The Games We Play

I have criticized hospitals, patients, and insurance companies in my prior diatribes against our current health care system. Now, its time to take on physicians. What are we doing incorrectly? What are the games we play?

Our current health care system emphasizes specialization but as a byproduct it breeds laziness. It promotes waste and inefficiency. And physicians profit from this.

Lets say a surgeon is paid $5,000 for a gallbladder operation. The patient and the insurance company aren't paying the surgeon $5000 just to take out a piece of tissue. They are paying the surgeon to do a procedure and make sure the patient does well. This involves making sure the post-op course and well as the intra-op course are uneventful. However, here is what really happens. The surgeon pockets the $5,000 but before he does that he gets a primary care physician to see the patient prior to the surgery and get him tuned by doing all the pre-operation work. He removes the gallbladder but the operation is complicated by significant blood loss. Afterwards he forgets to make sure the patient's regular home medicines are ordered correctly. After the surgery, he consults medicine, renal, and cardiology to help him manage the patient post operation. This basically involves making sure the mistakes he made are managed. The surgeon sees the patient the day after surgery and then ignores the patient for the rest of the hospitalization.

Meanwhile, the renal, cardiology, and general medicine teams all bill the patient for their time, when in fact all they did was make sure the patient's chronic medical problems weren't worsened by the surgeons incompetence.

Its a win win for the medical system and the physicians. Everyone bills the patient separately for the same job. Lets examine this with an airplane analogy. You pay $500 to fly to Paris. When you get your credit card bill you find out that the pilot charged you $500 for taking off and then a separate pilot charged you $500 to land the plane. The stewardess charged you $50 to bring you those little bags of peanuts. By the way, those little bags of peanuts also ended up costing you $100. Total cost: A Total ripoff!

How about a new model for physician compensation for inpatient care. The surgeon gets paid $6000. However, this is the total amount that a patient or the insurance company will pay the hospital. If the surgeon wants a consult to help him manage the patient, he has to pay out of this total lump sum. So, if he wants a renal, cardiology, and general medicine consult because he forgot everything he learned in medical school, his total take home pay is less. But the patient pays one time for one procedure.

By the way, good luck getting your hand on any of the primary billing data for any hospital. That stuff is guarded like it is a national secret. No hospital will make public exactly how much profit it makes on individual procedures. Trust me, I've asked. Even I can't find out how much the things I am doing are costing the patient or how much profit I am making the medical system.

http://www.youtube.com/watch?v=xskFo75Wdhs

You Get What You Pay For

The healthcare reform debate continues to unfold and the arguments for and against reform are both full of contradictions. I can't help but think that a few years/decades from now, we'll look back and not believe we let this travesty unfold. In my effort to shed some light on the issue, I've put forth some of the arguments I hear the pundits making and my own rebuttals.




Arguments Against Reform:



We don't want bureaucrats involved in health care.



My reply: Guess what? Your access to health care is already controlled by someone in a far away location that knows nothing more about you than a few notes on his computer screen. Screeners for health insurance companies dictate who gets health care and what kind of care they get. Even with the best insurance plans, there are severe limitations on what kind of tests and drugs people have access to. For you to get your MRI or the newest drug, your physician and/or you end up spending hours on the phone with an insurance representative getting prior authorization. A recent study estimated that the paperwork required by insurance companies costs us $31 billion/year, or roughly 7% of all US spending on physician services.





Why is this fact so little publicized? If this is the case, why are so many people happy with the healthcare that they currently get? The reason most people are happy with their health insurance is because most people are healthy! Take a poll of the chronically ill and you'll get a much different viewpoint. I like to think of our current batch of insurance companies as highly paid backup quarterbacks. They are great and everyone loves them until they actually need them. When forced to utilize their services we quickly find out their extreme limitations. And of course, they are paid too much for doing absolutely nothing.







This is socialism! I hate socialism! The government needs to leave healthcare alone!

A national healthcare plan is no different that having public schools! Is that socialism? Is the fact that our current education system allows for public and private schools some left wing conspiracy? How is universal access to healthcare any different? The current plans allow you to participate in the public plan or pay more for the private plan. Sounds very similar to our school systems to me. And just like education, healthcare should be something that we should try to make available to everyone.



However, we should take a minute to examine the school analogy. The reason so many of our public schools are so horrible is because they are grossly underfunded. If we want the national healthcare plan to work, we have to be willing to spend more money.





We don't have the money to spend! It will cost TOO much!

Apparently we have enough money to spend to pay for new cars for people that don't need new cars! We have enough money to rescue failing banks. And my personal favorite, we have enough money to go oversees and kill a bunch of terrorists. What do you think kills more Americans? Terrorists or lack of health care? There are people dying everyday in your very city that can't afford the care they need and we don't want to spend money to help them. But if there is even a hint of a foreign threat that might endanger American lives, we're willing to spend whatever it takes to buy the latest bombs and planes. The VERY people against spending for healthcare due to financial concerns seem to be the people that would consider cutting back spending for our armed forces to be anathema. Confusing to say the least.







Arguments FOR Reform:



We don't have enough money!

My reply: The money argument is used by both sides of the healthcare debate. The people for health care reform envision cost savings by enforcing quality measures, regulating the types of procedures covered, and removing the profit motive. Another word for "Regulating the types of procedures covered" is rationing. It is true, that rationing in some form is already prevalent in the current health care system and in all aspects of life. If you don't believe me, take a look out on the street. Everyone isn't driving a Rolls Royce. If you wanted to get expensive procedures or drugs with the current healthcare plans, you would have to jump through many loopholes to qualify. This is rationing. Also, the current health care plans don't cover 45 million people. This is rationing.



However, switching to another form of rationing wherein you cover everyone but offer less services to each person is not a step in the right direction. As I have said before, our healthcare system is the best in the world and it is this great healthcare system that we are afraid of losing. I don't think that the proponents of health care reform want everyone to have access to crappy healthcare. They want everyone to have access to the best healthcare.



There are three variables involved here:number of people covered, services offered to everyone who is covered, and the total cost to the system. If you increase the number of people covered and hold cost stable (or decrease cost) then you HAVE to limit the number of services you offer to everyone in the plan. If you try to increase the number of people covered and offer everyone the same services, then you HAVE to increase cost.



The only way to limit costs in a national health system is to limit the access to care for everyone. These people argue that we are spending too much and doing too many procedures. A great example is the often quoted fact that the city of Boston has more MRI machines that the country of Canada. I like to believe that this might be the reason that you have Canadians coming to Boston to get healthcare instead of Bostonians going to Canada. However, the quality of the healthcare being offered in the US is a discussion for another post.



The current system waste too much money on end of life care. We need to focus on prevention.



President Obama recently used the death of his grandmother to explain how the US healthcare system wastes money. He thinks we need to provide less aggressive end of life case and focus more on prevention.



I would love to see ONE study that shows that prevention works. The sad truth is that the US healthcare budget cannot spend more money on prevention that the combined budgets of Big Tobacco, McDonald's, Coke, Pepsi, and Twinkies (who makes these by the way?). Also, as good as we are at taking care of medical problems, we cannot instill in people a sense of personal responsibility. People are going to gravitate towards instant gratification. Until we change our culture (eating habits, exercise routine, and our expectations for what healthy means) we will continue to have problems with chronic diseases. You can't imagine how many conversations I have had with people that weigh 250-300 lbs that don't understand that they are fat! The reason for this is because the patient's brother, his wife, his wife's brother, and all extended family and friends are actually fatter than he is. To him, being 250lbs is actually too thin! Until we realize as a society that we have to take personal responsibility for our health, no amount of money spent on preventative measures will make a difference. If you don't believe me, take some time to examine our own President who is a strong proponent of the national health care system and of focusing on preventative measures. If preventative measures work, why is he still smoking? He is a walking, talking example of the failure of preventative measures.



I apologize for the rambling nature of this post. There is so much ground to cover and it is sometimes difficult to focus in on what to talk about first. As you might have gathered, I hate the current health care system but I also think the focus by the Democrats to limit health care spending by instituting a single payer system isn't the right way to go.

However, unlike the town hall hecklers and the insurance industry that have no better alternative to offer, I would like to propose an alternative. Here are some of my ideas of how to institute health care reform:

1) Everyone gets access to a basic level of healthcare.

2) People have the option to purchase private healthcare out of their own pocket. If they do this, the amount they spend on private health care should be tax deductible.

3) There is NO role for insurance companies. People buy healthcare directly from the provider. If they want private healthcare, they pay whatever the provider bills them.

4) All healthcare providers are graded/evaluated under a national system and these evaluations are easily accessible to the public. This ensures that people know where they can get "quality" care and thus they can function as knowledgeable customers. The current healthcare system hides the true cost of healthcare from the consumer (patient) and hides the quality of the product being bought. We are paying some unknown amount for a service/good whose quality we can't judge.



5) We limit malpractice monetary rewards levied against individual physicians but at the same time we leave uncapped the amount of damages sought against health care systems. This ensures that hospitals will take a much more proactive role in picking out the bad apples.



6) We increase taxes on things that make us unhealthy. We tax unhealthy foods and we increase the tax on tobacco and alcohol. At the same time, we offer tax credits for restaurants that offer healthy food options. As an example, if McDonald's wants to sell fries and not pay more taxes, they can offer more salads. These costs will likely just be passed to the consumer but that isn't a bad thing. If you want to eat Twinkies all day, you shouldn't expect your neighbor to pay for you heart surgery in 20 years.



7) We stop covering medical problems caused as a direct result of breaking the law. For example, if you had a stroke or a heart attack because you were smoking crack. Guess what? You better have the money to pay for you medical coverage because neither the government nor any insurance plan will be obligated to cover your medical expenses. If you drive drunk and get in a car accident, you foot the bill. This seems simple to me. Our current system will pay for you to get all the medical care you need if you are the drunk driver and end up in a car accident. But the poor people you almost killed who might not have insurance are on their own. A fantastic system.



I would love to hear your thoughts on what I have proposed. Thank you for reading.

We Need To Spend more on Healthcare!

How much would you pay to spend one more year with your loved one? What is the value of knowing that if you get sick, you have the best medical care in the world right down the block? What is that peace of mind worth to you? Our country bemoans the cost of healthcare while sitting around a table eating KFC and McDonald's. Am I the only one who finds this just a little disingenuous. I maintain that our healthcare system is the best in the world and that it is a bargain. In fact, we should be paying more for the healthcare we get. I'd like to go over the biggest complaints against our healthcare system and hopefully explain why I feel so differently from the majority.

Widely held belief #1: Our healthcare system does not provide quality. In fact there are many countries that provide better care. The "I wish I lived in France or Canada complaint!"

The widely quoted studies that claim US healthcare quality isn't up to snuff do not take into account genetic and behavioural differences. For example, the incidence of coronary artery disease in the Japanese population is much less than that in the US. Do you think this is because we don't have good cardiac care or because we like eating at McDonald's?

Many commentators vilify the US for the fact that infant mortality in the US is higher than in many European countries. This sounds horrible until you look at the details and realize that many European countries only count infant deaths if the infant lives one month and then dies. Deaths in the first month aren't always included. Meanwhile in the US, all live births that end up dying count towards our statistics. Furthermore, we are much more aggressive with preterm births. The fact that our patient population is much sicker and we include all deaths in the statistics explains the gap in infant mortality.

While we'd love to think that the grass truly is greener across the border, lets take a closer look. In Canada you wait weeks, months, even years for procedures not deemed emergent like hip replacements. A set amount is allocated at the start of the year for each procedure and when the money runs out, so does any hope of you getting your procedure done that year. We aren't talking about breast implants and botox. I'm referring to procedures like knee and hip replacements so that grandma can walk again instead of spending another six months in a wheelchair popping narcotics to relieve the pain. Sounds like a great healthcare system.

Lets forget the fuzzy math and the unavoidable delays inherent in any system that rations healthcare. Ask yourself what you would do if your mom, dad, son, or daughter developed a serious medical condition. Would you take them to Canada, France, or Great Britain or would you take them to the top notch hospitals all across this country. Just to make the point further, one of the Canadian Parliament members who is a huge proponent of the Canadian healthcare system came to the US to get care when she developed cancer. People from all over the world fly into Boston and Baltimore in the hopes of having their disease treated. They don't fly to Paris for the healthcare.

Widely Held Belief #2: Even if we deliver good quality healthcare, it costs too much! This is the "I want to eat my cake and have it too!" complaint.

Healthcare does cost a lot of money but so does going oversees and killing Iraqis, so does giving subsidies to farmers, bankers, and auto workers, so does paying for your local NFL team to build a new stadium. Before saying that healthcare costs too much lets compare it to other expenses both at a national level and at a personal level. For every dollar in federal taxes, 41 cents was spent on war, preparing for future war, or paying off old wars (interest on the military portion of the national debt). 19 cents of the federal tax dollar was spent on healthcare. So, we spend twice as much money killing people as we do on helping our own citizens get the healthcare they need.

Oregon is one of the few states that has medical coverage for all its citizens. They have published their fee schedule that details reimbursement for all covered procedures. It makes for interesting reading. Lets go through it and try to compare how much Oregonians pay for various medical procedures and try to compare that to what else they could buy with the same amount of money.

Open chest heart massage: $110.67 or you could buy two tickets to watch the Portland Trailblazers (section 209, rows:a-h). Of course you'll have to pay extra for the parking and the food you eat at the game. So, a night out to watch a pretty bad NBA team vs open heart massage. Which one do you think costs too much?

Insertion of a pacemaker: $351.10. You could buy a Playstation 3 for $399. Of course you'll have to pay extra for any games you want to buy. So, the insertion of a device to keep your heart beating costs less than a Playstation 3 but we MUST be spending too much on healthcare, right?

Bone Marrow Transplant: $92.16. Or, you could spend one night at a Holiday Inn Express (20 miles outside Boston). This price doesn't include tax or any of those little drinks in the mini-bar.

Antibiotics for severe infections like pneumonia (zosyn): $5.57 per dose. Can you even get a meal at McDonald's for that much anymore?

Cesarean delivery: $1221.99 or about the same as a year's supply of diapers. This is a close call. What do you think should cost more?

The amounts quoted above might not jive with the amounts many of you see when you get you bill from the hospital. This is because a significant amount of money is skimmed off the top by insurance companies. Have you ever wondered why the tallest, newest buildings in many cities are owned by health insurance companies? While doctors, nurses, pharmacists, and drug companies offer something to the patient, I am at a loss for the value added role for insurance companies. The costs I listed above are what the hospital is actually reimbursed. A significant amount of a patient's total bill goes towards overhead and is lost due to inefficiency. This will be covered in another post where I discuss my dislike of insurance companies.

One other reason for the large healthcare costs in the US is due to the fact that we are the innovators for the rest of the world. The reason HIV drugs are available in Africa is because we spent the research dollars to develop them here for our citizens. The same can be said for ~ 90% of the medical breakthroughs over the last few decades. We develop the technologies and techniques that the rest of the world uses. Doctors and scientists from all over the world come here to learn and to help us further medical care. Innovation comes with cost.

My final point will probably be the most controversial one. Healthcare costs in the US are going up because we aren't taking care of ourselves. That's right, I am blaming the patient. We don't exercise, we eat too much, we drink too much, and we smoke. And then when we are 100lbs overweight and addicted to nicotine, we act surprised when we have a heart attack. When we get the hospital bill we get mad. We rant and rage and go on CNN and complain about how healthcare costs are ruining America. We now have the technology that allows you to live despite a lifetime of overindulgence but don't' expect that to be free. Everyday, you can scarf down your bag of Cheetos, chug a few cans of Budweiser, eat the box of Krispy Cream doughnuts, and take a long deep breath full of that great Marlboro air, and still live to see your grandkids have kids. Isn't America great? By the way, when you have that massive heart attack and go to the hospital to get your arteries opened up, the hospital will be paid $600 to place a stent in your heart. That is about the same as a person spends on cigarettes over a 4 month span. Do you still think we need to reduce health care costs?

I think everyone deserves quality health care despite their ability to pay for it. However, I think that a single payer system isn't the solution. And certainly, any healthcare reform that seeks to curtail healthcare spending is not going to result in better patient care. I'll discuss a few ideas in my next post but I would love to get your thoughts on healthcare spending.

Specializing

A few decades ago the medical school curriculum committee was meeting to discuss updates to the standard curriculum. As they debated on what courses needed to be added/dropped they decided to ask Dr. James Kirklin (CT surgeon) what information was important for medical students to learn prior to graduating. Without hesitating he replied, "They should know it all."

I want to be a cardiologist. Specifically, I want to focus on heart failure. But not just heart failure; I want to be an expert on acute heart failure. And if I really get to do exactly what I want, I'd like to work on peripherally inserted mechanical support devices for acute heart failure.

My own career goals make what I am about to say that much harder to believe. I hate the current medical model that emphasizes super-specialization at the expense of a broad based knowledge base.

It used to be that the same doctor that diagnosed your heart attack could take out your gallbladder and deliver your baby. Understandably, as knowledge about the various medical fields (Surgery and Medicine) grew, practitioners started focusing in on either surgery or general medicine. As we learned more about the body, these fields further subdivided and now you had speciality training in various subdivisions of either medicine or surgery (cardiology, pulmonary, renal, etc... or GI surgery, cardio-thoracic surgery, etc...). However, as recently as the 1950s, physicians were still trained in both surgery and medicine. In fact, it wasn't until the 1960s-1970s that you had many specialities grow and develop their own specific training pathways. Up to this point, the growth towards specialization dovetailed nicely with and likely contributed towards the explosion in knowledge about the various specialities.

However, sometime between the 1970s and now, we started fracturing the medical landscape into smaller and smaller pieces. Some of this was a direct result of the exponential increase in knowledge. You had cardiologists becoming sub-specialists in heart failure, catherization, or electophysiology. We also started to self-segregate based on other, less clear factors. You had the start of ER and hospitalist medicine. If you just want to focus in on the acute management of all medical problems but did not want deal with any of the long term management or consequences, you could train to be an ER physician. Likewise, if you just wanted to manage inpatient medical issues, you could train to be a hospitalist. These new subdivisions were not directly linked to organ systems or disease processes, but rather to certain situations in health care delivery.

Let me offer an analogy comparing our health care system to flying an airplane. Initially all pilots could fly all airplanes as there weren't that many different kinds. As varying models were designed, pilots started to specialize in certain types of aircraft. The Cessna pilot and the 747 pilot became specialists in their own type of machinery. However, what you didn't see happen is the development of a pilot who specialized in takeoffs, and one that specialized in landings, and one that specialized in flying through hurricanes. What you didn't see is one pilot managing the airplane during takeoff and then openly admitting that he didn't know (or care to know) about how to continue to fly the plane and/or land it, and that that was someone else's responsibility. Add a healthy dose of poor communications between all involved parties to this super fragmented model and you have a great recipe for chaos. If you think such a system of flying airplanes would surely lead to mistakes and deaths, then welcome to our current health care system.

As we have developed this amazing, detailed knowledge base about the human body, physicians have gravitated towards the fields and opportunities that most interest them while at the same time paying lip service towards retaining the basic knowledge base about the field as a whole. Despite my desire to focus in on a very specific patient population, I ardently believe that my ability to offer good care will involve more than a detailed knowledge about a focused problem.

Living or Dying?

Randy Pausch is a computer science professor at Carnegie Mellon. Carnegie Mellon's computer science department has a lecture series titled "The Last Lecture." The premise being that if this were your very last lecture, what would you talk about? They asked Dr. Pausch to give this years last lecture. While meant to be a fun and interesting interlude, this lecture took on much more significance when Randy learned that he had metastatic pancreatic cancer and this really would be his last lecture.

His talk was taped and posted on YouTube. You can watch it here. Over 2 million people have watched the video since it was posted.

Randy Pausch has a website where he posts frequent updates about his medical course. You can visit his website and find out how he is doing.

He even wrote a book titled The Last Lecture -- which you preview here. He did all this within the last year after finding out he had pancreatic cancer. Not bad.

Hope Renewed...


Ms. F lived. She beat the odds. She was found unresponsive at home covered in her own feces, surrounded by flies and maggots. No one knew how long she had been in this state. She was having trouble breathing and was put on a breathing machine as she was transported to our emergency department. Her temperature on presentation was 94.0, her respiratory rate was 40, her heart rate was 130, and her blood pressure was 80/40. She was completely unresponsive, even to painful stimuli. She was bleeding from every orifice except her eyes and ears. Her labs on admission showed a white count of 2.0, a hemoglobin of 5.0, and a platelet count of 10. Her BUN was 255 and her Creatinine was 10! All of here electrolytes were abnormal.

She was infected, her mental status was horrible, she was having trouble maintaining an adequate blood pressure, she required the support of a breathing machine, her kidneys were shutting down, and she was bleeding profusely.

Ms. F has a history of multiple sclerosis and her only other hospitalization had been for renal failure secondary to a neurogenic bladder. It turns out that this time she had also been experiencing decreasing urine output over the prior week or two. She had difficulty urinating and toxins built up that resulted in altered mental status. A CT scan done the night she came in to the hospital showed that she had retained so much urine that she had perforated her bladder.

Ms. F was on a ventilator for ~ 15 days. She received 15 units of blood and platelets over the first 2-3 days she was in the MICU. She was treated with very broad spectrum antibiotics. She underwent bladder repair.


She lived. She left the hospital a few days ago. She has two little kids at home. I met one of them -- a wide-eyed seven year old who will probably never know how close he came to losing his mom.


When she first came into the hospital, I had no idea if she would live. I thought for sure that she would pass away. Her recovery speaks to the strength of youth and the remarkable ability of the MICU nurses to deliver fantastic care.

Cases like hers remind me of advice that one of my surgery attendings once gave me. We had just left a patient's room where he had discussed the pros and cons of getting lung surgery to remove a tumor. The patient had asked my attending how long he had to live. As we left the room, my attending turned to me and said "Never be arrogant enough to think you know how long a patient has. You will always be wrong! Anything you say is a guess... an educated guess but a guess nonetheless."

So much of what we do involves predicting mortality. When a patient asks if he should undergo surgery or when the family asks how likely it is that their loved one will get off of the ventilator, they are really asking what their chances of dying are... And I don't know.

Ms. F was the exception. The next 99 people who come in with her problems will probably die in the hospital within a few days. The question is, do we treat those other 99 people just as aggressively in the hope that they turn around like Ms. F did? Or, do we tell the family that the chances of recovery are so small that they should make the patient comfortable and not pursue aggressive treatment?

The Last Day

I finished my MICU rotation yesterday. As I walked out I couldn't help but think of the failures I had, the people I wasn't able to help.

The 60 year old Boeing factory worker and father of four. He came in with profound hypoxia (unable to oxygenate his blood) and despite everything we did, we weren't able to improve his breathing. He was diagnosed with acute interstitial pneumonitis, a catch-all term that hides the fact that we don't know the cause or the cure. He was completely healthy prior to this hospitalization. He and his wife had been vacationing in San Diego just a few months prior. He died.

The 28 year old deaf/mute mother who had never been in the hospital other than to deliver her baby a few years prior. She also presented with shortness of breath and was soon put on a ventilator. It turns out that she had the flu and her lungs also had been infected with bacteria (staph aureus). We weren't able to help her breathing. She ended up going on the heart/lung bypass machine (ECMO) to give her one last shot. She died.

The 50 year old husband who presented with liver failure due to a disease known as primary sclerosing cholangitis (PSC). He had been on the liver transplant list until he developed an infection and was sent to the MICU. Based on verbal reports, they had actually found him a liver but just a few minutes/hours later, he became sicker, and they realized he had developed an infection. He was taken off the transplant list temporarily, started on antibiotics, and sent to the MICU. He never got a new liver. He was surrounded by family and friends. When I pronounced him dead, his mother looked at me and asked, "Thats it? Is he gone?" to which I could only nod yes. He died.

During my time in the MICU, I took a day off to go interview for cardiology fellowships. As I sat there through the interviews, with my interviewers telling me how impressed they were with everything I had done, I couldn't stop thinking about all the people that I had taken care of the last few weeks that hadn't made it. Its easy to tell myself I did my best and that these people probably wouldn't have made it anyway, but that excuse rings false. I don't like failure -- its a selfish feeling. I want to be better. I don't want my patients to die.