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More COVID-19 Coronavirus Thoughts

Photo of crown — Christian IV’s crown in Rosenborg Castle in Copenhagen, Denmark.

Social distancing is strange when it hits home. The last time we had kids and grandkids over for dinner, about a month ago, we tended to hold back giving the usual hugs. Three people were in the medical profession and two lived 5 miles away from the nursing home in Kirkland that had the big outbreak. It was like an Agatha Christie whodunnit murder mystery and we were all suspects!

At work we’ve been careful to conserve supplies for quite a while, particularly to help out for the places that really need them.

When wearing a gown I couldn’t swipe my badge to log in and out of the computer as my badge was under the gown (if over then it risked touching the patient if I was examining them). I had to pull the reader to me. Face ID doesn’t work with a mask. Last month I saw a new patient, who happened to have a cold, so we both wore masks. Neither of us really saw what the other looked like. More recently most everyone wears masks.

I often check a patient’s throat when doing a routine exam, but would skip it if not really needed to avoid having to be relatively close while they may be actively exhaling in front of me. When I do a physical exam on men, I’d think twice about telling them to turn their head and cough!

We’ve quickly changed how we practice medicine. We try to screen patients to prevent potentially sick patients from coming in. It doesn’t always work. They may have already had an appointment to follow up on their diabetes, and not mentioned that they had a cough. A phone screener may have asked if they went to South Korea or Italy or had known exposure, but that doesn’t mean they didn’t have exposure to someone sick that has yet to be diagnosed, and more recently travel history no longer matters. I documented any personal protective equipment (PPE) I used (mask, mask with eye shield, gloves, gown). That way if I later find out my patient was infected, I could look at what protection I wore. Because of equipment shortages I could not wear everything for every patient I see.

I purchased scrubs for the first time a few weeks ago. When I worked in the hospital many years ago, they provided them to us. Working in the clinic it was not considered acceptable attire for doctors. Because of the pandemic, administration authorized us to wear them. When I would get home, they would go straight to the washing machine, and I would head to the shower as a decontamination routine. We never made so much use of our LG Sidekick pedestal washer!

We’re heading towards doing telemedicine in a much bigger way. That protects our patients from being exposed coming in, and it protects health care workers, and other patients, from being exposed to sick patients. Various legal restrictions and how we are reimbursed has limited this, but now the government as temporarily removed many

restrictions and the government and private insurances are starting to pay for virtual healthcare. I was 17 minutes late the first time I did a case by phone. I was waiting for my nurse to check her in before I realized that I was supposed to call her! I also quickly realized that I needed to use my speaker phone as I could not type efficiently holding the phone with one hand. I’m now set up to do video visits from work or home, but it has been a challenge for many patients. The easiest way is to use a smart phone (iPhone or Android) and download the Epic MyChart app as we use Epic as our electronic medical record
(EMR). Then we can connect on our end using the Haiku app and have a secure video conference call. But some patients don’t have smart phones, and for those that do they often don’t understand that they need to download the app, and that there are a few steps they have to do on their end to actually connect. Some try to connect through MyChart on a browser, but that often doesn’t work. A couple of people couldn’t download the app because they didn’t remember their password for the app store. Another video app we’ve used, that is preferred by our legal department, is less intuitive and I’ve only been successful with it a few times. Occasionally we run into bandwidth issues and sound or video quality is not good. I’m not sure where the problem is, but I suspect it’s on the patient end as I’m connecting to a fast internet and Wi-Fi. When it works, though, it’s generally a good experience for patients and myself. Patients can show me a rash or swollen ankle. For both sides of a video conference, it’s helpful to have a good light source from the front. If it’s from the back one’s face is in the shadows. Try just using the rearview camera to get an idea of what you’ll look like (and what’s behind you!) beforehand. Although I think visits in person tend to be best, it’s certainly safer doing it virtually. Patients appreciate that, as well as the convenience.

People generally know that this pandemic has been hard on healthcare workers. What many people probably don’t realize is that in a healthcare organization a lot of others play important supporting rolls. As I serve on an informatics committee and am a Physician Builder, I’ve had a chance to see some of what’s going on. To place an order for a brand- new test, for example, some analyst had to build the functionality into our electronic medical record. There are many new workflows that were needed, including for telemedicine, and in the beginning the analysts were told we needed them yesterday.

Once a week I work with a family medicine resident to teach them geriatric medicine. I spoke with one last month that I wasn’t sure what was going to happen with her rotation since both I and my colleague were moving towards stopping seeing patients in the clinic. After she spoke with one of the faculty, they suggested she observe me doing telemedicine as I have a reputation for being good with computers. But how could I have her watch yet keep the recommended 6 feet of social distance? I did a test where I chatted with her over one of the apps and I was able to share the screen but then she went on vacation. I’m still trying to figure out a way that I can have a resident remotely do a video chat with the patient and myself. Not all the software we are using allows group video chats. Plus, I want it to be meaningful education for the residents.

I think this experience has brought increased camaraderie among doctors and others in healthcare, like serving together during war. Fortunately we have had less cases than expected in Washington so far, and we’ve not faced dire circumstances in my clinic.

Although it’s unpleasant to consider, on the plus side, this has finally got me to stop procrastinating and pushed me to get my estate plan and medical directive done.

Wasting Resources – A Day in the Life of Yours Truly

I’ve written before about some of the things that waste physicians time, and how trying to be a good steward of resources can be frustrating. As the saying goes, no good deed goes unpunished. So here are three such things I dealt with the day after April Fool’s Day.

I prescribed the diabetic medication alogliptin, the generic of Nesina, for one of my patients on a Medicare Advantage plan. I was told it wasn’t covered, but they would cover substitutes, including Januvia (sitagliptin). The cash price is a little over 4 times as much for Januvia! I don’t mind using Januvia from an efficacy point of view, but it was a waste of my time having to make the change, and tax payers are wasting money buying a more expensive drug. After any negotiated deals it may not be 4 times as expensive for the plan, but it’s hard to imagine it would be a cheaper option than what I prescribed.

I ordered a head MRI for one of my patients. A week ago I called Molina insurance after receiving a message that they required a peer to peer phone conversation with another physician. After 10 minutes on hold I left a message explaining why I had ordered the MRI (which I had already explained in my note and on the MRI request). As they still hadn’t approved it, I called back again today. I spent 3 minutes on hold, then 8 minutes talking to a staff member before she transferred me to a physician, then 3 minutes with him as he gathered the basic information then approved it. I did not give him any more information than I had provided in the first place. He said he didn’t have any information on why I had ordered the test or he would have approved it right away.

And the third thing? I can’t remember. No fooling!

As If I Have Nothing Better To Do

Ask most primary care physicians and they will probably tell you they waste a lot of time getting medications approved for their patients. I just dealt with this for one of my patients. He had been on it for four years, but they wanted some information from me. It seems they didn’t trust my judgement and wanted recent lab work to confirm he wasn’t taking too much, even though I had him on the lowest dose. The patient has insurance with Regence, and OptumRx manages the prescription benefit.

I called OptumRx and they first asked if I was a member or calling from a provider’s office. Well if they had separate numbers for each they wouldn’t have to waste time asking that question. Next they asked for my name and title. Then they asked for my NPI number. Once I gave it to them they looked up my name, so they could have skipped the question of my name and merely confirmed it after they had obtained it from the NPI number. Actually they should have already had my NPI number as it was attached to the prescription, that they paid for, and I’m sure is in their records already as they get that information when physicians apply to see (and bill) their patients.

Next they asked for the patient’s member ID number. I told them I didn’t have it, but I did have the reference number they gave when they asked for me to call. I was told they couldn’t use that information, so they asked for the patient’s name and date of birth. I gave it but the person couldn’t find the patient in their system. So she then asked for that reference number. After a while she said that patient wasn’t in the group she managed and she would have to pass me on to someone else.

The next person again asked some identifying information then wanted to know a test result the patient had, as well as the normal range for that test. I gave the three numbers and she said they would be in contact. Less than 30 minutes later it was approved, but that whole call took 9 minutes! That’s an incredible waste of my time just to give 3 numbers. They could have just asked my nurse to give the lab results to them over the phone or fax it to them and not have wasted my time at all. Besides the time I spent, there was also the time spent by a couple of staff members to get the message to me, and the subsequent fax confirming that it had been approved. We deal with lots of these things every day. If physicians were their paying customers, they’d be out of business with service like that.

Trump the Bureaucracy

About 6 weeks ago I referred a patient of mine with a knee problem to an orthopedic surgeon in my group. He ended up seeing someone else in the same group about 3 1/2 weeks later, and the doctor prescribed a knee brace.

A few days ago my patient said his insurance company wanted me to do a new referral, because I had referred him to a different physician than the one he ended up seeing. Even worse, he still did not have the brace because they required his primary care physician (that’s me) to write them a letter saying the brace was necessary.

I did write a letter saying that I’m not qualified to say whether or not the brace is necessary, and that if they wouldn’t approve it, then their medical director should contact the orthopedic surgeon to explain why not.

Physicians have far better things to do with their time than waste it on unnecessary paperwork. If we could only channel our collective anger and frustration with the system, as Donald Trump has been doing in the realm of politics, maybe we could spend more of our time treating patients, rather than placating the government and insurance companies.

A High Tech Call Schedule

Typical of many physicians, I have to take turns being on call. This mostly involves taking calls in the evening, at night, and on weekends for my patients, or those in my call group. I belong in a group with 6 other internal medicine doctors. We no longer have to go to the hospital to admit patients, since that is now done by dedicated hospitalists, but may answer calls about patients in our practice that show up in the emergency room, or are in a nursing home and having issues, or have significantly abnormal laboratory results that come back after hours.

My group takes call a week at a time, and the schedule is made each December for the following year. Each person in the call group submits a list of days they do not want to be on call, and the person making the schedule does their best to accommodate everyone. If someone needed to make subsequent changes, they would need to check the schedule and try and find someone to switch, or others would take their call in the event of a personal or family emergency. The call schedule was 12 pages of a printed calendar with the call person written for each day.

Last year the person making our schedules retired and I took over the duty, with the agreement that the schedule would be computer based. I created a Google Calendar, for the call schedule. I assigned each person their own color and created the schedule, after working it out on paper first to make sure I accommodated preferences, made the schedule as fair as possible in terms of amount of call and holiday coverage, and trying to spread out call.

I sent out invitations through Google Calendar. Now everyone in the call group can see their schedule on their computer. They can also use an app on their phone, as shown below. If changes need to be made to the schedule they notify me or our office administrator to make changes to the calendar. Everyone in the group then automatically gets the updated version if they check their calendar.

Recently I added a new twist. Having purchased the Amazon Echo, I added my Google Calendar to the app. Now I can ask Alexa what’s on my schedule, and she will read who is on call!

Medicare Payment Formula Finally Changed – Win or Loss?

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.

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.

Look 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.

How to Get Rich – A Guide for Pharmaceutical Companies

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.

If Doctors Ran Their Practice Like The Airlines

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!

Making the Affordable Care Act Individual Mandate Work

The Supreme Court has ruled that most of the Affordable Care Act, aka Obamacare, is constitutional.

In order to provide affordable care to all, insurance companies need the healthy to pay premiums, and not just the people who will use a lot of health care resources. In order to try and ensure this, Congress gave a penalty for those who don’t purchase an insurance plan. The problem is that the penalty is far less than the cost of insurance, and the only way they can even force you to pay is if you are getting a tax refund, in which case they can deduct the fine. So someone could elect to go without insurance, and, whether or not they pay the fine, just sign up if they need it. If enough people did that, the plan would not be sustainable. The penalty is $695, and up to $2085/year or 2.5% of income for a family, though it’s lower the first two years. A healthy individual might decide $695/year for no insurance is a better deal than $2000/year for insurance they don’t think they need.

So I propose a solution. Congress could pass a law saying that if someone does not get and maintain insurance within 1 year of when it becomes mandatory, and if they elect to get it later, they will be responsible for the first $10,000 or so expenses they sustain within the next 3 months of applying for insurance. If they get in a major accident or discover a lump that turns out to be cancer, they will still be able to get care and not be burdened with medical expenses that could easily far exceed $10,000. But for those considering going without insurance, even that would be a tough bill to pay.

Of course even now people go without insurance because they feel they can’t afford it. Although that could still apply after the Affordable Care Act goes into effect, the calculations change. Just as a poker player will adjust their bet depending on the size of the pot, I believe consumers would do the same. Instead of a cost of $2000/year versus $0, it would be $2000 versus $695, for example. Thus the cost of going without insurance in this example would drop from $2000 down to $1305 after paying the penalty (or tax, depending on your point of view). Balancing the benefits of having insurance and the risks of not having it, I think more people would elect to get insured with this plan.

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