Sunday, May 25, 2014

Are Emergency Rooms Admitting Too Many Patients?

This blog has discussed conflicts of interests.  Indeed, every player in the medical arena has found itself challenged by conflicts where one’s self-interest competes can skew what should be pure advice.   This issue is not restricted to the medical universe.  Every one of us has to navigate through similar circumstances throughout the journey of life.  If an attorney, for example, is paid by the hour, then there is an incentive for the legal task to take longer than it might if the client were paying a flat fee.  The fee-for-service (FFS) payment system that had been the standard reimbursement model in medicine has been challenged and is being dismantled because of obvious conflicts that were present.  (This is not the only reason that FFS is under attack, but it is the principal reason offered by FFS antagonists.)  Physicians who were paid for each procedure they performed , performed more procedures.   This has been well documented.  Of course many other professions and trades still operate under a FFS system, but they are left unmolested.   Consider dentists, auto mechanics and plumbers and contractors. 

FFS is not inherently evil.  But, it depends upon a high level of personal integrity which, admittedly, is not always present.   In my own life, I often hope and pray that the individual who is offering me goods or services is thinking of my interests exclusively.  Am I living in fantasy land?

The Rand Corporation released a study in May 2013 that demonstrated that emergency rooms accounted for about 50% of hospital admissions during the study period from 2003-2009.  When I have posted on Emergency Medicine in the past, it has stimulated a high volume of responses, some good, some bad and some ugly.  

I think it is inarguable that emergency room (ER) care wastes health care dollars by performing unnecessary medical care.  As a gastroenterologist, I affirm that the threshold for obtaining a CAT scan of the abdomen in the ER is much lower than it should be.   And, so it is with other radiology tests, labs, cardiac testing, etc.
I understand why this is happening.  If I were an ER physician, I would behave similarly facing the same pressures that they do.  They face huge legal risks.   They are in a culture of overtreatment and overtesting because they feel more than other physicians that they cannot miss anything.  They argue that they have only one chance to get it right, unlike internists and others who can see their patients again in a follow-up visit.  If an ER physician holds back on a CAT scan of the abdomen on a patient who has a stomach ache, and directs the patient to see his doctor in 48 hours, what is the ER physician’s legal exposure if the patient skips this appointment and ends up having appendicitis?

Keep in mind that we should expect that ERs to have higher hospitalization rates of their patients, since their patients are much more likely to be acutely ill.  

Is the Emergency Room a Revolving Door?

But even accounting for the sick patients in the ER, I think there is a significant percentage of ER patients who should be sent home and are sent upstairs instead. This would be an easy study to perform.  Compare the intensity of testing between the emergency room and a primary care office with regard to common medical conditions.  I would wager handsomely that the ER testing intensity and admission rate would be several fold higher than compared to doctors’ offices.  Want to challenge me on this point?

Even though I understand why ER docs do what they do, it is a bleeding point in the health care system that needs a tourniquet.  

It is clear that ER physicians are incentivized to admit their patients to the hospital.  Of course, they might be ‘encouraged’ to do this by their hospitals who stand to gain financially when the house is full.  Leaving the financial conflict aside, when an ER physician admits a patient, he is completely free of the risk of sending a patient home who may have a serious medical issue. I am not referring here to patients who clearly should be admitted, but to the large group of patients who most likely have a benign medical complaint, but the ER physician advises hospitalization ‘just to be on the safe side’.  These same patients if seen in their own doctors’ offices would never be sent to the hospital to be admitted. 

Where’s the foul here?  Here are some of the side-effects on unnecessary hospitalizations.
  • Wastes gazillions of dollars
  • Loss of productivity by confining folks who should be working.
  • Departure from sound medical practice which diminished the profession.
  • Emotional costs to the individuals and their families.
  • Unnecessary exposure to the risks of hospital life.
How can this runaway train be brought under control?   First, let’s try a little tort reform.   Second, pay a flat rate for an ER visit.  Under this model, if the ER physician orders an MRI on a patient with a back strain, the hospital swallows the cost.  Finally, when hospitals are penalized financially for hospitalizing folks who should have been sent home, we will witness the miracle of a runaway train performing a U-turn on the tracks.

While the Rand Corporation's results are not earth shaking on its face, my intuition, insider's knowledge and a tincture of cynicism all converge on the conclusion that for too many patients the ER has become a portal of entry in the hospital.  Is the greater good served if the ER is a revolving door or barricade?

Sunday, May 18, 2014

Should Physicians Offer Disclaimers to Patients?

Why does is seem that so much information given to us comes with disclaimers?  The weight loss product ads on TV that promise more than they will deliver, are always accompanied by 5 nanosecond disclaimers in a font size that can’t be discerned by the human retina stating that the results are not typical.

Watch the Pounds Melt Away!

It seems deceptive to be advertising a product by showcasing a performance that the vendor admits is not typical.

Let’s extend this philosophy to other professions and trades.
  • Financial Planner:   Invest with us and earn 20% returns annually over 5 years. Results not typical.
  • Attorney: When I catch your ambulance, I’ll make us both millionaires!  Results not typical.
  • SAT Tutor:  My students have the dilemma of choosing between Harvard and Princeton.   Make your kids my kids. Results not typical.
  • Airline Industry:  When our customers call us on the 800 line, a live human answers by the 3rd ring. Results not typical.
  • Politician:  I will always vote my conscience, mindful of those who elected me, without regard to politics or personal ambition. Results not typical.
Get the point?  All of the above claims may be true as isolated aberrational events, but most of us would agree that they are not typical.  How many weight loss pills would be sold if the viewers were shown the typical result? 

I went to a Chicago to spend a weekend with my pal, Lewis, who has been featured on the blog previously.  We treated ourselves to a high end hotel.  I approached the concierge for advice on a restaurant within walking distance.  Fortunately, we didn’t have a car since the hotel’s daily parking rate was actjually $75.00, including some exorbitant taxes.  Who says extortion isn’t legal?  I’ve stayed at hotels for less money than this.

I was interested in Thai cuisine and the concierge recommended a restaurant that was 15 minutes away on foot.  I then asked what I thought was a reasonable question from a guest who was new to the city.

“Will we be walking through safe areas?”

She offered a response that I won’t forget for a long time.

“I’m sorry, sir.  The hotel cannot give any safety advice.  This issue is left to the discretion of our guests.”

On my honor, I am fairly recounting the vignette without embellishment.  I won’t comment further as the absurdity of it is self-evident.

Thus far, I haven’t offered my patients any disclaimers when they come to see me, but perhaps I should remedy this for my own protection.  Consider the following hypothetical anecdote.

“Dr. Kirsch, do you think I should go through with the surgery?”

“I’m sorry, Mrs. Diverticulitis.  Our practice cannot offer opinions on specific medical or surgical options.  We defer these issues to the discretion of our patients.”

I hope readers agree that this post exudes wit and wisdom.  Yeah, I know.  Results not typical.

Sunday, May 11, 2014

Why I'm Against Wellness

I’m a physician and I’m against wellness.  Let me explain.

Wellness is the new health mantra that has much more to do with marketing than with evidence-based medicine.  Wellness institutions and practitioners are omnipresent promising benefits that are often untested or rejected scientifically.   Hospitals that years ago would have shunned new age healing arts, now offer yoga, meditation, Reiki and massotherapy.  Do they do so because they have had a Damascus Road experience and now believe that these techniques are effective?  Guess again.

Paul's Conversion on the Damascus Road

Wellness is no longer restricted to medical campuses, costly weekend retreats for emotional and physical catharses and ubiquitous yoga storefronts.  Wellness is now championed by corporate America.   Business leaders argue that keeping employees well is not only a demonstration of good corporate citizenship, but is also good business.   Healthy employees, they claim, will reduce health care costs.  I agree, but not for the reasons they offer.

Their premise that wellness program participants will use fewer medical resources sounds rational, but it may not be true, despite claims from human resource professionals who want to justify these programs.  Here’s the argument.  “If we lower employees’ blood pressure, bring their weight down and control their diabetes better, than these folks will avoid heart attacks, strokes and surgeries which will save mega bucks and improve productivity.”  

Sure it sounds right, but is it really true?  Shouldn’t corporations that know the cost of every widget be able to prove that this strategy is sound?   Last year, a major study on obesity published in the prestigious Journal of the American Medical Association concluded that overweight individuals live longer.  My point?  Just because something sounds like it should be true, doesn’t make it so. 

Many companies are now coercing employees with financial rewards and penalties depending upon their success and enthusiasm in participating in company wellness programs.  If you don’t make their health grade, then the employee will lose serious cash, which may be far in excess of actual medical costs incurred.  In other words, an unstated motivating factor here may be simply to get employees pay more health care costs.

Indeed, two studies published last year in Health Affairs, a peer-reviewed journal, strongly suggested that corporate wellness programs save company money simply by cost-shifting to employees.  Is this what is meant by corporate ‘wellness’.

The Plain Dealer (PD), Ohio's major newspaper reported last year that CVS Caremark is requiring employees to participate in its wellness program by May 1st or they will have to fork over $600 more for health care next year.  Do we really know that non-participants would drain the company’s coffers?   Realize that many employees change jobs every few years, and that adverse health effects of being obese or having elevated blood pressure may take decades to develop.   A CVS worker with a pair of love handles or modest hypertension, isn’t likely to consume more medical resources in the short term.  Yet, he would be docked on day 1 next year.  Does this policy pass the fair and reasonable test?

The PD article quotes CVS as claiming that their policy is “the most effective way to encourage our colleagues to take control of their own health…”  This statement breaks the needle on the hypocrisy meter.  The gall that CVS wants to serve as a health guardian, or should I say health police, while it sells cigarettes, alcohol, junk food and the sugary beverages that New York City Mayor Michael Bloomberg has outlawed for health reasons.  This is chutzpah of the first order. The court properly pushed back against Mayor Mike.

Sometime after the PD article broke, CVS announced that they would refrain from selling tobacco products.  What brought on this revelation?  Did they suddenly release that cigarettes were hazardous and might conflict with their healing mission?  Was it a marketing maneuver to rebrand the company?  While the outcome might be welcome, what was the motivation here. 

If a company truly believes that wellness is right for workers and business, then create a corporate culture that encourages this and provide leadership.   If it’s really as good an idea as they say, then folks over time will be persuaded to do join in.   Leave the financial rewards and penalties off the field. 

I’m not a wellness antagonist.   I support any activity that is safe and makes people feel better.  But making folks pay-to-play in the wellness game, doesn’t make me feel good.  Perhaps, I need to meditate more on this. 

First published in Crain's Cleveland Business, May 2013.

Sunday, May 4, 2014

Are Doctors Sued Enough for Medical Malpractice?

Remember personal responsibility?  There actually was an Era of Responsibility when folks admitted when they screwed up and didn’t blame others for their own mistakes.  I know this may seem incredible to the younger generation who simply assume that when something goes wrong today, it must be someone else’s fault.   In today’s culture, this is not scapegoating, but the pursuit of justice.  Welcome to the Era of Big Victim.

In the olden days, if someone slipped on ice and sustained injuries, he went to a doctor. Today, we could expect a court case where a jury would hear testimony from an Illumination Expert testifying that the wattage and angle of the sidewalk lighting was clearly deficient.   A Saline Expert would add that the salt that the proprietor applied to the sidewalk was not dispensed with a certified salt sprayer, thereby allowing dangerous ice crystals to survive.  Perhaps, an Ambulation Expert would instruct the jury that the soles of the fallen man’s shoes contained a design defect that the company knew, or should have known, made slipping more likely when the ambient temperature was between 26 and 28 degrees Fahrenheit at specified humidity levels, particularly in northeast Ohio. 

Warning: Ice is Slippery

The notion that the guy fell simply because he slipped or was careless, is irrelevant, immaterial and argumentative. 

Yeah, I know there is another side to the above vignette; but can any reasonable person deny that we are suffering litigation frenzy?  Using the Goldilocks formula, do we have too much litigation, too little or is it just right?   Any doubt on the outcome of a public referendum on this question?
No profession understands or endures the pain of wrongful litigation more than we physicians do.  I’ve been in the medical malpractice arena in the past, and I’m sure I’ll be invited back again someday for another engagement.  The assumption often is that an adverse medical outcome means a physician is culpable.  Thus far, I have been dropped from every case as every allegation ever made against me was baseless.  This very week, I (and many others) were dismissed from a frivolous lawsuit that my malpractice carrier estimated cost $11,750 to defend me.  You might think based on this amount that I went to trial, but I had only one meeting with my lawyer and the matter never even reached the discovery phase.  Imagine the annual total cost of unnecessary litigation in this country.  Any ideas out there for a better use of these gazillions of dollars?
Being dragged into the medical malpractice universe is a grueling, costly and unfair process that exacts a huge toll on innocent physicians. It demoralizes us.  It affects our doctor-patient relationships as we know that even long term patients who like and trust us can be persuaded to sue us when we have done nothing wrong.   Ever hear of defensive medicine?  Do you think that when we recommend a CAT scan and other tests that it is only for medical reasons?  I wish it were the case, but it isn’t. 

We have discussions in our medical practice on strengthening communications with patients.  We do this for the right reasons, although we are aware that failure to notify a patient of a test result could create legal exposure for us if this leads to an unfortunate outcome.  I understand and accept this.   However, does the patient have a responsibility here also?   Assume a gastroenterologist like me removes a polyp from a patient.  The doctor meets with the patient and the family afterwards and requests that the patient return in 2 weeks to review the pathology.  The recommendation is also given in writing.  Despite this, the patient doesn’t schedule the appointment or simply misses it.   The doctor, therefore, didn’t have the opportunity to advise that another colonoscopy would be needed in 3 years.  If the patient develops colon cancer 10 years later, is this our fault or his?

Lawyers, stop hyperventilating for a moment.   Yes, I know that physicians should have procedures in place to plug these leaks.  We do.   My question is not if we would be legally vulnerable.  In today’s world, we would be.  I’m asking from a moral perspective, would the development of colon cancer in this hypothetical example be the patient’s fault? 

Blaming others for our own misfortunes is not seeking justice.  Bad stuff happens.  Acts of God occur.  Perhaps, we should we start suing the Almighty for damages from floods, hurricanes and other natural disasters?