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Responsibility

Responsibility. The word rolls around the tongue, then slips out. I’m confident my grade school classmate, who was never without her dictionary, would have looked it up and noted among myriad definitions terms such as “accountability”, “duty”, “control”, “act independently”, “requirement”, or “moral obligation.” While in these definitions assignation has been given to individuals and groups, the preponderance have been allocated to individuals. I fear in this day and age that is no longer the case as, in my opinion, individual responsibility has been subsumed by advocates for group/society/government responsibility. This is never more evident than in health care.

I am confident that you all are aware of the raging debate in healthcare–right vs. privilege. Pick your stance. Regardless of your opinion, though, responsibility cannot be avoided. I was privileged to be part of three excellent medical practices and with that came the responsibility to provide the best advice and care I could to my patients. They, in turn, had the responsibility to assess this advice/care, decide if it was worthwhile or not and, if the former, to follow through or continue with it. Was it their right or privilege as it pertains to their health? Does it matter? They still had the responsibility.

Let me give you several scenarios to think about with a question at the end of each one. Read each and spend a minute or so thinking about how you would adjudicate the outcome. I’ll then give followup.

A). A 65 year old man with COPD due to smoking one pack of cigarettes a day is found to have a single nodule (“spot”) in the upper lobe of his right lung. Additional testing strongly suggests this nodule is cancerous. He is felt to be a surgical candidate for removal of the right upper lobe. However, because of significant cough and sputum (mucus) production the patient was strongly advised to quit smoking for at least two months (literature support for this) and take his medications. Smoking cessation assistance was offered. Surgery would be scheduled after a reassessment in two months. Should surgery be denied to the patient if he doesn’t quit smoking?

B). A morbidly obese woman is evaluated at a reputable bariatric clinic for weight loss surgery involving gastric banding. She receives instructions in dieting, portion size, and exercise as this would be the type of regimen she would have to follow postoperatively. She is to return in 3 months for re-evaluation. Should she have the procedure if she does not comply with her instructions?

C) A 42 year old alcoholic has had multiple hospitalizations for complications, especially bleeding, related to liver disease from his ongoing drinking of alcohol. Over time he has had multiple non-surgical procedures to treat/control his bleeding and there is nothing left to consider other than a liver transplant. Should the patient be offered a liver transplant if he does not abstain from alcohol?

D) A 20ish year old patient has end stage renal disease due to a chronic illness. Dialysis is required 3 times a week. The patient routinely misses dialysis days showing up either at the dialysis unit or, more often, at the ER when feeling poorly. The patient has received counseling on numerous occasions but to no avail as the patient feels they can best decide when dialysis is needed. The patient understands that showing up as an emergency disrupts dialysis access for other patients as there is rarely a vacant dialysis bed or additional dialysis nurses available. This has been a recurrent theme for the past several years. The patient is again brought to the ER, moribund, and in need of urgent dialysis. Should the patient be dialyzed?

As you can see, in each of the above scenarios each patient had been given a responsibility for an action that would have had a direct impact on their health. So what did you decide? Thumbs up or thumbs down?

In “A” the patient returned after two months but attempts to quit smoking were minimal. Citing increased risk the surgeon declined to operate and offered alternative treatments. Desiring surgery the patient went elsewhere and had an extended hospitalization because of multiple post-op respiratory complications. In “B” if the patient had not complied with the instructions given at the time of her initial assessment she would not have had the gastric banding because, if she could not control her diet and portion size pre-op, it was highly unlikely she would have complied post-op and this could have lead to significant complications. In “C” the patient had been repeatedly advised that he had to be abstinent from alcohol for at least 6 months before liver transplantation could have been considered. He continued to drink and never underwent transplantation. In “D” the patient was dialyzed, recovered, and has continued to disrupt the health care system as before.

As you can imagine from the above scenarios, patients A,C,D, by shirking their responsibility to try to improve their health situation, only added to the burden and cost of the health care system (you paid for “A” {Medicare} and “D” {Medicaid}). And, yes, before you scream, “But people do try to be responsible and still end up with untoward results!”, I understand and agree. The key word is try, really and truly. To me, and to other physicians, fully recognizing the challenges that our patients face, only ask that patients try and, if need be (which is often the case), to keep on trying to improve their health. When that happens we’re there for them and will continue to provide the support and care they need and are more than willing to go that “extra mile” when we see the effort being made on their part. What wears us out is the patient who, implicitly implying their “right” to health care, takes no responsibility for their health, does what they want to do no matter how egregious to their health, and then shows up on the health care doorstep demanding, “Doctor fix me!”

(If you wish to leave a comment, click on the particular blog title on the sidebar. This will open up that topic again and at the bottom of the narrative there will be a comment section). Earlier blogs: Inaugural, Oscar, “That will be $108”, SODA POP, can be found with “search.”

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Medicare and Medicaid–a Physician Recipient’s View

If you are looking for a political statement, don’t read any further. If you are looking for an endorsement for one of the myriad health care plans being proposed, don’t read any further. If you want to get an idea of the effect payment schedules have on a physician’s bottom line, read on. As it is unavoidable, however, there will be some comments regarding hospital reimbursement as it is all intertwined.

I want to point out that in my first practice (1985-1992), a small single specialty private group, revenue stream went directly to the practice, in the second practice (1993-2008) it went to a multi-specialty clinic with a flow-through mechanism (not salary) to the physicians after expenses, and in the third practice (2008-2018) I capitulated by working for a large medical system for salary. So in the first two scenarios my take home was directly based on how hard I wanted to work and, the harder I worked, potentially the more money I took home, while the less I worked the less money I would take home. In the last scenario I knew that, as long as certain work requirements were met, my salary was safe.

Did you ever stop to wonder why many physicians are reluctant to accept Medicare and/or Medicaid patients? Did you ever wonder why physicians prefer not to have Medicaid patients as part of their practice? Did you realize that the biggest threat that physicians have to government run healthcare is the fear by the feds and others that physicians won’t participate in the program?

Imagine this. You are a provider of a particular service (plumbing, legal, car repair, etc.) and you contracted with “Particular Service Insurance (PSI)” agreeing to receive payment through this. You provide a particular service for which you charge $100 (unbeknownst to your client or insurer your total cost is $90). The PSI assesses your service as only being worth $80 and, according the the contract, will only pay 80% of what is felt appropriate, in this case $64 ($80×0.8). So you, the service provider, will get a check for $64, you bill the client $16 ($80-$64), hope they pay it (many don’t), “eat” $20 ($100-$80), while realizing that you don’t break even on costs. And in this case it really doesn’t matter what you charge–$500, $1000, $5000–for that particular service if the PSI stipulates that it will only reimburse 80% of what it considers it’s “maximal allowable charge (MAC).” But you raise your charge for this particular service anyway, say to $500, because you also participate in “Particular Service Alternative Insurance (PSAI)”, which pays 150% of the PSI maximal allowable charge. So now your charge is $500, cost is still $90, the MAC is still $80, and PSAI payment is $120 (1.5 x 80). In the first case you lost $10 and in the second gained $30 so it stands to reason that, as long as you have more PSAI customers than PSI customers, you can keep the lights on. What if your customer doesn’t have PSI or PSAI but is private pay? You provided the service and charged the $500. Your customer admits they don’t have the money and you respond with a generous 30% discount–now the bill is only $350! Let’s talk “payment plan.” There is one other consideration before leaving this topic, however, as it pertains to someone who has PSI but you, the provider, don’t participate. You could balance bill, meaning you expect full payment from the customer while PSI will reimburse their participant for what is allowable. Balance billing can work as long as the State where you have your business doesn’t prohibit balance billing but a number of them do.

The above is the bare bones mechanism for Medicare (PSI), commercial insurance (PSAI) and self pay (“payment plan”). There is one more health insurer, however, Medicaid. The basic mechanism for this is quite simple: charge what you want, Medicaid pays what it wants and payment is invariably below your cost. Talk about bad debt! Econ 101 points out that any business will always have a degree of bad debt but that if that debt exceeds a certain threshold the business will be adversely affected more and more to the point it can no longer be sustained.

So now your business starts to “cost shift” by charging higher and higher prices to mitigate Medicaid losses, offset PSI losses, and improve revenue by trying to bring in more customers with PSAI. The PSI company starts to gradually increase its MAC as it is realizing that PSI customers can’t find providers where the PSI is accepted. Despite this your true costs have also been slowly increasing and you are still losing money with PSI customers. The PSAI company, not be be outdone, also begins to negotiate lower reimbursement rates on the order, say, of 120-130% of the new MAC.

The following insert gives a nice summary and, while the information is somewhat dated, I highly doubt the trends have changed.

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A few examples:

In the late 1980’s our group took care of a Pennsylvania Medicaid patient who had suffered a perforated colon during a colonoscopy, underwent surgery, and was admitted to the ICU. The patient was transferred from the primary service to the critical care service (our group) for streamlining of care. While critically ill and experiencing many complications, the patient improved over time and 6 months later was able to be discharged from the hospital. Our group submitted a bill for $10,000 for the 6 months (daily management, after-hour bedside management, procedures) to Medicaid. Their response was something to the effect, “Services rendered were under a global fee system for which you have already been reimbursed.” The payment? $70.

During this same time frame our group, in conjunction with another non-hospital health care entity, began a program for chronic ventilator patients, the majority of whom would never live independent of mechanical ventilation again. The patients’ insurance was a mix of Medicare and commercial. We were good at what we did, the census grew to somewhere between 15-20 patients, and patients were happy. Unfortunately in this case we were too good at what we did and many patients lived more that a year. Why is this important? Because after a year most insurance coverage, including Medicare, “went away” as these were the “rules of the insurance game.” Once this coverage was gone patient insurance now came under the umbrella of Pennsylvania Medicaid. As time went on, as you could anticipate, daily costs far exceeded Medicaid reimbursement and the program folded.

As one last example in the above time frame Pennsylvania passed a law linking physician licensure to forgoing balance billing for Medicare patients. There was a large single specialty group in town who saw Medicare patients in their office but the vast majority of patients were commercial pay. In response to the law, the group adjusted its practice to limit (ration?) the number of Medicare patients seen in a given month, thereby freeing up additional slots for commercial paying patients while complying with the letter of the law.

In the 1990’s because of our location in Indiana our multi-specialty clinic physicians would see a number of Kentucky, Illinois, and Tennessee Medicaid patients, as well as those from Indiana. Part of the reason was the small hospital located across the street from the Clinic would accept these out of state patients in transfer, usually in a trauma related situation, or the patient would just show up in the ER for treatment often requiring hospitalization. Payments whether to the hospital or physician from you-name-the State were abysmal . The standing joke was that it cost more to mail the bill to the State than what was received in payment. This was especially so for Illinois. By the way, the hospital closed in the late 1990’s in large part due to lack of realistic reimbursement for services provided to Medicaid patients. (More and more I think this is happening to small hospitals–usually, but not exclusively, rural).

The above are just a smattering of examples; I am confident there are many more that could be listed by others. My purpose was to give you an idea of why there are doctors who are reluctant to accept Medicare patients and even more are reluctant to accept Medicaid. In part this is why there is an ever increasing amount of fraud with both insurances (typically services billed but never delivered), why doctors are abandoning private practice and joining large health care systems for a salary, and why fewer and fewer doctors are not moving to small towns to practice.

(If you wish to leave a comment, click on the particular blog title on the sidebar. This will open up that topic again and at the bottom of the narrative there will be a comment section).

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The Four Reasons

On a daily basis in physicians’ practices discussions regarding initiation, continuance, or withdrawal of care occur. While these can happen a physician’s office, not infrequently the more intense discussions occur in the hospital where there can be a pressing immediacy to arrive at a crucial decision. When a patient-doctor relationship has been on a long term basis that discussion, while potentially difficult, has a foundation of trust which can prove to be invaluable to both patients, their families and physicians. Unfortunately consultants and hospitalists (hospital based physicians) often do not have the luxury of having that relationship. We meet the patient and/or family for the first time and begin to hash out a diagnostic and therapeutic game plan. It is especially challenging in the world of critical care medicine as stresses and uncertainty can be high on both sides to begin with as the patient’s life is often in the balance. That needed foundation of trust must develop quickly regarding recommendations pertaining to initiation, continuance, or withdrawal of care. Decisions regarding any of them can be difficult, especially the last. Over my career I’ve come to appreciate that, at least in my own mind’s eye, there are four basic reasons that influence any particular decision by patient or family (or proxy) especially regarding withdrawal of care. While not mutually exclusive those reasons, along with some examples, are as follows:

LOVE I think the most common reason of all. The patient wants to do right to themselves but also family. Family wants to do right by the patient and themselves.

Consider the following: As a first year (1980) medical resident on call I was urgently summoned to the bedside of a man who had cancer metastatic to bone and lung. He was beginning to experience respiratory distress which, if it continued, would require transfer to the ICU, intubation, and initiation of mechanical ventilation. While arrangements were being made I was told by nursing that a rather large contingent of family were in the waiting room and wanted to speak to the doctor. As the attending physician had not yet arrived from home I was “the doctor.” Inwardly shaking as I was new to this side of medicine, I introduced myself to the family consisting of several brothers and their spouses and the patient’s wife. I explained the current situation regarding the patient and the plan to move him to the ICU. “Do what you need to do,” said one of the brothers in a firm voice with several others murmuring their assent. There was a moment of silence and then, in a very forceful tone, a voice cried, “DON’T YOU DARE!!” It was the patient’s wife who then explained that the patient had been in excruciating pain for weeks, only getting worse despite increasing analgesics, but “hung on” primarily for the benefit of family. My attending, who knew the patient quite well, by this time had arrived, concurred with the wife, and the transfer was stopped. (The family had also agreed to the final decision). So I present this as an example of love from several different perspectives and the influence it can have on medical decision making. It is also an example of how a long term patient-doctor relationship can defuse a potentially contentious situation.

GUILT One of those niggling little concerns that occupies a niche in the back of the mind of a physician is the unexpected arrival of a distant relative of the patient who, while “distant”, is still part of the family and wants to be part of the medical decision making. This is not as uncommon as one may think. It arises usually in the scenario of a patient who is critically ill, highly unlikely to survive, and with whom family discussions have been ongoing, especially regarding prognosis and increasing considerations for withdrawal of aggressive care while still providing comfort care.

Consider the following: At one time I cared for an elderly individual who had developed a severe pneumonia leading to respiratory failure, intubation, and mechanical ventilation. Her condition gradually became worse and organs began to fail. It was becoming obvious to me and to family members that recovery was highly unlikely and there were daily discussions regarding the advisability of withdrawing aggressive care while maintaining patient comfort. The family had been wrestling with this decision but was slowly coming to grips with the situation. They wanted to be sure that all family members were in agreement “to let her go” as long as comfort was maintained. Enter the distant relative, a sister, who lived afar, barely kept contact with anyone, and never visited until now after she had been contacted (out of courtesy) by one of the family. We met, discussed her sister’s condition and her ongoing clinical decline as well as the consideration for moving to comfort care only. I suggested she speak with her family members as a final decision should be made soon. As I had mentioned earlier, the family was on the verge of unanimously agreeing to comfort care only but, with the sister’s arrival, unanimity was lost. She steadfastly refused to agree to anything but ongoing aggressive care “to give my sister every chance.” As explained to me by a family member family cohesiveness was important and, even though the sister was “late to the table,” family was family and decisions had to be unanimous. Ongoing discussions were to no avail, even one to forgo CPR in case of a cardiac arrest. Several days later the patient not unexpectedly suffered the feared cardiac arrest and could not be resuscitated. Afterward, as they were leaving the ICU, a family member pulled me aside to explain the reason the sister was so adamant to keep going was that she felt guilty about the lack of interaction with her sister through the years and she wanted to try to make up for it.

HATE I have debated this to myself through the years wondering whether someone could be so despised that family or proxy would want the patient to experience ongoing suffering. Something along the lines of, “that SOB was so mean and hateful through the years that it is now time for some payback.” Through the years I’ve heard colleagues occasionally comment on some “crazy and nonsensical” decisions made by family or proxy regarding patient care as pertaining to continuing aggressive care in what was perceived (at least by the doctor) as futile, leaving them to wonder if this was “payback” time. Were these decisions out of love, or hate? As I do not have any specific instances that I can recall during my years of practice I have no specific example for the latter.

THE CHECK Social Security is a wonderful thing for many elderly individuals providing some, if not all, of their financial support. The support from Social Security Disability also has a financial role in the lives of many non-elderly people. Unfortunately that financial dependence can have an untoward effect on decision making by family or proxy.

Consider the following two examples: 1) I participated in the care of an elderly woman admitted to the ICU after experiencing a devastating stroke. It became apparent over time that she was not going to recover and discussions were held with the family on a daily basis regarding her ever increasing poor prognosis and consideration of withdrawing the support of the mechanical ventilator. All eventually agreed but requested a “stay” of a few days so that, obstensibly, additional family members could arrive to say their “goodbyes.” While this was partially true, one of the family confided in me that they wanted to be sure her Social Security check arrived and was deposited before stopping care. While not an overly big issue, it did result in several more days of additional expenses to her medical bill to be paid, in her case, by Medicare. Multiply this by repeated scenarios across the nation and…well, I leave any conclusion to you.

2) On several occasions I helped care for a young man, late 20’s or early 30’s, who several years prior to our initial meeting had suffered a broken neck. This resulted in quadriplegia and reliance on a mechanical ventilator. He lived at home with his live-in girlfriend (routinely introduced in this day and age as “my fiancee”) and their two children. She was a bastion of support but had her hands full between his care and the care of the kids. Recurrent infections, whether urine or respiratory, over time became more frequent leading to repeated and longer hospitalizations. A confounding problem was that the infections became more difficult to treat as resistant bacteria were coming to the forefront. As time went by the armamentarium of antibiotics shrank and eventually became exhausted. The girlfriend understood that there was little else to be done therapeutically. During his last hospitalization the patient could no longer participate in his care and discussions regarding withdrawal of the ventilator were with the girlfriend. There was no “push” from the medical side to withdraw but each day the infection would get worse and all knew it was a “matter of time” before the patient died. During one of our conversations the girlfriend brought up the fact that they lived on the patient’s Social Security Disability income and she did not know how she could “make it” without that support. She continued to delay her decision until mother nature took its course. I never knew if she was able to keep the SSD benefits or not.

So there you have it: the four reasons that influence decision making on the part of family or proxy–love, guilt, hate(?), “the check”. But before you go, let me leave you with one more example and let you decide the reason for the decision. To make it easier, it was not “the check.”

An elderly man was admitted to my service in the ICU with neurological symptoms, generically labeled as “altered mental status” for which there are a variety of possible explanations. As the patient was non-communicative, through the EMR we discovered several medical problems requiring daily medication. Ongoing review of his primary care physician’s notes lead to the discovery that the patient’s wife had died about a year ago and he was “lost” without her. He no longer enjoyed life and, while denying any thought of harming himself, told his physician that he wanted to live out his days in peace and would want no heroic care in any event–“just let me go”. Unfortunately the patient did not fill out a living will or other advanced directives. A son, from what I recall an only child, arrived shortly after the patient had been admitted and was quickly updated. Over the course of the next day a number of diagnostic studies were done but the cause of the patient’s symptoms remained elusive. During this time the patient was becoming less responsive leading to an increased risk of aspiration. I discussed this with the son, pointing out that usually in this type of situation intubating the patient is a prudent step to protect the airway as much as possible. I also noted the conversation the patient had with his physician. While we still had a window of time before a final decision had to be made about intubation, the son wanted to think about it overnight. He returned the next day finding his father no better or no worse and that we were still at a loss to explain the patient’s current situation. At the son’s not unreasonable request, it was mutually decided to proceed with intubation and mechanical ventilation “for a few days” until the diagnostic evaluation would be completed. I did explain to the son that at the end of the road would be a decision of extubation versus tracheostomy if the patient’s condition did not improve. I did remind the son again of his father’s comments over the course of the last year. At that time the son indicated to me that he wasn’t thinking about a tracheostomy. Shortly after this I rotated off service, filling in my counterpart about the service and especially this particular case. Time passed and I would periodically check with my counterparts regarding this particular case. Details after I left the ICU service remain sketchy but this I know: 1) the cause of the patient’s condition was never specifically found but postulated to be related to severe cerebrovascular disease, 2) the patient never woke up, 3) a tracheostomy was eventually done at the insistence of the son even though numerous physicians advised against this while repeatedly reminding the son about his father’s wishes to “just let me go” and, 4) the patient was eventually transferred to a nursing home. So, dear reader, I leave it to you to decide the reason for the son’s actions.

(If you wish to leave a comment, click on the particular blog title on the sidebar. This will open up that topic again and at the bottom of the narrative there will be a comment section).

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Housecall

“Let’s go.” I was still rubbing sleep from my eyes as my father and I piled into his Pontiac for a housecall. I’d looked at the kitchen clock before we left, 2:30 in the morning. As I have mentioned on other blogs in 1979 as a medical student I was doing an outpatient rotation with my father, a general practitioner, and housecalls were still part of his routine.

We lived in the country but quickly traversed the 6 miles to the town where he practiced. It was a small blue collar town with a large foundry as its primary employer. Rowhomes lined many of the streets and it was onto one of these that we turned. At the far end of the block we could see the flashing lights of the ambulance, beckoning us to arrive as quickly as we could.

Dad had briefed me about the patient on the way to the house. As I don’t remember the names of the family we’ll call them George and Emily. George had been one of my father’s patients for over 20 years and so was quite familiar with George’s health history. He was in his late 60’s with a longstanding history of heart disease. Several heart attacks left him over the years with progressive heart failure and a “cardiac cripple” leading to a poor quality of life. His wife, Emily, had called dad a short time ago asking he come as George was increasingly short of breath.

As we exited the car, dad “popped” the trunk, pulling out his medical bag. Inside were his tools of the trade, stethoscope, otoscope, sphygmomanomter, tongue blades, bandages, tape, analgesics (both oral and injectable), diuretics (oral and injectable), and antibiotics. All neatly compartmentalized and within easy reach. As we climbed the stairs and crossed the small porch to enter the house I noticed a few neighbors on nearby porches looking on. The foyer of the house was neat and tidy while in the background I noticed some areas of drooping wallpaper as well as a couple of religious statues.

Emily had greeted us at the door. Once in the foyer we could hear a commotion coming from upstairs. A rhythmic cadence of, “one, two, three…fifteen, breathe,…one, two…” Emily gave my father some additional information regarding how George had been over the last 1-2 days, sleeping more, ankles more swollen, breathing harder, culminating tonight with George in extremis. We quickly climbed the stairs and entered the master bedroom. George was on the floor undergoing CPR by the two members of ambulance crew. One looked up and recognized my father, “Hey, Doc (to everyone in town he was known as “Doc”), need some help,” as he continued his part of the resuscitative effort. “How long has he been down?” asked Dad. “Weak pulse when we got here, diaphoretic, gasping respirations and then, boom, out like a light. We started CPR right away, working on him for 20-30 minutes but no return of pulse.” With that my father simply said, “That’s enough, boys.” The crew nodded, stopped, and for a final time checked for a pulse that was nonexistent.

Emily had not gone upstairs with us. We descended to the foyer and my Dad offered his condolences and words of comfort. Both Emily and Dad knew that George’s heart failure would ultimately lead to his death and were comfortable with that understanding. As we were leaving, Emily called to my father, “Doc, how much for the housecall (I think his charge was somewhere between $5 and $8)?” Dad waved away her question saying, “I didn’t do anything so not to worry.” Her soft voice’s reply still drifts through my memory, “Sure you did, you cared enough to come.”

This was the only “true” housecall I ever made. Periodically I wonder what would have been different in this day and age. In George’s case summoning of the ambulance would have lead to the resuscitative efforts in the home, establishment of an airway, transport to an emergency room, and ongoing attempts at resuscitation if there had been no family physician to intervene. Would it have made a difference? I don’t know. George had end-stage heart disease known to family and family physician but not the ER docs.

So, excluding concierge physicians who serve only a very small segment of the patient population, a final thought: are “country docs” still making housecalls? Do they still “pop” the trunk to get their medical bags, filled with the basic tools of the trade and a variety of medications? Do they still provide sage advice to family or health care personnel in afterhour situation’s like George’s? Or have they succumbed, like many of us, to advising, “Go to the minute clinic/urgent care/emergency room,” in those afterhour situations?

(If you wish to leave a comment, click on the particular blog title on the sidebar. This will open up that topic again and at the bottom of the narrative there will be a comment section).

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On the Evolution of the Medical Record

He wouldn’t have survived. My father, that is, a general practitioner of 40 plus years who began practicing in the early 1950’s (see Inaugural). And the survival to which I refer? Whether or not he would have survived the transition from his office medical record system to an electronic one. Let me explain by tracing the path we physicians took with regards to the evolution of the medical record document by starting with the my father’s simple, but effective, system.

It goes without saying that medical records were handwritten for centuries. My father’s were no different. While confident that that there may have been some refinement in his medical record system over time, I can only spotlight the one he had in place when, as a medical student, I did an outpatient rotation (1979) in his office. The record consisted of a 5×8 lined index card upon which the date, chief complaint, and vital signs were written in by the nurse. After talking with the patient and completing a pertinent examination my father would fill in the blanks with a few historical comments, clinical findings, diagnosis, and either treatment or diagnostic studies to be ordered. So the information on the card would look something like this:

Oct 30, 1979 c/o: earache B/P 132/74 P 78. 2 day h/o throbbing left ear pain, low grade fever Exam: bulging red left TM, right OK, throat OK, H/L OK DX: left otitis media Rx: amoxil

Since he would see 40-60 patients a day (morning/afternoon/evening hours) he needed to record pertinent, brief, and concise information and the 5×8 card system sufficed. After the patient visit the card would be filed away until the next time. Thus was my introduction to outpatient medical record documentation.

I joined a single specialty (pulmonary/critical care) group in the summer of 1985. As we were a consultative service the understanding was that the initial consult, usually a letter to the referring physician, would be dictated but that any subsequent office notes were to be handwritten (dictation costs were substantial). The system worked but on more than one occasion it was a challenge to decipher a certain squiggle or abbreviation in the note, whether mine or one of my partner’s. Even so, patient care did not suffer.

Beginning in 1993 I moved to my second practice in Indiana. The multi-specialty group I had joined had a similar medical record policy, dictated notes/letters with the first patient visit, handwritten notes thereafter. Over time clinic sub-speciaists made arrangements with the clinic administration to allow us to dictate most, if not all, of our office notes in order to maintain our efficiencies in the office and permit us to better tend to our hospital and administrative duties. Dictation costs were always an ongoing issue, however.

My North Carolina practice (2008) had similar policies regarding dictation and handwritten notes. It was around this time, however, that the approach to medical record taking began to change for a variety of reasons. Payers were bemoaning the perceived lack of adequate documentation and health care providers were bemoaning the lack of access to medical records in order to provide timely care. With that in mind, allow me to say a few words about how things were and then comment on where things stand now.

Let’s first start with the purpose of the medical record. It is a repository of information, both current and past, in an effort to provide a story about a particular patient–the problem (history, etc), pertinent and succinct additional information, physical findings, pertinent diagnostics, diagnosis, and treatment plan. The record should then comment on the success (or lack thereof) of the treatment and what additional actions may need to be taken. Over time it can leave a legacy about the health history of any given patient that can be referred to on a periodic basis as may be required.

Regarding office records, whether it was my father’s 5×8 card, dictated reports or handwritten notes, payment by third party payers (private insurance, Medicare, Medicaid) was based on these. By these records doctors were essentially saying to payers, “Here is what I did; now pay me.” Third party payers would but, over time, began to feel (not without justification in some instances) that the documentation was inadequate to support the amount of payment. So different methadologies were developed and physicians were trained/counseled to try to keep up with the ever increasing and more complex documentation requirements. At its bare bones, the system consisted of a number of “bullet points” (e.g. histories {current, family, past medical}, exam {brief, pertinent, detailed}, medical decision making {simple, moderate, complex}). The more bullet points that ended up in the document, the better the justification for the charge. In many physician practices it was routine to have a compliance officer periodically review a physician’s notes to be sure they were “just right” as underbilling cost the practice money (third party payers were happy because they saved $) and overbilling could create a host of not inconsequential problems. The unwritten rule among physicians was if you were going to screw up the billing, underbill. The electronic medical record was touted as making billing better and easier.

Hospital records were also part of the evolutionary process from the written word to electronics. Initially most documents were handwritten with efforts to include the pertinent and avoid the superfluous (mostly successful on both accounts). In time many hospitals offered dictation ($$) for the admitting history, operative notes and, ultimately, discharge summaries. Hospital daily notes were different. Beyond the joke, many physicians have lousy handwriting and trying to decipher some squiggles in a note was frustrating and time consuming (the best interpreter of physician handwriting was the unit secretary). And hospital notes were often very brief. A surgical note might consist of nothing more than the comment, “Wound looks good; patient doing well,” but surgeons were paid a one time global fee for their service. A non-surgeon, however, was paid piecemeal, on work done on a given day which was justified by a note that better be more than just a one liner. Just as in the office, through the note physicians were saying, “Here is what I did; now pay me,” and, again, third party payers began to demand better and more complete documentation. Thus another impetus behind the electronic medical record (EMR).

Within the last 10 years there has been a huge push to implement an EMR. Congress appropriated millions of dollars to help physicians and health care systems purchase the hardware and software needed. Voice recognition systems became popular and so those entities with a computerized system could type their notes or dictate using a voice recognition system (while you could “train” the system to recognize medical terminology and phraseology often times what was said [despite training] wasn’t comprehensible to the system and gibberish would result–sometimes amusing but, obviously, confusing). Proofreading was always a requirement with dictation via voice recognition but could be laborious and time consuming and, with a full panel of patients, whether office or hospital, was often not done. Oh, for the days of “Battlestar Galactica” and Lorne Greene whose voice recognition system was perfect every time!

So, what are the positives about the EMR? Legibility of the note. Availability–no longer having to “hunt” for the chart (just a computer terminal). Quicker access to test results both current and historical as well as other historical information. More efficient rounding–prior to the EMR a physician would usually see one patient, write a note, and move on to the next patient. With an EMR a physician could now see a number of patients allowing more rapid assessments and interventions before sitting down to “batch write” their notes at one time. Off site review— If you were a physician in a (safeguarded) system one could review a patient’s chart or complete a daily note while at home (I knew any number of primary care doctors who would finish the day in the office, then have family time, and then spend time late at night completing their office documentation). If you were a physician receiving a patient transfer from another hospital in the system, pertinent records from the transferring hospital could be reviewed prior to the patient’s arrival. Payer review–third party payers could have an easier time finding their “bullet points”.

And the negatives of an EMR? Linkage–as software packages differ the EMR of one hospital system or physician practice won’t necessarily be able to “talk” with the EMR of a different hospital/physician system even if just across town, let alone in a different state, unless the software packages are identical and security agreements are in place. Cheating–hospital notes can be copied forward on a daily basis sometimes with minimal, if any, changes made thereby dulling the narrative. Hospital notes can begin to read like “War and Peace” when the requirements of a note, concise, pertinent, and to the point (a “Goldilocks” kind of note–just right) are ignored. Notes, whether office or hospital, can be preloaded with “bullet point” historical information and carried forward even though the information is not pertinent at that time. Most health care personnel make every attempt to do it right but there are some whose favorite words are “cut,” “copy,” and “paste.” Downtime–in the “old days” if a patient chart could not be located it was one chart and, while disruptive for that patient, no one else was affected. With an electronic system, if it goes down, then ALL charts are “lost” (at least for the moment) and significant disruptions on a variety of levels could occur until the system is restored. Cost–despite the previous federal subsidies I have no doubt that these systems continue to have an ongoing financial burden to any system or practitioner. Hardware, software, updates, support personnel to help the non-computer literate people (like me) address IT challenges–the costs add up. And it is to this that I want to make my final point.

I began this blog by stating that I didn’t think my father would survive with that survival related to the dawn of the EMR. His was a large primary care practice in a small town. I never knew his cash flow so I don’t know if the federal subsidy would have been enough to get an EMR up and running in his office, let alone how it would have disrupted the office work flow. But most importantly, with all the time consuming documentation requirements, I don’t think he could have continued to see those 40-60 patients a day. Fortunately he retired before all this came about, but I always wonder about current small 1-2 physician practices in those very small towns, away from the “big cities” and their large health care systems, who are trying to make ends meet and take care of their patients while dealing with an EMR. So what would have been the biggest compromise of patient care then, the 5×8 index card or the EMR?

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HOSPITALIZED SODA POP

Now don’t get me wrong. I like soda pop–all kinds. I have for over 60 years and will continue to enjoy an occasional one. While keeping that in mind though, before I comment further I need to momentarily switch gears and say something about cigarettes.

When I was a kid I would periodically accompany my father, a general practitioner (see Inaugural), on rounds at the hospital. Now my father smoked as did many physicians and nurses of the day. It was not uncommon to see cigarette smoke wafting through the air at the nurses’ station and doctors writing their notes while holding a lit cigarette in one hand. And it was not out of the ordinary to see a patient with a burning cigarette as long as there was no oxygen on in the room. Cigarette vending machines were also commonplace. Clearly all that has changed for reasons now well known.

Now back to soda pop. As commented upon in one of my previous blogs (Oscar) morbid obesity and super morbid obesity are becoming commonplace. Especially in recent years it was not an infrequent observation of mine as I entered this type of patient’s hospital room (or any patient’s room for that matter) to see one, if not two, if not more, sodas sitting on a patient’s bedside table. Regular size, individual size, and even an occasional 32 ounce size carbonated beverage would rest there. Sometimes brought in by family (especially the 32 ounce ones) but most often ordered from the hospital dietary department. More and more these sodas would be “diet”, lulling, in my opinion, the patient (or anybody else) into thinking that these could be consumed with impunity in the belief that they were “healthier” and the contribution to weight gain, let alone other medical problems (e.g. diabetes, heart failure), was negligible if not impossible. It became a common practice of mine to point out the potential problems that many of these individuals could face in light of their ongoing consumption and, not infrequently, I would remove them from the bedside table (sometimes throwing them directly into the trash to make a point). While there were some who acknowledged a new understanding that “diet” sodas may not be all they are cracked up to be, many didn’t care and the tables would be repopulated with soda the next day.

So why did I bring up cigarettes? Next time you wander through the halls of a hospital, as I have on many an occasion while making rounds, take note of the number of soda vending machines there are, or go down to the hospital cafeteria and see the available array of soda fountain options, or watch as a patient orders a soda from the hospital dietary department. My guess is the hospitals make significant money on selling sodas just like they used to with cigarettes while giving the patient what they want. So is health care sending the wrong message to patients just the way we did with cigarettes “back in the day?” Is it time for hospitals to be “soda pop free” just as they are now smoke free?

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“That will be $108…”

Several years ago one of my family members developed a respiratory tract infection that required an antibiotic. The prescription for a generic drug was called to the pharmacy of record and I went to pick it up. The pharmacy technician, smiling sweetly, looked at me and said, “That will be $108,” paused, then added, “Do you still want the medicine?” Taken aback my first thought was, “But I have private health insurance with pharmacy benefits…”; it turned out the $108 was my copay! My second thought, as I pulled out my credit card, was, “I can afford this, but how many people couldn’t and would have to walk away thereby risking their health even more?” The third thought was, “This was a (expletive) generic!”

With the above vignette in mind let’s now scoot down the rabbit hole of “transparency in medical pricing”, the new buzzword/slogan of the day on how to reduce the cost of medical care. Now don’t get me wrong, I’m all for it. But don’t think for a moment it will be the panacea for bringing down health care costs. So here’s my perspective.

Diagnostic radiologic tests, such as MRI’s, CT scans, mammography, ultrasound testing and the like should be amenable to this type of strategy. Just be sure you are willing to drive to wherever the best price is, that the study itself (not just the report) would be available to your physician to review if so desired and, if insured, that your insurance covers (at least some of) the cost.

Another area where there may be promise is for elective surgical procedures. Lasik eye surgery and cosmetic procedures are examples touted as to how price transparency can lead to greater competition and falling prices. Price compare that total knee/hip/shoulder replacement and review the quality metrics of the hospital and surgeon. Elective hernia repair, gallbladder surgery, open heart surgery–go for that comparison and priceline! Time is on your side to make an informed choice. But what happens when the best hospital or surgeon isn’t a participating provider in your health insurance? “Do you still want the medicine…” or are you willing to settle for less? It is one thing to forgo getting your nearsightedness corrected but that debilitating painful arthritic hip, bothersome hernia, or pesky coronaries are something else.

What happens if a surgical procedure isn’t quite elective? I once experienced abdominal pain severe enough for me to show up in an emergency room on a Friday evening. Evaluation lead to the finding of a severely diseased gallbladder with the recommendation for laparoscopic removal. Since it was not an overly acute situation, the surgeon would have given me the weekend “to think about it.” As I wasn’t feeling the best, I stayed and went ahead with the recommended surgery. From start to finish, ER, surgery, post-op recovery, my total stay in the hospital was 13 hours. My hospital bill was almost $40,000, a not insignificant chunk of which came out of my pocket. So, should have I gone home “to think about it?” If price transparency had been in place would I have availed myself of it–looked for competitive laparoscopic cholecystectomy “deals”?

What about the outpatient medical care side of things? In my first blog (Inaugural) I mentioned that my father was a family physician. At least until Medicare came into being his general office charge was $5 a visit ($7 if you got a shot) all the while seeing a lot of people and giving good service. If we had “price transparency” back then his rates would have been competitive and simple. Now in this day and age, it is anybody’s guess. There are currently 5 “levels” of medical office charges (level 1 the lowest; 5 the highest) depending on the complexity of the visit. Can the consumer really differentiate between the care provided at a level 3, 4, or 5 visit just by reviewing a priceline? By all means publish the prices but be sure quality metrics are displayed as well.

Last, but not least, is price transparency for drugs. I get it that big pharma has to make money to stay in business; I get it that patents run out; I don’t get the pricing. Fortunately there are already a variety of means to shop around for medications taken on a chronic or maintenance basis (e.g. antihypertensives, cholesterol lowering drugs, etc.). Drug discount websites are starting to pop up. I recently saw an ad in a local newspaper listing a wide variety of medications along with their prices from a Canadian website. As I perused the list and prices I wondered if these drug manufacturers were held to the same regulations that U.S. manufacturers are regarding drug safety, purity, bioavailability, and efficacy, or were the drugs purchased at a discount here in the U.S., shipped to Canada, then resold to U.S. customers. And how do you deal with the 4, 5, 6, or, now, 7 figure drug prices (think biologics, think chemotherapy meds)? It may mean speaking with your physician to see if that 6 figure drug can be replaced with a 5 figure drug with the same efficacy. It may mean a lot of bake sales or mortgaging the house or asking…”do you still want the medicine?” What about a drug that is needed for an acute problem (e.g. acute bronchitis)? Do you ask for a prescription that you can hand carry (meaning first a trip to the doctor’s office) to a pharmacy after you “price compare” or just have the prescription phoned in (office visit or not) and hope there is no sticker shock?

Where does one find the pricing information? What comparisons will it have regarding individual vs. employer supplied vs. no insurance? Will it be published on local, regional, state, or federal websites? Newspaper? Town crier? And what if a given patient has no access computer? And what if no one really avails themselves of the information? And will it truly lead to gradual price reductions?

So, have at it. It is at least a start. Every little bit helps to pull back the curtain on health care costs. Review those posted prices but don’t think it will revolutionize pricing. I suggest to you a recent piece in the Wall Street Journal (“Posting Health Prices Online Isn’t Cure-all; June 27, 2019; A5) for a nice summary of where we are with price transparency. Then go one step further and look at a one or two of the State websites listed in the article–eye-openers! Then decide if we’re down the rabbit hole.

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Oscar

We met several months after I had finished my fellowship in 1985 and joined a pulmonary and critical practice in Pennsylvania. With my addition there were now five in the group and responsibilities were rotated among three hospitals. It was now my turn to staff the relatively smallest of the three. This is where I met Oscar. I had heard about him but this was my first encounter.

Oscar was 500 pounds plus; no one knew for sure as he couldn’t walk down to the loading dock scales to be weighed (that’s how we did it in 1985). If he had been 10 feet tall he might have been approaching ideal body weight but he didn’t come close. Hospitalizations were a recurrent theme for him; morbidly obese with chronic respiratory failure (at that time just starting to be recognized as the Obesity-Hypoventilation Syndrome).

Oscar’s care was always a challenge. His recurrent episodes of respiratory failure had lead to placement of a chronic tracheostomy tube so the easiest part of his care was attaching him to a ventilator; ventilating him was a different story. There was a massive chest that had to move in order to get lung inflation and we were using “state of the art” ventilator settings that, today, would make any self respecting pulmonologist cringe. Venous access (superficial veins quickly evaporated and cannulating central veins was always an adventure) and nutritional support (yes, even though he was obese starving him was not a good idea) were ongoing issues that always posed difficulties.

Nursing care was the lynchpin in Oscar’s recovery. The ICU nurses were always dismayed when he was admitted because they knew what was coming. Strained backs and shoulders (there were no lifts for this size patient back then), skin care, bowel regimens, clogged tubes and a host of other issues were recurrent themes. Yes, they would grumble (try changing a bed with an essentially immobile 500 pound person in it) and bitch but never ignore what needed to be done. And, in time, Oscar would get better and go home. Backs and shoulders would get better; “Oscar stories” would be swapped; all while awaiting the next go round.

Why did I tell you about Oscar? Because in 1985, Oscar was a relative rarity. Not any more. The explosion of Oscars, termed “super morbidly obese” in this day and age, has lead to a sea change in health care. Many hospitals have installed (at no small cost) ceiling lifts in some ICU rooms to take the physical burden off nurses. Utilization of smaller portable lifts (again $$) was an option as long as a certain weight wasn’t exceeded. Transfers between hospitals not infrequently occured when morbidly and, especially, super morbidly obese patients exceeded the weight limit of diagnostic radiology tables at the transferring hospital. Whether inpatient or outpatient more and more of these patients with their chronic respiratory failure require sophisticated ventilatory support either with a respiratory device termed “BiPAP” (Non-invasive Positive Pressure Ventilation = patient/machine interface by mask) or a “true” ventilator (patient/machine interface by tube in airway) adding to the cost of healthcare. And this is just some of the issues on the medical side. Think about the poor surgeon needing to surgically invade the abdomen or chest of one of these types of patients.

Will things change? I doubt it. Processed foods, lifestyle, the sense of entitlement, and lack of self responsibility all play into the mix. There are even TV shows about super morbid obesity (albeit not necessarily glorifying the situation). Some people get it; some try to do what’s right; many don’t. Some are successful with weight loss; unfortunately, the majority aren’t.

Let me leave you with two stories and a final thought.

Sometime in the not too distant past our group (my third practice) received in transfer an “Oscar” from an outside hospital. The patient had had a large thigh abscess that needed some extensive surgery and the patient had been intubated for this. There was concern at the other hospital that the patient might experience complications after extubation and so the reason for a weekend transfer. Extubation at my facility was successful and the patient did well but still needed a bit of time in the ICU. On rounds I was speaking with his nurse who brought up a situation she had with the patient and family the previous day, Sunday. The family had brought in a 12 piece fried chicken dinner with all the fixin’s. The nurse explained to them that the meal would have to be eaten elsewhere as not everyone could eat in the ICU room at the same time. She was then informed that this meal was entirely for the patient as this was their custom on Sundays and that she best not interfere. She didn’t. There were no leftovers.

The heaviest patient I ever helped care for weighed almost 1000 pounds. Although this person was recovering from a brief illness, because of their weight a longer hospital stay was required. I commented to one of the nurses one day of how nice the patient was (some aren’t). Her reply, “Of course they’re nice because they’re totally dependent on others for their care and food.” So I started to think about who were this patient’s enablers–parents? friends? aides?–who would continue to acquiesce to requests for “food” when a large portion of what was eaten was in the “junk” category (this was confirmed by the dietitians at the hospital).

So, what to do? The universal prescription is, “Eat right, eat less, exercise.” While a small part of the patient population may have a disease with a predilection toward obesity/morbid obesity, the larger part doesn’t. The plethora of self help books, advice columns, dietitian counseling (my daughter, a dietitian, commented once that one of the most frequent responses to her advice is, “I know, I know, but…”), physician and nurse counseling, and event TV shows (…”Biggest Loser”) have done nothing to stem the tide. So, for too many the prescription for self discipline is not picked up leading to continued poor dietary habits, lack of exercise, continued sense of entitlement, and an ever increasing strain on the health care system.

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Inaugural

It’s time. Time, time, time. Almost 35 years of stimulating and successful medical practice in Pulmonary and Critical Care Medicine built on 4 years of medical school, 5 years of post doc training, bolstered by teaching and continuous interactions between physicians, nurses, therapists, administrators and, especially, patients now put to rest. The memories, observations, and perspectives generated over that time, however, will not be. These are the reasons for this blog with this, the inaugural. So I write as a release for me, for commiseration (perhaps) from physicians, and for the general public to provide, hopefully, some insight into how things in medicine were, and are. My opinions are mine and mine alone and not connected in any way to my prior three employers.

As part of this inaugural blog I think it best I share a little personal history as incidents from this will likely wend their way into future commentaries.

I am the son of a son of a physician. Grandfather was a surgeon (National Health), my father a general practitioner, and me. A poor start in college lead to some medical school waitlists but no acceptance. A year in graduate school lead to the conclusion that neither I nor the school thought it would be a good idea to continue. Through my father’s contacts at the local hospital I was hired as an “orderly” (1970’s) which now, in this day and age, would likely translate to “nurses’ aide.” I worked third shift (11P-7A) to get as much experience as I could. Two years later a fortuitous phone call from an uncle lead to me starting medical school in Guadalajara, Mexico. After spending another two years south of the border I took part I of the medical board exams, did well, and was able to transfer back to the States for my final two years.

As previously mentioned, my father was a general practitioner (one year post doc training) building a large practice in a town of 13,000 beginning in the early 1950’s. Rounds at the hospital every day followed by morning, afternoon, and evening office hours Monday through Friday (he took Wednesday afternoons as down time) topping off the week with Saturday morning office hours. Housecalls were also part of the mix as were patient calls to our house (two phone lines, one for patients, the other “private”, each with distinctive rings). All of this plus deliveries, periodic ER call, and administrative duties at the hospital. Despite the work load he made most of our ball games, all graduations, and even found time for fishing.

I recall having conversation with my father sometime in the early to mid 1970’s about medicine. He was of the opinion that “medicine isn’t what it used to be” citing more government intrusion (beginning with Medicare in 1965) and gradual loss of physician autonomy. I countered with my observation that I would be entering medicine at “this” particular point in time and could only count on my perspective going forward. Now, as I was closing the chapter on my medical career, when asked by my younger colleagues and housestaff about my time in practice I would respond, with some bemusement and astonishment, “medicine isn’t what it used to be,” echoing those prescient comments from many years ago.

So, to close, “medicine isn’t what it used to be” will be the general theme underlying future writings. Positives and negatives will be commented upon and no attempt at apologetics will be made. I do plan to have some fun with this, however. Enjoy.

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