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Sunday, August 30, 2009

Computers and the medical record

Many of the elected officials who I respect--President Obama, our own Idaho congressman Walt Minnick, and anybody else appropriately fired up about health care reform--say that we will all be better off when the records of our blood tests, medical procedures and office visits are made accessible by computer. It sounds simple and beautiful. Two and a half years after starting to use such computerized medical record keeping system I have a few opinions about how good it is, and what it is really good for.

In a state of unrealistic optimism, many health care reform proponents are saying that electronic medical records will, when combined with Americans adopting healthier lifestyles, save enough money to pay for health care for the presently uninsured. Healthier lifestyles are indeed a money saver, but I'm not exactly sure what transformation is supposed to happen to make us eat less crap and stop smoking.

On the other hand, though, a computerized medical record is not a cost saving device.

Having records kept in a way that is readable, easily communicated, and coordinated with things like recommendations for preventive medicine does make patients' care better. Or it would, if doctors could learn how to use it. Some health care providers take to computers like seals to the ocean, and some find that it just doesn't suit their style. Some run screaming in the other direction. When we launched our computerized medical record keeping system, everyone reduced the number of patients they would see in a day by half, and even with that everyone in my office at some point became so frustrated and hopeless that they cried. After adjusting to the system, which took a year, (yes, a year) we no longer cry, but we still can't see as many patients in a day as we could when we were scrawling notes on paper, and phoning in orders for various things. Because of the stress of adjusting to the new system, several providers left our practice, which resulted in staff cutbacks, service cutbacks, and almost made our business fail.

Now, about 2 1/2 years later, we have recovered. We know how to use our system, and it only crashes occasionally. It helps me remember what I did last time, to know what other docs did at remote locations, to review results, and my notes are always legible. If someone wants a note produced I can do that pronto, and I have instant information about drug interactions, costs and medication allergies. I can ask questions, document answers, and not have to ask the same questions again.

But it's not cheaper. Because I can document all I have done conveniently, I can bill more successfully for what I do, but it all takes time, and so I see less patients and each one costs the insurer, or the individual, more. Overhead for us is probably a bit higher, because, although we no longer have to handle paper charts, we now have to pay many 10s of thousands of dollars yearly on tech support, after the hundreds of thousands of dollars that the software and hardware cost in the first place. The software is also, still, deeply flawed.

Electronic medical records really are the wave of the future. This particular progress is unavoidable, and in the end, a positive step. But, though it is better in so many ways, it is not going to save the billions of dollars that we need to save to balance our federal budget.

Do no harm

After finishing medical school, we all stood together in the big hall where we had been educated for 4 years, and took the hippocratic oath. The only part of the oath that I remember well is "primum, non nocere." Those words recognize that a doctor has the ability to harm as well as help, and needs to have the humility to recognize that.

Today in the New England Journal of Medicine, the most well regarded journal of research and practice for internists, an article appeared that referred to medical harm. I think it may be available to non subscribers at http://content.nejm.org/cgi/content/full/361/9/841. The author looks at the evidence of help and harm from radiological procedures that are done to prevent disease.

The number of CAT scans and heart imaging studies that are done is rapidly increasing, and yet there is no evidence these save lives or improve health in most instances. There are definitely times when they are helpful or appropriate, but most of them may be time and money wasted.

But waste is only part of the picture. Most imaging procedures expose people to radiation, and at this point, with the amount of tests people have been getting, about 2% of cancers may be attributable to radiation from CAT scans. The number of CAT scans performed has quadrupled since 1992, and when I look at the graph, there does not seem to be any evidence of this growth slowing. So the extra CAT scans done today will be responsible for an even larger percentage of cancers in future years.

It is hard to track the harm done by radiation exposure because it happens so many years after the actual procedure, which makes it difficult for doctors or patients to put the harm concept together with the test that's done "just to make sure everything's OK." In order to do no harm, we so strongly need good doctor and patient education about the reasons to do and not to do expensive testing, and more universal understanding that what we pay the big bucks for in medical care is not necessarily what makes us healthier.

Thursday, August 27, 2009

Why do doctors make so much money?

In the discussion of why American health care is so expensive, it is certainly necessary to entertain the question of why doctors salaries are as high as they are. The average American makes $38,000 a year, and the average primary care doctor makes around $150,000 a year. These numbers vary by geographical region, certainly, and the primary care doctors I talk to in my small Idaho town mostly make less than $100,000. But they certainly do command a higher salary than teachers or carpenters or most university professors at our esteemed and underpaid state university. So why is this?

To practice medicine, a doctor has to finish 4 years of university, 4 years of medical school and at least 3 years of residency as an MD in training. In order to get into medical school, they need to be in the top of their university classes, and have finished a set of premedical requirements that is heavy in science and math. Medical school is an order of magnitude harder than university. The first two years are spent trying to memorize a tremendous amount of information on anatomy, physiology, biochemistry and the myriad of diseases of the human body, along with their molecular mechanisms and present treatments. The second 2 years are spent intensively practicing medicine, usually in a hospital setting, under the close supervision of teaching doctors and residents in training. Medical school is long, hard and painful, and is essentially all consuming. After these 4 years an MD degree is awarded and the graduate starts residency. The residency years are paid, but at a lower rate than many jobs. In 1987, in my first year out of Johns Hopkins, I worked about 80 hours a week, was often up all night, caring for desperately sick and wildly complicated patients, and made about $18,000. That was the most money I had ever made in my life and I was very proud. But it wasn't even minimum wage, I don't think. After 3 years of this, the resident becomes a full fledged, employable, and usually indebted doctor. On average, a new doctor will have over $150,000 in educational debt.

So the freshly fledged doctor emerges, blinking, into the sunlight of the real world, with enough debt to have bought a house, exhausted, and jobless. The new job, once obtained, is hard. There are new systems to learn, the pace is faster than in training, and the new guy frequently will be given the extra work that nobody else wants. The hours are long, and many of them unpaid.

Now don't get me wrong. I have no cause to complain. I have the best job in the world and I love it. It was just really hard to get to this point, and I don't think that many qualified people would do it if the salary weren't good.

Wednesday, August 26, 2009

Cost shifting--is that why hospitals charge so much?

If health care costs go down significantly, as providers order less unnecessary tests, and as tests and procedures come down in price due to the incentives of actual competition (OK, I'm making a rather huge and optimistic assumption) hospitals will see less money coming into radiology departments and labs. When there are more primary care doctors available to see patients, and patients seek care earlier in the course of their illnesses, there will be less patients seen in emergency rooms, and hospitals will see that revenue go down.

Or will they?

If we truly get universal healthcare, the amount of uncompensated care that hospitals have to cover will be dramatically reduced or completely eliminated. Right now if an uninsured young man is brought into the emergency after a gunshot wound, that man will get top of the line trauma care, with specialists called in, multiple imaging procedures, needed surgery and medications, and the hospital will simply eat those costs. It is not clear to me how great of a loss of income hospitals will face if there is comprehensive and cost saving health care reform.

At this point our hospital runs in the black, though not far in the black. When I look at the hospitals charges for tests and procedures I see that they are significantly higher than I think they should be, comparing them to the same procedures done at doctors' offices or the same procedures a few years ago. But hospitals spend huge amounts of money on uncompensated care, or poorly compensated care, and high charges for tests and procedures are part of the income that offsets these losses.

For a health care reform solution that saves significant amounts of money to allow hospitals to survive, there must be universal health insurance, and that health insurance must adequately compensate hospitals for their services.

While everything is on the table, medicare and medicaid payments to providers (doctors and hospitals) needs to be on the table as well. I know these payments are barely adequate or inadequate to pay for a doctor's services in the office, and I expect they are also close to inadequate in their payments to hospitals. In order for patients who are insured with a publicly funded plan such as medicare or medicaid to be assured access to care these programs must pay providers for what they do.

Tuesday, August 25, 2009

Cost transparency--what's not to like?

Cost transparency, that is making sure that patients and providers know what everything costs at a time that is relevant for discussing options, is a great idea. The effects of sharing this kind of knowledge would be powerful. Cost could become part of conversations about what is the most appropriate care. A patient could ask if a particular $3000 test would really change their treatment, for instance. If everyone knew, up front, what things were supposed to cost, billing errors and fraud would be much easier to identify. And when things cost way too much, we could start asking why, and begin the process of making these costs competitive.

There are, however, some pretty serious obstacles to making this information available.

I would like a patient to know, before she even sits down with me, how much her visit will cost. Unfortunately, I don't know. The amount of time and complexity of the encounter, including office procedures that might have to happen, will unfold during the visit. Now the patient could have a sheet that gives costs for various things that might happen, but that, too, gets pretty complex. Here is an example. Just recently we raised our rates for office visits. Now a detailed office visit, which may take about 30 minutes and involve research or consultation with other doctors, carries a price tag of $160. That is the price that all insurance companies and uninsured patients see on their bill. Medicare will pay $86, Premera $127 and Blue Cross about $150. Depending on the patient's specific policy, they may have to pay a part of that as a copay, or even be billed for the difference. The uninsured are discounted according to whether they pay at the time of service, and sometimes, at the discretion of the provider, their financial situation.

For costs to be truly transparent, they must be presented in a way that just about anyone can understand, without requiring that person be computer savvy or able to sift through a packet of insurance materials.

Providers of medical goods and services could be required, at the time of service, to provide a list of costs of the most common items that they offer and provide information on costs for less common items quickly at a patient's request. Insurance companies could be required to produce an easily understandable list with information on how much they pay to be available to the patient at the time they received services. This information could be accessed online or by telephone by the provider's staff.

The trick with all of this is to make the information clear, relevant and to avoid adding a layer of complexity to an already complex system. Processes that require more time per patient inevitably make an office less efficient, and thus more expensive, which is exactly what we're trying not to do.

A single-payer health insurance system would make cost transparency a piece of cake, but maintaining truly independent health insurance companies does make the process more challenging.

Why isn't malpractice reform an issue for the democratic party?

Malpractice reform is not traditionally an issue that Democrats support. Why?

I think it is because democrats feel strongly that everyone, no matter how poor or disenfranchised, has a right to his or her day in court.

This is good: we are right to hold on to systems that allow people who have been wronged to be heard. But our tort system does not work in the case of medical injury and malpractice.

Most people with a medical injury never sue for malpractice. Most of their injuries are too small for a lawyer to take the case, and many of the injured don't want to enter into the complex and contentious world of the legal system.

Most cases that go to court are ones in which a person has a very bad and often expensive outcome, in which a lawyer could hope to get an amount of money worth his or her time. Most of these cases have no convincing level of negligence, and so there is no significant benefit for the injured party.

During the time that the case is being prepared, usually a number of years, the injured party must continue to be injured, and so has a powerful motivation not to get his or her life back on track, and not to heal up from whatever bad thing happened. The provider being sued is encouraged by the lawyer representing him or her to feel sure of how good and appropriate the care was, and thus not learn from any mistakes.

I have noticed that in my hospital when something bad happens to a patient, and there is no perceived risk of a malpractice suit being brought, that the whole medical community comes together with meetings and discussions to figure out just what happened, and what can be done to make it never happen again. They will organize educational opportunities, change protocols, talk to patients and families who were involved. If the event has a threat of malpractice, all discussion is hushed.

Doctors live in fear of being called into a malpractice case, which will use up countless hours of their productive life, and leads to bitterness and isolation. The vast majority of doctors will at some point be sued for malpractice, but that doesn't make it any easier on each individual, who is ashamed and shaken.

Bottom line--the malpractice system is horribly ill. It is damaging to everyone who comes in contact with it, and continuing to do it they way we do is a huge missed opportunity for improving health care and reducing unnecessary costs.

To fix the problem, in a way that is substantial and could really work, we need major changes. The whole process of taking care of medical injury and negligence could be taken out of the courts and placed in the hands of a board, consisting of physicians and lay people, with the ability to give no-fault compensation to the injured party, analyze and remedy whatever process led to the injury, and educate and punish, if appropriate, anyone who was negligent.

How to fix it

The problem:
Health care costs too much, insurance costs too much, and people are suffering because of money spent directly in bills or indirectly through taxes. Because of the cost of insurance and health care, too few people have access to it.
Scope of the problem:
Huge. Because of the lack of access, America’s indicators of overall health, including infant mortality and average age at death aren’t as good as most countries we consider our peers. Because of the cost, average Americans’ take-home salaries are significantly lower than they would be and federal and state governments are unable to afford other basic services such as education and other social services.
Causes of the problem:
1. Doctors practice medicine that is not cost effective because of worry about malpractice, and perceived patient expectation that costs are not a consideration where health is concerned.
2. The number of primary care physicians is shrinking because primary care physicians are not paid as well as medical specialists who do procedures. Doctors who do primary care try to do as many procedures as possible because they are paid better for them. Because they are paid poorly, primary care doctors have to see more patients, and so they spend less time with each patient. It takes more time in an appointment to discuss with the patient whether they actually need an expensive procedure or medicine than to simply order the procedure or medicine (examples: MRI or CT scans, x-rays, and antibiotics.) One MRI scan costs about as much as 50 office visits.
3. Even though insurance companies make it difficult for doctors to order tests or expensive medicines, the threat of malpractice is so great that we spend the time it takes to get authorization to do these things, and subsequently have even less time to spend with patients.
4. Almost no stakeholder, not patients or doctors, knows how much anything in medicine costs. The insurance rules and coverage are so complex that costs of procedures, medications, office visits or referrals are not known at the time they are prescribed so cost cannot even enter the equation.
5. Because billing is so complex, and insurance rules are so complex, certainly a huge amount of billing mistakes and fraud happen on a regular basis.
6. The staffs and administrations of insurance companies are very large and expensive and the billing departments of doctors’ offices have to be large and expensive to deal with them. The system is adversarial rather than cooperative and wastes a great deal of money.
7. Medical devices, procedures and medicines are too expensive because the risk of liability reduces competition. iPods have gotten cheaper and better in the last 5 years and MRIs and appendectomies have gotten more expensive.
8. Uninsured and low income patients don’t come in to see a primary care doctor because they can’t afford it. Instead, they get the most expensive kind of care, which is hospital based, when their preventable problems become emergencies.
Solutions:
1. Cost transparency: patients and doctors need to know what everything they do will cost ahead of time. Patients should know the cost of an office visit when they see the doctor and know what their portion of that cost would be. Doctors should know that as well. The same is true for surgeries, scans, lab tests, medications. This will not be practical in every situation. There will be emergencies and unexpected costs, but these things should be the exception not the rule. Doctors will find it much easier to practice cost effective medicine when they actually know what the costs are. This will require a significant change in the way insurance companies operate.
2. Tort reform: doctors practicing cost effective medicine need to be protected from being sued for being responsible about expenditures. Some level of tort reform on a federal level to prevent lawyers from benefiting from huge settlements will help get doctors to do what they already know how to do: take care of patients.
3. Pay adequately for primary care: it takes time and intelligence to counsel patients in such a way that they feel satisfied without unnecessary tests or medications. Surgical specialists will also be more likely to counsel patients rather that doing procedures if they are compensated adequately for the time spent counseling.
4. To alleviate the primary care shortage, consider a program to subsidize medical education for primary care doctors. High educational debt drives graduates into high compensation practices including specialty medicine and primary care in big cities.
5. Educate doctors in cost effective medicine. We are required by our malpractice carriers to take continuing education in risk reduction, and it would be simple to require a certain amount of time for learning about cost effective practice in order to qualify for updating our licenses. A large amount of research has already been done in the field of effective medicine and evidence based practice, such that there are clinical practice guidelines for many common diagnoses. Doctors know these exist, but are usually not familiar with them.
6. Provide adequate insurance to those who can’t afford it, based on the most effective and efficient models available. (Consider Medicare, Group Health, and other countries with good health indicators.)


Bad Ideas:
I have read many proposed solutions to the healthcare crisis, and a few have seemed particularly poorly conceived.
1. Across the board cuts in payments to doctors: if we make less money for each patient we see, we will have to see more patients in a day, and do more procedures in a day to pay off our educational debt, which will make health care less effective and more expensive. Costs for procedures and medical equipment may need to be cut, but that needs to be combined with some significant changes that allow it to be easier for us to do business. Doctors in the US do not make significantly more money, corrected for cost of living and average salary, than doctors in countries whose health care systems are more cost effective. In Moscow, Idaho, primary care physicians make about the same salary as a good accountant does. Medical education takes a minimum of 7 years postgraduate education and is very expensive and competitive. If the practice of medicine doesn’t offer a decent competitive salary, the people who are qualified to go into medicine will do something else, and physicians will leave their practices.
2. Requiring low income patients to shoulder more of their insurance and healthcare costs: In my experience, low income patients have no extra money to spend on insurance or co-pays and simply will not pay these bills. If there is a “public option” insurance offered by the government and patients on minimum wage are told they need to shoulder 15% of the costs and pay 20% of their medical bills, they will either remain uninsured or will fail to pay their portion of bills, and lose their access to their doctors for bad debt.


Monday, August 24, 2009

How to waste over $21,000 before lunch

Health care in the United States is too expensive, and because it is too expensive, a large number of Americans do not have access to it. The story that is not being told in the national debate about health care reform is what exactly costs too much, and how to remedy the situation. Unnecessary costs directly related to the practice of medicine are only a portion of the waste, but the magnitude of this kind of expenditure may be huge. Saving a fraction of this money could make it possible to give health care to everyone who needs it, withhitout any negative impact on our national budget.

The schedule below is a reasonable scenario of what happens in many primary care offices. The costs are inexact, but within range. The major causes for this waste are pretty easy to remediate: 1. primary care doctors don’t spend enough time with patients because they are underpaid for counseling. 2. Providers and patients don’t know what things cost. 3. Doctors are afraid of being sued for malpractice. 4. Our culture in medicine discourages considering costs in decisions about care.

This is my morning, as a primary care doctor in rural Idaho. It is not a real morning, but it could have been.

8AM—arrive at the hospital, perform two treadmill tests with nuclear imaging, ordered by physicians for patients at low risk, because of concern about malpractice should they have a heart attack. Each costs $3000, one unnecessary, the other of which could have been done without nuclear imaging at my office for $200.

9AM—see two patients at the hospital. One remains in the hospital because she can no longer live at home and can't afford to go to any of the extended care facilities that have openings, at a cost of $1000 for the day. The other is there because she wasn’t insured and waited too long to see a doctor for her migraine headache, costing $2500 for her MRI scan of the head and $1200 for her day’s stay at the hospital, and $600 emergency room fees.

9:45—get to the office late because the uninsured patient was news to me, so I didn’t plan on seeing her. See my first patient who has a physical scheduled. She wants “a complete lab workup” even though all of her labs were normal last year and nothing has changed, because her insurance will cover it. She has been having back pain. Since I don’t have time to talk to her about the natural history of back pain I order an MRI scan and physical therapy. Labs: $120, MRI$2500, 8 physical therapy appointments $1000.

10:30—next patient has numbness in his fingers when he is anxious. He can’t afford counseling and I don’t have time to discuss relaxation techniques with him so I refer him to a neurologist. He will see the neurologist 3 times, at a cost of $150 per visit, and she will order a head MRI scan for $2500.

10: 45—next patient has a cough and a stuffy nose for 4 days. I think it is viral, but she is sure she needs antibiotics. I don’t have time to explain the side effects and futility of antibiotics so I prescribe an antibiotic. She says the generic doesn’t work. Cost is $120 for that and $200 for an inhaler which is what I think will work, though if she just waited she wouldn’t need that. Because she smokes and I am worried about being sued, I order a chest ex-ray. That is another $200.

11:00—patient comes in for followup on his diabetes. He has been in poor control, but since I don’t have time to counsel him on diet and exercise in a way that will probably have an impact, I prescribe a new medication. He is already on generic pills, so I have to prescribe insulin, and because time is an issue, I use the newest insulin delivery system which is easier to explain. This costs $150 and doesn’t make him any happier, plus his risk for complications is just as high because he will continue to gain weight.

11:15—the next patient comes in for followup of an abdominal CAT I ordered because I didn’t have enough time to counsel the patient on how to avoid constipation. The CAT discovered a cyst on his kidney and a nodule on his adrenal gland. He is beside himself with worry, even though both of these things are usually normal findings. I reassure him that I will get a followup CAT scan to make sure they are normal, which will use a better technique and cost $2000 (but I don’t tell him this because I don’t know what it will cost and have no idea what his insurance will pay.) Because he is so worried I don’t have time to see my next patient who has to leave, and go to the emergency department with her pneumonia at a cost of $1500.

So… before lunch over $21,000 has been wasted. And this may significantly underestimate potential for cost savings because most primary care providers in the US see more patients than this, often one every 10 or 15 minutes, and have even higher rates of testing and referrals than I mention.

It is likely that, with malpractice reform, increase in payment for counseling in primary care, a knowledge of and willingness to discuss costs, and the universal access to health care that would then be affordable, nearly all of this $21,000 + could be saved.