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Wednesday, June 29, 2011

Physician extenders

I think the use of physician extenders is a great and necessary idea and will enhance patient care if deployed correctly. However, it is not being uniformly deployed in such a way. Extenders should do tasks which do not require skills which can only be acquired via more extensive training. Extenders should not be used to deal with problems beyond their training and skills.

What are extenders used for in the real world. I see circumstances where extenders are used very appropriately. However, more often I see extenders used for simple financial reasons. Low margin endeavors induce physicians and health systems to use lower cost extenders, no matter how complex and difficult the task.

The worst offenses involve the use of extenders to manage patients before or after procedures. Expensive proceduralists, who in order to cover their salaries must spend their time doing high margin activities, cannot be burdened with the responsibility of preparing their patients for or caring for their patients after they are the recipient of procedures.

I do hospital consults on a regular basis and I see some of the sickest patients you can imagine. They have undergone solid organ transplants, bone marrow transplants, or have decompensated after long bouts of chronic disease and toxic therapies. Some of these patients are cared for primarily by hospitalists. Others are the responsibility of extenders under the supervision of physicians whose primary expertise lies in the operating suite. While some of the extenders I work with are remarkable clinicians who have developed remarkable expertise, others have simply been put in situations which has not allowed for the development of requisite professional competence, yet requires them to manage remarkable complexity. We end up with very odd lines of authority where extenders on a given hospital floor ostensibly answer to an absentee attending physician while the defacto attending is the consultant dejour who may be called in to put out some particular fire that day.  

The same thing happens in the ambulatory setting although perhaps the stakes are much lower. A substantial portion of the most complicated outpatient referrals I receive show little or no evidence of any MD involvement in the records forwarded. When I ask the patients who they saw, it is rarely if ever the physician in the practice. In these cases I virtually never receive a call from the physician involved. Communicating with your colleagues is also a low margin activity.

The reason is clear. The services delivered complicated patients which require synthesis of information, weighing of options, and nuanced thinking are low margin services. These services will be delegated to lower paid professionals no matter how complex they might be.  A payment system which assigns low value to these activities virtually guarantees they will be increasingly performed by lesser trained personnel, no matter how difficult or important the task may be.

July 1 transitions

July 1st is approaching and with it comes the transition of close to 30,000 positions involving resident physicians and those doing clinical fellowships. There was a point where all that was required was to show up. It was wise to bring your toothbrush if you might be on call the first day.

The world has changed. There are hours of training for the proliferation of electronic medical records. Many training programs may be sited at multiple hospitals and clinics, each having its own unique and quirky medical records.  There on line courses in privacy, infectious diseases, safety, harassment, cultural sensitivity. There are security cards, keys, pictures, and an endless series of site specific details.

The July 1 disruptions were famous even before the new challenges the new complex transitions provide. Housestaff  always carry some real patient care load responsibility. While concern has been voiced about duty hours and their effect on safety, imagine how the yearly workforce disruption should be viewed.

Given the complexity of onboarding all these candidates and requiring them to transition and start all at the same time, why do we continue to do business this way? Would it not be wiser to stagger transitions? What other business conducts itself this way? I can think of none and for good reason.

Morphing triangles into lines

I have previously blogged on how messy triangles can be, whether economic or relationships. The three-way transactions in health care create all types of problems in terms of mission and resource allocation. Patient motivations to over-consume at the all you can eat health care buffet, encouraged by the pay per click culture are leading us to bankruptcy.

Today Pittsburgh insurer Highmark announced it was to acquire a large chain of hospitals in western Pennsylvania. This is an interesting scenario. When health systems and payers form single entities, it goes a long way to eliminate the three way economic transactions in the health care economy. We end up with patients who pay for a service and health systems which provide that service for some sort of fee. How the fee is structured and what it actually pays for is up for grabs. I suspect it will be some sort of hybrid where the public will pay up front for something and then be nickeled and dimed to death when they find that everything is ala cart.

I suspect it will not be so simple to pull this off. We are talking about the merging of two different types of business with two very distinct cultures and business models. The product of these mergers is will either be a company which uses a health care delivery system business model and culture or an insurance model and culture. In some sense, the ACOs model is attempting to do the same thing, encouraging partnering of traditional payers and those who deliver services to patients, primarily to limit cost although some lip service is devoted to safety and quality. It is easy to measure money and difficult to measure relevant quality and safety metrics. Success will primarily be measured financially.

In each case, the last entities standing will be ones which adopt the most of the insurance company culture and business models. Hospital business plans for the most part look to bill aggressively and focus on high margin (expensive) interventions. When payers and providers merge into single entities, these activities just represent cost centers. I suspect that insurers will look at hospitals they acquire like any other business entity would new acquisitions.  Hold on to the assets that bring value to the company and gut the rest. Hospitals cost insurers great amounts of money. When they acquire hospitals is there any reason to think they will not still cost them huge amounts of money?

Obviously some elements of hospitals will need to exist in order to deliver services which bring value to patients. The question is, what are those services and who and how will they be delivered? It is easy to predict they will be delivered in such a way that will cost the least amount possible. Pressure from government may come to bear to force these merged private entities to deliver high end services. I doubt this since both the Feds and states will be looking to save money in the health care realm. They are unlikely to champion expensive interventions when they will also be earnestly exercising cost control. 

With the evisceration of hospital power, where will still be a need for physicians and other health care professionals. In contrast to the current state, those who will be most valuable will be those whose activities will bring the most value to patients while costing their health systems the least amount of money. In the present hospital culture, those who bill the most are celebrated as the rainmakers. In the future culture where insurers run hospitals, these physicians are just overhead. Those who have the knowledge, know how, and processes to care for patients in low cost settings will control the resources. 

How quickly will this happen? Someone will get the rules right. If early hospital/insurer mergers show financial windfalls, there may be a stampede to the merger altar. Free standing insurers without linked health systems will be at the mercy of integrated systems. Similarly, health systems without captured covered lives may also find themselves out in the cold. 

Survival will require flexibility, nimbleness, and ability to ruthlessly cut costs. Those who can cut costs while also demonstrating quality and safety will be the new nobility of health care. Those who just cut costs will be part of a large commodity business.

Saturday, June 25, 2011

Allocation of the scarcest resource of all...time

I am a fan of Robert Centor's blog, DB's Medical Rants. I think the title is somewhat misleading since I view a rant as the product of simply blowing off steam. Dr. Centor's "rants" are almost always more thoughtful and provocative than the term rant would imply. In a recent piece, he makes a link between time and cognition:
A recurrent theme here is time.  One must take enough time to take a history, do a physical exam, and consider the problem.  Cognition does take time.  Cognition can save money.  If we paid cognitive only physicians for their time, perhaps we would need less tests.

If the health care system is to be efficient and provide value, it should provide incentives to optimally convert time expended to value to patients. In this realm, it fails miserably. Dr. Centor's astute observation is just part of the puzzle.

Let us think about other scarce resources and how mechanisms in place drive us to wise use of them. The reality is for most scarce resources scarcity is local. That is why market allocation mechanisms work better than all other approaches. Markets can react to local conditions to place value on specific items. Take water for example. There is little premium paid for fresh water in Minnesota but a marked premium which may be required in Death Valley. If water prices were set administratively as prices are set in much of health care, there would be no way to appropriately price water in both contexts. Undervalue water and it simply would cease to be available in the desert. Overvalue and people would overpay where there is no scarcity. 

How can this be applied to time and in particular time within health care interactions? How is time valued within health care? It depends upon whose time we are considering. From a physician's perspective, the return on his or her time investment depends upon a payment system which is divorced from the value actually actually delivered to specific patients. For me, I almost invariably see time committed to thinking about what I am doing translating to lower rates of financial return. Think more, lower your income.

As Dr. Centor notes, cognition is associated with saving money but the issue is who benefits from this? The sad reality is given the present payment scheme it is not the physician. For the most part the more I reflect upon what I do, the less I will test and intervene. My own practice experiences may provide evidence in only a narrow clinical realm but I suspect this conflict of interest permeates throughout the entirety of practice. The more one uses one's brain, the more these fundamental conflicts become apparent. Granted a specific patients may fulfill data driven (or more consensus driven) criteria for a particular intervention, but does this patient really benefit from colonscopy, angiography, stents, MRI, breast biopsy, prostate biopsy, skin biopsy, chemotherapy, CAT scan, ultrasound, PSA, or whatever? More specifically, is it worth my time as a physician to invest the time to even raise these questions? From a financial sense the answer is unquestionably no. Going farther I will venture to say that too much cognition in this realm is financial suicide.

Thinking may deliver value to patients but use of cognitive tools will be an increasingly rare event if deployment of these tools rarely rewards (or event punishes) those who use them. One would think that a payment system which creates a scarcity of cognition would also allow for some sort of escape mechanism. Unfortunately, patients are generally not in the position to deploy their own resources to reward cognitive work. Until recently, physicians simply could not accept additional monies outside of the conventional payment system unless they withdraw entirely. Retainer medicine has provided an alternative model. For most physicians, it is simply easier to focus on narrow high margin medical interventions and cultivate the strategic incompetence which allows them to avoid substantial cognitive work. Oddly enough, it is the innovators who have struggled to maintain the importance of cognitive approaches  through retainer medicine who have been criticized for not living to up to their obligations to society. How ironic to be victimized both my the payment system and for their attempts to deliver what delivers real value to the public.

For time to be valued, it has to be valued by those who derive value from it (patients) in a way where the value of specific time blocks is context specific. One size will not fit all. The IPAB will get it wrong more often than it gets it right, much as the RUC before it. Rational and imperfect people will respond to incentives built in and the behavior of the few physicians who most successfully game the system as it relates to investment of time will quickly spread to become the norm, well before any command and control system can respond.

In an ideal world patients with problems best addressed by with action will be able to find physicians of action and patients needing a more cognitive approach will have access as well. The value of the respective approaches is dependent upon the context. The question is how do we get there?  Markets are the best tools now available to respond to the value question in a context specific manner. Until the market deniers in health recognize this, time as well as all other scarce resources in health care will be squandered.

Tuesday, June 14, 2011

Thoughtful vs. not thoughtful/Effective vs not so effective


There is no question as to which approach is MUCH more effective, even if it is short sighted and wrong. Politics trumps truth, every time. Move problems into the political realm and they will be decided by emotion as opposed to data, perception as opposed to reality, and the appearance of truth, whether true or not.

Wednesday, June 8, 2011

The Radio Fence Principle

My wife and I get out to walk around the neighborhood. Sometimes we take our dogs, sometime not. I remmeber as a child that walking around the neighborhood could be a dicey activity since many of the dog owners simply left their dogs to run. That simply does not happen any more where we live.

One tool which is used to confine dogs is the Radio fence. It is really an amazing device and I marvel at how well it works. I think there is are deeper principles which we can learn from the electric fence.

Why do these devices work so well? It is because they do two things extremely well. First, they provide warning when your pet is approaching a boundary which they should not cross and the warning gets more pronounced as the the pet gets closer to the boundary. Second, the consequences of crossing the boundary are consistent and substantial.  Pets guided by this technology get robust and consistent feedback

I am not one to suggest that people would be better off if our lives were so constrained and defined and every realm we operated in was bounded by such bright lines. However, I see the consequences of lack of feedback everywhere in the human world. We look at the latest scandal in Washington and I can only wonder how Representative Weiner could do such a stupid thing? The answer...lack of feedback. He had been doing this for a while with no particular consequences or warning that he was venturing out of the bounds of acceptable behavior.

Within every profession, there are individuals who push the envelope on acceptable activities. Rarely do they get early (or any) negative feedback from their peers. The mortgage business melted down because there was little useful feedback when an entire industry wandered down a financial dead end.  The King of Torts Richard F. "Dickie" Scruggs , former A6A naval bomber pilot, prominent trial lawyer, and the brother-in-law of former U.S. Senate Majority Leader Trent Lot pleaded guilty of bribery in 2008 and was sentenced him to 7 years. Dr. Mark Midei, a Baltimore Cardiologist purportedly implanted stents in hundreds of patients who did not need them. In each case described above, the perpetrators were not called out early for their behavior, they were in many cases idolized by their peers for their financial success. They were celebrated as being at the top of their games until they were indicted.  Within medicine, peer review is supposed to keep such impulses in check. Bob Wachter blogged on the inadequacies of the present system when Dr. Midei's case hit the press.

The lesson of the radio fence is clear. Any system which does not combine consistent feedback in the form of consistent warnings and consistent consequences will fail. Bad outcomes is often followed by the cry for more rules. However, more rules will not accomplish anything if they create more ambiguity in terms of lines which cannot be crossed and are not accompanied by tools allowing for consistent enforcement.

The Political Class and Trust

At the Hot Air I came across a link which posted a video Representative Weiner in full denial mode prior to having to fess up to his Twitter shenanigans.  The video is remarkable in that Representative Weiner projects remarkable confidence bordering on arrogance. It is hard for me to understand how such a mind works. We now know that he was simply expressing one lie after another, yet he was able to project complete confidence in his claimed role as victim of a cruel hoax.

The debates regarding the role of character in the political class are endless. However, I believe that Michael Rizzo on Unbroken Window has hit the nail on the head
You have to click through and watch the video of him getting apoplectic that this was some vast conspiracy against him in light of the evidence we have now. And I am supposed to trust these clowns with health care reform, making budget deals, honestly appropriating highway funds, passing regulatory reforms, etc?    
This is the reason that the reach of the state and politics needs to be limited. Those who are most successful in this realm are the least encumbered by ethical baggage which facilitates trust. Hayek understood this when he noted that the more power is concentrated, the more the least trustworthy element of society will seek to be control that power. It is a dangerous combination for the least honorable element of society to be placed in a realm where they are given more and more power and less and less accountability.

Saturday, June 4, 2011

Awash in the wrong data

I had a meeting a few weeks back with one of the business people at my institution who acts as a liaison with the IT group. It was was rather enlightening. He had a wealth of information regarding the strengths and weaknesses of our institution and a different perspective from my own.  I have my own vision regarding how we can use technology to interface with and collect information from patients in a structured way and how this shift could change how we do business.

 I am consistently struck by how often I am placed in clinical situations where I am required to address patient's questions where I have little or no real data. How often does this intervention work? How quickly can I expect to see results? What side effects can I expect and when? When I described this observation to my IT/business colleague, he was surprised. In his world, the problem he faces is more often too much data. How can we have too much data at the same time as what appears to be little or no data relevant to the needs of patients and clinicians at the point of service?

The answer is both observations are true. While we may collect mountains of data, little of it is actually collected from patients and the quality of the data collected at the point of service is simply dismal. In particular, the work flows linked to ambulatory patient encounters basically guarantee that the information collected will be at best sketchy and more often than not simply wrong. When patients are referred to me, the notes fall into two basic categories; unreadable hand written notes or computer generated templated notes which may be readable but are devoid of actual useful content. You can mine either of these sources for data and it is likely to be useless.

When patients or referring offices call to set up an appointment , there is little effort to actually identify the reason for the appointment. The idea is to secure an appointment, any appointment with any warm bodied provider with any available time slot. Wrong doc? Not enough time? Insufficient information regarding what has been done before? No matter. As long as the slot is filled, the co-pay collected, and the documentation sufficient to justify the billing, everything is copacetic. I am awash in data showing my scheduled to arrived ratio, my no-show rate, room utilization, and information on waits and delays. I have no idea on who actually calls us and what the nature of their problems are. I know what books of business that we want to expand because they are profitable. I have not idea of what services I need to expand because patients actually want and need them. We do not collect that data. I don't think anyone does.

This situation can only be fixed by changing the work flows associated with ambulatory encounters. However, when I outlined my approach to fixing this, my business/IT colleague had one question for me. "How are you going to monetize this?"Collecting information in a structured format from patients in an ongoing fashion between encounters will take IT resources, equipment, time and money. How can we pay for this. Surely something which brings value to patients can be monetized.

Actually not under the present business model. In many respects, health care entities may be better off not collecting this type of data since we might find something which forces us to respond. There is no CPT code for being more responsive to patient needs or wants. Creating a system to get rapid feedback from your customers is only good for the respective business if they can leverage improved information into a more profitable business model. At this point the there is no way to monetize such an innovative approach. It will not happen until it makes good business sense.

Clayton Christensen talks about the entrance of the mini-mills into the steel industry, focusing on rebar steel. It was the perfect product having no specs and it was buried in concrete so no one could check if it was really substandard. In the ambulatory medical world where there are few if any specs, ambulatory care begins to look like rebar steel. With rebar, the measures of quality are whether the building falls down, a pretty uncommon event. With health care, we focus on high stakes yet infrequent events for any one specific person (like life and death) an ignore whether what we do on a day to day basis may waste people's time and add little or no value to most people we interface with. We simply do not collect the information we need to address such questions.