Thursday, November 15, 2018


The doctor is in ...

Is It Possible That All Healthcare Needs to Know We All Learned In Kindergarten?



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US Healthcare is sick and getting sicker, and while its chaotic complexity suggests to many that it will need to fail big before it can be rebuilt, some simple rules may help to get it back on track. As this the time of year when many of us prepare to send our children on grandchildren off to school in the hopes that they will learn what they need to succeed, I thought we could revisit the lessons of Kindergarten and their application to healthcare. The following list, initially from “ALL I REALLY NEED TO KNOW I LEARNED IN KINDERGARTEN” by Robert Fulghum.  has been adapted (read ‘man-handled’) for applicability to US healthcare. You’ll find the original list here:

  • Share everything – In healthcare, this means share ALL the data, all the information, all the acquired wisdom. Interoperable systems are essential. Price transparency is the right side of history. Automated, coordinated, connected systems are essential.  Healthcare is too much of a team sport not to share all that we know, so that we can quickly understand what works, what doesn’t, and what it’s all going to cost.
  • Play fair – It isn’t fair when decisions are made without a person’s input.  It isn’t fair that a patient should bear the risks, the pain, the scars and the costs without having unfettered access to all the relevant information. Shared decision making is part of playing fair in a world where healthcare is meant to happen for patients and with patients, but not to patients.
  • Put things back where you found them. Except for things like an infected appendix or a malignant growth, this continues to make great sense.  And as we go about transforming healthcare, we must recognize that wholesale, sweeping changes are easier to envision than execute.  While progress requires change those changes that align with / enhance / expedite existing workflows will be easiest to achieve.

The Destructiveness of Measures


A little box pops up before him asking if he asked the patient about the exercise.  He mumbles something under his breath, clicks a little box beneath the question, then moves on.

This is what medicine has become:  a series of computer queries and measures of clicks.  It must be measurable, quantifiable, and justifiable or it didn’t happen.

Do they ask if I asked them about if they used cocaine?  Of course not: too politically incorrect.

Do they ask if I really listened to their heart?  Of course not – this activity is not a paid activity.

Do they ask about the myriad of phone calls and e-mails to arrange for a procedure?  Nope.

Do they measure my time with the patient when I go back to see them on the same day?  Nope – not paid for.

So what’s the motivation for doctors to be doctors?  Are we retraining our doctors from care-givers to data providers?  What are we losing in turn?

The Medical Home Bandwagon and the One-Hoss Shay: Expectations and Assumptions


Have you heard of the wonderful one-hoss shay that was built in such a wonderful way? Logic is logic. That’s all I say. Now in building of a chaise, I tell you there is always somewhere a weakest spot. — Oliver Wendell Holmes (1809-1894)

Expectations are high. States, health plans, and the Medicare program are making substantial financial bets that implementation of the medical homes will lead not only to improved care but also to long-term savings, largely by reducing the number of avoidable emergency room visits and hospitalizations for patients with serious chronic illness. Some see the medical-home model as a means of reversing the decline in interest in primary care among medical students and residents, and others argue the broad implementation would reduce health care spending overall. — Elliot Fisher, MD, MPH, “Building a Medical Neighborhood for the Medical Home,” NEJM, Sept. 2008

When people jump on the bandwagon, they get involved in something that has become very popular. The term “bandwagon” is usually applied to politics but spills over into other fields. It is also called the herd instinct, or going for the apparent winner. — Various Sources

When I think of the Medical Home, a concept introduced by the American Academy of Pediatrics in 1967, just now rapidly gaining speed and traction, two images spring to mind,

  1. A bandwagon.
  2. The wonderful one-hoss shay, which ultimately collapsed because of minor defects in its construction.

Everybody is jumping on the medical home bandwagon. And for good reasons. It’s so damn logical. Health costs are out of control. The population is aging. Countless studies show primary–based systems are popular, cost less, satisfy patients, and achieve better quality and outcomes. Besides, American primary care physicians are unhappy with the present system, and so are American patients. It’s time for a change. The problem, logic says, stems from our specialty-dominated, fragmented system and growing shortages of primary care physicians.

A New Approach?
Why not, then, create a new approach where primary care physicians form medical homes, and with the help of a newly hired care coordinator, and a team of providers operating under the guidance of the doctor, offer continuous, comprehensive, coordinated care of chronic diseases (the 4 C’s of medical homes)?

Logic Builds Momentum

The logic of this approach explains why everybody is enthusiastically leaping on the medical home bandwagon. Leapers include:

  • Medicare and CMS, who are paying for a three year demonstration project, to be completed by 2010, to see if this new wagon works, has wheels, saves money on hospitalizations, and makes for a sustainable growth rate for health costs.
  • The Obama Administration, which has vowed to reform health care and save money through more primary care physicians, prevention, EMR use, and chronic care management – the medical home pillars.
  • Major primary care associations – the American Academy of Family Practice, The American Academy of Pediatrics, The College of Physicians, and The America Osteopathic Association – have joined forces under the umbrella of the Patient-Centered Primary Care Consortium to issue a set of Joint Principles and are churning out white papers on medical homes.
  • State legislators, who have taken the lead from state medical societies and the Physicians’ Foundation, and are endorsing Medical Home demonstration projects in at least 20 states. The numbers grow each month.
  • Academic institutions, such as Johns Hopkins, Duke, and the University of Rochester, who are pouring money and other resources into building and testing medical homes and other outreach programs.
  • The American Medical Association, the American Association of Medical Colleges, and societies of medical directors and state medical society executives, all of whom have bought into the concept.
  • NCQA, who think medical homes contribute to improved medical care.
  • Even the health plans, especially Aetna and the UnitedHealthGroup, who would like to serve as intermediaries in the process, selecting what doctors qualify for being medical home participants and what they will be paid.

“Almost” Everyone
Almost everyone, in other words, across the political spectrum have concluded medical homes are a leap forward and are willing to climb aboard for a bandwagon ride. The key phrase here is “almost” everyone. Forming and paying for medical homes are very much political processes, where “everybody” may not include those who want a piece of the action or feel their economic status is threatened.

It is assumed, of course, coordinated, comprehensive, continuous care of chronic disease in an aging population is an overwhelmingly logical thing. I agree, but it is still useful to examine medical home assumptions.

I am reminded of the story of the economist stranded on a desert island with fellow castaways. The castaways are surrounded by thousands of miles of ocean, but are blessed with cases of canned goods from their sunken ship. But, alas, they have no way of opening the cans.

The group turns to the economist for an answer, and he says, “First, assume a can opener.” We’re assuming here that medical homes will serve as can openers to save the system. The cans, however, may be full of worms.

Perhaps it’s time to examine the assumptions that might cause the wheels of the Wonderful One Hoss Shay, known as Medical Homes, to come off.

  • The first assumption is that there are enough primary care physicians to make medical homes enough of an impact to make a difference reforming the system. The stark truth is that a desperate shortage of primary doctors already exists, most medical students and residents shun primary care, and we have no idea how many primary care doctors would bother to go through the paperwork to qualify or to build the infrastructure (an EMR and a hired coordinator are mentioned as necessary medical home ingredients), to undergo the scrutiny of being audited for quality or complying with performance compliance markers, or to be paid enough to be motivated to create a medical home. Venture capitalists, alert entrepreneurs, retail clinic operators, and major corporations like Walgreens sense a primary care vacuum and are moving fast to set up primary care based worksites in major corporate sites having sufficient numbers of employees.
  • The second assumption is that new payment platforms will help create and sustain medical homes and be sufficient incentive to recruit primary care doctors through more lucrative “blended” payment systems – fee-for-service, a capitation fee for managing a patient panel, and patient-centered bonuses for rapid responds to same day visits and email or phone to patients. The predominant mindset among American physicians it to cure, fix, restore, or repair swiftly and episodically rather than manage or coordinate over the long haul. Whether new payment schemes will lure U.S. primary care doctors is unknown, as is how much money will be required to win the hearts and minds of primary care doctors or whether lack of adequate compensation alone is the basic “turn-off” for medical students or residents considering primary care.
  • The third assumption rests on the notion that every medical home physician will have an EMR and will be able to talk, refer, and send complete electronic patient information to, other entities in the medical neighborhood – clinical colleagues, hospitals, pharmacies and other care providers. This is a giant leap of faith since only about 15% of physicians currently have EMRs and PHRs are in their infancy. It may be this barrier can be overcome through federal subsidies for EMRs, requiring physicians to meet connectivity standards, and rewarding collaboration through payment increases, pay for performance bonuses, and shared savings, but, in my opinion, the system is at least a decade away from this electronic utopia.
  • The fourth assumption is that primary care physicians will be comfortable with collectively “managing” the medical affairs of patient panels, making the data entries required, and massaging, analyzing, and responding to data determining the outcomes of a population health model. American primary care doctors, weary and wary of paperwork and third party hassles and managerial manipulations, may respond by choosing to opt out by rejecting Medicare and Medicaid participation; treating individual patients as they see fit; retiring; seeing fewer patients; going into concierge, cash-only, locum tenens practices; seeking employment outside the medical home, or medical careers unrelated to direct patient care. Instead we may see armies of physician extenders managing diabetes, hypertension, stable coronary artery disease, congestive heart failure, chronic obstructive lung disease, osteoarthritis, depression, upper respiratory infections, and gastro-esophageal reflex.
  • The fifth assumption is that patients would welcome such a model. In his popular blog, KevinMD, Kevin Pho, says many patients may be annoyed by being asked to be in a medical home, when they only have one symptom or one disease that may not need to be “managed.” Also Americans are mobile with 20% of Americans moving each year. Many patients may not be looking for a personal physician or a medical home. Finally, keep in mind that most people who frequent emergency rooms do so because the emergency rooms are “there,” not because they are uninsured, underinsured, or lack a primary care doctors (Myna Newton, et al, “Un insured Adults Presenting to U.S Emergency Departments, “ JAMA, October 22-29, 2008).
  • The sixth assumption is that the medical home is a politically and financially neutral concept. This isn’t the case. Nurse practitioners, nurse doctors, physician assistants, and other medical specialists will lobby to set up their own Medical Homes, if for no other reason, than to make up for the primary care shortage. Another, probably more important factor, may the resistance of specialists. Organized medicine, now dominated by specialists, is aware that Congress’s present Sustainable Growth Rate (SRG) is supposedly revenue neutral, meaning if you reward primary care physicians through Medical Homes, you take away from specialists.

The medical home movement is logical and is intended to correct the current costly fragmented specialist dominated system by creating “homes” for patients with chronic disease to receive more coordinated and comprehensive care at less cost with better results. Medical homes are currently riding a political bandwagon, but the assumptions that the system will be transformed by medical homes remain politically and pragmatically untested. That’s why multiple demonstration projects are underway. Meanwhile, let us hope for the best and pray that a fundamental shift in the system towards more primary care occurs. Making medical homes a reality will take hard work and political arm-twisting.

Dropping Out


After 18 years in private practice, many good, some not, I am making a very big change.  I am leaving my practice.

No, this isn’t my ironic way of saying that I am going to change the way I see my practice; I am really quitting my job.  The stresses and pressures of our current health care system become heavier, and heavier, making it increasingly difficult to practice medicine in a way that I feel my patients deserve.  The rebellious innovator (who adopted EMR 16 years ago) in me looked for “outside the box” solutions to my problem, and found one that I think is worth the risk.  I will be starting a solo practice that does not file insurance, instead taking a monthly “subscription” fee, which gives patients access to me.

I must confess that there are still a lot of details I need to work out, and plan on sharing the process of working these details with colleagues, consultants, and most importantly, my future patients.

Here are my main frustrations with the health care system that drove me to this big change:

  1. I don’t feel like I can offer the level of care I want for my patients. I am far too busy during the day to slow down and give people the time they deserve.  I have over 3000 patients in my practice, and most of them only come to me when there are problems, which bothers me because I’d rather work with them to prevent the problems in the first place.
  2. There’s a disconnect between my business and my mission.  I want to be a good doctor, but I also want to pay for my kids’ college tuition (and maybe get the windshield on the car fixed).  But the only way to make enough money is to see more patients in my office, making it hard to spend time with people in the office, or to handle problems on the phone.  I have done my best to walk the line between good care and good business, but I’ve grown weary under the burden of having to make this choice patient after patient.  Why is it that I would make more money if I was a bad doctor?  Why am I penalized for caring?
  3. The increased burden of non-patient issues added to the already difficult situation.  I have to comply with E/M coding for all of my notes.  I have to comply with “Meaningful Use” criteria for my EMR.  I have to practice defensive medicine to avoid lawsuits.  I have more and more paperwork, more drug formulary problems, more patients frustrated with consultants, and less time to do it all.  My previous post about burn-out was a prelude to this one; it was time to do something about my burn out: to drop out.

The Samurai Physician’s Teachings on the Way of Health


Every now and then the title of a book influences your thinking even before you read the first page.

That was the case for me with Thomas Moore’s “Care of the Soul” and with “Shadow Syndromes” by Ratley and Johnson. The titles of those two books jolted my mind into thinking about the human condition in ways I hadn’t done before and the contents of the books only echoed the thoughts the titles had provoked the instant I saw them.

This time, it wasn’t the title, “Cultivating Chi”, but the subtitle, “A Samurai Physician’s Teachings on the Way of Health“. The book was written by Kaibara Ekiken (1630-1714) in the last year of his life, and is a new translation and review by William Scott Wilson. The original version of the book was called the Yojokun.

The images of a samurai – a self-disciplined warrior, somehow both noble master and devoted servant – juxtaposed with the idea of “physician” were a novel constellation to me. I can’t say I was able to predict exactly what the book contained, but I had an idea, and found the book in many ways inspiring.

The translator, in his foreword, points out the ancient sources of Ekiken’s inspiration during his long life as a physician. Perhaps the most notable of them was “The Yellow Emperor’s Classic on Medicine”, from around 2500 B.C., which Ekiken himself lamented people weren’t reading in the original Chinese in the early 1700′s, but in Japanese translation. One of his favorite quotes was:

“Listen, treating a disease that has already developed, or trying to bring order to disruptions that have already begun, is like digging a well after you’ve become thirsty, or making weapons after the battle is over. Wouldn’t it already be too late?”

Ekiken’s own words, in 1714, really describe Disease Prevention the way we now see it:

“The first principle of the Way of Nurturing Life is avoiding overexposure to things that can damage your body. These can be divided into two categories: inner desires and negative external influences.

Inner desires encompass the desires for food, drink, sex, sleep, and excessive talking as well as the desires of the seven emotions – joy, anger, anxiety, yearning, sorrow, fear and astonishment. (I see in this a reference toarchetypal or somatic medicine.)

The negative external influences comprise the four dispositions of Nature: wind, cold, heat and humidity.

If you restrain the inner desires, they will diminish.

If you are aware of the negative external influences and their effects, you can keep them at bay.

Following both of these rules of thumb, you will avoid damaging your health, be free from disease, and be able to maintain and even increase your natural life span.”

On the topic of Restraint, the Yellow Emperor text states:

In the remote past, those who understood the Way followed the patterns of yin and yang, harmonized these with nurturing practices, put limits on their eating and drinking, and did not recklessly overexert themselves. Thus, body and spirit interacted well, they lived out their naturally given years, and only left this world after a hundred years or more.

Information Blocking–Gropper & Peel Weigh in


Today is the last day for public comments on the proposed CMS regulations regarding Medicare hospital inpatient prospective payment systems (IPPS). While there are several changes proposed, the one that’s raised lots of attention has been the idea that access to Medicare may be denied to those providers guilty of information blocking. Here are the comments submitted by Gropper & Peel from Patients Privacy Rights— Matthew Holt

Executive Summary of PPR Comments on Information Blocking

Information blocking is a multi-faceted problem that has proved resistant to over a decade of regulatory and market-based intervention. As Dr. Rucker said on June 19, “Health care providers and technology developers may have powerful economic incentives not to share electronic health information and to slow progress towards greater data liquidity.” Because it involves technology standards controlled by industry incumbents, solving this problem cannot be done by regulation alone. It will require the coordinated application of the “power of the purse” held by CMS, VA, and NIH.

PPR believes that the 21st Century Cures Act and HIPAA provide sufficient authority to solve interoperability on a meaningful scale as long as we avoid framing the problem in ways that have already been shown to fail such as “patient matching” and “trust federations”. These wicked problems are an institutional framing of the interoperability issue. The new, patient-centered framing is now being championed by CMS Administrator Verma and ONC Coordinator Rucker is a welcome path forward and a foundation to build upon.

To help understand the detailed comments below, consider the Application Programming Interface (API) policy and technology options according to two dimensions:

API Content and Security Institution is Accountable Patient is Accountable
API Security and Privacy
  • Broad, prior consent
  • Patient matching
  • Institutional federation
  • Provider-directed interop
  • Compliance mindset
  • Directed authorization
  • Known to the practice
  • Individual credentials
  • Patient-directed interop
  • Privacy mindset
API Content / Data Model
  • Designated record set
  • FHIR
  • Patient-restricted data
  • De-identified data
  • Bulk (multi-patient) data
  • Designated record set
  • FHIR
  • Sensitive data
  • Social determinants
  • Wearables and monitors

This table highlights the features and benefits of interoperability based on institutional or individual accountability. This is not an either-or choice. The main point of our comments is that a patient-centered vision by HHS must put patient accountability on an equal footing with institutional accountability and ensure that Open APIs are accessible to patient-directed interoperability “without special effort” first, even as we continue to struggle with wicked problems of national-scale patient matching and national-scale trust federations.

Here are our detailed comments inline with the CMS questions in bold:

Malpractice Claims Feel Endless Because…They Are.


I am very fortunate to have never been sued. That is not necessarily because of my amazing ability as a physician. I always practiced in Veterans Affairs medical centers, where my status as a federal employee meant I would not get sued by my patients. I also had an incredibly appreciative patient population.

But I know that most of my physician peers have been sued, successfully or unsuccessfully, at least once in their careers. And I know that these lawsuits take an emotional toll upon them. To make matters worse, malpractice lawsuits have a nagging tendency to drag themselves out for months upon months. Consider this figure, from a study led by an economist at the RAND Corporation. It shows that malpractice claims related to temporary injuries take a median of a year to resolve, while those dealing with fatalities or permanent injuries take a median of 18 months.

A Permanent “Doc-Fix” Remains Elusive



For now, all those physicians who threatened to make a mass exodus from Medicare can take a breather. Last week, the House voted to once again delay the mandated 21% cut in physician fees by another six months; thereby ensuring that the fight over the sustainable growth rate (SGR) will be resurrected sometime around Thanksgiving.

So far, Congress has kicked the SGR can down the road 10 times since 2003—four times just this year alone. The targets have long been considered unobtainable and the mandated physician payment cuts are opposed in Congress by Democrats as well as Republicans and supported by nearly no one. The level of anxiety among doctors continues to escalate every time the issue is raised—even though the cuts have never gone into effect for more than a couple of weeks. Why not get rid of this devilishly frustrating formula once and for all?

The short answer is that getting rid of the SGR—even though it has never led to any savings in Medicare—is just too expensive on paper. The Congressional Budget Office establishes a “baseline” projection of future spending and revenue that takes into account that all current laws will be enforced. Legislation that eliminates the SGR targets would then be scored by the CBO as adding to the deficit—to the tune of $276 billion between 2011 and 2020 even if Medicare payment rates to doctors were frozen at 2009 levels. In the current economic climate, it will be very hard to get enough members of Congress to agree to a permanent “doc fix” that eliminates the SGR targets without also finding a way to pay for it.

Managing Physician Skepticism About the Affordable Care Act


Let’s play a game. Today we are going to pretend you are a Vice President for Medical Affairs, or a Chief of Staff, or a health system CEO about to announce a collaboration with a major health insurer like CMS or a regional Blues Plan. You’ve done your homework, read the journals, listened to the experts, anticipated the future and haven’t applied enough skepticism in reading all those pro-EHR and pro-bundled payment posts on THCB.  You really believe payment reform and the EHR are the way to go.

You’ve called a meeting of your organization’s physician staff – the professionals you are counting on, caring for all those patients – and your job is go to the front of the auditorium and convince them that the success of your new venture relies on lowering health care costs with new payment arrangements that align incentives, in tandem with the launch of a new EHR.

Armed with a 30-slide PowerPoint filled with the latest consultant nostrums, you launch into your presentation.  The physicians listen in respectful silence.  After a few easy questions, there’s always that one doc in the back of the room who uncomfortably points out that the evidence about the ability of payment reforms and the EHR ability to optimize costs is uneven and that organization is making a huge bet.  Many of the docs in the room nod in agreement.  That’s when you realize that the insights of all those economists, policymakers, politicians and bloggers mean nothing if you don’t have the physicians on board.

That’s the real message behind this telling survey that was just published in JAMA.  While the overwhelming majority of physicians agreed that they have responsibility for health care costs, higher percentages felt hospitals, health systems, insurers, pharma, medical device manufacturers and personal injury attorneys had a greater mandate.  In other words, everyone is responsible, but the physicians’ duty is superseded by their ethical obligation to advocate for their patients regardless of cost.  The survey also showed that not all physicians are convinced that the electronic health record (74%) is a cost-reducing panacea, while a minority felt readmission penalties (41%) and bundled payments (35%) were likely to lead to lower costs.

So what do you do? How do you convince physicians to get on board and make this thing work? What can you possibly tell them to convince them that they should set aside their preconceived notions about the grand adventure you are all about to engage on is a worthy one?

Giving Consumers the Tools and Support They Need to Navigate Our Complex Healthcare System



As physicians and healthcare leaders, we are already well aware that the majority of patients do not have the information they need to make a medical decision or access to appropriate resources, so we didn’t need to hear more bad news. But that is precisely what new research once again told us this spring when a new study showed that almost half of the time, patients have no idea why they are referred to a GI specialist.

While the study probably speaks to many of the communications shortcomings we providers have, across the board our patients often don’t know what care they need, or how to find high-value care. Last year, my organization commissioned some original research that found that while a growing number of patients are turning to social websites such as YELP, Vitals, and Healthgrades to help them find a “high quality” specialist, the top-ranked physicians on these sites – including GI docs – are seldom the best when we look at real performance data. Only 2 percent of physicians who showed up as top 10 ranked on the favorite websites also showed up as top performers when examining actual quality metrics. (The results shouldn’t surprise you as bedside manner has little to no correlation with performance metrics such as readmission rates).


As providers and health care leaders, we lament that our patients are not better informed or more engaged and yet across the board, we have not given them the tools or resources they need to navigate our complex system. But now for some good news: all hope is not lost, and patients can become better consumers, albeit slowly, if we all do our part.