Judging Physician Quality by Reputation Among Peers

A doctor’s greatest strength is his or her reputation. We spend our entire professional lives creating and protecting this precious asset.

Neil Baum, MD, author Marketing Your Clinical Practices; Ethically, Economically, 4^th Edition

How does one judge quality of a physician’s work?   The current fashion is to measure outcomes, or how often a physician complies with guidelines,  or to somehow increase quality by paying-for-performance,  or to do physician satisfaction surveys , or to consult the growing number of physician ratings systems on the Internet, or to call the local medical society.  

But these approaches may miss a critical factor by which physicians are judged – their reputation

How does one judge a physician’s reputation?

It may be  through:

·         word of mouth from patients or colleagues.

·          the institution with which he or she is affiliated.

·          number of scientific papers he or she has published.

·         Angie’s List.

·         health care ratings on the Internet.

·         Online reputation, as defined in  Establishing, Managing, and Protecting Your Online Reputation ( Kevin Pho, MD and Susan Gay, Greenbranch Publishing, 2013).

·         Participating in social media sites with judgment by readers.

·         Managing patient expectations, as explained in  Managing Patient Expectations: The Arts of Finding and Keeping Loyal Patients (Susan Keane Baker, Jossey Bass, 1997).

·         Qualifying as one of Top Doctors in America,  as listed by Castle Connolly Medical Ltd , publishers of America’s Top  Doctors, America’s Top Doctors for Cancer, Doctors in New York City Metro Area, or Top Doctor articles in New York, New Jersey, Westchester, Chicago, Atlanta, Philadelphia, Boston, Gulf Shore Love, Boca Life, Palm Springs Life and other magazines across the country.
 

Reputation-Based Quality

The Top Doctors approach is reputation-based. It uses extensive surveys of physician nationwide .   From these surveys,  peers  identify other doctors as the “best of the best”  A research team reviews   credentials , and they are listed in Top Doctor publications or in a newspaper ads.(in the interest of full-disclosure, I have been on the Medical Advisory Board of America’s Top Doctors for the last 10 years)

The August 3, 2013,  New York Times contains a full-page ad listing the top 16  doctors in the nation in neurological specialties. All are affiliated with major hospitals, and 12 of the 16 are neurosurgeons, with special expertise in brain or spine surgery or certain brain lesions,    Others are neurologists, neuro-oncology, or interventional neuroradiology.

Is reputation among peers the best way to identify top doctors?   Among physicians, this is considerd  a reliable approach, especially when combined with other quality criteria and extensive review of credentials.

Tweet:  Multiple approaches exist to identify top physicians , but one of the best is his her reputation among based on  broad surveys among peers.

 

Of Time, Physicians, and Obamacare

Effective people know that time is the limiting factor. The output limits of any process are set by the scarcest resource. In the process we call ‘accomplishment,’ that resource is time.”
“Time is also a unique resource. One cannot rent, hire, buy, or otherwise obtain more time.”
“The supply of time is totally inelastic. No matter how high the demand, the supply will not increase. There is no price for it and no utility curve for it. Moreover, time is totally perishable and cannot be stored. Yesterday’s time is gone forever and will never come back. Time is, therefore, always in exceeding short supply.”

Peter Drucker (1909-2004)

The health reform law robs practitioners of time to spend with patients.

Instead it burdens them with rules, regulations and mandates to meet compliance standards, to enter data for their EHRs, to make sure every computer “i” and “t” is crossed, to participate in organization meetings.  Add to these requirement waiting  on telephone hold with third parties, managing a small business,  and seeing a patient every 10 minutes to make ends meet, and you have a time problem.

 Doctors no longer have time to spend with patients. This is especially true with women physicians, who have more family obligations than  male counterparts. A current article  in the Wall Street Journal, “The Real Women’s Issue: Time” hits the nail on the head.

Lack of time is an issue for all physicians.  It is the main cause of physician burnout.  It’s a central  issue of physician dissatisfaction. It’s often why physicians abandon independent practice to become hospital employees. Hospital employment is  a search for more time  to spend with patients,  family, and one’s self.  It is seeking more “quality time,” for sanity.

Whether an innovation creates more time is also the main reason an innovation succeeds or fails. If it complicates rather than simplifies a doctor time by consuming more time to maser, it will fail.   If it is too difficult to understand in this fast-paced world of the social media, it will fail. If it takes more of the physicians’ and patients’ time, it will fail.

On the other hand, if it frees up time for the doctor, it stands a good chance of succeeding. If it effectively delegates tasks to staff, to patients, or to other caregivers, it’sprobably a winner. If it cuts through bureaucratic requirements while meeting government or other third party standards, it is marketable. If it speeds an effective response to health emergencies – a heart attack, a stroke, a life threatening infection or injury, it will work. If it cuts waiting times for patients, go for it.

Tweet: Innovations that save time for doctors to spend more time with patients have a good chance for succeeding in the marketplace.

A Weapon of Mass Distraction?  Obama Mocking of the  IRS Scandal as Phony, Ugly, and Derisive

“Reeling and Writhing, of course, to begin with, the Mock Turtle replied, “ and the different branches of Arithmetic – Ambition, Distraction, Uglification, and Derision,”

Alice’s Adventures in Wonderland

The tongue-in-cheek satire below reminds me of President Obama’s characterizing attacks on his administration as “phony scandals.” 

Consider  the IRS scandal -  targeting conservative groups and denying them tax exempt status,  the Obama appointed top  IRS lawyer meeting in the White House the day before the targeting took place, the new IRS chief saying he prefers the current IRS health plan to Obamacare, the former IRS chief visiting the White House 157 times in two years before the targeting took place,  “rogue agents” in Cincinnati saying they got their marching orders from Washington, Lois Lerner taking the  Fifth, the headquartering in the White House of the IRS team responsible for implementing Obamacare.   

A phony scandal, a GOP weapon of mass distraction, happenstance, an coincidence,   that’s all it is, Obama says.

Well, maybe.

But this satire shows the power of the bully pulpit  in demonizing political opponeents.

Satire

‘A public school teacher was arrested today at John F. Kennedy International airport as he attempted to board a flight while in possession of a ruler, a protractor, a compass, a slide-rule and a calculator. At a morning press conference, Attorney General Eric Holder said he believes the man is a member of the notorious Al-Gebra movement.”

“He did not identify the man, who has been charged by the FBI with carrying weapons of math instruction.”

' ‘Al-Gebra is a problem for us', the Attorney General said. 'They derive solutions

by means and extremes, and sometimes go off on tangents in search of absolute values.'They use secret code names like "X" and "Y" and refer to themselves as ‘unknowns"’ but we have determined that they belong to a common denominator of the axis of medieval with coordinates in every country. As the Greek philosopher Isosceles used to say, ‘There are 3 sides to every triangle.’

“When asked to comment on the arrest, President Obama said, ‘If God had wanted us to have better weapons of math instruction, He would have given us more fingers and toes.' "

"White House aides told reporters they could not recall a more intelligent

or profound statement by the President. It is believed that another Nobel Prize will follow.”

Tweet:   The evidence is piling up, or bringing into question, whether IRS targeting of conservatives, is a  phony scandal or for real.

The Obamacare Health System-Physician Computer Game

“Let’s play a game. Today we are going to pretend you are a Vice President for Medical Affairs, or a Chief of Staff, or a health system CEO about to announce a collaboration with a major health insurer like CMS or a regional Blues Plan. You’ve done your homework, read the journals, listened to the experts, anticipated the future and haven’t applied enough skepticism in reading all those pro-EHR and pro-bundled payment posts on THCB. You really believe payment reform and the EHR are the way to go.
 

You’ve called a meeting of your organization’s physician staff – the professionals you are counting on, caring for all those patients – and your job is go to the front of the auditorium and convince them that the success of your new venture relies on lowering health care costs with new payment arrangements that align incentives, in tandem with the launch of a new EHR.
 

Jaan Sidorov, MD, “Managing Physician Skepticism About the Affordable Care Act,” The Health Care Blog, August 1, 2013

This morning I awoke and read the above words of Jaan Sidorov, MD. Sidorov is a primary care internist and former Medical Director at Geisinger Health Plan with over 20 years experience in primary care, disease management and population-based care coordination.
 

Sidorov’s blog drew 20 responses – some negative, some positive – as befits the controversial Affordable Care Act (ACA) and its emphasis on computerization.   Practicing physicians  often view the ACA witht its computer requirments with skepticism. 

Which is understandable since we all resist change. Also some of its provisions, e.g. electronic health records and Accountable Care Organizations,  transform  their usual way of doing things,  threaten their autonomy, and, in effect, transfer much of their authority to a parent organization, be that hospital employers,  health systems, or a new computer system that disrupting their usual practice patterns.     
 

With regard to the new computer system, the question becomes,  as Alice in Wonderland said,  “Which is to be master, that’s all.”  
 

How does one play the Obamacare computer game when talking to physicians within your organization?
 

Here is a couple of takes on how to play the game.

1. John Irving, a principle in the Health Care Blog,  one of America’s most widely read health blogs.

Great question. Here’s what I wouldn’t do. I wouldn’t sit those physicians down in front of me and say “we’re doing this with you or without you. you can come along for the ride or not. we don’t really care which” which when you get right down to it is the approach a lot of large organizations are using.
 

I wouldn’t insult their intelligence with canned management talking points about quality and efficiency and evidence. They’ve heard them before. I wouldn’t wave my hands in the air and talk about the “magical things that EMR is going to do for us.” These are smart people. They’ve turned on their EMRs. They get it. But talking about technology like we’ve just discovered the Internet and entered the Golden Age of Happiness and Joy isn’t going to do it .
 

I’d talk to them like human beings. And I’d show some degree of empathy. I’d say, look – this is going to hurt. Actually, it is going to hurt a lot. However, by the time we’re done, we’re going to have a better system and most of the problems we’re facing will have gone away. Ten years from now, the things we’re talking about now will sound laughable to you. You’ll forget there was a time when you couldn’t email a patient – or get an instant lab result – or call in a specialist at a major academic medical center using Google Glass …

2.      Richard L. Reece, MD, Medinnovation blog

John: If I were addressing a group of skeptical physicians about the changes taking place, I would say it differently. I would say things are going to be different, perhaps better because of organizational and technological support, and coordinated team care, but maybe worse if you are wedded to the concept of personal autonomy for physicians.

Technological changes  will come in the form of diagnostic support, instant access to historical information, data about drug interactions, and electronic connections to patients and colleagues. The underlying idea behind these changes, advocated by both private sector and government , is to make care better and more cost-effective. But achieving these outcome will not be easy.

This is an era of experimentation, a search for a better way of doing things. Sometimes experiments fail, like ACO “savings,” EHR “efficiencies,” pay for value,” but these xperiments  are gropings for better ways of doing things. Sometimes things get worse before they get better.

Will the change to a new computer system be hard? Yes. Change is always hard.

Let’s face it. You will have to become skilled and comfortable with entering, absorbing, and interpreting data electronically. Some of you will not like with computer system-driven care. You will find it lessens your personal productivity. It will be awkward to use and to digest. Some of you, particularly older physicians, may drop out, retire, form concierge practices, or join physician-driven groups.

But most of you will hang in there, welcome organizational transformation, and understand the need for management systems that promise better, more cost-effective care. We hope you will be leaders in this transition. There is a better world coming. Accept it. Help shape it.

 Conclusion
 

Adjusting to Obamacare,  if one assumes it will go forward, is basically a computer game.    Computerized data will be the basis for paying doctors for performance,  for the evidence judging that performance, for the use or non-use of electronic health records,  for prescribing,  for allocating “savings” from Accountable Care Organizations, for communicating with patients and colleagues,  for following guidelines.  

As a modern Sherlock Holmes might say if he were referring to Watson, IBM's supercomputer now being applied to healthcare, " Come, Watson, come! The game is afoot."

Tweet:   If one is VP of medical affairs,  how does one persuade skeptical doctors the  new EHR computer system will benefit both them and patients.

 

 

 

 

Obamacare Flaw: Lack of Cost Controls Due to Lack of Market Competition

We do not have a functioning market in health care.

Paul Ryan (R-Wisconsin), Candidate for Vice-President in 2012 Election

There is no market price health care competion, and there is no transparency either. This is true in spite of candidate Obama’s declaration ,”A democracy requires accountablity, and accountability requires transparency.” Yet, five years into his presidency,   these lofty words have not  produced lower costs.

Indeed, the opposite is true.   Instead of accountability, transparency, and promises of lower costs, we have:

·         Spikes in premiums in most individual and small group markets

·         Increased costs for providers  through fines, penalties, new taxes, regulations, and compliance mandates

·         A proposal for an Independent Payment Payment Advisory Board (IPAB), which critics claim is a rationing board

·         Guidelines, protocols, and algorithms designed to lower costs by weeding out “unnecessay” care

·         Implementation and carrying costs two to three times the original estimates

·         Hospitals, physicians, and other caregivers keeping their fees secret until the uncertainty over Obamacare clears.

·         With hospital and physician consolidation and market monopolies or domiance, higher rather lower prices

·         Little, if any market price competition, in most markets

What the secret of lowering health costs?   Maybe it's a simple as this: Making prices transparent  by posting these prices for everybody to see.  Because of a ideological adversion to market-driven phenomonon,   the Obama administration has not highlighted market pricings   as a means of driving costs down.   Not in a big way. but in a small way.   On May 8, 2013,  HHS posted on a government website what Medicare pays for 100 common procedures in hospitals along with hospital chargemaster prices.  But most health consumers do not read govenrment websites, and this posting is likely to have little effect.

The Surgery Center of Oklahoma,  a free-standing center owned by 40 surgeons and anesthesiologists,  took a different tack.    Four years ago, the center began posting prices for its procedures, which were often 7 to 8 times below prices of  hospitals in Oklahoma City and environs.  The local TV station broadcast the news.   Almost immediately,  visitors from other parts of the U.S. and Canada began to showup for surgeries.  People from other cities began asking for lists of the Center’s prices.

Openly  listing prices and broadcasting those prices on local media had a contagious effect.  Other hospitals began to list their prices.   As John Goodman, a conservative health care economist and father of  the health savings accounts concept,  noted,  “Once one hospital in a city does it, everybody has to do it.”   The Surgery Center's move to posted prices makes sense.   Health savings accounts with high deductibles may make patients price conscious, but it is hard to comparison shop if you can’t find  the prices offered by physicians and hospitals.

I have been aware of the Oklahoma City Surgery Center’s price posting policies for some time.  I wrote a blog post on it  on Novemeber 17, 2012 “Oklahoma’s Free Market Medicine, “ in which I concluded,” In Oklahoma City, population 1.3 million, an independent surgery centers charges far less than traditional hospitals.” 

 

Posting lower prices is the sine qua non for lowering  prices in a market-driven society. Walmart, which started in nearby Arkansas,  learned this early on, and is now the nation’s largest retailer.   Maybe a seemingly small thing,  posting your prices for all to see for surgical procedures,  is the start of something big and will spread to other cities and other health care sectors.

Tweet:   A surgery center in Oklahoma City, by posting its lower prices,   has become a destination for cost-sensitive health care consumers.

 

Source:  Tina Rosenberg,  “Revealing a Health Care Secret; The Price,",   New York Times,  July 31, 2013.

Ten GOP Strategies Using Obamacare for Target Practice

Be sure you positively identify your target before you pull the trigger.

Tom Flynn, American author (born 1955), Editor of Free Inquiry magazine

The main target for the next years should be growth and job creation.

Mariano Rajoy (born 1955), Prime Minister of Spain

How can Republicans block, delay, or repeal Obamacare?   That is the burning question of the day.  No one, to my knowledge, has a single answer, other than dramatic defunding and shutdown of the government.  But this is a risky political strategy, for the GOP is likely to be blamed.

Here are ten strategies suggested by Sarah Kliff, who writes a regular column for the Washington Post on health reform issues and GOP House Speaker, John Boehner, who yesterday used the term “targeted strategies” in a closed door meeting with Republican leaders.

From Sarah Kliff comes these 5 ideas (“How Republicans Could Actually Derail Obamacare,” Washington Post, July 31, 2013

1.       Lobby hard against Medicaid expansion.

2.      Convince young healthy people not to sign up for the law's subsidies, and do a drive with the old and sick.

3.      Chip away law piece by piece.

4.      Elect a new president in 2016, preferably one who opposes Obamacare

5.      Set expectations high for Obamacare’s rollout.  Like really, really high

From John Boehner (“Boehner Lays Out ‘Targeted Strikes’ Strategy on Obamacare,” Roll Call, July 31, 2013)

1.       Get IRS ourtof Obamacare.

2.      Protect taxpayers, require verification of subsidies

3.      Stop IPAB, Obamacare’s rationing board

4.      Get rid of Obamacare slush funds.

5.      Continue to have targeted, regular votes through fall.

 

The main strategy, it strikes  me, would be to emphasize Obamacare as an impediment to economic growth and job creation. Full-time jobs are what Americans want and where Obama is most vulnerable.  Reality -lack of jobs and economic growth - tends to be immune to rhetoric.

Tweet:   This blog post contains ten possible GOP strategies for targeting and derailing Obamacare.