On a recent shift in the Emergency Department, a resident boasted to me that she had convinced a patient to have an MRI done after discharge, rather than in the hospital. She was proud of this achievement because MRIs cost much more in the hospital than they do elsewhere – sometimes thousands of dollars more. To advocates of “cost-conscious care,” a new movement in medical education that aims to instill in young doctors a sense of responsibility for the financial consequences of their decisions, this story seems to belong in the ‘win’ column.
But this story also raises troubling questions: Why wasn’t the resident more concerned about how the hospital’s charging practices were leading her to delay care for her patient? What about the prolonged anxiety the patient would suffer? What about the extra day of work she would have to miss? And most importantly, why does an MRI cost thousands of dollars more in the hospital than it does across the street?
Like many doctors, she had fallen into the ‘transparency trap.’ This phenomenon is an unintended consequence of price transparency efforts that have come in response to patients and doctors being kept in the dark for decades about the prices of common services. Unfortunately, as the CEO of one large hospital put it, “the vast majority of [prices] have no relation to anything, and certainly not to cost.” In fact, studies have shown that in a functional market, MRIs would cost somewhere around $250, and we wouldn’t be nearly as concerned about doing too many of them.
This week marks the sixth anniversary of the Patient Protection and Affordable Care Act (ACA). But it’s hardly anything to celebrate. The ACA was intended to make health coverage affordable using an age-old strategy referred to as OPM (other peoples’ money). For instance, ACA regulations require insurers to accept all applicants — including unprofitable ones — at rates not adjusted for their health risk. Premiums can vary somewhat based on age, but not health status. A plethora of new taxes (mostly on medical care and health insurance) are supposed to somehow make coverage more affordable. Other funding mechanisms include draconian cuts to Medicare and higher deficits to expand Medicaid.
The concept of restrictive (oh let’s call them euphemistically “narrowed”) networks has for decades been the third rail of healthcare. Ask Hillary Clinton, who put her foot on that third rail in the 1990’s while attempting to reform healthcare. In the same vein, HMOs in the 90’s also tried to restrict networks, resulting in vicious backlashes.
One of those backlashes was the enactment in many states of so-called “any willing provider” or “freedom of choice” legislation. At last look, some 27 states still have a form of such legislation on their books. Most credible studies show that such laws increase the cost of healthcare.
Moreover, the ability of insurers to remove physicians from their network in many states is severely restricted by so called “fair hearing” legislation that makes the pain of achieving physician expulsion worse than the pain of leaving under performing physicians in network.
We understand that when a physician cries “foul” against an insurer, public sentiment will favor the physician, and over the years, it certainly has been reflected in this and other legislative attempts to tie insurers’ hands. After all, no one wants to go to the prom with a health insurer.
As a result of this and other phenomina, there has been the highly chronicled swoop toward mediocrity in the delivery of healthcare in the United States. And insurers have certainly contributed here. Up to now, insurers have paid physicians using the fee for service payment method. This method merely requires physicians to demonstrate that they performed a function, at which point they are paid at an amount that does not vary regardless of quality or outcome. This is a completely volume driven environment with predictable results.
The Obama Administration this month released final numbers on enrollment for the 2016 coverage year in the health insurance exchanges, as well as overall statistics on coverage gains to date under the Affordable Care Act (ACA).
The numbers emerge as the ACA turns 6 years old this week—on March 23. They were also released just as House Republicans issued their proposed 2017 federal budget. That budget, once again—you guessed it—repeals the ACA. The Republican budget is a counter to the Administration’s budget proposed in February. The release of both triggers the annual bruising battle over funding of the federal government, which again this year could end in prolonged stalemate.
You could be cynical or blasé about the Republicans’ persistent mission to kill the ACA—that is, if you don’t support that mission. But I think this piece of political theater continues to warrant contempt. Why? Because even if a Republican were elected President in November, the law is now technically impossible to gut completely. And Republicans know it.
There are a host of reasons the law cannot be nixed in its entirety, and these deserve more attention and discussion, on THCB and elsewhere, at a later time. In the context of this blog, I’ll just point out the obvious: it would simply be unacceptable (and political suicide) to strip 15 to 20 million people of their coverage. In addition, realistically, any insurance scheme to replace Obamacare would very likely be structured in a similar way—through private-sector insurance companies and plans operating in a regulated marketplace for people without employer-sponsored coverage. That’s why Republicans rarely talk about alternatives to Obamacare in any detail.
Patients with End Stage Renal Disease (ESRD) constitute a high-cost, high-need population that can greatly benefit from targeted policy initiatives to improve care coordination. In 2010, patients with ESRD made up 1.3% of the Medicare population, but accounted for 7.5% of total Medicare spending, amounting to over $20 billion.1 Adoption of the accountable care organization (ACO) model for ESRD has the potential to improve care coordination and patient outcomes. Due to complex health needs, patients in this population can require visits to multiple providers with multiple care plans. By bringing these providers together under the same organizational structure, accountable care provides the opportunity to improve quality through coordination. Though just over 1 million ESRD beneficiaries participated in the Pioneer ACO program, to date no direct studies have examined the effect of ACOs on management of ESRD.
As I entered CaringBridge through the technology door, the software engineer in me always seeks data to validate the personal experiences of patients, caregivers, family and friends sharing a health journey. So I could hardly wait to dig into the motherlode of facts and figures published in Caregiving in the United States 2015, a major report produced by AARP and the National Alliance for Caregiving.
The numbers were big, with 43.5 million Americans fitting the definition of “caregiver:”
“A person who has provided unpaid care to a relative or friend over the last 12 months that may include helping with personal needs or household chores. It might be managing a person’s finances, arranging for outside services, or visiting regularly to see how they are doing. The person receiving care does not necessarily live with the caregiver.”
Over the past two years, policy makers across the nation have been actively adopting policies in support of the rapid adoption of telehealth. From states affirming that health insurance plans should appropriately cover care provided through innovative technologies, to Congress contemplating multiple proposals for telehealth expansion within Medicare – telehealth is fast becoming a permanent part of our healthcare ecosystem.
This movement has been most clearly demonstrated by state medical boards. It has been their job to answer the questions: can physicians use technology to extend the reach of their care? Can telehealth be used to create a treatment relationship, and if so, are their limitations to this relationship?
Overwhelmingly, the resounding answer to these questions has been a consistent one – yes, you can use robust telehealth technologies to provide care and the main limitation is simple – uphold the same standard of care. The Federation of State Medical Boards has upheld this concept.
But if you’ve been following this movement, you know there’s a rather large blip on the national map: Texasa state with more than 27 million residents and a clear need for increased access to care – was recently ranked “worst in telehealth” by the National Center for Policy Analysis. The good news: despite restrictive rules and a lawsuit that’s hindering progress, telehealth is working in Texas and changes, they are a coming.
I have some strategies for preventing “physician burnout.” I am a little over 70 years old and am not experiencing any of the symptoms of “physician burnout.” I do not state this out of any sense of pride, but I have tried to be introspective about this so as to offer some advice as to how to avoid this problem.
My approach is fourfold. I shall begin by reviewing the definition of burnout, and, in particular, physician burnout. Much has been written about this recently, but in order to address the individual issues, it is important that we are using the same definitions. Secondly, I shall review some facts about the reality of American medicine. Third, I shall articulate a paradox between what seems to be an epidemic of physician burnout in the context of the reality of American medicine. Finally, I will offer a nine point set of suggestions, which are meant to help to avoid the symptoms and signs of this syndrome.
Job burnout is not a new idea, and it is not specific to medicine. It has been in the psychology/psychiatry literature for quite a long time. It may be defined as a feeling of emotional exhaustion characterized by cynicism, depersonalization and perceived ineffectiveness.
In recent years, many have argued that “burnout” is extremely prevalent; not only in society as a whole but in particular in medicine. It has been said that 50% of physicians have at least one of the three cardinal features: exhaustion, depersonalization and inefficacy. The problem with these kinds of data is that are no adequate controls. It is probably quite common for many people, at some point or another, to experience one or more of these cardinal features. The real question is whether this is more than in a control population and whether they are persistent, rather than transient, symptoms. That information is not available. For these reasons, it is likely that the problem of “burnout” is being exaggerated. Nonetheless the problem undoubtedly does exist in an unknown proportion of physicians.
At the annual South by Southwest (SXSW) conference a wide range of industries and creative artists come together to explore transformation through interactive technology. It’s not just healthcare people talking to healthcare people!
One of my favorite presentations this year was by Max Levchin, one of the founders of Paypal. He began by challenging the audience to focus on big problems, Problems That Matter. (I’m presuming the job a guy I shared an Uber with told me about—managing the social media profile of a dog—wouldn’t qualify.)
Levchin highlighted four key trends in business and technology—waves the audience could ride to catalyze meaningful change. Though I was consciously stepping outside of the healthcare track, nearly half of Levchin’s points explicitly referenced opportunities in health and healthcare, while it was easy to draw relevant lessons from the ones that didn’t. Big trends include:
1. Beneficence (AKA “doing good”). Increasingly businesses are providing value and benefit to consumers, even at the expense of higher profit margins. For example, Levchin most recently launched Affirm, a lending service focused on millennials, that specializes in transparency: clearly telling consumers how much they are being charged for financial services. While competitors typically obfuscate their fees (often unbeknownst to consumers), Affirm is in the business of doing well by doing good.
I like healthcare journalists. Some of my best friends are healthcare journalists. I’d rather read Larry Husten on clinical trials than the constipated editorials in peer review journals. Healthcare journalists are an important force against overdiagnosis, overtreatment, overprescription, overdoctoring and overmedicalization. They’re articulate and skeptical. But they seem to have a blind spot – overoutrage.
Overoutrage is excessive moral outrage. Outrage is excessive anger. Anger is excessive emotion. Emotion is excessive anti-reason. Overoutrage is the mother of all overdoing.
Overoutrage is the healthcare journalist’s kryptonite. These skeptical Rotweillers become credulous poodles when they see overoutrage. Overoutrage axiomatically assumes a moral high ground – for the transgression must have been severe for the outrage to occur. Overoutrage is circular reasoning without an exit. Overoutrage is more powerful than any randomized controlled trial. Much of healthcare policy, indeed civic life, is shaped by it.
A recent event highlights this phenomenon very well. NEJM’s national correspondent, Lisa Rosenbaum, wrote about a surgeon’s determined, and widely publicized, advocacy to ban morcellation, a procedure to treat uterine fibroids. Dr. Hooman Noorchashm’s wife, Amy Reed, underwent morcellation to treat uterine fibroids. Unbeknownst, she had uterine cancer, and the morcellation almost certainly worsened the prognosis by spreading the cancer beyond the uterus. Banning morcellation would be a no-brainer except that morcellation has fewer complications than open surgery for fibroids, and that the chances of undiscovered uterine cancer in a woman with fibroids are exceedingly rare.