Monday, August 29, 2016

Practicing Medicine My Way.

My thoughts settled on the Frank Sinatra song, My Way, when asked about necessary resources for rural healthcare to survive. Seven years ago, my father and I changed office buildings.  We closed the office that Friday to allow three full days to get settled.  However, we ended up seeing sick patients in the parking lot (seriously), while the movers were loading up the truck. “All we need is a stethoscope, otoscope, and a pen to practice,” my father declared.  I have never forgotten his sound advice.

The thing missing from health care today is a long-term relationship built over time between the physician and patient. Patients need physicians who can look into their eyes and know if they are “sick” or “not sick.” Do you realize how rare and valuable that is? After 15 years taking care of the same child over and over, I know them like the back of my hand. I can read their minds. That is real medicine for the real world. 

 “I’ve lived a life that’s full. I’ve traveled each and every highway; and more, much more than this, I did it my way.”

My way of providing high quality care to patients would allow for adequate time to spend with them.  It can take an hour or more to answer questions from vaccine-hesitant parents. Believe me, that is time well spent. I wish a government bureaucrat could observe the complicated conversations with parents who are making important decisions for their children.   Talking is a primary care physician’s job, let me do it.

My way would deliver comprehensive care to my patients. Ideally, my practice and my patients could benefit from having a behavioral therapist 2 days/week, a social worker 3 days/week, a lactation consultant 2 days/week, a child psychologist 1day /week, and a child psychiatrist one day/month. Access to a dermatologist would be pretty awesome, but I won’t go overboard.

My way would trust the physician to treat the patient.  Elimination of all government mandates which overemphasize the need for data collection, yet serve as obstacles to provide care for the sick.  Offering one Medicaid plan as opposed to six Medicaid plans in one state would decrease our administrative burden tremendously.  I do not need a CEO, CFO, CMO, or BSO to tell me how to practice nor do I intend to listen to any who are going to take away my livelihood by reducing reimbursement rates based on ridiculous patient outcomes.

 “I planned each charted course; each careful step along the byway…I did it my way.”

My way would pay physicians for their time.  If I spend an hour with a patient, what the heck does the government or insurance think I was doing, playing tidily-winks? I was exchanging information. A physician must be able to afford food, shelter, and clothing; it is essential to have enough revenue from our work to take care of ourselves and our families. 

My way of providing accountability is simple. Look at physician outcomes; not patient outcome measures. How many visited my office and then visited the ER within 24 hours? Do NOT look at how many patients from my panel went to the ER. That is ludicrous and does not reflect care provided in any way; that data reflects a decision made by a patient.  There is no cost or copay to discourage them from going to the ER.   What percentage of patients came in for well child checks? NOT what percentages are fully immunized? Parents have a right to refuse immunizations.  How many asthmatics were hospitalized who were not on a steroid inhaler? Doing it my way, the answer is zero in the last 15 years. There are twenty more metrics off the top of my head that would provide more useful information. 

“But through it all, when there was doubt, I ate it up and spit it out.  I faced it all, and I stood tall; and did it my way.”

My way of making technology useful would be insisting data entry took 60 seconds or less.  If I see 15-20 patients per day, it should take 15-20 minutes to finish documentation and go home. That is what it takes me right now.  Do not force me to use technology which makes it more difficult to care for the sick.  Our time with patients is precious.  If pundits want data, they can send me a person to collect it from my charts. There is little use for red-tape disguised as technology and accountability; I would unplug my computer, if given the choice.

My way is the “9am rule.” If anything happens and a patient wants to be seen the following day for acute illness, accident, or injury, they walk in at 9 am and are fit into the schedule — no matter what. Do you know the comfort that brings to the family of a small child? They are never afraid to wait it out at home and avoid the ER because they know they can be seen. That type of service is popular, beneficial, and should be reimbursed adequately at urgent care rates.

“To say the things he truly feels; and not the words of one who kneels.  The record shows I took the blows – and did it my way.”

My way would involve fewer bureaucrats making significant healthcare decisions that impact the entire country and its population at large.  Both patients and physicians are taking blows from those in charge of the system who know nothing about the world of primary care.  The simple premise businessmen are unable to comprehend:  the provision of basic primary care requires a stethoscope, otoscope/ophthalmoscope, and a pen. The pen does double duty too; as a writing instrument and tool for emergency tracheotomy.  And that’s all folks!

“Yes, it was my way.”

Yes, I will figure out how to do it my way.  There will be many others who will do the same.  

Friday, August 26, 2016

My Ideal Electronic Health Record

Give me technology which improves my life and that of my patients, or give me death.  Medical records must be informative, efficient, and flexible; like the physicians they serve.  For me, a medical record does not contain just a collection of problem lists, prescribed medications, and immunizations; it is a noteworthy account of the health care provided to another human being over a lifetime. 

Recently, I attended a baby shower of a patient who is now an adult.  (I am a pediatrician.) I brought her medical chart wrapped with a satin bow as one of her gifts.  I was her physician for many years; my father had taken care of both her and her mother as children.  Her growth, development, immunizations, and illnesses were all recorded; but so were 25 years of life experiences, trials, triumphs, and tribulations.  The back section contains drawings she had given me, newspaper articles of her achievements, graduation announcements, and her wedding invitation.  Obviously, medical records register growth parameters, vital signs, and sick visits; but they also encompass my relationship with my patients. 

New technology must be better than what I already use; otherwise there is no reason to change.  In 2009, the Department of Health and Human Services led many to believe (incorrectly) “using electronic health records will reduce administrative burdens, cut costs, reduce medical errors and most importantly, improve the quality of care.”  Few, if any, of these goals have materialized.  IT experts are tinkering with the grand design of a documentation method that has satisfactorily served physicians for hundreds, if not thousands, of years.  It is no small undertaking; a certain degree of diligence is required for conversion to experience success. 

Administrators, MBA’s, and CEO’s know nothing of providing patient care, yet they spend obscene amounts of money on fancy automated systems which are grossly incompetent at facilitating our workflow.  Electronically generated notes take up to six faxed pages instead of the requisite one, yet provide little in the way of useful information.   How is that an improvement on what we had before?  Non-physician health leaders are missing the forest for the trees as they search for innovative ways to enhance data collection while overlooking the accumulation of critical information to support proper medical decision making. 

Electronic records need to be user friendly, free or low cost for physicians, and reduce the workload, but current systems are far too cumbersome to accomplish this task.  The more complicated and structured the program; the less likely it appears to improve patient care while increasing the physician burden at the same time. Few primary care physicians have weighed in on technology needs because we are busy seeing 20-40 patients per day.   We do not need computers to do the thinking; we need them to do the documenting with speed and accuracy.  

To improve care quality, adaptability is also imperative in any electronic system.   Using a simple, basic, and more customizable interface would allow each specialty to tailor the structure to fit their individualized needs.    Clicking pre-defined boxes on a computer screen does not capture the essence of each patient nor adequately describe the distinctive features of various medical conditions.

Visually, my ideal EHR would be a “paper chart” on a computer screen.  The first page would be a standard intake form providing the general health background, birth history, past medical and surgical histories, allergies, immunizations, medication list, and pertinent family history.  The second page is the problem list and other necessary details depending on medical specialty.  The third and fourth pages would be growth charts and then the immunization record follows.  Those pages could be accessible by tabs on the left hand side of the screen to review or update when necessary.

Pressing the edge of the screen would allow review of previous notes with one touch.   There would be tabs on that right side to review labs, radiology reports, and “one-page” notes from consulting physicians with the impression and plan succinctly summarized at the top.  The last tab in the bottom right corner of the screen would contain scanned newspaper articles, pictures, notes, and cards from my patients; I call that my “friendship” section. It is a “custom” add-on that should be offered to primary care physicians like me. 

The structure for each note would be SOAP in format; it would take 60 seconds to record an office visit by dictation. A program would convert the dictation to a word processing document in the SOAP layout.   Auto-fill would be unnecessary with such a swift and efficient system.  It must be resistant to crashing and have an auxiliary back-up to store new notes if glitches arise so as not to negatively impact patient care.  Our office has been open during earthquakes, a flash flood, when the power is out, in a windstorm, and when there is snow, sleet or hail (just like the post office.)  Our paper records have never been inaccessible or unusable.  

Do not forget the fundamental purpose of medical records in the first place.  They are a chronicle of diagnoses, treatments, and follow up for myriad of medical conditions. Systems attempting to be “one size fits all” lead to over collection of redundant information in the name of comprehensiveness. Unfortunately, no single system has yet achieved the Holy Grail of being cheap, efficient, and accessible while improving the quality of patient care.  Only technology that enhances the practice of medicine for physicians should make the final cut.  

It is vital that new technology benefits both patients and physicians, enriching our non-judgmental, empathetic, and long-term relationships.   Seven years ago, I lost a college-aged patient in a car accident.  Placing the final dictation in her chart a week later gave me the opportunity to reflect on our relationship and her assorted illnesses, injuries, and well visits over almost two decades.  What a treasure to behold after years of friendship and medical care.  Her paper chart was tangible proof of a life well-lived.

I recently contacted her mother to inquire if she wanted her daughters’ medical chart.  She said it was a gift to see her daughter through the eyes of her physician, who was there every step of the way.  Medical records are more than metadata on a computer screen; they are a sacred chronicle of our enduring connection with our patients in life, and even in death.   When an EMR can do that, I will be thrilled to embark on a digital journey.  Until then, give me paper or give me death. 

Tuesday, August 23, 2016

Spanking and Science Part 3: Medical Literature Opposing Spanking:

There have been many review studies on the topic of spanking children spanning the last 40 years. Next up, I will give you Dr. Gershoff’s, the leading researcher of the anti-spanking opinion. 
Most anti-spanking literature involves editorials, reviews, and commentaries. Lyons, Anderson, and Larson reviewed articles published between 1984 and 1993 that addressed corporal punishment.  83% of those 132 articles were editorials or commentaries without scientific data to support the conclusion.  The remaining 17% of studies included severe physical abuse used with spanking.  Editorials tend to be opinion-driven and not necessarily scientific. 
Both Larzelere and Gershoff’s conducted large review studies on the same subject.  Both included 18 of the same studies.  The Gershoff review included 70 studies the Larzelere review did not.  Dr. Gershoff used a less restrictive definition of spanking, 65% included corporal punishment studies that allowed punching, hitting with a belt, striking hard with an object, and beatings. The majority of published research denouncing spanking suffers from the design flaw that corporal punishment is addressed as one group, without differentiating spanking and abuse. Please keep this fact in mind as you read below.   
The literature review by Dr. Elizabeth Gershoff (2002) consisted of 88 studies.  She examined the relationship between corporal punishment and compliance of the child, aggression, criminal and antisocial behavior, quality of the parent child relationship, mental health, and abuse.  Spanking was associated with immediate compliance, considered to be the only positive finding.  Her analysis found detrimental effects in children over 6 years of age when spanking was used more than three times per week, though the definition of spanking was not clearly defined, which makes interpretation difficult.  
The consistent finding was spanking frequency positively correlates to aggression and misconduct.   It is very important to note the difference between “correlation” and “causation.”  Because of its methods and by her own self-critique, Dr. Gershoff’s meta-analysis cannot determine whether spanking causes increased misbehavior or whether difficult child temperament causes parents to use discipline more frequently.    
“Spanking” was associated with decreased internalization of morals, diminished quality of the parent-child relationship, poorer child mental health, and anti-social behavior.  Dr. Gershoff emphasizes her study could not support the conclusion spanking causes damage, nonetheless, her study results are consistently used to support spanking bans. 
Dr. Murray Strauss is a proponent of the idea children who are spanked are more likely to resolve conflicts with violence as adults.  His studies are “cross-sectional” meaning survey-based.  He collects information retrospectively and relies on the memory of parents.  His studies support the assertion that spanking produces undesired life outcomes, such as alcoholism, marital violence, depression, and suicidal ideation.  Evaluation often focused on spanking adolescents, instead of limiting spanking to young children, the only age group pediatricians and psychologists support for an occasional spank.   
Conclusions are therefore derived from “physical punishment during the teen years,” with teenagers being hit more than 30 times per year.  Spanking teenagers has never been a recommended intervention and is highly unlikely to be effective.  Evidence for Dr. Strauss’ conclusions disappears when effects of spanking are limited to children 2-8 years of age.  Interestingly enough, some cross-sectional studies linked childhood aggressiveness to maternal permissiveness and negativity even more than abusive physical discipline measures correlated, but that is a discussion for another time.
Reviewing the anti-spanking literature revealed no randomized clinical trials exist proving spanking is ineffective or harmful.  Many challenges were identified when drawing conclusions from Dr. Gershoff’s review study.  Spanking is defined loosely, making the definition subjective. The research tends to be correlational; therefore, cannot support causation for spanking being beneficial or detrimental.   
Important aspects of parenting are unaccounted for such as nurturance, other discipline method use, parental attitude, or the child’s misbehavior.  No other discipline methods were studied in conjunction with spanking.  The final most concerning issue is that frequent misbehavior and challenging child temperament can be predictive of subsequent child behavior problems could lead to misinterpretation of the results.  
What all experts who research corporal punishment can agree upon is the developmental outcome of child-rearing is primarily determined by the overall quality of the parent-child relationship.  Immediate compliance clearly follows spanking, age tends to moderate the outcome of spanking (detrimental outcomes are more likely with children over 8) especially for 10-12 years of age, and frequent corporal punishment is associated with more negative outcomes.  Interestingly, Dr. Gershoff agrees that harmful effects of punishment do not differ when spanking, verbal punishment, loss of privileges, and grounding were compared.    
I do hope this information is helpful to you all!

Thursday, August 18, 2016

Spanking and Science: Part II

In 1996, numerous pediatric experts gathered to develop a consensus statement regarding corporal punishment including spanking. The group agreed on the following: The strongest studies do not indicate a link between spanking and later violence. They do not support the idea spanking is detrimental. Spanking should not be used as the only method of discipline.

One of the most comprehensive meta-analyses was conducted by Dr. Robert Larzelere, in 2007. He reviewed 50 years of research on child discipline and identified 26 separate studies on child outcomes of physical punishment. This is the first scientific review to compare child outcomes of physical discipline with alternative discipline tactics. It also distinguished between overly severe discipline and non-abusive physical discipline, where previous studies did not. The authors conclude a two-swat spanking is one of the most effective forms of discipline in defiant 2-6 year olds.

“Conditional” spanking, defined as “two open-handed swats, not out of control due to anger,” led to better outcomes in 10 of 13 disciplinary tactics, with 2-6 year olds. One completed in 1994 by Larzelere found mild spanking was not only beneficial for children between 2-6 years of age, but enhanced the effectiveness of time out when used as the back-up method.
Spanking was the most effective intervention compared to alternative methods, except when it was severe (beating a child or striking in the face or head.) Interestingly enough, spanking was found to reduce substance abuse more than nonphysical punishment.

The use of spanking during childhood in a nurturing environment is not a predictor of adult dysfunction. This study reinforces this fact and found ALL types of corrective discipline (time-out, removal of privileges) are associated with subsequent aggression. When Larzelere reviewed articles written between 1974 and 1995, the studies linking aggression and spanking came from cross-sectional studies of teenagers, measured severe forms of punishment, and humiliation tactics (i.e. striking in the face.)

In 1979, the Swedish enacted a spanking ban, making this form of punishment illegal. Larzelere conducted the best quality follow-up study, which demonstrated child abuse was 49% higher in Sweden compared to the US two years after the spanking ban went into effect. Swedish criminal records indicated child abuse in Sweden increased 489% between 1981 through 1994; a 672% increase in minors assaulting minors resulted. Banning spanking clearly did not reduce the incidence of child abuse nor did it decrease violence in a population of children no longer being punished physically.

Under 5 years of age, parents often use praise, ignore negative behaviors, or use time-out. Time out instituted early is very effective especially with compliant, mild mannered children. However, for some defiant children time-out is ineffective. Time-out may be more effective with a back-up tactic for emphasis.

Dr. Diana Baumrind endorses the idea that punishment is effective and is not intrinsically harmful to a child. She is best known for identifying three parenting styles: Authoritarian, Permissive, and Authoritative. Authoritative parenting is recognized by most pediatric experts as the optimal style of child rearing, which includes physical discipline. She asserts scientists have overstepped in claiming spanking causes lasting harm because there is no hard science to support it.

Authoritative parents make reasonable developmentally appropriate demands of their children and encourage a genuine respect for authority. They are consistent; using reasoning, power, and reinforcement to achieve objectives. They strike a fine balance between control and nurturance, which sets the standard for future expectations and promotes a child’s independence.

Dr. Baumrind’s study, from the Family Socialization and Developmental Competence Project, followed families for 12 years assessing negative outcomes. It is a well-designed prospective study, making it reasonable to draw conclusions. They found authoritative parenting led to the production of socially responsible and assertive children, who felt a sense of purpose and were oriented toward achievement. Parents in this study favored spanking over all other negative forms of punishment. Evidence from this study revealed, an occasional swat on the rear end, delivered between 4-9 years of age, was not harmful.

Permissive parents in this same study admitted to “explosive attacks of rage in which they inflicted more pain or injury upon the child than they had intended.” They became “more violent because they felt they could neither control the child’s behavior nor tolerate its effect upon themselves.” This phenomenon has implications in statistics from Sweden collected after the spanking ban was enacted. This type of overwhelming anger, was not determined to be harmful, however my concern is it could be.

Ultimately, the developmental outcome of child-rearing is primarily determined by the overall quality of a parent-child relationship. Non abusive spanking by loving parents who use correct methods were able to achieve effective behavioral management and a rapid re-establishment of affection between parent and child following interventions.

The above studies overall demonstrate optimal child development results from a parent’s balanced use of firmness (which may include occasional spanking) and a high degree of encouragement, praise, and love, kind of like making meringue (see previous post “Drawing a Line in the Sand.) 

Spanking and Science, By Request

The debate on spanking reflects a deep chasm in our society and its views on discipline.  A 1999 study found that 94 percent of 3 and 4 year olds had been spanked at least once by a parent in the last year.  In deciding how to discipline their children, parents often look to pediatricians and psychologists for advice.  It is something parents are clearly using, so guidelines might be helpful. A reader recently challenged me to find research that an occasional spank on the rear end is effective and not harmful.  It turns out, the volume of research finding that spanking is both effective and not harmful is so vast, it needs to be broken into a four-part essay.
My goal in writing this is educational;  please keep my intent in mind while reading.  Many of you might object to spanking children altogether on moral grounds, the depravity of causing pain to another human being, or the double standard of a society that does not condone hitting others, yet does tolerate the hitting of a child by its parents.   Your moral objections have validity, however my job as a physician and scientist is not to preach morality, rather to inform or educate using empirical evidence.

The bottom-line is this:  The question as to whether or not spanking is beneficial or detrimental has not definitively been answered by science.  The one thing expert psychologists on both sides of the debate agree upon is the data is not conclusive.  I will present the research, opinions, and conclusions from four of the foremost experts on spanking over four blog postings.  I stand by my assertion, as a parent, you should trust your instinct and make the best decision for you and your child.  NO scientific proof exists to the contrary.  My goal for you after this journey is to feel better informed, more confident in your decisions regarding discipline, and comfortable with the different perspectives and opinions of others.

Overall, the experts are split 3-1 with the belief occasional spanking does indeed have benefit, when guidelines are in place.  Dr. Robert Larzelere is the most well-known research psychologist in spanking and discipline techniques.  Dr. Diana Baumrind is another psychologist renowned for delineating the authoritative, authoritarian, and permissive parenting styles.  Dr. Elizabeth Gershoff, is a research psychologist who is cited most often by 100% anti-spanking advocates and I will present her data in post 3.  Finally, Dr. Mark Roberts is the author of the ONLY four randomized clinical trials of spanking and discipline alternatives ever done in clinically defiant 2-to-6 year old children.
I would like to start off with a clear definition.  Spanking is defined as “physically non-injurious, intended to modify behavior, and administered with an open hand to the buttocks.”  Spanking is recommended as a back-up method to other discipline strategies, such as time out, barrier, reasoning, and removal of privileges.

The best type of study is a meta-analysis, which is a review of many scientific studies on a particular subject, in this case, child outcomes of corporal punishment.   The next best type of study is a randomized controlled trial, where there are two groups and an intervention.  Data is gathered moving forward from that time.  Prospective studies (following subjects forward over time as well) is the next best, however it is difficult to draw conclusions regarding causation.  Cross-sectional and retrospective case studies are subject to inherent biases in collection of information that do not allow for definitive conclusions to be drawn. Many of the studies on spanking are not high quality and the majority done properly by scientific standards show there is a benefit to non-abusive spanking, which has made interpretation of the data even more troublesome.

One study that I came across and found interesting was conducted by Ray Guarendi at the Childrens Hospital in Akron, Ohio, who was interested in the secrets of highly successful families who reared extraordinary children.  50 state winners of the teacher-of-the-year award were asked to name the most outstanding children they had taught over the course of their careers.  The parameters were not to select the highest academic achievers, but those who exhibited the most self-motivation, empathy for others, morality, and strength of character.  The families of these students were thoroughly evaluated and spanking was among the many aspects of parenting studied.

The findings were 70% of parents utilized some physical punishment with their children.  Some relied upon it often while others only used it rarely.  “Spanking was considered to be one tool in a parent’s discipline repertoire.”  Most began spanking at 18-24 months and phased it out after 6 years of age.  Spanking was not the primary method nor the last-ditch intervention.  Spanking was used for situations such as teaching a child to avoid danger, punishment for deliberate defiance, and in response to disrespectful behavior.  Spanking was not used for accidents, childish behavior deemed developmentally appropriate, or impulsiveness.

This retrospective study was based on parental recall, so there are limitations when drawing a definitive conclusion.  A majority of parents with outstanding children were willing to spank and considered it a healthy discipline option.  Spanking does not in and of itself lead a child to be aggressive nor is it abusive according to many parents participating in this study.  The youngsters in these families were identified as emotionally mature and capable.  They neither viewed spanking as the psychological dark side of discipline nor as a form of brutality.  Spanking is not required to be a good parent or raise outstanding children and a significant minority of parents chose not to spank for personal and practical reasons.

These numbers will lay the stage for my next few posts.  I would like to mention that no one is “pro-spanking” per se; in general most feel it is not harmful and is a useful tool in the toolbox to have for a defiant child or as a back-up to alternative discipline methods.  A third post will cover how most anti-spanking recommendations evolved then I will conclude with my own suggestions based on the science and endorsed by most pediatric experts and psychologists.  Please feel free to comment if you have questions or clarifications, but for now please hold off on judgement as we embark on this journey. Together.  Thank you for reading.

Wednesday, August 17, 2016

Building Better Metrics: Invest in “Good” Primary Care and Get What You Pay For

In 1978, the Institute of Medicine published A Manpower Policy for Primary Health Care: Report of a Study (IOM, 1978) where they defined primary care as “integrated, accessible services by clinicians accountable for addressing a majority of heath care needs, developing a sustained partnership with patients, and practicing in the context of family and community.” The four main features of “good” primary care based on this definition are: 1. First-contact access for new medical issues, 2. Long-term and patient (not disease)-focused care, 3. Comprehensive in scope for most medical issues, and 4. Care coordination when specialty referral is required.  These metrics ring as true today as they did many years ago.

Estimates suggest that a primary care physician would spend 21.7 hours per day to provide all recommended acute, chronic, and preventive care for a panel of 2,500 patients.  An average workday of 8 hours extrapolates to an ideal panel of 909 patients; let us make it an even 1000 to simplify.  A primary care physician could easily meet acute, chronic, and preventative needs of 1000 patients, thereby improving access.  Our panels are much larger due to the shortage of available primary care physicians and poor reimbursement which keeps us enslaved.  Pay us what we are worth and then utilize this “first-access” metric to judge our “quality.”

Hippocrates said “It is more important to know what sort of person has a disease than to know what sort of disease a person has.”  Primary care physicians excel at knowing their patients. Continuity of care and long-standing treatment of families within the larger context of the community is our raison d’etre.  Numerous studies have confirmed accessible, comprehensive, and integrated primary care is associated with better clinical outcomes and lower costs.  Track how long our patients have been with us as yet another reimbursable measure. 

The significance of enduring patient relationships at small practices cannot be overemphasized; our practice has had more than 3 dozen families for 46 years, which is older than one of the physicians (me) at my two-physician practice.  The commonwealth fund in 2014 found an inverse relationship between practice size and preventable hospital admission rates, precisely because we know our patients better. Practices with one or two physicians had preventable hospital admission rates that were 33% lower than practices with 10-19 physicians, and practices with 3-9 physicians had a reduction of 27% comparatively.  CMS plans to bonus large practices with more than 100 physicians because they believe “bigger is better.”  What on earth do you think their preventable hospital admission rates will be?  Likely more than twice the rate when compared to small, but mighty solo or two-physician practices. 

A third worthwhile metric would be evaluating whether primary care physicians are able to provide comprehensive care to meet the majority of medical needs.  A study by the Robert Graham Center evaluated 3,652 physicians and 555,165 Medicare patients and found that patients of physicians who provided a wider range of services experienced fewer hospitalizations and incurred lower health care costs.  Costs were reduced by 10-15% and patients were 35% less likely to be admitted to the hospital when physicians could provide comprehensive care.  Dr. Kevin Grumback, who wrote a commentary accompanying the study, said “This probably trumps any other innovation in terms of reducing Medicare costs.”  Increasing health care costs have far outpaced economic growth for many reasons; relying on specialists to meet a wider scope of health needs has undoubtedly contributed to increasing expenditures.  As a pediatrician, Obamacare plans refused to reimburse me for cauterizing an umbilical granuloma because the procedure was considered too specialized.  Any mammal with opposable thumbs can treat an umbilical granuloma. What is the purpose of this narrow-minded short-sightedness?

Studies have demonstrated preventive services are delivered more efficiently and cost-effectively by primary care physicians.    Primary care physicians order fewer tests than specialists and help protect their patients from inappropriate and unnecessary care resulting in significant reductions in health care expenditures. Even when costs are calculated for treating common conditions, such as pneumonia, specialty care is more expensive compared to primary care and patient outcomes are no different.  Metrics should reward us for utilizing the full breadth of our skillset.

Finally, primary care physicians should coordinate care when specialty referral is required.  This is one of the largest drivers of redundant evaluations and testing.  Records without critical interoperability, specialists are starting fresh with each new patient and often repeat testing unknowingly due to inept communication.  Physician to physician conversation is paramount; primary care physicians need sufficient reimbursement for the work and time involved.  This would allow for a more focused, efficient evaluation by the specialist and reduce spending.   

If primary care physicians were paid what they are essentially worth, there would be more of us to go around and health expenditures would decrease substantially.  The physician workforce in the United States is currently 80% specialty, 20% primary care.  Over a 40-year medical career, the income gap is 3.5 million, on average, between a primary care physician and a specialist.  Increasing by one primary care physician per 10,000 people, decreases mortality by 5.3% thereby avoiding 127,617 deaths per year in the U.S.  Payment methods must better reflect the value of services provided by primary care physicians especially in small practice settings. Reimbursement for conversation and less for testing and procedures results in the right kind of care.

Building better metrics is about incentivizing delivery of superior quality health care.  Small practices are the first point of access for many underserved populations.  Increasing the number of primary care physicians compared to specialists would control escalating costs, but our income must reflect our work.  The physician-patient relationship is a tremendous therapeutic force.  Business entities must recognize that power of relationships built over decades in small practice settings and harness it.  We are clearly worth our weight in gold; isn’t it time for those in power to recognize our value? 

Monday, August 15, 2016

The Office of Civil Rights: The Tale of a Medical Records Renegade

According to Wikipedia, the Office for Civil Rights (OCR) is a sub-agency of the U.S. Department of Education that is primarily focused on protecting civil rights in federally assisted education programs and prohibiting discrimination on the basis of race, color, national origin, sex, sexual orientation, gender identity, handicap, age, or membership in patriotic youth organizations.  What has that got to do with charging individuals for medical records?  Apparently, a whole lot. 

Recently, I received a letter from OCR that a patient reported my practice for not agreeing to mail (for free) all medical records as requested.  There are basic rules in place as part of HIPAA and HITECH for everyone’s protection:  a release of records must be signed and include a copy of photo identification to protect from a security breach.  The individual requesting a file refused to submit a signed release form, and was unwilling to provide a copy of photo identification; rather the Office of Civil Rights was contacted and opened an investigation against us for discrimination. 

I am a pediatrician, so the patient in question is a child.  I have never laid eyes on the particular parent who was requesting records and have never seen a picture either.  I do not know their race, color, national origin, sex (it is a gender-neutral first name), sexual orientation, gender identity, handicap, age, or status of membership in a patriotic youth organization.  Could someone please tell me how I can discriminate against them?  

Charges for copies of medical records vary state to state. Our malpractice insurance company mails out a postcard each year, updating the allowable fees according to the law, and my office follows the rules to the letter.  Washington State allows $1.12 per page for the first 30 pages, $0.84 per page thereafter, and a $25 clerical searching and handling fee.  I turned all the necessary records over to OCR for review. 

Today, an email received from my “equal opportunity specialist,” informed me charging patients one per-page fee for the first 30 pages and a different (cheaper) per-page fee for the remainder does not appear to be a cost-based calculation, in his opinion. It is not compliant with the Privacy Act; therefore, I must change my policy.  Now is he an accountant or lawyer, cost-based calculation is a matter of opinion right?  Currently, thirty-three (33) other states have the exact same rule, with variable “per-page” charges.  How can so many states be getting away with this?  Side note, what on earth does this have to do with Civil Rights?    

Additionally, the $25 “fixed fee”, may not include costs associated with verification; documentation; searching for and retrieving the PHI; … even if such costs are authorized by State law.  The “searching and handling fee” is apparently not permissible either.  Being the thorough investigator that I am, I discovered twenty-seven (27) of 50 states charge a “search fee.”  In all fairness, one calls it a “certification” fee.  The very broad interpretation of the law by OCR supersedes 60 state statutes which are now out of compliance.  

My response to my very busy OCR lawyer/stalker was to respond with the Omnibus Rule, effective 9/23/2013, which "allows for the identification of labor costs for copying protected health information (PHI), which can include a reasonable cost-based fee for time spent creating and copying the file".  Our new policy now has a $25 clerical labor fee for staff time needed to copy records.  Take that, OCR.  No dice. My captor will not allow that on grounds “changing the name of the fee” in principal does not change its purpose.  Seriously, I could not make this stuff up.  When did we physicians give up our freedom and basic right to earn a living?  

There are 650 lawyers at the Office of Civil Rights.  Does anyone else feel our tax money is being wasted chasing down medical record renegades charging illegal “search” fees?  I figured out their angle.  Every case must appear to be a civil rights issue, and then these lawyers have job security.  My practice just happens to be their current victim.   

In my opinion, there are a lot of important civil rights issues playing out in the rest of the country right now.  Those issues need attention, time, and care.  We should demand OCR is a good steward with tax money that supports them.  What happens if an important governmental figure finds out all 649 lawyers are not necessary to keep OCR up and running?   Lawyers at OCR would rather take on namby-pamby stuff, like harassing a rural primary care physician’s office with nothing better to do than save lives and treat children. 

Bring it on, OCR; I have more in store for you.  If it is that easy to open a case, I am fully prepared with a complaint of my own.  I happen to have been born and raised in Washington State.  I am Irish Catholic with a Middle Eastern last name.  I am married to a man who is half-Scottish and half-Hispanic.  We have four children who are Irish, Scottish, French, Dutch, Spanish, Arabic, and Turkish.  After the rigidity demonstrated by the lawyer from the Office of Civil Rights, I feel harassed and discriminated against based on my “ethnicity” and am thinking of filing my own case of harassment.  That should prevent OCR lawyers from focusing on real civil rights issues in America.  Do you agree job security is their goal now? 

Friday, August 12, 2016

Building Better Metrics: Using Physician Outcomes

Quality measures began as tools to quantify the healthcare process, using outcomes, patient perceptions, and organizational structures associated with the provision of high-quality health care. Overall, the goals should focus on delivery of care that is effective, safe, efficient, and equitable.  Did you notice a particular word missing?  Yes, I missed the word physician too, because they have been left out of the conversation entirely.     

Measuring quality healthcare by a patient lab result is like recording a patient’s temperature by waving the thermometer near their face.  One has little to do with the other except for the slight appearance of connection.  Quality must be measured by physician outcomes and not those of patients.  For instance, our county does not have fluorinated water.  Measuring the percentage of children that have cavities is a patient outcome and not an accurate reflection of medical care provided.  A physician outcome would be calculating the percentage of children who received a prescription for supplemental fluoride during their office visit. 

If the intended goal is to reduce unnecessary ER visits, then we must determine the root cause.  Patients with private insurance rarely go to the ER for non-emergencies because they pay a large out-of-pocket cost.  Those on Medicare or Medicaid visit the ER for free.  There is no disincentive to visiting the ER, but there needs to be.  In addition, it makes no sense to penalize me for an unnecessary ER visit if I have not seen and evaluated the patient in my office.  The common sense solution is to figure out how many patients seen in my office were then seen in the ER within 24 hours.  That may be a quality indicator.

Asthma and diabetes are two chronic conditions with large costs to the healthcare system.  Compiling statistics about the number of patients who are not well controlled on daily medications is a patient outcome.  How about looking at whether or not patients who presented with these conditions were prescribed the proper maintenance medications in a timely fashion?  How about checking whether we emphasized the importance of daily use of these chronic medications in our clinical note?  Those are physician outcomes and could be used to determine quality. Why are we allowing patient outcomes, for which they alone bear responsibility, to burden us as physicians? 

How about paying me for the time spent completing oral rehydration for a moderately dehydrated child in my office?  It takes a few hours to orally rehydrate an infant or small child properly.  In my humble opinion, it is time well spent and avoids an ER visit.  I bill for extended time, but am rarely paid.  It is one of the most satisfying things I do, no parent has required more than one session in my office to be successfully taught this skill to use at home with successive children.  Return on investment for those three hours is unbelievable and pays dividends for years; a parent will almost never need to go to the ER for dehydration again.  How about a metric covering the amount of money saved by patients, insurance, and the government once a pediatrician has taught this essential skill to a family?  

My fifth suggestion would be to look at the percentage of children under 5 years of age seen for well child visits annually, rather than viewing value from percentage of children up-to-date on immunizations?  In states, like Washington, there are vaccine exemptions for every reason under the sun.  That metric penalizes a physician for a patient outcome, of which they have no control?  A physician outcome would be documenting the recommendation for immunizations during a well visit by the primary care physician. 

A metric tracking exceptional physical exam skill is another worthy physician virtue.  For instance, how frequently does a pediatrician diagnose rare congenital conditions when evaluating a new patient?  Top notch physical exam skills are essential and it this metric would preferentially favor experienced physicians who pay close attention to detail. In 15 years, my list includes a half dozen boys with undiagnosed undescended testicles,  two children with choanal atresia requiring surgical intervention, 4 with chromosomal deletion syndromes, and my “holy grail”, an undiagnosed aortic coarctation (narrowing of the main vessel supplying blood to the body) suspected based on physical exam alone.  

My idea of “value” is best illustrated by sharing my coarctation story.  A boy came into my office for a well child visit.  He had some behavioral issues, had seen multiple pediatricians over the years due to frequent moves, and brought scant records with him.  He was restless and it was difficult to palpate femoral pulses, but I do this on each and every child at their yearly physical.  Despite my persistence, I was unable to palpate them successfully.  A quick glance at his slightly elevated blood pressure, 128/90, made me pay closer attention.  I repeated it myself with a similar result. 

I discussed my concerns with the family, referred him to a cardiologist, and called to discuss the case with the specialist.  Doubtful, the cardiologist told me she would let me know what she thought after evaluation.  Indeed, my diagnosis was spot-on! He underwent surgical correction for his congenital anomaly, (like the others who have transferred in to my practice) and it was a success.  He became quite the star athlete in high school and is entering college this fall.  

Value can be defined as both a noun and a verb.  The former denotes having importance, worth, or usefulness. Experienced physicians have stories exactly like the one above; because our care provides tremendous value to the patients we serve.  Business people in healthcare prefer to use value as a verb because it signifies having a monetary gain attached.  Government and insurance companies should stop wasting dollars and cents chasing visions of value, rather use common sense and give physician outcomes the attention they deserve.  Healthcare will be on better footing now and into the future. 

Tuesday, August 9, 2016

Love and Hate with Formula 409

I use Formula 409 for almost everything, especially when cleaning the bathrooms in our home.  With three young boys, I am wiping up urine around the toilet daily, so I keep a spare bottle in there.  My children have never been gastronomically adventurous, so I have never worried much about them trying to drink the chemicals. 

But I never thought much about what else they might do with chemicals either.  One night last summer, in my haste to get everyone into bed and go to sleep myself, I left the bottle of 409 on the windowsill in the bathroom instead of inside the cabinet.  All four children were snuggled and tucked into bed by 7:30pm.   There was pure bliss for one whole minute as I sat down to read a book. 

Then there was the blood curdling scream.  “My eyes are burning, oh my eyes.  Mommy, help me.”  My daughter was upset and screaming in pain.  I went tearing out of my room and ran into the bathroom.  “Ow, my eyes are stinging.” It was hard to decipher exactly what she was saying besides having pain in her eyes.  “What happened?” I asked, thinking to myself, how did you damage yourself unattended in less than 60 seconds?  “It sprayed me.” Then it dawned on me, slowly, as she is still screaming.  Oh No.  She sprayed 409 in her face.  What on earth possessed her to spray it at her face? 

She does not spray perfume on her skin, she does not like to run in the sprinkler, and prefers baths to showers because she does not like water sprayed in her face.  “Why did you spray that in your eyes?”  I asked.  “I don’t know.”  As if a 3 year old would launch into an explanation about her thought processes before spraying cleaning chemical in her eyes.  My two older boys came out of their room and were trying to figure out what happened.  I am thinking out loud about how best to rinse her eyes out as quickly as possible.  My oldest says, “Mom, go get a syringe.” 

Brilliant!  This is one of the reasons I had so many children.  So they could help me during a crisis when I am unable to think fast enough to fix whatever mishap has occurred.  I ran down the stairs and found a large medicine syringe and returned.  It was like having a built-in, home-grown, expert surgical team that could read my mind.  One son said, “I will hold her down”, and the other said “I will hold her head still.”  I did not have to give one word of instruction, which was pretty impressive.

“The solution to pollution is dilution.”  They held their screaming sister down without missing a beat.  I used a 10ml syringe and a bowl of cold water and repeatedly rinsed her eyes out until it felt like enough.  We dried her eyes; I thanked my boys, put eye drops in her eyes, and sent everyone back to bed for the second time that evening.  This time they stayed asleep.  My daughter has never sprayed anything in her eyes since.  Lesson learned for her, my boys, and me.  I hope. 

Tuesday, August 2, 2016

MACRA is to Medicine what No Child Left Behind was to Education

The No Child Left Behind (NCLB) Act is to the education system what MACRA is to healthcare.  Why must we keep repeating history?
NCLB significantly increased the federal role in education by holding schools accountable for the academic progress of all students. NCLB held teachers responsible for education of children; MACRA-proposed changes will hold physicians responsible for the medical progress of our patients.  The largest problem with this approach is students and patients go home each day to whatever environment in which they live.  Neither teachers nor physicians have control outside classrooms or offices.  We cannot be held responsible for their sedentary lifestyles, unhealthy addictions, or poor diets.
NCLB placed a special focus on ensuring that states and schools boost the performance of certain groups, such as English-language learners, students in special education, and poor and minority children, whose achievement, on average, trailed their peers. MACRA-proposed changes want to improve preventative care for targeted chronic diseases, such as diabetes, asthma, and high blood pressure because their lives are not as productive and cost more compared to healthier counterparts. It is a tall order. 
Educating students with special needs is no easier than treating patients with chronic disease.  Lofty goals require additional personnel and incentives.  NCLB was underfunded with a punitive focus; MACRA is incentivizing data collection hoping to demonstrate value in patient care.  Rewarding physicians for statistics and penalizing them for taking the time to place hands on their patients will undoubtedly have disastrous results. 
States not in compliance with NCLB requirements risked losing federal Title I money.  Physicians not fulfilling MACRA data requirements will lose income, being reimbursed less per patient visit if they do not fall into line.  Survival of rural and small primary care practices, of which there are 200,000 in the U.S., will be in jeopardy.   
NCLB was criticized for expanding the federal footprint in K-12 education, and for relying too heavily on standardized testing.  MACRA will undoubtedly grow the healthcare footprint by relying on large entities to administer assembly line medicine to the masses. The health of the people will not improve using this approach. We are not widgets; we are individuals.  Testing will be ordered because the checklist mandates it, not because it is essential. Scarce health resources will be squandered unnecessarily. 
NCLB was passed in 2002 and by 2006, 29 percent of schools were failing to make adequate yearly progress.  In 2010, 38 percent of schools were failing to meet NCLB’s achievement targets. By 2011, U.S. Secretary of Education Arne Duncan, as part of his campaign to get Congress to rewrite the law, issued dire warnings that 82 percent of schools would be “failing” that year.  Did you notice the upward trend in failure rates? 
MACRA was authorized in 2015.  I wonder where we will be 10 years from now.  It is highly likely the failure rate at reaching targeted goals will approach 80% by then.  Do we need to repeat our mistake before reassessing and changing course?  The amount of money wasted on a ‘one-size-fits-all’ plan is astounding already. EHR’s did not improve the quality of healthcare, why would “value” reimbursement strategies? Or what about the idea of “virtual groups” created to help small practices report statistics to the government?  Honestly, the whole point of primary care is to not be “virtual”, rather to be real.   
NCLB’s solution for failure was to grant state waivers, now in place in 42 states, Puerto Rico, and the District of Columbia.  These waivers allowed “failing” states to get out from under burdensome mandates of NCLB in exchange for embracing certain education redesign priorities.
Can I please obtain and fill out a clinic waiver now so it is at the head of the line?  Administration of universal education and healthcare are linked.  Education is the very core of what physicians do on a daily basis. Teachers educate students; physicians educate patients (if we are allowed adequate time to do so.)  You cannot enforce standards for every student in every school across America any more than you can enforce standards for every patient in every medical office throughout the nation. 
Success in health and education cannot be legislated.  Well it can be, however it is unlikely to experience successful implementation.  Americans are fiercely independent and take our freedoms quite seriously.  We will not be placed on an assembly line, poked and prodded under the guise of “prevention”, and give up things we love, like candy, potato chips, cigarettes, booze, and opiates in the name of better health.  It will never happen.  People will continue to ignore health maintenance recommendations for hypertension and diabetes.  Must we spend billions of dollars to prove failure is inevitable?  We are highly unlikely to entice the return of good quality physicians once the exodus begins.