Friday, September 26, 2014

From The Healthcare Blog: How To Discourage A Doctor

Dalai's note:  A piece by Dr. Richard Gunderman posted on  It is unclear whether or not Dr. Gunderman's "discovery" is a real document or not. Still, it would seem to explain a lot of what we are seeing in healthcare today...

How To Discourage a Doctor

Not accustomed to visiting hospital executive suites, I took my seat in the waiting room somewhat warily.

Seated across from me was a handsome man in a well-tailored three-piece suit, whose thoroughly professional appearance made me – in my rumpled white coat, sheaves of dog-eared paper bulging from both pockets – feel out of place.

Within a minute, an administrative secretary came out and escorted him into one of the offices. Exhausted from a long call shift and lulled by the quiet, I started to doze off. Soon roused by the sound of my own snoring, I started and looked about.

That was when I spotted the document on an adjacent chair. Its title immediately caught my eye: “How to Discourage a Doctor.”

No one else was about, so I reached over, picked it up, and began to leaf through its pages. It became apparent immediately that it was one of the most remarkable things I had ever read, clearly not meant for my eyes. It seemed to be the product of a healthcare consulting company, presumably the well-dressed man’s employer. Fearing that he would return any moment to retrieve it, I perused it as quickly as possible. My recollection of its contents is naturally somewhat imperfect, but I can reproduce the gist of what it said.

“The stresses on today’s hospital executive are enormous. They include a rapidly shifting regulatory environment, downward pressures on reimbursement rates, and seismic shifts in payment mechanisms. Many leaders naturally feel as though they are building a hospital in the midst of an earthquake. With prospects for revenue enhancement highly uncertain, the best strategy for ensuring a favorable bottom line is to reduce costs. And for the foreseeable future, the most important driver of costs in virtually every hospital will be its medical staff.

“Though physician compensation accounts for only about 8% of healthcare spending, decisions that physicians strongly influence or make directly – such as what medication to prescribe, whether to perform surgery, and when to admit and discharge a patient from the hospital – have been estimated to account for as much as 80% of the nation’s healthcare budget. To maintain a favorable balance sheet, hospital executives need to gain control of their physicians. Most hospitals have already taken an important step in this direction by employing a growing proportion of their medical staff.

“Transforming previously independent physicians into employees has increased hospital influence over their decision making, an effect that has been successfully augmented in many centers by tying physician compensation directly to the execution of hospital strategic initiatives. But physicians have invested many years in learning their craft, they hold their professional autonomy in high esteem, and they take seriously the considerable respect and trust with which many patients still regard them. As a result, the challenge of managing a hospital medical staff continues to resemble herding cats.

“Merely controlling the purse strings is not enough. To truly seize the reins of medicine, it is necessary to do more, to get into the heads and hearts of physicians. And the way to do this is to show physicians that they are not nearly so important as they think they are. Physicians have long seen the patient-physician relationship as the very center of the healthcare solar system. As we go forward, they must be made to feel that this relationship is not the sun around which everything else orbits, but rather one of the dimmer peripheral planets, a Neptune or perhaps Uranus.

“How can this goal be achieved? A complete list of proven tactics and strategies is available to our clients, but some of the more notable include the following:

“Make healthcare incomprehensible to physicians. It is no easy task to baffle the most intelligent people in the organization, but it can be done. For example, make physicians increasingly dependent on complex systems outside their domain of expertise, such as information technology and coding and billing software. Ensure that such systems are very costly, so that solo practitioners and small groups, who naturally cannot afford them, must turn to the hospital. And augment their sense of incompetence by making such systems user-unfriendly and unreliable. Where possible, change vendors frequently.

“Promote a sense of insecurity among the medical staff. A comfortable physician is a confident physician, and a confident physician usually proves difficult to control. To undermine confidence, let it be known that physicians’ jobs are in jeopardy and their compensation is likely to decline. Fire one or more physicians, ensuring that the entire medical staff knows about it. Hire replacements with a minimum of fanfare. Place a significant percentage of compensation “at risk,” so that physicians begin to feel beholden to hospital administration for what they manage to eke out.

“Transform physicians from decision makers to decision implementers. Convince them that their professional judgment regarding particular patients no longer constitutes a reliable compass. Refer to such decisions as anecdotal, idiosyncratic, or simply insufficiently evidence based. Make them feel that their mission is not to balance benefits and risks against their knowledge of particular patients, but instead to apply broad practice guidelines to the care of all patients. Hiring, firing, promotion, and all rewards should be based on conformity to hospital-mandated policies and procedures.

“Subject physicians to escalating productivity expectations. Borrow terminology and methods from the manufacturing industry to make them think of themselves as production-line workers, then convince them that they are not working sufficiently hard and fast. Show them industry standards and benchmarks in comparison to which their output is subpar. On the off chance that their productivity compares favorably, cite numerous reasons that such benchmarks are biased and move the bar progressively higher, from the 75th “Increase physicians’ responsibility while decreasing their authority. For example, hold physicians responsible for patient satisfaction scores, but ensure that such scores are influenced by a variety of factors over which physicians have little or no control, such as information technology, hospitality of staff members, and parking. The goal of such measures is to induce a state that psychologists refer to as “learned helplessness,” a growing sense among physicians that whatever they do, they cannot meaningfully influence healthcare, which is to say the operations of the hospital.

“Above all, introduce barriers between physicians and their patients. The more directly physicians and patients feel connected to one another, the greater the threat to the hospital’s control. When physicians think about the work they do, the first image that comes to mind should be the hospital, and when patients realize they need care, they should turn first to the hospital, not a particular physician. One effective technique is to ensure that patient-physician relationships are frequently disrupted, so that the hospital remains the one constant. Another is. . . .”

The sound of a door roused me again. The man in the three-piece suit emerged from the office, he and the hospital executive to whom he had been speaking shaking hands and smiling. As he turned, I looked about. Where was “How to Discourage a Doctor?” It was not on the table, nor was it on the chair where I had first found it. “Will he think I took it?” I wondered. But instead of stopping to look for it, he simply walked out of the office. As I watched him go, one thing became clear: having read that document, I suddenly felt a lot less discouraged.

Thursday, September 25, 2014

"Value-based care: Bad for doctors, bad for patients?"

Dalai's note:  Here is another piece cross published from I have a huge level of antipathy toward "Value-Based" reimbursement. From the beginning, I smelled a rat. How could we in radiology in particular prove the "value" of what we do in a manner that would convince those who hold the purse strings that we should actually be paid for our efforts? If, for example, we tell the ER doc that his order for a CT is inappropriate, we save the system money, and risk a lawsuit. If we let it go through, and it is negative as expected, we are dinged for charging the system for something that didn't produce "value". In other words, we are screwed either way.  What follows is a much better analysis of a sorry situation...
Value-based health care is antithetic to patient-centered care. Value-based health care is also diametrically opposed to excellence, transparency and competitive markets. And value-based health care is a shrewdly selected and disingenuously applied misnomer. Value-based pricing is not a health-care innovation. Value-based pricing is why a plastic cup filled with tepid beer costs $8 at the ballpark, why a pack of gum costs $2.50 at the airport and why an Under Armour pair of socks costs $15. Value-based pricing is based on manipulating customer perceptions and emotions, lack of sophistication, imposed shortages and limitations. Finally, value-based prices are always higher than the alternative cost-based prices, and profitability can be improved in spite of lower sales volumes.
Health care pricing is currently a smoldering mixture of ill-conceived cost-based pricing with twisted value-based pricing components. For simplicity purposes, let’s examine the pricing of physician services. As for all health care, the pricing of physician services is driven by Medicare. The methodology is neither cost-based nor value-based and simultaneously it is both. How so? Medicare fees are based on relative value units, which are basically coefficients for calculating the cost of providing various services in various practices, of various types and specialties. The price, which is also the cost since it includes physician take home compensation, is calculated by plugging in a dollar value, called conversion factor. The conversion factor, which is supposed to represent costs, is not in any way related to actual production costs, but instead it is calculated so the total cost of physician services will not exceed the Medicare budget for these services. Buried in this complex pricing exercise is a value-based component. A committee of physicians gets to decide the requisite amount of physician effort, skills and education, for each service. Whereas in other markets the value decision hinges on buyer perceptions, in health care it is masquerading as cost.
The commercial insurance market adds a more familiar layer of complexity to the already convoluted Medicare fee schedule baseline. Unlike Medicare fees, which are nonnegotiable, private payers will engage in value-based negotiations with larger physician groups and health systems that employ them. Monopolistic health systems in a given geographical area can pretty much charge whatever the market can bear, just like the beer vendor at your favorite ballpark does, and brand name institutions get to flex their medical market muscles no differently than Under Armour does for socks. This is value-based pricing at its best. Small practices have of course no negotiation power in the insurer market, but as shortages of physician time and availability begin to emerge, a direct to consumer concierge market is being created, providing a new venue for independent physicians, primary care in particular, to move to a more profitable value-based pricing model.
Unsurprisingly this entire scheme is not working very well for any of the parties involved, except private insurers who thrive on complexity and the associated waste of resources. Upon what must have been a very careful examination of the payment system, Medicare concluded that it does not wish to pay physicians for services that fail to lower Medicare expenditures, and Medicare named this new payment strategy value-based health care, not because it has anything in common with value-based pricing, but because it sounds good. Another frequently used term in health care is value-based purchasing, which is attempting to inject the notion of quality as the limiting factor for cost containment. However, since Medicare is de facto setting the prices for its purchases, there is really no material difference between these two terms.
We need to be very clear here that value-based health care is not the same as quality-based health care. The latter means that physicians provide the best care they know how for their patients, while the former means that physicians provide good health care for the buck. To illustrate this innovative way of thinking, let’s look at the newest carrots and sticks initiative, scheduled to take effect for very large medical groups (over 100 physicians) in 2015. Below is a table that summarizes the incentives and penalties that will be applied through the new Medicare Value-based Payment Modifier.
Value based care: Bad for doctors, bad for patients?
There are several things to note here. First, if your patients receive excellent care and have excellent outcomes, you will receive no perks if that excellence involves expensive specialty and inpatient services, whether those are the accepted standard of care or not. You would actually be better off financially if you took it down a notch and provided mediocre care on the cheap. The second thing to notice is that you will not get penalized for providing horrendously subpar care, if you do that without wasting Medicare’s money.
Another intriguing aspect of this new program is that you have no idea how big the incentives, if any, are going to be. The upside numbers in the table are not percentages. They are multipliers for the x factor. The x factor is calculated by first figuring out the total amount of penalties, and that amount is then divided among those who are due incentives. If there are few penalties, there will be meager incentives. Lastly, those asterisks next to the upside numbers, indicate that additional incentives (one more x factor) are available to those who care for Medicare patients with a risk score in the top 25% of all risk scores.
As with everything Medicare does, this too is a zero sum game. For there to be winners, there must be losers. One is compelled to wonder how pitting physician groups against one another advances collaboration, dissemination of best practices, or sharing of information, and how it benefits patients. Leaving philosophical questions aside, the optimal strategy for obtaining incentives seems to be transition to a Medicare Advantage type of thinking: get and keep the healthiest possible patients, and make sure you regularly code every remotely plausible disease in their chart. Stay away from those dually eligible for Medicare and Medicaid, the very frail, the lonely, the infirm, or the very old, and don’t be tempted to see a random person who is in a pinch, because there is always the chance that he or she will be attributed to your panel following some hospitalization or other misfortune.
The Value-based Payment Modifier is for beginners. It is just the training wheels for the full-fledged risk assumption that Medicare is seeking from physicians and health care delivery systems in general. The grand idea is not much different than providing an aggregated and risk adjusted defined contribution for a group of assigned members, and having the health care delivery system absorb budget overruns, or keep the change if they come in under budget. There is great value in such a system for Medicare and commercial payers certain to follow in its footsteps, and perhaps this is why they decided to call it value-based. Ironically, the equally savvy health care systems are fighting back precisely by building the capacity to create a true value-based pricing model for their services through consolidation, monopolies, corralled customers, artificial shortages, confusing marketing, and diminished physicians.
It is difficult to lay blame at the feet of health systems for these seemingly predatory practices, because transition to a perpetual volume-reducing health care system is by definition unsustainable. The infrastructure and resources needed to satisfy all the strategizing, optimizing, counting and measuring activities required for value-based health care, whether the modest payment modifier or the grown up accountable care organization (ACO), are fixed costs added to health system expenses year after year. However, the incentives or shared-savings are temporary at best, because at some point volumes cannot be reduced further without actually killing people. Either way, in the near future, and for already frugal systems, in the present, all incentives will dry up leaving only massive outlays for avoiding penalties coupled with increased risk for malpractice suits.
And as these titans are clashing high above our little heads, two outcomes are certain: Individual physicians will be paid less and individual patients will be paying more for fewer services. This is how we move from volume to value. Less volume for us, more value for them.
Margalit Gur-Arie is founder, BizMed. She blogs at On Healthcare Technology.

Monday, September 08, 2014

I never understood the loss of empathy during medical training. Until now.

Another incredibly powerful post published on, this from an anonymous medical student. Read it and weep. I did.

It was 4:30 a.m., and I was on the side of the road, drenched in sweat and tears. I had finally slowed my breathing to normal. I was going to be late for rounds. No time to obsess over possible questions. No time to memorize lab values, or practice regurgitating them.

I thought of home. My family and friend, who I hadn’t seen in months. I cringed when I estimated how long it had been since I called them. And the place itself. The dry, clean heat of the desert. The pump jacks that dotted the landscape. The men with their muddy work boots and weathered skin. The brave, unconventional beauty, the humility of the region. And my heart ached to be there, to go back to a time where I was bright and hopeful. I think that’s where most of my sadness came from. Grieving the loss of her, the girl who wanted to do something that mattered.

I attended my dream school. I remember the day that I received my acceptance letter as one of the happiest in my life. I was going to learn from some of the smartest doctors in the world. I felt blessed. As a young man, my grandfather had crossed the border to pick cotton. His third grade education and shaky English would keep him working manual labor jobs for his entire life. My father was the first to graduate from high school. He, like most men back home, worked in the oilfields. And I was going to medical school. My family couldn’t help me fill out the applications or pay for the MCAT (I worked at a coffee shop to cover that). But they were my biggest fans, my cheerleading squad.

My decision to choose medicine was emotionally motivated. My mother became very sick during my junior year. She spent months in hospitals, on respirators and feeding tubes. I watched my mom suffering, and I hated that I didn’t understand what was going on, that I couldn’t help. Soon after she came home, I announced I was going to medical school. I had never been so sure.

We experienced intense stress and pressure to perform, to produce results. Early on, I stopped attending lectures, and watched from home. I could speed up the recording and learn twice as fast, I reasoned. Alone in the small apartment that my loans afforded me once I paid the hefty tuition bill, I worked diligently to produce what were considered mediocre grades at my institution. It is difficult to explain the isolation, the emptiness of this time. Those are two years I’ll never get back. Two years of youth and good health spent in an apartment.

I would call my friends and family often in the beginning, sobbing and anxious. But how could they understand? To them, to the outside, a doctor’s life seemed very glamorous indeed. After a while, I stopped calling.

The only patient contact I received were not real patients. They were actors. Once or twice a semester, we would conduct earnest interviews with these pretend patients. We would be timed, filmed, and graded. Even our interactions with other human beings were carefully scripted and judged. If my university believed in one thing, it was that there was no human enterprise on Earth that could not be held to a rubric. They had yet to fail in their quest to quantify, to measure all of the qualities of an ideal doctor.

Then the grand finale: step 1, or as I like to call it: “The Most Important Test On The Planet: If You Screw Up You Will Never Get The Residency That You Have Dreamed About Since You Were Three Years Old.” Weeks of cramming material into my head. I drank coffee. I studied. Period. I was motivated by the promise of the clinical years. I was finally going to be able to interact with humans again. I prayed that the motivation, the drive I had lost somewhere along the way would return.

My happiest times in school were early in the morning, before the residents and the attendings were around to expose the holes in my knowledge, or reprimand me for forgetting to test cranial nerve IX, or scold me for my presentation being too long (or too short, depending on the person.) It was listening to my patients as they told me about their children. Their patience as I clumsily stumbled through the interview. The way their face relaxed as I told them that I would bring up their concerns to the doctor. Holding their hands and telling them it was going to be alright. Laughing, connecting, loving. Ironically, the shortest parts of my day. No time for that sort of thing with notes to write, tests to study for, articles to look up.

I attempted to explain the situation to the school psychologists. I tried to convey the sense of loss, the unmet expectations, the dying of a dream. I was told I was experiencing severe depression and anxiety, feelings that were internally generated. No possible flaw in the system, they rationalized. After all, there were rubrics. I was assured it would take months to treat me. Best to get on with it, numb up in time for the next rotation. Instead, I took a leave of absence.

I have been silent for too long. I have asked, “What’s wrong with me?” when I should have been asking, “What’s wrong with this?” I am compassionate and hardworking, yet I have been daily made to feel inadequate. I have been isolated from the people and the pursuits I love. I have given up everything, paid thousands of dollars, thousands of hours. I have repeated to myself over and over, “there is only medical school.” I almost believed it.

I never understood the trend of loss of empathy during medical training. Until now. See, when you’re in so much pain that if you thought of your life past this moment, this singular point in time, you would implode, pain seems as natural as breathing. Pain is part of life. Pain is nothing. You can’t stop to nurse your own wounds, you can’t talk about how much you hurt. So how could you possibly have enough room in your broken heart to take on someone else’s pain? So you don’t. You cover your bases and survive. You become that machine that you swore you’d never become. Because it hurts too much to feel, and it’s so much easier to float than swim.

I fantasize daily about leaving medicine for the endless sky back home. I miss the person that I was so very much. But I’m still here. And I hold onto my faded dreams in my little hands.


I remember that hospital room that smelled of isopropyl alcohol and sickness. I remember changing the sheets my mom soiled because the nursing staff was short in our small hospital. I remember the cold, detached doctors that came for ten minutes once a day. I remember how they spoke in riddles, how they seemed so far away. I remember.

I promise I won’t forget. I’ll never forget.