The Covert Rationing Blog

Throwing It To The Dogs

July 15th, 2008 by DrRich

Robert Pear reported this week in the New York Times that, in narrowly averting the scheduled 10.6% pay cut for doctors (and in the process taking the popular Medicare Advantage program away from seniors), congresspersons of both parties have come to recognize that “the formula for paying doctors is broken.” For their insight in reaching this conclusion, we all should be proud of the cleverness of those whom we persist in electing.

Doctors now have an 18-month reprieve before the next round of pay cuts are scheduled to kick in. And members of Congress, who were unable to stomach the blowback that would have occurred if they had allowed the relatively “small” pay cut this year, fully realize that they’re not going to get away with the next one either, which is scheduled to come in at 20%. This gives them 18 months to find a solution to the physician reimbursement mechanism which, DrRich reminds you, they all agree is broken.

That reimbursement mechanism, of course, is so fundamentally ridiculous that it can only be understood by recognizing that it is a fairly typical bureaucratic attempt to covertly ration healthcare. Covert rationing requires systems that maximize complexity and inefficiency. So, while regulators might have achieved the desired cost cutting by the simple expediency of declaring an arbitrary series of pay cuts for doctors, they instead saw fit to conjure up a truly Byzantine system of rules, formulas, regulations and calculations, whose machinations are somehow linked to projected changes in GDP, which themselves are the product of arcane and mystical divinations made by such prevaricators as econometricians. This sort of “system” serves covert rationing well. It allows Congress to represent the physician pay cuts as being the result of a scientifically derived and economically justified process, which is so finely calibrated as to make it nearly a crime for Congress (or anyone else) to “adjust” it .

We aren’t supposed to notice that the physician reimbursement mechanism fails to recognize even the most basic principles of economics. And if doctors point out that neither the number of sick people nor the overhead of medical practices track in any way with the projected GDP, they reveal themselves as being either unsophisticated or greedy. Either way, they can be safely ignored.

At least, that’s how the process is supposed to work. With this latest round of scheduled pay cuts, however, while Congress did its best to take the issue to the wall, in the end our elected representatives were forced to admit that the physician reimbursement system simply doesn’t work. By this admission we can only conclude that the reimbursement system at last has become politically infeasible. .

Infeasible though it might be, Congress is far from prepared to come up with a substitute. As Mr. Pear reports, “Democrats and Republicans agree that. . . fixing it would be phenomenally expensive.” For instance, if Congress were to do what at first blush seems to be the most logical thing, that is, to simply repeal the current mechanism and allow payments to doctors to grow at the rate of medical inflation, the Congressional Budget Office estimates it would cost Medicare $65 billion in the first five years and nearly $200 billion in the next five years. You go tell the voters that doctors are worth that kind of money.

The bottom line: Paying doctors in some reasonable manner is simply not an option.

The solution Congress is turning to, according to Mr. Pear, is to assign the job of figuring out physician reimbursement to the doctors themselves: “Lawmakers are pleading with physicians’ groups to come forward with a comprehensive proposal.”

We have seen, of course, the sort of thing that happens when you turn over to “physician’s groups” the honor of figuring out how the limited physician reimbursement pie is going to be divvied up. The RUC is the result of such an effort, and there, as one would expect, the powerful specialists have completely overwhelmed the voice of the relatively weak primary care physicians, much to the detriment of not only the PCPs, but also of patients, the healthcare system, and the healthcare budget itself. (While some may consider it ironic that a process initiated in an effort to covertly ration healthcare ends up increasing costs, this is actually the most common outcome of the programmed inefficiencies that invariably accompany covert rationing efforts.) In any case, Congress now proposes more of the same - that is, let the doctors figure it out.

DrRich has pointed out many times that doctors really do want to do what’s best for their patients, and that indeed, wanting to do what’s best for their patients is as high as number three on doctors’ priority list. Priority number one is maintaining their individual viability as practitioners (a priority that requires them to keep the payers happy above all else). And priority number two is protecting the integrity their professional turf, that is, maintaining the prerogatives of their specific medical specialty. (Cynics should recognize that no doctor who ignores priorities one and two will very long be in a position to exercise priority three.)

Congress is now proposing to remake the physician reimbursement system by turning it into a turf battle among physician groups. The battle will be bloody.

Congress is faced with a kennel full of starving dogs, of many various breeds, and has decided it will feed them with a single lamb shank. Rather than figuring out how to distribute the lamb shank so that smaller (yet valuable) dogs will not be torn apart in the struggle, they have elected instead to just go ahead and toss the shank over the fence, and let the dogs figure out how to divide it up. The result will not be pretty, nor will it be hard to predict.

DrRich would rather not watch. He merely (as a courtesy, no more), shouts this new warning to PCPs (the smallest dogs in the kennel). He will then hide his eyes from the carnage.

Posted in Healthcare economics, Primary Care in America | 8 Comments »

Getting Square With the Nurses

July 9th, 2008 by DrRich

Last month, DrRich wrote about how “doctor-nurses” are fixing to displace primary care doctors, and how the noble American Medical Association – champion, as always, of the American PCP – is mobilizing with decisive action to prevent this tragedy from taking place.*

One of the more remarkable responses to this article came in the form of a blog entry by DrRich’s colleague Annie, an entry which was, let’s say, critical.

DrRich is very sorry to have raised Annie’s ire, especially since Annie represents a combination of two of DrRich’s favorite kinds of people – nurses, and students of the Constitution. It is in this latter capacity that she writes for the blog Home of the Brave, a site that, if a bit leftward-leaning for DrRich’s tastes, is nonetheless dedicated to the very worthwhile goal of discussing “U.S. history, the state of the union, the state of the U.S. Constitution.” DrRich even gave top billing to one of Annie’s posts last week in Medical Grand Rounds – her nicely tuned article showing what the Founders might have said about the current sad state of the American healthcare system, an article which he now recommends again to everyone.

This public recognition of Annie’s obvious merits, despite the article she had written in response to DrRich’s posting on doctor-nurses, ought to attest to DrRich’s essential fair-mindedness and objectivity. For in that article Annie was less than kind to DrRich’s sensibilities. For instance, referencing DrRich, Annie said,

A few physicians are skeered of a new demon. They’ve got their Salem witch hunter judicial robes on, and they’re ready to order the press, the pyre or just a good old pompous piosity to their screed. What has their panties all in a bunch?

Doctorally educated nurses. I. am. not. making. this. up. They’re afraid of nurses.

What nurse bashing this is and based on what? Fear of competition?

Annie goes on some more about DrRich’s manhood and such (for the record, DrRich does NOT wear panties), but you get the idea.

More relevantly (more relevantly, at least, to everyone else if not to DrRich), Annie’s post points out that: a) nurses with doctorate degrees are not a new phenomenon; b) the vast majority of nurses are not out to displace physicians, or to usurp the title “doctor;” c) since there is an acknowledged shortage of PCPs, surely something has to be done to fill the void, and nurses – working in full partnership with doctors, as always – can help; d) the formidable Mary Mundiger (formidable, at least, to the lily-livered DrRich) does NOT speak for the large majority of nurses; and e) the organization that actually does speak for most nurses is the very reasonable American Association of Colleges of Nursing (AACN).

And the AACN is greatly disturbed by ideas, put forth by misguided paranoids like DrRich, that doctor-nurses may be getting ready to take over for actual physicians, and is distressed by the blowback that has already been experienced by the nursing profession as a result of such ideas. Indeed, Annie points out, the AACN is so alarmed by the resolutions being considered by the AMA (described here) - resolutions that, if passed, would potentially result in sending nurses a strongly worded letter - that it has issued a white paper itself urging the AMA not to take such drastic action.* This white paper passionately expresses

concerns regarding Resolutions 303 and 214, which are coming forward to the American Medical Association (AMA) House of Delegates. . .AACN is distressed by the tone of these resolutions, which may weaken the good working relationships established between many physicians and nurses….AACN requests that the AMA withdraw Resolutions 303 and 214, and if that is not possible, we urge members of the AMA’s House of Delegates to vote against these measures.

That is (Annie assures us, and the AACN certainly confirms), nurses, even most of the doctorally trained ones, want to play nice with physicians. And DrRich’s screed on the impending take-over of American medicine by hordes of aggressive nurses is both overdone, and very counterproductive.

In response, DrRich can only offer that he fervently desires that Annie, and any others who may have been offended by his earlier post, go back and read it again, but this time read it keeping in mind the following prompt: Irony. For DrRich’s comments were mainly aimed at satirizing the response of the emasculated and morally bankrupt medical establishment to the inevitable encroachment by nurses on what has traditionally been medical turf. DrRich was attempting to be ironic. (A colleague of DrRich’s, reading Annie’s posting, commented that those who miss the poorly-hidden subtleties of irony also may be likely to miss the well-hidden subtleties of difficult medical diagnoses. But this is unkind and likely incorrect, and DrRich chooses not to subscribe to it. Besides, this snide comment presupposes that DrRich does irony well, which may not be a good bet.)

Furthermore, DrRich would like to go on record to say that virtually everything Annie says (except for the personal stuff about his cowardice, Puritanical judgmentalism, exaggerated piety, panties, etc., much of which is simply not true) is pretty much correct. DrRich agrees that the large majority of nurses have no intention or desire to fundamentally displace American PCPs. And DrRich further agrees that doctors who resent nurses because they think they’re after their jobs are badly misguided.

But it’s not because ascendant nurses aren’t about to displace them that they’re misguided. They are indeed about to be so displaced. Rather, they’re misguided because most nurses don’t want any part of it either, just like Annie says.

Anyone who had read DrRich’s earlier articles on the plight of the PCP would understand that he does not consider the prospect of nurses encroaching on the turf of PCPs to be evil or bad, but simply the normal pattern in a modern society wherever advancing technology enables lesser-trained individuals to do things that in the past required highly-trained specialists. DrRich would never bash nurses for simply playing their natural part in the evolution of a technological society. He would sooner criticize a grizzly bear for dining on the entrails of an elk which had died of the mange.

The quotation Annie provides from the AACN white paper, protesting because the AMA is accusing nurses of doing what nurses are, in fact, doing (however involuntarily it may be) is quite telling. The train is leaving the station. The writing is on the wall. While it is clearly not Annie’s intent, or the AACN’s intent, or the AMA’s intent for nurses to replace PCPs, it’s happening just the same, as the night follows the day. Neither the PCPs, nor the nurses who may be startled and intimidated by the prospect, can ultimately stop it.

Those doctors who do view the encroachment by nurses as an unadulterated evil deed will see the protestations of innocence by the AACN - while events on the ground so clearly contradict them - as something similar to the soothing murmurings of the Japanese Ambassador while preparations for Pearl Harbor were in their final stages. They will see it as disingenuous at best, treachery at worst. But viewing it this way is simply wrong.

The posting by Annie and the white paper of the AACN are actually indications that most nurses are as apprehensive as are the PCPs they are displacing. And why shouldn’t they be? Look at the new responsibilities and risks the nurses will be acquiring - medical, moral, legal, financial and otherwise. Historical upheavals like this are often unkind to all parties involved, even the supposed “winners.”

If further evidence is needed that DrRich is correct (beyond simply studying the history of technological societies), simply read the July 2008 Update of the Hospital Outpatient Prospective Payment System issued by CMS. This document (if you can get through it) among other things removes language from the Medicare Benefit Policy Manual that had required that “services furnished in provider-based departments of hospitals must be rendered under the direct supervision of a physician who is treating the patient.” That is, non-physician care providers are now allowed to provide care for Medicare patients in a hospital outpatient department without any supervision by any physician who is caring for the patient.

CMS is already there, and is very obviously clearing the path for the inevitable. Everybody needs to get ready for this - the PCPs, and the patients, and even the reluctant nurses.

* This is an example of irony.

Posted in Primary Care in America | 5 Comments »

Medical Grand Rounds, Vol 4, No. 41

July 1st, 2008 by DrRich

Welcome to Medical Grand Rounds, Volume 4, Number 41, July 1, 2008. This week, bloggers from across the Internet have submitted articles that will help us celebrate the 232nd birthday of the United States of America. Their patriotic postings, organized according to their relationship to the Founding, follow:

Lists of Grievances

Annie at Home of the Brave sets the tone for this week’s Grand Rounds. She does a brilliant job showing what the Founders might have said about the current state of the American healthcare system, in What They Were Saying: A Riff on the Declaration and Resolves of the First Continental Congress. The First Continental Congress, of course, met in 1774 to petition King George for a redress of grievances stemming from the Intolerable Acts. The King rebuffed their petition and a shooting war broke out the following year, which led to, well, quite a bit. (Faced with their own intolerable Acts, many doctors, in stark contrast to the Founders, simply keep their heads down and continue making those little marks on their Pay For Performance checklists.)

Ian Furst of Wait Time & Delayed Care is Canadian and knows something about healthcare and the bureaucracy (not that doctors in the U.S. have any excuse not to know the same thing). Ian analyzes the results of England’s 4-hour ER wait-time guarantee, and shows once again how bureaucrats tweaking one variable in a complex system always manage to create interesting unintended consequences. But, since these unintended consequences will always require further bureaucratic activities in order to produce corrections, they guarantee perpetual growth of the bureaucracy, and thus are seen, by the people who really matter, as exceedingly good things.

Speaking of the proper limits of government, Doc Gurley considers, in her post, Hope and Death, the implications of the California Assembly’s latest bill, essentially requiring doctors to tell patients when they are terminally ill. This information, no doubt, would substantially lower patients’ expectations, and patients with low expectations can be managed very cheaply. (Which explains the legislative impetus to become involved in such matters.) But as Doc Gurley points out, the definition of “terminally ill” is often in the eye of the beholder, and the definition favored by those running the healthcare budget may be quite different from the definition patients (and doctors, if left to their proper medical functions) would favor. Doctors not wanting to break the law (or expose themselves to yet another, particularly promising, form of healthcare fraud) will predictably begin shading the definition of “terminally ill” toward the cost-saving side, i.e., making the determination somewhat earlier than traditional (or proper). DrRich predicts that our faithful public servants will soon take note of the prolonged anguish that will ensue as a result of the newly prolonged (by legislation) duration of terminal illnesses, and their bureaucratic compassion will move them to legislate a mitigation; namely, a law requiring the easy availability of physician-assisted suicide.

The Happy Hospitalist this week offers one of his patented, in-depth analyses of the utter mess that Medicare has become, in This is What You Voted For. For a system that produces the exact opposite of what it says it wants to produce, you can hardly beat Medicare. Happy says, “Look out America, get ready for even lower access to cheap effective [primary] care and a highly expensive and wasteful proceduralization [by specialists] of your friends and family. . .Well America, this is what you voted for. I hope you’re ready to live with the consequences.” Taking into account the bizarre incentives, Byzantine inefficiencies, and systematized grievances that are provided in such luxurious abundance by Medicare, Happy (and DrRich) can only marvel in dazed wonderment that anyone thinks that turning the whole healthcare system over to these people is a good idea. Imagine our honored forebears clamoring to turn over the entire colonial economic system to the perpetrators of the Stamp Act!

And anyone who still thinks any government knows how (or can know how) to run a healthcare system should become a regular reader of Dr. John Crippen’s NHS Blog Doctor, to get a taste of what healthcare across the pond is really like. His recent posting, The Rise of the Healthcare Professionals, describes just a few examples of the systematized dumbing-down of healthcare that has accompanied England’s NHS, and will accompany any system in which codified policies, procedures, and guidelines, handed down from on-high and strictly enforced, replace genuine medical thought.

Inalienable Rights

DrRich has always been amused by those boutique diseases that doctors occasionally invent in order to justify new avenues for payment. Psychiatrists (in DrRich’s humble opinion) have been particularly adept at this game. Dr. Shock MD PhD gives us his opinion on the latest such neo-diagnosis - Internet Addiction. Dr. Shock, we are happy to note, is not enamored with this new disease, and to his very great credit finds in America’s founding documents an inalienable right to the Internet. All self respecting bloggers must unite against declaring as a disease the robust appreciation of the Internet!

The anonymous blogger who writes How to Cope With Pain wonders in Can I Still Blog? whether blogging is an inalienable right - and concludes that while it may be a right, the fact that something is a right does not necessarily relieve you of the attendant risks or consequences. So that’s why all those other physician-bloggers choose to remain anonymous! Is it too late to inform you that DrRich is actually a 58-year-old housewife from the upper Midwest who learned everything she knows about medicine from Dr. Kildare reruns?

Alvaro at Sharp Brains talks about the inalienable right of men and women to own functioning brains - and what they can do to keep them - in Why We Need Walking Book Clubs.

Theresa Chan at Rural Doctoring tells a painful story, in Another Reason Why Healthcare is Going Down the Toilet, documenting how some patients (and patients’ families) feel they have an inalienable right to all the time and toil they desire of physicians, and for free.

The Spirit of the Individual, That Which Made America Great

Rob, at Musings of a Distractable Mind, shows us that the independent, creative spirit that made America what it is remains alive and well - even in PCPs! DrRich has long maintained that PCPs need to think outside the box in order to salvage their profession, and in What are You Going to Do? Rob demonstrates thinking that is, uh, way outside the box.

Over at Insure Blog they’re talking about another aspect of the right to fend for yourself - this time, using a patient’s own cloned immune cells to treat cancer. This research, which comes from the UK, is not funded by the National Health Service, nor has the NHS expressed the least interest in it. So, one might say, the British government is keen to remain “independent” of potentially expensive cancer cures. Read about it in Interesting Cancer News.

David E. Williams at the Health Business Blog tells us about an idea whose time has surely come - enticing patients to take their medication by rewarding them with chances in a lottery. Now, what can be more American than that? Go read You gotta play to win.

Kim of Emergiblog reminds us in Give Me Empathy, or Give Me . . . Another Nurse, how, when we are sick and frightened, nothing can soothe us like the presence of a confident, knowledgeable and empathetic nurse. The continued empathy of nurses is quite remarkable to DrRich, who notes that nurses are under as much stress from the bureaucracy as are doctors. Add to that the stress from being expected to follow orders from those harried, frustrated, angry, not-always-clear-thinking doctors, while still doing the right thing for the patient - dual responsibilities that are not always 100% in alignment. Continued empathy under such challenging conditions can only be attributed to individual character and dedication.

Kerri of Six Until Me reminds us in My Own Shoes that knowledgeable, intelligent and rational patients will always take doctors’ recommendations under advisement, but may ultimately decide that their own personal situation is best served by some deviation from those recommendations. Such patients are not being “non-compliant;” they are considering the doctor’s advice within the context of the totality of their lives (which will always include data their doctors can never fully understand), and exercising their own individual judgment.

Christian Sinclair at Pallimed reports on the practice of hospice medicine during the ongoing Midwestern floods. His report reminds us of America’s greatest asset - the dedication, ingenuity and spirit of individual Americans - which is always most impressive under the toughest of circumstances.

Christine of You Don’t Look Sick tells us how patients can take a major step toward declaring their own independence from a hostile healthcare system - by taking charge of their own medical records. Great advice for any patient.

Standing Up To Powerful Authorities

Dr. Mintz takes on the all-powerful popular media in telling us the truth about the 8 drugs that doctors wouldn’t take. It is very popular to bash the drug companies these days, and accordingly, any negative news about (expensive) new drugs is invariably hyped far beyond any objectivity. DrRich would likely say that this behavior is just another example of covert rationing. But Dr. Mintz more usefully provides the objective truth about these “never drugs.” Perhaps, as a follow-up, he should write about the 8 sources of medical news that doctors (at least the smart ones) wouldn’t read.

JunkMD over at Progress Notes sounds like he’s just about ready to tell the feds what they can do with their latest pay cut. In They Just Don’t Get It, he is fed up both with his Medicare-age Senators and with fellow citizens who expect him to just sit there and take it. Maybe, he allows, it’s time to consider retainer medicine. “Opponents of this model wonder who will see the patients who can’t afford a retainer physician. Well, if none of us are in business, it won’t matter.” That sounds about right to DrRich.

DrRich his own self offers an alternative (and most uplifting) explanation for the fact that doctors apparently owe the IRS multi-millions of dollars in unpaid taxes. Rather than merely being tax cheats, perhaps these physicians are emulating their forebears who nobly defied oppressive Acts of Parliament by throwing tea into Boston harbor. But then again, perhaps not.

The Freedom From Misinformation Act

Dean Moyer of The Back Pain Blog helps one reader declare her independence from misinformation by answering the question Can Herniated Discs Really Heal?

Dr. Paul Auerbach at Medicine for the Outdoors tells those who are exposed to the smoke from wildfires (now raging in California) how to stay healthy. Being aware of oncoming threats in this case is a bit more complicated than “one if by land, two if by sea,” but is no less important.

When DrRich was a medical student, the only decent doctor show on TV was Marcus Welby, MD - a series that was heavy on personal interaction but weak on medical information. So cracking the books was the only good option for learning a little medicine. Today, medical students have many more options. Monash medical student, for instance, is fighting misinformation (his and ours) by reviewing episodes of House.

David Harlow of HealthBlawg reports on the launch of the Massachusetts eHealth Collaborative’s latest Health Information Exchange (HIE). An HIE is more about interdependence than independence, but then, our Founders also banded together (vowing to hang together so as not to hang separately), in their struggle for autonomy.

And Dr Penna reports on new information on Genetic Risk Factors for Alzheimer’s Disease. If you decide to get the test, don’t tell the government or United HealthGroup.

The Obligations of the Individual in a Free Society

Marshall, the Episcopal Chaplain at the Bedside, reminds us in Returning to those Hard Conversations that doctors caring for the terminally ill should more often just say the plain truth, even when it’s painful (for the doctors) to do so.

Dr. Val and the Voice of Reason informs us that it’s plain to both the Surgeon General and to any beat cop that “most people just don’t know what it means to be a good citizen anymore.” Read her plain-spoken interview with Sgt. Zlotkus here, then go do the right thing.

Tories

Some, when a growing conflict reaches the point of no return, will always side with the more powerful disputant. In the Colorado Health Insurance Insider, Louise writes about why doctors are unhappy, and postulates that as a result many physicians now say they are in favor of universal, single-payer (i.e., government) healthcare. DrRich simply notes that after the American Revolution, thousands of Americans who had favored continued rule by the King moved to Canada and got what they desired; and finds it interesting that today’s Americans who want the sovereign power to take over healthcare could do exactly the same thing (if they were to lose the “healthcare wars,” as unlikely as it now may seem), and with precisely the same result.

Am Ang Zhang of The Cockroach Catcher blog tells us about the systematic abuse of the diagnosis of Post Traumatic Stress Disorder by “an alliance of antiwar psychiatrists, VA hospital administrators, and patients who never saw combat or even Vietnam service but found that reciting the PTSD symptoms would result in the awarding of disability payments.” Read about it in PTSD: Diagnosis du Jour. Even John Adams has an opinion about this one.

Picnic Advice, or Don’t Be Stupid

RLBates of Suture For a Living wants to make sure we have a happy 4th. She posts again this year on fireworks safety - a matter whose importance she, a plastic surgeon, unfortunately knows all about.

The Samurai Radiologist at Not Totally Rad offers advice on keeping kids from ingesting foreign objects in Coming Soon to a Child’s Stomach Near You. SR helpfully reports on a missive he received from a concerned parent who is dismayed by the existence of such a thing as Kellogg’s Lego Fruit-Flavoured Snacks: “I just spent the first three years of my son’s life trying to get him not to eat blocks, and now you’re telling him they taste like [fornicating] strawberries. Thanks a lot assholes.” Picnic advice like this you can’t get just anywhere.

What Doesn’t Kill You Will Make You Stronger

Americans have learned repeatedly that adversity produces strength. So, if the rising prices of food have you down, Walter, at Highlight Health, urges you to be of good cheer! In The Upside of High Food Prices he describes how more people are eating local produce - and eating healthier. He neglects to point out (though DrRich will kindly take up the slack) the other problem caused by cheap food that is now being mitigated. We refer, obviously, to the fact that cheap food is the chief source of what has become the latest scourge-of-society: obesity.

Service and Sacrifice

Fighting for what you believe in is always costly, and the cost is never more apparent than in Healthline’s posting on Suicides in US Troops. If you know a serviceman or servicewoman this holiday, let them know how much we all love them and value their service and sacrifice.

The Most Important Aspect of Any Holiday

Bongi at other things amanzi offers us the sad and most affecting story of little k. On this holiday - or any holiday - the best lessen we can take away from k’s story is to gather around us those we love, give them a hug, then count our blessings and thank God for every one of them.

Next Week’s Grand Rounds

Next week Grand Rounds will be hosted by The Blog that Ate Manhattan.

Posted in Uncategorized | 15 Comments »

Are Doctors Garnishing Tax Payments to Recover Funds From Medicare?

June 25th, 2008 by DrRich

The Wall Street Journal recently reported that Congress is urging Medicare administrators to assist the IRS in garnishing payments to doctors (and other “contractors”) who owe federal taxes. The Government Accountability Office estimates that providers owe more than $2 billion in back taxes, and withholding Medicare payments to providers is seen as an expeditious method of collecting those owed monies.

DrRich is shocked (shocked) not only that a body of Solons such as Our Congress could so egregiously misinterpret the actions of forthright American physicians, but also that the WSJ itself (a bastion of American capitalistic thought) could fail to recognize the true nature of those actions.

For DrRich suspects there is an alternative explanation that places the alleged tax deficiencies of American doctors in a somewhat different, and far more heroic, light. Namely, when (if) doctors are withholding tax payments, they are not doing so as common tax cheats. Heavens, no. Rather, they are doing so for entirely justifiable and noble (if illegal) reasons.

First, they are trying to break even. In contrast to what is seen with most of the revered professions (wherein the payment due to the professional is transparently negotiated, or is simply “set” by the professionals themselves according to what the market will bear), the pay of physicians is determined by Acts of Congress. Even now, before the next set of impending, Congressionally-determined physician pay cuts, Medicare does not reimburse doctors enough to cover the overhead of most office visits.* Some say this makes the business of office practice economically dicey. In fact, it is already impossible for a stand-alone, independent primary care doctor to make a living caring for Medicare patients.

Second, Medicare has successfully inculcated the Fear of God into physicians regarding the now-federal crime of healthcare fraud. The penalties for committing healthcare fraud are so onerous that merely being accused of it is enough to induce most physicians to beg for a settlement deal, regardless of the strength of their defense, and regardless of the fact that most such settlements are personally and professionally ruinous. And the opportunities to be accused of fraud are unlimited for even the most fastidiously honest among physicians. (The arcane E&M coding rules, which have been formally proven impossible to follow, afford the opportunity for the feds to point the fickle finger of fraud, quite arbitrarily, toward any American doctor who treats Medicare patients, at any time.) Not wanting to appear fraudulent to Medicare is foremost in the minds of American doctors (which pushes “wanting to help their patients” down to Number Three on physicians’ priority list, right after “wanting to avoid spurious malpractice suits”).

As a result of these two considerations, it is conceivable** that some physicians, wanting to continue the noble practice of caring for Medicare patients, but at the same time wanting to be fairly reimbursed for same (at least to the extent of breaking even), have made a simple calculus. Inasmuch as the government owes them fair reimbursement for services they render to government entitlees, and inasmuch as the government has not been forthcoming with said fair reimbursement (and promises to be even less forthcoming in the very near future), therefore (some physicians may have concluded), they will simply exercise whatever opportunities they may find to recover some of these owed funds on their own initiative. For much the same reason that Congress is proposing to garnish Medicare payments to doctors, perhaps some doctors are garnishing tax payments to the IRS.***

It would indeed be telling if physicians who reach such conclusions (if indeed there are such physicians) have decided to recover funds they feel the government rightfully owes them, not from Medicare, but instead from the IRS. These doctors would obviously have concluded, quite logically, that dealing with the wrath of the IRS is far, far less intimidating than dealing with the wrath of the federal healthcare fraud establishment, whose tactics would make the average American physician beg for the rights and considerations afforded to your average Guantanamo detainee (especially since last week.)

Small wonder that the relatively meek and unassuming IRS has asked for the help of their nastier federal brethren in cracking down on recalcitrant doctors.

Whatever the correct explanation for it, however, the prospect of the IRS and Medicare teaming up in enforcement efforts ought to send chills through every American physician, and should stimulate among them significant second thoughts about their career paths.

Speaking of which, here’s a second thought they should consider, and soon.

*These comments, as usual, pertain almost exclusively to PCPs. Specialists (such as DrRich when he still practiced), are doing just fine, what with the procedure-based reimbursement system their brethren on the RUC have arranged for them. Unlike PCPs, who lose money every time a Medicare patient darkens their door, specialists can make up for lowered per-unit reimbursements by cutting corners and increasing the volume of procedures they perform. It’s not particularly pleasant (or safe), but it is what it is, and the specialists have learned to get by.

**Note to IRS and CMS agents: Hi, fellas. DrRich has no personal knowledge, direct or indirect, of any of this sort of illegal behavior; he is simply taking known facts and extrapolating them to their logical conclusions.

***It is a law of history that bad law and bad regulations eventually create contempt for authority, and progressively render various illegal actions rationalizable, reasonable, justifiable, and finally, ethical. Even those who sympathize with physicians on this matter (and DrRich suspects these are few indeed), would say that that the rationale for not paying owed taxes has progressed certainly no further than the “rationalizable” stage, if that. But the natural tendency of governmental authority to progress toward arbitrariness is the very thing that  led Jefferson to muse that continued societal vitality might require revolutions every few generations. I’m just sayin’.

Posted in Healthcare economics | No Comments »

Another Reason To Let the Doctor-Nurses Take the Whole Thing

June 18th, 2008 by DrRich

According to NewScientist Magazine, David Fishbain, Professor of Psychiatry and Behavioral Sciences at the University of Miami, says that up to 1 in 20 patients would like to kill their primary care physicians.*

He learned this interesting tidbit in a survey he conducted among 800 patients undergoing physical rehabilitation or suffering significant pain. He presented his findings at the American Pain Society meetings in Tampa in May.

DrRich, who knows his readers, suspects that several who are physicians and who are unreasonably upbeat or excessively cynical (either personality trait will do) are at this moment thinking, “Sure they want to kill me. But as they’re disabled, their chances of success seem low.”

So chew on this. In a control group of patients not suffering from pain or disability, Fishbain reported that “only” 1 in 50 admitted to having murderous tendencies toward their doctors.

The math is not pretty: the typical primary care physician with a patient load of 3,000 souls can assume that at least 60 of these individuals (up to 150, if he/she treats a lot of patients with pain or disability) would not only like to see them dead, but would be pleased to be the instrument of their demise. (These statistics assume, of course, that everyone who wants to see their doctor lying lifeless in a pool of blood are comfortable admitting this fact to medical researchers doing written surveys.)

We have expended much space on this blog describing how physicians have been maneuvered into covertly rationing healthcare at the bedside, how they have allowed themselves to be limited to 7.5 minutes per patient encounter, and how they have acceded to spending those 7.5 minutes making little marks on a handed-down-from-on-high Pay For Performance checklist (thus leaving little or no time for whatever pressing issues may be on the patient’s own agenda). We have described how, to assuage guilt and to make such behaviors seem less than reprehensible, revered medical organizations have formally amended the code of medical ethics, thus officially wrecking the classic doctor-patient relationship - and committing professional suicide.

The fallout from these developments has landed disproportionately on the PCP, the gatekeeper for the bulk of expensive medical services, whose actions the healthcare system must control at any cost. The loss of PCPs’ professional integrity and their ability to act as autonomous advocates for their patients has done far more than the steady ratcheting down of their pay to make primary care medicine exquisitely unattractive, both to current practitioners and to potential future PCPs. (As per design, says DrRich.) Consequently, this carefully manufactured “PCP shortage” will soon become the medical crisis du jour.

When this crisis is finally ripe for unveiling, the healthcare system will be ready with a solution. Doctor-nurses (the healthcare system fervently hopes) will be more malleable than today’s PCPs, less encumbered by tradition, attitude, and delusions of autonomy, and more likely to follow whatever guidelines the “experts” choose to hand them.

But what about the risk to doctor-nurses from murderous patients?

If the healthcare system is wise enough to create enough of these doctor-nurses, they will be able to relax the 7.5 minute-limit-per-patient-encounter, thus decompressing some of the frustration patients now feel when they leave the doctor’s office, and preventing doctor-nurses from becoming as much a target for patients’ wrath as PCPs apparently are today. To receive that extra time however, doctor-nurses will need to use it wisely, unlike their physician forebears. They will need to spend it engaging in relationship-building and other feel-good activities, instead of (as physicians all too often are wont to do) uncovering new, potentially expensive medical issues that need to be explored.

Doctor-nurses are in the catbird seat, and as long as they follow the script and stick to the guidelines, they’ll be given enough time to keep their patients from hating them.

As for the soon-to-be-obsolete PCPs, DrRich has previously made them some friendly suggestions for salvaging their professional integrity, and he cannot understand why they are not adopting them. Are they waiting for the bullets to fly?

*Thanks to Laura Dolson, Guide to Lowcarb Diets at About.com, for pointing DrRich to this important study.

Posted in Primary Care in America | 7 Comments »

Hey PCPs - Here They Come!

June 17th, 2008 by DrRich

The June 16 issue of AMANews reports that the National Board of Medical Examiners will begin offering a certification examination this fall for graduates of “doctor of nursing practice” programs. Revealingly, the test will be based on Step 3 of the U.S. Medical Licensing Exam.

Doctor-nurses will soon be Board Certified, just like, uh, doctor-doctors.

The AMA leadership sees this development as potentially alarming. Doctor-nurses, they suspect, may soon use their new NBME certification status as “as leverage to seek scope-of-practice expansions that cross into medical practice.”

Mary Mundinger, the leading spokesperson for doctor-nurses and not one to mince words, has chosen not to soothe such suspicions. Says Doctor Mundinger, “While a primary care physician went to medical school and did residency, a nurse practitioner with a DNP has achieved many of the same competencies but through nursing education. They have the same skills in identifying a disease state and treating it, but it’s a different hybrid of care.” In other words doctor-nurses have simply taken a different pathway to the same end. Indeed, once doctor-nurses demonstrate their clinical competence, Mundinger maintains, the legal pathways will open to the expansion of their scope of practice.

But the mighty AMA is having none of that. At press time, the AMA House of Delegates was considering several new resolutions that would challenge this clear encroachment on the turf of American PCPs. For instance, the AMA will consider endorsing a policy that recommends that the title “doctor” be reserved for physicians (and dentists, podiatrists, PhDs, and certain sports figures such as Dr. J. - but not for nurses). Another resolution the AMA may (or may not) consider would recommend that the title “resident” be reserved for those in a medical (or dental or podiatry) training program and, presumably, for denizens of nursing homes - but not for those in the “residency” portion of the doctor-nurse training program. The House of Delegates may even consider resolutions protesting the NBME’s decision to offer a certification exam to doctor-nurses in the first place. (The NBME has already responded to such complaints: “We’re a testing organization, and this fit our mission,” said a NBME vice president who, incidentally, is an MD himself.) Finally, the AMA may resolve to “insist” that doctor-nurses practice medicine only under the supervision of doctor-doctors. The American Academy of Family Physicians has threatened to join the AMA in considering these strong actions.

So, it appears, the professional bodies representing the interests of American PCPs may very well adopt the same Ultimate Weapon often employed by the United Nations when it confronts aggressive, threatening dictators around the world (such as Iranian President Ahmadinejad who, while ignoring calls from the UN to abandon his nuclear weapons program, simultaneously threatens Israel with annihilation). In other words, the AMA and AAFP are very close to pulling the trigger to counter a clear and present, self-declared, existential threat with the dreaded Strongly Worded Letter.

Dr. Muldinger is, no doubt, really, really scared.

This is all, of course, a kabuki dance. If the government, the insurers, the AMA, and their own specialist colleagues really cared about primary care physicians, they would not have systematically devalued their training, expertise and time. They would not have allowed the practice of primary care medicine to be reduced to a series of handed-down “guidelines.” If their own professional organizations cared about them, they would not have adopted a new code of medical ethics that make doctors primarily responsible to society’s needs instead of the needs of their patients, thus removing any true professional distinction doctors might have from “lesser” practitioners like doctor-nurses.

The remarkably anemic response of the AMA and AAFP to the aggressively ascendant doctor-nurses, of course, merely reflects how truly weakened the position of PCPs has become. PCPs are, and have allowed themselves to become, well and truly screwed.

Having taken such careful pains to make primary care medicine so exquisitely unattractive to present and future physicians as to assure that the growing “PCP shortage” will become the next real medical crisis, the healthcare system is now grooming its solution to this manufactured crisis, namely, the doctor-nurses. These doctor-nurses will fulfill all the criteria the healthcare system desires for its practitioners of primary care medicine (no matter what healthcare reforms we may end up with). They will be “doctors” who are duly “certified” in primary care medicine by respected testing organizations, who have just enough training to diagnose and treat the average patient (i.e., the ones with high blood, low blood, fat blood and sugar), and who will cheerfully, unquestioningly (and with far better compliance than MDs - what with their traditions, attitudes, etc. - can ever hope to offer), follow whatever guidelines are handed down to them by the experts. And they will do it all for less pay and with less lip than the now-obsolete physician PCPs. These new practitioners of primary care medicine will be a perfect fit.

DrRich sees no future in PCPs wasting what little emotional and professional capital they may have left in fighting an ultimately doomed rear-guard action against the doctor-nurses. Given the present state of our healthcare system, the rise of doctor-nurses is as inevitable as the rise of the middle class at the end of the feudal era. There’s little to be gained here in fighting history.

Instead, PCPs need to recognize the realities, and completely reinvent themselves. DrRich has previously suggested how they might approach this difficult but enlivening task. Now that the doctor-nurses have taken another major step to becoming the primary care deliverers of the future (an eventuality which the healthcare system has done everything to arrange), perhaps more PCPs will begin to think more usefully about how they can reinstate their professionalism, and remake themselves in a more sustainable form.

But whatever they do, hitching their hopes to the verbal ejaculations of the AMA, the AAFP, or any other of the professional organizations that have led them to this impasse, seems a particularly useless strategy, every bit as useless as sending the blue-helmeted peacekeepers off to fight your battles for you.

Posted in Primary Care in America | 14 Comments »

The Right Way to Think About Medical Ethics

June 11th, 2008 by DrRich

Wherein long-time readers of this blog (or anyone who has merely read the title of this post) will be reminded that DrRich, not unlike some more well-known figures, does not mind audacity.

Both Dr. Gault and Sandy Szwarc have recently revisited the current state of medical ethics, and once again, both have found modern medical ethics wanting. Dr. Gaulte recounts the recent, sad history in which ethicists steeped in utilitarianism have seen fit to add the ethical precept of Social Justice to the individual physician’s ethical obligations. While this change brings medical ethics more in line with the actual behavior of American doctors in the wild, Ms. Szwarc nicely elaborates for us why this change in ethical precepts poses a grave threat. (She even bravely uses the “other” N-word, that word which today is invariably banned in polite conversations on ethics, but which, for better or worse, is unfortunately quite illustrative of the ultimate fruits of utilitarianism. Utilitarianism has again become fashionable after an all-too-brief time-out, and so we must not insult or embarrass respectable modern ethicists by dwelling too deeply on the lessons of history.)

DrRich himself has pointed out that by making Social Justice a chief ethical mandate of physicians at the bedside, doctors have not only committed professional suicide, but have formally embraced the covert rationing of their patients’ healthcare, and all of the social ills that flow therefrom (social ills whose enumeration is the main subject of this blog).

So several of us in the medical blogosphere have made, and continue to make, the point that the “new” medical ethics is counterproductive to the medical profession, to society, and to patients. But still, it must be acknowledged that the “old” ethics, under which the doctor’s only obligation was to the rights and welfare of the individual patient, no longer seems feasible. Any doctor who doggedly sticks to classic medical ethics today is likely to find him/herself out on the street in short order. And besides, the argument of the utilitarians that Social Justice must be honored within the healthcare system is, in fact, legitimate and essential.

Acknowledging that it does little good to criticize the status quo without offering something better, DrRich feels obligated to propose a different way of looking at medical ethics that a) honors the classic ethical obligations of physicians, and b) honors the needs of society. If he has seen fit to label this proposed solution for medical ethics “the right way,” it is more in the way of challenging his critics to engage in debate than to declare a final victory. Though, if critics fail to engage, DrRich will naturally assume he must indeed have nailed it.

“Classic” medical ethics.

Classically, doctors have been obligated to recognize two ethical precepts: Patient Welfare and Patient Autonomy.

The precept of Patient Welfare (also called the precept of beneficence, or “first, do no harm,”) obligates the doctor to always behave in a way that accrues to the benefit of the individual patient. The doctor’s patient comes first, and must be the doctor’s primary concern, above, for instance, personal and financial considerations.

Under the precept of Patient Autonomy, patients are acknowledged to have the right to self-determination regarding their own healthcare. Fundamentally, this means that patients have the right to know, and the doctor is obligated to inform them, of any and all information that might help them make their decisions regarding their own healthcare.

So classically, doctors were obligated to do whatever they must to assure that their individual patients were fully informed about all their medical options, and to act to assure that their patients got the care they needed (as long as, fully informed, they agreed to it).

Since under classical medical ethics the doctor’s one and only ethical obligation was to the patient, classical ethics did not allow the doctor to recognize any limits. Whatever bit of medical care promised even a small hope of benefitting the patient, doctors were obligated to offer it, no matter how expensive it might be to do so. This ethical system worked well enough until 40-50 years ago, since medical technology up to that time was relatively primitive, limited, and cheap.

The “New” medical ethics.

DrRich will not review here how skyrocketing costs, produced by rapidly advancing technology and an aging population, eventually led to the unavoidable need to ration healthcare, or how, because we’re Americans and Americans don’t ration, the unavoidable rationing was necessarily covert. (See virtually any post ever written on this blog for details.)

But, by the 1990s, medical ethicists became troubled that doctors who were forced to conduct covert rationing at the bedside could not do so under the classic ethical precepts that obligated the doctor to the welfare of their individual patients. But rather than pointing out that their behavior had become unethical, and calling for doctors to insist on being allowed to practice medicine without violating their fundamental ethical and professional obligations, ethicists instead began calling for a “new ethics” that would encompass doctors’ actual behavior.

This feat was accomplished in 2002, when the ABIM Foundation, the ACP-ASIM Foundation, and the European Federation of Internal Medicine published their manifesto, Medical Professionalism in the New Millennium: A Physician Charter. In it, these respected organizations proclaimed a third ethical precept: The principle of Social Justice. Social Justice charges physicians to work for “the fair distribution of healthcare resources.” That is, it specifically and directly justifies bedside rationing. (For a fuller discussion of this point, go here.)

That this third medical precept so directly contradicts the first two is either ignored by ethicists or celebrated as “balance.” DrRich’s only surprise is that ethicists have not (yet) found within this utter contradiction the virtue of diversity (the uber-virtue, from which the seven classic - though subsidiary - virtues must necessarily spring).

The negative implications of this official “new” medical ethic on doctors, patients, and society are truly staggering. For a masterful discussion of those implications, DrRich refers you to again to Ms. Szwarc. Here, DrRich will take only enough space to reiterate for his physician colleagues that once we physicians adopted this new ethic, we surrendered any claim we might have had to the title “professional,” and accordingly, we made ourselves fair game to any treatment, tactic, or travesty that any more powerful interest group (such as trial lawyers, Congress, or doctor-nurses) can get away with foisting on us. Physicians no longer have any ethical standing for turning such attacks aside. Rather, as non-professionals, our ability to withstand attacks can only be proportionate to whatever socioeconomical or political pressure we can muster.

So if “classical” medical ethics has been rendered obsolete by rising costs that mandate limits on spending, and if “new” medical ethics is irredeemably bad, then what are we to do? The answer of course, is “right” medical ethics.

The “Right” medical ethics

Medical ethics would be “right” if it could be made to comport with the classic notion of the doctor’s primary obligation to his/her individual patients, and yet respect society’s need for cost control. That is, the “right” ethics will recognize that society’s needs and the needs of individual patients are often in conflict, and will provide an ethical framework for resolving these conflicts.

We can profitably address this problem if we think of the ethics of healthcare as being organized into two concentric spheres. The outer sphere holds the ethical precepts adopted by society in order to guide the behavior of the healthcare system for the entire population. These outer-sphere precepts help ensure that the needs of society as a whole are served in an ethical manner by the healthcare system.

Contained within (and therefore subject to) that outer sphere of societal precepts is an inner sphere which holds the ethical precepts that govern the behavior of the healthcare system (including the behavior of physicians) toward individual patients. Inner-sphere precepts help ensure that individual needs within the healthcare system are addressed in an ethical manner - yet, in a manner consistent with outer-sphere (societal) precepts.

So, while the physician’s primary ethical obligation must be for the benefit of the individual patient, and thus while the physician must operate according to ethical precepts that honor this duty to individual patients (the inner-sphere precepts), their behavior must also conform with the ethical constraints imposed by society on the entire population (the outer-sphere precepts).

Because doctors and patients operating within the inner sphere must honor outer-sphere ethical precepts, it would be easy to surmise that the needs of society must always take precedence over the needs of the individual. To some degree this is the case. But it is more useful to think of the inner-sphere precepts as an immutable core of ethical beliefs that serve the fundamental American commitment to the autonomy of the individual, and of the outer sphere as a coating, fashioned by society and therefore changeable, that places a limit on individual autonomy, while protecting its essential immutability.

The inner sphere - ethical precepts for individuals

The inner sphere of ethical precepts - the core - obligates physicians to place the interests of their individual patient above all else, within the bounds imposed by society. This inner sphere holds the two ethical precepts of classical medical ethics, described above - patient welfare and patient autonomy.

While individual autonomy is critical, it has its limits. When a patient demands that everything possible be done for them, they are exceeding the bounds of autonomy if doing “everything” means that some other individual would thereby be deprived of what otherwise would be rightfully theirs. These bounds of autonomy are defined by the outer sphere.

The outer sphere - ethical precepts for society.

Under any equitable healthcare system we are going to have to carefully define our outer sphere ethical norms, because those are the standards that bound and govern the inner-sphere behaviors of doctors and patients. The outer sphere also consists of two ethical precepts, societal beneficence and distributive justice.

Societal beneficence (or social welfare) requires the healthcare system to maximize the overall public good realized from whatever resources society expends on healthcare. Social welfare is not the same as patient welfare, because what is optimal for an individual patient may often reduce overall benefit to society, and vice versa.

Distributive justice requires the benefits of the healthcare system to be distributed fairly, that is, in a way that does not discriminate against individuals or groups based on who they are.

The outer-sphere precepts honor society’s right to accrue optimal benefits from whatever resources society provides collectively toward healthcare. That is, the outer-sphere precepts recognize society’s legitimate interest in limiting and equitably distributing society’s collective resources.

Medical ethics and the spheres.

Now it is easy to see why the American healthcare system is presently inequitable and unethical. A hallmark of our system is the lack (thanks to our culture of no limits) of effective outer-sphere societal norms that would bound the appropriate behavior of individual physicians and patients. This lack makes it entirely feasible and very common for some patients to soak up a disproportionate share of publicly funded healthcare resources while others (though they are also paying into the system) are left with next to nothing.

Establishing equity should have nothing to do with adjusting the inner-sphere precepts. Individuals in the United States (to paraphrase the Declaration of Independence) have a self-evident right to their individual autonomy. The inner-sphere precepts are granted to us by the Creator, by natural law, or at the very least, by the Magna Carta and its derivative documents. As Americans we should avoid modifying the inner-sphere precepts at all costs, since, once we do, we are abandoning our foundational principles.

It is the outer-sphere precepts - those that can be negotiated legitimately by society, and which can legitimately limit the scope of inner-sphere behaviors - that we need to get into proper order.

A properly functioning system of medical ethics, therefore, would have society negotiate a set of outer-sphere precepts that would transparently define the rules for how society has chosen to set limits on healthcare spending. Then, within that system of societal rules, doctors and patients would work together, under a fully restored doctor-patient relationship, to assure that every patient receives all the information he needs on all the legitimately available medical options, and that the doctor leaves no stone unturned in obtaining those legitimate medical services for her patient.

In stark contrast is the process which gave birth to the “new” medical ethics now being promulgated by medical ethicists and the medical establishment now under their thrall. The current ethical model was the result of ethicists responding to the lack of functional outer-sphere precepts by simply moving the principles of societal beneficence and distributive justice (lumped together as Social Justice) down into the inner sphere, where individual doctors are expected to deal with them. You can’t actually do that, of course, because these are intrinsically outer-sphere norms. But our present-day ethicists have deemed it so, thus formally placing doctors into the position of having to serve the best interest of their patients (individual beneficence and autonomy) while at the same time, rationing healthcare covertly, at the bedside (societal beneficence and distributive justice). These interests, being often in stark conflict, simply are not possible for a physician to manage at the bedside. Charging doctors with the obligation to act in such an illogical, nonsensical and indeed impossible manner produces no good, and much harm.

Ethicists behaving badly

DrRich has thought long and hard about why medical ethicists have created such a non-solution for us. Are they stupid? DrRich thinks not, having tried unsuccessfully to read some of the arcane literature they produce, which is chock full of logical legerdemain, and by which (it appears to DrRich) they can justify almost any behavior you care to imagine. The stupid could simply not do that.

Rather, DrRich sadly concludes, it is cowardice. For, once ethicists determine that it is the obligation of society to establish the rules for limiting the rising cost of healthcare, the ethicists will be placed squarely in the line of fire; that is, the ethicists themselves will be asked to lead the process. Finding that to be a very scary prospect (many ethicists having chosen their field of endeavor, it seems to DrRich, precisely because it allows them to substitute critical commentary for difficult action), they instead have placed doctors in the position of having to ration healthcare for society at the same time they are supposed to be advocating for their individual patients. If there ever was an example of ethicists behaving badly, this is surely it.

If it’s any consolation to them, DrRich would like to assure modern ethicists that, having observed their recent behavior, he personally would never choose to burden them with the task of determining society’s rules for rationing healthcare. Indeed, if DrRich were in charge ethicists would have nothing to worry about, and might just as well tell us the truth.

Posted in Medical ethics | 4 Comments »

Smile When You Call Me Optimist

April 14th, 2008 by DrRich

In a previous post, DrRich gave his thoughts on the distressing condition of the American primary care physician (PCP), and described how the feds, the insurance companies, and the currents of history are conspiring to fundamentally devalue and disrupt their once-honored profession. Further, he attempted to describe some options that disaffected PCPs might explore which might possibly open the door to new, more sustainable business models.

This posting has generated a robust commentary, for which DrRich is grateful, as he thoroughly enjoys engaging in give-and-take with his readers, whose thoughtfulness and intelligence invariably challenges him to bring his analyses into sharper focus.

And based on this most recent commentary, DrRich finds that there is indeed an issue that clearly needs more focus - that of his purported optimism. It seems that some readers, in perusing the previous post, came away with the idea that DrRich is saying something like this: While history is demanding that PCPs must suffer a great disruption, history also points the way to their salvation; that, indeed, PCPs merely need to jump in the boat, and the currents of history will sweep them into the promised land.

To the extent that he created any impression that the transformation he’s proposing for PCPs is likely to be automatic, or straightforward, or easy, or without significant hazard, or (least of all) universal, DrRich most humbly apologizes.

He would like to set the record straight.

Here’s what history dictates: As long as there are free markets, the “final solution” being embraced by the insurers and the feds - that of a dumbed-down, malleable population of front line medical practitioners (whether made up of indoctrinated younger physicians, “broken” older physicians, ascendant nurses, or some combination of these) who will provide all basic medical services and control access to more specialized services - will ultimately not prevail. The large number of patients who have needs that will not be met by this solution will create an irreducible demand that the market will somehow conspire to meet. That, if anything, is the “optimistic” part of DrRich’s synthesis.

PCPs are in an unique position to fulfill much of this demand, and DrRich tried to describe two general pathways that might be explored for doing so (there are almost certainly others). But he certainly did not mean to imply that this would be easy to do, or that more than a minority of PCPs would embark on such a path, or would be able do it successfully. Indeed it seems likely that most PCPs will take the course of least resistance, as they seem to be doing now, gradually allowing themselves to be absorbed by the diminished model now being offered by the insurers and the feds, complaining about but not really fighting their fates, and all the while hoping for early retirement.

History reveals this to be the general rule. Most persecuted Puritans did not migrate to the New World (where they faced hurdles arguably even more off-putting than the threat of malpractice suits and specialist-dominated credential committees). Most Goths, upon being overrun by the invading Huns and facing the choice of absorption or migrating to territory occupied by somebody else, did not move south to sack Rome. Most PCPs will likewise accept their fate, and simply try to make the best of it.

Any pioneering PCPs who attempt instead to blaze these new trails will face huge hurdles, and they’re hurdles anyone (including DrRich) can see very clearly. They include the strong opposition (to put it mildly) PCPs will get from specialists as they explore ways to encroach on their turf; the attacks they’ll suffer from malpractice lawyers as they undertake to perform services traditionally done by specialist physicians (lawyers being the specialists’ great allies in this instance); the steady resistance of the insurers; the notion dearly held by most of the public that people shouldn’t have to pay for ANY of their own healthcare; and the parallel notion dearly held by many government officials that people shouldn’t be ALLOWED to pay for any of their own healthcare, and that any attempts to arrange for people to do so should be met with the most extreme prosecutorial wrath.

So, while DrRich believes history helps to explain what’s going on in the world of the American PCP, and helps (at least vaguely) to point the way for some of them, history rarely unfolds easily, or quickly, or without pain, bloodshed, tragedy and travesty. Generations (or centuries) can pass before a resolution is reached.

But if some insist on characterizing this as optimism, who is DrRich to object?

Posted in New business models for healthcare, Primary Care in America | 4 Comments »

Primary Care: Time to Reboot

April 8th, 2008 by DrRich

American primary care medicine has entered into a period of change. “Change” is perhaps too mild a term; many - especially the primary care practitioners (PCPs) themselves - might call it a period of crisis. In any case it is change so profound that one might be forgiven for thinking Senator Obama is already president.

Consider. PCPs have been hogtied to a dysfunctional reimbursement system that (thanks to the government, the insurers, the AMA, and their own specialist colleagues) has drastically and systematically devalued their training, expertise, and time. The very concept of what a PCP is and does (and indeed, what they should be called - whether PCP, family doctor, general practitioner, gatekeeper, or medical homemaker) seems in constant flux.

Whatever it is PCPs do, the government, the insurance industry, and experts on medical policy have spent years making the primary care job seem, well, easy. Their practices have been reduced to a series of discrete, easily cookbookified tasks. Each of these tasks can be directed by “guidelines” (devised, of course, by non-PCP “experts”), compliance to which can be easily tabulated and monitored, thereby to determine the adequacy of the individual PCP’s performance. And, because their job is now so codified, they are expected to perform it accurately and reproducibly in a matter of minutes (some say 7.5 minutes per patient encounter, though others will allow up to 12.5), just like any other rote industrial process.

To make matters worse, PCPs are slowly awakening to the realization that they are being squeezed out from the bottom. Some of what they do (the really easy stuff) is being corporatized into mini-clinics by the large drug store chains, and the rest is being threatened by newly assertive nurse practitioners and doctor-nurses, who are at least tacitly supported by the insurance industry. (Thanks to Dr. Poses for pointing out the relationship between doctor-nurses and big insurance.)

No wonder PCPs have become so terminally frustrated.

It is natural for PCPs to want to fight the changes that are destroying their profession, and causing their numbers to dwindle. Many have offered ideas. Gain the public’s support by alerting them to the impending and dangerous shortage of PCPs. Improve PCP payment schedules. Forgive the student loans of young doctors who choose primary care. Lobby congress for pro-PCP legislation. Offer novenas.

Some of this (DrRich is thinking the novenas) might hold off the inevitable for a time. But PCPs are fighting more here than just the government, the insurers, their specialist colleagues, and nurses filled with thoughts of vengeance (for 150 years of having to give unquestioning obedience to arrogant, clueless and unfeeling doctors, if you care to ask them). The PCPs are fighting history.

What is happening to PCPs is what happens to many experts whose jobs are fundamentally based on knowledge and/or technology. That is, as knowledge and technology advance, some (and perhaps a lot) of what the experts do can be sufficiently simplified and “democratized” that less well-trained individuals become enabled (or believe they are enabled, which amounts to the same thing) to do it themselves.

This is what the market is telling PCPs has happened to them. A substantial part of what they do indeed has been reduced to guidelines and cookbooks (thanks to remarkable advances in clinical studies and medical technology). The typical patient (note: DrRich said “typical”) with hypertension, diabetes, cholesterol abnormalities, and common infections can be relied upon to respond reasonably well to reasonably standardized therapy. And the market is saying to the PCP: “We can find ways of doing this without you.”

The same thing has happened countless times in history. The 1500-year monopoly enjoyed by the clergy in interpreting the Word of God was completely disrupted by the printing press and by the upstarts who translated scripture into the vernacular. The music industry has been fundamentally disrupted by digital recording software, which enables anyone with a PC to do things that had always required multi-million dollar studios. Ditto for book publishing. Ditto for real estate agents, accountants, car dealers, teachers, newspapers. All are wrestling to one degree or another with the “creative destruction” that is produced by advancing knowledge and/or technology.

For the most part, of course, nobody (except, perhaps, the doctor-nurses) will come right out and tell the PCPs to go away altogether. Instead, they’re telling them to dumb down, to just follow the rules, to stick to the guidelines and be paid to perform (one thinks of trained seals), to become like the lesser-trained practitioners who inevitably will be replacing them over the next decade or so. That’s where the profession is going, they’re being told. Get with the program, adapt to reality - or don’t let the door hit you where you keep your wallet.

Looking at the situation from this more historical perspective, one can see why it seems futile for PCPs to respond by railing and complaining, by lobbying for the public and the legislatures to understand that they’re actually quite important, by appealing to their specialist colleagues for more than lip-service support, or by trying to convince more medical students to choose a disintegrating profession such as this.

PCPs are in the path of a tidal wave of disruption, triggered by economic realities and enabled by technology. They are unlikely to prevail by a’wishing, and a’hoping, and a’singing, and a’praying.

From the perspective of history, it becomes apparent that what PCPs need to do is reboot. They need to reinvent themselves in a way that is compatible with the new reality. So far, they seem to be seeing only the disruption part of the creative disruption now tearing their profession apart. They need to find the creative part.

From a simple examination of history, two possibilities will immediately come to mind.

1) Just as advancing medical knowledge and technology has made it possible for lesser-trained individuals to encroach on their turf, so have the same advances made it feasible for PCPs to encroach on the turf of their snugger (and smugger) colleagues - the specialists. Observing how some of the bread-and-butter skills of the PCP have been sufficiently reduced to the point that nurses can do it, one finds it inconceivable that similar basic skills now monopolized by specialists haven’t been similarly reduced. It is undeniably true that for a lot of what specialists do, one doesn’t actually need a specialist anymore to do it. (As a cardiologist, DrRich knows for a fact that this is the case, but unfortunately he is bound by blood-oaths extracted by the high priests of his guild - oaths which mortgaged the immortal souls of his progeny down through 10 generations - not to mention the specifics. Sorry.) But look around. You’ll find examples easily enough.

Fundamentally, advancing technology allows individuals to migrate upwards into areas formerly occupied only by more specialized individuals. This is a law of technologically progressive societies. That nurses are aggressively migrating upwards onto the turf of PCPs is merely a case in point. So, rather than fighting a doomed-by-history rear guard action against the advancing army of nurses, why should PCPs not instead launch a blessed-by-history invasion of their own, against the smugocracy (the people whose jobs end in -ologist)? Heck, they’ll even have the insurers and the feds on their side for once (for the same reason the doctor-nurses now do). Wouldn’t that be novel?

2)Another law of technologically progressive societies is that, whenever specialists are displaced by upwardly mobile, technology-enabled non-specialists, there will always be a portion of the customer base that is likewise displaced. That is, the new, less-sophisticated service providers will be able to provide useful services to a majority of customers - but not to all customers. The customers with high-end needs, who are left out under the new regime, present a new business opportunity.

PCPs operate in a world where the majority of their patients probably have relatively common, relatively easily cookbooked medical problems, and most of these patients will do just fine with their new doctor-nurses. But a substantial minority will have high-end needs, either in terms of complex medical problems that cannot be reduced to simple treatment pathways, or in terms of atypical medical problems that are not easily diagnosed.

DB has discussed at some length this “long tail” in the patient population, as defined by some aspect of material complexity in their medical conditions. The long tail simply cannot be served by guideline-directed care, whether administered by doctor-nurses, or by those more malleable (or complexity-averse) PCPs who will simply allow themselves to be absorbed by the new, dumbed-down primary care regime. Long-tail patients, the outliers, will not be small in number. They will comprise an important new business opportunity, “new” because it is a niche that is not recognized today, as it will be when these patients are being systematically (instead of randomly) culled out.

That business opportunity can be filled by many of today’s PCPs. These will be doctors who enjoy puzzling through complex diagnostic problems, and dealing with complex management issues, and have been trained to do so. To DrRich, this spells “internist.” Doctor-nurses can’t do this job. Specialists can’t do it either. This will be a specific niche for internists.

The best part is that the feds and the insurers, in selling us on the dumbed-down PCP model, are busily assuring us that there is no substantial need for sophisticated PCPs (hence, the appropriateness of doctor-nurses). And in proving the point they’ll be able to rely on carefully constructed, population-based outcome measures (which, since they speak to the average patient, will look very favorable) to marginalize the complaints of the outlying patients. Having refused to acknowledge the existence of complex patients, they’ll hardly be able to make special provisions for their care.

This leaves the door wide open for internists to establish practices to provide healthcare services to patients with difficult diagnostic or management problems, who are being neglected and mishandled by the “official” healthcare system. (These patients know who they are, and are desperately looking even today for somebody to help them.) And since to insurance companies and the feds these patients don’t exist, these practices will have the opportunity to operate outside the system, as private-pay practices, which will eliminate the demeaning checklists, the one-size-fits all guidelines, and the stifling time limits under which PCPs now must operate. And, like plumbers and electricians, they can get paid for what their time and expertise is worth.

(To those of you who immediately object to such a thing because asking patients to pay themselves for medical care is unethical, DrRich asserts it is indeed possible to do this entirely fairly and ethically, while allowing almost anyone who wants this kind of service to have it, and some day he will describe how. But for now, just celebrate the right of people to spend their own money on their own healthcare even when it’s provided by actual physicians, just as [DrRich suspects] you celebrate their right to spend money on chelationists, homeopaths, or reiki practitioners.)

The bottom line, as DrRich sees it, is that the identity crisis now being experienced by American PCPs, while certainly catalyzed by healthcare economics and politics, is a manifestation of the natural and inevitable disruption produced by advancing knowledge and technology. PCPs may be the first, but all physicians will soon face similar challenges as long as medicine continues to advance.

If the PCPs respond logically to this crisis - that is, instead of fighting it, recognizing the opportunities it presents - their specialist colleagues will soon experience their own “encroachment from below,” which is the hallmark of a mobile, technologically progressive society.

Posted in New business models for healthcare, Primary Care in America | 19 Comments »