Ideal Medical Practices

Which path will we as professionals choose: the wallet or what's best for our patients?

I just read Atul Gawande's piece in the New Yorker.

Whom do we want in charge of managing the full complexity of medical care? We can turn to insurers (whether public or private), which have proved repeatedly that they can’t do it. Or we can turn to the local medical communities, which have proved that they can. But we have to choose someone—because, in much of the country, no one is in charge. And the result is the most wasteful and the least sustainable health-care system in the world.

As a profession we have a choice.  The choice between doing good and doing well is false.  I choose both.   I believe the ethical practice of medicine is ultimately consistent with doing well as a professional.

Health insurance policies at the moment force us to choose between doing good and doing well and this is wrong. I have to choose between working outside of insurance and delivering highly ethical health care to the few who can afford it or take the insurance company strictures that force the unethical practice of medicine.  This is wrong.  We need a better way.

Bested by Slovenia. I feel so inadequate.

Ok, so we all know how nightmarish it can be dealing with the health insurance industry (lest we forget - adding an average of $68,000 per doc per year just to medical practices' costs).

One piece that always makes me nuts is trying to find out if someone's insurance is active.  I call and wait on hold or I just wing it and sometimes fail to get paid.  [Of course it's just such a gas having to assume that about every 5th or 6th person has no health insurance given our willingness to ration care by income.]

"The new system enables healthcare providers to instantly and accurately check a patient's health insurance status and allows for health claims to be processed online."
This is from Slovenia.

Slovenia can do this and the US can't. 

Even though the US has a GDP 29,909% larger than Slovenia. 

Go figure.

Another PCP bites the dust

You've probably heard that there's a primary care shortage.  Maybe you've read or heard about the Physician's Foundation study describing the overwhelming number of PCPs who want out of this toxic environment.   We have people desperately searching for a PCP and we have good caring people forced out of the profession.

These statistics miss the very real pain and anguish of people who entered primary care to help people when they find the environment for primary care toxic to the ethical practice of medicine.  These voices need to be heard.

I'm asking people to post in the comments section below personal examples of primary care practitioners leaving primary care because they just can't stand the toxic environment any longer.

L Gordon Moore MD

Looking for stories on health care denied, delayed, or rationed by our current system

As a doc I've long had to deal with haphazard and arbitrary rationing in the US as people I am willing to help for free are then unable to get the meds I prescribe or tests I recommend.  I've dealt almost daily with insurance plan denials that keep my patients from getting needed care.  I - and more importantly my patients - have suffered maddening delays as we've jumped through administrative hoops.

On this blog we've had practitioners and doctors posting our side of this misery but the patients dis-served are the ones really suffering.  I want people to post comments about the rationing by denial, the delays by administrative craziness, the delays brought by all the hoops and challenges to getting the care you need.

We need to change this mess.  The status quo is too rotten to continue.  Change will only happen when the public outrage over this mess forces change in the hurtful and destructive policies that ration, deny, and delay care.

Please post your stories in the comments section below.
Thanks
L. Gordon Moore MD

Health insurance is dragging out the same old tired attacks on reform

Here we go again.  They show up at the table and talk about how ready they are to reform and as soon as your back is turned, look out for the knife.

Health care reform requires three legs:
 - people have access to care (coverage)
 - we change the way the money flows inside health care (payment reform)
 - we change the way health care works (health care re-design)

Right now we're in this horrible stalemate in which we can't deliver on more than the little bits of primary care due to the lack of willingness of the insurance industry to fund the full scope of work.  We could do so much more to meet the needs of our patients if we could afford really good information systems and work collaboratively across silos to coordinate and improve outcomes.

What's in the way of this work?  The companies with the money won't fund the work.
Worse than that, they keep us running around chasing down details to satisfy their clerks to the tune of $31Billion per year in extra costs to medical practices alone.

Want to talk about denying choice?  Let's talk about the insurance clerks who deny care, deny procedures, deny referrals, deny drugs?  The current insurance stranglehold is not a system of free choice.

Want to talk about rationing?  Let's talk about creating co-payment that are prohibitive and make it so hard that many people skip needed doses of medicine to make the pills 'last longer.'  How about denying access to certain doctors or procedures based on insurance company rules?  How about "Pre-existing conditions" not being covered?  How about "this is not a covered benefit?"  The current insurance stranglehold is rich with rationing.

Want to talk about a system that results in waits and delays?  Let's talk about patients being told that they can't start their cancer treatment until approved by an insurance clerk and then reviewed by an insurance medical director.  How about prior authorization requirements that take endless paperwork and tie medical practices and patients up in administrative knots.  The current insurance stranglehold is a system of intolerable waits and delays.

To imply that we now have a system in which ANY patient can get the care they need with FULL CHOICE and NO HASSLE and NO DELAYS is flatly untrue. 

Don't be fooled by the insurance industry propaganda - they have a clear objective to keep their stranglehold on the money and total control over our miserable system.

Read more by Paul Krugman on this issue.

Why Times Are Dark...

Yesterday, a patient of mine came in complaining of pain in her neck radiating to her right hand with intermittent numbness. She is also having pain in her lower back which shoots like a knife to her right big toe. The pain has been going on for the past year or two, but the patient is working 2 jobs to make ends meet and does not have the time to come in. She is a wonderful historian and would rather grin and bear the pain than take medication for it. Unfortunately, the pain has gotten bad enough that she cannot walk >100 feet without having to stop and she is now having difficulty sitting due to the resulting neck pain. Last year, she went through PT and Chiropractic care with little benefit. So I decided to get both an MRI of the cervical spine and of the lumbar spine.

That is when the insanity started. The patient has a PPO, but in Virginia all patients with this insurance who need an MRI have to have prior authorization. My nurse called the intake nurse. Thirty minutes of grilling later, the nurse denied the authorizations stating that my patient could not be in that bad of pain because I had not prescribed a narcotic for her. My nurse countered that the patient was having weakness, but this did not matter. So, upon their request, we faxed in the chart. Today, we got the call that I needed to do a peer to peer call with the insurance physician. I called and had to leave a message for the physician to call me back. When he called back, he reiterated that the patient had no objective signs in the note (the patient did have a normal exam when I saw her) and that he was suspect of any problems because she really had not been placed on strong pain medications yet. He also felt that if only we had an EMG showing the radiculopathy then it would be ok to get the MRI. After I protested a bit ("is it really standard of care to get a EMG before an MRI??"), he decided to compromise. "I tell you what, which area is hurting her the worst? What if I approved that MRI but not the other?" I was somewhat dumbfounded except to say, "How do the results of the Lumbar MRI translate to what is going on in the C-spine and vice versa. That makes no sense at all" He then got mad, told me that he would have to push this up to the Neurologist for final evaluation and would get back to me. Click, the conversation was over.

So here I sit, furious. There are so many things wrong with this one case, that I'm sure I will miss some, but let me try to itemize them. From the treating doctor's perspective:

1. The patient has a PPO and is paying a lot of money for this. That designation apparently means nothing any more.

2. Insurance companies place prior auths as roadblocks to care to decrease costs. The problem is that they have no data as to who is ordering inappropriate MRIs or too many MRIs, so they penalize everyone. No one at this insurance company can tell me whether I am an overutilizer or an underutilizer of the MRI scanner (I would be surprised if I order more than 2/month).

3. The process of attempting to getthe prior auth wasted 40 minutes of my nurse's time and 10 minutes of my time not including the time it takes to print and fax the patient's chart. This time is UNCOMPENSATED and serves only to save insurance companies money. It does not augment my relationship with my patient. It does not improve my ability to take care of my patient. It does not assist my patient in any way.
4. The frustrations of having to get prior authorizations make me reconsider whether to even order the test, which is indeed the purpose. But, when I begin to question my clinical judgment because of the roadblocks I might face, I subject myself to a higher risk of malpractice. So these useless procedural steps INCREASE my liability.
5. The clinical algorithms are flawed and inconsistently applied. Show me a clinical guideline which states patients should be on narcotics before an MRI can be obtained. Better yet, show me one which states patients should undergo an EMG first. There aren't any because that is not standard of care.
6. If the insurance doctor was willing to negotiate with me, then he has proven there is no clinical basis for his decision making. It is just about saving money. 
7. If I did not believe the tests were necessary, I would not have ordered them. Further, if a nurse or a physician who has never met the patient can diagnose and determine the appropriateness of therapy through the phone, then why am I even needed? Ironically, according to their own representative, this insurance company does not pay for phone call visits because their feeling is that it is impossible to diagnose and treat the patient outside the office.

So here is the real issue. My patient remains in pain because an administrator (physician or otherwise) has determined she is not worthy of the procedure. This decision will cost much more money in both the short and long term. Why? In the short term, I'll likely end up referring her to ortho, who will do X-rays, get the MRIs approved and maybe give her a few steroid injections before likely talking her in to surgery. In other words, her care now becomes fragmented, which will increase costs tremendously. And, because we learn from past experiences, my office will be more likely to refer other patients directly to specialists instead of ordering the appropriate diagnostic tests and waste untold amounts of time on the phone justifying our decisions. In the long term, these stupid administrative games sap the energy out of primary care continuing to kill the one area of medicine which has been shown to decrease costs.

Recapping, prior auths lead to no short term gains, no long term gains, a disruption of the doctor patient relationship, and a waste of the office's time all wrapped into a package which demeans the primary care doctor's judgment, increases his liability and encourages doctors to flee primary care like never before. Maybe the insurance executives share the same great insight as the financial sector executives. My fear is that if their vision continues, we will face the same nasty fate.

John Brady, MD, FAAFP

Looking For Hope In A Dark Time

A colleague of mine recently expressed his "crisis of faith" that he is becoming increasingly frustrated with the lack of real reform in the insurance industry. He feels they are all lip service, have no real interest in change, and is becoming increasingly convinced that it is impossible to work within the system to affect the change necessary to increase quality and save the Doctor-Patient Relationship. Here is my response to him (and now to everyone):

I should know this off the top of my head, but isn’t it Corinthians which is read at nearly every Christian wedding, “…above all else these three things remain—faith, hope, and love. And the greatest of these is love.” In a crisis of faith, when hope is no more, we need to step back and try and find the love which brought us here to begin with. Perhaps in capturing the essence of that initial passion, we can rekindle an ember of hope that things can/must get better, and if our collective embers get together, maybe the resultant fire will be noticed by someone who has the power to change the wind. We have a lot of embers burning all over the country. The question is how do we form our collective fire? What direction do we need to go? How do we get noticed? And just as importantly, how do we retain the values we set out with in the beginning while enjoying the journey along the way?

 

Maybe insurances are not willing to change—yet. But people are listening, and people (patients, doctors and businesses) want change. Insurance companies will change when forced to. The key is to have all our ducks in a row when they come knocking.

I have crises every time I think about insurances. They are the black holes for hope (or perhaps more aptly the dementors in the Harry Potter series). But that is why we have to keep even the smallest of embers burning and work tirelessly for change. If we don’t, things will not change, and everyone will suffer.

 

John Brady, MD, FAAFP

The Village Doctor

Why I'm in this for the long run

Anna Maria Izquierdo-Porrera MD PhD describes below how it is she is able to continue to practice in and build ideal medical practices supporting vulnerable populations in Maryland.

I was at a triple aim meeting last month and Don Berwick used a metaphor that resonated tremendously with me. Let me share it.

He and his wife a building a house in the forests of the Northeast that will ran with 2000 watts (the equivalent of a hair drier). They are very committed to the endeavor. They have people around them giving advice and designs but they are faced with tough decisions at every turn. They are investing time, money, energy and personal interest. At the end though they will have a model, they will have learned how to build a 2000 watt house and when the time is good and the political and social climate changes making a 2000 watt house the acceptable option he will be there to teach us how to build it.

This is what we are doing. We are learning how to build a 2000 watt house of medicine. We are learning how to provide spectacularly good care. We have choices before us but if we manage, when the political and social climate changes we will be there to teach them how to do it. We will be the proof it can be done.

Me, personally... I sleep very well at night knowing I am doing the right thing. It may not be very economically sound but in my book a good night sleep is priceless.

Never give up, never surrender!

Anna Maria

Coding Questions

I was on another list serve this am and someone asked how to code for immunizations. Having worked on doing this for the past 6 years, I was more than happy to help out. But, the larger issue here is why an obviously intelligent person cannot figure out how to get reimbursed for giving immunizations.

Medical coding is a game played between the doctor's office and the insurance company. The doctor's office wants to get paid for the service rendered and the insurance company wants to make sure the appropriate service was done. Initially, it kind of made sense to set things up this way. But now there are over 10,000 codes with millions of possible combinations, which has spawned multiple industries with coding classes and coding experts to "help doctors maximize their profits" and numerous software programs to "look for irregularities and deny claims." The codes also change every few years just to make it even more confusing. It is actually so complex and convoluted that most doctors do not understand how to do it even though it represents the way most of us get paid.

And yet, as we discuss how to save money in the medical system, this area remains the elephant in the room--an area of huge financial waste, an area of huge frustration for docs, and an area that does absolutely nothing to enhance the doctor-patient relationship. I know I long for the day I no longer have to help others figure out how to get paid for providing essential services.

John