Thursday, June 26, 2014

Are we taking patient satisfaction too far?

"Patient satisfaction" has become quite the buzzword for us in the medical care field.  Of course we want our patients to be healthy, and if possible we would also like them to be happy.  However, sometimes the two are mutually exclusive, or at least mutually elusive.  Patient satisfaction is even starting to be factored into how we're paid- starting last year, Medicare started making incentive payments to hospitals based on how they did on surveys.  Some doctors are even having part of their salary based on how they score in surveys.

On the surface, this sounds like a pretty good idea, right?  If someone is satisfied, they must have gotten good care.

Not so fast.  Press-Ganey is the largest company involved in making patient satisfaction surveys.  But even they admit that the response rate on surveys is so low that it does not produce meaningful results.  Even more disturbing is that physicians who are a minority race are more likely to receive low scores.

And the worst part of this whole thing?  Patients who are more satisfied have worse outcomes.  They have more hospitalizations, more health care expenses, and a higher death rate!    If you think about it, it's easy to see why.  A patient wants a stress test, just to "make sure" his heart is OK.  It's not indicated, as he has no cardiac risk factors and no chest pain.  If he doesn't get it, he's unsatisfied.  If he does get it, he's happy.  But what if the stress test is positive?  Then he gets a cardiac catheterization- a procedure with definite risks.  The cath is normal.  So, now this patient has added at least $10,000 to the nation's health care tab.  He had a risky procedure.  Luckily, there was no permanent harm done.  The patient is satisfied, and thinks, "I'm so glad we made sure everything was okay!"  But in reality, he received bad, expensive, and risky medical care.

Anyway, this is what has triggered this little rant of mine.  It's an article on NPR written by an emergency physician, detailing a patient's experience.  In a nutshell, the patient had a heart attack at a restaurant.  He refused an ambulance and his wife drove him to the ER.  Once there, he received exemplary, fast care.  He had an EKG within 3 minutes, an immediate diagnosis of a heart attack and was taken to the cath lab.  In 22 minutes, the clogged artery in his heart was opened with a balloon a stent was placed.  The patient recovered perfectly- so perfectly, in fact, that he was back at work and exercising again in 2 weeks.

But the story doesn't end there.  The patient and his wife then lodged a complaint with the hospital that there was no communication and he didn't even know that he had a heart attack until his second day in the hospital.

Well.  I have to say that I find this pretty hard to believe.  The husband signed a consent.  Unfortunately, the anesthesia given can often cause amnesia for the events preceding it.  As for the wife, I would venture to say that given the panic of the situation her recall might not be that great.

In my experience, when I was doing hospital medicine, I would always introduce myself to patients.  I'd see them, examine them, and review the plan with them. And often, a few hours later, a nurse would page me and ask when I was coming to see the patient.  I'd already seen the patient, but they  thought that I was the nurse or a therapist, even though I had introduced myself.  Or they just forgot the visit all together.  A hospital is a disorienting place to be, and that can be made worse by medications and illness.

But let's say that in this particular case of the heart attack patient, the patient and his wife are correct.  The ER staff didn't explain to them what was happening.  They treated the disease only.  But was their sin so bad?  Seconds count in a heart attack.  Every second wasted is more dead heart muscle.  This story makes me wonder if we've gotten so used to the every day miracles that modern medicine performs that we have forgotten how things used to be.  Heart disease deaths in the United States peaked in 1968.  Since then, we've added 6.6 years of life expectancy, and 70% of this increase is due to a decrease in heart disease.  The estimate is that 1.7 million lives are saved in the USA annually that would otherwise be lost to heart disease.  1.7 million.

I'm sorry the patient and his wife were unhappy.  But, I have to say, I also think they are terribly ungrateful, and I'm more sorry for the doctors and nurses who had to deal with the inevitable fall out from the complaint.  They busted their butts and saved that patient's life, and for their amazing efforts they were called on the carpet.

For me, personally, if it comes down to a life-or-death situation, I want a doctor who can kick ass, not kiss ass.  Niceties and hand-holding be damned.

Friday, June 13, 2014

Well, I stand corrected.

I recently posted about the absurdity of the new ICD-10 coding system, which features various crucial codes, such as "bitten by orca" and "sucked into jet engine."  In my usual sarcastic manner, I pointed out how silly the level of detail of the coding system is.

Well, I stand corrected after reading this article today.  It appears that Harrison Ford was injured on the set of the new Star Wars film, when the hydraulic door of the Millennium Falcon starship fell on his ankle.  Poor guy.  He was airlifted to the hospital and is expected to do ok (and I must say that Harrison Ford is looking mighty good at 71).

But now we're left with a conundrum.  How should we code this encounter?  See, using ICD 9, I would code it as 928.21 (crush injury, ankle).  But now...there are so many choices!  How about... W23.0XXA (Caught, crushed or pinched between inanimate objects).  Oh, but wait.  That code excludes inanimate mechanical forces involving military or war operations, so that's out.  I mean, the is Han Solo we're talking about, and he's fighting the forces of the Empire.  So....Y36.101 (war operations involving destruction of an aircraft, civilian)?  Maybe...

Wait!  I've got it!  V95.40XA (unspecified spacecraft accident injuring occupant, initial encounter)!!!

Whew.  That was close.  Thank heavens for ICD-10!

Tuesday, June 3, 2014

Thanks to Marni's Army for a great season!

Marni's Army hit the road again this year.  Hard to believe it's our 10th anniversary!  Thanks to a fabulous group, I think we had our best year yet.  Everyone was so dedicated, and I'm so proud of the progress of all our runners and walkers.

Be sure to check out all the pictures at the Facebook group!

Friday, April 25, 2014

On my lack of psychic powers

Imagine, if you will, two scenes:

Scene 1



MECHANIC: Hi, this is Joe's Garage.  How can I help you?

MRS. JONES:  This is Mrs. Jones.  I've been bringing my car to you for several years for repairs. I last brought it in about a year ago.  Now it's making a horrible noise whenever I apply the brakes!  And sometimes the steering wheel does this crazy vibrating thing while I'm driving!  It's so bad sometimes I can barely hold onto it!

MECHANIC:  Wow.  I'm sorry to hear that.  It sounds like it might be serious.  Why don't you bring the car right over so we can check things out?

MRS. JONES:  No, I don't want to bring the car in.  Can't you just tell me how to fix it over the phone?

MECHANIC:  Errrr.  Well.  I'm not really sure what's wrong.  I have to drive the car and really take a good look at it to figure out the problem.

MRS. JONES:  Well, I really don't feel like paying to have you look at it.  It's so expensive!  You just saw the car a year ago, isn't that good enough?  I really feel like you're taking advantage of me.

MECHANIC:  I'm sorry, Mrs. Jones.  I'm not sure what to tell you.  I really need to see the car.

MRS. JONES:  This is ridiculous.  You just want my money. I'm just going to keep driving the car.  If it keeps making the funny noise I'll just turn up the radio volume.

MECHANIC:  Mrs. Jones, this could be serious!  It could be dangerous to drive the car!  You really need to get this checked out!!

MRS. JONES:  Well, you should have thought of that before you got so greedy.


Scene 2



NURSE:  Hi, this is Primary Care Associates!  How can I help you?

MRS. JONES:  Hi.  I have a really bad earache.  It's my left ear.  It's also really itchy.  Oh, and I can't hear out of it.

NURSE:  Wow. I'm sorry to hear you're not feeling well.  I can fit you in with the doctor this afternoon, OK?  Let me just get your name and date of birth.

MRS. JONES:  No, I don't want to come in.  Can't she just call something in over the phone? I use Rite Aid.

NURSE:  Well, I'm really sorry, but she's going to have to take a look at your ear to figure out what the problem is.

MRS. JONES:  I TOLD you what the problem is!  It hurts and it's itchy.  And I can't hear!

NURSE:  Right, but there are a lot of different things that can cause those symptoms.  We need to make a diagnosis in order to give the proper treatment.

MRS. JONES:  It's too expensive.  I have a $20 copay, you know.  I just saw the doctor 3 months ago for my high blood pressure.  Why would she have to see me again?  You know what, just forget it.  I'll take some ibuprofen.

NURSE:  Mrs. Jones, you should really get checked out!  If it's an infection it could lead to complications. We can get you in today!  Why don't you come on over?

MRS. JONES:  Well, you should have thought of that before you got so greedy.  I'm going to find a new doctor, one that cares about her patients more than money.


So, what's the difference between these two scenarios?  Both are patently absurd, right?

I have no experience as a mechanic, but my guess it that only one is likely to happen in real life.  Scenario number two happens to me frequently.  It doesn't always get as far as a patient firing me as a doctor, but it has occurred.  

I'm not trying to be greedy.  Really.  But I am trying to practice good medicine, and that includes a good history and physical exam.  The problem is that I attended the University of Rochester, not Hogwarts School of Witchcraft and Wizardry.  Therefore, I didn't take the class in Divination, which includes crystal ball gazing and predicting the future.  I also didn't take Occlumency, which involves mind-reading.  So, I'm stuck with the old-fashioned method of actually seeing a patient face-to-face and examining them.  Sorry.

I've said it before and I'll say it again- it's bad practice to treat someone over the phone.  Even the New Hampshire Board of Medicine agrees with me.    So, I'll continue to stick to my guns on this one.  If it costs me a few patients, so be it.

Wednesday, April 16, 2014

The Woo-O-Meter

There's a lot of garbage on the internet.  A lot.  My patients are constantly bringing in things that they print off the web that sound great- supplements, weight-loss drugs, cancer cures.  When you read it, it all sounds amazing.  I'm just grateful that they trust me enough to get my opinion before they go wasting money on many of these things.

The problem is that any idiot can write anything they want and get it out on the internet.  And once it's out there, it can get picked up and repeated again, and again and again...until what was once fiction starts to take on the veneer of fact.

It can be difficult to tell truth from fiction, or, as I like to say, true from woo.  What is woo?  I'm not really sure of the origins of the word, but most people think of it as pseudo-scientific thinking.  It's not just someone throwing out a line of bull.  It's bull that is cloaked in a shroud of scientific-sounding words and phrases.  This often makes it sound just plausible enough that you might fall for it.

Therefore, to help you all figure out True from Woo, I've created the Woo-O-Meter.  It takes 18 separate criteria and uses them to calculate a score of "True" or "Woo".  A few criteria might require some defining.  The "Quack Miranda Warning" is the standard disclaimer that claims have not been evaluated by the FDA and that the product is not intended to treat, prevent or diagnose any disease. Woo purveyors seem to think this gives them carte blanche to make all sorts of outlandish claims.  PubMed is a database of basically all published journal articles.  A link is provided in the table.  Impact factor is a measure of how prestigious a journal is (because there are a lot of journals out there that are crap and will publish anything).  The table has a link to a database of impact factors.

So, to use the Woo-O-Meter, all you need to do is find a questionable article/blog post/advertisement, plug the information into the table below, and read the meter!

Let's give it a try, shall we?

Check out this blog post.  The blog came to my attention because of some rather extreme anti-vaccine views the writer was expressing.  While reading more of her blog, I came across this post about curing ADD and bipolar disorder with essential oils.  It's a moving testimonial about a mother stopping her son's psychiatric meds and using essential oils instead.  Per her report, her son was completely cured.  The blog author then goes on to say this:
Wow! I love this testimony. I love that this sweet boy is happy and healthy and whole again. This testimony is what Young Living Essential oils are all about. Health and healing using God’s medicine!
One of the most effective approaches to treating ADD and ADHD – without drugs – is the use of pure, therapeutic-grade essential oils per a study conducted in 2001 by Dr. Terry Friedman that compared the effects of lavender, vetiver, and cedarwood essential oils in improving focus and learning in ADD and ADHD kids.
One of the oils Rebecca mentioned above is called Vetiver. Vetiver oil is psychologically grounding, calming, and stabilizing. One of the oils that is highest in sesquiterpenes, vetiver was studied by Dr. Terry Friedmann for improving children’s behavior.
“The American Medical Association Journal published a two year case study (1999-2001). Stating that Dr. Terry Friedmann M.D. found children who previously had been diagnosed with ADD/ADHD were administered therapeutic essential oils by inhalation that got noteworthy results. The essential oils used were Lavender, Cedarwood and Vetiver”
Dr. Friedmann found a 53% performance increase with Lavender, 83% performance increase with Cedarwood, and 100% performance increase with Vetiver.

I mean, wow.  That sounds pretty impressive, doesn't it?  I'm practically ready to go order some oils, and I don't even have ADD.

However, before we whip out our credit cards, let's fill out the Woo-O-Meter.  We're going to add points for mentioning Western Medicine and pharmaceuticals.  We also have to give a point for the Quack Miranda Warning, as it appears at the end of the blog post.  Of course, another point for using testimonial and for linking to a sales site.

Now, you'd think we could also add a point for the amazing sounding study.  However, no citation is given.  A quick search in PubMed confirms that no only does no such study exist in the Journal of the American Medical Association, but there are actually no studies at all published by a Dr. Terry Friedmann.

Our final Woo-O-Meter verdict is this:

And there you have it.  Something that sounded terrific, when looked at critically, is clearly woo.

So, please, don't allow yourself to be taken in by woo.  Feel free to use the Woo-O-Meter for yourself- the spreadsheet can be downloaded.  Share far and wide, and don't forget to think critically!

Wednesday, April 9, 2014

How Rich is Your Doctor?

Those damn rich doctors.  Bilking Medicare for billions a year.  Driving their Porsches and BMWs everywhere.  At least, that's what the New York Times and most media outlets would have you believe.

Today, to great fanfare, Center for Medicare Services (CMS) released the billing data of over 800,000 doctors.  This was done in the name of transparency.  Unfortunately, the data is anything but clear, helpful, or correct.

I looked up several doctors that I refer to.  There is no way their data is correct.  For example, one oncologist that I frequently refer patients to only had data for 10 patients.  I'd guess that I alone send her more than 10 Medicare patients a year.

I found my data somewhat depressing.  My reimbursement for an average visit with a Medicare patient is $47.  My reimbursement for a complex medicare patient is $73.  Those visits typically last about a half hour.  Keep in mind that that $73 has to cover my office's overhead, which runs...high.  Really high.  It also covers the work I and my staff do later on, like refilling meds over the phone, filling out the various forms that I'm always complaining about, reviewing lab and radiology results, consulting over the phone with other doctors...still think that doctors get paid too much?

Well, plenty of the commenters at the NY Times do.  What frightens me the most about the release of this data is that it is completely misunderstood.  For example:

What I learned about my opthamologist from this release is telling. That she alone in her practice of several was reimbursed close to $300K just for medicare reveals the tip of an iceberg. This is a small part of her practice, which suggests that her income is well into seven figures. While I’m all for her “right” to make as much money as you want, at what point does that become too much when it becomes an unreasonable burden on healthcare costs?

I recently switched to an ACA plan. I recently learned that this doctor’s practice is dropping two major insurers (including mine - all plans, not just ACA conforming.) I can only assume that the practice is gaming the system, pulling out to renegotiate compensation by these insurers, and in the meantime leaving their patients insured by these plans in the dark, not to mention in the lurch. All this for the sole sake of maintaining their very high compensation?

Many doctors have pulled out of ACA and Exchange plans altogether because the small percentage of patients seen under these plans have (relatively) low reimbursement rates. But, since this is fractional to their overall practices, they stand to lose little, if anything, considering some of these may be new patients.

Doctor’s carte blanche to opt out of these plans might well doom the independent insurance aspect of ACA altogether. Is it any wonder that the AMA was so staunchly opposed to the ACA?

Maybe I should bring a chicken to barter with on my next visit.
This commenter, like many, seems to think that her ophthalmologist actually was paid and got to keep  $300,000 from Medicare.  In fact, ophthalmologists have really taken a beating today.  However, one must keep in mind that most of these billings are for injections of Lucentis (I covered this in an earlier blog post).  The doctor has to buy the drug in advance, and actually only gets paid about 6% of the cost of the drug.  The rest of the money goes right out to the pharmaceutical company.  And that's before they even tackle their office overhead.

Then there's this one:

Medicine used to attract people who cared mostly about alleviating human suffering. The data has clearly shined the line on the lack of ethics among practicing physicians. Why the decline in ethics and medical ethics in particular? The profession's resistance to transparency, the false worship of technology, the lack of independent auditors to prevent or minimize fraud and waste, and the self-serving fee-for service practice. Can this nation ignore the threats of sickness-for-profit enterprises?
Ouch.  That hurt.

And this one:

I've been reading a number of responses here, allegedly from doctors themselves, that appear to care more about the billing and what they are paid per visit than patient outcome. (I'll bet they deal mostly with seniors too because the inevitable outcome is finite.) I have worked in the medical industry for years. This is a word of advice to all of the patients reading this column. The next time you go to your doctor, specialist or primary care, take a look at the car parked in the doctor's reserved spot n the parking lot, usually behind the office out of sight, then look at the doctor's trophies (photos, plaques, etc.) around his/her personal office. You'll be able to quickly determine what this doctor is really in the business for ego or patient outcome. You would not believe how many luxury cars and pictures of ski trips, fishing trips, etc. are out there.

These are the same providers who are also supporting the efforts to repeal the Affordable Care Act. Always follow the money trail. Those most fervently against reform are those profiting the most in the first place. 
Hmm.  Well, I don't have a reserved spot.  In fact, all of us who work in the building are told to park towards the back of the lot, so as to leave closer spots for patients.  I also don't ski.  Or fish. I seem to be doing everything wrong!

Now that we've thoroughly vilified physicians, I suggest we look at the bigger picture.  Payments to physicians were $77 billion.  Total Medicare expenditures were $600 billion.  That means the physician payments made up a measly 12% of total expenditures.  What about the other 88%?  Where is the transparency there?  Why have physicians been chosen as the scapegoat for out-of-control medical spending in this country?  If we want to have a true conversation about costs, lets look at the other culprits- pharmaceutical companies, medical supply companies, and hospital costs.

For the record- I drive a 2004 Honda with over 100,000 miles on it.

Thursday, April 3, 2014