Sunday, August 25, 2019

Do Patients Like Weekend and After Hours Medical Care?

I have previously expressed how physicianss feel about treating patients that they do not know in a prior post, which readers are invited to review.  This post is the other side of the story.   

Nowadays, patients are used to seeing physicians who are not their doctors.  Often, patients may be seeing a nurse practitioner, a highly trained professional for their medical care, instead of a physician.  A generation ago, patients nearly always saw their own physician, including if a patient was hospitalized. Imagine that, your own primary care doctor sees you in the hospital, an event that occurred when dinosaurs roamed freely.

The medical universe has changed.  Hospitalists care for most hospitalized patients, which in my view, has vastly improved the quality of hospital medical care.  It is commonplace for patients who need to be seen right away in the office, to see a doctor who is available, who may not be the physician of record.  Pregnant women today often see many obstetricians in the group since it is unlikely that the patient’s designated obstetrician will be on-call on D-day.  One of Cleveland’s corporate medical giants boasts that they offer ‘same day appointments’, which is true if a patient is willing to see a medical professional several zip codes away, not the patient's actual doctor.

In the olden days, one doctor did it all.

Understandably, if you call your physician after hours or on the weekend, you will most likely connect with one of your doctor’s partners.  This is why it is not advisable to call the emergency on-call physician 9 pm for a conversation about your chronic arthritis.

Patients are now used to seeing strangers prescribing their medications and ordering their diagnostic tests.  Hospitalized patients may be treated by several physicians they do not know. They have adjusted as best they can, but there are obstacles and drawbacks to this medical care paradigm.
  • It is unsettling for patients to be confronting several medical professionals for their care.  Similarly, if you are reading 4 or 5 books at once, are you really able to keep the separate stories straight in your mind?
  • There is unavoidable loss of continuity when there are multiple physicians at the table.  Hospitalists do a great job.  But, do we really think that all of the nuanced knowledge and objective data can be seamlessly transmitted to your primary care physician whom you will see after you are discharged?
  • What if different primary care physicians who are seeing the same patient have different opinions?  Who does the patient believe?
  • Even in the computerized era, it’s astonishing how often new physicians do not have easy access other physician’s medical records.  Does the weekend physician consultant who is seeing you in the hospital know that another doctor already ordered an ultrasound of the gallbladder a few months ago across town?
  • When there are too many physicians involved in a single patient’s care, medical testing and costs tend to increase, which does not increase medical quality.  In my experience, a new doctor is more inclined to order a medical tes, than to advise watchful waiting, a strategy that the doctor who knows the patient well would more likely rely on.  For example, if I see a patient I know for years with the same stomach pain, I may react differently than another gastroenterologist seeing him for the first time. 
Oftentimes, patients and physicians meet as strangers.  This reality creates many challenges.  Both sides need to be understanding.


Sunday, August 18, 2019

Should Doctors Offer a Money Back Guarantee?

It may seem odd that a gastroenterologist patronizes fast food establishments several times each week.  I’m in one right now as I write this.  I eschew the food items –though French fries will forever tempt me – and opt for a large sized beverage.  In truth, I am not primarily there for a thirst quenching experience, but more to ‘rent a table’ so I can bury myself in some reading.  Indeed, many thousands of New York Times issues have been devoured at these tables.  I saw a sign posted on the wall here that I had not seen before.

Sorry, No Refunds

Refunds?  How often can this happen in a place like this?  We all know that food items in these institutions are remarkably consistent, which is one of benefits that customers enjoy.  Your Big Mac or Whopper will taste the same in Pittsburgh as it does in Peoria.  I questioned the server on this new development and she explained that increasingly customers were demanding refunds for contrived reasons in an effort to bilk the restaurant.  At some point, the restaurant decided to put an end to this practice. 


Refund Free Zone!

I wonder how my patients would react to being greeted by such a sign in my office?  Of course, physicians do not offer refunds or a money back guarantee for our services, as other industries boast.  Nearly every infomercial includes the tag, “and if you don’t agree that these _____  are the best you’ve ever used, simply return it for a full refund – no questions asked!”  Not so in the medical profession.   We are paid regardless of the outcome or your satisfaction.  It is true that physician reimbursement policy is evolving away from fee-for-service (FFS) toward a value-based system.  In other words, physicians won’t be paid separately for every medical service we provide you, but for the overall ‘value’ we provide, which is a somewhat amorphous concept.  FFS clearly incentivizes the medical profession to overtreat patients because we are paid more for doing more, even if such care may not be truly necessary.   It remains to be seen if the value-based payment approach will protect patients and be fair to physicians. I have my doubts.

Many professionals are paid regardless of how their clients fare.  It you lose your case in court, your lawyer will still be paid.  If a judge is overruled on appeal, his wages aren’t reduced.  If your investment underperforms, your financial planner doesn’t return his fee to you.  Tradesmen, on the other hand, make a commitment to satisfy us as a condition for getting paid.  If we hire a plumber to unclog a sink, for example, he understands that if he doesn’t deliver, then we won’t either. 

What if all of us were paid on results rather than on time expended?  Would this lead to higher quality goods and services?  Could it really apply to the medical profession?  If a patient comes to see me with abdominal pain, which often defies explanation even after a thorough medical evaluation, is it fair that I wouldn’t be paid if the patient’s pain persists?

None of this applies to Whistleblower readers.  These posts are free so don't ask me for refund.  

Sunday, August 11, 2019

Joining a Clinical Trial Helps Others

From time to time, I am asked by someone about participating in a medical research study.  These situations are usually when an individual, or someone close to them, has unmet medical needs.  Understandably, a patient with a condition who is not improving on standard treatment, would be amenable to participating in a clinical trial to receive experimental treatment.

I find that most folks misunderstand and exaggerate the benefits they may receive as a medical study participant.  Sometimes, I feel their ‘misunderstanding’ is fueled by study investigators who may overtly or unconsciously sanitize their presentation to patients and their families.  There is no malice here.  Investigators have biases and likely believe that their experimental treatment actually works.  Their optimism is likely evident in their communications.

Here’s what an investigator might say to a patient.

I thought you would be interested in a new clinical trial testing a new medicine for your disease.  Preliminary data show promising results. 

If you were a patient, wouldn’t you infer that the drug might help you?

Patients, I have found, are of the mistaken belief that they may directly benefit from the drug being tested.  Of course, this makes sense to them.  Their rheumatoid arthritis drug isn’t working.  They are informed of a clinical trial of a new treatment for patients who do not respond to conventional treatment.  Obviously, they enter this trial with the hope that their condition will improve.  Unfortunately, this is the wrong way to approach a medical study.


Louis Pasteur - Legendary Medical Researcher

Clinical trials are not designed to benefit the participants.  They are performed to generate new knowledge that may help future patients.  This is the key point that so many study participants are not fully aware of, and they should be.  The investigators do not know important data about safety, efficacy and dosing.  These are among the fundamental data that the study – and future studies – will determine.  If medical investigators knew that the drug actually worked, then there would be no need for a clinical trial.  There’s a reason behind the term experimental treatment.

If you want to enter a clinical trial, know that you are doing so to help others who will come after you.  This is a selfless and praiseworthy event.   Indeed, we have all benefited from the sacrifice and altruism of prior patients who agreed to create new knowledge to help us.   If we enter a study we may not personally receive a return on investment for our efforts, but we are paying it forward to others.

Sunday, August 4, 2019

Transparency in Health Care Costs - New White House Proposal


Opaque:  adjective, not able to be seen through; not transparent

Medical pricing is beyond opaque.  It’s a riddle wrapped in a mystery inside an enigma.  Many readers will recognize that this clever phrase is not my own.

Throughout my career, I have been unable to provide an accurate answer to the perennial inquiry, how much does a colonoscopy cost?  Patients, of course, find this to be baffling.  This ignorance is certainly not restricted to my specialty of gastroenterology.  Does it make sense, for example, that the same medication may have wildly different pricing at different pharmacies or in different cities?   In contrast, we would expect to find a similar price for a gallon of milk among supermarkets. 

My strong suspicion is that seemingly irrational, inflated and complex medical pricing is all by design to serve those on the billing end – hospitals, pharmaceutical companies and pharmacy benefit managers.  Before you accuse me leaving physicians off of this list of Greed & Shame, may I remind you that we physicians do not set our own prices; they are all dictated by the payors.  When we send you a crazy bill, it is all according to your insurance company requirements and policies - not us.  Same for the copays patients fork over when they come to see us.  While we are the target of griping and sniping, these cash extractions are mandated by your insurance companies.

The medical arena is unique.  It does not allow consumers to utilize price comparison as they do when purchasing appliances, vacations, private schools,  apartment rentals or an apple.  It is unlikely that one would sign an apartment lease without being told what the monthly rent charge would be.   But, we will proceed to a CAT scan examination without knowing the cost or if a nearby competitor can provide the same service for less.


Fairly Easy to Determine the Cost Before the First Bite


Recently the White House launched an initiative to require physicians and hospitals and insurance companies to inform patients of the costs of medical care in advance.   Of course, this concept should be welcomed and applauded.  Push back against it was locked and loaded before the new policy was announced.   Who’s against price transparency?  Hospitals and insurance companies and drug companies are united in their opposition.  They claim, among other things, that they would be forced to surrender proprietary information,  that medical prices would actually increase and that the public would not be well served.   I am not an economist, but I surmise that exposing the buried secrets of medical pricing will empower the rest of us in making better choices.  Real and open competition will bring prices down, as is true in all other spheres of commerce.

Some economists are warning that this issue is extremely complex and that the outcomes may be paradoxical.  I'm willing to take a chance.

My goal before I retire years from now is to be able to tell a patient how much their colonoscopy will cost.  

Transparent: adjective, allowing light to pass through so that objects behind can be distinctly seen.

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?