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To What End?

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To What End?

To what end? 

Those three words have become something of a mantra, a mission, a philosophy of care. 

  • To what end do I prescribe a medication?
  • To what end do I make a diagnosis? 
  • To what end do I order tests? 
  • To what end am I documenting? 
  • To what end is there a patient record? 
  • To what end do I send a person to a specialist? 
  • To what end do patients need to come to see me in the office? 
  • To what end do my patients have me as a doctor? 

 


     

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Washington, We Have a Problem

“Daddy?”

“Yes, Jonathan?”

“Sometimes my leg hurts.”

“Yes?”

“Why does it hurt?”

“Uh, that’s a tough question.  Does it hurt a lot?”

“No, just every once in a while.”

“OK, and where does it hurt.”

He gives an expression of disbelief at the stupidity of the question.  ”My leg!”

“Where on your leg?”

“I don’t know,” patience now growing thin.  ”I just want to know what’s causing it.”

“Well, Jonathan, it doesn’t work that way.  My main job is to make sure there is nothing bad going on, and then to make a person feel better.  If the problem a person has is not a danger to them or is not causing trouble, we usually don’t know the cause.  It’s certainly nothing serious.”

By this point I had lost.  I had lost his interest in the subject, and, more significantly, I had lost his faith in me as a doctor.  He is our concrete thinker; presently about to graduate from Georgia Tech with a degree in industrial engineering (and looking for a job, I might add).  He didn’t have desire to understand the subtleties of practicing medicine; he just wanted answers.  My lack of answers was a big mark against me.

It turns out that Jonathan is not alone in this. People come to me for answers, and my profession pitches doctors as the ones with answers.  We fix problems.

This, of course, is not true – a fact that I have come to see as a core problem in the practice of medicine in America, and a reality that (as everything seems to do) comes largely from the way we pay for medicine.  We are paid to fix problems.  How do we fix problems?  With procedures.

The best evidence for this are the things at the heart of health care: codes.   There are three types of codes that dominate the financial and clinical lives of anyone in health care:

  • ICD codes – Codes for medical problems
  • CPT codes – Codes for medical procedures
  • E/M codes – Codes used by doctors who don’t do procedures so they can get paid for office visits.

What this encourages from the medical profession is predictable: lots of problems treated by lots of procedures.  This is good for doctors who do procedures, especially ones that are cutting-edge (like robotic surgery) or ones that seem particularly dramatic and/or heroic (open heart surgery, heart stents).  These are the things the headline consuming public is most hungry for.  Just like it grabs more headlines to catch a terrorist plot just before it has its horrible effect than to prevent it early in the process, it’s a lot sexier to do a procedure to treat heart disease than to simply prevent the disease in the first place.  Which is the better outcome?  Preventing heart disease.  Which is paid more?  Not even close.

The Problem with Problems

A more subtle (and perhaps more significant) effect of this mindset is the way in which everything is labeled as “problems” or “diseases.”  A recent ruling of the AMA that obesity is a “disease” stirred up quite a bit of controversy. The AMA ruling does nothing to change the nature of Obesity, and clearly is more a discussion of semantics, politics, and funding, than it is a true medical question.  In reality, I used to not be able to bill the ICD-9 code for obesity and get paid, but now I guess I could (if I did that kind of thing any more).  I suspect this opens the door for more procedures to be paid for by insurers, as the response to any problem is always a procedure in our system.

There is pressure now to respond to each “problem” with a procedure, or at least a thing to eliminate it as a problem.  Examples:

  • Sinus infections are routinely treated with antibiotics despite no evidence that it actually helps.  Having marketed our profession as problem-fixers, we are met with patients expecting a fix to their problem.  They are disappointed (and even angry) when we don’t “do something” for a “problem” that will resolve on its own, even if the intervention probably causes more harm than benefit.  Problem: sinusitis.  Procedure: antibiotic.  Check.
  • Cholesterol treatment is another example of this.  High cholesterol, be it LDL, Total, or Triglyceride is seen as a “problem,” even in people who are not at risk for heart disease.  I’ve seen many low-risk patients come to my practice on cholesterol medication that does little more than improve their numbers.  The evidence shows that certain high-risk people benefit from being on certain medications which lower the cholesterol.  For folks outside of those high-risk groups, the medications simply make numbers look better (at best) and potentially harm them (at worst).  Problem: High Cholesterol.  Procedure: Cholesterol drug.  Check.
  • Depression and anxiety are normal emotions.  Life is painful and unsure.  There only are two ways to avoid these emotions: die or get stoned.  My personal experience (some fairly recent) is that the times of life most marked by anxiety and depression are accompanied by significant personal growth.  Before everyone gets mad at me for saying these aren’t diseases, I must add that there are cases of both of these emotions that are terribly destructive and potentially fatal if not treated.  But we physicians have lowered the price of admission to treatment, including people going through hard times as those who have clinical depression.  Responding to TV ads about “that pill that will make me happy,” we are met with patients expecting us to “fix their problem” – a problem that is not really a problem; it’s life.  Problem: Anxious and Depressed People.  Procedure: Medication.  Check.

A Better Way

I think there’s a better way to look at things.  I’ve said this before, but I am coming to grasp just how radical this approach is and just how much it undermines our health care system.  There is something far more important than problems:

Risk.

When someone comes to my office with chest pain, my thoughts do not go to the question: “what is going on?”  A more important problem comes first: “is this a dangerous situation?”  I want to know if the person is ready to die from a heart attack or other serious problem.  This is true in nearly every decision I make as a doctor when faced with a condition.  Could that cough be latent lung cancer?  Could that headache be a brain tumor?  Could the depressed man kill himself?

Risk-reduction also rules how I approach disease.  I treat cholesterol and hypertension, not because they themselves are problems, but because they can lead to heart disease, stroke, and other problems.  High cholesterol is not, in my opinion, a “disease” for most people; it is a risk factor.  I treat diabetes mainly to prevent the complications.  Do I care if a 90 year-old has an A1c of 8?  No way.  It doesn’t increase their risk enough to matter.

This does not mean we approach “prevention” like the system presently does: throwing procedures at it.  The health care system doesn’t reward having healthy patients, it rewards doing procedures reported to prevent problems.  Yet the system is not addressing the true goal of prevention: risk reduction. We are “rewarded” by ordering tests, whether or not they reduce risk.  PSA testing is a perfect example of this, as are many other misguided attempts to treat prevention as another problem to  fix with a procedure.

The problem with this, of course, is that it far more to the financial benefit of doctors (and drug companies) for us to address every problem and show we are giving “good care” by checking off the box next to each problem.  In the bigger picture, risk-reduction makes the jobs of future cardiovascular surgeons (and drug companies) much less secure.  It attacks the revenue stream of most doctors and hospitals (and drug companies) right where it counts: you can’t make nearly as much money off of healthy people as you can people with “problems.”

This is why, I believe, any system that profits more from people with “problems” than those without is destined to collapse.  Our system is opposed to the goal of every person I see: to stay healthy and stay on as few drugs, have as few procedures, and avoid as many doctors (and drug companies) as possible.

What would happen if we prevented disease?  What would happen if people didn’t have medical problems?  For society it would be great.  For the health care industry it would be a huge problem.

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More Trouble

I remember going to see the movie "Oliver" in the theater when I was a kid.  Since this was my first movie in a theater, my mom made me a treat: a bag full of raisins and chocolate chips (Raisinets for Dutch people) and sent me there with my sister.  It was a fine film, with Oliver getting kicked out of the orphanage when he wanted more gruel, the dastardly Bill Sykes threatening Oliver and sweet Nancy, the funny and clever artful dodger and Fagan teaching Oliver about life on the street, and with (spoiler alert!) good overcoming evil in the end Oliver getting adopted by a rich dude so he can get all the gruel (or real Raisinets) that he wanted.  And though my memories of the movie are still vivid, my strongest memory was the look on my sister's face when I walked out of the theater covered with melted chocolate chip goo.  It went into family lore (and wouldn't have happened if they had sprung for Rasinets, I might add).  I think they still don't trust me with chocolate chips.

oliver_p&b

The key line in the film comes when Oliver loses a bet and goes up to the gruel-master and says: "Please Sir, I want some more."  Which, as I am sure Oliver expected, causes the gruel-master to break into the song, "Oliver! Oliver! Never before has a boy wanted more!" and the whole dining hall to pull out musical instruments and singing harmony to the gruel-master's admonition.

I can see why Oliver was scared.  A whipping is welcome compared to his whole world breaking into song and dance.

cardassian-kardashian

Asking for "more" has caused trouble over the ages.  Adam and Eve wanted more food choices, the people of Pompeii wanted more mountain-side housing, Napoleon and Adolph Hitler wanted to spend more time in Russia, and America wanted more of the Kardashians. We can all see what destruction those desires reaped.

Americans have been viewing health care the same way, always wanting more: more antibiotics, more technology, more robots doing more surgery, more expensive treatments for more diseases.  The result: health care costs more in America than anywhere else.  Some folks think that our "more" approach makes our health care "the best in the world," after all, where else can you get so many tests just by asking.  MRI's for back pain, x-rays for coughs, blood tests for anyone who dons the door of the ER.  "Tests for everyone!" shouts the bartender. "Tests are on the house! "

They aren't, of course, and we are paying the price for "more."  This hunger for "more" is fueled by the media's fascination for the "latest thing," the long disproved idea that technology will solve everything, and docs who aren't willing to take time to explain why it's actually better to do less.  It's hard to do, when we are paid more to spend less time with patients, and when the system is willing to pay for more and more.

There is a voice against this: the "Choosing Wisely" campaign, which argues against unnecessary treatments and tests.  This is a welcome voice of reason in the cacophony of cries for "more."  Yet the battle goes against the irresistible tide of our payment system.  The root problem is this: there are a whole lot of people whose jobs depend on America's addiction to "more."  The payment system has created an ecosystem that thrives off of waste (of which I once wrote an allegorical fantasy).  True health care reform will be catastrophic to many who work in health care, with many very nice and hard-working Americans losing their jobs at the ACO factory, at Meaningful Use Inc., and even at Stents-R-Us hospital here in my home town.

This is what you get when you make disease more profitable than health, when we treat problems instead of people.  The simple fact that our system would be destroyed if everyone got healthy should tell us something is terribly wrong.  Doctors want their offices full, not empty.  The goal of every patient - to be healthy and to stay away from the doctor - goes directly against the economics of "more."

I have always tried to be a non-test orderer.  I was trained well by docs who believed it weak-minded and bad care to blithely order tests and prescribe medications without a well-defined reason.  This has always made it harder for me, as it's far more time-consuming to explain why a drug or test is not needed than to simply order it.  But in my new world, one in which an empty office is a good thing, I've found my patients much more open to my aversion to "more."  The main reason for this is that I am giving them more of me.  More of me means they can call if they don't get better, or if their symptoms develop.  They know I won't force them to take more of their time and spend more of their money to get my attention.

Ultimately, I want my patients to see as few doctors, be sick as infrequently, and be on as few drugs as possible.  I hope to wage an all-out assault on "more."

Here are my rules to battle "more"

  1. Never order a test that doesn't help you decide something important.  Ordering tests "just to know" does much more harm than good.
  2. Use consultants only to do things you can't.  Orthopedists will aways give an NSAID and physical therapy for problems, so I don't send patients to them unless they've failed those treatments (where appropriate).  I am just as good at ordering PT, and am more careful with NSAID prescriptions than they are.
  3. Don't give a patient a drug without explaining to them why they need it.  If I can't make a good case for a drug, I shouldn't be giving it.  This is not simply "to lower your cholesterol," or "to treat your blood pressure," but because doing so will raise your life-expectency.
  4. Remember the number that really matters: how many birthdays a person gets to celebrate in health. I don't care about blood pressure, LDL, or even A1c if treating it doesn't raise the birthday total.
  5. Don't forget about another number: how much money patients have in their wallets.  There's no point in ordering a drug they can't afford, or making them pay for a test they don't need (even when they ask for either).

I hope my new world of less overhead, less regulation, and less antacids for me continues on this trend toward less sick patients, less drugs, and less tests.  Perhaps I need to break into a song and dance number whenever my patients ask for "more."

That would teach them.

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The Virtue of Unnecessary Care

I case you didn't hear the news: the American Healthcare system is in financial crisis. One of the biggest culprits indicted in this crises is "unnecessary care," with estimates ranging from $500-$650 Billion (total spending estimate is $2.6 Trillion) going toward things labelled "unnecessary."  Personally, I think this is an underestimate, as it doesn't take into account the some big-ticket items:

  • Brand name drugs given when generics would do
  • Antibiotics given for viral infections (and the additional cost due to reactions and resistance)
  • Unproven costly care considered "standard of care" (PSA testing, robotic surgery, coronary stents)
  • The unnecessarily high price of drugs.

One of the main reasons I am an advocate of EMR is to measure and analyze care, eliminating that which is wasteful, futile, or even harmful.  The biggest burden on our system is not the fact that we have a hyper-complex payment system that hides the true cost of care.  The biggest burden is the wasteful care that this system agrees to pay for.  In fact, I suspect that the main reason our system has become hyper-complex and covert in its spending is to hide this waste from prying eyes.

It sounds easy.  Just eliminate costly unnecessary care and save the system.  While you are at it, why not bring world peace, eliminate poverty, and make a detergent that cleans, softens, and deodorizes all at once?

Yes, the problem is daunting, but the only way we can get out of the financial vortex we are in is to cut the cost.  Between the two, I favor eliminating unnecessary care over that which is necessary.  I suspect most of my readers share that emotion.  So, like peace and poverty, we need to take a bunch of smaller steps on the way to solving the problem.

But hold on, campers, I am going to pour a little water on your campfire before we all start singing Kum-By-Ya.  I don't think all unnecessary care is bad.  Yes, you read me right, I think that sometimes it is a good thing to waste money.  I've personally given "unnecessary care" several times over the past few weeks.

One time I did it was when I sent a man to hospice.  Hospice itself saves a tremendous amount of money, keeping the cost of end-of-life care under control while giving the patients maximum comfort.  But typically, you don't give drugs to prevent long-term problems to patients with a short-term life expectancy.  This man has been my patient for a very long time, and has been on the blood thinner Coumadin for the entire time I've cared for him.  He's always been very aware of his lab results and the need to keep his blood thinned to just the right levels.  He's been faithful in his taking of his medication and going for his monthly lab test.  To him, the Coumadin is at the center of his healthcare universe.  So when I sent him to hospice, I didn't have the heart to suggest stopping the blood thinner.  It was always part of his self-care.  It was always a way in which he exerted control over his medical problems.  I may be wrong, but stopping the medication would probably leave a gaping hole in his life when I was trying to make him the most comfortable.  I just couldn't do that to him.

I've had other elderly patients of the same cloth.  They don't resent the need for taking medications; they structure their days around these medications.  I have to give a very convincing argument to them when suggesting that any of these medications be stopped.  I do my best to minimize the length of the list, but I don't fight too hard.

Finally, there are the unnecessary or unproven tests.  I now routinely discuss the pros and cons of PSA testing, mammography, and Pap smears with patients.  The older a person gets, the less benefit these tests yield.  But even when I think these tests are not needed, I do give the patients the option to get them done.  Most people are relieved when I get them off of those hooks, but some are uncomfortable.  Some people find comfort in doing something rather than leaving things to fate, God, or whatever.  I do my best to dissuade and educate them, but in the end, the choice is theirs.

I don't want to suggest that I do this to most of my patients.  I routinely look at medication lists and remove whatever is unnecessary.  I am a minimalist when it comes to ordering labs, consults, or tests - only getting those I truly believe are helpful.  Most of my patients appreciate this fact, and would gladly live with as little time spent devoted to medical care as possible.  I am probably more aggressive than most in this regard.  But it is dangerous to become too rigid in our view of medicine.  Medical care is not done via mathematical formula or actuarial table, it is done face-to-face between patient and provider.  The care is based on science, but the application of the science is done by humans on other humans.

So what's the point?  The point is that care is always, in the end, personal.  I don't think we should be spending money on procedures, drugs, or hospitalizations that are not needed.  I do, however, worry that the push toward evidence-based care will start in the wrong place.  The additional cost I add to care is quickly outspent by a single hospital stay, unnecessary surgery, or even ER visit.   Those with the most money to lose in this game of cutting cost will fight the most to keep their ground.  Da Vinci surgical company undoubtedly has scads of lobbyists pushing for coverage of their procedures.  Drug companies will fight to keep the cost of their medications as high as possible.  So who will fight for my patients?  Who will fight to keep my little old man on coumadin when it's not needed?

We must cut the cost of care, but beware of what care is cut.  Cut the big-ticket items that drive up cost.  Cut the unnecessary MRI scans, cardiac caths, and the improper use of antibiotics.  Pay only for screening tests that really prevent disease, not just ones that have been hyped by the media.  But let me care for my patients.  After all, the system is about them.

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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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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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No T

I've been tired lately.  I've been gaining weight and feeling unmotivated as well.  I thought that maybe it was because I wasn't sleeping enough and was eating too many donuts.

Then my life changed.

I saw a commercial that talked about "Low T" being associated with ALL OF MY SYMPTOMS!!!  It seems obvious that my sleeping and donut-eating habits aren't the culprit.  What luck!  I just need to rub a gel on my body and everything will be great.  I am going to get checked for "low T."

Play this scenario (sans hyperbole) 100 times, and that is what I've been hit with.  Multiply that times the number of PCP's in the US, and you see evidence of very good marketing.  Testosterone replacement for men has become the new magic bullett, a counterpoint to the request for thyroid tests by my female patients - with one big difference: it's clearly safe to replace a thyroid hormone deficiency, but not so clear with testosterone.

Today's NY Times addressed this very issue, comparing testosterone replacement to one-time dogma of estrogen replacement in women:

Despite beliefs based on observational evidence that estrogen therapy enhanced the health and well-being of menopausal women, when a definitive study was finally done, clinicians and researchers were shocked to discover that the risks of long-term hormone replacement could outweigh its benefits.

Would a similar study of testosterone therapy for men experiencing “andropause” likewise reveal more hazard than help? The answer would be welcomed by an estimated four million men in the United States who have subnormal levels of this important hormone, a common result of advancing age.

Yes, I lived through the estrogen replacement therapy about-face caused by the landmark study, The Women's Health Initiative.  The medical community was convinced that estrogen replacement gave a good enough heart disease and osteoporosis risk-reduction that it would easily offset any slight increase in breast-cancer risk.  There was even a retrospective study supporting this hypothesis.  The WHI not only didn't show a cardiac benefit, it showed an increase in risk.  Wyeth pharmaceuticals, the company who makes Premarin and other estrogen replacement drugs (and the company who funded the study) was devastated, and never really recovered.

So now we have commercials for "low T" blasting the airwaves, suggesting a treatment that may not be safe.  Is that ethical?  Again, from the NY Times:

Late last year, for example, a six-month federally financed study of a testosterone gel put a surprising hitch in efforts to improve the lives of aging men who experience a decline in energy, mood, vitality and sexuality as a result of low testosterone levels. The study, conducted among 209 men 65 and older who had difficulty walking, was abruptly halted when those using the hormone had an unexpectedly high rate of cardiac problems.

The article goes on to point out that the evidence is unclear at this point, and that the study mentioned had flaws.  Still, it stirs up the ghosts of hormones past, with the strong possibility that treating "low T" will cause harm.  And at least estrogen therapy had clear benefits (osteoporosis) and studies that supported the replacement therapy.  Unanswered too is if the therapy increased prostate cancer risk (one of the main treatments for prostate cancer is castration, which is cutting the body's production of testosterone almost completely - no pun intended).

So how should I respond to these men who just want a little "get up and go?"  Why is it that I have to fight against a potentially harmful advertising campaign?  What is the service (aside from that to investors) the drug companies perform by educating men about "low T?"  It puts doctors like me in a situation where we could potentially harm our patients.

So what are the limits to advertising by drug companies?  Most people are not in favor of any of such advertising, but the government has so far allowed it.  Are there ethical guidelines?  Consumers assume these ads are being vetted.  I really wonder about this in light of the "low T" campaign that is allowed to go forth despite lack of proven health benefit ("get up and go" doesn't qualify as a health benefit) and significant potential risk.  I had a man with known coronary heart disease recently insist on getting checked for "low T."  I told him that the no matter the lab result, I would not prescribe it for him.  He insisted, and yes, the level was low.

Now his doctor is standing in his way to a better life.

Thanks a lot, drug companies.

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