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The Healthcare Problem

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The Cost of Success

For those of you who didn't know, I entered the National Novel Writing Month "contest" (which has no winners).  I got to the goal of 50,000 words yesterday. One of the main questions that is asked in my novel (which may or may not ever see the light of day) is this: What would happen if a wonderful cure came along that would take away most, if not all sickness? Remember, it is fiction.

The answer is, of course: utter chaos and collapse of our system.

Our system is designed to deal with sickness.  It is designed to fix problems.  If a wonder-drug came along, here's what I think would happen:

  • Pharmaceutical companies and hospitals would have to oppose it, as they would suffer financial ruin if people became healthy.
  • Doctors, especially those focused on chronic illness or treatment of serious problems, would take a huge cut in pay.
  • A huge number of healthy people would enter the workforce, disrupting an already fragile economy.

Human stupidity, of course, would remain.  There would be some work for those in the medical profession, but only a fraction of what is there now.

I don't think anyone expects this "wonder drug" to appear any time soon, so what's the point of entertaining this scenario?  Looking at the extremes can often give us insight to our current problems.  One of our biggest problems is this: our system thrives on its own failure.  If we fail to keep people well, the healthcare economy improves.  There are more jobs to be had to treat and take care of these sick people.  There is more need for new drugs to treat the increased number of sick people.  Hospital beds are full, and doctors are busy.

Life is good for those of us in medicine when we fail.

I think this truth is not lost on some of those people who are cynical about traditional medicine.  They see the motivation to keep people sick, and assume that there is a conspiracy afoot to accomplish this goal.  Now, if there is a conspiracy, it doesn't include me.  I do see success in keeping people healthier than if they didn't see me, and nobody has tried to bump me off yet.  I'll let you know if they do.

But despite the fact that I don't see a conspiracy to make people sick, I do see a lack of a conspiracy to make people well.  It's not an organized conspiracy; it's just a sin of omission.  Success of our system, defined as people being kept healthy, comes at a huge cost.  Why would people strive for success when the prize would be a pink slip?

Again, I am not saying that this is a conscious decision.  I don't think there is a back-room deal between pharma, hospitals, and the government to prevent wellness.  No, I just see a total lack of an organized effort to fix things.  We are giving absolutely no motivation for success.  There is nobody in the healthcare industry who truly benefits from health.  If this is our goal (and I think it should be), shouldn't we somehow make it worth someone's while to keep people healthy?

Why aren't we setting goals to shut down hospitals, not keep them profitable?  Why aren't we trying to motivate well care and prevention so that sick care and intervention will stop being so profitable?  This can't be lost on those whose livelihood depends on the failure of the system.  There will be great inertia to the sacred idea of treating the sick, and a reluctance to abandon it for the idea of eliminating the sick (through prevention, not euthanasia).

Would your kids clean their rooms if you docked their allowance for doing it?  That's what we are doing.  That's how our system is designed.  We should not be surprised at failure when success comes at such a high cost.

Until things are changed at the most basic level, success in healthcare will be a purely fictional idea.

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The Seduction of Primary Care

Hey there, big, smart, good-looking doctor....

Are you tired of being snubbed at all the parties?  Are you tired of those mean old specialists having all of the fun?

I have something for you, something that will make you smile.   Just come to me and see what I have for you.  Embrace me and I will take away all of the bad things in your life.  I am what you dream about.  I am what you want.  I am yours if you want me....

Seduce:   verb [ trans. ]

attract (someone) to a belief or into a course of action that is inadvisable or foolhardy : they should not be seduced into thinking that their success ruled out the possibility of a relapse. See note at tempt .

(From the dictionary on my Mac, which I don't know how to cite).

If you ever go to a professional meeting for doctors, make sure you spend time on the exhibition floor.  What you see there will tell you a lot about our system and why it is in the shape it is.  Besides physician recruiters, EMR vendors, and drug company booths, the biggest contingent of booths is that of the ancillary service vendors.

"You can code this as CPT-XYZ and get $200 per procedure!"

"This is billable to Medicare under ICD-ABC.DE and it reimburses $300.  That's a 90% margin for you!"

This is an especially strong temptation for primary care doctors, as our main source of income comes from the patient visit - something that is poorly reimbursed.  Just draw a few lab tests, do a few scans, do this, do that, and your income goes up dramatically.  The salespeople (usually attractive women, ironically) will give a passing nod to the medical rationale for these procedures, but the pitch is made on one thing: revenue.

Our practice has succeeded despite the fact that we don't do a lot of procedures.  We are in a shrinking minority, and the monthly cash-flow is putting increasing pressure on us to think about "alternative sources of revenue."  Most of my colleagues in private practice have labs, x-ray equipment, or do procedures.  Some do such medically vital services as hair removal.  I haven't had the stomach to go that direction...yet.

Who's at fault for this?  Is it the doctors, who are seeking profit over what's best for the patient?  Is it the vendors, who find loopholes in the reimbursement structure to milk extra dollars out of the system?

If you leave meat on the floor, don't be surprised when your dog eats it.

The payment for the E/M codes (the codes used to bill for doctor's visits) are low and the payment for CPT codes (the codes used to bill for procedures) are high.  This is how our system is set up (with great thanks to the RUC) and it is one of the main reasons we spend so much money on healthcare.  We aren't doing healthcare, we are doing sick care.  Healthcare is prevention, which takes face-to-face encounters with the patient.  It involves talking and listening, and talking and listening are not deemed valuable by our system.  We are paid to do, not to educate or listen.

It takes great resolve to resist this siren's call.  A few years ago, we made a deal with one of the other practices in our building to buy a portion of their x-ray equipment.  It seemed to be a good way to make money off of something we do normally in practice.  But a few months into this deal, we realized two things:

  1. We weren't ordering enough x-rays to be profitable.  We had established a mindset of ordering x-rays that minimized their use.  It was a nuisance to wait for the reading on an x-ray and it was inconvenient and costly to the patient, so we made most of our judgments based on something else: the physical exam.
  2. We were ordering a lot more x-rays than we had before.  Instead of trying to find reasons to not order x-rays, we were now financially motivated to order them.  So if someone hurt their ankle, we were much more likely to order one.  If someone had a chronic cough, we were much more likely to order a chest x-ray.  The change wasn't that we were hungry for profit, it was just that we were suddenly 180 degrees from our previous mindset: we were trying to find medical justification to order more x-rays.  It was incredibly seductive.

We did back out of the deal, feeling that the care we gave wasn't better and not liking the fact that we were losing money.  But would we have backed out if our practice wasn't already financially stable?  We are a well-run practice that has been successful despite our non-reliance on procedures, but what of the other practices out there that aren't so successful?

One of my favorite sayings is: your system is perfectly designed to yield the outcome you are currently getting. Nowhere is this more true than in healthcare.  We have set up a system that encourages consumption.  We pay doctors more to do more.  We pay doctors less to spend time with patients.  We want our doctors to do better care, but we pay them to do worse care.  We want to save money, but we reward those doctors who spend the most.

So why not change?  Why not pay more for E/M codes and less for CPT codes?  Yes, some doctors will abuse this system by running patients through their office and spending little time with them, but at least it will increase availability of doctors to see patients.  There will always be those who take advantage of any system; that shouldn't stop change.

I went into medicine to take care of people, not spend their money.  Why can't we have a system that doesn't force me to decide between the two?

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Vote Llamacrat!

"So what do you think about the election?"

"So What do you think about Obamacare?"

"What do you think about this healthcare situation?"

I get these questions throughout my day. My patients are mostly suburban and white, so their view is overall on the conservative side. Yet I have found that few see the results of the election as a hopeful sign for healthcare. I don't either.

Anyone who reads this blog regularly knows that I am a "flaming moderate" when it comes to politics. I don't have much faith in anyone who identifies too strongly with one party of the other. I am really angry with congress and their lack of gonads to work on really coming up with solutions. Interestingly, my patients, regardless of their political leaning, agree with much of what I say. Here are the things they all seem to agree with:

1. Congressional politics is hurting us - Members of congress (both sides are equally guilty) are more focused on what is good for their party than what is good for those who they represent. If a democrat is elected to this district, I expect him/her to represent all of the people in that district, not just the democrats (the same is obviously true for republicans). This doesn't mean they must lose all of their ideology, but ideology should be a means, not an end. The reason to hold an ideology is to come to solutions to problems with that ideology as a vehicle. The goal is to help the people you represent through your ideology, not bang them over the head with it.

2. There are many villains in this story - I like to rail against congress (it's a hobby), but the president is to blame, as are past presidents who allowed the situation to get this bad. Obama inherited a bad situation, he didn't create it. Many of the bad things happening were set in motion during the Bush administration (or earlier). Now, Obama's leadership style of letting congress shape healthcare reform has created lots of problems. Then there is the system that lets money influence policy (which has been evolving over a long period of time). Lobbyists for those with money leverage the compulsion of politicians to be re-elected and get what they want by well-placed "contributions."

3. We can't afford to wait - The past two years has proven that even with a very large majority, a party can't get things done without cooperating with the other party. In two years we may get a different president, but is there anyone out there that thinks our government will work any better? If the republicans gain power, the democrats will unite and block anything they try to accomplish. Simply putting a different captain at the helm of a sinking ship won't change the final outcome. Healthcare is a mess, and that mess is getting worse, not better. Gridlock is unacceptable.

4. Our situation is scary - Our government doesn't work any more. The system we have thrives on debate, influence peddling, and party politics. It has survived over 200 years that way. The thing that scares me and most of my patients is the lack of any willingness to work together. If they were in a room with one exit, the democrats and republicans wouldn't agree on how to get out of it. Politics of party is so acute, inflamed by the ideologues on one side vilifying the ideologues on the other, that it seems impossible to get anything significant done. One commenter on my last post suggested that we are seeing the death-throes of our government. If our way of solving problems is screaming and pointing fingers, I begin to agree with that.

What to do about all of this? Do we form a third party? (I would suggest llamacrat as the name of the party). Do we write congresspersons? Do we get pitchforks and torches and march on Washington DC? Do we whine a lot in blog posts, hoping someone else will do stuff?

I don't really know. I do think that congress should be scared, not empowered. The people voted for change in the past 3 elections, which means there is overall dissatisfaction with all involved. Another 2 years of do-nothingness will prove only that our country is in danger. The mandate of this election is a "mad as hell" mandate.

I beg with any politician crazy enough to read what I write: please don't put re-election or party politics ahead of the people you represent. The election was not a game with winners and losers, it was a statement by the American public that you guys are screwing things up. Govern us. Lead us. Take care of us. Fix our problems.

If you don't, the llamacrats will be breathing down your necks.

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Different Lunatics, Same Asylum

The top vote-getting answer on my poll about what people feel about the election: Different lunatics, same asylum. We are getting jaded by our system.  Being the "flaming moderate" that I am, I find it hard to hear the substance of the rhetoric on either side, just the shrillness and rancor of the voices. From the physician's perspective, it is very hard to know who to favor in this election.  The democrats seem to love lawyers and hate tort reform, and they also favor an expansion of government.  The republicans love big businesses and "free market," accepting the bad behavior of insurance and drug companies as "the market working itself out."  They both seem hell-bent on sticking it to the other party at the expense of getting anything done - and this in a time of crisis for our industry.

The results of this playground brawl between the two gangs of bullies is that all of us wimpy kids (the ones without power) end up lying bloody in the dirt.  Here are the facts as I see them about healthcare in our country:

  1. It costs far too much.  The top item on the agenda needs to be cost control.  The only way to control cost is to stop paying for things that are unnecessary or for which there is a cheaper alternative.  I know that's not simple as it sounds, but so much of the discussion is about coverage and how things are paid, while the real issue is not who pays, it's what and how much gets paid.
  2. Too much of the cost is hidden.  How much does it cost to see the doctor?  That's an incredibly complicated question.  It depends on the insurance carrier, the doctor in question, the way the doctor codes the visit, and the nature of the doctor's ordering practice.  The same thing is true on a grander scale for hospitals.  Drug costs are hidden by copays (allowing companies to wheel-and-deal to get drugs on formularies).  Insurance companies hide their administrative cost and pass on any increases on to the people buying the policies.
  3. It is totally disorganized.    Nobody knows what anyone else is doing.  As much as people rail against the mandated EMR, the coordination of care will be impossible without it.  We need to know what has been done using clinical information, not billing data.  Up to now the insurance industry has controlled the information about what is done on patients, using the withholding of payment as the club to change physician behavior.  While there is risk that doctors might get screwed with the recording of our behavior, not doing so makes the chance of real improvement nearly impossible, leaving the payors with the data and hence with the most power.
  4. Nobody is pointing out the naked emperor.  It is insane that drugs cost as much as they do.  It is crazy that we pay what we do for technology.  What exactly is it in the 2 day ICU stay that costs $100,000?  Price gouging is rampant because it is allowed (and even encouraged by our system).  Why can a drug company raise the price of a gout drug by 5000%?  Because the FDA lets them.  Why can granny in the nursing home with alzheimer's get put in the hospital and spend a week in the ICU?  Because Medicare pays the hospitals and physicians who put her there.  The credit card bill is shooting up, yet we are not asking why we keep spending so much?
  5. The people with the most at stake are those with the least power.  Patients (and primary care physicians) are the ones with the most at stake.  The discussion is being run by politicians (who don't have to use the plan they pass), hospitals, specialty organizations, insurance companies, and other health-related industries.  Those with money can most influence the process to their advantage, and patients are definitely not the ones with the money.
  6. We cannot afford gridlock on this issue, but that is undoubtedly what we will get.  I have not met one person, liberal or conservative, who is optimistic about the next two years.  We are living with a cancer but are unable to do anything about it.  That cancer is not going to sit around and wait for the politicians to agree, it will spread and will choke out any hope of survival.

I am not too charged up this election season.  It seems that very few people look with optimism on what's going to happen over the next 2 years.  The best thing we can do?  Raise your voice.  Vote in a way that will change the process.  We need to change the asylum and make it into a place where things get done.  We need people with the political gonads to work with others not in their party.  We need more sense and less shrillness.

If we don't get this fixed soon, the patient will be beyond saving.

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Losing Patients With Insurers

We are losing patients.  Certain insurance companies are trying to "play hardball" with doctors, unwilling to negotiate with us over their outlandishly low rates.  We have lost patience.

So the signs went up in the exam rooms today:

As of the start of the year, we will only accept X, Y, and Z Medicare advantage plans, and we are presently negotiating with A and B insurance companies.  Please consider this when enrolling in plans.

It is highly likely we will drop one of the insurance plans altogether, and we are one of the last practices in our town to accept them.

Patients are distraught.  Some of them who have seen us for years are now going to have to go elsewhere, while others that just joined our practice because their previous doctors dropped out of the plan will once again have to find a new doctor.  Patients aren't mad about this, just sad.  The conversations go like this:

"So you are dropping X insurance?"

"We will if they don't change.  They are paying us significantly less than other plans."

"That's crazy.  We just left a doctor because of the same thing.  Now we have to move on."

"Yeah, I am very sorry about that.  I just want to see patients; I don't want to do this kind of thing."

"Well, I don't blame you.  They pay $1000 for an ER visit for an ear infection, and they won't pay you what you charge?"

"Apparently not.  They have been playing hardball with primary care docs recently.  That's why nobody is accepting it any more."

"I don't know what we are going to do.  I hate changing doctors again."

"Call your employer and tell them about this situation with the insurance they've chosen.  The only way things will happen is if employers get mad at the insurance companies."

There is no anger, just disappointment and frustration.  Patients are victims of the strategy insurance companies are using to cut cost.  But why cut primary care?  Why low-ball the one group of doctors who don't cost that much and who can actually save money?  It makes no sense to me.  It certainly doesn't make sense to my patients.

Come December, we may be putting a similar sign up:

Due to the 23% cut in our reimbursement by Medicare, we are no longer accepting new patients and may soon be forced to drop Medicare altogether.

It's happening in a lot of offices already.  The problem is that these patients won't have an employer to tell.  These patients won't have a choice.  Medicare won't come back to the table if there are no PCP's.  They don't negotiate their rates.

See those clouds on the horizon?  They look harmless, but they're not.  It's a storm that will kill a lot of people if we don't do something soon.

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Doctors, Hospitals, and the Yankees

Joe Boyd hated the Yankees.

"Those damn Yankees.  Why can't we beat 'em?"

Then he got the opportunity to save his beloved Washington Senators by making a deal with the devil - giving up his soul in exchange for being transformed into "Shoeless Joe" to propel his team to win the World Series.

Interesting.  I think a lot of doctors are making their deal with the devil.  They are looking for a small gain in comparison to a long-term of misery.  True, Joe Boyd made out in the end; but that will only happen if someone from Hollywood writes our script.

Here's the problem: at the core of our problems with healthcare is the total lack of cohesive communication.  Doctors have no idea what other doctors have done with a patient.  Tests get ordered, medications get changed, procedures, hospitalizations, even surgeries are done without communication to other doctors who would benefit from this information.  The conduit of communication is this:

Doctor: "So, how have you been doing over the past few months?"

Patient: "Didn't you get the notes from the hospital?  I was in for two weeks.  I had a heart attack and a stroke and now I am in rehab for both of these."

Doctor: (checks chart uncomfortably) "No, I didn't hear about it.  Why don't you tell me about it...."

Situations like this happen daily at my office.  Patients are started on medications by specialists without my knowledge.  Lab tests are done that I have no access to.  Huge changes happen in the lives of the patients for whom I have cared for over a decade, and I get nothing.  Even consults I order are done without any communication back to me.  On the other side of things, my patients are hospitalized without any consideration of the care I have been giving over the past decade.  Patients are treated as if their care starts from scratch every time they enter a new venue.

It hurts my care for the patient.  It hurts the other doctors' care for the patient. It hurts the patient.

And it costs a lot of money.  Disorganized, we cannot beat this behemoth of dollars spent.  Without good communication, communication that allows each person involved in the care of the patient to see exactly what is going on with the patient, the spending continues.

So what can be done about it?  How can the care of the patient be organized?  One common solution is the Integrated Delivery Network, or IDN.  An IDN is a network of doctors linked together through a hospital.  The care is integrated through a common record, or at least through a conduit that eases the flow of the patient from point of care to point of care.  Academic medical institutions are IDN's as are many private hospitals (such as Kaiser - although Kaiser operates as its own insurance carrier as well).  This seems to make sense.  It breaks down barriers of communication and improves care.

But there's a catch: the hospital.  Hospitals are often thought of as being on the same side as doctors - after all, doctors work for hospitals, right?  While this is somewhat true for specialty physicians, many of whom make their revenue from procedures done on hospitalized patients, it is not true of primary care physicians.  Hospitals are centers of care, yes, but they are also centers of spending.  A hospital is not motivated to save patients money.  Their profit is driven by patients being sick, getting tests and procedures done, and racking up cost.  A patient can spend in a day in the hospital more than they will spend in a lifetime at my office.  In this situation, the patient is treated as a commodity - something to use for a profit.

Does the hospital want me to be responsible, not ordering unnecessary tests, keeping patients healthy and out of the hospital?  Do hospitals want me to get patients in hospice at the end of their lives, eliminating unnecessary hospital stays?  Do hospitals want me to keep patients out of the ER?  They won't get mad at me if I am the only one doing it, but all doctors getting responsible would be bad news for their bottom line.  Selling myself with a hospital will put me in a conflicted position: wanting to please my employer, yet wanting to do what's best for the patient.  In this way, IDN's are fatally flawed.

So what can be done?  How can communication be fixed without letting the hub of the communication network be a source of spending?  Think back to the conversation I recounted above.  Who was the hub in that setting?  The patient.  Perhaps we should consider this model when moving toward a communication network.  Perhaps a patient-centered communication model would optimize communication without raising cost.  After all, shouldn't I answer to the patient - the one who is spending the money and the one who receives the care - for the decisions I make?

What if we set up a decentralized communication network that was linked not by doctors, hospitals, or insurance companies, but by permissions given by a patient?  Here's what I mean:

  • I would have access to any records on the patient on any clinical database that the patient allowed me access to.  Instead of importing labs into my system, I would have access to the laboratory's system for any patient I had permission from.  That way if the patient had labs done by another clinician, I could see the results.  If the patient was at the hospital, I would have access to those records as well.
  • I would give access to any clinician who was given permission by the patient to see my records.  If the patient was in the emergency room or in the hospital, the doctors there could see what I have been doing with the patient in the outpatient setting.  If a consultant wondered why I ordered a consult they would have easy access to my documentation of this.

Sounds risky?  I think it is less risky than a centralized database with all the information in one location.  Sounds hard? Isn't what I described just a description of what the internet is?  Information on my blog is not downloaded on your computer, you just have access to it.  If I wanted to deny access, I could.  If I wanted to limit that access, I could do that as well.

This is exactly what happens with banks as well.  The consumer has control over access to bank accounts.  If they want to allow their gas company to draft from their checking account every month, they can.  They are not required to gather all of the banking information in one location, it is spread out among many.

In baseball, often it is the team who spends the most money who wins in the end.  Those of us who grew up hating the Yankees can attest to that ugly fact.  Healthcare is presently run by those who control the money: the insurance companies and the drug companies.  They win because we can't afford to fight them.  They win because the minute they get behind, they find a way to use their money to get back on top.  But we don't beat such spending by selling ourselves to fix our short-term problems.

To fix this problem, we don't need more of the same.  We need the whole way the system is set-up to change.  We need the rules to change.  We need a change in ownership.

Dare we admit that the real answer to our problems is in the hands of our Washington Senators?

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Customer Service

Gosh, a whole lot of huffing over a little word!

Customer.

OK, now grab a paper bag and breathe slowly and steadily into it.  I know it's hard to hear that word.  I am sorry to have caused such trouble.

Some folks misunderstood my last post, thinking that I thought patients should only be considered customers, or that they should be referred to as customers.  I never said that, nor did I imply it.  I simply said that patients are customers.  They are.  Medical care is not free, and it is being paid for by the patient (directly or indirectly).  Medicine is a business that has been so mismanaged that we are now in a crisis over its financial side.  The trouble is the cost of care.  Cost implies money is used, and trading money for services or goods is what business is about.

We've been spending our dollars on healthcare like a person irresponsibly running up a credit card bill they can't pay back.  The pain doesn't happen now, it happens down the road when the collectors knock.  We can't order whatever tests we want or prescribe gazillion dollar drugs without remembering somebody will have to pay the bill.  Ignoring the business of medicine has gotten us into deep doo-doo.

This fecal vortex is not limited to the financial side of the business; we have also neglected customer service.  Doctors have "waiting rooms."  What other business admits up front that it won't serve you in a timely manner?  I suppose we could call airports "delay zones," but I doubt the airline industry would accept that like we have in medicine.  Whenever I post on doctor/patient interaction, I am flooded with stories from patients who are treated poorly by doctors and their offices.  People are there for good medical advice, right?  No, they are there to be cared for, and a huge part of that care is determined by how they are treated in the office.

Early in our practice, we decided we wanted our practice to be like the department store, Nordstrom's.  Perhaps in the present day I'd more compare it to the grocery store, Trader Joe's.  These stores do not focus on having the lowest price, the biggest sales, or the best advertising.  Instead, they focus on the customer experience.  They want people to have a different experience when they come to their store.  The staff is helpful and courteous; they make their store to meet the needs of their customers, not expecting their customers to adapt to their store.  When people leave these stores, they feel good about their experience.  They feel like they were the center of attention and got their needs met.  They are extremely loyal to these stores.

I want my patients to feel the same way when they leave my office.  I want patients to brag about our office and how well they are treated.  To meet our patients' needs, we have a walk-in clinic every morning from 7:30-8:30, every evening from 5:00-7:00, and Saturday morning from 8:00-11:00.  Our patients love this.  It fits their needs.  They don't have to call to make an appointment; they just show up.  We do have tight rules around this to prevent abuse; we don't see chronic problems, nor do we see things that are at all complex.  The visits are limited to "quick sick" problems.

Oh yes, it also is hugely profitable.  We make over 25% of our revenue from this.  That is good business: making a profit off of making people happy.  We identified a need of our patients and met it.  Because of its popularity, the wait times for our walk-in clinics are sometimes longer, but because we are meeting their overall needs of availability, people rarely complain and usually enthusiastically thank us for doing this.

Does this customer-oriented approach mean that we say the "customer is always right" and so give antibiotics when not appropriate, or give in to demanding patients?  No.  It's actually the opposite.  Since we are meeting our patients' needs, they seem all the more willing to listen to us when we tell them they don't need an antibiotic, or that they do need to come back for another visit because the problem is too complex.  They believe us when we say we care about them because we run our business in a way that sends that message.

One doctor who took offense to my last post objected to my classification of medicine as a business, saying: "No, sir, it is not business, it is care, and I am truly disappointed you want to defend it as business."  That's like saying a restaurant is not a business, it is the provision of food.  Healthcare is care.  I don't disagree with that (read the rest of my blog if you don't believe me!).  It is also a business.

I won't call my patients "customers," but I will treat them that way.  I will treat them like I owe them something because they have paid me.  I will treat them like they deserve a good experience when they come to my office.  I will listen to their needs and do my best to meet them.

Doing so is good care.

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Drug Down

I used to defend pharmaceutical companies.  "What companies out there have contributed more good?  Should care manufacturers make more when all they do is make transportation that breaks after a few years?"  It made sense to me that you should put a pot of gold at the end of the rainbow so that companies are motivated to invent more drugs and innovate.  We throw a lot of money to athletes and movie stars who simply entertain us, shouldn't we do better to those who heal us?

I used to say that.  I don't any more.

No, I don't think the drug companies are "evil."  People who say that are thinking way to simplistic.  These companies are doing exactly what their shareholders want them to do: make as much money as possible for as long as possible.  That's what all companies do, right?  They are simply working within the system as it is and trying to accomplish the goal of making money.  To say that they should "sacrifice" is foolish.  They are simply playing by the rules that have been set out there.  Those rules are the thing that has to change.

The system that allows them to charge $200 per month for a drug that does the same thing as 5 other drugs on the market is the real villain here.  The system that does not obey the rules of free-market is what is at fault.  Those drug prices are absolutely killing us - literally at times.  The entire healthcare system operates under a stealth billing system that allows for exorbitant charges.  Why can hospitals charge $10 for a dose of Tylenol?  Because nobody sees it unless they read the fine print, and because it gets paid for.  Why can a company charge $100 for a hemorrhoid cream that has the same things in it that over-the-counter drugs have?  Because insurance pays for it and nobody complains.

It's crazy.  It's how our system works.

Here are my top gripes about drugs and what they cost:

1.  All the drugs in a class always cost about the same. Why do all of the blood pressure, reflux, or antidepressant medications in a class always go for about the same price?  I have never in my 16 years of practice seen two drug companies go head-to-head in a price war.  Isn't that what the free-market system encourages?  Shouldn't competition drive the price down?  It doesn't in our healthcare system.

2.  Drug rebates. Most folks don't realize it, but drug companies pay insurance companies "rebates" if their drugs are chosen for their formulary.  This means that it is often not the real price for the drug or its superiority to the competition that determines formulary status, it is the "rebate" that the drug companies agree to pay.  In other circles this is called "extortion."  "I promise that my friend Vinny won't beat you up if you pay me $10 per week."  And do you think the "rebate" is sent back to the policy-holders of the insurance company in the form of lower rates?  Do I have to ask that question?

3.  Drug Marketing. Yes, the direct-to-consumer marketing nauseates me.  The plethora of drug reps pounding us to use their drug instead of their competitors makes me tired.  I am all for education and for companies being allowed to market.  How could a product be sold if it isn't marketed?  But when the marketing budget exceeds the R and D budget for a drug, something is way off.  The goal is to make a "blockbuster" drug that they can milk for a long time, and so they get docs to prescribe and patients to demand the drugs with the best profit-margins.  This happens because there is no competition between manufacturers on price, it is instead a marketing war.

4.  Patent Extensions. The patent process is supposed to protect the inventor of a product from having the idea stolen and used by someone else.  What the process has become, however, is a game to give companies exclusivity on a drug and hence higher-margins for as long as possible.  The system doesn't protect, it endows.  It turns drug development into a Vegas game with a chance to hit the jackpot if all of the columns line up.

5.  Generics. It used to be simple with generics: since there was no R and D involved, the drugs would be lots cheaper and so would reduce cost.  This isn't the case now.  When Effexor XR and Adderal XR went generic, the companies who made the drugs were granted the exclusive right to make the generic for 6 months.  Yes, the drugs were still made by one manufacturer, and that manufacturer had no motivation to lower the price at all.  There are also a bunch of generics that are priced suspiciously close to the price of the brand-name drug.  Why is that?  How can they be allowed to charge so much when they have no marketing or R and D?  The profit margins must be staggering.  Yes, that is the case.  Check out the generic drug companies' stock prices.  They are very successful.

6.  The FDA. The FDA has been the subject of much ire - some deserved, and some not.  But the presence of people from the drug industry in the FDA, as well as some of their decisions, has made their trustworthiness hard to hold on to.  Why is the generic drug Colchicine (a drug for gout that cost under $10 per month) being taken off the market leaving only Colcrys, a drug that costs $4.50 PER TABLET??  The reason is that colchicine is a very old drug, and so didn't have to go through the rigors of approval for use in gout.  But it works great, and was a very cheap way to relieve gout sufferers' pain quickly.  Now the company who makes Colcrys got its version of colchicine approved for use in gout, making the rest of the drugs "illegal."  They are being forced off of the market by the FDA, leaving a drug that costs 50 times more.  Surely it doesn't cost the manufacturer 50-times more than it did for the generics.  This isn't the first time this has happened, and with the jackpot won by the manufacturer of Colcrys, it will probably not be the last.  What's the FDA's role in this?  They hand out the golden tickets and take away a great medication for people who need it.

If we are going to fix our system, we need to become more transparent in our charges.  We need to make it so we know when we are being gouged, and when something actually costs a lot.  We still need to reward those who do great things.  We still need to motivate companies to innovate and to improve products.  But the nature of the current system turns our healthcare system into a source of quick money for many companies.

We can't expect things to improve until we change this.

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What Can We Do?

In response to my past two ennui-ridden posts, I got several comments asking the question, what can we do? Ellen asked this:

Now that I read your blog, I once again wonder what I can do. I do believe the public is sick of the "lying sacks" - which is what my daughter calls politicians. I am sick of their lies and self-serving ways, too. If you have suggestions, please let me know. I do not believe the politicians represent their constituents - they represent themselves and those who bribe them with political contributions.

Another reader emailed me this:

So I am coming to you, with admitted ignorance about what my role is, and asking you what we as patients, consumers or recipients of Medicare/Medicaid can do to help implement solid change in the system?  I want to make a difference in the health care system and am a pretty good advocate.  Wearing the pink ribbons for breast cancer awareness is not my calling, I instead want to use this energy to advocate for real change. Any direction or advice you could offer would be greatly appreciated.

Good questions.

When I hear people saying that we need to get involved and not just sit around and gripe, I think at least I am writing about it in a forum where people actually hear about the issues. There is truth to this; blogging has offered me a great soap box to stand on that an otherwise average primary care physician would never have had.  My posts being republished on the Better Health Network, MedPage Today, and The Health Care Blog allows my voice to be heard at a level I never could have imagined.

Yet I stop when faced with questions like the ones my readers posed.  How can we turn a cry for sanity into real change?  How can we make a real difference by affecting a change in our system?  It's all fine and good to raise awareness, but being aware the boat is sinking is not the same as fixing it.

I don't really know.  The problem is that the nature of real change is a subject of much debate.  Some would say that real change must include government-run care for all.  Some would say that we should fix the tort system.  Some would say that primary care should be encouraged with better reimbursement.  Some would say that the government should stop meddling so much.  But all (except for those in total denial) would agree that our system is on the verge of collapse.

What is the common ground?  What are the nonnegotiables that are not politically polarizing?  Are there any? Or is this just a political battle, and not a battle of wisdom over folly?

So I turn the question back to my readers: can we come up with a list of non-negotiable changes that our system must have?  Can we create a healthcare (or health care, if you are that kind of person) declaration of sanity/bill of rights?

What do you think?  I really want to know what you think are the things that we could actually all agree on.  Rhetoric is fine (and I am good at it), but at some point we need to step beyond the rhetoric and actually work together.  We are asking congress to put down partisanship, yet can we do the same?  Can we do better?  Can we give a cogent and reasonable list that both Democrats and Republicans could agree on?

I want to know too.

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The System Goes Flat

I got a flat tire this weekend.  There were clues that I chose to ignore - the alignment going out suddenly, the steering wheel jiggling when I drove - but the sudden thwacking sound as I sped down I-20 was a clue I couldn't ignore.  I pulled off, then unknowingly stood in a fire ant bed while I changed my tire.  It still itches.  That's not the point of this post, but I just needed to gripe a little.

Yesterday we went to the tire shop and found out that not only were both of my front tires worn out, but my rear tires were old and cracked - at least that is what the guy told me.  I went ahead and changed all four tires, leaving the car at the shop for the morning.  About two hours later I got a call, saying that my brake fluid was "really bad," and that I also needed an air filter changed.  I was suspicious, but I did know I needed the filter, and the charge wasn't that much.

Car repair places are like this for me.  It always seems that they find something new wrong with my car that needs fixing.  I go in thinking I am going to spend X dollars, and end up spending 2X.  The problem is that I can't do without the car, and I don't know enough about cars to do the work myself.  This ignorance causes me to put off getting things fixed on my car, as I don't like spending money beyond expected.  I don't wait for the "check engine" light to come on, but the fear of expense, along with the fear of repair men taking advantage of me, keeps me away from auto repair shops.

Sound familiar?

It takes circumstances like this to remind me that my patients can feel the same way.  They come into my office and I order tests, find problems, send them for consults, and prescribe medications.  What would be a relatively inexpensive visit ends up being quite expensive.  Then I tell the patient they need to come back in a month, and they look at me with pleading eyes and ask: "could you make that two months?"

The big difference between me and the car repair place is that most of the ways I rack up the patient's bill is by sending people other places.  I don't increase my profits by referring the person to cardiology or by ordering an MRI scan.  I do get a little of the suspicion when I schedule follow-up, but hopefully patients don't see me as suspiciously as I see the car repairman.  But I am positive that people cancel follow-up visits, avoid preventive care, and don't take medicines because they don't think it's worth the cost.

This is the achilles heel of procedure-based billing.  If I get paid more for doing more, I am financially motivated to do something that may or may not be also motivated by medical need.  Once I come under suspicion of putting my financial interest above the patient's medical interest, the foundation of care, trust, is undermined.

The decision as to what is necessary and what is not isn't as clear as it seems.  We used to have access to x-ray equipment for which we made profit from each x-ray we ordered.  To be financially viable, we had to order a certain number of tests, and we would profit significantly by doing even more.  A funny thing happened: I ordered more x-rays.  People with a cough, who I would have previously just watched now got an x-ray.  People with ankle sprains got x-rays as well.  I never ordered them frivolously, but I became increasingly uneasy with the increase.

We no longer do x-rays, and we do only a few lab tests in the office (mainly for convenience).  Many (most?) of my colleagues, however, have bought in to this system that rewards doing more.  Hospital-owned practices exist so that the doctors will order ancillary tests and procedures at their facility.  This is the system that has put down primary care - one that devalues the office visit - and yet we buy into it to offset this devaluation.  Thus far, our office has done quite well without, but the lure of new well-reimbursed procedures is always there.

Some have touted a free-market system where docs post their fees and are paid cash for what they do.  Some feel the solution is the HSA account that pays from a tax-sheltered fund for care.  But I wonder if any cost containment will ever be possible with a system that pays more for quantity, but less for quality.  In this kind of system, the patient is in charge of cost-containement, by rejecting care offered them, by questioning the motives of doctors, and by waiting until small problems become big problems.

It's very hard, if not impossible, for patients to know if what  is being done is actually necessary.  I don't know if I really needed my brake fluid changed; I'll never know.  But I did wait until the tire blew on I-20.

And those ant bites really itch.

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