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The Economics of Mid-Levels

Another old post from The Physician Executive with currency in today’s environment. 

 

I was once a family physician delivering babies in an East Coast big city.

No, I am not a masochist, I was a family practice residency faculty.

Given the intense turf wars caused by an oversupply of competing specialists, it was an unpleasant environment to work. The concentration of specialty providers in big cities and urban areas poses some problems when it comes to costs. Frequently, one looks to mid-levels as a way of addressing problems in health care. Indeed Physician Assistants and Nurse Practitioners have a potentially important role to play in health care, but where?

Jason Shafrin at the Health Economist takes a look at midwives (included in the ranks of nurse practitioners for most of the latter part of the past century.)

I like midlevel providers like nurse practitioners and physician assistants because of their ability to bolster the ranks of primary care, the main engine of cost containment in health care. They can be invaluable in rural areas where it is difficult to entice specialists, even where there is a critical mass of demand for their services.

On the other hand, Jason’s post appears to be looking at midwives as a less costly alternative to obstetricians. A commenter on my site reminded me of Milton Friedman’s assertion that licensing leads to higher costs without assuring quality. In medicine, we have established a complicated and lengthy licensing process in the secure belief that the alternative was the chaos of snake-oil salesman that populated the United States at the turn of the last century. In other words, there was a compelling societal reason to limit and license people delivering health care.

I’m not sure what we accomplish by looking at mid levels as alternatives to established specialty providers. Moreover, specialists and midwives are equally maldistributed, being over-represented in metropolitan areas, where competition finds a way of increasing costs. Yes, health care acts strangely and higher concentrations of specialists tends to increase costs rather than reduce prices as one would expect.

On the other hand, finding an incentive to better distribute physicians may be a subtle way of improving physician incomes and health outcomes and reduce costs.

I want to make it clear once again, this is not a tirade against nurses or midwives. Nurses have saved my backside too often not to be collaborative and old school midwives working in labor and delivery taught me everything I know about delivering a baby.

I am questioning how we make policy in the face of a web of data and mess of potential starting points from which to approach the data.

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Christmas and Change

I wrote this 6 years ago. It is oddly suited today, because the more we learn, the more we discover to learn. The better I get, the worse I was.

 

Merry Christmas. Christianity was seen by Bertrand Russel as an excuse for mediocrity. I think this perception can arise from Christianity’s insistence on the potential for change.

Christianity is (or at least should be) about forgiveness and redemption above all. That means no matter how inadequate we are, how erroneous our ways, how mediocre our performance, there is always the opportunity for improvement. This position can sometimes seem to excuse past mediocrity, perhaps even celebrate it and reward it.

I was an awkward child, and a certain social awkwardness has penetrated into my adult life. But I am getting better. I have made many mistakes and continue making them. But I need to be free of the baggage of past errors in order to progress. For this reason perhaps, Christianity seems so ready and willing to forgive everything, in heaven if not on earth.

There can be no redemption without guilt. There can be no change without mediocrity. They are the catalysts for change.

Have a warm and happy day.

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A Splintered House

This is the text of a speech I gave to the Clark County Medical Society’s New Physician Reception in 2013.

Thank you to our sponsors and guests, to the Board of the CCMS and especially to each of you for coming. To all the new physicians; welcome to Clark County and to the medical society. I want to take a few minutes tonight and talk to you about our medical society and its history, my personal spin on what has happened to medicine in the 72 years since CCMS got started and how the House of Medicine became splintered. I would also like to talk a little about what our future might look like under the current and coming reality. Life is changing quickly for physicians these days.

“Clark County Medical Service Corporation” was established in 1941. The articles of incorporation, written under the name “Clark County Medical Society, Inc.”, were signed by Clyde B. Hutt, MD, as President and L.E. Hockett, MD as Secretary/Treasurer and were approved and filed on December 3, 1942. The constitution and by-laws of 1942 were amended on May 6, 1947 and adopted by membership on May 4, 1948. The bylaws have stood unamended since the last review and overhaul accomplished in 1991. They have withstood the test of time.

Medicine was simpler back in 1941. The bulk of CCMS membership knew each other. The largest group in town was the Vancouver Clinic and it had four doctors: a GP, a surgeon, a pediatrician and an OBGYN. If you wanted to hang a shingle, you may have wanted to meet the local docs so they could tell patients about you and maybe put in a good word for you at local merchants and businesses or maybe the bank. The county medical society was a way to let people know what your special interests and skills were and this was the way you got most of your referrals.

No I am not going to wax sentimental about the golden age of medicine. County medical societies had a dark side: they were exclusive and closed old-boys clubs that enforced standards of behavior in a manner that would be frowned upon today. They focused too much on their own interests and not enough on the health of the people they served. Keeping an eye on the money worked well for the US medical societies, and their parent organizations all the way up to the AMA, until the first turf wars erupted. I don’t need to belabor strife within the House of Medicine.

At the turn of the last century, there was a tug of war in the House of Medicine regarding the need for specialization: Some thought that generalism was necessary to understand the whole person, others thought that specialism was the way of increasing the relevance of physicians and to provide the best possible care for individuals. This was all derived from scientific medicine and the notion prevalent in an industrial society that there was more value in specializing.  Sir William Osler, perhaps the largest historical proponent of scientific medicine was ambivalent about the notion: “[Specialization]’” he said and I am quoting here, “must then be associated with large views on the relation of the problem, and a knowledge of its status elsewhere; otherwise it may land him in the slough of a specialism so narrow that it has depth and no breadth, or he may be led to make what he believes to be important discoveries, but which have long been current coin in other lands. It is sad to think that the day of the great polymathic student is at an end; that we may, perhaps, never again see a Scaliger, a Haller, or a Humboldt—men who took the whole field of [human] knowledge for their domain and viewed it as from a pinnacle. “

One of the earliest specialty societies was the American Academy of Pediatrics, hatched about 15 miles from here at an AMA meeting in 1930. In 1933, dermatology, OB-GYN, ophthalmology and ENT were the founding members of the ABMS. 1941 marked the year that the CCMS was founded and that Anesthesia became America’s 15th recognized specialty. Today we have splintered into between 130 and 157 specialties and sub specialties depending on how you count them and nearly as many specialty societies.

I think that is the word that best represents the House of Medicine today: splintered.

But somehow I think that people with an MD or a DO degree after their name may share certain characteristics more than a similar day-to-day existence within their own narrow silos of specialty and employment.

Somehow I think that people whose primary role is to help patients navigate our current morass of regulation, government, insurance, corporations, pharmaceuticals, manufacturers of various gadgets and medical technologies from titanium hips to scribe-friendly keyboard operated EHRs… somehow these people who bear the primary responsibility for trying at least to improve the health of well-being of their patients (and by consequence our community) have more in common than their differences would suggest.

When I first got to Clark County 4 years ago, I set about charting a course to understand how I could personally influence the course of events impacting my life. I have a MPH,  so I was interested in my role as an advocate for patients and how I could impact the epidemiological measures of health. I looked at what my specialty society was doing in the local community. I found the impact was driven by individuals, many of whom were involved with the local residency. The point is that my specialty association’s largest impact was being felt at the national level and had recently hired a lobbyist at the state. At the local level it was not any association, it was the individuals. I think this is probably true for each of our specialty associations. We can do at least as well locally.

So I believe that medicine has a role in improving the health of our communities. It may follow that when we band together and work towards that purpose, we may have better chances of success. It’s a subject for another day, but medicine has a role. It must have a role if the industry is to remain relevant as a social good, otherwise, we might as well all quit and become bankers, because that’s where the real money is.

Don’t get me wrong, I proudly carry the flag of my specialty society, but the fact is that all our specialty societies are somehow vaguely inadequate to the grass roots tasks. Its not just primary care, but all aspects of medicine that are at work in this town, from the anesthesiologist and the gynecological oncologist and the cytogenetic geneticist. We have more impact as a House of Medicine united in this one common mission that we agree on than worrying about turf wars.

And the impact is felt community by community. A truism in epidemiology is that you need large numbers to detect small changes, but it tells you nothing about what happens to individuals. And communities are made up of individuals, states are made up of communities and nations are built on states. It all starts where you live and work and being concerned for the health of your neighbors and the people around you. The health of Clark County depends in a small way on each one of you. The health of Clark County needs you to speak for it and for its concerns.

One aspect that has helped the health of Clark County has been the role of CUP. CCMS has advocated and will continue to advocate on behalf of this local non-profit community-based health plan both because it works for the community’s health and because it is a significant employer. We were concerned with toxic byproducts of a recycling plant and successfully shot it down. At the state, with other medical societies, we helped overturn the rule that emergency rooms wouldn’t be paid if their services were retrospectively judged not to be emergencies. Physicians got involved to work with the DOH and saved them more money than they envisioned by their prior plan. We also fought the B&O tax which no longer applies to physicians in WA. We are now looking at the impact of a coal terminal on our coast as well as the trains have along the route, so we are supporting studies to clarify the impact and publicize our concerns. At the state we have also supported public health nurses working on STD’s and providing the related questions and answers assistance, reproductive equity in the state and pushed for medical staff reviews that are not quite so abusive of physicians.

Only here in Clark County can you speak out about our lack of availability of fresh food in a wasteland of fast food. Only in Clark County can you do something about obesity in your community. Only in Clark County can you set up community forums to counter the vaccine objectors’ propaganda that makes us so vulnerable to epidemics IN THIS COUNTY!

I hope you each continue to support the county medical society, I hope you get involved, speak up, be a light for others to follow, be obnoxious if you want, just speak!!! And tell you colleagues about the society. You need to take responsibility for your own “belonging” to a group you believe in. And if the AMA or WSMA or even CCMS does something you disagree with, remember that your voice counts. Without that voice, it’s not surprising the organizations do things that don’t meet with your approval. You won’t win every battle in a democracy, but you will win some/ You will make a difference.

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Argument for Big Pharma

Not a big fan of big pharma. Not a big fan of big insurance. Come to think of it, I’m not a big fan of anything big: government, hospitals, or anything else for that matter. This bias is evident in this post from The Physician Executive.

 

Peter Pitts appears to be a very intelligent person. As a former head of the FDA, he knew how to find the money and took off to run the Center for Medicine in the Public Interest, generally recognized as a front for Big Pharma. I like reading his posts, for the same reason I like reading the Cato; I am always looking for good arguments on the side of any position.

So I came across this interesting article suggesting that we need to stop insurance companies from switching people to generics all the time. This was published the same day that Wal-Mart added terbinafine, once $300 a month, to it’s $4 generic list.

As a clinician, my frustration is that insurance companies, or more specifically the pharmacy benefit managers, forcing patients to change meds. They insist that a certain medication in a given class is not covered and the patient must change to a different drug in the same class. It’s like don’t take amoxicillin, you have to take penicillin. Alternatively, the physician can somehow demonstrate or certify an adverse reaction or lack of effect before they authorize going back to the original drug. I already know drug A doesn’t work, from experience on the previous insurance. The insurance requires that we try Drug A again, before they reimburse for Drug B, which the patient has been taking for a long time.

I understand the complications of dealing with expanded formularies and the inefficiencies of having to stock so many similar drugs. I also understand the value of the discounts available when you order in bulk.

I just don’t think it’s a good idea to swap chemical entities because I have a healthy respect for the risks of consuming anything on a regular and ongoing basis. Once you have a functional and safe regimen, it is unwise to change.

Here’s the bone I’m going to throw to Big Pharma; sometimes a softer argument makes a greater effect than one so strident, the bias encourages the reader to discard it without a thought.

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Finding a match in your doctor.

From The Physician Executive in 2007, but I could have written it last week.

CNN had an article on how to fire your doctor.

I agree. Sometimes it’s about chemistry. Some patients and I are like oil and vinegar, others like fire and gasoline. I have always invited these patients to seek care elsewhere with no hard feelings.

Somewhere in the corporate transition, this message got lost. My previous employer almost had a hissy fit.

The alternative is an unhappy patient who doesn’t trust their doctor, who doesn’t really like their patient but is seeing them begrudgingly out of some kind of moral obligation.

If that isn’t a recipe for a lawsuit, I don’t know what is.

Each physician-patient relationship is different. You are looking for a match. This applies to the patient, but is also good practice for the organization.

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Health Care: The Blind Men and the Elephant

From The Physician Executive in August of 2007.

In health care, management and policy are a couple of steps removed from patient care. Physicians and other health care workers have insights that sometimes fall on deaf ears. But this is the era of Babel in health care; I don’t believe we have a common language yet, so we can actually understand what each of us are saying.

Health policy is a large enough field that, as in medicine, specialties are starting to emerge. When I speak with health policy types and health economists, they often see the world through the glasses of their area of interest. I know of an economist who specializes in transplant allocation. Another health economist is a state secretary of health (how rare is it that government hires a real specialist for any post, instead of a politician?) Some people are dedicated to providing care for the poor, other would like to preserve choices and options, which are usually relevant to the wealthiest and most privileged.

These different perspectives yield emphasis by turns on primary care or specialties, ambulatory or hospital care, cognitive versus procedural practitioners… Health wonks are like blind men trying to figure out what an elephant looks like.

Biological organisms are not mechanical, and this has an impact in various aspects of the health system. I recall an Operations Manager who couldn’t understand why the clinical staff didn’t follow medical guidelines the same way his computer staff created patient files. (This represents the mis-application of Six-Sigma to the wrong level of outcomes.) One of the most dynamic classroom discussion I experienced was when a bunch of mid-career professionals tossed around my assertion that “protocols” and “guidelines” are not the same thing. We settled on protocols for processes and guidelines for diagnosis or treatment. It’s too bad that medicine cannot be based entirely on empirical evidence, as an epidemiologist (I think) commenter to this blog asserts.

The complexity of people as biological and social organisms leaves us with so many unknowns, I am amazed at how much information we have that is actually actionable. But health care remains governed by careful judgment informed by some data, to help navigate the unknowns.

Experience can be a fickle teacher. So much of our perceptions are shaped by personal experiences, and then confirmed by the consequent bias. If we have a bad experience a physician, we are looking for confirmation in any trace of behavior of every subsequent interaction. So outliers can begin to distort our opinion of things: the greedy doctor, the uncaring insurance company, the bean-counting administrator, the abusive patient or the ignorant bureaucrat… These people exist for sure, but the vast majority are working stiffs who show up for work and try to do the best they can before getting home to their families and an over-leveraged mortgage.

In all this, it is the emotional context of health care that is the most ignored. The fear and despair that physicians and nurses see is forgotten in epidemiologists’ regressions, economists’ differentials and executives’ spreadsheets. No, the golden age of medicine is gone and good riddance, but something else this way comes and we don’t yet know what it looks like. Let’s just make sure it works for the middle: the normal patients, health care workers and administrators who show up every day and stay for every shift, no matter how terrible the things they see.

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Underfunded, undervalued

This is one of my favorite posts from The Physician Executive, which is especially relevant today as we enter the conversation of reforming payment from our current fee-for-service model to a pay-for-value system in which primary care may finally get the recognition it needs to actually serve its role within the health system.

 

Funny that people complain about how hard it is to get a good doctor. Sometimes it is important to ask why things are as they are, rather than complain about why they are not better.

I remember a conversation with an internist a couple of years back, who was complaining about how her family physician was so useless…it takes forever for the office to get back to her, appointments are a bear to get, refills take forever and it’s like getting teeth pulled to get him to call her back.

If a primary care doc is running all day trying to get patients through, then I assume he’s busy. That’s good thing. I’ve never waited for reservations at a bad restaurant. A good rule of thumb is that the better doctors’ offices are more crowded.

I know some physicians who have also had the business sense to build incredible systems that can get 30 patients or more in and out daily and still do a good job at it. Not everyone has the administrative skills to do that, even if they are excellent doctors. If the doctor doesn’t spend enough time to listen, the question must turn to what they’re paid for.

Generally, I view phone calls as a waste of time, because they frequently represent an inappropriate service to deliver by phone. Some advice can be safely dispensed at a distance, but nothing is certain without a proper examination. Oh, and that’s what usually what physicians are paid for. They are not paid to dispense advice, provide basic health education, prescribe medication without an assessment, complete forms for patients who haven’t been seen in two years and coordinate referrals for patients who bypassed them entirely and went straight to the specialist. They are paid by the visit, where an examination frequently takes place.

Our physicians at a facility for low-income individuals are allocated fully 20% of their time to do unremunerated administrative functions, only some of which ethically seems appropriate. We stretch the rules in recognition of our patients’ socioeconomic constraints and only because we receive sufficient grant income to support the loss. In private practice… fuggedaboudit. The only reason to do it, is to preserve goodwill, which doesn’t really pay the bills. (This only applies to traditional fee-for-service environments. More about capitation some other time, because that’s a whole different ball of wax.)

Why do physicians with very busy offices have to be so busy? I mean, are they just greedy, churning people like so many little factory widgets? I suspect, while there are some bad apples in the barrel, the majority are skating trying to cover their overhead, payroll, malpractice and hopefully come close to the national average of $150,000 in income. Remember the big bucks are usually reserved for cardiologists, neurosurgeons and other proceduralists, without which no health system would have credibility (source: healthcareerexplorer.com/salaries/neurosurgeon/). What’s the use of preventive services if there is no available curative services should prevention fail?

My friend, the internist completed her rant by saying there was no value to primary care since her family doctor couldn’t provide the service she required.

I wondered out loud if that was the way the world always worked, “Underfund the service you need so that it can’t do the job and then complain that it has not value.”

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Employed Physicians Becoming More Common

I am on a roll finding old posts from The Physician Executive that are still relevant today. In fact, this post is more relevant today than it was in August 2007.  We now must need to be concerned about how physicians are being managed and in the face of large integrated health systems with an incentive to encourage increased testing and referral. This will still be a major policy issue for the next decade.

Interesting post by Dr. Reece about physician-hospital collaborations at medinnovationblog. There is no question that community hospitals exist in a challenging environment, but each specialty now has its own financial realities that can color the relationship between physician groups and hospitals. My comment, is the most recent trend towards hospital-employed physicians accomplishes two things:

1) it puts physician executives in greater demand
2) it may put more hospital functions under greater physician influence or control.

Surely there are numerous other forces at work here and only the smartest and best informed physicians will win. I don’t believe the golden age of medicine was very good for patients, at least on a population basis. However physicians are often well-positioned to consider the patients’ best interests. Hopefully, the current grass-roots push towards more accountability and better quality-of-care data will combine with a strong physician perspective and professional management skills at hospitals to improve health outcomes overall.

Then again, the landscape may prove just too complex to navigate.

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Envelopes and the Greek Medical Business

This post on informal payments from The Physician Executive was one of my most popular. Originally published Aug 15, 2007. Dangerously, I have to note it is one of my favorite jokes. 

 

If you think we have problems in the US, you should try Greece.

There had been talk of a socialized system several years and a couple of prime ministers ago. There seems to be a modicum of a centrally funded, insurance-based system now. However, the WHO’s description of Hellenic healthcare tells me it still runs the old-fashioned way:

[Informal payments] are especially prominent in the case of in-patient care, and are made to doctors, mainly surgeons, in public but also in private hospitals. These payments are also made in the case of outpatient care. The rationale is to jump the queue or to secure better quality services and greater personal attention by the doctor. Unofficial payments are considered to be a major problem in the Greek health care system. It is estimated that about half the total private expenditure on health care involves informal payments. There is no really reliable estimate of the size of the unofficial market, partly because it is so widespread, and partly because of the complexity of the Greek health care system.

Almost 60% of total out-of-pocket payments (official and unofficial) are made to doctors and dentists (especially those in charge of facings), 20% go toward pharmaceuticals, with the rest being mainly expenditures on private diagnostic centres and private clinics. Out-of-pocket payments (both official and unofficial) represent roughly 6% of household income (1990 figures).

So these informal payments are made under the table, usually cash stuffed into an envelope and they are fairly common, even in the out patient arena. Traditions die hard, and the tradition of the “fakelaki” (the Greek word for envelope) is alive and well. I believe these payments are outlawed in the government-run clinics, but common prejudices take effect: Greeks are nearly Italian in their disregard for authority and let’s face it, doctors can’t be any good if they works for the government! You and I may know it’s not true, but there’s no accounting for consumer decisions.

My suspicion is that the lowest risk way of buying a stake in Greek Healthcare is to buy a stake in an envelope factory.

Aide, gela!

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Vaccinate, Support Local & Subscribe

Our clinic, Lacamas Medical Group, runs a couple of free immunization clinic for kids in Camas and Washougal who could not ordinarily pay for their pre-school physicals and vaccines. The Camas-Washougal Post Record, supports us in this endeavor, once running a free ad and this year sending a reporter. This is a link to her story on the web, but they held back a significant chunk for the print edition i wish it had all been online, but I understand why they do that.

I think this may convince me to subscribe. It is a very good publication by the standards of a local weekly newspaper. Moreover it is local, with local news and full of information about local businesses. We can complain about the lack of ethics in corporate America all we want, but without supporting local business, like the Post Record and the businesses that advertise in it, all is for nought.