Sunday, April 26, 2015

Tara Reid And The High Cost Of Health Insurance

One of Ms.Reid's more demure photos.
This is a story about one of the largest health insurance companies in the country, the company's former chief technology officer, and the married executive's affair with a B-List actress. Blue Shield of California has filed suit against its former CTO, Aaron Kaufman, over improper charges he made on his corporate account, much of it spent to see his girlfriend Tara Reid. They claim he misspent over $100,000 in a job that he held for less than two years.

Mr. Kaufman is accused of spending over $17,000 to go to Florida to visit Ms. Reid, over $800 for one night at the W Hotel in Fort Lauderdale, and more than $1,300 for drinks at a nightclub in Hollywood. However it was a bowling party that really got the company's attention. Mr. Kaufman spent $879.84 at the bowling alley in which Ms. Reid was present. Ms. Reid, star of such seminal films like Sharknado 2 and American Pie 2, started acting inappropriately and passing around pictures of herself doing said acts.

Shortly afterwards, the executive's transgressions became public knowledge at the company's offices and Mr. Kaufman was fired on March 10. The company said that 75% of his corporate charges could not be verified as being legitimate.

This being America, Mr. Kaufman sued Blue Shield for wrongful termination. He claimed that he was let go right before he was supposed to receive his annual bonus of $450,000. He said he had to use his corporate card because he is currently going through a divorce and his bank and credit accounts have been frozen. Don't shed a tear for Mr. Kaufman though. He has landed on his feet quite nicely and is now executive vice president and chief product officer of a Las Vegas company called SocialWellth.

Blue Shield of California will also do just fine. In 2013 the nonprofit insurer made a net income of $171 million. Its top ten executives together earned over $14 million. You just have to wonder how many shenanigans are going on with the company's corporate accounts if one person can ring up six figure expenses after working only two years. How much of the escalation in insurance premium costs is due to corporate cover up of their profligate employees instead of rising medical costs like the company claims?

Friday, April 24, 2015

MOCA 2.0. Pay Now Rather Than Pay Later

The world of maintenance of certification as imposed by the American Board of Medical Specialties is facing a backlash as never before. Following the spectacular expose published in Newsweek about the greed and impropriety at the American Board of Internal Medicine, in which millions of dollars were paid out in executive salaries, real estate, and first class air travel, hundreds of doctors rose up in protest. In a surprising turnaround, the ABIM apologized for the excessive burden that the MOC has become and promised to reform the process.

Every physician wondered which medical board would follow the ABIM's changes. Now the American Board of Anesthesiology has decided that its MOCA program also needs to be changed. In an email to anesthesiologists yesterday, the ABA calls its new program MOCA 2.0.

MOCA 2.0 has several major modifications from 1.0. One of the biggest is the removal of the much despised simulation exam. This portion is hugely disruptive to most anesthesiologists, requiring them to spend thousands of dollars for the exam, travel to a simulation center, and time spent studying for and taking the test. It was one of the most divisive tests ever devised by the ABA and the ABMS, no matter how popular the organizations claim the simulations are. I count myself as one of the lucky ones who was first board recertified before the simulation was enacted and now it is being abolished before my next recertification. Hallelujah. There will be no tears shed for the end of this monstrosity.

Next, the recertification exam itself is gone. Can you believe it? No more exams again, EVER! Instead, the ABA has instituted an online program called MOCA Minute. Once a week, the ABA will post a question on its website that had the highest failure rates during certification exams. The user will have one minute to answer the question. If they answer the question incorrectly, there will be a brief explanation of the answer but it doesn't count against anything. No punishment. No repeating another question. The diplomate will have to answer 30 questions per calendar quarter or 120 per year. They can be bunched up together so one doesn't have to log in every week. But the ABA will only count 30 per quarter even if you answer more. This prevents people from doing all their requirements at the end of the year. The MOCA Minute does not replace the CME requirements that are already a part of MOCA or for your state medical licensure.

MOCA Part 4, or the Improvement in Medical Practice, is still evolving. This portion has always been nebulous in its requirements and implementation. They are withholding details of the new system for now.

Has the ABA also changed the cost of participating in MOCA? Yes and no. Thousands of dollars have now been saved by eliminating the simulation exam. But the ABA still expects one to pay $2,100 to be recertified. Instead of paying it all at once to take the exam, now they want to extract $210 every year for ten years. Credit cards accepted.

What hasn't changed? The need to be board certified by the ABA in the first place. Many lifetime certified physicians are still incensed that their certificates now read certified but not participating in MOC on the ABA's website, an asterisk in a perfectly legitimate career. Even these new changes will not appease doctors who feel any extra work to maintain their certificates is overly burdensome. These are the people who are flocking to the alternative certification program NBPAS. But for now, the removal of the recertification exam and the simulation is a huge step forward. Hopefully the ABA will continue to be responsive to the outcry of its members for simplification of a process that has huge implications for their livelihoods.

Wednesday, April 22, 2015

All Work, No Pay

Here are the latest numbers for anesthesiologists' salaries as compiled by the physician placement firm Jackson & Coker. This is based on the income of over 31,000 anesthesiologists that the company his hired out.

The average annual salary is $355,413. The average benefits is $71,083. This produces a total compensation of $426,495. Hospitals can afford this income because an anesthesiologist brings in an annual revenue of about $1,352,120.

When calculated on an hourly basis, the average anesthesiologist earns $171. Add in the benefits and the average total compensation works out to $205 per hour. An anesthesiologist will bring in revenue of about $650 per hour.

It's easy to see that anesthesiologists bring in a lot of money to hospitals. Meanwhile, despite all the hard work and potential medical malpractice, about two thirds of the money goes to somebody else besides the physician. That speaks volumes about the state of medicine in the country today.

Tuesday, April 21, 2015

The 2015 Medscape Anesthesiology Compensation Report

It's that time of year again. Medscape has released its annual physician compensation report for 2015. Full disclosure, I participated in the survey but again I didn't win the prize for filling out the poll. Darn you Medscape. This year there were nearly 20,000 doctors who joined the survey and about 1,200 of them were anesthesiologists. As a comparison, there are nearly 65,000 practicing anesthesiologists in the country so take this small sample size with a grain of salt.

So how much money did anesthesiologists make last year? Drum roll please. Aaaand the answer is--we are doing pretty darn good. Medscape found that the average anesthesiologist made $358,000. That is up 6% from the previous poll. We came in fourth place amongst all physicians, trailing only the orthopods, cardiologists, and gastroenterologists.  This is better than last year when we came in sixth place, following urologists and radiologists too.

If you're looking for the most income, being self employed is where it's at. Male private practice anesthesiologists made $420,000 and females made $362,000. If employed by a hospital, the income drops to $328,000 for men, $289,000 for women. That is a significant difference in anybody's book. Why is there such a large difference between men and women? Is there gross sex discrimination in the anesthesia workplace? Part of the answer maybe that twenty percent of the female anesthesiologists said they work part time while only eight percent of the men did. Pay commensurate with hours put in, the great American way.

The location of the job also figures into the compensation. A single specialty group practice anesthesiologist made the most money, averaging $429,000. Meanwhile if one worked in an outpatient clinic, the income falls to $316,000. The least compensated anesthesiologist works in an academic institution, pulling in an income of only $247,000. It also helps to work in the South Central states like Texas and Oklahoma. The chintziest states are located in the Northwest and Northeast.

With our rising incomes this year, are anesthesiologists happy with their profession? Survey says 53% of us are satisfied with our jobs, about middle of the pack of all physicians. Forty nine percent of anesthesiologists said they would do the same thing all over again. The most satisfied physicians not surprisingly are dermatologists, where 73% said they would choose the same field. This is a number that is far and away much higher than any other specialty. The least happy doctors are, unsurprisingly, internists. Only one quarter of them would choose to do the same thing over again. Sad that so many doctors out there are not doing a job they love.

In summary, anesthesiologists who filled out Medscape's survey made more money this time than the last one. We're still satisfied with our jobs. And we're very glad we didn't go into Internal Medicine. Hopefully this will provide additional incentive for all the medical students who just matched into an anesthesiology program.

Sunday, March 22, 2015

No Match Day For Law Students

Another year, another Match Day has come and gone for our nation's medical students. This is the moment every medical student looks forward to as he or she powers through another sleepless night of study and clinical rotation. The exhausting work all becomes worthwhile when the soon-to-be physicians are told where they are going to be working for the next several years. Cheers erupt. Champagne, or beer, is consumed. Everybody gets a slap on the back as the end to medical school is finally in sight.

Meanwhile, our professional colleagues over at the law school next door don't get quite the same exaltation. Many of them will not have a job when they finish school in just a few short months. In fact, quite a few were probably deceived by their own schools in the beginning when they advertised the job placement success rate of their graduates.

The U.S. News and World Report has ranked law schools for years. One of the criteria is how many of the graduates have jobs after graduation. The definition of jobs has proved to be slippery. At first, the schools counted any jobs held by their graduates as a success, whether it was negotiating international contracts for a Fortune 500 company or slinging hamburgers at McDonald's. Once that deception was discovered, the magazine tightened up eligibility so that only jobs requiring a law degree were counted. This dropped the employment rate of 2011 law school graduates to a shockingly low number of 55%.

Now another law school trick has been uncovered. Many students are still not able to find jobs that use their expensive degrees. So the schools are paying employers to hire their graduates. The schools subsidize the employers up to $4,000 to hire their students for one year, which conveniently falls within the guidelines of meaningful job placement of nine months that the magazine uses. This helps both the students pay off their school loans and increases the status of the school in that precious rankings list. News of this manipulation has caused the the American Bar Association and U.S. News to deemphasize jobs that the school purchased for their graduates.

How big of an affect will this new criteria have? At some schools, it will make a huge material difference. George Washington University law school reported that only 469 graduates of 603 students from 2013 had a job requiring a law degree nine months after graduation. In other words, over twenty percent of their students couldn't find a job that utilized their expensive degrees at least nine months afterwards. Horrible numbers for any job. However now we know that 88 of those jobs the students held were actually sponsored by the school. So the under employment rate for GW law school graduates is in reality almost 37%. If a school advertised that 37% of their graduates won't be able to find a meaningful job after graduation, do you think anybody will apply there?

What's worse, GW subsidized the employers $1.8 million to hire their graduates for one year. Guess who has to pay that money? Not the school or their faculty. That money is surely factored into the expensive law school tuition of the students who are still in the classrooms. These kids are heading towards a brick wall at graduation while paying to take care of older students who have already hit that unemployment wall.

George Washington University isn't the only law school to manipulate its numbers. Similarly, The College of William and Mary and Emory University also pay for the jobs of about 25% of their recent graduates. W&M used $814,000 last year to subsidize their students' jobs.

Of course the schools defend their actions in this deception. As the dean of GW law school, Blake Morant, puts it, "I tend to look at the program as back-end financial aid." It's a pathetic aid package being paid for on the backs of their new students.

So for all the medical students who have their new jobs all lined up starting in July, congratulations to all of you. Whether you got your first, second, third, or lower choice location, at least all of you will have a job following graduation. Your buddies who went into law school can only look at you enviously as they pour another Venti caramel latte behind the counter at Starbucks.

Saturday, March 21, 2015

Proof That Doctors Have Lost Control Of Medicine

I recently received this email from the California Society of Anesthesiologists. It's headlined, "Setting Up PQRS Reporting Through the ASA QCDR (NACOR)." Huh? What the hell did I just read? It looks like some toddler had just randomly lined up a bunch of alphabet letter blocks. Am I supposed to make sense of this?

Alas, these abbreviations are all important initiatives doctors have to know in order to receive their already compensation from the government. Medicare demands that doctors prove they are giving their patients high quality services or their reimbursements will be penalized. Thus we have the Patient Quality Reporting System, the Qualified Clinical Data Registry, and the National Anesthesia Clinical Outcomes Registry established by the American Society of Anesthesiologists. I won't even go into the details of TIN levels, NQS, or AQI.

This goes to show how inconsequential doctors now are when Washington makes healthcare policies. Medical students and residents are too busy studying real medicine. There are thousands of facts to memorize before one is conferred a medical degree. Yet they are taught none of these acronyms as part of their medical school curriculum. But these letters are actually more important to their careers as doctors than knowing which erectile dysfunction drug is the longest acting. No matter how smart a doctor you are, or how much your patients love you, the feds will cut your income unless you can document you are giving "quality" care. Quality as defined by them, not you, your colleagues, or your patients.

Maybe med schools should devote a semester to teaching future physicians about how to survive in a government run healthcare world. It will certainly be more practical and beneficial than memorizing the Krebs cycle.

Friday, March 20, 2015

The Anesthesia Standby

A gastroenterologist I was working with the other day asked me about Sedasys, the self administering propofol infusion pump. I told him that very few places have been using it even though it's been on the market for awhile. It doesn't provide very much sedation as the patient has to be alert enough to respond to the machine before it will continue the infusion. And when, not if, a patient goes into respiratory distress, who's going to be responsible for the airway. The GI doc?

He replied that since there are anesthesiologists working in other rooms at the surgery center, there will always be one around as a standby for an airway emergency. After all, no anesthesiologist will cruelly let a patient die if there is something he can do to prevent it, right? That would be completely unethical as a physician and against the principles of the Hippocratic Oath.

I was livid with anger. I just wanted to sock him in the jaw but that would be breaking my Hippocratic Oath. This guy was taking advantage of anesthesiologists to further his money grubbing career. Unfortunately, he's not the only one.

Our Cardiology department is notorious for using anesthesiologists only when they need somebody to save their butts. Too many times they decide they can't wait for an anesthesiologist to help sedate a very sick patient before starting their cardiac cath. Then halfway through the procedure, as they somehow start dissecting the left main coronary artery, we will get an emergency call for an anesthesiologist to come stat to the Cath Lab to intubate and resuscitate the patient. They know they can get away with this behavior because we oblige them time and time again.

Another recurring issue is the cardiologist who is too impatient for an anesthesiologist to become available so he can put in a pacemaker that was not originally on the surgery schedule. Even though he may be 45 minutes late on all his cases, if an anesthesiologist isn't ready when he is, he will take the patient into the room himself and start sedating with Versed and Fentanyl. When he starts digging into the left pectoralis to form the pocket, the patient becomes difficult to control because he's not alert but still not adequately sedated. Then the call goes out to get an anesthesiologist ASAP.

When I'm faced with a situation like that, I am always tempted to turn around and walk out. I have never met this patient before. The patient is already sedated and it will be impossible for me to get an adequate consent for me to give anesthesia. That's practically assault in the eyes of the law. Plus this is not an emergency procedure that I can attribute for lack of a consent. But my professional side eventually takes over and I help the cardiologist finish his case. Why? Because it would do nobody any good for the patient to not have his pacemaker put in. He could hurt himself by squirming around on the OR table and his pacemaker might not be positioned properly. Sigh.

It's infuriating that other doctors prey on the good intentions of anesthesiologists to further their own agendas. We are physicians too. We deserve the same considerations for establishing a proper doctor-patient relationship as other physicians. I will gladly do my share to help a patient who is truly in dire straits. But if the problem is created by another doctor who knows beforehand that there's a high likelihood that he may need the services of an anesthesiologist during a procedure and doesn't request one before the start of a case, what are my obligations to help him out? Sadly, I just bite my tongue and assist anyway I can until the patient is safely in the recovery room. Because as an anesthesiologist I will never abandon a patient to heartless doctors.