully not much dirt will stick as I dust myself off and move on.
CEO turnover at hospitals is 14% - 18% according to the ACHE. Secondary turnover (other executives leaving) is also high; 77% for CMO's. Competitors frequently take advantage of instability to poach senior executives, physicians and other key staff. Most CEO positions get filled within a year. The average tenure of a CEO is 5.5 years.
I can't find any references this morning, but out of a vague cloud of memory, I recall that CMO's last an average of 3 years. One of my colleagues tells me she had read it was 18 months!
This may seem strange to many folks in health care, but not so in the business world. The other kind of CMO (chief marketing officer) had an average tenure of 23 months in 2006.
So why do I do this? I am certainly asking myself the question as I read about Jay Parkinson's entrepreneurial approach to the health system.
I know that there is value in approaching health person by person, as in any form of medical practice. But enabling others to do the same is a matter of scale. I'm just thinking out loud here, but this health care system is not likely to be overhauled in its entirety, but rather incrementally. Even universal health care will only address the 14 - 18% of the population that really needs a little more help. We may or may not be reaching a tipping point that may or may not fundamentally change the way health care is delivered. There may or may not be disruptive technologies that will destroy the current health infrastructure.
Would you rather work within the system, outside the system or just chuck it all and keep seeing patients, giving up all semblance of an ability to influence the system or the health of populations? Or some combination of the above?
Fortunately my situation allows me the luxury of time to figure it out. The last thing you want is to jump from one bad job to another. So excuse me while I pursue the really important things in life and cruise out to the mountains in my Jeep for a little off-roading!
Tuesday, June 3, 2008
However, it is a fantastic example of how not to produce a sensible solution.
The FTC has been invited to comment and its first salvo is pretty negative, as reported here (sub req) and here.
We already know that the FTC believes that retail clinics have the potential of "making basic health care more accessible and affordable." This is the worst piece of hocum perpetrated on the American people since the war on terror.
The Illinois Medical Society, whose advocacy informed the bill, clearly took every possible step to restrict retail clinics (taken from their press release):
Everything is perfect until the last two clauses. The latter is clearly designed to expose the profit motives of pharmacy chains who speak with forked tongue: on one hand promote improved access to health care but on the other sell products deleterious to the health of the people whom they purport to serve. The former is pure protectionism.
The facility must have a referral system to physician practices or other health care entities appropriate to the patient's symptoms outside the limited scope of services provided by the facility.
The facility shall provide notification of any patient visits and outcomes to the patient's designated physician.
The facility shall establish appropriate sanitation and hygienic protocols. The facility shall have a designated receptionist and waiting area.
At the conclusion of each visit, patients shall be given a written notice stressing the importance of having a personal physician who can provide the full range of health care services. Patients shall be notified in writing of their opportunity to purchase medications from any provider whenever they receive a prescription at a clinic.
Illinois health care services provided must be in accordance with a limited scope of services as determined by the facilities' medical director and approved by the Department of Public Health.
No health care services may be provided unless a physician licensed to practice medicine in all its branches, an advanced practice nurse (APN), or a physician assistant (PA) is on the premises at the time the services are provided.
The facility must have a medical director who is a physician licensed to practice medicine in all its branches with active medical staff privileges to admit patients to a local licensed hospital. Collaboration of APNs or supervision of PAs shall not be construed to necessarily require the presence of a collaborating or supervising physician as long as methods of communication are available for consultation with the physician in person or by telecommunications in accordance with written protocols.
The facility shall maintain medical records for all patients for the period required of a licensed hospital under the Hospital Licensing Act.
All personnel shall wear on his or her person a clearly visible identification indicating his or her professional licensure status while acting in the course of his or her duties.
The facility shall operate under written protocols approved by the medical director and the APNs or the PAs providing services at the facility.
Payers shall not be allowed to waive or lower co-payments or offer financial incentives for visits to retail-based clinics in lieu of visits to primary care physicians’ offices.
Individual stores wherein these clinics exist will be prohibited from selling tobacco and alcohol products.
There are also clauses that restrict advertising fee comparisons by retail clinics, that a medical director can oversee no more than two retail clinics, a required receptionist and separate waiting area as well as an exemption for hospital or physician-owned retail clinics. In fact, higher copays for retail clinics would really make a lot of sense: if you want convenience you should have to pay for it.
So it's OK for us, but not for other people?
Every action provokes a counter-action. Did Illinois physicians think that there would not be objections to some of these clauses? To restrict advertising is simply wrong. There is no rationale for a medical director supervising the implementation of policies at more than one clinic. The need for a receptionist and waiting area does not level the playing field as much as prohibit a field of economic activity that relies on low overhead. The exemption... well, the US is the place I would expect such a two-faced clause to be challenged and ripped apart by adherence to simple constitutional principles. The exemption alone does more damage to the credibility of the bill, its sponsors and its advocates than any hard-nosed competitor could wreak.
This bill seems to be intentioned to provoke the reactions of external stakeholders. It appears to be the product of a purely confrontational approach to protecting one's turf, rather than a collaborative approach to promoting the health of the population.
Like it or not, external stakeholders have a lot to say about how we run our business. Removing the most restrictive clauses would let the rest of the bill stand on its own and make sure the correct message gets out: retail clinics add absolutely no value to the health system if the care delivered there is provided without the context of continuing primary care.
Market forces must decide the ultimate fate of retail clinics, maybe then, the FTC would revisit their assumptions about how the health care market actually works.
Monday, June 2, 2008
In case you've not been paying attention, there have been two waves of adverse event reports starting with reports of neuropsychiatric effects, such as suicide and depression. Now there are reports of convulsions in drivers and even simple personal accidents. The FAA banned pilots from taking the drug and sales of Chantix (varenicline) are collapsing.
I am not a fan of big pharma and only rarely do I become a grudging apologist, but I will take a healthy skeptical approach to the situation and shoot from the comfort of my lounge chair.
Part of this tempest is a study by the Institute For Safe Medicine Practices, which is involved in a new pilot method of reporting adverse events. As far as I understand, the pilot involves quarterly analysis of the Adverse Event Reporting (AER) Database, which accepts electronic side effect reports.
All adverse events are recorded and linked to a drug. At the point that a report, or any number of reports are made, there can be no assumption of causation. There are a set of epidemiological principles for establishing causation out of associations.
There is an additional problem that is well-known with voluntary reporting mechanisms... the same thing that customer service people know. A few people who squawk the most have the potential of skewing your results. Electronic reporting should make reporting more complete and thus less susceptible to the bias introduced by voluntary reporting. On the other hand, one could hypothesize that electronic reporting amplifies distortions in public perception.
Once a few reports are made, such that an association is reported in the media, things may snowball. People may begin report minimal events that they would not have otherwise reported or events that they did not consider to report. The media is incapable of shading nuances of association and causation or the real meaning of a further investigation by the FDA. Once reports exist, the FDA and the ISMP have no choice but to issue warning statements.
That does not mean varenicline is a bad drug, nor that it is more unsafe than continuing to smoke. It does mean that a new monitoring system is functioning as designed (assuming it is not being manipulated or introducing worse biases than it was intended to prevent.) We will have more information about adverse events for new drugs sooner and more accurately, for the benefit of empowered consumers.
Why should sales go down?