My Blog

March 2, 2013

CORE MEASURES GONE WILD

Filed under: Uncategorized — Tags: , , — admin @ 5:05 pm

Juan Gonzales, (not his real name), is a somewhat demented elderly Hispanic male, who I met last week in an intensive care unit. He spoke little English, and I spoke limited Spanish.  His devoted family was at the bedside, and fortunately his daughter was able to provide some history. He was admitted with palpitations and dizziness and atrial fibrillation with a rapid response. His family had just moved him from Miami, where they said he had three prior strokes. As I went over his medications, all seem appropriate except for two antibiotics ordered from the ER, azithromycin and ceftriaxone. He had no fever, a normal white blood cell count, no cough or dyspnea, and benign urinary sediment. His lactic acid level was also normal. His chest X Ray did show heart failure and the report also said “cannot rule out lower lobe pneumonia.” By all clinical and objective criteria, this man did not have an infection that needed to be treated. However, the ER team is so sensitive to missing sepsis that I guess any reason to give empiric antibiotics is not missed.

 

I have witnessed this trend before, and have to wonder how much this over use of antibiotics has contributed to drug resistant bugs in the hospital.  As a physician in training, we had a fraction of the drug resistant problems encountered in most hospitals today. I can’t believe that our hand washing and sanitizing was that much better in the “old days.” I am no infectious disease or public health specialist, but I do believe that the unintended consequences of this, and other mandated core measures and protocols, have created as many problems as they have solved.

 

There certainly is a role for guidelines and workflows. I am sure that more post-MI patients are discharged on aspirin, beta-blockers, and statins, than before they were instituted. Yet, the cookbook approach to medicine also makes us clinically lazy and treating problems where none existed. I have had to wage a campaign at some of my local hospitals to educate the coding folks, (not so fondly referred to be one nurse as the “clipboard people”) to not say a patient has congestive heart failure, because his B-NP level was 102 (normal being 1-100).  And therefore I don’t need to order beta-blockers, ace-inhibitors, or an echocardiogram.

 

Speaking of echocardiograms, if the patient had one last month and returns again in heart failure, he really doesn’t need another one, unless of course he has had an MI. Probably one of the most abused and over-ordered cardiology tests, doctors and coding staff seem too rushed to even look if the patient has had an echo in the recent past. And oh by the way, Medicare won’t reimburse us for reading more than one every six months, without an appeal and extra documentation.

 

Another time I was approached by a core measure nurse, to ask why a patient had not gotten aspirin within 24 hours of his admission. The answer, which of course I had to document in the chart, was because the poor soul was in shock and on a ventilator, and his enzymes did not turn positive until 36 hours after admission.

 

The Joint Commission has now recommended no less than 14 different “National Hospital Quality Measures”, ranging from Myocardial Infarction to Tobacco Treatment. So expect the ranks of the clipboard team to swell in the future. Some of these make sense and are useful, like a “timeout” before surgery or an invasive procedure, to make sure the correct patient and site of operation are confirmed. But do I really need a timeout before I administer a treadmill stress test?

 

All of these policies are well intentioned. However, once Medicare started supplying financial incentives, and disincentives, and the Joint Commission penalized hospitals for poor compliance, you knew abuses weren’t far away. I suppose as doctors, we had this coming for not remembering to do all those little things that make patients better, and avoiding those that make them sicker. It just seems that common sense has once again taken a back seat to bureaucracies and insurance companies.

 

I do what I can, albeit small, to make application of these guidelines more rationale. But sometimes, I feel like Don Quixote, tilting at windmills. As for Mr. Gonzales, I stopped his antibiotics, treated his atrial fibrillation, and he did just fine.

 

 

DOCTORS AND THE INFORMATION TECHNOLOGY PARADOX

Filed under: Uncategorized — Tags: , , , , — admin @ 5:03 pm

I recently sat in a small room, in the bowels of a local hospital, training for the impending implementation of CPOE. For those not familiar with current health care acronyms, this stand for Computerized Physician Order Entry. Nearing the end of my medical career, I could not help but admire the timing of this phenomenon. “They’ve finally done it,” I mused silently. They have replaced the medical secretary with none other than the physician. I supposed this was inevitable. After all, for years now I have been stuffing my own charts with order sheets and progress notes, applying patient labels to same, retrieving my own lab and radiology reports, etc. This was just the logical conclusion

But for one who has been an EMR advocate, the irony did not escape me. For almost ten years now my cardiology group practice has had an EMR, and although it took me a good 6 months to become comfortable with it, I now couldn’t imagine going back to a paper chart. So why is the hospital equivalent so painful for myself and many other older doctors?

Lack of compatibility and conformity is one big reason. I am on staff at six local hospitals, which have three separate electronic health records. That means learning the ins and outs of three completely different means of accessing and inputting data. There are three different sets of user id’s and passwords, which change at different times and all with variable character requirements. If I read EKG’s or diagnostic studies, it is probable that I must use a different application with other unique id’s and passwords as means of navigation.

How bad is it? Well, because of this, and other personal applications that I access, I succumbed to a password keeper application. In less than six months, I now have about 75 different apps, or programs, passwords, which are now kept quite nicely on my IPhone, IPad, home computer, and in the “Cloud.” For those of you technologically challenged, the “Cloud” is a mysterious data storage area kept in a baffling location, holding onto a humungous number of bits, (or is it bytes?), of information all over the world. You can dump, and retrieve, data into and out of it with the touch of a keystroke. (Provided of course that you remember the correct use id and password.)

IT, or information technology, is a wonderful thing. Yet, because of the ease, and wealth of information that can be handled, there is a tendency to abuse it. How much better is my life after reading, (or deleting), 100 or more emails a day? Do I really need a weekly e-mail update from the medical staff secretary about which drugs are now unavailable due to a “national shortage?” If I order it, and the pharmacy doesn’t have it, they will let me know, and I will order something else.

It is easy to loose site of the fact that IT is just a tool, and like any tool, can be used to improve our lives, entertain us, or to do evil, as in identity theft. My gripe is that is the push for a nationalized electronic health record has come without any true means of having seamless integration of the multitude of programs. Few records, like hospital and physician offices, “speak to each other” electronically, and therefore create as many problems as they solve. Physicians’ efficient use of preciously limited time has become another victim.

We were sold a false bill of goods. Optimistic predictions by a RAND study in 2005 helped drive explosive growth in the electronic records industry and encouraged the federal government to give billions of dollars in financial incentives to hospitals and doctors that put the systems in place. (And oh by the way, RAND’s 2005 report was paid for by a group of companies, including General Electric Co. and Cerner Corp., that have profited by developing and selling electronic records systems to hospitals and physician practices. Cerner’s revenue has nearly tripled since the report was released, from $1 billion to a projected $3 billion in 2013.) But evidence of significant savings is scant, and there is increasing concern that electronic records have actually added to costs by making it easier to bill more for some services. Whoops.

The US health system is so large and heterogeneous that it is virtually impossible to integrate it in a seamless fashion. Imagine if we could carry around a microchip that stores all of our medical history and testing so any health care provider could access it instantly. So if you just had a coronary stent a few years ago in Miami, and while vacationing in Seattle you have chest pain, a local ER doctor can instantly read your old EKG and cath reports. Now that would be progress and provide potentially billions in savings. Of course there are privacy issues to overcome, but don’t tell me that the technology is not there to accomplish this.

We must standardize more. A decade or more ago as diagnostic studies became increasingly computerized, the cardiology and radiology fields faced a similar crisis. Ultimately, a universal display format called DICOM, was adopted, so viewing studies anywhere on any computer was feasible.

This is the only way for medicine and IT to become maximally useful and make doctors more efficient. Hopefully someone will spearhead this effort, but I will likely be retired and out fishing on my boat by then.

January 19, 2013

Guns, Doctors, Patients, and the Second Ammendment

Filed under: Uncategorized — Tags: , , , , — admin @ 10:41 am

Recently both President Obama and the AMA have called for physicians to talk with their patients about gun ownership, especially if they sense mental health issues. This request sounds innocuous enough, but let’s explore the implications and the reality here.
First I need to issue a disclaimer. I am neither a member of the NRA nor do I necessarily feel that more gun laws and bans will reduce the recent tragedies in Newtown, Ct. or Aurora, Co. Gun safety should be of paramount importance to all gun owners. However, if I am going to ask all my patients about gun safety and ownership, then there are a few other dangerous things I need to engage them with as well.
“Do you own a pool?” (Quite relevant since we live in Florida.) “If you do, do you have small children at home or as guests? Do the neighborhood children come by? Do you have a pool fence and is it locked at all times? Have you thought about how many accidental drowning of children there are in Florida every year? Have you taken a course in pool safety?”
Or how about this topic: “Do you own a dog? What kind of dog is it? Were there any pit pulls in its family lineage? Do you have small children at home or grandchildren? Has your dog ever bitten anyone? (Okay, the mailman doesn’t count.) Have you taken a course in dog safety ownership?”
You see where I am going with this of course. First of all, I, and most doctors, don’t have the time to engage in this dialogue with my patients, since I am too busy asking about percentage of seat belt use, quitting smoking, updating medicine lists and system reviews, and filling out ridiculous “meaningful use” of EHR forms, just to get paid from Medicare. And even if I did have time, it is really none of my business. And if even if it was my business, asking this would not prevent a mentally aberrant person from finding weapons and using them in a hideous fashion.
The fatal flaw in this logic is that the desire to do good, does not lead to good results. In fact the opposite is often the case. A recent Opinion piece in the Wall Street Journal, (January 16,2013), by Jeffery Scott Shapiro highlights this paradox. He was a criminal prosecutor in the District of Columbia from 2007-09. In essence, during the strictest gun ban years, the rate of homicides increased. Ultimately in 2007, the U.S. Court of Appeals in D.C. ruled the city’s gun ban to be unconstitutional. The US Supreme Court also affirmed the ruling the next year. Since the ban was struck down in 2008, the homicide rate dropped from 186 to 88 in 2012, the lowest number since the original ban law was enacted in 1976.
Recent shooting tragedies do launch a knee jerk reaction by well-intentioned politicians, but as usual, the beneficial results of new laws often achieve the opposite, since the criminal, or deviant mind, will always find a way to purchase weapons. So following are my thoughts on what might help.
Loosen the HIPAA laws so deranged individuals can have their psychiatric history quickly accessed by mental health providers. Tighten the “gun show” loopholes, so gun purchases meet the same measures at shows as at a gun store. If the government insists on throwing more money at a problem, (and they excel at always doing so), then invest in more mental health professionals and treatment facilities. Make it easier for teachers, (who want to), learn gun safety and obtain concealed weapons permits. Every adult who supervisors school outings in Israel is trained in weapon use and carry semi-automatic guns on field trips. You never hear about these tragedies in that country.
But mandating doctors to ask patients about gun possession? You can count me out on that one. This is an invasion of privacy, and worse, will do nothing to curtail the periodic catastrophe that occurred at Sandy Hook.

–– “To be prepared for war is one of the most effectual means of preserving peace. A free people ought not only to be armed, but disciplined.”
– George Washington, First Annual Address, January 8, 1790.

 

September 16, 2012

Rethinking Health Insurance

Filed under: Uncategorized — Tags: , , — admin @ 4:36 pm

RETHINKING HEALTH INSURANCE

Recently a neighbor backed into my car while I was leaving a food store. The damage was minimal, but she offered to have her insurance company pay for the repair. After contacting the company, I was offered several body shops, and chose the one closest to my home. The work was completed in only two days, and while it was in the shop, I decided to also have some dents and scratches fixed, which were unrelated to the accident claim. To my surprise the mild fender damage, which was covered by the other driver’s company, was paid in full without an estimate. The amount was approximately $500. A scratch on the other side, and four dents, were repaired, for which I paid separately a little over $400. So I spent, (out of pocket), for three times as much work, and paid less than the insurance company did. This got me thinking about how insurance adds to the costs of services in the auto industry, and how that might be relevant to health insurance.

Having practiced medicine for over thirty years, I am convinced that when it comes to the cost of healthcare and insurance, insurance is the problem and not the solution. Health insurance is not sold in a truly free market, like home, disability, and life insurance products, etc. Let’s look at some parts of healthcare where traditional insurance does not cover the cost of the service. In his excellent book on this subject, “Priceless,” John C. Goodman, states the case quite well. LASIK eye surgery and “cosmetic surgery prices, rarely covered by insurance, has been falling over time in real terms––despite a huge increase in volume and considerable technical innovation (which is blamed for increasing costs for every other type of surgery).” Since insurance does not dictate the prices and reimbursements for these procedures, doctors are free to repackage their services competitively, and patients are free to negotiate.

Even how health insurance functions in this country makes it quite different than all other insurance products. Automobile insurance protects against unforeseen and catastrophic events, such as a vehicular damage, theft, and human injury. There is no “preventive” insurance as seen with health care. If I pay a premium to GEICO, it does not cover the cost of tire rotations, brakes, new batteries, or oil changes. Similarly, homeowner’s insurance pays for storm damage to a roof, but not the price of roof replacement from normal wear, tear, and aging. Even the assumed theory that preventive care reduces overall health care expenditures is arguable.

Part of the difference may be historical. Post WWII, employers were not allowed to raise wages, so to attract better employees, they began to offer health insurance as a fringe benefit of employment. Soon unions used employer-sponsored health insurance as a bargaining chip in labor negotiations, and we all know the rest of the story. Health insurance is unique in this regard. After all, most employers don’t offer auto, home, or property insurance. The historical basis for this phenomenon, and our assumption that it is only humane and kind to make sure all of our citizens are protected for illness, have lead to the unintended consequences of waste, fraud, abuse, and price escalation. Soon it will also lead to rationing of care.

Although the Affordable Care Act of 2009 (ACA or Obama care) guarantees health insurance for all, it does nothing to increase the number of providers who will deliver these services. The approximately $750B of Medicare “cost savings” will be derived from reduced payments to hospitals and providers, making access to scarce providers even more difficult. A more complete critique of ACA, and its destructive effects on healthcare however, is subject for another blog.

So back to my car and health insurance. If I had been able to get a competitive price for damage repairs from several collision shops, I am sure that the insurance company could have saved money. Instead, they pay top dollar and pass it along to their customers. Similarly in my practice, there is no incentive to hold down the number of tests I order, since the prices are essentially fixed by Medicare, so that I, the provider, as well as the patient, the consumer, have absolutely no say in the matter. HMO’s, or the new ACA mandated Accountable Care Organizations, (ACO) are no better. Their incentives are every bit as perverse––just 180 degrees in the opposite direction. Fee-for-service, or traditional Medicare encourages too much testing and services that possibly cause improvement in the quality of care; whereas the HMO and ACO are incentivized to withhold care, and thereby increase their profits, again at uncertain damage to the patients’ health.

Free market and competitive solutions would help, but with the injection of the ACA as the law of the land now, I fear this will never happen, no matter who wins in November. As long as we view health insurance, rather than access to healthcare, as a right in this country, the problem will only get worse. But don’t believe me. Recently I cared for an elderly man from Great Brittan, who was hospitalized here for a heart problem. He was more than eager to share his thoughts about the British National Health system. After railing against it for several minutes, he summed it up with this, “You people are making a big mistake in this country.”

September 6, 2012

Speaking Different Languages

Filed under: Uncategorized — admin @ 6:22 pm

SPEAKING DIFFERENT LANGUAGES

We are speaking different languages in this country, and I don’t mean English or Spanish. Having been born and raised in a predominantly liberal New York Jewish home, I came to accept early on the language and viewpoints of progressives.

Going to college in the 60’s, I protested the war, marched on Washington, and became familiar with the language and teachings of Karl Marx. I thought my college’s Young Republicans and Young Americans for Freedom were geeks and not cool. Throughout medical school, and post-graduate training, I was too busy with my career to be interested in politics; but do remember casting my first Presidential vote for Hubert Humphrey over Richard Nixon in 1968. I could not bring myself to vote for George McGovern in1972, but did vote for Jimmy Carter in 1976.

It was only after the ensuing recession, hyperinflation, and long gas lines that I voted for Ronald Regan. Ever since then I have voted for the most conservative candidates I could find, with a few principled exceptions. Prior to the 1990’s, there were few popular voices of conservatism. I don’t remember much about Barry Goldwater, but do recall the popular political television ad that was used to defeat him––the young girl picking flowers and looking up at a mushroom cloud. The message could not have been more direct or simpler¬––elect Barry Goldwater and nuclear Armageddon was certain to follow. Lyndon Johnson won by a landslide over him in 1964.

William F. Buckley, Jr. was dry and witty, but for me he was as exciting to watch as paint drying. Working throughout medical school and post-graduate training in several Veterans’ Administration Hospitals, (as most doctors do), gave me first-hand experience on the inefficiency and wastefulness of federal government programs. Thus my conservative values grew out of what just seemed logical––fiscal restraint and less government. I do however disavow the Republican Party’s social conservative agenda.

Ronald Regan had the knack for speaking directly to the everyday person, and with his election, the seeds of modern conservative values and thought were reborn.

However, things really began to change in 1989, with the birth of the Rush Limbaugh radio talk show. The popular, but bombastic, talk show host, touched a previously untapped nerve in mostly Middle America. Not only was he entertaining, but he seemed to echo deeply held, but heretofore, invalidated beliefs of many citizens. Prior to Rush, media was largely controlled by entities who shared common progressive values, such as NBC, CBS, ABC, PBS, The New York Times, The Washington Post, etc. Cable television accelerated the change even more. First there was CNN and MSNBC. But 1996 was a pivotal year, when the FOX news channel was born, brainchild of media mogul, Rupert Murdoch. At launch, only 10 million households were able to watch Fox News, with none in the major media markets of New York City and Los Angeles. As more homes added cable in the next decade, FOX’s growth was nothing short of explosive. In the 2000 presidential election, Fox News, which was available in 56 million homes nationwide, saw a staggering 440% increase in viewers, the biggest gain among the three cable news television networks. Dovetailing with the success of a conservative choice for news programming, conservative talk radio likewise exploded since the turn of the century.

The traditional, or “mainstream media,” did not receive this successful competition kindly. And time has done little to warm relationships between these two polar political viewpoints. Judging from television ratings, traditional media has a right to be upset. Attempts to compete in the lucrative talk radio market by liberal “Air America,” ended in disaster and bankruptcy.

As of August 7, 2012, FOX beat all of its competitors, (CNN, MSNBC, HLN, and CNBC), handily in all ages and demographics, all daylong. The vitriol between the left and right has only grown worse with time. The discourse has become personal and offensive, and usually untrue or half-true. Easy 24/7 Internet access to partisan blogs and websites has only inflamed emotions faster and stronger. Can we get out of this jam?

I am convinced that a large part of the problem is, to quote a famous line, “A failure to communicate.” We are speaking completely different languages. Popular names such as “left” or “right” oversimplify the divide. The beliefs are at times so different, that any calm and rationale discussions on most topics are laced with cynicism, sarcasm, and even outright rage. On the one hand is a camp that firmly believes that the free market picks winners and losers, and the latter tend to be poor, weak, disabled, or people of color. Greed and monetary success is by its very nature evil, and can only be tempered by the kindness of government, rules, and regulations. Furthermore, they believe that the financial apocalypse of 2008 was the direct result of the excesses of capitalism.

The other side believes as strongly that free markets will make better and more humane choices than governments. Although many on this side grant that unrestrained market forces may have contributed to the global recession of the last decade, that equally culpable was rigged and misguided government rules and bureaucracies, such as Fannie Mae, Freddie Mac, and the Community Reinvestment Act. This decade, the use of public stimulus funds to finance weak businesses, such as the solar industry, has only added fuel to the fire and widened the divide.

Everything has become viewed from these two filters, even if it is not political. A return to reasonable dialogue might start with eliminating emotionally charged words, such as liberal, socialist, Marxist, and communist. Ditto for fascist, Nazi, and even Republican on the other side. I prefer the terms conservative and progressive, as they seem less “charged,” and indeed more accurately describe one’s philosophy.

Negative political advertisements, slurs, and mudslinging are as old as Aaron Burr and Alexander Hamilton, and we all know how that ended. If we ever are to attain more civil discourse, we need to understand and speak each other’s language. Name-calling and demonization do not help either. To agree to disagree is sometimes the only option, but the lost art of negotiation and compromise is the only thing that can restore respect and sanity.

September 1, 2012

Technological Challenges for the Aging Doctor

Filed under: Uncategorized — admin @ 12:56 pm

TECHNOLOGY CHALLENGES FOR THE AGING DOCTOR

I recently was on vacation in Rocky Mountain National Park. Suspended on an overlook of astonishing beauty at 11,000 feet above sea level, I stared out at the tundra and bits of August snow that still clung to the highest peaks. Suddenly my attention was snapped from the massive boulders and landscapes to the ringing of my cell phone. It was a referring doctor asking me about a mutual patient with uncontrolled high blood pressure who needed to be seen as soon as possible.

The good thing about mobile communication devices is that just about anyone who has your number can you reach you anytime and almost anywhere. That’s also the bad thing. I know––I should have turned it off, but I had forgotten. I politely explained to the doc that I was out of town, but would let my office know that the patient needed to be seen that week.

As many things in life, technology offers both improvements and harmful distractions. No longer do I have to tell my family and friends where I am going or how I can be reached––they simply call, email, or text me. Gone are the days of pagers, (which I curiously still see on the hips of some doctors––probably the same ones without an EMR or office fax machine), but largely everyone has a cell or smart phone.

I often joke that as an aging physician, I am confronted by two diverting curves on a graph, each one heading in opposite directions. One is the number of useful synapses left in my brain plotted on the horizontal axis, against my chronological age, on the vertical axis. That curve is heading down. The other has the same aging axis, but lists the number and types of new technological devices and inventions. This curve is heading north. I’m not sure when it happened, but I am guessing the lines crossed a few years ago.

Instant informational access is a two-edged sword. On the one hand, I do believe that smart phones and tablets and a good EMR, improves the speed and quality of patient care. However, the Internet has opened up a veritable Pandora’s box of self-diagnosis options for my patients as well. Or as my sister likes to term it, “Dr. Internet.” I remind my patients about the old saying of “A little knowledge can be a dangerous thing,” but most of them then look at me in mild shock or disbelief. It is as if they are thinking, but not saying, “I know you went to medical school and did all that training for all those years, but I think WebMD is just as smart as you are.” To which I think silently, “So if everything you need to know is on the World Wide Web, then why are you here?”

Mind games aside, I believe that I have kept up with the technological advances in medicine, and am convinced that the benefits outweigh the risks, (such as device addiction, distraction, and depersonalization). However, the doctor-patient face-to-face, (not FaceTime) relationship, must be preserved. Technology, in whatever form, is just a tool, and like any tool can be used for good or well, Angry Birds.

July 26, 2012

I did build my small business with help, but not from Uncle Sam

Filed under: Uncategorized — Tags: , , , , — admin @ 3:32 pm

MY SMALL BUSINESS HAD HELP, BUT NOT FROM UNCLE SAM

Over 30 years ago, I began a cardiology group practice in St. Petersburg, Florida, Bay Area Heart Center. I invested $30,000––all of my savings at the time, and worked 90-110 hours per week for three years before I hired a partner. Since then the practice has grown to over 45 employees, including twelve physicians. I was taken aback by President Obama’s recent remark, “If you’ve got a business — you didn’t build that. Somebody else made that happen.”

Did I have help building this business? Yes. I have been graced with fine physician-partners, nurses, physician assistants, secretaries, medical assistants, and a remarkably proficient and dedicated administrative staff. But in all due respect, Mr. President, I must disagree with you. I did build my business, and nobody else made it happen. Moreover, along every step of the way, the federal government has been more of an impediment to the growth of my business than a facilitator.

From Medicare dictating to me how much I can charge a patient for my services, to OSHA requirements against using lip balm in “patient-care” areas; federal rules, regulations, and bureaucracies have heaped increasing administrative costs on my business without one iota of improvement in patient care. Now with the sword of “Obama Care” dangling over us, the outlook is even direr.

Most small business owners I know work incredibly hard and sacrifice personal health, well-being, and relationships to grow their company. We aren’t looking for a handout or a free ride. We would however appreciate the government unshackling us form a tsunami of regulations which only choke and impede our ability to compete in the free market.

The burdensome rules in the healthcare field could, and probably do, fill the federal registry. Profits in private medical practices are becoming so squeezed that a recent CNN Money survey (June 27, 2012) polled 673 physicians across 29 specialties by MDLinx, a medical reference website for physicians. 17% of all doctors with a private practice said they could foresee closing it within a year if their financial situation doesn’t improve. The major reasons sited were significant school debt, rising business expenses and administrative hassles, shrinking insurance reimbursements and costly malpractice insurance.

My office nurse spends the better part of one whole day instructing a new employee on HIPAA, OSHA, and other alphabet soup agency rules and policies so we can stay within compliance guidelines. And this time doesn’t even account for electronic medical record training or how to do the job for which he or she was hired. So for those one to two days, our nurse cannot assist doctors or contribute to actual patient care. And if the new employee decides to quit within the 90-day probation period, the nurse must do this all over again. In fact probably the fastest growing position in small businesses these days is the compliance officer.

Also consider this: a cardiologist’s office is a hazardous place to work. According to OSHA, dangerous substances such as alcohol wipes and disinfectants (which anyone can purchase in a drug store) must be described to employees. To comply with OSHA, you must have a written list of the hazardous chemicals stored or used in your office. For each of these, your employees must also have access to the manufacturer-supplied Material Safety Data Sheet. The MSDS outlines the proper procedures for working with a specific substance and for handling and containing it in a spill or other emergency.

HIPAA was meant to protect patient’s privacy. Who could possibly be opposed to that? Unfortunately, the regulations are too open to interpretation. This means every facility has a different policy. Thus, when you sign in at the front desk to be seen, you might not see other patients’ names. However, when it is your turn to see the doctor, you can hear someone yell, “Mrs. Smith, please come back now.”

The goals for many federal government mandates are well intentioned, but the execution of them, and impact on physician offices, are counterproductive. Through Medicare, or CMS, financial incentives, we are encouraged to report Quality Measures, submit paperless drug orders, and use EMR. However, the programs don’t work in tandem with all health care providers resulting in costly duplication of time and effort.

Many other mandates are completely unfunded, resulting in the doctor and his staff doing more work in order to get paid less. For example, CMS requires us to pay for a translator for any patient who doesn’t speak English at the cost of $150 per hour, which is more than the reimbursement for a typical office visit. Medicare recently took away all codes related to performing consultations, resulting automatically in cuts to specialists.

Innovations in healthcare don’t come from some federal agency “think-tank,” which is kind of an oxymoron. If you look around from city to city, the best centers of excellence, be it an eye, orthopedic, or heart institute, are named for private citizens who are philanthropists¬¬––not some senator or congressman.

It doesn’t take government to help small businesses to grow, Mr. President. The best it can do is get out of the way and let the free market and the American spirit of entrepreneurship flourish.

Meaningless use and meaningful headache

Filed under: Uncategorized — admin @ 3:30 pm

MEANINGLESS USE; MEANINGFUL HEADACHE

By now, unless you’ve been living inside a cave, and are a physician, you have heard about “Meaningful Use” of the electronic medical record, or EMR. Meaningful Use refers to a set of 15 criteria that medical providers must meet in order to prove that they are using their EMR as an effective tool in their practice. There are 10 additional criteria that are considered a la carte menu items, from which only five need to be demonstrated by the medical provider. In total, each provider must complete 20 Meaningful Use criteria to qualify for stimulus payments during stage one of the electronic health reimbursement, or EHR incentive program.

Here are the 15 required criteria:

Demographics (50%)
Vitals: BP and BMI (50%)
Problem list:
ICD-9-CM or SNOMED (80%)
Active medication list (80%)
Medication allergies (80%)
Smoking status (50%)
Patient clinical visit summary
(50% in 3 days)
Hospital discharge instructions (50%)
- or -
Patient with electronic copy (50% in 3 days)
e-Prescribing (40%)
CPOE (30% including a med)
Drug-drug and drug-allergy interactions
(functionality enabled)
Exchange critical information
(perform test)
Clinical decision support
(one rule)
Security risk analysis
Report clinical quality
(BP, BMI, Smoke, plus 3 others)

Since my cardiology group has had an EMR since 2004, a lot of this has become routine and easy for us. And although I am a big proponent of the EMR, I am NOT an advocate of meaningless rules and criteria, which do nothing to promote improved patient care, in order to be reimbursed or “incentivized” by Medicare. Following are two cases in point.

One of the criteria calls for listing the patient’s smoking history and how you have advised them to quit smoking, if they are active smokers. Most of my patients fall into two categories––they either quit smoking years ago––or they are active smokers with little motivation to quit. Nonetheless, in the latter group, I must document on each visit that I have counseled them to quit smoking and their acceptance or rejection, of smoking cessation advice. Since the inception of this rule in our EMR program, I would estimate that less than two-dozen patients have consented to join our “Smoking Cessation” clinic. If they don’t want to quit the first or second time I ask, I doubt they will by visit # 20 or 30. Patients quit when, and if, they are ready to quit. I have yet to meet a patient who doesn’t know that smoking is bad for their health.

The second one is likewise absurd. We must document the patient’s body mass index, or BMI, on each visit. While I feel documentation of this is useful, the requirement that they be counseled every visit to lose weight, is a waste of time. There is no more vexing problem encountered in most physicians’ offices, then our failure to help patients lose weight in a safe fashion––and this is not from lack of trying. Data suggests that few patients are willing to adopt real lifestyle changes in order to lose weight. Most just want a magic pill or surgery. The majority likely has more interest watching “The Biggest Loser” on television than listening to me preach.

This is, in a nutshell, what is wrong with evidence-based guidelines and mandates. Like most government ideas, the initial intents are lofty and beneficial. However, once mid-level bureaucrats make decisions on how to implement these rules, the end result is more non-productive work for physicians and little, or no, improvement in quality of care for patients.

March 23, 2012

New Doctors: Working Too Much or Too Little?

Filed under: Uncategorized — admin @ 7:36 am

One of the newest partners in my medical practice laments how many hours he has to put in to build his practice. Sometimes he must even work until eight or nine o’clock at night, even if he is not on call. I am sorry––but he won’t get any sympathy from me. I recall the days––now too many years ago––of building my now 12-man cardiology group. I was in practice by myself for three years before my first associate joined me. I had cross coverage from another cardiologist on some weekends, but that meant only four days off every month. Meanwhile, I had to make time to interview dozens of candidates and their spouses, including wining and dining, while still taking call and carrying a full office and hospital consulting schedule. It was not unusual for me to complete rounds at midnight, so exhausted I just fell into bed.

Make no mistake, however, about these days of the “iron men.” I believe this type of work schedule was, and still is, extremely unhealthy for a doctor, his family, and potentially dangerous to his or her patients. I do agree that a more humane training schedule for medical students, interns, and residents was long overdue. But as the saying goes, “the devil is in the details.” Newer physicians simply won’t tolerate what we had to put up with our training. As a fourth-year medical student at a large county hospital in Cleveland, Ohio, I recall working up fourteen admissions in one night and being ready to present the cases to the chief medical resident and attending by 7 AM. Had I not taken some histories while I was examining the patient, I would never have been ready at “morning report.” I would have been “toast.”

Medicine is moving inexorably to “shift work.” ER docs have always done this, and now hospitalists have done the same. In the future, more and more specialties will follow similarly as reimbursements decline, and the corporatization of medicine grows. On balance, I think that this is a good thing. If I have a heart attack at 3AM, I would take a rested cardiologist, over one who just finished working a 14-hour day, without equivocation.

If I sound conflicted, it is because I am. I think wistfully of my days off “24 on/24 off” ER rotation during my internship at the University of San Diego in 1975. As I drove home in my yellow VW beetle on Interstate 5, I had to keep the windows down and play “Hotel California” by the Eagles or Jethro Tull at full volume, just to keep from nodding off. Later, my wife would plead with me to “please stay awake.”

These are bittersweet memories. Just as a prisoner-of-war comes to identify with his captors, we too reflect with some admiration at our tormentors. There was the chief surgical resident who said, “The only problem with taking call every other night is that you miss half the cases.” Another resident told the interns that if they enjoyed their sleep, then they should go into something like pathology or dermatology. Unfortunately I enjoyed cardiology too much.

Thinking back, I would likely make the same choices. Yet I can’t help but feel that today’s crop of docs are too soft, and expect too much money for too little work, I also think that their families and patients will reap the benefits as much as they will. And in the end, that’s not a bad thing.

March 7, 2012

Death By A Thousand Forms

Filed under: Uncategorized — Tags: , , — admin @ 7:06 pm

DEATH BY A THOUSAND FORMS

One of my practice’s head nurses, who usually have a high tolerance for frustration, finally showed some exasperation. It seems that the she had just spent 15 minutes on the phone explaining to a representative from “Express Scripts,” why one of our patients needed to take Pradaxa, a new anti-coagulant, rather than warfarin. The aggravation grew from the assertion by the faceless voice on the phone telling her that this medication could be prescribed only for “nonvalvular atrial fibrillation.” Here’s the rub––all of our prescriptions for Pradaxa read “for nonvalvular atrial fibrillation to prevent this sort of red tape––the agent just hadn’t bothered to read that.

Far from being unusual, this kind of scenario plays out daily in our office, and those of thousands of physicians, across the country. Indeed, I would assert that it is rapidly becoming the rule, and not the exception. It seems that every decision we make as doctors, from test ordering to prescription writing, is questioned or blocked by a bureaucrat, allegedly on behalf of the patient to keep medical care “cost-effective.” This nifty euphemism really means less expense and more profit for the pharmacy or radiology “benefits manager “ and/or insurance company. It is certainly not “cost-effective” for neither the doctor nor the patient.

Our professional decisions are under assault by hundreds of delaying forms and phone call approvals. This adds to our “overhead” with no increase in reimbursement. Out of sheer frustration, and lack of staffing to battle this leviathan of corporate officialdom, we often give up. They win, and the patient looses.

RMJ, another one of my patients with end-stage heart and lung disease is on round-the-clock oxygen. On his last visit he showed me a form from his oxygen supplier––“Respiratory Pharmacy.” It said, “Take this Sheet with you to ALL Doctors Visits.”
The letter then stated, “Your Doctor(s) must write that you must use.. the oxygen…in your Progress Notes. If your Doctor fails to document your ‘continued use and need’ of these items, you will not be able to get the service, supplies, or medications.”

It goes on further to say “Medicare will not pay for your…oxygen…if your Doctor does not write that you ‘continue to use and need’ this item.” There is zero that RMJ likelihood will not need oxygen.

PBM, or pharmacy benefits managers, seem to troll the price sheets daily for deals on generic drugs. So this week, they might approve an ace-inhibitor for the treatment of hypertension, and not an ace-receptor blocker, and then next month, they may allow the latter. All of this of course entails phone calls from distressed patients, and more forms to complete. As a direct consequence, avoidable delays in medication administration, and missed doses, are all too common.

Changes in commercial health insurance policies are not immune either. One of my wife’s medications was questioned because she hadn’t tried a generic instead. We went through this all last year––alas, with a different insurer.

Medicare Part D has spurred another thorn in the side of physicians’ offices. They change yearly the medications they cover and don’t. So the same patient, who has done well on the same medication, must have more forms completed every January that were justified and finally approved only one year before.

These are more ways that the private practice of medicine will die––not death by a thousand cuts––but death by a thousand forms and phone calls.

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