Sunday, January 26, 2014

Can Doctors Charge Late Fees?

I admit that I have a rudimentary knowledge of the business world, but I’m improving.  I now know, for example, that a C-suite does not refer to the procedure room where I do colonoscopies.  I am aware that executive coaching does not refer to advising top managers on their golf swing or tennis overhead.  I used to think that LLC stood for Long Live Colonoscopy, but now I know better.  CFO, Chief Flatulence Officer?

While patients and physicians operate under oral agreements, business agreements are generally established in writing.  In these documents, terms are outlined including contingencies in the event that foreseeable obstacles or disputes develop.  Oftentimes, the two parties do not agree that a contractual term has been violated.  This is when the fun begins.   With a little luck, the legal profession enters the arena and can speedily resolve the disagreement in a matter of several years after impoverishing both sides.

A common contractual feature is a requirement that goods and services be delivered on time and on budget.    A contractor might be subject to a penalty if his project is not completed by the agreed date.  This is a reasonable concept and serves as an incentive for on time performance.  In real life, this may not be as clean as it sounds.

Customer:  “You’re a week late so you owe me half a gazillion dollars.”
Contractor: “It’s not our fault that the city planner delayed us.  Go fight City Hall.”

Other professions are not subjected to financial incentives to deliver on time.  Consider our beloved airline industry where customers are hassled and fleeced before they are herded onto airplanes to sink into a seat narrower than most humans.   Air travel has delivered some celestial benefits to us.  It has increased our spirituality.  We pray that our luggage won’t arrive in the wrong continent.  We pray that our bottle of mouthwash in our carry-on bag won’t be confiscated.  (This critical security policy is from the same TSA brainiacs who initially gave a green light to bringing pen knives on board.) We fervently pray that the passenger seated in front of us will not lean his seat back while our tray table is down which would impale us. 

 Air Travel - More Relaxing than Root Canal

Shouldn’t the airlines be penalized when flights are delayed?  At present, they game the system by artificially lengthening the estimated travel time so that many flights will arrive ‘on time’ even when there are delays.   When a flight is delayed an hour, what loss do passengers incur?  Shouldn’t they be made whole for their loss?   Perhaps, an extra bag of honey roasted peanuts would mollify the restive crowd. 
On time performance is a live issue in the medical profession.

Do patients deserve to be compensated when physicians are late?  Should it depend upon the reason?  Is a delay because of a medical urgency non-compensable?  Should there be a no fault system where patients are compensated for delays regardless of the explanation?

Stand down readers.  This concept might work in both directions.  What pound of flesh should be exacted from patients who wander in late or simply fail to show up?  The latter occurs even when patients have been contacted the day prior to remind them of their solemn obligation to keep their appointments.  It is particularly vexing when a colonoscopy patient fails to show leaving us with nurses, a nurse anesthetist and a doctor with unscheduled time off that could have been used by another patient.

Insurance carriers will not permit physicians to charge patients who leave us flat.   It’s in our contract, a document that offers us no relief when these companies don’t deliver.

If you have suggestions on what should be done to late physicians or patients, you are encouraged to do so at this time.

Sunday, January 19, 2014

When Should a Patient Reject Colonoscopy?

Many times over the years, I have witnessed the following scenario in my exam room.  Here’s the set up of this one act play.

I’m seated at my desktop computer.  The patient is seated before me.  The patient’s daughter is seated next to her mother.

Elderly patient
Attentive daughter
The doctor

Curtain's Up

Scene I

A patient comes to see me in the office with medical issues that strongly suggest that a colonoscopy should be performed.  As an aside, it is not my practice style to issue a colonoscopy edict, but rather to present the patient with available options, which should always include no testing as an alternative.  I may at that point strongly urge that the patient accept my colonoscopy recommendation, but at least the patient then knows the options with their respective advantages and drawbacks.

[Reader aside: Examples of medical issues that lead most gastroenterologists and physicians to advise colonoscopy include:
  • Rectal bleeding
  • Change in bowel habits
  • Anemia, or low blood count, with a suspected intestinal bleeding site
Several times over the course of my near quarter century career, an intelligent patient who has a good reason to have a colonoscopy declines to proceed with one and opts for nothing.]

Scene II

The patient declines any form of colonic intrusion.  The attentive daughter becomes apoplectic over mom's decision.  

“Mom, you have to get this done.   I did it and it was a breeze.  Even Uncle Harry did it and he’s older than you.”

Of course, the patient’s view dictates the outcome, as it should.  The patient in these cases is elderly and uses an entirely different playbook from the child, who would readily consent to the procedure herself.  The child is entirely well meaning and frightened that her parent might harbor a serious condition, which is entirely possible.  The patient views this issue, and life in general, through a different lens.  Decisions are weighed using a different set of weights and measures.  The parent may have lived a long an full life and has personal priorities that differ from those of younger loved ones.  When I witness these occasional conflicts in the office, the child is clearly vexed while the patient is at peace.

Most of the time, a parent and child are in agreement with the chosen course of action.  But, not always.  These situations taught me an important lesson that I never learned in medical school.   Patients are unique individuals whose view of the world, accumulated life experiences and station in life may lead to unpredictable decisions.   These plays often have surprise endings.  

Sunday, January 12, 2014

Measuring Medical Quality: Move Over Pay-for-Performance

Obamacare has promised to provide all of us with quality medical care that is affordable and accessible.  The very name of the law is the Affordable Care Act, which I have maintained will be short on both affordability and quality care.  Most of the country agrees with me.  The postponement for a year of the  corporate mandate to provide insurance in businesses with at least 50 full time employees was a great relief to these businesses and to Democrats across the country who were shivering from fear that voters would hold them accountable in 2014 when the country witnessed the debacle.  Was this solely a policy decision independent of politics?  I won’t insult readers’ intelligence by weighing in here.

Mandate Postponed from Electoral Anxiety?

How will the Obama and insurance company vanguards of bureaucrats ensure quality?  They will measure of bunch of silly stuff that is easy to measure but counts for almost nothing.  What really counts can’t be easily counted.  But, these guys will count what is easy to count and pretend that it matters.

Let’s have readers try their hand at measuring medical quality.  Depending upon your responses, you might gain a position with the Department of Health and Human Services.

Which of the following is the best measurement of quality of an obstetrician?
           (1)    The percentage of Pap smears done on his patient population
           (2)    The percentage of mammograms done on his patient population
           (3)    Judgment of when a Caesarean section is appropriate
           (4)    Patient satisfaction score

Which of the following is the best measurement of quality of a ccardiologist?
(1)    The doctor puts heart into his work
(2)    The doctor and his staff have a good rhythm
(3)    The doctor has a good beat
(4)    The doctor knows when chest pain is serious

Which of the following is the best measurement of quality of a pediatrician?
(1)    All appropriate vaccines are administered
(2)    The physician rates very highly on surveys grading compassion and caring
(3)    The practice uses a nurse practitioner available for same day appointments
(4)    The pediatrician knows when a sick child should be hospitalized. 

How can the government and insurance companies use your responses in measuring physician quality?  Is it possible that what truly counts in medicine isn’t that easy to measure?

Sunday, January 5, 2014

Do Physician Rating Sites Make the Grade? Find a Doctor on Angie's List

I’ve never logged onto Angie’s List, but I might be on it.  Physicians are now routinely rated on various internet sites that the public can view before making appointments, or just as a parlor game.  You can look up doctors just as you would check ratings on toaster ovens, snow blowers, cars and restaurants.

Are these sites truly useful?

Can a grading site inform the public about a physician’s medical quality?

Can a visitor to the site be confident that the view expressed is true and objective?

I’m skeptical.

Easier to rate a fridge than a doc

I’ve thought deeply on the issue of medical quality since I was a medical intern in 1985.  Indeed, it was my preoccupation with this subject that led to the birth of this blog years ago.  Review the blog’s categories at the right of your screen and note how many labels include the term ‘quality’.   A recurrent theme here is how difficult it is to measure medical quality, even for medical insiders who know the blood and guts of the business.  Pay-for-Performance is an example of the government’s feeble effort to measure medical quality.  I have devoted several posts to exposing this sham and explaining its systemic flaws.

If physicians and health care experts can’t define and measure medical quality, then I am deeply skeptical that on-line rating sites can succeed where the medical profession has failed.  That this sites are filled with advertising communicates that their true mi$$ion may be unstated.

Nevertheless, these programs are here to stay and we can expect more competitors to materialize.  Let’s face it.  The public loves rating everything.  Each year, parents of high-schoolers race for the U.S. News and World Report annual college ratings, even though seasoned educators know that this is a poor resource for choosing quality higher education.   Throughout the country, there are lists of our best doctors, hospitals, athletes, musicians and chefs.   Sometimes, these lists defy logic.  How many #1 cardiologists can one city have?

Just ‘google’ the phrase ‘list of the 100 best…’, and see what pops up.

Doctor rating sites are likely to be sites where disgruntled patients express themselves.  This creates an indelible stain on a doctor’s reputation who cannot expunge the false claim.   It is well accepted that dissatisfied customers are more likely to speak out, which creates an unbalanced record of performance for doctors and various businesses.  I acknowledge that some on line criticisms may be valid, but others may false and defamatory.  How can a reader discern the truth? 

Consider the following hypothetical criticisms:

Keep away from this doctor.  He’s only in it for the money.
Perhaps, this is a patient who wouldn’t pay his bill.

I’ve never seen a doctor so insensitive to my pain.  After seeing him, I had to go to the emergency room for some relief.
Perhaps, this a patient who demanded narcotics, and the doctor declined to accommodate this request.

Warning!  This doc is in the pocket of insurance companies.  He was pushing me to try a different medication.
Perhaps, this patient was offered an inexpensive alternative that was medically equivalent.

Remember, one thing that on-line grading sites do not offer is both sides of the story.  Readers are counseled to assume there is another side, which may be where the truth lies.

New companies are emerging that promise to combat on-line attacks against physicians and others.  A component of their strategies is to encourage favorable comments to be added to the sites to provide balance and to suggest that a negative comment is an outlier.  All this sounds more like a game to me than true quality assessment.

Who’s grading the grading sites?  Will Angie take this on?