Sunday, August 18, 2019

Should Doctors Offer a Money Back Guarantee?

It may seem odd that a gastroenterologist patronizes fast food establishments several times each week.  I’m in one right now as I write this.  I eschew the food items –though French fries will forever tempt me – and opt for a large sized beverage.  In truth, I am not primarily there for a thirst quenching experience, but more to ‘rent a table’ so I can bury myself in some reading.  Indeed, many thousands of New York Times issues have been devoured at these tables.  I saw a sign posted on the wall here that I had not seen before.

Sorry, No Refunds

Refunds?  How often can this happen in a place like this?  We all know that food items in these institutions are remarkably consistent, which is one of benefits that customers enjoy.  Your Big Mac or Whopper will taste the same in Pittsburgh as it does in Peoria.  I questioned the server on this new development and she explained that increasingly customers were demanding refunds for contrived reasons in an effort to bilk the restaurant.  At some point, the restaurant decided to put an end to this practice. 


Refund Free Zone!

I wonder how my patients would react to being greeted by such a sign in my office?  Of course, physicians do not offer refunds or a money back guarantee for our services, as other industries boast.  Nearly every infomercial includes the tag, “and if you don’t agree that these _____  are the best you’ve ever used, simply return it for a full refund – no questions asked!”  Not so in the medical profession.   We are paid regardless of the outcome or your satisfaction.  It is true that physician reimbursement policy is evolving away from fee-for-service (FFS) toward a value-based system.  In other words, physicians won’t be paid separately for every medical service we provide you, but for the overall ‘value’ we provide, which is a somewhat amorphous concept.  FFS clearly incentivizes the medical profession to overtreat patients because we are paid more for doing more, even if such care may not be truly necessary.   It remains to be seen if the value-based payment approach will protect patients and be fair to physicians. I have my doubts.

Many professionals are paid regardless of how their clients fare.  It you lose your case in court, your lawyer will still be paid.  If a judge is overruled on appeal, his wages aren’t reduced.  If your investment underperforms, your financial planner doesn’t return his fee to you.  Tradesmen, on the other hand, make a commitment to satisfy us as a condition for getting paid.  If we hire a plumber to unclog a sink, for example, he understands that if he doesn’t deliver, then we won’t either. 

What if all of us were paid on results rather than on time expended?  Would this lead to higher quality goods and services?  Could it really apply to the medical profession?  If a patient comes to see me with abdominal pain, which often defies explanation even after a thorough medical evaluation, is it fair that I wouldn’t be paid if the patient’s pain persists?

None of this applies to Whistleblower readers.  These posts are free so don't ask me for refund.  

Sunday, August 11, 2019

Joining a Clinical Trial Helps Others

From time to time, I am asked by someone about participating in a medical research study.  These situations are usually when an individual, or someone close to them, has unmet medical needs.  Understandably, a patient with a condition who is not improving on standard treatment, would be amenable to participating in a clinical trial to receive experimental treatment.

I find that most folks misunderstand and exaggerate the benefits they may receive as a medical study participant.  Sometimes, I feel their ‘misunderstanding’ is fueled by study investigators who may overtly or unconsciously sanitize their presentation to patients and their families.  There is no malice here.  Investigators have biases and likely believe that their experimental treatment actually works.  Their optimism is likely evident in their communications.

Here’s what an investigator might say to a patient.

I thought you would be interested in a new clinical trial testing a new medicine for your disease.  Preliminary data show promising results. 

If you were a patient, wouldn’t you infer that the drug might help you?

Patients, I have found, are of the mistaken belief that they may directly benefit from the drug being tested.  Of course, this makes sense to them.  Their rheumatoid arthritis drug isn’t working.  They are informed of a clinical trial of a new treatment for patients who do not respond to conventional treatment.  Obviously, they enter this trial with the hope that their condition will improve.  Unfortunately, this is the wrong way to approach a medical study.


Louis Pasteur - Legendary Medical Researcher

Clinical trials are not designed to benefit the participants.  They are performed to generate new knowledge that may help future patients.  This is the key point that so many study participants are not fully aware of, and they should be.  The investigators do not know important data about safety, efficacy and dosing.  These are among the fundamental data that the study – and future studies – will determine.  If medical investigators knew that the drug actually worked, then there would be no need for a clinical trial.  There’s a reason behind the term experimental treatment.

If you want to enter a clinical trial, know that you are doing so to help others who will come after you.  This is a selfless and praiseworthy event.   Indeed, we have all benefited from the sacrifice and altruism of prior patients who agreed to create new knowledge to help us.   If we enter a study we may not personally receive a return on investment for our efforts, but we are paying it forward to others.

Sunday, August 4, 2019

Transparency in Health Care Costs - New White House Proposal


Opaque:  adjective, not able to be seen through; not transparent

Medical pricing is beyond opaque.  It’s a riddle wrapped in a mystery inside an enigma.  Many readers will recognize that this clever phrase is not my own.

Throughout my career, I have been unable to provide an accurate answer to the perennial inquiry, how much does a colonoscopy cost?  Patients, of course, find this to be baffling.  This ignorance is certainly not restricted to my specialty of gastroenterology.  Does it make sense, for example, that the same medication may have wildly different pricing at different pharmacies or in different cities?   In contrast, we would expect to find a similar price for a gallon of milk among supermarkets. 

My strong suspicion is that seemingly irrational, inflated and complex medical pricing is all by design to serve those on the billing end – hospitals, pharmaceutical companies and pharmacy benefit managers.  Before you accuse me leaving physicians off of this list of Greed & Shame, may I remind you that we physicians do not set our own prices; they are all dictated by the payors.  When we send you a crazy bill, it is all according to your insurance company requirements and policies - not us.  Same for the copays patients fork over when they come to see us.  While we are the target of griping and sniping, these cash extractions are mandated by your insurance companies.

The medical arena is unique.  It does not allow consumers to utilize price comparison as they do when purchasing appliances, vacations, private schools,  apartment rentals or an apple.  It is unlikely that one would sign an apartment lease without being told what the monthly rent charge would be.   But, we will proceed to a CAT scan examination without knowing the cost or if a nearby competitor can provide the same service for less.


Fairly Easy to Determine the Cost Before the First Bite


Recently the White House launched an initiative to require physicians and hospitals and insurance companies to inform patients of the costs of medical care in advance.   Of course, this concept should be welcomed and applauded.  Push back against it was locked and loaded before the new policy was announced.   Who’s against price transparency?  Hospitals and insurance companies and drug companies are united in their opposition.  They claim, among other things, that they would be forced to surrender proprietary information,  that medical prices would actually increase and that the public would not be well served.   I am not an economist, but I surmise that exposing the buried secrets of medical pricing will empower the rest of us in making better choices.  Real and open competition will bring prices down, as is true in all other spheres of commerce.

Some economists are warning that this issue is extremely complex and that the outcomes may be paradoxical.  I'm willing to take a chance.

My goal before I retire years from now is to be able to tell a patient how much their colonoscopy will cost.  

Transparent: adjective, allowing light to pass through so that objects behind can be distinctly seen.

Sunday, July 28, 2019

Value Based Pricing in Medicine - A 'Stinging' Issue!


Some professionals and businesses get paid regardless of their outcome.  They are paid for their time and expertise.  For example, if you hire an attorney, unless you have a contingency fee arrangement, you will be billed regardless of the outcome.   If you sue a business because you allege a product you purchased is defective, but the business counters that you damaged it by using the wrong tools to assemble it, there is no guarantee that you will enjoy a legal victory.  However, if your lawyer has invested 20 hours of labor as your advocate, he or she will certainly enjoy a financial victory if an hourly rate is in place. 

Similarly, if your financial advisor, who is paid on commission, advises that you invest in a certain product, and the investment declines 10%, only one of you will take a major hit.  Guess who?
If you treat yourself to expensive theater tickets, but you find that the performance was dull and uninspiring, do you expect to be given vouchers for another show as you exit?

See my point?  In these instances, and so many others, we pay regardless of the outcome.  The concept of paying for results, which is much more attractive to the consumer, has yet to gain a solid footing in the commercial world.

But, that may change.  It certainly has in medicine.  The fee-for-service era, when every service is reimbursed – regardless of the outcome – will be entirely phased out.  Physicians, hospitals, nursing homes, rehabilitation centers will be paid if they meet designated quality benchmarks.  If these standards are exceeded, then a bonus payment may be forthcoming.  If the standard is not reached, then the provider may be coughing up a penalty. 

Beware the Hornet's Nest!


The concept is attractive in medicine and in commerce overall.  Consider these two hypothetical examples under the fee-for-service model.

A patient sees a gastroenterologist.  Although a colonoscopy is not medically necessary, the physician advises it and performs it.  There is a complication and the patient is hospitalized for 5 days.  Emergency surgery was needed to repair the complication.  All physicians, hospital consultants, the hospital and a few days of post-discharge rehab are all reimbursed.

A patient sees a gastroenterologist.  A colonoscopy is not medically necessary and is not ordered.  The patient is advised to continue Metamucil and to return in 6 months.  The physician is compensated at a mid-range level office visit level.

The absurdity in the above example is apparent.  The wrong incentives are in place.

Here’s the challenge in rewarding outcomes. 
  • What are the quality outcomes that will merit compensation?
  • Is there a fair and reproducible manner to measure the outcome?  (How would you precisely measure improvement in fatigue, depression and abdominal pain?)
  • Would physicians and hospitals be penalized if patients did not follow medical advice and had poorer outcomes?
  • Should specialty physicians who have trained longer than primary care physicians expect higher reimbursement levels?
  • How do you reward a physician who does not order unnecessary tests, consultations or prescriptions? How could you reliably measure this?
  • If a hospital receives a ‘lump sum’ fee for a patient’s care, how is this fairly divided among the hospital and the various physicians?
Let’s be truthful.  Some forces advocating for value based pricing - pay for outcome - are pursuing this strategy to save money as much or more than to enhance medical quality.  The potential conflicts of interest are self evident. 

And, there’s the risk of going too far.  If I see a patient with abdominal pain and after appropriate testing determine that diverticulitis is the culprit, I will likely prescribe medication. If the patient doesn’t respond to the proper treatment, should I have to forfeit my reimbursement?  Would this be fair?  An unwelcome outcome is not evidence of deficient medical care. 

Value Based Pricing, like many slogans, is attractive.  But, there may be a hornet’s nest lurking below.







Sunday, July 21, 2019

Walk a Mile in their Shoes - Lessons from a Backyard Rodent


“He ate my dahlia!” exclaimed the lady of the house. 

Our backyard is a menagerie.  We are often perched at the window gazing at birds hovering over our feeders, raccoons climbing tall trees, ground hogs, possum, wild turkey, deer, a red tail hawk, a seemingly misplaced spring peeper, stray cats and scampering squirrels and chipmunks.

And, the lady was correct.  A chipmunk, who seems to know our property as well as a trained surveyor, hopped into the newly created dahlia flower pot and enjoyed a colorful repast.  As of this writing, there is one remaining, lone dahlia, which might be on his menu later for dinner or a midnight snack.


Where Have All the Flowers Gone?


I will take issue, ever so gently, that the resourceful rodent ate ‘our’ dahlia.  I suspect that readers have uttered or heard similar phrases, such as 'the deer ate our flowers!'  Let’s consider the issue from the animal's points of view.  
  • The land that we claim title to is their home.  So, for starters, there is a property dispute.
  • They and their descendants were there long before we were.  Perhaps, they have a home invasion argument?
  • They are seeking food and shelter in accordance with their needs and instincts on their home turf. How would we react if a higher power summarily banned us from all supermarkets and restaurants?
  • They have to contend with human interlopers placing various repellents, barriers and obstacles impeding safe passage to their food supply. 
So, is the hungry little chipmunk a perpetrator or a victim?   Now, don’t get your acorns all riled up over this.  I’m trying to make a point.  It’s a matter of perspective.  Issues, arguments and positions can appear radically different if considered from another viewpoint.   Being mindful of this, I think, allows for a much more fruitful dialogue.  Which of the following examples do you think is more likely to lead to a constructive outcome.

“I’m right and you’re wrong.  You’re just like your mother!”

“Wow, I never really thought of it that way before...”

Issues of perspective affect all of us, in our professions and occupations and in our lives.  Here’s a few hypothetical but plausible scenarios in the medical world where there might be another legitimate point of view to be considered than the one expressed.  
  • A doctor mentions to his staff, “…that last patient was demanding.”
  • A patient develops a wound infection after surgery and complains that ‘something messed up’. 
  • A patient states that the staff was rude when she was told she would need to reschedule after arriving 30 minutes late for a routine office visit.
  • A patient’s family claim that a physician years ago missed a diagnosis.
  • A doctor complains that a hospital nurse took too long to call him back.
  • A patient files a complaint with hospital administration because the Emergency Department physician would not refill his pain medicines and he left in severe pain. 
  • The doctors are pressuring us to ‘pull the plug’. 
So, whose side are you on, the lady’s or the chipmunk’s?





Sunday, July 14, 2019

Do Patients Like Electronic Medical Record Systems?


I have penned several posts on the pitfalls of the electronic medical record (EMR) system that we physicians must use.  Indeed, I challenge you to find a doctor who extols the EMR platform without qualification.  Sure, there are tremendous advantages, and the ease of use has improved substantially since it first came onto the scene.  But, keep in mind that these systems were not devised and implemented because physicians demanded them.  To the contrary, they were designed to simplify and automate billing and coding.  While this made their tasks considerably easier, it was at physicians' expense.  Features that helped billers and insurance companies didn’t help us take care of living and breathing human beings.   It made us focus on silly documentation requirements in order to be fairly reimbursed.  And, it offered very clumsy mechanisms to record a patient’s history – the story of your symptoms – which is our most valuable piece of medical data.  You simply can't click your way through a patient's narrative. 

Admittedly, the process is much better now than it was a decade ago.  But, it cannot replicate the experience of pen & paper when physicians could use eye contact, facial expression and nodding of the head during office visits.  Indeed, this is how I practiced for the majority of my career. 
A recent job change has given me the pleasure of learning a brand new EMR system.   Learning a new system has been like a undergoing colonoscopy – uncomfortable but necessary.  I wonder how many hundreds of clicks I perform each week as I navigate through a system that seems to have no boundaries.  While some of my colleagues use voice to text technology, or have a scribe shadowing them, I rely upon my 10 digits tapping across the keyboard to get the job done.  And, since I worked as a typist prior to becoming a gastroenterologist, I can look my patients in the eye while typing.  (Interesting that a typist and a gastroenterologist both need to be digitally skilled.  Perhaps, in my retirement I will study piano?)


Pre-EMR Technology



I wonder how the EMR arena has been for patients.  Please share your experiences here especially if you are old (ancient) enough to be able to compare current click medicine to pen & paper documentation.  How has your office visits changed?  Do you think EMR has changed the doctor-patient relationship?  Share your frustrations.  Let me prompt you with Frustration #1.  Why don't all the EMR systems communicate with each other?  Why is this promise still unfulfilled?

Using the ubiquitous rating system, how many stars would you award the EMR experience?

Sunday, July 7, 2019

Is E Pluribus Unum 'Fake News'?



The colonists were not united in the mission to achieve independence from Great Britain. Indeed, there was tension between the Loyalists, who wanted to remain British, and the Patriots, who demanded separation.  Ultimately, the nation came together as the the great experiment in American democracy commenced.  This is embodied in the nation's original motto e pluribus unum, translated from Latin as 'out of many, one.  Have we remained true to this principle?


Challenges and Choices Before Us in 2019

Divide or heal

A cudgel or an olive branch

Dialogue or lecture

Accusation or apology

Breaking or bending

Sneering or smiling

Entitlement or generosity

Shouting or singing

A polemic or poetry

A fist or a handshake

Saying no or saying yes

'You are wrong' or 'I am wrong


In your view, dear readers, how are we doing?  Should we adopt a new motto, to unum de multis, out of one, many?





Sunday, June 30, 2019

Why I Left Private Practice


After 20 years, I have left private practice and joined with the Cleveland Clinic.  To those who know me and this blog, this development may seem surprising, if not shocking.  On many levels, I’m shocked at this unexpected denouement of my career.   Let me explain.

First, these past two decades in private practice have been fabulous.  Our amazing staff and my partner worked hard every day to provide concierge level care to our patients.  We survived only because we provided a level of service that the surrounding competitors simply could not rival.  We provided customized and personal attention.  Our patients were happy and satisfied.  And, so were we.  So, why did we make a change?

Over the past few years, my partner and I had become uneasy about our practice’s ongoing viability.  The economics of a 2-person private practice are increasingly challenging.  Consider the math.  There is ongoing downward pressure on reimbursement with inexorable upward movement on expenses.  We cut every expense that we could – including the physicians’ salaries.  The only expense that remained sacred was our staff’s compensation.  We knew that if we didn’t retain our outstanding medical and administrative staff- the crown jewels of the practice - that the enterprise would decay.  


The math was against us.

Additionally, my partner and I were on-call for hospital work and emergencies every other weekend and every other holiday.  And, this schedule became more burdensome when one of us was on vacation.  This was our situation for years and we were unable to solve it.

And finally, we worried that if our still independent community hospitals were acquired by a larger entity – which we think will happen – that this could herald the abrupt demise of our practice. 
So, this was our mindset when the Cleveland Clinic approached us and expressed interest in our practice.  Twenty meetings or so later, here we are.  My new office is just down the street from my prior practice and I am honored that my former patients are following me.  Of course, it’s a transition from being president of my practice to becoming an employee of a large medical enterprise, but my partner and I correctly judged that this was the right decision at a most propitious moment in the life cycle of our practice.   Frankly, we got lucky.  We saved our practice and much of our staff have joined us.

Our staff and us had some sad goodbye moments.  But, there were some joyful goodbyes as well.  Imagine my mirth and euphoria in saying goodbye to working on weekends, nights and holidays!  Yes, I deserve a lighter load after nearly 3 decades of hard core specialty care; but life isn’t fair and we don’t always get the fair shake we merit.   Conversely, sometimes we catch a break that we didn’t earn.

If the Clinic and I remain happy with each other – and so far we are – then this will be my final gig. I’ll keep you posted, from time to time.


Sunday, June 23, 2019

Is My Doctor Any Good?

When I meet patients in the office, our conversations do not focus exclusively on the medical issue at hand.  Of course, if you come to see me with a stomach ache, at some point I will direct the dialogue toward your abdomen.  Often, our conversations are far removed from livers and pancreases, and deal with more personal vignettes and anecdotes.   Why does this happen?  First, I enjoy it; and secondly, it helps me to understand the patient better as a human being.  I won’t give this up, despite the many forces – Electronic Medical Records in particular – that conspire to dehumanize the medical experience. 

I am a trained typist and had several secretarial jobs in my younger days.   The tool of the trade then was a contraption unknown to the generation whom are now soldered to their smart phones.  It was called a typewriter.  For those curious, you might actually be able to palpate one of these dust covered devices in your grandmother’s attic.  My favorite was the IBM Selectric, which had a sphere covered with raised letters and characters which rotated with each key stroke before striking the paper.  Oh, the simple world devoid of Google, cut & paste, Instagram and Wikipedia.  Kids today would never give up their technology, and they have no clue what they have given up in exchange for 
it.

The IBM Selectric Typeball

When a new patient arrives, I always ask how they came to see me in particular.  Sometimes, I am gratified to learn that a satisfied family member referred them.  On other occasions, they have selected me at random, a seemingly chancy method of selecting a physician.  These folks likely would do more due diligence in purchasing a washing machine. 

If they have a primary care physician (PCP), I always ask if they are satisfied with the care there.  These have been extremely valuable inquiries and are unique opportunities for me to learn of patients’ views on their PCPs.   Of course, their review may not be the full story.  And, I would not allow one bad review to change my impression of a doctor.  But over time, I accumulate more data on individual physicians.  For example, if nearly every patient cared for by a Dr. Kildare offers a glowing tribute, this will weigh heavily when I form an opinion.  Similarly, when we read reviews on line for various products and services, they carry more weight if there are a large number of reviews, rather than one or two, leaving aside for a moment the pitfalls of relying upon on-line product and service 'reviews'. 

The truth is that doctors have little clue about what actually goes on in our colleagues’ offices. Physicians and their offices may treat medical colleagues differently than they do their patients.  I’m amazed how often a patient’s experience differs from my impression of a physician who may be quite cordial with me in the elevator.  And, it goes both ways.  I’ve met doctors who seem to me to deficient in social skills and yet, patients love them.

If primary care physicians are smart and seasoned, they will ask their patients about us - the specialists.  Are we as nice to their patients as we are to them?

So, when you come to see me in the office to discuss your heartburn and your hemorrhoids, don't worry.  We''ll get around to it.  First, we may reminisce about milk bottles, fountain pens, paper road maps, Encyclopedia Britannica and my beloved IBM Selectric.

Sunday, June 16, 2019

Medical Risks and Benefits - Shades of Gray


Readers know how strongly I feel that my profession is suffering from the twin chronic diseases of Overdiagnosis and Overtreatment.  Here's a primer on how physicians make medical recommendations to our patients.

Take a look at this grid I prepared, which is worth a full year of medical school.


                                    Low Benefit                   High Benefit

Low Risk                                                           Medical Sweet Spot!

                                 ________________________________________
                       

High Risk                DANGER ZONE!


When we physicians are contemplating a treatment, or are weighing one treatment against another, we are aiming for the Medical  Sweet Spot highlighted in blue above.  We want low risk and high reward for our patients.   Would we ever consider a treatment within the DANGER ZONE?  We would if the patient’s medical circumstance were dire and there were no superior options.  For example, if a patient was under a serious threat of a severe outcome, we might consider a treatment with considerable risk that had limited evidence of efficacy.  Of course, it may be that an informed patient might decline the treatment. 



There are times when the Danger Zone is reasonable.

Obviously, medicine is a murky discipline and most treatments do not fall neatly into one of the 4 quadrants of this grid.  Moreover, medical experts often disagree to the extent that a treatment is safe or effective.  In other words, different physicians may place the same treatment in different regions of the grid.  This is one reason why pursuing a second opinion can become more bewildering than clarifying.   Just because a second opinion is different from the original, doesn’t make it right.  To further confuse you, two differing medical opinions can both be right!

How does an average patient make sense out of this morass?  By asking the right questions.
  • What are my reasonable treatment options?
  • What is the scientific evidence supporting each of these options?
  • What is the scientific evidence of the risks?
  • Does my personal medical situation favor one option over another?  (For example, if a medical option’s risk is to suppress the immune system, and you already have a diminished immune system, then this option may not be suitable for you.)
  • How will I be monitored for adverse drug reactions? 
  • Is no treatment an option?  Where would this choice fall on 'grid'?
In my view, the 'no treatment' option should be considered much more often.  Why do so many patients and physicians move this option ‘off the grid’?






Sunday, June 9, 2019

Medicare for All - Bad Medicine for the Country


Last week, I presented my discerning readers with arguments supporting Medicare for All.  Here in Part II, I will offer a few rejoinders and caveats to those proposals.  

Senator Bernie Sanders deserves credit for advancing this issue into our national conversations.  And, many of his 22 rivals who are angling for the Democratic nomination for president in 2020, have embraced the position in their collective leftward migration.  Indeed, if this leftward drift persists, we may soon be regarding Comrade Bernie as a moderate!

First of all, the Medicare for All being proposed now should be renamed as it goes far beyond our current Medicare system.  The New & Improved Medicare for All promises the following additional benefits which are not included in conventional Medicare.
  • Vision coverage
  • Dental coverage
  • Hearing Aids
  • Long Term Care
  • Medical Care for Illegal Aliens
  • Minimal cost sharing, meaning no copays or deductibles

I’m surprised that the generous proposed benefits do not include coverage for pets, plants and backyard animals.  Doesn’t an ailing rose bush deserve healing?  Do you really want to be seen as campaigning against roses, lilacs and lilies?  Do you want to be labeled as a puppy hater?


Medicare for All supporters
Please come home.


And, how do we pay for all this?  The standard bromide is to tax the wealthy, but will there be enough left from the greedy 5% after they have funded the Green New Deal, Free College For All, Refinancing Student Debt and raising teacher salaries by $13,500?  Incidentally, the European nations who have nationalized their health care provide fewer benefits to their populace than do our Medicare for All proponents, a fact that is omitted from the presidential candidates' stump speeches.   The strategy is to promise everything, claim that we can afford it or may even save us money, and when the cold reality emerges years later, blame someone else. 

Look, I agree that health care reform is necessary, overdue and very complicated.  And, we all know how the dysfunctional process is tainted by dozens of well-heeled constituents who think of their own interests and not the greater good.  Feel free to peruse my postings under the Health Care Reform Quality category on this blog for additional rants.   I’m also skeptical that the Medicare for All crowd is focused on our interests rather than their own political interests.  For many of them, the notion of taking down the corporate framework of our medical system dovetails perfectly with their anti-Wall Street mission.   If Medicare for All is such great idea, then let’s pilot it in a few regions of the country and let us measure the medical and financial outcomes.  When we have a new medical treatment that we think might work, we study it on a small group for obvious reasons.  We don't open it up to the entire country and hope for the best.

There may be a planet out there where every individual can enjoy every conceivable benefit at low cost, or better yet, at a cost borne by others.  But, we live on planet Earth.  Hopefully, the Medicare for All space travelers can return back home so we can have a more down to earth discussion on how to make progress.

Sunday, June 2, 2019

Medicare for All - A Moral Imperative


Brace yourselves.  Over the coming months and longer, you will be hearing presidential candidates and their acolytes proclaiming the moral imperative of a Medicare for All program.  Is this just an electioneering slogan or is this really the Holy Grail of health care reform? 

Nearly all Whistleblower posts are stand alone essays.  This Medicare for All entry, will be a rare departure from this tradition and will be a two-parter.  If you like Part I today, then you will have strong incentive to visit this site next week.  And, if you find today’s post to be disappointing, then I invite you back next week with the hope that you will find the conclusion to be more captivating and riveting than this post.  How's my salesmanship?

Let’s try to agree on one thing before we disagree over everything else.  Conceptually, we all support any health care system that provides high quality medical care, with reasonable access into the health care arena and is cost effective.   We do not have these 3 pillars uniformly presently today.  More accurately, these 3 pillars are in place for many of us, but this is not a universal phenomenon.  Obamacare promised progress on all 3 of these fronts, but most of us agree that it did not deliver.  We all are aware of the ‘if you like your doctor, you can keep your doctor’ falsehood.  Additionally, most of us have not found that Obamacare has resulted in better or cheaper health care.  I agree that Obamacare did increase access, mostly with Medicaid expansion in various states, but the access improvement is less than you might think.  Prior to Obamacare, about 15% of us lacked medical insurance and now it is closer to about 10%.  Yes, this is real improvement, but it represented incremental improvement.  Seems like it is costing the nation years of turmoil and division for insuring another 5 or 6% of us.

Young George Washington Knew You Needed 3 Pillars To Keep It Steady.

Medicare for All proponents offer these arguments.
  • Health care for all is a human right and a moral imperative.
  • We are the only industrialized nation that does not provide this benefit to its people.
  • We need to cut down Big Pharma and the Insurance Companies who are gouging all of us.
  • We need a standardized benefit package across the board so no one is left behind.
  • We will save a fortune by cutting administrative costs.
  • We will enjoy better health by emphasizing preventive care and treating active medical issues sooner.
  • Current spending at about 18% of our GDP and is not sustainable.
These arguments seem meritorious.  Don't be swayed yet.  There's a reason in our system of jurisprudence and debate that judgement is reserved until the other side has been heard. 

Next week, if you will kindly return, I’ll offer some ripostes to the Medicare for All arguments. 

Sunday, May 26, 2019

Memorial Day 2019 - Let's Pause in Gratitude

I have never worn the uniform.  My dad joined the Navy during World War II and served for 39 months.  He was never deployed beyond our borders.  One of his brothers signed up for the Army and the other brother joined the Marines.  They were all the children of immigrants.  They didn't expect any recognition for their service.  This is simply what everyone did. 

While I do not advocate resuming the military draft, I would support every citizen performing some manner of compulsory service to the nation.  It would devote massive human energy to unmet needs. It would establish a culture of service that this country sorely needs.  It would bind us closer to each other and to the nation.  Imagine the experience of young citizens across racial, gender, religious and socioeconomic lines collaborating together on a worthy endeavor.

Can you propose a legitimate argument against such a proposal?

I'm so grateful to all who serve and have served and I meditate over the incalculable sacrifices that millions have made for the rest of us.   I can't begin to contemplate the costs that so many have borne.  Only, the survivors, their families and their loved ones can speak to this experience.

A trenchant phrase is displayed at the Korean War Veterans Memorial in Washington, D.C.


'Freedom is Not Free'

On Memorial Day, let us remember...





Sunday, May 19, 2019

Why Patients Avoid Colonoscopies - A Plea to Choose Wisely.

                                                            
Exercising good judgement can mean the difference between life or death.  Life can be unforgiving of the choices me make.  As we all know, many life events are beyond our control and understanding.  But, there is much we can do to shape our personal paths to a brighter destination.

Consider some of the choices listed below that many folks make every day.  Are any of them familiar to you?
  • Texting while driving.
  • Riding a motorcycle.
  • Riding a motorcycle without a helmet.
  • Lifting an object that we know is too heavy for us.
  • Getting into a car when the driver has had one too many.
  • Driving a car when we have had one too many.
  • Giving your social security number to a caller who is promising you a tax refund.
  • Responding to an email from Nigeria alerting you to a wad of cash waiting for you.
  • Using your date of birth as your password for your on-line bank accounts.
  • Rushing through a yellow light so we won’t be late for a movie.
  • Eating street food in a foreign country that appears undercooked.
  • Skipping a ‘flu shot’ and other recommended vaccines.
  • Getting chest pain for the first time after shoveling snow and decided it was just heartburn.
Get the point?

All of the above activities can end tragically depending upon the choices we make.  But, they can easily end well for us.  Every day, we confront forks in the road when we must make choices.  Sometimes, we choose the wrong road.  Sometimes, we make no choice at all.  The point here is that we have a choice. 

A Velocycle - Safer than a Motorcycle

I see this issue in my gastroenterology practice.  I’ve done about 30,000 colonoscopies in my career, a number so large, that I can barely believe it myself.  Fortunately, the results of nearly all of them are normal or show benign findings.  Telling a patient and their family that all is well after the procedure is a pleasure that hasn’t changed over the years.

But, not every colonoscopy result is innocent.  As you might imagine, I have confronted a lot of colon cancer in my career.  When I discover one, I am aware that life for that person and his loved ones is about change profoundly.  Life changes in an instant.

While colon cancer affects the patient and his family most deeply, it’s a heavy day for the gastroenterologist also.  We are human beings.  What makes the day even darker for us is when the patient had faced a fork in the road, but made the wrong choice.  Consider the following examples which I have seen repeatedly in my practice.
  • A patient turns 50 but chooses not to have a colonoscopy, against the advice of his doctor.
  • A patient has rectal bleeding and ignores it.
  • A patient was told of hemorrhoids years ago.  Rectal bleeding develops and he assumes that his hemorrhoids are active again.  He does not consult his physician.
  • A patient’s bowel changes, but he decides that this must be a side-effect of new medication.
  • A patient has a large colon polyp removed by his gastroenterologist.  He is advised to return in a year for another colonoscopy, but he does not do so.  He is too busy.
Colon cancer, unlike so many other cancers, is a preventable disease.  I am not suggesting that modern medicine can prevent every case of colon cancer.  It can’t.  I am stating that the majority of colon cancers that I have discovered were in people who did not choose wisely when they should have.  They ignored.  They denied.  They delayed. 

Time after time, I have seen intelligent people who have had rectal bleeding for months before they decided to see me. 

Every expert will attest that the earlier colon cancer is diagnosed, the better the prognosis will be.  But more importantly, timely colonoscopy can prevent the disease altogether.

I haven’t made perfect choices at every fork in the road that I’ve faced.  But, when I turned 50, I did the right thing.

We can’t control everything.  But, there is much that we can control.  For example, you have chosen to read this post.  How you decide to use it is your choice. 


                                                                                        

Sunday, May 12, 2019

Charity Encourages Generous Donations - New Standard for the Industry?


This really happened.  The vignette I present now occurred 3 days before its posting on this site.  My good friend Bill invited me to a fundraising dinner to support a Jewish organization.  I declined the invitation, but told Bill that I would be pleased to make a donation to support a cause that was important to him.  I connected to the website which led visitors quickly to the Donate page.  Charitable enterprises want to make it as easy as possible for you express your generosity and separate you from your funds.  Haven’t you noticed that every museum visit leads to the gift shop? 

I quickly filled in the credit card information and then scrolled down and typed $50 in the Customized Donation window.  This box allowed donors to designate their own amount, bypassing the default listed uber high dollar amounts that appeared higher up on the page.  The entire process expended about 3 minutes and ended when I clicked on the Donate Now button.   It’s the same process that we all use to purchase items on line.

Immediately, I received an e-mail receipt, which I opened for no clear reason as I generally ignore these notifications.  At first glance, I noted a donation amount of $18,000 which, of course, was incorrect.  On closer inspection, as my pulse rate quickened, this is exactly what the receipt claimed was transacted. Most likely, I thought I must be suffering from some transient blurry vision from over-caffeination, a previously unknown complication. But, squinting failed to change the number.  I did not panic, because I am a medical professional, who is steeled to maintain my equipoise when unexpected turbulence confronts me.  This is when seasoned pros must let their training and muscle  memory kick in.  In other words, I panicked.  



At least they thanked me!


I called Visa, whom I regarded as culpable, or at least guilty of contributory negligence, by facilitating this fraudulent transaction.  After exposure to the highly personalized menu tree, and hitting the zero on the phone repeatedly until my index finger was nearly calloused, a human-sounding voice emerged that claimed to be emanating from an actual human.  I was grateful to have discovered an escape from the menu tree, a labyrinth that can keep clients and customers trapped for months or longer.  Most of these lost souls go mad simply from being forced to hear, ‘Please listen carefully as our options have changed’, at high volume and without pause.  Visa-man advised me that I had no recourse available with them; I needed to take it up with the charity.

A few nanoseconds later, I phoned the charity and immediately was greeted by a voice mail.  When would I hear back?  What if the call came while I was doing a colonoscopy?  Should I answer anyway?  (I was leaning 'yes' on this.) What if the religious charity didn’t consider my donation as a human error, but as a divine stroke for which I would be rewarded in the hereafter?  Would I risk selling my soul for a mere $18,000? (I was scared to lean yes on this one.)

In less time than it seemed, a rabbi called and promptly and courteously returned me to the status quo ante.  He made me whole.  How did this escapade happen?  He explained that the Donate page was defaulted to donate 18 grand, and unless this box is unchecked by the donor, this will be the amount transferred.   I congratulated the rabbi on having such an effective donation process, and he assured me with a laugh, that he would attend to the glitch. 

We have all clicked on the wrong box or sent a text message to an unintended recipient, which can result in amusing or serious consequences.   In this case, my ‘error’ wasn’t one of commission, but of omission.  I failed to ‘opt out’.

Physicians, at least honest ones, can relate to this anecdote.  In the electronic medical era, how many of us have placed an order on the wrong patient?  Wouldn’t it be a shame if a doctor ordered a colonoscopy on Bill by mistake?

Sunday, May 5, 2019

Why Smart Doctors are not Enough

I’ve delved into the issue of medical judgment more than once on this blog.  I have argued that sound judgment is more important than medical knowledge.  If one has a knowledge deficit, assuming he is aware of this, it is easily remedied.  A judgment deficiency, per contra, is more difficult to fix.
 
For example, if a physician cannot recall if generalized itchiness can be a sign of serious liver disease, he can look this up.  If, however, a doctor is deciding if surgery for a patient is necessary, and when the operation should occur, this is not as easily determined or taught.  

Medical judgment is a murky issue and often creates controversies in patient care.  Competent physicians who are presented with the same set of medical facts may offer divergent recommendations because they judge the situation differently.  Each of their recommendations may be rationale and defensible, which can be bewildering for patients and their families.  This is one of the dangers of seeking a second opinion, as this opinion may not be superior to the first one.  Patients have a bias favoring second opinions as they pursue them because they harbor dissatisfaction, or at least skepticism, with the original medical advice.  If the second opinion differs from the original, it reinforces their belief that the first advice was inferior.  
Second Opinions Can Cause a Tug of War

Here are some scenarios which should be governed by medical judgment.

A 70-year-old woman with severe emphysema uses an oxygen tank.  She has never had a screening colonoscopy.  Professional guidelines suggest that screening begin at age 50.  Does a colonoscopy make sense for her considering her impaired health?

A 40-year-old man has had 1 week of stomach pain.  This started 10 days after he took daily ibuprofen for a sprained knee.  The physician suspects he might have an ulcer.  Should this patient undergo a scope examination to make a definite diagnosis?  Should the doctor prescribe anti-ulcer medication without determining if an ulcer is still present?  Should the ibuprofen be stopped if the patient states he has significant pain without it? 

An 80-year-old woman had some recent dizziness and nearly fainted.  The doctor sees her in the office two days later and questions her carefully.  He suspects that the patient was simply dehydrated.  Should the doctor simply reassure the patient or arrange for a neurologic evaluation to make sure that a more serious condition is lurking?  

Of course, you want your doctor to know a lot of stuff.  More importantly, you want a physician who can give you sound and sober advice.  Knowledge and scholarship are important physician attributes, but healing demands more.  At least, that’s my judgment. 


Sunday, April 28, 2019

End of Life and the Medical Profession


Physicians and nurses deal with the deepest issues of the human condition – life and death.  Our profession brings new life into the world and does our best to bring comfort and peace at the journey’s end.  It is a profound and emotional experience for medical professionals to be with a patient and family when life ends.

There are other professions who routinely confront loss of life.  Law enforcement personnel, paramedics, firefighters and soldiers all are exposed to events that most of us would never wish to experience.

The medical profession and society is struggling to preserve our humanity in a 'cut & paste' world where one's worth is determined by the quantity of twitter followers.  

Hugging a child.  There's no 'app' for this.

On my very first day of medical internship in Pittsburgh, I was called by a nurse to pronounce a patient dead.   I had never seen the patient before.  The only deceased individual that I had any close contact with was the cadaver we studied in medical school.  I entered the room and did not know what I was supposed to do, never have been given any training or guidance on this responsibility.  I learned an important lesson then.  New interns know nothing.  Experienced nurses know a lot.  Ask for their help.  An arrogant intern will be permitted to sink.  The humble intern will be rescued.

This was an elderly patient from a nursing home and this outcome was anticipated.  The nurse patiently guided me through the requisite steps.  I performed this function multiple times throughout my internship and residency, but the only actual memory of these events is with that first patient on my very first day.  It imprinted upon me, much as the first day that I was introduced to the cadaver as a first year medical student in anatomy class. 

Being present with patients and families at profound moments is a privilege and a responsibility.  As we are all suffocating from dehumanizing technology in every sphere of our lives, there are experiences still that cry out for our humanity.   If you or someone you loved was facing difficult medical choices, who would you want in the room with you?  A physician, who might deliver wisdom and compassion or Alexa?

Sunday, April 21, 2019

Musings on Religion


There is a confluence this weekend of holy days from two venerable monotheistic religions.  Today is Easter, which represents the anniversary of the resurrection of Jesus Christ, a foundational theological principle of Christianity.   Christians await the Second Coming, when they believe that Jesus will return to establish a world of peace and justice.

Passover, which began on Friday evening, celebrates the iconic and gripping tale, chronicled in the Book of Exodus, of the emancipation and liberation of the Jews who were enslaved under a cruel Egyptian regime.  The yearning for freedom and resistance against tyranny carefully documented in the Torah, is truly a universal template that is relevant to this very day. 

Jews Crossing the Red Sea Leaving Bondage Behind

The religions are so deeply intertwined.  While I am neither a Christian nor a scholar, I have taken some effort to study the New Testament so that I might gain some understanding of this ‘offshoot’ of my own religion.   Indeed, true scholars of Christianity teach that it is not possible to understand Christianity without having a deep understanding of Judaism.  When one considers that Jesus, his disciples, the pharisees, the priests and other figures highlighted in the New Testament were all Jews, it is obvious that understanding their birth religion is a prerequisite to understanding how and why Christianity developed and thrived. 

Consider some fascinating queries.  Did Jesus eat matzoh on the Passover?  Was the Last Supper a Passover meal?

I am not na├»ve and am well aware of the deep hostility that Jews have suffered from Christians both centuries ago and in recent times.   There has been a rapprochement, but the work is not finished.  And, my own house is not yet in order.    Many Jews and others are troubled by the principles and actions of the current Israeli government.  I presume these leaders, like Jews throughout the world, were at Passover meals, called Seders, this weekend, when they read about the plight of their subjugated ancestors. Did the ancient Exodus narrative offer them any perspective on current events?  In our own country, ignorance and prejudice against Islam has been used for malign purposes.

Many believe that religion has caused far more harm than good for humanity.  As we gaze around the world today, their argument is very plausible.  Where do we go from here?   Who will reach across rather than turn away?    Who will listen with an open mind and an open heart?  

Must we all wait for an apocalypse, described in Revelation, or a series of catastrophic plagues, as appeared in Exodus, for a peaceful world to emerge?   Is there anything we can do now?





Sunday, April 14, 2019

Step Therapy - Pharmacy Benefit Managers are at it again!


Among the many tools that insurance companies wield to save money is a technique called ‘step therapy’.  This is a technique that exasperates patients and physicians.  Here’s how it works. 
A patients comes to his doctor with a medical issue.  The doctor, who presumably has a decent measure of medical training, experience and judgment, decides to prescribe a medication, in an effort to ameliorate the patient’s distress.  Let us call this magic elixir Pill A.  The doctor zaps this prescription to the pharmacy at the speed of light using the ever trustworthy electronic medical record.  The satisfied patient leaves with the mistaken impression that his cure is just around the corner.

Here’s where the fun begins.  Of course, the patient may receive the typical denial as Pill A is not on the formulary.  Keep in mind that an insurance company’s denial doesn’t mean the patient can’t fill the prescription.  Insurance companies would never interfere with a physician’s medical judgment.  The patient is still free to take the prescribed drug.  The fact that it costs $2,200 per month is but a trifle.   If Pill A costs a fortune and the insurance company’s alternative Pill B is cheap, then can we really argue that insurance companies are not practicing medicine?

Physicians in Asylum Driven Mad by Step Therapy

In the above example, usually Pill A and Pill B are medically equivalent, so the cheaper drug delivers the same benefit.  Sometimes, however, the doctor’s preference is medically superior.  Either way, the process burns up hundreds of hours per year for physicians and our staffs. 

Step therapy is when Pill A is denied because the doctor has not tried different types of medication first, which are not equivalent and are often inferior.  In order to get Pill A to be covered, the doctor must demonstrate that he has tried other medications first, and that they were not effective.  So, under this genius system, a patient receives drugs that cost money and likely won’t work.  After enduring this experiment, the  insurance company may ultimately cover the medicine that should have been prescribed in the first place.  Usually such approval is for a limited time guaranteeing that the physician can look forward to a sequel in the near term.  

Imagine if a patient suffered a serious side-effect from one of the step therapy drugs that the doctor knew was a waste of time.

I’ve argued on this blog on the need to reduce overutilization and to cut costs.  A fundamental premise of this blog is that less medical care can increase medical quality.  Step therapy managed to both increase costs while it cuts quality, not an easy feat.

We need to step up and step on step therapy.

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