Tag Archives: healthcare reform

Changing the Mindset in Medicine To Improve Outcomes: Prevention Rather Than Reaction

Much of my medical training in residency and fellowship was all about learning to react to particular clinical situations.  Long nights of call with exposure to a high volume of patients allowed me to quickly recognize common signs and symptoms, develop a working differential diagnosis and initiate testing and therapy right away.  This rapid fire exposure to disease was incredibly important in my development as a physician.  Moreover, the ability to react to clinical findings is essential in providing quality medical care as well as producing positive outcomes.

However, very little of my training focused on prevention.  Even today, residents and other physicians in training spend far more time treating disease rather than figuring out how to derail the disease process (even before it begins).  Certainly, we all learned about proper timing of routine screening tests for colon cancer, breast cancer, prostate cancer, etc.  In contrast, we did not spend much time learning effective ways in which we could counsel patients about lifestyle modification and risk reduction.  We did not talk much about how to educate patients about potential diseases that they may be at risk for and the potential negative impacts these diseases might have on an individual patient’s overall health status and quality of life.

Today in the Wall Street Journal, an article detailing a new report of an overall reduction in preventable cardiovascular death in the US today was published.  On first blush, this sounds like a very positive report–fewer Americans are dying of heart disease.  However, on closer examination, the data becomes quite disturbing–the largest reduction in preventable death was in the older population (greater than 75).  In the younger population (age less than 65) the decline was much less impressive.  Subgroup analysis revealed significant racial and geographic disparities as well–African Americans had a two fold higher rate in preventable cardiovascular death.  Residents of the southern states were also found to have much higher rates of preventable death.

Why is this?  What can we do to impact the large number of preventable cardiovascular deaths?

Based on this data, it seems to me that we are now seeing a large number of younger patients who are at risk for cardiovascular disease that are not being aggressively screened, evaluated and treated.  Many of these younger patients are not seeking medical attention until they experience their first (and often fatal) cardiac event.  According to the CDC nearly a quarter million of the 800K annual cardiovascular related deaths are preventable.  Long standing cardiovascular disease and its myriad of complications are expensive…in terms of dollars and in terms of human life.

The solution is all about prevention.  As cardiologists we must be more vigilant and screen young at risk populations more aggressively.  We must treat hypertension, hyperlipidemia and diabetes in younger patients.  We must spend more time counseling patients about lifestyle modification–not just smoking cessation.  Other healthcare providers in both primary care and in other specialties must also redouble their efforts on prevention.  We must all work together and refer patients who are at risk to the proper provider.  In addition, we must pay extra attention to higher risk groups such as minorities and we must focus efforts in geographies such as the south with higher than average preventable death rates.

Most importantly, we must all work to change the mindset in medicine.  Clinical competence and the ability to think on our feet and react is certainly essential and should remain a cornerstone of training.  However, we must also look a little deeper.  Obviously, we all love to be cast as the hero in the medical drama and save a life with an emergency procedure–however, it is just as heroic to prevent the emergency in the first place.  We must strive to train physicians who not only are able to react to disease and its presentations but who are also adept at recognizing risk and counseling patients to prevent negative outcomes later in life.

Ben Franklin had it right way back in the 1700s.  Even though we didn’t listen to Ben then, we have a real opportunity to listen and act now!  Remember–”an ounce of prevention is worth a pound of cure!”  Now that’s a low cost way to reduce the costs of healthcare AND save lives in the US today.

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Limiting Choices and Destroying Relationships: Early Consequences of the Affordable Care Act

Providing healthcare to all is a noble goal.  Providing choice, however, is an entirely separate issue.  Successful partnerships between doctor and patient are developed over time.  These partnerships do not happen easily and most, just like a long standing marriage, take a great deal of work.  As I have mentioned in previous blogs, when patients are engaged and participate in their care, outcomes are improved.  It is easy to see how costs can be lowered through improved outcomes–the focus is shifted to prevention rather than “salvage”.

Last week in the Wall Street Journal, author Anne Mathews discusses the issues surrounding “choices” in the healthcare marketplaces that begin functioning in October.  Many insurers are making “deals” with hospitals and physicians–they will be included in their plans as preferred providers if they are willing to settle for pre-negotiated lower reimbursement rates.  Many major healthcare systems such as UCLA in California, Rush and Northwestern in Chicago and Vanderbilt in Tennessee are being excluded as preferred providers in many plans due to the fact that they are unwilling to accept the terms dictated by the insurers.   These institutions,  and many others like them,  employ many of medicine’s leaders in patient care and research.  Many patients have developed long standing relationships with physicians at these institutions and are now forced to make a “choice”—either continue with their preferred provider at an increased out  of pocket cost or change physicians and start over in their new healthcare plan.

Starting over with a new physician is a lot like divorce.  Divorce is not easy–it is fraught with uncertainty and can be emotionally painful.  It is difficult to face change when so much time has been invested in building a productive doctor-patient relationship.  However, with the pending implementation of the Affordable Care Act (ACA), patients are now being forced to choose between a doctor they trust and lower insurance premiums.  Physicians and hospital systems are being forced to accept payments at whatever level the insurers choose to dictate–irrespective of the cost of the procedure or the staffing and overhead incurred.  Once again, the reform of healthcare in the US is doing little to assist the patients who need help the most.  Instead of working to build relationships, streamline care and focus on prevention, the ACA is forcing “divorce” proceedings on many doctors and their patients.  Moreover, the “choice” that is supposedly supplied by the pending healthcare exchange marketplaces will be severely limited when they open in October.  The government cites a lack of time to prepare for the healthcare law rollout–Others cite a poorly thought out, complicated and unworkable plan.  More than a dozen ACA “deadlines” have already been missed and there will certainly be more to come.

No one argues that the current healthcare system in the US is on life support and badly in need of reform.  However, the current ACA plan is not the answer.  Based on the basic tenet of coverage for all at affordable prices, the ACA is not living up to its billing.  Now, as the law begins its rollout process, many of the finest academic medical institutions in the country are not going to be accessible to many Americans due to contractual issues with the insurance industry.  Ultimately this will create more of a medical care divide in the US.  Academic teaching hospitals provide cutting edge care and access to new potentially life saving technologies before these are available in the mainstream.  Those with rare diseases or those with disease processes that have failed other treatments often turn to academic institutions such as Vanderbilt, UCLA and Rush for experimental therapies that may provide hope for a cure.  Now, as long as the healthcare exchange plans are able to dictate which physicians and institutions are included in their respective plan, only the wealthy and privately (non government exchange or marketplace) insured will be able to have an opportunity to participate in ground breaking and potentially life saving clinical trials.  Ultimately patients will suffer.  Ultimately human beings will be denied potential life saving therapy–all because of limited choice and the coverage “assigned” by insurance companies hoping to limit cost–but at what price?

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The Future of Medicine: Coding For An Orca Bite

When I was in medical school in the mid-1990s at Wake Forest University, the only thing I knew about “codes” was how to use an ATM machine (which was often linked to a very empty bank account).  As my training progressed through internship, residency and fellowship, the idea of coding provider services never even crossed my mind.  No one taught me anything about the “levels of service” or what an ICD-9 (The International Classification of Diseases) code actually was even though the coding system has existed for more than 30 years.  I remember my teachers and mentors scribbling on a card in the front of the chart whenever they interacted with a patient, but I had no idea what the exercise was about.  Years later, I am all too familiar with coding of patient services.

Billing codes serve as a way for the Center for Medicare and Medicaid Services (CMS) to create a payment schedule for services rendered based on diagnoses.  Each diagnosis is given a particular code and then there are “modifiers” that attempt to make the billing code more specific.  Government bureaucrats created a massive list of poorly contrived codes that have been utilized for the last decade known as ICD-9.  Over the years, those responsible for these codes have realized that in order to accurately document medical conditions and improve billing accuracy (and reduce fraud) that these codes are in need of updates.  Thankfully, our government has been working on this new system tirelessly over the last several years.  In fact, the Wall Street Journal reported on the development of this new brilliant system as early as 2008.  Next year, the new set of billing codes will go into effect–they have been created with the goal of improving the specificity of the diagnosis and improving care (through quality measures).  This brilliant work and expansive list of new codes (approximately 150,000 codes as compared to the current 18,00) includes such ingenious diagnoses as code W5621XA “bitten by an orca, initial encounter”.  Another important code that has been created is the commonly used W6112XA-”struck by a macaw”.  As a practicing physician, I am relieved that when the next patient who visits my office after suffering “a burn due to water skis on fire”–I can quickly and easily document the encounter using the ICD-10 code V9109XA.

As government seeks to continue to regulate healthcare and contain costs, it seems to me that our efforts in reducing costs and improving quality of care are a bit off track.  Instead of working to improve efficiency and reduce redundancy in healthcare, we are now focusing on creating codes for injuries that may only occur to Wile E. Coyote during an epic battle with the RoadRunner.  As a physician, I have been required to complete nearly 20 hours of online training to help me understand the new ICD-10 coding system.  After an endless marathon of computer modules, I still have no idea how or why the ICD-10 system will improve my ability to care for patients or improve either the efficiency or quality of care in my practice.   In fact, I am certain that the new coding system will actually add more hours of documentation to my already burgeoning pile of electronic paperwork.  Eventually something has to give….there are only so many hours in the day.  Personally, I would rather see patients and care for those that need my help rather than coding for an attack by a talking bird or a personal watercraft injury due to burning water skis.

Our healthcare system has lost its way.  The new coding system is just one example of misplaced priorities within regulatory agencies.  Instead of creating codes for ridiculous scenarios, we should be training docs to provide thoughtful efficient care. We should be teaching doctors to communicate with each other about patient care and to avoid unnecessary testing.  Time, money and energy could be much more effective if spent on engaging patients in preventative care strategies and modification of risk factors.  Until then, I can at least sleep well tonight knowing that there is in fact an ICD-10 code for the next patient who walks in my office after being “hurt at the opera” …I will be able to quickly use code Y92253.

Please note:  All of the codes mentioned in this blog are REAL.  They are all part of the 150,000 codes that doctors and billing specialists are supposed to know and implement in the next year.  You can verify all codes by using this ICD-10 code look-up website

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Considering A Divorce From Your Doctor? Here’s What You Need to Know

Just As in marriage, the ability to communicate is essential to any successful doctor-patient relationship.  In fact, the most successful doctor-patient relationships are a lot like a marriage.  Both parties must be willing to listen, to negotiate and to support each other’s decisions.  As I have stated in many previous blogs, outcomes improve significantly when patients are engaged in their own healthcare.  Engagement only occurs when doctors and patients are able to effectively work together to solve health problems.  The days of the paternalistic physician dictating lifestyle changes and treatment plans are long over.  Today, patients are better informed and armed with information as they enter the office for consultation.

Unfortunately, just as in marriage, not all doctor-patient relationships work out.  Sometimes changes have to be made in the spirit of moving forward with effective healthcare. This week in the Wall Street Journal, author Kristen Gerencher addressed the issue of “When to fire your Doctor”.  In this piece Ms Gerencher provides sound advice on how to determine when it is time for a change.  She mentions 5 warning signs that may indicate that a divorce and remarriage to another provider is important.  In particular, if you feel worse when you leave your physician’s office than when you arrived, it may be time to consider a change.

Here’s my take on the warning signs that the WSJ mentions:  (the warning signs listed are directly from the WSJ article, the commentary below each one is mine)

1. You leave with more questions than answers.  

It is critical that physicians take the time to communicate clearly to patients.  Essential to this communication is allowing time for questions AND clarifying any misunderstandings or addressing concerns about a treatment plan.  This can be challenging for doctors in the current healthcare environment where federally mandated documentation requirements and pressures to see more patients in less time are limiting the time once dedicated to patient discussion.  However, it is essential to the health of the doctor patient relationship that physicians do not allow these conversations to be pushed aside.  Remember, patient engagement is key.  An informed patient is much more likely to be engaged.

2. Your doctor dismisses your input.

In the age of the internet, patients often come armed with lots of information (lots of which is unreliable and shady at best) that is obtained from online searches.  Rather than simply dismiss the information as junk, it is important to guide our patients to more reliable and more accurate sources of internet information such as MedPage Today and other good patient friendly information sites.

3. Your doctor has misdiagnosed you.

Medicine is not a perfect science.  It is important that you work with your doctor every step of the way along your path to diagnosis.  Mistakes in diagnosis happen–however, these mistakes are not always negligence.  Consider if your physician has carefully considered your problem and has provided a well thought out differential diagnosis before leaving due to a misdiagnosis.  It is important that communication continues during the process of misdiagnosis.  If there is no good communication at this stage, it may be time to choose another provider.

4. Your doctor balks at a second opinion

A good physician is never afraid of a second opinion.  In fact, I often welcome a second opinion in cases where there are multiple choices of a plan of action.  It is essential that patients feel comfortable with their treatment plan–a feeling of comfort breeds engagement and engagement is key for success.  As physicians, we must be willing to put our egos aside in order to provide the best possible care for our patients.

5. Your doctor isn’t board certified.

When choosing a physician, it is vital that you examine his or her background and training.  Typically, doctors must complete a course of training in residency and fellowship in order to be boarded in a particular specialty.  Board exams (some written and some oral) must be passed and competency must be proven.  Once certified, physicians must maintain competency through continuing medical education and re-certification every 10 years.  If your doctor is not board certified, it is not necessarily the end–ask why.  There are several reasons that they may not be including overseas training that is not recognized in the US by the US societies responsible for board certification.

Choosing a doctor is a lot like choosing a spouse.  Decisions should be made in cooperation with one another and both sides must contribute to planning and execution of the chosen course of action.  Patients must weigh options, consider pros and cons and discuss issues with their provider and the provider’s staff when unhappy with a particular physician or physician group.  IF communication is not productive and there is no engagement, patients must make a change.  Good healthcare is a two way street.  Doctor and patient must work in concert in order to achieve optimal outcomes.

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“Welcome to the Affordable Care Act Call Center, Please Press One for Healthcare, Two for….”

Although tax season has come and gone again in the US, many of us have had the regrettable occasion to call the Internal Revenue Service (IRS) call center to ask a question or confirm a policy or procedure. (and no, this blog is not at all about the recent IRS scandal–I promise). At least in my case, the call center can quickly become an endless loop nightmare of computerized voices and it is very easy to get lost in the depths of the “automated menu” if you are not careful. Often, calls to the IRS call center involve hours of hold times–even my most clever tricks such as pushing “0” at every prompt and claiming ignorance once an actual human being comes on the line doesn’t always help. Large government agencies are often unwieldy and thousands of employees may be located in call centers in vastly different parts of the country–often these employees have very different understandings of policies and procedures and the agency often lacks standardization in response to consumer inquiries. In addition to IRS call centers, there is an IRS website with numerous difficult to understand PDF files of tax rules and regulations (which sometimes appear to be written in some ancient language).

Because of my experience with the IRS (government run) call center and website, I was intrigued while reading the New York Times today when I came across an article describing the Federal government’s plan for developing an “Affordable Care Act” Call center. According to the Times, the call center will be tasked with handling all of the questions and consumer issues that will begin to occur this fall when the health exchange requirement portion of the “Affordable Care Act” goes into effect. The Obama administration apparently realized this past week that most states are completely unprepared for setting up the required “marketplaces” where Americans can buy health insurance that will be required by law starting January 1, 2014. (really, we are unprepared to insure millions of new patients in just a few short months?) The government proudly announced plans to create a website AND a call center where Americans can go and prepare themselves for the October 1st opening of the marketplaces. The call center will be staffed with nearly 9000 operators who will be available 24 hours a day to make sure the every American understands the new health care act and its provisions. (I would love to meet just one of these 9000 as almost no practicing physicians in the US today fully understands the new health care act and its implications). Although this call center will create much needed jobs, it will also increase the costs associated with health care reform as even more government employees will be required to fill these roles. I expect that this call center (as well as the website) will not be the holy grail and fountain of information that our government expects it to be. The new healthcare law is incredibly complicated and is confusing for almost all of us. I am not sure how the average American is going to be able to understand and interpret all of the rules and regulations and make well informed choices as the new healthcare exchange deadlines approach.

There is no doubt that the healthcare system in the US is on life support. Our nation spends more dollars on healthcare per capita than any other industrialized nation on earth. Our costs are high and our outcomes are similar to other industrialized nations where costs are not nearly as astronomical. Obviously changes in our current system need to be made BUT I am certain that the current “Un-Affordable” Care Act is NOT the answer. The legislation is complex and expensive. In addition, moving this legislation forward when the states and other government organizations lack the infrastructure to support it is irresponsible. As a nation, we need to regroup and take from the Affordable Care Act those things that are both good for American citizens and fiscally responsible and leave the waste and political provisions behind. A Call Center and website will NOT make the new Affordable Care Act any more Functional or Affordable–and will not facilitate the establishment of the enormous state by state infrastructure required for its implementation.

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The Doctor Patient Relationship On The Brink of Extinction: The Impact of Physician Post Graduate Training

It is unfortunate, but now medicine is “on the clock”.  We now must not only battle disease, but we must also battle time.  Physicians are asked to do more in less time.  Innovations such as EMR (which in theory are supposed to increase efficiency) sometimes actually slow clinical practice to a halt.  Additionally, ongoing debate exists as to how best train medical residents and prepare them for the practice of medicine.  Technology and mhealth applications are changing the way in which doctors and patients interact.  Training programs have been evaluated multiple times over the last 20 years and sweeping changes have occurred in the way in which the ACGME regulates the working hours of physicians in training.  These changes have a significant impact on the way in which physicians practice once they have completed their residency and fellowship commitments.

Medicine, more than any other profession, is best learned through experiential training.  “Hands On” contact with patients and families allows residents to immerse themselves in disease and the continuum of care.  Studies from the late 1980s (published in the New England Journal of Medicine) suggested that although resident hours were long and arduous, much of their time was spent doing paperwork and tasks such as drawing blood and transporting patients–even in the era of the 100+ hour week for interns only 20% of the work time was spent in direct patient care.  In the early 2000s with increasing pressure from politicians and other organizations, the ACGME issued a statement limiting the work hours of housestaff to 80 hours per week.  The arguments that led to the limitations in work hours revolved around mistakes and errors during times of sleep deprivation.  Citing patient safety and resident “burn-out” advocates for change stressed that care and learning would both improve if rules were put into place to limit consecutive as well as cumulative work hours.  However, a recent study in the Journal of General Internal Medicine explored the difference in mortality pre and post reform.  Interestingly, there was no overall change in mortality pre and post reform.  In fact, when interviewed, residents and attending physicians complained about the dangers of the “patient handoffs”.  In the old days, the “sign outs” would occur only once a day–in the evening to the on call team. Lists were prepared from every team and a verbal sign out would occur doctor to doctor and team to team.  In the morning, the on call doctors would discuss the overnight patient events with each team and ensure a proper continuum of care.   In the new system with trainees coming and going at different times, there are many opportunities for miscommunication and sometimes important patient care issues get lost in translation.  Many times the night call team is not even associated with the particular service they may be covering and may only cover a night or two here and there–resulting in zero continuity of care and no investment in the overall outcome of the patient.  More importantly, trainees never truly understand the entire course of a disease process as they frequently only see a portion of the span of therapy due to work hour limitations.

Clearly, the current system for training physicians is lacking.  Neither pre reform guidelines nor post reform guidelines are adequate.  This week in the New York Times, author Pauline Chen provides a nice review of the course of reform in medical education.  However, near the end of her essay, Dr Chen makes her most important points–ultimately, by limiting time spent with patients, we are working to eliminate the formation of the doctor patient relationship.  In fact, some data suggests that in addition to a training curriculum for residents most institutions also have a “hidden curriculum” that affects the attitudes of physicians toward their patients once in practice.  If the institution is heavy on paperwork and intern “scut work” there is little time for direct patient interaction.  These training experiences can shape the way in the doctor relates to patients throughout his or her career.  It is essential that we continue to teach doctors how to be healers.  No matter what the working hour limitations may be in the future, we must continue to foster skills for building healthy doctor patient relationships in our physicians in training.   In addition, we must help residents with time management and discover ways to improve the time that they spend in direct patient care while in training.  If we do not, we will find that the art of medicine may in fact be lost forever.

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Primary Care Shortage? It’s Time to Examine Medical Education in the US

When I was in medical school in the 1990s, students were given a bleak picture of the life of a subspecialist. We were told that there would be few job opportunities and that the only way to ensure a job was to pursue a career in primary care. Many of my classmates did go into primary care but the majority of us accepted residency positions in surgery, neurosurgery and other medical subspecialties. As we completed our training, we found that there were actually plenty of job opportunities for subspecialists. In fact, other than in underserved areas, shortly after my graduation from medical school primary care doctors were abundant. However, times are now much different. As discussed in the New York Times this week, it is becoming more and more difficult for patients to find primary care doctors. In a very short time, there will be more than 40 million newly insured patients that flood the system. All of these patients will need primary care providers.

Today’s medical students are saddled with enormous debt. The average cost for a medical education at a public university is $29K per year for four years; the median cost at a private school is nearly $50K per year for four years. Many students leave medical school and enter residency training programs with between $200 to $300K in debt. The cost of a medical education has risen almost 300% over the last 20 years. Now, particularly in primary care, salaries and reimbursements are significantly lower than in previous decades. Add to that the ever-increasing burden of paperwork and administrative duties that are required of primary care physicians and it becomes obvious why there is a shortage of newly trained primary care practitioners. Many students pursue a medical education to make a difference and to help people–many enter school wanting to be primary care providers and work in underserved areas. However, the financial realities of debt often force students to change their minds and seek residencies in subspecialties that hold the promise of better financial return.

Healthcare reform is important. We must focus on providing quality care to patients who need it in the US today. However, we must also reform the medical education system. No longer can we continue to allow the costs of tuition to rise to astronomical levels and at the same time lower the potential earnings for medical school graduates. If we continue on the current path, we will make a medical education an “upside down” investment. Moreover, allowing the tuition of medical schools to soar will make it more difficult for bright students with limited financial means to attend. We will, in fact, self-select medical school classes of the financially privileged and prevent other very talented less affluent students from attending. Although I was fortunate enough to receive an academic scholarship to medical school, I often ate macaroni and cheese and ramen noodles for weeks at a time in order to make ends meet. I had a job moonlighting as an MCAT preparatory course instructor. But, I did have access to an excellent medical education. In addition to containing the cost of a medical education, we must also address the issue of the investment of time–is it really necessary for physicians to attend four years of undergraduate work and then four years of medical school? In many countries in Europe, a combined track of 6 years produces well trained physicians that do very well in US residency training programs. Many students do not begin their careers until their early 30s due to the combination of undergraduate and graduate degrees coupled with prolonged fellowship training programs.

The US offers some of the very best training for physicians in the world. We are fortunate to have some of the finest institutions with cutting edge technology. Our students are able to be trained in the most sophisticated medical procedures and are able to participate in research that makes a difference in the lives of many patients. However, the medical education system in the US is currently broken and something must be done to fix it quickly if we are going to keep up with demand. No longer can we squeeze the young physician at both ends–astronomical educational costs, prolonged times to acquire both undergraduate and graduate degrees must be addressed as salaries and earning potentials continue to be regulated, lowered and limited. Primary care doctors are essential. They are the entry point for patients and the stewards of our healthcare. Yes, there is a shortage of primary care physicians today and even greater shortages loom ahead. In order to fix this problem, we must closely examine the system and make changes that allow for access for all qualified students with a more reasonable time investment. In the end, our goal should be to produce the best physicians in the world, who are motivated to care for the patients who desperately need them today and in the future.

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