Thursday, September 20, 2018

Physicians

Physicians
The doctor is in ...

How To Discourage a Doctor

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Screen Shot 2014-09-18 at 2.28.53 PMNot accustomed to visiting hospital executive suites, I took my seat in the waiting room somewhat warily.

Seated across from me was a handsome man in a well-tailored three-piece suit, whose thoroughly professional appearance made me – in my rumpled white coat, sheaves of dog-eared paper bulging from both pockets – feel out of place.

Within a minute, an administrative secretary came out and escorted him into one of the offices. Exhausted from a long call shift and lulled by the quiet, I started to doze off. Soon roused by the sound of my own snoring, I started and looked about.

That was when I spotted the document on an adjacent chair. Its title immediately caught my eye: “How to Discourage a Doctor.”

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.

Stay Out of my Wellness

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By VA WEST HAVEN COE CLINIC

On a sunny New England morning at a secluded guest house with a perfectly manicured lawn, medical residents, each with their own brightly colored yoga mat, were getting ready to assume the downward dog position. They were on an annual retreat organized by their residency program to promote wellness. One embraced the opportunity with delight, smiling through every pose.  Another grimaced  as his back spasmed. And yet another wandered off towards a lake to find his own kind of respite.

Physician wellness has become something of a buzzword in recent years, and rightfully so considering that the rates of burnout and suicide within medicine are rising. Individual residency programs have found burnout rates between 55% and 76%. Such burnout erodes well-being over time and may be contributing to suicide, which is now the second leading cause of death among residents nationwide. In 2014, the suicides of two medical interns in New York prompted the American College of Graduate Medical Education to take action. A series of initiatives to combat burnout were rolled out, including the consideration of wellness in its review of residency programs during site visits. In 2017, emergency medicine physicians convened the first Residency Wellness Consensus Summit to devise a module-based curriculum on wellness. Hospital systems have attempted to respond as well, through the hiring of chief wellness officers.

It is unsurprising that the medical community has taken such an analytical approach towards diagnosing burnout, much as we do with other diseases, in search for a cure. But perhaps such a prescriptive approach fails to capture the highly individualized and somewhat abstract concept of wellness. The reasons for resident burnout are personal and vast. Decreased wellness has been attributed to the lack of time for self-care, inadequate sleep, social isolation, negative work environments, excessive paperwork, long work hours, poor relationships with colleagues, and insufficient mentorship, among others in a lengthy list. Any attempt to standardize the definition of wellness should be met with caution.

So how do we as a society go forward in ensuring our resident physicians are well?

Physicians: Sermo allowing docs to discuss chart errors about them! by Matthew Holt

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Sermo got some press this week about a thread that’s of lots of interest to all of us–medical errors and inaccurate records:


Several years ago, Botney visited a specialist to check out a
bothersome lump in his cheek. He took some medicine and the problem
went away.Out of curiosity, Botney thumbed through his chart and was
surprised to find a note from the doctor saying he had a stroke."I
never even had the symptoms of a stroke. No visual changes, no
weakness, no numbness, nothing," Botney, an anesthesiologist at Oregon
Health & Science University, said in a telephone interview from
Portland.

The key difference here is that
physicians were talking about this with other physicians. The next
question is whether this will blossom as an issue because it’s now
being talked about online? Or will it get hidden under the medical
carpet as has been the issue of medical errors for all these years?

Also worth noting that one of the leading docs in the patient safety movement, Bob Wachter, has a new-ish blog out too that’s well worth a look. I’m happy to report that Bob is also now a contributor at THCB. If you haven’t yet, immediately sally forth and read his recent posts "Dennis Quaid’s Kids – Are VIPs Safer?" and  "When is a Medical Error a Crime." Both have interesting comment threads developing.Comment on this post at the Health 2.0 Blog

 

How to Avoid Being a Dumb-Ass Doctor, Blog Edition

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Evil Dr Rob Part 2It’s been two years since I first started my new practice.  I have successfully avoided driving my business into the ground because I am a dumb-ass doctor.  Don’t get me wrong: I am not a dumb-ass when it comes to being a doctor. I am pretty comfortable on that, but the future will hold many opportunities to change that verdict.  No, I am talking about being a dumb-ass running the businessbecause I am a doctor.

We doctors are generally really bad at running businesses, and I am no exception.  In my previous practice, I successfully delegated any authority I had as the senior partner so that I didn’t know what was going on in most of the practice.

The culmination of this was when I was greeted by a “Dear Rob” letter from my partners who wanted a divorce from me.  It wasn’t a total shock that this happened, but it wasn’t fun.  My mistake in this was to back off and try to “just be a doctor while others ran the business.”  It’s my business, and I should have known what was happening.  I didn’t, and it is now no longer my business.

This new business was built on the premise that I am a dumb-ass doctor when it comes to business.  I consciously avoided making things too complicated.  I wanted no copays for visits (and hence no need to collect money each visit).  I wanted no long-term contracts (and hence no need to refund money if I or the patient was hit by a meteor or attacked by a yeti).   The goal was to keep things as easy as possible, and this is a very good business policy.

An Alternative Proposal For Certification

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John HalamkaSome have suggested that my comments over the past few months about the Meaningful Use program, MACRA/MIPS, and Certification imply that we should just give up – throw out the baby with the bath water.

That’s not what I’ve written.

Here’s a clarification.

I believe MACRA/MIPS is the right trajectory – create a set of desirable policy outcomes, then enable clinicians to choose technology, quality measures, and process improvements that are relevant to their practice.

Although the current MACRA formula is overly complex, it’s the right idea and I’m confident that CMS will revise the notice of proposed rulemaking appropriately.   My metric for MACRA’s success is simple – can a clinician keep three goals in mind while seeing a patient and be rewarded if successful i.e.:

1. Ensure care is delivered in the most appropriate location in the community (urgent care, home care, rural hospital)

2. Focus on wellness/prevention

3. Avoid redundant and unnecessary testing, medications, and procedures

My issue is that MACRA currently “inherits” the flawed 2015 Certification Rule that is a kitchen sink of immature standards and a black hole for developers.   Overly zealous regulatory ambition resulted in a Rule that has basically stopped industry innovation for 24-36 months since it has listed every use case for every purpose including those unrelated to Meaningful Use and MACRA.

Does Free Medical School Decrease Social Justice?

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BY ANISH KOKA, MD

The hottest medical school in the country right now is the New York University School of Medicine thanks to the gift of a generous benefactor that promises to make medical school free for all current and future medical students.  The news was met with elation from the medical community of physicians that groans frequently about student debt loads routinely north of $200,000 upon matriculation.  Not surprisingly, the technocrat class of public health experts and economists did not share in the jubilation.  The smarter-than-the-rest-of-us empiricists are, after all, trained to think in terms of social justice and net benefits to society.   The needs of medical students are far down the list of priorities when forming this social justice utopia.

Contemporary arguments for social justice in some form or the other trace their roots to the philosopher John Rawls and his 1971 magnum opus – “A Theory of Justice”.  In words that would infuse liberal thought for a generation, Rawls laid out a blueprint for a just society by proposing a thought experiment called “the original position”.  This was a hypothetical scenario where a group of people are asked to form the rules of a society which they will then occupy. The catch is that the people making the decision do so behind a ‘veil of ignorance’ not knowing the disadvantages conferred by any number of attributes (age, sex, gender, intelligence, beauty, etc. ) they may be reincarnated with. Rawls posited that under conditions in which there was a possibility of being born as a disadvantaged member of society, social and economic inequalities would be arranged to be of greatest benefit to the least advantaged members of society.

At first glance, it would seem that the objections to tuition-free medical school rest on a social justice framework that does not seem to comport with gifts to the soon-to-be-wealthy.  After all, the $200,000 investment for medical school pales in comparison to the lifetime earnings of the average physician who is assured at least a six-figure income in seeming perpetuity. But it is not entirely clear that one has to even combat Rawlsian ideals to rebut the social justice do-gooders with strong opinions on how other people should spend their money.  A Rawlsian framework never intended that everyone in society would be able to achieve the same outcome regardless of starting position.  Rawls actually went out of his way to argue that inequalities were justified in society as long as the operating rules served to raise the position of those worst off in society.  A rising tide should lift all boats – the rich may become richer, as long as the poor become richer as well.

Stifling Primary Care: Why Does CMS Continue To Support The RUC?

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Last October, the Wall Street Journal ran a damning expose about the Relative Value Scale Update Committee (RUC), a secretive, specialist-dominated panel within the American Medical Association (AMA) that, for the past two decades, has been the Centers for Medicare and Medicaid Services’ (CMS’) primary advisor on valuation of medical services. Then, in December, Princeton economist Uwe Reinhardt followed up with a description of the RUC’s mechanics on the New York Times’ Economix blog. We saw this re-raising of the issue as an opportunity to undertake an action-oriented campaign against the RUC that builds on many professionals’ work – see here and here – over many years.

We have focused on rallying the primary care and business communities to pressure CMS for change, and are contemplating a legal challenge. But the obvious question is why these steps are necessary. Why doesn’t CMS address the problem directly? Why does it continue to nurture the relationship?

The Negative Consequences Of The RUC

There is overwhelming evidence that the RUC has used flawed and capricious methodologies. It has systematically under-valued primary care and operated without regard for financial conflicts of interest. Its influence has compromised care quality and facilitated the primary care labor shortage. The Chair of the Medicare Payment Advisory Commission (MedPAC) is on record before a Congressional Committee describing its harmful characteristics. We know that the valuations it recommends – and CMS accepts – are major contributors to unnecessary utilization and cost. Former CMS Secretary Tom Scully has publicly condemned it as “indefensible.”

In studying the RUC closely, we have come to believe that the structure of CMS’ relationship with the RUC has violated the management and reporting requirements of a “de facto” Federal Advisory Committee. Meanwhile, the nation generally and publicly funded health care programs specifically are under intense fiscal pressures that have resulted, at least in part, from the runaway health care costs associated with the RUC’s influence.

Treating Chest Pain With a Cup of Tea

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flying cadeuciiIt is very early.  I am running to the ‘clinical decision unit’ (CDU) to see a patient of mine sent in the night before from a local skilled nursing facility.  Also known as clinical observation units,  ‘obs’ units, or short stay observation units, these units were designed to help decompress busy emergency rooms and divert unnecessary, expensive inpatient admissions.  The units are typically adjacent to emergency departments, and usually are run by emergency physicians.

My particular patient was admitted due to an episode of chest pain at her facility.  A brief conversation the prior night with the emergency room staff revealed chest pain that clinically was not typical for any of the feared diagnoses of a heart attack, pulmonary embolism or an aortic dissection.  An electrocardiogram and cardiac enzymes were also initially unremarkable.  Regardless, the patient was elderly and had multiple other comorbidities, and was somewhat confused.  I recommended a short stay to allow anything malignant to declare itself.

And so, here I was, at the observation unit, digging through pages upon pages of printed gibberish that clearly had achieved the nirvana stage of meaningful use (for those wondering, that’s after stage 3).  Ironically, the most useful piece of information lay in a handwritten progress note describing the episode. I could see why the patient had been brought here to be further evaluated, but after 18 hours of negative biomarkers, electrocardiograms, and no recurrence of symptoms, I felt comfortable letting her go back to where she came from.  I told the ER staff… who cancelled her stress test.  A stress test? Yes, a stress test had been ordered prophylactically.  We practice in a climate where every bad outcome has the potential for litigation – malpractice lawyers would have a field day with the case of anyone going to the ER, being discharged without some type of cardiac imaging study, and having a heart attack.  My recommendation to discharge the patient shifts the liability of an adverse outcome from the ER squarely on to my shoulders, and thus, poof goes the stress test.

Big Names, Big Ideas at Health 2.0 Fall Conference

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The Annual Health 2.0 Fall Conference has harnessed the creativity and passion of health care’s brightest professionals to tackle the industry’s most intractable problems and leverage technology-enabled solutions to drive more compassionate, more accessible patient-centered care.

Check out the full agenda of our eleventh show, Oct. 1-4, in the heart of Silicon Valley.

Our killer line up of speakers covers the full spectrum of healthcare, and includes:

Innovative leaders, including Jason Pyle, CEO of Base Health; Simon Kos, CMO of Microsoft; Aashima Gupta, Global Head, Healthcare Solutions, Google; Brian Otis, CTO of Verily Life Sciences; Daniel Kraft, Founder and Chair of Exponential Medicine; and Jeff Margolis, CEO of Welltok.

Policymakers, such as HHS CTO Bruce Greenstein; ONC National Coordinator Don Rucker; former ONC Director David Brailer; and former U.S. CTO Aneesh Chopra.

Patient advocates, including Dave DeBronkart (e-Patient Dave) and Patient Power President Andrew Schorr.

Representatives from more than two dozen major health systems, including UPMC, Mount Sinai, Dignity Health, UCSF, and more!

Major healthcare investors, including Providence Ventures, Merck Ventures, GE Ventures, and more!

Check out our full line up of speakers.

Limited amount of tickets are available. Register Today to secure your place at the Fall Conference-event starts this Sunday.