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Tuesday, July 26, 2016

Health care costs, mandates, and the changing health care workforce

Health care delivery is both already expensive and also saddled with unsustainable cost increases. The reasons for this are multiple. Just to name a select few, health care historically has operated under the assumption that improvement (or perceived improvement) is worth it, no matter what the cost. In addition, health care is very labor intensive and the labor is very expensive. In addition, it is about to get even more expensive.

I have little doubt that Hillary Clinton will be elected the next president of the US. I also have no regret that the next president will not be Donald Trump. I will derive some degree of satisfaction when the first person looks at him after the election and addresses him as a "loser" and I hope the habit continues for a long time. However, I have some great reservations regarding some of the planks of the Democratic Party Platform, relating to generous paid leave provisions.

For those us who need to balance budgets, legally mandating that employees can take generous time off with paid leave means figuring out how to pay them. For expensive people, this can get very expensive and we have lots of expensive labor in health care delivery. Increasing labor costs will not decrease the cost of delivery services. In fact, the effect is quite the opposite! How will I figure out how to pay the salaries of $100K+ professionals who are not at work? How many people on paid leave can we afford at any given time?

I have little doubt that these mandates will be established but I have to ask, how is this going to work? How are we going to find a way to delivery health care services at steeply lower costs when mandates drive up the cost of the biggest part of our overhead (labor)? I see there are only five options.

Option 1 is to pay everyone less money.
Option 2 is to hire less expensive labor, that is substitute nurses for doctors, health techs for nurses, etc.
Option 3 is to stop hiring people and automate
Option 4 is to stop offering services which are too expensive to deliver
Option 5 is really a hybrid of all the above which is to increase efficiencies and generate more value per unit of labor paid for.  However, there is no way that one can garner efficiency gains from people who are on paid leave.

I believe the pressures to cull the workforce and eliminate workers, especially expensive workers will be huge. Couple this with changing payment patterns and I believe physicians will be in the cross hairs. Physicians bring lots of unmeasured value into care delivery now but the thing that is measured is money. We measure little else. Up to the current time, fee for service has been mostly dependent upon MD's to drop bills. For health systems, doctors are needed for cash flow because doctors can submit bills and allow facilities to operate. When bundled payments go directly to health systems (as proposed under MACRA) and doctors are primarily salaried and are no longer required for billing, health systems will view MD's primarily as the most expensive part of their workforce. Where can costs be cut? Why are we paying these guys so much?

Tuesday, July 12, 2016

Movement from informal to formal processes in medicine

I have had a robust exchange with colleagues regarding how one should acknowledge another physician's opinion in the medical record. I am of the mind that the only opinion that one should write in the record is your own. I have no desire for any of my colleagues to record my opinion in their notes, unless they forward those for me to sign or write an addendum.
However, my opinion on this activity is not held universally, not by a long shot. Within other fields, especially radiology and pathology, there is a long tradition of bedside clinicians visiting and consulting these specialists, in their "houses". Rounds used to start in radiology and there would be extensive discussions with care teams, resulting in radiologist opinions being paraphrased in the medical record. Whether what the radiologist intended to communicate routinely ended up in the notes on the floor is not so clear.Similarly, glass slides routinely circulate in Pathology departments and colleagues are called upon to render inter-departmental consults, ranging from formal to very informal. The language incorporated into various reports may include a host of concurrences from physicians whose signature never appears on the final report.
Historically, critical decisions in medicine, especially in the most challenging of cases, were often made after generating a form of consensus, whether that consensus was derived from Grand Rounds, tumor board, or informal solicitation of opinions. The transcripts from these conferences and informal activities were generally non-existent and the consensus recorded tended to be ephemeral and biased through the lens of whomever wrote something in the chart. It may have been heavily influenced by one or a few strong and charismatic clinicians who would sway the audience based upon their confidence and experience. 
All of these activities were highly informal processes. Individual attendees tended to take away what they wanted to take away and the patients cared for had little or now idea what actual conclusions were drawn and how they were arrived at. They were simply informed that we had a conference and the agreement of the group was, whatever. Individual accountability and hard evidence was not something on the radar. 
Looking back nostalgically, we believe that these activities enhanced patient care, irrespective of the actual outcomes. They certainly made the care teams feel better and there was a certain simplicity and finality which appeared to be achievable which does not appear to be achievable now.  While the human contact did unquestionably facilitate communication, the model was not scalable. It depended on small groups who were familiar with everyone involved. The decision trees were not so arborized. The information to be managed was on a much more limited scale.
It is a different world now. We aspire to do more, much more which requires much more complex systems to manage. The teams are larger and the workloads more specialized. Communication becomes even more essential under these conditions and when communication fails, we ascribe those failures to leaving the informal systems behind. However, when systems become more complex, informal communications will not suffice. Each decision branch point, which may be dependent upon particular fidelity on terms of information transition, becomes a possible pitfall. A process with three steps has a much lower failure rate than one with five, or ten, or fifteen. Informal verbal communications are fraught with error and should not serve as the foundation for critical information flow.

Sunday, July 10, 2016

People can be strange and unpredictable

I am reading a book titled "Heaven's Ditch: God, gold, and murder on the Erie Canal". It is quite an interesting story, about the best of humanity, the worst of humanity, and the weirdness of humanity, all wrapped up in one nice package. The best is the fact that in the early part of the 19th century, the Erie canal was built. It took vision, chutzpah, drive, and incredible people. It was an engineering marvel which fundamentally changed the course of history in the US. The worst is that many of those involed were simply awful people who did awful things to other people.

However, it is the weirdness background which simply blows me away. The canal was built in western New York during a time of great religious revival. It was not just religious revival but all forms of spiritual, mystic, and magical thinking. It was where Joseph Smith's family ended up before the trek west. People became wrapped up in all manner of superstition. Joseph Smith, before he found the gold tablets and launched the Mormon sect, was one of may people who used special stones he placed in his hat to see the future. People, including Smith, were using divining rods to find casks of money buried in the ground.

While among my peer group currently, the acceptable facade to display is one of rationality and linear thought (sort of Mr. Spock like), I think this is not how many (most?) people really operate. Beneath the facade there are a jumble of emotions which can drive some peculiar behavior. Most of the peculiar behavior likely can be characterized as quirky and some of it as annoying. It then can go on to move into the territory of very odd, strange, really strange, and then downright disturbing. With enough concentration of people, likes can link up and amplify the quirkiness and strangeness. The internet has been very conducive to this. The fun end of this spectrum is where things like DragonCon reside. At the less benevolent end you might find congregations of people with more sinister motives.

I don;t think there has been any real fundamental change in the underlying DNA. There have always been people who have been at the fringes, did not play well with others, and/or simply had evil motives. If they were charismatic and could convince others to team up and do nasty acts, they could cause great destruction. However, individual actors were very limited in their reach. With great effort they could harm to a few others. Weirdness did not translate to far reaching effects.

Technology has greatly leveraged human capabilities. However, it has also leveraged the ability of individuals to cause great harm to many people. Anarchists more than 100 years ago began this using bombs to target populations. We were distracted for a while from this by wholesale slaughter by state actors and then the cold war and worry about state mediated thermonuclear annihilation. Now, this same phenomena is back.

It is hard to believe that single person human capability in terms of destruction can be scaled back. States may do their best to control armaments in the hands of their populace (with or without the second amendment), but progress in terms of miniaturization and energy concentration is not likely to stop. Research efforts to place more powerful and easily used tools in the hands of soldiers will invariably mean that the fruits of these endeavors ends up in the hands of ordinary people. It has happened with granola bars and it will happen with weapons.

I think this has happened to some degree in the past.  Throughout history, various parties have held monopolies on violence and those monopolies were disrupted by transitions of power and weapons into other hands. No state power means anarchy and chaos, while nothing but state power means totalitarianism. We do not want the constant war of every person against every other person but we do not want to cede total control to a unilaterally armed state because a few bad actors don't realize they are better off by giving up the right to annihilate those around them.

And what we are back to is the realization that people can be strange and unpredictable and we have to live with that.