Medicare Payment Formula Finally Changed – Win or Loss?

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Congress passed a  law in 1977 linking Medicare payments for physician services to growth in the economy.  Because it failed to take into account inflation and other factors, Congress has had to act 17 times to prevents cuts to physician pay under the sustainable growth rate (SGR) formula. This year physicians were set to get a 21% pay cut this year. This created a lot of stress and uncertainty for physicians, and caused some physicians to stop accepting Medicare patients.

The Senate recently voted to repeal this formula, 92 to 8. The bill was already approved by the House, and now President Obama has signed the bill.

That sounds like a great triumph for physicians. Although this may prompt some to pull out their imaginary violins in mock sympathy, I’m not so sure it will turn out to be such a great deal for physicians, which actually only consumes 12% of the Medicare budget.

The bill freezes the current rates, then increases them 0.5% a year from 2016 to 2019. For 2020 through 2025 there is no increase, and from 2026 onwards it increases by 0.75% per year. That is far below the current rate of inflation, and there is no provision if inflation gets worse than the currently low rate. That effectively means a real loss every year into the indefinite future.

There is a provision to transition payments to reward physicians for quality, rather than quantity. That is good in theory, but we’ll have to see how that works out in practice. Quality healthcare is very difficult to measure, and there is a risk that quality will be defined based on what’s easy to measure, and that will lead to physicians and other healthcare providers to concentrate on what they are rewarded to do, and not what may be in patients’ best interest. I hope I’m wrong.

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Healthy Kitchens, Healthy Lives

 

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Dr. David Eisenberg with his son and daughter demonstrating healthy cooking.

I recently attended the 11th Healthy Kitchens, Healthy Lives Conference put on by the Harvard School of Public Health and the Culinary Institute of America. It was a literally delicious combination of lectures from physicians, dieticians,  chefs, and others.

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Chef Adam Busby of the Culinary Institute of America

There were 411 people registered for the course, coming from 35 states, and internationally from 29 countries. Including spouses, faculty, chefs, and exhibitors, more than 550 people attended. For those registered, 59% were physicians, 11% nutritionists, 5% nurses & nurse practitioners, 5% masters of public health, and 20% others (chefs, psychologists, physical therapists, exercise trainers, physician assistants). The majority of physicians were internal medicine and family medicine, but also pediatrics, OB/GYN, sports medicine, psychiatry, anesthesiology, cardiology, endocrinology, and surgical specialties. A diverse group, indeed.

We had lectures from top notch physicians, dieticians, chefs, and others. Many were book authors. I already made a couple of recipes from Suvir Saran autographed book.

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Dr. Eward Phillips talking about exercise.

They fed us well, with something like 350 different healthy dishes to try.

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We also had a hands on kitchen session, then ate our own cooking.

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Chef Thomas Wong

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Now the challenge is how to use all the information and get my patients to eat healthier. As a start, I’ve posted some healthy recipes on Pinterest.

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Patient Satisfaction / Physician Dissatisfaction

Have you received a survey after you visit your doctor? You may be surprised to learn that how you rate them may affect their pay, their mental health, and even possibly your health.

Surveys, as administered by Press Ganey, and the CG-CAHPS,  are questions regarding various aspects of the care patient’s receive. Although that may seem reasonable, besides potentially incentivizing bad medicine, it’s exaggerated because they only count “top box” scores. That means on a scale of 1 to 5, only the 5 scores count, so that getting a 4 is no different than getting a 1, and if the score is 0 to 10, then only a 9 or 10 count. The scores only count if you answer “Always,” except for the question, “Using any number from 0 to 10, where 0 is the worst provider possible and 10 is the best provider possible, what number would you use to rate this provider?.” In that case, only a 9 or 10 count.

I’m not sure how this rating system was developed, but I think it may have had roots in the hospitality business. A patient may stay with their doctor if they rate them as being good, as opposed to excellent, but if someone better comes along, they may change. So if if you want high customer loyalty, you want to aim for excellence. Thus from the point of view of the physician, or rather the point of view of the administrator who pays the physician, one should strive for the top box scores.

In practice it’s not so simple. Take the question, “In the last 12 months, when you phoned this provider’s office during regular office hours, how often did you get an answer to your medical question that same day?” The only one that counts is the answer “Always.” So imagine you call 5 minutes before close to ask if you need to get lab work done before your appointment next week. Chances are for such a non-urgent question, it won’t even get to the doctor to answer before the next day, assuming you didn’t call on a Friday, and the doctor is in the office that day. You be perfectly satisfied to get a call back the next day, but if you answered the question honestly, you’d mark “Usually,” which when scored, would be the same as if you marked “Never.”

Although customer satisfaction is important in the medical field, it’s not the only thing that counts. I’ve had patients leave my practice solely because I told them things they didn’t want to hear, such as they needed to stop smoking, cut back on alcohol, exercise more, and lose weight.  I try to do it compassionately and offer them help, but it doesn’t necessarily make patients want to give you a good score.

What’s makes the system worse, is that when comparing scores, it’s graded on a curve. By definition, no matter how good doctors are, there will always be some that are on the high end of the curve, and some on the low end. This in turn is used to save money by paying the people lower on the curve less.

Sochi TimesLook at the charts above. The one on the left represents 47 individuals who were rated on something, showing their percentile rank, ranging from zero to the 100th percentile. Clearly there is a wide range in how well they did.

What about the chart on the right? Those are the same individuals showing the time in seconds they spent completing the task. There is less than a one second difference between the top 12 people. There is less than a two second difference between the person at the 49th percentile, and the one at the 85th percentile. So it should be easy to move up the percentile ranking, shouldn’t it?

What do these graphs represent? The results of the 2014 Olympics Alpine Skiing Downhill Men’s Final in Sochi.

What’s the point? Percentile rankings are not a good measure of excellence when the differences are small. In the Olympics we care who is number one, but patients want excellent care, and don’t distinguish between different doctors or institutions if they need a magnifying glass to see the difference. We all have room to improve, but it’s demoralizing to be told one is in the 20th percentile. I’d much rather be told I was only 6 seconds behind the winner.

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January Resolutions

Ladybug_6D300This is the time of year people make New Year’s resolutions. Many goals get made repeatedly each year because it’s hard to sustain changes in habits to make progress in things like losing weight. People start off good, but a year is a long time.

If you are trying to lose weight, stop smoking, exercise regularly, or achieve some other goal that eludes you, try making a resolution to do those things for the month of January. It’s a lot easier to do something (or not do something) for a month, than to keep it up for 365 days.

At the end of the month the work you’ve done towards your goal may have almost turned it in to an ingrained habit, making it all the easier to make a resolution for February, an even shorter month.

With two months under your belt, you are well on your way. Happy New Year!

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When is DNR not DNR?

Montparnasse Cemetery viewed from Montparnasse Tower. Copyright 2013 Daniel Ginsberg

Montparnasse Cemetery viewed from Montparnasse Tower. Copyright 2013 Daniel Ginsberg

Patients are often encouraged to make wishes known with a living will or other instrument. If someone says they would not want resuscitation if their heart stopped, they are said to be DNR, as in Do Not Resuscitate, or more accurately DNAR, Do Not Attempt Resuscitation. Success rates one month after out of hospital cardiac arrests when CPR is performed are only about 4.9% to 9.2%.

In Washington State per a directive it often say,

“(a) If at any time I should be diagnosed in writing to be in a terminal condition by the attending physician, or in a permanent unconscious condition by two physicians, and where the application of life-sustaining treatment would serve only to artificially prolong the process of my dying, I direct that such treatment be withheld or withdrawn, and that I be permitted to die naturally. I understand by using this form that a terminal condition means an incurable and irreversible condition caused by injury, disease, or illness, that would within reasonable medical judgment cause death within a reasonable period of time in accordance with accepted medical standards, and where the application of life-sustaining treatment would serve only to prolong the process of dying. I further understand in using this form that a permanent unconscious condition means an incurable and irreversible condition in which I am medically assessed within reasonable medical judgment as having no reasonable probability of recovery from an irreversible coma or a persistent vegetative state.”

For many patients this is reasonable, but not for all. No one lives forever, but even a generally healthy 98-year-old does not have a terminal condition. Many of my older patients tell me they are DNR, but most are surprised when I tell them their health care directive says they would want to have CPR and get shocked with a defibrillator if their heart stopped, as they do not have a terminal condition.

I think this is probably a failure of lawyers drawing up the health care directive to modify the language to what makes sense for their clients. I’m not a lawyer, but they might add something like:

(b) If I attain the age of 80-years-old, then I do not want to have my life artificially prolonged, other than using medications, including intravenous medications, and oxygen. An exception is that if I’m undergoing a procedure and develop a cardiac rhythm not compatible with life, then I would approve of an immediate attempt at shocking my heart back into rhythm if the physician deems there is a reasonable chance of success.

Just because a lawyer inserts boilerplate language, does not mean it cannot be changed.

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FMLA Paperwork

I’m often asked to fill out FMLA paperwork, formally known as Certification of Health Care Provider for Employee’s Serious Health Condition (Family and Medical Leave Act). This is either because my patient is ill and they or a family member need to take time off work, or because my patient needs to take time off to care for a family member. Employers want the form as proof that the time taken off is legitimate, even though it is not paid time off.

The four page form is onerous to fill out. If you read the fine print you can see that the Department of Labor estimated it would take 20 minutes to fill out. That’s more time than I get to see a complex medical patient, and at most we charge $25, and often don’t get paid at all. It may be a service to patients, but most of the information requested is not needed, and is not the employer’s business. This task usually falls to primary care physicians. If it’s something we need to do, it should be as simple as possible and not waste our time filling out irrelevant information.

Below is a letter I sent as a suggestion to simplify the form to a single page (formatting of the form altered a little for web display). It has been over two years without a response. Continue reading

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Epic SmartPhrases

If you do not use the electronic medical record Epic Hyperspace, this article is probably of no interest to you.

I previously wrote that I have done a lot of customizations to Epic. In this post I’ll explain how I use SmartPhrases. These are text, ranging from one word, to multiple pages of material, generated by typing the name of the SmartPhrase, preceded by a period.

My approach is to be modular in creating SmartPhrases, as I’ll demonstrate below. I also don’t like to pull in information into my note, such as past history, labs, etc. as the information is already in Epic and it just clutters up the note (I do bring in much of the information for physicals because I think that’s the one time it’s useful to have everything in one note. If acting as a specialist and doing a consultation I might do the same.) Unless I’m doing a physical, which has its own scripts, my baseline script is .soap which looks like this: Continue reading

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How to Get Rich – A Guide for Pharmaceutical Companies

The Changling Ming Dynasty Tomb of the Yongle Emperor

The Changling Ming Dynasty Tomb of the Yongle Emperor – copyright 2012 Daniel Ginsberg Photography

Thanks to Congress, Medicare is not allowed to negotiate for the cost of medications. The bill was shepherded through by congressman Tauzin, the chairman of the House Energy and Commerce Committee that regulates the industry, who subsequently stepped down then took a job as the President and CEO of the Pharmaceutical Research and Manufacturers of America. This is a lobbyist group for pharmaceutical companies.

Here’s a suggestion to pharmaceutical companies; the next time you come out with a new first in class medication, for which there are no other medications that can be substituted, price it at 10 billion dollars a month. After the first prescription gets filled, it may move Congress to act, but by then you will be set and it won’t matter if you don’t sell another pill.

Posted in Business of Medicine, Medical Politics, Pharmaceuticals | Tagged , , , | 2 Comments

Quitting Smoking and Happiness

The FDA is proposing a new rule in regards to tobacco regulation. As detailed recently in the New York Times, the benefits of stopping smoking, such as less heart and lung disease, would need to be discounted 70%, making it that much harder to justify spending money on smoking cessation. It sounds like something inserted at the bequest of tobacco lobbyists. Tomorrow is the deadline to make a public comment. Here is what I submitted:

I think it’s a dire mistake to discount the economic and health benefits of stopping smoking because of the loss of enjoyment. Although smokers may get temporary enjoyment from smoking, they also get enjoyment from being healthy. Surely one gets more pleasure taking a walk in a park and living at home, than pushing an oxygen tank down a hall in a nursing home because of severe emphysema. Smokers die at a younger age than they otherwise would. What about the enjoyment their partners, children, and grandchildren lose when the smoker dies prematurely? Loss of enjoyment should not be part of the equation, unless it’s a negative number which would serve to magnify the cost smoking places on individuals and society.

Posted in Government, Legal, Medical Politics | Tagged , , , | 1 Comment

If Doctors Ran Their Practice Like The Airlines

Copyright: <a href='http://www.123rf.com/profile_itrace'>itrace / 123RF Stock Photo</a>Physicians could make so much more money if we could charge like the airline industry does.

Starting with appointments, there would be a surcharge for the most popular times. Last minute appointments are extra, on the theory that the patient would be willing to pay more if they are acutely ill. If we have a particularly light day, we might run a special and see patients at a discount. It goes without saying that when booking an appointment in advance, you’d would have to use your credit care to make a non-refundable deposit.

When you check in for your visit, it would cost $5 if you want to sit down while you wait. Magazines can be rented for $1 and there would be water bottles for sale if you’re thirsty. You can pay $7 for two hours of wi-fi to access the internet, or if you are sick or a hypochondriac and visit often, pay $10 per month for unlimited use.

If you’re one of those couples that book your appointments together, there will be a surcharge if you want to share the same room.

Just like it costs more for each piece of luggage you take on the plane, we would charge for each prescription we write. Medications that were more complicated to prescribe would have a surcharge. Want a form for work, to get out of jury duty or a parking permit? That will be extra.

When it comes time to undress for an exam, prepare to bring your own gown, or fork over $2.50 for the paper version. Don’t skimp paying 50 cents for the lubricant!

Do all these charges sound bad? Don’t worry. Hand washing is still complementary!

Posted in Business of Medicine, Medical Humor | Tagged , | 1 Comment