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Archive for February, 2010

We are the problem … and the solution

An article, Cost of Doing Nothing by Reed Ablelson in this morning’s New York Times, illustrates clearly why no matter what happens in Congress over the next few weeks our Health Care will never be the same. Our current system is simply unsustainable and incremental changes have done nothing to curb the escalation in health care costs. It is apparent that large changes are coming. The question is not if but when and by whom? 

I was struck by how much blame each of us carries in this dilemma. Most physicians in this country are payed by what they do, not what they produce. As a result we are all under pressure to bring in enough income to pay our nurses and staff. Estimates vary but most primary care physicians (of which I am one) need to post at least $400,000 – $600,000 a year in order to make ends meet (staff, malpractice, lease, equipment, supplies, etc.) and even then profit margins are very slim.
In large multispecialty groups where salaries are often calculated by Relative Value Units (RVUs), physicians need to crank out 5-6,000 units just to break even. What’s insidious is that a physician will tally up more RVU’s for procedures than brain work. So it’s much simpler to do something to a patient than work with the patient … a lot simpler and a lot more profitable.

This has led to serious shortages of primary care physicians and an abundance of specialty physicians partially due to the high cost of medical school, the need for repayment of student loans and prestige that comes with disciplines with high revenue potential.
We physicians have lobbied heavily to keep our costs from dropping, forcing Congress to delay each year the implementation of the Sustainable Growth Rate formula that was voted into law in 1992. These small, yearly decreases in payment have gradually accumulated to where a massive 21% cut in Medicare payments is scheduled to go into effect this coming Monday, March 1, 2010 (was to have taken effect January 1 but Congressional action forestalled it until February 28 and will be in effect barring further action by Congress). The AMA is confident that emergent legislation will prevent these cuts from taking effect and forestall them yet another year and CMS is holding payments for 10 days to allow action to take place. Physicians have seen real reimbursement declines in the face of increasing costs everywhere else so the net effect of inaction might be to further reduce the access of patients to physicians.

Eventually, the system will collapse and the results will be catastrophic not only for physicians, their offices and staff but for Medicare patients who may not be able to get in to see a physician at any costs because doors will be shut to them as it is to many Medicaid patients around the country.
Physicians can still afford to do this because there are enough privately insured patients to generate the revenue needed to keep their doors open for now. At some point this house of cards crumbles.

We patients are also to blame. In the last 20 years we’ve seen an ever increasing cost of health care diverted towards chronic diseases that are in large measure preventable. Obesity, diabetes, high blood pressure, coronary artery disease and many forms of cancer can be directly linked to lifestyle choices.
In addition we choose ignore “natural” ways of preventing diseases through immunizations and dietary changes.
When we hurt our backs we refuse to go to physical therapy and instead insist on medications, MRI’s and even surgery when the evidence points to better results with simple physical therapy.
We patients insist on antibiotics when we feel bad even though repeated studies have shown for many of these conditions we will get better faster without them.
It is infinitely cheaper to stop smoking and avoid lung and heart disease than to pay for cigarettes, medicine and procedures. Yet we complain about the cost and effort involved in smoking cessation programs (even though they are less expensive than the monthly cost of a pack-a-day cigarette habit).

And it’s worse when we’re healthy! We often choose not to purchase health insurance, which only drives up the cost of health insurance for everyone. If only sick people purchased health insurance it would be more costly than medical care (providers of health insurance have the cost of medical care, their own business and profits to shareholders to address). Insurance only works when a critical mass of enrollees never utilize their insurance.
And then there’s politics. The cost of being a politician by its vary nature will prevent the politician from making the hard choices. It’s simply much easier and less costly for supporters to pull funds from anyone making a hard decision since most hard decisions adversely affect a critical mass of supporters in the short term.

So what are we to do? Well, for one we need to act because no one else is going to.

For my own part I have resolved to be a role model for my patients. I am trying very hard to make the decisions I ask my patients to do. My diet has changed as have my exercise habits. In addition I have started listening more to my patients (it does adversely affect my income potential for the organization for whom I work). I make sure that each hour an appointment slot is left open for same-day appointments. I have encouraged patients to log into our web portal for routine things that can be treated without a face-to-face visit. I’m using this web portal to communicate directly with patients instead of having protecting myself from them using the phone triage, nurses and other barriers. This lowers the number of staff needed to meet their needs and, yes, has the potential to increase my own work. We’ve stopped taking samples in our offices and are working with patients to chose generic medications wherever possible.

There are many other things that we’re going to try over the next year to continue to provide more value for a unit of cost and all of you are encouraged to suggest ideas.

As patients it is usually less expensive to do the right things. First, change our lifestyles to maximize our genetic potential. We do need to stop smoking. We do need to move rather than sit. There’s no reason we shouldn’t all be at our ideal body weight and should constantly strive to maintain that weight.

We do need to be proactive and strengthen ourselves to grow old rather than sit back and let it happen. We do need to leverage our own immune systems and get vaccinated (which is really the best natural approach to preventing diseases) not only for ourselves but for those around us. It is much less costly to get vaccinated than to get sick, no matter how minor that illness is. The complications from vaccinations are infinitely smaller than the complications from any of the diseases.

When we do get sick it is our responsibility to learn about our illness and help the physicians make decisions. It’s my experience that most bad decisions are made from lack of information than from malpractice. It is our responsibility to know what over-the-counter medications, vitamins, herbal supplements and our past medical histories. Make sure the physicians making decisions are aware of this. If the recommendation is something other than medicine we need to follow that advice (physical therapy and counseling are effective and even if they are not “covered” by most plans are the things that will cost you less in the long term). If medicine is prescribed we need to know the medicine and take them as directed along with redoubling our efforts to make the changes necessary in our lives to decrease the need for those medications.

We all need to purchase insurance. Purchase only catastrophic if nothing else so that we don’t wreck our lives, the lives of our loved ones or undermine public budgets when major illness or injury strike.

We all need to wear seat belts, stop driving under the influence of mind-altering drugs, alcohol or texting. We need to wear helmets on bicycles, motorcycles and other vehicles without roll-over protection.

We need to care for others and not be responsible for hurting others.

Finally, we need to begin rewarding those politicians who make hard decisions. We need to counter the fringes and participate in elections. Neither the left or the right are going to be able to solve our problems. The center will and we need to begin rewarding those who work with others and not those who are obstructionists.

The bad news? It’s always easier to do nothing and be a victim than it is to do something positive and avoid being a victim. But that’s what we need to do if we went to lower the cost of health care and become part of the solution, not the problem.

Ideal Exam Room: A Primary Care Physician’s Wet Dream

There’s
a certain irony in that the more specialized a practice gets the more
technology there is available to help the physician. A retinal subspecialist is
a good example where they have in office orbital CT scanners and a host of
other extremely expensive tools available for the physician’s use at the time
of the visit.  On the other side of equation the primary care physician
who has to deal with the entire body and mind is often left with only a paper
chart, a stethoscope and devices that haven’t changed much in 100 years to
study the patient, derive a diagnosis and treat the patient.  The stark
reality is that this is completely backward!  The physicians needing the
most technology are those who are asked to treat the most conditions.

What’s
silly is that by the time a patient is seen by the subspecialist the diagnoses
have already been made (usually by other physicians higher up in the tree) so
the need for extremely expensive equipment is superfluous and supports
subsequent specialized treatments.

It’s
my opinion that if technology was available at the front lines many diseases
would be diagnosed, caught and treated long before they require subspecialised
therapy or treatment.

We’re
all familiar with the Tricorder was suddenly available only the
subspecalists would be given them and the physicians who would derive the most
benefit would be prohibited from using them either by
cost or reimbursement.

There
are many devices such as a dermatoscope, tonopen, digital o
phthalmoscope, otoscope, not to mention digital scales are
available but outside the reach of most primary care physicians.  Yet, if
each exam room was equipped with these digital devices AND connected to their
electronic medical records many diseases that now are missed could be diagnosed
earlier, more accurately and treated at a much lower cost than they are now.

On
the pure information front, I find the time cost of logging into multiple
systems (our own EMR and those of nearby hospitals, reference labs not
interfaced without our system, imaging
centers, online reference sources such
as UpToDate,
ePocrates,
MDConsult
an
d a host of other tools that I wind up using in the exam room prevents me
from exploiting them in the typical 10-15 minute appointment. Even though
we’ve equipped the PCs in each exam room with 21” swivel monitors we find
there’s a lot of visit time that could be saved if the all of the information
needed at the time of the visit didn’t need to be navigated to.

When
not seeing patients I usually grab all of the computers to which I have access,
splay them up in front of me (including one of the units from the nearest exam
room).  Productivity increases
dramatically.  Most information
resources are at my fingertips in parallel rather than serially if restric
ted
to a single machine or reduced screen real estate.  This is exactly why traders in most brokerage houses sit
behind multiple displays in order to work.  Time is money and faster, better (well, maybe) are made if
one doesn’t have to
waste time navigating to that information.

So
what am I saying?  

I
am confident that if we would put the most technology possible into the hands
of front line physicians who have to address the broadest spectrum of patient
concerns we might be surprised at how much more efficient, productive and cost
effective healthcare would be.

So
one day I see myself practicing in a room with all of the tools at my and my
patient’s fingertips.  Any
questions could be quickly answered, the record would not have to be populated
with vague text but actual images of the pathology observed, sophisticated
imaging and testing could be accomplished at the point of care before the
patient left the room. The patient and I would have a very good understanding
of the next steps rather than waiting for all the ordered tests to come back as
the patient is sent across town f
or them, paying higher and higher prices the
closer we get to the definitive diagnosis.

And
then I
wake up only to have had a wet dream.  I have to return to the small,  cramped, jail-cell exam room with the
one computer and a variety of relatively low-cost analog devices and try to
answer difficult questi
ons. Often having to disappoint the patient by sending
them on to another person or facility to eventually get to their answers.