The New HMO Fiasco

There is no more perverse, more derailed concept in today’s health care environment than fee-for-service. Even Wikipedia knows true evil when it encounters it. Let’s read their definition:

Fee-for-service (FFS) is a payment model where services are unbundled and paid for separately. In health care, it gives an incentive for physicians to provide more treatments because payment is dependent on the quantity of care, rather than quality of care. Similarly, when patients are shielded from paying (cost-sharing) by health insurance coverage, they are incentivized to welcome any medical service that might do some good. FFS is the dominant physician payment method in the United States,[1] it raises costs, discourages the efficiencies of integrated care, and a variety of reform efforts have been attempted, recommended, or initiated to reduce its influence (such as moving towards bundled payments and capitation). In capitation, physicians are discouraged from performing procedures, including necessary ones, because they are not paid anything extra for performing them.

And yet, year after year, American health care has managed to stay afloat with this supposedly deranged scheme. In fact, provider payments have continued to spiral lower even as the overall cost of caring for our nation has increased dramatically. By most estimates, physician services only account for 10%-15% of annual spending.

Read the rest of my post at The Medical Bag.

When In The Course

As high school teachers go, he was an anomaly.  A rare mix of humor and excitement, he was able to extract from his students the last ounce of concentration left at the end of a busy school day.  He taught my United States history class.  Long after I had collected acceptances from colleges my senior year, I sat engaged and learning a subject I frankly had little interest in.

He was constant energy.  He zoomed about the room, the tempo of his voice nearly as erratic as it's volume.  The attention demanded by his motion was only second to the content of his lecture. He made history both intoxicating and palpable.  A memorizer of theorems, a solver of equations, I struggled to imbibe the spray of knowledge shooting in my direction.

I never studied so hard, and yet looked forward to each and every lesson plan.

One afternoon he walked into the classroom and wordlessly turned on the overhead projector.  I read quickly through the large text on the screen:

When in the Course of human events, it becomes necessary for one people to dissolve the political bands which have connected them with another, and to assume among the powers of the earth, the separate and equal station to which the Laws of Nature and of Nature's God entitle them, a decent respect to the opinions of mankind requires that they should declare the causes which impel them to the separation.

We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty and the pursuit of Happiness.--That to secure these rights, Governments are instituted among Men, deriving their just powers from the consent of the governed, --That whenever any Form of Government becomes destructive of these ends, it is the Right of the People to alter or to abolish it, and to institute new Government, laying its foundation on such principles and organizing its powers in such form, as to them shall seem most likely to effect their Safety and Happiness. Prudence, indeed, will dictate that Governments long established should not be changed for light and transient causes; and accordingly all experience hath shewn, that mankind are more disposed to suffer, while evils are sufferable, than to right themselves by abolishing the forms to which they are accustomed. But when a long train of abuses and usurpations, pursuing invariably the same Object evinces a design to reduce them under absolute Despotism, it is their right, it is their duty, to throw off such Government, and to provide new Guards for their future security.--Such has been the patient sufferance of these Colonies; and such is now the necessity which constrains them to alter their former Systems of Government. The history of the present King of Great Britain is a history of repeated injuries and usurpations, all having in direct object the establishment of an absolute Tyranny over these States. To prove this, let Facts be submitted to a candid world.

It was the first two paragraphs of the declaration of independence.  Our assignment was to memorize the words.  Then we would have five minutes to write the paragraphs by rote memory.  The groans and sputters from the students lasted nearly the whole class.

Each night I sat with paper and pencil.  The first few days were spent memorizing.  My surprise, however, was that speed was also an issue.  Not only did I have to know the material, I had to be able to spew it back on command.  Occasionally my hands would cramp, and I would have to stop for a few minutes and rest.

By the day of the quiz, I must have written those paragraphs hundreds of times.  I and my classmates  finished with just seconds left.  Our teacher dutifully walked up and down the aisles collecting the loose-leaf papers covered with mostly illegible sprawl.  And then he paraded up to the front of the classroom, and with great pomp and circumstance he threw them into the trash.

The collective gasp was interrupted by a particularly brave girl in the front row.  She wanted to know why it was so important to memorize the words when we could look them up.

The teacher smiled wryly and a sparkle flashed across his face:

One day there may no longer be paper, or computers.

We all sat dumbfounded wondering if our beloved teacher had finally fallen of his rocker.

But strangely enough, years later, I still have those words deeply ingrained in my memory.

When in the course of human events... 

Maybe he was trying to teach us that the tyranny of despotism was not something read on paper but carried in one's bosom.  Our forefathers didn't need to memorize words because the fight for freedom and equality was emblazoned on their backs from personal experience.  Generations later, prospering from the battles our ancestors won, my teacher wanted his students to hold these ideas (and words) as dear as those who originally wrote them.

This is our foundation.

I find so many parallels with what is happening in medical education today.  We love to dispense with the old ways in favor of all that is new and shiny.  We are starting to talk of discarding large chunks of medical education as irrelevant.  We have mostly abandoned physical exam skills due to the flexibility and ease of diagnostic testing.

And I see my old teachers standing in font of me as if they were addressing a high school US history class:

What if there were no CT scans?

Is Medicare Unnecessarily Complicated?

I had one crowning achievement during my college career. Freshman year, I took the most challenging course the university had to offer. I still wake up in the middle of the night in a cold sweat with differential equations flying through my brain. Advanced calculus not only had a difficult subject matter, it also had a professor known for challenging even his most avid students.

I remember tackling the material with a voracity that I had never displayed in my course work before. I ate, slept, and inhaled the complex mathematical formulas. I couldn’t believe my eyes when I got the final grade back. 

A+.

Over the years, I have used the same skills gleaned from this class to build a successful career: hard work, methodical attention to detail, and a fastidious sense of organization. For the most part, I have been able to thrive in most settings. There have been few hurdles that I have not been able to eventually leap over.

Little did I know, however, that I would face my greatest challenge this year as I formed my own medical practice. For the first time, I was solely responsible for all the administrative work and credentialing with Medicare.

And it’s been a comedy of errors....

Read The rest of this post at The Medical Bag.

Losses and Gains

Loss is something all humans face in their everyday lives.  As a physician, the effects are often magnified.  People die, they move away, they graduate from your services, or occasionally they pursue care elsewhere.  Parting can sometimes bring relief, and others a deep sense of failure.  But with Clara, I'm not sure we actually parted.  Mostly, I was left with confusion.

Clara came to me by way of the nursing home.  Her family had brought her to the hospital when she became too weak to rise out of the reclining chair in her living room.  The hospital stay was short.  Multiple diagnoses were made: dehydration, deconditioning, and a urinary tract infection.  Her  transfer to the the skilled nursing facility was meant to give a few weeks of therapy to gather strength.

I came to see her from time to time.  Clara liked the personal interaction of the therapy room, but her daughter was unhappy with the pace of improvement.  We had a family meeting and adjusted the treatment plan accordingly.  I explained that Clara was well into her nineties, and sometimes improvement was not as fast or complete as we wish.  Her daughter heard my words, but seemed reluctant to agree with such uncertainty.  She was sure her mother just needed more pushing.

One night, I got a call from the nurse on duty informing me that Clara had fallen,  I came early the next morning to evaluate.  The staff had reported no pain at the time, but when I entered her room I new immediately that the hip was broken.  Her lower extremity was deformed and rotated inward.  We called an ambulance, and she was taken to the hospital.

I visited Clara everyday.  I discussed with her surgeon and family the prognosis.  The operation was a success, although Clara developed an infection and had to stay a few days in the intensive care unit.  Eventually, I wrote the order to transfer her back to the nursing home.

The head of nursing called later that day to tell me that Clara had decided to switch physicians.  Since we had formed what I thought was a strong doctor-patient bond, I took the news poorly.  A few days later she wheeled into me while I was leaving another patient's room.  She apologized that her daughter had demanded that she change physicians, and hoped I would continue to stop by and see her socially.

Over the next few months I interacted with Clara more than ever.  She searched me out at the nursing home, and showed off her progress each time.  First she was able to stand.  Then walk.  Finally she was chasing me up the stairs.

And I marvel now at how once again I lost a patient,

and yet this time gained a friend.

Is Doctoring Easier For Men?

She was everything one could ask for in a medical resident. During the few weeks she had been shadowing in my office, I found her fund of knowledge to be exceptional. Her intuition was right more times than not. And she negotiated the fine line between detached clinician and caring advocate. My patients loved her.

Did I forget to mention that she was exceptionally attractive? I hope so. I really feel that such things have little relevance in medical training (or life in general). Sure, I could tell that she was careful about how she presented herself. She dressed over-conservatively in an attempt to deflect attention from her looks. I occasionally noticed a prolonged stare by a young patient or a twinkle in an elderly gentleman’s eye, but for the most part everything ran smoothly.

Read the rest of my post at The Medical Bag.

The Spoils Of War

There was once a kind and merciful General.  His joy of the study of war could only be matched by his love for the soldiers who trained dutifully beneath him.  Day in and day out, he could be seen in the barracks beside his men.  He was both dogged and forgiving, relentless but affable.  His mind was laser sharp, and his physical agility could match that of any of his much younger recruits.

He was a nationalist.  More willing to devote his life to the calling of country than to risk those of the young people who gathered around him.  So his attention to detail was incessant, his expectations for his pupils absolute.  His men both feared and adored him.  Their greatest dread was disappointing the man who placed so much energy into their training.

And this General gained the reputation of having the tightest, most well trained crew. Their physical abilities only outmatched by their mental toughness and strategic planning.  Other troops vied to join this proud gathering of young men.  Many found that they were not tough enough, their skills too weak.

Because of his great ability and courage, the General was often asked to lead his men into battle.  He studied each engagement with great concentration, and spent many a night locked away in his office trying to divine the infinite possibilities of war.  He did not take such responsibilities lightly, and felt the acute sting of placing his troops in harms way.

There was one painful truth to being the General.  While he studied maps and battle formations, it was his men who put their lives on the line.  He encouraged, threatened, and persuaded such young hearts to risk all for him.  For country.  

He had once done so.  He had watched his brothers fall in battle beside him, and yet carried on.  He had tasted both blood and sweat stream from his own brow.  He had seen many victories and quite a few losses over the years.  He survived long enough that eventually he was promoted out of the line of fire.  His knowledge and abilities were now thought too precious.

Year after year he toiled in the name of war.  Engagements were won and lost.  At the end of the day it was often hard to tell the difference. Each battle zone was littered with the bodies of men whom he loved dearly.

Some lives saved,

others mortally wounded by decisions that only he could have made.  

Mortally Wounded

Neither of the two most important people in Aaron's life could stand to be in the same room with each other.  There was a long colorful history between his ex-wife and his brother, and as his disease began to accelerate, the feuding became quite intense.  They argued over Aaron's advance directives.  They both tried to coerce and manipulate themselves into commanding positions.  The shouting became louder, the fury more fierce.  Aaron, for his part, was fading under the colossus of his difficult to treat leukemia.  Any bit of energy left after chemotherapy, was quickly snuffed out by his loved one's bickering.

We talked in the office the day before he was to enter the hospital for the bone marrow transplant.  He was afraid.  His brother sat quietly by his side and listened intently.  A truce had momentarily been arranged.  Aaron's ex would drive him to the hospital and keep him company until his brother got off work.  The next week was then cleaved between schedules and availability.  Each visit timed precisely in order to avoid an unexpected crossing of the two offended parties.

Everything went as planned, until it didn't.  Hospital's rarely run on tight schedules, and neither do people.  Before long, Aaron's brother was angry because the chemotherapy schedule had been changed.  And his ex's car broke down and she couldn't come when promised.  The inevitable chance meetings between the two became a poignant explosive metaphor for the turmoil taking place in Aaron's body.

I walked into his room on the morning of the actual transplant.  Aaron was sitting alone in bed trembling.  He was tired and afraid.  His brother and ex had run into each other in the hospital lobby, and both left the premises fuming.  Consumed by their hatred for one another, they abandoned Aaron in his greatest time of need.

Eventually, I raced out of the hospital to drive across town to my first appointment in the office.  By then the nurses and doctors were shuffling in and out of his room.  But Aaron had no confidant; no protector from all that the cancer, chemotherapy, and the hospital had to ensnare him in.

He was alone.

A victim of a disease,

mortally wounded by those purported to love him.