Big Brother will be watching!
As I was driving home from the airport Wednesday morning I heard an enlightening interview on NPR, my default radio station.
Massachusetts, under then-governor and future Republican presidential candidate Mitt Romney, implemented the nation’s first full-court press toward insuring everybody. Now they’re having trouble paying for it. Imagine that! Who woulda thunk? So Congress is watching closely.
“The first thing they decided – unanimously and right off the bat – was that the current way of paying doctors, hospitals and other medical providers has got to go," reports Richard Knox. "… Massachusetts is going to try to kill off fee-for-service.”
Massachusetts policymakers want to replace it with "global payment" – paying groups of health care providers a flat yearly fee for each patient they cover. "Global means it's for all services," says Dr. Rick Lopez, chief physician executive of Atrius Health, one of Massachusetts' biggest doctor groups. "It includes when the patient comes in to see the physician, hospitalization, pharmacy, skilled nursing facilities, home care services – the whole spectrum."
Gee, that sounds a whole lot like “full capitation,” doesn’t it? That means they’re going back to “gatekeepers,” aren’t they? Remember how much fun that was? The calls in the middle of the night for permission to patronize the ER for belly pain? Patients questioning our integrity and commitment to them, rather than our income?
Ah, but this time it will be different! The problem in the 1990s was that there was no way to track, identify, prosecute and execute the bad apples in the primary care specialties. But now there IS a way! Read this carefully:
"To avoid a repeat of that experience, advocates of global payment say health providers will have to be watched closely. 'You need someone monitoring this,' says Nancy Kane of the Harvard School of Public Health. 'You can't just walk away because you've set the limit.' Kane is a health care finance expert who also served on the recent Massachusetts Payment Reform Commission. She says there are ways these days to prevent stinting on care. 'There's a lot of quality measuring that can go on now that didn't used to be available,' she says. 'We now have electronic medical records. It's easier to monitor what's going on. So I think the whole reporting system and the intention to maintain a monitoring infrastructure is all critical to avoiding the bad days of managed care.'"
Academics and bureaucrats love terms like “monitoring infrastructure.” That’s an Orwellian term for “Big Brother Is Watching You.” It sounds so easy, and so painless. But, of course, the Devil is in the details.
And, of course, there's the problem of the surgeon who examined my nurse for five minutes, sent me a three-page dictation, and charged for a top-dollar consultation physical. The system Massachusetts is heading toward will punish the honest, and reward the liars. Next step: Every encounter will be filmed by a hidden camera, and stored on government servers.
Until I heard the italicized comment above, I thought my friends in the blogosphere – who viewed the EMR as a plot by insurance companies to deny care – might be a bit paranoid. Mea culpa. They were right all along.
Dr. David Kibbe, who is as close as it comes to a guru in FP-IT, penned a great opinion piece in the latest Family Practice Management. He advocates plug-and-play modularity for components of the electronic medical record. Rather than a single vendor providing a comprehensive program at an extortionate price, with the separate elements always lagging the latest innovations in the marketplace, these elements should be disintegrated.
As Paul Nutting wrote in his initital assessment of the National Demonstration Project, “[I]t is possible and sometimes preferable to implement e-prescribing, local hospital system connection, evidence at the point of care, disease registries, and interactive Web portals without an EMR.”
To which I say, “Amen.”
Dr. Kibbe goes on to describe the ugly political state in which the Academy is trapped. (It essentially backed the wrong horse in the Derby, and now there's no winning ticket to cash.) Big vendors are fighting tooth-and-nail to slow the shift to plug-and-play modularity – that is, the same way you can buy separate applications, cheap, for your iPhone. They succeeded in getting the Feds, as part of their incentive program to adopt EMRs, to mandate comprehensive applications from single vendors.
This is an old, and familiar, political game. This is how we continued to subsidize tobacco farmers while we stigmatized tobacco users. This is how we continue to subsidize corn farmers while Americans are fattening on fructose-flavored soft drinks. This is why politicians should be banned from certain activities.
The fundamental problem, of course, is that we are led by politicians. They’re not bad people. They’re just different than those of us who would rather deal with chronic fatigue syndrome than collaborative back-scratching.
I suppose it’s my own fault – me, and tens of thousands like me. I never liked committee meetings. I liked patients. Mea culpa, mea maximal culpa.
Posted at 11:37AM Aug 27, 2009 by Doug Iliff | Comments[0]
Family (physician) values
I know I’m fakin’ it. I’m not really makin’ it. This feeling of fakin’ it – I still haven’t shaken it. – Simon and Garfunkel
Bill James is a world-renowned baseball analyst. After laboring for years in near-obscurity, his views are now near-gospel in many professional circles.
For four years we were contemporaries at the University of Kansas. He was the last Kansan drafted for the Vietnam War; my lottery number was 313, so I was safe. He went on to fame as a statistical genius; I passed on that internship at Sports Illustrated to attend med school.
C’est la vie. Look who gets to blog for Family Practice Management, Bill! Can you hear me now?
Bill once wrote, and no truer words have ever been writ: “One of the unwritten rules of economics is that it is impossible, truly impossible, to prevent the values of society from manifesting themselves in dollars and cents. This is, ultimately, the reasons why athletes are paid so much money.”
Allen Barra, writing in the Wall Street Journal, adds this: “It isn’t some vague indefinable ‘they’ who pays the players. It really isn’t even the owners. It’s you, or rather, it’s us. If we put our money where our mouths are and support cancer, AIDs or Down syndrome research and then buy our tickets with what’s left over, athletes and rock stars will actually be paid what we pretend they should be paid.
“The fault lies not in our All-Stars, but in ourselves.”
Barra is quoting the Bard, as I was on June 1. It all comes back to Shakespeare, and ourselves, in the end. Society gets what it deserves; doctors get what we deserve.
Since I’ve fallen into a rut of quotations, let's make it a little deeper by paraphrasing Lincoln: "Now we are engaged in a great civil war, testing whether that profession, or any profession so conceived and so dedicated, can long endure."
Week by week, we’re watching it play out in Washington. Will family medicine survive? We are met on a great battlefield of that war. It’s an ugly process. It’s unbelievably messy, and contentious. Winston Churchill said: "Democracy is the worst form of government, except for all those others."
For all its inconsistencies, sham, pretense, inefficiency and corruption, democracy always beats tyranny or oligarchy, just as free markets always beat central planning. Sometimes it takes a long time.
In the end, all you can control is what is under your own thumb. Society is going to get the health care it wants and deserves, and you are going to get the medical career you want and deserve.
Make no mistake: You are not a helpless pawn in an inscrutable system. Our situations are all different, but we have this in common: We are free moral agents, and our actions (but not our passions) will always have an effect.
Are you fakin’ it? Are you murmuring and complaining about the System, or the Man? Get off your keister, and make something happen!
Posted at 09:50AM Aug 18, 2009 by Doug Iliff | Comments[0]
How to manage media medicine
In a prescient letter to the Wall Street Journal, Homer Jack Moore, MD, responds to a previous article bemoaning the ignorance of the medical profession about fibromuscular dysphasia:
“Your report reminds me of yet one more reason why medical care in the U.S. is so vastly expensive with little extra gain in any actual outcomes. While the implication in this article that American doctors know little or nothing about this 'common' disease is terrific for newspaper circulation, it results in terrible practice of medicine. FMD was fully reviewed in the New England Journal of Medicine in 2004 (in a report co-authored by Dr. Jeffrey W. Olin, no less), and in multiple other medical journals since then. I know what it is. So do my colleagues.
“But never mind that. I can now full well expect a flood of anxious young women (and gentlemen, too, even though FMD is even more rare in men than women) in my office, being among them those afflicted with migraines, aches and pains, anxiety neurosis, depression and other of life's ills, who have all now become convinced that the doctor is a dolt; that indeed, all life's problems would have long been solved had just that right test been done. And they will demand, now, that these tests be done, paid for with other people's money, of course. And I, knowing full well that there is no particular advantage to even the smallest particle of risk of being at the wrong end of some lawyerly deposition inquiry, will give them exactly what they demand.
“Alas, the overwhelming majority of these people will still have only what they ever had: migraines, aches and pains, anxiety neurosis, depression and other of life's ills. But in the vanishing few that, lo, do turn out to have unsuspected FMD, my advice to them, for the most part, will be exactly the same as it ever was: Take an aspirin every day.”
Ever feel like Dr. Moore does? Me too.
I think, honestly, that medical writers are better than ever in my lifetime. Often I get tipped off to relevant scientific developments by reading their columns.
But then there are the cheap-shot artists just looking to make a buck. They start with a sob story, add a dash of factoids, and then bake into an epidemic. Usually an epidemic ignored by the medical establishment; something common. After all, a malady experienced by 1 out of 10,000 patients strikes 35,000 in America every year. Pretty common, right?
There are two ways to deal with this problem, to avoid wasting time playing whack-a-mole with patient questions.
My first effort, early in my career, was to browse the contents of magazines like Ladies Home Journal and Men’s Health in an attempt to stay abreast of the breaking misinformation. That didn’t last long. There was too much trash, and it was depressing.
Then I started my own information campaign. I wrote my own practice newsletter once a year – for an example, see the dig at Dr. Gott at the end of last year’s newsletter. When I read something egregious in the local newspaper, I wrote back for publication. When the Internet revolution came along, I steered patients to reliable sites.
Before too many years had passed, my patients viewed me as the authority to be reckoned with, not the hack in the magazine. I had gotten ahead of the information curve, at least in their minds. That doesn’t stop them from asking questions, but it does stop them from questioning my answers – most of the time.
Unless writing is excruciatingly painful for you, I think you will find this useful, and maybe fun. Start with the mini-lectures you give every day. We all have them. Why not write them down? Let your personality flow through.
One of the worst pieces of advice I got in medical school was to guard my ‘professionalism’ – which meant, act like a talking robot. Balderdash. We’re all unique, and the better patients get to know us, the better they’ll sort themselves into good matches with their primary physician.
The Academy has hundreds of patient information sheets available, but they’re pretty bland. Not bad, just safe and boring. The rule seems to be “don’t say anything that stands a remote chance of being misconstrued” – like they are written by a committee. And they often advise to consult your doctor for this, check with your doctor for that – for stuff, it seems to me, ordinary commonsense people usually handle without consultation, except maybe from Grandma. If I wanted to engender dependency, I’d become a Democrat.
Frankly, when I write an information sheet it is with the intention that they won’t consult their doctor. That’s how I get an uninterrupted night’s sleep.
Posted at 06:26AM Aug 07, 2009 by Doug Iliff | Comments[3]
