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Would You Like Fries With That?

Glancing through the latest issue of  Anesthesiology News, the independent newsletter for anesthesiologists, I was yawning through subjects like Enhanced Recovery After Surgery, aspirin for cardiac surgery, and stellate ganglion blocks for PTSD (?!) when I turned to page 30 and there, luminous on their glossy paper, two articles about “customer value”.  Here’s how one of them starts:

“Like all workers, anesthesiologists must determine the best way to serve their ‘customers’ – the hospital, surgeons, patients and bill payors.” (Crist, C.  Marketing 101 for Anesthesiologists: show your value. Anesthesiology News, 41(4), April 2015, p30).

(The italics around the word customers was not added by me.)

“Anesthesiologists should follow age-old marketing advice: Identify customer needs, develop products to meet those needs, and communicate those products to the consumer.”

(The need for marketing might have to do with the ongoing CRNA-MD war being fought between the ASA and the AANA.  Maybe.)

“Show that you can get it done.  Be a hard worker, facilitator and collaborator.”

The authors suggest that instead of sitting by our anesthesia machines we should be helping the surgeon tie his gown, answer phones for the nurses, and open sterile packaging for the scrub techs.  This is how we prove our value to our customers, the surgeons and OR nurses.  Sort of a generally nice, helpful guy.  Like a waiter.  This kind of behavior is, incidentally, what is recommended to medical students to prove that their presence in the OR is not just a hindrance and/or nuisance.

Then, on the very same page, a lawyer by the name of Mark Weiss tells us that our real value is measured by our ability to create an “experience monopoly”.  The EM, or E +Phe+PQenv = strength of unique experience, is “providing such a valuable experience to patients, referral sources and facilities that they deem you their preferred partner, one that they can’t see themselves doing without.” (Weiss, M.  Do you make this mistake concerning customer value? Anesthesiology News, 41(4), April 2015, p30-31).

Mr. Weiss points out that people have preferred dry cleaners or restaurants because of the personal and environmental touches that give customers a good experience and thus keep them coming back.  In medicine, this lawyer suggests, an EM has three components: expertise, physical environment, and relationship environment.  And expertise is the least important.

“Of course, the goal is for you to increase the level of performance within your medical group across each of the components.  Note especially that you must focus on the human experience and environmental factors – all physicians understand the importance of medical expertise, yet that expertise alone, and certainly, that expertise tamped down by the impact of a poor environment and an even poorer experience is worthless in terms of creating relationships with patients, referral sources and facilities that over a career will prove extremely valuable.”

Expertise worthless, waiterly obsequiousness priceless.  Got it.

So I’ve got my order book and my pen, my apron, my black running shoes, and a big wide grin.  I went to waiter school, and I’m ready to serve.  But there’s a problem.  Nobody in my restaurant wants the same thing.  Everyone wants it their way.  If I make suggestions based on my experience with the food I’m told to stay out of it and bring me what is requested.  One guy says he wants cheap food and doesn’t care much about quality.  Another customer says quality is his highest value, and you “can’t put a price on quality, am I right?”  The lady at table 8 insists on putting ketchup on her tacos even though I know it is not standard of care for tacos and might even be harmful to her.  But I am a waiter, here to please, so I bring the ketchup.  Soon after, the cook comes to me complaining that I am overusing ketchup for unnecessary and frivolous uses and must refuse ketchup for all tacos in the future.  My boss tells me to hurry up with my orders, then gives me three more tables.  Now the food is coming out quickly, but the dishes aren’t being cleared and the aesthetic experience in the restaurant is tarnished.  I’m still smiling, but I’m now I’m confused.  Why did I go to waiter school if no one takes my advice?  Why is the guy who wants cheap food sitting with the oil baron for whom price is no object?  How can I please the lady who wants ketchup on her tacos, and who will give me a good or bad evaluation in the form of a tip, and the cook who considers ketchup on tacos to be wasteful at best and malpractice at worst?  And where’s the bus boy?

 

Internal Motivation

Everyone is very excited about Congress’s elimination of the annual CYA known as The Doc Fix.  For a refresher go to the excellent piece at The Health Care Blog by Steven Findlay (http://thehealthcareblog.com/blog/2015/04/08/sgr-rip-hopefully/).  Also in that legislation was an increasing push toward paying doctors for a group of patients, instead of by individual or by service, and giving monetary rewards to doctors who have better quality metrics.  This is supposed to save money by taking away the doctor’s incentive to see more patients and order more tests.  It is also supposed to increase quality by tipping the doctors, as I’ve discussed before.

OK, so I have a primary care doctor.  I am healthy, I eat right, I don’t smoke, I drink moderately (most of the time), I (used to) exercise.  Most men and women in my particular demographic do all of these things as well.  I have access to quality food, a gym membership, and health insurance.  Say my doctor participates in the proposed arrangement: she gets paid for a block of patients and, if those patients do well, she gets a bonus.  I love my PMD, but she would be getting a bonus for doing NOTHING.  I haven’t seen her in at least 5 years. The annual physical has been largely discredited, I haven’t reached the age-related screening test juggernaut, and I have the freedom to do everything I can to be healthy.

Let’s say I am not healthy.  I’m overweight, in my 50’s, I have a bad knee and had a heart attack last year.  My blood pressure is high and I quit smoking, but not soon enough.  Maybe I live in a low-income neighborhood and healthy food is not readily available.  I can’t exercise because my knee is bad, and also because I’m working two jobs, one during the day and one at night.  Let’s say my PMD has been seeing me once a month, has given me blood pressure medication, sent me to the office nutritionist and the social worker, checked my blood sugar and cholesterol, ordered my mammogram and colonoscopy, and kept the office open on Saturdays so I can actually make an appointment.  Despite these interventions I’m still overweight, my blood pressure is still high (because I can’t afford the co-pay), I haven’t had my screening tests (because I work two jobs and those guys don’t work weekends).  Now my PMD, who has worked her butt off for me, gets no bonus.

Health care administrators seem to be operating under the assumption that doctors won’t do good work without monetary incentives.  They also assume that people’s health depends on the good work of doctors.  They further assume that the quality indicators they have chosen actually indicate quality, and finally, that doctors have full control over their quality numbers.

But Shirie, you say, you are always complaining and moaning about how broken the system is.  How about you give us an alternative?  Not everyone can be an arrogant one percenter like you.

Provide health care for all patients who want it, change malpractice laws, and salary everyone.  Give every doctor a salary commensurate with the amount of money and time doctors spend in training so that they can support their student loans, their office overhead, and a moderate lifestyle.  So doctors go to school, graduate, and get good jobs.  If said doctors want to make more money they either a) quit and go into banking, or b) earn bonuses by taking care of sicker patients, or underserved populations, or the poor.  This solution offers the following advantages:

1. Doctors have good jobs that they don’t have to stress over.  Each patient gets the time they need and there are no production pressures. Quality rises as a result.

2. All patients have access to health care, so there are no uninsured folks waiting until their diseases are really bad before seeking help.  On the other hand, people who don’t choose to take charge of their health don’t penalize their doctors as a result.

3. Bonuses earned are for useful work, not data points.

4. Tests and medications are not ordered on-demand or because of fears about litigation.

5. All the overhead and CEO salaries for private insurance companies goes away.

But Shirie, you say, you arrogant one-percenter socialist, won’t that make doctors lazy, since they have no incentive to do a good job?  They can just while away their days because they get paid regardless.  Well, isn’t that what all the members of the US Congress are doing most of the time?  My kids’ kindergarten teacher gets a salary.  Why wouldn’t she do the same?  My mailman gets a salary.  What prevents him from wrinkling and/or soaking my mail and delivering it days late?  There is the threat of being fired, of course, but there is also the possibility that the teacher and the mailman like what they do and care about doing it well.  Why do we assume that doctors, or anyone else, will do a terrible job unless we incentivize and/or punish them?  We are not toddlers.  Most of us have an internal motivation to be good at what we do.  We just need to be given the right environment in which to do it.

 

Money Matters

I have been blogging now for about three years, posting once or twice a week and accumulating 240 posts.  I have my little flock of loyal readers and have managed to contribute a few drops in the ocean of the health care policy debate.  But just this month two pieces made some bigger waves, one ending up briefly fluttering about Twitter, the other offered up to the vast and lawless hordes of Reddit.

I doubt that my wisdom, erudition, literary skill, or ability to mix metaphors made these two posts so interesting to so many people.  The subject matter has hit a nerve.  The first post was about how we use and misuse numbers in medicine, and the second made the case that patients are not customers in the retail sense.

The opinions in both cases were pretty much split between people who agreed with me wholeheartedly and those who thought me the most misguided idiot doctor ever to approach a keyboard. Why these subjects?  Why are issues of buying, selling, ratings and statistics in health care so polarizing?  In general commerce whole industries have grown up around the insatiable need for ratings and deals.  People buy stuff on Amazon based on how many stars it has and how big the discount is.  Why is medicine different?

Maybe it is not different.  There are plenty of people who think healthcare should be cast into the competitive marketplace and allowed to sink or swim based on quality indicators and pricing.  Doctor rating websites and magazine hospital rankings provide plenty of opinions and statistics about a vast array of measurements of quality.  Recent pushes towards pricing transparency would allow direct comparisons on the price of procedures, tests, and devices.  A healthcare consumer can theoretically pick a doctor based on a star rating and haggle him or her down on the price of a knee replacement or echocardiogram.  But is that what we want?  To approach our health needs like buying a car or shopping for appliances?

Say you decide to buy a new dishwasher.  First you have to determine that you need a new one, that is, you have to diagnose your problem – “sick dishwasher, terminal condition”.  So you go online to Amazon or Consumer Reports to see which dishwashers get the best ratings.  You notice that the consumer reviews are all over the place.  People either love or hate any given model.  In fact, there are very few middle-of-the-road opinions.  You decide to buy the one with the highest star rating without really knowing or caring that the rating is just a statistical result of positives vs. negatives from consumers who may or may not be anything like you.  You decide to go to Best Buy or Sears to buy the dishwasher you’ve chosen.  The salesperson you deal with wants you to buy a more expensive unit.  The salesperson doesn’t care if you can’t afford it, or if your house is too small, or if the unit is really the best one for your situation, or whether you really need a new dishwasher in the first place.  His job is to get the most money out of you.  Your job is to get the best deal out of him.  Neither of you is at all concerned about the best interests of the other.  Neither of you is looking for a human relationship.  The only thing between you is money.
And that is where the polarization comes from.  Money.  A wise man once said (OK, the best man at my wedding, but he is super wise): all marital conflict is about money.  All commerce is about the money, and since health care is a commodity, bought and sold on a marginally open market, health care is all about the money.  The relationship between doctor and patient has become all about the money as well.  The minute a patient walks into the doctor’s office money is on the table in the form of a co-pay and a request for health insurance information. Resentment around doctor’s salaries blinds people to the administrators and pharmaceutical companies who are pulling in many magnitudes more than your average primary care doctor.  High profile stories of doctors with financial ties to various organizations erodes trust.

Many people don’t realize it, but medical students are taught virtually nothing about money.  It never comes up.  Students are too busy learning how to take care of people, the professionalism and ethics surrounding their chosen field, and how to pass all three parts of the US Medical Licensing Examination.  Most graduating doctors know very little about billing and virtually nothing about cost.  You know what graduates know a lot about that sort of thing?  Business school grads.

Money comes between husbands and wives, doctors and patients, buyers and sellers.  Anything that comes between the doctor and the patient sitting in front of him or her separates two human beings and disrupts the relationship upon which we build trust in each other.

Working for Tips

New York Medicaid officials are doing an “experiment” that should strike fear, anger, and outrage in the hearts of doctors who take care of medicare patients in New York (NY has the highest Medicaid budget of any state).

As any doctor who has a high volume of Medicaid patients knows, medicaid pays practically nothing.  Doctors who take Medicaid usually have to carry a bigger patient load to survive.  Medicaid patients are often sicker than the general population, with complicated diseases that are compounded by their environments.  They seek treatment in emergency rooms more often than other populations, have less access to healthy lifestyle choices, and live in more dangerous neighborhoods.

Visits to hospitals and emergency rooms are expensive (unlike doctor visits that are reimbursed for pennies on the dollar), and Medicaid officials want to decrease costs.  They’ve decided that if doctors worked harder, people would be healthier.  To make them work harder, they’ve decided to link their pay to hard work.  So if patients are healthier, that means the doctor is working harder and thus deserves monetary compensation for his efforts.  If the patients are sicker, the doctor is ineffective and does not deserve to be so rewarded.

NY medicare is suggesting that the doctors, many minority, who work with the poor, also many minority, should join together into Accountable Care Organizations that, in effect, give bonuses to doctors whose patients are healthier.  Here is how Anemona Hartocollis of the New York Times explains this awesome idea: (http://nyti.ms/1yrZqdw)

Medicaid officials hope to inspire these providers to work together and take a more active role in looking after their patients’ health, rather than simply waiting for them to show up when ill. The hope is that if they can do a better job of getting patients to, for example, quit smoking or manage their diabetes doctors could reduce costly visits to hospitals and their emergency rooms.

For each group the state will set goals for a range of measures, such as how well the group manages diabetes cases — based on those patients’ eyesight, cholesterol readings, kidney function and other tests — and whether it can reduce preventable hospital admissions, such as those created by poor follow-up care. A group can get a bonus each year by making progress toward its goals.

In the future, if the experiment works, providers may be paid solely based on outcomes rather than volume of services, with better-performing groups earning more than those whose patients are in worse shape.

New York is spending $1 billion a year for five years on this experiment. $5 billion.  To save money.

Look, people.  Doctors who take care of Medicaid patients are not sitting around twiddling their thumbs waiting for someone to come in with a disease.  They are doing their professional best to take care of the people who come to see them.  Let’s take a look at a composite person who might seek the doctor’s care:

This patient, unlike many of this doctor’s patients, has a job.  It is minimum wage, but there are plenty of people out there who would be glad to take the patient’s job if, for instance, they had to be absent in order to go to the doctor.  The patient probably has to take the whole day off because public transportation is slow, and the doctor has long wait times because his patient load is so big and his patients have so many problems.  The patient will probably have gone to an emergency room for his/her care a number of times because the ER is open 24 hours and he/she doesn’t have to ask the boss for time off.  He/she might only be able to get to a doctor during the day on the weekends because it’s too dangerous in the neighborhood to be going out at night.  The patient finally gets in to see the doctor, having made an appointment and managed to show up for it.  The doctor sees that her problem list includes diabetes, high cholesterol, and emphysema.  He checks on the dose of her diabetes drug and decides to change to a different drug.  He suggests that she/he try to eat a little better and smoke a little less.  He tells the patient to follow-up with him in a week to see if the new diabetes drug is working.  The patient goes to the pharmacy but is told the new medication requires pre-approval.  The patient doesn’t know what to do about this and so leaves empty-handed.  The following week the babysitter doesn’t show.  He/she now misses the follow-up appointment and now also doesn’t have a job.  So the patient goes to smoke a cigarette.

But, according to New York’s medicaid officials, this patient is doing poorly because the doctor isn’t working hard enough.

How ’bout using some of that $1 billion a year to pay doctors a reasonable amount so they have a lighter patient load?  How about financing weekend or evening office hours?  How about providing free transportation to doctor visits?  How about providing home visits or work visits from doctors or nurse practitioners so that patients get their follow-up care?  How about using all that money to improve living conditions, invest more in local schools, subsidize healthy food, provide high-quality child care, raise the minimum wage, and create job opportunities?  Because these things are what improves patient’s health.  Not tipping the doctor.

Quality? Ask The Right Questions.

A few weeks ago I wrote a piece about performance metrics in medicine.  People asked me:  “Well, if you don’t like the metrics, what would you use?”  So I thought about this, and the best way I can think of to explain what I mean is to use an example from a different field: education.

Standardized testing has become ubiquitous in schools.  The numbers generated are used by administrators to judge quality.  It’s easy to use as a metric because you get a nice quantifiable number that you can compare directly with other nice quantifiable numbers.  My kids have to take these tests starting in 3rd grade (about age 9).  From age nine on, children are being used to generate numbers for the adults.  Specifically, for people who make the rules and do the hiring and firing.  What’s in it for the kids?

Well, proponents would say that it helps teachers measure students’ progress.  I guarantee you the teacher every third grade classroom knows how each student is progressing, seeing as that teacher is with the students every day.  A number on a test won’t surprise her (or him).  Additionally, the teacher is in a much better position than a computer to understand why a student is under performing.  The same is true, or should be true, for parents.  Most parents, at least in elementary school, will already be well acquainted with the educational progress of their kids.  The number won’t surprise them either.  It could make them feel competitive with other parents for whose kid had the highest scores, but that doesn’t benefit the kid.

Proponents say that testing allows teachers to know if they are meeting educational benchmarks.  Believe me, they already know.  A third grade teacher teaches third grade every year.  He knows what the benchmarks are.  Even if every single one of the kids in the teacher’s class are performing below the benchmarks, he knows that they are and most likely also knows why.

Some will say that testing promotes learning.  Yes, certain kinds of tests, used in specific ways, can be very useful learning tools.  But it has been known since at least 1988 that standardized tests don’t measure cognitive function. (Marzano and Costa, Educational Leadership, May 1988.)  They measure how well a kid has memorized something, but can tell you nothing about whether or not the kid understands what he learned or if he can apply the new knowledge to his existing knowledge to solve problems.  Also, the time required for administering these exams takes time away from the activities that would have helped that kid understand what he has memorized.

So getting numbers from kids doesn’t really benefit them at all.  It doesn’t help teachers or parents much.  It is great for administrators.  If I enroll my kid in a new school, am I going to ask the principal how the school did on standardized testing?  Maybe, but that only gives me an idea if the students in the school do well on standardized tests.  That’s all it means.  In order to find the best teacher for my kid, I’m going to ask other parents.  “Hey, my kid is going into first grade this fall.  Who do you recommend for a teacher?  Who’s the best?  My kid has X personality, just like your kid.  What teacher was the best fit for your kid when she was in first grade?”  Other parents will know, I guarantee.  They are in the best position to know.  They have seen the teachers work. In my public school, and I guess in most, parents don’t get to choose the teacher.  But what if they were?  It would be immediately clear to everyone who the good teachers are.  No numbers required.

Let’s look again at the 30-day mortality metric.  That number is acquired from hospital data, and as we have seen, can be gamed to some extent.  We also know that the 30-day mortality measures only how many patients died within 30 days.  That’s it.  There are no qualifiers in there for degree of illness, severity of atherosclerosis, co-morbid conditions, etc.  So you might know the number, but it doesn’t really tell you anything.  It doesn’t help the surgeon, who knows what is number is compared to other doctors and knows what the benchmarks are.  He wouldn’t use his number to measure how good a surgeon he is.  He’d use it to compete with other surgeons.  The number doesn’t help the patient in an emergency situation since the patient doesn’t get to decide who his doctor is.  The only people the 30-day metric helps is administrators and payors.

How do you know who the good surgeons are?  Ask their colleagues.  Not their fellow surgeons.  Ask the nurses they work with, the anesthesiologists or critical care doctors or radiologists.  And don’t just ask them who is the best, but ask them “Who would you want to do your own surgery?”  Believe me, they know.  They are in the best position to know.  I personally know who I would want to take out my appendix or gallbladder, should I need it, and would wait a good long time to get the surgeon I want.  Do I know this doctor’s 30-day metric?  Not at all.  I’ve seen him work.

 

Enough!

My Au Pair is on vacation this week.  Miami.  Lucky girl.  After a week of unremitting motherhood I have found myself saying to my children things I swore I would never say.  Like “Because I said so!” and “Enough is enough!”.  My kids are six years old and under, so perhaps such non-logic works.  Unfortunately, I sometimes find myself wanting to say the same things about to fully grown adults.

A few days ago WBUR.org (Oh, my beloved NPR, how could you!) published a piece about the so-called “Home birth Caesarean Section”, otherwise known as “Holy %$^&# there a big problem, call a doctor!”.  (http://commonhealth.wbur.org/2015/03/what-to-expect-when-youre-birthing-at-home-a-c-section-possibly#more-49283)  It seems that women, wanting an “ideal” home birth and finding themselves or their babies in dire straights, need years of therapy to assuage the guilt, shame and terror that accompanies transfer to an hospital and the subsequent medical interventions that save the lives of themselves and their offspring.

People, women used to die in droves while undergoing “ideal”, “natural” childbirth.  The reason they don’t anymore is not because midwives and doulas have perfected breathing techniques and patented birthing benches.  It is because of science and medicine.  The anti-vaccine movement is a parallel example.  Children don’t die in droves anymore from measles; why?  Medicine and science.

Enough is enough!  Science is not the enemy.  Doctors are not out to ruin your beautiful, natural, organic lives.  Use the advances that scientists and doctors have worked so hard to discover and develop.  All our lives are immeasurably easier because of what these men and women have done.  Do what we say, because we say so, just every once in awhile.  Please.

You’ll Get Used To It.

When I was a young violin student I had to change violin sizes at various times as I grew.  Each time felt funny, and each time my teacher would say  “You’ll get used to it”.  The Affordable Care Act, i.e ACA, i.e Obamacare, is now hated by fewer people.  Only 43% of Americans oppose it, down from 53%.  Pundits are saying this is because the recent open enrollment period went smoothly.  That may be true, but if we take a lesson from history we can see that slow acceptance of the ACA is to be expected.  We’ve gotten used to it.

Take, for example, the New Deal.  The New Deal was a set of laws enacted in the wake of the Great Depression.  These laws resulted in policies and institutions such as the FDIC, the criminalization of child labor, the Fair Labor Standards Act that established the 40 hour work week, and Social Security.  Most people today would consider much of the New Deal to have been a pretty good idea.  But that was not the case in the 1930s when these laws were passed.  Rich people didn’t like it.  Republicans didn’t like it (they thought the Social Security Act smacked of socialism.  Funny, huh?).  Conservatives thought there was too much infringement on individual rights.  A third of the public didn’t like it, as judged from the 1936 election.  Doomsday predictions claimed that the legislation would take away human rights, create too much big government, and ruin the constitution.  Some would still argue that these predictions came true to some extent, but no one wants a repeal of child labor laws, and Social Security is now a political third rail.

In the case of the ACA, the opposition has been remarkably similar.  Infringement on individual rights, states rights, big government, socialism, unconstitutionality, all these accusations have been thrown at the ACA.  Additionally we have been told that the ACA would bankrupt the government, limit physician choice, and establish death panels.  Some of these claims are still under review.  But health care spending has gone down, more people have access to health care, and no death panels have materialized.

Parts of both the New Deal and the ACA either didn’t work or were deemed unconstitutional.  But some parts stayed, and eventually became part of life in America.  People got used to it.  Just as people are getting used to the ACA.

As Congressional Republicans are acutely aware, it is much easier to prevent something from happening than it is to take it away once it has happened. This fact is based in the human tendency to give much more weight to loss than gain.  We see this in end-of-life discussions, where doctors find it is more painful for families to decide to remove life support than to decide not to institute it.  Such tendencies can be positive or negative.  At work it is well known that once a new rule gets instituted we’re stuck with it; a rule, once made, is virtually impossible to get rid of, even if it doesn’t have the desired effect.  Standardized testing in public schools is here to stay too, even though such testing has been shown to be a poor measure of real learning.  On the other hand, a rule that works and makes sense, like a seat belt law, will also never go away, and eventually people get used to it and lives are saved.  Once people got used to Social Security it became impossible to take it away.  Once people get used to having insurance it will eventually become impossible to take it away.

Once something becomes status quo people tend to forget what they were so worried about.

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