Random Thoughts from a Restless Mind

The announcement came in the mail, by email, and proclamation at a dinner. My good friend (and personal physician) would be retiring from the practice of medicine at age 55 to take a position as a very senior hospital administrator. This news was delivered by another physician friend, a 55 year old orthopedic surgeon who put my wife back together after a Humpty Dumpty fall off a horse, during a dinner at which he described his intent to drastically reduce his call schedule and ER coverage. That morning in the OR I was chatting with an industry rep who was telling the story of an extraordinarily talented 45ish year old cataract surgeon who has limited his daily volume to 6 cases (that’s what he’s contracted for with Kaiser) despite the fact that he is able to complete this schedule by 9:30 AM. I thought of all of this while I, a 52 year old eye surgeon somewhat famous for my ability to handle a crushing workload without sacrificing either outcomes or a pleasant patient experience, was mapping out my 2014 office and OR schedule with a reduced work week and additional vacation days.

Have you noticed? There are fewer of us out there doing our jobs. Fewer doctors, that is. We’re slipping away, young and old. The last vestiges of the physicians who lived through the Golden Age of medicine are hanging up their spurs, taking down their shingles, and riding off into the sunset. They are being replaced by an almost equal number of youngsters just out of training, young bucks saddling up yearlings and slowly joining the rodeo. Those of us in the middle, mid-career docs of all sorts, we’re still there. Sorta.

The stands are full. All sorts of spectators and commentators are there to see the healthcare rodeo. The reporters and the pundits, the bloggers, those who dwell in the halls of academe and the basements of the bureaucracy fill the bleachers, prepared for much back-slapping and self-congratulation as the fruits of their intellectual labors, the young buck docs, take over for the much-maligned Marcus Welby generation. The kids’ll be OK, better than OK, because the audience has successfully changed everything about how doctors are trained and made it the way they, the audience, think it SHOULD be. No need to worry about the newbies and all of the non-doctor “healthcare providers” and how slow they are in general, or how they work fewer hours, or take more time to handle a visit–those docs in the “sweet-spot” in mid-career are there to take up the slack until the audience’s brilliance is born out. Sorta.

Everything seems to be a bit chaotic at the healthcare rodeo. There are so many more things that need to get done. It’s not enough to rope and tie that diabetic, there seem to be too many diabetics now. Those young docs spend an awful lot of time just outside the ring doing non-doctor stuff. Where are the grooms, the seconds, the helpers? Why aren’t they doing all that stuff outside the ring so the doctors can get in there and ride? It looks like there are a bunch of those mid-career guys and gals over there outside the ring too, doing non-doctor stuff. It sure seems to take a lot of time. The young bucks seem to take that all in stride. Maybe a stray shrug of a shoulder, but not much more. It’s all they’ve ever known. The mid-career docs seem to be making do. Sorta.

Something’s just not quite right, though. The numbers just aren’t quite working. Matching the number of docs retiring with the number of newly-trained docs seems to be coming up short. All of those newly empowered other “healthcare providers” don’t seem to be making much of a difference, either. There seem to be too many patients, too many people who need both sick and well-care, and too few doctors to provide it. The pundits and the professors say the solution is not more doctors but more other “healthcare providers” and new technology. Help is on the way they say. Preparing the path to this end seems to involve a PR campaign that not only minimizes the contribution of doctors in general, it denigrates the efforts of the one group of docs that is keeping it all afloat: the mid-career physicians who are neither old enough to retire nor young enough to not know any better.

The whole house of cards depends on these men and women going to work and doing just what they’ve been doing for 20+ years. Seeing lots of patients in any given time slot. Performing lots of surgeries efficiently and well. Showing up in the ER for a consult or answering the phone at 3 AM. All for lower pay and less respect. The whole thing rests upon the presumption that they will continue to do this regardless of the non-medical impositions of the new “way it should be”, regardless of the continual battering of their self-worth. Thus far that’s how it’s playing out. Sorta.

There’s something afoot, though. Quietly and without much fanfare, the mid-career doc is slipping away. She’s sliding out the side door and taking a job in administration. He’s slipping in a 4-day weekend every month, on top of the 4-day week he started working a couple years ago. While nobody noticed she started to limit the number of surgeries she would do in a day, ducking out at noon on OR day instead of 2 or 3, the backlog of cases now building up to months rather than weeks. Oh sure, they are still counted as a full-time doc on everyone’s ledger, it’s just that they aren’t as full-time as they used to be, as full time as the system is counting on them to be. The net effect is that with the same number of doctors counted we actually have FEWER docs available to see more patients.

You see, the mid-career physician is also listening to what the editorialists and the bloggers and the academics and the bureaucratic minions are saying, about the “way it should be” and how they really feel about worth of doctor work, and in response they are slip sliding away.

Told to do more for less some of those mid-career warhorses are just doing less. All those men and women who are the equivalent of “innings eaters” on a Major League pitching staff are no longer as available, effectively reducing the number of physicians available to take care of patients. If the new “way it should be” is correct this should pose no problem, right? Just have all those folks who used to be seen by a physician seen by a “healthcare provider.” Got a sore throat? CVS or Walmart is just around the corner and they do the same quicky Strep test your doctor would have done. Surely the AP nurse will notice that tender spleen, or that especially swollen tonsil encroaching on the midline like your 55 year old doc with 25 years of experience would have. No worries. You can follow up with that nice new doctor in the big clinic, that ACO thing you’ve read about. There’s an opening in 12 weeks. Your old doctor who would have stayed late in the office to see you in follow-up in a day or two is no longer available.

He started a new career selling veterinary supplements at rodeos. Slip sliding away…

The onus for reducing healthcare costs has been placed squarely in the middle of the backs of physicians. At the same time, physicians are being graded on how well they “satisfy” their patients. Rock, meet Hard Place. Hard Place, Rock.

Two recently published studies referenced pretty much everywhere have shown that individual patients specifically do NOT want to take cost into consideration when it comes to making decisions about their own care. In addition they also do not want their physicians to give any consideration to cost concerns when diagnosing or treating their own illness. Indeed, when given the choice between two treatments of nearly equal efficacy, study subjects overwhelmingly chose the more expensive option for themselves even when the difference in efficacy was very small.

While the authors of the articles citing these studies were shocked at these findings, the only surprise in my mind is that anyone is the least bit surprised by any of this.Think about it. You will personally pay little to none of the difference in cost of the treatment out of your own pocket for a treatment or a test that someone has labeled “better” or “more effective”. You’re telling me you’re not gonna choose that one? Please.

The two great forces aligned against one another in the “Healthcare Reform” debate advocate respectively: market-based incentives in which a patient is given better information in return for shouldering more of the financial decision-making and the importance of the quality of the exerience, and top-down command and control strategies in which both carrots and sticks are applied to doctors in an attempt to get them to provide better care with a more friendly consumer experience while at the same time spending less money. Physicians must provide more and better for less, and must do so under the same zero-sum malpractice game of “GOTCHA” rules we have now.

All of the responsibility for lowered costs with better outcomes and a better quality experience for the patients is shouldered by docs in Obamacare. Accountable Care Organizations (ACO) are lauded for paying physicians a set salary rather than by work done. Unless, that is, you do less work, quality notwithstanding. Getting great outcomes, following best practices, and receiving high satisfaction marks get you a pay cut if you see fewer patients, generate lower test fees, or do less surgery. The Rock.

Play by the rules, see your prescribed load of patients, get great outcomes and practice to the letter of evidence-based medicine, but fail to get those high customer satisfaction marks? Ah…welcome to the Hard Place. Your pay depends on satisfying your patients. Meeting their expectations both for their experience as well as their care. You know, those same patients who only care about the cost of someone else’s healthcare, not theirs. Fail to order the test that rules out the 0.00001% chance of that rare tumor on Anderson Cooper Live last night? BZZZZZT. Bad doctor. 1 out of 10 on the patient satisfaction survey and a trip to the principal’s office to learn about your pay cut.

Man. It wasn’t enough to be in the crosshairs of every plaintiff’s lawyer under the sun (so Doctor, isn’t it possible that you might have saved this patients vision if you’d ordered that MRI to evaluate her headache?). Nope, now we are responsible for balancing the Federal budget while simultaneously giving every patient whatever care they’ve seen on Dr. Oz (“PET Scans–your doctor KNOWS you need one if you have a headache! You could go BLIND!!”). It’s a lot to ask of your doctor.

Unless, of course, it’s someone ELSE’S headache.

Apple just released a smaller Tablet, the iPad Mini, and was razzed by the cognoscenti because it broke no new ground. “Reactive.” “The first  time Apple plays defense.” “Nothing to see here, people. We’re walking…we’re walking.” While the Apple Fan Boys (and Girls) were lining up to add to their Apple quivers, the rest of the consumer world reacted with a communal shrug. Why? No real innovation, and that was a surprise in the world of consumer electronics recently dominated by Apple’s serial innovation.

It makes you wonder a bit, doesn’t it, why there’s so little innovation in the world of medicine when it comes to the storage and transfer of information. With all of the cool stuff already available (voice recognition, “pens” that convert script to text, intuitive “next step” software), why do we have such stodgy, clunky software attached to yesterday’s hardware in all of our EMR choices? For heaven’s sake, we don’t even have a universal platform upon which the various and sundry products are built, and so we continue to have interoperability issues more than 10 years after folks started putting this stuff into play. Why is that?

Every computer product I’ve bought and used over the last 10 years has been easier to use than the one it replaced. Each one has allowed me to do more, and usually with a smaller and less expensive gadget. I know it’s a cliche by now, but my phone has more computing power than the first SERVER I bought to run an entire medical business. For $400. I can talk to it, order it to do stuff, and get all kinds of help I never needed faster than I could realize I needed it, and it fits in my pocket. Yet in a medical office state of the art consists of serial drop-downs and mandatory field entries that may or may not include anything germane to my patient. Able to chat with my cell phone through a bluetooth headset, my EMR demands my full, undivided attention, with gaze fixated on screen.

How come?

In the world of consumer electronics the game is all about predicting what the next, big “gotta have it” gadget or service will be. The most exciting and successful products almost invariably carve out new territory and then go on to viral-like growth because they fulfill a need. This kind of technological progress is so powerful that the people who buy this stuff abandon perfectly functional gadgets that do everything one needs or wants in favor of that next, new-better gadget. This phenomenon in turn drives the makers of consumer electronics to create, to innovate. But not in medicine.

Why is this so?

The so-called “market” for EMR is simply non-existent. The power of innovation, either in response to consumers established, stated needs and desires or in anticipation that something new and better will simply take off in the marketplace is non-existent. The kinds of companies that seemingly come out of nowhere were bludgeoned by government mandated requirements that tiny, bootstrap companies just couldn’t fund the effort. Big companies that innovate like a tiny start-up and create whole, new categories, like Apple, simply didn’t. They all just doubled down on old tech and old ideas, an entire industry making iPad mini’s and calling it progress. The perceived danger of innovating and then having a revolutionary product found to lack “meaningful use” stifled the entire industry. Innovation in EMR was DOA.

And now? Now we have the largest medical institutions in the country abandoning their own efforts at software development and marching like lemmings to the Epic sea. The real-world analogy would be the government saying that you could create any type of gadget you could think of to listen to music, but you can only sell record players and vinyl albums on which you must listen to the songs in the exact order in which they appear on the disc to be assured that the check would clear. Oh, and the doc or nurse could only listen through noise-cancelling headphones that would need to be removed in order to talk to a patient.

It doesn’t have to be like this, of course. All it takes is one company with a little vision and some gumption to find a single big-name player with the courage to see that the status quo is sick. Sure, the vast governmental bureaucracy needs to fix a target and then get out of the way so that something that looks like a real consumer electronic product can emerge. That’s all, really. One product that feels like as “0f course” as the iPod, discovered and purchased by one person who folks watch like TechCrunch, a dispassionate and largely uninterested government standing to the side, idle.

A 7″ computer that could power my company 7 years ago hits the market to a collective yawn? Is it really so much to ask for this type of innovation in EMR?

I have been pretty generous in sharing my thoughts about some of the ills of our American Healthcare system, especially with regard to the barriers erected between physicians and patients. I find the various proposals now before our legislative bodies in Washington to be rather curious, even offensive. Since when does the United States of America adopt wholesale an economic solution from another country? Especially another country that is in some way otherwise riding the considerable coattails of the U.S. economy?

The “baby with the bathwater” approach in the halls of our Capitol and the editorial offices of our leading media outlets (WSJ excepted) is about as wrong-headed as you can get.  What we need is an AMERICAN solution to the challenges that we presently face with the economics of healthcare in the U.S., using our present system as the foundation.

Not surprisingly, I have some thoughts!

1) Malpractice tort reform. See my thoughts in “Tort Reform = Healthcare Reform”. Effective reform will dramatically reduce the scourge of defensive medicine with its attendant costs and risks to patients. Defensive medicine represents 15-25% of all medical costs in the U.S. That’s 15-25% of $2.5 Trillion. Do the math. While we’re at it, how is it good for the country to allow the tort bar to advertise for cases? Rake the muck in the hopes of unearthing errors or imagined?

2) Tax Reform #1: Remove the tax deduction for employer-offered health insurance. Provide a 100% TAX CREDIT to the lowest 60% of wage earners for the purchase of health insurance. Provide a progressive TAX DEDUCTION for the upper 40% of wage earners.

Tax Reform #2: Remove the tax deduction for advertising as a business expense for Hospitals. If we are concerned about unnecessary increased utilization of medical resources why are we allowing advertising by hospitals? For that matter, remove the tax-exempt status of any hospital or  provider that advertises. How is it appropriate to allow a hospital system to advertise to increase revenue, deduct that advertising as an expense, and still be not-for-profit? If it looks like a for-profit business, acts like a for-profit business, and sounds like a for-profit business, tax it like a for-profit business.

3) Insurance Reform #1: Reverse all of the for-profit conversions of previously not-for-profit health insurance companies. Who was the genius who thought THIS was a good idea? I don’t remember insurance premium increase that were quite so massive when all of the Blue Cross/Blue Shield plans were not-for-profit, do you? And while there were $Million execs in the non-profits I don’t recall any $10, $20, or $100 Million execs. Removing the need to answer to the stock market will create companies that will compete quite nicely with the for-profit companies without the horror of a government run system. Let the equivalent of NGO’s compete with the United Healthcares of the world.

Insurance Reform #2: Remove state-level coverage mandates and create a minimum federal set of mandates for comprehensive insurance policies. A REAL minimum. REAL medically necessary items. No Viagra or artificial  insemination coverage. Allow cross-state competition for the business. Real competition always drives prices lower.

Insurance Reform #3: Allow insurance companies (Medicare and Medicaid included) to discriminate IN FAVOR OF people who make healthy lifestyle choices (eg. no nicotine, no DUI, etc.). We are all so afraid of the stick that we refuse to allow any use of the Carrot.

4) Freedom of Speech/Restraint of Trade Reform #1: Abolish, once again, direct-to-consumer pharmaceutical advertising. There was a quantum leap in the utilization of all sorts of medications immediately following the 1997 rulings that allowed DTC pharmaceutical marketing. If it is so obvious that our ever-increasing levels of spending on medical care is a threat to the very existence of our fair Union, then DTC drug marketing is a version of yelling “FIRE” in a crowded theater.

Freedom of Speech/Restraint of Trade Reform #2: Begin a return to the professionalism of yesterday by prohibiting all forms of advertising by, or for, physicians. The AMA gets a lot of criticism, most of it well-deserved in my opinion, but the court and FTC rulings that prohibited the AMA from censoring physicians who advertised was a seminal event in the de-professionalism of doctoring and medicine. Doctors and other medical advertising was, is, and always will be wrong. While we’re at it, do the same thing for the rest of the lawyers and the practice of law.

5) Public Health. Finally, and most importantly, go to the true root of whatever “Crisis” we may have here in the United States, be it a “Healthcare Crisis” or a “Healthcare Finance Crisis” or what have you. We as a people are not healthy; certainly not as healthy as we ought to be. We are not healthy because of some wrong-headed previous Public Health decisions (simple-carbohydrate based diets, abolition of school phys-ed programs, tort-fearing closures of playgrounds, etc.). We are not healthy because our ability to treat the diseases that result  from poor lifestyle choices (cigarette smoking, alcohol abuse, preventable accidents, etc.) is SO GOOD that we are able to keep more and  more unhealthy people alive longer and longer, paying ever more to do so along the way.

This is where true leadership can make a difference. Remember JFK and the President’s Council on Fitness? I do. 8 pull-ups in the fifth grade for me. Polio, measles, smallpox and whooping cough were once the leading killers of children in the U.S. but are now historical footnotes due to Public Health initiatives. (A pox on all the cretins advocating against childhood immunization).

We lead the world in per capita alcohol related accidents and deaths, losing young lives by the thousands each year. We have ever more increasing numbers of truly obese citizens who go on to suffer the diseases caused by that obesity, and we pay ever more for their diabetes, hypertension, strokes and heart attacks. These lifestyle choices are root causes for our increased expenditures on Healthcare, much more so than all of the targets of Beltway demagoguery like insurance company expense ratios and pharmaceutical company profit margins. A solution to this issue, more than all of numbers 1 through 4 combined or any other proposal yet floated, is the true crux of the solution to any “Crisis” we may be facing. Everything else is only there to buy time. Time to get healthy.

Pick a number; choose an age. 40. 50. 60. Anyone under that age gets “Well-care” or “Get Healthy Care” starting right now. Over that age they can have “sick care” only if they wish, but under that age if you try to be healthy you get rewarded.

There are no votes to be had in making Americans healthier. Nothing but hard work on every side of the equation. Who will stand up and do the hard work? Who will lead?

Who will have the guts to not only say that the Emperor is naked,  but also drunk and fat and puffing away our economy.