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.
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.
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.
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.
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.
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.
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?
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?
Did 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.”
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.