Sunday, August 11, 2013

The Sunshine Act Exposes Physician Payments: New App Suggested

A few weeks back, a drug rep, aka a pharmaceutical representative, came to the office hawking a new constipation medicine.  These guys are in a tough racket.  They need to sell products that we physicians are often unable to prescribe.  It’s the Formulary, Stupid.

The Best Disinfectant

In the olden days, before I entered the hallowed halls of healing, pharm reps, or drug detailers, developed relationships with physicians who would then prescribe their drugs.  Physicians to this day deny the incontrovertible truth that we are influenced by pharmaceutical company marketing techniques, which still feature face time between sales folks and prescribing physicians. 

These days, many of the sales tools used years ago have been properly prohibited.  Physicians cannot be flown to exotic locales and paid big bucks so they can serve as ‘expert consultants’ who will be subjected to push polling on the new pharmaceutical product.  (Why didn’t any company ever ask me to serve as an ‘expert’?)

As is often the case, the new laws that are designed to promote ethical behavior and restrain corruption have become OperationOVERBOARD.   The Sunshine Act, a part of our beloved Obama Care Affordable Care Act (ACA), is now fully operational.  Pharmaceutical companies are now required to report to the Federal Government if a physician receives an individual item valued at $10 or more, or accrues an annual total of more than $100.  These ‘transfers of value’ will be posted for public viewing. 

We physicians do not want to be on the government’s Sunshine Act Wall of Shame, which conveys that we are evil and corrupt practitioners.  Will the public really be able to distinguish a tainted doctor who has taken possession of a $12.99 tote bag from another rogue who has  acquired a $14.95 breakfast tray for the staff?  Did the ACA consider that these dilemmas will vex and torture patients who may miss their doctors’ appointments as they will be spending so much time scrolling through the roles of tarnished physicians?  This will directly and negatively impact on their health.  The ACA should have had their IT folks incorporate a time limit on Sunshine Act website viewing.  This is an individual mandate that I could enthusiastically support.

Here’s how I intend to remain just under the government’s radar, although we are now learning that government surveillance is slightly more intrusive than it has admitted.

Consider these contraband items:

Tuna sub                             $5.99
Tuna sub with cheese     $7.49
Medium size beverage   $1.69
Large size beverage        $2.19
Chips                                     $.89
French fries                       $2.49       
Cheese fries                       $2.99
Cookies                                $.99

I will assume that the $10 total includes sales tax, but I will have to consult my accountant and attorney to verify this.  Obviously, if tax is excluded then I will have more funds available and would probably be able to add a peppermint patty to my food order while remaining comfortably under the mandated threshold. 
Although I enjoy cheese, and I am fortunate not to suffer the dreaded disease of lactose intolerance, I will order a cheeseless tuna sub so that I will have greater ordering flexibility.  I now have $4.00 left to spend, leaving aside the critical tax issue referenced above.   Readers who are computationally advantaged have already determined that I cannot enjoy a large size beverage along with cheeseless French fries.  Even a medium size beverage will put me over the limit.  I could order any beverage size with either chips or cookies.  I don’t really like these two items, but if eating vitamin fortified potato chips and omega-3 laced cookies will keep me off the list, then I will do the right thing.

I suggest that an entrepreneurial whiz kid design an App that can instantly provide physicians with all permutations of menu choices from area restaurants that will not cross the Sunshine Act’s $10 limit.   Hurry before Yelp administrators, who are avid Whistleblower readers, incorporate this feature into their App.

Does anyone out there think that our government needs a little sunlight shining on it?




Sunday, August 4, 2013

A Tale of Divine Healing: Faith and Reason

I’ve posted a piece on this blog on the issue of faith and reason in healing. Indeed, the protagonist of that post is an inspirational figure, a selfless man who exudes grace and humility. I was honored that the post was shared with many Catholic clergy who appreciated my heartfelt words for one of their own.

Faith and reason reentered my medical universe recently.

A patient underwent surgery to resect a colon cancer. The tumor had metastasized to the lymph nodes, an unfavorable prognostic event. The surgeon entered the room and advised the patient that her survival is likely limited to 1-2 years. The patient and her husband were devastated. The distraught husband spent the next 24 hours sobbing in a painful and despondent state. He related the tragic news to his 3 children, ages 3, 5 and 8.

Was this the appropriate time for the physician to relay such ominous news to a patient and family?

Was it prudent for the overcome husband to share this traumatic news with his 3 young children?

Readers’ responses to the above two inquiries may be influenced by knowing that the long term survival of colon cancer that has spread to the lymph nodes is 50%, which varies substantially from the physician's doomsay scenario.

The patient, while still recovering from surgery in the hospital, experienced a healing experience that she will remember until the end of her days. Her 3-year-old daughter approached her and told her that she is not going to die because God told the young child that her mother will live. The patient related that she felt an unusual sensation that began at the top of her head and rippled slowly down her body until it reached the soles of her feet.

The woman received no chemotherapy or any other treatments to the tumor.

So, whom do you believe, a trained medical professional or a 3-year-old child?

Since this surgery occurred in 1985, and the woman is thriving and well today, it is clear which of these two were correct.

The patient is convinced that she was divinely healed and this experience has understandably deepened her Christian faith.

I am not a Christian but I have enough humility to know how limited physicians like me are about the art and science of healing. Faith and reason can coexist. Is there truly a will to live? Can prayer heal the sick? Men of hard science also pray to God. Is this a dichotomy or a fusion?

Every physician has seen patients recover whom we were certain would succumb. Does science have all the answers? Does faith?

I do not offer this woman’s anecdote as proof of divine healing, although her young child's bedside pronouncement seems providential. There are many medical cases that carve a course that I would not have predicted and do not understand. What forces may be at play there? I can’t say for sure, but I know many believe that prayer may be more powerful than our most potent prescriptions. When you’re staring down a miracle, is that the time to diss the Divine One?

Will traditional medicine enter the New Age universe?  Will the Gates of Reason welcome Faith?

Any readers with relevant experiences are invited to share them.











Sunday, July 28, 2013

Physician No Show Appointments Demoralize Doctors

I’ve had two jobs since I completed a fellowship is gastroenterology over 20 years ago. For the first decade, I was a salaried physician. Afterwards, I promoted myself to private practice. Each model has its advantages and drawbacks, but for me the private practice model wins out. The climate in Cleveland is extremely inhospitable to private practice, because of two mega-medical institutions that incinerate private practices as their boiling lava flows across the region. So far, our practice is still viable, but the prospects for its long term health and welfare are questionable.

One of the advantages of working for a straight salary is that income dies not depend upon productivity. (My employer maintained that we had a productivity bonus, but in reality there wasn’t much the physicians could do to adjust their salaries in either direction.) One of the disadvantages of private practice, particularly where I practice, is the need to hustle aggressively for patients, a task I neither enjoy nor do particularly well. In my present professional world, an empty schedule means empty collections.

So, when a patient decides to miss an appointment, the ramifications are quite different for me now than it was during my first job. At least when I was reading The New York Times during a gap in the schedule while I was on salary, my paycheck didn’t change. Not so these days.

My partners and I are forever lamenting the empty spaces in our schedules when patients do not show up or call in advance to notify us that they will not be coming.

These acts hurt us economically and forfeit an appointment slot that another patient would have happily occupied. Moreover, not showing up is downright inconsiderate. Sorry, if some readers find this latter view to be harsh, but I don’t wish to sanitize it as a venial sin.

Of course, sometimes life happens and an appointment is missed or forgotten. As a member of the human species, I get this. However, many of the patients who are AWOL at appointment times have been contacted a day before by a living, breathing member of our superb staff. Here, the absence is inexcusable.

Should these patients be assessed a fee for failure to appear? If a patient does call to cancel, how much notice is reasonable? 24 hours? 10 minutes? What if their insurance companies prohibit us by contract from charging patients these fees? Then, what leverage do we have?

Should we leave a heartfelt flyer in the waiting room pleading for cooperation on this issue? What good would that do? The ones who really need to read it aren’t there.



Sunday, July 21, 2013

Electronic Medical Records Save Money! (Never Mind)

Electronic medical records (EMR) were supposed to rewire the medical grid.  It would increase efficiency, reduce redundancy, improve quality and reduce costs.  On  these measures I offer a grade of 0 for 4.  Ask any practicing doctor how EMR has impacted on his practice and be prepared for some remarks that differ from the government’s Kool Aid talking points.  EMR, thus far, hasn’t been ball bearings for the system.  More often, it gums up the works.


The EMR Maze - Enjoy!

The government spent billions of dollars with cash payments  to induce hospitals and doctors like me to jump on board the EMR express.  The Rand Corporation helped to fuel this euphoria in 2005 when it predicted exaggerated benefits of EMR.   By the way, this study was financed in part by EMR companies whom, I politely suggest, had a vested interest in the study’s conclusion.  Rand denies that they were unduly influenced by their backers, and I don’t claim that they caved on their principles.  Nevertheless, the propriety of taking money from folks whose survival may depend upon the study’s outcome is ethically problematic.  But, Rand was wrong and has publicly admitted it now.  The Rand folks are now back flipping across the countryside with new and improved pronouncements stating that EMR has added to medical costs and hasn’t delivered on its other rosy promises.

This wasn’t an epiphany.  Many folks in 2005 didn’t swallow the Rand bait.   The Whistleblower was blowing hard but apparently the frequency was above what human ears can perceive.  EMR is a money pit that has made many companies rich.  EMR systems are expensive, clumsy to use and do not communicate easily with other EMR systems.  Patients have the notion that the hundreds or more EMR systems out there can easily communicate with each other.  They can’t.  I have a few posts on EMR, and they’re not pretty.

The point here transcends the EMR mirage.  How many other promises of Obamacare will crumble in the years ahead?  Again, this won’t be a revelation.  Many of us were shouting about this on day 1.  No one could hear us above the din of health care reform.   Will these reformers, like Rand, admit that they were wrong as the evidence piles up?  Wouldn’t that be the fair and balanced thing to do? 

We’re in the Era of Medical Ridiculousness.  Call it EMR.

Sunday, July 14, 2013

A U.S. Marine's Gift to a Doctor

I saw an elderly patient a few months back for a gastrointestinal issue that fortunately led to a benign outcome.  He was a modest man who spoke softly and used few words.  As has been my custom for as long as I’ve sat across patients, I was interested to learn something of the man beyond the issue that brought him to see me.  Indeed, it is these vignettes that I regard as the gems of my practice.  Without them, I would be left only with the practice of medicine, and this would not be sufficient.

He wore a military baseball style cap, emblazoned with a U.S.M.C. label.  To those who do not immediately recognize what these letters stand for, then I suggest that you apply to medical school, become a physician, see patients so you also will have the opportunity to learn stuff that really matters.

I learned that he served in the Pacific theater in World War II and asked him about his service there.  While my father served in the war for 39 months, he remained in the United States, far from harm’s way.  As he was so mechanically incompetent, perhaps the government kept him home as they were fearful of placing a firearm in his hand.  He was stationed in California and likely would have been deployed to Japan had President Truman not ended the war in August 1945.

My patient described how he was shot in the head, with the bullet piercing the front of his helmet and then exiting out the rear.  No vital structures were injured.  He described the event as casually as one who had sprained an ankle in the parking lot.  I find that older veterans are characteristically modest and understated, two virtues that I wish were more contagious.

When I learned that he served on Iwo Jima, my eyes flickered wondering if he had witnessed the scene that has become America’s most iconic military image.  Yes, he had witnessed the legendary flag raising on Mount Suribachi.  I felt as if I were in the presence of an important man, though he would likely dispute that.

I saw this man back in the office recently, and at the conclusion of the visit, he gave me an envelope containing a gift.  It was his U.S.M.C. pin that he wore throughout his service.



“I want you to have this, doctor,” he told me. 

I accepted this important gift from an important man with deep appreciation.
We give what we can to our patients.   They have just as much to give back to us.

Semper fi, Elmer. 


Sunday, July 7, 2013

The Cost of Colonoscopy: A New Payment Model


There is a steady push to change the way that physicians are paid.  No compensation model is ideal.  The fee-for-service (FFS) model has become Public Enemy #1 as it is felt to be responsible for overtreatment generating excessive costs and utilization.   Salaried physicians may be freed from the FFS conflict of interest, but it has other drawbacks including a diminished incentive to provide exemplary service to patients and to referring physicians.  Since physicians did not initiate compensation and health care reform decades ago when we should have, we are now being squeezed hard by external forces that will overcorrect on the system’s deficiencies.  It’s always better to fix your own house.  There should be a lesson here for other professions who are in need of some reform and repair.  Teachers, in my view, were dragged into the education reform arena, and will suffer because of it.  Attorneys have been smug and cavalier about the legal profession’s obscene excesses and I believe that they will rue their inaction.

What do patients think about how their doctors should be paid?

I’ve done over 20,000 colonoscopies.  As I have written in this blog, I’m not even sure how much I charge for the procedure.  It’s not simply because I have little interest in the business of medicine.  It’s also because colonoscopies are like air travel.  No two passengers pay the same price.



Which system would you favor for pricing a colonoscopy?

(1)    Flat fee for the procedure for every insurance carrier.
(2)    Hourly rate.  If a colonoscopy is tough and takes twice as long, the physician should get double the dough.
(3)    Graduated rate depending upon experience.  Should a 20 year gastro veteran be paid the same as a green newbie?
(4)    Airline model.   We now know that various airline seats have been designated as premium seats because they afford an extra centimeter of leg room or the oxygen mask actually works.  Similarly, certain colonoscopy time slots could be subject to a surcharge, such as the first appointment of the day when the physician is energized and not yet running behind.  The 5 pm  slot, in contrast, would be discounted as the physician is fatigued and is trying to make a 6 pm dinner reservation. 
(5)    Name your own price model as is done with air travel, car rentals and hotel rooms.  Patients offer an on-line price in advance and the GI practice decides to accept this or wait for a higher bidder.  This adds a fun element to the colonoscopy adventure.
(6)    Patients decide after the procedure to pay the doctor what they feel the training, knowledge, experience and judgment are worth.   Some patients, I fear, may valuate the colonoscopy only by the 10 minutes duration.   This is not quite fair.  Once in Cape Cod, I saw a beautiful sand sculpture of a mermaid.  I asked the artist how long it took him to create the art.  His response was ’30 years and 7 hours’.  Get the point?
(7)    Barter system as functioned well historically.  One colonoscopy = 6 Box seats at sporting event = set of luggage = last year’s iPhone model = 1 hour plumbing service = 5 car gas fillups
(8)    No charge at all.  You can’t put a price on your health, and we shouldn’t try. 

While I’ve never regarded myself as business savvy, perhaps I’m onto something here.   What do readers think?  Is it time to take off the rubber gloves and wear suits and ties or should I keep my day job?