Sunday, April 28, 2013

Reduce Hospital Readmission Rates or Else!

I attended a medical staff meeting recently.  These are required meetings and attendance is taken, as was done when we were in kindergarten.   While some folks are interested in these meetings’ content, many are not and simply sign the attendance sheet and then slither out in a stealth fashion.   Sly doctors grab their pagers and then leave hurriedly pretending that they were summoned to an urgent medical situation, when they are actually heading for Starbucks.  

One of the community hospitals I attend initiated a dastardly procedure when administrators would not post the attendance sign-in sheet until the conclusion of the medical staff meeting.   Under the threat of picketing, a massive walk out, letters to the local paper and other unspecified measures, the evil decree was rescinded. Who says that physicians have no power today?

Sadly, most of these meetings have nothing to do with making us better doctors.  The agendas are full of medical coding and billing issues. Hospitals are hyperventilating over an increasing burden of mandates issued from Mount Medicare to preserve reimbursement.   At present, if physicians and hospitals somehow make it through the labyrinth of hoops intact, they will accrue a very modest increase in revenue.  In the near future, failure to comply will result in punitive financial confiscation. 

Physicians who make it through get paid more.  

Every hospital is armed with utilization personnel that are trolling through the wards scouring charts trying to verify that the medical documentation supports the highest reimbursement possible.  I don’t fault the hospitals for this.  We follow a similar path in our office.  The hospital hoops we are forced through are described as a palladium to protect patients, although I continue to argue that the motivation is to control costs.

This blog has several posts that argue that the government’s Pay-for–Performance initiatives are scams that ironically decrease medical quality, rather than enhance it as promised. 

At this recent medical meeting, the speaker was instructing us that if patients with certain diagnoses are discharged and then readmitted within 30 days, that the hospital would be financially penalized.  Obviously, there are many legitimate reasons that a sick patient would need to be re-hospitalized within a month, but this issue warrants a separate blog post.

Here’s what I learned.   If a patient returns to the emergency room within 30 days of a hospital discharge, all personnel will be notified that this is a ‘patient of interest’ (my term).  Every effort will be made to choose any pathway, except admission, for reasons unrelated to medical quality.  In fairness, once patients are discharged, medical professionals will stay engaged with them to verify they are complying with medical appointments and medications which should prevent disease recurrence and readmission to the hospital.
I found it galling that strong effort would be undertaken to restrict admission of only those who were recently discharged from the hospital.  Shouldn’t stringent hospitalization criteria be used for every patient seen in the emergency room?  Is it a wonder why cynicism is metastasizing widely? 

This is but a single example of how the medical profession is being forced to game the system to comply with a punitive financial penalty system that is poorly disguised as a medical quality initiative.  Hospitals are ‘teaching to the test’ so that they and physicians look good on paper so more cash will trickle in.  However, medical quality means more than checking off certain boxes required by an army of officials who don’t practice medicine.

The public would be horrified how much time and resources are devoted to feed this bureaucratic beast.   Is any of this making me a better doctor?  This is easy to determine.  Let me see if this box is checked off. 

Sunday, April 21, 2013

Boston Marathon vs Terror: Boston Wins

Ohio Stands With Boston

I called my son, a Tufts sophomore, hours after the Boston bombs exploded.  I already knew that he was ok, but a horror in your own neighborhood reaches deep into your gut, as I learned when senseless evil descended upon the small town of Chardon, Ohio a few years ago.

I couldn't reach him on his cell phone.  Later, he explained that cell phone coverage was blocked in order to prevent a phone from being used as a detonator.  This seemingly innocent comment demonstrates the shattering of innocence that has affected us all.

Yes, our society knows fear and anger more than ever before.  We stare evil directly in the eye and wonder if it is lurking beyond our view.  But when it strikes, resilience, fortitude, selflessness, bravery and love have prevailed every time, as we saw in the great city of Boston last week.  While the pain of those who suffered directly is unimaginable, the actions of good people are as real as it gets.

Hail to Boston.

Sunday, April 14, 2013

Medical Office Efficiency - The Times They are a Wastin'

Medical practices, particularly private businesses like mine, strive for efficiency. This has become more necessary as medical reimbursements inexorably decline while overhead and other expenses rise. This may be the point in this post when a reader will jump to the comment section below and carp how I and every other doctor are only in it for the money. Not so fast here. Yes, I would like to make a living and I believe that I deserve a decent one. In my case, I do not seek, and have never sought wealth. For small private medical groups, particularly in northeast Ohio, we are aiming to survive more than to thrive.

These days wasted time during the work week can be the tipping point that buries a private practice.

Where are the time sinkholes in medical practice?
  • No show patients – This is the ‘Wonder Bread’ of medical practices. It torments doctors in 12 different ways. Younger readers may need to Google to get this reference.
  • Late Patients – While these folks are less sinful than ‘Wonder Bread’ patients, they mangle the schedule and suck up physician and staff time. Should these patients be told that they need to reschedule? How late does a patient have to be before he is ejected from the office? Should he be told to sit tight in the waiting room until all of the on-time patients have been seen? Are we comfortable playing hardball with a 90-year-old woman who hobbles in on her walker 20 minutes late?
  • Delays in receiving requested medical records. Even in the electronic era, it can be mind boggling how much work is required to get a few papers faxed over. For doctors, this task becomes a competition where we gird our loins to beat the system.
  • Patient Paperwork – Our new patients fill out medical surveys that our staff then uploads manually into our EMR (Electronic Medical Record) system. Although these folks are told to arrive early, it never seems to be early enough. I often find myself in solitude in the exam room while the expected patient is in the waiting room pushing paper. In time, this clumsy process will be compressed and expedited, but our practice is not there yet.
  • Down on the Pharma – This is the IED (improvised explosive device) of medical practices. I cannot calculate how much time is vaporized re-prescribing medications that are not, or no longer on, the preferred list. If we guess the right medication, then we err on the number of pills permitted. If we opt for the mail order pharmacy, we learn that the local drug store was the proper destination. And, of course, if we were insane enough to memorize a particular patient’s proton pump inhibitor prescription pathway, it changes at year’s end.
There may be other reasons that challenge medical office efficiency. Perhaps, for instance, there is the rare instance when a physician is late. In this instance, any of my patients who are reading this post are invited not to comment.

Sunday, April 7, 2013

Does Medical Resident Work Hour Reform Reduce Medical Errors?

One of the points I offer in this blog and elsewhere is to be skeptical to assume that something is true because we think it should be.

We’ve been brainwashed to believe that obesity is a killer, despite research performed this year concluding that a little more weight may add years to your life.  Many argue that an assault weapons ban will save lives despite the absence of social science research that supports this.  Fewer guns should save lives, right? When skeptics like me point to Chicago which boasts extremely strict gun control legislation while being a murder theme park, we are given excuses to reject the data that contradicts gun control dogma.  Isn’t the term assault weapon itself unfairly charged and loaded?  I have supported medical education reform advocating that medical residents and interns should not be worked to exhaustion and yet be expected to administer high quality and compassionate care to ill patients.  I had believed that somnambulating medical interns were more likely to harm patients with careless care.  I believed that this was true because it seemed entirely self-evident.

Two recent studies published in the 3/25/13 issue of JAMA, the Journal of the American Medical Association, suggest that I was wrong.  

What should one do when a study contradicts a long held view? Two choices to consider.

(1) Reflect, consider the quality of the new information and modify your view.

(2) Attack the study as a Big Government, Big Oil or Big Anything conspiracy and hold your ground.

The latest information suggests that interns and residents who work fewer hours commit more errors.
Reasons include:
  • While residents work less at the hospital, they aren’t sleeping more.
  • Residents are now required to do the same amount of work in fewer hours.
  • Shorter shifts mean more ‘hand-offs’ of patients to the next crew of eager interns.
Obviously, cramming in the same amount of high-pressure work into fewer hours invites errors, particularly with relatively inexperienced physicians who may not be adequately supervised at night.  Medical handoffs are the event when interns who are leaving the hospital sign over the care of their patients to the next crew who must assume immediate responsibility for patients they may have never seen.  Hospitalized patients are complex.  The nuances of their condition cannot be seamlessly transmitted to doctors-in-training in a few sentences.  An intern may have to assume care of 10 or so new patients as he comes on shift.  Would you feel at ease if you were one of these patients?  Indeed, one of the defenses of the pre-reform system when interns were real men and worked until exhaustion was that there were fewer dangerous medical handoffs.

Now, these two studies are not determinative.  The increased error rates with shorter work shifts were volunteered by the doctors themselves, which is not scientifically rigorous.  I’m not ready to abandon my view that interns in my day were unnecessarily overworked, but it may be that the reforms that are in place left now have left us too far from a humane end zone.

Not every hypothesis needs to be tested.  Do we need a study to determine if highway driving while wearing a blindfold is dangerous?   Are we still entertaining the notion that it is better for patients and young physicians to meet when the doctor is disoriented from sleep deprivation?    Is there really a need to torture interns to buck them up for their later years in medical practice when they will likely sleep soundly through most nights? 

I’m against torture, even though I know its definition has been a matter of public debate.  Indeed, I’m pleased that my views coincide with national policy.

"We Do Not Torture"  

 "We Waterboarded U.S. Soldiers so it’s not Torture"

What if our senators and representatives had to legislate on four hours of sleep each night?  Care to predict the outcome?   Would the quality of legislation, comity and bipartisanship flourish?  One would surmise that exhausted congressmen would commit more errors, but who knows?  I say, let’s try the experiment for a year to test this hypothesis which may ultimately improve the political process.  I think there’s a reasonable prospect that congressional sleep deprivation may improve quality considering that these self-promoting, self-aggrandizing, self-serving and self-protective scoundrels have already hit bottom.  There’s only one direction they can go.  No need to sleep on this one.

Sunday, March 31, 2013

Medical Overdiagnosis and Overtreatment - Do Physicians Want Cost Control?

Truth is more absurd than fiction.  Mayor Michael Bloomberg’s wacky ban on certain sizes of sugary beverages, a scheme which was riddled with inconsistencies and exceptions, was properly squashed by a New York judge.  The mayor’s next play was to order all establishments that sell cigarettes to hide them from patrons.  I hope that this policy is examined in the same courtroom that ruled that the leaky soda ban was illegal.  Is this guy a mayor or an emperor?  Who can legitimately defend the government dictating to private businesses how they can display legal products to its customers?  Where would candy, potato chips and other poisonous snack foods be sequestered? 

Speaking of sequestration, which the president warned would crush the country, the earth still rotates, the sun rises in the morning and congress has a 15% approval rating.  In other words, not much has changed. 

We learned that there was not enough cash to fund White House tours for school kids.  Yet, we learned that Vice President Biden and his entourage spent $585,000 for a single night in a Paris hotel last month.  The VEEP & Co. were more frugal when they stayed in London on the same gig when the price tag for one night was a mere $459,000.  This seems a smidgen extravagant during such economically lean times and conveys a message of prodigal excess to the hoi polloi.   Is it possible that some of the expense for these 2 nights was excessive?  Was every government official on this junket essential to advance American interests?  While I don’t suggest that the VEEP stay in a Bed & Breakfast or a youth hostel, I’ll bet that these obscene hotel costs could have been reduced without jeopardizing our foreign policy interests.
$585,000 + $459,000 = Lots of White House Tours for Kids

 Motel 6 Next time?

I know from my own profession how many zillions of dollars are wasted that generate income for various constituencies but don’t advance the greater good.  I have admitted repeatedly that I and my colleagues are one of these constituencies.  While the phrase cutting waste is an attractive populistic utterance, the substitute phrase cutting income is more provocative.   Every dollar of waste is someone’s income who likely doesn’t view his earnings as wasteful spending.  Of course, this is not particular to the medical arena; it’s true of every profession, trade and institution.

I have railed in this blog about the explosion of unnecessary radiology testing in medicine.   CAT scans of the abdomen have largely replaced physicians’ examining abdomens, similar to how echocardiograms have replaced actual physicians discerning subtle heart sounds and murmurs with the antiquated medical instrument known as a stethoscope.   While those who overdiagnose and overtreat, including gastroenterologists, justify their practice patterns as sound medicine, watch these practice styles screech to a halt once punitive payment policies against medical overuse are implemented. 

This week I saw a patient with abdominal pain who had a normal ultrasound of the abdomen 2 days prior to hospitalization at another institution.  The dictated report was on the chart for all to review.  The attending physician had ordered a special gallbladder test, but the radiologist had insisted that an ultrasound be repeated first.   Did we expect that a 2nd ultrasound 48 hours later would show new findings?

I see this stuff every day and it is these observations that led to the creation of this blog.  There is waste in the care of every patient, including mine, but the system has been immobile and immutable.  The medical industrial complex is a lumbering ocean liner whose course extraordinarily difficult to alter.  Every real reform threatens powerful, highly motivated and well-funded players. 

Obamacare has smashed through the barricades and promised to be the panacea that eluded us for over half a century.  I have been a deep skeptic and my skepticism has deepened with time, along with the rest of the country.  Let’s watch what actually happens to medical costs and quality as the government rules and regulations coerce doctors, patients and employers.  When the myths of Obamacare are exposed, will the president come clean to our kids when they are finally allowed to visit the White House?

Sunday, March 24, 2013

Sequestration Closes the White House

Fortunately, the sequester did not incinerate Caribou Coffee, where I suck down several hot chocolates each week.  Luckily, Cleveland hasn’t passed a Big Government Big Edict against Big Beverages, as Mayor Michael Bloomberg rammed through last year in New York City.  Recently, a New York state judge refused to drink the mayor’s Kool Aid and ruled against the absurd, loophole-ridden government intrusion.  

Sorry, Mike.  I suggest that you console yourself with a beer, which apparently is much safer than soda since no restrictions were placed on sizes of alcoholic beverages that may be sold.     

I will try to crank out at a blog post now, but my heart is ponderous as I contemplate the plight of our nation’s children.   The barricades have been erected at 1600 Pennsylvania Ave.  White House tours have been cancelled, yet another apocalyptic consequence of sequestration.  It’s not clear to me who was responsible for this.  The White House?  The Secret Service?  Personally, I think it must be George Bush’s fault and expect that Harry Reid and Nancy Pelosi will soon declare this publicly. 

Sorry kids.

The Obama administration faults the GOP for failing to ‘compromise’ on what they describe as a balanced approach to our nation’s fiscal situation.  Let me elucidate the meaning of the word compromise.  It means surrender and cave.  The Dems want more revenue, aka taxes, although the GOP just consented to a gazillion or so dollars of tax increases on the wealthy, which took effect on January 1st.  Wasn’t that a compromise?  If the GOP cave again now, or should I say compromise, does any breathing American believe that they won’t be asked to do again and again?

One thing is for sure.  Both sides have only one issue on their minds – the 2014 midterm elections.  I predict that the GOP will retain the House and that the intransigence will persist.  Then, for the next 2 years, both sides will calculate every uttered syllable and act toward prevailing in the upcoming presidential election.  Remind me, why is the world laughing at us?  There’s something to be said for benevolent dictatorships.

Who can help to diffuse the hyperpartisanship and tamp down the political hyperventilating?   Who can cut through the Machiavellian maelstrom to bring sanity to chaos?  There is a singularly gifted individual has the requisite diplomatic skills to triumph in this mission impossible.  America needs Dennis Rodman now more than ever. 

Who’s going to break the news to our kids that the White House is off limits?  We may need to recruit professional counselors to manage their grief, but there may be a dearth of therapists who have been decimated by the sequester.  A spoonful of Haagen Dazs can help ease the bitter medicine down our youngsters' gullets.  (I mention the word gullet so I can justify this rant in a medical blog.)   Let’s give each of our neglected kids a milkshake to calm and comfort them, while this beverage is still legal.