Categories

Tag: Physicians

Doctors Should Be Paid for Outcomes. But Which Outcomes?

flying cadeuciiShould 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…

The Medical Chart: Ground Zero for the Deterioration of Patient Care

emr note

EMR Alert – Featuring radiologist note in illegible font color

For the past couple of years I’ve been working as a traveling physician in 13 states across the U.S.

I chose to adopt the “locum tenens lifestyle” because I enjoy the challenge of working with diverse teams of peers and patient populations.

I believe that this kind of work makes me a better doctor, as I am exposed to the widest possible array of technology, specialist experience, and diagnostic (and logistical) conundrums. During my down times I like to think about what I’ve learned so that I can try to make things better for my next group of patients.

This week I’ve been considering how in-patient doctoring has changed since I was in medical school. Unfortunately, my experience is that most of the changes have been for the worse.

While we may have a larger variety of treatment options and better diagnostic capabilities, it seems that we have pursued them at the expense of the fundamentals of good patient care.

What use is a radio-isotope-tagged red blood cell nuclear scan if we forget to stop giving aspirin to someone with a gastrointestinal bleed?

Continue reading…

The ICD-10 Extension: For Whatever Reasons, Congress Did the Right Thing.

flying cadeuciiDid you hear the one about the CMS administrator who was asked what it would take to delay the 2014 ICD-10 implementation deadline? An act of Congress, he smugly replied, according to unverified reports.

Good thing he didn’t say an act of God.

So, now that CMS has been overruled by Congress, who wins and who loses? Who’s happy and who’s not?

The answers to those questions illustrate the resource disparity that prevails in healthcare and, mirroring the broader economy, threatens to get worse. The disappointed Have-a-lot hospitals are equipped with the resources to meet ICD-10 deadlines and always felt pretty confident of a positive outcome; the Have-not facilities were never all that sure they would make it and are breathing a collective sigh of relief.

First off, it is necessary to recognize that ICD-10 is far superior to ICD-9 for expressing clinical diagnoses and procedures. Yes, some of the codes seem ridiculous … “pecked by chickens,” for example. But people do get pecked by chickens, or plowed into by sea lions, so I believe the intent is positive, as will be the results.

An example: I saw my physician this past week at a Have-a-lot health system in San Francisco and I asked what she thinks of the ICD-10 extension.

“We’re already using (ICD-10) in our EHR and it is much better than ICD-9,” she said. “When I want to code for right flank pain, it’s right there. I don’t have to go with back pain or abdominal pain and fudge flank in. It’s easier and more accurate.”

“If I was still on paper and not our EHR, which I like,” she added, “my superbill would go from 1 page to 10. SNOMED works.”

Continue reading…

Let Doctors Be Doctors

flying cadeuciiIt’s a strange business we are in.

Doctors are spending less time seeing patients, and the nation declares a doctor shortage, best remedied by having more non-physicians delivering patient care while doctors do more and more non-doctor work.

Usually, in cases of limited resources, we start talking about conservation: Make cars more fuel efficient, reduce waste in manufacturing, etc.

Funny, then, that in health care there seems to be so little discussion about how a limited supply of doctors can best serve the needs of their patients.

One hair-brained novel idea making its way through the blogs and journals right now is to have pharmacists treat high blood pressure. That would have to mean sending them back to school to learn physical exam skills and enough physiology and pathology about heart disease and kidney disease, which are often interrelated with hypertension.

Not only would this cause fragmentation of care, but it would probably soon take up enough of our pharmacists’ time that we would end up with a serious shortage of pharmacists.

Within medical offices there are many more staff members who interact with patients about their health issues: case managers, health coaches, accountable care organization nurses, medical assistants and many others are assuming more responsibilities.

We call this “working to the top of their license.”

Doctors, on the other hand, are spending more time on data entry than thirty years ago, as servants of the Big Data funnels that the Government and insurance companies put in our offices to better control where “their” money (which we all paid them) ultimately goes.

In primary care we are also spending more time on public health issues, even though this has shown little success and is quite costly. We are treating patients one at a time for lifestyle-related conditions affecting large subgroups of the population: obesity, prediabetes, prehypertension and smoking, to name a few that would be more suitable for non-physician management than hard-core hypertension.

It is high time we have a serious national debate, not yet about how many doctors we need, but what we need our doctors to do. Only then can we talk numbers.

Hans Duvefelt, MD is a Swedish-born family physician in a small town in rural Maine. He blogs regularly at A Country Doctor Writes where this piece originally appeared.

Health Information Technology: Sorry, There’s No Turning Back!

flying cadeuciiThe American Recovery and Reinvestment Act of 2009 (ARRA), sometimes called the Stimulus Actwas an $831 billion economic stimulus package enacted by the 111th Congress in February 2009 and signed into law on February 17, 2009 by the President.

It included $22 billion as incentives to encourage adoption of certified electronic medical records in hospitals and medical practices. The rationale behind the policy directive was clear: system-wide implementation of electronic medical records enables improvement in diagnostics and treatment coordination, fewer errors, and better coordination of patient care by teams of providers.

Almost immediately, the medical community cried foul.

Their primary beef: the cost to implement these new systems would not be recovered by the incentives.

Similarly, physicians pushed back on the conversion of the U.S. coding system from ICD-9 to ICD-10. They did not question the need for the upgrade: the increase from 19,000 to 68,000 codes is necessary to more accurately capture all relevant clinical aspects of a patient’s condition and align our data gathering with 20 other developed systems of the world where ICD-10 is already used.

That health insurers, medical groups, hospitals and others must use the same coding system that reflects advances in how we diagnose and treat seems a no brainer. But some physicians pushed back due to costs and disruption in their practices.

Last week, physicians won a battle: the Centers for Medicaid and Medicare Services (CMS) announced it was delaying the deadline for implementation of ICD-10 for a year, to October 1, 2015.

Continue reading…

How Should Doctors Get Paid? Hourly Wage, Piecework or Quality?

flying cadeucii

A long time ago, when I worked in Sweden’s Socialized health care system, there were no incentives to see more patients.

In the hospital and in the outpatient offices there were scheduled coffee breaks at 10 and at 3 o’clock, lunch was an hour, and everyone left on the dot at five. On-call work was reimbursed as time off. Any extra income would have been taxed at the prevailing marginal income tax rate of somewhere around 80%.

There was, in my view, a culture of giving less than you were able to, a lack of urgency, and a patient-unfriendly set of barriers. One example: most clinics took phone calls only for an hour or two in the morning.

After that, there was no patient access; no additions were made to providers’ schedules, even if some patients didn’t keep their appointments, not that there was a way to call and make a same-day cancellation.

As my father always said: “There must be a reward for working”.

But, high productivity can sometimes mean churning out patient visits without accomplishing much, or it can mean providing unnecessary care just to increase revenue. For example, some of my patients who spend winters in warmer climates come back with tall tales of excessive testing while away.

A recent Wall Street Journal article offers an interactive display of doctors who collect the highest Medicare payments. The difference between providers in the same specialties across the country makes interesting reading. It is hard to imagine that many individual doctors are billing Medicare more than $10,000,000 per year.

So it might make sense to insure against paying for excessive care by also demanding a certain level of quality.

But defining quality is fraught with scientific and ethical problems, since quality targets really aren’t, or shouldn’t be, the same for all of our patients.

Continue reading…

What a Physician-Led ACO Can Teach Us about Getting It Right

Farzad MostashariSeveral of the provisions included within the Affordable Care Act in 2011 designate Accountable Care Organizations (ACOs) as formal, contractual entities.

However, in the real world ACOs come in a variety of shapes and sizes.

When compared to larger, hospital-sponsored ACOs, rural and small physician-led ACOs face a tough challenge, because despite limited resources they need to come up with substantial upfront capital and infrastructure investment to establish a strong ACO foundation.

To help ease this burden, 35 ACOs were selected to participate in the Advanced Payment Model ACO demonstration through a grant program from the Center for Medicare and Medicaid Innovation (CMMI). The grants provided a portion of upfront capital to determine whether or not this financial assistance would help ease the startup burden for smaller ACOs, and increase their success rate.

One of those 35 organizations includes the central Florida-based Physicians Collaborative Trust ACO, LLC (PCT-ACO). They are participants in the January 2013 Medicare Shared Savings Program (MSSP) ACO cohort, along with 106 other ACOs.

Larry Jones, PCT-ACO’s CEO, describes his personal mission as an effort to “preserve and protect the independent practice of medicine.” For over 25 years he has been advocating for physicians through their efforts to organize, negotiate with health plans, and other challenges.

Continue reading…

It’s Raining Cataracts, Hallelujah

flying cadeuciiCMS released new data, shrouded thus far in needless secrecy: how much it pays individual physicians.

Unlike the Shroud of Turin, no one will question its authenticity. But authenticity doesn’t guarantee the data won’t intrigue, confuse, anger, perplex, confound and burn a few innocents at the stakes. That is before we conclude that more research is needed, or more colloquially stated, we still don’t have a clue.

Medicare bounty hunters, the modern day witch finders, are licking their lips for their share of the looted spoils. Academic researchers will be dissecting both wings of the bell-shaped curve of variation in payment to set the next battle between good and evil. But all eyes (pun intended) are upon Florida; specifically one particular provider.

The provider, an ophthalmologist, (you can look up the name) billed CMS for $21 million.

CMS paid ophthalmologists $ 5.6 billion. That’s more than the GDP of Burundi. CMS paid over a billion dollars for treatment of macular degeneration with Lucentis (Genentech).

Take a deep breath now. The treatment of one organ in over 65 year old American citizens is equal to the GDP of one African nation. Gini would have turned beetroot with embarrassment.

Diabolical? Scandalous? Shocking? Surprising?

None of the above, actually. If you think about it.

As we age, and age we do thanks to our lives being constantly “saved” by prevention, regulation and cures, arteries harden, brain atrophies and bones thin. And eyesight falters. Lens fog. Macula degenerates, reducing central vision making it difficult to read.

As we age, we consume more medical services. Yes, take that as an economic truism. And no, I’m not applying for membership of the Death Panel.

Here’s the thing. It’s nice to be able to see when you’re 75. It’s also nice to see when 85, and damn essential when 90.

Otherwise you might trip over the walking stick, fracture the neck of the femur, develop a clot in the deep veins, then a clot in the pulmonary arteries, then a raging pneumonia in ICU, followed by septic shock and a cardiac arrest. Then perhaps you may rest in peace. But not before a few interns have fractured half a dozen ribs during a well-intentioned but hopelessly misguided cardiopulmonary resuscitation that family members lobbied for to assuage their guilt for never visiting you in your nursing home.

Continue reading…

Going after the Wrong Doctors

A recent ProPublica expose co-published with the Boston Globe typifies a growing gotcha genre of health journalism that portrays doctors as the enemy in a struggle for honesty and openness in medicine.

These reports make unfounded leaps in their efforts to subject doctors to levels of skepticism once reserved for politicians and lawyers. They’re going to end up doing patients a disservice.

For this particular hunting expedition ProPublica set its sights on Dr. Yoav Golan, an infectious diseases specialist caring for patients at Tufts Medical Center in Boston who also works with pharmaceutical companies developing antibiotics.

But in its zeal to argue how physicians like Golan are corrupting medicine through their industry partnerships, ProPublica went to press without an iota of evidence Golan is corrupt.

A close look at Golan’s impressive career suggests quite the contrary and raises questions about ProPublica’s claim to objectivity.

Yoav Golan is a remarkably bad choice for anyone who hopes to use him as a poster boy of pharma-physician malfeasance.

As Tufts said in a statement in response to the ProPublica story, Golan enjoys international respect in the infectious diseases community and has assisted the development of “two important antibiotics, including the first antibiotic developed in the past 25 years to treat the growing threat of deadly C. difficile.”

(Disclosure: I held an academic appointment at Tufts for one year when I was practicing in Boston, but in another department and I never met Golan before this story.)

That antibiotic, fidaxomicin, is pricey, and you’d think an industry shill would liberally advise its use. Yet Golan and his team advised a Tufts committee setting internal standards for its use that the hospital should heavily restrict the drug. “We were very active in making sure it’s not used in pathways where it’s not cost effective,” Golan told me.

Continue reading…

How Should Doctors Get Paid?

It’s a strange business we are in.

I can freeze a couple of warts in less than a minute and send a bill to a patient’s commercial insurance for much more money than for a fifteen minute visit to change their blood pressure medication.

I can see a Medicaid or Medicare patient for five minutes or forty-five, and up until now, because I work for a Federally Qualified Health Center, the payment we actually receive is the same.

I can chat briefly with a patient who comes in for a dressing change done by my nurse, quickly make sure the wound and the dressing look okay and charge for an office visit. But I cannot bill anything for spending a half hour on the phone with a distraught patient who just developed terrible side effects from his new medication and whose X-ray results suggest he needs more testing.

As a primary care physician I get dozens of reports every day, from specialists, emergency rooms, the local Veterans’ clinic and so on, and everybody expects me to go over all these reports with a fine-toothed comb.

A specialist will write “I recommend an angiogram”, and we have to call his office to make sure if that means he ordered it, or that he wants us to order it.

An emergency room doctor orders a CT scan to rule out a blood clot in someone’s lung and gets a verbal reading by the radiologist that there is no clot. But the final CT report, dictated after the emergency room doctor’s shift has ended, suggests a possible small lung cancer.

Did anyone at the ER deal with this, or is it up to me to contact the patient and arrange for followup testing? All of this takes time, but we cannot bill for it.

Most people are aware these days that procedures are reimbursed at a higher rate than “cognitive work”, but many patients are shocked to hear that doctors essentially cannot bill for any work that isn’t done face to face with a patient. This fact, not technophobia, is probably the biggest reason why doctors and patients aren’t emailing, for example.

Continue reading…

Registration

Forgotten Password?