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?