Enjoy our most current issue of the most popular medical e-newsletter on the internet.
Blogs and Thoughts for July 12th to July 18th, 2018
Here is what we had this past week:
- Ridiculous Study of the Week: Try My Better Hamster Wheel
- Is This What All Hospitals Think of Primary Care Docs?
- When Ivory Tower Idiots Attack DPC
- Why Aren’t These People At Work? by Pat Conrad MD
- Ridiculous Study of the Week: EHRs Save Lives
- Friday Funny: The People Trying to “Fix” Our Healthcare System
- Quote of the Week: Selina Meyer
1. Ridiculous Study of the Week: Try My Better Hamster Wheel
July 18, 2018
A study just came out showing that paying more for Medicaid patients doesn’t entice doctors to take any more Medicaid patients. You don’t say?
Boosting Medicaid payment levels did not incentivize primary care physicians (PCPs) to accept more patients with the government-sponsored health insurance, a longitudinal analysis of claims data for over 20,000 physicians revealed.
A few observations to start this off. I looked at the study briefly and it really doesn’t make sense. If a doctor is employed and is paid by an RVU system then it doesn’t matter if Medicaid is paying her employer more as she gets remunerated the same. In other words, the doctor doesn’t care as she just sees the patients in front of her. So the doctor isn’t the rate limiting step here. It seems to me that the employers or hospital systems should be the ones scrutinized over this.
Also, there is no mention that Medicaid patients are really hard to care for. Let’s be honest. We all know it. I am not saying that every Medicaid patient is difficult in complexity or baggage but on the whole they are a much more difficult population. I worked in a FQHC for 10 years so I have a lot of experience in this. So would a private doc open to Medicaid patients if she is “almost” being paid the same as Medicare? Probably not.
My favorite part of the piece, however, is what I really want to highlight. Another ivory tower idiot had to tell the world how to fix this problem. This one from Harvard Medical School:
Allan H. Goroll, MD questioned whether an increase in fee-for-service (FFS) reimbursement is the appropriate way to incentivize Medicaid participation. “This is not to deny that an astronomical increase in evaluation and management valuations might have some result, but certainly not the aforementioned raising of FFS pay from an impossibly low Medicaid level to an undervalued Medicare level,” he wrote. Goroll noted that methods meant to increase volume will have little effect on practices that are already overloaded or caught in the “hamster wheel.”
Yes, the dreaded hamster wheel. Docs are dying out there trying to finish their day. The last thing they care about is adding more difficult patients. Maybe he is onto something. Maybe he will recommend DPC? Then it goes on:
The current FFS payment model, he wrote, is derived from recommendations by the “specialty-dominated” American Medical Association’s Resource-Based Relative Value Update Committee, which “has routinely undervalued primary care evaluation and management services for decades, forcing primary care practices to maximize volume to stay in business.”
Exactly, he does get it!
He pointed to other payment models, such as one he helped develop that substitute FFS with a prospective, risk-adjusted comprehensive payment for delivery of comprehensive care. While a base payment covers practice expenses, a bonus payment is tied to specific patient- and cost-related measures.
And my bubble is officially burst. I always underestimate the egos of these pompous jerks. He actually is pushing a payment model he developed! And what is his system? It’s “a prospective, risk-adjusted comprehensive payment for delivery of comprehensive care. While a base payment covers practice expenses, a bonus payment is tied to specific patient- and cost-related measures.” I don’t know what any of that means other than it will 100% fail. He just let the hamster off one wheel and put it on another.
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2. Is This What All Hospitals Think of Primary Care Docs?
July 17th, 2018
Becker’s Healthcare spoke with Cathy Jacobson, president and CEO of Milwaukee-based Froedtert Health, prior to speaking on a panel at Becker’s Hospital Review 7th Annual CEO + CFO Roundtable titled, “The Digital Imperative: The Open & Shut Case for Innovation”. All this gobbledygook means she is a pretty big deal to other administrators. I was tipped off by Shane Purcell MD about her thoughts on primary care physicians highlighted in the piece:
Q: What’s one conviction in healthcare that needs to be challenged?
CJ: That every patient needs a primary care physician. As we start stratifying our patients into distinct populations based on their health needs and develop that insight further into consumer driven wants, we are finding that a substantial sector of the population does not want or need a primary care physician relationship. People need primary care but not necessarily a physician relationship. We need to stop trying to fit patients into our health system-driven model and develop the means to serve their health needs on their terms. If we don’t, someone else will.
How does that make you feel? Pretty crappy, right? I have known this for a long time. Hospitals want patients to be linked to THEM and not you as a doctor. You should have noticed their commercials over the years with hospitals saying “as your healthcare provider”, etc. It is about wordplay and confusion to make patients feel that the hospital is the doctor and the doctor is the hospital. We know that this isn’t true. If doctors and nurses left the system then they pretty much just have an empty building. In fact, if a doctor is missing for a day there is panic and mass hysteria. If a CEO or other administrator goes missing for a month no one notices. But the patients don’t know this as no representative organization (AMA, AAFP, ACP) has made a campaign to push back (Thanks, guys!). Linking patients to a hospital and not a doctor has been the goal for years because hospitals want the patients’ loyalty (and money) so that their doctor has to refer to them and if the doctor leaves they can just replace her with another doctor or MLP. We are being treated as pawns in a chess set.
The sentence “People need primary care but not necessarily a physician relationship” is very disturbing to me and goes against EVERYTHING I believe in. With one sentence she wipes us out totally. With one sentence she disrespects 2/3 of all doctors. And there will be no repercussions for this. None. But you want to know the truth? The truth is that she and other administrators are afraid. They know they’re the ones who are not really needed. If the future leads to doctors unhinging themselves from the hospitals then we take back control of our future and the reigns of healthcare. The ones who serve the patients’ “health on their own terms” will be us. We are the “someone else” she is worried about.
It’s time we shake the box. It’s time we free ourselves from being shackled to hospitals. It’s time for a physician ONLY revolution. What are we waiting for?
3. When Ivory Tower Idiots Attack DPC
July 16, 2018
A recent JAMA article called Direct Primary Care One Step Forward, Two Steps Back recently came out and they did their typical routine of attacking DPC. In the article they say:
Proponents of DPC argue that the model generates system-level cost savings, improved patient outcomes, broader access to care, and clinician and patient satisfaction. Because DPC models do not rely on fee-for-service reimbursement, physicians are able to devote resources to previously nonbillable care coordination efforts. With a smaller patient panel and because DPC physicians do not bill third-party payers, physicians can focus on building therapeutic, longitudinal relationships with patients. DPC advocates suggest that these changes yield significant improvements in both patient and population-level health outcomes, reducing the rates of hospital readmissions, specialist visits, radiologic and laboratory testing, and emergency care.
Okay, so far, so good but then they go on to say:
“Individual DPC practices have indicated that practice-level data on outcomes support these claims; however, no study, to our knowledge, has produced data to support anecdotal claims by individual practices.”
Okay, to their knowledge, there is no evidence but then they go ahead and basically say we are going to cause tons of problems including:
- Targeting healthier patients and declining coverage to the ill.
- It is unlikely that patients most in need of care would be willing or able to afford an appropriately risk-adjusted retainer in a DPC setting.
- DPC fails to address fundamental market inefficiencies and facilitates a substantial gap in catastrophic coverage
- DPC circumvents the quality metrics and incentive structures designed to improve population health and reduce national health care expenditures. DPC practices once held accountable through value-based payment systems have no obligation to report or measure quality metrics.
- Lessons learned from DPC—mainly the potential utility of global capitated payments—should be applied when developing new payment reform models and envisioning a new future for primary care delivery. However, DPC is not the answer to the problem
Remember when they said there was no evidence? So, all their “conclusions” are based on what? Fear and hatred. This article was written by ivory tower “doctors” from Warren Alpert Medical School. They do not want DPC to succeed but it is succeeding and that pisses them off. In fact, this article in Medical Economics by Kimberly Corba DO shows that DPC may be the link to the “fourth aim”, which is “improved clinician and staff work life.” Now you can really see why his makes them mad. These non practicing doctors do not want practicing doctors to enjoy their patients and their career. They want us stuck under their control and to be their guinea pigs as they experiment on us with any new bogus fad like quality metrics and healthcare teams. But again, these are NOT proven either. Their logic is ridiculous.
Our jobs are simple. Doctors see patients directly without the interference of the insurance companies, the government or these ivory tower idiots. Their big complaint is that we cherry pick but the truth is that everyone one of us see very complicated patients of all races and socioeconomic status and most of us give away 5-10% of free care. And we do a better job with these patients because we spend time with them. For the rest we charge a very reasonable price, less than a cell phone bill or a cable bill.
I for one would like to respond to these authors, and every other critic of DPC, by saying “Be Well”. You can try all you want to stop us but it’s not going to happen. We get the last laugh while you are stuck in your miserable windowless office trying to make yourself feel important. The truth is…you aren’t.
4. Why Aren’t These People At Work? by Pat Conrad MD
July 15, 2018
This week I shelled out $731 to Uncle Sam for the privilege of being able to legally prescribe controlled medications. As a full-time ER doc, I have to have a current DEA number or I can’t work. Last week the rat-licking scumbags at Blue Cross raised their premiums another 10% for no apparent reason, and dutifully vacuumed that money out of my bank account. I have to shell it out for lack of a better option, in order to continue having health coverage.
So perhaps you’ll understand my complete and total lack of sympathy for those on whom the compassionate classes would further bestow victim status in this latest news on the Medicaid front. The reliable old Kaiser Family Foundation is wringing its hands that between 1.4 and 4 million Medicaid recipients might lose their benefits if states begin instituting work requirements for those able-bodied that are on the program. The states will have this flexibility as a result of the Trump Administration seeking trying to help states in dealing with crushing Medicaid budgets. CMS reported in April that there were 67,305,506 Medicaid recipients (excluding the little CHIP’rs), so 4 million losing said coverage comes to less than 6% of the total. That total, interestingly enough, grew over 16 million in the preceding 5 years. So thanks, ObamaCare.
Kaiser estimates that about 23 million would be affected by the new rules, because they are not elderly or disabled, adding that most of these have jobs. So about a third of all adult Medicaid recipients might be affected, and most of them work. So what is the problem? All one has to do to keep their “gold card” current is to work 20 hours per week or attend job training classes. What’s the problem?
Kaiser: “In all scenarios, most people losing coverage are disenrolled due to lack of reporting rather than not complying with the work requirement.” You mean all they have to do is fill out the paperwork?
Kaiser: “Adults who are already working likely will have to report and document their hours… There is a risk of eligible people losing coverage due to their inability to navigate these processes, miscommunication, or other breakdowns in the administrative process.”
You mean beneficiaries are too stu-, uh, mentally infirm to fill out the forms? So by implication, Kaiser (soon to be joined by other ostentatiously compassionate hand wringers) is suggesting that a great many working poor could lose access to health care because they can’t be bothered to fill out the forms, which might be too hard anyway.
Which reminds me of a funny story. Last week in our little rural ER, one of the frequent fliers came in – on the ambulance, of course – for a trivial complaint. He was transported, triaged, examined, all free of charge, in accordance with federal EMTALA requirements. While awaiting discharge, the very pleasant lady from the business office brought a packet of forms for him to complete for financial assistance. She had brought this packet to him on previous occasions, as this was his 24th visit in recent months. In fact, this time she had even filled out most of the forms and only needed a few items like his signature, driver’s license, and work place (he does work). She pointed out that he could quickly get this information and she would handle the rest. He demurred. She pointed out that they had done this dance many times. He yelled at her, demanding that she not treat him like he was stupid. She responded, “Then stop acting like you’re stupid!” He cursed her and stomped out AMA.
The patient is (too) well known to us, and is assuredly not illiterate. He has his own car, and a job. He is also entitled and able to play the system without fear of consequence. For those of you who don’t spend any time in emergency departments, you had better believe this sort of scenario is playing out in every ER nationwide.
There are truly disabled people for whom the state – NOT the federal government – should provide some safety net. I am happy to contribute my share for those, and glad to treat them. There are also the working poor, for whom the state should offer assistance as needed, as well as accountability. Those able-bodied, otherwise mentally competent who cannot be bothered to get off the couch should not get health coverage on the taxpayer dime. If I have to fill out paperwork to care for them, and for myself, then I will have no sympathy when they cannot put forward even this minimal effort on their own behalf. The implication of the Kaiser piece is that productive citizens who pay the damn freight should have no say in the matter.
5. Ridiculous Study of the Week: EHRs Save Lives
July 14, 2018
The idea that an electronic health record (EHR) or electronic medical record (EMR) saves lives never occurred to me. I would think that good doctors with good nurses on a good team in a good hospital really did the trick. But what the hell do I know? To a few researchers, however, they found it their mission to place all the importance on the EHRs. This is what they found:
Evidence linking electronic health record (EHR) adoption to better care is mixed. More nuanced measures of adoption, particularly those that capture the common incremental approach of adding functions over time in US hospitals, could help elucidate the relationship between adoption and outcomes. We used data for the period 2008–13 to assess the relationship between EHR adoption and thirty-day mortality rates. We found that baseline adoption was associated with a 0.11-percentage-point higher rate per function. Over time, maturation of the baseline functions was associated with a 0.09-percentage-point reduction in mortality rate per year per function. Each new function adopted in the study period was associated with a 0.21-percentage-point reduction in mortality rate per year per function. We observed effect modification based on size and teaching status, with small and nonteaching hospitals realizing greater gains. These findings suggest that national investment in hospital EHRs should yield improvements in mortality rates, but achieving them will take time.
I cannot find the full study and refuse to pay money for it. I just don’t care enough. I am no statistician, but it is hard to fathom that a .11% or a .09% change in mortality rate means anything. I am also perplexed with the “new function adoption” discovery they found. What does that mean? “Hey, Barbara, I found the a way to copy and paste! Let’s just use that instead of adding any new information?”
Overall, this study just seems ridiculous. It is has no depth. No “aha” discovery. Intuitively, EHRs can be good if they are workable and not overly complicated. Once you mix in quality indicators, absurd layers of security, and fluffed notes for billing then they become a piece of crap. Just my thoughts.
6. Friday Funny: The People Trying to “Fix” Our Healthcare System
July 13, 2018
This is what happens behind the scenes. Ivory tower doctors, MBAs, administrators and politicians are deciding our future while we walk off the cliff like lemmings. Let’s stop this madness.
Thanks www.bizarro.com for another great cartoon.
7. Quote of the Week: Selina Meyer
July 12, 2018
“I’ve met some people, some real people, and I gotta tell ya, a lot of them are f**ing idiots.”
Julia Louis-Dreyfus as Selina Meyer in Veep
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UNTIL NEXT TIME, KEEP SMILING, KEEP LAUGHING AND KEEP OUT OF REHAB!
Douglas Farrago MDTweet