Tuesday, July 29, 2014

Why Pay For Performance Doesn't Work

The New York Times had an editorial the other day asking why the government's pay for performance initiatives haven't worked out as planned. By penalizing bad outcomes and incentivizing good outcomes, the government hoped to save money in the long run. Paying doctors to have fewer patients getting readmitted within thirty days after hospital discharge or making sure patients get the proper treatment for acute MI or pneumonia sounds like a reasonable way to reduce healthcare costs.

Yet according to the newspaper article, multiple medical studies have failed to show any change in outcome. Though initially there may be an improvement in quality measures such as patients getting adequate blood glucose monitoring, over the long term there are no differences between doctors who get incentive pay and doctors who don't.

Scientists and politicians are puzzled by this stasis. Why don't patients do better when doctors are given more money, or in reality penalized for not following "best practices" policies? The blame always seem to lead back to physicians. Doctors are just too stubborn. They won't change their practice after working the same way for decades. Doctors make too much money. A few dollars extra per patient is not enough to get them to follow the new government mandates. Doctors are cherry picking the best patients, leaving the sickest to the tertiary hospitals and their employee physicians to treat and who are the least likely to be affected by the new incentives.

I think the reason pay for performance hasn't worked as well as planned is also the most obvious. Let's face it, doctors are already working as hard as they can to give the best possible treatment to each and every patient we meet. We are not holding back our care just because we feel the reimbursements are inadequate, which they are. For any given patient and illness, we do our utmost to ensure the patient has a good outcome. Whether the patient is a homeless person who comes into the ER for an acute MI or the local millionaire who is fishing buddies with the city mayor who comes to the ER with the same thing, we treat each person's illness the same. Now the bedside manner and hospital amenities may be different between the two, but taking care of the chief complaint will be unsurprisingly similar. In fact, when I have a VIP patient, I have to mentally tell myself to treat this person no different from anybody else. Any deviation from my usual standard practice just because the person on the operating table is the mother of the hospital CEO is when catastrophe can occur.

What happens when the patients are discharged is something different and beyond the control of physicians. The millionaire may be able to afford a home health nurse who can attend to his needs 24/7. The homeless person will probably go to a shelter but quickly check himself out and stop taking his medications, necessitating a quick readmission in the emergency room. But that is not the doctor's fault even though we and the hospital are the ones who get money taken out of our pockets for it.

But don't concierge doctors give better care because patients pay them more money out of pocket? In a word, no. Patients buy better access to doctors in a concierge service. There is no evidence that concierge medicine is better medicine. Patients may feel they are getting superior treatment because they have their physicians' personal cell phone number and can arrange for an appointment at any time, but that is not the same thing as getting better health care.

So this puzzlement about why pay for performance doesn't seem to be effective is no mystery to any working doctor. Only the most cynical politicians and lawyers would devise these pay for performance initiatives. We are already doing the best we can with what we get. We don't mistreat patients just because they don't have enough money. Giving us more money is not going to change how we have practiced successfully for years. The people who are making these rules are the least qualified to tell us how to take care of our patients. Is it any wonder that P4P has been a failure so far?

Monday, July 28, 2014

Hell Hath No Fury Like A Cardiologist Scorned

"Anesthesia REFUSED to do (procedure)!! Refused to do it if we were in room with crash cart!!!!"

This was the note left in the patient's chart by the cardiologist the day after I canceled an elective procedure on an unstable patient. During the preop discussion with the surgeon and the cardiologist, I explained my reasons for why the patient was unfit for an elective surgery. The cardiologist's solution was that he would stay in the room during the procedure to monitor the patient and resuscitate him if he experiences sudden death. When pigs fly, I thought. Such arrogance. As if this cardiologist had ever responded to a Code Blue anywhere in the hospital in the past twenty years.

Though surgeons and other doctors may think otherwise, anesthesiologists give very serious thought before cancelling any case. It is a heavy burden that we alone have to make and it is usually not a very popular decision. The surgeon is raring to go, having scheduled this case weeks ahead of time. If he's not operating, he's not making a dime. The operating room usually has already opened the case cart and thus is ready to bill the insurance company for the equipment. The patient and his family have taken time off from work to prepare for the operation. So stopping an operation carries a lot of consequences for everybody involved, including the anesthesiologist. Cancel too many cases and you become an obstructionist. Have too many postop anesthesia complications because of poor preop assessment and you are labeled a cowboy, or worse, reckless. No, it's a very fine line we walk on every patient we meet.

The number one, and really only, reason anesthesiologists cancel cases is because of patient safety. This is absolutely the main purpose of our preop exam. Is the patient well enough to survive an operation? If for any reason we have our doubts, the prudent anesthesiologist will discuss his concerns with the patient and surgeon and explain why the operation should be postponed until the patient has had a more complete work up or optimization. Usually the patient will be sympathetic because it is his life on the table we're discussing. The prudent surgeon also listens to her anesthesiologist since our only goal is to provide the patient with a safe operation. Only the imperious ones fight us to continue the case. When they become nasty and belligerent, it makes it that much easier for us to cancel the case.

Can't the surgeon just ask for another anesthesiologist? Of course she can. And that is certainly her right to ask for a second opinion. The surgeon might happen upon an anesthesiologist who doesn't mind taking on a little more risk than me. Some anesthesiologists tolerate more risks than others, just like some surgeons will perform the most perilous operations on the least favorable candidates, cases that no other surgeon is willing to touch. But we are dealing with a human life here. If the patient and his surgeon are willing to take a chance on his life by finding an anesthesiologist who might give an anesthetic to an unstable patient, then that is the team's mutual decision. Hopefully the logic laid out in my note will be so overwhelming that no other anesthesiologist will dispute it. But if the anesthesiologist disagrees with my clinical judgement and proceeds, well that is his medical license and patient's life that is on the line, not mine.

So to the cardiologist who deemed me an obstructionist in writing on a medicolegal document, you can just shove it up your histrionic behind. I can sleep knowing I helped a patient that day from winding up in intensive care postop with multiple lines and tubes coming out of every body orifice, if he was lucky to survive the operation. Though he didn't get the procedure he was supposed to that day, my act of compassion by stopping the surgery will significantly increase his odds of survival the next time he comes down to the operating room.

Thursday, July 24, 2014

An Obama Visit Is A Public Health Hazard

President Obama is visiting Los Angeles again. This will be over a dozen times he's been here mainly to hit up millionaire limousine liberals in Hollywood for money. After so many visits, why are people still inexplicably giving thousands of dollars for a blue plate special at the local Beverly Hills hotel just to hear him speak?

Obama in L.A.
Every time he comes, the Westside of LA becomes a total traffic nightmare. Congestion is bad enough on a normal day. But when the president and his motorcade arrive, the Secret Service closes off the roads that they will be traveling. This makes the gridlock unbelievably agonizing. As a bonus, for security purposes, the SS doesn't tell anybody where the street closures will be so you don't even know which streets to avoid until it's too late.

While all these visits have been an aggravation and a nuisance, now it has risen to the level of a public health hazard. One of the blockades happened to take place near Cedars-Sinai Medical Center when a woman in labor needed to get to the Emergency Room. The presidential entourage wasn't even anywhere near that street yet but the security detail refused to let the woman cross the street to get to the hospital. The poor woman could not do anything about the situation and resignedly sat down on a sidewalk bench to wait for security to let her cross the road and deliver her baby safely.

We doctors already know the president doesn't have the best interest of the general population at heart. Obamacare was passed not because he cares about the health of his fellow Americans. It was done to gain votes for the Democratic party and to capture voters dependent on government largesse for generations to come. But this denial of one of the most basic needs, to deliver a baby, is beyond the pale. Who knows how many people with urgent medical needs like chest pain or shortness of breath were diverted to more distant locations because their local hospital was made inaccessible by this presidential visit.

I say Mayor Garcetti should refuse the president any more fundraising visits. The only people who benefit from his fundraisers are the millionaires who still flock to see him while the 99% of the rest of us just burn up more fossil fuels, vastly increase our carbon emissions, and get denied basic healthcare needs. No More Bama in L.A.!

Sunday, July 20, 2014

The Revolving Door Of Nursing Managers

Our procedure center is a pretty stable unit. We have employees who have worked there for ten to twenty years. We all know each other like family. We've seen each other's children being born, grow up, and graduate from school. It is a very comforting place to work.

But one position that seems to have constant turnover is our nursing manager. The nursing manager, as the title implies, manages the nurses' activities. She (they have almost always been she) makes the call schedule. She determines what time nurse comes in and when they leave. She makes sure the payroll is made out properly. She plots the yearly vacation schedules. She intervenes in interpersonal conflicts at work. In essence, the nursing manager is in charge of almost all aspects of the nurses' work.

Unfortunately this important position has seen a continual flux in our center. The problem, I feel, is that whoever accepts the job is not really in it for the long haul. Our nursing managers tend to view the job as resume padding, not the final role for a career well done. They always seem to be looking for the next rung up the ladder of their nursing career.

Because so many of them view this assignment as a temporary stop, we don't get the best people to help manage our busy unit. We basically get two types of personalities that accept this appointment. One is the politician. She is always on the go, attending every possible meeting she can to shake hands and have face time with her superiors so that she can get promoted as quickly as possible. Her office door is always locked because she is somewhere else cavorting with people who might give her the promotion she so desperately craves. The job of the nursing manager then falls upon the most senior nurse on the unit, who usually does a pretty good job as she's had to do this many times before.

On the other end of the spectrum is the micromanager. And this one is actually worse. The micromanager will do everything possible to demonstrate to everybody, especially her bosses, that she is fully in charge of the unit. Even if her decisions make absolutely no medical or common sense. For instance, one of our recent nursing manager's first executive decision on the unit was to reverse the order of the bed numbers in the unit. What used to be bed numbers one through ten became numbers ten through one. There was absolutely no reason to do it. It did not improve patient safety or increase the efficiency of patient care. On the contrary, for weeks afterwards people went to the wrong bed because everybody was so used to the old numbering system. But the manager showed that she was the boss and could make people do whatever she wanted.

Another time the nursing manager suddenly decided that every patient who went to the recovery room after a procedure needed to be hooked up to a transport monitor for vital signs during the short traveling distance, which is literally just down the hall. A defibrillator also had to accompany the patient each time. It didn't matter if the anesthesiologist was going with the patient or that the patient was stable, awake, and breathing room air after a short MAC case. The manager insisted that this was the new safety standard being adopted nationwide and we had to follow it. When the anesthesiologists objected, she simply ordered her nurses to put the monitors on the patients themselves. Needless to say, the nurses weren't terribly happy about this either since they were the ones who had to bring all those heavy monitors back to the unit after dropping the patient off in recovery. Many monitors were lost because of her new rules.

But like the weather in the Midwest, if you don't like what you currently have, just wait around a little bit and a new one will show up shortly. The average length of employment of our nursing managers is usually about eighteen months to two years. They have all gotten promoted to a higher position or have been fired unceremoniously after stepping on too many toes. We're still waiting for the one manager who can find satisfaction in her work without constantly longing for a higher position. I'm not holding my breath.

Thursday, July 17, 2014

In Remembrance Of Scott

I just found out my old friend Scott has died. When I got my medical school newsletter, I was shocked to find his name among the list of alumni who had passed away. It just doesn't seem right that somebody so young and vivacious could have disappeared at the prime of his life.

Scott and I started medical school together. He was tall, lanky, with a thick crop of curly brown hair and a deep husky voice. He was also a cancer survivor and one of the most interesting persons I had ever met.

We met each other through a mutual friend when we all decided to be roommates together. I didn't know him very well at the time. But Scott was easy to like. He had a ready smile and a very dry sense of humor. I've seen him annoyed but never saw him lose his temper. Whereas other medical students can be extremely competitive and cutthroat, he was much more laid back. He didn't get the best grades but he wasn't the worst student either. He just didn't take his studies as seriously as the rest of us. He wasn't the type to pull all nighters or dissolve into a morass of self doubt if he didn't ace an exam. He was even keeled when the rest of us were tossed around by our own storms of emotional distress. He knew there were more important things in life than getting straight A's and brown nosing the right professor for a research spot.

My friend also didn't hang out with the other med students much. Medical students can be quite insular and clannish. Instead Scott preferred the company of the music school students at the university. Because they were constantly coming over to our house, I got to know many of them. And they are VERY different from med students. The first giveaway was the alternative dress and piercings. And the tattoos. I don't think any medical student would be allowed in the hospital if they showed up looking so rebellious. But they were all very friendly and seemed to have a lot more fun than us. I could see why he liked to be around them more than with his own classmates.

Besides being more inclusive, there was another reason Scott enjoyed his time with the music students. They were heavily into marijuana. Nowadays, he could probably get some back alley "doctor" to write him a prescription for medical marijuana since he actually had a legitimate reason to take it. But back then, he was simply just another pothead who enjoyed a toke now and then.

He was the first person I knew who used marijuana routinely. He even offered me a puff one time, not in a pushy sort of way but because he knew I was curious. Unfortunately my strict upbringing caused me to pull back from the temptation. In retrospect it was probably a pretty lame choice. Even presidents of the United States now admit to partaking weed in their youths without any apparent consequences to their health or occupation. But I declined and he never asked again.

I was always afraid that when my parents visited they would see or smell the pot in the house. But Scott was very discreet. I never saw him stoned, staring into a lava lamp and uttering nonsense. He rarely smoked his marijuana or cigarettes indoors. He even kept his plants in his room well out of sight. No one would ever suspect he had a weed garden growing there. My parents were never the wiser.

Halfway through medical school, Scott's cancer came back. He had to drop out of school for over a year to start his treatments. Our little household broke up and we each moved on to different roommates and locations. I kind of lost track of Scott after that. But he did come back and complete his medical degree. He went on to train at a prestigious subspecialty in the upper Midwest and had a thriving practice afterwards. He got married and had several children before his cancer recurred one last time.

Thank you Scott for showing me how beautiful life is outside the confines of our parochial scientific institutions. You faced down your illness with a sunny disposition and never wallowed in self pity. I will always treasure how you opened my eyes to all the possibilities that exist if one is willing to step out of family and social expectations and lead a life of one's own choosing. You were truly an inspiration for my young, developing self. Farewell my friend, until we meet again.

Wednesday, July 16, 2014

Saving Medicare Becomes Doctors' Burden

The Congressional Budget Office released a new report yesterday and it was all good news for Medicare. According to the CBO, the government healthcare program for the elderly and disabled will remain financially solvent for five more years than previously predicted. Instead of going bankrupt in 2025, it is now going to fall into the abyss in the year 2030. Hmm, that's right about the time I'll become eligible for the program. But anyway, that's beside the point.

The reasons the CBO gave for increasing the longevity of Medicare aren't anything to celebrate though. The agency states that Medicare will be helped by a lower than projected rate of economic growth. Since people spend more on health care when their incomes go up, a worse economy will cause people to use less, thus saving the government money. Sinking the economy to improve a government program doesn't sound like such a great bargain in my opinion.

The CBO also says that interest rates are likely to fall since the economy won't be as robust as predicted. This will save the government billions in interest payments. I find this hard to accept since interest rates are already being kept at near zero by the Federal Reserve. How can the rates possibly go lower over the next quarter century? Even if they did fall from its current miniscule yield, I'm not sure how much money the government will save if rates fall from 0.25% to 0%.

Then the agency gives the healthcare industry a kick in the guts when it finally states what will help keep Medicare solvent for the next fifteen years--lower payments to doctors and hospitals. It is counting on Congress holding the line on sustainable growth rate reimbursement cuts to take place next April. That means a 24% chop to doctors payments unless they do another doc fix. According to the report, "Evidence suggests that hospitals and other providers may be able to achieve significant productivity gains or to restrain the growth of their costs in some other way."

In other words, work harder, make less money. They are projecting the number of patients using Medicare will increase by the millions every year for the next fifty years. However they are counting on doctors seeing all those new patients for the same amount of money they are getting now. The best deal the AMA could get to fix the SGR formula last spring was for reimbursement increases under the level of consumer price inflation for five years then a pay freeze for the next five. Even with defeatist negotiating tactics like that, the AMA still couldn't get Congress to pass a doc fix, which both political parties pledged they wanted.

So if you think you are working to the point of exhaustion already, the federal government has news for you. This is the golden age of healthcare reimbursements for doctors and hospitals. The situation is likely to deteriorate badly in the near future. And if doctors don't accept their duty to see patients for whatever price is dictated to them, then they will be the ones responsible for the eventual bankruptcy of Medicare.

Thursday, July 10, 2014

Why Being A Doctor Is Better Than Working For Silicon Valley

Click to enlarge to appreciate the enormity of anesthesiologists' salaries.
This graph has been making the rounds on the internet for the past week. It illustrates the best paying jobs in America as reported by the Bureau of Labor Statistics. I made a screen capture to show only the top 25 or so occupations. To see the entire list of 820 job classifications, go here. According to the BLS, anesthesiologists earned the highest salaries in the country with a median income of almost $240,000 per year. This was followed closely by surgeons, oral surgeons, OB/GYN, and orthodontists. In fact, of the top 15 highest paid jobs, only two (chief executive and petroleum engineer) are not healthcare related. It is interesting the the federal government doesn't specifically mention highly paid specialties like neurosurgery, orthopedic surgery, or gastroenterology. If they did, the top fifteen would all be medically related professions.

Even though doctors are listed by the federal government as having the highest paying jobs in the country, we can't help but read about and envy all those young punks who barely graduate from college and become instant millionaires working for some flash in the pan internet company. It's just innate human nature to think the grass is greener on the other side of the 101 freeway. But the reality is that striking it rich in Silicon Valley is more akin to winning the lottery. The vast majority of workers in the tech industry toil away in anonymous cubicles for electronics companies that may never go public. Most of these kids will never cash in on a headline grabbing IPO as their companies labor to attract eyeballs and in-app purchase money 99¢ at a time. Worst of all, the longevity of a career in computer science can be extremely limited as the next crop of graduates who have been trained in the latest technologic innovations quickly supplant the previous years' workers with their eagerness, energy, and knowledge.

By contrast, nearly everybody who finishes medical school is virtually guaranteed a six figure income right after residency. Unless the physician dedicates his life to research or charity work, it is almost a certainty that he will land in the top reaches of the BLS salary list. Now this elevated income comes only after years of training, high student debt load, and delayed gratification. But it is there for everybody once the grueling process to become board certified is completed. There will be no fantastic IPO on the NASDAQ that will vault the physician into the Forbes 400 but it is still a good steady job that can last decades and sustain a nice upper middle class lifestyle. That too is worth something.