Dr. Cranquis' Mumbled Gripes

thuc:

The Dedicated Doctor [infographic]

No doubt about it, becoming a physician is hard work and a long road. Healthcare reform is here so…

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An inspirational infographic by the Alpha Infographicist thuc.
One not-so-inspiring comment, though: yes, more doctors are needed, yes, more spots are opening up in med schools, more jobs will be available for med school graduates, more patients are going to become insured under Obamacare — BUT since jack-squat is being done about proportionally improving reimbursement for all those doctors (new and old) and alleviating the massive debt which med students have to incur in order to become underpaid doctors, it’s still going to be tough to keep those doctors in business. Because it IS a business.
/rant

The Dedicated Doctor [infographic]

No doubt about it, becoming a physician is hard work and a long road. Healthcare reform is here so…

View Post

An inspirational infographic by the Alpha Infographicist thuc.

One not-so-inspiring comment, though: yes, more doctors are needed, yes, more spots are opening up in med schools, more jobs will be available for med school graduates, more patients are going to become insured under Obamacare — BUT since jack-squat is being done about proportionally improving reimbursement for all those doctors (new and old) and alleviating the massive debt which med students have to incur in order to become underpaid doctors, it’s still going to be tough to keep those doctors in business. Because it IS a business.

/rant

numberneededtotreat:

YouTube | The History of EHRs

Excellent, short description of one reason why electronic medical records are terrible—the original development has not been driven by creating a clinical tool for doctors, but more of an administrative tool for others in healthcare (i.e.—administrators and payers)

Agree, agree, agree. My particular thoughts on this video:

“Meaningful Use” — HAHAHA! What a waste of time. Do you know that my EHR now REQUIRES me to enter a blood pressure on any patient AS YOUNG AS 2 YEARS OLD before I can actually “see” the patient? Even though no study shows that measuring BP in all kids under 12 provides any useful data to improve their health? “But it’s required, for meaningful use” whine the EHR people. FACE-SLAPS ALL AROUND.
Yay Epocrates!
Have you ever tried to read an old visit note in an EHR? Think about how much scrolling and scrolling and scrolling you did before you finally found the one tiny sentence or phrase which actually gave you any clinically-useful information. The rest of that crap? Coding and Billing fluff.
@ 2:05, I love the woman who is just standing there staring at the white board in the background. That would be me if I was ever trapped in one of these types of meetings. Maybe doodling a tiny Cranquis curb-stomping a tiny laptop, Office Space style.
Dr. Dombrowski’s idea of “getting all the governmental agencies… on the same page” about EHR is nice and all — but unless doctors/nurses/PEOPLE WHO ACTUALLY SEE PATIENTS are in charge of those much-needed revisions, things will never ever improve with EHR.

US Healthcare Woes: A letter to doctors from the Dallas County Medical Society President

Dear Colleague,

Earlier this week Gov. Rick Perry sent a letter to US Health and Human Services Secretary Kathleen Sebelius and stated that Texas is opposed to the expansion of Medicaid as provided in the Patient Protection and Affordable Care Act and to creating a state insurance exchange. This announcement came on the heels of the Supreme Court’s decision to uphold the PPACA.

Both decisions affect Texans as many Texans depending on government-funded health insurance face a crisis in access to health care. The problem is that having coverage is not the same as having access, and access to a waiting list is not access to health care. Handcuffed by stifling regulations and money-losing reimbursement levels, an accelerating number of physicians have stopped accepting new patients who have government-funded health insurance — Medicaid and Medicare. Only 31 percent of Texas physicians accept new Medicaid patients. The negative trajectory of this number is just as alarming, having been 42 percent in 2010. In Dallas County the numbers for 2012 are even more bleak — just 24 percent of physicians accept new Medicaid patients. At this rate you have to wonder when the acceptance rate for our county will fall into the teens, or if we will actually see single digits. Since 2010, the percentage of Texas physicians accepting new Medicare patients fell from 66 percent to 58 percent. In regard to dual-eligible (Medicare-Medicaid) patients, 40 percent of physicians statewide and 32 percent in Dallas County accept them. Coupled with the potential negative impact of the Medicaid 1115 Waiver on hospital reimbursement for low-income patients, we could be facing a devastating perfect storm of decreasing patient access.

This is why the proposed expansion in Texas of the Medicaid program under the PPACA by itself is not the answer for uninsured and low-income patients. Why expand coverage in an insurance plan that has shockingly limited and unacceptable access to care? This simply gives false hope to the 25 percent of our fellow citizens who are uninsured that their participation in the Medicaid program will dramatically improve their ability to access the healthcare system. We need a plan that expands coverage and access to care.

The gold standard for this access must embody timely access to quality, cost-effective care. A key ingredient of this expansion of access is the streamlining of the oppressive and progressively costly regulatory process so we physicians can devote more of our time to caring for patients and less to caring for paperwork. Paperwork never healed anyone. Improving patient access to health care also must involve increasing physician reimbursement to viable levels where we do not face the prospect of paying out of our pockets for every Medicaid patient we see. By working with our legislators and congressional representatives, we physicians can have a significant impact in improving access to the healthcare system for the uninsured of our state. We physicians must be forceful advocates for our patients. However, we should not put the cart before the horse. Instead of initially expanding coverage to the uninsured of our state to an overly flawed and ineffective insurance system, we should first concentrate our efforts on improving actual access to care through the Medicaid plan we currently have in place. Let’s get to work.

Sincerely,

Richard W. Snyder II, MD
President
Dallas County Medical Society

I bolded the statements that I feel are particularly overlooked in the whole Obama Care kerfuffle. For more physician opinions on PPACA, including my own, see my Obama Care tag.

Cranquis on SCOTUS upholding the Affordable Healthcare Act

whimsicalfirefly submitted:

HI! With the heart of Obama’s health care reform ruled as constitutional just now, I was curious how you think this will affect doctors?

Oh joy a question about politics I cannot contain my excitement.

(Nothing personal! I just hate politics. So this reply will be short.)

First, let’s get the term straight: The Affordable Care Act (aka Obama Care) is not healthcare reform, it’s healthcare insurance reform. And you can (attempt to) fix the insurance system all you want, but until you fix the healthcare system itself, costs will continue to skyrocket and reimbursement will not be able to keep up.

Second: read this prior post where I discuss my main objections to the ACA, plus what I think would really need to change in the US healthcare system for actual healthcare reform.

Lastly: read the reblogged posts under my Obama Care tag, particularly the excellent posts by WayfaringMD and Jay Parkinson, for more MD perspectives on the issue.

The Challenges that come with Obamacare

wayfaringmd:

about-hortense replied to your post: Great, lots more people are about to have insurance.

i don’t understand the meaning of that BUT. This topic intrigues me a lot and, as a non-american, I’d like you to stretch out ya point of view which, obviosuly, lingers behind that opening adversative.

What I was referring to is that there’s a huge deficit of primary care doctors in this country, and our system does not do a very good job of encouraging trainees to go into primary care.

Putting it simplistically, billing in the American medical system is based on procedures, tests, and the complexity of diagnoses. Doctors bill a certain amount for different things, and insurance companies generally pay a higher percentage of what doctors charge than government programs like Medicare and Medicaid pay. So the more patients you have with private insurance, the better your reimbursement rates.

The problem is that things like preventive care and regular follow-ups for chronic conditions (things which should theoretically save the system money by preventing conditions that require expensive procedures and tests) are not considered complex enough to warrant decent pay from government payor sources (Medicare/Medicaid). And guess what takes up the majority of primary care docs time? You guessed it, preventive care and follow up visits.

Read More

I’ll post a little more about my thoughts on the ACA later (only because a reader directly asked me to comment on it, sigh — Cranquis hate politics, Cranquis smash), but this post pretty much sums up my feelings on it already.

$jayparkinsonmd: In 2009, I was included in Esquire Magazine’s annual year end Best and Brightest list of about 20 people they think are doing wonderful things. It’s still one of my professional highlights. One of the others that year was a gentleman named Daron Acemoglu. I was fortunate enough to sit next to him for about a three hour dinner and drinks shindig put on by Esquire. Needless to say, he’s an impressive guy. He’s just published a book called “Why Nations Fail.” The essential argument of the book is that “the wealth of a country is most closely correlated with the degree to which the average person shares in the overall growth of its economy.” According to Acemoglu’s thesis, when a nation’s institutions prevent the poor from profiting from their work, no amount of disease eradication, good economic advice or foreign aid seems to help: I observed this firsthand when I visited a group of Haitian mango farmers a few years ago. Each farmer had no more than one or two mango trees, even though their land lay along a river that could irrigate their fields and support hundreds of trees. So why didn’t they install irrigation pipes? Were they ignorant, indifferent? In fact, they were quite savvy and lived in a region teeming with well-intended foreign-aid programs. But these farmers also knew that nobody in their village had clear title to the land they farmed. If they suddenly grew a few hundred mango trees, it was likely that a well-connected member of the elite would show up and claim their land and its spoils. What was the point? This reminds me so much of physicians in America. Primary care is in such a bad state. Only about 5% of graduating residents are choosing primary care mostly because primary care doctors can expect to earn $3.5 million less than a specialist over their lifetimes. There’s really no rosy future that suggests this will get better. Currently, our medical industry is composed of 75% specialists and 25% generalists, exactly opposite of the UK and Canada, both of which rank much higher than us in nearly all health statistics. In the next decade or two, when boomers retire, primary care is essentially dead. And this is the elephant in the room for Obamacare. Obamacare depends on primary care to control costs, by creating the theoretical Accountable Care Organization. With only a tiny fraction of the physician workforce being primary care over the next decade, the ACO model falls apart. Now back to Daron’s theory…$

jayparkinsonmd:

In 2009, I was included in Esquire Magazine’s annual year end Best and Brightest list of about 20 people they think are doing wonderful things. It’s still one of my professional highlights. One of the others that year was a gentleman named Daron Acemoglu. I was fortunate enough to sit next to him for about a three hour dinner and drinks shindig put on by Esquire. Needless to say, he’s an impressive guy. He’s just published a book called “Why Nations Fail.” The essential argument of the book is that “the wealth of a country is most closely correlated with the degree to which the average person shares in the overall growth of its economy.” According to Acemoglu’s thesis, when a nation’s institutions prevent the poor from profiting from their work, no amount of disease eradication, good economic advice or foreign aid seems to help:

I observed this firsthand when I visited a group of Haitian mango farmers a few years ago. Each farmer had no more than one or two mango trees, even though their land lay along a river that could irrigate their fields and support hundreds of trees. So why didn’t they install irrigation pipes? Were they ignorant, indifferent? In fact, they were quite savvy and lived in a region teeming with well-intended foreign-aid programs. But these farmers also knew that nobody in their village had clear title to the land they farmed. If they suddenly grew a few hundred mango trees, it was likely that a well-connected member of the elite would show up and claim their land and its spoils. What was the point?

This reminds me so much of physicians in America. Primary care is in such a bad state. Only about 5% of graduating residents are choosing primary care mostly because primary care doctors can expect to earn $3.5 million less than a specialist over their lifetimes. There’s really no rosy future that suggests this will get better. Currently, our medical industry is composed of 75% specialists and 25% generalists, exactly opposite of the UK and Canada, both of which rank much higher than us in nearly all health statistics. In the next decade or two, when boomers retire, primary care is essentially dead. And this is the elephant in the room for Obamacare. Obamacare depends on primary care to control costs, by creating the theoretical Accountable Care Organization. With only a tiny fraction of the physician workforce being primary care over the next decade, the ACO model falls apart.

Now back to Daron’s theory…

Enrollment In High-Risk Insurance Pools Inches Up, But Remains Low →

jayparkinsonmd:

One of the hallmarks of Obama’s healthcare reform was ensuring that people with pre-existing conditions would not be denied health insurance. The clause went into effect in September 2010.

Since then, out of 4 million eligible Americans, 18, 313 people in the US have signed up for the Pre-Existing Condition Insurance Plan.

Why?

The premiums are too expensive. And very few people know that these plans exist because insurance companies surely won’t spend money advertising them.

Just because insurance policies now exist for these people doesn’t mean people can afford them. Keep in mind, by 2020, the average premium for all of us in America will be about $29,000 per year. At that time, we’re all going to have a pre-existing condition called “we can’t afford your damned mandated health insurance.”

Haha! Love it: “I’m afraid I have bad news, Mr. Jones — you have Broke-itis. There is no cure.”

Anonymous Asks:

In your opinion, how will Obama's health care reform affect doctors/future MD's?

cranquis Said:

Aloha, Ben Dover! I am so glad that I have already posted my thoughts on Obama-care in a couple of prior posts, so that I don’t have to spend time dwelling on this political stuff again. Check those posts out… hopefully they will answer your question. :)

(It’s not that I don’t like answering questions, Ben — I just get so frustrated with politics that it chafes my chaps to write about it.)

minutiarum Asks:

I understand your gripes about reimbursement and EMR. But if it was properly implemented (give doctors money for equipment and staff training), do you think that EMR would improve patient care? What are your thoughts on the other aspects of the bill (Coverage for pre-existing conditions, requirement to have health-insurance, research on the effectiveness of treatments, etc)?

Thank you for taking the time to answer my questions. Your blog is amazing.

cranquis Said:

Ok, first of all — where is that money for EMR supposed to come from? That’s right: my taxes. Where will a greater proportion of the tax money come from? Hmm, well, who pays higher taxes: the patients who don’t have health insurance, or the doctors? Hmm…

But yes, in some magical world where real-life in-practice doctors could design an EMR program from the ground up, and be able to re-design/adjust it easily without layers of bureaucracy and non-medical software programmers clogging up the works, YES: EMR could improve patient care.

I think the concept of “pre-existing conditions” is an annoying yet realistic component of determining which patients will likely consume a greater portion of the insurance “pie”. Now, if you have nationwide health care insurance that automatically covers all pre-existing conditions WITHOUT finding a way to compensate financially for the extra burden incurred by a diabetic-hypertensive-smoker, compared to a non-smoking healthy specimen of manliness (like myself), then the end result is: everyone pays the same amount into the pot (taxes), but some people will consume WAY more of that money. Fair? I think not. So then how do you make the math work out? Well, here’s an easy way: don’t pay the doctors equitably for the extra care and effort required for those complicated patients! DOH.

Requirement to have health insurance: I repeat, if nationwide health insurance has to cut back on reimbursement to doctors in order to make ends meet in the budget, why would any doctor want to accept that insurance? (“Will you be paying cash today, Mr. Brown, or will you be providing free car repairs for the doctor for the next month?”) So at that point, what good did it do to give everyone health insurance?

Research on the effectiveness of treatments = EBM (Evidence-Based Medicine). YES, I AM TOTALLY IN FAVOR OF THIS! It’s a concept which has really only showed up in med schools in the past 10-15 years [citation needed], so the “older generations” of doctors still tend to use a lot of “in my experience” and “well I heard somewhere” (Anecdotal Medicine) to back up there current treatment practices without actually checking to see if the research backs it up! EBM is awesome.

But something else needs to go hand-in-hand with EBM in order for doctors to be able to practice medicine safely, relying on the research without having to worry so much about “But what if this patient is the 1 in a thousand/million patient that DOESN’T fit the research, and I get SUED?” — TORT REFORM. As long as patients can sue the pants/underwear/scrotal skin off of doctors because of a “random” unexpected poor outcome while attempting to follow EBM guidelines, doctors will continue to use the Shotgun Approach for patients: BLAST THEM WITH ANTIBIOTICS AND FULL-BODY SCANS AND UNNECESSARY HOSPITAL/ER VISITS AND TOO-SOON SPECIALIST REFERRALS, so that a future judge/jury can’t say “You didn’t do enough for this patient!” I can’t begin to estimate just how much $$ is WASTED each day by doctors ordering tests that won’t change their treatment plan, just to appease the patient (either because the patient is currently demanding the test, or because the doctor imagines the patient complaining later that the doctor DIDN’T do the test).

I have a colleague who regularly walks out of exam rooms with a throat culture swab, hands it to the nurse, and says, “Go ahead and do the strep test, but I’m sure it’s going to be negative.” 5 minutes and one pointless test later, he goes back in the room and tells the patient, “Well, it appears you don’t have strep throat, because the test was negative.” ARRGH! You already knew the patient didn’t have strep throat, based on your physical exam! But that’s Defensive Medicine for ya — doctors are running scared of patients and their lawyers.

(So this whole post makes me sound like a greedy elitist doctor. Not at all. Our country should not have so many un-insured patients — it’s shameful. But the current health-care-reform bill(s) are really “Health-Care-Insurance-Coverage-Reform.” Hence my skepticism.)

Hope this helps. Sorry I took a while to reply — I always procrastinate replying to these “political” questions, cuz I hate the whole topic. :p

zenbound Asks:

Hi Dr. Cranquis,
As a medical student who was accepted from a rural area, I just wanted to know what your thoughts are on the state of health care and the disparity between urban and rural practice. Do you see any changes for the better in the coming years? Also, love your writing!

cranquis Said:

Howdy — thanks for the compliment! Glad you’re enjoying my writing.

Congratulations on being a medical student, and not just any med student — but a med student that is actually paying attention to the Bigger Picture when it comes to the US Health-Care system. I really think the only way that we physicians, as a profession, are going to have any hope of revamping this mess is if doctors start getting educated and knowledgeable about the politics and economics of health-care from the get-go!

My thoughts on the state of US health care? Ok, here they come… (Just give me a moment to emotionally prepare myself to lose half of my Tumblr followers, who will inevitably disagree with me)

People think doctors are complaining about medicaid/medicare under-funding and reimbursement cuts because we’re “a bunch of rich nerds that work 4 hours a day and then jump in our Porsches to drive to the golf-course”. (Reference) NOT TRUE. We’re barely getting paid enough to cover our overheads and to pay our staff. Reimbursement for doctors is being calculated on formulas and data that are 20+ years out of date. Yet, when doctors try to raise these points in the media, we’re shouted down as “just being greedy”.
Doctors need to get off their lazy butts and start kicking up a stink in the political arena. The problem is, we’re too busy taking care of sick people, to have time to educate ourselves on the slimy world of “political lobbying” — which is the only way that anything gets done in Washington nowadays. We don’t have time to organize grassroots campaigns. And our “official” political body, the American Medical Association, is a corrupt bed-fellow of our political system, which is more worried about generating huge profits for drug company CEOs and insurance company stockholders, than it is about ensuring that the few doctors we HAVE can afford to stay in business, and to encourage up-and-coming NEW doctors (like yourself) to actually consider going into medicine (rather than choosing a financially- and legally-safer field, like say, Hired Assassin or Meth Lab Owner).
We NEED to reform the legal system which is handcuffing physicians into practicing “defensive” medicine. “Oh, this guy probably doesn’t have a broken ankle, I have excellent guidelines which indicate that, based on a physical exam, he has less than a 10 % chance of having a fracture, but I’d better get an xray anyways, because if he is one of the 10%, he could turn around and sue me for a bajillion dollars!!” EVERY DAY, doctors across our nation order hundreds of tests (lab work, xrays, CT and MRI scans) that have a low probability of contributing any useful information to a patient’s particular case, NOT because those tests are medically indicated, but because the doctors are AFRAID to “leave themselves open” to a lawsuit for missing some unlikely condition or complication. As long as malpractice lawsuits have no limits on damages sought, doctors will be open targets in the court-room, and this will directly affect the use of medical resources in the clinic-room (which, in turn, ramps up the costs of health-care nationwide!). Certain specialties (OB-GYN, most noteably) now have to carry such high malpractice insurance to protect against ridiculous lawsuits (“You delivered a baby 16 years ago, and now that patient is having dyslexia and behavioral issues in school, and his family is suing you because they claim you gave him brain-damage during the delivery!” — NOT MADE UP), that it’s affecting the rates at which med students decide to enter those specialties.
One of the big pushes in Obama-care is to make sure that all doctors are using EMR (Electronic Medical Records). Sounds good, and it does have some good aspects — I’d love to be able to instantly look up how many times my drug-seeking patients have gotten Vicodin from doctors 3 towns away, for example… but it has it’s dark side too. Why? Most EMR software is useless and un-intuitive to use, designed by computer programmers working with “consulting” physicians who don’t actually see patients. They slow down health-care, not speed it up. If you are a rural small-town doctor with a private practice, the overhead costs for converting your 6-room clinic to handling EMR (including Wi-Fi, networked printers, purchasing all the laptops and servers and software, training your staff, and hiring someone to come fix all the never-ending crap that jinxes computer systems) will destroy you — because you’ll have to raise your costs, so patients will get upset and start going elsewhere. And it appears that clinics using EMR don’t actually generate better patient care! True, the longer that a doctor uses EMR, the better he/she gets at it, but forcing doctors to add the costs of EMR to their already over-burdened budgets, without repairing the broken billing-reimbursement system first, is STUPID.
Bottom Line: You can “reform health care insurance” all you want, Obama — but if every patient in America has health-care insurance which reimburses doctors a pittance of the doctor’s actual costs, and the patients can sue the butt off their doctor on a whim, and the cost of prescription medications continues to skyrocket to keep padding the drug company wallets — it’s all gonna come crashing down.
(In case you haven’t figured it out yet from this rant: NO, I do not see any changes for the better in the coming years. *sigh*)

I’m not sure what exactly you mean by “the disparity between urban and rural practice”… can you clarify that question? Then I’ll try to answer it.

(Ugh, just writing about all this crap is giving me an ulcer and a headache.)