Would You Consider Joining Local 911?

In the interesting blog Physicians must unionize.  Here’s why, the author recommends that physicians create a union to protect their interests from governments, health systems, and the endless prevailing forces that the individual has no control over.

I would suggest reading the article as maybe the time has come for physicians to get organized and protect their substantial interests.

These interests include autonomy, financial security, work conditions, and protecting the greatest guild ever created. Physicians have reaped the benefits since the 1960’s thanks to a fee for service model and Medicare guaranteeing a financial floor to generate exceptional incomes for 30-40 year careers. Along with social status and respect, it is a great job.

However, practice and personal satisfaction has significantly decreased in the last decade. More government mandates (usually unfunded), hospitals employing physicians, and the destruction of the personal doctor-patient relationship has been steadily on the rise.

Physicians are generally organized if at all by specialty societies with varied interests. This diminishes the overall power and clout of all physicians. Critics would argue that doctors are overpaid compared to the world market and are chief offenders at driving up costs.

A similar argument can made against the National Football League Players Association (NFLPA). It has been called a joke because it represents rich football players. The football players do make great sums of money but their careers last 3-5 years with lifetime physical disabilities to follow.  Physicians can earn significant amounts of money over 30-35 years without similar threat to life or limb.

The union could  represent the physician body in the ongoing financial negotiations with CMS, insurance companies and hospitals, work rules, malpractice, contracts, Electronic Health Record implementations, ICD -10 implementation, and etc.

The individual has lost any clout to fight these forces or influence the decision making. A physicians’ union would put the “players” back in the discussion. And yet, there may be ethical and practical considerations that might keep some from wanting to join a union.  For example, would you cross a picket line to help the bleeding patient on the sidewalk?  Most would say yes, despite getting roughed up or jettisoned from the union.  And then, how many times have you seen a hundred or more physicians in a meeting (think union meeting) that agree on anything?  Younger physicians steer clear of medical entities, such as the AMA, which has a pre-union character to it.  Perhaps they realize that the results of joining could include an early retirement a la Jimmy Hoffa.  Lots to think about before unionizing.

"Hindsight is Always 2020. Ask My Dog"

After reading and digesting the article What Will EHRs Look Like in 2020?, my partner Don Kamens, MD had some insight to share- Enjoy!

 

When a physician practicing 15 years from now (2030) looks back one decade (to 2020) will he or she see a quantum leap in usability and functionality from our current time?  Certainly, in the decade 2005 to 2015, the leap has not been quantum, but impaired.  Impaired by such encumbrances as MU (meaningful use) and similar constraints that require caregivers to work with keyboards and mouse, rather than with patients. 

Interestingly MU is also the answer to a famous Zen koan that means "nothing, nothingness, or not at all." It applies in the EHR realm too. In Zen, the question that yields MU, "Does a dog have the essence of Buddha?" contains about as much meaning as meaningful use in the EHR realm. None. Ask my dog, he will tell you. Or he will bark at you.

EHRs bark at physicians too.  Ask the users.  As one punster said, "it's a ruff situation." Indeed, after a particularly trying shift, most ED docs would rather be wresting with the pit bull who bit the patient in room 14, than with the EHR to complete notes, and get home.  Many would choose the dog as an easier path .  

It is also interesting that a section in the JAMIA article is headed Billing Requirements Now Drive Much of Documentation.  Now?  Billing requirements have been driving documentation since well before the advent of EHRs, as they are now known.  Indeed, "justification of evaluation and management codes" has been with us for many, many pre-silicon decades. The difference now is that these justifications are now viewed as electronic data, rather than as marks or notes on paper.  But the information is not substantively different at all; it is identical, just gathered and assembled differently, and more transferable, interoperable. Severing the calcified link between a physician's account of clinical work done and payment received will need  surgical intervention. Many are pushing for outcome-based reimbursement schemes. But few physicians want to see outcome-based payment systems, as those with poor outcomes sometimes require the most work.  

What is missed in this analysis, is that the EHR in 2020, when looked at with 20-20 hindsight, should not repeat the mistakes of the past.  But it will.  It will because the perspective of guidance in this realm is incorrect, and far too quantitatively based.  Medicine has quantitative aspects, but it is far from a quantitative science. It is largely qualitative, and heavily subjective. 

What is the fundamental mistake that has been repeatedly made with EHRs that will perpetuate the sins of the past?  Well, one would hope that in 5 years, approaching the EHR on a case would be greeted with a sigh of relief, rather than with the trepidation of taking the first step from basecamp to climb Everest.   EHR developers should be using the experience of video games, Roku's, automobile driver interfaces, Khan Academy, from (yes) smartphones and cool apps.  It's not happening at the moment.  And it is not happening particularly because of the constraints that MU and related rules put on the system.  

Ask any Zen adept. Emptiness ! MU is nothing. Or ask any ED doc forced to use an EHR that drives him or her nuts.  Or ask my dog.

Why the Consumer “Loves” the Emergency Department

The article US Emergency-room Visits Keep Climbing posted in the Wall Street Journal reports the not unexpected rise in Emergency department visits.  This was an easily predictable event.  Despite the official pronouncements that the Affordable Care Act would limit such events, there are multiple reasons for the rise:

1. Lack of access.  With the addition of multiple new Medicaid patients, without the adequate primary care infrastructure, these patients are voting with their feet.
2. High deductible health insurance plans that are de facto catastrophic self-pay policies.  The consumer cannot afford both the premiums and the deductible on their salaries.  They make the choice of care, which the Emergency department provides without mandatory upfront payments.
3. The Emergency departments, in general with all their technology, access to specialists, convenience, and board certified/experienced physicians, make an attractive package.
4. Private practice phone trees start out with call 911 and then, go to the Emergency department.
5. The Emergency department has the capacity to do an extensive medical evaluation that might take 4-6 weeks with multiple appointments in under 4-6 hours.
6. Immediate gratification of the consumer.
7. Emergency departments advertise wait times- patients will be seen in under 30 minutes and special Fast-track aka Urgent care areas for low acuity patients.
8. Call ahead or online appointments in the Emergency department.
9. Primary physicians' use of the expertise and technology of the Emergency department as an extension of their practices.
10. Emergency department 24/7 hours of operation.

 

The problem is the cost associated with the ED visit.  The consumer is paying for the 24/7 infrastructure, which is massive.  These include the staff, physicians, Nurse practitioners, Physician assistants, techs of various types, on-call consultants, etc.  The prices are a reflection of the disconnect between charges and costs that are rampant in hospitals and insurance company contracts.  With an appropriate cost and charging scheme, the Emergency department could be quite cost-effective because everything and everybody is already there.

Hospitals and EDs compete for business because they are the main driver of hospital admissions where the money is.  The Fast-Track low acuity patients help pay the freight to generate more admissions. 

One of my prior blogs offers the suggestion that the Emergency department become the center of health care with primary care, specialists and urgent care as the spokes of a wheel.  This would provide constant direct interaction directing the consumer to the best logical point of care.  This is controversial, but reality is when the family member is ill, the first impulse is to go to the Emergency department.

Is Lack of Interoperability a Factor in Emergency Department Revisits and Readmissions?

In the revisit rates and associated costs after an emergency department encounter article, discusses the results and they are complex.  One interesting fact stand out.  The number of patients who seek further health-care from another ED is extremely high.  It is worth reading, but it is difficult to make sweeping judgments or generalizations.

People who return to the ED have multiple forces and motivations in play, including but not limited to:

1.      Convenience

2.      Impaired follow-up access.  For example, even though a patient may be instructed to recheck or follow-up with a primary care physician within a certain time frame, many cannot get a timely appointment without an established primary care network.  Many specialists will not see them without cash or health insurance, and those with coverage may have their access limited by policy requirements and unaffordable co-pays.

3.      Treatment failure.  Some patients do not get better.

4.      Dissatisfaction. Patients may feel their care was inadequate: questions were not addressed, testing was insufficient, or prescriptions given were inadequate or unaffordable.

5.      Narcotic Overlay.  If the patient was previously prescribe a narcotic(s) and/or wanted to receive a narcotic prescription that was not given, an added dimension for returning to (some) ED, is present.

6.      Mental Disturbance.  Many individuals have underlying psychological problems along with inadequate local community psychiatric/social support.  When a social worker is not available, some patients seek this kind of support from the ED, despite an actual need for individualized social services.

7.      The patient likes the ED or a particular ED doctor. 

These are extremely complex system level problems.  A potential solution may be to provide a social worker to help sort out the medical system, in addition to simply handing the patient discharge instructions.  Some institutions have established a system along these lines, called a medical advocate system.

Going to a different Emergency Department for a second or third visit seems to be a part of this phenomenon.  And there, in particular, is where the issue of interoperability arises.  Let’s assume that your EHR system is inherently good enough for internal interoperability, and that you have access to all the prior records- Right??  Now what about when the patient shows up across the river?  Would life not be simpler if each emergency department’s electronic health record had the interoperability capacity to talk to each other, to share data, and relate to the second ED what the first encountered and found?  This might lessen the need for repeating the entire work-up and admitting the patient.

Of course, from a practical standpoint, patients who are evidently sicker and return to the same or different emergency department usually get admitted to the hospital.  Repeat discharge happens, ut it does so with peril, as there are frequently solid medical, medical-legal, and logistic reasons, to keep the patient the second time.  Because beware willing to send home potential high risk bounce-back patients overall costs are inevitably driven up.
True interoperability, particularly by the establishment of industry-standard and required electronic documents, would greatly enhance patient safety by giving the next provider a better feel for what might have occurred at prior visits.

We're on the "Eve of Destruction"

In the song We're on the Eve of Destruction, singer Barry McGuire laments the end of western civilization due to endless worldwide strife in the 1960-1970's.  In the article The Awful (and not so creative) Destruction of Medicine, a similar argument is made for the end of private practice medicine in the United States.

The author of the article states that only 30% of physicians remain in private practice and that the "Marcus Welby Era" is long deceased.  The endless new government mandates are eliminating the private practitioner.

The physician is now part of interchangeable puzzle where everyone especially the payers have a say in the patient care and reimbursement.  The physician is no longer the centerpiece of healthcare.  The article makes a strong case that the modern day era of medicine from 1960-present is essentially over and rapidly changing.

What's a classically trained physician to do???

The best solution is to view the rapid change and chaos as an opportunity rather than a huge negative.  Realize that before Medicare started paying physicians in the 1960s that medical care was totally different.  Periods end and new approaches need to be analyzed and taken advantage of.

Potential Solutions:

1. Take some business classes or get an MBA
2. Attend some coding and reimbursement classes
3. Analyze and embrace your technology
4. The age of automatic physician entitlement is over.  This doesn't mean it still cannot be fulfilling and financially sustainable.
5. Your Medical degree is a ticket to multiple opportunities
6. Attend a meaningful use lecture or two
7. Understand that the accountable care organization (ACO) is code for 21- 1st century HMO.
8. Rethink your hiring practices.  Get professional consultations to get improved financial situations.  Hire consultants not employees.
9. Pick software that pays for itself downstream.
10. Learn the new rules and adapt
11. Realize to succeed you will need the proper software, highly trained medical assistants, and possibly voice activated technology such as Dragon to make one complete medical technology unit.

The future is still bright for the agile and well informed.  Make your theme song, The Future's so Bright, I Gotta Wear Shades.

Avoiding the Potential Legal Quicksand of Opening ann Urgent Care

Opening an urgent care can be a fulfilling experience but to be successful takes more than good medical care.

The Top Four Legal Issues to Consider When Opening an Urgent Care Center article describes significant legal issues that need to be considered during the planning stages. In addition to the usual components of a business such as location, leadership, work-flow processes, and timing; the medical business has certain legal concerns.

1.       Corporate practice of medicine is outlawed in some states and mechanisms including a “friendly PC” model can be used.

2.       State licensure requirements including a CLIA certificate of waiver for laboratory testing, x-ray permits, and any other licenses needed in that state.

3.       Understanding any EMTALA requirements is key to the viability of the center. Particular attention needs to be paid to the “naming of the center”.  Adding the word Emergency will imply, the center is a 24 hour practice that is specifically under the EMTALA laws. Hospital owned urgent cares must have their legal team evaluate any responsibility to the law.

4.       Have your insurance contracts in order prior to opening or face a potential cash flow issue. These negotiations take time.

Some other issues of particular significance are:

1.       Location, Location, Location

2.       Times of service

3.       Types of providers

4.       Credentialing those providers. This is a cumbersome time consuming task which may need to be outsourced.

5.       Marketing-Establishing contact with the local community by providing school physicals, blood pressure checks, flu shots, etc.

6.       Being undercapitalized and suffering cash flow issues

7.       Picking an Electronic Health Record and Practice Management system that is efficient and pays for itself.

8.       Understanding the difference between using a billing company and doing self-billing.

9.       Hiring the right practice manager.

10.     Not expecting a “paycheck” right away.

11.     Fill in the blanks

12.     Hiring a consultant to help with the start-up, if these steps are too daunting or too much aggravation.

With a proper vision, an urgent care can be an enjoyable way to provide quality medical care. This can lead to career longevity and adequate reimbursement.

Single Payer System vs. the Present American Health-care System: A Personal Experience

The following medical experiences happened to my extended family.  They show the multiple complex problems in providing medical care at an affordable price.  The people involved have given me permission to give brief details of their journey through the medical world.

The first patient is a young male who experienced multiple episodes of tachycardia (fast heartbeat), sweating, anxiety, stress, headache, and weakness for greater than 3 years.  He had high blood pressure while on multiple medications with minimal control.  His friend consulted me about what could be wrong as she had witnessed several events herself, and decided he wasn't exaggerating or having a panic attack.

We looked up pheochromocytoma also known as PCC is a neuroendocrine tumor of the adrenal glands that secretes high amounts of catecholamines, mostly norepinephrine, plus epinephrine to a lesser extent.  His symptom complex matched 9 out of 10 on Google.  She wrote down the potential diagnosis and suggested work-up.  She presented what she had found to his doctor.

The patient is a Spanish citizen on a national health insurance.  The doctor had never heard of this illness, but referred him for testing.  It took approximately 60 days to get a specific urine test, which tested positive.  He was then referred to the specialists where he was admitted and waited 5 days for a cat scan to confirm and locate the tumor.  He was operated on 2 months later and is doing well.

Pheochromocytomas are a potentially high risk problem leading to stroke and other cardiovascular events.  He received multiple medications to control his blood pressure with multiple negative side effects.  He is off most of his medications now.

The problem was taken care of, but took 6  months.  His personal direct cost was negligible, but indirect costs including problems at work, anxiety, and stress were very high.

Our second patient is a young female with non-ruptured appendicitis who went to the emergency room in the US.  She was diagnosed and sent to the hospital for outpatient surgery.  She was discharged from the surgical area 6 hours post-operatively.  She made an uneventful recovery.

Her care was excellent, but the downside is she has a $10,000 deductible health insurance plan.  She is basically a de-facto high deductible insurance self-pay patient.  Her bill including emergency department, diagnostic tests, ER physician, radiologist, anesthesiologist, operating room and surgeon was approximately $47,000.  The event lasted less than 24 hours and shows the major disconnect between actual costs, charges, write-offs, and negotiated prices per insurance plan.

As health care costs spiral out of control, these two examples at different ends of the spectrum show the fundamental flaws in both systems.  The present system does not work for the low-income high-deductible patient (majority of people).  The single payer system probably does not cost less, but spread the costs over the entire population.  The price is lack of efficiency and time wasted.

These real-life examples create an interesting dichotomy.