When four physician certification boards founded the American Board of Medical Specialties (ABMS) in 1933, those forward thinking organizations—and their professional society sponsors—launched a national movement toward ever increasing physician accountability. Back then, quackery was rampant, so “board certification” meant a lot to patients. The ABMS has since grown to 24 member boards, all ostensibly dedicated to serving “the public and the medical profession by improving the quality of health care through setting professional standards for lifetime certification.”
Because information and technology now advance so rapidly, those one-time lifetime certificates from years ago may no longer be enough. A doctor who passed a test in 1990 isn’t necessarily competent today. The boards have thus changed their approach to certification; for newly minted physicians, time-limited (e.g., 10 year) endorsements now replace the lifetime ones granted to their predecessors. Initially contingent on additional examinations each certification cycle, these newer time-limited endorsements now additionally require ongoing participation in Maintenance of Certification (MOC®) programs.
As the Senate debated the fate of the Affordable Care Act (ACA) in Washington this past summer, healthcare was front and center in newspapers and conversations around the country. While insurance coverage and the affordability of care certainly warrant the level of nationwide attention they received, they comprise only one dimension of the systemic deficits in US healthcare: access to care. Meanwhile, the pressing need to reform our broken delivery and payment structures and address the more than $1 trillion of waste in our system was being overlooked by lawmakers in DC.
Luckily, on the other side of the country, entrepreneurs and venture capitalists throughout Silicon Valley are paying plenty of attention to opportunities to improve the efficiency of healthcare. In the first quarter of 2017, while policymakers fought about repeal-and-replace, investors poured almost $1.5 billion into digital health startups (mostly in the San Francisco Bay Area). This is on top of over $29 billion invested in healthcare startups between 2010 and 2016. Many of these budding companies are poised to significantly improve the way healthcare is administered and enhance the experience of providers and patients in novel, tech-enabled ways. Unfortunately, in addition to the myriad barriers facing any new startup, healthcare startups also encounter several unique obstacles rooted in policy failures that severely limit their potential to disrupt a system badly in need of disruption.
In an age where big data is king and doctors are urged to treat populations, the journey of one man still has much to tell us. This is a tale of a man named Joe.
Joseph Carrigan was a bear of a man – though his wife would say he was more teddy than bear. He loved guitar playing, and camp horror movies. Those who knew him well said he had a kind heart, a quick wit and loved cats.
I knew none of these things when I met Joe in the Emergency Department on a Sunday afternoon. I had been called because of an abnormal electrocardiogram – the ER team was worried he could be having a heart attack. Not able to make sense of the story on the phone, I was in to try to sort it out. Joe was gruff, short with his answers – but clearly something just wasn’t right. He was only 54 but had more problems than the average 50 year old. Progressive calcification of his aortic valve some years ago had caused intolerable shortness of breath resulting in replacement with an artificial valve. Longstanding diabetes had resulted in kidney failure and dialysis, and most recently abnormal liver tests had revealed the presence of the early stages of cirrhosis from hepatitis C. Yet Joe continued to live an active life – with only a tight circle of family and friends aware of the illnesses beneath the surface.Continue reading…
The physician-patient relationship is a bedrock of the U.S. health system. Strong relationships are associated with higher ratings for physicians and better outcomes for patients but there’s a catch.
In Secretary of Health and Human Services’ Tom Price Senate confirmation and many times since, he has vowed his administration will seek to restore that relationship. But what patients associate with a strong relationship is increasingly at odds with how physicians think. And the gap between the two seems to be widening.
Per the American Medical Association, the physician-patient relationship is a formal or inferred relationship between a physician and a patient, which is established once the physician assumes or undertakes the medical care or treatment of a patient. It is a responsibility physicians don’t take lightly and most believe they do it well.
The physician-patient relationship has been widely studied. A framework developed by Ezekiel and Linda Manuel has been widely used to categorize the four roles physician play in these relationships: guardian, technical expert, counselor, and friend. In interacting with patients, physicians play all four. Researchers have linked a physician’s personality with their bedside manner. Surveys show most physicians lean toward a more paternalistic approach in dealing with patients and the majority think friendships with patients must be approached with caution. Academics have studied the dynamic between physicians and patients, observing that the physician is the ‘power’ figure in most. Studies have linked a physician known to have a prickly personality with more patient complaints and, in some specialties, a higher susceptibility to lawsuits. And physicians routinely compare notes among themselves about problem patients with whom interactions are routinely difficult.
There is a grassroots movement, 4300 strong, known as “Save Our Hospital” gaining notoriety in Albert Lea, Minnesota.This story is symptomatic of the fact that hospital consolidation has slowly become a national pastime.With declining revenue under the Affordable Care Act, mergers increased by 70%, leaving small communities scrambling for healthcare access.The latest casualty in the ‘hospital-consolidation-for-sport’ trend is Albert Lea, a small city located in Freeborn County, Minnesota.
Known affectionately as the ‘Land between the Lakes,’ it has a population of 18,000 spread over 14 square miles.Not surprisingly, Mayo is their largest employer; the 70-bed hospital serves almost 60,000 in a region including patients who live in Iowa.In Rochester, MN, the Mayo Clinic is regarded by many as one of the premier medical facilities in the country.Originally of humble origins, founder William Mayo opened a practice during the Civil War and later, passed it down to his sons; today, the Mayo Clinic flagship is located in Rochester, Minnesota and plans to become a renowned premier medical destination for the world.
Corporations with such lofty ambitions tend to make “small” sacrifices along the way; often, on the back of a beloved rural town.On June 12, Mayo clinic administrators announced they would transition all inpatient services to Austin, more than 20 miles away.Mayo cited ongoing staff shortages, reduced inpatient censuses, and ongoing financial difficulties as their reasons for hospital closure.Rural care was mentioned to be at a crisis point, which is an altogether callous assessment of the troubling situation facing communities across this country.
On July 17 of this year, I journeyed from Charlottesville Virginia, where I live, to Seattle to have my cervical spine rebuilt at Virginia Mason Medical Center, whose Neuroscience Institute has a national reputation for telling patients they don’t need surgery. It was my fifth complex surgical episode in 29 months, after more than fifty years of great health. My patient experience has been wrenching, and it made me question yet again the conventional wisdom about doctors and patients that dominates much of our current health policy debate.
None of these interventions was remotely elective: head and neck cancer, nerve grafting surgery to restore use of my right hand and a musculoskeletal trifecta- two hip replacements and cervical spine surgery. All five surgeries were successful, and I have fully recovered and returned to my busy life. The technical quality of the surgical care was flawless. Only three of the people who touched me were over forty, and three of the procedures were performed by women. It was stirring to watch and be helped by the remarkable teams and the teamwork they displayed.
In retrospect, it was dizzying how fast the acute phase of these interventions was over. I walked on my new hips an hour after waking up, and spent only three nights in the hospital after my spine was rebuilt! Most of the actual recovery, and large amount of the clinical risk, actually took place out of the hospital, placing a premium on preparing me and my family for the transition.
As hospital consolidations sweep the nation, the monopolies being created are having a profound impact on life in small town America. Lee County, in Southern Georgia, is a little place with big dreams; they are resolutely determined to build a 60-bed community hospital and provide local residents with real choices. For years, two competing hospitals served the population of 200,000 spread over six counties: Phoebe-Putney and Palmyra Park. Phoebe-Putney Memorial Hospital put an end to that by securing a 939-bed hospital monopoly and an ample market share.
Their efforts began in 2003, when Phoebe-Putney Memorial Hospital in Albany, Georgia successfully opposed a bid for a Certificate of Need (CON) to open an outpatient surgery center. Frustrated from a free-market perspective, accountant Charles Rehberg and a local surgeon, John Bagnato, began sending anonymous faxes to local business and political leaders, criticizing the financial activities of the local hospital. These faxes quickly gained notoriety, becoming known as “Phoebe Factoids.” Concerned about negative publicity, Phoebe Putney executives hired former FBI agents to intimidate these men.
In biology, it is clear that access to more genes leads to greater overall health. This is true because it allows for a greater likelihood that a genetic defect can be compensated by a gene from a different pool. This is the reason that inbreeding leads to more genetic diseases. This same phenomenon exists in social science. Complex social networks are healthier than more narrow (constrained) ones. Dr. Amar Dhand of the Brigham and Women’s Hospital’s Department of Neurology has, for example, shown that people are more likely to get to the emergency room in time to receive a clot busting therapy for stroke if they are part of a more complex, rather than constrained, social network.
The probable reason for this effect is the diversity of ideas that are available in the complex social networks is greater than in the narrow ones. Despite these advantages, human beings tend to resist diversity, depending instead on a competing drive to create cliques and clubs. In Arlie Russell Hochschild’s book, Strangers in Their Own Land, she attempts to understand what she sees as a paradox. Why do people vote in manners that seem to be contrary to their own self interest? In fact this is not a paradox, but rather simply a competition between two deeply ingrained human traits; one biological and the other sociological.
The phenomenon of professional burnout is a case in point. It is generally defined as a sense of cynicism, depersonalization and ineffectiveness. Some believe that we are in the midst of an epidemic of burnout, affecting as many as half of medical doctors, for example. The causes of burnout are protean, but at the core of the problem is the perception of unfairness; that one is the subject of a form of bias or prejudice whereby certain resources are unfairly distributed by a powerful force, such as the employer or the government. Any individual or group may be subject to this perception. Much of the conflict that is being expressed around the world can be understood as an analogue to professional burnout, in other words, caused at its root by a perception of unfairness. So what is perception and from where does it arise?
Eventually, the share of the American economy absorbed by healthcare will stop rising. The question is when, and how much more collective damage will be inflicted in the process. As it turns out, there is a solution under our noses that is nearly ubiquitous in business, personal finance, and government programs worldwide. It can be used to bring manageable, relatively predictable transformation, rather than sudden wrenching change. It is a called a “budget.” It is well past time to embrace the discipline of budgets in healthcare financing.
The basic idea is clear: set a limit on how much money can be spent for healthcare. Almost every wealthy nation disciplines its spending with a budget for healthcare expenditures. The United States does not, still retaining for the most part an open-ended model in which rates for individual services are set, without overall limits on what is spent. The discipline brought by budgets allows other nations to spend roughly half what the United States does per person, despite the fact that life and health are valued in France, The United Kingdom, Israel, and Germany no less than in the United States.
Global healthcare budgets aren’t a policy of the left or the right. The use of budgets has become associated with the political right in America, despite the fact that nearly every socialized universal healthcare system in the world has one. The fact that this isn’t about left or right becomes clearer when considering that even in America both sides have advanced their own versions of capping healthcare expenditures by a budgeting mechanism.
There is an old Vulcan proverb saying that only Nixon could go to China. Only a man who used to work for Joseph McCarthy could set America on a path to better relations with a virulently Communist country. A few years after Nixon went to China, Menachem Begin, the Israeli Prime Minister who represented people believing that the state of Israel should start at the Nile and end at the Euphrates, gave Egypt back all the lands conquered in a recent war and made a lasting peace with Israel’s largest enemy. They said back then that only Begin could make peace with the Arabs.
Today, I want to submit to you that only Trump can make single-payer health care happen in this country. Only a billionaire, surrounded by a cabinet of billionaires, representing a party partial to billionaires, can make that hazardous 180 degrees political turn and better the lives of the American people, and perhaps the entire world as a result. Oh, I know it’s too soon to make this observation, but note that both Mr. Nixon and Mr. Begin were deeply resented (to put it mildly) in their times, by the same type of people who find Mr. Trump distasteful today. The liberal intelligentsia back then did not have the bona fides required to cross the political chasm between one nation and its ideological enemies, or as real as death immediate foes. The liberal intelligentsia today lost all credibility in this country when it comes to providing a universal solution to our health care woes.
Free health care (and free college) are not solutions. These are rabble rousing slogans to gin up the vote, slogans that end up in overflowing trashcans left in ballrooms littered with red white and blue balloons after everybody goes home to get some sleep before the next round of calls to solicit funds from wealthy donors for the next campaign. Providing proper medical care to the American people is a monumental enterprise that engages tens of millions of workers from all walks of life, every second of every day, in every square mile of habitable land, littered with the hopes and fears of hundreds of millions of invisible men, women and children who call this great country their home. This is not something that can be made free. Nothing is free in our times, not even sunshine and fresh air.