This morning, as I wrote this some time ago, a patient came to my office for a
colonoscopy. I sent her packing. Here’s what happened.
In our Ambulatory Surgery Center (ASC), in my prior private practice, we introduce light
into dark spaces every day. This is
where we perform colonoscopies and upper endoscopies. We have a program in place where referring
physicians can have their patients contact our ASC and schedule a procedure
without seeing us first in the office for a consultation. Obviously, we have to have a vigorous screening process in place We do not want to meet a person for the first
time for a colonoscopy and discover that he has complicated medical issues and
is dragging an oxygen tank behind him.
Our screening system works extremely well, but it is not
perfect. On occasion, it misfires The patient arrived at our office at 7:00 a.m. after a 45 minute drive. She had
ingested the required purge, often the highlight of the
experience. I hadn’t seen her for
years. She was suffering from severe
pulmonary disease, smoked cigarettes and used supplemental oxygen at night. Clearly, this was not
an appropriate patient for our out-patient facility. Our nurse anesthetist and I conferred and
agreed that we should not proceed because of safety concerns.
I explained to the patient, her husband and her daughter our
reasons for cancelling the case. It was
a long conversation. At first, she was
disappointed for all of the obvious reasons.
She had endured a day of a clear liquid diet
followed by ingesting our prescribed liquid dynamite to cleanse her colon. She and her family had taken an early and long drive. After she had ventilated her
transient exasperation, she quickly came to understand that our sole objective
was to protect her.
Why am I sharing this vignette? Every doctor could relate similar
anecdotes. I share this typical scene
from our practice, which I offer as an example of sound medical judgement. We did the right thing and protected a
patient’s health. We considered the
risks and benefits of the procedure and sedation, and chose safety. Doctors (or patient) shouldn’t try to get away with stuff.
When the Medical Quality Police evaluate me, as is being
done by our hospitals, insurance companies and the government, how will they
measure our performance this morning?
They won’t and they can’t. So much of the good work that a doctor, a
policeman or a teacher does, can’t be measured.
I work with great nurses every day, but there is no formula that exists
that can measure what they do. What has
happened is that these professions are now assessed by box-checking bureaucrats
who are charged with measuring all kinds of silly stuff that doesn’t
matter. Do I get any credit, for
example, when I advise a patient that he doesn’t need a colonoscopy or a CAT
scan? Ask your doctor about this issue during
your next appointment, but bring some Maalox with you because your physician’s
esophagus will start sizzling.
Medical Quality Measuring Device
Look up Pay for Performance on this blog and elsewhere to find
out more about this scam.
Incidentally, there’s happy ending to the woman whose case
we cancelled. Since she was prepped for
a colonoscopy, we sent her to the hospital where I did the case safely later in
the day.
How do you define a high quality physician? If you are able to define it, how would you
measure it?
We have a system that is beyond dysfunctional. We and are predecessors are all to blame. We are incentivized to do things to patients, not for them. Procedures are often over-reimbursed while thinking is usually under-reimbursed. We are not paid for reviewing records, which is why some centers seem to prefer to repeat procedures rather than scan through 1000 pages of medical records to find the previous endoscopy report or zinc level. Bonuses are based on RVUs, which are mostly generated by procedures. We've allowed MBAs to run medicine, many of whom know little about medicine but a lot about cutting costs. Initially, efficiency is improved but they often fail to recognize whereupon inefficiency starts to increase because of cost cutting. Clinicians and their business partners try to maximize revenue while payors try the opposite - much like lawyers in arbitration where each side starts at a point where they know their position is unacceptable. Where is the patient in all of this?? What is needed are fully integrated systems - but even then the right pocket will complain that the left pocket is getting too much money. Doctors are at least partially to blame here. They/we didn't want to be involved so much in the development of billing systems - or even EMRs for that matter (which is why they are not as user-friendly as they should be) because (the collective) we stuck our heads in the sand. It is unfortunately too late to scrap teh billing system in order to bill by complexity of thinking rather than by time or by procedure. That's where the patient really suffers. Physicians are paid for doing - but not necessarily for doing the right thing. Payors have problems too. There are things that are paid for that never should have been and there are things not paid for that should be - and there are also those that try to game the system. This is why our health care system stinks, but I think many of us do the best we can within these constraints.
ReplyDeleteAlan, thanks for your thoughtful and expansive comments. If you have been a Whistleblower reader for some time, you know that I largely agree with you. The fee-for-service model, which was my primary method of reimbursement for most of my career, misaligns physicians’ and patients’ interests. Currently I am on salary which I think is a much better model as long as the salary is fair. As you might expect, the definition of what constitutes a fair salary is rather elastic. Additionally, there is a zero sum element to this game in that paying some specialists more will likely come at the expense of others within the medical arena - causing an internecine conflict. With regard to the issues you raise, I think we are headed toward higher ground as value based pricing is gaining a foothold in the medical landscape. I agree as well that EMR’s were developed with billers and coders - not physicians - in mind. Astonishingly, we do not have a universal EMR which was the original promised included with the seduction many years ago.
ReplyDeleteThere are many moving parts in this 4 dimensional chess game. Tug on one thread and their may be unintended effects in other regions of the tapestry.