The Institute of Medicine in 2010 famously recommended that nurses should be encouraged to practice “to the full extent of their education and training.”Often, you’ll hear people advocate that every healthcare worker should “practice at the top of their license”.
What this concept is supposed to mean, I think, is that anyone with clinical skills should use them effectively and not spend time on tasks that can be done by someone with fewer skills, presumably at lower cost.
So I would like to know, please, when I’ll get to practice at the top of my license?
As a physician who specializes in anesthesiology at a big-city medical center, I take care of critically ill patients all the time.
Yet I spend a lot of time performing tasks that could be done by someone with far less training.
Though I’m no industrial engineer, I did an informal “workflow analysis” on my activities the other morning before my first patient entered the operating room to have surgery.
I arrived in the operating room at 6:45 a.m., which is not what most people would consider a civilized hour, but I had a lot to do before we could begin surgery at 7:15.
First, I looked around for a suction canister, attached it to the anesthesia machine, and hooked up suction tubing. This is a very important piece of equipment, as it may be necessary to suction secretions from a patient’s airway. It should take only moments to set up a functioning suction canister, but if one isn’t available in the operating room, you have to leave the room and scrounge for it elsewhere in a storage cabinet or case cart.
This isn’t an activity that requires an MD degree. An eight-year-old child could do it competently after being shown once.
Continue reading “Scope of Practice: Playing at the Top of My License?”
Filed Under: OP-ED, THCB
Tagged: frontline health workers, Karen S. Sibert, Physicians, practice of medicine, Scope of Practice
May 20, 2014
Writing in the Wall Street Journal (WSJ) Dr. Daniel F. Craviotto Jr. an orthopedist, made a plea to physicians to declare independence from third parties and emancipate themselves from servitude to payers, mandates and electronic health records (EHR).
As rants go, this was a first class rant. But its effect was that of a Charles de Gaulle’s whisper to Vichy France rather than a Churchillian oratory at the finest hour.
The article went viral (it has been tweeted nearly 3000 times), though with little virulence. And it is not WSJ’s paywall to blame.
The author might have assumed that most the healthcare community in general and physicians in particular wish to be free from regulations. I have serious doubts that this assumption is correct in the aggregate. The relationship between regulators and physicians is more complex and symbiotic than it first appears.
Some physicians believe in bureaucracy. Rationalism will march us out of our healthcare wilderness. This belief in scientific managerialism, faith in technocracy, is the new theism. The rationale of the new theists is that regulations fail not because they are inherently useless but because there are so few of them, and even fewer that are actually smart.
Like the first religions started with polytheism, the new believers want more agencies, more alphabet soups, more gods.
Continue reading “Doctor Paul Revere Fails to Light the Fire”
Filed Under: THCB
Tagged: health care delivery, ICD-10, Mandates, Outcomes, Physicians, practice of medicine, Quality improvement, Saurabh Jha
May 13, 2014
A study by Stanford researchers in the current issue of Health Affairs is likely to intensify growing tension between health insurers and hospitals.
At issue: the impact of physician-hospital consolidation, or vertical integration as some academics prefer to call the trend.
The researchers analyzed 2 million claims submitted to insurers by hospitals from 2001 to 2007, evaluating the impact on hospital prices, volumes (admissions), and spending for privately insured, non-elderly patients. Using data from Truven Analytics MarketScan.
They constructed county-level indices of prices, volumes, and spending and adjusted for enrollees’ age and sex. “We measured hospital-physician integration using information from the American Hospital Association on the types of relationships hospitals have with physicians.”
What they found is not surprising: vertical integration involving physician-hospital consolidation results in better care and higher costs. They found hospital prices increased 2%-3% each time physician-employing hospitals’ market share increased by one standard deviation. And overall spending on services at the hospitals that employed physicians increased while the utilization of services (volume) at those hospitals didn’t change.
They concluded the following:
“We found that an increase in the market share of hospitals with the tightest vertically integrated relationship with physicians—ownership of physician practices—was associated with higher hospital prices and spending.
We found that an increase in contractual integration reduced the frequency of hospital admissions, but this effect was relatively small. Taken together, our results provide a mixed, although somewhat negative, picture of vertical integration from the perspective of the privately insured.”
What’s the significance of the study?
1-Hospitals and physicians will bolster their position that vertical integration is necessary to improved outcomes. The shift from volume to value via accountable care organizations, bundled payments, medical homes, and value based purchasing require closer collaboration between physicians and hospitals.
“Clinical integration” is central to each, and payers– Medicare and private insurers– are promoting these risk-based contracting efforts energetically while cutting reimbursement rates for services aggressively. So the provider position is this: ‘We get better results. We built what you said you wanted.
It’s costly to make the change, especially while since Medicare and Medicaid don’t cover our costs, demand is soaring and our bad debt from the uninsured increasing. You told us to build it, but you don’t want to cover our costs.’
Continue reading “A Closer Look at Physician-Hospital Alignment”
Filed Under: Uncategorized
Tagged: Hospitals, Paul Keckley, physician-hospital consolidation, Physicians, Vertical integration
May 12, 2014
On April 29, Dr. Daniel Croviotto published an editorial in the Wall Street Journal, “A Doctor’s Declaration of Independence,” in which he argued that it is time to “defy healthcare mandates issued by bureaucrats not in the healing profession.”
Dr. Croviotto does a good job of articulating his frustration with the increasingly burdensome bureaucracy and regulations placed on care. Many physicians and nurses share his frustration. I once did, until I saw a way out of the cynicism and frustration – a way that can improve the quality and lower the cost of care for all Americans.
No matter how misguided we think the federal government is in its electronic health record mandate or other requirements, simply defying mandates as Dr. Croviotto proposes is not likely to accomplish much. Those who signed the Declaration of Independence knew it was only an initial step toward ridding the country of tyranny. They had to create a new vision for a better, more effective government.
Similarly, the medical profession needs to move beyond cynicism to create a vision for a better, more effective healthcare system.
Continue reading “A Declaration of Independence Is Only the Beginning”
Filed Under: OP-ED, THCB
Tagged: frontline health workers, health care delivery, Hospitals, John Haughom, LEAN, Physicians, practice of medicine, process improvement, Quality
May 7, 2014
In the forty years since I started medical school, I have worked in socialized medicine, student health, a cash-only practice and a traditional fee for service small group practice. The bulk of my experience has been in a government-sponsored rural health clinic, working for an underserved, underinsured rural population.
Today, I will pull together the threads from my previous posts in the series “How Should Doctors Get Paid?” I will make a couple of concrete suggestions, borrowing from all the places I have worked and from the latest trends among the doctors who are revolting against the insurance companies by starting Concierge Medicine and Direct Primary Care practices.
Because I am a primary care physician, I will mostly speak of how I think primary care physicians should be paid.
I will expand on these concepts below, but here are the main points:
1) Have the insurance company provide a flat rate in the $500/year range to patients’ freely chosen Primary Care Provider, similar to membership fees in Direct Care Medical Practices.
2) Provide a prepaid card for basic healthcare, free from billing expenses and administration.
3) Unused balances can be rolled over to the following years, letting patients “save” money to cover copays for future elective procedures.
4) Keep prior authorizations for big-ticket items, both testing and procedures, if necessary for the health of the system.
5) Keep specialty care fee-for-service.
6) Have a national debate about where health care ends and life enhancement begins and who should pay for what.
Health insurance needs to be simple to understand and administer. It needs to promote wellness, and it needs to remove barriers from seeking advice or care early in the course of disease. It needs to empower patients to use health care services wisely by aligning patients’ and providers’ incentives.
Health insurance should not be deceptive. It should not promise to pay for screenings (colonoscopies and mammograms) and stop paying if the screening reveals a problem (colon polyps or breast cancer). It should offer patients the right to set their own priorities for their health while demanding concern for our fellow citizens’ right to also receive care.
Continue reading “A Swedish Country Doctor’s Proposal for Health Insurance Reform”
Filed Under: OP-ED
Tagged: Hans Duvefelt, health reform, Physicians, primary care, socialized medicine
May 4, 2014
Honest Pay for Honest Work.
Times have changed. And it’s time they change again.
In the past, medical care was more episodic than it is now. People went to see the doctor when they felt unwell. Diabetes affected mostly older patients, who didn’t live long enough with the disease to develop complications.
There were no blockbuster drugs for high cholesterol, Hepatitis C, fibromyalgia or chronic heartburn; we didn’t manage nearly as many patients on multiple medications as we do now.
In those times, a payment scale based on the length and complexity of the visit made sense, and there wasn’t much doctor-patient interaction between visits.
Today, we manage more chronic conditions, use more medications, do more laboratory monitoring, more patient education, and more administrative work on behalf of our patients than before.
Payment scales based only on what we do in the face-to-face visit have become hopelessly antiquated and stand in the way of the new demands of society – physicians providing longitudinal care for chronic conditions in patient-centered medical homes.
Continue reading “Who Should Pay Doctors?”
Filed Under: Physicians, THCB
Tagged: Chronic conditions, Hans Duvefelt, Insurance claims, Physicians, practice management, Reimbursement
May 1, 2014
After my last post about “the gift of cancer” I must say that CLL has felt much less like a gift this month.
Joining the ranks of those with “a diagnosis” has given me a some insight into what our patients face all the time.
Recently, I received my second dose of humility. I capped off a truly exhausting week in the hospital with a routine lab follow-up.
The last day of my 85-hour week I had my CBC checked, and my platelets dropped from the 100s to the 30s.
My first reaction was denial. Lab error.
Unfortunately, they dropped further the next day and I realized that the little red bumps on my legs weren’t some skin reaction, but petechiae. Bummer. Turns out that in addition to the 2% of people diagnosed with CLL under age 40, I also joined the 20% who develop idiopathic thrombocytopenic purpura (ITP).
The treatment of choice for ITP is prednisone 1mg/kg. So after a visit with my oncologist, I started 80mg of prednisone.
I realized with more than a little chagrin that I have a double standard about therapeutics. I was surprised at how much I despise being on prednisone.
I had never taken it before, and I would guess that I prescribe it every week, if not every day, that I work in the hospital. I have always felt that prednisone is fine for my patients to take.
Steroids work to help clear up that asthma flare, quickly improve that gout pain, or even help with a burst of energy in the last days or weeks of life for a terminal patient.
But for me? No thank you.
Continue reading “The Gift of Cancer”
Filed Under: Physicians, THCB, The Vault
Tagged: Brett Hendel-Paterson, Cancer, leukemia, Oncology, Physicians, Wellness
Apr 30, 2014
In the 2012 National Residency Match Program Survey, which is sent out to residency program directors around the country by the NRMP, the factor that was ranked highest with regards to criteria considered for receiving an interview—higher than honors in clinical clerkships, higher than extracurricular experiences or AOA election, and even higher than evidence of professionalism, interpersonal skills, and humanistic qualities—was the USMLE Step 1 score.
When considering where to rank an interviewed applicant, the Step 1 score took a backseat to some of the aforementioned criteria that are perhaps more telling of what kind of person the interviewee is, although it was still one of the highest considered criteria for ranking applicants as well.
When a single exam is given this level of importance in determining a future physician’s most critical period in career development—their residency—we have to look carefully at our system.
Two points of consideration come to mind. First, is it wise to weigh a test score so heavily? Many students and faculty could easily point out that student performance on exams by no means always reflects their clinical acumen and social skills when seeing patients.
Medicine is, after all, an art far more than a science.
Nonetheless, it would be foolish to assume that scores have no worth—a high score on an exam, particularly a behemoth such as the USMLE Step 1, points out many qualities in an individual: hard work, persistence, discipline, and frankly, an understanding of textbook medicine.
And thus, we are left somewhere in the middle—perhaps we should weigh scores less than we do, but when you have to sort through thousands of applications, the only standardized metric to quickly compare is, in the end, a number somewhere between 192 and 300.
Continue reading “Should Medical Schools Teach to the Boards?”
Filed Under: THCB
Tagged: Abraar Karan, FutureMed, Medical Education, Medical Students, Physicians, USMLE
Apr 29, 2014
Doximity, known as the LinkedIn for doctors and a frequent Health 2.0 participant, raised $54 million in a Series C funding round led by T. Rowe Price and Draper Fisher Jurveston with participation from Morgan Stanley Investment Management.
Doximity claims more than 40% of US physicians as active users, and in January of this year announced that their physician network has grown to more than 250,000 members.
Doctors can use Doximity to collaborate on cases, further their careers, and stay up to date on specialty-specific news, but that’s not where they make their revenue.
“There are a lot of things we can do to make medical networking more efficient,” Doximity CEO Jeff Tangney told Health 2.0 when asked how the funds would be used.
“If you think about it, how would your life be different if you weren’t able to use email in your job? How out of touch would you be? That’s what it’s like to be a US physician. We see a lot of opportunity to improve the connectivity of physicians as a new business area.”
Like LinkedIn, Doximity is a recruiting tool for people looking to hire doctors. Tangney didn’t reveal all the numbers, but he did say that Doximity was cash flow positive in January for the first time. He also said that Doximity has 55 employees, somewhere around 200 hospital clients, and that a subscription to the recruiting product costs $12,000 per seat per year to send 50 messages per month.
With some back of the envelope math, and a guess of a burn of about $10-12 million a year, it figures out to about four subscribed seats per hospital. With about 5,000 hospitals in the US and some other revenue streams to pursue, it looks like Doximity has room to grow at a bare minimum.
Continue reading “Doximity Raises Another $54M to Pursue LinkedIn’s Business Model Too”
Filed Under: Health 2.0, THCB
Tagged: Doximity, Jeff Tangney, Kim Krueger, Matthew Holt, Physicians, Social Media
Apr 29, 2014
Should we be paid for outcomes?
This is often proposed, but I have trouble understanding it. Real outcomes are not blood pressure or blood sugar numbers; they are deaths, strokes, heart attacks, amputations, hospital-acquired infections and the like.
In today’s medicine-as-manufacturing paradigm, such events are seen as preventable and punishable.
Ironically, the U.S. insurance industry has no trouble recognizing “Acts of God” or “force majeure” as events beyond human control in spheres other than healthcare.
There is too little discussion about patients’ free choice or responsibility. Both in medical malpractice cases and in the healthcare debate, it appears that it is the doctor’s fault if the patient doesn’t get well.
If my diabetic patient doesn’t follow my advice, I must not have tried hard enough, the logic goes, so I should be penalized with a smaller paycheck.
The dark side of such a system is that doctors might cull such patients from their practices in self defense and not accept new ones.
I read about some practices not accepting new patients taking more than three medications. In the example I read, the explanation was not having time for complicated patients, but such a policy would also reduce the number of patients exposing the doctor to the risk of bad outcomes.
A few comparisons illustrate the dilemma of paying for outcomes:
Do firefighters not get paid if the house they’re dousing to the best of their ability still burns down?
Does the detective investigating a homicide not get a paycheck if the crime remains unsolved?
Does the military get less money if we lose a war?
Even if we were to accept and embrace outcomes-based reimbursement in health care, how would we measure outcomes?
Continue reading “Doctors Should Be Paid for Outcomes. But Which Outcomes?”
Filed Under: THCB
Tagged: Hans Duvefelt, Outcomes, Physicians
Apr 28, 2014