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Moral Injury: A Physician’s Premature Retirement

Calder Wedding

BY HAYWARD ZWERLING

Synopsis:

  • After a 3 decade career in a solo private practice the healthcare environment shifted
  • As an employed physician, my institution’s policies hindered my ability to care for my patients
  • The consequent moral injury left me unwilling to re-engage with the healthcare industry

I retired early from the profession that I loved because the devolution of the healthcare system had made it impossible for me to provide care to my patients in a manner which met my own standards. The resultant “moral injury” left me leary of again becoming involved with our healthcare system in the near future.

My Early Career

Although I had originally planned a career as a physician-scientist, it became apparent toward the end of my training that this was not the best career path for me and I choose to pursue a career in private practice. 

My first post-training job was as a physician working in a clinic owned by Blue Cross and Blue Shield (1989-1991.) After two years in this relatively low stress environment it became clear that taking care of young, healthy patients was not much fun nor interesting.

I then joined Dr. LP’s private medical practice where I learned how to run a private practice.  It was in this setting that I began to create an electronic medical record program for my practice, ComChart EMR. ComChart evolved into a minor commercial endeavor, it was a hobby that earned me some money, and it connected me to many interesting physicians around the US, some of whom I continue to hear from to this day.

After a couple of years practicing alongside Dr. LP I decided it was time to strike out on my own. I built out a new office and soon thereafter added a nurse practitioner.

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Talking Politics in the Exam Room: A Physician’s Obligation to Discuss the Political Ramifications of Science with Patients

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By HAYWARD ZWERLING

I walked into my exam room to see a patient I first met two decades ago. On presentation, his co-morbidities included poorly controlled DM-1, hypertension, hyperlipidemia, and a substance abuse disorder. Over the years our healthcare system has served him well as he has remained free of diabetic complications and now leads a productive life. Watching this transformation has been both professionally rewarding, personally enjoyable, and I look forward to our periodic interactions.

At this visit, he was sporting a MAGA hat. I was confused. How can my patient, who has so clearly benefited from America’s healthcare system, support a politician who has tried to abolish the Affordable Care Act, used the bully pulpit to undermine America’s public health experts, refused to implement healthcare policies which would mitigate COVID-19’s morbidity and mortality, and who minimizes the severity of the coronavirus pandemic every day. Why does he support a politician whose healthcare policies are an immediate threat to his health and longevity?

My brain says, “You are the physician this patient trusts to take care of his medical problems. You must teach him that COVID-19 is a serious risk to his health and explain how the President’s public health policies threatens his health. You must engage in a political conversation.”

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How to End Egregious Medical Bills (while minimizing the impact on the provider’s bottom line)

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By HAYWARD ZWERLING, MD

I recently saw a patient who received a bill for an outpatient procedure for $333. The Medicare allowable reimbursement for the procedure was $180. I have seen other medical bills where the healthcare provider was charging patients more than 10 times the amount they expected to receive from Medicare or any insurance company.

Another one of my patients had an unexpected medical complication which necessitated a visit to an emergency room. He received a huge bill for the services provided. When I subsequently saw him in my office (for poorly controlled diabetes) he told me he could not attend future office visits because he had so many outstanding medical bills and he could not risk incurring any additional medical expenses. While I offered to see him at no cost, he declined, stating the financial risk was too high.

A patient is required to pay the entire medical bill if they have:

  • no insurance
  • poor quality insurance
  • a bureaucratic “referral problem”
  • an out-of-network provider, which means they have no contractural relationship with the healthcare provider/institution, as might result from an emergency room visit or an unexpected hospitalization.

Hospitals, physicians and other healthcare providers usually do not know what they are going to get paid for any given service as they contract with many insurance companies, each of which has a different contracted payment rate. Healthcare providers and institutions typically set their fee schedule at a multiple of what they expect to get paid from the most lucrative payer so as to ensure they capture all the potential revenue. In the process, they create an economically irrational fee schedule which is neither reflective of a competitive marketplace nor reflective of the actual cost of the services provided.

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One Physician’s Frustrations of Practicing Amidst the CHIPHIT Complex and Implications for the Future of the U.S. Healthcare System

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By HAYWARD ZWERLING, MD

The high cost, low quality and systemic inequities of the U.S. healthcare system have been the impetus for its redesign. Our healthcare system is now controlled by Consolidated Healthcare institutions, Insurance companies, Pharmaceutical companies and Health Information Technology companies (CHIPHIT complex). The CHIPHIT complex, along with the Federal Government, will create and control our future healthcare system. Ominously missing from this list are independent healthcare policy experts, independent healthcare providers and members of the general public.

Historical precedents have demonstrated that the CHIPHIT complex is incapable of creating the healthcare system we need.

Thus, if we hope to build a low cost, high quality, egalitarian healthcare system, physicians and their professional organizations must take an emphatic stand against the CHIPHIT complex today.

Consolidated Healthcare Institutions

There are innumerable mandates which make running a small medical practice very difficult. As a result, many younger physicians will no longer attempt to start a new medical practice and existing profitable practices, which are looking to off- load their regulatory burdens, are being acquired by large healthcare institutions and private equity firms.

While these consolidated healthcare institutions vocalize their desire to improve our healthcare system, many enforce a uniformity on the practice environment which belies the reality of patient care; that there is no “best” practice model, nor are there information technology tools which work well for all physicians. This imposed uniformity stifles physician innovation, which is a necessary precondition to improve our healthcare system.

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A Modest Health Care Economics Experiment to Fight Rising Costs

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By HAYWARD ZWERLING, MD

Healthcare providers, medical institutions, local pharmacies and pharmaceutical companies generally set the price of their products/services well above the payment they expect to receive from all insurers. These healthcare vendors set their fee schedule at 150%, 200% or 1,000% of the maximum payment they expect to receive from their most generous payor.

Here in Massachusetts, when a healthcare product or service is consumed and the patient has health insurance, the vendor submits a bill to the insurance company who specifies the “allowed fee,” which is considerably less than the “billed fee,” and the vendor “writes off” the balance of the  “billed fee” from their books.

For example, I recently had some blood tests done at Quest Diagnostics. Quest Diagnostics sent a bill to my insurance company for $660. The “allowed payment” was $110, so Quest wrote-off $550 and the “allowed payment” of $110 was divided between me and my insurance company.

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After the American Health Care Act

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BY JOHN IRVINE

We asked THCB’s editors and bloggers for their reactions to Friday’s news. Here are their first impressions.

DANIEL STONE, MD

The late UCLA Professor Richard Brown, once commented that the Clinton healthcare initiative failed because the status quo was everyone’s second choice. Some of that logic applies to today’s failure to vote on the AHCA. Additionally, no one ever lost money betting against the rollback of an established entitlement program.

The Republicans opponents of the ACA have not yet faced the fact that the reason coverage is so expensive is because the care is so expensive. You can’t have cheap insurance for expensive services. So, something “better and cheaper” was a never more than a slogan. That slogan showed the AHCA to be the bait and switch that it was.

Health insurance has evolved to serve two purposes; to protect against health related financial catastrophe and to finance care. The ACA, with its high deductibles does a better job with the former than the latter. (Although opponents give short shrift to the mitigation provided by the provision of preventive services without charge.) It will be hard to satisfy the diverse collection of stakeholders with anything much different.

This is another illustration of the fact that anything approaching universal coverage is challenging for the developed world’s outlier on healthcare cost. Medicare has around 15% lower costs than commercial plans. The only practical way out of the cost vs access quandary is to harness the commercial insurance overhead/waste/profit and direct it toward coverage.

So, to paraphrase Keynes, in the long run, we’re in both single payer and dead. It’s just a question of whether we’re all dead first or just some of us.

JOHNATHAN HALVORSON

My immediate reaction is that now they are going to nibble at the ACA for 4 years. I’d actually have preferred the House passed this monster of a bill, which the Senate would have rejected, and then had to answer for it in 2018.

Energy and Commerce committee is not going to rewrite the AHCA now and is instead turning to CHIP reauthorization (where they may sneak in ACA cuts) and exchange stabilization.

MICHAEL MILLENSON

I think Jonathan Chait’s piece in NY Magazine addresses a lot of the substantive issues very well, particularly noting high up the opposition of a broad array of conservative experts.

Let me comment briefly on a small political point. Trump issued an ultimatum asking for a vote, just like you’d do if you last paid attention to how Congress works during 8th-grade civics class. But, clearly, when it became clear they would lose, Trump Congressional allies who are more sophisticated explained to the White House why you didn’t want to expose GOP House members to casting a potentially toxic vote in a sure-to-lose cause, and so the president “requested” that the vote not be held; i.e., put the onus on himself, not Ryan.

Translation: Trump is learning how politics really works and is adjusting to reality. That will likely help him in the future.Continue reading…

The HIT Emperor Has Never Had Any Clothes

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By HAYWARD ZWERLING, MD

Over the last several months, I have worked to make the following the official policy of the Massachusetts Medical Society:

That the MMS will advocate to our State and Federal Representatives to end all legal constraints and financial inducements arising from the use or non-use of Office of National Coordinator (ONC) Certified EHR Technology.

That the MMS will encourage our Massachusetts Federal Legislators to introduce legislation to end the ONC’s EHR certification program, and will ask the President of the United States to immediately request that such legislation be introduced.

While the MMS’s Committee on Information Technology voted unanimously to support the above proposal, the MMS rejected the above and choose instead to make the following official MMS policy:

That the MMS will work with appropriate government entities to foster EHR innovation, affordability, and functionality by modifying the certification process for EHRs to improve patient care.

Without a doubt, ONC’s EHR certification program has stifled innovation in EHRs in particular and in health information technology (HIT) in general. In addition, the data accumulated to date has shown these ONC’s Certified EHRs have failed to have a meaningful impact on either the cost or quality of healthcare.

The 6 December 2016 issue of Annals of Internal Medicine has an article which shows that for every hour a physician is involved with direct patient care results in an additional 2 hours of EHR work (in the office/clinic) and then more EHR work from home. No wonder MDs are so dissatisfied with the practice of medicine. The accompanying editorial (Ann Intern Med. 2016;165:818-819) concludes “Now is the time to go beyond complaining about EHRs and other practice hassles and to make needed changes to the health care system ”

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How to End MACRA, Meaningful Use and ONC Certified EHRs Programs/Mandates

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By HAYWARD ZWERLING, MD

flying cadeuciiWhile the Federal Government’s promotion of EHRs via the HITECH act has been successful at increasing the prevalence of EHRs, their continued advocacy of Certified EHRs, Meaningful Use (MU) mandates and MACRA seriously impedes innovation in health information technology realms. For this reason, I think it is time for our Federal politicians to alter provisions of the HITECH ACT so as to end all legal mandates resulting in Certified EHRs, MU and MACRA.

Unfortunately most medical societies have been complicit with the Federal Government / ONC by making encouraging public statements about the evolution of MU into MACRA, and refusing to advocate for an alteration in Federal law which would end the legal underpinnings of MU, MACRA and ONC Certified EHRs. It is my opinion that these organizations are fearful of antagonizing the Federal Government and concerned that if they did such advocacy work, they would be excluded from influencing ONC’s evolution of the HITECH mandates.

Given the failure of these organizations to take a definitive stand against MU, MACRA and ONC Certified EHRs, it is time for the physician to take control of the reins of their organization and use their organization’s influence to end these HITECH mandates.

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On THCB

The Black List Part II (Features Which Should Be In Every EHR, But For Some Reason Aren’t)

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By HAYWARD ZWERLING, MD

I have been involved in HIT for 2.5 decades as a designer and primary programmer of a commercial EMR which I developed for my practice and was sold from 2000 until 2015. As a result of that experience, and 15 years of interactions with the physicians who used my EMR, I developed some insights about which features have real utility to the practicing physician and how to design an EMR so that it is efficient and intuitively obvious how to use the EMR. I have since learned that many of those useful features and design considerations have not been incorporated into all EMRs.

In my previous posting on The Health Care Blog , I discussed some EMR features which would be expected to appear in the Progress Notes and Labs section of the EMR. In this posting, I will discuss some other useful features/EMR insights which, I hope, will eventually be incorporated into all EMRs.

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