The Hippocratic Message in a Bottle

I like reading Dr. Kevin Pho’s blog. I read, or at the very least scan, his diverse collection of essays every day. The posts themselves are mostly good, but I like reading the comments section more, and most of all I like the anonymous comments, because those are rare insights into how regular, everyday doctors think. I read Health Affairs and JAMA and NEJM and the New York Times to figure out what “thought leaders” say, and medical associations’ websites for “leadership” messaging. And guess what? The anonymous, and sometimes not so anonymous, opinions of the rank and file are diametrically opposed to official party lines. Of course, most doctors don’t read or comment on blogs, don’t speak at conferences and don’t write opinion pieces for mass media outlets. Over the years, I spoke with many members of the silent majority, not a representative sample by any means, but a good indicator that anonymous commenters are closer to being representative of popular opinion than their much more visible counterparts, most of whom have quit the practice of medicine years ago, if they ever practiced at all.

There is a dark cloud of discouragement, dejection, disheartenment, and all other synonyms of despair, hanging over the medical profession. It’s not that all physicians live in constant gloom and doom, although quite a few do, particularly those still in private practice, but the profession itself seems to be losing its luster. Some doctors seem content to pragmatically adapt to the new and duller definition of their old profession, but in other quarters there is deep seated anger stemming from the perception that this is something purposely inflicted on physicians by a power hungry government, greedy businesses and an ignorant and ingrate populace. No matter how the conversation starts, the question seems to always be whether there is anything that can be done to turn the tide. And no matter what is said and done, the exchange of opinions always devolves (or evolves, depending on your position) to money – cash, payment, reimbursement, fees, compensation for long years of learning and training, and for performing arduous work that is really (or at least should be) beyond monetary valuation. And this, my friend, is the most counterproductive narrative of all. This is where you shoot yourself in the foot, albeit with undeniable gusto. Regardless of its merits, this is a nonstarter.

The hurricane hitting health care today can be traced in its entirety to money. We would not be having this dialogue if medical care was affordable for the average American, and if the sum total of national expenditures on health care would be hovering around 10 to 12 percent of the inadequate measure called gross domestic product (GDP). You can engage in the futile exercise of splitting hairs trying to allocate blame for runaway costs away from doctors, but you would find yourself outgunned, outnumbered, and late to the game. The mass media is chockfull of randomly chosen inflammatory examples of the small fortunes charged by physicians and hospitals for stitching a pinky finger. The shining bright lights make every pharmaceutical hotdog cast a shadow the size of the Keystone XL. Large insurance companies are providing interviews to anyone willing to listen, on their strategy for keeping premiums affordable for the working man by expelling “low value” providers from their “high value” networks.  And Medicare just announced that it will be releasing information on how much money it pays to individual physicians, because the “public has a right to know”. How do you fight that?

The same way George Washington fought the war of independence – you redefine the battlegrounds and meet the enemy at a time and place of your choosing; a time and place where your inferior force is actually an advantage. So first of all, you don’t discuss money, and you certainly don’t go into endless tirades about your accounts receivable and accounts payable over the last 30 years. Why? Because complaining about the frosting on your cake while your audience is starving is not a very endearing or effective method for garnering support and sympathy. There is no way you can convince the nine out of ten Americans who would gladly trade places with you, that your work is hard, your life is hard, and your six figure income is inadequate compensation for lack of joy at the office. There is no way you can explain to a nation that makes on average around $50, 000 a year, that $150,000 is not good enough. And bluntly telling them that they are too stupid and too lazy to do what you do, and that’s why they are deservedly worse off, is not going to get you much applause either.

The second rule of engagement is that you should never confuse your arguments with political partisanship. Why? Because, the moment you do that, you lose half your audience, and it doesn’t really matter which half. If you are ever going to win this battle, you need all the hearts and souls you can get. You don’t discount half the country by calling them irresponsible moochers, and you don’t throw out the other half by labeling them heartless disciples of Ebenezer Scrooge. Your best, and arguably only, weapon in this fight is that both halves still trust your professional voice. You don’t further diminish that trust by descending into the political swamp to meet your enemy. You pick your time and place. You choose to fight on the moral high ground.

You took an oath to help the patient in front of you, to the best of your ability and judgment. Whatever modern enlightened technocrats think about ancient oaths, potions and incantations, there is an implied promise here to conduct one’s professional life in an ethically responsible manner, which is more than can be said about any other secular profession. So what happens when your ability is harnessed by entities whose sole raison d'être is to increase shareholders profits by any means necessary, and your judgment is subordinated to agencies that live and die within political election cycles? Your ability is steadily crippled by diluted training and limited practice, and your judgment is shelved in favor of shiny fly-by-wire instrument panels (medicine is like aviation, remember?), configured by invisible and unaccountable hands. This is what the public needs to know and thoroughly understand.

If you are going to speak up, make public statements, write blogs, start a movement, or just post an anonymous comment somewhere, you should stick to your high ground, your guns and your strategy to inform the public about health care issues that matter to individual people, their children, their parents and anyone else they hold dear. You can write stories, relate experiences, compose elaborate treatises, sponsor studies and do research, and all of these things need to be about the one patient in front of you. When people come to you for advice, they should understand that it’s not necessarily your advice they are getting now. When the frightened ask you what you would do in their place, they need to know that you may not be at liberty to give them an honest response. They need to know that advocating for your patients, may draw disciplinary actions from your handlers, and financial retribution from your masters. They need to know that medical ethics are largely outside your control now, and subject to lobbying and political patronage arrangements. They need to know that the archaic words of Hippocrates are turning into a largely empty exercise before graduation parties begin. But most of all, they need to know that you are asking them for help.

And next time you lament the loss of joy and the diminishing status of your profession, you will have to give Old Hippocrates some credit, because two and a half millennia ago he forewarned all doctors of the fate awaiting them, if his moral prescription was ignored: “If I fulfill this oath and do not violate it, may it be granted to me to enjoy life and art, being honored with fame among all men for all time to come; if I transgress it and swear falsely, may the opposite of all this be my lot.” What’s your lot look like these days? And what are you planning to do about it?

VIDERI QUAM ESSE

I was reading the popular HIStalk health IT news/opinion site the other day when I ran into a blurb stating that beginning in 2014, a new “North Carolina law requires hospitals with EHRs to connect to the state’s HIE and submit data on services paid for with Medicaid funds”. For the uninitiated, HIE stands for Health Information Exchange, and in this context it refers to a federally funded organization whose mission is to facilitate clinical information exchange in the State. There are similar organizations in most every State, funded back in 2009, alongside Meaningful Use and other shovel ready economic stimulus activities, through the ARRA and its HITECH Act.

The noble goal of HIE organizations everywhere is to improve care for patients by simplifying interoperability between disparate EHR technologies, allowing clinicians timely access to relevant, up-to-date medical information at the point of care. It makes perfect sense that North Carolina would like to “nudge” hospitals into sharing information with community physicians to improve care coordination and hopefully outcomes for its citizens. What doesn’t make any sense at all though, is the narrow requirement for Medicaid information only. Wouldn’t North Carolina want better care coordination for all people? And how does a hospital submit data only for a subset of services (not necessarily a subset of patients)? And why is this limited to submission, and there is no requirement that hospitals avail themselves of HIE data submitted by others? Obviously, I needed a bit more information to satisfy my foolish curiosity….

The first step was to check out the North Carolina HIE. Like many other organizations of its kind, the NC HIE chose to create a clinical data repository to be fed by prospective customers with “prescriptions, vaccinations, allergies, lab and test results, image reports, conditions, diagnoses or health problems and medical visit notes”, and with hospital ADT (admission-transfer-discharge) information as well. So far, like similar HIE organizations across the country, NC HIE is failing to garner active support from local hospitals. In an interview with the Carolina Journal earlier this summer, Mark Bell, CIO of the North Carolina Hospital Association (NCHA), suggested that “[t]ypically, a provider will not be thrilled with the idea of somebody else making money off of their data” which seems to be a “hot button topic”. Indeed, the NC HIE client list is remarkable for the absence of North Carolina’s famous academic centers of excellence and their affiliates. 

Mr. Bell’s hardly novel implication that some HIE organizations are seeking “to aggregate all that data and sell it to anyone who wants to buy that data, or for research, or a number of other uses” does raise the uncomfortable specter of patient privacy. According to its website, the NC HIE is an “opt out” exchange, which means that patients are “automatically” enrolled in the exchange whenever they “visit a participating doctor or hospital”, at no cost to the patient, of course. For inquiring minds, the NC HIE explains that it is only acting “as a “virtual medical record department” to collect and store medical records, and allow authorized providers to review and upload records”, and that “[h]aving a third party manage medical records is common practice”. Right. People may still opt out by calling a certain phone number or by mailing a certain form. As with most HIE organizations that engage in data accumulation, the “opt out” mechanism does not prevent patient information from being sent to the HIE, being stored in the HIE database, being disclosed to public agencies, or being used for other purposes when required or as permitted by Applicable Law. It only prevents disclosure to doctors and hospitals that are actually treating the opting out patient.

With that in mind, let’s go back to the brand new Applicable Law. The original bill contained language stating that effective January 1st 2014 “any hospital, as defined in G.S. 131E-76(c), that has an electronic health record system shall connect to the NC HIE and submit individual patient demographic and clinical data on services paid for with Medicaid funds”. This is a pretty lucrative arrangement for the NC HIE, which stands to gain approximately $5.5 million per year from subscription fees (at $250 per bed per year) alone, and undetermined amounts from interface charges, which as we all know can run into tens of thousands of dollars for each facility. Forcing the rich and famous North Carolina health systems to support the floundering public exchange may have been good enough reason to introduce this legislation, but that’s not the end of the story. The final bill, which is now the law of the land in North Carolina, was amended to include the following: “The NC HIE shall give the Department of Health and Human Services real-time access to data and information contained in the NC HIE”, and goes on to specify that the “Department of Health and Human Services and the NC HIE shall execute an agreement regarding the utilization and sharing of data and information contained in the HIE Network”, in a manner that complies with HIPAA and federal law. Note that the amendment language is not specific to “services paid for with Medicaid funds”.

It looks like the State of North Carolina came up with a rather innovative method for participating in what Mr. Bell from the NCHA terms a “hot button topic”. I am not sure how, or if, the State is planning to enforce this law, and I am not sure if hospitals will take the extra trouble (and expense) needed to segregate and submit to the State only those medical records that contain a Medicaid charge, but one thing is certain: individual patients in North Carolina have absolutely no say in this matter.  And so we take one more step on the road to trusted exchange.

Top 10 Accomplishments of American Health Care

It’s that time of year when the OECD publishes its "Health at a Glance" comparative health indicators, and The Commonwealth Fund follows with an international survey of health care related activities. A cursory review of these documents always ends up with the customary assessment of American health care: much more expensive than all others, wasteful and inefficient. But this is the month of December, and health care workers are people too, so maybe a short moratorium on bad news and criticism may be in order, allowing these folks to pursue a little bit of happiness during the Holiday season. A deeper dive into the vast amounts of data in the OECD report exposes all sorts of measures where the United States health system performs magnificently. Therefore, without further ado, let’s look at the top 10 achievements of American health care.

Number 10: Generic prescription rates in America are highest in the world. In fact the rates are so high, that the OECD didn’t dare show them. The best generics utilizer in the OECD report was Germany at 76% of prescriptions volume in 2011. The U.S. comes in at a whopping 80% in 2011 and 84% in 2012. Not only that, but the U.S. is also #1 in per capita spending on medications, and if 80% are low priced generic drugs, imagine how many more drugs we get to take. This speaks volumes about our new value based health care system.

Number 9: America was once again able to maintain the second lowest number of physicians per capita among developed nations, and well below the OECD average. Obviously, this spells productivity like no other metric can, and it’s most likely due to labor saving innovations, such as Electronic Health Records. With medical school graduation numbers at the bottom of the pack, the future will no doubt bring many more innovations to further increase the efficiency of American doctors.

Number 8: Americans are making big strides in technology use for communicating with their doctors. We beat practically every single developed country at some email metric, which is irrefutable proof that Meaningful Use is working.

Number 7: As in previous years America is holding the line on hospitalizations. Way below the OECD average and practically last in cancer discharges (except Mexico, where they don’t have cancer), our health system figured out much more cost effective ways of treating an increasingly older population, which leads us to #6.

Number 6: No one, and I mean no one, spends less of their health care money on hospitals than the U.S. We are #1. And no one spends more than us on more efficient outpatient care, which includes inpatient physician services when billed separately. It seems that all those inflammatory articles in the media regarding hospital price gouging, are pure nonsense.

Number 5: Not only does America have less hospital beds than most OECD countries, we are not using them very much. With an occupancy rate second to last, it seems that if we closed a third of our hospitals, as some reformers are suggesting, we would be just fine (with room to spare), and we could save oodles of cash. Finding inefficiencies that are easy to fix is a good reason to celebrate.

Number 4: Quality of care for the people that do end up in a hospital is pretty good. On multiple variables of mortality and surgical complications, the U.S. is consistently among top performers. Not absolute best, but a top performer nevertheless. Not to mention that compared to the best performers, your chances of leaving an American hospital with an instrument lodged in your bowels are much lower than in some very high performing countries. For all the alarmists having visions of Jumbo Jets crashing out of the sky daily, killing thousands of innocent patients unbeknownst to anybody else, slow down folks, there are no Jumbo Jets; maybe a Cessna here and there, but definitely no Jumbo Jets.

Number 3: Our children are the best in the whole wide world. The Puritan founders would have been so very proud of them. American kids are dead last when it comes to drunkenness and smoking. Although they are just average when it comes to eating their fruits and vegetables, our 15 year old boys and girls are the most physically active of all other OECD nations. Strangely enough, they are also among the chubbiest, but with all that physical activity, this is bound to resolve itself in the long run. It may be too late for us, but the future looks bright for the young ones.

Number 2: America is the healthiest nation in the world, bar none. Yep, you heard right. Almost 90% of Americans consider themselves healthy, and I have no reason to doubt their self-assessment. Much has been said about other countries, having higher life expectancies. The difference between the U.S. and Japan is over four years of life, but consider this: less than 1 in 3 people in Japan report being healthy. I don’t know about you, but 78 years of healthy life sounds much better to me than 82 years of living with disease.

And the Number 1 accomplishment of American health care is (drumroll please) Obamacare. Yes, Obamacare went viral, probably through the Internet or something like that, because Obamacare is now a global phenomenon affecting every single OECD nation.

A couple of weeks ago Paul Krugman, winner of the 2008 Nobel Prize in Economics, and self-described liberal, let us in on a little secret. Obamacare, it seems, is the only logical explanation for the reduced growth of health care spending in the U.S., and Obamacare began “bending the curve” from the moment it was signed into law in 2010, long before it was formally implemented. Since according to OECD data, all other nations have experienced the same “curve bending” effect since 2010, we must conclude that Obamacare has reached all developed nations instantaneously (the Internet is very fast).

And in some cases (such as the UK, not to mention Greece) Obamacare seems to be working even better than in the U.S. So here you go, once again America saves the world…. Merry Christmas American Health Care!

The Implausible Manifestation of a Doctor Shortage

In a New York Times opinion piece Scott Gottlieb, MD joins forces with Ezekiel Emanuel, MD to inform us all that “No, There Won’t Be a Doctor Shortage”, and just to clarify, Dr. Gottlieb goes on to say in a subsequent Forbes article “That Doesn't Mean You'll Have Access To Them”.  Doctors, it seems, are destined to be like the lights of Hanukkah candles – only for looking at, not for using. As tempting as it may be, let’s not hastily assume that the more fortunate members of society, like the authors of these articles, are brazenly suggesting that maintaining a good supply of doctors for themselves, is as simple as denying everybody else access to physicians. Of course not.

To dispel our concerns that an aging population and expansion of health insurance may somehow require more doctors, Drs. Gottlieb and Emanuel urge us to look at the great State of Massachusetts where universal insurance has been in place for years and no shortages have been observed. According to the Census Bureau, Massachusetts has almost double the national average number of doctors per population, and by the authors own admission, its “experience may differ from other areas”. Looking at Mississippi, for example, would have been a stretch I suppose. Either way, policy makers should be all set, since the only place where doctors seem to be growing on cherry trees is our nation’s capital. Other than that, the New York Times article contains the usual innovative fare, being repeated now in most health care journals over and over again. The future holds marvelous technology advances that will minimize duration, complexity and intensity of treatments and non-physicians of all stripes will be delivering most of this now routine care (one interesting suggestion was that pharmacists should deliver urgent care). The main idea is that instead of “expanding our doctor pool, we should focus on increasing the productivity of existing physicians and other health care workers”.

Increasing worker productivity is where America’s exceptionalism truly shines. Labor productivity (i.e. the ratio of output to input) has increased in the U.S. by 254% since WWII (see graph above), and really accelerated in the new millennium. Unfortunately, compensation for this wonderful productivity, took a different path somewhere in the early seventies, hence the gaping divide between America and a handful of very wealthy individuals who benefit financially from productivity gains. The conservative Dr. Gottlieb and the progressive Dr. Emanuel are merely suggesting that this very successful business model should now be applied to the horrendously inefficient health care sector.  If you think about it, it becomes abundantly clear that this suggestion is actually an imperative. If we don’t find a way to integrate medical services in the lower-wages/cheaper-products innovation cycle, all those wonderfully productive workers will be unable to afford the medicines needed to sustain their blessed productivity.

The New York Times opinion piece, and the many others like it, are the theoretical foundation leading experts such as Dr. Gottlieb to conclude that “there’s every reason to believe that technology will continue to make the aging process itself (and the treatment of many diseases) a far less resource intensive endeavor – and ones that require fewer physician inputs for a higher level of “outputs” in terms of improved healthcare”. This is very similar to how restaurant chains, or canned food manufacturers, have a Chef that is shown designing fabulous new dishes, using market fresh ingredients, on TV commercials, but the actual “outputs” in each establishment, or can, require practically no Chef inputs. And this is why health care is strongly encouraged to learn from other industries that mastered the art of maximizing outputs to inputs ratios. Fair enough, but how do we know that we have enough Chefs or doctors to start with? Luckily, Dr. Gottlieb has valuable insights on this question as well. The argument is that “if there was a shortage of physicians, it wouldn’t be so easy for the Obamacare health plans to push around doctors and trim their pay”. The same logic is used very effectively by defense attorneys in rape cases where the victim did not scream or kick hard enough. 

When analyzing things from an economic perspective, shortage of something implies that demand exceeds supply, and demand does not mean need or even want; it means willingness to pay. For example, one could observe that we have no shortage of private trainers, not because people don’t need to work out, or because they wouldn’t want a personal trainer, but because most folks are not willing or able to pay for one. Demand, and subsequent shortage, is also a function of culture. There is no shortage of wholesome and freshly prepared foods today, because our culture has been altered to have different expectations from food. Preemptively changing perceptions and expectations is therefore paramount to preventing shortages. So if back in the 1990s HMOs were “soundly rejected” by the people, according to Dr. Gottlieb, “[w]hat Obamacare, in effect, tells Americans, is that the White House believes many people made the wrong choice when they rejected those HMOs in favor of PPO plans that offer broader access to providers”. Of course we did.

You hear frequently today how fixing health care requires a cultural change; how we must choose wisely and how we should not expect that everything is done to prolong individual lives; how we should become more accepting of death and how we should quit running to the doctor every time we are sick; how we should learn from Rwanda and how we should fear the killing fields of conventional medicine; how we should value fast service and convenience above intrinsic quality. All these things are necessary to bring demand for physician services more in line with productive workers’ ability to pay for medical care, and as worker compensation continues to shrink, we may end up with a surplus of doctors, which in turn will make pushing them around and trimming their pay even easier, as Dr. Gottlieb writes in conclusion: “In the future, there will be enough doctors for you to choose from. Problem is, in many cases, the Obamacare health plans won’t pay for you to see them”. And it won’t need to, because by then, you will be conditioned to not demand to see them.

Everywhere on this planet, physicians’ professional status, autonomy and compensation, are inextricably tied to the same metrics for the patients they serve. It is plausible and perhaps understandable, that physicians who were and still are the highest paid professionals in the land, considered themselves immune to the increased exploitation and marginalization of all other American workers, including highly educated ones. The almost linear relationship between worker compensation and physician compensation, and the mathematical impossibility of becoming rich by tending to a nation of impoverished workers, must have escaped our best and brightest, until now.

The harsh (and unpleasant for some) reality is that unless you can find your way to medically pamper “Internet moguls”, or happen to practice medicine on TV or at the New York Times, you are in the same boat as the McDonald's workers now rioting in the streets, perhaps in a much nicer cabin (for now), but same boat nevertheless. Something to ponder upon…

Update 12/11/2013: For a bit different, but more authoritative perspective, see Prof. Casey B. Mulligan's Economix article today.

What’s next for Primary Care?

As Obamacare is winding its way through a hellish bureaucratic labyrinth of its own creation, accompanied by cheers and boos from the blood thirsty spectator crowds, confusion, fear, trepidation, despair and exhilaration, are gripping America’s doctors all at once, because whatever else is accomplished in the next decade, medicine will never be the same. At the confluence of cutting edge technology, great poverty and unimaginable fortunes, a new vision for the practice of medicine is beginning to emerge. Medicine was formed during times when sickness was never far from death. It was devised by old men who went to bed every night thinking that they may never awaken, and it was institutionalized by women who shunned life’s earthly pleasures. They understood the fears of old age, the loneliness of disease, and the comfort and serenity that come with putting your life in the hands of God, when all was said and done. They built houses for the poor and sick and downtrodden, with larger than life Doctors as God’s emissaries, and pious Sisters as angels of mercy.

Over the last century, science and technology changed hospitals from places of suffering, grief and death, to places of hope and new beginnings; from dreary Spartan wards for the dying, to plush private suites for the soon to be healthy; from whispered footsteps in the twilight, to shiny instruments of mechanical shops; from final moaning and groaning, to humming of machines and laughing soundtracks of sitcoms punctuated by shrill alarms and flashing lights. Dying in a hospital is now considered a failure of sorts, a preventable and costly mistake. There is no place for God in a modern hospital, and there is no place for special emissaries or angels. And when God vacates the premises, big business comes in to take His place. Today’s technology driven medicine is shaped by young and invincible entrepreneurs, in search of fame and fortune. Masters of their own fate, bursting with self-quantified health, brilliantly educated in the intricacies of computerized logic, armed with stacks of data points, and carefully clad in black turtlenecks, hoodies, tee shirts and designer jeans, these modern knights of the business round table are engaging in the timeless quest of vanquishing death, or at the very least making it less expensive for the rest of us.

So where does all this leave primary care? Primary care is now considered routine care; routine, like changing oil on an automobile. Sticking a needle in your arm so you never, ever die from a plague is no longer a miracle, just like switching the lights on, or flushing the toilet is no longer deserving of thought. Miracles only happen in hospitals now, and not very often either. Primary care doctors are increasingly banned from hospitals, and asked to stick with routine care and leave the complex stuff to their betters. And primary care doctors agreed to this arrangement, mostly voluntarily, and explained (mostly to themselves) that routine care nowadays is pretty complex on its own, and arguably even more complex than the narrowly specialized interventions occurring in hospital settings. Maybe so, but routine complexity is what technology entrepreneurs eat for breakfast. Terminology is important.

When health care reformers say that primary care is foundational to reform, they mean routine care. They mean vaccines given on schedule, screenings done on time, lifestyles assessed and documented, educational materials handed out, and referrals coordinated to completion. They mean managing populations, stratifying risk, conducting outreach, dotting every BP and crossing every A1c. Welcome to Lake Wobegon primary care where all patients come in correctly diagnosed and ready to be tracked. These things can be automated with the right technology and properly trained teams of workers, supervised by medical professionals providing spot checks and quality assurance. High tech and high deductibles will combine forces to turn routine primary care into the first medical service to become a retail product, with its Med Emporium, Osler 5th Avenue, and eventually, Hello Kitty Diabetes toolkits sold at Amazon.com. The question is no longer how to stop the train; the question is where primary care goes from here.

Let It Go!

When primary care physicians became overworked and underpaid, something had to give. Inpatient care, arguably the high end portion of practicing at the top of one’s medical license, was snatched away by hospitals oblivious to their mission statement, and a good portion of complex care had to be offloaded to secondary care, just so primary care can keep up with demand for routine care.  Primary care became literally broken, and with it, the entire system downstream was broken too. In a fool’s errand type of strategy, routine primary care now includes tasks aimed at gluing primary care together again (e.g. transitions of care management, exchange of clinical information across facilities). Furthermore, routine care is being expanded to include things previously in the purview of public health (e.g. health literacy, physical activity, safe sex), stuff that grandma used to do for us (e.g. eat your string beans, keep your hands out of the cookie jar) and new retail oriented things (e.g. online shopping, consumer experience, values and preferences).

Today, in a plot twist worthy of Beckett himself, tech entrepreneurs in concert with non-physician workers are vying for the business at the low end of primary care. The new routine care will be catalogued, standardized, sterilized, automated, delegated, computerized, transformed and reformed. If you hang on to it, it will drag you down to wherever it’s going. Let it go! Let it go to your “team” (read, staff), or (gasp) let it go to Med Emporium.

Insurers, who could not be made to understand the importance of continuous, comprehensive primary care, seem perfectly willing to support the low skilled, electronic strings and duct tape of the new and expanded routine care. If you have an entrepreneurial gene in your DNA, hire staff, promote your office manager to Chief Quality/Compliance Officer, your receptionist to Care Coordination Manger, the triage nurse to Director of Resource Allocation, and delegate the bejeebers out of your daily work. Become the CEO, and get a secretary (a.k.a. scribe), so you never have to click another box, or type another embarrassingly misspelled sentence. Double your patient population, and let your NPs see the f/u for diaper rash, sports physicals, strains and sprains, the new wave of statin seekers, and everything that your Director of Resource Allocation deems routine.  Grab the fluctuating 25% or so of patients that are most complex and be their Comprehensivist.  Hospitals are routinely inventing specialties, from hospitalists to intensivists to nocturnists, to further fragment continuity of care and increase profits. It’s time to learn from the experts.

Instead of waiting for the System’s other shoe to drop (on your head), proclaim yourself a specialist in the absolutely last remaining piece of what was once primary care. Grab it and hold onto it like dear life, because it will be nibbled on from below and from above incessantly. You will have to compete with the low prices of Med Emporium on one hand and with the natural expansionist tendencies of hospitals on the other. You will have to find a way to get paid for your new specialty services, and just like every other entrepreneur, you will have to take risk; the more complex the patients are, the bigger the risk and the larger the rewards. Fortunately, the new health care law encourages precisely this type of advanced payment models. Go for it! Spend a leisurely hour with each patient needing comprehensive care, while your routine side of the business is humming along on its own.  With proper planning, you can collect the customary and usual fees for your greatly expanded panel, plus the special fees for Comprehensive care, plus any shared savings you can generate from keeping these select folks out of hospitals and emergency rooms. You’ll have to do a bit of marketing and engage in some creative contract negotiations (get a lawyer), but the sky may very well be the limit.

Don’t Let Go!

What if you have no entrepreneurial markers in your DNA? What if the previous few paragraphs made you sick, depressed or really angry? Fortunately, Obamacare is on your side.  For all the docs who argued that health insurance destroyed the doctor-patient relationship because it inserted itself in the payment process, and for all those who argued that insurance should not pay for routine oil changes, this is your lucky day, because it doesn’t anymore. With the exception of the very poor and the very old, people will now need to pay for primary care out of their own pocket. That’s what high deductibles mean. A good portion of these people will become savvy shoppers and choose the technology enabled do-it-yourself method, or go to Med Emporium on an as-needed basis, but there will be more than enough patients (perhaps in higher income brackets), seeking quality over cheapness. The same folks that buy artisan bread and free range eggs from local farmers will bring their family to you, if you promise to provide hand-made wholesome and holistic primary care.

Direct primary care, whether concierge, or ideal or micro, or contracted by employers and even forward thinking insurers, will most likely explode in size during the next decade. There is a huge continuum of service definitions here, and you should be able to find your comfort zone. You can go back to being a country doctor in the midst of a bustling metropolis, and care for multiple generations at home, in clinic, at the hospital, nursing home and eventually hospice. You can dial back a little bit, or a lot, and contract with midsize employers to provide outpatient primary care. You can be a high-tech, electronic-everything doctor, or an old fashioned one, or perhaps a unique combination of both.  Here too, the sky seems to be the limit.

So what’s next for primary care? It seems that for physicians, the door is closing on the treadmill now known as primary care practice, but countless windows are being opened simultaneously. You just have to look up and find yours. Whether you choose to stay in the system, step half way in and half way out, or do it your way all the way, there will always be a need for good doctors. Whether you choose to run the patient mills at Med Emporium, or run your own exquisite Osler 5th Avenue, or start the Hello Kitty Diabetes Company, or care for people slowly and thoroughly, one at a time, from start to finish, primary care may just be the best place to be in right now. You should be thankful this week, because the best is yet to come…

The Upcoming Bipartisan, Bicameral, Doc Fix

The Sustainable Growth Rate (SGR) formula was enacted into law in 1997 to tie Medicare payment for services to physicians to the overall status of the economy. Basically, if the U.S. Gross Domestic Product (GDP) does well, doctors get more money, and if it does poorly, doctors get less money for the same service. A decade of tinkering with legislation for circumventing the application of the SGR formula, preferably a few days before or after it was due to take effect, resulted in failure to save $150 billion dollars over the last decade. For the next decades, the Congressional Budget Office estimates that avoidance of the SGR formula will fail to save us a mere $139 billion, so this should be a perfect time to let bygones be bygones and come up with a more gentle strategy to cut physicians’ Medicare reimbursement. More gentle, because if we do decide to cash in on our SGR savings on January 1st, doctors are looking at an approximately 24.4% cut in the Medicare fee schedule for 2014.

Building on H.R. 2810, the “Medicare Patient Access and Quality Improvement Act of 2013” approved by the House Committee on Energy and Commerce, the new proposal to fix the SGR comes from the House Ways & Means and Senate Finance Committees with support from both Democrat and Republican members, hence the bipartisan and bicameral labels. It is currently in draft form and it is open for public comment until November 12, 2013. This is a short document, and you should read it before it’s transformed into a 1000 page cleverly titled Act. The idea behind the proposal is very simple, and it is widely used in other service industries, where patrons pay a base price for the service, and discretionary bonuses, gratuity, or tips, are available to service providers based on quality of service. There is a small difference though, since the proposal is supposed to be budget neutral (i.e. a zero sum game). Thus, a sufficient number of physicians will need to be penalized to balance the bonuses awarded to better performers.

Below is a simplified summary of the eight point proposal to repeal the SGR, and replace the straight fee for service payment system with quality adjusted risk-based contracting:

• The Medicare physician fee schedule will be (sort of) frozen for the next 10 years. After 2023, the fee schedule will be adjusted upwards by 2% annually if you take risk for your patients through an advanced alternative payment model (APM), or just 1% annually if you don’t.
• The heart of the proposal consists of bundling the multitude of incentives and penalties currently enacted by CMS, into one Value-Based Performance (VBP) Payment Program, beginning in 2017. It’s not that you won’t have to report quality measures or be a meaningful user, you will have to do those things and more, but there will be a single aggregate score to trigger incentives/penalties, calculated as follows:
• Quality Measures reporting – exactly what you think this is – Weight 30%
• Resource Use – similar to the CMS Value Based Modifier initiative, with an added requirement for claims self-reporting (subject to payment reduction) – Weight 30%
• Clinical Practice Improvement Activities – basically patient centered medical home (PCMH) or patient centered specialty practice (PCSP) certification – Weight 15%
• EHR Meaningful Use – it seems that all that is needed here is the use of a certified EHR – Weight 25%
• Practices that have very few Medicare patients are exempt and practices that have significant revenues in at-risk contracts (see below) are excluded from the VBP program. This is a budget-neutral item, meaning that high performer bonuses are directly proportional to the number of penalized poor performers. The pool available for bonuses starts at 8% of the total physician payments in 2017 and increases in subsequent years.
• Since the stated goal of this permanent SGR fix is to eliminate fee for service, an additional 5% bonus will be made available to those who have significant revenues tied to at-risk contracts. The thresholds begin at 50% and go up to 75% revenue. Both Medicare and commercial payer revenues can be counted for this purpose. It is interesting that the thresholds are for revenue, not patients, and it is also interesting that private payers can be counted, although it is not clear if the bonus is 5 percent of Medicare payments, or 5 percent of all payments. A seemingly simpler alternative to obtaining the 5% bonus is to have a “significant share” of revenue in a patient-centered medical home (PCMH) model that has been “certified as maintaining or improving quality without increasing costs”. This will require some explanation in the final bill because PCMH is usually not tied to revenue shares, and because I am not aware of anybody with the ability to certify that a certain PCMH model will increase quality, but not costs.
• For those practicing in a PCMH, or a comparable specialty model (e.g. PCSP), special care coordination codes will be created. The description here sounds very similar to the new Transitional Care Management CPT Codes following hospital discharge. Note that payment for these codes is also budget neutral within the physician fee schedule, so for each care coordination code paid out, someone or something else will be paid less.
• Along with ending fee for service, the proposal will also improve the fee for service schedule, by thoroughly evaluating and “identifying and revaluing misvalued services” to facilitate “smooth downward payment adjustments” The yearly downward target is 1% per year, and if not enough misvalued services are identified, the entire fee schedule will be revised downward by the missing amount. If more than 1% reduction is found, the funds will remain in the budget neutral pool to offset bonuses and other changes.
• The proposal will also ensure that physicians practice medicine correctly. Mechanisms will be put in place to make sure doctors consult appropriate clinical decision tools before ordering “advanced imaging and electrocardiogram services” (no idea why electrocardiogram of all things is specified here). The “tools” will report back to the Secretary of Health and Human Services that such consultation occurred prior to ordering. “Payment would not be made for the advanced imaging or electrocardiogram service if consultation with appropriate use criteria did not occur.” Physicians found to order too many of these services will be required to obtain prior authorization in the future. If things go well, other services will also become subject to appropriate use surveillance.
• To support all these activities, qualified entities that are receiving Medicare and Medicaid data for public reporting, will be authorized to sell analyses and reports to physicians, as well as commercial insurance companies and employers too.
• Transparency will be facilitated by publishing physician payment and various performance metrics measured through the program, so the public can search for physicians by name and get all the data they need to select providers.

Bottom Line

Although right now this is just a proposal, it is very likely that sometime around January 15, 2014, this, or something very similar to it, will become the law of the land. For small independent private practice, the increase in bureaucratic burden will be significant and the reach of insurers into your everyday work will become palpable. Noncompliance with the new regulations means that your topline will remain flat for the next 10 years, minus any penalties, rejected claims and downward adjustments, which may or may not be significant depending on your specialty. Initially, this may only affect the Medicare portion of your practice, but it will not remain that way for long.

If you want to continue practicing medicine and remain independent, you have three basic choices: 1) Join a larger entity, such as an accountable care organization, and accept risk for most of your patients in a managed care environment; 2) Adapt to the new paradigm by getting yourself a certified EHR, obtaining PCMH recognition, and learning how to practice under increased supervision; and 3) Stop accepting insurance and switch to a direct pay model. Since the program is slated to begin in 2017, you have 3 years to make an informed decision.

3 Reasons Why I Don’t Like Obamacare

If you are a staunch conservative who believes that free markets should solve health care, or that poor people should work harder and have more skin in the game, or that governments should stick to building armies, you don’t need to read this post, unless of course you enjoy being aggravated by clueless liberals.
If you are one of the talking heads posing as a progressive, while repeating the empty slogans of Obamacare (e.g. no one can be denied care any longer, children under the age of 26 can stay on parents’ plans, not perfect but a good a first step, etc.), you should probably not read this either, because you are far beyond the point where independent thinking is an option. If you are none of the above, and have a few minutes between updates on the completely irrelevant status of the Obamacare website, you may want to read on.

Obamacare Strengthens Medicaid

Medicaid is the public health insurance plan for the poor. Medicaid’s continued existence is an affront to human decency. Unlike Medicare, Medicaid is administered by the States. Subject to certain minimums, the States get to decide what medical services are covered, which medications are on formulary, how much money hospitals and doctors are paid, and who is eligible for Medicaid in the State. Some States have the gall to run lottery systems for choosing the lucky poor that are covered by Medicaid, while others have first-come-first-served brief enrollment windows. States are at liberty to decide that they will not cover certain conditions and certain medications, or other therapies, not because these are medically unsound, but just because they can. People on Medicaid have a Medicaid insurance card to let every hospital and every doctor know that they are poor, and that services will be reimbursed with peanuts, if at all. Obviously, many physicians do not accept Medicaid.

Having poor people segregated in a defective insurance plan, separate and hardly equal, should be no more acceptable than any other form of segregation. Medicaid needs to be dismantled and all beneficiaries along with all the funds, including States responsibilities, should be funneled into Medicare, the Federally administered insurance plan, for those who cannot, or will not, purchase private insurance. Instead, Obamacare pours billions of dollars into keeping Medicaid alive on one hand, and privatizing its operations on the other (e.g. managed care, health exchange vouchers, etc.), with a net result of transferring a few more Medicaid cents from health care delivery to private corporations.

Obamacare Voucherizes Health Insurance

The Obamacare health insurance exchange is a marketplace where individuals and small businesses can shop for insurance plans that meet new minimum standards. The plans are sold by private insurance companies, and a formal exchange is needed because Obamacare will pay the private insurance companies a portion of the premiums. The Federal subsidy, or voucher, amount is calculated based on means testing. Those who are poor (but not poor enough for Medicaid) will receive a larger voucher than those who are better off financially. This is in effect a progressively defined contribution. Let’s illustrate this with an example. Say the Jones family, which is not completely destitute, received a $2,000 premium discount. Mrs. Jones goes and uses her brand new insurance to have a mammogram which according to the law carries no cost sharing. Say they find something that should be biopsied. This procedure is subject to the Jones family deductible. If the Joneses have the cash to pay for everything until the out-of-pocket maximum is met, Mrs. Jones will get the treatments she needs. If they don’t have the money, the story will have a different ending. So the benefits are not predefined, but the contribution is. This is the definition of a voucher.

Obviously, if this is good enough for the federal marketplace, it should be good enough for the employer sponsored group market as well. Private exchanges, where employees get a fixed voucher contribution, are already operational and will most likely flourish in the future. I haven’t heard of any pay increases for workers sent to private exchanges to “shop” for a plan that best fits their “needs”. Eventually, as the contributions fail to keep up with costs of care, all health insurance will become just catastrophic insurance. And as middle class wages keep going down the drain, catastrophic insurance premiums will inch up, because those who cannot afford routine care will be experiencing lots of catastrophes. If you want to talk about death spirals, this is a perfect time to do so. 

Obamacare Creates a Tiered Medical System

Much has been said about the transparency of the health insurance marketplace, where for the first time people can get clear information about health plan choices and make apples to apples comparisons. Well, it’s not really the first time, but it helps that plans are labeled by actuarial value, and it helps that there are navigators helping folks make sense of a very complex transaction. However, while you can get information on the costs of insurance, there is no information about the product itself. Health insurance is basically a financial arrangement for paying for health care. Health care is the actual product being bought. Unless we believe that health care is a commodity, then in order to evaluate the product, we need to know who is delivering care. I’m not sure if shoppers on the marketplace are aware of the fact that the financing instruments they are purchasing on the exchange will only work with increasingly narrower networks of health care providers. 

This is similar to buying a new television set, hooking it up and finding out that it can only receive and display channels 501 through 550. You may get lucky and these are the channels you watched anyway, or maybe these are very good channels, but then again you may not be so lucky. Now, there is nothing inherently wrong with selling TV sets that have limited channels, if people want to buy them, but there is plenty wrong with purposely hiding this particular information from buyers. And there is plenty wrong with a government advertising free and discounted TVs that have bigger screens and better picture than your dinky old TV, without telling you that you may not be able to watch premium channels on many of them.

Of course, if this little marketing maneuver works on the federal exchange, it will quickly spread to the private group exchanges, and soon we will have clinics and hospitals for the well-heeled and larger institutions for the shoeless. It’s anybody’s guess where the better doctors will be found. No, not really. Narrow networks are designed by insurance companies to put pressure on physicians and hospital to lower their charges, either for the sheer privilege of being in-network, or for the additional promise of filling out all seats, with plenty stand-by customers, just in case. This is strictly about money, and has nothing to do with excellence or quality. Exclusive networks of high quality delivery systems are usually more expensive (see Kaiser plans in California).

So basically Obamacare is taking another step towards privatization of health care financing, and the inequitable distribution of resources inherent to private markets. Some conservatives became concerned that if Obamacare does not work as expected, the progressives will have a field day instituting single payer in its place. I wouldn’t worry too much, because Obamacare is great for those who extract profits from health care, and they won’t let it fail. Besides, progressives have lost their way long ago, and single payer is not in the cards for the foreseeable future. If it were, the Obamacare bureaucracy nightmare would have been replaced by folding Medicaid into Medicare, and the insurance marketplace would consist of Medicare, and its defined benefits, as the only game in town for all.

So if your beliefs are on the conservative side, you should support Obamacare. You may have to wait a few years, but it’s going where you think it should go, where the Heritage Foundation wanted it to go. If you happen to be a liberal, and feel compelled to support an embattled President, just because he is better than the alternative, remember DOMA, GLBA and PRWORA. Were you cheering for Bill back then too?