"Ask Your Doctor," "See Your Doctor"

So run taglines on ubiquitous pharmaceutical commercials. One ad even goes so far as to say, “If you have an erection lasting more than four hours, see your doctor.” Chances are your doctor will see you because he/she has never seen a four hour erection.

If I were the doctor, I wonder how I would handle the problem. Is there a known antidote? Would a bucket of ice water do? Do I refer this rare rigidity problem to an urologist who knows about priapism? Do I go to the Internet? I just googled for an answer and didn’t find any in medical texts.

According to Slate Magazine, a non-medical publication that usually only talks of political resurrections, says of a four hour erection,

”At least 38 men who have taken Viagra have gone blind, and the drug's manufacturers said it would consider adding a warning to the label. Drug companies already warn consumers that Viagra and competitors like Levitra and Cialis have several other side effects, like blurred vision, headaches, indigestion, and painful erections that last four hours or more. What do you do with an erection that won't quit?”
“Call your doctor—and be very, very afraid. Though the makers of erectile dysfunction drugs list prolonged, unwanted erections as a potential side effect, urologists have their doubts.
Priapism, a rare condition defined by prolonged erections in the absence of sexual arousal, is associated with certain blood diseases, hypertension, and recreational drug use. No matter what its cause, priapism can be dangerous if left untreated. A man who has a painful erection for more than 12 hours is at high risk for permanent damage.”
I don’t want to make too much fun of this. It is no laughing matter when blood for your brain and other vital structures pools in another organ..

Besides, the idea of asking or seeing your doctor for every possible side-effect is a serious business.

I don’t blame the pharmaceutical industry. What they advise is a safe and easy thing to do, and it’s good malpractice cover. Moreover, it may flatter some doctors to be asked. But, sad to say, doctors don’t know everything. And doctors may be a bit irritated spending time answering questions posed by the pharmaceutical industry, or feeling pressured to prescribe every pill that alluring Pharma ads recommend.

I suppose it all comes down to a matter of patient-doctor trust, which, according to a recent NYT article, is slipping with ¼ of patients saying they distrust their doctors. This may be because, given declining reimbursements, doctors can’t afford to spend more than 8 minutes or so per patient. One suggested solution is to have patients show up with a list of questions – no more than three please. Most doctors don’t have the time to go through the complete list of side-effects or contraindications rolled out on those ads or on medical websites.

I suppose the doctor could say, ask your drug manufacturer or their lawyers, or I can’t protect against all eventualities listed by the drug manufacturer, but that would be tacky and might destroy the image of the all-knowing, all-seeing, and all-answering doctor.

Reference

Tara Parker-Pope, “Doctor and Patient, Now at Odds, “ New York Times, July 29, 2008.

Interview with Health Care Buzz Word Expert

Medinnovation: Are you a health care buzz expert?

Buzz Word Expert: Indeed, I am. My remarks will reek of transparency, interoperability, transferability, the scholarship of quality and will be evidence-based and digitally-supportable.

Medinnovation: Well said. Can’t ask for anything more than that. But what exactly is a health care buzz word?

Buzz Word Expert: It is a fashionable word or concept associated with health care not understood by outsiders. It’s an inside game only buzz word experts can play.

Medinnovation: Could you be more specific?

Buzz Word Expert: Specificity is not the name of our game. The word or concept must be nebulous, noble, notable and express a common good for mankind. It must represent a quest for the Holy Grail. It must be unanswerable, unchallengeable, and smack of apple pie, motherhood, and fatherhood – all expressed in high-order language and words.

Medinnovation: Anything else?

Buzz Word Expert: Yes, the buzz words must be polysyllabic, and it helps if they come in bursts of three that can be used in any combination: quality information infrastructure, interoperable transparent organizations, performance improvement methodologies, evidence-documented medicine, comprehensive coordinated delivery, actionable support systems, implementable interventions, systematic re-engineering, measurable output parameters, and documentable quality indicators. These are admirable examples. The concepts have to be big, and the words have to be big too.

Medinnovation: It there any room for verbs?

Buzz Word Expert: Of course, Everything must be integrated, coordinated, digitally organized, universally applied. There is no space here for individualism.

Medinnovation: Why can’t you just use simple concepts and simple words for doctors. You might say, for instance: This is the right thing to do. Here are end points to aim for. Here is how to make patients healthy and well. Here is a check list to follow in your practice?

Buzz Word Expert: That is much too transparent and too easily understood by doctors, who we try to keep as “outsiders” in the quality game.

Medinnovation: Who are the “insiders?’

Buzz Word Expert: The “insiders” are outside experts, middlemen, and managers who must come up with a framework, the profits, the transferable information databases, all of which they can use to intervene to institute improvement in the multiple dimensions of quality to justify their continuing existence.

Medinnovation: Like health plans?

Buzz Word Expert: That’s a good example. Health plans can no longer justify their 10 to 20% administrative load by simply paying bills promptly, easing doctor transactions, partnering with physicians, or paying for people with pre-existing illness. Health plans must do something else to oversee the quality and outcomes processes and metrics to keep patients and their bottom lines well.

The insurers must demonstrate they can cut costs, improve health of members, or enhance quality of care and its various and multidimensional measurements at costs employers, doctors, and consumers will swallow. To care out these noble and irrefutable goals, health plans must manage care by data-mining and preventive and predictive model algorithms in order to splice, slice, dice, parse, and predict what might go wrong and how to make it right.

Medinnovation: But how do health plans justify costs of doing all these things? How do they convince skeptical doctors who have yet to see benefits for themselves or their patients on the ground? How do they overcome doctors’ deeply embedded suspicions that health plans rarely do anything constructive that is tangible in the trenches?

Buzz Word Expert: Health plans combine evidence-based medicine with evidence-based management to implement and intervene to impose quality improvement strategies of the highest order and the greatest magnitude and greatest good for all.

Medinnovation:: In other words, talk big, aim high, and let others walk the talk and absorb the cost.

Buzz Word Expert: Something like that.

Saving Money by Paying Primary Care More

Here are five notable and quotable responses to “Trying to Save by Increasing Physicians’ Fees” (NYT front page, July 21, 2008).

“Early intervention is medically effective, but there’s no good reason it cannot be financially effective in our current system of using commercial insurance companies. ” Bert Hansen, Teacher, History of Medicine, Baruch College

“Medicare now pays doctors only to specific medical procedures. Medicare does not pay doctors to listen to patients and to communicate.” Newton Minow, Chicago

“While it is sound to pay primary-care doctors enough so that they spend more than eight minutes with a patient, it is also important for doctors to really know their over time – for many years.” Sara Hartley, MD, University of California, Berkley, School Public Health

“An aspect that should be addressed is whether physician’s skills in obtaining clinical information’s have atrophied. If so, that would impede the desired result.”
Roy T. Steigbigel, MD, Professor of Medicine, SUNY

“Most doctors know how and want to provide good care for their patient’s the current health care payment system insidiously interferes. It is refreshing to see that thdse pilot project variants of the concierge practice have recognized this.” Dean E. Kross, MD, cardiologist, Pittsburgh

The American public doesn’t yet recognize primary care verges on obsolescence because of practitioner dispair over lack of money and other issues. A national physician organization is nearing the end of a massive survey of all primary care physicians to bring this truth home. Once the truth is known, perhaps health policies will change.

Boxed In, but Not Out: Eight Evolving Physician Business Models

Converging events – health reform, Medicare cuts, electronic monitoring, pay or punishment for performance, government oversight as far as the eye can see – have boxed physicians into the corner.

Doctors are being told they must generate, share, and compare data; acquire and use IT tools, adhere to guidelines, join larger groups, and work with themselves and others to achieve scale and infrastructure.

How to get out of the box? This may not be possible or desirable. But the answer may to build your own box. Two ways, for physicians to take control of their clinical and economic destinies by one, creating their own organization; or two, incorporating themselves into new organizations that have elements critics lambaste them for not having or not deploying.

Here, in no particular order, are eight evolving physician business models.

1. Specialty Walk-in Clinics - The Jewett Orthopedic Group in Orlando and Winter Park, Florida, has set up a series of orthopedic walk-in clinics where those with minor injuries can be seen by an orthopedic surgeon, have x-rays taken and interpreted, and have casts applied. This is convenient and accessible access to specialty care at work.

2. New Locations in Abandoned Retail Spaces – A number of physicians and health care enterprises are moving into medical malls and commercial building to set up practices. The lease is cheap, reconstruction is affordable, parking is ample, foot and car traffic is heavy, and access is easy.

3. Big MACCs (Multispecialty Ambulatory Care Centers )- A cardinal rule of innovation is: “Hit ‘em where they ain’t.” Following this dictum, medical entrepreneurs have organized Big MACCs in underserved medical areas where retirees and urban expatriates are moving, where major highways intersect, and where the “new-old” are seeking specialty care, pharmacy and physical therapy services. Big MACCs sometimes constructed with help of hospitals. Most often they are not placed on hospital grounds, but more often in non-urban settings.

4. Free-Standing Procedural Centers - Americans prefer to have certain procedures – cosmetic, ophthalmologic, bariatric, hernias, gallbladders, minor orthopedic surgeries, biopsies and, even births and vaginal hysterectomies, and other unmentionables – performed during the day, where they can enter in the morning and are home at night.

5. Medical Homes, Office and Institutional Based – “Medical Homes” are on everybody’s lips, Medicare, the United Healthcare Group, the American Association of Medical Colleges – as well the national primary care organizations – endorse medical homes. The Duke medical home team has dropped hospitalizations 68%, ambulance transport 49%, ER visits 41%, and asthma-related admissions 40%. But my sense is: physicians have yet to find the model that avoids burdensome paperwork, pays adequately, and helps retain some semblance of control and independence.


6. Retail Clinics and Worksite Clinics - Some tout these as the next retail wave, either alone or in tandem. Walgreen will soon have 500 retail and worksite clinics operating, CVS and Walmart are in the game, and Pitney Bowes has a number of worksite clinics. For primary care doctors, the attractions of worksite clinics are 30-40% more pay, owner-installed EMRs, online access to best practice guidelines, a ready audience of patients, and the ability to control specialty referrals.

7. Hospitals are Physician Partners and Employers – This is a movement that has been accelerating for the last five years, especially among young doctors seeking a balanced life style, free time, fringe benefits, payment of educational and malpractice debts, and opportunities for executive advancement. Hospitals are now busy hiring consultants to build medical staff development plans. One problem here is that the “medical staff” is not a business entity; others are control, capital, and cash distribution issues. In the upper Midwest, hospitals, who have capital and brand name recognition, are acquiring multispecialty groups, who may have neither. Across the U.S. Walmart is opening 400 more retail clinics, to be owned, staffed and run by hospitals with the help of hired physicians.

These models share certain things in common, need for enlightened physician business leadership, necessary capital, adequate information infrastructure, compliance
Regulations, affordable and suitable real estate, and physician supply demand analysis. It is apparent surgical and procedural based specialists have the where-with-all and like-mindedness to put together business entities quicker than primary care doctors with less resources and more diffuse interests.

Physicians: Health Cost Elephants in the Room?

Call it what you will - gaming, flat of the curve medicine, perverse fee-for-service incentives, doing more to make more, inappropriate testing or treatment to maximize income, defensive medicine, self-referral, or, on the flip side, enlightened self-interest.

Whatever you call it, a bevy of critics are saying the elephant in the room causing excessive health costs are “ungoverned” doctors in small practices, large practices, and academic medical centers are ordering tests, doing operations, mindlessly over-using technology, referring to themselves, buying unneeded technologies, cutting deals -- all to maximize income rather than practicing “quality” medicine to make patients better or to enhance outcomes. These critics tend to inhabit office suites of payers far removed from action on the ground and from what drives doctors and their patients.

I run across these critics often when I write of health reform. Their comments, generally nonspecific or sotto voce so as not to be overhead, run along these lines,” We’r to blame for these high costs.” “We’re the villains.” “What else can you do in a system like this when Medicare and health plans keep ratcheting down your reimbursements.?” Or, “It’s just plain greed.”

Now I am not one to sit in judgment of my fellow physicians. We all do things for a reason, and all of us take steps to stabilize our revenues. There are a lot of factors at work here, including high education debts and escalating, escalating overhead, and whole new set of suggested (expesnive) solutions – protocols, evidence-based medicine, P4P, and, of course, that ceaseless pressure to install EMRs at your own expense in the name of quality.

And the solutions are myriad as well;

• Place doctors on salary to remove financial incentives.
• Slash pay gaps between specialists and primary care doctors and produce more of the latter, who cost less.
• Make all pricing and costs transparent and public.
• Bundle hospital and doctor bills so consumers can know in advance what to expect.
• Place computers at doctors’ fingertips so they can compare, share, and judge what works.
• Use “systems engineering” to redesign the whole system to ensure the best care at the best time for the right reason.
• Encourage doctors to join large groups with enough data infrastructure so outside payers and inside physicians can oversee each other.

There are, of course, two main schools of thought:

• One, let government take care of everything – pricing, regulations, monitoring of quality, and auditing, punishment, and rewards for physicians who play the government game.
• Two, wait for the storm of changes now moving through the marketplace - retail clinics (now numbering about 1000), worksite clinics (perhaps 500), and high deductible health plans (15% of employees now belong), and outrage over high costs to induce competition and bring costs down.

I happen to think “the system” and “American culture” dictates how physicians and patients behave. Each rests on believes in individualism, choice, and freedom to chose what technology and treatment options to pursue. In short, free enterprise.

\It may be that pay-for-performance programs, initiated and monitored by government, as in England, where 25% of physician income, is tied to quality, is a partial answer, but that approach is easier said than done, and doctors may exclude patients from P4P targets to increase income, a practice know as “gaming.”

In the long run, savvy informed patients spending their own premium monies, may the best safeguard against excess care.

Obama Plan

What: Obama health reform plan

Why: Because at this point (July 22, 2008), Obama leads McCain 4.4% in aggregate polls, is a 2:1 favorite among Intrade oddsmakers, and is favored to win presidency.

When: His plan proposes to cut health costs by $214 billion and to cover all Americans by end of first term

How: By saving $77 billion with computerized health records, $46 billion by reducing administrative costs, and $81 billion by preventive and chronic disease management programs, and an unspecified amount by eliminating “unneeded procedures ”in plan largely devised by unpaid advisors from Harvard.

Where: Everywhere as directed by government.

Who: Obama wants government do job by spending more than $100 billion - $50 billion on EMRs and another $50 billion or so on tax subsidies for the “poor” and “middle-class” so they can join such plans as Federal Employee Health Benefit Program (FEHBP). Presumably money to pay for this would come from taxing the “rich”, i.e. ending Bush tax cuts for this group and by internal savings, such as having government negotiate lower Medicare drug prices.

Conclusion: Noble, but perhaps undoable in 4 years, maybe even in 10. It is true system is “bloated’ with waste, but government has poor record for containing costs: the “rich,” historically and paradoxically, pay less taxes when taxed more; health plans and drug companies and lobbyists will resist Obama’s plans to make them take all comers regardless of health status, and to negotiate drug prices; Medicare’s pilot project to coordinate care was cancelled because it failed to save money; and who is to say when a procedure is “unneeded “ – A Medicare official, a physician, or a patient.