Understanding The HITECH Act: HIPAA On Steroids

By Jeffrey Segal MD JD & Michael J. Sacopulos JD

Understanding the law before you send your patients any e-mail.

Snail mail is becoming less popular as the calendar pages turn. E-mail and social media networks have changed how we communicate. Before clicking the send button in an e-mail template, healthcare professionals should better understand that HIPAA violations have also entered a new era. More cases are prosecuted with assessment of both statutory civil fines and criminal penalties.

A little background: Even though HIPAA passed in 1996, little prosecution followed when patient privacy was violated. Since the law took effect in 2003, nearly 45,000 complaints were filed with the Health and Human Services (HHS) Office for Civil Rights. Of these complaints, only 775 cases were referred to the Department of Justice or the Centers for Medicare and Medicaid Services for investigation. None resulted in direct civil monetary penalties.

Then, in 2009 the HITECH Act (“HIPAA on steroids”) was enacted. This act intended to increase HIPAA confidentiality protections of Electronic Protected Heath Information(ePHI), instill tough civil and criminal penalties for violations, mandate notification of breaches of HIPAA protected heath information, and extend the definition of covered entities to include business associates. A tall order indeed.

For example under the tougher HITECH Act, in April 2010 a former employee of a hospital was sentenced to four months in prison for accessing the medical records of his coworkers and various celebrities. He had no “valid” reason for accessing these records.

According to the Health and Human Services (HHS), penalties have increased. Prior to the HITECH Act, the HHS Secretary could not impose a penalty of more than $100 for each violation or $25,000 for all identical violations of the same provision. Section 13410(d) of the HITECH Act strengthened the civil money penalty scheme by establishing tiered ranges of increasing penalty amounts, with a maximum penalty of $1.5 million for all violations of an identical provision.

Just how "high tech" are physicians when it comes to communicating with patients?

A survey by the health information firm Manhattan Research in 2009 found that 42 percent of physicians had some online communication with patients.

The American Academy of Family Physicians reported in a 2009 survey that just 6 percent of responding members had performed a Web-based consultation - that number was more than double the 2.6 percent who had done so in 2008.

But is all of this electronic communication legal?

The HITECH Act requires that all communications involving ePHI be encrypted.  HHS recently adopted National Institute of Standards and Technology guidelines for encryption.  This means that if a physician wants to consult, refer, or prescribe for a patient by e-mail, the e-mail had better be encrypted.  Of course most patients do not have software to decrypt.  So what alternatives do healthcare providers have? And, more importantly, how can this be made easy and pragmatic. Email was designed to simplify, not complicate.

Healthcare providers may seek their patient's consent to communicating via unencrypted e-mail.  While HHS does not provide a standard form for securing patient consent, basic "informed consent" strategies should apply.  First, get the patient's consent in writing.  The patient should not be given just a binary choice – but a menu of choices.  For example, a patient may wish to electronically receive information on appointment dates but not test results.  The consent document – as is standard with most routine HIPAA forms -should also note that the patient may withdraw his or her consent at a later time. This can be part of an expanded HIPAA form the patient signs when first seeing you in the office.

Here are some more recommendations when communicating with patients electronically:

1) A physician may be held responsible for a delay when responding to a patient's e-mail. Solution: A physician that wishes to accept e-mail from patients should use an auto response feature that informs the patient that a) the physician typically responds to e-mail within XXX number of hours/days; b) if the patient requires immediate attention, the patient should telephone the physician's office or contact an emergency healthcare provider.  

2) If a patient initiates an e-mail with a physician, Rachel Seeger of HHS Office for Civil Rights says that it is assumed that the patient consents to unencrypted communication.  "If this situation occurs, the healthcare provider can assume (unless the patient has explicitly stated otherwise) that e-mail communications are acceptable to the individual”.

3) If a physician does end up sending a patient an e-mail, double check the recipients’ e-mail address before clicking the send button. This is to prevent the e-mail from being sent to the wrong person, therefore sharing private information to an unintended party. Good advice also in the non-healthcare world.

4) Add any e-mail a patient sends (and any response) to the patient's chart.

5) In the HITECH Act code 170.210 section B states that the date, time, patient identification and user identification must be recorded when electronic health information is created, modified, deleted, or printed; and an indication of which actions occurred must also be recorded. This means if you send an email to a patient with protected health information – and delete it – you will need a record of what was deleted and when. This is not dissimilar to crossing out a line in a paper medical record- updating the record – with a date of the update.

6) Since communicating with patients via e-mail is becoming stricter, more physician offices and hospitals are using portals as a means of communication. This allows the patient to sign in with a secure username and password to view their records and communicate with their physicians. The security rule allows for Electronic Protected Heath Information (e-PHI) to be sent over an electronics open network, as long as it is adequately protected.  Of course, this is more complicated than using Outlook or gmail.

The HITECH Act has ushered in a new era of technology requirements and standards that must be met by physicians.  Given HHS's recent enforcement efforts, physicians should use caution when electronically communicating with patients.  By working within the boundaries of the six points above, physicians should comply with the HITECH Act. 

Jeffrey Segal MD JD and Michael J. Sacopulos JD are with Medical Justice, a Medical Spa MD Select Partner that protects physicians from frivilous lawsuits.

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Medicine & Motherhood

By Dr. Dawn Barker

Until recently, it was easy to reply when an inquisitive acquaintance asked, “What do you do?” I would answer that I was a child and adolescent psychiatrist. Easy.

The most difficult part was trying to explain that yes, a psychiatrist is a medical doctor, and no, I’m not a psychologist and there is a difference. But when faced with the same question these days, I struggle to answer. Of course, I am still a psychiatrist, and those certificates on my office wall are still valid. But my role now is so much broader and difficult to define.

Almost two years ago, I stopped work to have my first child, with a plan to take a year’s maternity leave. I was surprised when many of my friends and colleagues were shocked that I was taking so much time off. I replied with my standard child psychiatry spiel about the first year of an infant’s life being critical for secure attachment development, but the reality was that I wanted to stay at home with my new baby. I looked forward to having a year when I didn’t have to deal with acutely distressed patients, and the equally distressed hospital system. If I was going to be woken at night, I wanted to deal with my own child’s need rather than someone else’s. In fact, I wasn’t sure that a year would be long enough.

Before that first year was up, I was pregnant again, and I officially resigned from my position at work. I have recently had my second child, and now haven’t worked in medicine for almost two years. I always thought that society frowned upon women who went back to work when their children were young; instead, it seems that the opposite is true, and professional women are somehow expected to return to work quickly and hand over the raising of their children to someone else.

So what do I do now? I have been writing: I’ve written a novel and won a publisher’s manuscript development competition; I’ve kept a blog of my parenting experiences; I’ve written a few articles for magazines. Would I call myself a writer? I still can’t help but feel embarrassed to say that. It doesn’t seem like a ‘real’ job. I’m not earning a living from it, so I can’t really say it’s what I ‘do’.

Do I say that I’m a mother, or a housewife? In reality, that is what I do every hour of the day: I look after my family physically and emotionally, and I run a household. But I hesitate to define myself as a homemaker. I want people to know that I can do more than that, even though I know that raising children is difficult and tiring and incredibly important – but it is undervalued in our society. There seems to be more value placed on professional women returning to the workforce and employing someone else to look after their children.

There are days when I wish I was at work, having a coffee with other adults while we discuss a challenging clinical case, or reading a magazine while I eat lunch without a toddler trying to escape from a high chair next to me. Then I remember – that rarely happened when I was working. I was just too busy. It’s then that I remind myself: even the worst day at home with two young children is nowhere near as bad as the worst day at work.

Doctors should be the most supportive of professions when it comes to our colleagues becoming parents. We work every day with patients in difficulty and know the importance of a strong family, and yet our profession is one that makes it very difficult to balance both a working and parental role. Part time work is difficult to manage, clinical meetings and ward rounds are often held very early or after hours, and the on call work can be brutal. But we are more than doctors; we are mums and dads and wives and husbands, and we shouldn’t have to pick one or the other. We can’t do it all, and maybe we should stop trying to.

So when people ask me what I do now, I tell them that I am a psychiatrist who has taken a few years off to raise my family, and I also write on the side. And that’s an identity that I am happy with.

About: Dawn Barker is a Child and Adolescent Psychiatrist, writer and mother, based in Perth, Western Australia. She blogs at psychiatristparent.wordpress.com

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Pricing, Cognitive Dissonance, & How To Charge More

Your profits are in your prices. Where are the psychological triggers you can use to raise your prices and charge more?

You'd like to be able to charge a premium for your services and rake in the big bucks, right? Then why are so many physicians and clinics utilizing the slow death spiral of constantly trying to undercut the competition and using discounting coupon services like Groupon. Why are some physicians able to charge 50% more for Botox and others are trying to give it away and scrambling for any new patient. Where's the disconnect?

Guess what. It's psychological.

Look, there are only two things that determine ANY price.  Put these lines on a graph.

1. How much you're willing to sell something for.
2. How much someone's willing to pay for it.

That's it. Just those two things, and the second of those is based on psychological triggers more than anything else. (Of course, those two lines cross at some point or you're pricing yourself out of the market and in big trouble.)

As a physician running a cosmetic medical practice or medical spa, when you’re essentially selling time, how do decide where you can set — and then raise — your rates?

Guess what? People actually want to pay a lot.

I learned this as a young painter in New York. My paintings sold between $25,000 and $60,000. Why? It's pretty simple. I wouldn't sell them for less and I could easily get buyers who would pay that amount. I could find lots of buyers that would purchase my work as fast as I could produce it. I had both the skills and business savvy to understand that the quality and uniqueness of my work created the demand and drove up my prices. I didn't just set my prices high. I started by creating a unique niche that I completely dominated; beautiful, realistic women in oil with old world craft. I would never have been able to charge $60,000 for paintings that no one wants and anyone could produce.

Even more, I set myself up as able to demand those prices. Believe me, no one want's to pay $50,000 for a painting. They only pay that amount for a story, and the story is around something that's unique and scarce.

People want to pay a lot for cosmetic treatments.

If you don't know it already, you're in the vanity business. People will pay outrageous prices for vanity. Think of the prices that high end vanity commands; $600 for a felt purse by Kate Spade, $1,150 pumps from Christian Louboutin, the $84,000 Audi A8, the Omega Seamaster watch, any Apple product... The cost is actually integral to the enjoyment.

People want to pay a lot for your cosmetic treatments IF you position yourself correctly AND your treatments are both unique and scarce.

No one wants to pay more for the same coach seat on an airline, but there's obvious satisfaction when someone describes the purchase of an expensive luxury item, even if the price is never mentioned.

If you cater to the lowest common denominator, you'll have to price your services that way too. Specialize in a lucrative niche and your services become not only unique, but scarce as well. Uniqueness and scarcity work hand-in-hand to drive up demand and allow you to raise your rates.

So uniqueness and scarcity are primary ingredients to any offering that want's to charge a premium. We'll deal with both uniqueness and scarcity in other posts. What I want to talk about here is the psychology of pricing and how it relates to your own pricing and your customer loyalty.

Once you have something that's both unique and scarce, you can move on to increasing your prices.

Where's your current pricing?

I’ve met many, many physicians who under price their services.The primary reason that's give is that they have to have low prices to remain competitive in an every more productized marketplace, where every corner has a medical spa trying anything to attract new clients.

This can be true — especially around mass consumer treatments like Botox and laser hair removal — but whatever the reason, charging too little for your services is self-sabotage for two primary reasons:

1. When you don’t charge enough you end up resenting your clinic. You do too much work for too little money. It’s not worth it. (Try to tell me this isn't the primary reason that so many physicians would like to leave clinical medicine.)
2. A low price tells patients that you’re not worth it. It may be all smoke and mirrors in the beginning, but if you want to be perceived as the best, you’d better price your services accordingly. Low prices are THE primary indicator of low quality.

I've seen any number of small clinics where the marketing and pricing plans, if there was one, wasn't well articulated or just rattling around in the physicians head. As a result, these clinics, in an effort to build their own business, underbid services on low quality clients. As a result, they ended up with lots and lots of low fee procedures and special offers. Instead of focusing on high quality premium treatments, these staffs are pushed to get things done as fast as possible to keep the treatments profitable despite the low fees. This poor quality of training, service and oversight leads to mistakes. Clients nitpick and try to get additional discounts or haggle about pricing. Accounts receivable grows. Lawsuits happen. It's no surprise when clients start leaving for the next low bidder to open up shop.

Remember, people value things by price. Just one of the reasons why I’m sitting in Starbucks right now drinking a $4 coffee.  (And no, I don’t think $1 coffee is their best move.)

One of the primary components in positioning yourself is how you price your services.

Price Influences Your Perception Of Quality

As price goes up, so does your perception of quality AND pleasure (satisfaction).

I don't know this for sure but I would bet that 'premium' medical providers are sued less frequently and have higher satisfaction rates than lower priced physicians. It could well be that being the low cost provider puts you at greater risk for lawsuits for a number of reasons. (If you have any relevant information to this, please leave it in the comments.)

A well known study out of the California Institute of Technology and Stanford University details how price influences peoples perception of quality in wines.

Antonio Rangel, an associate professor of economics at Caltech, and his colleagues found that changes in the stated price of a sampled wine influenced not only how good volunteers thought it tasted, but the activity of a brain region that is involved in our experience of pleasure. In other words, "prices, by themselves, affect activity in an area of the brain that is thought to encode the experienced pleasantness of an experience," Rangel says.

Rangel and his colleagues had 20 volunteers taste five wine samples which, they were told, were identified by their different retail prices: $5, $10, $35, $45, and $90 per bottle. While the subjects tasted and evaluated the wines, their brains were scanned using functional magnetic resonance imaging, or fMRI.

The subjects consistently reported that they liked the taste of the $90 bottle better than the $5 one, and the $45 bottle better than the $35 one. Scans of their brains supported their subjective reports; a region of the brain called the medial orbitofrontal cortex, or mOFC, showed higher activity when the subjects drank the wines they said were more pleasurable.

But the experiment was rigged. While the subjects had been told that they would taste five different wines, they had actually sampled only three. Wines 1 and 2 were used twice, but labeled with two different prices. One wine 2 was presented as a $90 bottle (its actual retail price) and also as a cheaper $10 wine. When the subjects were told the wine cost $90 a bottle, they loved it; at $10, not so much.

In a follow-up experiment, the subjects again tasted all five wines but without any prices; this time, they rated the cheapest wine as their most preferred.

Previous marketing studies have shown that it's possible to change people's perception of how good an experience is by changing their beliefs about the experience. For example,  moviegoers report liking a movie more when they hear how good it is beforehand. Studies show that the neural encoding of the quality of an experience is actually modulated by variables such as price, which people believe is correlated with experienced pleasantness.

The results make sense. Your brain encodes pleasure because it is useful for learning which activities to repeat and which ones to avoid, and good decision making requires good measures of the quality of an experience. But your brain is also a noisy environment, and "thus, as a way of improving its measurements, it makes sense to add up other sources of information about the experience. In particular, if you are very sure cognitively that an experience is good (perhaps because of previous experiences), it makes sense to incorporate that into your current measurements of pleasure." Most people believe, quite correctly, that price and the quality of a wine are correlated, so it is therefore natural for the brain to factor price into an evaluation of a wine's taste.

How 'Cognitive Dissonance' Affects Pricing

Cognitive dissonance is that uncomfortable feeling you get when you're holding conflicting ideas simultaneously. The theory of cognitive dissonance proposes that people have a strong motivational drive to reduce dissonance since it causes internal conflict. They do this by changing their attitudes, beliefs, and actions. Dissonance is also reduced by justifying, blaming, and denying. It is one of the most influential and extensively studied theories in social psychology.

I'm not trying to force a psychology degree on you but  it is useful to have understanding some basic underpinnings of behavior and how they affect pricing, such as why critics don't like your favorite wine, and how wineries get away with charging $500 for a bottle.

Have you ever noticed fans almost never complain about lousy music concerts or albums, yet critics frequently give them poor reviews? What's going on? Are critics just inherently nasty?

Maybe, but the fact is that there's a psychological principal at work that's also in effect every single time you exchange something of value (money) for a product or service.

Here's an example of cognitive dissonance at work.

In a landmark study by Leon Festinger and James Carlsmith, seventy-one male students in the introductory psychology course at Stanford University were asked to spend two hours doing a very boring task, sticking wooden pegs in holes.

Participants were divided into three groups. Some were paid $20 (a lot of money back in 1959). Some were paid $1. And some were told they were volunteers and paid nothing. All were told what their payment (or non-payment) would be before they began.

After two hours of what was surely hellish tedium, participants were asked to rate the 'enjoyment' of the task.

So what do you think? Which of the groups ($20, $1, nothing) thought that sticking pegs in holes for two hours was the most fun?

Here's the answer: The group that was paid $1 found the task most pleasurable. The group paid $20 found it the most boring.

Why? Cognitive dissonance at work.

Here's the way that cognitive dissonance is at work in the real world:

1. If you are induced to do or say something which is contrary to your personal opinion, there is a tendency for you to change your opinion to bring it into correspondence with what you have done or said.
2. The greater the pressure used to elicit the overt behavior (beyond the minimum needed to elicit it) the weaker the tendency to change the opinion.

Let's discuss the first point. In the peg study the task was, objectively, tedious and boring, but people who were paid $20 could easily explain to themselves why they did it: they wanted $20. They rated the task as the most boring. People who were volunteers and got nothing could tell themselves they did it to advance science. They found it less boring than the $20 group, but still somewhat boring.

But here's where cognitive dissonance comes in. The people who were paid only $1 couldn't reconcile with themselves why they spent two hours putting round pegs in round holes. Their brain held two dissonant thoughts: "This task is dull" and "I'm wasting my time for a $1." The second statement was 'fixed' and couldn't be changed, so the brain unconsciously modified its belief about the first to decrease the conflict. People decided they were having fun; otherwise they would be fools for doing it at all.

But don't forget the second point; The greater the pressure used to elicit the overt behavior (beyond the minimum needed to elicit it) the weaker the tendency to change the opinion.

This is why the 'soft sell' can be so effective. Using less 'pressure' to elicit the behavior actually results in the strongest tendency for a person to modify their opinion.

Let's apply this lesson to how pricing affects the enjoyment of a product or service.

When you pay for anything; food, Botox, liposuction, or wine — your brain knows the price, and you're pretty sure that you're not stupid. So, if you pay $200 to see a live band and they're all singing off-key, your brain can change its evaluation of the performance to "charmingly gritty and spontaneous" or "incredible live performance". Your subconscious is pushing you to find the experience pleasurable.

But the critic sitting in back didn't pay for his tickets. He's just there to do a job, and his brain knows that. If the concert is bad and he says so, that doesn't make him a fool for going, he's just more objective.

Think about it: How often have glossed over a obvious shortcoming in order to avoid tainting your enjoyment of something you've paid a lot for? I know I do it all the time.

Here's what W. Blake Gray says about cognitive dissonance and wine.

I get a lot of free wine, and I pay for wine frequently also. Even though I'm aware of cognitive dissonance, I still think I'm more likely to give the benefit of the doubt to a so-so wine I order by the glass in a restaurant over a wine I taste in a professional setting. I'm paying for it, I'm no fool, it can't be that bad.

There are several implications here:

1. Why do fans of an expensive wine like it more than the critics? Simple: they're paying for it
2. The more money the wine costs, the more powerful the effect of cognitive dissonance. You can freely diss Two Buck Chuck, but that overripe $60 Syrah? It must have some good points. Many Napa Valley vintners understand the implication of this: Charge more, and while the wine might be difficult to sell, people who do buy it will like it more. Hows that for increasing your customer satisfaction?
3. Why does Robert Parker give higher scores to wines than other critics? To his credit, he is well-known for paying for a lot more wines than any other critic. He chooses what to pay for, he doesn't taste blind, and I submit that even for a man whose palate is as consistent as anyone in the business, cognitive dissonance is at work.
4. Why does wine taste better in the tasting room? There are other factors at work as well, but consider this potential dissonance: "I drove out of my way to get here and chose this winery over its neighbors. Plus I paid a $10 tasting fee." Cognitive dissonance is a good motivator for every tasting room to charge a modest fee. (Sorry, consumers.)
5. Why don't professional critics rush to embrace funky, expressive wines, especially those in niche categories? We don't have to; we don't have the cognitive dissonance of "I paid $12.99 for this no-added-sulfite 'organic wine' and it smells like feet." Mmm, feet.
6. How do the Bordeaux first growths get away with those outrageous release prices -- over $500 a bottle for some? In Hong Kong, people are thinking in Cantonese, "I paid $900 for this wine. And I am no fool. This is so worth it." Cognitive dissonance knows no language barrier.

Cognitive Dissonance & Irrational Customer Loyalty

Of course pricing isn't the only factor we're discussing. Let's talk some cognitive dissonance and how it leads to irrational customer loyalty, just what we're looking for.

In a study looking at why cognitive dissonance with dentists and their patients, Duke University behavioral economist Dan Ariely revealed the probability of two dentists separately finding the same cavity in an X-ray as being about 50%. And often, what dentists think is a cavity, turns out to be nothing. All the more odd, then, that as patients, we’re incredibly loyal to our dentists - more faithful, in fact, than to other medical practitioners.

Why? It's cognitive dissonance here as well. In order to rationalize all of the unpleasant poking, scraping and drilling that dentists subject us to, we convince ourselves that our particular dentist knows best:

"Dentistry is basically the unpleasant experience. They poke in your mouth. It's uncomfortable. It's painful. It's unpleasant. You have to keep your mouth open. And I think all of this pain actually causes cognitive dissonance - and cause higher loyalty to your dentist. Because who wants to go through this pain and say, 'I'm not sure if I did it for the right reason? I'm not sure this is the right guy.'"

(Kinda reminds me of Stockholm Syndrome in which people who are kidnapped actually begin to identify with their captors.)

But cognitive dissonance accounts for more than our loyalty to dentists. It also generating increased revenue for dentists and adding to their profits.

And it increases over time.

Imagine that at some point in your dental treatment, you have a choice between two treatments that have exactly the same possible outcome, but one of them is more expensive to you and better financially for the dentist. Which one would you choose, and how would the duration of the relationship with your dentist be affecting that?

It turns out that the more time people have been seeing the same dentist, the more likely the decision is going to go in favor of the dentist. People are going to go for the treatment that is more expensive but has the same outcome. More out of pocket for them, more money for the doctor. So in this case, loyalty actually creates more benefit for the dentists with no better potential outcome for the patient.

Now, while it may sound like I'm advocating standing on a patients toes while injecting Botox... not so.

There may be some effect of cognitive dissonance at work when you're performing a Melasma or other treatment where there's some pain and downtime, but what we really want to focus on here is how pricing your treatments higher, can actually increase both your patient satisfaction and revenue at the same time.

Does A Premium Price Drive Actual As Well As Perceived Value?

I would say yes in many instances.

Take a look at these medical spa training manuals and you'll see that they're more than a big hardcover at Barnes & Noble, much more. But we deliver on those prices since the quality of the content is so far above what you can get elsewhere. This isn't generic information, it's specialized, and it's valuable.

The medical spa staff training manuals are priced where they need to be to make the creation and distribution profitable enough that it's worth creating AND creates an incentive for buyers to actually use the information. Some of the most successful medical spas and cosmetic clinics around are using these training manuals. Do you think that someone who's at all serious about their business thinks anything at all about dropping $300 on a product that can optimize their operations and train their staff? Are you kidding?

Sure, I could give all that stuff away. Perhaps there are those that think that I should. This isn't for them. We give away 99% of everything for free already, but real products that give you the most benefit aren't valued if they're free.

It's not about information. It's about motivation. Paying a premium for them actually gives you more value... and pleasure.

Clarity

Look, you know more about your own situation than I do. I'm not trying to convince you to raise your prices if you can't support it, but hopefully you've got something to think about. There's a lot of obvious, anecdotal and researched evidence that shows that higher prices will make you more money and make your patients happier... but pricing is the second step. Creating a service menu and reputation that is unique and scarce is step one.

Pricing is one of the things that all physicians and medical spas struggle with. It is one of the handful of items that actually dictate how much money your clinic will make and where your profits are.

One last point: You've been reading this post for something like 3 minutes now. Isn't this the most interesting blog you've ever read? Please tell your physician friends. They're no fools either.

References

Marketing actions can modulate neural representations of experienced pleasantness published January 14 2008 in the early online edition of the Proceedings of the National Academy of Sciences.

Cognitive Cinsequences Of Forced Compliance Leon Festinger & James M. Carlsmith First published in Journal of Abnormal and Social Psychology

William H. Cummings, M. Venkatesan (1975), Cognative Dissonance and Consumer Behavior: A Review Of The Evidence in Advances in Consumer Research Volume 02, eds. Mary Jane Schlinger: Association for Consumer Research, Pages: 21-32.

The Gray Market Report, Why Expensive Wines Taste Better: Psychology 101 W. Blake Gray

Cognative dissonance on Wikipedia

Assembly Line Medicine & The Patient-Doctor Relationship

By Kenneth A. Fisher, M.D.

The latest data from The Organization of Economic Cooperation and Development is for 2008.

At that time the United Kingdom spent 8.7% of gross domestic product (GDP) on health care while the United States spent 16.0%. The amount spent in U.S. purchasing power parity dollars in the United Kingdom was $3129/person compared to $7538/person in the United States. The disparity in the amount of GDP spent on health care between the U.S. and other industrial countries is similar. A recent Rand Corporation study documents that this imbalance in the per-cent GDP devoted to health care has a negative impact on the U.S. economy and jobs.  Furthermore, this impact will become more evident when per-cent GDP for health care in the U.S. reaches 20% or more.  Unfortunately, the Chief Actuary for the Center for Medicare and Medicaid services predicts that per-cent GDP devoted to health care in the U.S. will exceed 20% when our new health care bill reaches fruition in 2014.  This is an issue of concern for many thoughtful Americans. In the U.S. in 1940 health care accounted for 4.5% of GDP, increasing to 12.2% in 1990 with an estimated 18% for 2010. Why has American medicine become so expensive compared to other countries despite having such a negative impact on the health of the economy?

I submit the major reason is the downgrading of the previous close-knit relationship between the doctor and patient. The causes for this are multiple, but the largest factor is the physician reimbursement schedule for Medicare and Medicaid. Medicare as the largest insurer in the U.S. drives private health insurance reimbursement rates. Initially Medicare adopted a Blue-Cross-Blue Shield (BCBS) payment schedule. BCBS was founded by surgeons and its payment schedule was procedurally oriented.  The Congress of the U.S. probably more than in other countries is heavily influenced by commercial entities and sub-specialty physician groups, both of which emphasize payments for technology and procedures. In 1992 Medicare adopted an even more complex system of reimbursement, Resource Based Relative Value Scale, which again favors technology and procedures.

The result of this 50 year odyssey is insufficient reimbursement for doctor-patient interactive time.   This decreased time has led to assembly-line medicine. Many if not most physicians in the U.S. spend about ten minutes face to face with a patient during a visit. This is grossly inadequate; core skills atrophy.  History taking and physical exam skills of many perhaps most physicians in the U.S. are inferior to those in Great Britain. Recently some prominent American physicians have commented and written about this problem (i.e. Dr. Abraham Verghese), but no formal rectifying action has taken place.  As confidence in and time for history taking and physical exam skills diminish, reliance on technology increases.  As patients consult with multiple physicians there is little coordination and care suffers.  As hospitals and pharmaceutical companies advertise, patients become less influenced by the decisions of their primary physician. As the trust relationship dwindles, patients are more confused as to the appropriateness of care, especially in end-of-life situations.

Congressional attempts to control spending, with the ever present lobbyists have only exacerbated this problem. One group, trial attorneys, seem to have an undue influence, increasing defensive medicine.  We seem to be in a deteriorating cycle, more assembly line medicine, less reliance on human skills, greater costs leading to more assembly line medicine and so forth. One could ask, “Where are the medical societies, why don’t they speak out about this issue?” I believe the answer is that our societies are looking at short term gains, see themselves as just another lobbying group and are afraid to impact the income of some segments of our profession.

In my opinion the U.S. must provide universal coverage at about 15% of GDP. This means that the documented approximately 30% of care that is non-beneficial, costing about $700 billion/year must be addressed and significantly decreased. This can only happen if physicians combine their efforts to dramatically improve the patient-doctor relationship by insisting on an increase in funding for patient visits, while working together to control non-beneficial activity. Being a physician is a person-to-person relationship involving humanity, judgment, knowledge and skills.

Signature: Doctor Fisher is a board certified Internist and Nephrologist. He has published many scientific articles and is the author of, In Defiance of Death: Exposing the Real costs of End of Life Care (Praeger 2008). Recently he published an electronic book, The Ten Questions Walter Cronkite Would Have Asked About Health Care Reform. He blogs at www.drkennethfisher.com 

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I Know What Kind Of Experiences I Will Want My Patients To Have.

By Isaac van Sligtenhorst

I know what kind of experiences I will want my patients to encounter.

We wait.....and wait......and wait in the Clinical Trial department.  Finally, someone whom we presume is the research coordinator, as she fails to introduce herself, enters the room.  My brother did not get into the PI3K inhibitor clinical trial as the company had temporarily halted enrollment.  She starts going into a potential alternative clinical trial for my brother.  She starts spouting off words like 'Bendamustine' and 'Avastin' and then asks if he has questions.  Really?  Short of someone with training in oncology, what person is going to know what these words mean, much less if these are good drug options for him?  I ask for some basic enrollment questions and she's not even up to speed on the specifics.  Great.  She leaves (thankfully) and we wait for the doc....and wait.....and wait.  Nearly three hours after our appointment time, the doc walks in, sits down, and the first thing out of her mouth is, "do you have any questions for me?"  I can hear my brother's frustration as he tries to wrap his brain around what in the world is going on.  We showed up early that morning so he could get bled to determine if he'd be eligible for a PI3K clinical trial.  Now we have a Plan B thrown out there with absolutely no background given and the doc is asking for any questions.  Fine.  I've got one.  "I thought avastin was contraindicated in squamous cell tumors.  Can you please comment on the risk of hemoptysis in combining avastin with a cytotoxic agent in the context of a squamous cell morphology?"  No?  Then please go do your homework first before entering into the room.  I understand this doc was covering for another but have the professional courtesy to at least glance at the chart before entering the room.  Walking in with no prior knowledge of the patient's diagnosis and status just isn't helpful at all.  At least review the bloodwork, but no, we didn't even get that.

Experience #2

Again, we wait.....and wait.....and wait.  This time it’s for Supportive Care to review my brother’s pain management.  The wait is not quite as bothersome because A) we didn't have an appointment and it was only through their kindness that they agreed to squeeze my brother in and B) there's a comfy bed for my brother to snooze in.  But still we wait.  The nurse comes in and he gathers the basics.  Back to waiting and the nurse quickly peaks his head in.  My mom asks, "any idea how much longer it's going to be?"  Just a few more minutes.  The doctor is reviewing my brother's chart.  What a novel concept.

He comes in and begins the usual, "tell me what's going on."  My brother has to be sick of repeating his story hundreds of times over and I suppress the urge to give a quick medical review of him to save time but I know the doctor needs to hear it from the patient's mouth.  From his accent, I can tell the doctor is Canadian, eh, but I don't hold it against him, eh.  He is soft spoken, calm, patient, and attentive.  My brother asks him some questions.  I ask some.  And my mother asks some.  He thoughtfully engages each one in turn, draws diagrams to help explain his logic, and gives firm answers when necessary.  He is clearly in charge of the situation and carries a certain degree of quiet confidence (reviewing the chart helps, too).  But most importantly, he has the presence of mind to look at my brother's pain management thus far, looks at the severity of pain being experienced and says, "this obviously isn't working.  Are you game to try something different?"

I know what kind of experiences I will want my patients to encounter.

About: Having spent nearly 15 years at the bench in drug discovery, Isaac van Sligtenhorst now helps his dad and brother walk through their fights against cancer, while during his spare time he is currently attending med school at UT Health Science Center in Houston, Texas. He blogs at
http://heartofalonelyhunter.blogspot.com

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Patient Protection & Affordable Care Act, A British Perspective

By Dr. Diego Fox

Patient Protection and Affordable Care Act, a British perspective

It has long been a commonly held British view that falling ill in the United States of America can be a very expensive business for the patient. When President Obama declared his intention to address this problem, many here naturally assumed he intended to introduce an American version of our NHS. We also naturally assumed that this idea would be almost universally welcomed by Americans. The subsequent bitter and sustained opposition is something few Brits can understand, particularly when it is seen that the proposed changes are, to us, just a tiny step towards what we were perhaps expecting.

To understand our perception you first would have to understand a little of our system of healthcare.

At the beginning of the twentieth century in the coal mining communities of the Welsh valleys a new means of health provision was being tried. Every employee would contribute a small part of his wages into a central fund. This fund was used to enable the community to employ one or more doctors, who would then provide health care to the miners and their families. No payment was required for treatment, but only those who paid into the scheme could benefit. Some schemes were even able to provide for a hospital, such as the one at Tredegar, which opened in 1904.

These schemes were run by trustees, one of whom was Aneurin Bevan, who subsequently became government Minister for Health, just after the second world war. In 1948 he applied exactly this scheme on a national scale as the National Health Service. Literally overnight, on July 5 1948, almost every hospital in Britain became state owned and run, and almost every hospital doctor became a state employee. General practitioners, although supposedly independent, were nonetheless paid by the state also. The system is paid for by a specific tax, “National Insurance”, paid by all employees, and there is also an employer contribution for each worker. This contribution is compulsory.

Despite 15 major reorganisations since 1948 these principles remain. Most hospitals remain state owned, and virtually all doctors are employed, directly or indirectly by the state. To this day no patient is ever asked for money for NHS treatment. The medical profession, who in 1948, bitterly opposed the inception of the NHS are now almost to a man totally committed to it. Any perceived threat to the NHS arouses the most bitter and universal opposition from doctors and the general population alike.

Compared to the creation of the NHS, the US reforms are modest indeed. In essence there is to be some extension in eligibility for the already existing medicare and medicaid. There is also to be improvement in affordability of health insurance, and assistance with premiums for those of low/moderate income. These are hardly ground shaking changes. Also firms are to be encouraged to make provision for employee’s healthcare, something better employers do already.

So what the objectors are so angry about is difficult to understand, certainly to us in the UK. I have had a good look at a web site called obamacaretruth.org  where many of the arguments are cited to try and get a feel for the objections and I am still really none the wiser. I was particularly interested that they cited the Stafford scandal, implying that the entire NHS is like that. Now the NHS has many imperfections and if I were to go into them this article would double in length. But In fact although one or two places have caused serious concern the vast majority of our patients in the UK view their experiences of NHS care in a very positive light. Most are grateful and appreciative. Particularly those who have had expensive treatment of life threatening conditions, without having to worry about paying for it.

I am left with the impression that the objections boil down to a perception that those who will get free healthcare are somehow “freeloading”, as if they get deliberately ill in order to get free treatment.

So should the American medical profession have anything to fear from the reforms? I can’t see that they should. Unlike the NHS, American  hospitals are not about to be taken over by the government, and doctors are not about to be forced to work for the state. As far as doctors are concerned it should be very much business as usual.

It has long been a source of puzzlement to Europeans that the richest country in the world should be so reluctant to provide decent health cover for it’s poor. Is this because in Europe decent healthcare is considered a right, whereas in the US it is considered a commodity? It is my view that one of the hallmarks of a truly civilised nation is that it looks after it’s sick. Aneurin Bevan thought exactly the same when he said, “We ought to take pride in the fact that, despite our financial and economic anxieties, we are still able to do the most civilised thing in the world - put the welfare of the sick in front of every other consideration.”

The US healthcare reforms are a long way short of providing this ideal, but they are a small step in that direction. If even this small step fails the rest of the civilised world will simply not understand.

About: Dr. Diego Fox (Dr Zorro) is a full time NHS Consultant in his late 50s. He blogs at http://vulpesmax.blogspot.com

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It's The Hard Docs Life

Clinical medicine still has some humor left.

I ran accross ZdoggMD (Zubin Damania MD) on LinkedIn. He's a doc that has a rather specialized niche in medical comedy and produces music videos like this one. 

Thanks to ZdoggMD.com

Yo, ZDoggMD dropping some mad verse ’bout the struggles of being a hospitalist. Strictly for my homies!

Here are the lyrics.

It’s the Hard Doc’s Life for us
Hospital Doc’s Life for us
Specialists, they got it made
We do the work while they get paid
It’s the Hard Doc’s Life

From standing on the unit roundin’
To learning some of the thickest charts a doc has ever seen
and hearing some of the sickest hearts a doc has ever heard
Do the weekend, working nights and, all the shifts between
You know me well from Pull & Pray and the Ulcer Rap
Still I take crap from insurance and the housestaff
Eff that

To PCPs treatin’ sick folks
Mad props
While the consultant’s tellin’ dick jokes
That flop

I fill out paperwork all day long
No doubt
Then nurses tell me that I did it wrong
White out

See 20 patients but get paid squat, uh uh
The radiologist just bought a yacht, what the?!?
Nurses be laughin’ at the ties I bought
Shop frugally and save money at Marshalls and Ross
Payless
They call a code when I come thru
Just don’t be asking me to run it, man, I got notes to do.

It’s the Hard Doc’s Life for us
Orthopods consulting us
See their train wrecks every day
They fix the bone then walk away
It’s the Hard Doc’s Life

I flow for those gomed out; sundowning
Locked down in the Posey vest, just tryin’ to bust out
I roll with old folks, got no veins for IV pokes
Septic and found down, in stool, a Code Brown
Yellow gown itchin’, deep in debt from med school tuition
c diff, MRSA, up in my kitchen?!?

Intern’s bitchin’ bout work hours, he’s checkin’ the clock
But I’mma be on call whether I’m on call or not
We went from lukewarm to hot; fillin’ the hospitals with docs
Who practice evidence based logic like Spock
Straight talk from my homies who work in the ED
Mad luv, ‘less you’re calling ’bout another syncope
I disagree with the phony UM docs, mess with my homies
I’m like still, y’all don’t control me, s***
I like to bill, but when my patient census ain’t improving
I’m tryin’ to dispo everything moving

It’s the Hard Doc’s Life for us
Too many patients for each of us
Try to discharge, make ‘em pack
Overdo it, they bounce back
It’s the Hard Doc’s Life for us
Hospital Doc’s Life for us
Hardest job we’ll ever do
Next to cleanin’ baby poo
It’s the Hard Doc’s Life

About: Zubin Damania MD is a physician specializing in inpatient internal medicine and a member of the multi-specialty Palo Alto Medical Foundation. He practices at Stanford University Medical Center and Washington Hospital (in Fremont, CA). His current project merges his medical background with his extensive experience teaching and performing stand-up comedy for diverse audiences. As ZDoggMD, he writes, performs, produces, and distributes satirical yet educational videos and music relating to important topics in healthcare.