Tuesday, February 28, 2017

Blood, Guts, and MACRA

Sean MacStiofain said “most revolutions are caused… by the stupidity and brutality of governments.” Regulation without legitimacy, predictability and fairness always leads to backlash instead of compliance.  If something is not done to stop MACRA implementation, more physicians will opt-out of Medicare and Medicaid than is fathomable.  Once DRexit begins, there will be no turning back. 

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) is destructive to the physician patient relationship because it prevents physicians from prioritizing patient care.  MACRA supporters like to point out this legislation was passed with bipartisan support; in reality, it was passed simultaneously with repeal of the Sustainable Growth Rate Formula. The SGR was holding billions hostage and lawmakers had a gun to their head, leaving them no other choice. There is nothing bipartisan about that.

The Sustainable Growth Rate Formula was enacted through the Balanced Budget Act of 1997 and was designed by lawmakers to control Medicare expenditures. The SGR formula limited the annual increase in cost per Medicare beneficiary to the growth of the national economy.  Under the SGR formula, if overall physician costs exceeded target expenditures, a reduction in payments would be triggered.  Expenditures continued to climb, so Congress stepped in 17 times with short-term legislation (referred to as “doc fix”) to avert the payment reduction since 2002.

These patches kept increases in physician payments below inflation which ultimately resulted in a huge discrepancy between the actual level of Medicare physician-related spending and the target in the SGR formula. In 2015, if Congress did not act by March 31, payments to Medicare physicians would have been reduced by 21.2 percent.

Enter stage left, MACRA, known as the Permanent Doc Fix, which was passed concurrently with the Sustainable Growth Rate Formula repeal legislation.  This was the original repeal and replace.  MACRA established yet another new (and untested) method by which to pay doctors.  MACRA is the largest scale reform on the American health care system since the Affordable Care Act in 2010 and the jury is still out how great (or not) that system is working for the American people.   

Under MACRA, the Secretary of the Department of Health and Human Services was tasked with implementation of a Merit Based Incentive (MIP) program which consolidated three useless incentive programs into one big colossal unworkable program for eligible physicians everywhere. The legislation also allows for Advanced Alternative Payment Models (APM), which shockingly, are not actually saving money on care. 

Even better, MACRA related regulations also addressed incentives for use of health IT by physicians and other care providers.  Similar in scope to the Meaningful Use (aka Meaningless Abuse) Program except, now on steroids.  The Government Accountability Office in partnership with the DHHS have been assisting with the implementation of electronic health records (EHR) nationwide, while at the same time comparing and selecting programs for providers. 

So to recap, Congress has been working on a “doc fix” system in conjunction with every lobby possible on the planet EXCEPT that of Practicing Physicians since 1997.  They “repealed and replaced” SGR (first disaster) with the atrocity known as MACRA, which will end in a mass DRexit.  They are rapidly moving ahead with non-evidence based payment methods intended to decrease costs, yet are highly unlikely to be successful based on recent studies.  On top of all that, they are selecting computer systems for physicians which incentivize computer data entry while discouraging the placement of hands on patients.  Did I miss anything?

Recent studies show physicians spend twice as much time on technology than we do with patients.  Maybe with full MACRA implementation, we can be retrained as data entry clerks to treat conditions instead of people.  Imagine if we just called in prescriptions for hypertension, diabetes, or even started chemotherapy regimens without seeing patients at all?  MACRA pays us more for “doing less,” so now we can practice “drive-by medicine.”  I wonder if health outcomes will improve and mortality will be lower when compared with “drive-by shootings.”   

Controlling costs involves four major pillars of change to our healthcare system, about which I have been writing for some time.  Listening to a talk given recently by the executive director for the Association of Independent Doctors, Marni Jameson, helped focus the strategy.  The first cost control pillar is to educate patients and lawmakers as to how consolidations of hospitals and medical practices raise costs, reduce quality, decrease access, eliminate jobs, and result in unnecessary testing and procedures. The second pillar is to increase price transparency, so consumers can compare costs and choose the most affordable option. The third pillar is eliminating the onerous ‘facility fee’ to bring payments of hospital-employed doctors in line with the lower payments to independent doctors for the same care.  The final pillar is ensuring hospital profits are taxed equally across-the-board, regardless of whether they are non-profit or for profit institutions.

In the next four posts, I will cover these issues in more detail as each deserves its own separate discussion.  It will be an interesting mathematical exercise to calculate the forecasted cost savings of these four interventions alone.  If you are reading this post, you have skin in the healthcare game, whether as physicians, lawmakers, economists, hospital administrators, government, or IT experts alike.  As I have said before, we will ALL be patients eventually. 

Tuesday, February 21, 2017

Gaming the System: Pediatrics, Mammograms, and MACRA

As physicians ready themselves for the future of medicine under onerous MACRA regulations, it seems appropriate to glance into the future and visualize the medical utopia anticipated by so many.  Value-based care, determined by statistical analysis, is going to replace fee for service.  

Six months ago, I received my first set of statistics from a state Medicaid plan and was told my ER utilization numbers were on the higher end compared to most practices in the region.  This was perplexing as my patients tend to avoid ER visits at all costs and can be found milling about in my parking lot at 7am on Mondays with their sick children waiting for my office to open. 

I requested more detailed reports on ER utilization and was given a 20 page list with codes that needed to be hand matched to patient names.  Being a committed and diligent physician, I spent a random Saturday evening matching up 420 names to individual 15-digit codes after putting my children to bed.  Of my top 20 utilizers, only 8 were actually patients.  The remaining 12 had been “on my panel list” during the reporting period but had never set foot in my office.  Of the top 100 utilizers, only 42 were patients.  In the interest of accuracy, I requested they re-run the numbers using my patients only.  Mr. IT informed me the inaccurate panel would make no difference.  He might have failed statistics in college but who is keeping track. 

I have spent 6 months on what I call obsessive-compulsive panel management (OCPM.)  My Medicaid panel has been closed for the last 9 months in anticipation of opting out by 2019.  OCPM meant 150 non-patients on my panel needed to be reassigned to primary care physicians who had space to accept them. Apparently, no physicians have requested this before, the insurance administrators were stumped as was the state department of health.  After more than 200 hours spent on this process (instead of seeing patients), I have whittled down the list to a comfortable 316 as of January 1st 2017. 

Last week, I received the second round of numbers, covering the period ending in the previous year.  Panel management was going on during this period but was by no means complete, so it is still not an entirely accurate reflection of my “quality”.  Mr. IT could not believe the difference in just one reporting period!  I would argue the accuracy of the panel had an impact on those statistics, but what do I know about such things?

He was excited that we have not admitted a single asthmatic patient in the entire reporting period, which is obscenely lower than the nearest practice in the region and the lowest in the state.  I almost told him we have not admitted an asthmatic patient in more than 15 years but thought he might have a heart attack.

Asthma admits will be metric #1 to demonstrate my high quality.  My ER utilization numbers are below the local region and on par with state numbers. I suspect accuracy is still not quite where it needs to be but have no interest in spending a free Saturday night matching up names and numbers manually to figure this out.  At least we are trending in the right direction.  There is metric #2. 

The search began for metric #3.  My frequency of ordering imaging studies (excluding X-rays) was above average.  Interesting, since I ordered only one test on a child with kidney stones last year.  After inquiring if the data reflected all scans done on patients from my panel or the just studies ordered by me personally, Mr. IT did not know.  He is working on it and will get back to me in a month or so, when he figures out how to do that sort of thing.  He could tell me there was a disproportionate number of echocardiograms ordered. 

Armed with that information, I could hazard a guess where my ‘quality problem’ lies; I have a large  population of children with cyanotic congenital heart disease, referred to me by a certain pediatric cardiac surgeon who thinks I provide quality primary care.  Many of these children get echocardiograms before and after cardiac surgery, other procedures, or whenever deemed clinically necessary by the specialist. 

Why do we have to employ an IT guy to give me information I already know?  Why is the government paying him to do something I can do in my head?  Why am I being penalized for a specialist ordering necessary imaging studies on pediatric heart patients?  How does this demonstrate quality?

The search for Metric #3 continued. I have many families who are vaccine hesitant or non vaccinating and do not have the heart to turn their children away.  Vaccination refusal is properly documented in the chart but the world of statistics does not account for these subtle nuances. There are companies emerging who can look at coding and catch specific words or phrases which help show quality.

While I have poorer numbers on percentage of immunized children, it turns out I had a perfect score on my mammogram recommendations. What mammogram recommendations?  Last year, I evaluated a parent having an asthma exacerbation and while I wrote her prescriptions, we discussed her family history of breast cancer and the need to schedule a mammogram.  My rate is at 100% because she is the only patient last year I evaluated who falls into this category and I happened to document the preventive recommendation purely by coincidence.  Bring on Metric #3.

MACRA lets physicians pick and choose which metrics are evaluated for “quality.”  This pediatrician is wholly committed to tracking mammogram recommendations at all applicable patient encounters in the future to demonstrate the highest quality patient care I am capable of providing.  I read a recent blog post from a cardiologist who might track how often he orders imaging for back pain, since he had a 100% score in that particular category. 

Imagine what quality metrics the pediatric cardiac surgeon is going to track.  He would do well to collect statistics on how often he images patients for appendicitis because it is likely a rare occurrence.  Things are really looking up for the use of data and technology in healthcare. Costs are likely to keep rising with everyone scoring in the 99th% percentile once they figure out how to game the system.  But we certainly cannot stand in the way of science or progress now can we? 

Tuesday, February 14, 2017

Physician Suicide: We Must Stop Losing Our Own

In the past few weeks, we have lost two female physician colleagues tragically to suicide, a pediatrician and psychiatrist.  In the general population, males take their lives at four times the rate of females.  However, for physicians specifically, the suicide rate is evenly distributed between genders; making our occupation the one with the highest relative risk for women to die by suicide.  This is what I wish would change about being a female physician; we must stop losing our own. We need to support each other, love one another, and face our challenges together. 

Fifteen years ago, a surgeon called me in to evaluate a child with 3 days of fever, abdominal pain, and vomiting.  Her initial white blood cell count had been 36,000, but she had been discharged home from the ER with a diagnosis of viral gastroenteritis.  Two days later, she returned with lethargy, continued symptoms and a white blood count on admission of 32,000.  The surgeon sought my input before taking her to the operating room. 

Tiffany was 12 years old the first time I walked into her hospital room.  Her mother was sitting next to her daughter on the bed quietly stroking her hair.  Tiffany had poor color, delayed capillary refill, and was ill to the extent she could not localize pain to her abdomen.  Her vital signs revealed tachycardia, lower than normal respiratory rate of 6, hypotension, and fever.  She needed fluids, antibiotics, and pressors for impending septic shock.  After I stepped out of the room to write orders, she coded within minutes.  Anesthesia managed her airway and I straddled her tiny body while performing chest compressions.  Following a lengthy resuscitation, she stabilized. 

Later that afternoon, the surgeon performed an appendectomy which included removal of 30cm of necrotic bowel, giving her the best possible chance for survival.  Remarkably, she pulled through and recovered.  She needed a primary care provider after discharge from the hospital; a job I readily accepted.  She informed me at the ripe old age of 14, she was going to cut patients open and save their lives.  She studied hard and began college classes as a junior in high school.  She shadowed me countless times in my office; her enthusiasm for medicine was infectious. Her commitment to a surgical career was unwavering.    

We remained in close touch after she left for college.  She lost her father to a heart attack during her senior year.  As an only child, her mother and best friend were her strongest sources of support. Whenever home on break, she would stop by to update me on her life and see patients with me.   She graduated from college with honors and was accepted into the medical school of her choice.     

Tiffany was born to be a healer; she had a laser-like focus about her future plans.  During her fourth year of medical school, her best friend was killed by a drunk driver on a busy freeway.  Tiffany was devastated beyond belief.  Seeing her at the funeral, I knew something was terribly wrong.  She looked pale, thin, and seemed despondent.  Her mother recognized her sadness and thought I could help. 

Tiffany was reluctant, but I insisted on going for a walk after the funeral.  It was a rare sunny day and we ambled down the forest path in silence for a good while before she shared her thoughts.  In her final year of medical school, she felt like her world was literally falling apart.  She was lost and uncertain of what she wanted out of life.  She could not eat, sleep, or find the joy she once had.  I listened for a long time, before carefully formulating my response. 

I reminded her of the day a resilient 12 year old girl coded right before my very eyes, yet stubbornly refused to die.  “You survived for a reason.  Only you can decide for what purpose you were given a second chance. Find something you are passionate about.  Do it for your mother, your father, and your best friend; but, most importantly, do it for yourself.  Being a physician is challenging at best and unbearable at worst.  You must find a way to celebrate your successes, grieve your losses, accept the things that cannot be changed, and embrace relentless uncertainty, or you will not be able to thrive.”

Six months ago, she entered her third year of a competitive surgical residency on the opposite coast.  We remained in touch but with each passing year, she has seemed more distant.  There is a season for everything, and maybe we have had ours.  Then a month ago, I received a letter in the mail and recognized her handwriting: 

“Residency has dimmed my love for medicine.  There are days I am thrilled to walk through those hospital doors and days when my heart is filled with dread.  Life is too short for regrets, so I have decided to take a leave of absence and discover where my heart truly lies.  Thank you for never giving up on me.

The last time we saw each other, I was contemplating taking my own life.  I could not face you knowing what was in my head and my heart.  You were right to be unrelentingly persistent.  Your reminder that I almost died, yet survived against all odds, was the one thing I needed to reflect upon and remember.  Fifteen years ago, you could have given up, walked away, and not given me that second chance.  You refused to let me die.  I do hold the power to direct my own life.  Thank you for saving me twice.”

The journey to becoming a physician is fraught with peril.  We spend years acquiring the expertise to comfort and heal others, yet those skills are attained at a great personal cost to women in particular.  Among female physicians, the relative risk of suicide is 2.3 times greater than the general female population.  Each and every tragic loss of a female colleague should be honored as if we lost a part of ourselves.  Their struggles must become ours; their survival is imperative for us all. If you are struggling, please know, we are here, we are listening, and we care. 


This essay is dedicated to every female physician, resident, or medical student who has considered suicide or taken their own life.  May they find peace and comfort and may we find a way to reach out to one another when we find ourselves in need of support. 

Friday, February 10, 2017

Free-market Medicine:  Can Independent Practices Stay Viable Using Price Transparency?

The market for medical tourism grows as Americans increasingly seek medical care outside of the United States and pay cash for services.  Patients know they can obtain adequate quality care in Mexico for out of pocket costs far lower than their insurance plans with high deductibles would cover.  Posting basic outpatient visit and simple procedure prices could benefit our independent practices in the same way.  The only thing worse than not having health insurance, is having coverage be so expensive you cannot afford to utilize it when necessary.  It is like sleeping next to a chocolate cake every night while on a diet.  

Mexico lags behind most Organization for Economic Co-operation and Development (OECD) countries in health status; however, they are the best in one significant category.  They have the lowest healthcare expenditures of all the OECD countries, making visitation of the free-market medicine “concept” worthwhile.  A majority of healthcare in Mexico is provided via private entities or private physicians. The private organizations operate entirely on a free-market system, less than 10% of Mexicans have health insurance, so most pay “out of pocket.”

My family spent a week in Mexico over Christmas and on the day we were due to fly home, my youngest son developed a very high fever.  Fever reducers were administered and all was well until he vomited all over himself, his blankie, and the ground at the resort entrance.  By the time we arrived at the airport, he did appear a bit limp and lethargic.  “Is he sick?” the ticket agent asked.  “Not really,” I lied.   “Does he have a fever?” she asked.  “Not at this time,” I responded.  “You must be cleared by the physician at the airport before I issue your boarding passes”, she stated.  “Does it help that I am a pediatrician?” Nope. 

Resigned to my fate, I waited in a quiet corner until a young physician and his medical assistant approached.  He introduced himself and asked me a few questions before suggesting an anti-emetic injection prior to the flight.  Needing to obtain a weight on my son, we followed him to the clinic, which looked like a mini-ER including two fully stocked treatment beds yet surprisingly no additional staff.  The physician gave him a quick shot on the rear (Metoclopramide), filled out some PAPER-work, and handed me my copy of the encounter including an itemized bill:  300 pesos for the visit and 100 for the injection.  I paid him in cash, approximately $20 USD. 

As he escorted us back to the airport waiting area, we shared some frustrations about our respective careers.  He told me about a young child from the day before who was severely dehydrated to the extent he required significant fluid resuscitation.  Due to the child’s precarious hydration status, an IV had to be placed in his jugular in order to successfully deliver fluids.  This young general practice doctor had a wide repertoire of skills, despite access to little in the way of resources. 

Which brings me to the point, I need a light, a stethoscope, and a pen to heal and comfort human beings; the rest is basically nonessential.  This Mexican physician and I fundamentally do the same thing every day; except he has no receptionist, no billing personnel, no manager, no administrator, no care coordinator, and definitely NO EMR in his emergency clinic.  He documented the visit in less than 3 minutes (like I do), signed it, and handed me the top page for my records.  His care was good, his skills were solid, and his decision-making sound; I would have treated any other child the same way.

From an economic standpoint, there are two basic approaches to any service-oriented occupation.  The first is “how much revenue can be generated?”  The second is “how can one deliver quality for a reasonable price?” It is slowly dawning on misguided health economists that the former method is outrageously expensive.  The latter, a free-market system, is efficient, effective, and helps control cost, but there are fewer kickbacks available for the cartel of healthcare administrators and government lackeys that way.  The free market discourages waste and ensures both physicians and patients are mindful of expenditures, which is supposed to be the goal, right? 

85% of medical problems can be handled in a private clinic or a Direct Primary Care (DPC) setting and 70% of surgeries can be handled in an outpatient ambulatory surgery center, yet our government preferentially backs large hospital practices employing physicians and subsidizing their expensive surgical suites.  Health care expenditures rise by the day, yet physician compensation has been relatively flat over the last few decades.  The increasing cost is due to the assorted “add-on fees” of large institutions, which should affectionately be called “administrator, manager, or IT surcharges.”  This is the reason parents are charged $39.35 to hold their newborn infant after delivery at the hospital.  In my office, it is totally FREE to hold your own newborn.  What a great deal!

Physicians should post prices for general well and sick visits, basic procedures, and other regular services when feasible, allowing patients to make better informed decisions.  A business that provides value to the consumer will undoubtedly thrive.  The larger the physician repertoire, the more a consumer reaps the benefits of your expertise, and the busier the practice becomes.  Private specialty care could be provided in this straightforward, streamlined way as well.   Patients are clearly willing to travel outside the country for good quality medical care at a pre-defined cost, so why not walk across the street from the large hospital waiting room to an independent physicians’ office? 

Free-market medical care encourages healthy competition; which is bad for the “administrators” and “managers” but very good for patients and physicians.  Domestic medical tourism could grow as informed consumers are able to search for the right quality at the right price.  My recent brush with free-market medicine is a beacon of light for how simple medicine used to be.  If independent private physicians come out of the shadows and into the light, embrace price transparency where feasible, then larger institutions will never be able to compete with us.  Now what exactly are we afraid of?



Friday, February 3, 2017

Inseparable: The Physician and The Mother

I could never have brought comfort, healing, and second chances to others without being a physician, but I would never have been a mother to countless children without being a female.  Just as medicine has facets of both art and science, our femininity is where our courage, fortitude, and unique ability to restore health and wellness derive their foundation.  Possessing the unique innate aptitude to empathize with others allows us to form enduring intimate relationships with those for whom we care.  Witnessing first-hand the results our positive contributions can make is absolutely breathtaking.   

Last week, I received a phone call from a mother with 13 year old twins.  We first met more than 12 years ago when her daughter was terribly sick from urosepsis after being admitted to our local hospital.  She called while my children were taking dance lessons and was frightened because her son had a fever of 105 degrees and seemed ill.  She sounded terrified and needed advice.  She has never called me after-hours before.  I recommended a fever reducer and gave her two options:  to go to the nearest urgent care or come to my house after dance lessons were over for me to evaluate him.  She asked her son and he wanted to come to my home. 

By the time he walked in my front door, he was smiling, down to 100.4, and looking pretty stealthy.  He hugged me and thanked me for seeing him.  His mom mentioned he was crying at the thought of going to the hospital or urgent care.  Having known him for more than a decade, it was fairly straightforward to evaluate him, reassure mom it was a virus, and send him home with instructions for fever management and good hydration.  “Wow! You are a doctor and a mom rolled into one,” he exclaimed.   

Last month, a seventeen year old came in for an appointment unaccompanied.  She has been under my care since she was three.  We share a close relationship that could only exist after many years together.  She is the only child of a single mother, who has done an excellent job raising this young woman on her own.  Her father left the family years before due to addiction and mental illness.  As I entered the room, she seemed nervous and mentioned feeling awkward.  “My dear, I have known you far too long for awkwardness, just talk like always,” I reassured.  She explained she had been dating someone special and was interested in obtaining birth control.  She sighed and informed me she understood this would only prevent pregnancy and planned to use condoms for protection from sexually transmitted diseases. 

After a pause, I asked if he was good enough for her.  She smiled and nodded affirmatively.  She reassured me this was her decision; she had given it much thought and felt ready.  She smiled and acknowledged I might not be ready.  I emphasized how proud I was of who she had become, shared my admiration for her mature approach to making this adult decision, and applauded the deliberate way she was wisely guarding her future. “Do not worry about me, I can handle this,” I replied. 

Our question and answer session went back and forth and a birth control method was prescribed.  As the visit came to a close, I inquired why her mother had not accompanied her.  She responded “it was too difficult to handle the reaction of two mothers at the same time.” She preferred approaching each of us separately.  I asked how she thought our ‘talk’ went, and she agreed it had been easier than she anticipated.  As we walked out to the front, her mother hugged me knowing what had just transpired.  I smiled and asked how she was doing.  She took a step back and assessed her beautiful 17 year old daughter and replied, “Our little girl has certainly grown up and matured into a wonderful human being.”  Indeed. 

There is no greater compliment than having someone I took care of as a child return as a parent with their own little one.  Upon reflecting on second generation patients, a twenty-six year old mother named Sally jumps out immediately.  Her mother and mothers’ female partner, Anna, came in together for that first appointment many years ago when Sally was 10 years old.  Sally’s biological mother was not exactly the mothering type; in contrast, Anna was warm and engaging. 

When Sally was 17 years old, her biological mother died of a drug overdose.  Anna took Sally in, yet had no legal standing to allow for medical decision making.  We worked hard to get Sally emancipated; she went on to finish college and graduate with honors.  When she became pregnant a few years later, she waltzed back in to my office requesting me as the pediatrician for her son.  That boy is the spitting image of his mother, who I recently gave immunizations to at his four year well checkup.   

We started discussing the trials and tribulations of parenting, being that we have children who are the same age.  “My mother was dreadful, I could not have done it without you and Anna; she is my second mom and you are my third” she stated.  Tears sprung to my eyes and I replied, “Your mother loved you in the only way she knew, but you should be so proud of all you have accomplished, and in what a wonderful mother you have become.”  We embraced and tears started running down her face as well.  Her son, Aiden, looked at us woefully and said, “My shots really hurt, so how come you guys are crying?”  We both burst out laughing.

As physicians, we do our best to set patients up for successful futures. This instruction can begin when a person is a few days old and may continue for a lifetime.  In primary care, we observe children grow into adults, finish their educations, and embark on families of their very own.  The single greatest aspect of medicine for me has been to realize the impact our lasting relationships can have; something that was facilitated by being a female physician. 

February 3rd is National Women's Physicians Day, please join me in celebrating those who blazed our trail.  #NWPD #iamblackwell #womendocsinspire