This is the story that Emmett Henderson, a Harvard-trained urologist told me.
One warm July 4 Sunday evening, his answering service connected him to his long-term patient "Joe" - a local plumber. They agreed to meet in a local hospital emergency department at 9 p.m. where Emmett spent an hour successfully attending to Joe's problem. When Joe offered to pay him, Emmett deferred, saying that he would send a bill.
A few days later, Emmett received a furious phone call from Joe who, incensed about the fee amount, accused him of being unscrupulous, of overcharging, of being a robber and a thief and without conscience. Emmett listened without comment and then explained that, on the first workday after the July 4th weekend, he had called the plumbers' union, had inquired how much it would cost to have a plumber come to his house on Sunday night, July 4 for an hour's work and that's what he billed Joe.
Joe paid the bill without further protest.
Monday, September 29, 2008
Wednesday, September 24, 2008
Restoring Healthcare to Our Suffering Economy
My take on the presidential candidates health care reforms: McCain, no real plan, no change; Obama, the country's financial collapse trumps any consideration of health care reform in the immediate future.
Our economy is sick. People, whose homes have fallen in value, whose retirement savings are rapidly shrinking as bonds, stocks and saving wane, feel poorer. American jobs (not already lost) are in jeopardy. Families' confidence in their abilities to pay mortgages, credit card debt and other obligations has diminished. Trips to the supermarket and gas station reveal prices which are substantially higher than they were a year ago. The unemployed, uninsured, underinsured, poor or about-to-be poor, or those depending on (federally subsidized) state Medicaid will not have access to, or be able to afford, necesary and appropriate health care. Is this really the time to ignore the health care system crisis because we have a national and international financial crisis?
Our country needs to ask whether the enormous resources being spent today on health care buy health care. Do dollars spent to offset insurance company or health plan marketing costs buy one doctor's office visit or one school nurse's office, or one vaccination for a child, or one bottle of insulin for a diabetic? Health insurance sales commissions don't buy health care. Does 25% of the health insurance or plan dollar buy health care? No, it buys administrative overhead, and no administrative overhead has ever cured a sick father, delivered a newborn, or taken care of a child with cancer.
Our federal employees, including Congresspeople, have an excellent menu of health services from which to choose. These plans are not burdened by high marketing and commission costs. Medicare is efficiently run and does not need high administrative overhead to get its job done. Let's piggyback onto these systems, providing accessible lower cost insurance, which provides needed, professionally accepted standards of care to all. Let's start by providing access to insurance through existing mechanisms which have proved track records.
Our economy is sick. People, whose homes have fallen in value, whose retirement savings are rapidly shrinking as bonds, stocks and saving wane, feel poorer. American jobs (not already lost) are in jeopardy. Families' confidence in their abilities to pay mortgages, credit card debt and other obligations has diminished. Trips to the supermarket and gas station reveal prices which are substantially higher than they were a year ago. The unemployed, uninsured, underinsured, poor or about-to-be poor, or those depending on (federally subsidized) state Medicaid will not have access to, or be able to afford, necesary and appropriate health care. Is this really the time to ignore the health care system crisis because we have a national and international financial crisis?
Our country needs to ask whether the enormous resources being spent today on health care buy health care. Do dollars spent to offset insurance company or health plan marketing costs buy one doctor's office visit or one school nurse's office, or one vaccination for a child, or one bottle of insulin for a diabetic? Health insurance sales commissions don't buy health care. Does 25% of the health insurance or plan dollar buy health care? No, it buys administrative overhead, and no administrative overhead has ever cured a sick father, delivered a newborn, or taken care of a child with cancer.
Our federal employees, including Congresspeople, have an excellent menu of health services from which to choose. These plans are not burdened by high marketing and commission costs. Medicare is efficiently run and does not need high administrative overhead to get its job done. Let's piggyback onto these systems, providing accessible lower cost insurance, which provides needed, professionally accepted standards of care to all. Let's start by providing access to insurance through existing mechanisms which have proved track records.
A Question From Anonymous
Anonymous asks: "Wouldn't the patient be better of [sic]if his or her gp hands them off to a specialist better qualified to handle his or her specific disease?"
Response: Let's suppose that you had seen your OB/GYN physician once or twice a year for twelve or thirteen years, the OB/GYN had operated on you and diagnosed advanced ovarian cancer, and before sending you to an oncologist, had carefully avoided telling you the diagnosis, what it meant and his plan to never see you again. Would you trust that OB/GYN? Would you feel abandoned? Would you trust the oncologist or would you begin to wonder if the oncologist would abandon you, too?
There's a difference between a referral to a skilled specialist and abandonment of a patient. There's a difference between finding the most competent physician to deal with a life-threatening disease and dumping the patient on the new doctor without even having the courtesy to give the patient the diagnosis, the meaning of the diagnosis and explain the limits of your future relationship.
As one who practiced specialty medicine, I heard the complaints and anger of patients (and their families) whose doctors unceremoniously and without warning dumped them. The sunshine enema didn't mitigate their hurt, their doubts, their anger and their grief. Trust, and a working relationship between a physician and a patient is built on mutual respect and a willingness to discuss the truth.
Response: Let's suppose that you had seen your OB/GYN physician once or twice a year for twelve or thirteen years, the OB/GYN had operated on you and diagnosed advanced ovarian cancer, and before sending you to an oncologist, had carefully avoided telling you the diagnosis, what it meant and his plan to never see you again. Would you trust that OB/GYN? Would you feel abandoned? Would you trust the oncologist or would you begin to wonder if the oncologist would abandon you, too?
There's a difference between a referral to a skilled specialist and abandonment of a patient. There's a difference between finding the most competent physician to deal with a life-threatening disease and dumping the patient on the new doctor without even having the courtesy to give the patient the diagnosis, the meaning of the diagnosis and explain the limits of your future relationship.
As one who practiced specialty medicine, I heard the complaints and anger of patients (and their families) whose doctors unceremoniously and without warning dumped them. The sunshine enema didn't mitigate their hurt, their doubts, their anger and their grief. Trust, and a working relationship between a physician and a patient is built on mutual respect and a willingness to discuss the truth.
Wednesday, September 17, 2008
The Sunshine Enema
The sunshine enema is not something advertised in your spam email inbox. It's quite different. You may have already had one, without noticing.
I was introduced to the sunshine enema, early in my practice, when physicians would send newly diagnosed patients with cancer or leukemia (or sometimes walk down the hall with their arms around their shoulders) to introduce them to me. The physician usually said something like this: this is Dr. Kaplan who specializes in taking care of people with your illness. He will be taking good care of you and you will soon be feeling much better. You won't need to see me any more because he is now your doctor. If your family has any questions, have them call the good Dr. Kaplan.
Lest you think this was a complement to me, be assured, it wasn't. It was a way to avoid the truth, shift professional responsibility to someone else, and to deceive the patient and his/her family, giving them the illusion that their usual doctor was honest and open. In fact, the usual doctor often hadn't even told the patient the grim diagnosis.
No one talks about the potential for "pay for performance" to cause physicians and other health professionals to cherry pick their patients and to send many of them on to other professionals "who specialize in taking care of people with your illness" rather than bear the professional responsibility, potential financial risk, and likelihood of being labeled as less than expert under the new system. Particularly if you, or a family member, has a rare, difficult to treat, or potentially very serious illness you may find yourself cherry picked right of your customary doctors' offices and into the hands of a new set of professionals who represent the new dumping ground.
When our political candidates tell us that they have a fix for what is ailing the health system, and paint glowing pictures of the bright new world ahead, they are giving us all "the sunshine enema." And it doesn't cause us a moment's discomfort - yet.
I was introduced to the sunshine enema, early in my practice, when physicians would send newly diagnosed patients with cancer or leukemia (or sometimes walk down the hall with their arms around their shoulders) to introduce them to me. The physician usually said something like this: this is Dr. Kaplan who specializes in taking care of people with your illness. He will be taking good care of you and you will soon be feeling much better. You won't need to see me any more because he is now your doctor. If your family has any questions, have them call the good Dr. Kaplan.
Lest you think this was a complement to me, be assured, it wasn't. It was a way to avoid the truth, shift professional responsibility to someone else, and to deceive the patient and his/her family, giving them the illusion that their usual doctor was honest and open. In fact, the usual doctor often hadn't even told the patient the grim diagnosis.
No one talks about the potential for "pay for performance" to cause physicians and other health professionals to cherry pick their patients and to send many of them on to other professionals "who specialize in taking care of people with your illness" rather than bear the professional responsibility, potential financial risk, and likelihood of being labeled as less than expert under the new system. Particularly if you, or a family member, has a rare, difficult to treat, or potentially very serious illness you may find yourself cherry picked right of your customary doctors' offices and into the hands of a new set of professionals who represent the new dumping ground.
When our political candidates tell us that they have a fix for what is ailing the health system, and paint glowing pictures of the bright new world ahead, they are giving us all "the sunshine enema." And it doesn't cause us a moment's discomfort - yet.
Sunday, September 14, 2008
Chief of Staff Rounds
After I became the Chief of Staff of a large hospital, I met with its President and invited him to join me on morning administrative rounds every two weeks. Our first rounds took us to the intensive care unit where the chief nurse recognized and welcomed me. Then she turned to the Hospital President and said that visitors were not allowed in the ICU unless they were known members of a patient's family. When I quickly introduced them, and she realized that he was her boss, she was mortified; he did not smile.
A few weeks later we met again for our rounds and walked to the psychiatry inpatient unit. This time, the chief nurse recognized the President. Her welcome was the announcement that this was the first time he had visited the unit in over two years and she had been wondering when he would show up to see what was going on. She wasn't smiling and neither was he.
He never accepted my invitation to make rounds again.
A few weeks later we met again for our rounds and walked to the psychiatry inpatient unit. This time, the chief nurse recognized the President. Her welcome was the announcement that this was the first time he had visited the unit in over two years and she had been wondering when he would show up to see what was going on. She wasn't smiling and neither was he.
He never accepted my invitation to make rounds again.
Thursday, September 11, 2008
As Much Time As They Needed
A. B., one of my early partners was an experienced Mayo-trained internist who had practiced long enough, in what was then a rural area, to have acquired a clientele of dairy farmers. A.B. loved his work, enjoyed collaborating with new young well-trained doctors, but most of all prided himself on his skill and his commitment to patients.
He had some quirks. When his dairymen called him at 3:30am, just before going to take care of their cows, and complained of minor problems, A.B. called them back at 11:00pm to find out how they were doing. He and they knew the limits of his patience, but he and they knew his competence, dedication and willingness to take care of serious problems at any time.
One day at 6:30pm, when A.B. was unlocking the practice's front door to allow a patient and her difficult husband to leave, the patient thanked him. The husband said, "Doc, I'll bet you will be unhappy when we have socialized medicine." Without any pause, A.B. replied "Oh no, under socialized medicine I would have been out of here an hour ago."
Today, we don't talk about socialized medicine. Our talk of health care reform, health care efficiency, pay-for-performance, economics, triage and universal health insurance has drowned out discussion of health care provider competence, commitment to patients, ethics and integrity. A. B. was certainly aware of the economics of practicing medicine, but he was never financially rich. When his heart gave out, and he retired, he retold the story of opening the door at 6:30pm, with wistfulness because he knew that the relationship between patients and their physicians was changing: the joy of medical practice was being replaced by the increasing burden of health care efficiency, payment for performance, health care economics and guidelines of care.
A.B. spent as much time with his patients as they needed, day or night; does your physician spend 10 minutes of undistracted time with you?
He had some quirks. When his dairymen called him at 3:30am, just before going to take care of their cows, and complained of minor problems, A.B. called them back at 11:00pm to find out how they were doing. He and they knew the limits of his patience, but he and they knew his competence, dedication and willingness to take care of serious problems at any time.
One day at 6:30pm, when A.B. was unlocking the practice's front door to allow a patient and her difficult husband to leave, the patient thanked him. The husband said, "Doc, I'll bet you will be unhappy when we have socialized medicine." Without any pause, A.B. replied "Oh no, under socialized medicine I would have been out of here an hour ago."
Today, we don't talk about socialized medicine. Our talk of health care reform, health care efficiency, pay-for-performance, economics, triage and universal health insurance has drowned out discussion of health care provider competence, commitment to patients, ethics and integrity. A. B. was certainly aware of the economics of practicing medicine, but he was never financially rich. When his heart gave out, and he retired, he retold the story of opening the door at 6:30pm, with wistfulness because he knew that the relationship between patients and their physicians was changing: the joy of medical practice was being replaced by the increasing burden of health care efficiency, payment for performance, health care economics and guidelines of care.
A.B. spent as much time with his patients as they needed, day or night; does your physician spend 10 minutes of undistracted time with you?
Wednesday, September 10, 2008
What Does "Pay For Performance" Mean?
September 8, 2008 NY Times has a fine essay on "Pay For Performance" (P4P) by Sandeep Jauhar, a cardiologist on Long Island, in which he discusses some "P4P" pitfalls .
The Fall, 2007 Health Care Financing Review (vol 29,Number1) is devoted to Pay For Performance. In Thomas and Caldis' introductory article, Emerging issues of Pay-for-Performance in Health Care the authors define P4P in economic terms: " . . . to include any type of performance-based provider payment arrangements including those that target performance on cost measures." Articles which follow state some less than rosy conclusions, such as "The bonuses are sensitive to disease manager perceptions of intervention, effectiveness, facing challenging targets, and the use of actual-to-target quality levels versus rates of improvement over baseline." Another article notes "Like all payment innovations, the P4P demonstration faces some challenges . . . .it remains to be seen how much control a demonstration participant can exert over its assigned beneficiaries when they retain freedom of provider choice and have limited incentives to restrain their use of services." A fourth article recognizes that without changes in physician behavior, the gains from redirecting patients from lower to high efficiency and quality providers are likely to be limited. Even the mechanics of statistical analysis, as described in a fifth article, are uncertain: ranking of small hospitals will be problematic.
Jauhar notes that legislation of professional behavior is likely to be associated with unintended consequences, such as physician avoidance of providing care to very sick, dying, high risk patients because they do not wish to be stigmatized by poor outcomes, or pressure upon a physician to treat prematurely or without knowing the necessary medical facts and test results. He describes the unthinking conversion of "guidelines" to performance standards, against which physicians are measured by hospitals, payers and Medicare.
In hospitals, medical staff members may labeled competent or incompetent, prudent or wasteful, good or bad, depending on whether their performance meets "guidelines" that were never intended to be mandatory. Jahuar describes Medicare's voluntarily physician self-report to Medicare on 16 quality indicators with financial rewards for compliance. Jauhar discusses the current "team" approach to medicare care in today's hospitals, in which it is difficult to assign either praise or blame to any of the many physicians, nurses, paramedics, respiratory therapists, surgical assistants, pharmacists, physical therapists and others involved in patients' care.
Driving P4P are economists, business people and economic analyses. The difficulty is that economists and business people are not physicians, and have no reason to understand that 50% of the the drugs, protocols and systems of treatment that they glorify today will prove to be either of no benefit or positively harmful in a few years. P4P focuses on efficiency ("cost control"), while claiming to promote quality, on maintaining the status quo, rather than innovative care which may prove to be better or worse than the "guidelines," and on satisfying marketing demands of payers who want to be able to claim that that their network contains "P4P" certified health care providers.
Jauhar has done the public a service by openly discussing P4P. Stay tuned: there's more to come.
The Fall, 2007 Health Care Financing Review (vol 29,Number1) is devoted to Pay For Performance. In Thomas and Caldis' introductory article, Emerging issues of Pay-for-Performance in Health Care the authors define P4P in economic terms: " . . . to include any type of performance-based provider payment arrangements including those that target performance on cost measures." Articles which follow state some less than rosy conclusions, such as "The bonuses are sensitive to disease manager perceptions of intervention, effectiveness, facing challenging targets, and the use of actual-to-target quality levels versus rates of improvement over baseline." Another article notes "Like all payment innovations, the P4P demonstration faces some challenges . . . .it remains to be seen how much control a demonstration participant can exert over its assigned beneficiaries when they retain freedom of provider choice and have limited incentives to restrain their use of services." A fourth article recognizes that without changes in physician behavior, the gains from redirecting patients from lower to high efficiency and quality providers are likely to be limited. Even the mechanics of statistical analysis, as described in a fifth article, are uncertain: ranking of small hospitals will be problematic.
Jauhar notes that legislation of professional behavior is likely to be associated with unintended consequences, such as physician avoidance of providing care to very sick, dying, high risk patients because they do not wish to be stigmatized by poor outcomes, or pressure upon a physician to treat prematurely or without knowing the necessary medical facts and test results. He describes the unthinking conversion of "guidelines" to performance standards, against which physicians are measured by hospitals, payers and Medicare.
In hospitals, medical staff members may labeled competent or incompetent, prudent or wasteful, good or bad, depending on whether their performance meets "guidelines" that were never intended to be mandatory. Jahuar describes Medicare's voluntarily physician self-report to Medicare on 16 quality indicators with financial rewards for compliance. Jauhar discusses the current "team" approach to medicare care in today's hospitals, in which it is difficult to assign either praise or blame to any of the many physicians, nurses, paramedics, respiratory therapists, surgical assistants, pharmacists, physical therapists and others involved in patients' care.
Driving P4P are economists, business people and economic analyses. The difficulty is that economists and business people are not physicians, and have no reason to understand that 50% of the the drugs, protocols and systems of treatment that they glorify today will prove to be either of no benefit or positively harmful in a few years. P4P focuses on efficiency ("cost control"), while claiming to promote quality, on maintaining the status quo, rather than innovative care which may prove to be better or worse than the "guidelines," and on satisfying marketing demands of payers who want to be able to claim that that their network contains "P4P" certified health care providers.
Jauhar has done the public a service by openly discussing P4P. Stay tuned: there's more to come.
Sunday, September 7, 2008
Back To The Basics
It's fall, the season for kids to return to school and for the spectacle of stadiums full of football fans. Because we understand that our kids won't get a good educational foundation unless their schools emphasize the basics, we demand emphasis on the basics. We see that winning football coaches emphasize mastery of the basics and that winning teams don't get to the superbowl because of technology or gimmicks: they get there with hard work and competence in the fundamentals of football.
Those who plan and operate our health system haven't mastered the fundamentals. They focus on gimmicks such as unproved electronic medical records, grandiose medical edifices (Freud would have explained that they have edifice envy), complex PPOs, HMOs, copayment schemes, roadblocks of eligibility criteria, constructing barriers to payment, and creating rules which guarantee large numbers of uninsured.
I suggest we think about the basics. Let's educate our kids well enough in primary and high school so that they can learn to understand the world around them. Our colleges should be more than advanced high schools: they should help their students study social and scientific principles, to think, question, and develop a lifelong commitment to learning and to developing a respect for personal integrity and ethical systems. Our medical schools should be peopled with faculty who are not only scientists, but are expert skilled physicians, nurses and other health providers and planners who understand and value clinical care and value not just "the faculty agenda" but the art of teaching. We should encouraging the brightest and best of our young people to study sciences, medicine, health care and public service in an environment free of ethical conflicts of interest.
Our students should understand how they fit into society, why they will enjoy unique privileges and opportunities, and how to deal with professional rights and professional obligations which are in constant tension. They should be taught the use of constructive self criticism and correction, which are invaluable skills in science and health care.
And only then can we start to build a health care system that makes sense.
Those who plan and operate our health system haven't mastered the fundamentals. They focus on gimmicks such as unproved electronic medical records, grandiose medical edifices (Freud would have explained that they have edifice envy), complex PPOs, HMOs, copayment schemes, roadblocks of eligibility criteria, constructing barriers to payment, and creating rules which guarantee large numbers of uninsured.
I suggest we think about the basics. Let's educate our kids well enough in primary and high school so that they can learn to understand the world around them. Our colleges should be more than advanced high schools: they should help their students study social and scientific principles, to think, question, and develop a lifelong commitment to learning and to developing a respect for personal integrity and ethical systems. Our medical schools should be peopled with faculty who are not only scientists, but are expert skilled physicians, nurses and other health providers and planners who understand and value clinical care and value not just "the faculty agenda" but the art of teaching. We should encouraging the brightest and best of our young people to study sciences, medicine, health care and public service in an environment free of ethical conflicts of interest.
Our students should understand how they fit into society, why they will enjoy unique privileges and opportunities, and how to deal with professional rights and professional obligations which are in constant tension. They should be taught the use of constructive self criticism and correction, which are invaluable skills in science and health care.
And only then can we start to build a health care system that makes sense.
Thursday, September 4, 2008
McCain's Evocative Speech
Today, I listened hard to the McCain's nomination acceptance for a fleshed-out health policy, but it wasn't there. We heard about oil and other matters - not about the issue that affects the health and well-being of all Americans.
But it wasn't a complete bust. His talk of honor, duty, country and his experiences in and after Viet Nam, tied-in with a discussion earlier in the day during a chance meeting with an old colleague, a health care businessman. Each of us, independently, has noticed the lack of commitment of many young physicians to their profession. They are 9-5ers who check in at 9, leave at 5, have no ongoing responsibilities for patient care when they are off, and live like any hourly factory worker. He summed it up neatly: the older generation gets out of bed in the morning and go to bed at night, knowing that they are physicians; the newer generation are physicians when they put on their white coats from 9 through 5.
It's no accident that each of us has chosen the same community doctor as personal physician since this doctor is imbued with the spirit that we value. His sense of self-worth, professional honor, integrity commitment and duty have not been diminished by trivializing and unrealistic television programs, administrative bureaucracies, arrogant obstructive payers, and destructive political rhetoric. He is a professional.
So there's real American value in what McCain said tonight. His personal values resonate beyond his military service. His military family was overt in its respect for honor, duty and country. My father was a lawyer who patiently explained to me, when I was a youngster, that a commitment to a profession and clients (or patients) is different from any other role in society in terms of trust, integrity and duty. Perhaps it's time to remind our physicians of this difference and the reasons that they are given their license and franchise by society.
But it wasn't a complete bust. His talk of honor, duty, country and his experiences in and after Viet Nam, tied-in with a discussion earlier in the day during a chance meeting with an old colleague, a health care businessman. Each of us, independently, has noticed the lack of commitment of many young physicians to their profession. They are 9-5ers who check in at 9, leave at 5, have no ongoing responsibilities for patient care when they are off, and live like any hourly factory worker. He summed it up neatly: the older generation gets out of bed in the morning and go to bed at night, knowing that they are physicians; the newer generation are physicians when they put on their white coats from 9 through 5.
It's no accident that each of us has chosen the same community doctor as personal physician since this doctor is imbued with the spirit that we value. His sense of self-worth, professional honor, integrity commitment and duty have not been diminished by trivializing and unrealistic television programs, administrative bureaucracies, arrogant obstructive payers, and destructive political rhetoric. He is a professional.
So there's real American value in what McCain said tonight. His personal values resonate beyond his military service. His military family was overt in its respect for honor, duty and country. My father was a lawyer who patiently explained to me, when I was a youngster, that a commitment to a profession and clients (or patients) is different from any other role in society in terms of trust, integrity and duty. Perhaps it's time to remind our physicians of this difference and the reasons that they are given their license and franchise by society.
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