Physicians

Physicians
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The Angry Physician

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I think I speak for most physicians when I say that we did not choose to go into medicine to shape health care policy.  Medicine is a calling, and I treated it as such.  I immersed myself with taking care of patients, and keeping up with the ever changing knowledge landscape that is medicine. I left the policy making to the folks I voted for the last 8 years. These were the adults, the intellectuals –  they would take care of the task of taking out the bad elements of our healthcare system and leaving the good.  I truly believed.  I eagerly began the ehr/meaningful use saga believing this would result in better care for patients.

It took me two years to realize the meaninglessness of meaningful use.  I still can’t believe how long it took me to realize that creating a workflow in my office to print out and deliver clinical summaries to patients didn’t do anything other than fill the trashbin. I still held out hope.  I thought – this was a first draft, improvements would come.  What came instead were positively giddy announcements of the success of the meaningful use roll out. The administration was actually doubling down.  There was no acknowledgment for the mess that had been created – onward and forward on the same road we must continue to march.  Except the road would no longer be paved and we would be walking uphill.

Don Quixote and the Health Professional’s Endless Quest

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April 22 marks the 400th anniversary of the death of the greatest novelist who ever lived, Miguel de Cervantes. Though the day will pace unnoticed by most physicians, it is in fact one many should note. Why? Because both his life and work can serve as vital sources of inspiration and resilience for health professionals everywhere.

In a 2002 Nobel Institute survey, 100 of the world’s most highly regarded writers named his Don Quixote the greatest novel of all time, outscoring its nearest rivals –works by Dickens, Tolstoy, and Joyce – by more than 50%. Said the head judge who announced the results, “If there is one novel you should read before you die, it is Don Quixote.”

How a Physician Can Work With a Not Yet Approved Drug Through Compassionate Use

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Screen Shot 2016-04-18 at 8.05.22 AMIn a time when evidence-based prescribing and clinical guidelines are hot topics in medicine, trying to access a not-yet-approved drug to use in a patient can feel like navigating uncharted waters. Many physicians are unaware that the US Food and Drug Administration (FDA) allows the use of unapproved drugs outside of clinical trials and — even if they did know it is possible — have no idea how to access such investigational drugs for their patients.

This knowledge is largely sequestered into certain clinical specialties, such as oncology or rare disease, and it is not taught in medical school or during residency: instead, is largely self-taught. Thus, while some physicians have become very accustomed to requesting pre-approval access to drugs, the majority lack this knowledge. In this essay, I use a fictional case to trace the process for requesting access to an unapproved drug. I hope to explode several myths about the process, such as the notion that the FDA is the primary actor in granting access to unapproved drugs and the belief that physicians must spend 100 hours or more completing paperwork for pre-approval access.

Imagine you are a physician, and you have a pregnant patient who has tested positive for Zika. While she is only mildly ill, she’s terrified that her unborn child may be impacted by the virus, which has been provisionally linked with microcephaly and other abnormalities. She’s so concerned that she is contemplating an abortion, even though she and her husband have been trying to have a child and were overjoyed to learn she was pregnant.

Check Your 2015 Open Payments Data

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The Centers for Medicare & Medicaid Services’ continues to publish data from applicable manufacturers and group purchasing organizations (GPOs) about payments they make to physicians and teaching hospitals on its website. We’re pleased that the public has searched Open Payments data more than 6.3 million times. Doctors, teaching hospitals and others receiving payments or other transfers of value that are sent to us from reporting entities, should take steps to ensure that this information about you, your related research, ownership, and other financial concerns are accurate.

Doctors and teaching hospitals have the chance to review and dispute the information shared about them before we post the new and updated Open Payments data on June 30, 2016. The data we post on June 30th is now available for review through May 15, 2016. Since April 1, this is the only chance for these health care providers to dispute inaccurate or incomplete data before we post it. After that they only have until the end of the year that this financial data is published to review and dispute any payment records and how it was attributed from GPOs, drug and device manufacturers.

Any doctor or teaching hospital that wants to look at the financial information reported on them by manufacturers and GPOs can register on the Open Payments website to create an account or log if they already have an account. Visit our website for instructions and quick tips.

What Is Patient-Centered Care? What Isn’t Patient-Centered Care?

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Rob LambertsMy last post discussed the wide gulf between healthcare and the rest of the world in the area of customer service. To sum up what took over 1000 words to express: customer service in healthcare totally sucks because the system promotes that suckiness and does nothing to penalize docs who make people wait, ignore what they say, rush through visits, and over-charge for their care. We get what we pay for.

But shouldn’t we judge the system for what it was build for: the quality of the care we give? Sure, the service is overwhelmed with serious suckitude, but that can be forgiven if we give good quality care for people, right?

Even if that was the case, there is no excuse for the lousy service people get from our system. The lack of respect we, as medical “professionals” show to our patients undermines the trust our profession requires. Why should people believe we care about their health when we don’t care about them as people? Why should they respect us when we routinely disrespect them? No, the incredibly poor service we have all come to expect from hospitals and doctors is, and never should be overlooked or forgiven.

Still, I already wrote a post about that. Go back and read it if you missed it. This post isn’t going anywhere. Now I want to cover the actual care we give, and how it too has moved away from the needs of the people it is supposedly for. The people question how much providers care (verb) mainly based on the (lousy) service they get. The care (noun) we give is all about the quality of the product purchased by whoever pays for that (be they third-party or the patients themselves). The real question I am asking here is not if this care is good or bad (the answer to that is, yes, it is good and bad), but whether it is patient-centered.

How I Learned to Stop Worrying and Love For-Profit Medicine

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flying cadeuciiWhen I started medical school, my South Asian immigrant parents quietly hoped I would find my way to cardiology or another glamorous specialty. Instead, I spent a decade — first as a medical student, then as an intern and resident in internal medicine — focused on advancing the right to health among poor people and others with little access to quality health care.

Through high-impact nonprofit organizations, political campaigns, and grassroots organizing in urban communities and among health professionals, I was part of an incredible community focused on making American medicine better, safer, and affordable to all.

So when it came time for me to find a “real job” after my residency, I assumed it would be in a nonprofit organization with a laser-like focus on transforming underserved health. Imagine my astonishment, then, to discover my life’s work in Iora Health — a private sector, venture-backed, for-profit primary care startup.

Profit and medicine

Critics have said that for-profit medicine makes money by finding ways to avoid caring for sick people “in their time of greatest need.” It’s also been pointed out that the Hippocratic oath doesn’t mention “money, financing, or making a profit.”

Financing Physicians: A Modest Proposal

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flying cadeuciiIn 1729, a bold and innovative thinker named The Very Reverend Jonathan Swift made “A Modest Proposal,” the subtitle of which was “For Preventing The Children of Poor People in Ireland From Being a Burden to Their Parents or Country, and For Making Them Beneficial to The Public.” One more thoughtful suggestion by Sir Jonathan was that Irish children, if prepared properly, made fine eating, having been assured by a “very knowing American…acquaintance” that at a year old, they are delicious, “whether stewed, roasted, baked, or boiled.”

While that suggestion never did catch on, it did represent a different insight as to a possible solution to a seemingly intractable problem, and it provoked quite a discussion. We have a new such problem, and it has to do with physicians. Today’s physicians, in their quiet moments, usually admit that their profession and they are in deep trouble.  Physicians too often work too hard for too little; they spend too little time on what they consider to be the “practice” of medicine; they believe they are disrespected by hospitals and insurers; primary care docs envy specialists; specialists despise hospitals; and worst, they just flat do not like their day jobs to the point that there is rampant burnout, anger, and depression. Not quite Marcus Welby.

It starts after med school, if not during. The plight of newly “minted” physicians is dire. Unless they come from families of wealth or get some miraculous form of a free ride, they end their education and training with debt often exceeding $200,000. And given the length of time it takes for them to start making decent income, they will have lost at least 8 years of saving and investing, plus the time they need to pay that debt back. They also have to purchase exorbitantly priced malpractice insurance. Meanwhile they do things like get married, have children, and buy houses and cars, like many other professionals. Their plight is well described in a recent article which should cause even the most idealistic young man or woman to think twice before entering medicine. The burnout and depression statistics of practicing physicians today are astounding.

What Might We Expect in the MACRA Proposed Rule?

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Nearly a year ago President Obama signed the Medicare Access and CHIP Reauthorization Act (MACRA) into law. MACRA, among other things, repeals the 1997 Balanced Budget Act’s Sustainable Growth Rate (SGR) formula for calculating annual updates to Medicare Part B physician and other eligible professionals’ payment rates.1 The bill received overwhelming support in both the House and Senate, only 45 out of 529 total votes cast opposed the bill despite the fact the legislation is estimated to add $141 billion to the federal deficit by 2025.2 Support for the legislation can, in part, be attributed to the Congress having grown tired of rescinding SGR mandated payment cuts or passing nearly 20 “doc fix” “patches,” over 18 years. Presently, Medicare physicians are awaiting CMS’s proposed rule that will define how the agency intends to implement the six sections of MACRA Title I, or how the agency will annually update physician performance beginning in 2019 based on the use of the law’s Merit-Based Incentive Payment System (MIPS) and its Alternative Payment Models (APMs) pathway. The proposed rule, expected to be published in the next few weeks, is highly anticipated because the rewards and penalties under either MIPS and APMs can be significant.

Meaningful Use: RIP

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Richard Gunderman goodA decade ago, electronic health records were aggressively promoted for a number of reasons.  Proponents claimed that they would facilitate the sharing of health information, reduce error rates in healthcare, increase healthcare efficiency, and lower costs.  Enthusiasts included the technology companies, consultants, and IT specialists who stood to reap substantial financial rewards from a system-wide switch to electronic records. 

Even some health professionals shared in the enthusiasm.  Compared to the three ring-binders that once held the medical records of many hospitalized patients, electronic records would reduce errors attributable to poor penmanship, improve the speed with which health professionals could access information, and serve as searchable information repositories, enabling new breakthroughs through the mining of “big data.”

To promote the transition to electronic records, the federal government launched what it called its “Meaningful Use” program, a system of financial rewards and penalties intended to ensure that patients would benefit.  Naturally, this raised an important question: if digitizing health records was such a good idea, why did the federal government need to impose penalties for health professionals who failed to adopt them?  Perhaps electronic health records were not so self-evidently beneficial as proponents suggested.

Re-imagining the Doctor’s Appointment

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Jo JoThink about your experience in going to a standard doctor’s appointment. You fight traffic or parking hassles to get to the doctor’s office. You often wait past your appointment time in the lobby, and once you actually get into the exam room, you wait again for the doctor to actually arrive. While it may be a few minutes, it can sometimes feel excruciatingly long. The doctor arrives, and despite all the paperwork and information you shared with the receptionist or the nurse, you repeat much of this information. Once you finish your exam and discussion with the doctor – during which you sometimes take notes, sometimes not – you walk out and have that awkward moment at the front desk, wondering if you can leave freely or if you owe large sums of cash.

Sound familiar? Perhaps. Sound like many other consumer experiences these days? Not really. The simple truth is that tech-enabled consumer experiences – from booking restaurants and flights to ride requests and mobile commerce – have changed our expectations as a society. We expect
to have more control over when and where we have these experiences. We don’t wait, or if we do, we know exactly how long we will have to wait. In comparison to other consumer experiences, the doctor appointment experience — from self-diagnosis to follow-up — fails to meet today’s new standards for convenience, information and speed.

Think about the typical journey. 70 percent of people are researching symptoms and ailments online before going to the doctor, but more than half (54%) don’t write down or capture this information and other medical information before going to the doctor. We live in a world of online reservations and booking, but 88% of doctor’s appointments are still scheduled by phone, subject to wait times and potential back-and-forth. Another potential breakdown in the patient journey is communicating the purpose for the doctor visit and checking in to the appointment. Because so many are booking appointments via phone, 70 percent of people explain the purpose of their visit to the receptionist over the phone, hoping that the information is accurately captured and communicated to the doctor.

And when you arrive, the litany of forms begins.