Ideal Medical Practices

Letter to the Editor - ethical case for health reform now

Today, my local newspaper posted an editorial about why we should delay health care reform for at least another year. Here is my response:

To the Editor:

The four pillars of medical ethics are beneficence (provide good care), non-maleficence (do no harm), respect for autonomy and social justice. While the first two seem to get a lot of attention in medical schools and the press, the last two, and particularly the pillar of social justice, are rarely mentioned. Estimates are that each year nearly 20,000 Americans die from not being able to have access to health care. Health care costs are the number one cause for personal bankruptcy and are therefore the most common factor in keeping people in poverty.  Every passing day pushes more citizens into financial crises and forces more to silently but tragically die an unnecessary death.

Every passing day also allows those who reap financial treasure through the status quo to continue to pump fear and doubt into anyone who will listen. Their tactic, which has worked quite well over the past five decades of inaction, seems to be working again as support for health care reform has started to wane even though no alternative legislation has been suggested. The longer health care reform is put off, the less likely it will be to pass.  

So why rush to push reform through? We cannot and should not continue to wait for the perfect piece of healthcare legislation to magically appear when people are dying. Waiting turns our back on the pillar of social justice and is therefore simply unethical.

John Brady

Positive Deviants

Dr. Atul Gawande is quickly becoming my hero. Two weeks ago, I read his article in the New Yorker Magazine entitled "The Cost Conundrum" where he went to McAllen, Tx to figure out why healthcare there costs more than any other place in the country. By getting past all the stereotypical (and inaccurate) reasons people give for high medical costs, he delivers perhaps the most honest look at medical economics that I have ever read.

This week, Dr. Gawande is at it again. His current article is a print out of the commencement address he gave at the University of Chicago School of Medicine. In it, he states the solution to the health care crisis lies in finding "positive deviants." These are people and organizations who are doing what is right as opposed to doing what makes the most money. He believes that by following their example, the rest of health care can and will benefit. I love this idea because he is not saying we need to spend billions of dollars looking for a solution. He is saying that we have the solution right under our noses, we just have to look more to the fringe than the mainstream to find it.

Having spent the last 6 years of my life trying to figure out how to deliver great care to my patients despite the toxic insurance environment, I understand exactly what he is saying. Mainstream medicine is wrought with practices which have done a great job maximizing revenues from procedures and labs. But this has only served to increase overall costs while neither increasing life expectancy or the patient's quality of life (in fact, many times it decreases them). Financially, the temptation is constantly looming to jump into the fray and start offering more procedures even though ethically, offering these tests creates a dilemma of whether the decision to test is being done because of true evidence-based medical necessity or because it generates money. Despite this, there remains a staunch group of us on the fringe (in the ideal medical practice movement and otherwise) who continue to sacrifice in order to fight the honorable fight for our patients. I love the idea of being a positive deviant. I'm sure my patients love it too.

John Brady MD

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

Q: What are your plans for the PCMH? Another response

I plan to work on NCQA certification for a patient centered medical home very slowly.

I fear that by just saying “bah humbug” immediately gets me dismissed as someone not interested in moving family medicine forward, but if I were able to qualify as a Level 3 PCMH (and I think I can), then hopefully I can work from within the system to tell people the certification is ridiculous and will not result in a better or more efficient system. Why?:

1) A huge portion of the PCMH is database stuff—Do you have the EMR necessary to collect the data? Do you have protocols for how to handle the collected data? Do you have authorized personnel who can then translate the data to the patient and to the government?

My tangential question is “how many docs enjoy doing billing?” The answer is, of course, none. Why? It is a mind numbing, frustrating, infuriating process of data processing. So, how many docs will do their own data collecting? Well, none. So are we just creating an entirely new field of “chronic disease analyst” so we can then pay someone else the extra income we are making (if we make any) so the appropriate boxes will be checked? Well, yes. So how does having more people between the doctor and the patient strengthen the doctor-patient relationship and how does that impact a med student’s decision to choose family medicine as a career?

2) The PCMH criteria are skewed toward large practices—I have to write up protocols stating that I have written guidelines on how to treat diseases so all the providers (which would be me) follow the same guidelines. Umm, I hope that I am relatively consistent with how I treat my diabetics, but the protocols must be written anyway.

3) There is little evidence which shows incentive payments for data analysis actually improves outcomes. This is a little scary to talk about, but there was a study (Coleman et al., “The Impact of Pay for Performance on Diabetes Care in a Large Network of Community Health Centers”) which showed that P4P initiatives lead to increased testing, but that there was little impact on the results. In fact, overall HgbA1C went up showing that getting the data does not necessarily mean that data will impact the patient’s life resulting in better outcomes. Think about this for a moment. The entire argument for the patient centered medical home is that it will save money through providing superior care, but there is paltry evidence (that I have seen) which shows giving docs incentives to meet a laundry list of guidelines works. This is no surprise because data collection is not as important as a good relationship in instigating change.

 4) Does going through the process actually make a practice better? Not likely. Practices which are doing a good job will likely get certified but the process will not make them better. Poorly performing practices cannot get certified so they won’t try. Others will do what they need to do to get certified but will not change the way they practice. This is because changing behavior, even if it is dysfunctional, is very difficult (ask anyone on a diet).

I always go back to the most important question in such passionate discussions. Does what I am doing improve my relationship with my patient? Having looked through the certification process a fair amount, I do not believe getting certified will. And, if it does not improve that relationship, then it will not succeed in improving quality or stopping the failure of primary care to recruit new docs into the ranks. Unfortunately, my fear is that it is a potentially dangerous distraction at a critical time in our specialty--which is why we need to speak up now.

John Brady MD
Newport News VA

Am I a Healing Professional or Bill Collector?

About every 6 weeks or so I go through the onerous task of posting the Explanation of Benefits from the insurance companies, sorting through what patients owe, and packaging up and sending off the invoices. This process is painful to accomplish and therefore serves as a great force for my creative juices--should I rant about poor reimbursement, administrative trivia which results in rejection of claims (discussed so nicely in Megan's post), or perhaps the stupidity of a process which is so complex, three different entities have to be billed in order to collect one office visit charge? Those are valid and important topics, but during this round of billing, I became more aware of the constant struggle I have between being a healing professional and getting paid for being a healing professional.

When I first opened my office nearly 6 years ago, the average copay was $15 with the top end being $25. Now, even though the insurance allowable has not appreciably increased, the average copay is $25 with many people having high deductible plans and therefore having to pay 100% of the allowable. This trend not only represents a shift of cost from the employer (who pays the premium) to the patient (who pays the office visit) but also a shift in collections from the insurance company (who collects the premium) to the doctor's office (who collects the office charge).

Some people hail this trend as a good thing. After all, if patients know how expensive medical care is, they will be more apt to choose wisely when they need that care. Others feel in a capatalistic free market society, people speak with their money, and so the good docs will get paid because patients feel they are worth it. I disagree with both these theories. Shifting costs to the patient causes many of my patients to avoid coming in for routine (but important) follow up care, and I have plenty of patients who are truly grateful for the care I give but cannot afford to pay me--especially during the recent economic downturn.

The difficulty for me is that there are different forces at play. The first is the value placed on family physicians by our society. We incurred the cost (both in money and time) of medical school and residency. We take on the responsibility of the health of our patients and collectively the health of the nation. And yet, the end of primary care looms as medical students shun primary care for more lucrative specialties. Certainly, as a nation we have to come to grips with how and how much our primary care docs are compensated. But, we are also healing professionals and we know intrinsically that our patients' health are in many ways directly related to their financial situation. Should I send those going through difficult times to collections for not paying me the $50 they owe? Although it may be the correct business decision, it does not seem to jive with being a healing professional and it certainly does not augment the doctor-patient relationship (upon which everything in medicine should be based).

Some docs realize early on they do not have the stomach for the nasty job of collections and hire a collections agency or business manager to do it for them, but this does not solve these underlying conflicts, it just removes the doctor from the front lines. So I wonder, am I a healing professional or a bill collector? Can I wear both hats at the same time or does wearing one exclude me from the other? Will there finally come a day when I can focus only on healing? If so, that would be a glorious day for me and my patients.

John Brady

Newport News

The treadmill

"What do you do with the rest of your day? I mean if you only see 12 people a day, you must play a lot of golf." So asked one of my esteemed colleagues after I had completed a lecture on the Ideal Medical Practices concept. His question, dripping with the sarcasm of disbelief, took me by surprise. After all, I don't even play golf.

Docs get paid for quantity. The more patients seen in a day, the more money billed to insurances and the more collected. Perhaps because of this dysfunctional payment system or perhaps just because of some bizarre machismo drive, many docs take pride in the treadmill. I remember when I was a medical student and one chief resident passed the other and said, "See this face? This is a face that has slept 3 hours this week." It was a Thursday. In residency, the attendings would tell us how when they were residents, they worked 130 hours a week and fought over patients because they so wanted to learn. Intrinsic in these comments is that somehow those who sleep or have interests outside of medicine are somehow inferior or less committed. But I remember how terrible I felt after working 40 hours straight with no sleep. I know how poor the care was when I saw 63 patients in a single day at my previous practice. So when does the push for productivity become toxic?

I pondered this question again today as I took care of a patient dying of liver failure. She needs a transplant, but the next available appointment with the specialist at that hospital is in July. I looked to try and get her an appointment at a clinic closer to home, but even they are booked out over a month. How is it possible to not feel burned out if you know you are booked up for the next 5 months? How do you fit in the critically ill if your schedule is already full? If you do fit them in, how does that impact the other patients who you now cannot spend as much time with? When does the empathy wane and the apathy take over?

I have the breathing room in my office to try and coordinate the care of this unfortunate lady. I'm sure doing this will take hours and hours over the next few days and (hopefully) weeks. I will not collect any money doing this, but will have the satisfaction of knowing that I am doing what I can to help someone in need. I can only hope that I can find someone in the hospital system who also feels care should come before money and quality should come before quantity. Someone who can use their skills to assist this lady in ways I cannot. Unfortunately, with the system set up the way it is, the likelihood of finding that physician seems to be getting slimmer. Some days I wish I would have taken up golf...

John Brady MD

Newport News, VA

Concerns about the NCQA PCMH

I remain very concerned about the use of the NCQA PCMH guidelines as the measuring stick for quality. There are numerous reasons as to why that particular measurement will not likely improve quality:
1) It is primarily focused on database infrastructure. Although this is
nice and helpful, adding a computer system to a dysfunctional practice
will lead to a dysfunctional practice with a computer system--not a
medical home
2) 60% of primary care docs are in 1-5 doc practices with little time or
money for IT development. They can and should be encouraged to provide
great primary care, but they cannot afford to buy the robust systems
necessary to do all the functions put forward in the PCMH guidelines.
Further, is it right to expect a practice to shell out $100,000 or more
for a new system with simply a promise of potential reimbursement later?
3) By having much of the system set up for database analysis and process
improvement, are we simply creating another industry we get to argue
with? Ex. How many docs like to do their own billing? How many do you
think will like to do their own database analysis? If we don't do it
ourselves, it becomes increased overhead and another potential wedge
between the doctor and the patient.
Some truths we do know--The system is broken. Quality medical care is
rare to find. Docs are not rewarded for quality care. Quality in primary
care is measured (by the patients--who know) as access, efficiency,
continuity, good information and coordination. Anything which distracts
us from focusing on these things is likely not going to help. We also
know that docs whose practices are focused on quality will not likely
improve much by going through this process and those who don't care
probably won't understand/care.
I believe the PCMH designation is something which is well intended. I
believe it has some good things associated with it. But, it will not improve the doctor-patient relationship in most offices and therefore is not likely to save money or primary care. We have to begin looking for the real answer.

John Brady

Newport News, VA

Lunch with a Friend

Last week I had lunch with a friend. Then I listened to someone being interviewed on NPR. In a twisted kind of way, the two things got me thinking about primary care.

My friend is a family doctor in a large multispecialty practice. From the outside he appears happy. He has lots of patients, works hard, and is well compensated (compared to other primary care docs). He believes he is giving good care to his patients, but he is constantly running over an hour behind because he likes to make sure his patients get the education they need. His group is willing to listen to the individual providers and work with them to make things better, and he loves the collegiality of the larger system. But sadly, he feels like he has lost his calling. Although he readily admits he could forsee continuing on in this manner until retirement at age 65, he no longer feels passionate about what he does. Financial reimbursment insanities have forced the scope of his practice to narrow to a point where he is doing nothing but geriatrics. He likes geriatrics, but he longs for the generalist vision he initially fell in love with but feels he can no longer attain. After all, there is not enough time to do simple dermatologic procedures when a derm referral is readily available within the group. He has done hundreds of vasectomies, but cannot continue these because in our state, doing one/year pushes the malpractice premium to that of a urologist, so he cringes every time he sends one of these to the urologist down the road. He loves the idea of Family Medicine but admits that if a med student rotated with him, they would not choose family medicine as their calling. There is no more edge, no more variation. Everything has become somewhat vanilla with no spice.

Then I listened to an interview on NPR where an author was discussing her book. The interviewer asked if she was afraid of publishing her views knowing some religious groups would find them offensive. She stated something like she is a writer. She has to write. She cannot be worried about what others might think because if she did not write, she would cease to exist. (Ok, that was totally my take and not the actual transcript. Suffice it to say, her passion was palpable).

So, I could not help but wonder what happens to the passion of most primary care docs. We all had the passion of that author at one point. We all remember the first unusual diagnosis, the first procedures, the fear of leaving the shelter of residency, and the excitement of spreading our own wings and doing our own thing. During that time, we too were passionate. What happens? Do we become like dogs in our own Skinner Box being inundated by random insanities until we succumb to learned helplessness? If we told the author she could only write about noncontroversial topics, would she lose her passion and desire to be an accountant instead?

Life without passion is not something I am willing to resign myself to. I have to believe we can change the system so those of us who are passionate can continue to be so for years to come and those whose passion has been lost in the ashes can potentially be rekindled. Doing this is essential for our lives and the lives of our patients.

John Brady, MD, FAAFP

Newport News, VA