Imagine that?….It doesn’t work and costs more…..More Bad News for Obamacare

Recently the Blue Cross Blue Shield Association published a report detailing the effects of the Affordable Care Act legislation on consumers and insurance companies. Now granted, the BCBSA is a conglomeration of independent BCBS insurers so we must read the document with a pinch of skepticism. In the analysis, the BCBSA collected data of every individual market health insurance carrier and product sold in the US.

Major Points to consider from the report:

Choice of carriers declined in all markets

United Healthcare (UHC) has confirmed that it will be dropping out of a majority of ACA exchanges in 2017. While posting a predicted loss of $650 million dollars in 2016 (after a loss of $475 million in 2015), United executives are concerned that more losses are on the way if they continue to insure the Obamacare pool of patients. With the departure of UHC, many worry that choice will decline even further—some areas may only have as few as two choices. Ultimately, this move will drive prices even higher for exchange participants. Fewer choices almost always result in less competition –less competition can lead to lower quality products and care. According to a study conducted by Kaiser, the impact of shrinking choices in the marketplaces can be very significant—particularly in southern states and rural areas. United accounts for nearly 71% of all enrollees currently and 29% of counties that are currently served by Untied would only have ONE choice of carrier if UHC pulls out. Overall, 1.8 million enrollees will be left with 2 choices of carrier and 1.2 million will have only ONE choice.

-New enrollees received significantly more care and those insured by the exchanges had costs nearly 25% higher as opposed to those insured via employers

Not surprisingly, those enrolled in the exchanges accounted for more emergency room visits, more inpatient admissions, more prescription drug costs and inpatient admissions than those that were insured in traditional employer based systems. Many Obamacare enrollees have waited until a major illness occurs before signing up and gaining access to care. Once treatments are completed, many of these same patients simply drop out—thus skewing the insured pool to those with higher costs–with fewer “young and healthy” patients on board to help fund the more expensive treatments required by many of the newly insured.

New enrollees are much sicker—More Diabetes, heart disease, HIV and Hepatitis C

Over the last three years, it has become apparent that new enrollees in the exchanges tend to have more medical problems. Many have gone without treatment for a long time prior to acquiring insurance. These patients often have very advanced disease (along with multiple disease related complications) and by the time they gain access to care and most require expensive, intensive treatments. Newer drugs for diseases such as hepatitis C are priced exorbitantly and costs for a 12-week course of therapy can reach $80 thousand dollars or more. Obesity and obesity related illnesses are epidemic in the US today. Obesity places patients at risk for diabetes, heart disease and other potentially debilitating and costly chronic diseases—accounting for 150 billion dollars of healthcare expenditures in the US annually. Until we focus on preventative efforts and individual accountability these costs will continue to rise.

What is to be done to save healthcare in the US?

We must revamp the system. This job will require Congressional action and actual bipartisan cooperation and support. Moreover, both the legislative and executive branches of government will have to come together and actually compromise in order to stop the implosion of the best healthcare system in the world. While providing expanded access to healthcare for all Americans is an important goal, we must develop a system that rewards good health choices and focuses more on disease prevention. We cannot expect, nor rely on, young healthy Americans to completely fund healthcare those who do not even attempt to modify risk and engage in their own healthcare.   We must set up a system of individual accountability where premiums are tiered based on health choices—lower premiums for those who DO NOT smoke, those who exercise and those who avoid other high risk behaviors for example. At best, healthcare in the US is headed for disaster. Unless we can address the rising costs, diminishing choice and pending physician shortages we will soon become a single-payer system—just ask the Canadians how well that has worked out north of the border….

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Making Progress in Social Media and Medicine: Engagement at ACC

This week at the American College of Cardiology meetings I was amazed by the uptick in Social media engagement. While 75% of all fortune 500 companies are represented and active on twitter, doctors have been quite slow to enter into the social media space. Many of us have who have pioneered social media in medicine have often felt like Dr. Sisyphus as we push the “Social Boulder” up the hill in order to show our colleagues the value of digital engagement. However, it appears that finally the tide is turning…..

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From the very outset of the meeting the hashtag #ACC16 began trending. Just in time for the annual sessions, the American College of Cardiology recently created and published a Cardiology Hastag Ontology reference guide in order to bring together the broad topics within cardiovascular disease so that common subjects of discussion can be easily identified, searched and catalogued.

Analytics from #ACC16 demonstrated that by meetings’ end, there were nearly 3600 individual tweets, 35 million individual impressions with roughly 1500 members participating via social media platforms such as twitter. During the meeting, there was an average of 155 tweets per hour and many participants “live tweeted” during important presentations such as the late breaking clinical trials sessions on each day. Leadership in digital engagement was spread among individual attendees, twitter feeds from the college itself as well as feeds from institutions such as the Mayo and Cleveland Clinics. Interestingly, the “Top 10 Influencers” by impressions were not the same as the Top 10 by tweets—suggesting that WHAT you say may be more influential that HOW MUCH you say in the digital space.

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Screenshot via Symplur at #ACC16

Furthering the importance of social media and mobile health in medicine at ACC, a novel study evaluating the use of digital tools for engaging patients on outcomes was presented at the meeting as well. Researchers from Mayo clinic investigated whether or not patients undergoing cardiac rehabilitation would benefit from using specially designed health tools on their smartphones. In the study, 80 patients were randomized to a group having access to a smartphone mobile health tool with cardiac rehabilitation versus rehabilitation alone. Primary endpoint was total weight loss in the 12-week time period. The mobile tool group lost four times as much weight compared with those undergoing 12 weeks of cardiac rehabilitation alone. This randomized controlled trial is the first in the U.S. to look at how adding the use of mobile and wireless devices concurrently with cardiac rehab might improve health outcomes—and clearly demonstrates the power of patient engagement via digital platforms.

Once again, social media sessions were included as part of the Annual Scientific Meetings academic programming. I was honored to chair and participate in the session alongside many distinguished colleagues. The session was well attended and each talk was delivered in a TED talk style format—emphasizing audience engagement, interaction and story-telling. Slides contained images rather than charts and each speaker shared real world experiences and examples of social media and digital successes. Topics included the use of social media for connectivity, engagement and innovation.   The expanding use of mobile tools for the advancement of clinical trials was explored as well as issues surrounding direct patient engagement.

It is clear that the American College of Cardiology has embraced the digital space. As cardiologists we are innovators and social media and digital engagement should be no exception. The future of social media in medicine is limitless—it is my hope that in 2017, we add to the numbers of active healthcare providers on social media.   Ultimately, engagement can only help the people that we are pledged to serve—our patients. Through embracing our digital future in medicine, we can improve outcomes, improve disease awareness and access to care and provide new tools for disease management. Lets all be part of the leading edge of the bell curve—As Rogers shows us in Diffusion of Innovations, we must be the early adopters…not the laggards, in order to maximize success.

 

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Rogers, EM Diffusion of Innovations, 2003

Are We Really Better Off With Obamacare? Examining The Blue Cross Blue Shield of North Carolina Debacle

The snowball effect has begun. Earlier this year, United Healthcare announced that they were unlikely to continue to participate in the Affordable Care Act (ACA) exchanges in 2017. As the largest Obamacare insurer, United’s announcement may be the harbinger of things to come—I predicted that others would follow. Many patients will likely will be left with even less choice and may be left with no insurance at all.  Many of the insurers that remain in the Exchanges are not able to provide the services that they promise to their patients.  Case in point–Blue Cross/Blue Shield of North Carolina.

This past month, Blue Cross/Blue Shield of North Carolina announced that they may leave the Affordable Care Act exchanges. BCBS is the state’s largest insurer and is the only company that has provided health insurance policies through the ACA in all 100 counties in North Carolina. The insurer has reported a second consecutive financial loss in spite of raising rates more than 35%. Rumor has it that BCBS may no longer provide insurance through the ACA exchanges unless it is granted yet another rate hike by the State’s insurance commissioner. IN addition to reporting financial losses, BCBS has struggled to provide basic services to its customers in North Carolina. Software “snafus” and a lack of staffing in call centers has resulted in many insured patients reporting to hospitals and physician offices and finding that they have either no insurance (via a computer database) or not the same insurance they signed up for. Some patients report that they have been charged twice for coverage and others have been charged incorrect amounts. When customers have turned to BCBS for answers, they have been unable to speak with customer service representatives without extended wait times lasting hours at a time. IN response, BCBS of North Carolina’s CEO made several public apologies via television and print media and promised to “get it right” in the future. However, lapses in service continue to plague North Carolina customers. For example, since January the customers have experienced the following issues:

-Nearly 7% of 25K customers were put into the wrong plans

-3200 customers had their bank accounts drafted for the wrong amounts (most were over-drafted)

-Many customers never received their insurance cards or received them late

-The company’s phone lines backed up. They have the capacity to deal with 20K calls a day, but received nearly 100K on certain days in January, 2016

Why is this Happening? Why Can’t BCBS Do more?

The simple answer:  Follow the Money. BCBS–and others  like it–are designed as a for-profit entity. It probably does not surprise anyone that these insurers are NOT providing insurance services in order to make the world a better place.  Rather, insurers are taking a calculated actuarial risk on a patient population that they insure in order to “play the odds” and make a profit.  Ideally, insurers want to insure large populations and provide few costly services.

I spend a great deal of my time arguing with BCBS and other insurers as to the appropriateness of medications, tests or procedures that my patients may need. Even though I have trained for nearly a decade and have multiple board certifications, awards and honors, insurers have their own way of looking at prescribed treatments–often it involves cost rather than efficacy as a bottom line for decision making.  Every single week I must deal with insurance “denials” and even though I am the expert in cardiovascular disease, I must speak with a “physician representative” on the phone in order to argue that an indicated medical test be approved. Many of the insurance “physician representatives” have no training in cardiovascular disease and are simply reading a script or checklist in order to determine an approval or disapproval status for a particular patient. They do not routinely examine the individual case–unless a clinician, like myself, appeals the denial and takes the time to argue the case specifics. In my opinion, insurers today are looking for higher premiums and work diligently to avoid as many “payouts” as possible. Unfortunately, it is our patients who suffer the most. It is hard to both prevent chronic disease and treat acute events when patients are afraid to come to the doctor for evaluation due to high costs passed on by insurers.

The “Buck” does NOT stop here….

As you might imagine, the “buck” is quickly passed when BCBS of North Carolina is asked about the reasons for the recent avalanche of errors and poor customer service. CEO Brad Wilson is quick to place the blame firmly on everyone BUT his own organization—the Affordable Care Act, software companies from other states, billing errors by third party companies—you name it.  BCBS claims that they recently implemented a new customer service record system and that a third party company (hired by BCBS to handle billing) is responsible for the errors in billing that many patients have experienced. In addition, a whistleblower claims that BCBS leadership knew about the potential for errors when implementing the new systems but declined to address these concerns prior to the roll out.  BCBS vehemently denies the whistleblower’s claims.

While Mr Wilson has issued multiple public apologies on behalf of his organization, little has been done at this point to correct the problems.

And the problems continue…

More recently, BCBS released privileged health information from one customer and their family to another customer by mistake. Last month, a family went online to check their information on the “secure” BCBS patient/customer website and found another family’s names, medical histories, social security numbers and other sensitive information listed on their account in addition to their own. When the customer tried to contact BCBS to report the error and data breach, she was placed on hold for hours—ultimately she was told that it was due to an error made by another third party vendor from Utah. When she contacted the company in Utah, they blamed BCBS of North Carolina. Bottom line…no accountability….AND these folks want to raise your rates? Really?

What is Next?

While there are no easy answers, we must hold insurers accountable for their actions. They must accept responsibility for lapses in coverage, breaches of sensitive data and they MUST provide the services for which they are contracted. Insurers must be held to the same high standards that all healthcare professionals are held to when it comes to working with customers and patients.  While cost controls are a reality of modern healthcare, we must put patients first. Insurers must be forced to approve tests, medications and procedures that are deemed appropriate by the preponderance of the data—less focus on cost, more focus on quality.

These changes in insurance will not come without legislative action. The ACA has provided for significant regulations on physicians, hospitals and other healthcare providers. However, nothing is being done to ensure that insurers provide affordable, quality healthcare and allow patients Access to the institutions and therapies that they deserve. While the ACA was designed to provide access and affordable quality healthcare for all Americans, it has fallen far short of this lofty goal. It is my hope that the next administration will focus on the patient—and require insurers to become more accountable.  As voters and as medical professional, we must reach out to our representatives in Congress and demand action.

As for North Carolina BCBS, the story is not yet over.   The State Attorney General is now involved and has sent a formal letter to BCBS leadership. I fear that BCBS will likely follow the lead of United Healthcare and withdraw from the exchanges in 2017. If this happens, hundreds of thousands of North Carolinians will be without viable healthcare. In a state with a high prevalence of heart disease, obesity, diabetes and other chronic diseases, patients will suffer and I fear that preventable deaths from treatable illnesses will only increase.

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Taking It to Heart: What Every Woman Needs to Know in February

February is National Heart Month and the Go Red for Women campaign reminds us to bring awareness to cardiovascular disease in women all month long.  Today in the US nearly 44 million women are living with heart disease.  Even though heart disease is quite prevalent in women, only 1 in 5 women are aware that they are at risk for developing a cardiovascular problem in their lifetime.

Cardiovascular disease is the #1 Killer of American women. More women than men die of heart disease every single year—in fact, one woman dies from heart disease every 80 seconds. Most women believe that their greatest health risk comes from breast cancer. However, one in eight women will develop breast cancer in their lifetime and one in THREE women will develop cardiovascular disease. Nearly 90% of all women have at least ONE risk factor for heart disease.

Heart disease affects men and women differently.   Biologic and hormonal differences in men and women contribute to the ways in which heart disease develops and progresses.   Studies have shown that after menopause, women have an even higher risk for heart disease—Estrogens seem to promote better cholesterol profiles as well as have other cardio-protective metabolic effects.

Women tend to present to a healthcare provider far later in the course of the disease process and have more diffuse and widespread cardiovascular disease as compared to men. While we are making progress in reducing deaths from heart disease in the US, rates continue to be disproportionately high in women.   In fact, women who suffer from a heart attack have a much higher mortality in the first year following the event. In the first six years following a first heart attack, women have a much higher rate of a second heart attack as compared to men.

So, What Can Every Woman Do to Prevent Heart Disease?

As we recognize February and the American Heart Association’s Go Red for Women campaign, here are Four Questions for Every Woman Must Consider:

  1. How big a problem is cardiovascular disease in women?

Women are under-treated and underserved when it comes to heart disease. Heart disease has long been associated with men—truth is, it affects both sexes equally. However, men tend to be treated more aggressively and earlier in their disease. Women present later and often have more extensive disease. MORE WOMEN THAN MEN DIE FROM HEART DISEASE IN THE US TODAY.

  1. What are the symptoms of heart attacks in women? Are they different from men?

In women, heart disease symptoms can be quite vague and nonspecific. Traditional symptoms are chest pain or pressure, sweating, nausea and pain in the arm or neck. Shortness of breath may also occur. Women may experience these traditional symptoms BUT sometimes they do not.

In women, symptoms are more difficult to tease out. Sometimes they may have a feeling of dread, flu like symptoms, fatigue, anxiety or pain in the back.   . The key to preventing unnecessary cardiac deaths in women is for both patient and doctor to KNOW their risks and interpret symptoms within the context of the risk.

  1. Are women and men with cardiovascular disease treated the same? 

There is a larger gender disparity in the way in which men and women are treated. Men are more likely to receive more timely and more aggressive therapies. Much of this disparity may be due to the fact that women are not diagnosed as quickly, may not recognize their own symptoms and may be billed as anxious or depressed when presenting with a heart attack—because they may have atypical symptoms. While there are lots of advanced treatments available for heart disease, men tend to be treated more quickly are more likely to receive advanced therapies—women do tend to have higher complication rates with cardiac catheterizations and bypass surgery and this increased risk may also explain some disparities in care.   Unfortunately, women who suffer a heart attack are less likely to be prescribed well-studied medications–such as ACE inhibitors, Aspirin, Statins and Beta Blockers–that have been proven to reduce mortality in patients with documented coronary artery disease. In addition, female patients are less likely to be referred to cardiac rehabilitation following a cardiac event even though studies show that women reap a bigger benefit than men from these activities.

  1. What can every woman do to reduce her risk for heart disease?

The most important thing all women can do is to recognize their risk for heart disease and engage with a healthcare provider. By understanding risk factors women are able to work to modify their risk through diet, exercise and, if necessary, treatment of other conditions such as hypertension, diabetes and hyperlipidemia. Women must work to take control of their own cardiac health—every woman must take stock in her own heart health—understand her risk and work with her healthcare provider to modify those risk factors

While we have made great strides in reducing cardiovascular death rates in women over the last 20 years, we still must continue to educate and advocate for women of all ages—this advocacy begins with dispelling the common myths surrounding heart disease in general. It is my hope that through efforts such as the Go Red campaign every February, we can promote better heart health for millions of American women. Ultimately, we must engage women and their families in order to most effectively eliminate needless cardiac related deaths in the next decade. Women MUST understand their individual risk and actively work to take control of their own heart health.  Physicians MUST engage with their female patients and advocate for them in order to ensure that all women get the very best cardiovascular care.

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Dr Kevin Campbell is the author of “Women and Cardiovascular Disease: Addressing Disparities in Care”

Mr Obama Went to Washington—And Placed Doctors In the Middle of a Gun Control Debate

 

First of all, let me make it clear—This blog is NOT about the issue of Gun Control. While the gun control debate is a very controversial issue and I certainly have an opinion regarding the protection of our Second Amendment rights, this particular blog is focused on the fallout that Presidential politics may have on our ability to care for our patients.

Obama’s executive action on gun control this week may have a significant and potentially long lasting impact on the doctor-patient relationship.   Doctors have always been held to a very high standard of conduct when it comes to protecting privileged patient information. When a patient steps into the exam room or establishes a doctor-patient relationship, a physician CANNOT discuss anything that the patient discusses (even with other physicians) WITHOUT the patient’s permission. Records cannot be released without a patient signature and, unless the patient makes statements that suggest that he or she is a danger to himself or others (or communicates threats), the physician cannot report any illegal activity to the authorities. This “zone of confidentiality” is in place in order to encourage patients to interact with physicians with HONESTY and develop TRUST with healthcare providers. This protected relationship is important as it provides doctors with accurate data when considering a diagnosis and treatment plan for a patient. More importantly, it protects patients from any repercussions from employers, family, government or others as a result of any information that they may voluntarily provide.

During his press conference, Mr. Obama outlined the specifics of his Executive Action (without Congressional approval) regarding changes to gun control laws in the United States. While the specifics of the new law are a bit difficult to understand it is clear that physicians are part of his plan for limiting access to guns. As part of the action, physicians apparently are no longer held to the high standards of the Health Care Portability and Privacy (HIPPA) act when it comes to patients with mental illness. The action relieves physicians of the duty to maintain complete patient confidentiality when an individual provider notes that a patient may be mentally ill—in fact physicians are encouraged to contact the National Instant Criminal Background Check System (NICS) and report the name of the patient. The NICS is a government organization that maintains a database that is used for determining if prospective firearms buyers are eligible to make a gun purchase. It was mandated by the Brady Handgun Violence Prevention Act (Brady Law) of 1993 and launched by the Federal Bureau of Investigation (FBI) in 1998. As part of the reporting process to NICS under the new executive action, no actual diagnosis or other privileged medical information can be revealed—only a physician’s hunch that a patient may suffer mental illness is necessary for disarming any patient. No guidelines as to what type of mental illness should be reported–so I guess anything is fair game from depression to social anxiety and beyond.  Any physician report, even without due process or investigation, will preclude a patient from purchasing a gun. More disturbing is the fact that ANY physician—even a cardiologist like myself who is definitely NOT trained in the diagnosis and treatment of mental disorders—MAY prevent a patient from purchasing a gun by filing such a report.

Don’t get me wrong—gun violence in the US is horrific. Mental illness is widespread and many patients go unnoticed, undiagnosed and untreated. No one with mental illness should be allowed to own or possess a firearm. We must make changes to prevent senseless killing. However, asking physicians to screen potential gun owners is NOT the answer. Our President should have thought more about the implications and fallout of using a “phone and a pen.” He may have forever changed the way doctors and patients interact and his executive action may serve to erode the purity of the confidential nature of the doctor patient relationship. His new “law” is also in direct conflict with a Supreme Court ruling from July 2015 when the Court upheld a Florida law that prohibits doctors from asking patients and families about gun use or possession.

As physicians our job is to use our training and our understanding of medical science to provide our patients with the best possible care in order to produce the best possible outcomes. We should NOT be put in the middle of a political debate regarding guns and mental illness.   We should not be put in a position to make a legal determination that may forever limit the rights of our patients. The Affordable Care Act and Electronic Medical Record mandates have already overburdened busy medical professionals in every specialty. Primary care doctors certainly screen for mental illness as part of their routine wellness visits (and are trained to do so) but surgeons and other specialists have little or no experience with the diagnosis of mental illness and quite honestly rarely consider these issues during a patient interaction. Psychiatrists and other mental health professionals are well equipped to make such determinations, but are often in short supply and unable to perform “emergency” consults outside of calls for commitments, etc from Emergency Department staff.

The unilateral actions of our President are likely to have far reaching (and likely unintended) impacts on healthcare. It is essential that there is a bond of trust between doctor and patient and this relationship must remain sacred. Patients should feel free to discuss anything with their physician without fear of legal repercussion or fear of imposed limits to their constitutional rights after a visit with their healthcare provider. I fear that patients may not be as forthcoming with their physicians during regular visits due to a perceived lack of confidentiality—how can they know that they will not be reported as mentally ill to the FBI?  This new law influences what doctors and patients may say to one another during the most critical part of the doctor-patient relationship, when the patient is most vulnerable—the private medical exam. Most importantly, patients may not follow up regularly with their physician due to a fear of being reported to government agencies and losing their right to bear arms. The exam room is designed to be a safe place—a place where patients can share intimate details of their lives and health history and develop a bond with their healthcare provider. I fear that this legislation will only serve to erode the sanctity of this very unique relationship and ultimately impact health outcomes in a negative way.

While in my state physicians do have an obligation to report any patient who communicates threats to harm themselves or others, this new “law” calls on physicians to do something quite different—report any patient whom you suspect MAY have any type of mental illness—irrespective of any stated threat or danger. Doctors need to care for patients. Doctors must respect patient privacy. Doctors should not be FBI informants. Politics has no place in the exam room and government should not be in the business of dictating the way highly trained medical professionals practice Medicine. As Doctors, we must stand up for our patients’ rights. We must protect our privileged relationships and we must leave gun control debates to the politicians and lawmakers. Gun violence prevention efforts should be focused on the communities in which they occur and target the criminals who commit the heinous acts—these laws should NEVER come between doctor and patient. So Mr. Obama, I implore you, let doctors do what they do best—Heal.

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On the Defense and Driving Up Costs: Doctors’ Diagnostic Choices Dictated by Fear Not Fact

For decades, many physicians have been pushing for comprehensive tort reform on the national level. Malpractice claims in the US are twice those of other developed countries such as England, Canada and Germany. Payouts in a US claim can easily reach 3 million dollars or more, in Germany most claims are around 30K dollars or less. A survey conducted by RAND in 2011 estimates that 99% of American physicians in high-risk specialties such as neurosurgery will face a lawsuit at least once in their career—In Europe, that number is only 20%. All the while, the costs of healthcare in the US are skyrocketing and the Affordable Care Act has been ineffective in reducing costs. While there are many causes of the inflated costs of care in the US, the ACA only addresses a few and leaves others unchecked.

Recently, an observational study of the relationship between physician spending and risk for malpractice claims was conducted in the US and the results were published in the British Medical Journal in October 2015. In the study, hospital data for more than 24K physicians were sampled and the investigators found that the higher the resource use, the lower the risk for malpractice claims—in a nutshell, doctors who ordered more tests were significantly less likely to be sued for malpractice. This finding was consistent across 6 of 7 different specialties evaluated and was particularly pronounced in Obstetrics. Defensive medicine, defined as medical decision-making and care provided solely for the purpose of avoiding malpractice litigation, accounts for a significant proportion of healthcare costs in the US today. Physicians, while striving to provide excellent care for their patients are faced with the harsh realities of our litigenous society—many are always looking over their shoulders for the next “ambulance chaser” to appear. In medical school, physicians are taught to think like Sherlock Holmes. When a patient presents with a set of symptoms and physical findings, we develop a differential diagnosis (a list of possible etiologies) and then we work to eliminate the possibilities through logic and objective data. The role of diagnostic testing is to help eliminate or confirm a particular diagnosis and allows physicians to zero in on a particular cause so that therapy may be initiated quickly. In many cases, a diagnosis can be confirmed simply by talking to and examining the patient—the Medical History and Physical Exam—which is becoming a lost art.

When defensive medicine is practiced, the entire system is perturbed. Why would we order a test when it is unlikely to substantially change what we do—Think “fork in the road”. If a test is ordered, the result should point us one direction or the other.

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So, just how can we expect to lower healthcare costs if we are playing defense in the clinics and emergency rooms of America? How does defensive medicine impact patients?

Data such as those recently provided by the BMJ suggests that the practice of defensive medicine is on the rise. It is also very clear that the over utilization of testing is a major contributor to the high costs of healthcare in the US. As physicians we are taught that the best time to order a test is when we have an intermediate index of suspicion or pre test probability of the presence of a particular disease state or finding—employing Bayesian statistics. If our pre test possibility is high then no testing is necessary—simply proceed with a therapeutic intervention. Conversely, if our pre test probability is determined to be quite low then no testing should be performed—simply move on to another diagnosis.

Defensive medicine and over testing effectively negates our statistical advantage when making a diagnosis. Multiple unneeded tests are ordered and sometimes these tests have false positive findings that may result in further testing and even unnecessary procedures. These procedures often are associated with complications—all of which could be avoided by more responsible and judicious use of diagnostic tests. Moreover, patients must deal with the psychological impacts that having a false positive test result often produces.

We must all work to continue to push for tort reform. Only by removing the motivation for frivolous medical lawsuits will we be able to better contain costs and limit testing to those tests that are clinically indicated. While physicians must be held accountable for their decisions and their actions (as well as their clinical judgment and thought processes), we must insist that there are more reasonable caps placed on damages. Those attorneys who repeatedly introduce ridiculous and frivolous complaints must be held accountable for the costs and waste that they place on the system. Until then, we will not be successful in curtailing costs and good physicians will continue to feel compelled to play defense in the clinic.

 

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Saving The World Through Better Coding! ICD-10 is HERE!

Thank goodness we made it to October 1st!  Finally ICD-10 codes have arrived in your doctor’s office and local hospitals!

Luckily we now all have a new medical coding system in place for our patients and their medical problems. Just by the fact that I now have the ability to code for an orca bite or (God forbid) an accident due to water skis on fire, I know that I will be able to provide better care for my patients.

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(Photo courtesy of PBS)

The use of ICD 10 is now mandated by the Federal government for hospitals and healthcare providers all across the US. Originally designed by the WHO as a way to track worldwide disease and collect health and wellness statistics, the ICD coding system was intended to be a way to identify and target certain diseases and injuries. The hope was that by tracking disease, specific interventions could be made in order to improve outcomes in areas where a particular health risk was present.

Since its inception, the US has adopted the coding system as a way to capture billing information for the purposes of reimbursing physicians and hospitals for the work that they perform. In the previous iteration, ICD-9, there were nearly 55K diagnosis and procedure codes. Under the new system there are almost 155K. Over the last year, doctors and hospital personnel have been required to undertake hours of “ICD-10” training in order to ensure competence with the new coding system by October 1st. The new system expands the types of diagnoses, and is intended to be much more specific—requiring that statements of laterality and the chronicity of a particular ailment or injury be included in the diagnostic code. For physicians, this means—you guessed it—tons of additional electronic paperwork. With EMR already in place (and barely functional in some instances) physicians are already overwhelmed with data entry and screen time. Now, in order to complete an office visit in the EMR, physicians must navigate a new, and even more cumbersome, coding system.   We have codes for injuries that occur while falling from a spacecraft, injuries sustained in a Macaw attack as well as a thermal injury that occurs while skiing on water skis that are, in fact, on fire.

Do any of these help us better care for our patients with diabetes, heart disease or hypertension? Do my patients benefit because I am able to carefully code in the EMR the fact that there chest pain is due to “native coronary artery disease with angina”? Wouldn’t the result be the same if I simply wrote in my office note that the patient has prior coronary artery disease and is having typical angina and likely needs an evaluation with a particular test?

In many cases, I expect that the codes that are recorded in the middle of a very busy office day will be no more accurate than the previous system—many providers will simply click a diagnosis that is “related” to the patient’s problem in order to move the electronic paperwork along. (Instead of searching an endless list of codes for the exact letter and number combination that is required).

When exactly did anyone prove—in a randomized controlled clinical trial—that more specific coding of diagnoses by physicians improved patient care and impacted outcomes?

I would argue that is simply the result of the combination of continued government ignorance (and arrogance) when it comes to dabbling (or meddling) in healthcare. Bureaucrats love to create paperwork, committees, meetings and agendas. They often pontificate on the benefits of a particular plan or algorithm even when they have no data to support their position. Doctors care for patients—our government should let us all do what we do best—Spend time with our patients, connect with them and work to improve their health. For now, however, we must continue to look for the right code–especially when we encounter a person who has been injured by a jet engine. Better learn that one—its an everyday thing around the primary care office. Ahh, here it is…. V97.33XD: Sucked into jet engine, subsequent encounter

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